Anti-depressants and side effects

Question 1

Treatments in general

note the mechanism of action

Answer 1

Question 2

TCAs

Tri-cyclic antidepressants

Answer 2

Question 3

SNRIs

Venlafaxine, duloxetine

These are norepinephrine, so:
Increases alertness, arousal and attention. Constricts blood vessels, which helps maintain blood pressure in times of stress.

Answer 3

Venlafaxine: Diastolic hypertension (note increase!! opposite to TCAs)

Question 4

SSRI

Fluoxetine, sertraline, paroxetine (not for preganant), citalopram, escitalopram, fluvoxamine

Answer 4

((Serotonin syndrome)):
(fever, myoclonus, hyperreflexia, altered mental status, cardiovascular collapse) can occur if SSRIs are used with MAOIs, illicit drugs, or herbal medications.

((Discontinuation syndrome)):
(flulike symptoms, nausea, insomnia, sensory disturbances) occurs with abrupt cessation of shorter-acting agents.

Question 5

Not that important!

MAOIs
Phenelzine, tranylcypromine, selegiline (also available in patch form)

Answer 5

Question 6

Side effects of ((Antidepressant drug discontinuation syndrome))?

Answer 6

paresthesia = tingling

Question 7

In which antidepressants you can see more Toxicity in overdose?

Answer 7

1. Tricyclic antidepressants (except Lofepramine)
2. Venlafaxine
3. MAOIs

Question 8

Which combination of antidepressants classes can cause serotonin syndrome as a result of drug interaction?

Answer 8

MAOIs + SSRIs

Interactions
Pharmacokinetic: cytochrome p450
Pharmacodynamic: MAOIs + SSRIs (serotonin syndrome)

Question 9

What are symptoms of Serotonin Syndrome?

Answer 9

Myoclonus = sudden, brief involuntary twitching or jerking of a muscle or group of muscles

Question 10

What are the best options in case you want to switch the treatment of mania?

Answer 10

SSRI is the best

Then MAOIs

The risk to have side effects due to (mania switch) is as such:
TCAs > SNRIs > MAOIs > SSRIs

Question 11

Do mood stabilizers protect from mania?

Answer 11

Lithium (Lithium carbonate or citrate, but not lithium orotate! ) added to an SSRI has a protective effect

Anticonvulsants appear not to

Higher levels of lithium (>0.8mEq/L) may also offer some protection from tricyclic-induced mania.

Lithium is particularly effective in preventing “suicide” in all major affective disorders (including schizoaffective, dysthymia and rapid cycling disorder as well as unipolar and bipolar disorders). Ongoing treatment for at least 2 years seems necessary.

Question 12

What are the side effects of lithium?

Answer 12

polyuria, polydipsia (thirsty although you drink a lot of water), pretibial edema, fine tremor, hypothyroidism

It has Narrow therapeutic index: 0.4–1.0 mmol/L

Question 13

What are the tests that you will perform as a monitoring Lithium?

Answer 13

Monitoring:

• Blood levels: every 3 months (Cardiovascular)
• U&Es, serum creatinine: every 6 months (kidney))
• TFTs: yearly (thyroid)

Question 14

What are the signs and blood levels of Lithium toxicity?

Answer 14

> 1.4 mmol/L:

• More marked polyuria/polydipsia
• Nausea/diarrhoea
• Gross tremor
• Muscle twitching
• Tiredness, sleepiness

> 2.0 mmol/L: may require “dialysis”

• Neurological signs
• Circulatory collapse

Note:
Concurrent use of Diuretics and NSAIDs can cause lithium toxicity

Question 15

What are the Differential Diagnosis of Major Depression?

Answer 15

ADJUSTMENT DISORDER: is a clinically significant distress following a profound life change (eg, divorce, unemployment, financial issues, romantic breakup, identifiable stressor); it is not severe enough to meet criteria for another mental disorder. It is >1 month and <6 months

Question 16

What are the treatments of adjustment disorder, and dysthymia?

Answer 16

Adjustment disorder:
=Psychotherapy focusing on coping skills and supportive counseling.
=No pharmacologic treatment.

Dysthymia:
=Psychotherapy is the most effective treatment.
=Often resistant to treatment. Consider antidepressants (eg, SSRIs)
and ECT: Electroconvulsive therap.

Question 17

Notice the difference between mania and hypomania

Answer 17

Question 18

What is the difference between Bipolar I, Bipolar II, Cyclothymic disorder?

Answer 18

Bipolar I:
■ Manic episode.
■ Major depressive episode not required for diagnosis.

Bipolar II:
■ Hypomanic episode.
■ ≥ 1 major depressive episode.

Cyclothymic disorder:
■ Alternating periods of the following symptoms for at least 2 years:
■ Hypomanic symptoms that do not meet criteria for hypomania.
■ Depressive symptoms that do not meet criteria for major depressive
episode.

Question 19

A 23-year-old woman complains of difficulty falling asleep and worsening anxiety that began 2 months earlier after she was involved in a minor biking accident (bike vs car) in which she did not suffer any injuries. Since the accident, she has refused to participate in any outdoor activities.

Dx?

Answer 19

Adjustment disorder

In which it consists of emotional and behavioral symptoms that develop in response to an identifiable stressor, lasts > 1 month and < 6 months, and does not have five or more symptoms of major depressive disorder.