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Mental Health > Case 1 - Depression and Suicide Risk > Flashcards

Case 1 - Depression and Suicide Risk Flashcards

1
Q

How long does it typically take for antidepressants to reach therapeutic dose?

A

~ 3-6 weeks

Thus if not therapeutic effect at ~ 2 months then:

  • Change dose
  • Switch to different antidepressant
  • Augment with another agent
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2
Q

All antidepressants have a similar response rate - what is this %?

A

~67% of pts respond to an antidepressant after 8 weeks (expect some benefit from 2 weeks onwards)

33% = non responders

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3
Q

What is the MoA of TCAs?

A
  1. Serotonin reuptake inhibition (SERT antagonism)
  2. Noradrenaline reuptake inhibition (NET antagonism)
  3. SHAM receptor antagonism:
    • S = serotonin (5HT receptors)
    • H = histamine receptors
    • A = alpha adrenergic receptors
    • M = muscarinic acetylcholine receptors
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4
Q

What are some side effects of TCAs?§

A

Histamine - R antagonism:

  • Sedation
  • Weight gain

Alpha adrenergic-R antagonism:

  • Drowsiness
  • Orthostatic hypotension
  • Reflex tachycardia
  • Erectile dysfunction

Muscarinic ACh-R antagonism:

  • Blurred vision
  • Glaucoma
  • Dry mouth (↓ saliva i.e. xerostomia)
  • Urinary retention
  • Constipation
  • Cognitive impairment
  • ↓ seizure threshold

Cardiotoxic:

  • Prolong QT interval
  • Arrhythmias
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5
Q

What are the differences between secondary and tertiary TCA’s?

A

Secondary:
Act primarily on noradrenaline reuptake inhibition
Same side effects as tertiary TCAs but less severe
E.g. desipramine, nortriptyline

Tertiary:
Act primarily on serotonin reuptake inhibition
Side effects = many
E.g. amitriptyline, doxepin, clomipramine

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6
Q

What are TCAs used to treat?

A
  1. MDD (major depressive disorder) –> not often!! other antidepressants are more commonly used due to TCAs side effects + toxicity in OD
  2. Neuropathic pain
  3. Migraine prophylaxis (amitriptyline)
  4. Chronic tension-type headache prophylaxis (amitriptyline)
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7
Q

List some conditions that SSRIs are used to treat?

A
  • MDD
  • GAD
  • OCD
  • Eating disorders e.g. Bulimia nervosa
  • Panic disorder
  • PTSD
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8
Q

Which SSRI is safest to use post MI?

A

Sertraline

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9
Q

Which SSRI is safest to use in children and adolescents?

A

Fluoxetine

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10
Q

What are some common side effects of SSRIs?

A

Side-effects:

  • GI disturbance (most common) - pain, diarrhoea, vomiting
  • Sexual dysfunction (30%)
  • Anxiety + agitation - pts counselled to watch for
  • Dry mouth
  • Hyponatraemia
  • Restlessness
  • Nervousness
  • Insomnia
  • Fatigue / sedation
  • Dizziness
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11
Q

What drug should be prescribed alongside an SSRI and why?

A

A PPI (proton pump inhibitor)

e.g. omeprazole, lansoprazole

Because GI disturbance is the most common side effect of SSRIs

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12
Q

What are common drug interactions for SSRIs?

A

NSAIDs e.g. aspirin
- (NICE: do not prescribe, but if you do, also give a PPI)

Warfarin / heparin
- NICE: avoid and consider mirtazapine

Triptans (avoid)

MAO-inhibitors
- risk of serotonin syndrome (excess serotonins impact on the CNS)

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13
Q

What is and what causes serotonin syndrome?

A

Serotonin syndrome is the result of excess serotonin acting on the CNS

Cause = serotonin increasing drug OD or combination

  • SSRIs
  • SNRIs
  • MAOI
  • TCAs
  • Ecstasy (MDMA)
  • Amphetamines
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14
Q

What are the features of serotonin syndrome?

How is serotonin syndrome managed?

A

FEATURES;

  • Rapid onset (min-hours of serotonin ↑)
  • Neuromuscular excitation e.g. hyperreflexia, myoclonus, rigidity, tremor
  • Autonomic NS excitation e.g. hyperthermia, sweating, dilated pupils, ↑ HR, HTN, diarrhoea
  • Altered mental state, agitation / irritability
  • Complications: seizures + rhabdomyolysis

MANAGEMENT:

  • Discontinue offending medications that ↑ serotonin
  • Supportive e.g. IV fluids, active cooling
  • Benzodiazepines (↓ agitation)
  • Severe cases = serotonin antagonist e.g. chlorpromazine or cyproheptadine
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15
Q

For how long should a pt continue to take an antidepressant after remission is induced?

