Depression

Question 1

What are the risk factors for depression?

Answer 1

• Genetics: 40-70%
• Gender- females 2x more likely
• Lack of parenteral care
• History of child sexual abuse
• Social adversity
• Physical illness e.g. kidney disease, diabetes
• Poor sleep and chronic insomnia
• Vit D deficiency
• Quitting smoking, increases risk
• Mother having post-natal depression = 5x fold
• Drugs

Question 1

When is depression highest?

Answer 1

Is highest in aged 40-59 and then 80+
- 1st episode often between 15-18 and most common 1st episodes at 30-40
- Higher in women than men

Question 2

What are the risks of untreated depression?

Answer 2

• Increase in drug or alcohol abuse or dependence
• cognitive impairment - inc poor interactions with friends or family
• poor work- increased absence, decreased productivity
• poor sleep
• suicidal ideation or acts

Question 3

What drugs can cause drug-induced depression?

Answer 3

• Over 200 meds e.g. steroids, benzodiazepines
• Anti-psyhotics
• Anti-convulsants
• NSAIDs
• CVD drugs e.g. CCBs, B-blockers
• caffeine/ caffeine withdrawal

Question 4

What are symptoms of depression?

Answer 4

Emotional:
Sadness
anxiety
irritability
lack of enjoyment
suicidal ideation
guilt

Physical:
Fatigue
loss of appetite
weight changes
insomnia/hypersomnia
sexual dysfunction
headaches

cognitive: Difficulties with;
attention/concentration
memory
decision making
mental sharpness
judgement
planning and organisation

Question 5

What are the 2 diagnostic tools?

Answer 5

• ICD-10: International classification of diseases
• DSM-5: Diagnostic and statistical manual of mental disorders

Question 6

What are the 5 stages of depression outlined by NICE?

Answer 6

• Sub-threshold: Few symptoms, feeling low but still can function
• Mild: Enough symptoms for diagnosis, but can function reasonably well
• Moderate: Range of symptoms and is not coping well
• Severe: Full set of symptoms, can’t function and may suffer some psychotic symptoms too
• Complex: Symptoms have failed to improve with treatment and may have psychosis, other symptoms and problems.

Question 7

What are examples of non-pharmacological therapy?

Answer 7

Social support is very important!
Mild:
- Guided self-help (books, leaflets)
- Computer based CBT
- Being more active e.g. group activities

High intensity:
- CBT, Interpersonal therapies, relaxation therapies, mindfulness therapies, counselling

Severe and complex depression:
- ECT- electroconvulsive therapies
- TMS- Transcranial magnetic stimulation

Question 8

Do you offer antidepressants for mild depression?

Answer 8

Not routinely- because of poor risk:benefit ratio.
But can consider in:
- patients with history of moderate-severe depression
- persistent sub threshold depressive symptoms for >2years
- Mild depression persistent following other interventions.

Question 9

What is the main AD that doesn’t require a low dose and slow titration?

Answer 9

Mirtazapine

Question 10

What are the usual first choice anti-depressants?

Answer 10

SSRIs e.g. citalopram, fluoxetine, sertraline

Question 11

What is an example of a drug that is licensed as an adjuvant anti-depressant?

Answer 11

Quetiapine XL- 150-300mg per day

Question 12

What medications have 2nd line use?

Answer 12

• Monoamine oxidase inhibitors- used less now
• SSRIs- Fluvoxamine, Paroxetine
• TCAs- Amitriptyline, Nortriptyline
• Lithium

Question 13

Is switching to another SSRI, when one is ineffective an effective option?

Answer 13

Yes, it has been found that switching to another SSRI is as effective as switching to another class of anti-depressants.

Question 14

What drugs have adviced timings that go alongside them?

Answer 14

• SSRIs and SNRIs: Take them in the morning- as serotonin and dopamine need to be compressed during sleep and so these drugs can cause sleep disturbances

Question 15

How long do anti-depressants take to work?

Answer 15

Around 4 weeks- but can take 2-6 weeks (4-6 weeks for optimum)
- If no improvement seen after 4 weeks, consider switching to another AD- check adherence first
if minimal improvement has occurred, continue until week 6

Question 16

Why do you need to cross-taper SSRIs and SNRIs when switching drugs?

Answer 16

Risk of serotonin syndrome

Question 17

Why can mirtazapine be a good drug to swap to?

Answer 17

It has little interactions

Question 18

What is serotonin syndrome?

Answer 18

This is a toxic state caused by an increase in brain serotonin activity. This can occur with combinations of SSRIs, SNRIs and tramadol - esp in overdose or during switches.
This is rare but serious and life-threatening!
Symptoms: restlessness, muscle spasms, tremor, rigidity, hyperflexia, shivering, elevated temp, arrythmias = can cause cardiac collapse

Question 19

What is a dangerous side effect of starting anti-depressants?

Answer 19

Increased risk of self-harm and suicide- especially in under 21s.

Question 20

What are examples of AD discontinuation symptoms?

Answer 20

These occurs when ADs are nor stopped gradually. They occur usually within 1-3 days and are rapidly suppressed by re-introduction of drug. Not to be confused with relapse symptoms (condition not managed without drug) that often occur 2+ weeks after discontinuation.
e.g.
Dizziness
light-headed
agitation
electric shocks in head
nausea, fatigues, headaches
flu-like symptoms

SNRIs- all of above +
restlessness
abdominal distension
congested sinuses

Question 21

Why don’t you want to give NSAIDs to a patient on SSRIs?

Answer 21

Because they both have an increased risk of GI bleeds.
SSRIs double the risk of Gi bleeds and this is increased 3-fold by concurrent NSAIDs.
If really have to use NSAIDs, concomitant PPIs can decrease risk.

Question 22

who would you not prescribe a SSRI to?

Answer 22

Do not prescribe selective serotonin reuptake inhibitors (SSRIs) to people:
- In a manic phase of bipolar disorder.
- With poorly controlled epilepsy.
- With known QT interval prolongation, or congenital long QT syndrome (citalopram and escitalopram).
- Concurrent use of drugs known to prolong the QT interval (citalopram and escitalopram).
- With severe hepatic impairment (sertraline).

Question 23

What are the effects of SSRIs on patients on Warfarin’s INR?

Answer 23

SSRIs increase INR- especially on fluoxetine and paroxetine. Least effect with sertraline and citalopram.

Question 24

What drug should not be given alongside tamoxifen and why?

Answer 24

Tamoxifen — avoid concurrent use with fluoxetine or paroxetine. Fluoxetine and paroxetine are potent inhibitors of the liver enzyme CYP2D6 and may reduce the plasma concentration of tamoxifen = this can increase the risk of recurrent breast cancer.

Question 25

What is the management of depression in children?

Answer 25

1st line: Fluoxetine
2nd line: Sertraline, Citalopram

Must be in conjunction with psychological therapies

Question 26

What is the AD of choice post MI?

Answer 26

Sertraline

Question 27

What can SSRIs and TCAs do to the heart?

Answer 27

They can increase the QT prolongation of the heart.

Question 28

What anti-depressants are contra-indicated in patients with known QT prolongation or on other meds that cause this prolongation?

Answer 28

Citalopram and escitalopram

Question 29

When is escitalopram contra-indicated or cautioned?

Answer 29

QT prolongation
Torsades des pointes
Recent MI
Bradyarrythmias
Hypokalemia
Hypomgnesiumia