DEPRESSION

Question 1

Depression

Answer 1

Condition characterised by:
- low mood
- loss of interest or pleasure in most activities

Question 2

What are the
screening questions that GP would ask if the patient is presenting with depression?

Answer 2

1. During the last month, have you often been bothered by feeling down, depressed, or hopeless?
2. During the last month, have you often been bothered by having little interest or pleasure in doing things?
   If they answer yes to either then further examination is required

Question 3

Psychological symptoms

Answer 3

Low self esteem
Worry and anxiety
Suicidal thoughts

Question 4

Physical symptoms

Answer 4

Lack of energy
Changes in weight/appetite
Insomnia/early morning wakeness

Question 5

Depression is a reduction of which neurotransmitters?

Answer 5

• Serotonin
• Dopamine
• Norephedrine at synaptic cleft

Question 6

Treatment summary

Answer 6

Mild
* CBT
Moderate-severe
* Antidepressants

Question 7

Remission

Answer 7

• Take for 6 months after remission
• 1 yr in elderly
• 2 years in recurrent.

GAD = 12 months due to high risk of relapse

Question 8

1. First line treatment

Answer 8

SSRIs

Question 9

Why are SSRIs first line?

Answer 9

• Better tolerated and safer in overdose
• Less sedating, anti-muscarinic, epileptogenic + cardiotoxic than TCAs
• MAOIs are rarely used (dangerous food + drug interactions). Reserved for specialist use.

Question 10

How long do anti-depressants take to work?

Answer 10

Min. 2 weeks.
Initially may feel worse - increased agitation, anxiety + suicidal ideation.
Review every 1-2 weeks at the start of treatment/
Wait at least 4 weeks (6 in the elderly) before deeming it ineffective.

Question 11

Drug choice

Answer 11

1st line = SSRI
2nd line = increase SSRI dose or switch to alternative SSRI
3rd line = SNRI
4th line = TCA or MAOI (consider risks associated with the two)

Question 12

How long does it take for anti-depressants to kick in?

Answer 12

• 2-4 weeks for full effect (6
  weeks in elderly)

Question 13

What may happen in the first 4 weeks of treatment?

Answer 13

• Agitation
• Anxiety
• Suicidal ideation
• Depression feels like it is worse
  Patients need to be counselled on that it will take a month to work

Question 14

How often should patients be reviewed for depression?

Answer 14

• Patients should be reviewed every 1-2 weeks at the start of anti-depressant treatment

Question 15

What is the main sign that anti-depressants are working?

Answer 15

• Improvement in sleep is the first benefit of therapy

Question 16

Once the patient is stabilised on anti-depressants, how long should they take it for?

Answer 16

• At least 6 months (12 months in the elderly)
• If history of recurrent depression, then for at least 2 years

Question 17

Other drug choices (apart from SSRI)

Answer 17

Lofepramine (TCA)
Reboxetine (SNRI)
Mocoblemide (reversible MAOI)

Question 18

Severe forms of depression

Answer 18

Other TCA
Venlafaxine
Vortioxetine (only if two other antidepressants have been tried + not worked)
Irreversible MAOIs must be initiated under specialist supervision.

Question 19

Last resort

Answer 19

Add another antidepressant class OR
Augmenting agent (lithium or antipsychotic) OR
ECT in severe refractory depression.

Question 20

Side effects (GENERAL)

Answer 20

Suicidal ideation + behaviour
Hyponatraemia
Serotonin syndrome

Question 21

Side effects - suicidal ideation and behaviour

Answer 21

At risk: children and young adults or history of suicidal behaviour.
Monitor at the start of treatment or after a dose change:
- Suicidal behaviour
- Self harm
- Hostility

Question 22

Side effects - hyponatraemia

Answer 22

Especially SSRIs
Common in elderly
- Drowsiness
- Confusion
- Convulsion

Question 23

Washout period

Answer 23

A specific timeframe during which one medication is discontinued before starting another.
Aim = clear the first medication completely from the patient’s system to avoid potential drug interactions or additive side effects, particularly serotonin syndrome.

Question 24

Switching - MAOIs

Answer 24

Wait 2 weeks before switching.
Moclobemide is short-acting/reversible and dose not require a washout period.

Question 25

Switching - SSRIs

Answer 25

Wait 1 week before switching.
Sertraline = 2 weeks
Fluoxetine = 5 weeks

Question 26

Switching - TCAs

Answer 26

Wait 1-2 weeks before switching
Imipramine or Clomipramine = 3 weeks

Question 27

Withdrawal

Answer 27

AVOID abrupt withdrawal.
Withdrawal reactions = 5 days of stopping.
Increased risk of withdrawal = suddenly stop after taking for 8+ weeks.
Gradually reduce dose over 4 weeks or longer (6 months in patients on long-term maintenance treatment)

Question 28

What antidepressants have a higher risk of withdrawal reaction?

Answer 28

Paroxetine
Venlafaxine