NR 546 final exam
Prefrontal Cortex Symptoms of MDD - ANSWER Concentration
Mental Fatigue
Mood
PFC & Amygdala Symptoms of MDD - ANSWER Guilt
Suicidality
Worthlessness
Striatum Symptoms of MDD - ANSWER Physical fatigue
Nucleus Accumbens Symptoms of MDD - ANSWER Pleasure interests
Hypothalamus Symptoms of MDD - ANSWER Sleep
Appetite
Thalamus & Hypothalamus Symptoms of Mania - ANSWER Decreased
sleep/arousal
Striatum Symptoms of Mania - ANSWER Motor/agitation
Prefrontal cortex (PFC) Symptoms of Mania - ANSWER Risk-taking
Talkative/pressured speech
Nucleus Accumbens & PFC Symptoms of Mania - ANSWER Racing thoughts,
grandiosity
PFC & Amygdala Symptoms of Mania - ANSWER Mood
Medication Management - ANSWER SSRI-Selective Serotonin Reuptake Inhibitors
*Inhibit 5 HT reuptake
SNRI-Serotonin Norepinephrine Reuptake Inhibitors
*inhibit 5-HT reuptake
*inhibit NE reuptake (increase energy, focus)
*increase DA in prefrontal cortex (increase cognition)
NDRI-Norepinephrine Dopamine Reuptake inhibitors
*inhibit DA reuptake (increase alertness, motivation)
*inhibit NE reuptake (increase energy)
SARI-Serotonin Antagonist Reuptake Inhibitors
Selective Serotonin Reuptake Inhibitors (SSRIs): Most adverse effects will subside
after 4-5 days once the body adjusts to increased serotonin levels. - ANSWER
diarrhea
headache
weight gain
sexual side effects
,Serotonin Norepinephrine Reuptake Inhibitors (SNRIs): Medications should not be
abruptly stopped to avoid discontinuation symptoms. NE effects of the medication
may increase anxiety in some clients. Report worsening anxiety to the provider. -
ANSWER elevated blood pressure
anxiety
insomnia
constipation
Norepinephrine Dopamine Reuptake Inhibitors (NDRI): Take medication in the
morning. Stop taking medication if seizures occur. Stop taking medication if anxiety
is noted. - ANSWER agitation
headache
dry mouth
constipation
weight loss
escitalopram (Lexapro) SSRI - ANSWER no known drug interactions
best tolerated SSRI
27-32 hour half-life good for forgetful prone clients
least CYP reactions
Substrate for 3A4
citalopram (Celexa) SSRI - ANSWER mild antihistamine effects; Half-Life: 23-45
hours
Weak Inhibitor of 2D6
fluoxetine (Prozac) SSRI - ANSWER longest half-life
Use caution in patients with comorbid anxiety due to risk for activation and panic
attacks
Half-Life: 2-3 days parent, 2 week metabolite
Inhibits 2D6 and 3A4
paroxetine (Paxil) SSRI - ANSWER also treats social anxiety and insomnia
associated with weight gain
will experience withdrawal with missed dose or abrupt stop
Half-Life: 24 hours
Inhibits 2D6
fluvoxamine (Luvox) SSRI - ANSWER treats anxious depression smokers require an
increased dose
Half-Life: 9-28 hours
Inhibits 3A4, 2C9, 1A2
sertraline (Zoloft) SSRI - ANSWER also treats social anxiety and hypersomnolence
Half-Life: 22-36 hour parent; 62-104 hour metabolite
Inhibits 2D6 and 3A4 weakly at low doses
venlafaxine (Effexor) - ANSWER treats both depression and anxiety disorders,
ensure trial of higher dose before switching to a different medication
Half-life: Parent drug 3-7 hour; metabolite has 9-13 hour
,duloxetine (Cymbalta) SNRI - ANSWER effective for atypical pain at higher doses;
appropriate for clients who present with somatic symptoms of depression; effective
for atypical pain, such as fibromyalgia and diabetic neuropathy
Half-Life: 12 hours
Inhibitor of 2D6
bupropion (Wellbutrin) - ANSWER NDRI may improve energy, alertness, and
motivation; not first-line treatment for anxiety; contraindicated in clients with a history
of seizures
Avoid in patients with comorbid anxiety
Half-Life: Parent 10-14 hours; Metabolite 20-27 hours
Inhibits 2D6
Serotonin Antagonist and Reuptake Inhibitors (SARIs) - ANSWER SARIs potently
block 5-HT2A and 5HT 2C receptors, which allow more 5-HT to interact at
postsynaptic 5-HT1A sites. Serotonin blockade and reuptake inhibition is present at
higher doses.
