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Psychiatry > Depression - Pharmacology > Flashcards

Depression - Pharmacology Flashcards

1
Q

Which drugs are usually first line in depression?

A

SSRIs

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2
Q

How long do anti-depressants usually take to work?

A

2-6 weeks

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3
Q

If you need a quicker response than what anti-depressants can offer, what treatment can be used?

A

ECT

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4
Q

How should anti-depressants be started and why?

A

Started at a low dose and titrated up, to avoid initiation side effects

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5
Q

In psychotic depression an anti-depressant and anti-psychotic can be combined. Which should be the long-term mainstay of treatment?

A

Anti-depressant

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6
Q

What should you do when prescribing anti-depressants in older people?

A

Lower the dose - usually half of the adult dose to start with

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7
Q

Why should you be cautious prescribing anti-depressants in younger patients?

A

They can sometimes cause agitation which leads to suicidal behaviour in young people

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8
Q

What defines non-response to an anti-depressant?

A

No or inadequate response after 6 weeks at the maximum or highest tolerated dose

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9
Q

Why is it important to check the BNF before changing anti-depressants?

A

Some drugs require a wash out period

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10
Q

What dose of anti-depressant should patients be continued on once there has been an effect?

A

The same dose! (the dose that gets you well keeps you well)

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11
Q

After a first depressive episode, how long should treatment with an anti-depressant be continued for?

A

6-12 months after full resolution of symptoms

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12
Q

After a second depressive episode, how long should treatment with an anti-depressant be continued for?

A

12-24 months after full resolution of symptoms

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13
Q

After a third depressive episode, how long should treatment with an anti-depressant be continued for?

A

Indefinitely (if the patient is willing)

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14
Q

When may anti-depressants be continued indefinitely after just one episode?

A

If the depression has been very severe

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15
Q

How should an anti-depressant be stopped?

A

By tapering the dose - never stop suddenly

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16
Q

When can an anti-psychotic be used in depression?

A

It can be combined with an anti-depressant in psychotic unipolar depression, and can also be used as an adjunct to an anti-depressant even if there are no psychotic symptoms

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17
Q

What tests should be checked before starting an atypical anti-psychotic and at 1 month?

A

BP, weight, lipids, blood glucose, ECG, FBC, Us and Es and LFTs.

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18
Q

After 1 months use of an anti-psychotic, how often should all the relevant tests be performed?

A

At least yearly, possibly more often depending on the results and other risk factors

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19
Q

In mood disorders, which type of anti-psychotic is more likely to be used?

A

Atypical

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20
Q

Why can foods containing tyramine not be consumed if on an MAOI?

A

Tyramine is a potent releaser of noradrenaline, and MAOIs inhibit the breakdown of noradrenaline. This can lead to a hypertensive crisis.

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21
Q

What are some signs which may signal a hypertensive crisis in a patient on an MAOI?

A

Headache, dyspnoea, nosebleeds, anxiety

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22
Q

What can a hypertensive crisis lead to in a patient on an MAOI?

A

Arrhythmias, stroke, seizures and death

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23
Q

How is a hypertensive crisis treated?

A

An infusion of phentolamine

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24
Q

What is an example of an irreversible MAOI?

A

Phenelzine

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25
Q

What is an example of a reversible MAOI?

A

Moclobemide

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26
Q

What is the advantage and disadvantage of a reversible MAOI compared to an irreversible one?

A

Less side effects, but less effective

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27
Q

What is the mechanism of action of MAOIs?

A

They work by irreversibly or reversibly blocking the monoamine oxidase enzyme to stop the metabolism of monoamine neurotransmitters. This means that the post-synaptic concentration of neurotransmitter is increased and hence the action of the neurotransmitter lasts longer.

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28
Q

The action of which neurotransmitters are increased by MAOIs?

A

Noradrenaline, dopmine and 5-HT

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29
Q

What are the indications for the use of MAOIs?

A

Only used in severe, treatment resistant depression

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30
Q

Why are MAOIs not used regularly?

A

Because of side effects and dietary restrictions, and many other drug interactions

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31
Q

What are the commoner side effects of MAOIs?

A

Postural hypotension, drowsiness, insomnia, nausea, constipation

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32
Q

What are some rare side effects of MAOIs?

A

Hypertensive crisis, hepatic impairment, seizures

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33
Q

What other medication should not be taken alongside MAOIs?

A

Nasal decongestants

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34
Q

What are the dietary requirements when taking MAOIs?

A

Cheese, wine, yeast products and anything else which is fermented

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35
Q

Why is there sometimes concordance problems with MAOIs?

A

3 times daily dosing

36
Q

What are the 3 different types of monoamine reuptake inhibitors?

A

SSRIs, SNRIs and tricyclics

37
Q

Name some examples of SSRIs?

A

Fluoxetine, sertraline, citalopram, escitalopram, paroxetine

38
Q

What is the mechanism of action of SSRIs?

A

These selectively block the reuptake of serotonin to increase the amount of neurotransmitter in the synaptic cleft so that the effects of serotonin last longer.

39
Q

What are the indications for the use of SSRIs?

A

Usually first line in depression, and also usually first line if an anti-depressant is to be used in bipolar disorder

40
Q

What are some side effects of SSRIs?

A

GI upset, nausea, headache, sweats, vivid dreams, agitation, anxiety, insomnia, sexual dysfunction

41
Q

What electrochemical imbalance may SSRIs cause in older patients?

A

Hyponatraemia

42
Q

When should SSRIs be taken and why?

