Depression

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Author:
timothy.pdlt
ID:
211909
Filename:
Depression
Updated:
2013-04-07 19:25:36
Tags:
depression
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Description:
therapeutics, side-effects, drug interactions
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  1. GoT of anti-depression Tx
    • Short term (w/in 3 months)
    • 1. stabilize s/s
    • 2. prevent complications
    • 3. minimize s/e
    • 4. induce remission
    • 5. improve QoL
    • 6. education

    • Long term (>3months)
    • 1. prevent relapse and recurrence
    • 2. maintain stable mood
    • 3. manage s/e
    • 4. education
  2. Patient counseling points
    • 1. purpose
    • 2. expected minimum Tx duration (min. 1y)
    • 3. time of benefit (2 weeks)
    • 4. side effects
    • 5. importance of adherence
    • 6. reassurance that not addictive
    • 7. don't stop when feeling better
    • 8. taper might be required when d/c
  3. Depression Tx guideline based on severity
    • 1. mild: watch and wait, supportive therapy, psychotherapy
    • 2. moderate: pharmacotherapy or psychotherapy
    • 3. severe: pharmacotherapy┬▒psychotherapy
  4. Phases of depression Tx
    • 1. acute phase: 1-6weeks
    • 2. continuation phase: 6-12weeks
    • 3. maintenance phase: 3-9months
  5. Considerations if depression Tx is initiated
    • 1. if response by 4-6weeks:
    • maintenance Tx
    • a. first episode: 1yr
    • b. 2 episodes: 1-2yr
    • c. 4 episodes: forever

    • 2. if partial response by 4-6weeks:
    • a. augment: Li, SGA, L-thyroxine
    • b. combine: CBT/IPT, bupropion

    • 3. if no response by 4-6weeks:
    • a. switch: another class
    • b. combine: SSRI/SNRI+bupropion/mirtazapine
  6. Multiaxial diagnosis
    • 1. Axis I: principal psychiatric or developmental disorder
    • 2. Axis II: mental retardation or personality disorder
    • 3. Axis III: other mental disorders
    • 4. Axis IV: severity of psychosocial stressors, GAF=1-6
    • 5. Axis V: GAF=1-90

    • GAF= global assessment of functioning
    • score of 91-100/100= no s/s
  7. Indications for antidepressants
    • depression
    • anxiety
    • ADHD
    • chronic neuropathic pain
    • migraine prevention
    • sleep disturbances
  8. Classes of antidepressants
    • 1. TCA
    • 2. MAOI
    • 3. RIMA= moclobemide
    • 4. SSRI
    • 5. SNRI
    • 6. SARI (Serotonin Antagonist and Reuptake Inhibitor)= trazadone, nefazadone
    • 7. NDRI (Norepinephrine-Dopamine Reuptake Inhibitors)= bupropion
    • 8. NRI (Norepinephrine Reuptake Inhibitor)= reboxetine
    • 9. NaSSA (Noradrenergic and Specific Serotonergic Antidepressant)= mirtazapine
    • 10. Heterocyclics= maprotiline
  9. Indications for antipsychotics
    • acute psychotic episodes (hallucinations)
    • chronic psychotic episodes (schizophrenia)
    • affective disorders (bipolar disorder)
    • agitated, aggressive states
    • Tourette's syndrome (inherited, multiple physical (motor) tics)
  10. Examples of traditional antipsychotics
  11. Examples of SGAs (available in Canada)
  12. Examples of mood stabilizers
    • lithium
    • VPA
    • CBZ
    • OXC
    • LTG
    • GBP, TPM?
    • antipsychotics?
  13. Indications of BDZs
    • anxiety, tension, agitation
    • procedure sedation
    • acute and chronic alcohol withdrawal
    • convulsion
    • sleep disorders
    • muscle spasms
  14. Examples of anxiolytics
    • BDZs (addictive, effective, early onset)
    • buspirone (no sedation/tolerance/addiction, late onset)
    • barbiturates
    • SSRIs/SNRIs
  15. Classifications of BDZs
    • 1. short-acting: midazolam
    • 2. intermediate: alprazolam, oxazepam, lorazepam
    • 3. long-acting: clonazepam, diazepam
  16. Examples of sedatives
    • barbiturates
    • chloral hydrate
    • zaleplon
    • zopiclone
  17. Onset of effect of antidepressants
  18. Efficacy of antidepressants
    • 1. reduction in mod-severe s/s= 50%
    • 2. prevention of relapse= 50%
  19. Risk of relapse (in 5years) without medication
    • 1. first episode= 50%
    • 2. two episodes= 70%
    • 3. three or more episodes= 90%
  20. Things to consider when starting therapy
    • severity
    • age (flouxetine has the best benefit/risk)
    • long-term adherence
    • previous Tx response
    • comorbidities
    • DI
    • accessability
    • PK
    • potential s/e
    • suicide risk
    • patient preferences
    • clinician experience
    • effectiveness of Tx
  21. SSRI doses for depression Tx
    1. citalopram/fluoxetine/paroxetine IR 10mg OD-->40mg OD

