Session 7 Flashcards
What are the costs to society of depression?
Care costs: treatment, friends and family care, employer and tax contributions
Productivity costs: lost earnings (patient and family)
Other costs: suicide, care burden, mortality
What did the Layard report recommend?
Choice of psychological therapy
Easy access to self help
More psychiatrists and CBT therapists
GPs to have 6 months psychiatric training
What is step 1 of the stepped care model?
Recognition of possible depression by GP/practice nurse
May present with physical symptoms
May be picked on on screening
When is screening for depression recommended and what are the 2 questions?
Past history of depression
Significant (disabling) illness
Other mental health problems e.g dementia
Whooley questions:
- Over the past month, have you been bothered by feeling down, depressed or hopeless?
- Over the last month, have you been bothered by having little interest or pleasure in doing things?
What is step 2 of the stepped car model?
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
What is step 3 of the stepped care model?
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
What is recommended if presenting with severe depression initially?
Combination of antidepressants and CBT
What is step 4 of the stepped care model?
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)
What is step 5 of the stepped care model?
(Now combined with step 4)
Inpatient care
Severe risk to life
Medications, combined therapy, ECT
Mechanism of action of SSRIs?
Block reuptake of serotonin into presynaptic neurones, increasing the amount in the synaptic cleft
Examples of SSRIs (6)
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
SSRIs side effects?
Nausea Sexual dysfunction Abdominal pain Insomnia Drowsiness Headaches Weight change Hypotension Increased risk of bleeding with NSAIDs
Mechanism of TCAs?
Block reuptake of noradrenaline and serotonin into presynaptic neurones
Examples of TCAs? (4)
Amitriptyline Dosulepin Doxepin Imipramine Lofepramine (safest in overdose) Trimipramine
Site effects of TCAs?
Cardiogenic toxicity (arrhythmias, heart block) Dry mouth Drowsiness Sleep problems Urinary retention/ constipation
Mechanism of action of MAOIs?
Irreversibly inhibit action of monoamines oxidase
Prevents break down of serotonin & NA in brain
Examples of MAOIs? (2)
Phenelzine
Trancylpromine
Side effects of MAOIs?
Weight gain Sleep problems Nausea Constipation Hypotension Hypertensive attack with interactions (cheese! broad beans! marmite! cough syrup! red wine)
Mechanism of action of SNRIs?
Inhibit reuptake of serotonin and noradrenaline
Examples of SNRIs? (2)
Venlafaxine (increases cardiac arrhythmias)
Duloxetine
Side effects of SNRIs?
Nausea sexual dysfunction sleep problems Constipation Hypertension
Mechanism of action of NaSSAs?
Noradrenaline and specific serotonergic agent
Antagonises alpha2-adrenergic receptors and certain serotonin receptors - increases NA and serotonin neurotransmission
Example of NaSSAs?
Mirtazepine
Side effects of NaSSAs?
Reduced compared to SSRIs due to only targeting specific serotonin receptors
Drowsiness
Weight gain
Mechanism of agomelatine?
Specific agonist of melatonin receptors and 5-HT antagonist
Example of serotonin antagonist and reuptake inhibitor?
Trazadone
Can cause drowsiness
Example of noradrenaline reuptake inhibitor?
Reboxetine
Can cause dry mouth
Contraindications for antidepressant use?
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)
What are some prescribing issues?
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
Epidemiology of depression
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
