Anti-depressants Flashcards
(27 cards)
How do you diagnose depression? (DSM V criteria)
At least 2 weeks of depressed emotions and at least 4 of the follow symptoms ‘SIGECAPS’ or some other mneumonic:
A SAD FACES
What are some neurological disease differentials for depressive symptoms?
- Neurodegenerative disease: Parkinson’s disease, Alzheimer’s
- Space occupying lesion
- Malignancy
- Collagen vascular disease (e.g. SLE)
What are some non-neurological differentials for depressive symptoms?
Endocrinopathies (DM, Cushing syndrome, Addison disease) Chronic renal failure Anaemia Other malignancy Viral illness
What are the different types of primary depression and give brief description for each.
- Melancholic depression: persistent feeling of sadness and hopelessness.
- Non-melancholic depression: in-response to a stressful life event, or as part of person’s personality type.
- Psychotic depression: psychosis + depression causing them to see, hear, believe things that aren’t real.
- Catatonic depression: not speaking or responding to things for a long period.
- Atypical depression: increased appetite, hyposomnia
What are secondary types of depression?
- Malignancy
2. Medications
Describe pathophysiology of depression.
Noradrenaline and serotonin are the main determinant
neurotransmitters in most mood disorders (also dopamine and acetylcholine)
After a stressful incident, the brain biology changes and so do the neurotransmitters, signalling systems and sometimes loss of neurons.
When is depression likely to relapse if they are taking antidepressants?
If the patient stops antidepressants immediately, it is more likely to relapse within 3 months. (ALMOST ALWAYS RELAPSES)
What can repetitive depressive episodes lead to?
Manic episodes and mental bipolar diseases instead of depression.
List the antidepressant classes commonly used.
- Selective serotonin reuptake inhibitors (SSRI)
- Serotonin noradrenaline reuptake inhibitors (SNRI)
- TCA
- MAOI
- Noradrenergic and specific serotonergic antidepressant
- Melatonin agonist
SSRI
MOA and name three agents.
Least side effects and safer in overdose.
Inhibits serotonin reuptake in the presynaptic cells by blocking reuptake transporters, and downregulates the autoreceptors. It increases serotonin transmission.
It also causes weak inhibition of noradrenaline and dopamine with adrenergic, histamine and muscarinic effects.
Fluoxetine, citalopram, paroxetine, sertraline
SSRI
Side effects?
Orthostatic hypotension
Sexual dysfunction
Changes in appetite and weight gain
Nausea, dizziness, insomnia, anxiety, tremor
Liver or renal impairment
Suicidality, depersonalisation or rebound anxiety
Hyponatraemia
Sweating
Decreased tolerance to alcohol
Serotonin syndrome if combined with other antidepressants (possibly fatal)
TCA
MOA and name examples.
Inhibits uptake of noradrenaline, dopamine, serotonin. It also blocks muscarinic cholinergic receptors, H1 receptor and alpha 1 adrenergic receptors.
Amitriptyline, imipramine, clomipramine
TCA
Side effects?
Dry mouth, blurred vision, constipation, urinary retention, drowsiness, anxiety, weight gain, postural hypotension, sedation, confusion, lower seizure threshold, serotonin syndrome
MAOI
MOA and name examples.
Inhibits monoamine oxidase, decreases metabolism of monoamine neurotransmitters including NA, serotonin, adrenaline and dopamine.
Isocarboxazid, moclobemide
MAOI
Side effects?
Orthostatic hypotension, peripheral oedema, headache, insomnia, weight gain, tremors, anxiety, sexual dysfunction, liver toxicity
Noradrenergic and specific serotonergic antidepressant
MOA and name examples,
Blocks alpha 2, 5-HT2C and 5-HT3 receptors.
Mirtazapine, Mianserin
NaSSA
Side effects?
Weight gain
Melatonin agonist
MOA and side effects?
MT1 and MT2 agonist, and 5-HT2C receptor antagonist.
Side effects include dizziness and GI symptoms.
What would you advice patients on with antidepressant prescription?
- Education on what the drug does
- Education on how it works
- Education on side effects
- Duration (1-2 weeks) until it starts working
- How long it takes for it to come to full effect (4-6 weeks)
- Emphasise medication compliance
- Drug interactions and contraindications
- Used in adjunct with non-pharmacological interventions (CBT, psychologist referral)
What drugs will antidepressants interact with?
Paracetamol, codeine and steroids Warfarin Antiarrhythmics Calcium channel antagonists Serotonin syndrome if other antidepressants are added.
How long should antidepressants be used for?
Continued for at least 6 months and preferably 12 months after a single episode of major depression as there is higher risk of relapse. But if the patient has a history of relapse then it should be used for a few years as there is increased likelihood of relapse.
If the patient improves, would you stop antidepressant straight away?
Yes
No
Why?
No. (risk of relapse and discontinuation syndrome)
Discontinuation syndrome:
- More likely to occur if they were on higher dose for longer
- Insomnia, sweating, nausea, sensory changes, postural imbalance, delirium
How do you discontinue SSRI?
Wean off slowly!
Doses halved every week until half of the lowest dose possible. Continue at this dose for 1 week before cutting off.
Educate family and friends about discontinuation syndrome and clinical presentations to recognise it.
How do you change antidepressant?`
- Assess, continue if patient responds well
- Increase dose if there is no initial response
- Assess response to higher dose for 2-4 weeks
- If there is no response, switch
- Partial response then increase dose (if maximum reached then change drug)
New drugs should be started at a low dose.
TCA and MAOI should be used only after first-line therapies are ineffective.
