depression 2 Flashcards
What treatment is not reccomended for patients with persistant subthreshold depressive episodes or mild to moderate depression?
AD drugs should be avoided!
In what cases could drugs be given to patients with persitant subthreshold depression or mild to moderate depression?
- subthreshold depression symptoms lasting for more than 2 years
- If there is a history of severe depression
- mild depression that is complicating the care of a chronic physical health problem
What treatment should be used for patients with severe depression?
AD AND high intensity pyschological innervation
When a patient first takes antidepressants what is it important to tell them?
- Initally anxiety symptoms may worsen
- May take time for drug to work
For patients on Antidepressants how long after remission should they continue them? Why?
6 months is minimum time. This is needed as it greatly reduces risk of relapse
What class of drug would be prescribed for a perons first episode of depression? Examples?
A generic SSRI e.g. fluoxetine, citalopram, paroxetine, sertraline
What Antidepressant drug would be prescribed for a patient for a reccurent episode?
An AD that they previously had a good response too. AVOID any tried before which they didn’t respond too or couldn’t tolerate
If a person has chronic physical health problem which antidepressant drug is preferred and why?
Sertraline - lower incidence of drug interaction
What are SSRIs mechanism of action and what are there assoicated side effects?
- Inhibit reuptake of 5-HT so that 5-HT can agonise 5-HT1A receptor. (agonism)
- 5-HT2 agonism: restlessness, agitation, sexual dsyfunction, anxiety
- 5-HT3 agonism : headache, Nausea, GI upset, diarrhoea (Hot Dogs Go Nuts)
Insomnia, weight gain/ loss
What are the risks associated with SSRIs?
- All AD associated with suicide risk and suicidal thoughts. Only AD suitable for U18 is fluoxetine
- SSRIs inhibit hepatic CYP450s. This effects metabolism and therapeutic range of other drugs
What are the contraindicatios and cautions associated with SSRIs?
- Contraindications: MAOIs, manic episodes
- Cautions: Antiepleptic, alchohol, anticoagulants, other ADS
What side effects out from withdrawl of SSRIs?
- Nausea, headache, flu like, fatigue
- insomnia, nervousness
- paraesthesia and electric shock feelings
- dizziness and vertigo
What are example of TCA drugs?
Clomipramine Amitriptyline Lofepramine
Imipramine Nortriptyline Trimipramine
Side effects of TCA drugs
- 5-HT2 antagonism: sedative, sexual dysfunction, anxiolytic (SAS)
- Muscarinic antagonism (M1): Dry mouth, blurred vision, constipation, palpitations
- Adrenergic antagonism (α1): Drowsiness, postural hypotension, tachycardia
- Histaminergic antagonism (H1): Drowsiness, weight gain
What drug interactions occur with TCAs?
Alcohol, other AD, Anti epiletpic drugs, anti arrhythmias, antipyschotics
What containdications/ cautions are there with TCAs?
- Heart block
- Arrythmias
- Severe liver disease
- pregnacny, lactation
What classes of MAOIs are there. Give examples
- MAOIs : Phenelezine, Isocarboxazid
Irreversible inhbition of MAO-A and B. Effects NA, DA, 5-HT and tryamine
- RIMAs: Moclobemide
Reversible inhibition of MAO-A. Effects DA, tryamine, phenylethylamine, benzylamine
What line of treatment are MAOIs? What are they used for?
2nd line therapies for treatments resistant depression with well established efficacy
Disadvantages of MAOIs?
What effect does this have on MAOs in the liver/ GI tract?
Drug and diet interactions.
MAOs in liver/ GI tract normally break down dietry amines (tyramine). Inhibition of these MAOs by MAOIs allows amines from diet and drugs to enter circulation and interact with 5-HT, DA, NA receptors.
Results in sympathomimetic effects: acute hypertensive crisis, severe headache and haemorrahage
What MAOIs are used in depression and what used in parkinsons.
What do each MAO metabolize?
- depression: MAOI-A or non selective
- Parkinsons: MAOI-B
- MAO-A: tyramine, NA, 5-HT
- MAO-B: DA
Describe what happens when MAOI-As are given if someone has a diet rich in tyramine
tryamine is normall absorbed minimally due to metabolism by MAO-A. With an inhibitor more tyramine is absorbed by the nerve terminal through a NA reuptake transporter. Inside T displaces NA and also causes the reverse transport of NA through NET. This means more NA released therefore more sympathetic effects
Should St John’s worts be recommended for patient with mild to moderate depression?
NO - may be benefical but there is uncertainity about approproate doses, serious drug side effects
Why is it important to take care when switching/ combining ADs?
Some drugs require washout periods. time depends on particular AD. Can lead to serotonin syndrome
What is serotonin syndrome and its associated side effects?
Rare but potentially fatal
Rapid onset with dose intiation or increase of dose of serotonergic drug
Altered mental, aggitation, tremor, shivering, diarrhoea, hpereflexia, hyperthermia
What is bipolar?
Mental health disease where someone goes from having periods of depressive episodes to a manic episodes
What symptoms occur with manic episodes?
- Elevated mood - increased energy, racing thoughts
- Increased self-esteem
- Reduced attention
People can become agressive, suspicous, recklessly spend etc
What are first line treatments of bipolar disorder?
- Antipsychotics
- Lithium salts
- Adjuction use of BZs
What is 2nd line treatment of Bipolar disorder?
Anti- convulsants e.g. sodium valporate and carbamazepine
Treatment of depressive episodes in bipolar illness
- Problem: antidepressants work but response rates are lower and there is a risk of inducing mania so
- If drug free then consider lithium or an antidepressants
- If severe depression/suicidal consider ECT
- If already on medication check compliance
- Careful withdrawal if on antipsychotic
- Additional mood stabilizer or additional antidepressant
How do Lithium salts work?
Complex biochemical effects
