Depression and the Pharmacology of Antidepressant Drugs Flashcards: Set 4

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Common major indications for antidepressant drug administration:Major depressive disorder, dysthymia, bipolar disorder (depressed type), panic disorder (with or without agoraphobia)
Secondary indications for antidepressant drug administration:Obsessive-compulsive disorder (primarily antidepressants affecting the serotonergic system), generalized anxiety disorder (GAD), social phobia, bulimia nervosa, attention-deficit/hyperactivity disorder (serotonergic antidepressants), diabetic polyneuropathy (mainly tricyclic antidepressants, e.g. imipramine), chronic pain syndromes (serotonergic agents), sleep disorders, enuresis (mainly serotonin-type antidepressants).
Anti-muscarinic cholinergic antidepressant side effects, often associated with tricyclic antidepressants (as well as monoamine oxidase inhibitors):Blurred vision, urinary retention, constipation, very dry mouth, memory problems, sinus tachycardia.
Antidepressant drug side effects due to alpha-adrenergic receptor blockade noted with tricyclic antidepressants, MAOIs, nefazodone, trazodone:orthostatic hypotension (drop in blood pressure upon standing), reflex tachycardia, diaphoresis, flushing, intensification of prazosin-mediated antihypertensive effects
Antidepressant drug side effects occurring as a result of histamine receptor blockade:Sleepiness (somnolence), hypertension, weight gain, enhancement of CNS depressant drugs.
Antidepressant side effects resulting from norepinephrine reuptake inhibition:Tachycardia, insomnia, anxiety, tremor, erectile and orgasmic dysfunction, inhibition of the antihypertensive action following guanethidine and guanadrel administration. Antidepressant drugs exhibiting this property include tricyclic antidepressants and most "heterocyclic"-structure antidepressants.
Antidepressant drug effects similar to those associated with Class I antiarrhythmic drugs (e.g. quinidine):Tricyclic antidepressant administration may cause abnormal propagation through the specialized cardiac conduction system. Tricyclic antidepressants may also cause orthostatic hypotension. Tricyclic antidepressants are more likely to induce symptomatic conduction abnormalities in those patients with pre-existing, asymptomatic conduction defects. TCAs may induce arrhythmias also in patients with subclinical sinus node abnormalities.
Management of cardiac-conducting system abnormalities related to TCA administration:If the patient is already taking a class I antiarrhythmic drug, the patient should be monitored especially carefully. Generally, patients should be evaluated for asymptomatic conduction abnormalities that may be pre-existing. Examples could include interventricular conduction delay and bundle branch blockade (varying degrees). The point of emphasis: patients with prolonged QT intervals are predisposed to ventricular tachycardia. ECGs should be obtained in those patients older than 40 years of age before beginning treatment with for example TCAs or trazodone.
Management of insomnia and anxiety side effects due to antidepressant drug administration:Anxiety may be minimized by initiating treatment with low-dose. Insomnia might be managed by adding trazodone at bedtime. One side effect associated with trazodone is priapism in some patients. An example of an antidepressant drug that may cause anxiety and insomnia's fluoxetine; also buproprion and desipramine may also cause anxiety.
Management of sexual dysfunction secondary to administration of serotonin reuptake inhibitor-type antidepressants:In this setting, libido may be in handstand delayed ejaculation prevented by neostigmine. Cyproheptadine may reverse anorgasmia.
Management of side effects associated with histamine receptor blockade caused by, for example, tricyclic antidepressants:Weight gain may be circumvented by using alternative agent such as buproprion, sertraline, trazodone or fluoxetine. Furthermore, fluoxetine and buproprion may cause weight loss.
Management orthostatic hypotension that occurs secondary to α-adrenergic receptor blockade as a result of, for example, TCA, MAOIs, trazodone are nefazodone administration:Orthostatic hypotension, slow dosage increases may be helpful. An alternative would be to use other antidepressant types such as SSRIs. Particular Attention should be paid to elderly, depressed patients susceptible to falling and fractures when prescribing antidepressant agents that may induce orthostatic hypotension.
Management of side effects associated with muscarinic, cholinergic receptor blockade, expectable with for example TCA-type agents:For dry mouth, candy or sugarless gum may be helpful. For constipation, maintaining adequate hydration and use of bulk laxatives may be helpful. For urinary retention prescribing bethanechol, a cholinomimetic (cholinergic receptor stimulant) may be helpful or using another drug such as sertraline, trazodone, or buproprion.
If an MAOI-type (monoamine oxidase inhibitor-type) antidepressant is used, these foods should be avoided, given that there classified as "very dangerous" if consumed in an individual who been taking an MAOI:All cheese (yogurt, cream cheese, cottage cheese are considered safe), sauerkraut
Examples of foods considered "moderately dangerous" that should be avoided by individuals receiving MAOI-type antidepressants:All fermented or aged foods (examples include age corned beef, fermented sausage, pepperoni, salami, summer sausage), fermented alcoholic beverages including red wine, sherry, beer, ale, vermouth.(Clear alcoholic drinks might be imbibed in "true moderation"), broad bean pods (includes English broad beans and Chinese pea pods), liver (chicken, pork or beef) or liverwurst, meet or yeast extracts, spoiled fruit (for example spoiled bananas, pineapples, figs, raisins or avocados)
Some drugs should not be ingested in patients taking MAOI antidepressants. A partial list includes:Amphetamines, asthma inhalants (excluding pure steroid inhalants), cyclopentamine, decongestants, cold and sinus medications, ephedrine, meperdine, metaraminol, methylphenidate, phenylephrine, phenylpropylamines, pseudoephedrine, serotonin-type antidepressants including clomipramine, fluoxetine, sertraline, fluvoxamine, paroxetine and others.
Examples of positive predictors of antidepressant response:Presence of vegetative symptoms such as anorexia, middle and late insomnia and weight loss, diurnal mood variation, acute onset, family history of depression, psychomotor agitation or retardation among others.
Examples of negative predictors of antidepressant response:Coexistence of other important psychiatric disturbances, especially if these present with hysterical are externalizing elements, psychotic features, chronic symptoms, hypochondriacal concerns or substantial somatic elements, the previous failure of drug treatment approaches, patient sensitivity to adverse reactions.
Electroconvulsive treatment:Almost all ECT treatments in the United States, 80%-90%, are employed for management of major depressive disorder. ECT is shown effectiveness in the major types of major depressive disorder. However, it may be less useful in those individuals whose depressive episodes occur in the presence of a concurrent mental or medical disease or in those patients whose depression was resistant to treatment with medication during the present episode.
Contraindications to ECT treatment:Probably no absolute contraindication but some relative contraindications.examples of the latter include some space-occupying intracerebral lesions, presence of increased intracranial pressure, unstable vascular aneurysm/malformations, intracerebral hemorrhage, pheochromocytoma, and recent heart attack.