Depression Flashcards
What are the three severities of depression?
Mild
Moderate
Severe
Depression is more common when in the presence of what other things?
Physical disease Excessive and chronic alcohol misuse Social stresses Interpersonal difficulties Lack of social support
Name the three main types of antidepressant.
Tricyclic antidepressants
Selective serotonin reuptake inhibitors
Monoamine oxidase inhibitors
What are the characteristic features of depression?
Low mood Early morning wakening Lethargic Anhedonia Feelings of guilt
How long do features of depression need to have been persisting for it to be classed as depression?
2 weeks
What is the most effective treatment for depression?
Combination of cognitive behavioural therapy and an antidepressant
What things can determine the choice of antidepressant prescribed?
Side effects (either positive or negative for patient)
Co-morbid illness
Interactions
How do SSRIs work?
Inhibit reuptake of serotonin within synapse, therefore prolonging its effects
Name the SSRIs.
Citalopram Escitalopram Fluvoxamine Fluoxetine Sertraline Paroxetine
What are the common side effects of SSRIs?
Nausea GI disturbances Dry mouth Insomnia Loss of libido
Why are SSRIs preferred over TCAs? (in terms of side effects)
SSRIs have no anti-cholingeric side effects
Why are SSRIs not prescribed to under 18s?
Studies have shown there to be a higher risk factor for the development of suicidal/self harm ideation in under 18s taking SSRIs
What is serotonin syndrome?
A toxic hyperserotonergic state
What is serotonin syndrome caused by?
Ingestion of two or more drugs that increase serotonin levels, e.g. SSRIs combined with MAOIs, dopaminergic drugs or TCAs
What are some symptoms of serotonin syndrome?
Agitation Confusion Tremor Diarrhoea Tachycardia Hypertension Hyperthermia
How can you reduce the effect of insomnia caused by SSRIs?
Advise to take in morning
What are some adverse effects of SSRIs?
Hyponatraemia
GI bleeding
Serotonin syndrome
QT prolongation
Why are patients gradually reduced off SSRIs instead of just being stopped?
Sudden stopping can lead to withdrawal syndrome
Why should care be taken when giving SSRIs to epileptics?
SSRIS lower the seizure threshold
What are the characteristics of withdrawal syndrome
Shivering Dizziness Anxiety Headache Nausea 'Electric shocks'
Name some tricyclic antidepressants.
Imipramine Amitriptyline Lofepramine Nortriptyline Clomipramine
How do TCAs work?
Potentiate actions of monoamines (serotonin and noradrenaline) by inhibiting reuptake into nerve terminals
What are the oldest antidepressants and therefore have the most evidence for them?
MAOIs
What are the antimuscarinic effects of TCAs?
Dry mouth Constipation Tremor Blurred vision Urinary retention
What cardiovascular side effects can TCAs cause?
QT prolongation
Arrhythmias
Postural hypotension
Why is it not wise to prescribe TCAs to patients with suicidal thoughts?
TCAs are toxic in overdose
What are some side effects of TCAs?
Weight gain
Sedation
Confusion
Motor incoordination
Why do TCAs have cardiovascular side effects?
Block the alpha1-adrenoreceptor
What are the contraindications of prescribing TCAs?
Prostatism
Narrow angle glaucoma
Recent MI
Heart block
In which patients should you be cautious to prescribe TCAs?
Those with:
Ischaemic heart disease
Epilepsy
What kind of drugs can TCAs interact with?
Those with sedative effect, e.g. Alcohol Opioids Sedative anti-histamines Anxiolytics Those that prolong QT interval, eg. Amiodarone Catecholamines, eg adrenaline
How does venlafaxine work?
Potent blocker of serotonin reuptake, with some action on noradrenaline reuptake
In which individuals should venlafaxine not be prescribed?
Those with uncontrolled hypertension
Those prone to cardiac arrhythmias
How do MAOIs work?
Irreversibly inhibit intracellular enzymes monoamine oxidase A and B, leading to increase of noradrenaline, dopamine and serotonin in the brain
What should be avoided when taking MAOIs?
Foods rich in tyramine, e.g. mature cheese, pickled herring, yeast extracts
In someone diagnosed with depression what should they be advised to stop doing?
Drinking alcohol
Taking depressive drugs, e.g. steroids
What are examples of MAOIs?
Phenelzine Isocarboxazid Isoniazid Tranylcypromine Moclobemide
What does monoamine oxidase A have a preference to?
Serotonin
What does monoamine oxidase B have a preference to?
Phenylethylamine
Dopamine
What are some adverse effects of MAOIs?
Postural hypotension
Atropine-like effects
Weight gain
CNS stimulation (insomnia, restlessness, hallucinations)
How long can MAOIs stay in the body after they are stopped?
Up to 3 weeks
What type of drug can MAOIs interact with?
Ephedrine-containing drugs, e.g. OTC cough and cold medications, other antidepressants
How does mirtazapine act?
Antagonises presynaptic alpha2-adrenoreceptors, enhancing release of serotonin and noradrenaline
Also blocks H1-receptors
What kind of drug is trazodone?
A tetracyclic antidepressant
How does trazodone work?
Blocks 5-HT(2a) and 5-HT(2c) receptors, blocking serotonin reuptake
What are the side effects of mirtazapine and trazodone?
Sedative effect
Risk of increased appetite (therefore weight gain)
Why are mirtazapine and trazodone less dangerous in overdose than TCAs?
Fewer autonomic side effects, so are less cardiotoxic
How does duloxetine work?
Inhibits both noradrenaline and serotonin reuptake
When is venlafaxine used?
In severe cases of depression
When is duloxetine used?
Major depressive disorder
Can be used to treat urinary incontinence and diabetic neuropathy
What is the first line treatment for depression in someone post-MI?
Sertraline
Which TCA has the least anticholinergic activity?
Lofepramine
What are the two subtypes of benzodiazepines?
Hypnotics
Anxiolytics
What are hypnotic BZDs used to treat?
Insomnia
Name some hypnotic BZDs.
Temazepam Nitrazepam Zopiclone Zopidem Zaleplon
What are anxiolytic BZDs used to treat?
Anxiety
Name some anxiolytic BZDs.
Diazepam
Chlordiazepoxide
Lorazepam
Oxazepam
How do BZDs work?
Agonists that bind to site on GABAa receptor, enhancing inhibitory effect of GABA by opening chloride channels
Why should BZDs not be taken with alcohol?
Danger of overdosing, due to both affecting same receptor (BZDs indirectly, alcohol directly)
What are some adverse effects of BZDs?
Drowsiness Falls Impairment judgement and dexterity Forgetfulness Confusion Irritability Aggression
What are BZDs usually indicated for?
Short-term relief of severe, disabling anxiety or insomnia
