antidepressants

Question 1

Markers of severe depression?

Answer 1

Suicide plan or ideas of self-harm.
Unexplained guilt or worthlessness.
Inability to function (eg psychomotor
retardation or agitation).
Concentration impaired.
Impaired appetite.
Decreased sleep/early waking.
Energy low/unaccountable fatigue

Question 2

Examples of SSRIs?

Answer 2

Citalopram, sertraline, fluoxetine, Fluvoxamine, paroxetine,

Question 3

examples of tricyclics?

Answer 3

Amitriptyline, Clomipramine, dosulepin, doxepin
Imipramine and lofepramine
Trimipramine

Question 4

Example of SNRI?

Answer 4

Venlafaxine

Question 5

When to avoid SNRIs? Monitoring? SEs?

Answer 5

If raised BP, raised or low U+Es, heart disease
monitor BP if on >200mg/day.

SE: Constipation; nausea;
dizziness; dry mouth; BP raised ; ADH raised; Na+ reduced; T° raised; dyspnoea, hallucinations, arthralgia

Question 6

Citalopram class? SEs?

Answer 6

SSRI

Nausea, vomiting, dyspepsia, diarrhoea, abdominal pain—also rash, sweats, agitation, headache, insomnia,
tremor,
anorgasmia/erectile dysfunction (sildenafil helps), Na+ reduced, GI bleeding

Question 7

How to help the erectile dysfunction caused by citalopram/sertraline?

Answer 7

Sildenafil (Viagra)

Question 8

How does the SE profile of fluoxetine differ to citalopram/sertraline?

Answer 8

Same SE profile except insomnia and agitation are commoner

Question 9

How does the SE profile of fluvoxamine differ to citalopram/sertraline?

Answer 9

Same SE profile except nausea is commoner

Question 10

How does the SE profile of paroxetine differ to citalopram/sertraline?

Answer 10

more antimuscarinic effects and sedation, also extrapyramidal SEs (rare)

Question 11

Amitripytyline common and other SEs?

Answer 11

Common: sedation, dry mouth, urine retention, blurred vision, postural hypotension, tachycardia, constipation

Other: arrhythmias;
convulsions (dose-related).

Question 12

Which tricyclics have the same SEs as amitriptyline?

Answer 12

Clomipramine, dosulepin, doxepin

Question 13

How do the SE profiles of Imipramine and lofepramine and trimipramine differ to amitriptyline?

Answer 13

Imipramine and lofepramine less sedating

Trimipramine more sedating

Question 14

Common side effects of tricyclics?

Answer 14

drowsiness
dry mouth
blurred vision
constipation
urinary retention
lengthening of QT interval

Question 15

Amitriptylline coomon uses?

Answer 15

commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)

Question 16

Most and least dangerous tricylics in OD?

Answer 16

lofepramine has a lower incidence of toxicity in overdose

amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose

Question 17

Which tricyclics are more and less sedative?

Answer 17

More: Amitriptyline
Clomipramine
Dosulepin
Trazodone*

Less: Imipramine
Lofepramine
Nortriptyline

*trazodone is technically a ‘tricyclic-related antidepressant’

Question 18

Which SSRI to use post MI?

Answer 18

Sertraline

Question 19

Which SSRI should be used in children/adolescents?

Answer 19

fluoxetine

Question 20

When should patients be counselled on after starting SSRI?

Answer 20

to be vigilant for increased anxiety and agitation after starting a SSRI

Question 21

Which SSRIs have higher propensity for drug interactions?

Answer 21

fluoxetine and paroxetine

Question 22

Which drugs do SSRIs interact with?

Answer 22

NSAIDs - NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
Warfarin/heparin - avoid SSRIs and consider mertazapine
aspirin
triptans - increased risk of serotonin syndrome
Monoamine oxidase inhibitors - increased risk of serotonin syndrome

Question 23

When to review patients after starting SSRIS? How long to continue Tx?

Answer 23

patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week.

at least 6mo

Question 24

How to stop SSRIs? Discontinuation symptoms?

Answer 24

gradually reduced over a 4 week period (this is not necessary with fluoxetine)

increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia

Question 25

Use of SSRIs during pregnancy?

Answer 25

BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
Use during the 1st trimester gives a small increased risk of congenital heart defects
- Use during the 3rd trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Question 26

Mirtazapine MOA? When to use? When to take?

Answer 26

blocks alpha2-adrenergic receptors, which increases the release of neurotransmitters.

In older people as fewer SEs and interactions than many other antidepressants.
Also mirtazapine can cause sedation and increased appetite - can be useful in older people.

In evening as sedative.