CNS - Depression Flashcards
Mild treatment depression?
CBT (Cognitive behavioural Therapy)
Moderate treatment for depression
Antidepressants (SSRI)
Pt returns 1wk later and says they feel worse after taking anti depressants, what should they do?
Continue to take as
First 1-2 weeks patient may feel worse
At what point is an antidepressant deemed ineffective?
4 weeks normal pt
Or 6 weeks in elderly
Pt is on remission how long after do they need to take?
6 months normal pt
1 year in elderly
2 years if recurrent
Depression first line?
SSRI
If SSRI doesn’t work then what?
1) Increase in dosage
2) Change to another SSRI
3) MIRTAZAPINE
4) If severe : TCA or venlafaxine
5) Mao inhibitors (Specialist/Rare)
V rare another class lithium
Severe refractory depression?
Electroconvulsive therapy
Next step after alternate SSRI doesn’t work?
Mirtazepine
Severe depression treatment?
TCA or Venlafaxine
If pt is 17 or less what antidepressant should be used?
Fluoxetine
If pt is at risk of bleeding which antidepressant should be used?
Mirtazepine
If pt is at risk of cardiac events which antidepressant should be used?
Sertraline
Why SSRI’s are preferred over TCA’s ?
Better tolerated
Overdose SSRI is a lot safer than TCA
SSRI SIDE EFFECTS?
GI disturbances
Weight gain
Sexual dysfunction
Insomnia (TAKE IN MORNING)
Risk of bleeding
QT Prolongation (Escitalopram/Citalopram)
Can I take Grapefruit juice with SSRI?
NO, AVOID GRAPEFRUIT JUICE (CYP450 Enzyme inhibitor)
It can increase plasma conc of SSRI
Leading to toxicity or even serotonin syndrome
SSRI is a CYP450 enzyme substrate
Can pt take OTC St John’s wort with SSRI?
No as it reduces SSRI effectiveness
St johns wort is a CYP450 inducer
SSRI should avoid being taken with which drugs to avoid QT prolongation?
Amiodarone, Sotalol, Quinolones
SSRI should avoid which other hyponatraemic drugs?
Diuretics, Carbamazepine
Serotonin syndrome autonomic effects?
Heating up symptoms
-sweating
-hyperthermia
-Nausea
-Diarrhoea
Serotonin syndrome neuromuscular excitation symptoms?
Teeth grinding
Tremors
Myoclonus (uncontrollable muscle contraction)
Serotonin syndrome Cognitive effects?
Headaches
Agitations
Hypomania
Confusion
Coma
Which drugs can cause serotonin syndrome?
- SSRI
- TCA
- MAO - I
- Triptans
- Tramadol
- lithium
- LINEZOLID ABX
If pt is more anxious agitated which TCA would they need?
Sedating TCA:
- Clomipramine
- Amitriptyline
- Dosulepin
- Trazadone
C-DATing
Which is the best sedating TCA
Trazadone
Highest risk of overdose TCA?
Amitriptyline or Dosulepin
Non sedating TCA?
Nortriptyline
Imipramine
Lofepramine
NIL
TCA Side effects?
Cardiac events
Anti muscarinics (dry mouth/constipate)
Seizures (reduces threshold)
Hypotension (more associated overdose)
Hallucination
CASHH
TCA avoid Grapefruit juice why?
It is a CYP450 inhibitor which will therefore increase plasma conc of TCA
Risk of toxicity = Serotonin syndrome
TCA AND OTC St John’s wort?
St John’s wort is an CYP450 enzyme inducer which will reduce TCA Effectiveness
Which other QT prolongation drugs should TCA AVOID?
Amiodarone
Sotalol
Quinolones
Which anti muscarinic drug should TCA avoid?
Atropine
Which anti hypertensive drug should TCA avoid?
Amlodopine
MAO inhibitors with Pseudoephedrine can cause?
Hypertensive Crisis
Mao inhibitors must avoid which foods?
Tyramine rich foods
Fatal SERIOUS REACTION WITH MAOI?
Clomipramine & Tranylcypromine
(TCA). (MAOI)
Which MAOI - b inhibitors cause Hepatotoxicity?
- Phenelzine
- isocarboxazid
How long must pt wait to switch from MAO inhibitor to another depressant?
At least 2 weeks
How long must pt taking Clomipramine/Imipramine take to switch antidepressants?
3 weeks
How many weeks for moclobemide to be stopped to start MAO INHIBITOR?
0 weeks
Do not start MAO inhibitor till how long after TCA stopped?
1-2 weeks
How long after SSRI has been stopped can you start MAOI?
1 week
How long after Fluoxetine stopped can pt start a MAO inhibitor?
5 weeks
Tyramine rich foods?
Yeast rich foods
- Marmite
- Salami
- Tofu
- Yeast
- Mature cheese