    2. paroxetine CR 12.5 OD-->50mg OD

    3. setraline 20mg OD-->100mg OD
  22. DI with SSRIs
    • SSRI+MAOI= serotonin syndrome
    • SSRI+NSAIDs= GI bleeding
    • SSRI+CYP inhibitors (macrolides, azoles, cimetidine)
    • SSRI+CYP inducers (rifampin, CBZ, PH, PHT)
    • SSRI= can decrease clearance of PHT, methadone, CLZ)
  23. Which SSRI is to choose?
    • citalopram: fewest DI
    • fluoxetine: most anorexic/stimulating, most experience with pregnancy
    • paroxetine: more anti-ACh/sexual side-effects but most indicated for anxiety
    • sertraline: worst diarrhea/male sexual dysfunction
  24. Bupropion doses for depression Tx
    bupropion XL 150mg OD-->300mg OD
  25. S/E of bupropion
    • agitation
    • insomnia
    • anorexia
    • decrease seizure threshold
    • anticholinergic
    • *least sexual dysfunction
    • *less weight gain
  26. Mirtazapine doses for depression Tx
    mirtazapine 15mg/d-->45mg/d
  27. S/E of mirtazapine
    • sedation
    • weight gain
    • *less GI s/e
    • *less sexual s/e
  28. Trazodone doses for depression Tx
    trazodone 150mg/d-->400mg/d
  29. S/E of trazadone
    • drowsiness
    • dry mouth
    • nausea
    • priapism
    • DI: potentiate CNS depressants, antihypertensives
  30. SNRI doses for depression Tx
    venlafaxine 37.5mg/d-->225mg/d
  31. S/E of venlafaxine
    • nausea
    • drowsiness
    • if >300mg/d: HTN, insomnia, restlessness, tremor
    • *less weight gain
    • *intermediate sexual dysfunction
    • discontinuation syndrome
  32. S/E of TCA
    • QT prolongation
    • anticholinergic (less in nortriptyline, desipramine)
    • weight gain
    • orthostatic hypotension
    • caution in: CVD, elderly, BPH, epilepsy
  33. S/E of moclobemide
    • *less sexual dysfunction
    • *good for anxious-phobic
  34. SSRI/SNRI discontinuation syndrome
    • esp. with venlafaxine and paroxetine
    • can be avoided by tapering over 1-4weeks
  35. S/S of SSRI/SNRI discontinuation syndrome
    • Flu-like s/s (sweating, myalgia)
    • Insomnia
    • Nausea
    • Imbalance (dizziness)
    • Sensory disturbances
    • hyper-arousal (anxiety, agitation, HA)
  36. Monitoring endpoints for antidepressants

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