Anxiety and Depression (Yvonne Mbaki) Flashcards
What is the NHS definition of anxiety?
A feeling of unease, such as worry or fear, that can be mild or severe.
Diagnosis is made if feeling of anxiety occurs all the time.
What different types of anxiety exist?
Panic disorder Obsessive Compulsive Disorder Post-Traumatic Stress Disorder Phobias Generalised Anxiety Disorder
What is Panic Disorder and what symptoms does it present with?
An intense / abrupt feeling of fear or discomfort and includes symptoms such a:
- Sudden temperature change (fight / flight)
- Chest pain (interruption to blood circulation -> palpitations)
- Overwhelming feelings
- Sickness and dizziness
What is OCD and the two aspects to the type of anxiety?
OCD is a combination of obsessive thought and compulsive activity
Obsession - unwanted/unpleasant thoughts that cause anxiety
Compulsion - repetitive behaviour a person undertakes to relieve the unpleasant feeling.
What are the symptoms and presentation associated with PTSD?
Experiencing a trauma / serious accident, natural disaster, criminal assault etc
Condition may develop immediately or years later.
Trauma interferes with normal functioning e.g. sleep
Symptoms include: nightmares, flashbacks, isolation etc
What are Phobias?
Phobias can be an intense fear of something specific that is in reality is of no or little actual danger
What is Social Phobia?
Fear of social or performance situation resulting from thoughts of negative judgement, embarrassment, humiliation. Person tolerates with dread or avoids the situation
What is GAD?
Generalised Anxiety Disorder
Disproportionate worry that cannot be controlled and is excessive about everyday things; job, chores, car repairs, late for appointments, health, family and finances.
In order to commence treatment for an anxiety disorder what is the first initial step?
Rule out organic disease
What organic diseases could be causing the general symptoms of an anxiety disorder?
Asthma SOB
Heart disease palpitations and tachycardia
Hyperthyroidism palpitations sweating and tremor
Vestibular dysfunction (problems with inner ear) dizziness
Hypoglycaemia dizziness
Menopause sweating
Phaeochromocytoma (adrenal tumour) palpitations sweating and tremor
What are the considerations made when assessing a patient presenting with potential anxiety disorder?
History of mental health Environmental stress Medical and drug history Degree of stress and functional impairment Risk of suicide
What is the aim of treating GAD?
Relieve symptoms, improve QoL and prevent relapse
What are the non-pharmacological treatment employed in the treatment of GAD?
CBT Meditation and relaxation techniques (Both recommended by NICE to complement any pharmacological treatment) Mindfulness Exercise
How can the autonomic symptoms of GAD be treated?
B-adrenoreceptor antagonists e.g. propanolol prn (must be titrated down, beta blocker)
Reduces autonomic effect
How is GAD treated pharmacologically?
Selective serotonin reuptake inhibitor (SSRi)
1st line - Escitalopram and Paroxetine
Sertraline (off label indication for GAD)
If no improvement within 2 months of treatment:
Increase dose to maximum
Swap to another SSRi
Consider serotonin noradrenaline-reuptake inhibitor (Venlafaxine and Duloxetine)
Consider anticonvulsant agent pregabalin (blocks glutamate, lots of side effects)
What are uses for benzodiazepines?
Anxiolytic Sedative (minor tranquilizers) Muscle relaxant (central effect) Hypnotic (induce sleep) Anticonvulsant Amnesic Reduce aggression Treat alcohol withdrawal
What are the properties of BDZ?
No enzyme induction making monitoring easy
Some tolerance
Dependence and withdrawal symptoms (short term)
Metabolism is through oxidation and conjugation
Oxidation is reduced by age; effects may be prolonged in older patients
Active metabolites
Relatively safe in overdose
Is BDZ suitable for treatment of GAD?
Drugs that have short half lives (1-10 hours) are generally hypnotics and not suitable for anti-anxiety treatment (temazepam, nitrazepam and zolpidem)
Drugs that have a long half life (1-4 days) are more suitable as anti-anxiety agents e.g. diazepam, chlordiazepoxide, lorazepam but use is restricted to 2-4 weeks and patients must be titrated down.
What is GABA?
The main inhibitory neurotransmitter in the central nervous system.
What is the GABA receptor structure like?
Cl- ion channel in the middle of the flower shaped receptor.
alpha 1, beta 2 and gamme 2 binding sites for alcohol/barbiturate, BDZ, steroids, picrotoxin site
How do BDZ’s work?
Occupy site on GABAa complex, increase the receptors affinity for GABA, greater flow of Cl- ions into the neurone
Hyperpolarisation occurs
What are the Diagnostic and Statistical Manual of Mental Health Disorders?
- Depressed Mood
- Loss of Interest or Pleasure
- Fatigue
- Feelings of Worthlessness
- Recurrent thoughts about death or suicide / attempts
- Reduced ability to think / concentrate
- Psychomotor agitation or retardation
- Altered sleep
- Significant weight changes
What are the various categories of depression?
Subthreshold - 2-4 symptoms; one core symptoms
Mild - In excess of 5 symptoms but minor functional impairment
Moderate - some marked symptoms, presence of functional impairment
Severe - multiple symptoms, markedly interfere with functioning
What is the emphasis on cause in mild to severe depression?
Mild depression is often the result of environmental factors and less so genetics
Severe depression is likely to be contributed to significantly by genetic factors, less likely to be purely environmental product.
What is the associated presentation of Bipolar Disorder?
Cycle between depressed mood and mania (hyper excitability)
Depressed mood - two weeks with core symptoms
Mania - elevated mood, increased energy, incomprehensible speech, racing thoughts, poor concentration etc
When does Bipolar Disorder commonly manifest?
First episode before 30 and peak incidence between 15-19 years of age
Increased incidence observed in ethnic minorites
How is Bipolar Disorder diagnosed?
Eliminate misdiagnosis of BD
Confirmed by specialist mental health professional
How is Bipolar Disorder treated?
Mania (acute phase) - antipsychotics (haloperidol, olanzapine, quetiapine, risperidone), if ineffective try a second. Lithium or sodium valproate added as third option
Maintenance - long term; continue treatment as above with lithium or sodium valproate long term
Psychological intervention CBT / talking therapy
Depression - quetiapine alone
SSRi fluoxetine combined with olanzapine
Olanzapine alone
Lamotrigine alone
Which system of the brain is attributed to depression?
Limbic system
Reduction in the size of thalamus, hippocampus and amygdala in depressed patients.
What is 5-HT Serotonins role in depression?
Depression due to reduced 5-HT, anxiety, obsessions and compulsions
What is noradrenaline NA role in depression?
Alertness, anxiety, interest in life
Role in reward and stress
Reduced NA compromises reward feeling
What is DA dopamines role in depression?
Attention, motivation, reward
Reduced tyrosine
What animal models have been used to show depression?
Forced swimming test
Tail suspension test (mice stop fighting until given an antidepressant)
Learned helplessness
Stress models (food deprivation / electric shocks)
Olfactory bulbectomy (removal - loss of interest until given an antidepressant)
What are the aims in management of depression?
Manage the suicide risk
Improve QoL
Prevent relapse
Treat symptoms
What non-pharmacological interventions can be used in treating depression?
High intensity CBT
Good sleep hygiene
What are the considerations when choosing a treatment plan for the treatment of depression?
Patient preference
Adverse effect profile
Toxicity in overdose
Interaction with other treatment
What is the first line choice for treatment of depression?
Generic SSRis: citalopram, fluoxetine, paroxetine, sertraline
Favourable side effects and less toxic in overdose
How should a patient be counseled on SSRi medication?
Symptoms may worsen before improving
Vigilant on suicidal ideas especially when starting or changing medication
Take 2-4 weeks for symptoms to improve
Medication taken for atleast 6 months after recovery to prevent relapse
What are the side effects of SSRis?
Nausea, vomiting, diarrhoea, dizziness etc
What is recommended to treat depression in <18 y/os?
Antidepressants avoided but fluoextine if necessary
Lifestyle advice including positive coping strategies
How do SSRis work?
Citalopram binds to 5-HT and blocks reuptake
Why do SSRis take 2-4 weeks to work?
SSRI blocks the 5HT reuptake transporter; this triggers the 5HT1 autoreceptor on the presynaptic membrane to activate. This activation stops the exocytosis of 5HT from the presynaptic membrane. It takes 2-4 weeks for the 5HT1 autoreceptor to become downregulated so that 5HT can be exocytosed into the synpatic cleft again.
What are SNRIs?
Venlafaxine, duloxetine
Serotonin-noradrenaline reuptake inhibitor
Similar to SSRis
What are TCA?
Tricyclic Antidepressants
Inhibit 5HT and NA reuptake
Amitryptaline and imipramine
Sedative properties (H1 receptor antagonism)
Anticholinergic SE - dry mouth, blurred vision
Cardiovascular and epileptogenic effects can be fatal in overdose
What are MAOIs?
Monoamine oxidase inhibitors
Phenelzine or tranylcypromide
Tyramine competes with NA for reuptake leading to hypertensive crisis
What class of drug is Mirtazapine?
Noradrenergic and specific serotenergic antidepressant NaSSA
Increases 5HT and NA release
What is St John’s Wort?
Not understood; herbal remedy from Hypericum perforatum
Should not be used in depression as lack of understanding re dose, drug interaction, potency etc
What is the order of drug choices in depression?
SSRis TCAs MAOIs NaSSA NARI
How can pharmacist’s help to complement sleep hygiene?
CBT
Sleeping tablets
BDZs temazepam or nitrazepam (2-4 wk use and titrate dose)
Z-meds; zolpidem, zoplicone
TAC
Melatonin (Circadin) short term in adults <55 y/o
