Psych Notes: Mood Disorders

**Mood Disorders** **Definitions** - Psychosis: a distorted perception of reality. - Hallucinations, delusions, disorganized thoughts and/or behaviors - Psychosis can be a symptom of: - Depression, schizophrenia, mania, delirium, major neurocognitive disorder, pe...

**Mood Disorders** **Definitions** - Psychosis: a distorted perception of reality. - Hallucinations, delusions, disorganized thoughts and/or behaviors - Psychosis can be a symptom of: - Depression, schizophrenia, mania, delirium, major neurocognitive disorder, personality disorder - Hallucination: false sensory belief that is NOT associated with an external stimuli - Hypnopompic/hypnogogic: false sensory perception occuring while waking up and falling asleep (non-pathologic) - Auditory: false perception of sound (hearing something) - Most common in psychiatric disorders. Command type is most serious (making you do things) - Visual: false perception involving sight - More common in medical conditions (drug intoxication, drug/alcohol withdrawal, delirium) - Olfactory: false perception of smell - More common in medical conditions (epilepsy, TBI) - Gustatory: false perception of taste - More common in medical conditions (epilepsy) - Tactile: false perception of things occuring in or on the body (bugs crawling on you) - Usually from drug use or alcohol withdrawal - Somatic: false perception of things occuring in or on the body (im pregnant) - Delusion: fixed false belief that the patient's culture and education cannot account for; unshakeable even with evidence proving it wrong (someone is watching me) - Paranoid (persecutory): irrational belief that one is being conspired against, spied on, followed, poisoned, drugged, or harassed - Most common - Patients with these delusions are often resentful, angry, and may be violent - Grandiose/Grandeur: irrational belief that one has a great but unrecognized talent (special powers), has made an important discovery, or is someone famous (i.e. God, Jesus, Trump) - Usually seen in mania but may occur in schizophrenia - Somatic: irrational belief that something is wrong with one's body - Infestation of insects, illness/disease, bowels have turned to cement, etc. usually seen in severe depression - Nihilistic: irrational belief that one has died or that the world is coming to an end - Erotomanic: person believes that they are loved intensely by another (usually a famous person) - Jealous type: concerns the fidelity of one's spouse (usually seen in paranoid schizophrenia or delusional disorder) - Delusions of sin or guilt: irrational belief that one has committed a terrible sin or is responsible for something bad (usually seen in severe depression or delusional disorder) - Delusions of control: irrational belief that one is being controlled by an external force - Thought broadcasting: belief that one's thoughts can be heard by others - Thought insertion: belief that others' thoughts are being placed in one's head - Thought control - Thought withdrawal - Ideas or delusions of reference: belief that the actions of others are being directed at the patient or are working against them somehow - TV characters are speaking to/about the patient - Think people are whispering about them as they walk past - Illusions: misinterpretation of an existing sensory stimulus\\ - Shadow looks like a car - Mirage on the road looks like a bear **MOOD DISORDERS** - Mood: how one describes their emotional state (sad, happy, irritable, etc.) - Can be masked as complaints of insomnia, fatigue, unexplained pain, etc. - Mood Episode: distinct period where an abnormal mood is present (depression, mania, hypomania) - Mood disorder: patterns of mood episodes (MDD, BPI, BPII, PDD) **Disorder: Major Depressive Episode** +-----------------------------------+-----------------------------------+ | **DSM 5-TR Criteria** | At least 5 of the following are | | | present every day for 2 weeks and | | | have caused a decrease in | | | function: | | | | | | 1. Depressed mood most of the | | | day and nearly every day | | | (subjectively or objectively) | | | | | | 2. Anhedonia (markedly | | | diminished interest or | | | pleasure in almost all | | | activities) | | | | | | 3. Significant unintentional | | | weight gain or weight loss, | | | or increase or decrease of | | | appetite | | | | | | 4. Insomnia or hypersomnia | | | nearly every day | | | | | | 5. Psychomotor agitation or | | | retardation | | | | | | 6. Fatigue or loss of energy | | | | | | 7. Feelings of worthlessness or | | | excessive guilt | | | | | | 8. Diminished concentration or | | | indecisiveness | | | | | | 9. Recurrent thoughts of death, | | | suicidal ideation, or suicide | | | attempt | | | | | | Symptoms must not be attributable | | | to a substance, another medical | | | condition, bereavement, and do | | | not occur in the context of a | | | psychotic disorder | +-----------------------------------+-----------------------------------+ **Disorder: Manic Episode** +-----------------------------------+-----------------------------------+ | **DSM 5-TR Criteria** | At