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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
Which SSRI has greatest risk of withdrawl
Paroxetine
26
**Interactions of SSRIs**
**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
What drugs increase risk of serotonin syndrome
St john's wort, amfetamines, sumatriptan, selegiline, tramadol, TCAs/MAOIs/SSRIs, ondansetron
28
Which anti-depressant is safe to use after an MI? Which class to avoid immediately after MI
**Sertraline** Avoid TCAs
29
**What is the dosing of TCAs**
OD - long half life
30
Name the least sedating TCAs
Imipramine, lofepramine, notriptylline
31
Which TCA is least dangerous in overdose
Lofepramine
32
Which TCA is most dangerous in overdose + not recommended in tx of depression
Dosulepin (+ Amitriptylline)
33
Which TCAs can also be used to treat neuropathic pain
Amitriptylline and notriptylline
34
Which TCA has the most marked anti-muscarinic SEs
Imipramine
35
Which compounds do agitated/anxious people **and** apathetic patients respond to? (sedating vs non-sedating compounds)
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
Interactions of TCAs
**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
List the sedating TCAs (5)
Amitriptylline, clomipramine, dosulepin, doxepin, trimipramine
38
Side effects of TCAs
**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
Mechanism of action of TCAs
Blocks reuptake of two monoamine neurotransmitters - serotonin + NA. Blocks ACh.
40
List the irreversible MAOIs
Phenelezine, isocarboxid, tranylcypromine
41
List the reversible MAOIs and what does this mean
Moclobemide - no wash out period
42
**Side effects of MAOIs**
**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
Which two MAOIs are more likely to cause hepatoxicity
Phenelzine and isocarboxaid
44
Which MAOI has greatest stimulatory action and what does this cause? Avoid with what other drugs
Tranylcypromine - hypertensive crisis (report throbbing headache) Stimulants - pseuderphredine, levodopa, DRAs, MAO-Bi, TCAs, esp tran + clomipramine (lethal)
45
Which two anti-depressant classes do you never prescribe together
TCA + MAOI = FATAL
46
**Patient counselling MAOI (food related) + how long to food + drug intereactions last for**
**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
When would you deem SSRI ineffective
4 weeks (6 weeks elderly)
48
How often is SSRI reviewed at start of therapy
Every 1-2 weeks
49
Over which time period is paroxetine withdrawn over
4 weeks - 6 months if long term therapy
50
**Hyponatremia occurs more in which drug class**
SSRIs
51
What antidepressant is also used to treat menopausal symptoms associated with breast cancer?
Venlafaxine

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