Mental Health Clinical Depression and Anxiety Flashcards
Describe the epidemiology of depression:
1 in 5 (19%) have symptoms of anxiety/ depression
Higher proportion in women than men
First episode often in ages 15-18
Most common first episode between 30-40
What are the risk factors for unipolar depression?
Genetics (40-70%)
Gender
Lack of parental care
Poor sleep (2x)
Vit D deficiency
Quitting smoking (increases risk)
Mother having Post natal depression (5x increase)
Drugs
Social adversity
Physical illness
What are the risks to individual for untreated depression?
Increase in risky behaviours e.g drug/alcohol abuse
Cognitive impairment, poor interactions
Poor work
Poor sleep
Suicidal ideation
What are the risk factors for recurrent unipolar depression?
Hx of frequent and/or multiple episodes
Onset after age of 60
Long duration of individual episodes
Family hx of affective disorder
Poor symptom control during therapy
Co-morbidity with anxiety disorder or substance abuse
What are the drugs that can induce unipolar depression?
Alcohol
Steroids (dexamethasone)
Benzodiazepines e.g diazepam, clonazepam
Antipsychotics
Anticonvulsants e.g carbamazepine, lamotrigine, levetiracetam, pregabalin, topiramate
NSAIDs
CV drugs e.g BBs, CCBs
Caffeine/ withdrawal
Name some examples of emotional symptoms of depression:
Sadness, anxiety, lack of enjoyment, suicidal
Name some examples of cognitive symptoms of depression:
Difficulties in attention and conc
Short/ long term memory loss
Name some examples of physical symptoms of depression:
Fatigue, eating/weight changes, loss of energy
Describe the ICD10 diagnosis of depression:
At least TWO key symptoms, most days, most of the time for at least 2 weeks, minimum 4 symptoms
Describe the DSM IV diagnosis of depression:
At least ONE key symptom, most days most of the time for at least 2 weeks, minimum of 5 symptoms
Name the key symptoms of depression:
Persistent sadness or low mood
Marked loss of interests or pleasure
Lack of energy (ICD10 only)
Name the associated symptoms of depression:
Disturbed sleep (increase or decrease)
Increased/decreased appetite and/or weight
Fatigue or loss of energy
Agitation or slowing of movements
Poor conc or indecisiveness
Feelings of worthlessness/ or excessive guilt
Suicidal thoughts/ acts
Name the 5 grades that NICE (CG90) has subdivided depression into:
Sub-threshold
Mild
Moderate
Severe
Complex
Describe sub-threshold depression:
Where person has few symptoms and feels low, but can still function
Describe mild depression:
Where person has enough symptoms for a diagnosis but can function reasonably well
Describe moderate depression:
Person has a range of symptoms and is not coping well
Describe severe depression:
Where the person has a full set of symptoms, can’t function and may even suffer some psychotic symptoms
Describe complex depression:
Symptoms have failed to improve with treatment and may have psychosis, other symptoms and problems
Name differential diagnosis’ of depression:
BPD
GAD
Drug induced- substance misuse
Schizophrenia or schizoaffective disorder
ADHD
Personality disorders
Normal bereavement
Physical illness e.g hormonal, infection
Dementia
Panic disorder
SAD
Name common co-morbidities of depression:
GAD
Psychosis
Insomnia
OCD
PTSD
Panic disorder
Dementia (esp early onset)
Describe Step 1 in the stepped-care model of depression treatment:
For all suspected presentations of depression
Assessment
Supoort
Psycho-education
Active monitoring
Onward referral for further assessment and intervention
Describe Step 2 in the stepped-care model of depression treatment:
Mild to moderaste depression
Low intensity psychological interventions
Medications (for moderate+) but for mild if past Hx/ other factors
Onward referral
Describe Step 3 in the stepped-care model of depression treatment:
Moderate to severe depression
Medication
High-intensity psychological interventions
Combine treatments
Onward referral
Describe Step 4 in the stepped-care model of depression treatment:
Severe/complex
Medication
ECT
Combined treatment
High intensity
Crisis service
Multiprofessional inpatient care
Describe low intensity psychological interventions:
Guided self help (books)
Being active
Computer/team based CBT
Describe high intensity psychological interventions:
Psychological therapies, CBT
IPT (interpersonal therapies)
General support and advice
ECT (electroconvulsive therapy) for acute severe depression- max 12
TMS (transcranial magnetic stimulation)
Describe the starting dose of antidepressants:
Almost all antidepressants (except mirtazapine) are more tolerable if started at a lower initial dose (half standard) and increased to the target dose over a few days/weeks
What is the starting dose/ exception of mirtazapine?
