Antidepressants Flashcards

1
Q

2 things which impact depression mood?

A

normal high/low mood but

  • duration
  • intensity of feeling
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2
Q

diagnostic features of depression (symptoms)

A

persistent sadness/low mood
and/or

marked loss of interests or pleasure

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3
Q

associated symptoms of the 2 major symptoms of depression?

A
physical
- Altered sleep
- change in appetite and/or 
weight
- fatigue/loss of energy
- agitation/slowing of movements
- poor concentration or indecisiveness

psychological

  • feelings of worthlessness or excessive or inappropriate guilt
  • suicidal thoughts or acts.
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4
Q

diagnosis of depression

A

Subthreshold depressive
symptoms: < five symptoms of
depression.

• Mild: >five symptoms and result 
in only minor functional 
impairment. 
• Moderate: between ‘mild’ 
and ‘severe’.
• Severe: Most 
symptoms present; markedly 
interfere with functioning.
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5
Q
Not solely based on 
symptom counting but 
on
• Severity
• Persistence
• Presence of other 
symptoms
• Functional and social 
impairment
A
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6
Q

aetiology and neurobiology of depression

what are the risk factors for vulnerability to depression?
3

A

biological vulnerability:
-genes, brain abnormalities, disordered biochem

psychological:
- Abuse, Neglect, Parental discord, poor attachment, Neuroticism

social:
- Unemployment, poverty, homelessness, chronic illness, poor relationships

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7
Q

the 3 risk factors of vulnerability to depression may lead to what which could lead to depression?

not always

A
- Stress
Bereavement
Trauma
Onset of 
illness
Chronic stress
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8
Q

3 hypothesis of neurobiology of depression.

not been validated

A

Monoamine hypothesis– low
monoamines (Serotonin & Nor Adrenaline)

(HPA) axes hyperactivity –
repeated Stress ->increased cortisol levels, & CRF -> reduced hippocampus (volume) & neurogenesis.

Brain areas implicated indepression - : prefrontal cortex (PFC), anterior cingulate cortex (ACC), primary and secondary
somatosensory cortex, insular cortex, posterior cerebellum,
amygdala, hippocampus, thalamus, nucleus accumbens

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9
Q

do most antidepressants work?

A

inc/reduce levels of NTs: serotonin…

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10
Q

normally what is the action of NTs e.g. serotonin?

A

normal neurotransmission.

  • elect activity passed through neuron
  • NT release from pre synaptic vesicles?
  • NT come into synaptic cleft (jnction between 2 neurons)
  • act on post synaptic receptors

and activity from this to post synaptic neuron

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11
Q

what happens to NT when activity done i.e. reached synaptic cleft and postsynaptic neuron?

A

NTs e.g. serotonin are metabolised by enzymes in synaptic cleft/ in pre synaptic neurone

or

taken back into pre synaptic neurone by reuptake transporter. metab/stored back into cell

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12
Q

name of the enzymes that break down NTs once used?

A

monoamine (5HT and NA) enzymes !!!!

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13
Q

treatment of depression?

A
• Medical: antidepressants 
• Adjuvant medication
• Psychological  therapies 
• Electroconvulsive therapy (ECT)
• Vagal Nerve Stimulation*
• Transcranial Magnetic Stimulation (TMS)*
• Deep brain stimulation*
* Experimental and yet to be recommended by NICE
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14
Q

Examples of Adjuvant medication to antidepressants?

A

Lithium, Antipsychotic medication,

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15
Q

nature of intervention for step 1 focus: All known and suspected
presentations of depression

A

Assessment, support, psycho-education, active

monitoring & referral for assessment & interventions

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16
Q

nature of intervention for step 2 focus: Persistent subthreshold
depressive symptoms; mild to moderate
depression

A

Low-intensity psychosocial interventions,
psychological interventions, medication and
referral for assessment & interventions

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17
Q

nature of intervention for step 3 focus: Persistent subthreshold
symptoms or mild to moderate
(inadequate response to initial intervn)
moderate and severe depression

A

Medication, high-intensity psychological
interventions, combined treatments,
collaborative care, and referral for further
assessment and interventions

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18
Q

nature of intervention for step 4 focus: Severe and complex
depression; risk to life; severe
self-neglect

A

Medication, high-intensity psychological
interventions, ECT, crisis service,
combined treatments, MDT & inpatient
care

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19
Q

first line pharm treatment of depression?

give example and mechanism of action

A

SSRIs (specific 5HT or NA reuptake inhibitors)
e.g. Citalopram

block presynaptic uptake rec = increases serotonin/ NAd

no anticholinergic effects

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20
Q

what are tricyclic antidepressants?