least 3 of the following for 1 | | | week or more: | | | | | | 1. Inflated self esteem or | | | grandiosity | | | | | | 2. Decreased need for sleep | | | | | | 3. More talkative than usual or | | | pressured speech | | | | | | 4. Racing thoughts or flight of | | | ideas | | | | | | 5. Distractibility | | | | | | 6. Increase in goal directed | | | activity or psychomotor | | | agitation | | | | | | 7. Excessive involvement in | | | pleasurable activities that | | | have a high risk of negative | | | consequences (shopping spree, | | | sex, business investments, | | | etc.) | | | | | | Symptoms are not due to substance | | | use or another medical condition | | | | | | Symptoms cause marked impairment | | | in functioning | +-----------------------------------+-----------------------------------+ **Disorder: hypomanic episode** - At least 3 of the symptoms listed for a manic episode occur consistently for 4 days - Similar to mania but milder and briefer **Mania** **Hypomania** ------------------------------------- ------------------------------------- Lasts at least 7 days Lasts at least 4 days Causes severe functional impairment No marked impairment of functioning May require hospitalization Does not require hospitalization May have psychotic features No psychotic features **Disorder: Major Depressive Disorder (MDD)** +-----------------------------------+-----------------------------------+ | **Etiology** | Most likely caused from decrease | | | of neurotransmitters, | | | specifically serotonin, | | | norepinephrine, and dopamine in | | | the brain | | | | | | Thyroid disorders (can cause T3 | | | to augment antidepressants) | | | | | | Multiple adverse childhood events | | | | | | Genetics (1^st^ degree relatives | | | are 2-4 times more likely to have | | | MDD) | +===================================+===================================+ | **Clinical Presentation** | Can have a gradual or sudden | | | onset | | | | | | Recurrent illness episodes occur | | | more frequently as the disorder | | | progresses | | | | | | If untreated, depressive episodes | | | can be self limiting but last | | | from 6-12 months | | | | | | Full recovery from one episode of | | | MDD occurs in 50% of cases by 6 | | | months | | | | | | Combined treatment with | | | medication and psychotherapy | | | significantly increase response | +-----------------------------------+-----------------------------------+ | **DSM 5-TR Criteria** | At least 5 of the following (must | | | include number 1 or 2) must be | | | present during the same 2-week | | | period and result in | | | deterioration of functioning) | | | | | | 1. Depressed mood most of the | | | day and nearly every day | | | (subjective or objective) | | | | | | 2. Anhedonia (markedly | | | diminished interest or | | | pleasure in almost all | | | activities) | | | | | | 3. Significant unintentional | | | weight gain or weight loss, | | | or increase or decrease of | | | appetite | | | | | | 4. Insomnia or hypersomnia | | | nearly every day | | | | | | 5. Psychomotor agitation or | | | retardation | | | | | | 6. Fatigue or loss of energy | | | | | | 7. Feelings of worthlessness or | | | excessive guilt | | | | | | 8. Diminished concentration or | | | indecisiveness | | | | | | 9. Recurrent thoughts of death, | | | suicidal ideation, or suicide | | | attempt | | | | | | Symptoms must not be attributable | | | to a substance, another medical | | | condition, bereavement, and do | | | not occur in the context of a | | | psychotic disorder | | | | | | No history of mania or hypomania | +-----------------------------------+-----------------------------------+ | **Treatment** | Hospitalization -- if patient is | | | a danger to themselves or others, | | | expresses suicidal or homicidal | | | intent and/or plan, unable to | | | care for themselves | | | | | | Pharmacotherapy | | | | | | - Antidepressants -- SSRI, | | | SNRI, TCA, MAOI, atypical | | | | | | - Second generation | | | antispcyhotics | | | | | | - Mood stabilizers | | | | | | - T3 or T4 | | | | | | Psychotherapy -- CBT, marriage | | | counseling, etc. | | | | | | ECT | +-----------------------------------+-----------------------------------+ **Disorder: Persistent Depressive Disorder (Dysthymia)** +-----------------------------------+-----------------------------------+ | **Etiology** | Chronic and persistent mild | | | depression that has been present | | | for at least 2 years | | | | | | Can have major depressive | | | episodes throughout | | | | | | Often occurs after a major | | | depressive episode | | | | | | Lifetime prevalence of 6% | | | | | | More common in women | | | | | | Often has an early onset | | | (childhood, adolescence, early | | | adult life) | | | | | | If before age 21, it is | | | associated with a higher | | | likelihood of comorbid | | | personality disorders and | | | substance use disorders | +===================================+===================================+ | **Clinical Presentation** | DD = 2 Ds | | | | | | - 2 years of depression | | | | | | - 2 listed criteria | | | | | | - Never asymptomatic