Depression Flashcards
What vitamin deficiency can cause depression?
Vitamin D
What medications can CAUSE Unipolar Depression?
-Alcohol
-Steroids
-Benzodiazepines
-Antipsychotis
-Anticonvulsants
-NSAIDs
-CVD drugs
-Caffeine / withdrawal
What are the three symptoms categories of Depression?
-Emotional
-Physical
-Cognitive
What are the key symptoms of Depression?
-Persistent sadness or low mood
-Marked loss of interests or pleasure
-Lack of energy
What are the associated symptoms of Depression?
-Disturbed sleep
-Decreased or increased appetite and/or weight
-Fatigue or loss of energy
-Agitation or slowing of movements
-Poor concentration or indecisiveness
-Feelings of worthlessness or excessive or inappropriate guilt
-Suicidal thoughts or acts
What is the ICD 10 criteria for diagnosis of Depression?
At least TWO key symptoms, most days, most of the time for at least 2 weeks, minimum 4 symptoms
What is the DSM IV criteria for diagnosis of Depression?
At least ONE of these key symptoms, most days, most of the time at least 2 weeks and minimum 5 symptoms.
NICE (CG90) has divided depression into five grades: What is the sub-threshold grade of depression?
Where the person has a few symptoms and feels low, but can still function.
NICE (CG90) has divided depression into five grades: What is the mild grade of depression?
Where the person has enough symptoms for a diagnosis but can function reasonably well
NICE (CG90) has divided depression into five grades: What is the moderate grade of depression?
Where the person has a range of symptoms and is not coping well
NICE (CG90) has divided depression into five grades: What is the severe grade of depression?
Where the person has a full set of symptoms, can’t function and may even suffer from psychotic symptoms too
NICE (CG90) has divided depression into five grades: What is the complex grade of depression?
Where the symptoms have failed to improve with treatment and may have psychosis, other symptoms and problems
What should all patients with suspected presentation of depression be offered?
STEP ONE
-Assessment
-Support
-Psycho-education
-Active monitoring
-Onward referral for further assessment and intervention
What is the treatment options for mild to moderate depression?
STEP TWO
-Low intensity psychological or psychosocial interventions
-Medication
-Onward referral
What is the treatment options for moderate to severe depression?
STEP THREE
-Medication
-High-intensity psychological interventions
-Combined treatments and collaborative care
-Onward referrals
What is the treatment options for severe and complex depression?
STEP FOUR
-Medication
-High-intensity psychological interventions
-ECT
-Crisis service
-Combined treatments
-Multi-professional and inpatient care
-Guided self help (books and leaflets)
-Being active
-Computer based CBT
Are examples of what type of interventions?
Low intensity psychosocial interventions
-Psychological therapies, CBT, Interpersonal therapies, relaxation therapy, anxiety management, mindfulness-related therapies and counselling
-General support and advice.
Are examples of what type of interventions?
High intensity psychological interventions
What is ECT?
Electroconvulsive therapy for acute severe depression
What is TMS?
Transcranial magnetic stimulation
What antidepression doesn’t need to be started low and why?
Mirtazapine!
What antidepressant is hard to get to the therapeutic dose due to side effects and poor tolerability?
Tricyclics
What combination / augmentation can be used in depression in adults?
Lithium, an antipsychotic or another antidepressant
What antipsychotic choices are available for depression?
Aripiprazole, Olanzapine, Quetiapine or Risperidone
What drug class is standard first line for depression?
SSRI’s - Citalopram, escitalopram, fluoxetine, sertraline
What are some examples of dose dependent SNRI’s?
Duloxetine, Venlafaxine
At what dose is venlafaxine a SNRI?
150mg/day
Lofepramine and Clomipramine are examples of what class of drug?
Tricyclic antidepressants
What SSRI shows discontinuation symptoms?
Paroxetine
Amitriptyline, Dosulepin, Doxepin, Imipramine, Nortriptyline and Trimipramine are examples of what type of anti-depressant?
Tricyclic
Irreversible inhibition of MAO-A and MAO-B enzymes. Used for more resistant depression and requires a tyramine-free diet, are what drugs?
MAOIs
-Isocarboxazid
-Phenelzine
-Tranylcypromine
What drug is a reversible inhibition of MAO-A, lacking the food and drink interactions?
Moclobemide
What type of depression is Lithium used for?
Bipolar depression
What antidepressants have the highest efficacy and tolerability?
-Agomelatine
-Escitalopram
-Vortioxetine
What antidepressants have higher efficacy but lower tolerability?
-Amitriptyline
-Mirtazapine
-Paroxetine
-Venlafaxine
What antidepressants have high tolerability but lower relative efficacy?
Citalopram, Fluoxetine, sertraline
What antidepressants have lowest efficacy and tolerability?
Fluvoxamine, reboxetine, trazodone
When should a SSRI be taken?
In the morning
When should mirtazapine be taken?
At night
What is a melatonin receptor agonist and improves sleep?
Agomelatine
How long can it take for antidepressants to work?
2-6 weeks to work then 4-6 for optimum effect
If no improvement can be seen after 4 weeks of a therapeutic dose what should we do?
1) Check adherence
2) Switch to another antidepressant
How often should a patient be seen after commencing antidepressant therapy?
Every 2-4 weeks for the first 3 months
Were switching from a first like SSRI what should we swap to?
Try another SSRI or better tolerated newer-generation antidepressant
If a patients tolerance is the issue with the antidepressant what should we do?
Try a different MOA, chemical group or a different drug from the same group
If lack of efficacy is the issue with the antidepressant what should we do?
Try a different class or mode of action
How do we switch between SSRI’s and SNRI’s?
Cross-taper
*carefully to avoid serotonin syndrome
What drug group can interact with SSRI’s?
Tricyclics
What antidepressant has a long half life?
Fluoxetine
How do you swap from fluoxetine to a reversible MAOI?
Taper and Stop fluoxetine and wait 5-6 weeks.
How do you swap from a non-reversible MAOI to Fluoxetine?
A 2 week washout period is required
How many failed antidepressants suggests a review of the diagnosis?
Two
Pt X with PMHx of Depression and takes a SSRI has come into the pharmacy with:
-Restlessness
-Myoclonus
-Tremor and rigidity
-Hyperreflexia
-Shivering / elevated temperature
-Arrhythmias
What is this and what other drugs can cause this?
Serotonin Syndrome
-SSRI’s
-Tramadol
-SNRI
Triptans
A patient with there first episode of depression, how long should they continue drug therapy for?
Six months after recovery at the same dose as this minimises relapse risk
A patient with there second episode of depression, how long should they continue drug therapy for?
1-2 years may reduce relapse
A patient with there third episode of depression, how long should they continue drug therapy for?
3-5 years or longer to reduce relapse
There is a potential increased risk of suicide within the first __________ of therapy?
Month
*NO large studies conducted on this
When can withdrawal phenomena occur on anti-depressants?
Within 1-3 days of stopping or reducing doses
How long does withdrawal phenomena occur when coming off antidepressants?
1-2 weeks
What can rapidly suppress withdrawal from anti-depressants?
Re-introducing the drug
Can withdrawal occur with missed doses of some antidepressants?
Yes
A patient represents with:
-Dizziness, light-headedness
-Sleep disturbances
-Agitation, volatility
-Electric shocks in the head
-Nausea
-Fatigue
-Headache
-‘Flu-like’ symptoms
What drug are they likely having discontinuation symptoms from?
SSRI
A patient represents with:
-Dizziness, light-headedness
-Sleep disturbances
-Agitation, volatility
-Electric shocks in the head
-Nausea
-Fatigue
-Headache
-‘Flu-like’ symptoms
-Restlessness
-Abdominal distension
-Congested sinuses
What drug are they likely having discontinuation symptoms from?
SNRIs - venlafaxine, duloxetine
If a patient has been on long-term therapy with an antidepressant, how should you withdraw their treatment?
Reduce by 25% every 4-6 weeks
If a patient has been on anti-depressants for 6-8 months, how should you withdraw their treatment?
Taper over 67-8 week period
If a patient has been on a antidepressant for less than 8 weeks how should you withdraw treatment?
Stepwise over 1-2 weeks
What antidepressants can cause anti-cholinergic side effects?
