Depression Flashcards
What is the treatment guidelines for depression?
Consider CBT and then + SSRI or TCA
SNRIs
If no response, consider TCAs,
moclobemide, irreversible MAOIs,
low-dose amisulpride (seek specialist
advice)
What is the risk with people under 25?
increased risk of suicide and SSRI’sc can cause over excitement, suicidal thoughts and tendencies and agression, so review after 1 week and regularly
DONT give TCA as toxic in overdose
What are the classifications of depressions?
subthreshold depression - <5 symptoms
mild - 1 or 2 more than 5 or 5
moderate - more then 6 symptoms
severe- affecting function and majority symptoms
What questionnaire as part of diagnosis?
DSM-IV (9 characteristics)
How are antidepressants stopped?
if taken:
<8 weeks = taper over 1 to 2 wks
if 6- 8 months - taper over 4 to 8 weeks
if long term use - then taper 1/4 dose every 6-8 months and monitor for withdrawal symptoms
How are SSRIs changed to TCA ?
vice versa
reduce dose of original drug and slowly increase dose of new drug over a 2 to 4 week period
How is MAOis changed into SSRIs or TCA’s? and vice versa
TCA/SSRI’s can be started after 3 weeks of last MAOi dose
for fluoxetine (long half life) after 5 weeks
What are the examples of SSRI’s
Sertraline
citalopram, escitalopram
fluoxetine, paroxetine , dapoxetine
fluvoxamine
vortiovexetine
What are the common SE of SSRI’s?
Gi discomfort
GI bleeds
Seizure threshold lowered
QT prolongation (cital + escital)
Erectile dysfunction
sleep disturbances
serotonin syndrome
When should monitoring of antidepressants be?
1 to 2 weeks after starting
at 4 weeks - if no improvement then increase dose or change drug
no changes usually until after 6 to 8 weeks if there’s no issues
What drugs can increase risk of serotonin syndrome?
Lithium
St johns wort
sumatriptan
MAOI’s
Tramadol
what are the symptoms of serotonin syndrome?
shivering
convulsions
tremors
restlessness
hyperthermia
come and death
What is the treatment of serotonin syndrome?
discontinuation of the serotonergic agent, support, sedation with benzodiazepines, and observation for at least 6 hours
What are the common interaction for SSRI’s?
(fluox+parox) with TCA = inhibit metabolism of TCA’s so TCA toxicity
(cital+esc) with lithium = prolonged QT
(fluox+parox) with tamoxifen = lower efficacy of tamoxifen
with NSAIDS and antiplatelets = increased risk of bleeds
What electrolyte disturbances can SSRI’s and TCA’s cause?
hyponatraemia
What are the examples of SNRI’s?
venlafaxine
duloxetine
Bupropion hydrochloride
bupropion + naltrexone
What are the SE of venlafaxine?
arrhythmias, ^BP, ^HR
nausea
headache
What are the CI for Venlafaxine and duloxetine?
venlafax- arrhythmias and uncontrolled hypertension
dulox- hepatic impairement and CrCl <30ml/min
What other indication may duloxetine be used for?
urinary retention
dose - 20mg BD initially then 40mg bd
What are the SE of duloxetine?
appetite decreased
anxiety
constipation
diarrhoea
asthenia(weakness)
confusion
chills
What are the examples of Atypical antidepressants?
mirtazapine and trazadone
What are the SE of mirtazapine?
sedation
increased appetite
confusion
GI discomfort
What are the SE of Trazadone?
Abnormal appetite, sedation and drowsiness
What counselling is important for mirtazapine?
If pt develops - infection symptoms, fever, sore throat any time during treatment see GP so they could do blood count to test if blood dyscrasia has occured
What are the examples of TCA’s?
amitriptyline, nortrityline
clomipramine, impiramine, trimpiramine, lofempramine
dosulepin
doxepin
What are the common SE of TCA’s?
sedation (amitrip)
weight gain ( blocks histamine)
postural hypotension
QT interval prolongation
dry mouth
erectile dysfunction
constipation
seizure threshold lowered
urinary retention
cardiac conduction abnormalaties
Why is alcohol contraindicated with TCA’s?
TCA increase effects of alcohol and cause repiratory depression
Why are TCA’s CI in heart disease?
causes arrhythmias and dangerous in over dose
What are the symptoms of TCA toxicity?
excitement
delirium
convulsions
dry mouth and dry skin
blurred vision
What is the treatment for TCA toxicity?
activated charcoal - to prevent further absorption
diazepam - convulsions
O2 and NaHCO3 - hypoxia and acidosis
What are the common interactions for TCA’s?
all MAOIs- severe toxic reaction (wait 3 weeks after dose )
lithium - ^ risk of neurotoxicity
terbinafine - ^ exposure to amitrip (adjust dose)
adrenaline/epinephrine - ^ effects of adrenaline (^BP and abnormal heart rhythm)
When should TCA’s be taken?
At night due to sedative effects
What are TCA’s contraindicated in?
heart disease/ block
arrhythmias
severe hepatic/ renal impairement
manic phase of bipolar
with MAOI’s wait 14 days at least
What are examples of MAOI’s
irreversible inhibitors of MAO-A and B - isocarboxazid, phenelzine, tranycypromine
seligiline (MAO-B)
moclobemide (reversible MAO-A)
What is the symptoms of the cheese reaction with MAOI’s?
throbbing headache
hypertensive crisis
haemorrhage
what are the common interactions of MAOI’s
decongestants, amphetamine
they reduce metabolism of opiods,alcohol and barbituates
TCA’s severe toxic reaction
adrenaline - hypertensive crisis
carbamazepine= severe toxic reaction risk
How long do MAOI adverse reaction taken to diminish?
Moclobemide - effects will finish when administration stops
for irreversible MAOI’s it can take upto 5 weeks
What is the treatment for MAOI overdose?
if hypertension - phentolamine
hypotension - posture
mania - chlorpromazine
What are 10 SE of amitriptyline?
Dry mouth
nausea
orthostatic hypotension
reduced libido
photosensitivity
visual disturbances
urinary retention
palpitations
sedation
tachycardia