for more | | | than 2 months | | | | | | Chronic condition | | | | | | Depressive symptoms are more | | | likely to resolve than in MDD | +-----------------------------------+-----------------------------------+ | **DSM 5-TR Criteria** | 1. Depressed mood for more days | | | than not for at least 2 years | | | | | | 2. At least 2 of the following | | | | | | - Poor appetite or overeating | | | | | | - Insomnia or hypersomnia | | | | | | - Low energy or fatigue | | | | | | - Low self esteem | | | | | | - Poor concentration or | | | difficulty making decisions | | | | | | - Feelings of hopelessness | | | | | | 3. During the 2 year period, | | | patient never goes without | | | symptoms for more than 2 | | | months at a time | | | | | | 4. May also meet criteria for | | | MDD continuously | | | | | | 5. No history of mania, | | | hypomania, or cyclothymia | | | | | | 6. Symptoms are not occurring | | | due to another psychiatric | | | disorder, substance use, or | | | medical condition | | | | | | 7. Symptoms cause significant | | | distress and impairment in | | | functioning | +-----------------------------------+-----------------------------------+ | **Treatment** | Combination of psychotherapy and | | | pharmacotherapy | | | | | | - SSRIs | | | | | | - CBT (cognitive behavioral | | | therapy) | +-----------------------------------+-----------------------------------+ **Disorder: Premenstrual Dysphoric Disorder (PMDD)** +-----------------------------------+-----------------------------------+ | **Etiology** | "late luteal phase disorder" | | | | | | Women who experience intermittent | | | severe depressive symptoms during | | | the luteal phase | | | | | | Prevalence in about 2% of women | | | | | | Environmental and genetic factors | | | play a role | +===================================+===================================+ | **Clinical Presentation** | Symptoms may worsen around | | | menopause and improve after | | | menopause | +-----------------------------------+-----------------------------------+ | **DSM 5-TR Criteria** | 1\. For most menstrual cycles, | | | at least 5 symptoms are present | | | in the final week before onset | | | of menses, start to improve | | | within a few days after onset | | | of menses, and become minimal | | | or absent in the week post | | | menses | | | | | | 2\. One or more of the following | | | are present: | | | | | | \- marked affective lability | | | (mood swings, feeling suddenly | | | sad or tearful, increased | | | sensitivity) | | | | | | \- marked irritability or anger | | | or increased interpersonal | | | conflicts | | | | | | \- marked depressed mood, | | | feelings of hopelessness, or | | | self-deprecating thoughts | | | | | | \- marked anxiety, tension, | | | and/or feelings of being keyed up | | | or on edge | | | | | | 3\. One or more of the following | | | must additionally present to | | | reach a total of 5 symptoms | | | when combined with above | | | criteria: | | | | | | \- decreased interest in | | | activities | | | | | | \- subjective difficulty in | | | concentration | | | | | | \- lethargy, easily fatigued, or | | | marked lack of energy | | | | | | \- insomnia or hypersomnia | | | | | | \- sense of being overwhelmed or | | | out of control | | | | | | \- physcial symptoms such as | | | breast tenderness or swelling, | | | joint or msucle pain, "bloating", | | | or weight gain | | | | | | 4\. Symptoms cause significant | | | impairment in functioning | | | | | | 5\. Symptoms are not due to | | | exacerbation of another | | | disorder, substance use, or | | | another medical condition | +-----------------------------------+-----------------------------------+ | **Treatment** | SSRIs are first line treatment | | | | | | - Fluoxetine (Prozac) | | | | | | - Paroxetine (Paxil) | | | | | | - Sertraline (Zoloft) | | | | | | - Can use as a daily therapy or | | | only during luteal phase -- | | | start day 14 and stop once | | | menses begins (\*\* note that | | | this won't really work in | | | real life) | | | | | | OCPs | | | | | | Oophorectomy or hysterectomy | +-----------------------------------+-----------------------------------+ **Disorder: Disruptive Mood Dysregulation Disorder (DMDD)** +-----------------------------------+-----------------------------------+ | **Etiology** | Fairly new diagnosis | | | | | | More common in males than females | +===================================+===================================+ | **Clinical Presentation** | Characterized by chronic, severe, | | | or persistent irritability in | | | children or adolescence | | | | | | About half of children will | | | continue to meet criteria 1 year | | | after diagnosis | | | | | | Very rarely convert to BPD | | | | | | Can appear comorbidly with MDD, | | | ADHD, conduct disorder, anxiety | | | disorders, and substance use | | | disorders | | | | | | CANNOT coexist with ODD, | | | intermittent explosive disorder, | | | or BPD | | | | | | High risk for depression or | | | anxiety in their adult years | +-----------------------------------+-----------------------------------+ | **DSM 5-TR