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Prescribing > Depression and Insomnia > Flashcards

Depression and Insomnia Flashcards

1
Q

Main features of depression

A

Persistent low mood

Loss of interest or enjoyment or pleasure in life (anhedonia)

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2
Q

The term referring to a loss of interest or pleasure in life

A

anhedonia

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3
Q

Symptoms reported by at least 90% people with depression:

A 
Loss of enjoyment from usual activities. 
Hopelessness. 
Disappointment with self
Irritability 
Difficulty sleeping.
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4
Q

Generally the causes of insomnia can be described as what?

A

Multi-factorial

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5
Q

Depression can be caused by illnessess such as

A

Dementia, Cushings, hyperglycaemia, hypothyroidism.

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6
Q

Which drugs can cause depression? [7]

C.B.L.A.I.C.L

A 
Corticosteroids 
Benzodiazepines
Levodopa
Anticonvulsants 
Isotretinoin
CCB
Lipophilic beta blockers e.g. propranolol.
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7
Q

What medication can cause insomnia? [5]

A

Diuretics, CNS stimulants e.g. dexamfetamine, modafinal, methylphenidate, SSRIs and many more.

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8
Q

Short term insomnia is

A

<4 weeks

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9
Q

Long term insomnia is

A

> 4 weeks

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10
Q

What secondary causes of insomnia are there?

A 
Sleep apnoea
Circadian rhythm disorders
Parasomnias
Narcolepsy
Stress
Anxiety
Depression
COPD, CHF etc.
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11
Q

Why should patients be advised to keep a sleep diary?

A

To try and find the cause of the insomnia. Aim to keep it for 2 weeks.

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12
Q

What should a sleep diary include? [6]

A

Time of going to bed and getting up.
Time taken to get to sleep.
Number of times of waking during the night and the duration of these episodes.
Episodes of daytime tiredness and naps.
Meal times and alcohol/caffeine consumption.
Each sleep episode should be given a rating.

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13
Q

Diagnosis of depression is performed according to what?

A

DSM-5 criteria.

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14
Q

According to DSM-5 when can a person be diagnosed with depression?

A

When 5/9 symptoms of depression and at least one core symptom.

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15
Q

If a person has at least two, but less than five, symptoms that are required for depression, they can be diagnosed with what?

A

Subthreshold depressive symptoms.

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16
Q

What is persistent subthreshold depressive symptoms?

A

2 years of depressed mood for more days than not, which is not the consequence of a partially resolved ‘major’ depression, and has at least two, but less than five symptoms that are required for the diagnosis of depression.

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17
Q

What other conditions can cause symptoms similar to depression? [4]

A

Hypothyroidism.
Anaemia.
Chronic infection
Endocrine disorders and cancers

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18
Q

What class of drugs would be appropriate first line treatment for depression?

A

SSRIs
Sertraline
Citalopram
Fluoxetine

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19
Q

When should SSRIs be taken?

A

After food in the Morning normally, as they can have a stimulating effect. If they do make a patient sleepy though, at night would be better.

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20
Q

Why should patients not stop taking antidepressants suddenly? are they addictive?

A

Not addictive. Sudden cessation can increase anxiety and when they feel it is time to stop they should discuss with prescriber and titrate down.

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21
Q

What basic health and lifestyle advice should be offered to those suffering from depression?

A 
Good sleep hygiene. 
Regular exercise. 
CBT
Healthy Diet
Avoid alcohol and drugs
Daily routine
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22
Q

When should benzos be used to treat insomnia?

A

Only when it is severe, disabling or subjecting the individual to extreme distress.

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23
Q

What dose of temazepam is recommended for insomnia treatment short term?

A

10-20mg at bedtime.
30-40mg in EXCEPTIONAL circumstances.
[Elderly: 10mg, 20mg if exceptional]

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24
Q

What dose of loprazolam is recommended for insomnia?

A

1mg at bedtime, increased to 1.5 or 2mg if required. [Elderly: 0.5 or 1mg]

25
Q

What advice should be given to those receiving benzos for insomnia?

A

Drowsiness, effects of alcohol enhanced - avoid.

26
Q

What Z-drug can be used for treatment of short-term insomnia?

A

Zopiclone: 7.5mg at bedtime.

Restricted to 2-4 weeks use due to risk of dependence.

27
Q

What dose of Zopiclone is used to treat short-term insomnia?

A

7.5mg bedtime, 3.75mg Elderly.

28
Q

What drugs can be used to treat long-term insomnia?

A

NONE

29
Q

Which two SSRI in generic form does NICE recommend as first line treatment for depression? why?

A

Citalopram or Sertraline because they have less propensity for interactions.

30
Q

Citalopram once daily dose for depression

A

20mg once daily, increased if necessary in steps of 20mg daily at intervals or 3-4 weeks. Max 40mg daily.

31
Q

Sertraline once daily dose for depression

A

initially 50mg once daily, increased in increments of 50mg at intervals of AT LEAST 1 week to 200mg daily. (Usual dose is simply 50mg daily)

32
Q

Why is paroxetine (SSRI) not first line for depression?

