Treatment of Mood Disorders Flashcards
When should antidepressants be considered for a patient with depressive symptoms?
Moderate or severe depression
Mild depression that has not responded to lifestyle measures/low intensity psychosocial intervention
Mild depression with a history of moderate/severe depression
What is the first line management for depression?
If mild/moderate: An antidepressant (normally an SSRI) OR High intensity psychological intervention: - CBT - IPT (interpersonal therapy)
If moderate/severe:
–> combine above treatments
Which factors should be taken into account when choosing an antidepressant?
Anticipated side effects
Potential interactions with other medications or physical illness
Previous antidepressants tried by the patients and their efficacy
How should a patient be monitored when starting an antidepressant?
If not at risk of suicide:
- check up two weeks after starting
If increased risk of suicide or < 30 years old:
- check up after 1 week
What should be considered if an antidepressant isn’t working?
Compliance Is the diagnosis correct? Substance misuse Physical illness Address other predisposing, precipitating and prolonging factors
How long should an antidepressant be taken with no improvement, before you consider increasing the dose or swapping to another drug?
4-6 weeks
What can be done if an antidepressant isn’t working?
Increase dose
Swap
Combine - most commonly SSRI/SNRI plus mirtazapine
How long should a patient take an antidepressant for in order to prevent relapse?
If first episode –> at least 6 months after full recovery without reducing dose
If second episode or more –> at least 1-2 years after full recovery without reducing dose
Some may require lifelong treatment
Which neurotransmitters are involved in development of depression?
Functional deficit of monoamine transmitters
–> in particular serotonin (5-HT) and noradrenaline
What are the different classes of antidepressants available?
Monoamine oxidase inhibitors
Monoamine reuptake inhibitors:
- tricyclics
- non-selective reuptake inhibitors (NSRIs)
- selective serotonin reuptake inhibitors (SSRIs)
- noradrenaline reuptake inhibitors
Atypical drugs (post-synaptic effects)
What is the mode of action of monoamine oxidase inhibitors and give two examples?
Inhibitors of MAO-A and B
- Phenelzine (irreversible)
- Moclobemide (reversible)
What are the side effects of monoamine oxidase inhibitors?
Hypertensive crisis (‘cheese reaction’) - must have restricted diet
Potentiates the effects of other drugs e.g. barbiturates
Insomnia
Drowsiness
Postural hypotension
Peripheral oedema
How do TCAs work?
Block the reuptake of monoamines (NA and 5-HT) into presynaptic terminals
Give 4 examples of TCAs?
Imipramine Clomipramine Dosulepin Amitriptyline Lofepramine
What are the common side effects of TCAs?
Anticholinergic: - blurred vision - dry mouth - constipation - urinary retention Sedation Weight gain Postural hypotension Tachycardia Arrhythmias Cardiotoxic in overdose
How do SSRIs work?
Selectively inhibit reuptake of serotonin from the synaptic cleft
Give 5 examples of SSRIs
Fluoxetine
Citalopram/Escitalopram
Sertraline
Paroxetine
What are the common side effects of SSRIs?
GI upset Headache Worsened anxiety Transient increase in suicidal ideation in <25 years Sweating Insomnia/vivid dreams Sexual dysfunction Hyponatraemia (in elderly) Discontinuation effects Increase risk of GI bleeding if taken with NSAIDs
What is the mode of action of SNRIs and give two examples?
Block reuptake of NA + 5HT into the presynaptic terminals
- Venlafaxine
- Duloxetine
What is the mode of action of mirtazepine?
Blocks alpha-2, 5-HT2 and 5-HT3 receptors
What are the side effects of mirtazepine?
Weight gain Sedation Constipation Dizziness Falls Dry mouth GI upset when taken with alcohol Unusual/vivid dreams Rare: blood dyscrasias, seizures
What is the advantage of taking mitrazepine with an SSRI?
Mirtazepine can block the serotenergic side effects of SSRI
Which antidepressants have the greatest risk of discontinuation symptoms?
Venlafaxine + paroxetine
shorter half life
Which antidepressants have the greatest toxicity in overdose?
Venlafaxine + TCAs
–> caution if suicidal
How should antidepressants be discontinued?
Gradually reduce dose over 4 weeks (or longer)
Which discontinuation symptoms may occur if an antidepressant is stopped abruptly?
