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Questions and Answers

What conditions is Bupropion specifically used to treat?

  • Anxiety disorders
  • Severe insomnia
  • Chronic pain
  • Hypoactive sexual disorder and obesity (correct)

    • Which atypical antidepressant is specifically indicated for postpartum depression?

  • Agomelatine
  • Brexanolone (correct)
  • Mirtazapine
  • Esketamine

    • In terms of pharmacology, what is the mechanism of Agomelatine?

  • Dopamine and norepinephrine reuptake inhibitor
  • 5-HT2C receptor antagonist and melatonin receptor agonist (correct)
  • Selective serotonin reuptake inhibitor
  • Nonselective serotonin antagonist

    • What is a common side effect associated with Mirtazapine?

    <p>Increased appetite and weight gain</p> Signup and view all the answers

    Which atypical antidepressant is also an NMDA receptor antagonist?

    <p>Esketamine</p> Signup and view all the answers

    What is an agent-specific side effect of Bupropion?

    <p>QT prolongation</p> Signup and view all the answers

    Nefazodone is primarily metabolized by which liver enzymes?

    <p>CYP3A4</p> Signup and view all the answers

    Which of the following is NOT a treatment use for Trazodone?

    <p>Obsessive-compulsive disorder</p> Signup and view all the answers

    What is a common side effect of Esketamine?

    <p>Sedation</p> Signup and view all the answers

    Vilazodone is indicated for which major depressive disorder treatment?

    <p>Not a first-line treatment</p> Signup and view all the answers

    What is the estimated lifetime prevalence of Major Depressive Disorder (MDD) in developed countries like the USA and Europe?

    <p>18%</p> Signup and view all the answers

    Which neurotransmitter is primarily associated with mood regulation in Major Depressive Disorder?

    <p>Serotonin</p> Signup and view all the answers

    What is the recommended initial treatment goal for managing Major Depressive Disorder?

    <p>Symptom remission</p> Signup and view all the answers

    Which of the following groups is associated with the highest prevalence of Major Depressive Disorder?

    <p>Whites</p> Signup and view all the answers

    What is a key characteristic of mild to moderate major depression?

    <p>Intact judgment with no imminent risk of harm</p> Signup and view all the answers

    Which pharmacological treatment combination has been shown to be more effective for depression?

    <p>Antidepressants plus psychotherapy</p> Signup and view all the answers

    What is a common psychosocial factor contributing to the development of Major Depressive Disorder?

    <p>Isolation and poor social networks</p> Signup and view all the answers

    Which of the following is not considered a first-generation antidepressant?

    <p>Selective serotonin reuptake inhibitors (SSRIs)</p> Signup and view all the answers

    What distinguishes severe major depression from mild to moderate major depression?

    <p>Existence of delusions or hallucinations</p> Signup and view all the answers

    Which of the following factors is NOT typically associated with the pathogenesis of Major Depressive Disorder?

    <p>Exposure to sunlight</p> Signup and view all the answers

    What is the primary goal of the acute treatment phase for depression?

    <p>Achieve remission</p> Signup and view all the answers

    What is the impact of childhood trauma on Major Depressive Disorder?

    <p>It can exacerbate depressive symptoms.</p> Signup and view all the answers

    Which of the following is NOT a recommended augmentative therapy for inadequate response to antidepressants?

    <p>Monotherapy with SSRIs</p> Signup and view all the answers

    Which secondary medical disorder is commonly associated with Major Depressive Disorder?

    <p>Cancer</p> Signup and view all the answers

    Which antidepressant category includes drugs like Citalopram and Sertraline?

    <p>Selective serotonin reuptake inhibitors (SSRIs)</p> Signup and view all the answers

    What should be avoided in the treatment of elderly patients with depression?

    <p>MAOIs</p> Signup and view all the answers

    In cases of treatment failure using two different medication classes, which therapy is typically NOT considered next?

    <p>Switching to an SSRI</p> Signup and view all the answers

    What is a common risk associated with the use of St. John's Wort as a treatment option?

    <p>Reduced effectiveness of antidepressants</p> Signup and view all the answers

    What is indicated as the general order of preference in choosing an adjunctive medication?

    <p>SGA ➔ Lithium ➔ Thyroid hormone</p> Signup and view all the answers

    What is the recommended duration for the maintenance phase of depression treatment?

    <p>12-36 months</p> Signup and view all the answers

    Which medication is specifically mentioned for resistant depression?

    <p>Lithium</p> Signup and view all the answers

    What is the primary use of Duloxetine?

    <p>Diabetic peripheral neuropathy</p> Signup and view all the answers

    What action is required when a patient displays agitation and neuromuscular abnormalities due to serotonin syndrome?

    <p>Continuous cardiac monitoring</p> Signup and view all the answers

    Which side effect is common to all SNRIs?

