depression

Medications worsening depression (12)

• Atomoxetine

• Indomethacin

• NNRTIs (REDEN)

• INSTIs (BCRED)

• Beta blockers (propranolol)

• Hormonal contraceptives

• Anabolic steroids

• Systemic steroids

• Inteferons

• Benzos

• Alcohol

• Varenicline

HI BABA VISAIN

Medical conditions contributing to depression (9)

• Parkinsons

• Dementia

• MS

• Hypothyroidism

• Vit D defiency

• Hypercalcemia

• Malignancy

• OAB

• Stroke

What is the most widley used depression assessment scale?

HDRS or HamD

Depression diagnosis with DSM-5 needing at least ___ symptoms present during the same ____ week period.

5, 2

DSM-5 criteria

• Mood

• Seep

• Interest/pleasure diminished

• Guilt or feelings of worthlessness

• Energy decreased

• Concentration decreased

• Appetite

• Psychomotor agitation or retardation

• Suicidal ideations

MSIGECAPS

CAM products for depression (3)

• SJW

• 5-HTP

• Valerian

First line TX for depression (2)

SSRI or SNRI

If a drug does not work after a trial of __-___ weeks, then TX can be reassessed

4-8

Postpartum depression TX

• Psychotherapy

• If on an antidepressant prior to pregnancy, can consider continuing

• If not on an antidepressant prior then consider SSRI

_____ are preferred if an antidpressant is needed during pregnancy

SSRI

What SSRI should be avoided during pregnancy?

Paroxetine due to adverse cardiac effects and persistent pulmonary hypertension of the newborn

Seretonin syndrome symptoms

• Nausea

• Diarrhea

• Tachycardia

• Dizziness

• Headache

• Agitation

• Hallucinations

• Muscle rigidity

All antidepressants carry what BW?

Increase in suicidal thoughts or actions in some children, teenagers, or young adults

• Medguide is required!

SSRI options (6)

• Fluoxetine (Prozac)

• Fluvoxamine

• Paroxetine (Paxil)

• Escitalopram (Lexapro)

• Citalopram (Celexa)

• Sertraline (Zoloft)

Full Fabulous PECS

Citalopram dosing

• 40 mg max

• Unless >60 years old then 20 mg due to QT risk

Escitalopram dosing

• 20 mg max

• Unless older adult, then max 10 mg

SSRI adverse effects (13)

• SIADH/Hyponatremia

• Fall risk

• Bleeding

• Sexual

• Somnolence

• Insomnia

• Nausea

• Dry mouth

• Headache

• Diaphoresis (dose related)

• Weakness

• Tremor

• Dizziness

What SSRI is most activating and therefore should be taken in the AM?

Fluoxetine

What SSRI is most sedating and therefore should be taken in the PM?

Paroxetine

What is the preferred SSRI in patients w cardiac risk?

Sertraline

Which 3 SSRI's are also approved for premenstrual dysphoric disorder (PMDD)?

Fluoxetine, paroxetine, sertraline

SSRI's DDI

• MAOI can cause HTN crisis or seretonin syndrome

• Concomitant QT prolonging meds

• AC, antiplts, NSAIDs, etc due to bleed risk

• CYP2D6 and tamoxifen with fluoxetine & paroxetine

What is the washout period for MAOI to SSRI switch?

• 2 WEEKS

• Or 5 weeks with fluoxetine due to long t1/2

Fluoxetine & paroxetine DDI with tamoxifen

They decrease tamoxifen efficacy, and venlafaxine would be preferred in place

SNRI options (4)

• Levomilnacipran

• Duloxetine (Cymbalta)

• Venlafaxine (Effexor XR)

• Desvenlafaxine (Pristiq)

Loung around and watch DVD

What additive AE does SNRI's have with NE compared to SSRI's? (4)

• Increased HR/BP

• Dilated pupils

• Constipation

• Excessive sweating

Max dose of IR venlafaxine is ____ mg/day

375

TCA options (9)

• Amitriptyline - tert

• Imipramine - tert

• Doxepin - tert

• Clomipramine - tert

• Trimipramine - tert

• Amoxapine - sec

• Protriptyline - sec

• Desipramine - sec

• Nortriptyline - sec

All Intelligent Doctors Carefully Take A Precise Diagnosis Naturally

When are TCA's taken?

QHS

TCA adverse effects (6)

• QT prolong

• Suicidal ideations

• Orthostasis

• Anticholinergic: dry mouth, blurred vision, urinary retention, constipation

• Weight gain

• Fall risk

What TCA can also be used for insomnia?

Doxepin (Silenor)

DA & NE reuptake inhibitors (1)

Bupropion (Wellbutrin)

Do not exceed more than ___mg/day of bupropion due to seizure risk

450

Bupropion adverse effects

• Dry mouth

• Insomnia/restlessness

• Tremors/seizures (dose related)

• Weight loss

What neurotransmitter causes sexual dysfunction?

5HT

T/F: Bupropion can affect sexual dysfunction

False - it doesnt act on 5-HT

MAOI options (4)

• Isocarboxazid (Marplan)

• Phenelzine (Nardil)

• Tranylcypromine (Paranate)

• Selegiline patch - MAOI-B selective

MAOI 2 week washout with wash drugs (4)

• SSRI (except flux is 5 weeks)

• SNRI

• TCA

• Bupropion

Mirtazapine (Remeron) MOA

Alpha-2 antagonist which increases NE & 5HT

Mirtazapine adverse effects (3)

• Sedation

• Increased appetite

• Weight gain

Trazodone MOA

Inhibits 5HT reuptake and blocks H1 and alpha1 receptors

Medication that has risk of priapism?

Trazodone

Nefazodone BW

Hepatotoxicity

TX resistant depression*

• Change to diff antidepressant (after 4-8 week trial)

• Increase the dose

• Use a combination of antidepressants with diff MOA

• Add adjunctive TX to augment antidepressant therapy: CABO QE

Adjunctive TX to add in resistant depression (6)

• Cariprazone

• Aripiprazole

• Brexipiprazole

• Olanzapine/fluxoetine

• Quetiapine

• Esketamine

CABO QE

What agent would you choose in a patient with bleed risk? (2)

• Buproprion

• Mirtazapine

What agent would you choose in a patient with insomnia? (4)

• Mirtazapine

• Paroxetine

• Trazodone

• TCA

What agent would you choose in a patient that has sexual dysfunction? (4)

• Bupropion

• Mirtazapine

• Vortioxetine

• Vilazodone

Causes weight loss (1)

Bupropion

Causes weight gain (2)

Mirtazapine

Paroxetine