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PHA333 > depression (PB) > Flashcards

depression (PB) Flashcards

1
Q

definition of depression

A

disorder of mood

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2
Q

classifications of depression

A

major depression (unipolar)

bipolar depression (manic depressive illness)

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3
Q

emotional symptoms of depression

A
  • sadness
  • loss of interest/pleasure
  • overwhelemed
  • anxiety
  • diminished ability to think or concentrate/indecisiveness
  • excessive/inappropriate guilt
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4
Q

physical symptoms of depression

A
  • vague aches/pains
  • headache
  • sleep disturbances
  • fatigue
  • back pain
  • significant change in appetite resulting in weight loss/gain
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5
Q

key symptoms of depression

A
  • persistent sadness or low mood

- marked loss of interests/pleasure

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6
Q

criteria used to diagnose depression/mental health disorders

A

ICD-10 (international criteria for disease)

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7
Q

How is depression divided using the ICD-10 criteria?

A
  1. subthreshold depressive symptoms - < 5 symptoms
  2. mild depression - few symptoms in excess of the 5 required to make disgnosis and symptoms only result in minor functional impairment
  3. moderate depression - symptoms or functional impairment are between mild and severe
  4. severe depression - most symptoms, they interfere with functioning, can occur with/wo psychotic symptoms
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8
Q

When to refer to mental health services?

A
  • poor/incomplete response to 2 interventions
  • recurrent episode within 1yr
  • relative referral
  • self neglect
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9
Q

When to refer to psychiatrist?

A
  • suicidal ideas/plans
  • psychotic symptoms
  • severe agitation with severe symptoms
  • severe self neglect
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10
Q

What is mainly mediated by 5HT?

A

sex
appetite
aggression

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11
Q

What is mediated by NA?

A

concentration
interest
motivation

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12
Q

What is mediated by both 5-HT and NA?

A 
depressed mood
anxiety
vague aches and pains
irritability
thought process

-> mediate broad spectrum of depressive symptoms

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13
Q

pathophysiology of depression

A
  • dysregulation of 5-HT and NA in brain strongly associated with depression
  • dysregulation of 5-HT and NA in spinal cord may be cause of inc pain perception among depressed patients
  • imbalance of 5-HT and NA may explain presence of both emotions and physical symptoms of depression
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14
Q

areas of key priority for implementation in depression

A
  • principles for assessment
  • effective delivery of interventions
  • case ID and recognition
  • low intensity psychosocial interventions
  • drug treatment
  • treatment for mod/severe depression
  • continuation and relapse prevention
  • psychological interventions for relapse prevention
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15
Q

classes of antidepressants

A
  1. monoamine uptake inhibitors
    - SSRIs, TCAs
  2. monoamine receptor antagonists
  3. monoamine recptor inhibitors
  4. melatonin receptor agonist
  5. miscellaneous
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16
Q

examples of SSRIs

A 
fluoxetine
paroxetine
sertraline
citalopram
escitalopram
fluvoxamine
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17
Q

examples of TCAs

A

imipramide
desipramide
amitriptyline
clomipramine

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18
Q

examples of monoamine receptor antagonists

A

mirtazapine
trazodone
mianserin

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19
Q

benefits of SSRIs

A

safer in overdose

don’t stimulate appetite

fewer antimuscarinic s/e than TCAs and NA uptake inhibitors

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20
Q

uses of SSRIs

A
  • depression (similar to TCAs but more expensive)
  • panic disorder (chronic anxiety, panic attack)
  • OCD
  • bulimia nervose (binge eating disorder)
  • seasonal affective disorder
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21
Q

adverse effects of SSRIs

A 
GI disturbances
- nausea
- dyspepsia
- diarrhoea
dry mouth
headache
insomnia
dizziness
sweating
erectile dysfunction
delayed orgasm
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22
Q

metabolism of fluoxetine (SSRI)

A

fluoxetine metabolised by liver to active metabolites nurfluoxetine (longer half life)

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23
Q

interactions with SSRIs

A

TCAs - inc conc of TCA

antiepileptics - inc risk of convulsions

aspirin, warfarin, NSAIDs - bleeding risk

MAOIs - inc risk of serotonin syndrome

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24
Q

c/i for SSRIs

A

hepatic and renal failure

epilepsy

manic pase

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25
Q

What SSRIs can prolong QT interval?

