Depression Flashcards
What are the risk factors for depression?
- 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
When is depression highest?
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
What are the risks of untreated depression?
- 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
What drugs can cause drug-induced depression?
- Over 200 meds e.g. steroids, benzodiazepines
- Anti-psyhotics
- Anti-convulsants
- NSAIDs
- CVD drugs e.g. CCBs, B-blockers
- caffeine/ caffeine withdrawal
What are symptoms of depression?
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
What are the 2 diagnostic tools?
- ICD-10: International classification of diseases
- DSM-5: Diagnostic and statistical manual of mental disorders
What are the 5 stages of depression outlined by NICE?
- 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.
What are examples of non-pharmacological therapy?
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
Do you offer antidepressants for mild depression?
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.
What is the main AD that doesn’t require a low dose and slow titration?
Mirtazapine
What are the usual first choice anti-depressants?
SSRIs e.g. citalopram, fluoxetine, sertraline
What is an example of a drug that is licensed as an adjuvant anti-depressant?
Quetiapine XL- 150-300mg per day
What medications have 2nd line use?
- Monoamine oxidase inhibitors- used less now
- SSRIs- Fluvoxamine, Paroxetine
- TCAs- Amitriptyline, Nortriptyline
- Lithium
Is switching to another SSRI, when one is ineffective an effective option?
Yes, it has been found that switching to another SSRI is as effective as switching to another class of anti-depressants.
What drugs have adviced timings that go alongside them?
- 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
How long do anti-depressants take to work?
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
Why do you need to cross-taper SSRIs and SNRIs when switching drugs?
Risk of serotonin syndrome
Why can mirtazapine be a good drug to swap to?
It has little interactions
What is serotonin syndrome?
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
What is a dangerous side effect of starting anti-depressants?
Increased risk of self-harm and suicide- especially in under 21s.
What are examples of AD discontinuation symptoms?
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
Why don’t you want to give NSAIDs to a patient on SSRIs?
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.
who would you not prescribe a SSRI to?
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).
What are the effects of SSRIs on patients on Warfarin’s INR?
SSRIs increase INR- especially on fluoxetine and paroxetine. Least effect with sertraline and citalopram.
What drug should not be given alongside tamoxifen and why?
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.
What is the management of depression in children?
1st line: Fluoxetine
2nd line: Sertraline, Citalopram
Must be in conjunction with psychological therapies
What is the AD of choice post MI?
Sertraline
What can SSRIs and TCAs do to the heart?
They can increase the QT prolongation of the heart.
What anti-depressants are contra-indicated in patients with known QT prolongation or on other meds that cause this prolongation?
Citalopram and escitalopram
When is escitalopram contra-indicated or cautioned?
QT prolongation
Torsades des pointes
Recent MI
Bradyarrythmias
Hypokalemia
Hypomgnesiumia
