A+ NR546 FINAL EXAM QUESTIONS AND ANSWERS LATEST
UPDATE
Newer tx for resistant depression: esketamine (Spravato)
nasal spray for the treatment of major depressive disorder (MDD) with acute suicidal
ideation or behavior
-reaches peak onset in the body in between 20-40 minutes
-risk of adverse outcomes due to sedation and dissociation
*must be administered in a supervised healthcare setting
Newer tx for resistant depression: Ketamine clinics
Ketamine is an N-methyl-D-aspartate (NMDA) receptor inhibitor, results in the
downstream release of glutamate
-high doses, ketamine may cause psychotic symptoms, in low doses, it has a rapid
effect on depression
-Ketamine clinics have provided intravenous ketamine for treatment-resistant unipolar
and bipolar depression
*required frequent dosing, inconvenient, expensive
Newer tx for resistant depression: dextromethorphan/quinidine (Nuedexta)
Researchers are investigating, related to NMDA
-currently approved by the FDA for the treatment of pseudobulbar affect
*combines dextromethorphan and quinidine as an oral treatment
considered when selecting an antidepressant medication
Client preference
Prior treatment response
Anticipated adverse effects
Comorbidities
Half-life and interactions
Cost
Antidepressants: Initiating Medication
Start clients on a single drug for 4-8 weeks to assess efficacy. Start with the lowest
recommended dose to reduce side effects. If a medication is not achieving efficacy:
-Increase the dose gradually to the efficacious dose range.
,-Switch to a different drug within the same class after an adequate trial which includes
higher dosing and a minimum of eight weeks of trial.
-Switch to a drug in a different class after an adequate trial which includes higher dosing
and a minimum of eight weeks of trial.
-Add a second medication as an adjunct.
Antidepressants: Discontinuing Medications
Don't suddenly stop or omit doses due to risk of discontinuation syndrome
-Paroxetine highest risk due to serotonin transporter inhibition and anticholinergic
rebound
-If a treatment course has lasted 8 weeks, discontinuation over 1-2 weeks is safe. Once
symptoms are in remission, continue treatment for 4-9 months to reduce the risk of
relapse
Antidepressants Important Prescribing Considerations: Black Box Warning
Suicide Risk with Antidepressant Drugs
-Clients with depression may consider or attempt suicide
-risk for suicide may increase at the start of treatment
-Antidepressant-induced suicide is more prevalent in children, adolescents, and adults
younger than 25 years.
Antidepressants Important Prescribing Considerations: Drug-Drug Interactions
Most antidepressant medications have serious drug-drug interactions. Carefully review
the client's history and current prescriptions before selecting a medication.
Antidepressants Important Prescribing Considerations: Serotonin Syndrome
potentially life-threatening condition reported with the use of serotonergic
antidepressants
-especially when they are used concomitantly with other serotonergic drugs (such as
triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, and
St. John's Wort), and with drugs that impair serotonin metabolism (particularly MAOIs)
S/S
-mental status changes (e.g., agitation, hallucinations, delirium, and coma)
-autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis,
, flushing, hyperthermia)
-neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia,
incoordination)
-seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea)
If such symptoms occur, clients should discontinue serotonergic agents and initiate
treatment of symptoms.
Clients should be educated about the signs and symptoms of serotonin syndrome and
monitored
-particularly during treatment initiation and dose increases.
match the specific complaint to the best antidepressant medication: Eric, 49, is
concerned about sexual side effects of antidepressant medications
Bupropion
-has fewer sexual side effects than other first-line treatments. Bupropion can also be
prescribed as an adjunct to a SSRI.
match the specific complaint to the best antidepressant medication: Terry, 76,
has lost several pounds in the past few months. She has little appetite.
Mirtazapine
-may be used to increase appetite/weight gain in older clients.
match the specific complaint to the best antidepressant medication: Karl, 35,
complains of "brain fog" as a part of his depression symptoms.
Vortioxetine
-can improve the speed of processing and cognitive function due to its unique
mechanism of action.