30mg is less sedating than 15mg OD
What is the specialist combination/augmentation if antidepressants fail?
Can consider lithium, an antipsychotic or another antidepressant
Be aware of increased SE burden and monitoring
What is the first and second line therapy for depression?
1st line SSRIs
TCA are difficult to get to the therapeutic dose due to the wide range of SEs giving poor tolerability
Name the antipsychotics used for depression:
Aripiprazole
Olanzapine
Quetiapine
Risperidone
Name examples of SSRIs first line in depression:
Citalopram
Escitalopram
Sertraline
Fluoxetine
Votioxetine (with cognitive enhancement)
Name examples of SNRIs:
Duloxetine
Venlafaxine
What is the problem with TCA and an outcome?
Toxicity at higher doses and alcohol expect lofepramine
Name examples of TCA first line in depression:
Clomipramine
Lofepramine
Name second line SSRIs for depression:
Fluvoxamine
Paroxetine
Name related antidepressants for second line depression:
Agomelatine
Reboxetine
Trazadone (SSRI with 5HT2 antagonist)
Name second line TCA for depression:
Amitriptyline
Dosulepin
Doxepin
Imipramine
Nortriptyline
Trimipramine
Name irreversible MAO inhibitors second line for depression:
Isocarboxazid
Phenelzine
Tranylcypromine
Name reversible MAO inhibitors second line for depression:
Moclobemide
What are the requirements to avoid when taking irreversible MAOi?
Tyramine free diet
Name the high efficacy and tolerability antidepressants:
Agomelatine
Escitalopram
Vortioxetine
Name high efficacy but decreased tolerability antidepressants:
Amitrptyline
Mirtazapine
Paroxetine
Venlafaxine
Name low efficacy but high tolerability antidepressants:
Citalopram
Fluoxetine
Sertraline
Name low efficacy and tolerability antidepressants:
Fluvoxamine
Reboxetine
Trazodone
Describe the STAR*D approach to treating depression:
Focus on remission not just response
Give pt 4 weeks to start to fully respond
Augmentation may be better if partial or incomplete response
Switching to another SSRI is as effective as other switches
Response decrease with more switches (esp after 2)
Describe the efficacy in relapse prevention of antidepressants:
Relapsed decreased, placebo= 4%, active 18%
Continue antidepressants decreased relapse 70%
Efficacy persists for up to 36 months
The NNT for reapply prevention is 4.3
When should you take most antidepressants and why?
Taken in the morning
During dreaming, serotonin and dopamine need to be completely suppressed for dreaming
Which antidepressants should be taken at night and why?
Mirtazapine- as serotonin repuptake counteracted by 5HT2- a histamine blocker, histamine keeps us awake
Agomelatine is a melatonin receptor agonist and improves sleep
What is the onset of action of antidepressants?
Response is not immediate, can take 2-6 weeks to work (4-6 for optimum effect), although some can see benefit after 1 week
The patient should be seen every 2-4 weeks for the first 3 months, then less frequently if treatment working
What if there is no improvement after 4 weeks of taking an antidepressant?
If no improvement (even minimal) after 4 weeks of therapeutic dose, check adherence then switch to another
If minimal improvement occurs, continue until week 6
What is the onset of action like of an antidepressant in elderly?
Time may need to be increased as response may be slower
What are the cautions when switching to another antidepressant from fluoxetine?
It has a long half life so caution of serotonin syndrome
To a reversible MAOi, taper and stop fluoxetine and wait 5-6 weeks
What should be the cautions when switching to another antidepressant from an irreversible MAOi?
A 2 week washout period is required
What should you review if there is any more than 2 failed ADs?
Need for review of the diagnosing e.g bipolar
What are main antidepressants which can show discontinuation symptoms?
Paroxetine
Venlafaxine
What are the symptoms of serotonin syndrome?
Restlessness
Myoclonus
Tremor and rigidity
Hyperfelxia
Shifting/elevated temp
Arrhythmias
It can be fatal due to cardiac collapse
What medication combinations can cause serotonin syndrome (serotohergic drugs)?
SSRIs
SNRIs
Tramadol
Triptans (not to be used with SSRIs)
How long should antidepressants be used for after the first episode of depression?
As long as needed to decrease relapse
6 months after recovery at same dose
How long should antidepressants be used for after the second episode of depression?
