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
what are the psychological symptoms of anxiety
trouble sleeping, lack of concentration, poor memory
feeling irritable
feeling depressed
loss of self confidence
what are some pharmacological treatments of anxiety?
SSRI’s and SNRI’s- evidenced based efficacy
Pregabalin - Reduces excitatory neurotransmission
Beta blockers- E.g. Propranolol - physical symptoms of anxiety
Buspirone- Non BDZ anxiolytic, has negligible sedative, muscle relaxant properties
Antipsychotics - e.g. Quetiapine- reduces symptoms in GAD
Homeopathic preparations - can have side effects and ineractions.
what are some non-pharmacological treatments of anxiety?
Relaxation strategies
Psychotherapy
Treat underlying depression
Encourage healthy eating
Discuss adequate/appropriate fluid intake
Explore sleep hygiene techniques
Promote exercise
Be sensitive to non-verbal expression of psychological distress
Maintain / encourage social activities
what is Bipolar Affective Disorder ?
A serious mental illness, with a long course that is usually characterized by both episodes of depressed mood and episodes of elated mood and increased activity (hypomania or mania)”
Highest lifetime risk of suicide attempts (up 20x)
Aim: to manage the episodes (acute) and increase the time between episodes (remission).
How is schizophrenia described ?
“I have bizarre delusions which include psychic battles in which people around me can be perceived as either ‘good’ or ‘evil’. Sometimes I am in a different time zone or move between periods of history in different lives.“ [Mind 2021]
who can schizophrenia effect ?
1 in 100 affecting men and women equally
Often diagnosed between ages of 18-35 years
Approximately 14 to 20% of people fully recover.
Approximately 75% will improve but have recurrent acute episodes or relapses
