Session 7

Question 1

What are the costs to society of depression?

Answer 1

Care costs: treatment, friends and family care, employer and tax contributions

Productivity costs: lost earnings (patient and family)

Other costs: suicide, care burden, mortality

Question 2

What did the Layard report recommend?

Answer 2

Choice of psychological therapy
Easy access to self help
More psychiatrists and CBT therapists
GPs to have 6 months psychiatric training

Question 3

What is step 1 of the stepped care model?

Answer 3

Recognition of possible depression by GP/practice nurse
May present with physical symptoms
May be picked on on screening

Question 4

When is screening for depression recommended and what are the 2 questions?

Answer 4

Past history of depression
Significant (disabling) illness
Other mental health problems e.g dementia

Whooley questions:

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

Question 5

What is step 2 of the stepped car model?

Answer 5

Presenting with mild depression in primary care

Watchful waiting, sleep and anxiety management, guided self help
Computerised CBT (x8 1hour weekly sessions, reports to GP)
Brief psychological interventions (problem solving, brief CBT)

Antidepressants NOT recommended unless other interventions have failed or history of moderate/severe depression

Question 6

What is step 3 of the stepped care model?

Answer 6

Moderate-severe depression, dealt with in primary care
SSRIs treatment of choice (citalopram/fluoxetine) - consider alternate if no response in 1 month
CBT psych treatment if choice (16-20 sessions over 6-9 months), 2 sessions per week for severe

Question 7

What is recommended if presenting with severe depression initially?

Answer 7

Combination of antidepressants and CBT

Question 8

What is step 4 of the stepped care model?

Answer 8

Dealt with by mental health specialist or crisis team
Treatment resistant depression (combination antidepressants wit CBT, lithium augmentation, venlafaxine, augmentation with another antidepressant)

Recurrent and relapse prevention (continue antidepressants for 2 years, CBT and mindfulness maintenance sessions)

Question 9

What is step 5 of the stepped care model?

Answer 9

(Now combined with step 4)

Inpatient care
Severe risk to life
Medications, combined therapy, ECT

Question 10

Mechanism of action of SSRIs?

Answer 10

Block reuptake of serotonin into presynaptic neurones, increasing the amount in the synaptic cleft

Question 11

Examples of SSRIs (6)

Answer 11

Citalopram (fewer discontinuation Sx’s, dose restriction due to QT prolongation
Escitalopram (dose restriction due to QT prolongation)
Fluoxetine
Paroxetine
Sertraline (give if cardiac problems)
Fluvoxamine

Question 12

SSRIs side effects?

Answer 12

Nausea
Sexual dysfunction
Abdominal pain
Insomnia
Drowsiness
Headaches
Weight change
Hypotension
Increased risk of bleeding with NSAIDs

Question 13

Mechanism of TCAs?

Answer 13

Block reuptake of noradrenaline and serotonin into presynaptic neurones

Question 14

Examples of TCAs? (4)

Answer 14

Amitriptyline 
Dosulepin
Doxepin
Imipramine
Lofepramine (safest in overdose)
Trimipramine

Question 15

Site effects of TCAs?

Answer 15

Cardiogenic toxicity (arrhythmias, heart block)
Dry mouth
Drowsiness
Sleep problems
Urinary retention/ constipation

Question 16

Mechanism of action of MAOIs?

Answer 16

Irreversibly inhibit action of monoamines oxidase

Prevents break down of serotonin & NA in brain

Question 17

Examples of MAOIs? (2)

Answer 17

Phenelzine

Trancylpromine

Question 18

Side effects of MAOIs?

Answer 18

Weight gain
Sleep problems
Nausea
Constipation
Hypotension
Hypertensive attack with interactions (cheese! broad beans! marmite! cough syrup! red wine)

Question 19

Mechanism of action of SNRIs?

Answer 19

Inhibit reuptake of serotonin and noradrenaline

Question 20

Examples of SNRIs? (2)

Answer 20

Venlafaxine (increases cardiac arrhythmias)

Duloxetine

Question 21

Side effects of SNRIs?

Answer 21

Nausea
sexual dysfunction
sleep problems
Constipation
Hypertension

Question 22

Mechanism of action of NaSSAs?

Answer 22

Noradrenaline and specific serotonergic agent

Antagonises alpha2-adrenergic receptors and certain serotonin receptors - increases NA and serotonin neurotransmission

Question 23

Example of NaSSAs?

Answer 23

Mirtazepine

Question 24

Side effects of NaSSAs?

Answer 24

Reduced compared to SSRIs due to only targeting specific serotonin receptors
Drowsiness
Weight gain

Question 25

Mechanism of agomelatine?

Answer 25

Specific agonist of melatonin receptors and 5-HT antagonist

Question 26

Example of serotonin antagonist and reuptake inhibitor?

Answer 26

Trazadone

Can cause drowsiness

Question 27

Example of noradrenaline reuptake inhibitor?

Answer 27

Reboxetine

Can cause dry mouth

Question 28

Contraindications for antidepressant use?

Answer 28

Cardiac disease (TCAs avoided, SSRIs first choice)

Hepatic impairment (use low starting dose, leave longer intervals between doses, citalopram best)

Renal impairment (start with low dose and increase slowly)

Question 29

What are some prescribing issues?

Answer 29

Need to allow 6 weeks good compliance before considering dose change (take about 4 weeks for full effect)

Change to another antidepressant if adverse effects intolerable

St Johns wort not recommended

Question 30

Epidemiology of depression

Answer 30

Women: 4-10% suffering at any one time, 10-26% lifetime risk
Men: 2-3.5% suffering at any one time, 5-12% lifetime risk