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Year 4 - Mental Health > Psych - Depression & Suicide Risk > Flashcards

Psych - Depression & Suicide Risk Flashcards

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1
Q

How long does it typically take for antidepressants to reach therapeutic dose?

A

~ 3-6 weeks

Thus if not therapeutic effect at ~ 2 months then:

  • Change dose
  • Switch to different antidepressant
  • Augment with another agent
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2
Q

All antidepressants have a similar response rate - what is this %?

A

~67% of pts respond to an antidepressant after 8 weeks (expect some benfit from 2 weeks onwards)

33% = non responders

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3
Q

What is the MoA of TCAs?

A
  1. Serotonin reuptake inhibition (SERT anatgonism)
  2. Noradrenaline reuptake inhibition (NET anatagonism)
  3. SHAM receptor antagonism:
    1. S = serotonin (5HT receptors)
    2. H = histamine receptors
    3. A = alpha adrenergic receptors
    4. M = muscarinic acetycholine receptors
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4
Q

What are some side effects of TCAs?

A
  • Histamine - R antagonism:
    • Sedation
    • Weight gain
  • Alpha adrenergic-R antagonism:
    • Drowsiness
    • Orthostatic hypotension
    • Reflex tachycardia
    • Erectile dysfunction
  • Muscarinic ACh-R antagonism:
    • Blurred vision
    • Glaucoma
    • Dry mouth (↓ saliva i.e. xerostomia)
    • Urinary retension
    • Constipation
    • Cognitive impairment
  • ↓ seizure threshold
  • Cardiotoxic:
    • Prolong QT interval
      • Arrhythmias
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5
Q

What are the differences between secondary and tertiary TCA’s?

A
  • Secondary:
    • Act primarily on noradrenaline reuptake inhibition
    • Same side effects as teritary TCAs but less severe
    • E.g. desipramine, nortriptyline
  • Tertiary:
    • Act primarily on serotonin reuptake inhibition
    • Side effects = many
    • E.g. amytriptyline, doxepin, clomipramine
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6
Q

What are TCAs used to treat?

A
  1. MDD (major depressive disorder) –> not often!! other antidepressants are more commonly used due to TCAs side effects + toxicity in OD
  2. Neuropathic pain
  3. Migraine prophylaxis (amitriptyline)
  4. Chronic tension-type headache prophylaxis (amitriptyline)
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7
Q

List some conditions that SSRIs are used to treat?

A
  1. MDD
  2. GAD
  3. OCD
  4. Eating disorders e.g. Bulimia nervosa
  5. Panic disorder
  6. PTSD
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8
Q

Which SSRI is safest to use post MI?

A

Sertraline

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9
Q

Which SSRI is safest to use in children and adolescents?

A

Fluoxetine

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10
Q

What are some common side effects of SSRIs?

A

Side-effects:

  • GI disturbance (most common) - pain, diarrhoea, vomiting
  • Sexual dysfunction (30%)
  • Anxiety + agitation - pts counselled to watch for
  • Dry mouth
  • Hyponatraemia
  • Restlessness
  • Nervousness
  • Insomnia
  • Fatigue / sedation
  • Dizziness
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11
Q

What drug should be prescribed alongside an SSRI and why?

A

A PPI (proton pump inhibitor)

e. g. omeprazole, lansoprazole
* Because GI disturbance is the most common side effect of SSRIs

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12
Q

What are common drug interactions for SSRIs?

A
  1. NSAIDs e.g. aspirin
    • (NICE: do not prescribe, but if you do, also give a PPI)
  2. Warfarin / heparin
    • NICE: avoid and consider mirtazapine
  3. Triptans (avoid)
  4. MAO-inhibitors
    • risk of serotonin syndrome (excess serotonins impact on the CNS)
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13
Q

What is and what causes serotonin syndrome?

A

Serotonin syndrome is the result of excess serotonin acting on the CNS

Cause = serotonin increasing drug OD or combination

  • SSRIs
  • SNRIs
  • MAOI
  • TCAs
  • Ecstasy (MDMA)
  • Amphetamines
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14
Q

What are the features of serotonin syndrome?