A

In the morning to try to avoid insomnia

43
Q

What is the outcome if a patient overdoses on SSRIs?

A

Relatively safe

44
Q

What happens if an SSRI is stopped suddenly?

A

Discontinuation syndrome - can result in shivering, anxiety, dizziness, ‘electric shocks’, headache and nausea

45
Q

Which SSRI gives the worst discontinuation symptoms and why?

A

Paroxetine because it has a short half-life

46
Q

What drug should SSRIs not be taken alongside and why? How can this be avoided?

A

NSAIDs- increased risk of GI bleed / Give patients a PPI

47
Q

Which SSRI is safest if there are pre-existent cardiac problems?

A

Sertraline

48
Q

Which SSRI is safest in epilepsy?

A

Citalopram

49
Q

Why should an ECG always be performed before and after starting an SSRI?

A

Risk of long QT syndrome which could lead to arrhythmias

50
Q

Why should SSRI use be restricted in younger people?

A

Transient increased risk of self-harm and suicide

51
Q

If an SSRI needs to be used in a younger patient, which is the safest to use?

A

Fluoxetine

52
Q

Give two examples of SNRIs?

A

Venlafaxine, duloxetine

53
Q

What is the mechanism of action of SNRIs

A

These selectively block the reuptake of serotonin and noradrenaline to increase the amount of neurotransmitter in the synaptic cleft so that the effects of serotonin and noradrenaline last longer.

54
Q

Why are SNRIs not usually used first line for depression?

A

More side effects than SSRIs (but less than tricyclics)

55
Q

When are SNRIs usually used?

A

When SSRIs and/or mirtazapine have not worked

56
Q

What may duloxetine be used for aside from depression?

A

Neuropathic pain or bladder instability

57
Q

What are the side effects of SNRIs?

A

The same as for SSRIs, but also hypertension and arrhythmias

58
Q

When monotherapy has not worked, venlafaxine works excellently in combination with which other drug?

A

Mirtazapine (California Rocket Fuel)

59
Q

When should SNRIs be taken and why?

A

In the morning to avoid insomnia

60
Q

Name some examples of tricyclic anti-depressants?

A

Imipramine, amitriptyline, clomipramine

61
Q

What is the mechanism of action of tricyclics?

A

Non-specifically block the reuptake of monoamines in the pre-synaptic terminals to increase the amount of neurotransmitter to make their actions last longer

62
Q

Tricyclic anti-depressants are equally as effective as SSRIs. Why are they not used first line in depression?

A

Cardiac side effects and danger in overdose

63
Q

What are some uses of tricyclics which are not depression?

A

Neuropathic pain, OCD, anxiety, migraine prophylaxis

64
Q

The side effects of tricyclics can be put into 3 groups. What are these groups?

A

Anti-cholinergic, anti-histaminergic and cardiovascular

65
Q

What are anti-cholinergic side effects seen in tricyclic anti-depressants?

A

Dry mouth, blurred vision, constipation and urinary retention

66
Q

What are anti-histaminergic side effects seen in tricyclic anti-depressants?

A

Sedation and weight gain

67
Q

What are cardiovascular side effects seen in tricyclic anti-depressants?

A

Postural hypotension, tachycardia, arrhythmias, cardiotoxic in overdose

68
Q

What is the remaining side effect of tricyclic anti-depressants which does not come under one of the 3 main groups?

A

Sexual dysfunction

69
Q

When should tricyclic anti-depressants be taken and why?

A

At night due to sedation

70
Q

Who should tricyclic anti-depressants be avoided in?

A

Older people, those with pre-existing cardiac conditions and those with suicidal intent

71
Q

What is the only atypical anti-depressant?

A

Mirtazapine

72
Q

What is the name of the drug class in which mirtazapine is found?

A

Noradrenergic and specific serotonergic antidepressants

73
Q

What is the mechanism of action of mirtazapine?

A

Works similarly to an SSRI but also blocks some post-synaptic receptors

74
Q

Which neurotransmitters are increased by using mirtazapine?

A

Noradrenaline and 5-HT

75
Q

When should mirtazapine be used first line?

A

If the patient has insomnia and/or poor appetite

76
Q

When is mirtazapine often used?

A

When SSRIs have not worked

77
Q

Mirtazapine is also a useful drug for the treatment of which common co-morbidity of depression?

A

Anxiety

78
Q

What are the main side effects of mirtazapine?

A

Sedation, hunger and weight gain, constipation, dizziness and falls, vivid dreams

79
Q

Mirtazapine can be used in combination with which other drugs?

A

SSRIs or venlafaxine

80
Q

What is the advantage of using mirtazapine in combination with SSRIs?

A

Blocks serotonergic side effects

81
Q

When should mirtazapine be taken and why?

A

At night due to sedation

82
Q

Can mirtazapine be given to people with cardiac problems?

A

Yes, this is relatively safe

83
Q

What happens if mirtazapine is taken with alcohol?

A

Causes GI upset

84
Q

When do you have to be careful about combining mirtazapine?

A

If the patient is taking other sedating agents

85
Q

You should always be aware of drugs causing cognitive impairment in the elderly. Which anti-depressants are most likely to cause this?

A

Tricyclics

86
Q

If elderly patients are prone to falls, which type of anti-depressant should you use? What are features which you should try to avoid?

A

You should stick to SSRIs and try to avoid any drugs which decrease BP or cause sedation

87
Q

What is probably the best all round SSRI?

A

Escitalopram

Psychiatry (20 decks)

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