Criteria** | 1\. Severe recurrent temper | | | outbursts manifested verbally | | | and/or behaviorally that are | | | grossly out of proportion in | | | intensity or duration to the | | | situation | | | | | | 2\. Temper outbursts are | | | inconsistent with developmental | | | level | | | | | | 3\. Temper outbursts occur 3 or | | | more times per week | | | | | | 4\. The mood between temper | | | outbursts is persistently | | | irritable or angry most of the | | | day, nearly every day, and is | | | observable by others | | | | | | 5\. Symptoms have been present | | | for 12 or more months without 3 | | | months symptom free | | | | | | 6\. Symptoms are present in at | | | least 2 settings | | | | | | 7\. Symptoms began before age 10 | | | | | | \- can diagnose between ages 6-10 | | | | | | 8\. no episodes meeting full | | | criteria for manic or hypomanic | | | episode lasting longer than 1 | | | day | | | | | | 9\. Behaviors are not explained | | | by another psychiatric | | | diagnosis, substance use, or | | | another medical condition | +-----------------------------------+-----------------------------------+ | **Treatment** | Since it is a new diagnosis, | | | there are no evidence based | | | treatments | | | | | | - Psychotherapy (\#1) | | | | | | - Medication to treat comorbid | | | disorders (if present -- | | | stimulants, SSRIs, mood | | | stabilizers, SGA) | +-----------------------------------+-----------------------------------+ **ANTIDEPRESSANTS** - **SSRIs** - Celexa (citalopram) - Lexapro (escitalopram) - Zoloft (sertraline) - Prozac (fluoxetine) - Paxil (Paroxetine) - Luvox (Fluvoxamine) **Celexa** +-----------------------------------+-----------------------------------+ | **Indications** | Depression (FDA Approved) | | | | | | PMDD | | | | | | Generalized Anxiety Disorder | | | | | | OCD | | | | | | PTSD | +===================================+===================================+ | **MOA** | Increases neurotransmitter | | | serotonin by blocking its | | | reuptake | | | | | | Mild antagonist at H1 histamine | | | receptor (drowsiness, dizziness) | +-----------------------------------+-----------------------------------+ | **Side Effects** | GI Effects | | | (constipation/diarrhea) | | | | | | Sedation or insomnia | | | | | | Headaches | | | | | | Dizziness | | | | | | Sexual dysfunction | | | | | | Sweating (night sweats( | | | | | | QTC prolongation (geriatric) | | | | | | Hyponatremia (geriatric) | +-----------------------------------+-----------------------------------+ | **Dosing** | 10-40mg/day | | | | | | Elderly: 20mg/day MAX | +-----------------------------------+-----------------------------------+ | **Special Populations** | Geriatric: do not use more than | | | 20mg/day | | | | | | Hepatic impairment: do not use | | | more than 20mg/day | | | | | | Children: monitor for suicidal | | | ideation (Black Box Warning) | | | | | | Pregnancy: weigh risks and | | | benefits | | | | | | Breast feeding: small amount in | | | breast milk | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Good for symptoms of both | | | depression and anxiety | | | | | | Sometimes not as well tolerated | | | as lexapro | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Indications** | Depression (Ages 12+ - FDA | | | approved) | | | | | | GAD (FDA approved) | | | | | | Panic disorder | | | | | | OCD | | | | | | PTSD | | | | | | Social anxiety disorder | +===================================+===================================+ | **MOA** | Increases NT serotonin (5-HT) by | | | blocking its reuptake | | | | | | \*does not affect histamine like | | | Celexa | +-----------------------------------+-----------------------------------+ | **Side Effects** | Sexual dysfunction | | | | | | GI upset | | | | | | Sweating | | | | | | Headache | | | | | | Dizziness | | | | | | Insomnia or sedation | +-----------------------------------+-----------------------------------+ | **Dosing** | 10-20mg/day (usually dose at | | | night) | | | | | | - Can start at 5mg with naïve | | | patient | +-----------------------------------+-----------------------------------+ | **Special Populations** | Hepatic impairment; no more than | | | 10mg/day | | | | | | Geriatric: do not use more than | | | 10mg/day | | | | | | Children; approved for depression | | | at age 12: black box warning | | | (increase suicidal thoughts) | | | | | | Pregnancy: weigh risk vs benefit | | | | | | Breast feeding: some drug found | | | in breast milk | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Has a faster onset of action | | | (than Celexa) | | | | | | Less side effects than most SSRIs | | | (well tolerated, less sexual | | | dysfunction reported) | | | | | | More potent than Celexa | | | | | | Less drug-drug interactions | +-----------------------------------+-----------------------------------+ **Lexapro (escitalopram)** **Prozac (fluoxetine)** +-----------------------------------+-----------------------------------+ | **Indications** | Depression (18+ FDA approved) | | | | | | OCD (7+ FDA approved) | | | | | | PMDD (FDA approved) | | | | | | Bulimia