Depression Flashcards
what are the core symptoms of depression?
- Low mood
- Loss of pleasure – stop doing things that you used to enjoy
what are the other symptoms of depression?
Fatigue/loss of energy
- Worthlessness, guilt – small incidence that happened in the past
- 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 do you start the treatment for depression?
- 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
- mild depression when you have tried everything for a few years and were not helpful you would move onto pharmacological interventions
how do you approach the treatment for depression?
- Balance guidelines and patient factors
- Allergies, co-morbidities, concurrent medications
- Tolerance/acceptability of side effects
- Patient preference
- Keep it simple
- Patient counselling
what are the differnt types of treatment for depression?
- SSRIs
- SNRIs
- Mirtazapine
- Tricyclics (and related)
- MAOIs
- Reboxetine
- Agomelatine
- Vortioxetine
what are examples of SSRI’s?
• Sertraline, Citalopram, Fluoxetine, Escitalopram, Paroxetine, Fluvoxamine
when would you use an SSRI?
• First line choice
- if it doesn’t work NICE suggest swapping to another
what are the side effects of SSRIs?
• Initial agitation, anxiety
– need to warn a patient of this so they aren’t surprised if this does happen
• GI side effects, hyponatraemia (low sodium, especially in the elderly)
- QT prolongation
what are the risk of SSRIs?
• Bleeding risk
– avoid using with NSAIDS/anticoagulants GI bleeds, may need omeprazole if wanting to give SSRI and aspirin
– Effect of platelets
what are examples of SNRIs?
Venlafaxine, Duloxetine
what issues may you have with SNRIs?
• Blood pressure –
o Venlafaxine contra-indicated in uncontrolled hypertension
what is mirtazapine?
• Considered to be a better tolerated antidepressant (newer)
• Side effects to note –
o Sedation – this might help if the patient is not sleeping very well
o , weight gain – might help if patient is easting very well
what are examples of tricyclics?
• Amitriptyline, Clomipramine, Nortriptyline, Lofepramine, Dosulepin
what are the side effects of tricyclics?
• Antimuscarinic side effects
o Constipation, urine retention, blood pressure, hypotension, sedation, falls, blurred vision (elderly AVOID)
• Cardiotoxicity – don’t use post MI
what are the risks of tricyclics?
• Risk in overdose – if patient has suicide risk do NOT give and if you had to would only give 7 days. Dangerous in overdose, due to cardiotoxicity
what are examples of MAOIs?
• Phenelzine, Tranylcypromine, Isocarboxazid
what is monoamine oxidase needed for?
• Monoamine oxidase is needed to break down tyramine, when you inhibit this it means you build them up to toxic levels and this may cause bleeds on brain.
what are strict rules of MAOIs?
• Strict dietary requirements – risk of hypertensive crisis
what is agomelatine?
• Novel target - Melatonergic agonist – works on melatonin
• Hepatotoxicity risk –
o cases of liver injury, including fatal hepatic failure, reported post-marketing.
• LFT monitoring – baseline, 3 weeks, 6 weeks, 3 months, 6 months
o People don’t want to do this so it is not well adhered
what is vortioxetine?
- Serotonin based
- Recommended by NICE as an option for treating depression in adults who have not responded to 2 antidepressants in the current episode.
- 3rd line treatment
how do you chose the anitdepressant?
• 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? ? Right time of time, every day?
• If changing due to side effects, think:
- which options would be better tolerated? has the side effect been stopping them do things within there life and has it had time to go away
• If switching – how can this be done safely? reduce down gradually? Leave a gap?? Use mawdsley interactions to see if this is needed. Check reference to be able to do this safely
what happens if there is no improvement?
• Time to improvement?
o 4 week trial based that you saw an effect but you may see change within 1-2 weeks.
o 1-2 weeks are when you will get the most side effects but these should fade out
o This may be longer in the elderly – 6 weeks
• Check compliance
• Increase dose
o If there was a slight improvement but not a major response you could change there dose
• Consider changing treatment – switching monotherapies
o Sometimes patients don’t want to increase dose they just want to change to a new one
• 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.
what is said about st.john worts and depression?
- Not recommended in depression.
- Not because it doesn’t work
- This is because we don’t have a regulatory body for this so when you buy It you don’t know dose, amount you are getting
- It alos have a lot of interactions
- Different potencies, potential for serious interactions.
- Efficacy?
when should you stop treatment?
• Continue for at least 6 months’ after remission
o People often don’t follow up on this
o Do this to prevent relapse
o If history of depression we could increase this to 2-5 years or even for life to prevent relapse
o We usually keep using them for elderly as if they relapse it usually causes multiple health concerns to prevent this happening (physical harm)
o Use the dose that they took from when they had the episode
