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B33CNS > Anxiety and Depression (Yvonne Mbaki) > Flashcards

Anxiety and Depression (Yvonne Mbaki) Flashcards

1
Q

What is the NHS definition of anxiety?

A

A feeling of unease, such as worry or fear, that can be mild or severe.
Diagnosis is made if feeling of anxiety occurs all the time.

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2
Q

What different types of anxiety exist?

A 
Panic disorder
Obsessive Compulsive Disorder
Post-Traumatic Stress Disorder
Phobias 
Generalised Anxiety Disorder
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3
Q

What is Panic Disorder and what symptoms does it present with?

A

An intense / abrupt feeling of fear or discomfort and includes symptoms such a:

  • Sudden temperature change (fight / flight)
  • Chest pain (interruption to blood circulation -> palpitations)
  • Overwhelming feelings
  • Sickness and dizziness
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4
Q

What is OCD and the two aspects to the type of anxiety?

A

OCD is a combination of obsessive thought and compulsive activity
Obsession - unwanted/unpleasant thoughts that cause anxiety
Compulsion - repetitive behaviour a person undertakes to relieve the unpleasant feeling.

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5
Q

What are the symptoms and presentation associated with PTSD?

A

Experiencing a trauma / serious accident, natural disaster, criminal assault etc
Condition may develop immediately or years later.
Trauma interferes with normal functioning e.g. sleep
Symptoms include: nightmares, flashbacks, isolation etc

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6
Q

What are Phobias?

A

Phobias can be an intense fear of something specific that is in reality is of no or little actual danger

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7
Q

What is Social Phobia?

A

Fear of social or performance situation resulting from thoughts of negative judgement, embarrassment, humiliation. Person tolerates with dread or avoids the situation

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8
Q

What is GAD?

A

Generalised Anxiety Disorder
Disproportionate worry that cannot be controlled and is excessive about everyday things; job, chores, car repairs, late for appointments, health, family and finances.

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9
Q

In order to commence treatment for an anxiety disorder what is the first initial step?

A

Rule out organic disease

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10
Q

What organic diseases could be causing the general symptoms of an anxiety disorder?

A

Asthma SOB
Heart disease palpitations and tachycardia
Hyperthyroidism palpitations sweating and tremor
Vestibular dysfunction (problems with inner ear) dizziness
Hypoglycaemia dizziness
Menopause sweating
Phaeochromocytoma (adrenal tumour) palpitations sweating and tremor

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11
Q

What are the considerations made when assessing a patient presenting with potential anxiety disorder?

A 
History of mental health 
Environmental stress
Medical and drug history
Degree of stress and functional impairment 
Risk of suicide
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12
Q

What is the aim of treating GAD?

A

Relieve symptoms, improve QoL and prevent relapse

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13
Q

What are the non-pharmacological treatment employed in the treatment of GAD?

A 
CBT
Meditation and relaxation techniques
(Both recommended by NICE to complement any pharmacological treatment)
Mindfulness
Exercise
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14
Q

How can the autonomic symptoms of GAD be treated?

A

B-adrenoreceptor antagonists e.g. propanolol prn (must be titrated down, beta blocker)
Reduces autonomic effect

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15
Q

How is GAD treated pharmacologically?

A

Selective serotonin reuptake inhibitor (SSRi)
1st line - Escitalopram and Paroxetine
Sertraline (off label indication for GAD)

If no improvement within 2 months of treatment:
Increase dose to maximum
Swap to another SSRi
Consider serotonin noradrenaline-reuptake inhibitor (Venlafaxine and Duloxetine)
Consider anticonvulsant agent pregabalin (blocks glutamate, lots of side effects)

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16
Q

What are uses for benzodiazepines?

A 
Anxiolytic 
Sedative (minor tranquilizers)
Muscle relaxant (central effect)
Hypnotic (induce sleep)
Anticonvulsant 
Amnesic 
Reduce aggression 
Treat alcohol withdrawal
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17
Q

What are the properties of BDZ?

A

No enzyme induction making monitoring easy
Some tolerance
Dependence and withdrawal symptoms (short term)
Metabolism is through oxidation and conjugation
Oxidation is reduced by age; effects may be prolonged in older patients
Active metabolites
Relatively safe in overdose

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18
Q

Is BDZ suitable for treatment of GAD?

A

Drugs that have short half lives (1-10 hours) are generally hypnotics and not suitable for anti-anxiety treatment (temazepam, nitrazepam and zolpidem)
Drugs that have a long half life (1-4 days) are more suitable as anti-anxiety agents e.g. diazepam, chlordiazepoxide, lorazepam but use is restricted to 2-4 weeks and patients must be titrated down.

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19
Q

What is GABA?

A

The main inhibitory neurotransmitter in the central nervous system.

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20
Q

What is the GABA receptor structure like?

A

Cl- ion channel in the middle of the flower shaped receptor.
alpha 1, beta 2 and gamme 2 binding sites for alcohol/barbiturate, BDZ, steroids, picrotoxin site

21
Q

How do BDZ’s work?

A

Occupy site on GABAa complex, increase the receptors affinity for GABA, greater flow of Cl- ions into the neurone
Hyperpolarisation occurs

22
Q

What are the Diagnostic and Statistical Manual of Mental Health Disorders?

A
  1. Depressed Mood
  2. Loss of Interest or Pleasure
  3. Fatigue
  4. Feelings of Worthlessness
  5. Recurrent thoughts about death or suicide / attempts
  6. Reduced ability to think / concentrate
  7. Psychomotor agitation or retardation
  8. Altered sleep
  9. Significant weight changes
23
Q

What are the various categories of depression?

