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Anti-depressants Flashcards

1
Q

What is the four stepped care model?

A

Stepped Care is a system of delivering and monitoring mental health treatment so that the most effective, yet least resource intensive treatment, is delivered first, only “stepping up” to intensive / specialist services as required and depending on the level of patient distress or need.

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2
Q

What are the four steps?

A

Step 1: suspected depression
Step 2: mild to moderate depression
Step 3: moderate to severe depression
Step 4: severe and complex depression

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3
Q

At which step is anti-depressants the first line treatment?

A

Usually medication is seen as the first line from moderate depression onwards. However anti-depressants may be initiated in mild depression only if there is a past history of depressive episodes, already tried psychosocial interventions or there is a persistent subthreshold depressive symptoms for more than 2 years now.

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4
Q

When should psychosocial interventions be used in the management of depression?

A

First line for mild depression as low intensity and then used alongside medication as high intensity therapy in moderate depression onwards.

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5
Q

What is the first line management for suspected depression cases?

A

Support and psychoeducation on how to manage depression, physician may choose to monitor.

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6
Q

What are some examples of low intensity psychosocial interventions?

A

Guided self help book
Computer based CBT

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7
Q

What are some examples of high intensity psychosocial interventions?

A

Individual CBT
Interpersonal therapies
Relaxation therapies
Anxiety management
Mindfulness related therapies and counselling

ECT and TMS in severe and complex depression only

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8
Q

How does ECT work?

A

Electroconvulsive therapy (ECT for short) is a treatment that involves sending an electric current through your brain. This causes a brief surge of electrical activity within your brain (also known as a seizure). It is administered under anaesthesia and alongside a muscle relaxant (Profolol and Suxamethonium).

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9
Q

What are the risks of ECT?

A

Can cause vomiting so don’t eat beforehand and can cause amnesia so patients will be monitored and asked orientating questions.

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10
Q

What is anti-depressant choice based upon?

A

Duration of episode
Previous anti-depressant response
Likelihood of adherence, potential adverse effects and patient preference

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11
Q

What is the first line therapy for unipolar depression?

A

SSRIs which include:
Citalopram
Escitalopram
Fluoxetine
Sertraline

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12
Q

What is the dosing regimen for anti-depressants?

A

Apart from Mirtazapine all should be started at a lower dose due to being more tolerable and then increasing to target dose over a few days or weeks.

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13
Q

Why aren’t tricyclic anti-depressants not first line therapy?

A

Difficult to get to the therapeutic dose due to causing a wide range of side effects such as poor tolerability. Additionally they cause toxicity in overdose and have adverse drug reactions with alcohol.

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14
Q

If patients fail to respond to multiple anti-depressants what are the possible options?

A

May consider using Lithium, an anti-psychotic or another anti-depressant however this should also be in consideration of the increased side effect burden and the increased monitoring requirements.

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15
Q

Which anti-psychotics are licensed to be used in treatment resistant depression?

A

Aripiprazole
Olanzapine
Quetiapine
Risperidone

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16
Q

What are some examples of SNRI anti-depressants?

A

These work by inhibiting noradrenaline and serotonin reuptake. They include:
Duloxetine
Mirtazapine
Venlafaxine

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17
Q

Which SNRI combination is good for treatment resistant depression?

A

Mirtazapine and Venlafaxine

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18
Q

Why is Mirtazapine often prescribed at 30mg rather than 15mg?

A

As an SNRI it has greater noradrenergic activity at 30mg than at 15mg so is less sedating at higher doses.

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19
Q

Which SSRI is good to be used in the elderly?

A

Vortioxetine due to causing cognitive enhancement which is unrelated to anti-depressant mechanism

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20
Q

What is Quetiapine licensed for?

A

Licensed as an adjunctive therapy with partial anti-depressant response.

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21
Q

What are some of the second line SSRIs?

A

Fluvoxamine
Paroxetine

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22
Q

What are some of the second line related anti-depressants?

A

Agomelatine - helps improve sleep also
Reboxetine
Trazodone - antihistamine activity

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23
Q

What are the tricyclic antidepressants?

A

Amitriptyline
Dosulepin
Doxepin
Imipramine
Nortriptyline
Trimipramine

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24
Q

What is the usual dose for TCAs?

A

125-150mg a day although 5% of Caucasians are CYP 2D6 deficient and in those patients a much lower dose is used.

