Depression

Question 1

Depression symptoms etc

Answer 1

Low mood
Change in appetite 
Worry and anxiety 
Suicidal thoughts 
Lack of energy
Insomnia

Question 2

Antidepressants work by increasing monoamine activity at the synapse. What are the different classes?

Answer 2

SSRI
TCA
MAOI

Question 3

What is first line to treat depression?

Answer 3

SSRI

Question 4

What are the different SSRIs?

Answer 4

Citalopram 
Escitalopram 
Sertraline 
Fluoxetine 
Paroxetine

Question 5

What do you do if a patient is not responding to first line treatment for depression?

Answer 5

Increase dose, switch SSRI to another one or consider mirtazepine

other choices:

Question 6

Can antidepressants be withdrawn suddenly?

Answer 6

No- risk of withdrawal reactions

Question 7

How long should an SSRI continue before being deemed in effective in adults and elderly.

Answer 7

4 weeks average

6 weeks in elderly

Question 8

How long do antidepressants take to work?

Answer 8

at least two weeks. At first you feel worse

Question 9

How long should treatment be continued for different indications?

Answer 9

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

Question 10

What is third line treatment?

Answer 10

Add another antidepressant
Add augmenting agent e.g. lithium or O, R or Q
ECT

Question 11

Side effects of antidepressants

Answer 11

Hyponatraemia
Suicidal ideation
Serotonin syndrome

Question 12

What are the triad of symptoms in serotonin syndrome?

Answer 12

Neuromuscular hyperactivity
Altered mental state
Autonomic dysfunction

Question 13

Wash out periods for SSRIs

Answer 13

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

Question 14

Which SSRI is safe in MI and angina?

Answer 14

Sertraline

Question 15

Which antidepressant is the only one licensed in children
What class is this drug

Answer 15

Fluoxetine

SSRI

Question 16

Which SSRI cause QT prolongation

Answer 16

Citalopram and Escitalopram

Question 17

SSRI are less sedating less cardiotoxic less epileptogenic and antimuscarinic then TCAs

Answer 17

SSRI are less sedating less cardiotoxic less epileptogenic and antimuscarinic then TCAs

Question 18

What are the side effects of SSRIs

Answer 18

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

Question 19

Interactions of SSRIs

Answer 19

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

Question 20

TCAs are MORE sedating MORE epileptogenic MORE antimuscarinic and more CARDIOTOXIC than SSRI

Answer 20

TCAs are MORE sedating MORE epileptogenic MORE antimuscarinic and more CARDIOTOXIC than SSRI

Question 21

Non sedating TCAs

Answer 21

NIL

Nortriptyline
Imipramine
Lofepramine

Question 22

TCA side effects

Answer 22

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

Question 23

TCA interactions

Answer 23

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

Question 24

Can MAOI be initiated by anyone?

Answer 24

Specialist only for irreversible

Question 25

What are the two types of MAOI

Answer 25

Reversible and irreversible

Question 26

Side effects of MAOIs

Answer 26

Tripple H

Hepatotoxic
Hypertensive crisis- discontinue if headache and more likely with tranylcypromine
Postural Hypo/Hypertensive responses- discontinue if headache throbbing

Question 27

Interactions of MAOIs

Answer 27

Hypertensive crisis

adrenaline noradrenaline, levodopa, MAOB, TCA

Question 28

Patient counselling MAOI

Answer 28

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