Treatment of Affective Disorder Flashcards
Why do Ps not always tell you the they are depressed?
Still lots of stigma surrounding mental health
When should you screen for depression?
Past Hx of depression
Significant physical illness
Risk of depression is significant - childbirth, postnatal, elderly, social isolation
Unexplained physical symptoms
What do we do for all Ps with depression?
Psychoeducation
Sleep hygiene advice
Actively monitor them
How do we treat mild-moderate depression?
Psychosocial and psychological interventions
How do we treat mild-moderate depression that does not respond to Rx?
Antidepressants + high intensity psychology
How do we treat severe or v severe depression?
Antidepressants
High intensity psychology
Specialist referral - crisis team - admission
What do we do for Ps in severe depression with high suicidal risk?
Urgent specialist referral + admission (detain if necessary)
Consider ECT
Antipsychotic medication if needed
What is psychoeducation?
Talking to P about their difficulties and trying to find ways to improve day-to-day things which will help - inc. relationships, exercise, die, and sleep
What are low intensity psychological interventions for depression?
Computerised CBT
Self help books
Group CBT
What are high intensity psychological interventions for depression?
Individual CBT
Other individual therapies
How does CBT work’?
Explores cognition behind the behaviour - collaborates with the P and gets P to complete tasks in order to better understand their behaviour and beliefs and change them
What do most antidepressants work on?
Monoamine neurotransmission - act to increase the amount of NT at the synapse
What are the monoamines involved in mood?
Serotonin
Noradrenaline
Dopamine
Why is it thought that antidepressants take so long to work?
Believed to be due to alterations in gene expression (down-regulation of receptors) and promotion of neurogenesis (in which monoamines may play a role)
Which parts of the brain are thought to have improved neurogenesis by increased monoamines?
Hippocampus
Prefrontal cortex
What is the response rate for Ps on antidepressants?
50% (compared to 30% on placebo)
How long do you have to continue antidepressants for? Why?
6 months
High rate of relapse if stopped before then
What do response rates for antidepressants tells us?
That we need to also have psychosocial and psychological treatments in connection with antidepressants
Name 5 antidepressant drug classes
SSRIs
SNRIs
TCAs
MAOIs
Monoamine receptor antagonists
Which is the first line antidepressant drug that we use?
SSRIs
How do SSRIs work?
Increase the amount of serotonin in the synapse by blocking its reuptake
What are the common side effects of SSRIs?
Nausea
Loss of appetite
Sexual dysfunction
Insomnia
Agitation
Anxiety
Headaches
What do you need to be careful about with SSRIs?
Can cause hyponatremia - be careful in older Ps or those with low Na.
Use with NSAIDs can increase chances of GI bleeds - need to prescribe PPI as well
What side effects to SNRIs have?
Similar to SSRIs
What do you need to be careful about with prescribing SNRIs?
Hypertension - SNRIs can cause an increase in BP
Are toxic in overdose
How do TCAs work?
Block monoamine reuptake - inc levels of serotonin and Nor in the cleft (and slightly more dopamine)
What are the problems with TCAs?
Adverse effects - are toxic in overdose - have interactions with there medications
Can have cardiotoxic effects
What are TCAs sometimes used for?
Neuropathic pain
What are the side effects of TCAs?
Sedation
Confusion
Loss of motor coordination
Anticholinergic effects
Cardiotoxicity
What are anticholinergic effects?
Dry mouth
Blurred vision
Constipation
Urinary retention
How do MAOIs work?
Inhibit monoamine oxidase from breaking down MAs in the cleft - thus increasing levels of 5HT, NOR & Dopa
What is the cheese reaction?
Tyramine in cheese is normally metabolised by MAO in gut - MAOIs block this - can cause sympathomimetic effects, hypertensive crisis & intercranial haemorrhage
What is it important to remember about MAOIs?
They cannot be prescribed with other antidepressants - is potential for interactions with them
Why is it important to engage with active monitoring when first prescribing SSRIs and SNRIs?
Is evidence for increased suicidal thoughts and acts - esp in children, adolescents and young adults.
What do you need to beware of when prescribing antidepressants, especially to older Ps?
Hyponatremia
What can hyponatremia cause?
Delirium, seizures & death
What are the withdrawal symptoms of antidepressants?
Diziness
Anxiety
Insomina & vivid reams
General malaise
Irritability
Headache
Electric shocks in arms and legs
Low mood, suicidal thoughts
Agitation
Does the fact that antidepressants have withdrawal symptoms mean they are addictive?
No - is the act there is a temporary deficiency of synaptic serotonin due to down-regulated receptors which need time to adjust.
How do you reduce antidepressants?
25% every 2-4 weeks
What is lithium used for?
As an add on to antidepressants when they dont work.
What do you need to be aware of with lithium?
Has a narrow therapeutic window - monitoring required.
Can also have drug interactions
What are the early side effects of lithium?
Polyuria, tremor, dry mouth, metallic taste, weakness & fatigue
What are the late side effects of lithium?
Tremor, nephrogenic diabetes insipidus, goitre, hypothyroidism, weight gain, GI symptoms, sedation, ECG changes, CKD
How often should you monitor lithium?
Frequently whilst establishing correct dose - then 6 monthly.
What should you check when P is on lithium?
Lithium level, renal function (U&E, eGFR), thyroid function tests
When is ECT used?
Severe depression when life is threatened AND there is a lack of response to the treatments
What is the general approach to managing bipolar disorder?
Treat acute mood episodes (e.g. depression or mania)
Maintain treatment to promote mood stability
Aim to prevent relapse
Why is it important to treat acute mania?
High death rate in mania
What do we do for manic Ps?
Stop antidepressants. If not on treatment - use antipsychotic. If on treatment - check compliance and considering adding/changing antipsychotic.
Which drug can be used as an adjunctive treatment for bipolar disorder? Why?
Benzodiazepines
Reduce overactivity, restore sleep
Which treatment is first line for maintenance treatment of bipolar disorder?
Lithium
Which drug is most commonly used as an anticonvulsant in bipolar disorder?
Sodium valporate
What is the downside of using lithium and anticonvulsants in treating mania in bipolar disorder?
They are slower acting than antipsychotics
What pharmacological treatments are used in bipolar disorder?
Lithium
Anticonvulsants (sodium valproate)
Antipsychotics
How is depression managed in bipolar disorder?
In a similar way to unipolar depression -
- Psychological & Psychosocial
- Antidepressants - often combined with mood stabiliser (lithium, valproate, antipsychotics)
When treating depression in bipolar depression, what do you need to be aware of?
Risk of manic switch - can tip P into hypomania / manic state
Which drug is first line for treating the MANIA of bipolar disorder?
Antipsychotics
Manic Ps need urgent treatment
How do we treat depressive episodes of bipolar?
Same as unipolar
Careful not to tip into mania
Antidepressant + mood stabiliser (lithium/valporate/antipsychotic)
What is the MAINTENANCE treatment for bipolar to prevent further episodes?
Lithium first line
Sodium valproate second line
Antipsychotics
Prevent relapse - needs multidisciplinary support
Name 2 drugs which are being consider for future treatment of depressive disorders.
Ketamine (NMDA blocker - rapid antidepressant)
Psilocybin (5HT agonist)
