Anti-depressants Flashcards
Why is the highest rate of suicide associated with anti-depressants in the first few weeks period?
Moos stays low but energy and motivation increases
What medication can cause serotonin syndrome?
SSRI + TCA /
MAOI / St Johns Wort / Ecstasy
What are the features of serotonin syndrome?
restless, fever, tremor, myoclonus (sudden involuntary jerking), confusion, fits, arrhythmias
How do you treat serotonin syndrome?
Supportive, monitoring and stop drugs
Who and when is the risk of hyponatraemia worse in?
Older thin females in summer.
Which anti-depressants are the worst for causing hyponatraemia?
SSRIs
Which antidepressants are least likely to cause hyponatraemia?
Lofepramine and mirtazipine
What are some side effects of mirtazipine?
Can be sedative and stimulate the appetite (so don’t give to fat people)
Which other two drugs apart from mirtazipine can be sedative?
Amytriptilline & Lofepramine
Trazadone is a TCA with a really bad side effect that is?
Priapism (erection that won’t go away)
Name some drugs which seriously interact with St. John’s wort?
Oral contraceptives, anti-coagulants and anti-convulsants
How long should you wait to see the effects of anti-depressants?
4-6 weeks
How long should you continue your anti-depressants for following recovery?
6-9 months
If multiple episodes of depression occur, how long should you stay on anti-depressants for?
2 years
If the anti-depressants aren’t working, before switching or augmenting, what should you consider?
Alcohol use may stop them working as alcohol is a depressant, check there are taking it right and for a reasonable length of time.
Which combination anti-depressants should never be used together of ?
TCA & SSRI
What are the main indications for lithium?
Treatment and prophylaxis for mania, Bipolar affective disorder (BAD), recurrent depression, aggressive or self-mutilating behaviour.
How is lithium excreted?
Via the kidneys so therefore clearance depends on renal function, fluid intake, Na intake
What is therapeutic range for lithium?
0.4-1.0mmol/L
Lithium is known for having a specific anti-suicide effect
LEARN
What baseline investigations are carried out before a patient is commenced on lithium?
Physical and weight, U/E’s, renal function, TFTs, Calcium, ECG & pregnancy test
How long does it take to reach stable lithium levels in the blood?
3 months
Which drugs should be avoided when a patient is on lithium and why?
ACE drugs, NSAIDs and diuretics (especially thiazide) they all interfere with lithium excretion. You can switch to a loop diuretic instead.
What are the early side effects of lithium?
Dry mouth, metallic taste, nausea, fine tremor, polyuria and polydipsia, fatigue
What are the late side effects of lithium?
Diabetes insipidous, hypothyroidism, ataxia, dysarthria, weight gain, arrythmias
What are the causes of lithium toxicity?
Renal failure, UTI, dehydration, NSAID use, diuretic use
What level of lithium is considered toxic?
> 1.5mmol/L
What are the early symptoms of a lithium toxicity?
Blurred vision, anorexi, nausea, vomiting, diarrhoea, coarse tremor, ataxia, dysarthria
What are the late symptoms of lithium toxicity?
Confusion, renal failure, delirium, fits, coma and death
How do you manage lithium toxicity?
Stop lithium, give fluids and start diuresis
What is the success rate of ECT in severe depression?
70-80%
What does NICE say that ECT should treat?
Severe life-threatening or treatment resistant depression, catatonia, or severe mania.
How often do you get ECT treatment?
2x weekly, approx 12 in total
What do you receive before ECT?
Short general anaesthetic and muscle relaxant
What are the common side effects of ECT?
Head ache, nausea and muscle pain and memory loss around the time of a seizure is common.
For mild to moderate depression, what treatment does NICE recommend?
Low intensity psychological interventions NOT medication
What is the IAPT?
Improving access to psychological Therapies- this is an initiative led to the training of large numbers of therapists and the provision of these therapists in primary care
What is the treatment of moderate to severe depression?
Combination of antidepressant and high intensity psychological treatment (usually CBT or IPT)
You must give advice also on lower intensity psychological interventions such as?
Sleep hygiene, regular exercise etc
What does high intensity psychological interventions involve?
CBT (16-20 sessions) over 3-4 months, IPT (16-20 sessions) over 3-4 months, behavioural activation, behaviour couples therapy
What was beck’s theory of depression?
It is caused by the cognitive triad of negative view of self, world and future
What are cognitive bias?
Catastrophising, jumping to conclusions, all or nothing, black and white thinking, personalising, generalising.
What are the three anti-depressants NICE recommends for mild to moderate alzheimer’s?
Galantamine, rivastigmine and donepezil (Acetyl-esterase inhibitors)
What does NICE recommend for severe alzheimer’s?
Memantine (a NMDA receptor antagonist)
What is a rumination?
A deep or considered thought about something.
What are obsessive thoughts?
