Wk 27 - Depression + anxiety in practice Flashcards
What are the symptoms of depression?
- Depressed mood
- Loss of interest
- Insomnia
- Appetite change
- Fatigue
- Inc/dec psychomotor activity
- Guilt or feelings of worthlessness
- Diminished ability to conc
- Suicidal ideation
What is considered a diagnosis of depression + subthreshold depression?
- Depression: 5/more
- Subthreshold: 2
What are the NICE guidelines for depressed adults?
- Assessment + management of suicide risk
- Manage co-morbid conditions: alcohol, substance abuse
- Discuss solutions contributing to depression
What are the 5 steps to support mental wellbeing?
- Connect
- Be active
- Keep learning
- Give to others
- Be mindful
Outline low intensity psychosocial interventions for depression
- Individual guided self-help
- Computerised CBT
- Structured group physical activity programme
- For: mild-mod depression + persistent subthreshold
Outline pharmacological interventions for depression
- Antidepressant
- For: Mod-severe depression, Mild-mod depression + persistent subthreshold
Outline high intensity psychosocial interventions for depression
- CBT
- Interpersonal therapy
- For: mod-severe depression
Outline the caution for cardiovascular disease + QT prolongation
- Antidepressant cause QT prolongation
- Med history, lab monitoring + baseline ECG needed to identify risk for QT prolongation before starting
Outline the MHRA drug safety for citalopram + escitalopram
Avoid in:
- Congenital long QT syndrome
- Pre-existing QT interval prolongation
- Combination w/ other medicines that prolong QT interval
What is recommended in patients w/ mild or moderate hepatic impairment or poor metabolizers of CYP2C19?
Dose red in 1st 2 wks
What drugs are associated w/ inc fracture risk?
TCAs + SSRIs
Which drugs are associated w. inc risk of postpartum haemorrhage when used in month of delivery?
SSRI/SNRI
What are the common adverse effects of antidepressants?
- Initial inc agitation + anxiety
- Suicidal thoughts in early treatment or after stopping
- Hyponatraemia
- Sexual dysfunction
- W/drawal effect
What is hyponatremia?
- Common in elderly
- Dizziness, drowsiness, confusion, muscle cramps + seizures
- Caused by SSRI
- W/in 30 days of starting
- Stop if identified + sodium levels normalised w/in 1-2 wks then change antidepressant
- Urgent care if severe
Outline SSRIs/SNRI + their bleeding risk
- Red uptake of serotonin by platelets
- Red ability of platelets to aggregate + so inc risk of haemorrhage
- Esp GI bleeding
Outline factors that increase bleeding when taking SSRIs/SNRIs
- Elderly
- History of peptic ulcers
- Excessive alcohol
- Co-admin NSAIDS, antiplatelet, corticosteroid + warfarin
What are monoamine-oxidase inhibitors?
- For: don’t respond to other antidepressants + patient refractory
- W/drawal symptoms
- Cause: hepatic impairment
What are the interactions of MAOIs?
- High tyramine food + drink - hypertensive
- SSRI, analgesic, opioids + migraine med - serotonin syndrome
- Potent NA effect (amphetamine) - synergistic effect on BP
- OTC decongestants
Outline the process of switching from an SSRI to a MAOI
- Washout period for at least 5 HL of SSRI
- 7 days or 6 wks for fluoxetine
- 2-3 wks after stopping MAOI
Outline the process when taking MAOI and undergoing surgery
- Local anaesthetic: Non-noradrenergic anesthetic agent used
- General anaesthetic: discontinue 10 days prior to surgery
What is serotonin syndrome characterised by?
- Altered mental status
- Neuromuscular hyperactivity
- Autonomic instability
- Agitation
- Confusion
- Delirium
- Hallucinations
What are neuromuscular features of serotonin syndrome?
- Shivering
- Tremor
- Teeth grinding
- Hyperreflexia
What are the autonomic features of serotonin syndrome?
- Tachycardia
- HT/Hypotension
- Flushing
- Vom + di
In severe cases, what are the symptoms of serotonin syndrome?
- Coma
- Seizure
- Hyperthermia
- Rhabdomyolysis
- Renal failure
Outline w/drawal symptoms
- Dizziness, nausea, anxiety , di, headache
- W/in 5 days of stopping
- Lasts less than 2 wks
What happens if discontinuation symptoms are severe?
- OG antidepressant reintroduced + tapered slowly
- Monitor symtpoms
Give examples of patient counselling points
- Symptoms of anxiety initially worsen
- Continue for 6 months following remission of symptoms to red relapse
- Sleep hygiene
