depression and anxiety in practice Flashcards
how can pharmacists be involved in the management of patients with depression?
– Signposting and referral of patients with suspected depression – Advice and monitoring of • Appropriate drug choice • Dosage • Drug interactions • Drug switching • Side-effects • Recognising withdrawal or serotonin syndromes
how can pharmacists be involved in the management of patients with depression?
– Signposting and referral of patients with suspected depression – Advice and monitoring of • Appropriate drug choice • Dosage • Drug interactions • Drug switching • Side-effects • Recognising withdrawal or serotonin syndromes
what may you consider asking someone who may have depression?
– During the last month, have you often been bothered by feeling down, depressed or hopeless?
– During the last month, have you often been bothered by little interest or pleasure in doing things?
how is depression diagnosed?
Diagnosis is usually confirmed by one of two main classification systems: DSM-5 or
ICD-10.
• NICE currently recommends the DSM-IV criteria (now DSM-5)
how is depression diagnosed by the DSM-V method?
- Depressed mood*
- Loss of interest or pleasure *(anhedonia)
- Insomnia or hyperinsomnia
- Appetite or weight change
- Fatigue or loss of energy
- Increased/decreased psychomotor activity
- Guilt or feelings of worthlessness
- Diminished ability to think or concentrate
- Suicidal ideation
depression diagnosed if 5 or more of these symptoms
subthreshold depression if at least 2 but less than 5 symptoms
how do NICE recommend that depression in adults should be recognised and managed?
• Includes assessment and management of suicide risk
– Frequent review; ask directly about suicidal thoughts and
intent and identify risk factors
– Crisis team assessment
• Identification and management of co-morbid conditions that are
associated with depression
– e.g. alcohol or substance abuse, anxiety, eating disorders
• Discuss practical solutions to stresses contributing to depression
– Financial worries, family, exam stress, poor living conditions,
bereavement
• Sources of support- family, friends, bereavement councillors
what is the ‘approach don’t avoid’ method?
– Mood changes? Withdrawn? Not collecting routine medication/antidepressants? Stockpiling medication?
– Provide opportunity to talk
– Ascertain the origin, extent and level of risk
– Buy time and provide signposting & potential pathways to recovery
what are some low-intensity psychosial interventions?
Individual guided self-help CBT
computerised CBT
structured group physical activity programme
what are some high intensity psychosocial interventions?
CBT
interpersonal therapy -IPT
how should the antidepressant be chosen?
– Acceptability
– Side-effect profile
– Patient preference
– Previous experience of treatments
– Propensity to cause discontinuation symptoms
– Safety in overdose (Increased risk with Tricyclic antidepressants)
– Interaction potential (drug/disease)
what is the current first line antidepressant?
NICE currently recommend SSRIs in generic form
what may you consider asking someone who may have depression?
– During the last month, have you often been bothered by feeling down, depressed or hopeless?
– During the last month, have you often been bothered by little interest or pleasure in doing things?
how is depression diagnosed?
Diagnosis is usually confirmed by one of two main classification systems: DSM-5 or
ICD-10.
• NICE currently recommends the DSM-IV criteria (now DSM-5)
how is depression diagnosed by the DSM-V method?
- Depressed mood*
- Loss of interest or pleasure *(anhedonia)
- Insomnia or hyperinsomnia
- Appetite or weight change
- Fatigue or loss of energy
- Increased/decreased psychomotor activity
- Guilt or feelings of worthlessness
- Diminished ability to think or concentrate
- Suicidal ideation
depression diagnosed if 5 or more of these symptoms
subthreshold depression if at least 2 but less than 5 symptoms
how do NICE recommend that depression in adults should be recognised and managed?
• Includes assessment and management of suicide risk
– Frequent review; ask directly about suicidal thoughts and
intent and identify risk factors
– Crisis team assessment
• Identification and management of co-morbid conditions that are
associated with depression
– e.g. alcohol or substance abuse, anxiety, eating disorders
• Discuss practical solutions to stresses contributing to depression
– Financial worries, family, exam stress, poor living conditions,
bereavement
• Sources of support- family, friends, bereavement councillors
what is the ‘approach don’t avoid’ method?
– Mood changes? Withdrawn? Not collecting routine medication/antidepressants? Stockpiling medication?
– Provide opportunity to talk
– Ascertain the origin, extent and level of risk
– Buy time and provide signposting & potential pathways to recovery
what are some low-intensity psychosial interventions?
Individual guided self-help CBT
computerised CBT
structured group physical activity programme
what are some high intensity psychosocial interventions?
CBT
interpersonal therapy -IPT
how should the antidepressant be chosen?
– Acceptability
– Side-effect profile
– Patient preference
– Previous experience of treatments
– Propensity to cause discontinuation symptoms
– Safety in overdose (Increased risk with Tricyclic antidepressants)
– Interaction potential (drug/disease)
what is the current first line antidepressant?
