Affective Disorders Treatments Flashcards
Depression: Screening Questions:
- during the last month have you
often been feeling down,
depressed or hopeless? - during the last month have you
often been bothered by having little
interest or pleasure in doing things?
General Approach to Depression Management:
Psychoeducation:
- nature of depressive illness
- talk about concerns the person
may have about their presenting
problems - day to day things that can impact
on mental health: work, family,
sleep, drugs - sleep hygiene
Psychosocial Interventions in Depression:
- regular exercise -> structured
group physical activity programme - befriending services
- local support groups
- social prescriber
Psychological Interventions for Depression:
Low Intensity:
- CBT
- guided self help book
- group CBT
High Intensity:
- individual CBT
- other individual therapies
CBT:
- involves linking thoughts, feelings
and behaviours - focuses on maladaptive thinking
Why do antidepressant have a delayed response time?
- downregulation of receptors due to
the increased neurotransmitter
release: via alterations in gene
expression - neurogenesis/synaptic plasticity in
the hippocampus and prefrontal
cortex
Principles of Antidepressant Treatment:
- short-term response rates in
clinical trials:- 50% on active treatment
- 30% on placebo
- SSRIs are first line
- onset of therapeutic effect delayed
- continue for at least 6 months:
high rate of relapse when stopped
before then
Abbrieviations:
- SSRIs
- SNRIs
- TCA
- MAOIs
- selective serotonin reuptake
inhibitors - serotonin and noradrenaline
reuptake inhibitors - tricyclic antidepressants
- monoamine oxidase inhibitors
Core Drug: Fluoxetine: Drug Class:
- antidepressant
- SSRIs
Core Drug: Fluoxetine: Mechanism of Action:
- SSRIs
- increase amount of serotonin in
the synapse by blocking its
reuptake
Core Drug: Fluoxetine: Side Effects:
- usually improve within a few weeks
***hyponatremia
- nausea and loss of appetite
- diarrhoea
- loss of libido
- insomnia
- agitation
- anxiety
- headaches
Core Drug: Fluoxetine/SSRIs: Main Interaction:
NSAIDs
Venlafaxine/ Duloxetine are
- SNRIs
Key differences between SNRIs and SSRIs
- SNRIs are more toxic in overdose
- similar adverse side effects
(nausea, GI, headache, anxiety,
hyponatremia) - caution in hypertension
Core Drug: Amitriptyline: Drug Class:
- antidepressant
- Tricyclic antidepressants (TCAs)
Core Drug: Amitriptyline: Mechanism of Action:
- block monoamine reuptake
- mostly serotonin and
noradrenaline - less affect dopamine
Core Drug: Amitriptyline: Side Effects:
- sedation
- confusion
- loss of motor coordinatinon (**falls
in the elderly) - anticholinergic effects: dry mouth,
blurred vision, constipation, urinary
retention - cardiotoxicity in overdose
Anticholinergic Effects:
- pupil dilation
- blurred vision
- dry mouth
- constipation
- urinary retention
Core Drug: Amitriptyline: Uses:
- avoid with elderly
- sometimes used for neuropathic
pain - avoided generally due to
anticholinergic effects
Antidepressants: Monoamine Oxidase Inhibitors:
- irreversible: phenelzene
- reversible: moclobemide
- prevents the breakdown of
monamines by the enzyme
monamine oxidase: increases 5-Ht,
noradrenaline and dopamine
content - tyramine is harmless normally
produced during cheese
fermentation - tyramine is normally metabolised
by MAO in gut wall and liver - MOAIs block metabolism of
tyrosine so that it is absorbed:
sympathomimetic effects can lead
to hypertensive crisis and
intracranial haemorrhage - drug interactions -> can not be
prescribed with other
antidepressants
Monoamine Receptor Antagonists:
- mirtazapine
- blocks alpha 2 adrenoreceptors,
and several 5-HT receptors - blocks histamine H1 receptors
- side effects include sedation and
weight gain
83 year old lady prescribed citalopram several weeks ago presents with sudden onset confusion. She has a delirium related to the citalopram – what is the likely cause?
Hyponatraemia
Antidepressants and hyponatremia:
- all antidepressants can cause
hyponatremia but SSRIs are worst - can cause delirium, seizures,
potentially fatal - more common in older people,
drug interactions - monitoring necessary
Antidepressant Withdrawal Symptoms:
- dizziness
- anxiety
- insomnia and vivid dreams
- general malaise
- irritability
- headache
- electric shock sensations in arms
and legs - low mood and suicidal thoughts
- agitation
Antidepressant withdrawal symptoms does not mean they are addictive.
- no sensitisation no higher dose
needed for same effect - no cravings
- temporary deficiency of synaptic
serotonin may need time for down-
regulated receptors to adjust (days-
weeks) - warn patients before starting
- reduce and stop slowly
Core Drug: Lithium: Drug Use:
Mood stabaliser
can be used in depression and bipolar disorder
Core Drug: Lithium: Depression:
- lithium augmentation
- lithium added to antidepressant
- can be very effective when other
treatments have not been - narrow therapeutic window
requires monitoring - drug interactions
Core Drug: Lithium: Mechanism of Action:
- monovalent cation
- similar way to sodium
- not fully understood
Core Drug: Lithium: Adverse Effects:
Core Drug: Lithium: Monitoring:
- frequent plasma lithium levels
whilst establishing dose - 6 monthly: lithium level, renal
function, thyroid function - additionally tests if physically
unwell or possibly toxic
Depression: Electroconvulsive Therapy:
- electric current applied to skull of
anaesthetised patient - produces a seizure
- motor effects of seizure prevented
using a muscle relaxant - used in severe depression when
life is threatened by not eating,
drinking or intense suicidal ideation - lack of response to other
treatments
Management of Unipolar depression:
- psychoeducation
- psychosocial interventions
- psychological interventions (low
and high intensity) - antidepressants
- antipsychotics for severe
depression with psychosis - ECT for severe depression and
immediate risk - MDT support from specialist
services
General Approach to the Management of Bipolar Disorder:
- treatment of acute mood episode:
depression or mania - maintenance treatment to
promote mood stability - relapse prevention
- often managed in specialist mental
health services
Bipolar Disorder: Acute Mania: Treatment:
- urgent response essential
- stop antidepressants
- if not any treatment yet, start
antipsychotic - if on treatment:
- check compliance and lithium
check levels - consider adding or changing
antipsychotic
- check compliance and lithium
- benzodiazepines may be used as
an adjunctive (additional
treatment) to restore overactivity,
restore sleep
antipsychotic will treat most wuickly but if on lithium then check levels
Maintenance Pharmacological Treatment in Bipolar Disorder:
- lithium is first line maintenance
treatment - anticonvulsants: valproate most
common - relapse prevention work
Bipolar Disorder: Depression: Management:
- similar to unipolar depression
(including psychological and
psychosocial interventions) - caution due to risk of manic switch;
drug treatment of depression can
flip into hypomania or mania - often need to combine an
antidepressant with a mood
stabiliser
Management of Bipolar Affective Disorder:
- treat manic: urgent, antipsychotic,
lithium levels - treat depression: antidepressant,
mood stabaliser to prevent manic
switch - maintenance treatment to prevent
further episodes:- Lithium first line, then valproate,
antipsychotics - relapse prevention work (MDT
support)
- Lithium first line, then valproate,
