Depression

Question 1

SSRIs

Answer 1

Sertraline
Citalopram
Fluoxetine* - safest in children

Question 2

TCAs

(C/I): arrhythmias, manic phase, heart block and MI

Cautions:
Diabetes, hyperthyroidism, CV disease, epilepsy, glaucoma

Anticholinergic syndrome
Drowsy
QT prolong

Answer 2

(sedating)
Amitriptyline
Dosulepin
(agitated)

(less sedating)
Imipramine
Lofepramine
Nortriptyline 
(withdrawn)

Question 3

MAOI
avoid OTC with decongestants
and food interactions e.g. cheese, salami, marmite
- specialist

Answer 3

Moclobemide - reversible
Phenelzine*
Isocarboxazid*
Tranylcypromine - hypertensive crisis

• = hepatoxic
• throbbing headache

Question 4

Antidepressants are used to treat:

Answer 4

Moderate-severe

Increases risk for anxiety, suicidal thoughts within first few weeks of treatment

Question 5

1st line treatment

Answer 5

SSRIs
Safer in OD
Less sedating
Less AM side effects/cardiotoxic effects
- sertraline is safe in those with unstable angina

Question 6

TCA

Answer 6

More toxic in OD * dilated pupils
More sedating
More AM/cardiotoxic

Question 7

St John’s Wort
(enzyme inducer)
e.g. with warfarin - increases risk of clotting

Answer 7

Mild depression - not recommended
API varies in different prep
Conc of interacting drugs can increase - toxicity increased

Question 8

Management

Answer 8

Review 1-2 weeks at the start of the treatment

Continue for 4 weeks before switching, if partial response continue for a further 2-4 weeks

Recurrent depression (maintenance) - at least 2 years

Question 9

Common side effects of all anti-depressants?

Answer 9

Hyponatraemia - especially in elderly *SSRI = most common

Signs of hyponatraemia
Drowsiness, convulsions, confusion

Question 10

Serotonin syndrome (SS)

Answer 10

Too high levels of serotonin

SSRIs or SNRIs/ with MAOI - most common - increase, OD or hours/days after starting

Question 11

Symptoms of SS

- withdraw med if symptoms occur

Answer 11

Tremor
Tachycardia
Shivering
Agitation, confusion
Neuromuscular hyperactivity

Question 12

Failure to respond:

Answer 12

Increase dose or switch to different SSRI or mirtazapine
Second line - reboxetine, lof, moclo
Venlafaxine (SNRI) - severe

Question 13

Don’t start MAOI until:

Answer 13

2 weeks after prev MAOI has been stopped
7-14 days after TCA as been stopped (3 weeks for imp)
1 week after SSRI (5 weeks for fluoxetine)