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bigfootedbertha
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How do you dx MDD?
Need to have 5 or more of the following sx present during the same two week period with a concurrent sad mood:
- SIGECAPS
- Sleep, interest, guilt, energy, concentration, appetite, psychomotor retardation/agitation, suicide
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What medications can cause depression?
anti-htn, interferon
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What does full remission mean?
period <2 mo during which an improvement of sufficient magnitude is observed, that the pt is asx
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What is partial remission?
Time period during which the pt has more than minimal sx but no longer meet the DSM-IV criteria for MDD
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What is recovery?
Full remission of sx for greater than 2 mo
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What is relapse?
return of depressive episode within two months of improvement
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What is recurrence?
New episode of depression (occuring after recovery)
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How long can it take depression meds to work?
4-6 weeks, but sleep improvement within 1-2 weeks
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What info do you need before starting SSRIs?
medical hx, current meds, PE, thyroid function tests
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What patient education do you give pts on SSRIs?
- They will not see an immediate response
- Changes are gradual
- They are NOT prn meds
- Pts will maintain or decrease weight
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How do you start dosing the elderly on SSRIs?
Half of starting dose
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Which SSRIs have a short half life?
Celexa, Zoloft, Paxil, and Luvox
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Can SSRIs be prescibed in pregnant women?
There's no answer, nursing not recommended
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How do SSRIs affect sexual function?
decrease in libido and delayed/complete inorgasma
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What are sx of SSRI withdrawal syndrome?
When does it start? How long does it last?
How do you avoid?
- N/V/Dizziness, vivid dreams, vertigo, malaise, HA
- Occurs with rapid stopping of short 1/2 life drugs, lasts 2-3 weeks
- Taper drugs over 1-2 weeks
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What info do you need before starting a pt on TCAs?
H+P, thyroid function tests, EKG,
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Describe TCA use in the elderly
- Not recommended due to profound hypotension, QT interval increase
- If you need to use a TCA, start with nortriptline
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Can pregnant woman use TCAs?
No, they are teratogenic (no nursing either)
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How do TCAs affect weight?
They increase weight by 25 lbs
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What type of diet does a pt on a MAOI need to follow and why?
Low tyramine 72h premedication, 10 days following in order to prevent a HTN crisis
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What are signs of a HTN crisis caused by MAOI? How do you tx?
- HA, < sweating, dizziness, diplopia, HTN)
- Tx with Procardia 10mg
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Describe elderly use of MAOI
Don't use due to orthostatic hypotension
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Can pregnant woman use MAOI?
use not established
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What are ADRs of bupropion?
- Insomnia, HA, Nausea, Agitation
- Above 450 mg = increased risk of seizures (lowers threshold)
- NO sexual dysfunction
- Do not give with SSRI, TCA, or MAOI
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What are ADRs of Effexor?
What are its DIs?
- Insomnia, HA, Nausea, Agitation, Sexual dysfunction
- Very few DIs
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What are common ADRs of nefazodone?
What are its DIs?
- Dry mouth, HA, dizziness, orthostatic hypotension
- Increases benzo levels (triazolam, alprazolam, diazepam)
- MAOI, cisapride are contraindications
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What are common ADRs of trazodone?
What are its DIs?
dry mouth, HA, dizziness, orthostatic hypotension, sedation, mental dullness, priapism
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What are common ADRs of Remeron?
What are its DIs?
- Sedation, dry mouth, constipation, constipation
- DIs=MAOIs
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What rx regimen do you follow if there is a partial response to MDD?
Lithium: response within 48h, continue for 1 week if you get a response...if not, d/c immediately
T3: response within one week, if not d/c
Ritalin: response within 1 week, if no response, then D/C
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What are the three phases of depression management?
- Acute (2-6 weeks to get pt into remission0
- Continuation: (6-12 months to maintain remission)
- Maintenance: (long term therapy for those at high risk for relapse)
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What is the Star D protocol?
Level one: SSRI to remission. If HAM-D not at 7 or less, go to level 2
Level two: switch SSRI to bupropion, sertraline, venlafaxine, or CBT OR augment SSRI with bupropion, buspirone, or CBT
Level three: Switch to: mirtazepine or nortriptyline OR augment with lithium, T3, bupropion, sertraline, or venlafaxine
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What were the results of the Star-D study?
Switching might be best if minimal or no response with drug intolerance
Augmentation might be best if there was a partial response
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Olanzapine
- Zyprexa
- Atypical antipsychotic
- Used in treatment-resistant depression
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TCAs should be avoided in what populations?
Elderly, arrhythmia, syncope, orthostasis
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Bupropion should be avoided in what populations?
seizure disorders
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Those with ADHD might receive benefit from what type of antidepressant?
bupropion
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Those with chronic pain might benefit from what antidepressants?
duloxetine, TCA
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In pts who are a suicide risk, what is the med class of choice? Which meds should be avoided?
- SSRIS (safer if you OD)
- MAOis are easy to OD
- TCAs and MAOIs have a narrow therapeutic index
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