1-2 years may reduce relapse
How long should antidepressants be used for after the third or more episode of depression?
3-5 years of longer
Describe the risk of antidepressants and suicide:
There is a potential increased risk of suicide and self-harm with in the first month of therapy (esp under 21s)
No large studies conducted on this
What are the characteristics of antidepressant discontinuation/ withdrawl phenomena?
Commence within 1-3 days of stopping or decreasing doses
Usually short lived (1-2 weeks)
Are rapidly suppressed by re-intro of drug
Distinct from relapse of recurrence which can occur 2+ weeks after discontinuation
Describe the discontinuation symptoms of SSRIs:
Dizziness, light headedness
Sleep disturbances
Agitation
Electric shocks in the head
Nausea, fatigue, headache
‘Flu-like’ symptoms
Describe the discontinuation symptoms of SNRIs:
Same as SSRIs but also:
Restlessness
Abdominal distension
Congested sinuses
What is the further advise for discontinuing antidepressants?
Avoid stopping while still in the higher relapse risk time period
For less than 8 weeks treatment, withdraw stepwise over 1-2 weeks
After 6-8 months treatment, taper over a 6-8 week period
After long term maintenance treatment, decrease dose by 25% every 4-6 weeks
What are the counselling points for antidepressants?
Start at a lower dose
SEs can be managed e.g nausea, anticholinergic, anxiety, weight, sexual
Antidepressants are not addictive
May start to work in a few days but take 4-6 weeks for full effect
Duration will depend on individual
Reassure about long term use
Name common SEs of SSRIs:
Nausea
Sexual dysfunction
Weight
Name common SEs of TCA:
Anticholingeric
Sedation
Decreased BP
Weight
Sexual dysfunction
Nausea
Name the common SEs of Mirtazapine:
Sedation
Weight
Name common side effects of SNRIs:
Sedation
Decreased BP
Nausea
Sexual dysfunction
Name common SEs of trazodone:
Sedation
Decreased BP
Weight
Sexual dysfunction
Nausea
Name common SEs of MAOi:
Anticholinergic
Decreased BP
Sexual dysfunction
Weight
Name and describe how to overcome anticholinergic SEs:
Blurred vision- don’t drive, usually wears off but if no switch or dose change
Constipation- lifestyle, laxative
Dry mouth- suck boiled sweets, mouth spray
Urinary retention- immediate medical intervention
Name central effects of antidepressants and their treatment:
Anxiety- start low then increase, split doses
Seizures- rare, usually need change or slow
Confusion- rare except TCA, change or slow
Dizziness- dose in evening
Headache- paracetamol
Insomnia- dose in morning
Nausea- with/ after food, split doses, XL
Sedation- don’t drive
Suicidal ideation- immediate
Name other SEs of antidepressants:
Hyponatraemia
Postural hypotension
Palpitations
Sexual dysfunction
Sweating
Weight gain
Describe hyponatrameia as a SE of antidepressants:
Tiredness, confusion, headaches, muscle cramps, fits
Immediate referral to doctor
Higher incidence if started in last months, after dose change or if person is older/ female
Describe sexual dysfunction as a SE of antidepressants:
Libio- probs due to depression rather than AD
Arousal (ED due to NOS inhibition- need PDE5i)
Anorgasmia (due to 5HT2A stim)- time dose when sexual activity is least likely, can omit or delay a dose a week
Which antidepressants are least affected by alcohol?
SSRIs
Venlafaxine
Votioxetine
Noritryptiline
Clomipramie
Which antidepressants give some additive sedation with alcohol?
Mirtazapine
Mianserin
Trazodone
Amitriptyline
Dozepin
TCA- may lower seizure threshold
Describe the interaction of NSAIDs and antidepressants?