How is serotonin syndrome managed?

A

Features:

  • Rapid onset (min-hours of serotonin ↑)
  • Neuromuscular excitation e.g. hyperreflexia, myoclonus, rigidity, tremor
  • Autonomic NS excitation e.g. hyperthermia, sweating, dilated pupils, ↑ HR, HTN, diarrhoea
  • Altered mental state, agitation / irritability
  • Complications: seizures + rhabdomyolysis

Management:

  • Discontinue offending medications that ↑ serotonin
  • Supportative e.g. IV fluids, active cooling
  • Benzodiazepines (↓ agitation)
  • Severe cases = serotonin antagonist e.g. chlorpromazine or cyproheptadine
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15
Q

For how long should a pt continue to take an antidepressant after remission is induced?

A

6 months

This reduces the risk of relapse into depression

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16
Q

What are the risks of stopping antidepressant medication too fast?

A

Discontinuation symptoms!!

  • ↑ mood change
  • Dysphoria (generalized dissatisfaction with life)
  • Restlessness
  • Difficulty sleeping
  • Unsteadiness
  • Paraesthesia
  • Sweating
  • GI symptoms: pain, cramping, diarrhoea, vomiting
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17
Q

Name some of the pros and cons of the following SSRIs

(think about: half life, P450, sedation, side-effects - mainly just study the table on otherside)

  • Fluoxetine
  • Sertraline
  • Citalopram
  • Escitalopram
  • Paroxetine
A
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18
Q

How should stopping treatment with SSRIs be done?

Is this different for any SSRIs specifically?

A

SSRI dose ↓ gradually over 4 weeks (varies for each pt)

  • Fluoxetine = reduction / cessation can occur faster with fluoxetine as it has a long half-life –> thus ↓ likelihood of withdrawal symptoms
  • Paroxetine = ↑ incidence of discontinuation symptoms
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19
Q

What conditions are SNRIs used to treat?

Name 2 examples of SNRIs.

A

Conditions:

  1. MDD
  2. GAD
  3. Social anxiety disorder (venlafaxine)
  4. Panic disorder
  5. Menopausal symptoms (venlafaxine)
  6. Diabetic neuropathy (duloxetine)

Examples:

Venlafaxine and Duloxetine

20
Q

What are the pros and cons of Venlafaxine vs Duloxetine?

A
21
Q

How do MAO inhibitors work?

A

Bind to and inhibit monoamine oxidase –> thus preventing inactivation of biogenic amines e.g.

  1. noradrenaline
  2. dopamine
  3. serotonin
22
Q

What are common side effects of MAO-inhibitors?

A
  • Orthostatic hypotension
  • Sexual dysfunction
  • Weight gain
  • Sedation
  • Dry mouth
  • Sleep disturbance
23
Q

What are the 3 main classes of ‘Mood-stabilisers’?

A
  1. Lithium - class of its own
  2. Anticonvulsants e.g.
    • sodium valproate (Depakote)
    • lamotrigine
    • carbamazepine
  3. Atypical antipsychotics e.g.
    • olanzapine
    • risperidone
    • quetiapine
    • aripiprazole
24
Q

Name 5 things that Lithium is liscened for treatment of?

A
  1. Schizoaffective disorder
    • i.e. abnormal thought process + abnormal mood - pt has symptoms of schizophrenia + mood disorder (bipolar or depression) but doesn’t meet criteria for either individually
  2. Bipolar disorder (prophylaxis)
  3. Recurrent unipolar depression (prophylaxis)
  4. Aggressive or self-harming behaviour (prophylaxis)
  5. Impulse control
25
Q

What is bipolar disorder (BPD)?

What are the types of BPD?

A

BPD = chronic mental health condition characterised by periods of mania/hypomania + episodes of depression

Types:

  • Type I disorder = mania + depression (most common)
  • Type II disorder = hypomania + depression
26
Q

What is the difference between mania and hypomania?