Role of L-Methylfolate in depression tx
Suboptimal folate levels in depressed patients (adjunct to antidepressant)
• L-Methylfolate is a bioavailable form of folate
• L-methylfolate, or 6-(S)-5-methyl-tetrahydrofolate, is derived from folate and is the
form that enters the brain and works directly as a methyl donor and monoamine
synthesis modulator
UPDATE
Newer tx for resistant depression: esketamine (Spravato)
nasal spray for the treatment of major depressive disorder (MDD) with acute suicidal
ideation or behavior
-reaches peak onset in the body in between 20-40 minutes
-risk of adverse outcomes due to sedation and dissociation
*must be administered in a supervised healthcare setting
Newer tx for resistant depression: Ketamine clinics
Ketamine is an N-methyl-D-aspartate (NMDA) receptor inhibitor, results in the
downstream release of glutamate
-high doses, ketamine may cause psychotic symptoms, in low doses, it has a rapid
effect on depression
-Ketamine clinics have provided intravenous ketamine for treatment-resistant unipolar
and bipolar depression
*required frequent dosing, inconvenient, expensive
Newer tx for resistant depression: dextromethorphan/quinidine (Nuedexta)
Researchers are investigating, related to NMDA
-currently approved by the FDA for the treatment of pseudobulbar affect
*combines dextromethorphan and quinidine as an oral treatment
considered when selecting an antidepressant medication
Client preference
Prior treatment response
Anticipated adverse effects
Comorbidities
Half-life and interactions
Cost
Antidepressants: Initiating Medication
Start clients on a single drug for 4-8 weeks to assess efficacy. Start with the lowest
recommended dose to reduce side effects. If a medication is not achieving efficacy:
-Increase the dose gradually to the efficacious dose range.
,-Switch to a different drug within the same class after an adequate trial which includes
higher dosing and a minimum of eight weeks of trial.
-Switch to a drug in a different class after an adequate trial which includes higher dosing
and a minimum of eight weeks of trial.
-Add a second medication as an adjunct.
Antidepressants: Discontinuing Medications
Don't suddenly stop or omit doses due to risk of discontinuation syndrome
-Paroxetine highest risk due to serotonin transporter inhibition and anticholinergic
rebound
-If a treatment course has lasted 8 weeks, discontinuation over 1-2 weeks is safe. Once
symptoms are in remission, continue treatment for 4-9 months to reduce the risk of
relapse
Antidepressants Important Prescribing Considerations: Black Box Warning
Suicide Risk with Antidepressant Drugs
-Clients with depression may consider or attempt suicide
-risk for suicide may increase at the start of treatment
-Antidepressant-induced suicide is more prevalent in children, adolescents, and adults
younger than 25 years.
Antidepressants Important Prescribing Considerations: Drug-Drug Interactions
Most antidepressant medications have serious drug-drug interactions. Carefully review
the client's history and current prescriptions before selecting a medication.
Antidepressants Important Prescribing Considerations: Serotonin Syndrome
potentially life-threatening condition reported with the use of serotonergic
antidepressants
-especially when they are used concomitantly with other serotonergic drugs (such as
triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, and
St. John's Wort), and with drugs that impair serotonin metabolism (particularly MAOIs)
S/S
-mental status changes (e.g., agitation, hallucinations, delirium, and coma)
-autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis,
, flushing, hyperthermia)
-neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia,
incoordination)
-seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea)
If such symptoms occur, clients should discontinue serotonergic agents and initiate
treatment of symptoms.
Clients should be educated about the signs and symptoms of serotonin syndrome and
monitored
-particularly during treatment initiation and dose increases.
match the specific complaint to the best antidepressant medication: Eric, 49, is
concerned about sexual side effects of antidepressant medications
Bupropion
-has fewer sexual side effects than other first-line treatments. Bupropion can also be
prescribed as an adjunct to a SSRI.
match the specific complaint to the best antidepressant medication: Terry, 76,
has lost several pounds in the past few months. She has little appetite.
Mirtazapine
-may be used to increase appetite/weight gain in older clients.
match the specific complaint to the best antidepressant medication: Karl, 35,
complains of "brain fog" as a part of his depression symptoms.
Vortioxetine
-can improve the speed of processing and cognitive function due to its unique
mechanism of action.
Role of L-Methylfolate in depression tx
Suboptimal folate levels in depressed patients (adjunct to antidepressant)
• L-Methylfolate is a bioavailable form of folate
• L-methylfolate, or 6-(S)-5-methyl-tetrahydrofolate, is derived from folate and is the
form that enters the brain and works directly as a methyl donor and monoamine
synthesis modulator