A

non-specific in uptake of serotonin/ NAd

amplify 5HT and NA

anticholinergic and other SE. e.g. cardiac therefore not first line

affect other recpetors

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21
Q

what are dual 5HT/NA reuptake inhib antidepressants?

and give example

A

SNRIs e.g. venlafaxine

block both serotonin and NAd.
amplify 5HT AND NA

no anticholinergic effects

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22
Q

why are dual 5HT/NA reuptake inhib antidepressants reserved for 2nd/3rd line treatment?

A

very powerful and have SEs such as cradiac. caution w patients w heart problems

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23
Q

what do atypical antidepressants do?

A

increase serotonin and NAd by diff mechanism

free of major tricyclic SEs

24
Q

mechanism of atypical antidepressants?

and give an example drug for each mechanism

A
  • stimulate 5HT1A rec (buspirone)

- or disinhibition of NA/5HT by blockade of inhibitory receptors e.g. mirtazapine

25
what do MAOIs depressants do?
block MAO receptors so less break down of NTs and more available in synaptic cleft for NTransmission
25
what do MAOIs depressants do?
block MAO receptors so less break down of NTs and more available in synaptic cleft for NTransmission
26
two types of MAOIs: selective and reversible | how do they differ?
selective - amplify 5HT, NA - dietary SEs (wine and cheese) reversible - amplify 5HT, NA - no dietary SEs
27
two types of MAOIs: selective (reversible) and (non-selective) irreversible give example of each
selective: - clorgyline reversible: - moclobemide non-selective... irreversible - phenelzine - tranylcypromine
28
7 types/examples of SSRIs?
1. Fluoxetine 2. Citalopram 3. Escitalopram 4. Sertraline 5. Paroxetine 6. Fluvoxamine 7. Vortioxetine
29
mechanism of action of SSRIs
Blockade of reuptake | of 5HT
30
SSRIs licensed uses?
``` Depression Generalized anxiety disorder Social phobia OCD Eating disorders ```
31
adverse/ side effects of SSRIs?
``` Nausea, Vomiting, Dyspepsia, diarrhoea, sweating, agitation, headache, insomnia Sexual dysfunction Hyponatremia (elderly!!) Cutaneous bleeding disorders ``` GI SEs
32
7 types/ examples of Tricyclic Antidepressants (TCAs)?
1. Amitriptyline 2. Clomipramine 3. Dosulpein 4. Imipramine 5. Lofepramine 6. Nortriptyline 7. Doxepin
33
mechanism of action of TCAs?
Non-selective inhibitors of amine | (5HT, NA) transporters
34
TCAs licensed uses?
Depression Nocturnal enuresis OCD Cataplexy
35
adverse/ side effects of TCAs?
``` Dry mouth, blurred vision, constipation, urinary retention. Postural hypotension Sedation Poor dental health Tachycardia / arryhtymia ``` heart SEs
36
non selective MAOIs particularly useful in?
atypical depression
37
how do the side effects differ for the two types of MAOIs?
MAO-A selective, reversible: - transient, stop when treatment stops non-selective, irreversible: - irreversible SEs actual SEs are the same
38
side effects of any MAOIs?
``` post hypotension dry mouht blurred vision urinary retention (atropine like effects) ``` weight gain restlessness insomnia (CNS stimulation)
39
SNRIs 2 examples
Venlafaxine | Duloxetine
40
mechanism of action of SNRIs
Serotonin- norepinephrine reuptake inhibitor similar to tricyclic
41
SNRIs licensed uses?
Depression Generalized Anxiety disorder
42
SNRIs adverse effects?
``` Nausea, dry mouth, constipation, increased BP. Somnolence, sweating, sexual dysfunction, headaches ```
43
mechanism of action of the newest antidepressant: Agomelatine?
Agonist at melatonin receptor and antagonist at 5HT2c receptor only licensed for depression
44
Adverse effects of Agomelatine?
Nausea, dizziness, headaches, somnolence, changes in Liver function tests
45
Mirtazapine SE that is good for people with what specific symptom of depression?
known to cause sedation good if have insomnia
46
Mechanism of action of Mirtazepine?
antagonist at central pre-synaptic alpha(2) -receptors. Increases both 5HT and NA
47
Mechanism of action of Reboxetine?
Specific Noradrenergic | reuptake inhibitors
48
Mirtazepine adverse effects?
Increased appetite, weight gain, drowsiness, oedema, headache, dizziness
49
Reboxetine adverse effects?
Insomnia, sweating, dizziness, dry mouth, constipation, urinary hesitancy, headache.
50
summary: treatment of Recent onset mild depression?
active monitoring, guided self help, CBT or exercise
51
summary: treatment of Moderate to severe depression?
Antidepressants (SSRIs)
52
summary: treatment For refractory depression?
antidep (SSRIs) | and add Lithium, or antipsychotic or another antidepressant
53
onset of action of antidepressants and what to warn patients about?
Onset of action 10-14 days, warn about withdrawal symptoms
54
duration of treatment with antidep?
After recovery from 1st episode treatment continued for 6-9 months, if 2 or more episode, continue treatment for 2 years