Affective Disorders Treatments

Question 1

Depression: Screening Questions:

Answer 1

• 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?

Question 2

General Approach to Depression Management:

Answer 2

Question 3

Psychoeducation:

Answer 3

• 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

Question 4

Psychosocial Interventions in Depression:

Answer 4

• regular exercise -> structured
  group physical activity programme
• befriending services
• local support groups
• social prescriber

Question 5

Psychological Interventions for Depression:

Answer 5

Low Intensity:
- CBT
- guided self help book
- group CBT

High Intensity:
- individual CBT
- other individual therapies

Question 6

CBT:

Answer 6

• involves linking thoughts, feelings
  and behaviours
• focuses on maladaptive thinking

Question 7

Why do antidepressant have a delayed response time?

Answer 7

• downregulation of receptors due to
  the increased neurotransmitter
  release: via alterations in gene
  expression
• neurogenesis/synaptic plasticity in
  the hippocampus and prefrontal
  cortex

Question 8

Principles of Antidepressant Treatment:

Answer 8

• 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

Question 9

Abbrieviations:
- SSRIs
- SNRIs
- TCA
- MAOIs

Answer 9

• selective serotonin reuptake
  inhibitors
• serotonin and noradrenaline
  reuptake inhibitors
• tricyclic antidepressants
• monoamine oxidase inhibitors

Question 10

Core Drug: Fluoxetine: Drug Class:

Answer 10

• antidepressant
• SSRIs

Question 11

Core Drug: Fluoxetine: Mechanism of Action:

Answer 11

• SSRIs
• increase amount of serotonin in
  the synapse by blocking its
  reuptake

Question 12

Core Drug: Fluoxetine: Side Effects:

Answer 12

• usually improve within a few weeks

***hyponatremia

• nausea and loss of appetite
• diarrhoea
• loss of libido
• insomnia
• agitation
• anxiety
• headaches

Question 13

Core Drug: Fluoxetine/SSRIs: Main Interaction:

Answer 13

NSAIDs

Question 14

Venlafaxine/ Duloxetine are

Answer 14

• SNRIs

Question 15

Key differences between SNRIs and SSRIs

Answer 15

• SNRIs are more toxic in overdose
• similar adverse side effects
  (nausea, GI, headache, anxiety,
  hyponatremia)
• caution in hypertension

Question 16

Core Drug: Amitriptyline: Drug Class:

Answer 16

• antidepressant
• Tricyclic antidepressants (TCAs)

Question 17

Core Drug: Amitriptyline: Mechanism of Action:

Answer 17

• block monoamine reuptake
• mostly serotonin and
  noradrenaline
• less affect dopamine

Question 18

Core Drug: Amitriptyline: Side Effects:

Answer 18

• sedation
• confusion
• loss of motor coordinatinon (**falls
  in the elderly)
• anticholinergic effects: dry mouth,
  blurred vision, constipation, urinary
  retention
• cardiotoxicity in overdose

Question 19

Anticholinergic Effects:

Answer 19

• pupil dilation
• blurred vision
• dry mouth
• constipation
• urinary retention

Question 20

Core Drug: Amitriptyline: Uses:

Answer 20

• avoid with elderly
• sometimes used for neuropathic
  pain
• avoided generally due to
  anticholinergic effects

Question 21

Antidepressants: Monoamine Oxidase Inhibitors:

Answer 21

• 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

Question 22

Monoamine Receptor Antagonists:

Answer 22

• mirtazapine
• blocks alpha 2 adrenoreceptors,
  and several 5-HT receptors
• blocks histamine H1 receptors
• side effects include sedation and
  weight gain

Question 23

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?

Answer 23

Hyponatraemia

Question 24

Antidepressants and hyponatremia:

Answer 24

• all antidepressants can cause
  hyponatremia but SSRIs are worst
• can cause delirium, seizures,
  potentially fatal
• more common in older people,
  drug interactions
• monitoring necessary

Question 25

Antidepressant Withdrawal Symptoms:

Answer 25

• dizziness
• anxiety
• insomnia and vivid dreams
• general malaise
• irritability
• headache
• electric shock sensations in arms
  and legs
• low mood and suicidal thoughts
• agitation

Question 26

Antidepressant withdrawal symptoms does not mean they are addictive.

Answer 26

• 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

Question 27

Core Drug: Lithium: Drug Use:

Answer 27

Mood stabaliser

can be used in depression and bipolar disorder

Question 28

Core Drug: Lithium: Depression:

Answer 28

• lithium augmentation
• lithium added to antidepressant
• can be very effective when other
  treatments have not been
• narrow therapeutic window
  requires monitoring
• drug interactions

Question 29

Core Drug: Lithium: Mechanism of Action:

Answer 29

• monovalent cation
• similar way to sodium
• not fully understood

Question 30

Core Drug: Lithium: Adverse Effects:

Answer 30

Question 31

Core Drug: Lithium: Monitoring:

Answer 31

• frequent plasma lithium levels
  whilst establishing dose
• 6 monthly: lithium level, renal
  function, thyroid function
• additionally tests if physically
  unwell or possibly toxic

Question 32

Depression: Electroconvulsive Therapy:

Answer 32

• 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

Question 33

Management of Unipolar depression:

Answer 33

• 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

Question 34

General Approach to the Management of Bipolar Disorder:

Answer 34

• treatment of acute mood episode:
  depression or mania
• maintenance treatment to
  promote mood stability
• relapse prevention
• often managed in specialist mental
  health services

Question 35

Bipolar Disorder: Acute Mania: Treatment:

Answer 35

• 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
• 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

Question 36

Maintenance Pharmacological Treatment in Bipolar Disorder:

Answer 36

• lithium is first line maintenance
  treatment
• anticonvulsants: valproate most
  common
• relapse prevention work

Question 37

Bipolar Disorder: Depression: Management:

Answer 37

• 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

Question 38

Management of Bipolar Affective Disorder:

Answer 38

• 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)