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PHA333 > depression and anxiety in practice > Flashcards

depression and anxiety in practice Flashcards

1
Q

classification system for depression

A

DSM-5

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2
Q

diagnosis of depression using DSM-5

A

diagnosed if > 5 symptoms

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3
Q

low intensity psychosocial interventions

A
  • individual guided self help (based on CBT)
  • computerised CBT
  • structured group physical activity programme
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4
Q

pharmacological interventions

A

antidepressants

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5
Q

high intensity psychosocial interventions

A

CBT

interpersonal therapy (IPT)

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6
Q

What should choice of antidepressant depend on?

A 
accceptability
s/e profile
patient preference
previous experience of treatments
discontinuation symptoms
safety in OD (inc risk with TCAs)
interaction potential (drug/disease)
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7
Q

recommended SSRIs to prescribe

A

generic

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8
Q

CVD and QT prolongation

A
  • 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
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9
Q

risk factors for QT prolongation

A
  • 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
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10
Q

citalopram/escitalopram

A

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
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11
Q

ways to prevent QT prolongation

A
  • ECG mesaurements for patients with cardiac disease

- electrolyte disturbances should be corrected before starting Tx

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12
Q

antibiotics that can prolong QT

A

erythromycin

clarithromycin

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13
Q

citalopram max daily doses

A

40mg adults

20mg >65yrs

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

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14
Q

escitalopram max daily dose for >65yrs

A

10mg/day

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15
Q

When are further dose reductions done for citalopram/escitalopram?

A

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

poor metabolisers of CYP2C19

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16
Q

CYP2C19 inhibitors and antidepressants

A

they inhibit metabolism of antidepressant and increase their serum levels

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17
Q

gastroprotection and SSRIs

A

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

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18
Q

antidepressants and # risk

A

small inc risk with TCAs and SSRIs

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19
Q

antidepressants and postpartum haemorrhage

A

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

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20
Q

general adverse effects of antidepressants

A
  • 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
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21
Q

hyponatraemia

A
  • 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)
22
Q

How do SSRI/SNRI inc bleeding risk?

A

by reducing the uptake of serotonin by platelets

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

23
Q

factors that inc risk of bleeding with SSRIs/SNRIs

A
  • elderly
  • patients with Hx of peptic ulcers
  • excessive alcohol use
  • co-administration with other drugs that have bleeding risk (NSAIDs, antiplatelets, CS, warfarin)
24
Q

How to reduce bleeding risk with SSRIs/SNRIs?

A
  • avoid SSRI/SNRI if at inc risk
  • avoid concomitant drugs that inc risk
  • if no alt, gastroprotection
  • gastroprotection in older people taking NSAIDs/aspirin
25
Q

interactions with antidepressants

A
  • 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)
26
Q

When are MAOIs used?

A

in pts that don’t respond to other antidepressants

27
Q

important point for MAOIs

A

significant food and drug interactions

28
Q

s/e with MAOIs

A

withdrawal symptoms

hepatic impairment

29
Q

When can hypertensive crisis occur with MAOIs?

A

MAOI taken with food/drink that has high tyramine content

30
Q

foods with high tyramine content

A
  • aged cheeses
  • ages sausages
  • broad bean plants
  • sauces like soy sauce
31
Q

drug interactions with MAOIs

A
  • 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

32
Q

How to switch from SSRI to MAOI?

A

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

33
Q

How to switch from MAOI to another antidepressant?

A

washout period of 2-3weeks after stopping MAOI

even when switching from one MAOI to another MAOI

34
Q

MAOI and meds with potent noradrenergic effects?

A

avoid

potential risk of synergistic effects on BP

35
Q

examples of meds with potent noradrenergic effects

A

stimulant meds - methylphenidate, amphetamine, modafinil

noradrenaline reuptake inhibitors - atomoxetine, reboxetine

some anesthetic agents

36
Q

anesthetics and MAOIs

A
  • local anesthetic, non NADergic anaesthetic agent used

- general anesthetic, input from anaesthetist, MAOI discontinued at least 10 days before surgery

37
Q

MAOIs and OTC cold remedies

A

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

38
Q

serotonin syndrome

A

excessive levels of serotonin

altered mental status, neuromuscular hyperactivity and autonomic instability

39
Q

symptoms of serotonin syndrome

A

agitation
confusion
delirium
hallucinations

severe
- drowsiness, coma, seizures, hyperthermia, rhabdomyolysis, renal failure, coagulopathies

40
Q

neuromuscular features of serotonin syndrome

A 
shivering
tremor
teeth grinding
myoclonus
hyperreflexia
41
Q

autonomic instability features of serotonin syndrome

A 
tachycardia
fever
hypertension/hypotension
flushing
diarrhoea
vomiting
42
Q

What can inc risk of serotonin syndrome?

A

concomitant use of antidepressants with other

serotonergic drugs
- tramadol, triptans

dopaminergic drugs
- selegiline

43
Q

SHIVERS

A 
shivering
hyperreflexia
inc temp
vital signs abnormal
encephalopathy
restlessness
sweating
44
Q

What antidepressants are harmful in OD?

A

TCAs

venlafaxine

45
Q

How to switch antidepressants?

A

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

46
Q

When is gradually reducing dose of antidepressant not possible?

A

severely depressed pts failed to respond to 1 antidepressant

severe adverse rxns

47
Q

What antidepressants can not be cross tapered?

A

MAOIs

-> always need washout period

48
Q

How to discontinue an antidepressant?

A

gradually reduce over 4 weeks to minimise discontinuation symptoms

49
Q

withdrawal symptoms of antidepressants

A 
dizziness
nausea
anxiety
diarrhoes
flu-like symptoms
headace
  • > usually within 5 days of stopping
  • > mild, self limiting, rarely last >1-2 weeks
50
Q

When are discontinuation symptoms common?

A
  • long tx course
  • antidepressant with short t1/2
  • pts developed anxiety symptoms at start of tx
  • pts taking other centrally acting drugs
51
Q

What to do if discontinuation symptoms are severe?

A
  • original antidepressant reintroduced and tapered slowly

- monitor symptoms

52
Q

counselling for antidepressants

A
  • 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)

PHA333 (27 decks)

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