Antidepressant Drugs

Question 1

what is prescribed for all levels of depression

Answer 1

Psychotherapy

• CBT
• lifestyle changes
• establishing routine

Question 2

when starting an antidepressant, how long do you wait to see if it improves symptoms

Answer 2

4 weeks

Question 3

if there has been no improvement after 4 weeks, what do you do?

Answer 3

change the drug

Question 4

if there as been some improvement after 4 weeks, what do you do?

Answer 4

re-evaluate after another 4 weeks

Question 5

how long should you stay on an antidepressant after improvement

Answer 5

at least 6 months - 1 year

Question 6

which antidepressant is usually first line

Answer 6

SSRIs

selective serotonin reuptake inhibitors

Question 7

mechanism of action of SSRIs

Answer 7

block reuptake of serotonin into presynaptic cell – increase serotonin in the synaptic cleft

Question 8

examples of SSRIs

Answer 8

fluoxetine
citalopram
sertraline
paroxetine

Question 9

how long do SSRI’s take to work

Answer 9

2-3 weeks

Question 10

which SSRI is best in adolescents

Answer 10

fluoxetine

Question 11

what pathway does fluoxetine block

Answer 11

CYP450

Question 12

which SSRI is best in epileptic patients

Answer 12

citalopram

Question 13

which SSRI is safest in cardiac patients

Answer 13

sertraline

Question 14

what drugs are contraindicated with SSRIs

Answer 14

triptans
NSAIDS
aspirin
warfarin

Question 15

side effects of SSRI’s

Answer 15

GI upset 
nausea
headache 
insomnia 
sweating 
sexual dysfunction 
vivid dreams 
worsened anxiety for first few days

Question 16

risk of SSRIs in younger patients

Answer 16

can increase risk of self harm in first few weeks

Question 17

side effect of SSRIs in the elderly

Answer 17

hyponatraemia

confusion, lethargy, nausea, headache, seizures

Question 18

when should SSRIs be taken and why

Answer 18

in the morning to reduce the effect on insomnia

Question 19

mode of action of TCAs (tricyclic antidepressants)

Answer 19

block the reuptake of serotonin + noradrenaline into presynaptic terminals

Question 20

which receptors do TCAs also block

Answer 20

muscarinic receptors , alpha adrenoreceptors and histamine receptors — leads to unwanted side effects

Question 21

examples of TCAs

Answer 21

amitriptyline
imipramine
lofepramine

Question 22

anticholinergic side effects of TCAs

Answer 22

blurred vision 
dry mouth 
constipation 
urinary retention
weight gain

Question 23

cardiovascular effects of TCAs

Answer 23

tachycardia
arrhythmia – prolonged QT
cardiotoxicity in overdose

Question 24

when are TCAs taken and why

Answer 24

at night due to side effect of sedation

Question 25

why should TCAs be avoided in patients with suicidal attempt

Answer 25

very dangerous in overdose -- cardiotoxicity

Question 26

anti-adrenergic side effect of TCAs

Answer 26

postural hypotension

Question 27

what ECG changes can be seen with TCAs

Answer 27

Long QT interval | ST elevation

Question 28

contraindications for TCAs

Answer 28

``` recent MI arrythmias severe liver disease mania high risk of overdose ```

Question 29

mode of action of MAOIs (monoamine oxidase inhibitors)

Answer 29

slows breakdown of noradrenaline, serotonin and dopamine by inhibiting the mitochondrial enzymes monoamine oxidase A and B

Question 30

which MAOI displays irreversible inhibition

Answer 30

phenelzine

Question 31

which MAOI displays reversible inhibition

Answer 31

moclobemide

Question 32

when are MAOIs used

Answer 32

atypical depression | 3/4th line in resistant depression

Question 33

side effects of MAOIs

Answer 33

hypertensive crisis | serotonin syndrome

Question 34

what leads to a hypertensive crisis with use of a MAOI

Answer 34

MAOIs inhibit MAO-A in the gut and the liver - the enzyme usually breaks down dietary tyramine build up of tyramine (from diet) increases noradrenaline causing vasoconstriction -- hypertension

Question 35

symptoms of hypertensive crisis

Answer 35

headache, SOB, flushing, high BP, anxiety, arrhythmia

Question 36

treatment of hypertensive crisis

Answer 36

alpha blockade -- phentolamine

Question 37

what foods must patients avoid on a MAOI

Answer 37

foods rich in tyramine - cheese - yoghurt - alcohol - meat - yeast

Question 38

what causes serotonin syndrome

Answer 38

if a MAOI is combined with another anti-depressant

Question 39

signs of serotonin syndrome

Answer 39

neuromuscular abnormalities altered conscious level autonomic instability

Question 40

contraindications of MAOIs

Answer 40

cerebrovascular disease pheochromocytoma hepatic impairment

Question 41

examples of serotonin noradrenaline reuptake inhibitors (SNRIs)

Answer 41

venlafaxine | duloxetine

Question 42

what can duloxetine be used for other than depression

Answer 42

neuropathic pain | stress incontinence

Question 43

example of an NaSSA

Answer 43

mirtazapine

Question 44

when is mirtazapine used

Answer 44

first line if patient has a poor appetite / insomnia

Question 45

side effects of mirtazapine

Answer 45

``` increased appetite weight gain sedation tremor peripheral oedema ```

Question 46

what is given with sexual dysfunction caused by SSRI

Answer 46

trazodone

Question 47

prior to starting ECT, how should antidepressant doses be adjusted

Answer 47

decrease dose gradually before starting ECT

Question 48

short term side effects of ECT

Answer 48

headache nausea short term memory impairment cardiac arrhythmias

Question 49

complications of SSRIs used in - 1st trimester - 3rd trimester

Answer 49

1st trimester = congenital heart defects | 3rd trimester = persistent pulmonary HTN