Trazodone - ANSWER The most common SARI, also blocks histaminergic and α-
adrenergic receptors.
Half-Life: 3-6 hours
Serotonin Antagonist and Reuptake Inhibitors (SARIs) - ANSWER Common Adverse
Effects
· sedation
· drowsiness
· blurred vision
· constipation
· dry mouth
Serious Adverse Effect
priapism
Serotonin norepinephrine receptor agonist, alpha2 receptor agonist - ANSWER
Mirtazapine
Serotonin multimodal (SMM)/serotonin partial agonist reuptake inhibitor (SPARI) -
ANSWER Vilazodone (Viibryd)
· Inhibits serotonin reuptake with partial 5HT1A agonism
Appropriate for depression/comorbid anxiety, its action is similar to a combination of
SSRI and buspirone
Serotonin multimodal (SMM) - ANSWER Vortioxetine (Trintellix)
· Acts as SSRI plus 5HT1A partial agonism
· Improves depression-related cognition
Tricyclic antidepressants (TCAs) - ANSWER Tricyclic antidepressants (TCAs)
possess both SRI and NRI properties, but they also block other receptors, including
α1-adrenergic, histamine-1, and muscarinic cholinergic receptors. TCAs are not used
, first-line because of the high incidence of adverse effects and the risk of potential
overdose and death due to overdose
Tricyclic antidepressants (TCAs) - ANSWER Drugs:
· amitriptyline (Elavil)
· desipramine (Norpramin)
· doxepin (Sinequan)
· imipramine (Tofranil)
· nortriptyline (Pamelor)
Tricyclic antidepressants (TCAs) - ANSWER Common adverse effects of TCAs
Alpha-1 adrenergic effects-Orthostatic hypotension
Histamine effects-Sedation
Histamine effects-Weight gain
Anticholinergic effects-Blurred vision
Anticholinergic effects-Urinary retention
Anticholinergic effects-Constipation
Anticholinergic effects-Dry mouth
MAOIs - ANSWER Last choice medication class for depression due to the many
potential, serious side effects. MAOIs have specific dietary restrictions that when
ignored, may be very uncomfortable or very serious for clients.
MAOIs - ANSWER Drugs:
· phenelzine (Nardil)
· selegiline (Emsam) - MAOI-B
· tranylcypromine (Parnate)
· isocarboxazid (Marplan)
MAOI's Key Points - ANSWER · Clients taking MAOIs are at high risk for
hypertensive crisis if tyramine is ingested.
· Do not prescribe any serotonergic agents within 2 weeks of MAOI discontinuation
due to an increased risk of serotonin syndrome.
Wait at least 5 half-lives after discontinuing a serotonergic medication before
initiating an MAIO.
Foods to Avoid When Taking MAO-A Medications - ANSWER · Red wine (Avoid)
· Sauerkraut (Avoid)
· Cheese (Avoid)
· Soy (Avoid)
· Smoked meats (Avoid)
Foods to Avoid When Taking MAO-A Medications - ANSWER Rationale: Limiting the
consumption of tyramine is necessary for orally available MAOIs due to inhibition of
MAO-A in the gut. Dietary restrictions are not required for the transdermal
formulation of selegiline.
Tyramine is present in many aged or preserved foods including aged cheeses, tap
and non-pasteurized beers, aged or smoked meat or fish, sauerkraut, kimchee, soy
products, and tofu.
