Anxiety and Depression Flashcards
(24 cards)
Depression is characterised by
absence of positive affect – loss of interest and enjoyment in ordinary things
and experiences
* low mood
* range of associated emotional, cognitive, physical and behavioural symptoms
* see DSM-5 or ICD-11 criteria for depression
Symptoms must cause clinically
significant distress or impairment in
function
* Must not be more easily explained by a
life event e.g. bereavement
Depression is defined as:
Presence of 5 or more symptoms
during 2 week period, where at least
1 of the symptoms is depressed
mood or loss of interest/pleasure
* Depressed mood most of the day, nearly every day
* Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, every day
* Significant weight loss when not dieting, or weight gain, or
decrease or increase in appetite nearly every day
* Slowing down of thoughts and reduction of physical movement
(observable by others, not merely subjective feelings)
* Fatigue or loss of energy nearly every day
* Feelings of worthlessness or excessive/inappropriate guilt nearly
every day
* Diminished ability to think or concentrate, or indecisiveness nearly
every day
* Recurrent thoughts of death, recurrent suicidal ideation without a
specific plan, or a suicide attempt, or a specific plan for committing
suicide
Risk Factors for depression
Being female (twice the rate for men)
* Family history
* Previous depression
* Chronic physical illness
* Stressful life events
* Alcohol or substance abuse
* Family disadvantages in early life
* Age of onset usually 20-40 years
* Some medications – progesterone, statins, steroids,
propranolol, mefloquine
Depression treatment
Do not offer antidepressant medication as first-line treatment for less severe
depression, unless it is the person’s preference.
* Options should be discussed with the patient and discussions should include:
* Risk of side effects
* Interactions
* Their physical health
* Medicines previously tried
* SSRIs are first line as they are equally as effective as other antidepressants and
have a favourable risk-benefit ratio
* Consider overdose risk
* Consider specific cautions, contraindications and risks
SSRI MOA
- Selectively inhibit reuptake of serotonin from the synapse
into the presynaptic neurone. - Increases amount of serotonin available in synapse
- Amount of serotonin builds up slowly and results in
increased occupancy of post synaptic receptors
SSRI side effects
- Nausea and diarrhoea
- Usually transient
- Bleeding disorders
- SSRIs deplete platelet serotonin – reduced ability to form clots
- Bruising, purpura, epistaxis, increased risk of peri-operative bleeding,
increased risk of cerebral haemorrhage, increased risk of GI haemorrhage
(especially with aspirin, NSAIDs and in elderly) - Caution in history of GI bleeding
- Consider PPI prescription if unavoidable
- Hyponatraemia
- Particularly in elderly
- Sexual dysfunction
Examples of SNRIs
- Venlafaxine
- Duloxetine- Less evidence for efficacy than venlafaxine
Venlafaxine safety profile
Can cause problems with BP, pulse,
arrhythmias at higher doses
* Greater risk in overdose than with SSRIs
Mirtazapine MOA
- “Noradrenalin and specific serotonin antidepressant” (NASSA)
- 5-HT and alpha receptor antagonist
- Enhances both noradrenergic and serotonergic neurotransmission (does not inhibit reuptake)
- Pre synaptic alpha auto-receptor antagonist on noradrenaline neurones
- Leads to loss of inhibition and an increase in noradrenaline and serotonin release
- Post synaptic 5-HT antagonist, specifically 5-HT2 and 5-HT3
- Leads to remaining serotonin concentration left to interact with the free 5-HT1 receptor
- Antagonism of 5-HT2 and 5-HT3 receptors thought to minimise sexual dysfunction and nausea
- Potent histamine H1 receptor antagonist
Mirtazapine side effects
- Sedation
- Weight gain
- Increased appetite
- Dry mouth
- Constipation
Less common antidepressants
- Tricyclic antidepressants (TCAs) – amitriptyline, nortriptyline, lofepramine
- Block re-uptake of both serotonin and noradrenaline
- Trazodone – 2
nd generation tricyclic - Vortioxetine – dual action SSRI and receptor modulator. Only consider vortioxetine when there