nervosa (FDA approved) | | | | | | Panic Disorder (FDA approved) | | | | | | Bipolar depression (in combo with | | | Zyprexa -- FDA approved) | | | | | | Social anxiety disorder | | | | | | PTSD | +===================================+===================================+ | **MOA** | Increases serotonin by blocking | | | its reuptake | | | | | | Antagonistic properties at 5HT2C | | | receptors increase norepinephrine | | | and dopamine NT | +-----------------------------------+-----------------------------------+ | **Side Effects** | Sexual dysfunction | | | | | | GI upset | | | | | | Insomnia or sedation | | | | | | Sweating | | | | | | Might increase agitation or | | | anxiety | +-----------------------------------+-----------------------------------+ | **Dosing** | 20-80 mg, every morning for | | | depression, anxiety, OCD | | | | | | 60-80 mg every morning for | | | bulimia | +-----------------------------------+-----------------------------------+ | **Special Populations** | renal impairment: not removed by | | | hemodialysis | | | | | | Hepatic impairment; lower dosages | | | | | | Geriatric: no dose adjustment | | | | | | Pregnancy: weigh risk vs benefit | | | | | | Breast feeding: some found in | | | breast milk | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Good for atypical depression | | | (hypersomnia, increased appetite) | | | | | | Good for patients with low | | | energy/fatigue | | | | | | Can be activating | +-----------------------------------+-----------------------------------+ **Paxil (paroxetine)** +-----------------------------------+-----------------------------------+ | **Indications** | MDD | | | | | | OCD | | | | | | Panic Disorder | | | | | | Social Anxiety Disorder | | | | | | PTSD | | | | | | GAD | | | | | | PMDD\ | | | Menopausal symptoms | +===================================+===================================+ | **MOA** | Increases serotonin by blocking | | | its reuptake | | | | | | Mild anticholinergic properties | | | | | | Mild norepinephrine reuptake | | | blocking action | +-----------------------------------+-----------------------------------+ | **Side Effects** | Sexual dysfunction | | | | | | GI upset | | | | | | Insomnia or sedation | | | | | | Headache | | | | | | Dizziness | | | | | | Weight gain | | | | | | Sweating | +-----------------------------------+-----------------------------------+ | **Dosing** | 20-60mg every morning | | | | | | For menopausal symptoms: 7.5mg at | | | bedtime | +-----------------------------------+-----------------------------------+ | **Special Populations** | Renal impairment: max 40mg/day | | | | | | Hepatic impairment: max 40mg/day | | | | | | Geriatric: max 40mg/day | | | | | | Children: black box warning | | | | | | Pregnancy: weigh risks vs | | | benefits | | | | | | Breast feeding: some found in | | | breast milk | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Good for anxiety | | | | | | Good for patients with depression | | | or anxiety symptoms in the form | | | of insomnia | | | | | | Not a good choice if symptoms | | | include fatigue, low energy, | | | decreased psychomotor activity | | | | | | ALWAYS TAPER SLOWLY -- HAS BAD | | | WITHDRAWAL SIDE EFFECTS | +-----------------------------------+-----------------------------------+ **Zoloft (sertraline)** +-----------------------------------+-----------------------------------+ | **Indications** | MDD\ | | | PMDD\ | | | Panic Disorder | | | | | | PTSD\ | | | Social anxiety disorder | | | | | | OCD | | | | | | GAD | +===================================+===================================+ | **MOA** | Increases serotonin by blocking | | | its reuptake | | | | | | Has some ability to block | | | dopamine reuptake | +-----------------------------------+-----------------------------------+ | **Side Effects** | Sexual dysfunction | | | | | | GI Upset MC = nausea and | | | diarrhea, especially in women | | | | | | Insomnia or sedation | | | | | | Headache | | | | | | Dizziness | | | | | | Sweating | +-----------------------------------+-----------------------------------+ | **Dosing** | 50-200mg/day (dose at night) | | | | | | Works better for anxiety at | | | higher doses (\>100mg) | +-----------------------------------+-----------------------------------+ | **Special Populations** | Renal impairment: not removed by | | | hemodialysis | | | | | | Hepatic impairment: lower dosages | | | | | | Geriatric: no dose adjustments | | | | | | Children: ages 6+ | | | | | | Pregnancy; weigh risk vs benefit. | | | MC antidepressant used in | | | pregnancy | | | | | | Breast feeding: some found in | | | milk | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Good for atypical depression | | | (hypersomnia, increased appetite) | | | | | | Try to avoid if patient has IBS | | | | | | "Well-loft" (in combo with | | | Wellbutrin) | +-----------------------------------+-----------------------------------+ **Luvox (fluvoxamine)** +-----------------------------------+-----------------------------------+ | **Indications** | OCD | | | | | | Social anxiety disorder | | | | | | Depression | | | | | | Panic disorder | | | | | | GAD | | | | | | PTSD | +===================================+===================================+ | **MOA** | Increases serotonin by blocking | | | its reuptake | | | | | | Binds at sigma 1 receptors | +-----------------------------------+-----------------------------------+ | **Side Effects** | Sexual dysfunction | | | | | | GI upset | | | | | | Sedation or insomnia | | | | | | Headache | | | | | | Dizziness | | | | | | Sweating | +-----------------------------------+-----------------------------------+ | **Dosing** | 100-300mg/day for OCD or social | | | anxiety disorder | | | | | | 100-200mg/day for depression | | | | | | Can either dose once a day or | | | split dosing (for OCD -- most | | | commonly see split dosing) | +-----------------------------------+-----------------------------------+ | **Special Populations** | Hepatic impairment: lower dosages | | | | | | Geriatric; slower titration (this | | | is for ANY psychotropic) | | | | | | Children: ages 8+ | | | | | | Pregnancy: risk vs benefit | | | | | | Breast feeding: some found in | | | breastmilk | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Mainly used for OCD | | | | | | Usually BID dosing which | | | decreases compliance | +-----------------------------------+-----------------------------------+ **SSRI recap: side effects include** nausea, vomiting, diarrhea, weight gain, sexual dysfunction, headaches, fatigue **SNRIs -- Serotonin Norepinephrine Reuptake Inhibitors** - Cymbalta (duloxetine) - Effexor (venlafaxine) - Pristiq (desvenlafaxine) - Fetzima (levomilnacipran) - Savella (Milnacipran) **Cymbalta (duloxetine)** +-----------------------------------+-----------------------------------+ | **Indications** | Major depressive disorder | | | | | | Generalized anxiety disorder | +===================================+===================================+ | **MOA** | Blocks serotonin and | | | norepinephrine reuptake pump | | | increasing amount of NT | | | | | | Weakly blocks dopamine reuptake | | | pump | +-----------------------------------+-----------------------------------+ | **Side Effects** | Nausea | | | | | | Diarrhea | | | | | | Dry mouth | | | | | | Constipation | | | | | | Sexual dysfunction | | | | | | Sweating | | | | | | Increased BP | | | | | | Urinary retention | +-----------------------------------+-----------------------------------+ | **Dosing** | 40-60mg/day in 1-2 doses | | | | | | MAX = 120mg/day | | | | | | TAPER to come off....withdrawal | | | SE | +-----------------------------------+-----------------------------------+ | **Special Populations** | Renal impairment: not recommended | | | in end-stage renal disease | | | | | | Hepatic impairment: avoid if | | | patient has liver issues; avoid | | | if co-existing alcohol use | | | disorder | | | | | | Cardiac impairment: caution as it | | | can increase BP | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Good for physcial symptoms of | | | depression | | | | | | Good for comorbid anxiety | | | | | | Combine with romeron | | | | | | Good for patients who fail SSRIs | | | | | | Not good for older men with | | | prostate issues (urinary | | | retention) | +-----------------------------------+-----------------------------------+ **Effexor (venlafaxine)** +-----------------------------------+-----------------------------------+ | **Indications** | MDD | | | | | | GAD | | | | | | Social anxiety disorder | | | | | | Panic disorder | | | | | | PTSD | | | | | | PMDD | +===================================+===================================+ | **MOA** | Blocks serotonin and | | | norepinephrine reuptake pump | | | increasing amount of NT | | | | | | Weakly blocks dopamine reuptake | | | pump | +-----------------------------------+-----------------------------------+ | **Side Effects** | Nausea | | | | | | Diarrhea | | | | | | Headache | | | | | | Insomnia | | | | | | Sexual dysfunction | | | | | | Sweating | | | | | | Increased BP | +-----------------------------------+-----------------------------------+ | **Dosing** | Comes in IR and XR | | | | | | - Most often you will prescribe | | | XR | | | | | | 75-225mg/day XR | | | | | | **TAPER THIS OR YOUR PATIENTS | | | WILL BE MAD AT YOU** | +-----------------------------------+-----------------------------------+ | **Special Populations** | Renal impairment: decrease dose | | | by 25-50% | | | | | | Hepatic impairment: lower dose by | | | 50% | | | | | | Cardiac impairment: use with | | | caution | | | | | | Elderly: risk of SIADH | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Good for comorbid anxiety | | | | | | Good for slowed symptoms of | | | depression | | | | | | Combine with Remeron | | | | | | Good for patients who fail SSRIs | | | | | | Abusable... | +-----------------------------------+-----------------------------------+ **Pristiq (desvenlafaxine)** +-----------------------------------+-----------------------------------+ | **Indications** | MDD | | | | | | GAD | | | | | | Social phobia | | | | | | Panic disorder | | | | | | PTSD | | | | | | PMDD | | | | | | Fibromyalgia | +===================================+===================================+ | **MOA** | Blocks serotonin and | | | norepinephrine reuptake pump | | | increasing amount of NT | | | | | | Increases dopamine transmission | +-----------------------------------+-----------------------------------+ | **Side Effects** | Insomnia/sedation | | | | | | GI upset (n/v/d) | | | | | | Sexual dysfunction | | | | | | Sweating | | | | | | Increase in BP | | | | | | Hyponatremia | +-----------------------------------+-----------------------------------+ | **Dosing** | 50-100mg once daily | | | | | | XR tablet only | +-----------------------------------+-----------------------------------+ | **Special Populations** | Renal impairment: 50mg/day max | | | | | | Hepatic impairment: 100mg/day max | | | | | | Elderly: higher risk of | | | hyponatremia | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Good for patients with | | | psychomotor slowing | | | | | | Good for physcial symptoms (pain, | | | fatigue) | | | | | | Not good for patients sensitive | | | to nausea | +-----------------------------------+-----------------------------------+ **Fetzima (levomilnacipran)** +-----------------------------------+-----------------------------------+ | **Indications** | MDD | | | | | | Fibromyalgia | | | | | | Chronic pain | +===================================+===================================+ | **MOA** | Blocks serotonin and | | | norepinephrine reuptake pump | | | increasing the amount of | | | neurotransmitter | | | | | | Increases dopamine transmission | +-----------------------------------+-----------------------------------+ | **Side Effects** | Nausea | | | | | | Vomiting | | | | | | Constipation | | | | | | Tachycardia, palpitations | | | | | | Urinary retention | | | | | | Sexual dysfunction | +-----------------------------------+-----------------------------------+ | **Dosing** | 40-120mg/day | | | | | | XR capsule | +-----------------------------------+-----------------------------------+ | **Special Populations** | Renal impairment: 80mg/day max | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Expensive! | | | | | | Bad for patients with urologic | | | disorders | +-----------------------------------+-----------------------------------+ **Savella (milacipran)** \*hardly see this prescribed +-----------------------------------+-----------------------------------+ | **Indications** | Fibromyalgia | | | | | | MDD | | | | | | Chronic pain | +===================================+===================================+ | **MOA** | Blocks serotonin and | | | norepinephrine reuptake pump | | | increasing the amount of | | | neurotransmitters | | | | | | Increases dopamine transmission | +-----------------------------------+-----------------------------------+ | **Side Effects** | Headache | | | | | | Insomnia/sedation | | | | | | Anxiety | | | | | | n/v/d | | | | | | sweating | | | | | | dry mouth, constipation | | | | | | sexual dysfunction | | | | | | urinary retention | | | | | | Increases HR and palpitations | +-----------------------------------+-----------------------------------+ | **Dosing** | 30-200mg/day in 2 divided doses | +-----------------------------------+-----------------------------------+ | **Special Populations** | Renal impairment: if severe, | | | 50mg/day max | | | | | | Cardiac: use with caution | +-----------------------------------+-----------------------------------+ | **Clinical Pearls** | Good for chronic pain | +-----------------------------------+-----------------------------------+ **SNRI Side effects in general:** n/v/d, dry mouth, constipation, increased BP, dizziness, urinary retention +-----------------+-----------------+-----------------+-----------------+ | Medication | Dosing | Stand out SE | Clinical Pearls | +=================+=================+=================+=================+ | Cymbalta | 30-120mg/day in | Fatigue (dose | Good for | | | divided doses | at night) | comorbid | | | | | chronic pain, | | | | | fibromyalgia, | | | | | peripheral | | | | | neuropathy | | | | | | | | | | Works well in | | | | | combo with | | | | | Remeron | +-----------------+-----------------+-----------------+-----------------+ | Effexor | 37.5-225mg/day | Activation, | Dose in the | | | | sweating | morning | | | | | | | | | | Good for low | | | | | energy/motivati | | | | | on | | | | | | | | | | Good for | | | | | treatment | | | | | resistant | | | | | depression | | | | | | | | | | Works well in | | | | | combo with | | | | | Remeron | | | | | | | | | | Hard to taper | | | | | off due to | | | | | withdrawal SE | +-----------------+-----------------+-----------------+-----------------+ | Pristiq | 50-100mg/day | Activation | Good for low | | | | | energy/motivati | | | | | on | +-----------------+-----------------+-----------------+-----------------+ **TCAs (Tricyclic Antidepressants)** - Commonly used for headaches, sleep, neuropathic pain, fibromyalgia. - One of the first approved antidepressants, and have since been replaced with newer antidepressants with few side effects - Side effects include: blurred vision, constipation, urinary