depression and anxiety in practice

Question 1

classification system for depression

Answer 1

DSM-5

Question 2

diagnosis of depression using DSM-5

Answer 2

diagnosed if > 5 symptoms

Question 3

low intensity psychosocial interventions

Answer 3

• individual guided self help (based on CBT)
• computerised CBT
• structured group physical activity programme

Question 4

pharmacological interventions

Answer 4

antidepressants

Question 5

high intensity psychosocial interventions

Answer 5

CBT

interpersonal therapy (IPT)

Question 6

What should choice of antidepressant depend on?

Answer 6

accceptability
s/e profile
patient preference
previous experience of treatments
discontinuation symptoms
safety in OD (inc risk with TCAs)
interaction potential (drug/disease)

Question 7

recommended SSRIs to prescribe

Answer 7

generic

Question 8

CVD and QT prolongation

Answer 8

• all antidepressants can cause QT prolongation
• med Hx, lab monitoring and baseline ECG to ID pts at risk of QT prolongation before starting antidepressant
• drug drug interactions can cause QT prolongation

Question 9

risk factors for QT prolongation

Answer 9

• cardiac conditions (bradycardia, MI, HF)
• electrolyte disturbances (hypokalaemia, hypomagnesemia, hypocalcaemia)
• female
• genetic polymorphisms
• > 65yrs
• congenital long QT syndrome, inherited cardiac abnormalities
• meds/disease that prolongs QT interval/affects electrolytes (diuretics, renal dysfunction)
• Hx of QT prolongation

Question 10

citalopram/escitalopram

Answer 10

associated with dose dependent QT interval prolongation

avoid in:

• congenital long QT syndrome
• known pre-existing QT interval prolongation
• comb with meds that prolong QT interval

Question 11

ways to prevent QT prolongation

Answer 11

• ECG mesaurements for patients with cardiac disease

- electrolyte disturbances should be corrected before starting Tx

Question 12

antibiotics that can prolong QT

Answer 12

erythromycin

clarithromycin

Question 13

citalopram max daily doses

Answer 13

40mg adults

20mg >65yrs

20mg hepatic impairment (metabolism slowed, higher serum levels, inc QT prolongation risk)

Question 14

escitalopram max daily dose for >65yrs

Answer 14

10mg/day

Question 15

When are further dose reductions done for citalopram/escitalopram?

Answer 15

first 2 weeks of treatment in patients with mild/moderate hepatic impairment

poor metabolisers of CYP2C19

Question 16

CYP2C19 inhibitors and antidepressants

Answer 16

they inhibit metabolism of antidepressant and increase their serum levels

Question 17

gastroprotection and SSRIs

Answer 17

gastroprotection (PPIS) recommended for pts at risk of bleeding disorder taking SSRIs

omeprazole is CYP2C19 inhibitor, caution, could inhibit its metabolism and cause QT prolongation

Question 18

antidepressants and # risk

Answer 18

small inc risk with TCAs and SSRIs

Question 19

antidepressants and postpartum haemorrhage

Answer 19

small inc risk of postpartum haemorrhage when SSRI/SNRI used in month before delivery

Question 20

general adverse effects of antidepressants

Answer 20

• inc in agitation, anxiety starting Tx
• suicidal thoughts and suicide attempts early in Tx or after stopping esp adolecents/young adults <30yrs, Hx suicidal behaviour, monitor behaviour
• hyponatraemia
• sexual dysfunction
• withdrawal effects

Question 21

hyponatraemia

Answer 21

• most antidepressants, SSRIs high risk
• more common in elderly
• dizziness, drowsiness, confusion, nausea, muscle cramps, seizures
• usually within 30 days of starting, can take months
• transient or persistent
• stop antidepressant and Na levels normal within 1-2 weeks
• urgent care if severe, Na <125mmol/L
• withdrawal symptoms may occur
• once Na normal, different antidepressant (diff class)

Question 22

How do SSRI/SNRI inc bleeding risk?

Answer 22

by reducing the uptake of serotonin by platelets

reduce the ability of platelets to aggregate and inc risk of haemorrhage, esp GI bleeding

Question 23

factors that inc risk of bleeding with SSRIs/SNRIs

Answer 23

• elderly
• patients with Hx of peptic ulcers
• excessive alcohol use
• co-administration with other drugs that have bleeding risk (NSAIDs, antiplatelets, CS, warfarin)

Question 24

How to reduce bleeding risk with SSRIs/SNRIs?