    <p>Transient nausea and gastrointestinal discomfort</p> Signup and view all the answers

    What intervention is required for a patient whose temperature exceeds 41.1 °C due to serotonin syndrome?

    <p>Sedation, paralysis, and intubation</p> Signup and view all the answers

    Which medication should be considered if benzodiazepines fail in a serotonin syndrome case?

    <p>Cyproheptadine</p> Signup and view all the answers

    What monitoring is essential for patients prescribed Levomilnacipran?

    <p>Blood pressure and heart rate</p> Signup and view all the answers

    What is the main mechanism of action of SNRIs?

    <p>Inhibition of serotonin and norepinephrine reuptake</p> Signup and view all the answers

    Which SNRI is noted for its application in the treatment of anxiety disorders such as SAD and GAD?

    <p>Venlafaxine</p> Signup and view all the answers

    What type of antidepressant is Bupropion, and what is its primary indication?

    <p>Atypical; treatment of depression</p> Signup and view all the answers

    What is a unique property of Brexanolone compared to other atypical antidepressants?

    <p>It offers a continuous intravenous infusion.</p> Signup and view all the answers

    In managing serotonin syndrome, why should antipyretics such as acetaminophen be avoided?

    <p>Increased muscular activity leads to ineffective treatment.</p> Signup and view all the answers

    Which Atypical antidepressant has a mechanism involving the inhibition of CYP2D6?

    <p>Bupropion</p> Signup and view all the answers

    Which medication is primarily administered for fibromyalgia among SNRIs?

    <p>Duloxetine</p> Signup and view all the answers

    What is the primary mechanism of action for selective serotonin reuptake inhibitors (SSRIs)?

    <p>They inhibit the serotonin reuptake pump.</p> Signup and view all the answers

    Which of the following is a common side effect associated with SSRIs?

    <p>Weight gain</p> Signup and view all the answers

    What is the recommended approach for switching between antidepressants?

    <p>Cross-tapering over a gradual period.</p> Signup and view all the answers

    What is the advised tapering strategy for discontinuing an SSRI?

    <p>Reduce the dose by 25% weekly.</p> Signup and view all the answers

    Which SSRI is known for having a prominent risk of QT prolongation?

    <p>Citalopram</p> Signup and view all the answers

    What is a common symptom of serotonin syndrome?

    <p>Muscle rigidity</p> Signup and view all the answers

    How should serotonin syndrome be diagnosed?

    <p>Clinical diagnosis based on symptoms.</p> Signup and view all the answers

    Which of the following symptoms would most likely indicate a mild form of serotonin syndrome?

    <p>Anxiety</p> Signup and view all the answers

    What might happen if an SSRI is discontinued abruptly?

    <p>It can cause discontinuation syndrome.</p> Signup and view all the answers

    What condition can occur as a result of excessive serotonergic activity after increasing an SSRI dosage?

    <p>Serotonin syndrome</p> Signup and view all the answers

    What is one potential effect of increased serotonin receptor binding in the postsynaptic neuron?

    <p>Enhanced neurotransmission.</p> Signup and view all the answers

    Why might an SSRI cause sexual dysfunction?

    <p>Through increased serotonin 2C receptor activity.</p> Signup and view all the answers

    What is a characteristic of serotonin syndrome that differentiates it from other similar conditions?

    <p>Life-threatening symptoms can develop quickly.</p> Signup and view all the answers

    Which neurotransmitter is primarily affected by SSRIs?

    <p>Serotonin</p> Signup and view all the answers

    What is the primary action of Vortioxetine on serotonin receptors?

    <p>It acts as a partial agonist at the 5-HT1B receptor.</p> Signup and view all the answers

    What is one major side effect common to Nefazodone?

    <p>Potential liver failure</p> Signup and view all the answers

    Which antidepressant is known for causing significant sedation as a side effect?

    <p>Trazodone</p> Signup and view all the answers

    Which of the following best describes the mechanism of action of Amitriptyline?

    <p>Blocks reuptake of serotonin more than norepinephrine.</p> Signup and view all the answers

    What type of depression are Monoamine Oxidase Inhibitors (MAOIs) particularly effective for?

    <p>Atypical depression</p> Signup and view all the answers

    Which side effect is most associated with Tricyclic Antidepressants (TCAs)?

    <p>Anticholinergic effects</p> Signup and view all the answers

    Which component of the treatment with antidepressants is often determined after reaching a therapeutic dose?

    <p>Duration to wait for response</p> Signup and view all the answers

    In cases of hypertensive crisis related to MAOIs, which food component primarily causes this reaction?

    <p>Tyramine</p> Signup and view all the answers

    Which of the following medications is a subsequent line of treatment after SSRIs and SNRIs?

