medication for mental health Flashcards
what is the ICD-11 depression diagnostic criteria ?
defined by theconcurrent presence of at least five out of a list of ten symptoms, which must occur most of the day, nearly every day, for at least 2 weeks
what are the 10 symptoms of ICD-11 depression diagnostic criteria ?
- persistent sadness or low mood; and/or
- loss of interests or pleasure
- fatigue or low energy
If any of above present, ask about associated
symptoms:
- disturbed sleep
- poor concentration or indecisiveness
- low self-confidence
- poor or increased appetite
- suicidal thoughts or acts
- agitation or slowing of movements
- guilt or self-blame
how are degrees of depression defined from the 10 symptoms?
Mild depression; A total of 4 symptoms must be present of which at least 2 must be key symptoms
Moderate depression; A total of 6 symptoms must be present of which 2 must be key with at least 3 and preferably 4 of the other symptoms
Severe depression; A minimum of 7 symptoms must be present including all 3 key symptoms with at least 4 of the ancillary symptoms, some of which should be of severe intensity
what are NICE guidelines [CG 2009] for treatment of depression?
Subthreshold / mild depression
- Consider a psychological intervention
- Individual guided self-help
- Computerized cognitive behavioural therapy (CCBT)
- Structured group-based physical activity programme
- Avoid the routine use of antidepressants
Moderate or severe depression
-offer an antidepressant and a high-intensity psychological intervention
which factors can affect antidepressant choice
Consider patients preference
Any co-morbidities & associated medication
Adverse effect profile e.g. sedation, sexual adverse effects, weight gain.
Level of “concordance” with medications (esp n.b with short T1/2)
Toxicity in overdose- avoid tricyclic antidepressants or venlafaxine if there is a history, or likelihood, of overdose.
Note QTc prolongation effect
What is Monoamine (or Catecholamine) Theory?
“proposes that depression is due to a deficiency in one or another of three monoamines, namely serotonin, noradrenaline and or/dopamine” (Stahl, 2000)
which classes of drugs are used to monoamine deficiencies in depression?
Selective Serotonin Reuptake Inhibitor (SSRI) e.g. Citalopram, Sertraline, Fluoxetine
Serotonin Noradrenaline Reuptake Inhibitors (SNRI) e.g. Venlafaxine, Duloxetine
MonoAmine Oxidase Inhibitors (MAOI) e.g. Phenelzine
TriCyclic Antidepressants (TCA) e.g. Amitriptyline
Noradrenaline Reuptake Inhibitor (NRI) e.g. Reboxetine
which factors can effect choice if antidepressants ?
efficacy of all equal- consideration of adverse effects guides choice.
Younger people
Antidepressants not recommended as
first-line
If so Fluoxetine first
Increases in risk of suicide
Elderly
More sensitive to adverse effects of antidepressants
Particularly hyponatraemia, sedation, hypotension, bleeding
Drug-drug interactions
Pregnancy/breastfeeding
Try to avoid all drugs
Risk vs. benefit
Antidepressants not contra-indicated in pregnancy/breastfeeding
what are side effects of SSRI
SSRIs – first-line due to tolerance and safety
Headache, GI symptoms
Sexual dysfunction
Hyponatraemia
Bleeding risk
what are side effects of TCA’s
TCAs – e.g. Amitriptyline, Clomipramine
Poorly tolerated – anticholinergic side effects common
Cardiac toxicity
Toxic in overdose
what are side effects SNRI’s/ others
SNRIs/others – e.g. Venlafaxine, Mirtazapine
Second-line
multiple Different side effects
what is the suggested duration of treatment with antidepressants ?
Single episode – 6-9months
Multiple episode - >2years
what are the recurrence rates of depression ?
50% after a first episode of depression,
70% after a second episode
90% after a third episode.
what is anxiety ?
Anxiety is a normal emotion
Symptoms can be psychological, physical or a mixture of both
Intervention is required when symptoms become excessively distressing or disabling, or reduce quality of life, in the context of the absence of any clear external threat
what are physical symptoms of anxiety ?
rapid and/or irregular heartbeat, sweating, panic attacks or dizziness
Fast breathing tense muscles
dry mouth, churning stomach
loose bowels, increased micturition