Restlessness Problems sleeping Unsteadiness Sweating Abdominal symptoms Altered sensations (e.g. electric shock sensations in head) Irritability, anxiety or confusion
When should you consider admitting a patient with depression?
If significant risk of suicide, self harm or self neglect
When should ECT be considered for depression?
Severe, life threatening depression
- when a rapid response is required or when other treatments have failed
What are the contraindication for ECT?
Absolute:
- recent MI (last 3 months)
- recent CVA
- intracranial mass lesion
- pheochromocytoma
Relative:
- angina
- HF
- severe pulmonary disease
- severe osteoporosis
- pregnancy
Which antidepressants are considered the ‘top 4’ and why?
Escitalopram - probably the best all round SSRI
Sertraline - good CV safety profile and allows easy dose titration
Mirtazepine - promotes sleep and appetite/weight gain
Venlafaxine - higher rates of adverse effects but may be more effective
What are the principles of treatment in bipolar disorder?
Acute treatment of symptoms: - reduce mood in mania - raise mood in depression Long term treatment (prophylaxis): - to stabilise mood
What are the principles for treating acute mania?
Maximise antimanic dose if patient already on maintenance treatment
Discontinue antidepressants
Combination therapy may be required
Likely require admission if manic
Which drugs are used to treat acute mania?
Antipsychotic first line:
- olanzapine, quetiapine or rispiridone
Other options:
- lithium, carbamazepine, ECT
Oral if possible, but IM may be required
Benzos can be used symptomatically for agitation, insomnia etc
What are the principles for treating acute bipolar depression?
Never prescribe antidepressant without an antimanic drug
Avoid antidepressants if recent manic/hypomanic episode or history of rapid cycling
SSRIs (particularly fluoxetine) preferable choice
Which drugs can be prescribed to treat acute bipolar depression?
Antipsychotic first line –> quetiapine or olanzapine
Antidepressant alongside antipsychotic, lithium or valproate:
- FLUOXETINE
Lamotrigine can be used but takes time to titrate
ECT
Lithium
What are the options for bipolar maintenance therapy?
Lithium is gold standard Other options: - antipsychotics - lamotrigine (if primarily depression) - valproate (if primarily manic) - carbamazepine
How is lithium therapy monitored?
12 hour post dose blood levels (narrow therapeutic index)
What are the side effects of lithium carbonate?
Dry mouth/strange taste Polydipsia and polyuria Tremor Hypothyroidism Long term reduced renal function Ankle swelling Nephrogenic diabetes insipidus Weight gain
What are the features of lithium toxicity?
Vomiting Diarrhoea Ataxia + coarse tremor Drowsiness/altered consciousness Convulsions Coma
What are the main side effects associated with valproate and carbamazepine?
Drowsiness Ataxia CV effects Induces liver enzymes Teratogenicity (valproate)
Why do you need to warn patients about a rash with lamotrigine?
Small risk of Steven-Johnson syndrome
Which antipsychotics might be used as mood stabilisers?
Quetiapine
Aripiprazole
Olanzapine
Lurasidone
Which tests need to be done prior to starting lithium therapy?
BMI U+Es including calcium eGFR TFTs FBC ECG if CV disease or risk factors
What needs to be monitored in a patient taking lithium?
Plasma lithium level + U+Es every 3 months
Every 6 months:
- BMI
- TFTs
more often if abnormalities
What is the management of depression in children?
CBT first (before considering medication)
Antidepressants:
- fluoxetine first line
- sertraline or citalopram
Which SSRI is good if cardiac problems?
Sertraline
Which SSRI is safest in epilepsy?
Citalopram
Which patients should TCAs be avoided in?
Cardiac problems
Suicidal intent
Older people
Which foods need to be avoided if taking a MAOI?
Cheese Red wine Fermented meats Marmite, Bovril Caffeine Broad beans Soy, tofu ...etc
What are the symptoms of a hypertensive crisis?
Headache SOB Nosebleeds Anxiety --> arrhythmias, stroke, seizure, death
How is a hypertensive crisis treated?
Phentolamine infusion
What are some of the drug interactions with lithium?
NSAIDs
ACE inhibitors
ARBs
Diuretics (thiazide worse than loop)