    <p>Atypical antidepressants</p> Signup and view all the answers

    Which antidepressant is best known for its potential to increase appetite and cause weight gain?

    <p>Mirtazapine</p> Signup and view all the answers

    What is the primary role of monoamine oxidase (MAO) in the body?

    <p>Degrade neurotransmitters such as serotonin and dopamine.</p> Signup and view all the answers

    Which of the following is NOT a commonly prescribed first-line antidepressant class?

    <p>MAOIs</p> Signup and view all the answers

    What is the risk of using antidepressants in patients with cardiac conduction system disease?

    <p>They may cause heart block and arrhythmias.</p> Signup and view all the answers

    What should be monitored in patients being treated with MAOIs?

    <p>Blood pressure stability</p> Signup and view all the answers

    Study Notes

    Major Depressive Disorder (MDD)

    • MDD is a mood state characterized by feelings of sadness, despair, anxiety, emptiness, discouragement, hopelessness, or appearing tearful.
    • It's a combination of signs and symptoms.
    • It's also a mental disorder with a distinct clinical condition, such as unipolar major depression.

    Learning Objectives

    • Understand the prevalence of depression in various populations (developed vs. developing countries, sex, race, and age).
    • Explain the pathophysiological mechanisms of depression.
    • Recognize signs and symptoms of MDD.
    • Recommend appropriate antidepressant therapy based on treatment phase and patient history.
    • Apply pharmacokinetic principles and patient-specific data in choosing the best medication.
    • Monitor treatment efficacy and adjust medications based on patient response and tolerability.

    Assessment

    • Assess history of present illness (depressive symptoms and their context, suicide risk).
    • Evaluate general medical illness.
    • Obtain family history and social history.
    • Perform mental status examination and physical examination.
    • Conduct laboratory evaluation.
    • Screen for depression.
    • Utilize diagnostic instruments.

    Epidemiology

    • Estimated lifetime prevalence is 12% in developed countries; 9% in developing countries like China, Mexico, and Brazil.
    • Depression is two times more common in females.
    • Within different racial groups, the prevalence of MDD varies according to the data presented
    • It's the 11th greatest cause of disability and mortality globally.
    • In the United States, major depression ranks second among all diseases and injuries, followed by persistent depressive disorder (dysthymia), which ranks 20th.

    Pathogenesis

    • Genetic factors influence response to antidepressants.
    • Early life adversity and childhood trauma contribute.
    • Social factors, such as isolation, poor social relationships, and criticisms, impact depression.
    • Psychological factors including negative thought patterns, early life losses, self-esteem issues, and difficulties managing losses and relationships contribute to MDD.
    • General medical disorders such as epilepsy, Parkinson's disease, Heart failure, HIV/AIDS, and cancer, can cause or increase the risk of MDD.
    • Medications like glucocorticoids and interferons also increase the risk of MDD.

    Neurobiology

    • Neurotransmitters, such as monoamines (serotonin, norepinephrine, and dopamine), are essential for brain function and emotional regulation.
    • The neurotransmitter GABA acts as an inhibitory neurotransmitter, while glutamate acts as the primary excitatory neurotransmitter in the brain.
    • These neurotransmitters and their roles in emotions, sleep, pain, homeostasis, signaling, memory, and cognition play a role in MDD

    Diagnostic Criteria & Classification (DSM-5)

    • Five (or more) symptoms present over a two-week period, representing a change from previous functioning. At least one symptom must be depressed mood or loss of interest or pleasure.
    • Depressed mood (sadness, emptiness, hopelessness, irritability).
    • Markedly diminished interest or pleasure in activities.
    • Significant weight loss, weight gain, or changes in appetite.
    • Insomnia or hypersomnia.
    • Psychomotor agitation or retardation (observable by others).
    • Fatigue or loss of energy.
    • Feelings of worthlessness or guilt.
    • Diminished ability to think or concentrate.
    • Recurrent thoughts of death or suicide attempt.
    • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • The episode is not attributable to the direct physiological effects of a substance or to another medical condition.
    • The occurrence of major depressive episode is not better explained by other mental disorders.
    • There has never been a manic or hypomanic episode.

    Mild to Moderate Major Depression

    • Manifestations include absence of suicidal or homicidal ideation or behavior, and no psychotic features or aggression.
    • Intact judgment and no imminent risk of harm to self or others.
    • Usually treated as outpatient or in a partial/day hospital program.

    Treatment Goals

    • The primary goals of initial treatment include symptom remission and restoring baseline functioning.

    Treatment

    • Antidepressants plus psychotherapy.
    • Classes of antidepressants, selecting an AD based on factors such as side effects, and the appropriate dose.
    • Psychotherapy (Cognitive-Behavioral Therapy [CBT] or Interpersonal Psychotherapy [IPT] ).
    • Randomized trials show greater efficacy with combined pharmacotherapy and psychotherapy.