A

citalopram

escitalopram

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26
Q

When to avoid citalopram and escitalopram?

A

in patients with existing QT interval prolongation

if patient already taking a medication that can prolong QT interval

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27
Q

What other meds can prolong QT interval?

A

TCAs
methadone
antipsychotics
erythromycin

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28
Q

max daily dose of citalopram

A

adults 40mg
elderly 20mg
hepatic impairment 20mg

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29
Q

max daily dose of escitalopram in elderly

A

max 10mg daily

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30
Q

counselling with SSRIs

A
  • takes 2-4 weeks for therapeutic effect
  • review pt every 1-2 weeks for at least 4 weeks
  • treatment continued for at least 6mths
  • recurrent depression pt -> treatment for 2yrs
  • withdrawal should be slow -> withdrawal depression
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31
Q

uses of TCAs

A
  • depression -> major and melancholic
  • atypical oral and facial pain
  • prophylaxis of panic attacks
  • phobia anxiety
  • OCD
  • nocturnal enuresis (involuntary urination while sleeping, imipramine)
32
Q

adverse effects of TCAs

A 
arrhythmias
anxiety
dizziness
headache
drowsiness
antimuscarinic effects
hyponatraemia (common in elderly)
33
Q

antimuscarinic side effects

A

dry mouth
blurred vision
constipation
urinary retention

34
Q

What is hyponatraemia?

A

deficiency of Na in blood

Na conc < 135 mEq/L

35
Q

metabolism of TCAs

A

metabolised in liver

36
Q

half life of TCAs

A

long 9-80hrs

-> most once daily dosing

37
Q

drug interactions of TCAs

A

MAOIs - risk of hypertensive crisis and hyperpyrexia

antiepeleptics - antagonise effect of antiepileptic meds and reduce seizure threshold

alcohol and antihistamines - inc sedative effect

antihistamines and anticholinergic - inc antimuscarinic effect

38
Q

ontraindications with TCAs

A 
recent MI, heart block
cardiac arrhythmias
epilepsy
mania
severe liver disease
39
Q

overdose with TCAs

A

OD can be fatal

due to cardiac arrhythmias

  • sinus tachycardia
  • prolonged PR interval
  • prolonged QRS duration
  • prolonged QT interval
  • non-specific ST and T wave changes
40
Q

hen is imporvement seen with TCAs?

A

after 2 weeks

41
Q

sedative effects of TCAs

A

sedative - amitriptyline

non-sedating - lofepramine, impiramine

-> may affect ability to drive

42
Q

SNRIs

A

serotonin and noradrenaline reuptake inhibitors

43
Q

examples of SNRIs

A

venlafaxine
duloxetine
desvenlafaxine

44
Q

uses of SNRIs

A

depression
anxiety
panic disorder
pain syndromes - fibromyalgia (duloxetine)

45
Q

adverse effects of SNRIs

A 
inc BP
weight loss
hepatitis
GI disconfort
dizziness and headache
46
Q

metabolism of SNRIs

A

metabolised in liver

47
Q

half life of SNRIs

A

between 5-11hrs

48
Q

venlafaxine

A

weak NA/5-HT uptake inhibitor
non-selective

  • depression
  • anxiety
  • panic disorder with/wo agrophobia
  • withdrawal effects if dose missed
  • s/e similar to SSRIs
  • useful in treatment resistant pts
49
Q

duloxetine

A

potent non-selective NA/5-HT uptake inhibitor

  • depression
  • anxiety
  • panic disorder
  • urinary incontinence
  • fibromyalgia
  • diabetic neuropathy (1st line)
  • less s/e than venlafaxine (include sexual dysfunction, sedation, nausea)
50
Q