SSRIs around 2x increase risk of upper GI bleeds and this is increased to 3 fold by concurrent NSAIDs, but decreases with concurrent PPIs
Duloxetine less of a problem
Describe the interaction of warfarin and antidepressants:
SSRIs significantly increase INR- fluoxetine and paroxetine
Least effect is citalopram and sertraline
Duloxetine
No INR- mirtazapine
Describe the interaction with an SSRI and tamoxifen:
Paroxetine may increase the risk of recurrence of breast cancer
Name medications that can decrease levels of antidepressants:
Smoking decrease (50%) duloxetine levels
St Johns wort
Antiretrovirals, ciclosporin, oral contraceptives, digoxin
Describe the interaction with Fluvoxamine and clozapine:
Increase clozapine levels- CYP1A2inhibition due to toxicity
Describe interactions with anticonvulsants and TCAs:
Carbamazepine decreases TCA (Cyp3A4)
Valproate increases TCA x2
Cannabis- delerium, tachycardia, mania
Describe the prescribing suggestions with antidepressants in children and adolescence:
NICE recommends fluoxetine 1st line, WITH psychological therapies, with sertraline or citalopram as second line
Fluoxetine is the only antidepressant licensed for depression (8-17) if unresponsive to 4-6 sessions of psychological therapies
Sertraline is licensed of OCD in ages 6-17 (but not depression and citalopram SmPC states it should not be used in U18s
Describe the risk of suicide in young people (U20) with antidepressants:
Exclude any possibilities of BPD
Counsel and be sure family is aware of possibility of suicidal ideation, esp if they become agitated
Start slowly e.g fluoxetine 10mg and increase slowly
Describe the use of antidepressants in pregnancy:
Risk of depression (poor bonding or self care) may be higher than the risk of antidepressants
There is some link between SSRIs and the incidence of autism
Paroxetine is best avoided
Most of the other ADs may have some risks but these can usually be manages
Little evidence of any detrimental effect on post natal development
Describe the use of antidepressants in the elderly:
No ideal antidepressant
SSRIs better tolerated than TCA but increase risk of GI bleeds
Increased risk of hyponatreamia, post. hypotension, falls and hemorrhagic stroke with SSRIs
Start low and go slow
Describe the use of antidepressants with cardiac disease:
SSRIs generally recommended
Mirtazapine maybe suitable alternative
SSRIs may protect against MI
Sertraline best choice post MI
CBT may be ineffective post MI, unless depression present pre MI
BB continue use PCI decreases risk of depression
Describe the cardiovascular effect of antidepressants:
Can increase QT interval- esp SSRIs and TCA
Citalopram CI if known QT, meds known to prolong QT and should only be used with caution with electrolyte disturbances and bradycardia- need ECG before
Escitalopram is also CI with QT prolongation, drugs causing QT and should be used with caution in pts at risk of Torsades do Pointes, recent MI, bradyarrthrimis, hypokalaemia, hypo magnesia
Describe the use of antidepressants in renal impairment:
No clear preferrered AD
Greater renal impairment, greater drug accumulation
ADRs such as confusion, post. hypotension and sedation may be more common
Start low and go slow
Care is needed with anticholingeric which may cause urinary retention and interfere with U&E measurements
Describe the use of antidepressants in hepatic impairment:
Start low and go slow, monitor LFTs regularly
More sensitive to common/ predictable SEs
Care needed with drugs with a high first pass clearance
In severe liver disease, avoid drugs causing marked sedation and/or constipation
Paroxetine is used by some specialised liver units
Name some support groups for depression:
Mind
CALM
Samaritains
Name different phobic disorders:
Specific phobia
Social phobia (social anxiety disorder, SAD)
Agoraphobia
Describe the epidemiology of anxiety:
Prevalence 0.9-28.3%
Mean age of onset- depends on type of disorder
GAD around 30
Describe the aetiology of anxiety:
Genetic factors (GAD stronger genetics)- some individuals are resistant and others are vunerable
Environmental (childhood trauma)
Psychological factors
Relationship problems
Unemployment
Social isolation
Co-morbidity
Describe the clinical features of anxiety:
Fearful anticipation
Irritability
Worrying thoughts
Dry mouth
Constriction of chest
Tremor
Headache
Hyperventilation
Name the main treatments for anxiety:
SSRIs (1st)
Benzodiazepines
Antipsychotics
Venlafaxine and duloxetine (GAD)
TCA (panic disorder)
Pregabalin (GAD)
Name benzodiazepines used in anxiety:
Lorazepam
Diazepam
Oxazepam
Clobazam
Name and describe antipsychotics used in anxiety:
SEs, limited evidence
Risperidone
Olanzepine
Quetiapine
Pericyazine
Describe SNRIs for anxiety:
Venlafaxine- at low dose an SSRI
Duloxetine- moderate effectiveness
Name and describe TCAs used in anxiety:
Clomipramine (2nd line OCD)
Imipramine
Name other medications for anxiety:
