Depression and anxiety

Question 1

Indications for SSRIs

Answer 1

• Better tolerated than TCAs, safer in overdose = 1sst line for depression
• Some are also licensed for anxiety, panic and OCD

Question 2

TCA MOA & SE

Answer 2

• Inhibit neuronal Na & 5-HT uptake
  
  • May lead to down regulation of presynaptic A2-adrenoceptors and 5-HT receptors and postsynaptic beta-adrenoceptors
  • Bind to histamine, A1, muscarinic, and 5-HT receptors
• Sedating, and dangerous in ovoerdose
• Antimuscarinic side effects
  
  • Dry mouth
  • Blurred vision
  • Constipatiopn
  • Urinary retention

Question 3

Cardiac effect of TCA

Answer 3

• QT prolongation
• potentiation of cathecholamines predispose to oheart block and arrhytmias; dangerous in overdose
• Not suitable in >70, IHD, suicidal

Amitryptiline useful in neuopathic pain, migraine prophylaxis and IBS at low doses

Question 4

NARI MOA

Answer 4

Selectively inhibit NA reuptake

Useful for those who cannot take TCAs but are resistant to effect of SSRI

Question 5

SNRI MOA

Answer 5

inhibit serotonin and NA reuptake, but dont bind additional recptors; no antimuscarin side effects, but some GI

ause hypertension

Question 6

MAO MOA and considerations

Answer 6

rarely used

• Cause catecholamien release and hypertensinon
• Interact with tyramine containing foods
• Take 2-3 weeks for effects to wear of fafter cessation

Question 7

Clinical use of ADs

Answer 7

MILD: Watchful waiting, reassess after 2 weeks, wait with AD

Nice reccoment SSRI as 1st line, but TCA if sleep is impaired

Avoid TCA if suicidal

2 weeks for antidepressants to work

CBT should be considered

Swap class if not working. Continue for at least 6 months following remission. If had 2 recent episode, continue for 2 years.

Reduce dose over 4 weeks or longer

Question 8

St Johns wort considerations

Answer 8

Similar mechanism to SSRI

DO NOT combine with conventional ADs

Enzyme INDUCER, interacts with amongst others

Warfarin, Carbamazepine /phenytoin, Ciclosporin, OC

Question 9

Depression management steps

Answer 9

Question 10

Managing bipolar

Answer 10

• Lithium foro acute and prophylactic
• AVoid in renal impairment
• Narrow indow, rewquires monitoring

Question 11

Using anticonvulsants and neuroepileptics in bipolar

Answer 11

Anticonvulsants

carbamaezapine and valproate: second line mood stabilizers

Lamotrigine and gabapentin unlicensed, but for when all else fails

Neuroepileptics

haliperidol and chlorpromazine

• useful for psychotic symptoms of manic phase

Question 12

main drugs for anxiety

Answer 12

beta-adrenoceptor antagonists

• propanolol

Benzodiazepams

• Induce sleep also
• Increase GABA activity
• Tolerance and dependence a problem
• Limited to 2-4 weeks

Antidepressants e.g. Buspirone effective(SE: dizziness, nausea, headache) But no sedation