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Pre reg > Depression > Flashcards

Depression Flashcards

1
Q

What are the psychological and physical symptoms of depression?

A

Psychological symptoms:

  • Low self esteem
  • Worry and anxiety
  • Suicidal thoughts

Physical symptoms:

  • Lack of energy
  • Changes in weight/appetite
  • Insomnia: early morning wakens
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2
Q

What are the different classes of antidepressants?

A

TCAs

  • Amitriptylline*
  • Doselupin*
  • Nortriptylline*
  • Imipramine*

TCA-related antidepressants

  • Mianserin*
  • Trazodone*

SSRIs

  • Citalopram*
  • Fluoxetine*
  • Escitalopram*
  • Sertraline*
  • Paroxetine*
  • Fluvoxamine*

Irreversible MAOs

  • Phenelzine*
  • Isocarboxazid*
  • Tranylcypromine*

Reversible MAOs (short-acting)

Moclobemide

SNRI

  • Duloxetine*
  • Venlafaxine*

Other antidepressant drugs

Mirtazepine

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3
Q

What antidepressants are first line in depression and why?

A

SSRIs

  • Better tolerated and safer in overdose than other classes
  • Less sedating, antimuscularinic, epileptogenic, cardiotoxic than TCAs
  • MAOIs rarely used as dangerous food and drug interactions
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4
Q

How long do antidepressants take to work?

A
  • *4 weeks**
  • *6 weeks in elderly**

Review every 1-2 weeks

Initially feel worse, increased agitation, anxiety and suicidal ideation

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5
Q

How long should antidepressants be continued after remission? (+ in elderly)

A

6 months

12 months elderly

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6
Q

How long should antidepressants be continued after remission in generalised anxiety disorder?

A

12 months - at high risk of relapse

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7
Q

How long should antidepressants be continued after remission in recurrent depression?

A

2 years

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8
Q

What if patient does not respond to first line treatment for depression?

A

Second-line

Increase SSRI dose

OR

Different SSRI

OR

Mirtazepine

Third-line

Add another antidepressant class

OR

Augmenting agent e.g. lithium or antipsychotic

OR

ECT

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9
Q

What are the side effects of antidepressants?

A

- Hyponatraemia:
drowsiness, confusion, convulsions
especially SSRIs

  • Suicidal ideation and behaviour
  • Serotonin syndrome
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10
Q

What are the serotonin syndrome symptoms?

A

- Neuromuscular hyperactivity (tremor, hyperreflixia, clonus, myoclonus, rigidity)

  • Autonomic dysfunction (tachycardia, BP changes, hyperthermia, diaphoresis, shivering)
  • Altered mental state (agitation, confusion, mania)
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11
Q

When is a washout period needed?

A

When antidepressant is stopped before switching to different antidepressant class to avoid serotonin syndromew

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12
Q

Washout out period for:

MAOIs

SSRIs

TCAs

A

MAOIs - wait 2 weeks. (Moclobemide no washout)

SSRIs - wait 1 week (2 weeks sertraline, 5 weeks fluoxetine)

TCAs - wait 1-2 weeks (3 weeks imipramine or clomipramine)

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13
Q

Which anti-depressants have greatest risk of withdrawl reaction and why

A

Paroxetine and venlaxfaxine - shorter half life

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14
Q

When do withdrawal reactions normally occur

A

Within 5 days of stopping antidepressant

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15
Q

What increases the risk of withdrawal reactions of antidepressants?

A

Stopped suddenly after taking for > 8 weeks

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16
Q

How to withdraw antidepressants safely

A

Reduce dose gradually over 4 weeks, longer if withdrawl (6 months in pts on long-term tx)

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17
Q

How do SSRIs work?

A

Inhibit reuptake of serotonin, increasing serotonin activity

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18
Q

List some SSRIs (6)

A

Citalopram, Escitalopram, paroxetine, fluoxetine, sertraline, fluvoxamine

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19
Q

Side effects of SSRIs

A

G - GI disturbances - N, V, D A

A - Appetite or weight disturbance

S - serotonin syndrome

H - Hypersensitivity reactions - stop if rash

Others - bleeding, QT interval, lower seizure threshold, movement disorders, dyskinesia, sexual dysfunction (may persist after stopping)

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20
Q

What the symptoms of SSRI overdose

A

N, V, agitation, tremor, nystagmus, drowsiness, sinus tachycardia, convulsions

Rare - results in serotonin syndrome (neuropsychiatric effects, neurmuscular hyperactivity and autonomic instability, hyperthermia, rhabdomyolysis, renal failure and coagulopahies (bleeding disorders)

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21
Q

MHRA SSRIs

A

Small increased risk of postpartum haemorrhage when used in the month before delivery

22
Q

Compared to TCAs SSRIs are less .. (4)

A

Sedating

Anti-muscarinic

Cardiotoxic

Epilpetogenic

23
Q

Which is the only anti depressant licensed in children?

