antidepressants

Question 1

what are they used to treat?

Answer 1

depression, anxiety, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobic states such as social anxiety disorderwh

Question 2

what is most favourable now?

Answer 2

SSRIs due to lower s/e profile and lower risk of toxicity

Question 3

how do SSRIs work?

Answer 3

SSRIs selectively inhibit serotonin reuptake, increasing its availability and enhancing mood regulation.

Question 4

when are SSRIs used?

Answer 4

SSRIs are first line for medical management of depression, generalised anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and phobic states such as social anxiety disorder.

Question 5

when should SSRIs be used with caution?

Answer 5

Should be omitted in mania
Should be used with caution in children and adolescents
Should be avoided in patients taking warfarin, due to increased risk of bleeding

Question 6

what SSRI best for pts with ischameic heart disease>?

Answer 6

sertraline

Question 7

what are s/e of SSRIs?

Answer 7

GI upset
Anxiety and agitation
QT interval prolongation (especially associated with citalopram)
Sexual dysfunction
Hyponatraemia
Gastric Ulcer

Question 8

how should you monitor SSRIs in young people?

Answer 8

In people aged 18-25 there is an increased risk of impulsivity and suicidal risk upon commencing antidepressant medication and so they should have a follow-up appointment arranged after one week to monitor progress. Initial reviews can otherwise be arranged 2-4 weeks after starting medication in patients >25.

Question 9

how long should SSRIs be used?

Answer 9

Continuation of antidepressants for at least six months post-remission is recommended to mitigate relapse risk. Tapering should be done gradually over a four-week period when discontinuing antidepressants.

Question 10

what is serotonin syndrome?

Answer 10

potentially life-threatening condition linked with increased serotoninergic activity in the central nervous system.

Question 11

when does serotonin syndrome present?

Answer 11

within the first few months of starting a Selective Serotonin Reuptake Inhibitor (SSRI) or due to drug interactions (SSRI + tramadol).

Question 12

what is serotonin syndrome characterised by?

Answer 12

mental status changes, autonomic hyperactivity, and neuromuscular abnormalities

Question 13

how do SNRIs work?

Answer 13

SNRIs work by increasing serotonin and norepinephrine levels, improving mood and anxiety.

Question 14

when are SNRIs indicated?

Answer 14

Question 15

when are SNRIs contraindicated?

Answer 15

Contraindicated in those with a history of heart disease and high blood pressure

Question 16

s/e of SNRIs?

Answer 16

Nausea
Insomnia
Increased heart rate
Agitation

Question 17

what are NaSSA?

Answer 17

Noradrenergic and specific serotonergic antidepressant

Question 18

how do NaSSA work?

Answer 18

NaSSAs such as mirtazepine also work by modulating norepinephrine and serotonin levels in the brain.

Question 19

when are NaSSA indicated?

Answer 19

Mirtazepine is a second line choice of medication for management of depression, though may be preferred if in particular there are concerns over weight loss, as one of it’s side effects is increased appetite. It may also be preferred if there are issues with getting to sleep as it is a light sedative and so it is usually taken in the evening.

Question 20

s/e of NaSSA?

Answer 20

Sedation
Increased appetite
Weight gain
Constipation/diarrhoea

Question 21

what are tricyclic antidepressants MOA?

Answer 21

Tricyclic and related antidepressants block the re-uptake of both serotonin and noradrenaline, and examples include amitriptyline, clomipramine and imipramine. They are also antimuscarinic

Question 22

indications to use tricyclics?

Answer 22

They are another example of second line choices for treatment of depression, and are sometimes. used in the management of panic and other anxiety disorders.

Question 23

when are tricyclics contraindicated?

Answer 23

Contraindicated in those with previous heart disease

Question 24

what can tricyclics exacerbate?

Answer 24

Can exacerbate schizophrenia
May exacerbate long QT syndrome

Question 25

when should tricyclics use with caution?

Answer 25

pregnancy and breastfeeding
May alter blood sugar in T1 and T2 DM
May precipitate urinary retention, so avoid in men with enlarged prostates
avoid in those on other CP450 medications or those with liver damage

Question 26

s/e of tricyclics?

Answer 26

anticholinergic effects:

Urinary retention
Drowsiness
Blurred vision
Constipation
Dry mouth

Question 27

what are key signs/symptoms of tricyclic toxicity?

Answer 27

drowsiness, confusion, arrhythmias, seizures, vomiting, headache, flushing, and dilated pupils

Question 28

how do you ix tricyclic toxicity?

Answer 28

blood tests (FBC, UE, CRP, LFTs), Venous Blood Gas, and an ECG to check for QT interval prolongation

Question 29

management of tricyclic toxicity?

Answer 29

supportive care based on patient symptoms, with considerations for activated charcoal within 2-4 hours of the overdose and intensive care review in severe cases.

Question 30

what are MAO-Is?

Answer 30

Monoamine oxidase inhibitors

Question 31

what are MOA of MAOIs?

Answer 31

Monoamine oxidase (MAO) normally metabolises serotonin and noradrenaline in the presynaptic cell. MAO inhibitors inhibit monoamine oxidase which leads to an elevation in brain levels of catecholamines and serotonin. It has a similar structure to amphetamine so this also affects the uptake and release of dopamine, noradrenaline, and serotonin.

Question 32

examples of MAOIs?

Answer 32

Examples include moclobemide (MAO-B inhibitor), phenelzine (MAO-A inhibitor).

Question 33

indications for MAOIs?

Answer 33

They were historically used to treat depression but are used less frequently now.

Question 34

when should MAOIs be used with caution?

Answer 34

Cerebrovascular disease
Manic phase of bipolar disorder
Phaeochromocytoma
Severe cardiovascular disease

Question 35

s/e of MAOI?

Answer 35

Hypertensive reactions (‘cheese reaction’) with tyramine-containing foods (so patients need to avoid pickled herring, Bovril, Oxo, Marmite, cheese, salami).

Should also avoid broad bean pods as these contain dopa.