Prefrontal Cortex Symptoms of MDD - ANSWER Concentration
Mental Fatigue
Mood
PFC & Amygdala Symptoms of MDD - ANSWER Guilt
Suicidality
Worthlessness
Striatum Symptoms of MDD - ANSWER Physical fatigue
Nucleus Accumbens Symptoms of MDD - ANSWER Pleasure interests
Hypothalamus Symptoms of MDD - ANSWER Sleep
Appetite
Thalamus & Hypothalamus Symptoms of Mania - ANSWER Decreased
sleep/arousal
Striatum Symptoms of Mania - ANSWER Motor/agitation
Prefrontal cortex (PFC) Symptoms of Mania - ANSWER Risk-taking
Talkative/pressured speech
Nucleus Accumbens & PFC Symptoms of Mania - ANSWER Racing thoughts,
grandiosity
PFC & Amygdala Symptoms of Mania - ANSWER Mood
Medication Management - ANSWER SSRI-Selective Serotonin Reuptake Inhibitors
*Inhibit 5 HT reuptake
SNRI-Serotonin Norepinephrine Reuptake Inhibitors
*inhibit 5-HT reuptake
*inhibit NE reuptake (increase energy, focus)
*increase DA in prefrontal cortex (increase cognition)
NDRI-Norepinephrine Dopamine Reuptake inhibitors
*inhibit DA reuptake (increase alertness, motivation)
*inhibit NE reuptake (increase energy)
SARI-Serotonin Antagonist Reuptake Inhibitors
Selective Serotonin Reuptake Inhibitors (SSRIs): Most adverse effects will subside
after 4-5 days once the body adjusts to increased serotonin levels. - ANSWER
diarrhea
headache
weight gain
sexual side effects
,Serotonin Norepinephrine Reuptake Inhibitors (SNRIs): Medications should not be
abruptly stopped to avoid discontinuation symptoms. NE effects of the medication
may increase anxiety in some clients. Report worsening anxiety to the provider. -
ANSWER elevated blood pressure
anxiety
insomnia
constipation
Norepinephrine Dopamine Reuptake Inhibitors (NDRI): Take medication in the
morning. Stop taking medication if seizures occur. Stop taking medication if anxiety
is noted. - ANSWER agitation
headache
dry mouth
constipation
weight loss
escitalopram (Lexapro) SSRI - ANSWER no known drug interactions
best tolerated SSRI
27-32 hour half-life good for forgetful prone clients
least CYP reactions
Substrate for 3A4
citalopram (Celexa) SSRI - ANSWER mild antihistamine effects; Half-Life: 23-45
hours
Weak Inhibitor of 2D6
fluoxetine (Prozac) SSRI - ANSWER longest half-life
Use caution in patients with comorbid anxiety due to risk for activation and panic
attacks
Half-Life: 2-3 days parent, 2 week metabolite
Inhibits 2D6 and 3A4
paroxetine (Paxil) SSRI - ANSWER also treats social anxiety and insomnia
associated with weight gain
will experience withdrawal with missed dose or abrupt stop
Half-Life: 24 hours
Inhibits 2D6
fluvoxamine (Luvox) SSRI - ANSWER treats anxious depression smokers require an
increased dose
Half-Life: 9-28 hours
Inhibits 3A4, 2C9, 1A2
sertraline (Zoloft) SSRI - ANSWER also treats social anxiety and hypersomnolence
Half-Life: 22-36 hour parent; 62-104 hour metabolite
Inhibits 2D6 and 3A4 weakly at low doses
venlafaxine (Effexor) - ANSWER treats both depression and anxiety disorders,
ensure trial of higher dose before switching to a different medication
Half-life: Parent drug 3-7 hour; metabolite has 9-13 hour
,duloxetine (Cymbalta) SNRI - ANSWER effective for atypical pain at higher doses;
appropriate for clients who present with somatic symptoms of depression; effective
for atypical pain, such as fibromyalgia and diabetic neuropathy
Half-Life: 12 hours
Inhibitor of 2D6
bupropion (Wellbutrin) - ANSWER NDRI may improve energy, alertness, and
motivation; not first-line treatment for anxiety; contraindicated in clients with a history
of seizures
Avoid in patients with comorbid anxiety
Half-Life: Parent 10-14 hours; Metabolite 20-27 hours
Inhibits 2D6
Serotonin Antagonist and Reuptake Inhibitors (SARIs) - ANSWER SARIs potently
block 5-HT2A and 5HT 2C receptors, which allow more 5-HT to interact at
postsynaptic 5-HT1A sites. Serotonin blockade and reuptake inhibition is present at
higher doses.
