Choosing the right treatment Flashcards
What is the treatment for mild depression?
Low intensity psychological interventions NO ANTIDEPRESSANTS (unless 8+ wks or previous depression)
What is the treatment for moderate depression?
ANTIDEPRESSANT + high-intensity psych intervention
What is the treatment for severe depression?
Rapid specialist mental health assessment
What are the 3 steps before starting antidepressants?
1-discuss choice of pharmacological/non-pharmacological therapy
2-S/E
3-Assess after 4wks
What things can the patient do themselves to improve their depression?
Exercising Engaging in productive activity Socializing Improve sleep Relaxation "self-soothing" techniques
What are usually 1st line in treating depression?
SSRIs
How does the dose change if the patient is old?
Half the adult dose to start with
then titrate up as with anyone
What two drug types are combined in psychotic depression?
Antidepressants
Antipsychotics
How long does antidepressants take to work? If needing a quicker response?
Normally take 2-6wks to work
If needing quicker response- ECT
How long should antidepressants be continued?
6-12 months after full resolution of 1st episode
12-24 months for a recurrence
After 3rd episode consider indefinetly
What is non-response defined as?
No response/inadequate response after 6wks at the max BNF dose or highest tolerated dose
TRUE/FALSE
If switching antidepressants one needs to be stopped before another one is started
Kinda
Doses should be cross tapered
If MAOI need a washout period of 2 weeks
Moclobemide washout period of 24h
What is gold standard in treatment of bipolar disorder?
Lithium
Lithium is safe to use in pregnant TRUE/FALSE
FALSE
Ebstein’s abnormality, floppy baby _ thyroid abnormalities
Why should you not change brands when prescribing lithium?
Different lithium salts have different bioavailability
Lithium has a narrow therapeutic index so therefore needs to be montiored. How is it monitored?
12h post dose blood and U+E every 5 days
Every 6 months - TFTs
+ lithium level/ U+E if dehydrated from physical illness, generally unwell or signs of toxicity
If you get hypothyroidism when on treatment of lithium for bipolar disorder what is done?
Treated with levothyroxine rather than stopping lithium
If lithium levels are progressively rising what should be suspected?
Progressive nephrotoxicity
What does lithium cessation precipitate in up to 50% of patients?
acute mania
discontinuation gradual over 2-4wks
If one family member responds well to treatment others will benefit from the same one TRUE/FALSE
TRUE
What are the common SE of lithium?
Dry mouth/strange taste GI upset Polyuria and polydipsia, neurogenic DI Tremor, Hypothyroidism, Wt gain Long term reduced renal function
What are lithium toxicity signs?
Vomiting Black diarrhoea Ataxia/coarse tremor Drowsiness Convulsions Coma
When should lithium be taken?
At night due to sedation
What two things should be checked before the initiation of anticonvulsants?
Platelet count
LFTs
Name 4 side effects of Carbamazepine (Tegretol)?
Drowsiness
Ataxia
Cardiovascular effects
Induced liver enzymes
Why is sodium valproate not used in women of child brearing age?
Risk of neural tube defects in child
If you do use then make sure they have effective contraception
What is the risk associated with lamotrigine?
Stevens-Johnsons syndrome
What is 1st line in bipolar disorders in mania?
Atypical antipsychotics (as mood stabilisers) e.g. Quetiapine, Aripiprazole, Olanzapine, Lurasidone
What are the side effects of Atypical antipsychotics?
Sedation
Wt gain ( a couple of stone)
Metabolic syndrome
TRUE/FALSE
Antidepressants can be used short term in severe depressive episodes but should never be used without a mood stabiliser
TRUE
What can be used an an emergency first line in depression?
ECT
With ECT the more depressed the more effective it is TRUE/FALSE
TRUE
With ECT how many treatments are usually given as part of the course?
9 treatments
Is unilateral or bilateral ECT more effective?
Bilateral more common, works quicker and more likely to give cognitive effects
What are absolute CI to ECT?
Recent MI (last 3 months)
Recent cerebrovascular accident
Intracranial mass lesions OR pheochromocytoma
What are the side effects of ECT?
Often a short lived tension headache, memory and cognitive problems
TRUE/FALSE
In Scotland you cannot give ECT to a person who has capacity and is refusing treatment even if they are detained under the MHA
TRUE
How does ECT work?
It causes a seizure in the brain
Almost resets the brain (disrupts the hyper connectivity between various areas of the brain that maintain depression) which allows your brain to grow, sprout new neuron connections and increase volume of hippocampus
What is behavioural activation?
Doing things that they enjoy
What is interpersonal therapy?
Concentrates on relationships with people and their complications
What is CBT based on?
Identifying an individuals automatic thoughts, cognitive bias and schemas.
It helps to identify that which perpetuates the anxiety/depression