Answer 24

• avoid SSRI/SNRI if at inc risk
• avoid concomitant drugs that inc risk
• if no alt, gastroprotection
• gastroprotection in older people taking NSAIDs/aspirin

Question 25

interactions with antidepressants

Answer 25

- drugs that inc QT prolongation - drugs affecting metabolism of concurrently Rx drugs (CYP450 induc/inhib) - drugs interactions that inc risk of serotonin syndrome - drug interactions that inc bleeding risk - interactions with warfarin - potential to antagonise the effects of anticonvulsants (caution with epilepsy drugs) - drugs that inc risk of sedation (TCAs) - drugs that inc risk of anticholinergic s/e (TCAs)

Question 26

When are MAOIs used?

Answer 26

in pts that don't respond to other antidepressants

Question 27

important point for MAOIs

Answer 27

significant food and drug interactions

Question 28

s/e with MAOIs

Answer 28

withdrawal symptoms hepatic impairment

Question 29

When can hypertensive crisis occur with MAOIs?

Answer 29

MAOI taken with food/drink that has high tyramine content

Question 30

foods with high tyramine content

Answer 30

- aged cheeses - ages sausages - broad bean plants - sauces like soy sauce

Question 31

drug interactions with MAOIs

Answer 31

- SSRIs - SNRIs - trazodone - clomipramine - some opioid analgesics, tramadol - triptan migraine meds - St John's Wort - meds with noradrenergic effects - anesthetics -> these inhibit serotonin reuptake, risk of inducing serotonin syndrome

Question 32

How to switch from SSRI to MAOI?

Answer 32

needs to be a suitable washout period of at least 5 halflives of the SSRI 7 days for most SSRIs 6 weeks for fluoxetine, long t1/2

Question 33

How to switch from MAOI to another antidepressant?

Answer 33

washout period of 2-3weeks after stopping MAOI even when switching from one MAOI to another MAOI

Question 34

MAOI and meds with potent noradrenergic effects?

Answer 34

avoid potential risk of synergistic effects on BP

Question 35

examples of meds with potent noradrenergic effects

Answer 35

stimulant meds - methylphenidate, amphetamine, modafinil noradrenaline reuptake inhibitors - atomoxetine, reboxetine some anesthetic agents

Question 36

anesthetics and MAOIs

Answer 36

- local anesthetic, non NADergic anaesthetic agent used | - general anesthetic, input from anaesthetist, MAOI discontinued at least 10 days before surgery

Question 37

MAOIs and OTC cold remedies

Answer 37

MAOIs can interact with OTC cold remedies or anti-congestants, incl nasal sprays they interact with MAOI effects and inc NA and/or 5-HT levels can inc risk of high BP or serotonin syndrome

Question 38

serotonin syndrome

Answer 38

excessive levels of serotonin altered mental status, neuromuscular hyperactivity and autonomic instability

Question 39

symptoms of serotonin syndrome

Answer 39

agitation confusion delirium hallucinations severe - drowsiness, coma, seizures, hyperthermia, rhabdomyolysis, renal failure, coagulopathies

Question 40

neuromuscular features of serotonin syndrome

Answer 40

``` shivering tremor teeth grinding myoclonus hyperreflexia ```

Question 41

autonomic instability features of serotonin syndrome

Answer 41

``` tachycardia fever hypertension/hypotension flushing diarrhoea vomiting ```

Question 42

What can inc risk of serotonin syndrome?

Answer 42

concomitant use of antidepressants with other serotonergic drugs - tramadol, triptans dopaminergic drugs - selegiline

Question 43

SHIVERS

Answer 43

``` shivering hyperreflexia inc temp vital signs abnormal encephalopathy restlessness sweating ```

Question 44

What antidepressants are harmful in OD?

Answer 44

TCAs venlafaxine

Question 45

How to switch antidepressants?

Answer 45

reduce dose of first antidepressant in increments and discontinue before starting 2nd antidepressant

Question 46

When is gradually reducing dose of antidepressant not possible?

Answer 46

severely depressed pts failed to respond to 1 antidepressant severe adverse rxns

Question 47

What antidepressants can not be cross tapered?

Answer 47

MAOIs -> always need washout period

Question 48

How to discontinue an antidepressant?

Answer 48

gradually reduce over 4 weeks to minimise discontinuation symptoms

Question 49

withdrawal symptoms of antidepressants

Answer 49

``` dizziness nausea anxiety diarrhoes flu-like symptoms headace ``` - > usually within 5 days of stopping - > mild, self limiting, rarely last >1-2 weeks

Question 50

When are discontinuation symptoms common?

Answer 50

- long tx course - antidepressant with short t1/2 - pts developed anxiety symptoms at start of tx - pts taking other centrally acting drugs

Question 51

What to do if discontinuation symptoms are severe?

Answer 51

- original antidepressant reintroduced and tapered slowly | - monitor symptoms

Question 52

counselling for antidepressants

Answer 52

- symptoms of axiety may initially worsen - take time to work (within 6 weeks) - take for at least 6mths following remission symptoms to reduce relapse - sleep hygiene if trouble sleeping - drug specific counselling (dose, s/e, monitoring)