Trazodone - ANSWER The most common SARI, also blocks histaminergic and α-
adrenergic receptors.
Half-Life: 3-6 hours
Serotonin Antagonist and Reuptake Inhibitors (SARIs) - ANSWER Common Adverse
Effects
· sedation
· drowsiness
· blurred vision
· constipation
· dry mouth
Serious Adverse Effect
priapism
Serotonin norepinephrine receptor agonist, alpha2 receptor agonist - ANSWER
Mirtazapine
Serotonin multimodal (SMM)/serotonin partial agonist reuptake inhibitor (SPARI) -
ANSWER Vilazodone (Viibryd)
· Inhibits serotonin reuptake with partial 5HT1A agonism
Appropriate for depression/comorbid anxiety, its action is similar to a combination of
SSRI and buspirone
Serotonin multimodal (SMM) - ANSWER Vortioxetine (Trintellix)
· Acts as SSRI plus 5HT1A partial agonism
· Improves depression-related cognition
Tricyclic antidepressants (TCAs) - ANSWER Tricyclic antidepressants (TCAs)
possess both SRI and NRI properties, but they also block other receptors, including
α1-adrenergic, histamine-1, and muscarinic cholinergic receptors. TCAs are not used
, first-line because of the high incidence of adverse effects and the risk of potential
overdose and death due to overdose
Tricyclic antidepressants (TCAs) - ANSWER Drugs:
· amitriptyline (Elavil)
· desipramine (Norpramin)
· doxepin (Sinequan)
· imipramine (Tofranil)
· nortriptyline (Pamelor)
Tricyclic antidepressants (TCAs) - ANSWER Common adverse effects of TCAs
Alpha-1 adrenergic effects-Orthostatic hypotension
Histamine effects-Sedation
Histamine effects-Weight gain
Anticholinergic effects-Blurred vision
Anticholinergic effects-Urinary retention
Anticholinergic effects-Constipation
Anticholinergic effects-Dry mouth
MAOIs - ANSWER Last choice medication class for depression due to the many
potential, serious side effects. MAOIs have specific dietary restrictions that when
ignored, may be very uncomfortable or very serious for clients.
MAOIs - ANSWER Drugs:
· phenelzine (Nardil)
· selegiline (Emsam) - MAOI-B
· tranylcypromine (Parnate)
· isocarboxazid (Marplan)
MAOI's Key Points - ANSWER · Clients taking MAOIs are at high risk for
hypertensive crisis if tyramine is ingested.
· Do not prescribe any serotonergic agents within 2 weeks of MAOI discontinuation
due to an increased risk of serotonin syndrome.
Wait at least 5 half-lives after discontinuing a serotonergic medication before
initiating an MAIO.
Foods to Avoid When Taking MAO-A Medications - ANSWER · Red wine (Avoid)
· Sauerkraut (Avoid)
· Cheese (Avoid)
· Soy (Avoid)
· Smoked meats (Avoid)
Foods to Avoid When Taking MAO-A Medications - ANSWER Rationale: Limiting the
consumption of tyramine is necessary for orally available MAOIs due to inhibition of
MAO-A in the gut. Dietary restrictions are not required for the transdermal
formulation of selegiline.
Tyramine is present in many aged or preserved foods including aged cheeses, tap
and non-pasteurized beers, aged or smoked meat or fish, sauerkraut, kimchee, soy
products, and tofu.
