Depression Flashcards
Depression symptoms etc
Low mood Change in appetite Worry and anxiety Suicidal thoughts Lack of energy Insomnia
Antidepressants work by increasing monoamine activity at the synapse. What are the different classes?
SSRI
TCA
MAOI
What is first line to treat depression?
SSRI
What are the different SSRIs?
Citalopram Escitalopram Sertraline Fluoxetine Paroxetine
What do you do if a patient is not responding to first line treatment for depression?
Increase dose, switch SSRI to another one or consider mirtazepine
other choices:
Can antidepressants be withdrawn suddenly?
No- risk of withdrawal reactions
How long should an SSRI continue before being deemed in effective in adults and elderly.
4 weeks average
6 weeks in elderly
How long do antidepressants take to work?
at least two weeks. At first you feel worse
How long should treatment be continued for different indications?
6 months after remission but 1 year in the elderly
recurrent depression is 2 years
and GAD is 12 months bc high risk of relapse
What is third line treatment?
Add another antidepressant
Add augmenting agent e.g. lithium or O, R or Q
ECT
Side effects of antidepressants
Hyponatraemia
Suicidal ideation
Serotonin syndrome
What are the triad of symptoms in serotonin syndrome?
Neuromuscular hyperactivity
Altered mental state
Autonomic dysfunction
Wash out periods for SSRIs
MAOI- 2 weeks but meclobamide doesn’t need one cause its reversible and short acting
SSRIs- 1 weeks. Sertraline= 2 weeks and 5 weeks for Fluoxetine it has a long half life
TCAs- 1-2 weeks but its 3 weeks for Imipramine and Clomipramine
Which SSRI is safe in MI and angina?
Sertraline
Which antidepressant is the only one licensed in children What class is this drug
Fluoxetine
SSRI
Which SSRI cause QT prolongation
Citalopram and Escitalopram
SSRI are less sedating less cardiotoxic less epileptogenic and antimuscarinic then TCAs
SSRI are less sedating less cardiotoxic less epileptogenic and antimuscarinic then TCAs
What are the side effects of SSRIs
GI disturbances
Appetite or weight disturbances
Serotonin syndrome
Hypersensitivity reactions
QT prolongation - citalopram and escitalopram
Reduce seizure threshold
Increased risk of bleeds
Movement disorders and dyskinesia
Interactions of SSRIs
Increased risk of bleeds- NSAIDS, anticoag and antiplatelets
QT prolongation- Amiodarone, Sotalol, Macrolides, Quinolone, TCA, lithium, quinine, Mefloquine and Chloroquine, Antipsychotics.
Loops/thiazides, B2 agonists and Corticosteroids, Theophylline
Increased plasma conc (enzyme inhibitors)
Hyponatraemia- NSAIDs,
diuretics , carbamazepine and desmopressin
serotonin syndrome
TCAs are MORE sedating MORE epileptogenic MORE antimuscarinic and more CARDIOTOXIC than SSRI
TCAs are MORE sedating MORE epileptogenic MORE antimuscarinic and more CARDIOTOXIC than SSRI
Non sedating TCAs
NIL
Nortriptyline
Imipramine
Lofepramine
TCA side effects
TCAs
T-CAs are more toxic in overdose than SSRI
C-ardiac side effects- QT, arrhythmia, HTN and heart block
A-ntimuscarinic side effects- dry mouth, blurred vision constipation, raised IO pressure, angle closure glaucoma
S-eizures
TCA interactions
QT prolongation
Increased sedation
Antimuscarinics- Antihistamines, Antipsychotics, Atropine
Serotonin syndrome
Hypotension
Hyponatraemia- NSAIDs, SSRI, diuretics, Desmopressin and Carbamazepine
Reduced plasma concentration (enzyme inducers)- Carbamazepine
Increased plasma concs( enzyme inhibitors)- Cimetidine
Can MAOI be initiated by anyone?
Specialist only for irreversible
What are the two types of MAOI
Reversible and irreversible
Side effects of MAOIs
Tripple H
Hepatotoxic
Hypertensive crisis- discontinue if headache and more likely with tranylcypromine
Postural Hypo/Hypertensive responses- discontinue if headache throbbing
Interactions of MAOIs
Hypertensive crisis
adrenaline noradrenaline, levodopa, MAOB, TCA
Patient counselling MAOI
Monitor BP, HR
Food high in tyramine to be avoided= mature cheese, broad beans, marmite,
eat fresh food only. avoid stale and moulding food
Avoid alcohol and low alcohol content drinks
Danger of food interactions can occur for up to 2 weeks after stopping
