Depressive Disorder

Question 1

How do depression present in the elderly

Answer 1

relatively high MOCA score
health anxiety,
agitation and sleep disturbance
Insomnia

Question 2

Management of depression

Answer 2

SSRIs are first line fluoxetine , sertraline , citalopram

==========

Switching to an antidepressant that is not an SSRI is recommended if a second SSRI produces minimal to no response.

Choices for switching include mirtazapine, bupropion, and venlafaxine

Question 3

what is the third line treatmnet for depression

Answer 3

non selective MAOI (selective for Parkinson’s ) - isocarboxazid
- tranylcypromine

TCA - Amitriptyline · Amoxapine · Desipramine

Question 4

TCA / amitriptyline is not used that often why ?

Answer 4

(adverse side-effect profile of TCAs more of an issue in the elderly) -

Question 5

Side effects of TCA overdose ?

Answer 5

main effect of TCAs is to increase serotonin and noradrenaline in the brain by slowing re-uptake, they also block histamine, cholinergic and alpha 1 receptors.

not good in elderly - anti-cholinergic effects give dilated pupils, dry skin, confusion, urinary retention and tachycardia.

DIVERGENT PUPILS

Question 6

what are the cardiotoxic side effects of TCA ?

Answer 6

potential prolongation of the QTc interval and a widened QRS complex. This can potentially lead to ventricular arrhythmias.

Question 7

neurological side effect of TCA ?

Answer 7

reduced Glasgow coma scale

Question 8

In overdose sertraline may present with serotonin syndrome but how can we differentiate that from TCA overdose ?

Answer 8

but skin would not be dry
No QT prolongation (CITALOPARM AN EXCEPTION)

Question 9

x

Question 10

x

Question 11

common side effects of serotonin syndrome due to SSRI toxicity ?

Answer 11

low Glasgow coma scale
dilated pupils
hyperreflexia, often with muscle rigidity and tremor

Question 12

what is a common side effect of mirtazapine

Answer 12

agranulocytosis

Question 13

Management of refractory depression

Answer 13

Lithium

Electroconvulsive therapy

Question 14

shown to be as effective as tricyclic antidepressants in the treatment of mild-moderate depression?

Answer 14

St John Wart

Question 15

x

Question 16

x

Question 17

x

Question 18

Short-term side-effects of Electroconvulsive therapy

Answer 18

headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia