Antidepressants

Question 1

Name the antidepressants and their starting dose that are preferred in postpartum depression

Answer 1

1) PO sertraline 50 mg ON
2) PO paroxetine SR 25 mg OD

Question 2

Antidepressants commonly associated with QTc prolongation

Answer 2

Escitalopram

Question 3

Antidepressant associated with the most weight gain as well as drowsiness

Answer 3

Mirtazapine

Question 4

Can fluoxetine be used in pregnancy?

Answer 4

Not recommended due to long half life which leads to accumulation in fetal circulation

Question 5

Which class or classess of antidepressants are most commonly associated with orthostatic hypotension?

Answer 5

• TCAs
• MAOI

Question 6

Supplement that can be recommended in patients with MDD?

Answer 6

Omega-3 fatty acid

Question 7

Preferred therapy for young people ≤18yo with mild depression?

Answer 7

Psychotherapy (e.g. cognitive-behavioural therapy, etc.)

Question 8

Preferred therapy for young people ≤18yo with moderate-severe depression? If pharmacotherapy is suggested, state the name, dose and titration

Answer 8

First line: psychotherapy for at least 3 months (NICE, 2019)
After that: can trial combined psychotherapy and pharmacotherpay:

Pharmacotherapy option: fluoxetine 10 mg OD, titrate up to 20 mg after 1 week if clinically required

Question 9

Is electroconvulsive therapy a long or short term? If it is short-term, state what else needs to be done after ECT.

Answer 9

Short-term therapy
- Maintained on anti-depressants after ECT

Question 10

When antidepressants are started, when will the emergence of suicide behaviour usually surface?

Answer 10

1-2 months after initiation of antidepressants

Question 11

If patient has agitation episodes upon initiation of antidepressants, what are the class of drugs that can be added to manage these symptoms?

Answer 11

Benzodiazepines (while the antidepressants take time to work)

Question 12

Treatment duration for the following patients:
a) First episode of depression without psychotic symptoms
b) Second episode of depression
c) More than 2 episodes of depression

Answer 12

a) Full dose of antidepressants for 6 - 9 mo
b) 1 - 2 years
c) > 2yrs or lifelong

Question 13

When is the earliest time that a patient can expect improvement after being newly started on antidepressants?

Answer 13

4-6 weeks for partial improvement

Question 14

How to switch from SSRI to SNRI for:
a) Low dose SSRI
b) High dose SSRI

Answer 14

a) Low dose: stop SSRI and start SNRi immediately
b) High dose SSRI: Cross-taper - decrease SSRI dose and initiate or titrate up SNRI dose at the same time

Question 15

Best antidepressant for patient who is smoking and is obese?

Answer 15

Bupropion (indicated for depression and smoking, and also has anotexic effect to help weight loss)

Question 16

HAM-D score for different severity of depression?

Answer 16

• Mild: 10-13
• Moderate: 14-17
• Severe: >17

Question 17

Do we start antidepressants in a patient with mild MDD?

Answer 17

No. Only start if non-pco was not effective for ≥6 mo

Question 18

What is an “adequate trial” of antidepressant

Answer 18

Newly started antidepressant with monitoring for at least 4-8 weeks, before deciding if it is effective or not

Question 19

Additional indications for duloxetine

Answer 19

1. Diabetic peripheral neuropathy
2. Fibromyalgia
3. Chronic musculoskeletal pain (e.g. OA knees)

Question 20

Non-pharmacological management of MDD

Answer 20

• Sleep hygiene
• CBT

Question 21

When switching SSRIs, when is washout period required?

Answer 21

When switching MAOIs
- Switch from MAOIs to something else: 24h (for moclobemide)
- Switch from something to MAOI: ≥1 week (5 weeks for fluoxetine)

Question 22

Is fluoxetine more likely to cause drowsiness or insomnia?

Answer 22

Insomnia

Question 23

Herb that has high potential to interact with antidepressant hence not recommended to be used?

Answer 23

St. John’s Wort

Question 24

Antidepressant(s) that has fewer CYP interactions

Answer 24

Mirtazapine, escitalopram, venlafaxine, desvenlafaxine, vortioxetine

Question 25

Goal of therapy in depression

Answer 25

Remission of symptoms

Question 26

Initial dose of mirtazapine in elderly?

Answer 26

7.5 mg ON (due to decreased clearance)