Stahl Chapter 7: Antidepressants, Complete Questions and Correct Answers, Updated 2024. 165 Questions and Answers. Verified Solution.
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Stahl Chapter 7: Antidepressants
Stahl Chapter 7: Antidepressants, Complete Questions and Correct Answers, Updated 2024. 165 Questions and Answers. Verified Solution.
what percentage of symptoms improve with a single antidepressant?
20-30%
Note: this is why we often prescribe multiple together whereas with schizophrenia usi...
Stahl Chapter 7: Antidepressants, Complete
Questions and Correct Answers, Updated 2024.
165 Questions and Answers. Verified Solution.
what percentage of symptoms improve with a single antidepressant?
20-30%
Note: this is why we often prescribe multiple together whereas with schizophrenia using
just 1 SGA is usually the rule.
in general what percentage of improvement is considered a response with
antidepressants? what is the goal for tx?
50%
Goal: complete remission of symptoms.
- due to the ineffectiveness of antidepressants, if multiple aren't used aggressively and
early, remission probably will not ever be reached.
what is remission?
asymptomatic for several months
what is recovery?
asymptomatic for at least 6 months
what is relapse?
depression returns before full remission of sxs or within first several months after
remission
what is a recurrence?
depression returns after a recovery (after 6 months of being asymptomatic)
what are the most common residual sxs to prevent remission and what are the
least common?
most common
- insomnia
- fatigue
- painful physical complaints
- problems concentrating
- lack of interest
least common
- depressed mood
- SI
- psychomotor retardation
what percentage of pts respond to 1st antidepressant after 3 months vs 2nd vs
3rd vs 4th?
1st: 33% respond, 67% don't
2nd: 20% respond, 47% don't
,3rd: 6-7% respond, 40% don't
4th: 6-7% respond, 33% don't
what is considered a nonremitter? what percentage of pts are nonremitters?
someone who doesn't respond after 4 different trials of antidepressants.
- 33% of people are nonremitters
what proportion of remitters relapse when comparing those that remitted at 1st
trial vs 2nd vs 3rd vs 4th?
1st: 33% at 12 months
2nd: 50% at 6 months
3rd: 50% at 6 months
4th: 30% at 3 months, 70% at 6 months
Conclusion: this means that the protective nature of remission almost disappears once it
takes 4 treatments to achieve remission.
How do older adults vs young adults differ in their response to antidepressants?
Older adults: if their first episode starts at 65 or older and their presenting sxs are lack
of interest or cognitive dysfunction rather than depressed mood they respond slower
and not as robustly, but they won't develop SI with antidepressants.
Younger adults: if younger than 25, they benefit more but have greater risk of suicidality.
why do antidepressants stop working?
when there is an acute increase in monoamine, receptors on the postsynaptic neuron
downregulate and desensitize overtime. Thus the monoamine has no receptors to bind
to and the antidepressant wears off.
why do people get SEs with antidepressants?
in depressed pts, there is an upregulation of receptors on the postsynaptic neuron.
When monoamines are acutely increased there are also increased receptors able to
bind, this overloads them with NT. Once the receptors downregulate and desensitize
due to increased monoamine, the SEs go away because the neuron has returned to a
normal state. This is also why it takes weeks for antidepressants to work, as genes turn
off to downregulate receptors they also increase the synthesis of BDNF.
whats the neurotransmitter receptor hypothesis of antidepressant action?
depression is caused by upregulation of monoamine receptors. So antidepressant
efficacy is due to downregulation it causes in the receptors. This is the reason for the
delayed clinical effects of antidepressants and development of tolerance to
antidepressant SEs.
what role does the somatodendritic area of the neuron play in depression?
in addition to monoamines being low at the synapse and thus antidepressants work on
the presynaptic neuron (SERT) but also at the somatodendritic end of the NE neuron.
NE is deficient at the presynaptic somatodendritic area as well which causes
upregulation in the receptors there possibly altering how NE is transmitted down the
axon. This is supported because when SSRIs are given 5HT rises much more in the
somatodendritic area in the midbrain raphe instead of areas where axons terminate.
what end of the neuron responds to antidepressants first?
somatodendritic area of 5HT neuron increases first, these are the 5HT1A receptors.
When they are stimulated, 5HT1A autoreceptors are stimulated. Over time,
, autoreceptors downregulate and are desensitized. When this happens 5HT can no
longer turn off its own release, causing a flurry of 5HT release from axons and increase
neuronal impulse flow. This causes the postsynaptic 5HT receptors to desensitize as
well and sends info to its nucleus to downregulate or desensitize its receptors as well.
How do SSRIs differ in MOA?
they all have a SERT antagonist as their primary action but differ in their secondary
actions.
Fluoxetine MOA
SSRI antagonist
5HT2C antagonist
- enhances release of NE and DA
- increases tolerability
- more activating (energizing, reduces fatigue)
- improves concentration and attention
NET antagonist: weak blocker, only relevant at high doses
what common antidepressants block 5HT2C? what about SGAs?
Fluoxetine
mirtazapine
SGAs:
- quetiapine
- olanzapine
- asenapine
- clozapine
What types of symptoms would be a good fit for fluoxetine?
Depressed pts with reduced positive affect, hypersomnia, psychomotor retardation,
apathy and fatigue.
what drugs are combined for treatment resistant unipolar depression and for
bipolar depression? why?
fluoxetine + olanzapine
MOA: because both are 5HT2C antagonists leading to enhanced DA and NE release in
the cortex to mediation of antidepressant actions.
what antidepressant would you use for bulimia? what dose?
High dose fluoxetine (only antidepressant approved)
- dose: 60mg qAM
what are cons of using fluoxetine or anything that inhibits 5HT2C? what types of
patients would you not want to give this to?
can be activating, so not good for pts with anxiety, agitation, insomnia, panic attacks
etc.
How long is fluoxetine's half life?
2-3 days, active metabolite is 2 wks
What formulations is fluoxetine available in?
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