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25
What are some of the MAO inhibitors used in depression?
These drugs irreversibly inhibit both MAO-A and B resulting in food/drink interactions including a tyramine free diet. Examples: Isocarboxazid Phenelzine Tranylcypromine Moclobemide (Reversible inhibition of MAO-A - doesn't have the same interactions)
26
Is St John's Wort effective anti-depressant?
Mechanism of action is unknown, completely unlicensed and interactions with a lot of medications. Patients should not take this alongside anti-depressants.
27
Which anti-depressants have the highest efficacy and highest tolerability?
Agomelatine Escitalopram Vortioxetine
28
Which anti-depressants have the highest efficacy but lower tolerability?
Amitriptyline Mirtazapine Paroxetine Venlafaxine
29
Which anti-depressants have a lower efficacy but higher tolerability?
Citalopram Fluoxetine Sertraline
30
Which anti-depressants have a lower efficacy and lower tolerability?
Fluvoxamine Reboxetine Trazodone
31
What is STAR*D?
STAR*D stands for Sequenced Treatment Alternatives to Relieve Depression was a collaborative study on the treatment of depression, funded by the National Institute of Mental Health. Its main focus was on the treatment of depression in patients where the first prescribed antidepressant proved inadequate.
32
According to STAR*D if a patient has partial/incomplete response what is the advised treatment?
Augment anti-depressants (to make larger; enlarge in size, number, strength, or extent; increase)
33
What was one of the key findings about switching anti-depressants?
Switching to another SSRI is as effective as other switches however the response goes down each time and therefore the first two anti-depressants that are tried - optimise this therapy by adjusting doses, times and managing side effects.
34
By continuing anti-depressants how does relapse risk reduce?
By 70% and efficacy continues up to 36 months post-treatment, perhaps even higher
35
When should SSRIs be taken?
Both SSRIs and SNRIs should be taken in the morning. This is because during dreaming serotonin and dopamine need to be supressed, by taking this medication at night therefore it prevents dreaming and leads to incomplete sleep, disrupted sleep architecture - no REM sleep.
36
When should Mirtazapine be taken?
At night due to serotonin reuptake inhibited by antagonism of 5-HT 2/3.
37
Which anti-depressants may help with sleep?
Those that have an antihistaminic side effect and Agomelatine is a melatonin receptor agonist and therefore leads to improved sleep.
38
How long do anti-depressants take to work?
Usually about 4 weeks to work. Some response can be seen 2-6 weeks but optimal response is about 4-6 weeks. Elderly can take longer to see a response
39
If there is no response to an anti-depressant after 4 weeks what should you do?
Check adherence following 4 weeks at the therapeutic dose and then switch anti-depressant
40
If there is only a minimal improvement to an anti-depressant after 4 weeks what should you do?
Continue to week 6
41
How frequent is monitoring for patients taking an anti-depressant?
Every 2-4 weeks for the first three months. May be less frequent if the treatment is working and more frequent if the patient is at risk.
42
If the patient has a tolerance issue with an anti-depressant what is an appropriate switch?
Trying one with a different mechanism of action, chemical group or another in the group
43
If the patient has a efficacy issue with an anti-depressant what is an appropriate switch?
Try a different class or mode of action
44
What is a good anti-depressant for switching?
Mirtazapine, not many interactions
45
What isn't a good anti-depressant for switching?
Fluoxetine - need to have extra considerations due to its long half life especially with MAOIs. TCAs also interact with SSRIs.
46
What are two cautions to bear in mind when switching anti-depressants?
Discontinuation syndrome (especially with Paroxetine and Venlafaxine due to their short half life) Serotonin syndrome
47
What causes serotonin syndrome?
It is a toxic state due to increased serotonin levels within the brain. Can be caused SSRIs, SNRIs and Tramadol
48
What are some of the symptoms of serotonin syndrome?
Restlessness Myoclonus Tremor and rigidity Hyperreflexia Shivering and elevated temperature Arrhythmias
49
What are key drug interactions to minimalise risk of serotonin syndrome?
Do not use SSRIs alongside triptans or Triptans with MAOIs.
50
How long should anti-depressants be prescribed for?
As the relapse rate of anti-depressants is high (40% within 2 years and 60% in 5 years) many will continue to reduce relapse so will take as long as needed.
51
Following the different episodes how long should anti-depressants be taken for to reduce relapse?
First episode: Six months post-recovery Second episode: 1-2 years afterwards Third episode: 3-5 years or longer significantly reduces relapse
52
Is there a link between anti-depressants and suicide?
Only in under 21s for the first couple of weeks of starting
53
