Depression/Anxiety Meds

DSM-5 Diagnosis of depression

5 or more symptoms during the same 2-week period and represent a change from previous functioning: 1) depressed mood most of day every day (or indicated by subjective report) 2) diminished interest or pleasure 3) weight loss/gain 4) insomnia/hypersomnia 5) psychomotor aggitation 6) fatigue 7)feeling of worthlessness 8)inability to concentrate 9) recurrent thoughts of death

What age range has the highest rate of depression?

Adults 18-29 y/o Women> men May be heritable

If your patient has a partial response to a medication (after maximizing dose) what do you do?

Consider augmentation -add non-SSRI, lithium, thyroid hormone, atypical antipsychotics OR Switch to a diff. Med -diff. SSRI or non-SSRI

Benzodiazepines

Clonazepam Diazepam Chlordiazapoxide Alprazolam Oxazepam Lorazepam MOA: GABA receptor agonist leads to enhancement of inhibitory GABA effects à ↓ stress response and relief of anxiety symptoms. Not good for long term (use for 2-4 weeks) Good for short term/acute anxiety

What are good Benzodiazepine options for the elderly?

Diazepam Oxazepam Lorazepam -little rebound= better options

What are first and second generation antidepressants?

First-generation ◦ Tricyclic antidepressants (TCAs) ◦ Monoamine oxidase inhibitors (MAOIs) Second-Generation ◦ Selective serotonin reuptake inhibitors (SSRIs) ◦ Serotonin-norepinephrine reuptake inhibitors (SNRIs) Atypical antidepressants=[US Boxed Warning]: Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 to 24 years of age) with major depressive disorder (MDD) and other psychiatric disorders; consider risk prior to prescribing.

Prazosin

MOA: alpha 1 blocker Used to: ↓ trauma-related nightmares ↑ REM sleep and total sleep time in PTSD ◦ Dosed daily at bedtime **titrate slowly due to orthostatic hypotension** -titrate to relief of nightmares

Hydroxizine (Atarax®, Vistaril®)

MOA: antihistamine (antagonism at H1 receptor)=calming and sedating effects Dosed multiple times/day SE: Anticholinergic effects: blurred vision, urinary retention, dry mouth, constipation, alterations in cognition, sedation

If the patient responds to a medication, how long should you leave them on the medication?

Maintain for at least 4-9 months for continuation And if necessary 12-36 months for maintenance

When is a patient a candidate for electroconvulsive therapy (ECT)

Patients with depression are candidates for ECT when: • a rapid response is needed • risks of other treatments outweigh potential benefits • history of poor response to antidepressants and a history of good response to ECT • patient expresses a preference for ECT

Monoamine Oxidase Inhibitors (MAOIs)

Phenelzine Tranylcypromine 2nd or 3rd line for anxiety SE: anticholinergic effects, weight gain, orthostasis, Insominia

SE of Benzos

Physical Dependence Withdrawal/abuse Toxicity in overdose Titration/taper schedule for complicated patients Rebound anxiety -elderly and kids more prone to SE

Panic disorder vs panic attack

Panic disorder is when you've had a panic attack and now you have anxiety about having another one all of the time. -panic attacks dont need tx -panic disorder DOES

What is first line TX for PTSD?

Psychotherapy considered first line in treatment -May include exposure to trauma related cues 1st Line Meds: SSRIs (fluoxetine, paroxetine, sertraline), OR SNRIs (venlafaxine XR) Prazosin (alpha 1 blocker)-useful for trauma related nightmares and improving sleep quality. Paroxetine-largest effect size for CAPS reduction (Clinician-Administered PTSD Scale)

What is an easy depression screen?

PHQ-9 Or PHQ-2 (is the first 2 questions of PHQ-9) Score 20-28=severe depression

What is a contraindication of using Benzos

-should not use for patients with past or present substance abuse

What are the 3 phases of depression tx?

