CNS - DEPRESSION

Question 1

What are the psychological symptoms?

Answer 1

• low self esteem
• worry and anxiety
• suicidal thoughts

Question 2

What are the physical symptoms?

Answer 2

• lack of energy
• changes in weight and appetite
• insomnia

Question 3

What is normally first line for depression?

Answer 3

SSRIs

Question 4

Why are SSRIs preferred over TCAs?

Answer 4

less sedating, less antimuscarainic, less epileptogenic, less cardiotoxic

Question 5

How long do SSRIs take to work?

Answer 5

• at least 2 weeks

- wait at least 4 weeks before deeming them effective

Question 6

What are the lengths of maintenance doses for SSRIs?

Answer 6

• 6 months after remission
• 12 months in generalised anxiety disorder
• 2 years in recurrent depression

Question 7

What are guidelines for treating depression?

Answer 7

• 1st line = SSRI
• 2nd line = Increase dose, try different SSRI or mirtazapine. Lofepramine (TCA) can also be used)
• 3rd line = add in another class or an augmenting agent (lithium or antipsychotic)

Question 8

What are the side effects of antidepressants?

Answer 8

• hyponatraeima - drowsiness, confusion, convulsions
• serotonin syndrome
• suicidal ideation

Question 9

What are the main symptoms of serotonin syndrome (overdose)?

Answer 9

• neuromuscular - tremor, myoclonus, muscle rigidity
• altered mental state - agitation, confusion, mania
• autonomic dysfunction - labile BP, urination, diarrhoea, hyperthermia, tachycardia

Question 10

Why is there a washout period before switching to a different class of antidepressant?

Answer 10

to avoid serotonin syndrome

Question 11

How long should you wait before switching antidepressants?

Answer 11

• MAOIs = 2 weeks. Moclobemide doesn’t require wash out period
• SSRIs = 1 week. Sertraline 2 weeks. Fluoxetine 5 weeks.
• TCAs = 1-2 weeks. Clomipramine 3 weeks

Question 12

What are the symptoms of antidepressant withdrawal?

Answer 12

GI upset, anxiety, influenza-like symptoms, sleep disturbance

Question 13

Which is the only antidepressant licensed for children?

Answer 13

fluoxetine

Question 14

Which SSRIs can cause QT prolongation?

Answer 14

citalopram, escitalopram

Question 15

What are the side effects of SSRIs?

Answer 15

• GI disturbance
• Appetite or weight change
• Serotonin syndrome
• Hypersensitivity reaction - hyponatraemia, rash
• Increased bleeding risk
• QT prolongation - citalopram
• Seizure threshold lowered
• Movement disorder

Question 16

What are the interactions of SSRIs?

Answer 16

• Inhibitors - increase cp
• NSAIDs, Aspirin, anticoags, anti-platelets - bleeding risk
• Drugs that prolong QT
• Drugs that increase risk of serotonin syndrome - e.g. sumatriptan
• Drugs that induce hyponatraemia

Question 17

What are the side effects?

Answer 17

• Cardiotoxic - prolonged qt, heart block, htn
• antimuscarinic - dry mouth, blurred vision, constipation, urinary retention
• sedation

Question 18

What are the interactions?

Answer 18

• Inducers - reduced cp
• Inhibitors - increased cp
• drugs that induce hyponatraemia
• drugs that prolong QT interval
• antihypertensives - increase risk of hypotension
• increased antimuscaranic effects
• increased risk of serotonin syndrome

Question 19

What are some irreversible MAOIs?

Answer 19

phenelzine, isocarboxazid, tranylcypromine

Question 20

What is the reversible MAOI?

Answer 20

moclobemide (short acting)

Question 21

What are the side effects of MAOIs?

Answer 21

• Hepatotoxicity
• postural hypotension
• potential hypertensive crisis - interacts with sympathomimetics, dopaminergic drugs, tcas

Question 22

What food should patients avoid if taking MAOIs?

Answer 22

Foods containing tyramine = strong cheese, cured/smoked meat and fish, beer, overripe fruit, broad beans, tofu