Depression - Clinical Flashcards
Depression Diagnosis:
Key Symptoms:
-Persistent sadness or low mood.
and/or
-Marked loss of interest of pleasure.
-Lack of energy (in ICD 10 only).
Associated Symptoms:
-Disturbed sleep (Inc or Dec).
-Increased or Decreased appetite and/or weight
-Fatigue or loss of energy.
-Agitation or slowing of movements.
-Poor concentration of indecisiveness.
-feeling of worthlessness or excessive/inappropriate guilt
-Suicidal thoughts or acts.
In order to diagnose:
-DSM needs at least ONE key symptoms, most days, most of the time for at least TWO weeks and a minimum of 5 symptoms
-ICD 10 needs at least TWO key symptoms, most day, most of the time for atleast TWO weeks, min 4 symptoms
Which of the following is NOT a differential diagnosis option for Depression?
a) Bipolar Disorder
b) Gen anxiety disorder
c) Drug-induced / Substance misuse
d) High blood pressure
e) Dementia
f) Panic disorder
g) Physical illness
h) Personality disorder / ADHD
Answer is D
What should the choice of antidepressant be based on?
-Duration of episode
-Previous antidepressant response
-likelihood of adherence, potential adverse effects, patient preference
which of the following SSRIs are NOT first line:
a)Citalopram
b)Sertraline
c)Fluvoxamine
d)Fluoxetine
e)Paroxetine
f)Escitalopram
Answer is C and E
Which of the following are NOT a first line Anti-depressant?
a)Duloxetine
b)Clomipramine
c)Fluvoxamine
d)Mirtazapine
e)Fluoxetine
f)Venlafaxine
g) Amitriptyline
Answer is C, and G.
Duloxetine, Venlafaxine and Mirtazapine are first-line SNRI
Fluoxetine, Citalopram, and sertraline are first-line SSRI
Clomipramine and Lofepramine are first-line TCA
When should Mirtazapine be taken?
a)At night
b)In the morning
Answer is A
Which of the following state is NOT true regarding onset of action of Anti-Depressants?
A) Patient may see some benefits the 1st or 2nd week using the medication
b) If there was no improvement in mood after 3 weeks of a therapeutic dose, medication should be switched.
c) Elderly may need extra time for the drug to work effectively.
d) The patient should be seen every 2-4 weeks for the first 3 months, then less frequently if treatment is working
Answer is B, the patient would need at least 4 weeks on a therapeutic dose before considering drug change.
Switching anti-depressants
-If the first SSRI shows no effect, try initially another SSRI or better tolerated newer-gen antidepressant
-If tolerance is the issue, try a different mode of action
-If efficacy is the problem try a different class or mode of action
-TCA’s can interact with some SSRI’s
-Cross-taper SSRIs and SNRIs very carefully to avoid seratonin syndrome
–CAUTION in changing from flouxetine to other antidepressant, as fluoxetine has a long half-life
–Caution from fluoxetine to reversible MAO inhib (eg Moclobemide), -taper and stop fluoxetine first and wait 5-6 weeks.
–Caution from a non-reversible MAO inhib (e.g Isocarboxazid, Phenelzine)
-Mirtazapine improves sleep, can be used in combination and is an easy to use antidepressant to switch to and from
-Beware of discontinuation symptoms (esp with Paroxetine [2nd line ssri] and Venlafaxine[1st line snri])
-Any more than 2 failed antidepressants (with adaquate dose and duration) suggests the need for a diagnosis review (e.g maybe Bipolar?)
Which statement is False a symptom of Serotonin Syndrome?
a)It is a relatively rare cause of serioud and life-threatening effects
b)Some symptoms include Restlessness, Tremor and rigidity,Shivering/Elevated Temp, Hyperreflexia.
c)It can be fatal due to respiratory depression.
d)It can occur with combinations of Serotonergic drugs. (e.g SSRI, SNRI, Tramadol, Triptans)
Answer is C, It can be fatal due to CARDIAC collapse
Duration of treatment:
-Continue for as long as is needed to reduce relapse
-First episode of depression: 6month after recovery at same dose reduced relapse risk
-Second episode of depression: 1-2 years may reduce relapse.
-Third+ episode: 3-5 years of longer significantly reduces relapse.
Drug-Drug interactions with Anti-depressants:
-Alcohol: Mainly due to increased sedation (Little to no effects with SSRIs, venlafaxine, vortioxetine, Nortriptyline and Clomipramine)
-TCA might lower seizure threshold
-NSAIDs: SSRI use roughly double the risk of upper GI bleeds, this is increased to 3-fold by concurrent NSAIDs (PPI reduce this)
-Warfarin: SSRIs significantly raise INR
-Tamoxifen: Paroxetine may increase the risk of recurrence of breast cancer.
-Smoking: reduces Duloxetine levels
-St. John’s wort
-Carbamazepine: Decrease TCA’s
-Valproate: Increase TCA’s
Which statement is TRUE about Pregnancy and Antidepressants
a) Using SSRIs while pregnant is completely safe.
b) Paroxetine use is preferred in pregnancy.
c) The risk of depression is lower than the risk of an antidepressant.
d) There is little or no evidence of any detrimental effect on postnatal development.
Correct answer is D.
-The risk of depression (poor bonding or self-care) may be higher than the risk of an antidepressant.
-There is some link link between SSRIs and the incidence is autism
-Paroxetine is best avoided
-Most of the other antidepressants may have some risks but these can usually be managed
-There is little or no evidence of any detrimental effect on postnatal Development
Elderly and Antidepressants:
Consult the product literature
-SSRIs are better tolerated than TCA’s, however there is an increased risk of bleeding.
-Increase risk of hyponatraemia, postural hypotension, falls and haemorrhagic stroke with SSRI’s.
-Start low, go slow
-Poor and erratic compliance
Hepatic impairment and antidepressants:
The greater the degree of hepatic impairment, the greater the impairment of drug metabolism, and the higher the risk of drug toxicity. More sensitivity to common or predictable S/E
-Start low, go slow, with regular LFT monitoring
-LFT’s do not necessary correlate with metabolic impairment, although they can give pointers.
-care is needed with a high first pass clearance
-In severe LD, avoid drugs causing marked sedation and/or constipation.
-Paroxetine is used by some specialised liver units with few apparent problems.
