Depression Flashcards by Ugne Dunskute

What causes depression and how antidepressants help ?

depression is caused by under activity of monoamine neurotransmitters. Antidepressants increase monoamine levels at synapse

How well did you know this?

Not at all

Perfectly

Name Tricyclic antidepressants ?

Amitriptyline 
Clomipramine
Dosulepin
Doxepin
Imipramine ( most antimuscarinic TCA )
Lofepramine ( hepatoxicity )
Nortriptyline 
Trimipramine

How well did you know this?

Not at all

Perfectly

Name tricyclic related antidepressants ?

Mianserin

Trazadone

How well did you know this?

Not at all

Perfectly

Name irreversible monoamine oxidase inhibitors ?

phenelzine ( hepatoxicity more likely )
isocarboxazid ( hepatoxcity more likely )
Tranylcypromine ( hypertensive crises more likely )

How well did you know this?

Not at all

Perfectly

Name reversible monoamine oxidase inhibitors ?

moclobemide ( no washout period needed: short acting )

How well did you know this?

Not at all

Perfectly

Name SSRIs ?

citalopram ( qt prolongation )
escitalopram ( qt prolongation )
fluoxetine ( only antidepressants licensed in children )
fluvoxamine
paroxetine ( greater risk of withdrawal reactions )
sertraline ( safer to use after MI, unstable angina )

How well did you know this?

Not at all

Perfectly

What are other antidepressant drugs ?

agomelatine ( hepatoxicity; give treatment booklet )
duloxetine ( SNRI )
flupentixol
mirtazepine ( blood dyscrasias )
reboxetine (NRI)
Tryptophan
Venlafaxine ( SNRI; higher risk of withdrawal reaction )
Vortioxetine ( works on serotonergic pathway )

How well did you know this?

Not at all

Perfectly

Why SSRIs are first line treatment for depression and not TCA’s ?

less sedating, less antimuscarinic, less epileptogenic, less cardiotoxic. Also safest in overdose

How well did you know this?

Not at all

Perfectly

When antidepressants are initiated how long does it usually take to work and how often patients should be reviewed at the start of their treatment ?

Takes at least two weeks to work : initially feels worse, increased agitation, anxiety and suicidal ideation.
Review every one to two weeks

How well did you know this?

Not at all

Perfectly

How long should GP’s wait before deeming SSRIs ineffective ?

Wait at least 4 weeks ( 6 weeks in elderly )

How well did you know this?

Not at all

Perfectly

How long SSRIs should be taken for ?

Continue for at least 6 months ( 12 months in elderly )
12 months in generalised anxiety disorder ( high risk of relapse )
2 years in recurrent depression

How well did you know this?

Not at all

Perfectly

What is a second line treatment in depression ?

Increase SSRI dose, change to different SSRI or mirtazapine

Other choices: lofepramine ( TCA ) reboxetine, moclobemide

How well did you know this?

Not at all

Perfectly

What is a third line treatment for depression ?

add another antidepressant class or augmenting agent : lithium or antipsychotic. 
Electroconvulsive therapy in severe refractory depression.

How well did you know this?

Not at all

Perfectly

Antidepressants side effects ?

Hyponatraemia ( drowsiness, confusion, convulsion) = especially SSRIs and in the elderly
Suicidal ideation and behaviour ( at risk are young children and adults ) = important to monitor for signs of this after dose change and at the start of the treatment
serotonin syndrome

How well did you know this?

Not at all

Perfectly

What are the signs and symptoms of serotonin syndrome ?

Neuromascular hyperactivity : tremors, myoclonus, muscle rigidity
Altered mental state : agitation, confusion, mania
Autonomic dysfunction: labile blood pressure, urination, diarrhoea, hyperthermia, tachycardia, pallor, sweating, shivering

How well did you know this?

Not at all

Perfectly

Why is washout period required when switching antidepressants ?

to prevent serotonin syndrome

How long is washout period for the following antidepressants :
MAOIs
SSRIs
TCAs

MAOIs wait two weeks before switching ( moclobemide does not require a washout period )
SSRIs wait one week before switching ( two weeks if sertraline, 5 weeks if fluoxetine )
TCAs wait one to two weeks before switching ( three weeks if imipramine or clomipramine )

When usually withdrawal effects occur ?

within five days of stopping

When would the risk of withdrawal reaction would be increased ?

if antidepressant is stopped abruptly after taking for 8 weeks or more .
Must reduce gradually over four weeks. 6 months in patients on long term maintainance treatment.

Which antidepressants have higher risk of withdrawal reaction ?

Paroxetine, venlafaxine

How does TCAs work ?

Inhbitis the reuptake of 5 HT and NA

Which TCAs are less sedating ?

Imipramine
Lofepramine
Noritriptyline
They are given for apathetic, withdrawn patients

Which TCAs are better to give for anxious, agitated patients ?

Amitriptyline, clomipramine, dosulepin doxepin trimipramine, mianserin, trazadone

Describe TCAs cardiac side effects ?

QT prolongation, arrythmias, heart block, hypertension

Describe TCAs antimuscarinic side effects ?

dry mouth, blurred vision, constipation, tachycardia, urinary retention, pupil dilation, raised intraocular pressure, angle closure glaucoma

What are other side effects of TCAs?

seizures, hallucinations, mania, hypotension, sexual dysfunction, breast changes, EPS

When TCAs are given with carbamazepine what interactions occur?

Reduced TCAs levels since carbamazepine is a inducer + risk of hyponatraemia

Which TCAs particularly can cause QT prolongation ?

clomipramine

Which drugs given with TCAs can lead to hyponatraemia ?

LOOP/thiazide, desmopressin, carabamazepine,

Which drugs given with TCAs can cause QT prolongation ?

amiodarone, sotalol, antipsychotics, citalopram/escitalopram, loop/thiazide, B2 agonists, corticosteroids, theophylline

Which drugs given with TCAs can lead to hypotension ?

alpha blockers, BB, ACE, ARB, CCB | Antipsychotics, levodopa/dopaminergics, NSAIDs, SGLT inhibitors, Loop/thiazide diuretics, sildenafil

Which drugs given with TCAs can lead to increased antimuscarinic effects ?

antimuscarinic drugs, atropine, antihistamines

Which drugs given with TCAs can lead to an increased risk of serotonin syndrome ?

MAOIs, selegeline, tramadol, amfetamines, sumatriptan, SSRIs, ondansetron, lithium

How does monoamine oxidase inhibitors work ?

Prevent breakdown of monoamine neurotransmitters , which include dopamine, noradrenaline and serotonin,

With which two monoamine oxidase inhibitors hepatoxicicity is likely ?

phenelzine, isocarboxazid

Which monoamine oxidase inhibitor has the greatest stimulant action ?

tranylcypromine, more likely to cause hypertensive crisis

What symptoms would prompt to discontinue MOAI's ?

palpitations or if frequent headaches occur. Discontinue if hypertensive crisis with throbbing headaches occur. Most likely to happen with tranylcypromine/

Which drugs given with MOAIs would lead to hypertensive crisis ?

pseudoephedrine, adrenaline, noradrenaline, levodopa, DRAs, MAO-B inhibitors TCAs ( potentially lethal, especially tranylcypromine and clomipramine )

How should patients who receive MOAIs should be counselled ?

- They should avoid food containing tyramine ( mature cheese, wine, pickled herring, game, broad bean pods, marmite or similar yeast extracts, fermented soya bean products . - Only eat fresh food, avoid stale or going off food. - Avoid alcohol / de-alchoholised ( low alcoholic drinks )