A

Mania:

  • Severe functional impairment or psychotic symptoms for > 7 days
    • ​E.g. delusions or hallucinations

Hypomania:

  • Decreased or increased function for > 4 days
  • No psychosis
27
Q

What tests need to be done prior to starting Lithium?

A
  • Baseline:
    • FBC, U+Es, TFTs
    • Weight + BMI
    • ECG
  • Pregnancy check:
    • Lithium is teratogenic in 1st trimester
    • Associated with Ebstein’s anomaly (tricuspid valve positioned lower - large R atria and small R ventricle = tricuspid incompetence or Wolff-Parkinson White syndrome)
28
Q

How is a pt on Lithium monitored?

A
  1. Check blood lithium conc after 5 days then …
  2. Lithium blood conc measured weekly after initiation + dose changes, until conc stable
    • Blood taken ~12hrs after most recent dose (tough level)
  3. Once lithium level is stable for 4 weeks - check 3 monthly
  4. Physical monitoring e.g. thyroid (TFTs), kidneys (U+Es, creatinine, eGFR) - check 6 monthly

Monitoring of Lithium is IMPORTANT due to narrow therapeutic range

0.4 - 1.0 mmol/L

It has a LONG half-life + excreted mainly via kidneys (hence kidney function is important)

29
Q

Side effects of Lithium are broken down into:

  1. Short / medium term
  2. Long term

What are some of the side effects?

A

Short / medium:

  • GI dysfunction (most common) e.g. ↓ appetite, nausea, vomiting, diarrhoea
  • Fine tremor
  • Polydipsia
  • Polyuria (2ndary to ADH antagonism)
  • Hair loss, acne

Long term:

  • CKD (20-40%)
  • Clinical / subclinical hypothyroidism (35%)
  • Hyperparathyroidism (+ resultant hypercalcaemia)
  • Euthyroid goitre
  • Nephrogenic diabetes insipidus
  • Cardiac arrhythmias (T-wave flattening/inversion)
  • Leucocytosis
  • ↓ seizure threshold
  • Weight gain
  • Cognitive slowing
30
Q

Lithium toxicity occurs above what blood conc?

What can precipitate Lithium toxicity?

What symptoms does Lithium toxicity present with?

A

Lithium toxicity is > 1.5 mmol/L

Precipitate Lithium toxicity:

  • Dehydration
  • Renal failure
  • Drugs: diuretics (mainly thiazide), ACE-i, ARBs, NSAIDs and metronidazole

Features of toxicity:

  • Mild (> 1.5): coarse tremor, hyperreflexia, vomiting, diarrhoea, ataxia, slurred speech
  • Moderate (> 2.0: blurred vision, delirium, syncope, convulsions
  • Severe (> 2.5): generalised seizure, oliguria, renal failure, coma
31
Q

How does sodium valproate compare to Lithium in terms of:

  1. Prophylactic treatment of mania
  2. Prophylactic treatment of depression
  3. Side effects
  4. Monitoring
  5. Pregnancy
A

Sodium valproate (Depakote)

  1. As effective as lithium in mania prophylaxis
  2. Not as effective as lithium in depression prophylaxis
  3. Better tolerated than lithium
  4. Less monitoring than lithium (FBC + LFTs only)
  5. Contraindicated for women of child-bearing age (teratogenic)
32
Q

What are some common side effects of sodium valproate (Depakote)?

A
  • Nausea, vomiting
  • Weight gain
  • Sedation
  • Tremor
  • Hair loss
  • Deranged LFTs
  • Thrombocytopenia / platelet dysfunction
  • ↑ risk of neural tube defect (due to ↓ folic acid)
33
Q

What 2 questions are asked to ‘screen’ pts for depression?

A
  1. During the last month, have you often been bothered by feeling down, depressed or hopeless?
  2. During the last month, have you often been bothered by having little interest or pleasure in doing things?

If ‘Yes’ to either question then a ‘mental health exam’ should be conducted by a competent practitioner.

