Depression Flashcards
Depression facts:
- More than 300 million people of all ages, worldwide, suffer from depression.
- It is the leading cause of disability worldwide.
- Affects more women than men.
- 4-10% of people in England will experience depression in their lifetime.
- sCan present with anxiety.
Symptoms of depression:
Diagnosed using DSM – 5 criteria (5 / 9 symptoms, with at least one core)
Core symptoms (most days, most of the time, for at least 2 weeks):
Low mood
Loss of pleasure
Other symptoms
Fatigue/loss of energy
Worthlessness, guilt (small past incident)
Recurrent thoughts of death, suicidal thoughts, suicide attempts
Reduced ability to think or concentrate, indecisiveness
Psychomotor agitation or retardation
Insomnia/hypersomnia
Weight loss or gain
Diagnosed using DSM – 5 criteria (5 / 9 symptoms, with at least one core)
Core symptoms (most days, most of the time, for at least 2 weeks):
Low mood
Loss of pleasure
Other symptoms
Fatigue/loss of energy
Worthlessness, guilt (small past incident)
Recurrent thoughts of death, suicidal thoughts, suicide attempts
Reduced ability to think or concentrate, indecisiveness
Psychomotor agitation or retardation
Insomnia/hypersomnia
Weight loss or gain
When to start pharmacological treatment?
Antidepressants should be considered for patients with:
- moderate or severe depression
- a past history of moderate or severe depression
- subthreshold depressive symptoms present for at least 2 years
- subthreshold depressive symptoms or mild depression persisting after other interventions
Approach to treatment:
- Balance guidelines and patient factors – some patients may request AD’s, use clinical judgement
- Allergies, co-morbidities, concurrent medications
- Tolerance/acceptability of side effects
- Patient preference
- Keep it simple
- Patient counselling
SSRI’s key points:
- Sertraline, Citalopram, Fluoxetine, Escitalopram, Paroxetine, Fluvoxamine
- First line choice
- Initial agitation, anxiety for first couple of weeks
- GI side effects, hyponatraemia (low sodium)
- Bleeding risk – avoid with NSAIDs due to serotonins effect on platelets
- QT prolongation only linked to citalopram and Escitalopram
- Fewer concerns about sedation, overdose risk, cardiac problems
- Sexual dysfunction
What are SNRI’s?
Serotonin and noradrenaline inhibitors.
Venlafaxine, Duloxetine
Venlafaxine seen more frequently, but can have problems with tolerability – not first line.
Blood pressure – Venlafaxine contra-indicated in uncontrolled hypertension.
Mirtazapine side effects:
- Considered to be a better tolerated antidepressant.
- Side effects to note – sedation, weight gain. Can sometimes work in the patients favour i.e. patients who have insomnia
- Blood disorders.
Tricyclics (TCAs) key points:
- Amitriptyline, Clomipramine, Nortriptyline, Lofepramine, Dosulepin
- Less well tolerated – not first line
- Antimuscarinic side effects – dry mouth, constipation, falls, blurred vision –> avoid in elderly
- Cardiotoxicity – cannot be used post MI
- Risk in overdose – not advised for patients with suicidal thoughts
- Trazodone – tricyclic related
Multipurpose
Used in pain relief
Monoamine oxidase inhibitors (MAOIs) key points:
- Phenelzine, Tranylcypromine, Isocarboxazid
- Moclobemide – reversible (RIMA) so can eat “small amounts”
- Strict dietary requirements – risk of hypertensive crisis
- Potential for interactions – got to leave a gap inbetween AD’s, interaction between MAOIs and serotonin
- Further down the line in terms of treatment
Not widely used
Can’t each cheese with MAOIs due to the inhibition of monoamine oxidase which breaks down tyramine.
Reboxetine (NARI) key points:
- Rarely used.
- Not recommended in the elderly
Agomelatine key points:
- Novel target - Melatonergic agonist
- Hepatotoxicity risk – cases of liver injury, including fatal hepatic failure, reported post-marketing.
- LFT monitoring – baseline, 3 weeks, 6 weeks, 3 months, 6 months
- NICE unable to make a recommendation about its use in the NHS for treating depression.
Vortioxetine key points:
- Serotonin based
- Recommended by NICE as an option for treating depression in adults who have not responded to 2 antidepressants in the current episode.
Choice of antidepressant: considerations
- Monotherapy first – SSRI, or better tolerated newer antidepressant. Switch if needed.
- Then, less well tolerated, older antidepressants.
- Before changing due to lack of effect, check:
- how long has the patient been taking the antidepressant?
- have they been taking it regularly?
If changing due to side effects, think:
- which options would be better tolerated?
If switching – how can this be done safely?
Then consider:
- combinations
- augmentation
What to do if lack of improvement?
- Time to improvement? 4 week trial
- Check compliance
- Increase dose
- Consider changing treatment – switching monotherapies
- Some improvement by 4 weeks, continue for another 2 – 4 weeks. Can consider switching if response inadequate, patient experiencing side effects, or patient prefers to.
Combination treatment:
- Specialist input
- Consider interactions
- Consider increased risk of side effects, combined side effects
Risk of serotonin syndrome – altered mental state, neuromuscular abnormalities, autonomic hyperactivity (increased heart rate, flushing) - Mirtazapine and Venlafaxine