1) acute phase (6-12 weeks)-this is where you want to see remission 2) continuation (4-9 months)-goal is to eliminate residual symptoms or prevent relapse 3) maintenance-lasting at least 12 to 36 months in which the goal is to prevent recurrence Goals of Treatment= Resolution of current symptoms (i.e., remission) prevention of further episodes of depression (i.e., relapse or recurrence)

If there is no response to initial medication given, what do you do?

1st: Ensure medication adherence Then consider switching to diff medication (Different SSRI, or non-SSRI antidepressant)

What is the triad of serotonin syndrome? What drugs cause it?

Any drugs that increase serotonin -SSRIs, SNRIs, MAOIs Triad of symptoms seen in SS includes: 1) mental status changes 2) autonomic instability 3) neuromuscular abnormalities

What treatment is NOT appropriate for PTSD?

Benzos ** -could potentially worsen it

Treatment regimen for GAD (generalized anxiety disorder)

Benzos are 2nd line due to SE Buspirone 2nd line due to limited efficacy Imipramine 2nd line due to SE Quetiapine XR 2nd line due to SE HYdroxizine helpful in short term management Use: Oxazepam, Lorazepam in the elderly

NDRI (Norepinephrine-dopamine reuptake inhibitor)

Bupropion (Wellbutrin)

When considering next-step antidepressant treatment in a patient who has not achieved full remission, which of the following approaches are supported by the evidence, according to the British Association of Psychopharmacology (BAP) guidelines and the STAR*D trial? A. Switch antidepressant B. Augment Antidepressant C. All the above D. None of the above

C. All of the above

What is the first line tx for panic disorder (PD)?

CBT +/- pharmacotherapy is considered 1st line 1st Line Meds: SSRIs (Citalopram, escitalopram, fluoxetine, Paroxetine) OR SNRIs (velafaxine XR)

What is the first line TX for OCD?

CBT and/or exposure with response prevention (ERP) considered to be equivalent or superior to pharmacotherapy 1st Line Meds: SSRIs (escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline)

SSRIs (MOA, SE, contraindications)

Citalopram, escitalopram, fluoxetine, paroxetine, sertraline

TCAs (MOA, side effects, CI)

Drugs: Amitriptyline (Elavil), Clomipramine, Desmiramine (Norpramin), Imipramine (Tofranil), Nortiptyline (Pamelor) Mechanism of Action: potentiate the activity of NE and 5-HT by blocking their reuptake. Adverse Effects: -anticholinergic effects -weight gain -dizzy -orhtostasis -sedation -memory impairment, and, at higher doses, delirium. NOTE: **Overdose can produce severe arrhythmias-can be fatal** CI: Administration with or within 14 days of MAOIs acute recovery phase of a myocardial infarction

What medication is good for acute anxiety

Hydroxizine--can use alone or as needed adjunct Or Benzos

Types of treatment options for depression (3):

Medication Psychotherapy Electroconvulsive therapy (ECT)

Serotonin and alpha-2 adrenergic receptor antagonists

Mirtazepine

What is first line tx for depression?

SSRIs -considered first-line due to safety in overdose and improved tolerability Meds: Citalopram (celexa) Escitalopram (lexapro) Fluoxetine (Prozac) Fluoxetine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft)

Panic disorder TX regimen

SSRIs best Velafaxine-(SNRI) shown to decrease overall severity of symptoms

What is first line treatment for Anxiety?

SSRIs first line in all anxiety disorders OR SNRIs may be first line in all disorder except OCD ◦Venlafaxine often SNRI of choice -Initiate at low doses to avoid increased anxiety, restlessness, jitteriness

Mixed serotonergic medications (Mixed 5-HT)

Trazodone Nefazodone Vilazodone (Viibryd) Vortioxetine (Brintellix)

Why do TCAs have limited use compared to other options?

Use limited as there is equally effective options that are safer in overdose and better tolerated -overdose is deadly**

SNRIs (serotonin-norepinephrine reuptake inhibitors)

Velafaxine (Effexor), Duloxetine (Cymbalta), Desvenlafaxine (Pristiq)

Can SSRIs be used in pregnancy?

Yes, but may have some side effects -but can administer some SSRIs in pregnancy