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)