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Psychotherapy: 117b - Antidepressants

Psychology26 CardsCreated about 2 months ago

This flashcard set covers the use of SNRIs and TCAs in managing chronic pain, with TCAs (notably amitriptyline) being especially effective for migraines. It also reviews key amino acid precursors: tryptophan for serotonin and tyrosine for dopamine and norepinephrine.

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Which classes of antidepressants are useful in the treatment of chronic pain?

SNRIs

TCAs

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Key Terms

Term
Definition

Which classes of antidepressants are useful in the treatment of chronic pain?

SNRIs

TCAs

Which class of antidepressants is especially useful for treating migraine?

TCAs

(Especially amitryptiline)

Which amino acid is a precursor for serotonin?

Tryptophan

Tyrosine is a precursor for which neurotransmitters?

Dopamine, NE

(Dopamine is a precursor for NE)

List 3 common features of all classes of antidepressants

  • Takes 3-8 weeks to be maximally effective

  • All have equivalant response and remission rates

    • 50-70% response...

If a patient experiences partial improvement at the maximally tolderated dose of antidepressant A, what is the next step in their management?

Add another antidepressant of a different class

OR

Tar...

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Psychotherapy: 117b - Antidepressants
TermDefinition

Which classes of antidepressants are useful in the treatment of chronic pain?

SNRIs

TCAs

Which class of antidepressants is especially useful for treating migraine?

TCAs

(Especially amitryptiline)

Which amino acid is a precursor for serotonin?

Tryptophan

Tyrosine is a precursor for which neurotransmitters?

Dopamine, NE

(Dopamine is a precursor for NE)

List 3 common features of all classes of antidepressants

  • Takes 3-8 weeks to be maximally effective

  • All have equivalant response and remission rates

    • 50-70% response

    • 35-50% remission

  • Placebo-drug differences depend on the level of severity of depression

    • More severe depression = less placebo effect

If a patient experiences partial improvement at the maximally tolderated dose of antidepressant A, what is the next step in their management?

Add another antidepressant of a different class

OR

Target residual symptoms with other treatments

Remeber: The goal of treatment is complete response

How should you select a first-line antidepressant?

(What factors should influence your decision?)

  • Side effect profile

  • Past response

  • Comorbid medical and psichiatric problems

Remember: no significant differences in efficacy among first line medications

Consider psychotherapy in addition

Which classes of antidepressants are first line for treating depression?

  • SSRI

  • SNRI

  • Mirtazapine

  • Bupropion

Select agent based on side-effect profile

All have comparable efficacy

TCAs and MAOIs are not first line due to higher side effect burden, potential for lethal overdose

What are the 6 most common side effects of SSRIs and SNRIs?

Which ones usually improve?

  • GI upset

  • Anxiety, agitation

  • Insomnia

  • Headache

  • Sweating

  • Sexual dysfunction

All except sexual dysfunction usually improve

List 3 serious risks of antidepressant treatment

  • Increased risk of suicidal thinking, behavior in young people

    • Highest in the first few days on the medication

    • Risk of treatment < risk of untreated depression

  • Serotonin syndrome

  • Do not give antidepressant monotherapy for anyone with bipolar disorder

    • Increases manic episodes

What is serotonin syndrome?

How can it be avoided?

Result of increased 5HT activity in the brain, usually from multiple serotoninergic drugs

  • Mental status change

  • Hyperthermia

  • Hyperreflexivity

Never combine MAOIs with TCAs or SSRIs

Which SSRI has the longest half life?

Why is this important?

Fluoxetine

  • No need to taper

  • Requires long wash-out if transitioning to MAOI

Which SSRI has the highest risk of drug-drug interactions?

Why?

Paroxetine

It is a potent CYP26 inhibitor

Which SSRI has the shortest half life?

Why is this important?

Paroxetine

Results in the worst discontinuation symptoms (must taper)

Which SSRI should be avoided in anyone with cardiac comorbidities?

Citalopram

Dose-depenent QT prolongation

Which SSRI is preferred in pregnancy?

Sertraline

What is the most common side effect of the SNRIs?

Hypertension

(In addition to the side effects common to all agents that increase 5HT and NE: GI upset, weight gain, sweating, sexual dysfunction)

What is the mechanism of action of TCAs?

Inhibit NE and 5HT reuptake

What are the common side effects of TCAs?

  • Sedation

  • Weight gain

  • Orthostatic hypotension

  • Arrhythmia (may be fatal)

  • Seizure

  • Sexual dysfunction

  • Anticholinergic effects

    • Dry mouth, urinary retention, constipation

What special diet must be followed when a patient is on a MAOI?

What happens if they do not follow this diet?

Tyramine free diet:

No aged cheese, red wine, fava beans, cured meats

Can cause hypertensive crisis if ingested while on MAOI

Which antidepressant should you prescribe to a patient that does not have anxiety symptoms and want to experience weight gain or sexual dysfunction?

Buproprion

May worsening existing anxiety symptoms

(Mirtazapine does not have sexual side effects, but can cause weight gain)

Which antidepressants carry the lowest risk of switch to mania if there is undiagnosed bipolar disorder?

Bupropion

Mirtazapine

What are the mechanisms of action of mirtazapine?

  • Alpha-2 block

  • Increased NE and 5HT release

  • Blocks 5HT-2 and 5HT-3 receptors

  • H1 block

Which antidepressant is often used elderly patients with insomnia and low appetite?

Mirtazapine

Side effects of sedation and weight gain may be helpful!

What is the mechanism of trazodone?

  • 5HT-2 receptor block

  • Alpha-1 block

  • Histamine block

(Not great for depression, effective for insomnia)

Which antidepressant has the potential side effect of priapism?

Trazodone