NICE currently recommend SSRIs in generic form
why should you be cautious of cardiovasicular disease and QT prolongation with antidepressants?
as antidepressants can cause QT prolongation
significant QT prolongation when another medication is known to affect the QT interval
what should be done if a patient is at risk for QT prolongation before starting an antidepressant?
Thorough medical history, laboratory monitoring, and a baseline electrocardiogram (ECG) necessary to identify patients at risk for QT prolongation before starting an antidepressant that may prolong QT interval.
what are the risk factors for QT interval prolongation?
cardiac conditions electrolyte distrubances female sex gentic polymorphisms 65+ congenital long QT syndrome concomitant medications or disease states that prolong QT interval history of QT prolongation
what are citalopram and escitalopram associated with?
dose dependent QT interval prolongation
when should you avoid use of citalorpam and escitalopram?
– congenital long QT syndrome
– known pre-existing QT interval prolongation
– or in combination with other medicines that prolong the QT interval
what should be corrected prior to antidepressant treatment?
electrolyte distrubances
what is citalopram max daily dose?
– 40 mg for adults
– 20 mg for patients older than 65 years
– 20 mg for those with hepatic impairment
what is esitalopram max daily dose?
older than 65 years is now reduced to 10 mg/day
what should be done in patients with mild or moderate hepatic impairment or in poor metabolisers of CYP2C19?
further dose reductions in the first two weeks of treatment is recommended
give an example where caution should be adviced for CYP2C19 inhibitors?
omeprazole= NICE recommends gastroprotection with SSRI in patients at risk of bleeding disorder
is there a risk of fracture with antidepressants?
small
increased risk of fractures associated with the
use of TCAs and SSRIs, and should take this
risk into account in their discussions with
patients and in prescribing decisions
is there a risk of postpartum haemorrhage with antidepressants?
SRI/SNRI antidepressant
medicines: small increased risk of postpartum
haemorrhage when used in the month before
delivery (January 2021)
what are some common adverse effects of antidepressants?
- Potential for an initial increase in agitation, anxiety on starting tx
- Suicidal thoughts and suicide attempts have been reported for all antidepressants early in treatment or after stopping treatment
- Hyponatraemia (see next slide)
- Sexual dysfunction
- Withdrawal effects
when would you consider hyponnatraemia ?
if the person develops dizziness, drowsiness, confusion, nausea, muscle cramps, or seizures
when does hyponatraemia usually occur?
Normally occurs within 30 days of starting antidepressant but can take months
when should urgent car be saught for hyponatraemia?
• Urgent care if severe (Na < 125mmol/L)
what should you do if you ifentify hyponatrameia? how long will it take to return to normal?
If identified stop antidepressant & sodium levels should normalise within 1-2 weeks
once sodium is normalised in hyponatraemia what should be done?
• Once sodium normalised, choose different antidepressant (try different class)
how do SSRIs and SNRIs increase bleed risk?
By reducing the uptake of serotonin by platelets, SSRIs reduce the ability of platelets to aggregate and thereby increase the risk of haemorrhage, particularly gastrointestinal bleeding.
what factors increase bleed risk?
– Elderly
– Patients with a history of peptic ulcers
– Excessive use of alcohol
– Co-administration with other drugs associated with the risk of bleeding
• NSAIDs, antiplatelet drugs, corticosteroids, and warfarin
what are measures to reduce risk of bleed with SSRIs/SNRIs?
– Avoid SSRIs/ SNRIs if possible if at increased risk
– Avoid concomitant drugs which increase bleeding risk
– If no suitable alternative can be found, consider gastroprotection
– NICE suggests gastroprotection in older people who are taking NSAID/aspirin
what are the main interactions with antidepressants?
• Drug/drug interactions which may increase QT prolongation risk
• Drugs with affect the metabolism of concurrently prescribed
medication (CYP450 inhibitors/inducers)
• Drug/drug interactions which may increase risk of serotonin
syndrome
• Drug/drug interactions which may increase bleeding risk
• Interactions with warfarin
• Potential to antagonise the effect of anticonvulsants
• Drugs that increase the risk of sedation (TCAs)
• Drugs that increase the risk of anticholinergic side effects (TCAs)
when are MAOIs used?
may be used in patients who do not respond to other antidepressants
may be useful in patients refractory to other treatment
what is the main point to be aware of when MAOIs?
there are signifigant food and drug interactions
Hypertensive crisis adverse reactions, which
have sometimes been fatal; can occur if an
MAOI is taken in combination with food or
drink that has a high tyramine content.
what can MAOIs cause?
Associated with withdrawal symptoms
• May cause hepatic impairment
what are some foods with high tyramine content?
aged cheeses
wine
soy sauce
dried and aged sausages
what must MAOIs NOT be copresecribed with?
