Depression and Bipolar Flashcards
What is bipolar disorder characterised by?
An imbalance of neurotransmitters in the brain, particularly dopamine, serotonin, and noradrenaline.
What tool can be used to help diagnose depression?
PHQ-9 mental health questionnaire.
What lifestyle advice can be offered to individuals with depression?
Physical activity on a regular basis.
Healthy diet.
Don’t over-use alcohol.
Maintain healthy sleep cycle.
CBT
What are first line treatment for depression?
Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs), although SSRIs are usually better tolerated.
What are common side effects of SSRIs and SNRIs?
GI discomfort
Headaches
QT interval prolongation
Sexual dysfunction
Drowsiness
Insomnia
Bleeding
What conditions are SSRIs and SNRIs contraindicated/cautioned in?
Poorly controlled epilepsy
Mania
Bleeding disorders
What medications do SSRIs and SNRIs interact with?
St John’s Wort and other antidepressants (serotonin syndrome)
Blood thinners (bleeding)
Name 3 SSRIs
Citalopram
Sertraline
Fluoxetine
Name 2 SNRIs
Duloxetine
Venlafaxine
Why are tricyclic antidepressants not recommended first line for depression?
Worse side effects and more dangerous at overdose (not ideal in depressed individuals)
What are some common side effects of tricyclic antidepressants?
Drowsiness
Constipation
QT interval prolongation
Anticholinergic syndrome
What conditions are tricyclic antidepressants contraindicated/cautioned in?
Arrhythmias
Mania
Heart block
Chronic constipation
Name 2 tricylic antidepressants
Amitriptyline
Nortriptyline
What can be done if someone isn’t responding to individual antidepressant treatment?
Either add an additional antidepressant from another class or add a second-generation antipsychotic.
Why is St. John’s wort not recommended for self treatment of depression?
Although there is some evidence that it can be effective, it is not recommended due to:
It is sold at unregulated doses
The risk of severe drug interactions.
Risk of serotonin syndrome.
What is serotonin syndrome?
Excessive levels of serotonin in the body cause:
Altered neuromuscular activity (tremor, rigidity)
Autonomic dysfunction (tachycardia, diarrhoea, hypertension)
Altered mental state (agitation, confusion, mania)
Why should antidepressants be titrated down rather than stopping abruptly?
Can cause withdrawal symptoms such as vertigo, dizziness, sweating, restlessness, abdominal symptoms, and recurrence of mood issues.
How should antidepressants be weaned?
Reduce dose by 50% at a time or by 25% at lower doses.
What is the monitoring required for depression/antidepressant treatment?
Review after starting treatment (2-4 weeks normally or 1 week if aged 18-25 or suicide risk)
Evaluate treatment concordance
Monitor for side effects and harms of treatment
Monitor suicidal ideation, especially in early weeks and during switching.
Monitor improvements with PHQ-9.
What should be done if a person taking antidepressants is diagnosed with mania?
Always start an antipsychotic and consider stopping antidepressant (this and weaning depends on severity of symptoms).
What is first-line treatment of mania or hypomania
One of the following antipsychotics:
Haloperidel (1st gen)
Olanzapine (2nd gen)
Quetiapine (2nd gen)
Risperidone (2nd gen)
What can be done if antipsychotic treatment not effective or poorly tolerated?
- Stop antidepressant if not already done so
- Offer an alternative of the 1st line antipsychotics
- Increase alternative to maximum dose
- Add lithium
- Add valproate (remember PPP)
What is important to remember if prescribing lithium?
Must prescribe by brand name as it is available as 2 salts which are not dosed equally.
How is lithium dosed?
Dose depends on lithium plasma concentrations to achieve 0.6-1mmol/L.
What monitoring is required for lithium?
Lithium levels are measured weekly after starting/changing dose until levels are stable. After that it is done every 3 months.
ECG also requires monitoring.
When should a plasma lithium level be taken?
12 hours post-dose.
Why does lithium require monitoring?
Long-term use a can cause:
ECG changes
Nephrotoxicity
Thyroid issues
Toxicity can cause:
Blurred vision
Tremors
Drowsiness
Death
What are some key lithium interactions?
Diuretics and NSAIDs - increase serum lithium
Carbamazepine and Haloperidol - neurotoxicity
Antidepressants - CNS toxicity
ACE inhibitors - decreased excretion
What baseline and continuous monitoring do antipsychotics require?
BMI - weight gain.
U&Es, including eGFR and creatinine.
FBC
Blood lipids - dyslipidemia
Plasma glucose or HbA1c - impaired glucose tolerance
Pulse and BP - increase HR and hypertension
ECG - QT prolongation
Prolactin - hyperprolactinaemia
LFTs - liver function
What are some side effects of antipsychotics?
Extrapyramidal symptoms (EPSE)
Weight gain
Sedation
Seizures
What does hyperprolactinaemia cause?
Low libido
Sexual dysfunction
Gynaecomastia - breast tissue growth
Galactorrhea - milk production
Menstrual abnormalities
What are extrpyramidal symptoms?
Dystonia - abnormal face and body movements
Pseudo-parkinsonism - tremor and bradykinesia (slowness of movement)
Akathisia (restlessness)
Tardive dyskinesia (rhythmic involuntary movements usually of the jaw).
How is bipolar depression treated?
- Either quetiapine or fluoxetine with olanzapine
- Lamotrigine