    Antidepressants

    • Second-generation antidepressants (SSRIs, SNRIs, atypical antidepressants, serotonin modulators)
    • First-generation antidepressants (TCAs, MAOIs)
    • Detailed table of medications and their uses.

    Selective Serotonin Reuptake Inhibitors (SSRIs)

    • Frequently used first-line antidepressants due to efficacy, tolerability, and safety in overdose.
    • Inhibit serotonin reuptake in the synapse.
    • Efficacy is similar across various SSRIs.
    • Tables detail different SSRIs, their doses, methods of administration, potential drug-drug interactions (DDI), and metabolism/elimination routes.
    • Side effects (e.g., sexual dysfunction, weight gain).
    • Instructions for switching between SSRIs and tapering doses to avoid discontinuation syndrome and serotonin syndrome.
    • Detailed information about serotonin syndrome- its causes, symptoms, clinical features including agitation, delirium, diaphoresis, tachycardia, hypertension, and hyperthermia., helpful tests (e.g., CBC, electrolytes, BUN, CPK), differential diagnoses (e.g., neuroleptic malignant syndrome, anticholinergic toxicity), and treatment in cases of serotonin syndrome.

    Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

    • Used for treating major depression, amongst other conditions.
    • Block the reuptake of serotonin and norepinephrine within neuronal synapses.
    • Detailed tables outline SNRIs, their use, doses, administration routes, DDI, and metabolism/elimination routes.
    • Side effects, including insomnia, agitation, sexual dysfunction, and urinary hesitancy.

    Atypical Antidepressants

    • Used for patients resistant to or intolerant of other antidepressants.
    • Detailed tables detail atypical antidepressants, administration, DDIs, and metabolism/elimination routes.
    • Side effects for specific drugs are given.

    Serotonin Modulators

    • Used as first-line treatment if the drug demonstrates strong characteristics.
    • Detailed tables of information on serotonin modulators detailing their action, administration, DDIs, and metabolism/elimination routes

    Tricyclic Antidepressants (TCAs)

    • Older class of antidepressants.
    • Detailed table outlining different TCAs, their mechanism of action, and potential side effects including anticholinergic effects, cardiac effects, including hypotension and potential for severe arrhythmias, and sexual dysfunction.

    Monoamine Oxidase Inhibitors (MAOIs)

    • Not typically a first-line treatment.
    • Inhibits MAO- enzyme that breaks down monoamines)
    • Dietary restrictions is a crucial aspect of treatment.
    • Detailed table providing information on different MAOIs, their administration, and potential DDI, including hypertensive crisis.

    Psychotherapy

    • Cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), family therapy, problem-solving therapy, and others are efficacious for mild to moderate depression.
    • Psychotherapy shows comparable efficacy with antidepressants, especially in an initial treatment.

    Severe Major Depression

    • Clinical features include suicidal ideation or behavior, psychotic features (delusions or hallucinations), catatonia, and grossly impaired judgment.
    • A combination approach of pharmacotherapy (SNRI or SSRI or other antidepressant) and psychotherapy is preferred.
    • Electroconvulsive therapy (ECT) is an alternative treatment option for patients requiring a rapid response, especially those with severe suicidal or life-threatening behaviors.

    St. John's Wort

    • An over-the-counter (OTC) product known as Hypericum perforatum.
    • Has affinity to various neurotransmitter receptors.
    • Efficacy has conflicting results in studies.
    • Significant drug interactions.
    • Should not be used in conjunction with other antidepressants.

    Treatment Approach

    • Explains phases of treatment for depression: acute, continuation, and maintenance phases, duration, and goals.

    Treatment Failure

    • If no response to antidepressants after 12 weeks or due to intolerance, consider switching to an alternate agent, augmentation therapy, or electroconvulsive therapy.
    • Detailed order of preference for choosing an additional or alternative treatment (e.g., from SSRI or SNRI to atypical, then serotonin modulator, and then TCA or MAOI).

    Special Populations (Elderly, Pregnancy, Pediatrics)

    • Treatment approaches for elderly patients, pregnant patients, and pediatric patients (including specific drug restrictions)
    • The risks associated with using antidepressants in these groups.

    Augmentation Therapy

    • Supplemental medications (second-generation antipsychotics, lithium, thyroid hormone, anticonvulsants, or a serotonin agonists) when response to initial agents is insufficient.

    General Considerations

    • Providing a general approach and considerations for selecting an antidepressant based on the individual's symptoms, comorbidities or preferences and known responses to previous treatments (e.g. family history of response to antidepressants).

    Side Effects

    • Discusses common side effects for each class of antidepressants, such as diarrhea, nausea, sexual dysfunction, somnolence, and weight gain.
    • Emphasizes the importance of careful dose titration in order to reduce side effects and enhance adherence in patients.

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