MAOIs must not be prescribed alongside SSRIs, or
other substances with serotonin reuptake inhibition
effects (including SNRIs, trazodone, and clomipramine),
due to the risk of inducing serotonin syndrome
what other medications have serotonergic effects and should also not be coprescribed with MAOIs/
ertain analgesics, opioids (e.g. tramadol), and some
triptan migraine medications. Some non-prescribed
substances taken by patients have SSRI-like properties,
including St John’s Wort, and so also must be avoided
when switching a patient from an SSRI to and MAOI what must be ensured?
ust ensure there is a suitable washout period of at least five half-lives of the particular SSRI. This would typically be approximately seven days for most SSRIs,
what is the exception to the washout period?
around six weeks for fluoxetine due to its much longer half-life
what is the advised wash out period after stopping a MAOI before commencing with an alternative antidepressant?
2–3 weeks is always advised after stopping a MAOI, before commencing an alternative antidepressant. This includes when switching from one MAOI to another MAOI.
why should medications with potent noradrenergic effects be avoided when taking MAOIs?
due to the potential risk of synergistic effects on blood pressure.
what should be done for surgeries needing general anesthetic when a patient is on an MAOI?
For surgical procedures needing general anaesthetic, input from an anaesthetist should be sought well in advance, as it is likely the MAOI will need to be discontinued at least 10 days prior to surgery. as can have serious interaction
what OTC remedies can MAOIs interact with? what would happen?
over-the-counter cold
remedies and/or anti-congestants (including
nasal sprays). This is because some of these
can interact with MAOI effects, and increase
levels of noradrenaline and/or serotonin. In
turn, this can increase the risk of high blood
pressure or serotonin syndrome.
how is serotonin syndrome characterised?
altered mental status, neuromuscular hyperactivity, and autonomic instability
what are the symptoms of serotonin syndrome?
agitation, confusion, delirium, and hallucinations
what are the neuromuscular features that can occur in serotonin syndrome?
profound shivering, tremor, teeth grinding, myoclonus, and hyperreflexia
what are the autonomic features that can occur in serotonin syndrome?
– Tachycardia, fever, and hypertension or hypotension
– Flushing, diarrhoea, and vomiting are also common
in severe cases of serotonin syndrome what may develop?
In severe cases, drowsiness, coma, seizure, hyperthermia, rhabdomyolysis, renal failure, and coagulopathies may develop
what can increase the risk of serotonin syndrome?
Concomitant use of antidepressants with other serotonergic drugs (tramadol, triptans) or dopaminergic drugs (selegiline) can increase the risk
– Close monitoring is advised if co-prescribed, alternative drugs would be a better option
what antidepressant is the least safe in OD?
TCAs and venlafaxine
what should be done when switching antidepressants in order to avoid precipitating drug interactions?
to incrementally
reduce the dose of the first antidepressant and discontinue it before starting the
second antidepressant. This is not always possible. In severely depressed patients who
have failed to respond to one antidepressant, or in cases of severe adverse reaction, it
may be necessary to shorten the process of substitution.
Cross-tapering is an option for some switches but should always be done cautiously.
how should antidepressants be discontinued?
• Reduce gradually over 4-weeks to minimise discontinuation symptoms
what are the withdrawal symptoms that can occur with discontinuation of antidepressants?
– Include dizziness, nausea, anxiety, diarrhoea, flu-like symptoms, headache
– Usually occur within 5 days of stopping treatment
– Often mild and self-limiting, rarely lasting for more than 1–2 weeks.
who are discontinuation symptoms more common in?
– longer treatment courses
– antidepressants with a short half-life (paroxetine)
– people who developed anxiety symptoms at the start of treatment
– people taking other centrally-acting drugs.
what should happen if discontinuation symptoms are severe?
– original antidepressant may be reintroduced and tapered slowly
– monitor symptoms
what are the main patient counselling/advice points for antidepressants?
• Symptoms of anxiety may initially worsen
• Antidepressants do take time to work
• Continue for at least 6 months following
remission of symptoms as this reduces risk of
relapse
• Sleep hygiene advice if having trouble sleeping
• Remember drug specific counselling aspects e.g.
dose, common side-effects, any monitoring
what are the NICE quality standards for anxiety disorders?
- Statement 1. People with a suspected anxiety disorder receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
- Statement 2. People with an anxiety disorder are offered evidence-based psychological interventions.
- Statement 3. People with an anxiety disorder are not prescribed benzodiazepines or antipsychotics unless specifically indicated.
- Statement 4. People receiving treatment for an anxiety disorder have their response to treatment recorded at each treatment session.
when anciety and depression co-exist what should be done?
decide which is the main problem and treat this first.
what considerations should you have for antidepressants?
• May see worsening of anxiety Sx at beginning
of tx –monitor closely for A/E
• Titrate dose slowly; final effective dose may go
above usual depression dose
• Watch out for withdrawal Sx, suicidal ideation
in younger patients as above
• Generally expect to see a response to
antidepressants usually within 6 weeks;
usually continued for at least 6-12m
