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What are early response symptoms antidepressants work on?
Sleep, appetite, and energy
What are delayed response symptoms?
Mood, social interaction, anxiety, and suicidal ideation
What antidepressants are better at reducing the time to onset of effect?
Studies show they are all similar
What antidep. Are used for melancholic depression?
benefit seen with TCAs, possible role of venlafaxine, mirtazapine
What meds are good for psychotic depression?
combination of antidep. + antipsychotic
MOA: what neurons do SSRI’s work on?
- 5-HT → Selectively inhibit the reuptake of 5-HT by blocking the 5-HT transporter
- - Pre / post synapse
- - down regulation of autoreceptors causes neuron to release more 5-HT at the axon
Which are the most potent 5-HT uptake blockers?
Citalopram (Celexa) and paroxetine (Paxil)
Which SSRIs have effect on norepinephrine
Fluoxetine (Prozac) and paroxetine (Paxil)
Which SSRI has the greatest anticholinergic activity?
What are anticholinergic side effects?
Dry mouth, increased perspiration, hypotension
Most common Adverse effect of SSRI’s:
- GI: diarrhea, nausea, bloating, cramping, heartburn
- Sexual dysfunction: greatest with paroxetine (Paxil), least with citalopram (Celexa)
Akathisia is most common with what SSRI?
How does serotonin syndrome manifest?
- autonomic and neuromuscular responses:
- GI complaints
- CV problems
- Respiratory depression
What causes serotonin syndrome?
Combo of SSRI + other drugs
When do withdrawal symptoms occur from SSRIs
What are withdrawal symptoms?
- flu-like symptoms
- shock-like sensations
When should you use most activated fluoxetine (Prozac)
Beneficial in pts. with sedation, fatigue, or decreased energy
When should you use less activating Paroxetine (Paxil)
Beneficial in pts complaining of anxiety, agitation, or insomnia
Which SSRI has a lower risk of sexual side effects?
Which SSRI’s have the least drug interactions?
Citalopram (Celexa) and Escitalopram (Lexapro)
What is the MOA of SNRI’s?
Block the reuptake of 5-HT and NE and to a lesser extent DA
What is meant by augmenting?
adding a drug to an existing antidepressant → combination therapy
In STAR D* what monotherapy should you start with?
Citalopram (Celexa) and then augment or switch depending on patient
What are 1st line agents for GAD?
- Selective serotonin reuptake inhibitors (SSRIs)
- Selective norepinephrine reuptake inhibitors (SNRIs)
Second line rx?:
- Used for: current/history of substance abuse, intolerant to BZ therapy, refractory GAD
- Less sedation and functional impairment than BZ
What are advantages of buspirone treatment of GAD
Lack of sedation and anxiolytic properties are major advantages
What are the treatment goals for GAD?
- Short term: Reduce severity and duration of symptoms. Improve functioning
- Long term: Reduce length of episodes, Reduce severity of episodes, Prevent recurrence, and Achieve symptom remission (Facilitate patient’s return to pre-morbid level of functioning)
What’s the moa of benzodiazepine?
Potentates inhibitory effect of GABA
SE’s of benzodiazepines?
- Varying degrees of lipophilicity: Affects ability to cross the blood-brain barrier
- May produce rapid onset of action
- Experience rush of euphoria
- Unpleasant feeling/loss of control
- MOST common = sedation
When do you use benzodiazepine?
Acute anxiety relief
Who should be careful rx benzod’s to?
Patients with co-morbid conditions – alcoholics
Should you quickly withdraw bezods?
NO – taper, withdrawal rxns
What’s the brand name of BUSpirone?
What is an adequate trial for GAD?
When does the majority of response occur for GAD rx?
Acute phase: period of 1-3 months
How long should you taper anxiety meds for?
4-6 months; maintenance phase = 1-2 years
Should buspirone be used for panic disorders
NO- might make it worse
Whats the Rx options for Panic disorders?
- 1st line Rx = SSRI , SNRI
- 2nd line = TCA
- benzodiazepines → acute response
Do you dose higher or lower of SSRIs and SNRI’s for panic disorders then for major depression?
Lower – half the dose
What has benefits for agoraphobia?
What is the brand name of Alprazolam?
Xanax – benzodiazepine
Brand name of fluoxetine?
Prozac – SSRI
What is the brand name for venlaxafine
Effexor - SNRI
Do beta-blockers have proven benefit for panic disorders?
Can we cure OCD?
Full remission is rare. Partial remission is Rx goal
What are the treatment goals for OCD?
- Reduction in the frequency of Obsessive thoughts and compulsive acts; Anxiety associated with SXs
- Impairment social & occupational function
How should you treat mild symptoms of OCD?
Cognitive beh. Therapy- may take 20 weeks to improve – may work better for compulsions
What is the 1st rx for OCD?
Whats the 2nd line rx for OCD?
What’ s the brand name of Clomipramine?
Anafranil – TCA
What is combination Rx for OCD?
SSRI + clomipramine, atypical antipsychotic
When do you consider lifelong treatment of OCD?
2 to 4 severe relapse; 3 to 4 mild relapses
What is the best pharm treatment for PTSD
- Early cognitive behavioral therapy + SSRI’s (1st line),
- venlafaxine, TCA’s, MAO-Is (2nd line)
- TCA & MAO-I (3rd line)
What are augmenting agents for treatment of PTSD?
- atypical antipsychotics
- prazocin → only with SSRIs for insomnia, psychosis hypervigilance
What is Prazosin used for?
Are benzodiazepines used for PTSD rx
NO – makes it worse
What are goals of treating PTSD?
- Reduction in core SXs (re-experiencing, avoidance, hyperarousal)
- Improvements in disabilities
- Improvements in co-morbid axis I
- Long-term goal is remission - Treatment response may take up to 36 months
When should Rx of PTSD be started?
Immediately - @ onset of symptoms
How long should you treat the first episode?
What is an adequate med trial for PTSD?
How do you treat moderate-severe PTSD and OCD
CBT & meds
What would you like to do?
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