management of depression and antidepressants

Question 1

management of mild depression

Answer 1

NOT ANTIDEPRESSANTS
CBT
lifestyle - sleep hygiene
mindfulness

Question 2

when would you prescribe medication for mild depression

Answer 2

if previously used

symptoms >8 weeks

Question 3

first line anti-depressant for moderate/severe

Answer 3

SSRI - increase until maximum tolerated dose

wait 4-6 weeks before considering changing

Question 4

2nd line after one SSRI

Answer 4

another SSRI

Question 5

3rd line after 2 SSRIs

Answer 5

SNRI

Question 6

4th line

Answer 6

TCA

Question 7

5th line

Answer 7

MAOI

Question 8

when should admission be considered

Answer 8

severe depression
suicide risk
impaired parental function

Question 9

what neurotransmitters are depleted in depression

Answer 9

monoamines - particularly serotonin

also noradrenaline and dopamine

Question 10

aim of antidepressants

Answer 10

increase monoamine conc in synaptic cleft

Question 11

how long should antidepressants be continued for after full-resolution of symptoms after 1st depressive episode

Answer 11

6-12 months

Question 12

if more than 3 episodes, how long should anti-depressants be continued for

Answer 12

indefinitely

Question 13

examples of SSRIs

Answer 13

fluoxetine 
sertraline 
citalopram 
escitalopram 
paroxetine

Question 14

action of SSRIs

Answer 14

block 5HT channels

Question 15

side effects of SSRIs

Answer 15

nausea and headache (resolve within 1 week)
sweating
vivid dreams
hyponatraemia (elderly)
increased self harm and suicide risk <25 years
risk of GI bled with NSAIDs
discontinuation symptoms

Question 16

what are some discontinuation symptoms

Answer 16

flu-like symptoms
GI upset
anxiety/agitation/insomnia

Question 17

what is the safest SSRI with cardiac problems

Answer 17

sertraline

Question 18

what is safest SSRI in epilepsy

Answer 18

citalopram

Question 19

which SSRI is associated with long Qt syndrome

Answer 19

citalopram

Question 20

what is only drug licensed to treat depression in children

Answer 20

fluoxetine

Question 21

examples of SNRI

Answer 21

venlafaxine

duloxetine

Question 22

action of SNRI

Answer 22

blocks reabsorption of serotonin and noradrenaline

Question 23

what else can SNRIs be used for

Answer 23

neuropathic pain and instability

Question 24

SE for SNRI

Answer 24

same as SSRI

Question 25

examples of tricyclics

Answer 25

amititriptyline
imipramine
dosulepin

Question 26

action of tricyclics

Answer 26

non-selectively block re-uptake of monoamines

Question 27

SE of tricyclics

Answer 27

anticholinergic (dry mouth, constipation, urinary retention, blurred vision - interferes with accommodation)
antihistaminergic (sedation and weight gain)
cardiac - tachycardia, arrhythmia, postural hypotension, cardiotoxic if overdose

Question 28

examples of monoamine oxidase inhibitors

Answer 28

moclobemide
phenelzine
tranylcypromine
isocarboxazid

Question 29

action of MAOI

Answer 29

decreased breakdown of monoamines

Question 30

side effects of MAOI

Answer 30

postural hypotension
drowsiness
insomnia
nausea/constipation
hepatic impairment
seizures 
peripheral oedema 
hypertensive crisis

Question 31

what is hypertensive crisis

Answer 31

cheese reaction
tyramine (in cheese alcohol, fermented meat, pate, caffeine) releases noradrenaline
this increases BP
no MAOI - unopposed increase in BP

Question 32

what is mirtazapine

Answer 32

blocks post-synaptic receptors (a2, 5HT2, 5HT3)

Question 33

when is mirtazapine used

Answer 33

combined with SSRIs or venaflaxine to decrease nausea
anxiolytic
safe in CVD

Question 34

what should be prescribed in psychotic depression

Answer 34

anti-depressant and anti-psychotic