A

6 months

This reduces the risk of relapse into depression

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16
Q

What are the risks of stopping antidepressant medication too fast?

A

Discontinuation symptoms!!

  • ↑ mood change
  • Dysphoria (generalised dissatisfaction with life)
  • Restlessness
  • Difficulty sleeping
  • Unsteadiness
  • Paraesthesia
  • Sweating
  • GI symptoms: pain, cramping, diarrhoea, vomiting
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17
Q

How should stopping treatment with SSRIs be done?

Is this different for any SSRIs specifically?

A

SSRI dose ↓ gradually over 4 weeks (varies for each pt)

Fluoxetine = reduction / cessation can occur faster with fluoxetine as it has a long half-life –> thus ↓ likelihood of withdrawal symptoms

Paroxetine = ↑ incidence of discontinuation symptoms

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18
Q

What conditions are SNRIs used to treat?

Name 2 examples of SNRIs.

A

CONDITIONS:

  • MDD
  • GAD
  • Social anxiety disorder (venlafaxine)
  • Panic disorder
  • Menopausal symptoms (venlafaxine)
  • Diabetic neuropathy (duloxetine)

EXAMPLES:
Venlafaxine and Duloxetine

19
Q

What are the pros and cons of Venlafaxine vs Duloxetine?

A

-

20
Q

How do MAO inhibitors work?

A

-

21
Q

What are common side effects of MAO-inhibitors?

A

-

22
Q

What are the 3 main classes of ‘Mood-stabilisers’?

A

-

23
Q

Name 5 things that Lithium is licensed for treatment of?

A

-

24
Q

What is bipolar disorder (BPD)?

What are the types of BPD?

A

-

25
Q

What is the difference between mania and hypomania?

A

-

26
Q

What tests need to be done prior to starting Lithium?

A

-

27
Q

How is a pt on Lithium monitored?

A

-

28
Q

Side effects of Lithium are broken down into:

  • Short / medium term
  • Long term

What are some of the side effects?

A

-

29
Q

Lithium toxicity occurs above what blood conc?

What can precipitate Lithium toxicity?

What symptoms does Lithium toxicity present with?

A

-

30
Q

How does sodium valproate compare to Lithium in terms of:

  • Prophylactic treatment of mania
  • Prophylactic treatment of depression
  • Side effects
  • Monitoring
  • Pregnancy
A

-

31
Q

What are some common side effects of sodium valproate (Depakote)?

A

-

32
Q

What 2 questions are asked to ‘screen’ pts for depression?

A

-

33
Q

What are the ICD-10 criteria for ‘Depressive disorder’?

A

-

34
Q

How is depression severity grade based on no. of ICD-10 symptoms?

A

-

35
Q

How are mania and hypomania defined (DSM-5)?

A

-

36
Q

What features of hypomania / mania might a pt have?

Think: DIGS FAST

A

-

37
Q

For the following split them into whether they convey a high or low risk of suicide:

  • Unemployed
  • Age < 45 years
  • Female
  • Male
  • Employed
  • Age > 45 years
  • Substance misuse
  • FHx of depression, substance misuse or suicide
  • Physical illness
A

-

38
Q

Mrs Banerjee has recently recovered from a major depressive episode on duloxetine 60mg orally daily. This was her third major depressive episode in the past four years. What is the best management advice to reduce her risk of relapse?

  • Remain on the current dose for 6-9 months, then taper and stop
  • Remain on the current dose for a year, then taper and stop
  • Remain on the current dose for a year, then reduce the dose by 50%
  • Remain on the current dose for at least 2 years, then reduce the dose by 50%
  • Remain on the current dose for at least 2 years, and potentially long-term
A

-

39
Q

For each severity of depression, how is it treated?

  • Mild
  • Moderate
  • Severe
A

-

40
Q

What conditions can mimic depression?

A

-

41
Q

How is an episode of hypomania / mania managed (5 steps)?

A

-

42
Q

How is an episode of bipolar depression managed?

A

-

43
Q

A 28-year old man present to his GP complaining that he cannot organism during sex with his partner. He did not have this problem before starting treatment for depression 6 weeks previously. Select the prescription ‘most likely’ to cause this?

  • Moclobemide 450mg PO daily
  • Mirtazapine 30 mg PO daily
  • Vortioxetine 15 mg PO daily
  • Sertraline 150mg PO daily
  • Agomelatine 50 mg PO at bed
A

-

Mental Health (5 decks)

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