A

Fluoxetine

24
Q

Which two SSRIs increase the risk of QT interval pro-longation

A

Citalopram and escitalopram

25
Q

Which SSRI has greatest risk of withdrawl

A

Paroxetine

26
Q

Interactions of SSRIs

A

Increased plasma concentration

  • Grapefruit juice (enzyme inhibitor)

Increased risk of bleeding

  • NSAIDs, anticoagulants, anti-platelets

For escitalopram/citalopram

  • Drugs that increase risk of QT prolongation

Increased risk of hyponatraemia

  • Diuretics

Increased risk of seretongeric effects/serotonin syndrome

  • St Johns Wort (not recommended), amphetamines, sumatriptan, tramadol, ondansetron, TCA/MAOI
27
Q

What drugs increase risk of serotonin syndrome

A

St john’s wort, amfetamines, sumatriptan, selegiline, tramadol, TCAs/MAOIs/SSRIs, ondansetron

28
Q

Which anti-depressant is safe to use after an MI? Which class to avoid immediately after MI

A

Sertraline

Avoid TCAs

29
Q

What is the dosing of TCAs

A

OD - long half life

30
Q

Name the least sedating TCAs

A

Imipramine, lofepramine, notriptylline

31
Q

Which TCA is least dangerous in overdose

A

Lofepramine

32
Q

Which TCA is most dangerous in overdose + not recommended in tx of depression

A

Dosulepin (+ Amitriptylline)

33
Q

Which TCAs can also be used to treat neuropathic pain

A

Amitriptylline and notriptylline

34
Q

Which TCA has the most marked anti-muscarinic SEs

A

Imipramine

35
Q

Which compounds do agitated/anxious people and apathetic patients respond to? (sedating vs non-sedating compounds)

A

Agitated and anxious patients tend to respond best to the sedative compounds, whereas withdrawn and apathetic patients will often obtain most benefit from the less sedating ones

36
Q

Interactions of TCAs

A

Reduced plasma concentration

Carbamazepine (enzyme inducers)

Increased plasma concentrations

Cimetidine (enzyme inhibitors)

Increased risk of hyponatraemia

Diuretics e.g. loop/thiazide

Increased risk of QT interval prolongation

Amiodarone, sotalol, antipsychotics, citalopram/escitalopram

Increased risk of hypotension

Antihypertensives, NSAIDs, antipsychotics

Increased antimuscarinic effects

Antimuscarinic drugs, antihistamines, atropine, antipscyhotics

Increased risk of serotonin syndrome

37
Q

List the sedating TCAs (5)

A

Amitriptylline, clomipramine, dosulepin, doxepin, trimipramine

38
Q

Side effects of TCAs

A

More sedating, epileptogenic, cardiotoxic and antimuscarinic than SSRIs

T - Toxic (more) in overdose than SSRIs

C - Cardiac SEs (QT pro-longation, arrythmias, heart block HTN)

A - Anti-muscarinic (dry mouth, blurred vision, constipation, tachycardia, urinary retention, increased IOP, glaucoma)

S - Seizures

Others - hallucinations, mania, hypotension, sexual dysfunction, breast changes, EPSE

39
Q

Mechanism of action of TCAs

A

Blocks reuptake of two monoamine neurotransmitters - serotonin + NA. Blocks ACh.

40
Q

List the irreversible MAOIs

A

Phenelezine, isocarboxid, tranylcypromine

41
Q

List the reversible MAOIs and what does this mean

A

Moclobemide - no wash out period

42
Q

Side effects of MAOIs

A

Hepatoxicity

More likely with phenelzine and isocarboxazid

Postural hypotension/hypertensive responses

Discontinue if palpitations or frequent headaches

Hypertensive crisis

Discontinue if hypertensive crisis with throbbing headache occurs

More likely with tranylcypromine

43
Q

Which two MAOIs are more likely to cause hepatoxicity

A

Phenelzine and isocarboxaid

44
Q

Which MAOI has greatest stimulatory action and what does this cause? Avoid with what other drugs

A

Tranylcypromine - hypertensive crisis (report throbbing headache) Stimulants - pseuderphredine, levodopa, DRAs, MAO-Bi, TCAs, esp tran + clomipramine (lethal)

45
Q

Which two anti-depressant classes do you never prescribe together

A

TCA + MAOI = FATAL

46
Q

Patient counselling MAOI (food related) + how long to food + drug intereactions last for

A

Tyramine containing foods (mature cheese, wine, pickled herring, game, broad bene pods) Eat only fresh food

Avoid stale

Avoid alcohol

Two weeks after stopping irreversible MAOI

47
Q

When would you deem SSRI ineffective

A

4 weeks (6 weeks elderly)

48
Q

How often is SSRI reviewed at start of therapy

A

Every 1-2 weeks

49
Q

Over which time period is paroxetine withdrawn over

A

4 weeks - 6 months if long term therapy

50
Q

Hyponatremia occurs more in which drug class

A

SSRIs

51
Q

What antidepressant is also used to treat menopausal symptoms associated with breast cancer?

A

Venlafaxine

Pre reg (45 decks)

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