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Psychiatry > Treatment of Mood Disorders > Flashcards

Treatment of Mood Disorders Flashcards

1
Q

When should antidepressants be considered for a patient with depressive symptoms?

A

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

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2
Q

What is the first line management for depression?

A 
If mild/moderate:
An antidepressant (normally an SSRI) OR
High intensity psychological intervention:
- CBT
- IPT (interpersonal therapy)

If moderate/severe:
–> combine above treatments

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3
Q

Which factors should be taken into account when choosing an antidepressant?

A

Anticipated side effects
Potential interactions with other medications or physical illness
Previous antidepressants tried by the patients and their efficacy

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4
Q

How should a patient be monitored when starting an antidepressant?

A

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

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5
Q

What should be considered if an antidepressant isn’t working?

A 
Compliance
Is the diagnosis correct?
Substance misuse
Physical illness
Address other predisposing, precipitating and prolonging factors
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6
Q

How long should an antidepressant be taken with no improvement, before you consider increasing the dose or swapping to another drug?

A

4-6 weeks

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7
Q

What can be done if an antidepressant isn’t working?

A

Increase dose
Swap
Combine - most commonly SSRI/SNRI plus mirtazapine

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8
Q

How long should a patient take an antidepressant for in order to prevent relapse?

A

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

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9
Q

Which neurotransmitters are involved in development of depression?

A

Functional deficit of monoamine transmitters

–> in particular serotonin (5-HT) and noradrenaline

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10
Q

What are the different classes of antidepressants available?

A

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)

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11
Q

What is the mode of action of monoamine oxidase inhibitors and give two examples?

A

Inhibitors of MAO-A and B

  • Phenelzine (irreversible)
  • Moclobemide (reversible)
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12
Q

What are the side effects of monoamine oxidase inhibitors?

A

Hypertensive crisis (‘cheese reaction’) - must have restricted diet
Potentiates the effects of other drugs e.g. barbiturates
Insomnia
Drowsiness
Postural hypotension
Peripheral oedema

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13
Q

How do TCAs work?

A

Block the reuptake of monoamines (NA and 5-HT) into presynaptic terminals

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14
Q

Give 4 examples of TCAs?

A 
Imipramine
Clomipramine
Dosulepin
Amitriptyline
Lofepramine
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15
Q

What are the common side effects of TCAs?

A 
Anticholinergic:
- blurred vision
- dry mouth
- constipation
- urinary retention 
Sedation
Weight gain
Postural hypotension
Tachycardia
Arrhythmias
Cardiotoxic in overdose
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16
Q

How do SSRIs work?

A

Selectively inhibit reuptake of serotonin from the synaptic cleft

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17
Q

Give 5 examples of SSRIs

A

Fluoxetine
Citalopram/Escitalopram
Sertraline
Paroxetine

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18
Q

What are the common side effects of SSRIs?

A 
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
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19
Q

What is the mode of action of SNRIs and give two examples?

A

Block reuptake of NA + 5HT into the presynaptic terminals

  • Venlafaxine
  • Duloxetine
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20
Q

What is the mode of action of mirtazepine?

A

Blocks alpha-2, 5-HT2 and 5-HT3 receptors

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21
Q

What are the side effects of mirtazepine?

A 
Weight gain
Sedation
Constipation
Dizziness
Falls 
Dry mouth
GI upset when taken with alcohol
Unusual/vivid dreams
Rare: blood dyscrasias, seizures
22
Q

What is the advantage of taking mitrazepine with an SSRI?

A

Mirtazepine can block the serotenergic side effects of SSRI

23
Q

Which antidepressants have the greatest risk of discontinuation symptoms?

A

Venlafaxine + paroxetine

shorter half life

24
Q

Which antidepressants have the greatest toxicity in overdose?

A

Venlafaxine + TCAs

–> caution if suicidal

25
Q

How should antidepressants be discontinued?

A

Gradually reduce dose over 4 weeks (or longer)

26
Q

Which discontinuation symptoms may occur if an antidepressant is stopped abruptly?

A 
Restlessness
Problems sleeping 
Unsteadiness
Sweating
Abdominal symptoms
Altered sensations (e.g. electric shock sensations in head)
Irritability, anxiety or confusion
27
Q

When should you consider admitting a patient with depression?

