Antidepressants

Question 1

Uses for SSRIs?

Answer 1

Mild-moderate depression
OCD
Bulmia nervosa
Panic/phobic disorder

Question 2

If there is no response to increased dose of an SSRI, what should be done next?

Answer 2

Switch to another SSRI (before trying a new class of drug)

Question 3

What SSRI has no withdrawal symptoms?

Answer 3

Fluoextine (long half life) (AKA prozac)

Question 4

Which SSRIs have fewer interactions in the others?

Answer 4

Citalopram and sertraline

Good to use in patients with other chronic diseases

Question 5

Cautions for the use of SSRIs?

Answer 5

Increased risk of bleeding - prescribe PPI in elderly or people taking NSAIDS/aspirin

Epilepsy

Children (can induce mania)

Question 6

Side effects of SSRIs?

Answer 6

GI disturbance: N+V+D, anorexia/weight loss

Anticholinergic (can’t pee, can’t see, can’t spit, can’t shit)

Hyponatremia

Sexual: dysfunction - ED, orgasm problems

Neuro: headache, anxiety

Rare: sedation, convulsions, suicide

Question 7

SSRI discontinue syndrome

Answer 7

Usually within first week of stopping suddenly

• -> dizziness, nausea, headache, lethargy
  (esp. paroxetine)

Resolves spontaneously within 3 weeks

Question 8

SNRI examples and uses

Answer 8

Venlafaxine and Duloxetine

Severe depression (resistant to SSRI)
GAD
Panic disorder, anxiety, OCD

Question 9

SNRI contraindications

Answer 9

Elderly
HTN (uncontrolled)
Arrhythmia

Question 10

SNRI side effects?

Answer 10

Same as SSRI + HTN

take baseline BP/ECG

Question 11

NASSA example

Answer 11

Mirtazapine

NASSA = noradrenaline and specific sermonic antidepressant

Question 12

Caution with NASSA?

Answer 12

Elderly and type II DM

Question 13

Side effects of mirtazapine?

Answer 13

Sedation (initially - becomes less sedative at higher doses)

Antiadrenergic ( sexual dysfunction, postural hypotension, tacky, sweaty, insomnia)

Question 14

NARI examples

Answer 14

Reboxetine

Question 15

Cautions for reboxetine?

Answer 15

Urinary retention and prostatic hypertrophy

Sleep problems

Question 16

Side effects of reboxetine?

Answer 16

Anti-ACh and Antiadrenergic

Question 17

Examples of tricyclic antidepressants

Answer 17

Tertiary amines:
Amitryptaline
Clomipramine
Imipramine

Secondary amines:
Nortryptalline
Dothiepin
Lofepramine (less toxic in OD)

Question 18

Uses of tricyclics?

Answer 18

Depression (esp inpatinets)
Bulmia nervosa

Amitriptyline - agitated depression
Cloripramine - phobic conditions, OCD
Imipramine - panic disorder, agoraphobia

Question 19

Contraindications for tricyclics?

Answer 19

Immediately after MI or arrhythmia
Mania Hx (risk manic switch)
Acute porphyria

Question 20

Caution for tricyclics?

Answer 20

Elderly
Glaucoma
Prostatic hypertrophy

Question 21

Side effects of tricyclics?

Answer 21

Cardiovascular - tachy, arrhythmia, ECG (flat T waves, Long QT), postural hypotension

Neurotoxic - confusion/delirium, convulsions

Anticholinergic
Antihistaminergic (drowsy, sedative, weight gain)

Question 22

Interactions of tricyclics?

Answer 22

Many!
E.g.
Dental anaesthesia (lignocaine), SSRI and MAOIs
(Nb. don’t start tricyclic until 2/3 weeks of stopping MAOI)

Question 23

Uses of MAOIs?

Answer 23

Refractory / atypical depression (over eating/sleeping)

refractory / atypical anxiety:
Phobic disorders with atypical, hypochondriacal or hysterical features
OCD
Agoraphobia

Question 24

Why are MAOIs not used often?

Answer 24

Poor tolerability and dietary restrictions (due to risk of hypertensive crisis)

Question 25

Contraindications for MAOIs

Answer 25

Cerebrovascular disease
Pheochromocytoma
Mania

Interacts with many drugs (even OTC) - therefore consult Dr before taking anything

Question 26

Side effects of MAOIs

Answer 26

Anticholinergic
Antiadrenergic
Heptotoxicity

Question 27

Hypertensive crisis and MAOIs

Answer 27

Avoid foods containing tyramine (cheese, red wine, bovril)

Early Sx - irritable, anxious, flushing
Mod-severe Sx - fever, restlessness, seizures, tachycardia

Question 28

Trazadone

Answer 28

5-HT2 antagonist / tricyclic related A/D

Useful for depression when sedation is required and unlicensed agitated dementia

S.E. = dyspepsia, hyper salivation, HTN
1% –> priapism

Question 29

Serotonin syndrome

Answer 29

Increased serotonin –> fever, restlessness, tremor –> arrhythmia, confusion and seizures

Occurs in SSRI, TCA, MAOI, st johns wort

Question 30

Hyponatremia

Answer 30

Anorexia, nausea and malaise –> headache, confusion, seizures

All A/D but SSRIs are worst (Mirtazapine and lofepramine have the lowest risk)

Typically small, thin old ladies with kidney problems
Can be exacerbated by diuretics

Question 31

Suicide risk

Answer 31

Highest risk 2-3 days discharged and in first week of SSRI (increased motivation)
Warn patient!

Question 32

Treatment withdrawal

Answer 32

Occurs within 5 days of stopping
Mild and self limiting (3 weeks)
SX: Flu-like, insomnia, agitated, irritable, vivid dreams

Most severe in venlafaxine and paroxetine

Question 33

Anticholinergic effects

Answer 33

Blurry vision (can't see)
Urinary retention (can't pee)
Dry mouth (can't spit)
Constipation (can't shit)

Cardiac: Tachycardia, palpitations
Cognitive: Drowsy, confusion, memory problems

Question 34

Antiadrenergic effects

Answer 34

Sexual: orgasm problems, erectile dysfunction
Head: drowsy, postural hypotension, insomnia
Cardiac: Tachy, sweaty

Question 35

Antihistaminic effects

Answer 35

Sedation and drowsy

Weight gain

Question 36

ECT indications

Answer 36

Severe depression
Mania
Catatonic schizophrenia
Neuroleptic malignant syndrome

Question 37

Absolute CI for ECT?

Answer 37

Raised ICP

Question 38

Short term SE of ECT?

Answer 38

Headache, confusion, muscle ache, short-term memory loss

Question 39

Long term SE of ECT?

Answer 39

Long-term memory loss