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MAJOR DEPRESSIVE DISORDER (MDD) – DSM-5 DIAGNOSTIC CRITERIA(APA) 5 or more s/s must be present for 2 weeks, noticeable change from previous fx, at least 1 must be depressed mood, or loss of interest/pleasure Depressed mood(irritability/anger), anhedonia, appetite, sleep, Psychomotor agitation or retardation, Fatigue, worthlessness or guilt, Diminished concentration, SI
ACUTE Phase treatment for depression Goal is ensuring patient safety. May require hospitalization to safeguard against possible suicidality, and restore treatment/stabilize.
CONTINUATION Phase treatment for depression Usually through outpatient services
MAINTENANCE Phase treatment for depression Outpatient clinic
DISCONTINUATION Phase treatment for depression Slow taper, if clinically prudent/close monitoring. Abrupt discontinuation may cause discontinuation syndrome/relapse
Antidepressant Classes (SSRIs)-Zoloft Serotonin- (SNRIs)- Effexor, Monoamine oxidase inhibitors (MAOIs)- Selegiline, (TCAs)-imipramine
Serotonin partial agonist/reuptake inhibitors (SPARIs) Example, vilazodone
Norepinephrine-Dopamine reuptake inhibitors (NDRIs) Example, buproprion
Serotonin Multimodal Antidepressant Medications (SMM) Example Vibryd
The serotonin transporter (SERT) is a monoamine transporter protein. This is a membrane protein that transports serotonin from synaptic spaces into presynaptic neurons. SSRIs block the SERT transporter= increased availability of serotonin in the synaptic space.
SNRIs do what bind to 5-HT and NA transporters to selectively inhibit the reuptake of these neurotransmitters from the synaptic clefts. the reuptake of both 5-HT and NA with differing selectivity.
OTHER TYPES OF TREATMENT Electroconvulsive Therapy(ECT) , Transcranial Magnetic Stimulation(TMS), Vagal Nerve Stimulation(VNS), Phototherapy: light for 30 minutes up to 2 hours, 1to 2 times daily
TCAs increase both norepinephrine and serotonin concentrations can ↑ serotonin more than ↑norepinephrine (clomipramine), others ↑ norepinephrine more than serotonin (nortriptyline or desipramine)- also amitriptyline (can decrease BP- alpha adrenergic effect)- anticholinergic s/e, used to tx chronic pain and migraine
MAOIs do what inhibit monoamine oxidase and breakdown of monoamine neurotransmitters- watch Tyramine- Amino acid which elevates BP- stay away from soy- HTN crisis
FDA-approved MAOIs Isocarboxazid (Marplan), Phenelzine (Nardil), Selegiline (Emsam), Tranylcypromine (Parnate)
HYPERTENSIVE CRISIS MAOIs(when medication is taken with food containing tyramine, a dietary precursor to norepinephrine)
CARDIOTOXICITY TCAs (especially in overdose, and possibly in patients with cardiac conditions) SEROTONIN SYNDROME
Black Box WARNING Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of (MDD) and other psychiatric d/o, ↑ risk in children, 18 – 25, No actual suicides
ASSESSING FOR SUICIDAL BEHAVIOR Past hx of SAor completed suicide by family members, Negativity/morbidity, current SI, Plan and intent, Means and access to commit suicide
Lethality of intended suicide action High lethality: gun, hanging- Moderate lethality: Overdose of toxic agents like aspirin, sleeping pills- Low lethality: superficial wrist cutting, breath-holding
Mirtazapine enhances neurotransmission by ↑ the concentrations of both serotonin and norepinephrine. Unlike the SSRIs, mirtazapine blocks specific serotonin receptors, reducing the potential to cause side effects such as sexual dysfunction
Bupropion (Wellbutrin)- add on to SSRI, avoid if hx of psychosis or at risk for seizures.
Mirtazapine (Remeron) sedating, stimulates appetite (good for elderly).
Fluoxetine: long half-life good for non-adherent patient, Insomnia is common
Citalopram (Celexa) /Escitalopram (Lexapro) fewer drug interactions.
Newer Antidepressants in the past 4 years, the FDA has approved 3 antidepressants—Vilazodone (SMM) Vibryd, Levomilnacipran (SNRI) Fetzima, Vortioxetine (SMM) Trintellix
The overall goal of the STAR*D trial was to assess the effectiveness of depression treatments in patients diagnosed with major depressive disorder, in both primary and specialty care settings. It is the largest and longest study ever conducted to evaluate depression treatment.
Created by: arsho453