They are ideas, impulses or images that enter the patient’s mind again and again in a stereotyped form- patient tries unsuccessfully to resist them. They are recognised as HIS OR HER OWN thoughts eventhough they are involuntary. May include fear of acquiring a disease, causing harm, causing harm to each other….’an decisive, endless conversation of alternatives, associated with an inability to make trivial but necessary decisions in day-to-day living.’
What are compulsive acts or rituals?
Stereotyped behaviours that are repeated again and again, they are NOT enjoyable nor do they result in the completion of useful tasks.
What is the function of this repetitive behaviour?
The function is to prevent some objectively unlikely event, often involving harm or danger to or caused by the patient, which they fear may occur otherwise.
How is the behaviour recognised by the patient?
Symbolic, pointless or ineffectual
If the acts are resisted by the patient, what happens?
The anxiety gets worse
What is the treatment for OCD?
CBT, ERP exposure and response prevention - repeated graded exposure to anxiety provoking stimuli.
What is the drug treatment for OCD?
SSRI (fluoxetine and sertraline) and TCA (clomipramine)
Surgery for OCD?
ECT/psychosurgery (leucotomy)
What is an acute stress reaction?
This is a transient disorder which develops in an individual without any apparent mental disorder in response to exceptional physical and mental stress.
What are the symptoms and how long are they usually around for?
The symptoms are mixed but could include being in a daze, disorientation, amnesia, panic and they normally start within minutes of the stressful event and usually subside within hours or days.
Name some symptoms of PTSD?
Hyperarousal/anxiety, with hypervigilence and increased startle reaction ie jumpy. Also experience numbness, emotional blunting, detachment from others, associated depression and suicidal ideation.
What does ICD 10 say about PTSD?
DELAYED or PROTRACTED response to stressful event.
How long is the latency period?
Onset follows the trauma with a latency period usually between 1-6 months
What is the lift time prevalence of PTSD?
1-10%
What are the predisposing factors for PTSD?
Compulsive, asthenic (weak physically) personality traits, previous history of neurotic illness, genetic (oversensitve amygdala & hippocampus, decreased hippocampal size of MRI)
What are the risk factors for PTSD?
Scale of trauma, previous experience, level of support available
What is the treatment for PTSD?
Trauma focused CBT, repeated graded exposure, testimony based techniques, EMDR (eye movement desensitisation and reprocessing) and antidepressants.
What anti-depressants are used for PTSD?
Paroxetine and mirtazapine
What is adjustment disorder?
It arises in the period of adaptation to a significant life change or stressful event
What is the stressor/adjustment normally?
The integrity of an individuals social network (bereavement, separation experiences), or the wider system of social support and values (migration & refugee status). It can also be a major difficult development or transition (going to school, becoming a parent, retirement, failure to obtain a personal goal).
What are the symptoms of adjustment disorder?
Depression, anxiety and inability to cope.
What is a dissociative (conversion) disorder?
Its the development of a physical function normally under voluntary control, or loss of sensation (LOSS OF SOMETHING)
Name some examples of dissociative disorders?
Amnesia, fugue (loss of awareness of ones identify), stupor (unresponsive), motor disorder, convulsions, trance & possession states, anaesthesia and sensory loss, no longer able to walk, no longer to feel something. NB: symptoms often reflect how a patient would think a disease would work, ie not in relation to dermatomes.
What was dissociative disorders used to be called? DISSOCIATE = LOOSE
Conversion hysteria, ie. what freuds patients suffered from.
What do patients present with when they have a somatisation disorder?
Multiple recurrent and frequently changing PHYSICAL symptoms.
How long do the symptoms have to be there for in a somatisation disorder?
2 years
What are the symptoms of somatisation associated with?
Symptoms are chronic and fluctuating, often associated with disruption of social, interpersonal and family behaviour.
When is the onset usually of somatisation disorder, and is it more common in men or female?
onset usually<30, F>M
What is the jist of other somatoform disorders?
Any other disorders of sensation, function and behaviour,
• not due to physical disorders
• not mediated through the autonomic nervous system
• limited to specific systems or parts of the body
• closely associated in time with stressful events or problems. · dysmenorrhoea
· dysphagia, including “globus hystericus”
· pruritus
· torticollis
What is hypochondriosis?
This is a persistent preoccupation with the possibility of having one or more serious and progressive physical disorders, ie. worries that they might develop an illness Patients manifest persistent somatic complaints or a persistent preoccupation with their physical appearance. Normal or commonplace sensations and appearances are often misinterpreted by patients as abnormal and distressing.
How many organs is attention usually focused on in hypochondriosis?
Usually one or two organs only
Are preoccupations in hypochondriosis psychotic?
No, they are NON- PSYCHOTIC. Marked depression and anxiety are often present
How does hypochondriosis affect men and women?
Equally M=F
What is body dysmorphic disorder?
A type of hypochondriosis
How long does hypochondriosis have to last for?
6 months with functional impairment