A

Subthreshold - 2-4 symptoms; one core symptoms
Mild - In excess of 5 symptoms but minor functional impairment
Moderate - some marked symptoms, presence of functional impairment
Severe - multiple symptoms, markedly interfere with functioning

24
Q

What is the emphasis on cause in mild to severe depression?

A

Mild depression is often the result of environmental factors and less so genetics
Severe depression is likely to be contributed to significantly by genetic factors, less likely to be purely environmental product.

25
Q

What is the associated presentation of Bipolar Disorder?

A

Cycle between depressed mood and mania (hyper excitability)
Depressed mood - two weeks with core symptoms
Mania - elevated mood, increased energy, incomprehensible speech, racing thoughts, poor concentration etc

26
Q

When does Bipolar Disorder commonly manifest?

A

First episode before 30 and peak incidence between 15-19 years of age
Increased incidence observed in ethnic minorites

27
Q

How is Bipolar Disorder diagnosed?

A

Eliminate misdiagnosis of BD

Confirmed by specialist mental health professional

28
Q

How is Bipolar Disorder treated?

A

Mania (acute phase) - antipsychotics (haloperidol, olanzapine, quetiapine, risperidone), if ineffective try a second. Lithium or sodium valproate added as third option

Maintenance - long term; continue treatment as above with lithium or sodium valproate long term

Psychological intervention CBT / talking therapy

Depression - quetiapine alone
SSRi fluoxetine combined with olanzapine
Olanzapine alone
Lamotrigine alone

29
Q

Which system of the brain is attributed to depression?

A

Limbic system

Reduction in the size of thalamus, hippocampus and amygdala in depressed patients.

30
Q

What is 5-HT Serotonins role in depression?

A

Depression due to reduced 5-HT, anxiety, obsessions and compulsions

31
Q

What is noradrenaline NA role in depression?

A

Alertness, anxiety, interest in life
Role in reward and stress
Reduced NA compromises reward feeling

32
Q

What is DA dopamines role in depression?

A

Attention, motivation, reward

Reduced tyrosine

33
Q

What animal models have been used to show depression?

A

Forced swimming test
Tail suspension test (mice stop fighting until given an antidepressant)
Learned helplessness
Stress models (food deprivation / electric shocks)
Olfactory bulbectomy (removal - loss of interest until given an antidepressant)

34
Q

What are the aims in management of depression?

A

Manage the suicide risk
Improve QoL
Prevent relapse
Treat symptoms

35
Q

What non-pharmacological interventions can be used in treating depression?

A

High intensity CBT

Good sleep hygiene

36
Q

What are the considerations when choosing a treatment plan for the treatment of depression?

A

Patient preference
Adverse effect profile
Toxicity in overdose
Interaction with other treatment

37
Q

What is the first line choice for treatment of depression?

A

Generic SSRis: citalopram, fluoxetine, paroxetine, sertraline
Favourable side effects and less toxic in overdose

38
Q

How should a patient be counseled on SSRi medication?

A

Symptoms may worsen before improving
Vigilant on suicidal ideas especially when starting or changing medication
Take 2-4 weeks for symptoms to improve
Medication taken for atleast 6 months after recovery to prevent relapse

39
Q

What are the side effects of SSRis?

A

Nausea, vomiting, diarrhoea, dizziness etc

40
Q

What is recommended to treat depression in <18 y/os?

A

Antidepressants avoided but fluoextine if necessary

Lifestyle advice including positive coping strategies

41
Q

How do SSRis work?

A

Citalopram binds to 5-HT and blocks reuptake

42
Q

Why do SSRis take 2-4 weeks to work?

A

SSRI blocks the 5HT reuptake transporter; this triggers the 5HT1 autoreceptor on the presynaptic membrane to activate. This activation stops the exocytosis of 5HT from the presynaptic membrane. It takes 2-4 weeks for the 5HT1 autoreceptor to become downregulated so that 5HT can be exocytosed into the synpatic cleft again.

43
Q

What are SNRIs?

A

Venlafaxine, duloxetine
Serotonin-noradrenaline reuptake inhibitor
Similar to SSRis

44
Q

What are TCA?

A

Tricyclic Antidepressants
Inhibit 5HT and NA reuptake
Amitryptaline and imipramine
Sedative properties (H1 receptor antagonism)
Anticholinergic SE - dry mouth, blurred vision
Cardiovascular and epileptogenic effects can be fatal in overdose

45
Q

What are MAOIs?

A

Monoamine oxidase inhibitors
Phenelzine or tranylcypromide
Tyramine competes with NA for reuptake leading to hypertensive crisis

46
Q

What class of drug is Mirtazapine?

A

Noradrenergic and specific serotenergic antidepressant NaSSA
Increases 5HT and NA release

47
Q

What is St John’s Wort?

A

Not understood; herbal remedy from Hypericum perforatum

Should not be used in depression as lack of understanding re dose, drug interaction, potency etc

48
Q

What is the order of drug choices in depression?

A

SSRis TCAs MAOIs NaSSA NARI

49
Q

How can pharmacist’s help to complement sleep hygiene?

A

CBT
Sleeping tablets
BDZs temazepam or nitrazepam (2-4 wk use and titrate dose)
Z-meds; zolpidem, zoplicone
TAC
Melatonin (Circadin) short term in adults <55 y/o

B33CNS (20 decks)

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