When does discontinuation/withdrawal symptoms occur from anti-depressants?
1-3 days after stopping anti-depressants and normally short lived. Can occur simply by missing a dose and is distinct from relapse which occurs earliest at 2 weeks.
54
What are some symptoms of SSRI withdrawal?
Dizziness Light headiness Agitation Volatility Electric shocks in the head Nausea Fatigue Headache Flu like symptoms
55
What are some symptoms of SNRI withdrawal?
Dizziness Light headiness Agitation Volatility Electric shocks in the head Nausea Fatigue Headache Flu like symptoms In addition: Restlessness Abdominal distension Congested sinuses
56
How should anti-depressants be withdrawn?
- Less than 8 weeks of treatment: Withdraw over 1-2 weeks - After 6-8 months of treatment: Taper over 6-8 week period After long term maintenance reduce by 25% every 4-6 weeks.
57
What are the main side effects associated with SSRIs?
Anticholinergic side effects are rare Nausea +++ Weight gain + Sexual dysfunction but may be due to the condition
58
What are the main side effects associated with TCAs?
Anticholinergic side effects are common Sedation +++ Hypotension +++ Nausea + Sexual dysfunction + Weight gain +++
59
What are the main side effects associated with SNRIs?
Anticholinergic side effects are rare Sedation + Hypotension + Nausea +++ Sexual dysfunction +++ Weight gain +
60
What are the main side effects associated with NaSSAs?
Anticholinergic side effects are rare Sedation ++ Weight gain +++
61
What are the main side effects associated with Trazodone?
Anticholinergic side effects are rare Sedation ++ Hypotension +++ Nausea +++ Sexual dysfunction + Weight gain +
62
What are the main side effects associated with MAO-I?
Anticholinergic side effects are common Hypotension ++ Sexual dysfunction + Weight gain +++
63
What is the appropriate management for blurred vision (anticholinergic side effect)?
Don't drive Side effect should wear off and if it doesn't consider switching or adjusting the dose of the medication
64
What is the appropriate management for constipation (anticholinergic side effect)?
Lifestyle advice/exercise Lactulose
65
What is the appropriate management for dry mouth (anticholinergic side effect)?
Suck a sweet/wine gum or mouth spray Careful due to weight gain
66
What is the appropriate management for urinary retention (anticholinergic side effect)?
Medical emergency go to A+E
67
What is the appropriate management for anxiety (central side effect)?
Start at a lower dose and consider a stepwise progression Could try splitting the dose daily
68
What is the appropriate management for seizures (central side effect)?
Some anti-depressants can lower the seizure threshold but it is rare Usually will require a change in medication or a much slower titration
69
What is the appropriate management for dizziness (central side effect)?
Take in the evening
70
What is the appropriate management for confusion (central side effect)?
Rare except for TCAs will need a change or a slower titration in dose
71
What is the appropriate management for headache (central side effect)?
Try Paracetamol
72
What is the appropriate management for insomnia/sleep disturbances (central side effect)?
Take in the morning/split doses
73
What is the appropriate management for nausea (central side effect)?
Take with or just after food Split the dose with breakfast and lunch time or try modified release
74
What is the appropriate management for sleepiness (central side effect)?
Due to the antihistaminic effect, don't drive or use machinery and use Mirtazapine 30mg instead of 15mg.
75
How should hyponatremia associated with anti-depressants be managed?
Monitor carefully from onset for the first 30 days. Symptoms can include: Tiredness Confusion Headache Inability to concentrate Muscle cramps Fits (refer immediately)
76
When is hyponatremia likely to occur?
Within 30 days of onset After a dose change If older or female
77
What is the appropriate management for postural hypotension?
Take care when standing up - try not to stand up too quickly Don't drive Check Bp
78
What is the appropriate management if palpitations occur?
May need Beta blockers
79
Which anti-depressants are associated with the lowest risk of sexual dysfunction?
Mirtazapine Agomelatine
80
What is the appropriate management for sexual dysfunction/loss of libido?
PDE5 inhibitors Time dose when sexual activity is least likely or omit or delay dose for a short period
81
What is the appropriate management for excess sweating?
Dose adjust
82
What is the appropriate management for weight gain?
Adjust diet
83
Which anti-depressants have excess sedation when taken with alcohol?
Mirtazapine Mianserine Trazodone Doxepin
84
Which antidepressants do not cause excess sedation when taken with alcohol?
SSRIs Venlafaxine Vortioxetine Nortriptyline Clomipramine
85
What is the interaction between SSRIs and NSAIDs?
Both increase the risk of gastric bleeds: SSRIs by 2 fold and then when taken alongside NSAIDs by an additional 3 fold.
86
What is the appropriate management between SSRIs and NSAIDs?
