General info

Question 1

What is depression?

Answer 1

Depressed patients often feel sad, hopeless and lose interest in things they used to enjoy.

Thought to be caused by underactivity of monoamine neurotransmitters.

Symptoms can be psychological and physical

Question 2

Psychological symptoms

Answer 2

Low self esteem
Worry and anxiety
Suicidal thoughts

Question 3

Physical symptoms

Answer 3

Lack of energy
Changes in weight/appetite
Insomnia/early morning wakeness

Question 4

Antidepressants - general MoA

Answer 4

Increase monoamine levels at synapse

Question 5

General guidance

Answer 5

1st line = SSRIs
- Better tolerated
- Safer in overdose than other classes.
- Less sedating, anti-muscarinic, epileptogenic + cardiotoxic than TCAs
- MAOIs are rarely used (dangerous food + drug interactions). Reserved for specialist use.

Question 6

How long do anti-depressants take to work?

Answer 6

Min. 2 weeks.
Initially may feel worse - increased agitation, anxiety + suicidal ideation.
Review every 1-2 weeks at the start of treatment/
Wait at least 4 weeks (6 in the elderly) before deeming it ineffective.

Question 7

How long should anti-depressants be taken for?

Answer 7

Continue for at least 6 months after remission (12 months in the elderly).
- 2 years in recurrent depression.
GAD = 12 months due to high risk of relapse

Question 8

Drug choice

Answer 8

1st line = SSRI
2nd line = increase SSRI dose or switch to alternative SSRI
3rd line = SNRI
4th line = TCA or MAOI (consider risks associated with the two)

Question 9

Other drug choices (apart from SSRI)

Answer 9

Lofepramine (TCA)
Reboxetine (SNRI)
Mocoblemide (reversible MAOI)

Question 10

Severe forms of depression

Answer 10

Other TCA
Venlafaxine
Vortioxetine (only if two other antidepressants have been tried + not worked)
Irreversible MAOIs must be initiated under specialist supervision.

Question 11

Last resort

Answer 11

• Add another antidepressant class OR
• Augmenting agent (lithium or antipsychotic) OR
• ECT in severe refractory depression.

Question 12

Side effects (GENERAL)

Answer 12

Suicidal ideation + behaviour
Hyponatraemia
Serotonin syndrome

Question 13

Side effects - suicidal ideation and behaviour

Answer 13

At risk: children and young adults or history of suicidal behaviour.
Monitor at the start of treatment or after a dose change:
- Suicidal behaviour
- Self harm
- Hostility

Question 14

Side effects - hyponatraemia

Answer 14

Especially SSRIs
Common in elderly
- Drowsiness
- Confusion
- Convulsion

Question 15

Serotonin syndrome

Answer 15

1. Neuromuscular hyperactivity (tremors, myoclonus, muscle rigidity).
2. Altered mental state (agitation, confusion, mania).
3. Autonomic dysfunction (labile BP, urination, hyperthermia, tachycardia, pallor, sweating, shivering).

Question 16

Washout period

Answer 16

A specific timeframe during which one medication is discontinued before starting another.
Aim = clear the first medication completely from the patient’s system to avoid potential drug interactions or additive side effects, particularly serotonin syndrome.

Question 17

Switching - MAOIs

Answer 17

Wait 2 weeks before switching.
Moclobemide is short-acting/reversible and dose not require a washout period.

Question 18

Switching - SSRIs

Answer 18

Wait 1 week before switching.
Sertraline = 2 weeks
Fluoxetine = 5 weeks

Question 19

Switching - TCAs

Answer 19

Wait 1-2 weeks before switching
Imipramine or Clomipramine = 3 weeks

Question 20

Withdrawal

Answer 20

AVOID abrupt withdrawal.
Withdrawal reactions = 5 days of stopping.
Increased risk of withdrawal = suddenly stop after taking for 8+ weeks.
Gradually reduce dose over 4 weeks or longer (6 months in patients on long-term maintenance treatment)
Driving = drowsiness

Question 21

What antidepressants have a higher risk of withdrawal reaction?

Answer 21

Paroxetine
Venlafaxine