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What are early response symptoms antidepressants work on?
Sleep, appetite, and energy
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What are delayed response symptoms?
Mood, social interaction, anxiety, and suicidal ideation
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What antidepressants are better at reducing the time to onset of effect?
Studies show they are all similar
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What antidep. Are used for melancholic depression?
benefit seen with TCAs, possible role of venlafaxine, mirtazapine
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What meds are good for psychotic depression?
combination of antidep. + antipsychotic
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MOA: what neurons do SSRI’s work on?
- 5-HT → Selectively inhibit the reuptake of 5-HT by blocking the 5-HT transporter
- - Pre / post synapse
- - down regulation of autoreceptors causes neuron to release more 5-HT at the axon
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Which are the most potent 5-HT uptake blockers?
Citalopram (Celexa) and paroxetine (Paxil)
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Which SSRIs have effect on norepinephrine
Fluoxetine (Prozac) and paroxetine (Paxil)
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Which SSRI has the greatest anticholinergic activity?
Paroxetine (Paxil)
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What are anticholinergic side effects?
Dry mouth, increased perspiration, hypotension
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Most common Adverse effect of SSRI’s:
- GI: diarrhea, nausea, bloating, cramping, heartburn
- Sexual dysfunction: greatest with paroxetine (Paxil), least with citalopram (Celexa)
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Akathisia is most common with what SSRI?
Fluoxetine (Prozac)
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How does serotonin syndrome manifest?
- autonomic and neuromuscular responses:
- Hyperreflexia
- Tremor
- GI complaints
- CV problems
- Seizures
- Respiratory depression
- Coma
- Death
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What causes serotonin syndrome?
Combo of SSRI + other drugs
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When do withdrawal symptoms occur from SSRIs
2-7 days
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What are withdrawal symptoms?
- Nightmares
- flu-like symptoms
- GI
- shock-like sensations
- insomnia
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When should you use most activated fluoxetine (Prozac)
Beneficial in pts. with sedation, fatigue, or decreased energy
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When should you use less activating Paroxetine (Paxil)
Beneficial in pts complaining of anxiety, agitation, or insomnia
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Which SSRI has a lower risk of sexual side effects?
Citalopram (Celexa)
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Which SSRI’s have the least drug interactions?
Citalopram (Celexa) and Escitalopram (Lexapro)
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What is the MOA of SNRI’s?
Block the reuptake of 5-HT and NE and to a lesser extent DA
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What is meant by augmenting?
adding a drug to an existing antidepressant → combination therapy
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In STAR D* what monotherapy should you start with?
Citalopram (Celexa) and then augment or switch depending on patient
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What are 1st line agents for GAD?
- Benzodiazepines
- Selective serotonin reuptake inhibitors (SSRIs)
- Selective norepinephrine reuptake inhibitors (SNRIs)
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Second line rx?:
- Buspirone
- Used for: current/history of substance abuse, intolerant to BZ therapy, refractory GAD
- Less sedation and functional impairment than BZ
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What are advantages of buspirone treatment of GAD
Lack of sedation and anxiolytic properties are major advantages
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What are the treatment goals for GAD?
- Short term: Reduce severity and duration of symptoms. Improve functioning
- Long term: Reduce length of episodes, Reduce severity of episodes, Prevent recurrence, and Achieve symptom remission (Facilitate patient’s return to pre-morbid level of functioning)
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What’s the moa of benzodiazepine?
Potentates inhibitory effect of GABA
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SE’s of benzodiazepines?
- Varying degrees of lipophilicity: Affects ability to cross the blood-brain barrier
- May produce rapid onset of action
- Experience rush of euphoria
- Unpleasant feeling/loss of control
- MOST common = sedation
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When do you use benzodiazepine?
Acute anxiety relief
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Who should be careful rx benzod’s to?
Patients with co-morbid conditions – alcoholics
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Should you quickly withdraw bezods?
NO – taper, withdrawal rxns
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What’s the brand name of BUSpirone?
BUSpar
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What is an adequate trial for GAD?
6-8 weeks
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When does the majority of response occur for GAD rx?
Acute phase: period of 1-3 months
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How long should you taper anxiety meds for?
4-6 months; maintenance phase = 1-2 years
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Should buspirone be used for panic disorders
NO- might make it worse
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Whats the Rx options for Panic disorders?
- 1st line Rx = SSRI , SNRI
- 2nd line = TCA
- benzodiazepines → acute response
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Do you dose higher or lower of SSRIs and SNRI’s for panic disorders then for major depression?
Lower – half the dose
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What has benefits for agoraphobia?
Alprazolam
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What is the brand name of Alprazolam?
Xanax – benzodiazepine
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Brand name of fluoxetine?
Prozac – SSRI
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What is the brand name for venlaxafine
Effexor - SNRI
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Do beta-blockers have proven benefit for panic disorders?
No
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Can we cure OCD?
Full remission is rare. Partial remission is Rx goal
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What are the treatment goals for OCD?
- Reduction in the frequency of Obsessive thoughts and compulsive acts; Anxiety associated with SXs
- Impairment social & occupational function
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How should you treat mild symptoms of OCD?
Cognitive beh. Therapy- may take 20 weeks to improve – may work better for compulsions
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What is the 1st rx for OCD?
SSRI
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Whats the 2nd line rx for OCD?
Clomipramine
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What’ s the brand name of Clomipramine?
Anafranil – TCA
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What is combination Rx for OCD?
SSRI + clomipramine, atypical antipsychotic
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When do you consider lifelong treatment of OCD?
2 to 4 severe relapse; 3 to 4 mild relapses
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What is the best pharm treatment for PTSD
- Early cognitive behavioral therapy + SSRI’s (1st line),
- venlafaxine, TCA’s, MAO-Is (2nd line)
- TCA & MAO-I (3rd line)
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What are augmenting agents for treatment of PTSD?
- atypical antipsychotics
- prazocin → only with SSRIs for insomnia, psychosis hypervigilance
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What is Prazosin used for?
Sleep disturbances
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Are benzodiazepines used for PTSD rx
NO – makes it worse
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What are goals of treating PTSD?
- Reduction in core SXs (re-experiencing, avoidance, hyperarousal)
- Improvements in disabilities
- Improvements in co-morbid axis I
- Long-term goal is remission - Treatment response may take up to 36 months
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When should Rx of PTSD be started?
Immediately - @ onset of symptoms
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How long should you treat the first episode?
1-2 years
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What is an adequate med trial for PTSD?
8-12 weeks
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How do you treat moderate-severe PTSD and OCD
CBT & meds
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