A

If significant risk of suicide, self harm or self neglect

28
Q

When should ECT be considered for depression?

A

Severe, life threatening depression

- when a rapid response is required or when other treatments have failed

29
Q

What are the contraindication for ECT?

A

Absolute:

  • recent MI (last 3 months)
  • recent CVA
  • intracranial mass lesion
  • pheochromocytoma

Relative:

  • angina
  • HF
  • severe pulmonary disease
  • severe osteoporosis
  • pregnancy
30
Q

Which antidepressants are considered the ‘top 4’ and why?

A

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

31
Q

What are the principles of treatment in bipolar disorder?

A 
Acute treatment of symptoms:
- reduce mood in mania
- raise mood in depression
Long term treatment (prophylaxis):
- to stabilise mood
32
Q

What are the principles for treating acute mania?

A

Maximise antimanic dose if patient already on maintenance treatment
Discontinue antidepressants
Combination therapy may be required
Likely require admission if manic

33
Q

Which drugs are used to treat acute mania?

A

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

34
Q

What are the principles for treating acute bipolar depression?

A

Never prescribe antidepressant without an antimanic drug
Avoid antidepressants if recent manic/hypomanic episode or history of rapid cycling
SSRIs (particularly fluoxetine) preferable choice

35
Q

Which drugs can be prescribed to treat acute bipolar depression?

A

Antipsychotic first line –> quetiapine or olanzapine
Antidepressant alongside antipsychotic, lithium or valproate:
- FLUOXETINE
Lamotrigine can be used but takes time to titrate
ECT
Lithium

36
Q

What are the options for bipolar maintenance therapy?

A 
Lithium is gold standard
Other options:
- antipsychotics
- lamotrigine (if primarily depression)
- valproate (if primarily manic)
- carbamazepine
37
Q

How is lithium therapy monitored?

A

12 hour post dose blood levels (narrow therapeutic index)

38
Q

What are the side effects of lithium carbonate?

A 
Dry mouth/strange taste
Polydipsia and polyuria
Tremor
Hypothyroidism
Long term reduced renal function
Ankle swelling
Nephrogenic diabetes insipidus
Weight gain
39
Q

What are the features of lithium toxicity?

A 
Vomiting
Diarrhoea
Ataxia + coarse tremor
Drowsiness/altered consciousness
Convulsions
Coma
40
Q

What are the main side effects associated with valproate and carbamazepine?

A 
Drowsiness 
Ataxia
CV effects
Induces liver enzymes
Teratogenicity (valproate)
41
Q

Why do you need to warn patients about a rash with lamotrigine?

A

Small risk of Steven-Johnson syndrome

42
Q

Which antipsychotics might be used as mood stabilisers?

A

Quetiapine
Aripiprazole
Olanzapine
Lurasidone

43
Q

Which tests need to be done prior to starting lithium therapy?

A 
BMI
U+Es including calcium
eGFR
TFTs
FBC
ECG if CV disease or risk factors
44
Q

What needs to be monitored in a patient taking lithium?

A

Plasma lithium level + U+Es every 3 months

Every 6 months:
- BMI
- TFTs
more often if abnormalities

45
Q

What is the management of depression in children?

A

CBT first (before considering medication)
Antidepressants:
- fluoxetine first line
- sertraline or citalopram

46
Q

Which SSRI is good if cardiac problems?

A

Sertraline

47
Q

Which SSRI is safest in epilepsy?

A

Citalopram

48
Q

Which patients should TCAs be avoided in?

A

Cardiac problems
Suicidal intent
Older people

49
Q

Which foods need to be avoided if taking a MAOI?

A 
Cheese
Red wine
Fermented meats
Marmite, Bovril
Caffeine
Broad beans
Soy, tofu
...etc
50
Q

What are the symptoms of a hypertensive crisis?

A 
Headache
SOB
Nosebleeds
Anxiety
--> arrhythmias, stroke, seizure, death
51
Q

How is a hypertensive crisis treated?

A

Phentolamine infusion

52
Q

What are some of the drug interactions with lithium?

A

NSAIDs
ACE inhibitors
ARBs
Diuretics (thiazide worse than loop)

Psychiatry (12 decks)

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