NRIs

A

noradrenaline reuptake inhibitors

51
Q

example of NRIs

A

reboxetine for depression

52
Q

reboxetine

A
  • NRIs
  • depression
  • s/e similar to TCAs
  • safe in OD
  • low risk fo cardiac dysrythmias
53
Q

example of a non-selective uptake inhibitor

A

St John’s Wort
weak NA/5-HT uptake inhibitor
non-selective

54
Q

St John’s Wort

A
  • non-selective uptake inhibitor
  • depression
  • few s/e
  • potent enzyme inducer
  • interacts with warfarin, theophylline, ciclosporin, oral contraceptives
55
Q

examples of monoamine receptor antagonists

A

trazodone

mirtazapine

56
Q

How does trazodone work?

A

weak 5-HT uptake inhibitor

blocks 5-HT2A, 5-HT2C, H1 receptors

57
Q

s/e with trazodone

A

redation
hypotension
cardiac dysrhythmias

58
Q

MOA od mirtazapine

A

blocks alpha2, 5-HT2C, 5-HT3 receptors

enhances NA

59
Q

s/e with mirtazepine

A

dry mouth
sedation
weight gain

60
Q

advantages of mirtazapine

A

may act more rapidly than other antidepressants

less nasuea and sexual dysfunction than SSRIs

61
Q

MAO A and B substrates

A

MAO-A -? 5-HT, NA, DA

MAO-B -> NA, DA

62
Q

example of MAOIs

A

moclobemide (depression)

selegiline (parkinsons)

rasagiline (parkinsons)

63
Q

uses of MAOIs

A
  • depression
  • atypical oral depression
  • phobia anxiety and depression with anxiety
64
Q

s/e with MAOIs

A 
orthostatic hypotension
weight gain
sexual dysfunction
dizziness
headache
aggravation of migraine
antimuscarinis effect (dry mouth, blurred vision, constipation)
65
Q

metabolism of MAOIs

A

in liver

66
Q

half life of MAOIs

A

1-4hrs

67
Q

interactions with MAOIs

A
  • accumulation of amine NT may result in hypertensive crisis and hyperpyrecia
  • sympathomimetics (cough/decongestants)
  • SSRIS, TCAs
  • levodopa
  • opioid analgesics (esp pethidine)
  • tyramine containing foods (mature cheese, beer, broad beans)
68
Q

c/i MAOIs

A
  • hepatic dysfunction
  • epilepcy
  • cerebrovascular disease
  • phaeochromocytoma (risk of hypertnesive crisis)
69
Q

important info for MAOIs

A
  • avoided due to severe s/e
  • s/e less with selective agents particulary MAO-B hibitors
  • withdrawan slowly (dependence and withdrawal syndrome)
  • don’t start antidepressants for 2 weeks after stopping MAOI (due to irreversible MAO inhibition)
70
Q

moclobemide

A

reverible MAO-1 inhibitor
less problematic
reserved as 2nd line treatment

71
Q

choice of antidepressant for pt on NSAIDs.aspirin

A

mirtazapine
trazodone
reboxetine
moclobemide

72
Q

What antidepressant NOT to give to pt on NSAIDs/aspirin?

A

SSRIs

-> inc bleeding risk

73
Q

choice of antidepressant for pt on warfarin/heparin

A

mirtazepine

-> NOT SSRI

74
Q

choice of antidepressant for pt on MAOI-B

A

mirtazepine
trazodone
reboxetine

-> NOT SSRI

75
Q

choice of antidepressant for pt on theophylline, clozapine, methadone, flecainide, propafenone

A

sertraline

76
Q

divisions of depressive disorders

A
  1. single episode depressive disoeder
  2. recurret depressive disorder
  3. dysthymic disorder
  4. mixed depressive and anxiety disorder

PHA333 (27 decks)

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