Depression therapy

Question 1

Antidepressant drugs are effective for treating moderate to severe depression associated with psychomotor and physiological change . What is usually the first benefit seen from therapy?

Answer 1

Improvement in sleep

Question 2

Ideally patients with moderate to severe depression should be treated with drug therapy and what else?

Answer 2

Psychological therapy in addition to drug therapy

Question 3

Psychological therapy should be used in the initial management of for mild depression. When would a trial of an antidepressant be considered in those with mild depression? (2)

Answer 3

1) history of moderate or severe depression

2) cases resistant to psychological treatments or in those associated with psychosocial or medical problems

Question 4

There is little to choose between the different classes of antidepressant drugs in terms of efficacy. What factors are considered when selecting the right drug?

Answer 4

1) Patient’s requirements
2) Presence of concomitant disease
3) Existing therapy
4) Suicide risk
5) Previous response to antidepressant therapy

Question 5

How long does it take for antidepressant therapy to start taking effect?
2) what treatment may be required in very severe depression while waiting for antidepressants to start working?

Answer 5

1) 2 weeks for the antidepressant action to occur

2) Electroconvulsive treatment may be required (also for severe refractory depression)

Question 6

List some of the side effects that may occur within the first few weeks of treatment in those taking antidepressants (3)

Answer 6

Increased potential for agitation, anxiety, and suicidal ideation

Question 7

which class of drugs is considered first-line for the treatment of depression and why?

Answer 7

1) SSRIs- well tolerated and are safer in overdose

↳ safe in unstable angina and in those who have has a recent MI

Question 8

List 4 SSRIs

Answer 8

citalopram, fluoxetine, sertraline, escitalopram

Question 9

1) Tricyclic antidepressants have similar efficacy to SSRIs, what why might they be discontinued in patients.
2) Explain why SSRIs are preferred to TCAs (2)

Answer 9

1) Side-effects, toxicity in overdosage also a problem

2) SSRIs are less sedating and have fewer antimuscarinic and cardiotoxic effects than TCAs

Question 10

List 4 TCA’s

Answer 10

Amitriptyline, lofepramine, clomipramine, imipramine

Question 11

Why should Monoamine oxidase inhibitors (MAOIs) be reserved for use by specialists in the treatment of depression?
2) Name 2 MAOIs

Answer 11

1) Dangerous interactions with some foods and drugs

2) Phenelzine and isocarboxazid

Question 12

why should axiolytics or antipsychotic drugs may be useful for managing agitated patients, why should be used with caution in depression?

Answer 12

1) Anxiety is often present in depressive illness, these drugs might mask the true diagnosis
2) under specialist they can be combined to treat depression with psychotic symptoms

Question 13

St John’s wort is a popular OTC treatment for mild depression. Why should in not be recommended for depression?

Answer 13

1) Enzyme inducer that has a number of important interactions, including with antidepressants
2) API varies between brands so switching can change the degree of enzyme induction and lead to toxicity with some drugs

Question 14

1) How often should patients be reviewed at the start of antidepressant treatment?
2) How long should treatment continue before deciding to switch to a different class due to lack of efficacy?
3) In the case of a partial response to drug therapy, how much longer should the trial be extended?

Answer 14

1) Every 1–2 weeks at the start
2) Continued for at least 4 weeks (6 weeks in the elderly)
3) Partial response- continue for a further 2-4 weeks

Question 15

Following remission, antidepressant treatment should be continued at the same dose for how long?

Answer 15

1) At least 6 months (12 months in elderly),

2) Or for at least 12 months in patients receiving treatment for generalised anxiety disorder

Question 16

Patients with a history of recurrent depression should receive maintenance treatment for what length of time?

Answer 16

At least 2 years

Question 17

what electrolyte disturbance is associated with the use of all types of antidepressants and which class does it occur most commonly in?

Answer 17

1) Hyponatraemia (usually in elderly)

2) More frequently with SSRIs

Question 18

Hyponatraemia should be considered in all patients who present with what symptoms?

Answer 18

Drowsiness, confusion, or convulsions while taking an antidepressant

Question 19

1) The use of antidepressants has been linked with suicidal thoughts and behavior. Which individuals are most at risk?
2) when should this be monitored in patients?

Answer 19

1) children, young adults, and those with a history of suicidal behaviour
2) montor behaviour e.g. self-harm, or hostility, particularly at the beginning or during dose changed

Question 20

what is serotonin syndrome is a uncommon adverse drug reaction caused by excessive central and peripheral serotonergic activity. What are the characteristic symptoms

Answer 20

1) neuromuscular hyperactivity: Tremor, hyperreflexia, clonus, myoclonus, rigidity
2) Autonomic dysfunction: Tachycardia, BP changes, hyperthermia, diaphoresis, shivering, diarrhoea
3) Altered mental state: agitation, confusion, mania

Question 21

Why does serotonin syndrome occur?

Answer 21

1) Can occur within hours or days following the initiation, addition, dose escalation, or overdose of a serotonergic drug, particularly when the first drug is an irreversible MAOI or a drug with a long half-life.
2) Can also occur with the replacement of one serotonergic drug by another without allowing a long enough washout period in-between

Question 22

How should serotonin syndrome be managed and which class of drug is normally associated with this condition?

Answer 22

1) Symptoms, range from mild to lifethreatening. Severe toxicity, is a medical emergency, usually occurs with a combination of serotonergic drugs, one of which is generally an MAOI
2) Treatment consists of withdrawal of the serotonergic medication and supportive care

Question 23

what pharmacological options are available for patients who fail to respond to SSRIs initially?

Answer 23

1) May require an increase in the dose, or switching to a different SSRI or mirtazapine
2) 2nd line- choices include lofepramine, moclobemide, and reboxetine
3) Other TCAs and venlafaxine considered for severe forms of depression

Question 24

If an SSRI is prescribed in older people who are taking NSAIDs or aspirin, what other drug might need to be added to therapy?

Answer 24

consider gastroprotection

Question 25

1) What drug is used to manage acute anxiety managed?
2) What drug is used to manage chronic anxiety (4w +)
3) Why might combined therapy with two drugs sometimes be necessary?

Answer 25

1) Acute: Benzodiazepine or buspirone HCL
2) Chronic anxiety: may be appropriate to use an antidepressant
3) Combined therapy with a benzodiazepine may be required until the antidepressant takes effect

Question 26

Generalised anxiety disorder, is a form of chronic anxiety, initial treatment involves psychological treatment. If drug treatment is needed, what should be prescribed?

Answer 26

1) SSRI: Escitalopram, paroxetine, or sertraline can be used. Duloxetine and venlafaxine (SNRIs) also recommended for the treatment .
2) Pregabalin can be considered if the above options fail or are CI

Question 27

Panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobic states such as social anxiety disorder are treated with which class of drugs?

Answer 27

1) SSRIs

Moclobemide is licensed for the treatment of social anxiety disorder