Depression

Question 1

How is depression diagnosed?

Answer 1

Either Via DSM-V or ICD-10

Question 2

How would you diagnose based on DSM-V?

Answer 2

There are 2 core symptoms - low mood, and loss of interest
for diagnosis, the patient must exhibit 5-9 symptoms which includes one of the core symptoms.

Symptoms should be present for at least 2 weeks and be of sufficient severity for most of each day.

Question 3

What is the proposed etiology of depression and how does that link to 1st line treatments?

Answer 3

Etiology is based on amine deficiency theory of depression, suggesting deficiency in the amines, particularly 5-HT (serotonin).
Treatments are based on this i.e selective serotonin reuptake inhibitors target the SERT transporter, Inhibits the reuptake of serotonin from the synaptic cleft so more serotonin is available to bind to 5-HT receptors and reduce symptoms.

Question 4

At roughly what threshold of depression would you initiate drug treatment?

Answer 4

Persistent subthreshold/mild to moderate with inadequate response to initial interventions/moderate/severe

Question 5

Common low intensity psychological interventions for subthreshold and mild

Answer 5

individual guided self help based CBT 12 weeks
computerised CBT
group physical activity programmes

Question 6

High intensity psychological interventions

Answer 6

Individual CBT 16-20 sessions over 3-4 months
interpersonal therapy ^same
Behavioural couples therapy

Question 7

Why are MOAIs not commonly used now?

Answer 7

Many side effects, and interactions with certain foods e.g. cheese can be life threatening

Question 8

1st line drug treatment in depression

Answer 8

SSRIs e.g. sertraline, fluoxetine, paroxetine, citalopram, escitalopram

Question 9

Side effects of SSRIs and why?

Answer 9

Nausea/vomiting - stimulation of 5-HT3 receptor in hypothalamus and brainstem- chemoreceptor trigger zone

Diarrhoea - 5-HT3 AND 5-HT4 stimulation

CNS e.g. anxiety - 5-HT2A, 5-HT2C

Sexual dysfunction 5HT3
Insomnia

Question 10

Dosage of sertraline

Answer 10

50mg, then increased if needed by 50mg weekly up to 200mg/day maximum

Question 11

Is suicidal ideation common in SSRIS?

What is it common with?

Answer 11

No

TCAs

Question 12

Interactions of SSRIs?

Answer 12

Increased risk of bleeding esp in elderly and people on NSAIDS/drugs that affect clotting e.g. aspirin, warfarin.
- consider PPI to protect gastric mucosa
NOTE: fluoxetine and fluvoxamine have higher risk of interactions than other ssris

Question 13

Which antidepressant causes weight gain?

Answer 13

Mirtazapine

Tricyclic antidepressants e.g. imipramine, amitryptylline

Question 14

Which antidepressants are toxic in overdose?

Answer 14

TCAs

Question 15

Which anti. depressant have anti muscarinic side effects e.g. dry mouth, consipation, urinary retention, blurred vision?

Answer 15

TCAs as they target mAchRs (non selective)

Question 16

Which anti depressants have sedation and drowsiness?

Answer 16

TCAs as target H1 receptors

Mitrazapine

Question 17

Which anti depressants have greater cardiovascular risk?

Answer 17

Venlafaxine
TCAs
Citalopram and escitalopram SSRIs cause QT interval prolongation

Question 18

What drug is better if QT prolongation?

Answer 18

Sertraline

Question 19

Which drugs have a higher tendency to lower seizure threshold?

Answer 19

TCAs

Some SSRIs e.g. citalopram (use sertraline in epilepsy)

Question 20

Counselling or advice for patients treated for depression?

Answer 20

• anti depressants are not addictive
• full effect takes time ~2-4 weeks
• must continue after remission for at least 6 mo
• There is a risk of discontinuation symptoms esp if stop abruptly or have drugs with shorter half life e.g. venlafaxine, paroxetine. Doses should be reduced slowly tapered down
  S/E and how to manage

Question 21

How are anti depressants initiated and followed up generally?

Answer 21

Start on lowest dose effective as an anti-depressant. Monitoring after 2 weeks, see regularly every 2-4 weeks in first 3 months then at longer intervals if response is good. Improvement should be after 2-4 weeks.

Question 22

What is serotonin syndrome?

Answer 22

Symptoms after either an increased SSRI dose or combo of drugs that enhance serotonin e.g. Tramadol, fentanyl, lithium, ondansetron, buspirone, st. johns wort.
- flu like symptoms, diarrhoea, sweating, confusion, convulsions

Stop offending drugs
Treat the symptoms e.g. cyproheptadine is an antihistamine which blocks the effect of the serotonin receptors

Question 23

what is the Interaction of MOAIs e.g. with food?

Answer 23

Irreversibly binds to the MAO enzyme disrupting its function. Tyramine is a potent releaser of noradrenaline and can increase BP. Normally tyramine doesn’t accumulate as it is broken down by MAO-A. Any foods high in tyramine e.g. cheese can cause hypertensive crisis as not enough broken down.

Question 24

What are the treatment aims in depression

Answer 24

Prevent suicide
Provide symptomatic therapy
Identifying possible causes (primary)
investigate social domestic and financial circumstances
initiate long term therapy to prevent relapse/recurrence

Question 25

Why are SSRIS preferred?

Answer 25

less side effects
More specific 
Less toxic in overdose
no anticholinergic effects
less sedating than TCAs 
Less suicidal ideation

Question 26

3 things you need to tell a patient when they start SSRIs

Answer 26

• take at least 4 weeks to start having an effect
• take for at least 6months-1 year (continue taking even when feel better for at least 6 months)
• risk of discontinuation symptoms, shouldn’t stop abruptly - taper down, and they’re not addictive