34
Q

What are the ICD-10 criteria for ‘Depressive disorder’?

A

Over a 2-week period:

Key symptoms (must have at least 2):

  1. Persistent ↓ mood
  2. Anhedonia
  3. Fatigue or ↓ energy

If any of the above then ask about:

  1. Sleep disturbance (EMW 2hrs before norm, difficulty falling asleep)
  2. ↓ appetite (belt loose, down a dress size)
  3. Poor concentration or indecisiveness
  4. Low confidence or low self-esteem
  5. Guilt or self-blame
  6. Agitation or slowing of movement (psychomotor retardation)
  7. Suicidal thoughts or acts
35
Q

How is depression severity grade based on no. of ICD-10 symptoms?

A
  • Mild = 2 core + 2 additional (4)
  • Moderate = 2 core + 3/4 additional (5/6)
  • Severe = 3 core + 5/6 additional (8/9)
36
Q

How are mania and hypomania defined (DSM-5)?

A

Hypomania:

  • Period of abnormally + persistently elevated, expansive, or irritable mood AND
  • abnormally and persistently ↑ activity or energy …
  • lasting at least 4 consecutive days and present most of the day, nearly every day
  • Episode NOT severe enough to cause impariment in social / occupational function or need hospitalization

Mania:

  • Period of abnormally + persistently elevated, expansive, or irritable mood AND
  • abnormally and persistently ↑ activity or energy …
  • lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is needed)
  • Episode IS severe enough to cause impariment in social / occupational function or need hospitalization
37
Q

What features of hypomania / mania might a pt have?

Think: DIGS FAST

A
  • Inflated self-esteem or grandiosity
  • ↓ need for sleep
  • ↑ talking
  • Flight of ideas / feel thoughts are racing
  • Distractibility
  • ↑ in goal-directed acitvity
  • Poor judgement - ↑ involvement in activities which could have painful consequences (e.g. spending sprees, sexual indescretion, foolish business investments)

All these are summarised as:

Mania = DIGS FAST = Distractibility, Irresponsibility, Grandiosity, Sexual hyperactivity, Flight of ideas, Activity increase, Sleep deficit, Talkativeness

38
Q

For the following split them into whether they convey a high or low risk of suicide:

  • Unemployed
  • Age < 45 years
  • Female
  • Male
  • Employed
  • Age > 45 years
  • Substance misuse
  • FHx of depression, substance misuse or suicide
  • Physical illness
A

Higher risk:

  • Unemployed
  • Age > 45 years
  • Male
  • Substance misuse
  • FHx of depression, substance misuse or suicide
  • Physical illness

Lower risk:

  • Age < 45 years
  • Female
  • Employed
39
Q

Mrs Banerjee has recently recovered from a major depressive episode on duloxetine 60mg orally daily. This was her third major depressive episode in the past four years. What is the best management advice to reduce her risk of relapse?

  • Remain on the current dose for 6-9 months, then taper and stop
  • Remain on the current dose for a year, then taper and stop
  • Remain on the current dose for a year, then reduce the dose by 50%
  • Remain on the current dose for at least 2 years, then reduce the dose by 50%
  • Remain on the current dose for at least 2 years, and potentially long-term
A

Remain on the current dose for at least 2 years, and potentially long-term

  • In high risk patients (e.g. > 5 lifetime episodes and/or 2 episodes in the last few years) at least 2 years at the dose needed to get them well should be advised and long-term treatment should be considered for most
40
Q

For each severity of depression, how is it treated?

  • Mild
  • Moderate
  • Severe
A

Mild:

  • Sleep hygiene:
    • Regular sleep/wake times
    • Avoid excess eating, smoking or drinking before sleep
    • Good environment for sleep
    • Regular physical exercise
  • Low-intensity psychosocial interventions - forms include; individual guided-self help (6-8 sessions face-to-face or phone), group-based CBT, computer CBT
  • Information on depression

Moderate:

  • Antidepressant (norm a SSRI and swap to another SSRI if response to 1st is inadequate)
  • Lithium - consider for augmentation of antidepressant if pt is willing to tolerate increased side-effects
  • CBT or IPT (interpersonal therapy) 16-20 sessions over 3-4 months OR counselling

Severe:

  • Higher initial dose antidepressant
  • Antipsychotic (is psychosis present)
  • ECT - consider for severe, life-threatening depression, where rapid treatment is required or other treatments have failed
41
Q

What conditions can mimic depression?

