Management of major depressive disorder 1.1.2 Flashcards
What are the treatment options for depression?
- psychotherapy
- pharmacotherapy
- electroconvulsive threrapy (ECT)
- antidepressant
What is the approptiate treatment for severity of depression?
- Mild depression
- Psycotherapy> effectiveness than antidepressants
- Moderate depression
- Psychotehrapy= effectiveness with antidepressants
- Moderate/ severe depression
- antidepressants> effectiveness than psychotherapy
What does psychological treatment of depression involve?
- structured problem-solving strategies
- stress management strategies
- CBT
- interpersonal psychotherapy (IPT)
- short term dynamic therapy
What is the efficacy of pharmacotherapy in depression?
- indicated in moderate/ severe depression
- benefit of AD therapy increasses with severity of illness
- present evidence suggests that all AD medications have similar efficacy
- individual response varies
- drugs differ in ADV EFF profile & safety in OD
The choice of antidepressant is based on…?
- prior response
- adverse effects profile
- family history of response to treatments
- potential for drug interactions
- safety in OD
- patient co morbidities
- simple dosing
- cost
- patient preference
What are the 1st line AD?
- SSRIs
- SNRIs
- Mirtazapine
What are the 2nd line AD?
- agomelatine
- moclobemide
- reboxetine
- TCAs
- mianserin
- irreversible non selective MAOIs
What are examples of augmentation therapy for depression?
- liothyronine (T3)
- lithium
- anti-psychotics
- psychostimulants
- tryptophan
What are some other options for pharmacotherapy?
- ECT
- omega-3-fatty acids
- hypericum- St Johns Wort
- exercise
How long does it take for an AD to reach therapeutic effect?
- generally around 1-3 weeks
How long does it take AD to reach the max therapeutic effect?
- 2-4 weeks
How do we commence AD therapy?
- generally start at a low dose & gradually increase over 2-4 weeks
What are the methods of switching AD?

What are the methods of switching antidepressants?
- Conservative switch
- Gradual tapering and cease
- Washout period of 5 half lives
- New drug commenced at dose as per guidelines
Why: reduce risk of adverse effects like serotonin toxicity, but patient’s risk of relapse is high as there is no antidepressant in the system. Withdrawl effects are worse but safer.
- Moderate switch
- Gradual tapering and cease
- Washout period of 2 to 4 days
- New drug commenced at low dose
Why: reduce risk of adverse effects like serotonin toxicity, but patient’s risk of relapse is high as there is no antidepressant in the system. Withdrawl effects are worse but safer.
- Direct switch
- First drug stopped
- New drug commenced the next day at a therapeutic dose
Why: very severe side effect eg. full body rash, stopped medication suddenly. Some antidepressants cause mania so has to be stopped suddenly. Patient preference is the third reason (e.g. venlafaxine, when tapering doses, withdrawal effects start and last for weeks/months, some patients prefer to ‘suffer for a few days’ and get over it.
- Cross taper switch
- Gradual tapering and cease
- New drug commenced at low dose at some stage in the reduction
- Dose increased to therapeutic dose when first drug has been ceased
Why: less withdrawal effect, less risk of relapse as there is medication in the body. Risk is that there is a larger risk of adverse effects as combining 2 antidepressants at the same time –> potential for serotonin syndrome and other side effects.
Hospital –> cross taper
Community –> cross taper if patient is at high risk of relapse or high risk of withdrawal symptoms
What are some withdrawal effects of antidepressants?
What in particular for phenelzine and tranylcypromine?
- phenelzine: psychosis and seizures
- tranylcypromine: may cause delirium
What can rapid withdrawal of the more potently anticholinergic tricyclic antidepressants (TCAs) (eg amitriptyline) result in?
- Cholinergic rebound (agitation, headache, sweating, gastrointestinal symptoms), parkinsonism and problems with balance.
- sailvation, lacrimation, urination, diarrhoea, GI distress, emesis
- SLUDGE = cholinergic effects
What is discontinuation syndrome? When is this likely to occur? What to do to avoid this?
- when a drug is stopped abruptly
- with a higher dose of drug
- longer treatment duration
- shorter half life drugs
- sometimes happens when the patient misses 1 or 2 doses
- GENERAL RULE: halve the dose every week until the daily dose is half of the lowest unit available, then stop after 1 week
What is the combinations that are used for antidepressants? How is it different to augmentation?
- Mirtazapine + SSRIs
- Mirtazapine + Venlafaxine
- SSRI + TCA
Different to augmentation = Involves using 2 or more antidepressant medications typically from 2 different mechanism classes
- Avoid using > 1 antidepressant drug –> Insufficient evidence to support combination therapy –> Serious adverse effects can occur
What is ECT?
- electro convulsive therapy
- Delivery of an electric current to induce a seizure for a therapeutic response (uni or bilateral)
- Indicated for severe and unresponsive forms of depression
- Response rate of 50 to 80%
- Treatments given 3 times weekly or ↓ if cognitive impairment emerges
- 6 to 14 treatments (up to 24 treatments)
- Side effects
- Memory loss, muscle aches and pains, headaches, transient confusion
Things you may consider with ECT & pharmacotherapy?
- Benzodiazepines should ceased because they raise seizure threshold and ↓ efficacy
- Little to be gained from continuing failed antidepressants during ECT – may ↑ adverse effects
- Lithium doesn’t ↓ efficacy but may ↑ postictal confusion
- Continuation of antiepileptic drugs during ECT may ↓ efficacy, prolong course and ↑ cognitive adverse effects
- Unless antipsychotics are ineffective or result in problems with ECT (e.g. clozapine and prolonged seizures) they can be continued and may improve results
Explain St Johns Wort
- efficacy in acute mild-moderate disease
- MOA- may involve increasing syaptic availability of serotonin & other neurontransmitters
- long term safety & efficacy not established
- risk of serotnin toxicity
- has a range on interactions-warfarin, COC
When does serotonin toxicity occur?
- Overdose of a single agent
- Simultaneous use of two serotonergic agents
- Failing to use appropriate washout period when switching agents
What are some symptoms associated with serotonin toxicity?
- can be a medical emergency & deaths have occurred
- shivering, sweating, mild tachycardia
- agitation, disorientation, muscle rigidity, tremor, hyperreflexia
- delirium, hypertension, hyperthermia,
- may have diarrhoea
What are some treatment options for serotonin toxicity?
- Cyproheptadine: 12mg single dose or 4-8mg TDS
- Chlorpromazine: 12.5-50mg slow IV infusion over 30-50min