Depression

Question 1

What are the symptoms of depression?

Answer 1

• Low mood
• Helpless
• Low self esteem
• Low sex drive
• Fatigue

Question 2

What is the treatment for mild depression?

Answer 2

CBT

Question 3

What is the treatment for moderate-severe depression?

Answer 3

First line: SSRI + CBT

• Alt: SNRI (duloxetine, venlafaxine)
• Alt: Antidepressant based on previous Hx

Taken for at least 6M

Reviewed w/in 2 weeks of starting

• If at risk of suicide or 18-25: reviewed after 1 week

Question 4

What is the treatment for severe depression + rapid response?

Answer 4

Electroconvulsive therapy

Question 5

Give examples of irreversible Monoamine oxidase inhibitor

Answer 5

• Phenelzine + isocarboxazid (INC hepatotoxicity)
• Tranylcypromine (INC hypertensive crises)

Question 6

Give an example of a reversible Monoamine oxidase inhibitor

Answer 6

Moclobemide (no wash out period - short acting)

Question 7

Give examples of selective serotonin reuptake inhibitors

Answer 7

• Citalopram (QT prolongation)
• Fluoxetine (children)
• Paroxetine (INC w/drawal reactions)
• Sertraline (safe in MI + unstable angina)

Question 8

Give examples of tricyclic antidepressants

Answer 8

• Amitriptyline (neuropathic pain)
• Lofepramine (safest TCA - Less sedating)
• Nortriptyline (neuropathic pain - Less sedating)
• Mirtazapine (s/e weight gain)

Question 9

What are the side effects of antidepressants

Answer 9

Drowsiness

Suicidal ideation + behaviour
- Monitor: start, dose changes

Hyponatraemia (drowsiness, confusion, convulsions)
- Esp SSRIs

W/drawal reactions
- High risk (shorter half life): paroxetine (SSRI) + venlafaxine

Serotonin syndrome
- Neuromuscular hyperactivity: tremor, muscle rigidity
- Alt mental state: confusion, mania
- Autonomic dysfunction: tachycardia, labile BP, urination, diarrhoea, pallor

Question 10

What are the washout periods when switching drugs?

Answer 10

Washout period needed to avoid serotonin syndrome

MAOI → 2 weeks
- Moclobemide: No wash out period

SSRI → 1 week
- Sertraline: 2 weeks
- Fluoxetine: 5 weeks

TCA → 1-2 weeks
- Clomipramine/imipramine: 3 weeks

Question 11

What is the MOA of SSRIs?

Answer 11

selectively blocks re-uptake of 5-HT from synapse = INC 5-HT levels

Question 12

What are the indications for SSRI?

Answer 12

• First line: depression + anxiety
• Safe in MI + unstable angina
• Fluoxetine: children

Question 13

What are the side effects of SSRIs?

Answer 13

Serotonin syndrome

INC bleed risk
- MHRA: Risk of postpartum haemorrhage if used in month before delivery

GI upset: N, V, D

Hypersensitivity (skin rash)

DEC seizure threshold

QT prolongation
- CI: citalopram + escitalopram

Appetite + weight gain/loss

Question 14

What are the interactions of SSRIs?

Answer 14

• Fluoxetine + sertraline are enzyme inhibitors → INC drug levels
• Grapefruit juice (inhibitor) → INC sertraline levels
• Hyponatraemia: Antidepressant, Carbamazepine, Desmopressin, Diuretic
• Bleed: Alcohol, Anticoagulants, Corticosteroid, NSAID
• Serotonin syndrome: Antidepressants, methadone, tramadol, St John’s Wort, sumatriptan
• Drugs that prolong QT interval (citalopram + escitalopram)→ arrhythmias
• Drugs that cause hypokalaemia (Salbutamol, corticosteroids, loop + thiazide diuretic, theophylline) → INC risk of torsade de pointes

Question 15

What is the MOA of TCA?

Answer 15

Blocks re-uptake of 5-HT + Na from synapse = INC 5-HT + NA levels

Also blocks many other receptors = side effects

Question 16

What is the indication of TCA?

Answer 16

Second line: depression + anxiety
- OD - long half life

Question 17

What are the side effects of TCA?

Answer 17

TCA compared to SSRI:
- INC: sedating, anti-muscarinic, cardio toxic
- Caution: significant suicide risk

Cardiac effects (arrhythmias)
- CI: arrhythmias, heart block
- Caution: CVD, hyperthyroidism, QT prolongation risk factor (clomipramine)

Anti-muscarinic effects
- Caution: urinary retention, enlarged prostate, chronic constipation, closed angle glaucoma
Seizures
- Caution: epilepsy

Question 18

What are the interactions of TCAs?

Answer 18

• Hyponatraemia: Antidepressant, Carbamazepine, Desmopressin, Diuretic
• Antimuscarinic effect: Antihistamine, Hyoscine, Alcohol, Benzo, Barbituate
• Antihypertensive → hypotension
• Dopaminergic drugs → hypotension
• Serotonergic drugs (Antidepressants, methadone, tramadol, St John’s Wort, sumatriptan)→ Serotonin syndrome
• Drugs that prolong QT interval (clomipramine)→ arrhythmias
• Drugs that cause hypokalaemia (Salbutamol, corticosteroids, loop + thiazide diuretic, theophylline) → INC risk of torsade de pointes

Question 19

What is the MOA of MAOI?

Answer 19

Blocks monoamine oxidase, monoamine accumulate: INC 5-HT, NA + DA levels

Question 20

What is the indication for MAOIs?

Answer 20

Depression (Rarely used due to food + drug interactions)

Question 21

What are the side effects of MAOIs?

Answer 21

Hypertensive crises
- Associated w intracranial bleed
- Caution: CVD
- CI: cerebrovascular disease (stroke), severe CVD

Hepatotoxicity

Postural hypotension (dizziness, blurry vision)
- DISCONTINUE if palpitations or frequent headaches

Question 22

What are the interactions of MAOIs?

Answer 22

Sympathomimetics → hypertensive crises
- Pseudoephedrine, oxymetazoline (OTC decongestants)
- Adrenaline, noradrenaline
- Amphetamines + methylphenidate
- Beta2 agonist

TCA → severe toxic reaction

Serotonergic drugs → Serotonin syndrome

Tyramine rich or dopa-rich food → hypertensive crises
- Avoid up to 2 weeks after stopping
- Eat fresh food
- Avoid alcohol