retention, increased appetite, dry mouth, n/v/d, heart burn, weight gain, fatigue, weakness, dizziness, sexual dysfunction, sweating, paralytic ileus, seizures, sudden death, arrythmias, increased ocular pressure, QTC prolongation - Elavil (amitriptyline) - Pamelor (nortriptyline) - Anafranil (clomipramine) - Norpramin (desipramine) - Tofranil (imipramine) - Sinequan (doxepin) - Asendin (amoxapine) **Monoamine Oxidase Inhibitors (MAOIs)** - Nardil (phenelzine) - Emsam (selegiline) - Marplan (isocarboxazid) - Parnate (tranylcypromine) - Block monoamine oxidase, which is an enzyme responsible for breaking down norepinephrine, serotonin, and dopamine - MANY food and drug interactions - Foods to avoid: wine (alcohol), cheese, sauerkraut, cured meats, beer, soy, poultry, fish, broad bean pods, chocolate, caffeine - BAD side effects - Postural hypotension, weight gain, sexual dysfunction, hypertensive crisis\*, seizures\* **Atypical Antidepressants** - **Wellbutrin (bupropion)** - **Remeron (mirtazapine)** - **Desyrel (trazodone)** - **Viibryd (vilazodone)** - **Trintellix (vortioxetine)** **Wellbutrin (bupropion)** +-----------------------------------+-----------------------------------+ | **Indications:** | MDD | | | | | | SAD | | | | | | Nicotine use disorder (aid in | | | smoking cessation) | | | | | | ADHA | | | | | | Sexual dysfunction | +===================================+===================================+ | **MOA:** | Blocks norepinephrine reuptake | | | pump, increasing transmission of | | | norepinephrine | | | | | | Blocks dopamine reuptake pump, | | | increasing dopaminergic | | | neurotransmission | +-----------------------------------+-----------------------------------+ | **Side effects:** | Dry mouth, constipation | | | | | | Nausea | | | | | | Weight loss, decreased appetite | | | | | | Insomnia | | | | | | Dizziness | | | | | | Headache | | | | | | Agitation, increased anxiety | +-----------------------------------+-----------------------------------+ | **Dose:** | Several dosage forms (SR, IR, XL) | | | (most often prescribe XL) | | | | | | 150-450mg/day | | | | | | DOSE IN THE AM | +-----------------------------------+-----------------------------------+ | **Special populations:** | Hepatic impairment: 150mg every | | | other day | | | | | | Elderly: caution as it can | | | decrease appetite | | | | | | Children: use with cation, | | | activation of suicidal ideation | +-----------------------------------+-----------------------------------+ | **Clinical Pearls:** | ABUSABLE | | | | | | Not the best monotherapy but good | | | adjunct (works well with Zoloft) | | | | | | Good for psychomotor slowing, low | | | energy | | | | | | Good for patients with sexual | | | dysfunction | | | | | | Good for patients wanting to lose | | | weight | | | | | | ADHD? (off label) | | | | | | SAD | | | | | | Can be anxiety producting | | | | | | \*\*\*do not use if patient has a | | | seizure disorder, alcohol use | | | disorder, or bulimia nervosa (all | | | can cause seizures) | +-----------------------------------+-----------------------------------+ **Remeron (mirtazapine)** +-----------------------------------+-----------------------------------+ | **Indications:** | Major depressive disorder | | | | | | Panic disorder | | | | | | Generalized anxiety disorder | | | | | | PTSD | +===================================+===================================+ | **MOA:** | Blocks alpha 2 adrenergic | | | receptors | | | | | | Increase norepinephrine and | | | serotonin transmission (this is | | | different than the reuptake | | | blockade) | | | | | | Blocks 5HT2A, 5HT2C, and 5HT3, | | | serotonin receptors | | | | | | Blocks H1 histamine receptor | +-----------------------------------+-----------------------------------+ | **Side effects:** | Sedation | | | | | | Weight gain/increased appetite | | | | | | Dry mouth | | | | | | Constipation | | | | | | Hypotension | +-----------------------------------+-----------------------------------+ | **Dose:** | 7.5-45mg nightly | | | | | | Works better for sleep and | | | appetite at lower doses (contrary | | | to what the patient thinks) | | | | | | Also comes in a disintegrating | | | tablet | +-----------------------------------+-----------------------------------+ | **Special populations:** | Renal impairment: use with | | | caution | | | | | | Hepatic impairment: may require | | | lower dose | | | | | | Elderly; used a lot to increase | | | appetite | +-----------------------------------+-----------------------------------+ | **Clinical Pearls:** | Remeron+Effexor or Cymbalta = | | | "California rocket fuel" | | | | | | Good for cancer patients or | | | elderly that have no appetite | | | | | | Good as an augmenting agent to | | | other antidepressants | | | | | | Probably not the best choice for | | | an overweight patient/low energy | +-----------------------------------+-----------------------------------+ **Deseryl (trazodone)** +-----------------------------------+-----------------------------------+ | **Indications:** | Depression | | | | | | Insomnia (primary or secondary) | |