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BNF > CHAPTER 4: CNS: Depression > Flashcards

CHAPTER 4: CNS: Depression Flashcards

1
Q

What is usually the first benefit of treatment with antidepressants for moderate-severe depression?

A

Improvement in sleep

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2
Q

As well as drug treatment, what else should patients with moderate-severe be treated with?

A

Pscyhological therapy

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3
Q

Should antidepressants be used routinely for mild depression?

A

No, psychological treatment should be considered initially

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4
Q

What are the three major classes of antidepressants?

A
  1. TCAs
  2. SSRIs
  3. MAOIs
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5
Q

How long can it take for antidepressant action to take place after starting drug treatment? What may be required in interim in severe depression?

A

2 weeks

ECT

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6
Q

Which class of antidepressants are better tolerated and safer in overdose than the others? They should be considered as first line

A

SSRIs

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7
Q

TCAs have similar efficacy to SSRIs so why are they more likely to be discontinued? (2)

A
  1. Less tolerable side effects

2. Toxicity in overdose

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8
Q

Which 3 effects do SSRIs have less of compared with TCAs?

A
  1. Less sedation
  2. Less antimuscarinic effects
  3. Less cardiotoxic
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9
Q

Which class of antidepressants has dangerous interactions with foods and drugs, should be reserved for use by specialists?

A

MAOIs

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10
Q

Which popular remedy for depression should NOT be prescribed or recommended for depression?

A

St John’s Wort

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11
Q

What effect does St John’s Wort have on metabolising enzymes?

A

Enzyme INDUCER

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12
Q

How often should patients be reviewed at the start of antidpressant treatment?

A

Every 1-2 weeks

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13
Q

How long should treatment be continued before considering whether to switch due to lack of efficacy? (elderly)

A

4 weeks (6 weeks)

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14
Q

Following remission, how long should antidepressant treatment be continued for at least? (elderly/GAD)

A

6 months (12 months)

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15
Q

How long should patients with a history of recurrent depression receive maintenance treatment for?

A

at least 2 years

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16
Q

Which electrolyte effect has been associated with all classes of antidepressant, especially SSRIs?

A

Hyponatreamia

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17
Q

If a patient on antidepressants (especially SSRIs) presents with drowsiness, confusion, or convulsions, what should be considered?

A

Hyponatreamia due to SIADH

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18
Q

What is there a particular risk of at the beginning of treatment or if a dose is changed?

A

Suicidal thoughts and behaviour

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19
Q

What is serotonin syndrome?

A

A relatively uncommon adverse drug reaction caused by excessive serotonergic activity

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20
Q

When is serotonin syndrome most likely to occur? (5)

A
  1. Initiation of treatment
  2. Dose increase
  3. Overdose
  4. Addition of new serotonergic drug
  5. Replacement of one serotonergic drug without allowing a long enough wash-out period between
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21
Q

Severe toxicity usually occurs when a combination of serotonergic drugs is used - involving which particular drug?

A

MAOI

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22
Q

What are the main areas which symptoms of serotonin syndrome fall under? (3)

A
  1. Neuromuscular hyperactivity
  2. Autonomic dysfunction
  3. Altered mental state
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23
Q

What are the neuromuscular hyperactivity symptoms of serotonin syndrome? (5)

A
  1. Tremor
  2. Hyperreflexia
  3. Clonus
  4. Monoclonus
  5. Rigidity
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24
Q

What are the autonomic dysfunction symptoms of serotonin syndrome? (5)

A
  1. Blood pressure changes
  2. Hyperthermia
  3. Tachycardia
  4. Shivering
  5. Diarrhoea
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25
Q

What are the altered mental state symptoms of serotonin syndrome? (3)

A
  1. Confusion
  2. Mania
  3. Agitation
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26
Q

What are the options is there is failure to respond to initial treatment with an SSRI? (3)

A
  1. Increase the dose
  2. Different SSRI
  3. Mirtazapine
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27
Q

Which drugs can be considered for more severe forms of depression (2)

A
  1. TCAs

2. Venlafaxine

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28
Q

Can a GP prescribe irreversible MAOIs?

A

No, specialist only

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29
Q

What are the options is there is failure to respond to treatment with two antidepressants? (3)

A
  1. Adding another of a different class
  2. Using an augmenting agent
  3. Use Vortioxetine
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30
Q

Give some examples of augmenting agents used when antidepressant treatment fails with 2 drugs (5)

A
  1. Lithium
  2. Aripiprazole
  3. Olanzapine
  4. Risperidone
  5. Quetiapine
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31
Q

Which 2 drugs are generally used to treat anxiety?

A
  1. Benzodiazepines

2. Buspirone

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32
Q

How long does anxiety have to last for it to be considered chronic?

A

4 weeks

33
Q

If anxiety lasts longer than 4 weeks, it is considered chronic. Which drugs may it be appropriate to start treatment with?

A

Antidepressants

34
Q

Which drug class do duloxetine and venlafaxine fall under?

A

SNRI

35
Q

What is first line for GAD?

A

SSRIs

36
Q

After SSRIs, what can be used to treat GAD?

A

SNRIs

37
Q

If a patient cannot tolerate SSRIs and SNRIs, what is used to treat GAD?

A

Pregabalin - licensed

38
Q

What is first line for panic disorder, PTSD and OCD?

