Anxiety and depression Treatment

Question 1

Where are the reductions in brain regions in depression

Answer 1

prefrontal cortex
hippocampus
Amygdala

Question 2

What is the HPA axis in depression

Answer 2

Hypothalamus releases CRH to anterior pituitary

Anterior pituitary releases ACTH to Adrenal cortex

Adrenal cortex releases cortisol

Depressed patients displayed HPA hyper activation

Question 3

What is

• CRH
• cortisol
• pituitary and adrenal glands
• negative feedback of HPA axis

like in depressed patients

Answer 3

increased cortisol in saliva, plasma and urine

Increased CRH in CSF and in limbic brain region

Increased size and activity of the pituitary and adrenal glands

Impaired negative feedback of HPA axis

Question 4

Mode of action of antidepressants

Answer 4

Enhance negative feedback in HPA axis and decrease HPA axis hyperactivity

Question 5

How to treat depression in those <18yo with mild depression

Answer 5

Psychological therapy e.g. CBT

Question 6

How to treat depression in those <18yo with moderate to severe depression

Answer 6

Psychological therapy

if not working, use combined therapy i.e. psychological + fluoxetine

If unresponsive to combined therapy, consider alternative psychological therapy

If experiencing side effects to fluoxetine, use sertraline or citalopram

Question 7

What to give to <18yo patients who are experiencing side effects to fluoxetine

Answer 7

sertraline or citalopram

Question 8

How to treat depression adults with mild depression

Answer 8

Appropriate psychological intervention

Not recommended drug treatment unless under certain circumstances e.g. previous history of moderate/severe depression

Question 9

How to treat moderate/severe depression in adults

Answer 9

Combined therapy (psychological + antidepressant)

Question 10

What are the 3 main modes of action of antidepressants

Answer 10

Reuptake inhibition
Receptor blocked
MOA enzyme inhibition

Question 11

Mode of action of Tricyclic antidepressant

other effects of TCA antidepressants

Answer 11

Inhibit serotonin and noradrenaline reuptake

sedative properties
Anticholinergic side effects (e.g. dry mouth, blurred vision)

CV effects can be Fatal in overdose

Question 12

Effect of Monoamine Oxidase Inhibitor reaction

Answer 12

Cheese reaction- MOA increases tyramine in periphery and this displaces noradrenaline from vesicle storage

-Too much noradrenaline present so you can hypertensive crisis

Question 13

Effect of SSRI

Answer 13

Selective Serotonin Reuptake Inhibitors

Question 14

advantages of SSRIs

Answer 14

favourable side effect profile and less toxic in overdose

Question 15

What is the first line option of antidepressants

Answer 15

SSRI (selective serotonin reuptake inhibitors)

Question 16

What are other antidepressant drugs

Answer 16

Serotonin-Noradrenaline Reuptake Inhibitor

Noradrenaline Reuptake Inhibitor

Mirtazapine

Question 17

Mode of action of Mirtazapine

Answer 17

Enhances NA and 5-HT transmission

Presynaptic a2 adrenoceptors responsible for inhibiting noradrenaline release are blocked

Presynaptic 5-HT2 responsible for inhibiting 5-HT release are also blocked

Question 18

What can be used to treat autonomic symptoms in anxiety

What is their mode of action

Answer 18

B-adrenoceptor antagonists

-Reduces autonomic effect

Question 19

What should you not do with B-adrenoceptor antagonists

Answer 19

Do not withdraw abruptly to prevent rebound effects

Question 20

How to treat anxiety symptoms

Answer 20

SSRI as first option

Psychological interventions

Question 21

When should you and should you not offer benzodiazepine for anxiety

Answer 21

Not offer it executor for short term use during a crisis

Question 22

What are Benzodiazepines used for

Answer 22

Muscle relaxation
Insomnia 
Pre-medicatin
Epilepsy
Alcohol withdrawal 
Anxiety

Question 23

How do benzodiazepines work

Answer 23

They are positive allosteric modulators on GABAa receptor complex

They occupy site on GABAa complex

Conformation change allows GABA to bind

GABA binding causes a conformational change in GABAa receptor chloride channel

There is a greater flow of Cl- into neurone

Hyperpolarisation=inhibition

Question 24

What is the depressed mood and the Mania mood like in Bipolar disorder

Answer 24

Depressed mood- period of at least 2 weeks with core symptoms accompanied by at least 4 other symptoms

Mania- elevated mood, increased energy, incomprehensible speech, racing thoughts, poor concentration

Question 25

What should be used to treat mania in bipolar disorder

what happens if that’s ineffective

What happens if that’s ineffective

Answer 25

antipsychotics: haloperidol, olanzapine, quetiapine or risperidone

If ineffective try a 2nd antipsychotic from above

If ineffective, add lithium or sodium valproate

Question 26

what is the maintenance (long term) of mania bipolar

Answer 26

Continue with whateverr treatment works

Long term treatment- lithium or sodium valproate

Psychological intervention

Question 27

What is the pharmacological interventions of treating the depression in bipolar disorder

Answer 27

Quetiapine alone

if not work: SSRI Fluoxetine combined with olanzapine

If not work: Olanzapine alone

if not work: Lamotrigine alone

Question 28

Why should there be blood monitoring of Lithium in bipolar

Answer 28

Has a very narrow therapeutic window