Antidepressants

Question 1

treatment for mild depression

Answer 1

watchful waiting

problem solving exercises

Question 2

treatment for moderate depression

Answer 2

1st line - SSRI
2nd line - try different SSRI/SNRI
3rd line- try adding mitazapine to the SSRI/SNRI
other - try antipsychotic for treatment resistant depression

Question 3

examples of SSRIs

Answer 3

Citalopram 
Sertraline 
Escitalopram 
Fluoxetine 
Fluvoxamine 
Paroxetine

Question 4

how to SSRIs work

Answer 4

block the re-uptake of serotonin by the pre-synaptic neuron so it stays in the synapse longer and has a greater effect

Question 5

SSRI side effects

Answer 5

GI symptoms 
-nausea 
-vomiting 
-diarrhoea 
agitation/restlessness 
insomnia 
dizziness 
headaches 
sexual dysfunction 
hyponatraemia 
bleeding 
worsened thought of hurting self or others (more in <30s)

Question 6

which SSRI is most likely to cause sexual dysfunction

Answer 6

paroxetine

Question 7

examples of SNRIs

Answer 7

venlafaxine
des-venlafaxien
duloxetine

Question 8

How do SNRIs work

Answer 8

block serotonin and nor-adrenalin re-uptake

nor-adrenaline re-uptake inhibition only occurs at doses above 150 mg

Question 9

side effects of SNRIs

Answer 9

similar to SSRIs +

• seizure in overdose
• hypertension
• discontinuation syndrome

has a higher rate of adverse effects than SSRIs

Question 10

with which SNRI should you avoid alcohol consumption

Answer 10

Duloxetine

-causes liver disease

Question 11

what is mirtazapine and how does it work

Answer 11

alpha 2 adrenoreceptor antagonist

increases nor-adrenaline concentration by blocking negative feedback on alpha 2 receptors

also block receptors which can cause SSRI side effects eg. sexual dysfunction, insomnia and nausea

Question 12

mirtazapine side effects

Answer 12

increased appetite
weight gain
sedation

Question 13

when is mirtazapine best used

Answer 13

in addition to SSRI/SNRI in treatment resistant depression

Question 14

examples of tricyclic antidepressants

Answer 14

Amitriptyline 
Clomipramine 
Dosulepin 
Imipramine 
Lifepramine 
Nortriptyline

Question 15

side effects of tricyclics

Answer 15

anti-muscarinic effects

• dry mouth
• constipation
• urinary retention
• blurred vision

anti-histamine effects

• sedation
• weight gain

alpha-1-adrenergic action

• dizziness
• orthostatic hypotension

blockage of sodium channels

• seizure
• comma
• cardiac arrest
• death

mania in bipolar
discontinuation syndrome
neurotoxicity
cardio toxicity

Question 16

when are tricyclics contraindicated

Answer 16

arrhythmia 
previous MI 
heart block 
mania 
hypomania 
acute porphyria

Question 17

what do mono-amine oxidase inhibitors do

Answer 17

instead of working on the pre-synaptic neurone to increase re-uptake, they block mono-amine oxidase which would usually work in the synapse to break down the neurotransmitter

Question 18

examples of reversible MAOIs

Answer 18

phenelzine

isocarboxazid

Question 19

example of non-reversible MAOIs

Answer 19

Moclobemide

-better tolerated

Question 20

side effects of MAOIs

Answer 20

Hypertensive crisis caused by tyramine containing foods

• cheese
• yeast extracts

postural hypotension

Question 21

What causes hypertensive crisis in MAOIs

Answer 21

Monoamine oxidase is present in the CNS but also in the periphery

It is used in the GI tract to break down tyramine

MAOIs inhibit CNS and GI monamine oxidase so the tyramine is not broken down and causes the hypertensive crisis

Question 22

what is serotonin syndrome

Answer 22

an acute neuropsych presentation caused by raised CNS serotonin activity

caused by simulataneous prescription of more than one antidepressant, or agents that increase serotonin function

Question 23

how does serotonin syndrome present

Answer 23

Agitation 
Sweating 
Confusion 
Myoclonus 
Nystagmus 
Headache 
Pyrexia 
Mood changes 
Fits

Question 24

treatment of serotonin syndrome

Answer 24

stop anti-depressants

supportive