A

High incidence of discontinuation symptoms

33
Q

What is the normal daily dose of paroxetine and the max daily dose?

A

20mg normally, max 50mg.

34
Q

Max citalopram dose for depression.

A

40mg (elderly: 20mg)

35
Q

Max sertraline dose for depression

A

200mg daily.

36
Q

Interval for citalopram dose increase:

A

3-4 weeks.

37
Q

Interval for sertraline dose increase:

A

At least 1 week.

38
Q

Why is fluoxetine not first line for depression treatment?

A

Higher risk of interactions. Citalopram/sertraline recommended instead.

39
Q

What is the dose of fluoxetine for depression treatment?

A

20mg daily, increased after 3-4 weeks, to max 60mg daily.

40
Q

What monitoring and follow up is needed for those receiving treatment for short term insomnia? (General)

A

Review after 2 weeks of treatment.
Refer for CBT if symptoms persist.
NO issue of further hypnotic prescriptions.

41
Q

What monitoring of those taking benzodiazepines for insomnia should occur? [7]

A
  1. drowsiness and lightheadedness
  2. Confusion and ataxia
  3. Falls and memory loss.
  4. Dependence
  5. Increase in aggression
  6. Muscle weakness.
  7. Benzodiazepine withdrawal syndrome
42
Q

What is benzodiazepine withdrawal syndrome?

A

Abrupt withdrawal may result in confusion, toxic psychosis (delirium), convulsions or a condition resembling delirium tremens. A benzodiazepine withdrawal syndrome can occur up to 3 weeks after discontinuation (it may occur within days of stopping a benzodiazepine with a shorter
half-life).

43
Q

What monitoring/advice should be given for those taking ‘Z drugs’? [3]

A
  1. Drowsiness may last until next day, do not perform complex tasks within 8 hours of taking Z drug.
  2. Effects of alcohol and other CNS depressants is enhanced. Avoidance of alcohol recommended.
  3. Zopiclone: most common side effect is taste disturbances.
44
Q

What should happen if treatment failure for short term insomnia has occurred?

A

Referral to sleep clinic or specialist.

IAPT: Improving access to psychological therapies for CBT.

45
Q

What monitoring of those with depression, not considered at risk of suicide, should occur? [3]

A
  1. See them after 2 weeks of initiation of treatment.
  2. See regularly every 2-4 weeks in first 3 months of treatment.
  3. <30yrs see them after 1 week.
46
Q

What should happen if a patient’s depression shows no improvement after 2-4 weeks of treatment initiation?

A

Check if the drug has been taken properly.

47
Q

What should happen if a patient’s depression shows no improvement after 4 weeks of treatment initiation + correct adherence? [3]

A
  1. Increase level of support (weekly face-face or telephone contact)
  2. Consider increasing dose of drug if well tolerated.
  3. Consider switching to other appropriate drug if original not well tolerated.
48
Q

If treatment failure with the initial SSRI occurs what should happen?

A
  1. A dose increase or
  2. Switching to alternative SSRI or
  3. If two SSRI fail, referral for second line treatment with Mirtazapine etc.
49
Q

If SSRI treatment failure has occurred (>1 drug tried or not tolerated), what second line options are there? [M,L,M,R]

A

Mirtazapine
Lofepramine
Moclobemide
Reboxetine

50
Q

Irreversible MAOIs can only be prescribed:

A

By specialists.

51
Q

Venlafaxine should only be considered for

A

More severe forms of depression.

52
Q

How should antidepressants generally be stopped or reduced?

A

Gradually, over 4-week period, although some patients may require longer periods: paroxetine due to shorter half-life. Does not apply to Fluoxetine because of long half-life.

53
Q

General side effects of SSRI include:

A

GI effects
Anorexia with weight loss and opposite.
Rash indicates need to stop treatment due risk of impending serious systemic reaction - possibly vascultits

54
Q

What is serotonin syndrome?

A

adverse drug reaction caused by excessive central and peripheral serotonergic activity. Onset of symptoms, which range from mild to life-threatening, can occur within hours or days following the initiation, dose escalation, or overdose of a serotonergic drug, the addition of a new serotonergic drug, or the replacement of one serotonergic drug by another without allowing a long enough washout period in-between.

55
Q

How do the tapering off periods for Paroxetine/Fluoxetine differ?

A

Paroxetine is longer due to short half-life.

Fluoxetine is shorter due to longer half-life.

56
Q

According to ICD-10, what are the KEY symptoms of depression? [3]

A
  1. persistent sadness or low mood;and/or
  2. loss of interests or pleasure
  3. fatigue or low energy
57
Q

Other than the 3 key symptoms of depression, what are the other associated symptoms? [7]

A
  1. Disturbed sleep
  2. poor concentration/indecisiveness
  3. low self-confidence
  4. poor or increased appetite
  5. Suicidal thoughts
  6. Agitation or slowing of movements
  7. Guilt or self-blame
58
Q

Venlafaxine would be a suitable medication for a patient with moderate depression.

A

False. Severe only.

59
Q

What is the most common side effect of zopiclone?

A

taste disturbances

Prescribing (7 decks)

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