Mirtazapine
Buspirone (not commonly used)
BB e.g propranolol
Antihistamines e.g promethazine and hydroxyzine
Describe mirtazapine use in anxiety:
Unlicensed, if pt has sleep issues/ depression
Describe buspirone use in anxiety:
Response 4 wks (10mg TDS) +ve no withdrawal
Describe propranolol use in anxiety:
10-40mg TDS
Somatic symptoms
Name SSRIs as a first line treatment for anxiety:
Escitalopram and paroxetine are licensed, other SSRIS likely to have similar efficacy and are widely used
Describe the counselling advise for SSRIs with anxiety:
Response isn’t immediate- 12 weeks
Initial worsening of symptoms common with SSRIs and venlafaxine- start off with low dose and only increase when SEs have decreased
Long term treatment may be required for severe
Stopping suddenly not recommended- discontinue over 4 weeks or longer
What are the monitoring requirements for patients under 30 for SSRIs for anxiety:
Increase suicidal thinking and self harm
Monitor suicide weekly for first month
Describe the dosing regime for SSRIS:
Increase dose every 2 weeks or as tolerated by patient
Short term benzo can help this initial anxiety and should only be used for few weeks
Describe the process for stopping diazepam:
It has a long half life- dose reduction effects not full apparent until about 4 weeks after that dose, leave plenty of time between dose reductions
The last few mg are the hardest to stop, with psychological dependence
Use liquid and then add diluent to bulk liquid
Describe what GAD is:
Where anxiety doesn’t go away (continuous) , lasts for at least 6 months and where the worry os out of proportion to the risk
5% incidence
Describe what Phobic anxiety is:
Intermittent anxiety needing a stimulus
Describe what panic disorder is:
Intermittent- occurrence with anything
Name the major symptoms for the DSM IV diagnosis of GAD:
Need both occurring more days than less for at least 6 months:
-excessive anxiety and worry about a number of events and activities
-difficulty controlling the worry
Name additional symptoms for the DSM IV diagnosis of GAD:
At least 3 out of 6:
-restlessness or feeling on edge
-being easily fatigued
-difficulty conc or mind going blank
-irritability
-muscle tension
-sleep disturbance
Name differential diagnosis’ of GAD:
Depression
Schizophrenia/ dementia as GAD 1st abnormality in these
Substance misuse
Physical illness e.g thyrotoxicosis and hypoglycaemia
Describe step 1 in the stepped care model for anxiety (NICE):
Assess GAD- all presentations
Describe step 2 in the stepped care model for anxiety:
Diagnosed GAD that has not improved after monitoring- low intensity psychological interventions
Describe step 3 in the stepped care model for anxiety:
GAD with inadequate response to step 2 marked functional impairment, choice of high intensity interventions or drug treatment
Describe step 4 in the stepped care model for anxiety:
Complex, refractory GAD- very functional impairment, specialist treatment, inpatient, crisis team
Name and describe the first treatment in the first line therapy for GAD:
SSRIs- fluoxetine/ sertraline- NICE recommends but is off licence
Withdraw after at least 12 months of treatment- for all
Name and describe the second treatment in the first line therapy for GAD:
Venlafaxine
Initially 75mg up to 225mg
Name and describe the third treatment in the first line therapy for GAD:
Pregabalin
Initially 150mg (2-3 divided doses) if required up to 600mg a day
Response time unclear but some effect in a week
Name and describe second line therapy/ short term adjuncts for GAD/ anxiety:
Benzodiazepines
BB- low dose short term
Antihistamines- low dose short term
Anti-psychotics- low dose short term
Venlafaxine/ mirtazapine
Prefab, often seen with SSRI
Busprione
Describe the incidence of OCD:
2-3% onset, usually starts in adolescence
Name and describe the first line treatment for OCD:
SSRI or clomipramine (TCA)
Other ADs seem ineffective
Describe the doses of medications for OCD:
Clomipramine 250-300mg/ day
Fluoxetine 60-80mg/ day
Sertraline 100-200mg/ day
In resistant OCD higher doses may be required
What should the duration for medications for OCD be like?
Max tolerated dose of an SSRI for 3 months
(over 25% response given adequate dose and duration)
Relapse prevention- continue for min 1-2 years
Gradually discontinue over several months
Describe the treatment for social anxiety:
SSRIs (e.g escitalopram) and venlafaxine licensed
Should be for at least 12 weeks
What is the first line treatment for moderate- severe panic disorder?
Self help and CBT should be encouraged
SSRIs first line- escitalopram, sertraline, citalopram, paroxetine and venlafaxine licensed
What is the 2nd line treatment for moderate to severe panic disorder:
Imipramine or clomipramine (unlicensed) if SSRI not suitable or no improvement after 12 week course
NICE do not recommend benzo (only ADs) in panic disorder but in practice may be used in emergency
