Antidepressants

Question 1

Sertraline
fluoxetine
paroxetine
citalopram

are examples of what

Answer 1

selective serotonin re-uptake inhibitors (SSRI)

Question 2

when starting an antidepressant what must you discuss with a patient

Answer 2

side effects
therapeutic effects
time taken to respond 
discontinuation symptoms 
safety net re suicide

Question 3

what is the mechanism of action of an SSRI

Answer 3

selectively block serotonin (5-HT) reuptake from the synaptic cleft

Question 4

what is the SSRI of choice in young people

Answer 4

fluoxetine

Question 5

what are SSRIs used in

Answer 5

1st line in depression

also GAD, panic disorder, phobia, OCD

Question 6

are SSRIs safe in overdose

Answer 6

yes

Question 7

SSRIs are associated with withdrawal symptoms, how long should the dose be tapered off

Answer 7

4 weeks and taper more slowly towards the end

Question 8

Can NSAIDs be given with an SSRI

Answer 8

advised against but can be, if they are need to co-prescribe a PPI

Question 9

what drugs used in cardiology should be avoided with SSRIs

Answer 9

warfarin
heparin
aspirin
- consider mirtazapine instead

Question 10

if an SSRI is used with a triptan or mono-oxidase inhibitor there is an increased risk of what

Answer 10

serotonin syndrome

Question 11

what are the main side effects of SSRIs

Answer 11

GI upset - abdominal pain, constipation, nausea
GI bleeds
sexual dysfunction
headaches
mood: agitation/anxiety, increased suicidality in young people
hyponatraemia
insomnia

Question 12

what is the concern with using SSRIs in the elderly

Answer 12

hyponatraemia and falls

Question 13

what specific side effects do paroxetine cause

Answer 13

more weight gain and sexual dysfunction

increased withdrawal effect

Question 14

what specific side effects do fluoxetine cause

Answer 14

insomnia
agitation
rash

Question 15

what specific side effects do sertraline cause

Answer 15

diarrhoea

Question 16

what specific side effects do citalopram cause

Answer 16

QT prolongation

Question 17

which SSRI is cardioprotective and therefore useful after an MI

Answer 17

sertraline

Question 18

what are the discontinuation symptoms of an SSRI

Answer 18

increased mood change
restlessness
difficulty sleeping/increased dreaming
unsteadiness
sweating
paraesthesia
GI symptoms

Question 19

if someone is starting an SSRI what can you advise them about the side effects of GI upset e.g. cramping, constipation, nausea

Answer 19

normally settle within a few weeks

Question 20

Amitriptyline, Norytrptiline, Lofepramine, Clomipramine imipramine, dosulepin, doxepin

are examples of what

Answer 20

tricyclic antidepressants

Question 21

what is the mechanism of action of TCAs

Answer 21

Block the reuptake of noradrenaline and serotonin from the synapse (non-selectively, also block dopamine, histamine and muscarinic ACh receptors)

Question 22

why do TCAs have an extensive side effect profile

Answer 22

also block dopamine, histamine and muscarinic ACh receptors

Question 23

why might a TCA impact a patients ability to drive/operate machinery

Answer 23

sedative

Question 24

are TCAs dangerous in overdose

Answer 24

yes - cardiotoxic

Question 25

what are TCAs used for

Answer 25

depression (less commonly now due to side effect profile and toxicity in overdose) neuropathic pain anxiety migraine prophylaxis

Question 26

what are the side effects of TCAs

Answer 26

- sedation, weight gain - dry mouth, constipation, blurred vision, urinary retention, sexual dysfunction - QT prolongation, tachycardia, hypotension

Question 27

venlafaxine and duloxetine are examples of what

Answer 27

serotonin and noradrenaline re-uptake inhibitors (SNRI)

Question 28

what is the mechanism of action of SNRIs

Answer 28

selectively block noradrenaline and serotonin reuptake (weak dopamine blockade)

Question 29

why are SNRIs preferable to TCAs

Answer 29

block major receptor blockade so reduced side effects

Question 30

when are SNRIs used

Answer 30

second line to SNRI in depression | anxiety disorders

Question 31

what are the side effects of SNRIs

Answer 31

GI upset | cardio - hypertension, palpitations, dizziness

Question 32

what kind of drug is mirtazapine

Answer 32

noradrenaline and serotonin specific antidepressant - atypical

Question 33

how does mirtazapine work

Answer 33

antagonises pre-synaptic noradrenaline, serotonin and histamine receptors (a-2, 5ht2 and 5ht3 receptors)

Question 34

why might mirtazapine be used and why

Answer 34

if patient experiencing weight loss and sleep disturbance - side effects include sedation and weight gain

Question 35

when should mirtazapine be taken

Answer 35

evening

Question 36

what are the side effects of mirtazapine

Answer 36

weight gain | sedation

Question 37

what kind of drug is moclobemide

Answer 37

reversible monoamine oxidase inhibitor (MAOI)

Question 38

what kind of drug is phenelzine

Answer 38

non-reversible mono-amine oxidase inhibitor

Question 39

how do monoamine oxidase inhibitors (MAOI) work

Answer 39

block monoamine oxidase (MOA-A and MOA-B) which prevents the breakdown of serotonin and noradrenaline (along with other neurotransmitters)

Question 40

what is a major adverse effect of monoamine oxidase inhibitors (MAOI) and how can it be avoided

Answer 40

hypertensive crisis (cheese reaction) non-reversible MAOI prevents breakdown of dietary tyramine. Tyramine is a substrate of MAO. Accumulation of tyramine causes noradrenaline release causing BP to sky rocket - avoid cheese, red wine and soy (food that contains dietary tyramine) - patients must be off TCA/SSRI for several weeks before starting MAOI

Question 41

what are the side effects of monoamine oxidase inhibitors (MAOI)

Answer 41

dizziness postural hypotension peripheral oedema anticholinergic - dry mouth, constipation, blurred vision, urinary retention and sexual dysfunction

Question 42

monoamine oxidase inhibitors (MAOI) are particularly good in what kind of depression

Answer 42

atypical depression

Question 43

what kind of drug is trazadone

Answer 43

serotonin antagonist and reuptake inhibitor (SARI)

Question 44

what is the mechanism of action of trazadone

Answer 44

potent serotonin and noradrenaline receptor antagonist

Question 45

is trazadone addictive

Answer 45

no

Question 46

what is the treatment of mild depression

Answer 46

``` active monitoring exercise guided self help CBT - antidepressants not generally recommended ```

Question 47

what would a general treatment plan of depression look like

Answer 47

SSRI unless reason it cannot be given if unsuccessful - increase dose or try a different SSRI if unsuccessful can augment with other drug