A

SSRIs

39
Q

What is the licensed treatment for social anxiety disorder?

A

Moclobenamide

40
Q

Which two groups can TCAs be roughly divided into?

A
  1. Sedating

2. Non-sedating

41
Q

TCAs which call into which group will benefit agitated patients?

A

Sedating

42
Q

TCAs which call into which group will benefit apathetic patients?

A

Non-sedating

43
Q

Give examples of sedating TCAs

A
  1. Amitriptyline
  2. Clomipramine
  3. Trazadone
44
Q

In most patients, long half life of TCAs allows for what?

A

Once daily administration

45
Q

At which time of day are TCAs usually administered?

A

At night

46
Q

Apart from depression, TCAs can also be used in which conditions?

A
  1. Anxiety
  2. Nocturnal enuresis
  3. Neuralgia
47
Q

Are TCAs recommended for use in children?

A

No, studies have shown they are not effective

48
Q

What are the dangers of MAOIs?

A

Interactions with drugs and food

49
Q

Give 4 examples of MAOIs

A
  1. Tranylcypromine
  2. Phenelzine
  3. Isocarboxazid
  4. Moclobenide
50
Q

Which crisis is associated with MAOIs?

A

Hypertensive crisis

51
Q

How long may response to treatment with MAOIs be delayed for?

A

3 weeks

52
Q

After the 3 weeks it takes to show a response in treatment, how many additional weeks can it take for response to become maximal?

A

Additional 1-2weeks

53
Q

After stopping a MAOI, how long should we wait before starting another anti-depressent?

A

2 weeks

54
Q

If starting the TCAs; clomipramine or imipramine, how long after stopping a MAOI should we wait?

A

3 weeks

55
Q

How long should we wait before starting a new MAOI after stopping an old MAOI?

A

2 weeks

56
Q

How long should we wait before starting a MAOI after stopping a TCA? (3 weeks for clomipramine and imipramine)

A

1-2 weeks

57
Q

How long should we wait before starting a MAOI after stopping an SSRI?

A

1 week

58
Q

How long should we wait before starting a MAOI after stopping fluoxetine?

A

5 weeks

59
Q

Which class of antidepressants carries a risk of postural hypotension as well hypertensive crisis?

A

MAOI

60
Q

Which side effects should patients be aware of when taking MAOIs as they can be sign of postural hypotenson and hypertensive responses? (2)

A
  1. Headaches

2. Palpitations

61
Q

Can MAOIs be stopped suddently?

A

No

62
Q

What are the withdrawal symptoms of MAOIs? (9) Symptoms increased after treatment of 8 weeks or more. Can occur within 5 days of stopping treatment

A
  1. Agitation
  2. Irritability
  3. Movement disorder
  4. Ataxia
  5. Insomnia
  6. Drowsiness
  7. Vivid dreams
  8. Cognitive impairment
  9. Slowed speech
63
Q

How long should the dose of MAOIs be withdrawn over? (Long term)

A

4 weeks (6 months if long term)

64
Q

Regarding food, what should patients taking MAOIs be counselled on? Can carry on 2 weeks after discontinuing treatment (2)

A
  1. Fresh food only, avoid if it is stale or gone off

2. No alcohol or “de-acoholised” drinks

65
Q

Which foods should patients taking MAOIs be particularly cautious of? (3)

A
  1. Meat
  2. Fish
  3. Poultry
66
Q

Which are the irreversible MAOIs?

A
  1. Isocarboxazid
  2. Phenelzine
  3. Tranylcypromine
67
Q

Which is the only reversible MAOI?

A

Moclobamide

68
Q

What is a sign of a nhypersensitivity reaction with SSRIs?

A

Rash

69
Q

What are the signs of SSRI overdose? (5)

A
  1. Nausea
  2. Vomiting
  3. Drowsiness
  4. Sinus tachycardia
  5. Convulsions
70
Q

What are the signs of SSRI abrupt withdrawal? (9)

A
  1. GI disturbance
  2. Headache
  3. Anxiety
  4. Electric shock sensation in the head
  5. Tinnitus
  6. Sleep disturbance
  7. Fatigue
  8. Flu-like symptoms
  9. Sweating
71
Q

How long should the SSRI dose be tapered over?

A

4 weeks, (6 months if long term)

72
Q

What can citalopram prolong?

A

QT interval

73
Q

What is the dose equivalence of oral drops compared with tablets?

A

8 drops = 16mg drops = 20mg tablets

74
Q

What class of drug is Venlafaxine?

A

SNRI

75
Q

What class of drug is trazadone?

A

Serotonin uptake inhibitor

76
Q

What are the symptoms of TCA overdose (can also occur as side effects at normal doses)? (9)

A
  1. Dry mouth
  2. Coma
  3. Hypotension
  4. Hypothermia
  5. Convulsions
  6. Cardiac conduction defects
  7. Arrhythmias
  8. Dilated pupils
  9. Urinary retention
77
Q

If a patient with bipolar is being treated with a TCA, when should it be stopped?

A

If they enter a manic phase

78
Q

What is the mechanism of action of Mirtazapine?

A

Presynaptic alpha-adrenoceptor antagonist which increases noradrenergic and serotonergic nuerotransmission

79
Q

Which drug is used to treat inappropriate sexual behaviour?

A

Benperidol

BNF (28 decks)

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