TCA, MAOI
What antidepressants can cause sedation?
TCA, SNRI, Mirtazapine (NaSSA), Trazodone
What antidepressants can cause a lowered BP?
TCA, SNRI, Trazodone, MAOI
What antidepressants can cause nausea?
SSRI, TCA, SNRI, Trazodone
What antidepressants can cause sexual dysfunction?
SSRI, TCA, SNRI, Trazodone, MAOI
What antidepressants can cause weight gain
ALL
What are some examples of anti-cholinergic side effects?
Blurred vision, constipation, dry mouth, urinary retention
What are some examples of central side effects?
Anxiety, Seizures, confusion, dizziness, headaches, insomnia and sleep disturbances, nausea, sleepiness or sedation, suicidal idealtion
What antidepressants have the lowered sexual dysfunction risk?
Mirtazapine and Agomelatine
What antidepressants have little effect with alcohol?
SSRIs, Venlafaxine, Vortioxetine, Nortriptyline, Clomipramine
What antidepressants when taken with alcohol can increase sedation?
Mirtazapine, Mianserin, Trazodone, Amitriptyline, Dozepin.
What drug when taken alongside alcohol might lower the seizure threshold?
Tricyclics
What is the issue with having NSAIDs and SSRIs together?
Double the risk of upper GI bleeds (reduced by having a PPI!)
How does taking a SSRI with Warfarin affect the INR?
Significantly raises INR
If a patient is taking paroxetine and tamoxifen what can this do?
Increase the risk of recurrence of breast cancer.
What can decrease duloxetine levels?
Smoking
How does smoking affect Clozapine?
Increases levels
For children and teenagers what does NICE recommend?
1st line - Fluoxetine + psychological therapies
2nd line - Sertraline or Citalopram
What age is fluoxetine licensed for?
8-17 if unresponsive to 4-6 sessions of psychological therapies
What age is Sertraline licensed for OCD?
6-17
Citalopram SmPC states it should not be used under what age?
18
There are links between what antidepressant and autism?
SSRIs
What antidepressant is best to be avoided in pregnancy?
Paroxetine
What antidepressants are better tolerated than TCAS but increase the bleeding risk?
SSRIs
What antidepressant group increases the risk of hyponatraemia, postural HTN, falls and haemorrhagic stroke?
SSRIs
What antidepressant is recommended in Cardiac Disease?
SSRIs
Can Mirtazapine be used in patients with Cardiac disease?
Yes
What drug group can protect against MI’s?
SSRIs
What antidepressant is the best drug choice post MI?
Sertraline
What antidepressants can increase the QT interval?
SSRIs and TCA’s
What drug is contraindicated in known prolonged QT?
Citalopram and Escitalopram
If a patient has electrolyte disturbances and bradycardia can SSRI’s be used?
Used in CAUTION!!
If patient has a renal impairment what adverse drug reactions are more likely?
Confusion, Postural HTN, sedation
Can serum creatine levels be normal in elderly even if they have renal impairment?
Yes
What can be an indication to metabolic impairment?
LFTs
What type of drug needs care when prescribed in Hepatic impairment?
Those with high first-pass clearance
In severe liver disease what should be avoided (antidepressants)
Those that cause marked sedation and/or constipation
What antidepressant is used by some liver units and displays few issues?
Paroxetine
What are the 4 theories of depression?
1) Monoamine theory 5HT
2) Inflammatory theory
3) HDA dysregulation
4) Structural changes in the brain
What does this:
-Acts on SERT
-Pre-synaptic terminal
-MAO prevent reuptake of 5HT, increase synaptic levels of 5HT
-Works on receptor
-Selectivity
SSRI’s
What does this:
-Acts on enzyme monoamine oxidase
-Inside the neuron drugs need to pass into
-MOA: binds to enzyme inhibits enzyme activity prevents degregation of 5HT and NA - consequence increased levels of 5HT-NA generally = MORE 5HT/NA released,
Have same outcome as SSRI but different MOA.
MAO Inhibitors
What antidepressant block monoamine reuptake?
Tricyclic antidepressants
What does fluoxetine act on?
SERT
What does Lorazepam act on?
GABAa receptors
What does Buspirone act on?
5HT1A receptors