A
  • Endocrine:
    • Addison’s disease
    • Hypothyroidism
  • Cardiovascular:
    • Congestive heart failure
    • Infarct
  • Nutritional:
    • Thiamine deficiency
    • Vit B12 and folate deficiency
  • Metabolic:
    • Hypoglycaemia
    • Hypercalcaemia (delirium)
    • Anaemia
  • Infectious:
    • HIV
    • Encephalitis
    • Post-viral states
    • Lyme disease
  • Neurological:
    • Parkinson’s
    • Huntington’s
    • Stroke
    • Temporal lobe epilepsy
  • Neoplasm:
    • Pancreatic
    • Brain
    • Systemic
  • Drugs:
    • Steroids
    • Propranolol
    • Parkinson’s drugs e.g. levodopa
    • Methyldopa (HTN med - can have parkinsonian side effects + depression)
  • Substance abuse:
    • Alcohol
    • Cocaine
    • Opiates
  • Miscellaneous:
    • Wilson’s disease
42
Q

How is an episode of hypomania / mania managed (5 steps)?

A
  1. Consider stopping antidepressant
  2. Antipsychotic (if not taking an antipsychotic or mood stabiliser) one of:
    • Haloperidol
    • Olanzapine
    • Quetiapine
    • Risperidone
  3. Try another antipsychotic from list above - if antipsychotic is not tolerated or not effective
  4. Consider adding Lithium - if 2nd antipsychotic is not effective at therapeutic dose
  5. Sodium Valproate - if lithium + antipsychotic is ineffective or lithium is not suitable
    • DO NOT USE in women of childbearing age

Note: DO NOT offer lamotrigine for mania (anticonvulsant sometimes used in bipolar)

43
Q

How is an episode of bipolar depression managed?

A

If not currently on any medication for bipolar disorder:

  1. Offer:
    1. Fluoxetine + Olanzapine (if person prefers, consider olanzapine alone)
    2. Quetiapine alone
  2. Lamotrigine alone - if no respone to fluoxetine + olanzapine or quetiapine alone
44
Q

A 28-year old man present to his GP complaining that he cannot organism during sex with his partner. He did not have this porblem before starting treatment for depression 6 weeks previously. Select the precription ‘most likely’ to cause this?

  • Moclobemide 450mg PO daily
  • Mirtazapine 30 mg PO daily
  • Vortioxetine 15 mg PO daily
  • Sertraline 150mg PO daily
  • Agomelatine 50 mg PO at bed
A

Sertraline 150mg PO daily

  • Moclobemide = MAO (somes studies indicate it actually ↑ libido)
  • Mirtazepine = TeCA / NaSSA - less likely to cause sexual dysfunction than other SSRIs
  • Vortioxetine = new antidepressant (SSRI + serotonin modulator) low incidence of sexual dysfunction
  • Agomelatine = new antidepressant (SSRI + serotonin modulator) low incidence of sexual dysfunction
45
Q

A 32-year old woman has recently started Lithium carbnonate (Priadel) 800mg orally at bedtime for bipolar disorder. Her 12-hour post-dose serum Lithium level is 0.7 mmol/L.

Select the adverse effect that is most likely to be caused by lithium.

  • Urinary retention
  • Hyperthyroidism
  • Muscle twitching
  • Hypersalivation
  • Tremor
A

Tremor

  • No urinary retention but polyuria
  • Euthyroid goitre or hypothyroid not hyperthyroid
  • Muscle twitching (myoclonus) does occur but not as common as tremor
  • Hypersalivation is with clozapine

Year 4 - Mental Health (6 decks)

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