management of depression and antidepressants Flashcards
management of mild depression
NOT ANTIDEPRESSANTS
CBT
lifestyle - sleep hygiene
mindfulness
when would you prescribe medication for mild depression
if previously used
symptoms >8 weeks
first line anti-depressant for moderate/severe
SSRI - increase until maximum tolerated dose
wait 4-6 weeks before considering changing
2nd line after one SSRI
another SSRI
3rd line after 2 SSRIs
SNRI
4th line
TCA
5th line
MAOI
when should admission be considered
severe depression
suicide risk
impaired parental function
what neurotransmitters are depleted in depression
monoamines - particularly serotonin
also noradrenaline and dopamine
aim of antidepressants
increase monoamine conc in synaptic cleft
how long should antidepressants be continued for after full-resolution of symptoms after 1st depressive episode
6-12 months
if more than 3 episodes, how long should anti-depressants be continued for
indefinitely
examples of SSRIs
fluoxetine sertraline citalopram escitalopram paroxetine
action of SSRIs
block 5HT channels
side effects of SSRIs
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
what are some discontinuation symptoms
flu-like symptoms
GI upset
anxiety/agitation/insomnia
what is the safest SSRI with cardiac problems
sertraline
what is safest SSRI in epilepsy
citalopram
which SSRI is associated with long Qt syndrome
citalopram
what is only drug licensed to treat depression in children
fluoxetine
examples of SNRI
venlafaxine
duloxetine
action of SNRI
blocks reabsorption of serotonin and noradrenaline
what else can SNRIs be used for
neuropathic pain and instability
SE for SNRI
same as SSRI
examples of tricyclics
amititriptyline
imipramine
dosulepin
action of tricyclics
non-selectively block re-uptake of monoamines
SE of tricyclics
anticholinergic (dry mouth, constipation, urinary retention, blurred vision - interferes with accommodation)
antihistaminergic (sedation and weight gain)
cardiac - tachycardia, arrhythmia, postural hypotension, cardiotoxic if overdose
examples of monoamine oxidase inhibitors
moclobemide
phenelzine
tranylcypromine
isocarboxazid
action of MAOI
decreased breakdown of monoamines
side effects of MAOI
postural hypotension drowsiness insomnia nausea/constipation hepatic impairment seizures peripheral oedema hypertensive crisis
what is hypertensive crisis
cheese reaction
tyramine (in cheese alcohol, fermented meat, pate, caffeine) releases noradrenaline
this increases BP
no MAOI - unopposed increase in BP
what is mirtazapine
blocks post-synaptic receptors (a2, 5HT2, 5HT3)
when is mirtazapine used
combined with SSRIs or venaflaxine to decrease nausea
anxiolytic
safe in CVD
what should be prescribed in psychotic depression
anti-depressant and anti-psychotic
