DEPRESSION Flashcards
Depression
Condition characterised by:
- low mood
- loss of interest or pleasure in most activities
What are the
screening questions that GP would ask if the patient is presenting with depression?
- During the last month, have you often been bothered by feeling down, depressed, or hopeless?
- 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
Psychological symptoms
Low self esteem
Worry and anxiety
Suicidal thoughts
Physical symptoms
Lack of energy
Changes in weight/appetite
Insomnia/early morning wakeness
Depression is a reduction of which neurotransmitters?
- Serotonin
- Dopamine
- Norephedrine at synaptic cleft
Treatment summary
Mild
* CBT
Moderate-severe
* Antidepressants
Remission
- Take for 6 months after remission
- 1 yr in elderly
- 2 years in recurrent.
GAD = 12 months due to high risk of relapse
- First line treatment
SSRIs
Why are SSRIs first line?
- 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.
How long do anti-depressants take to work?
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.
Drug choice
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)
How long does it take for anti-depressants to kick in?
- 2-4 weeks for full effect (6
weeks in elderly)
What may happen in the first 4 weeks of treatment?
- Agitation
- Anxiety
- Suicidal ideation
- Depression feels like it is worse
Patients need to be counselled on that it will take a month to work
How often should patients be reviewed for depression?
- Patients should be reviewed every 1-2 weeks at the start of anti-depressant treatment
What is the main sign that anti-depressants are working?
- Improvement in sleep is the first benefit of therapy
Once the patient is stabilised on anti-depressants, how long should they take it for?
- At least 6 months (12 months in the elderly)
- If history of recurrent depression, then for at least 2 years
Other drug choices (apart from SSRI)
Lofepramine (TCA)
Reboxetine (SNRI)
Mocoblemide (reversible MAOI)
Severe forms of depression
Other TCA
Venlafaxine
Vortioxetine (only if two other antidepressants have been tried + not worked)
Irreversible MAOIs must be initiated under specialist supervision.
Last resort
Add another antidepressant class OR
Augmenting agent (lithium or antipsychotic) OR
ECT in severe refractory depression.
Side effects (GENERAL)
Suicidal ideation + behaviour
Hyponatraemia
Serotonin syndrome
Side effects - suicidal ideation and behaviour
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
Side effects - hyponatraemia
Especially SSRIs
Common in elderly
- Drowsiness
- Confusion
- Convulsion
Washout period
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.
Switching - MAOIs
Wait 2 weeks before switching.
Moclobemide is short-acting/reversible and dose not require a washout period.
Switching - SSRIs
Wait 1 week before switching.
Sertraline = 2 weeks
Fluoxetine = 5 weeks
Switching - TCAs
Wait 1-2 weeks before switching
Imipramine or Clomipramine = 3 weeks
Withdrawal
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)
What antidepressants have a higher risk of withdrawal reaction?
Paroxetine
Venlafaxine