Use in caution in the elderly especially with SSRIs and NSAIDs known to cause gastric bleeds. Risk can be mitigated by using PPIs. Duloxetine is less of a problem.
87
Which anti-depressants do/don't cause an increase in INR?
Those that do: Paroxetine Fluoxetine Vortioxetine Some reports with St John's Wort, Duloxetine (careful when stopping), Venlafaxine Those that don't: Sertraline Citalopram Some reports with St John's Wort, Duloxetine, Venlafaxine No report: Mirtazapine Reboxetine Clomipramine
88
Which drug increases the risk of breast cancer recurrence when taken alongside Tamoxifen?
Paroxetine
89
Which anti-depressant interacts with smoking?
Smokers have their Duloxetine levels reduced by 50%.
90
What are some of the key interactions of St John's Wort?
- Induces the metabolism of anti-retroviral - HIV drugs - Causes a rapid reduction in Ciclosporin levels and alters the metabolism ratio - Reduces the effectiveness of the COC, EHC within 28 days of use. Use Copper IUD instead first line as 3mg of Levonorgestrel is unlicensed and affects Digoxin levels
91
Which anti-depressant affects Clozapine?
Fluvoxamine is a potent inhibitor of CYP 1A2 and therefore increases Clozapine levels. Other SSRIs can cause smaller increases in Clozapine levels
92
Which drugs interact with TCAs?
Carbamazepine induces CYP 3A4 reducing TCA levels by up to 50% Valproate can double TCA levels Cannabis can cause delirium, tachycardia, mania and other significant effects when taken with tricyclics Triptans
93
Which age groups are at an increased risk of suicidal ideation?
Children and that is with all anti-depressants
94
Which anti-depressants are licensed for children?
Fluoxetine for ages 8-17 years if other methods haven't worked Sertraline is licensed for OCD between ages 16-17 years
95
What is the appropriate management for increased risk of suicide in young people?
Ensure to exclude a differential diagnosis before initiation on to medication such as bipolar depression for the patient to be initiated on a mood stabiliser and anti-depressant Counsel the family to make them aware of suicidal ideation especially if agitated/akathisia after starting the anti-depressant Start slowly on Fluoxetine 10mg/day - increase gradually with tolerance
96
What is the appropriate management of anti-depressants in pregnancy?
Weigh up risks vs benefits Don't use Paroxetine Some link between SSRIs and autism Little to no evidence of detrimental effect on postnatal development
97
What are the best anti-depressants to use in the elderly population?
SSRIs are better tolerated than TCAs but do have an increased risk of GI bleeds associated with them especially when taken with other meds that also increase this risk Ensure dose is started low and titrated upwards slowly
98
What are some of the specific adverse effects that occur within the elderly?
Increased risk of hyponatremia Postural hypotension Falls Haemorrhagic strokes with SSRISs
99
What are the main considerations regarding anti-depressants and cardiac disease?
Need to be aware of anti-platelet activity and CYP interactions with cardiac drugs
100
What are the most appropriate anti-depressants to use post-MI?
SSRIs and Mirtazapine have been shown to have a neutral or even beneficial effect on CVD mortality. SSRIs are usually first line with Sertraline being the drug of choice as it may improve CVD risk factors - they don't need to be withheld post-MI
101
Is CBT effective for patients with depression and CVD?
It was be ineffective post-MI but if they had depression beforehand it may be effective.
102
What other CVD effects do anti-depressants have?
Possibly have an anti-coagulant effect or indirect reduction in arrhythmia frequency.
103
Do Beta blockers induce depression?
Can induce depression but when post PICC can reduce the risk of depression
104
Which anti-depressants in particular are known to cause QT prolongation?
Citalopram Escitalopram
105
What is the appropriate management for QT prolongation?
Citalopram and Escitalopram are contraindicated in known QT prolongation and cautioned if there is susceptibility to QT prolongation. Avoid two medications causing QT prolongation Monitor ECG
106
What are the main considerations for prescribing anti-depressants in renal impairment?
Some drugs are nephrotoxic and others can have the pharmacokinetic parameters altered by renal impairment Potential for accumulation
107
Which is the preferred anti-depressant for renal impairment?
No preferred drug just make sure start low go slow Anticholinergics may cause urinary retention and interfere with urea and electrolytes - may need to adjust.
108
What is the appropriate management for prescribing in hepatic impairment?
Start low and go slow, with regularly monitoring of LFTs although these may not directly correlate to the degree of impairment.
109
Which drugs need to be particularly cautious of in hepatic impairment>
Avoid drugs causing marked sedation and/or constipation Paroxetine? Extra caution is needed with drugs with a high first pass clearance

Mental Health (5 decks)

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