Workshop 7 – Depression: Current treatments & future challenges Flashcards
Which stage of depression (mild, moderate, severe) may be treated with complementary medicine? Discuss this medicine
Mild to moderate depression may be treated with St Johns wart.
St Johns wart is an enzyme inducer. It increases the metabolism of other drugs.
St johns wart interacts with SSRI - increases the risk of seratonin syndrome. This is caused by excessive central and peripheral seratonergic activity. The symptoms of seratonin syndrome fall into 3 catagories; neuromuscular hyperactivity - tremour, hyperflexia; autonomic dysfunction - tachycardia, blood pressure changes, shivering, diarrhoea; altered menta state - agitation, mania, confusion
What factors need to be considered when prescribing an antidepressant?
- Severity of condition
- Risk of suicide - Avoid TCA due to risk of cardiotoxicity in overdose. SSRI are better tolerated and are safer in overdose
- Side effects: SSRI are less sedating and have fewer antimuscarinic and cardiotoxic effects than TCA
- Age: TCA have very high cardiotoxicity and antimuscarinic side effects - blurry vision, constipation, dry mouth so not suitable for elderly. SSRI esp paroxetine can cause sexual dysfunction so avoid use in child bearing age/ younger groups - high risk of non adherance
- Gender: avoid TCA in woman due to weight gain
- Interactions: - Fluoxetine, sertraline, fluvoxamine have high drug interactions, - TCA not good in epilepsy as it increases risk of seizures, MOA have food interactions with cheese
- Side effects
What are the side effects associated with SSRIs?
GI side effects are the most common - usually there for the first 1-2 weeks because the body is getting used to the drug. Will eventually go away so dont stop taking the drug
CNS side effects - insomnia, anxiety, agitation, headaches, tremours.
Sexual dysfunction - inhibits nitrous oxide which in important for penile erection.
Fluoxetine side effects will take longer to go away - may be up to 4 weeks due to the drugs long half life. SSRI also have.
How can you manage the side effects associated with SSRIs?
Drug holidays - can miss dose over the weekend so it doesnt affect sexual function
Change the drug
Take viagra
Change to mirtazapine - less sexual dysfunction
For GI upset - take drug with food, drink fluid, exersice, eat fibre
For insomnia - good sleep hygeine, dont take dose at night
Dry mouth - drink more water, sugerless candy, keep teeth clean - dry mouth can increase the risk of infection
What counselling should be given when starting a patient on a SSRI?
Explanation of the drug - what its for, how it works, how/ when to take it
Emphasise that the drug doesnt work immediately - takes a few weeks to start - so important to continue taking it.
Side effects: nausea, headache, sexual dysfunction.
Dont stop taking it abruptly - may cause withdrawal symptoms
Which symproms of depression respond first to an antidepressant?
- Improvement in sleep
- Anxiety and agitation improve
- Appetite and weight changes
- Concentration and cognitive function may improve later
Describe the stages of depression management
Discuss choice of drug with patient. Include: Potential therapeutic effects. Possible adverse effects. Likelihood of discontinuation symptoms.
Suggest SSRIs as first choice
(e.g. sertraline)
Start the antidepressant
Assess the efficacy after 1-4 weeks.
If theres no effect, switch to a different antidepressant
What is ‘antidepressant discontinuation syndrome’
Symptoms that occur due to abrupt withdrawal of the drug. Symptoms that occur are; flu like symptoms, disturbed sleep, headche. Usually seen within the first 5 days of wityhdrawal. With drugs with longer half life, withdrawal symptoms may take weeks/ months to appear.
How are SSRI treatments stopped?
Depends on the patient.
If been on drugs for months - taper 5-10%
What are the risks of taking SSRI whilst pregnant?
Chance of child having behavioural problems
Risk of pulmonary hypertension
Neonatal withdrawal syndrome
Low birth weight
Explain what serotonin syndrome is and how it might happen
A relatively uncommon adverse drug reaction caused by excessive central and peripheral seratonergic activity.
Onset of symptoms which range from mild to life thretening, can occur within hours or days following the initial dose escalation, or overdose of the seratonergic drug
The characteristic symptoms of serotonin syndrome fall into 3 main areas, although features from each group may not be seen in all patients—neuromuscular hyperactivity (such as tremor, hyperreflexia, clonus, myoclonus, rigidity), autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea), and altered mental state (agitation, confusion, mania).
Treatment consists of withdrawal of the seratonergic drug
Explain the concept of ‘augmentation of antidepressant therapy for treating refractory depression’.
Augmentation is when an antidepressant is used with a non antidepressant drug and combination is when 2 antidepressant drugs are used together
Augment with lithium
Combine with second generation antipsychotic such as aripiprazole, olanzapine, quetiapine or risperidone or another antidepressant such as mirtazapine or mianserin
