Neurotransmitters involved in depression include
Serotonin, NE, epinephrine, dopamine, glutamate, acetylcholine
(serotonin may be the most important)
Diagnosis relies on symptom assessment according to
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
Most widely used depression assessment scale
The Hamilton Depression Rating Scale (Ham-D)
DSM- 5 Criteria
M SIG E CAPS
Mood: depressed
Sleep: increased/decreased
Interest/pleasure: diminished
Guilt or feelings of worthlessness
Energy: decreased
Concentration: decreased
Appetite: increased/decreased
Psychomotor: agitation or retardation
Suicidal ideation
Drugs that cause or worsen depression
ADHD medication, indomethacin, antiretrovirals, propranolol, hormones, steroids, clonidine, isotretinoin, methyldopa, methadone
Natural products used for treating depression
St. Johns wort, SAMe (s-adenosyl-L-methionine), valerian, 5-HTP (5-hydroxytryptophan)
If a drug does not work after _____, treatment should be reassessed
4-8 weeks
Mild depression should be treated with
psychotherapy (CBT) or medication
Initial treatment for depression in pregnancy
SSRIs (except paroxetine due to cardiac effects)
Potential risk of using SSRIs in pregnancy
Persistent pulmonary hypertension of the newborn
Preferred treatment in breastfeeding
SSRIs or tricyclics (except doxepin)
Brand name for brexanolone
Zulresso
Indication for Brexanolone
postpartum depression- C-IV (given as a continuous IV infusion over 60 hours)
Medications that are restricted to patients unresponsive to other treatments
phenelzine, tranylcypromine, isocarboxazid
Brand name for phenelzine
Nardil
Symptoms of serotonin syndrome
severe nausea, dizziness, headache, diarrhea, agitation, tachycardia, hallucinations or muscle rigidity
Serotonin withdrawal symptoms include
anxiety, agitation, insomnia, dizziness and flu-like symptoms
Which SSRI self-tapers
Fluoxetine (because of long half life)
All antidepressants carry a boxed warning of a possible
increase in suicidal thoughts or actions in some children, teenagers or young adults within the first few months or when the dose is changed
______ are required for all antidepressants
MedGuides
Physical symptoms such as low energy improve
within 1-2 weeks but psychological symptoms such as low mood may take a month or longer
MOA of SSRIs
increase 5-HT by inhibiting its reuptake in the neuronal synapse (they weekly affect NE and DA)
Brand name for citalopram
Celexa
What medication is the S-enantiomer of citalopram
escitalopram
Brand name for escitalopram
Lexapro
Brand name for fluoxetine
Prozac
Brand name for fluoxetine + olanzapine
Symbyax (used for treatment resistant depression)
Brand name for paroxetine
Paxil
What is the generic name of Brisdelle and what is it used for?
Paroxetine and used for moderate to severe vasomotor symptoms associated with menopause
Generic name of Zoloft
sertraline
Sertaline is preferred in patients with
cardiac risk
Most activating SSRI
Fluoxetine (take dose in AM)
Most sedating SSRI
Paroxetine and fluvoxamine (take dose in PM)
Which SSRIs are approved for premenstrual dysphoric disorder (PMDD)
Fluoxetine, Paxil CR and sertraline
Fluvoxamine is only approved for
OCD
Warnings associated with SSRIs
QT prolongation, SIADH/hyponatremia and bleeding (additive risk)
How many weeks is the washout period between MAO inhibitors and SSRIs
2 weeks (except fluoxetine)
Brand name of vilazodone
Viibryd
Drug class of Viibryd
SSRI and 5-HT1A partial agonist
Brand name of vortioxetine
Trintellix
Drug class of Trintellix
SSRI, 5-HT3 receptor antagonist and 5-HT1A agonist
MOA of SNRIs
increase 5-HT by inhibiting its reuptake in the neuronal synapse, also inhibit reuptake of NE
Brand name of venlafaxine
Effexor
Brand name of duloxetine
Cymbalta
Brand name of desvenlafaxine
Pristiq
Brand name of levomilnacipran
Fetzima
Which SNRI can leave a ghost tablet in the stool
desvenlafaxine
MOA of tricyclic antidepressants (TCA)
Inhibit NE and 5-HT reuptake, also block ACh and histamine receptors
Which category of TCAs are relatively selective for NE
Secondary amines
Tertiary amines can be slightly more effective but have a
worse side effect profile
Which medications are tertiary amines
amitriptyline, doxepin, clomipramine, imipramine, trimipramine
Brand name for doxepin
Silenor (used for insomnia)
Zonalon (cream used for pruritus)
Brand name for clomipramine
Anafranil
Brand name for imipramine
Tofranil
Secondary amines
Nortriptyline, amoxapine, desipramine, maprotiline, protriptyline
Which amine group have increased anticholinergic properties and are more likely to cause sedation and weight gain
Tertiary amines
Brand name for nortriptyline
Pamelor
Brand name for desipramine
Norpramin
Drug class for bupropion
dopamine and norepinephrine reuptake inhibitors
Brand name for bupropion
Wellbutrin
Zyban (for smoking cessation)
Contrave (for weight management)
Do not exceed bupropion ___ mg/day due to seizure risk
450 mg/day
Contraindications with bupropion
seizure disorder, history of anorexia/bulimia, abrupt discontinuation of ethanol or sedatives, MAO inhibitors, linezolid, IV methylene blue and other forms of bupropion
MOA of MAO inhibitors
inhibit the enzyme monoamine oxidase, which breaks down catecholamines including 5-HT, NE, Epi and DA
Brand name for isocarboxazid
Marplan
When changing from fluoxetine to MAO inhibitor, what is required
5 week wash out
MOA of mirtazapine in depression
has central presynaptic alpha-2 adrenergic antagonist effects which result in increased release of NE and 5-HT
Brand name for mirtazapine
Remeron
MOA of trazodone
Inhibits 5-HT reuptake, blocks H1 and alpha-1 adrenergic receptors
(rarely used as antidepressant due to sedation)
MOA of nefazodone
Inhibits 5-HT and NE reuptake, blocks 5-HT2 and alpha-1 adrenergic receptors
The American Psychiatric Association (APA) guidelines state that patients should receive a
4-8 week trial of medication at a therapeutic dose before concluding that a drug is not working
Agents approved augmentation therapy
aripiprazole, Symbyax, quetiapine ER, brexpiprazole, cariprazine, esketamine
Brand name for aripiprazole
Abilify
Brand name for quetiapine
Seroquel
Brand name for brexpiprazole
Rexulti
Brand name for cariprazine
Vraylar
Brand name for esketamine
Spravato (C-III)