has been limited response to at least 2 antidepressants (NICE 2022) - Reboxetine
- Monoamine oxidase inhibitors (MAOIs) – phenelzine,
- Risk of hypertensive crisis with consumption of tyramine rich foods
- Difficult to stop/swap
depression Further line treatment
- Increase dose (may not be more effective and increase side effects)
- Switch to medication from another class e.g., TCA or MAOIs
- Adding in another antidepressant e.g., mirtazapine or trazodone
- Adding in second-generation antipsychotic (unlicensed medication for
indication) or lithium - Electroconvulsive therapy, lamotrigine or triiodothyronine (unlicensed
medication for indication) - For chronic depressive symptoms alternatives include TCAs, moclobemide,
MAOIs, low dose amisulpride max 50mg daily (unlicensed medication for
indication)
Stopping antidepressants
- Antidepressants should be continued for 6 months after complete
remission of symptoms (longer if previous episodes) - Warn people about discontinuation symptoms if stopped abruptly or
miss a dose, but that not everyone will experience these symptoms - Consider pharmacokinetic profile (antidepressant with short half-life
should be tapered more slowly) and the duration of treatment - Slowly reduce dose by prescribing proportion of previous dose (e.g.,
50% reduction) - Consider smaller reduction e.g., 25% as dose becomes lower
- Consider using liquid preparations
- Speed of discontinuation should be led by the person. Can take
months
Antidepressants and suicide risk
- Conflicting claims that antidepressants reduce suicides rates and that they increase
the risk in certain patients - If a suicide risk exists or for people aged 18-25 years, when prescribing
antidepressant: - Assess baseline mental state
- Be aware of prevalence of increased suicidal thoughts, self-harm and suicide in the
early stages of antidepressant treatment and ensure risk management strategy in place - Review one week after starting antidepressant therapy or increasing dose. Review
again as often as needed, but no later than every 4 weeks - Consider individual circumstances when deciding frequency of ongoing reviews
- Consider toxicity in overdose. Do not routinely start treatment with TCAs, (greatest risk
in overdose) except lofepramine.
Serotonin Syndrome Symptoms
Restlessness
Diaphoresis
Fever
Tremor
Shivering
Muscle rigidity
Myoclonus
Confusion
Convulsions
Death
Other types of depression
- Other forms of depression may require different treatment
- Treatment resistant depression
-SSNRI/SSRI + mirtazapine, lithium, antipsychotics, ECT - Psychotic depression
-Antidepressant + antipsychotic - Post-natal depression
-SSRIs/SNRIs if benefits outweigh risks - Catatonic depression
-High dose lorazepam, ECT - Bipolar depression
-Mood stabilisers
Anxiety
Spectrum of disorders
including:
* Generalized anxiety disorder
(GAD)
* Panic disorders * Obsessive compulsive disorder
(OCD)
* Mixed anxiety and depression * Post traumatic stress disorder
(PTSD)
Anxiety Diagnosis
- Anxiety is a normal self-limiting emotion that we are all familiar with
- Is pathological when it interferes with an individuals ability to function in
day to day life - Lasts longer than 6 months
- Different anxiety disorders present differently but all have some
similarities
Anxiety Psychological Symptoms
- Fear
- Worry
- Poor concentration
- Poor sleep
- Nightmares
- Repetitive thoughts
- Irritability
- Restlessness
- Anticipation
- Sensitivity to noise
anxiety Physical Symptoms
- GI – nausea, wind, diarrhoea, epigastric pain, loss of appetite
- Respiratory – increased respiratory rate, chest tightness, overbreathing, tingling in hands and feet
- MSK – backache, headache, neck ache, shoulder pain
- Other – amenorrhea, chills, hot flushes, tremor, increased urination,
palpitations, loss of libido
anxiety drug treatment
- Psychological therapies are first line
- GAD
- Offer an SSRI. NICE guidelines suggest sertraline but this is unlicensed.
- If ineffective switch to alternative SSRI or an SNRI.
- If SSRIs or SNRIs not tolerated offer pregabalin
- Panic disorder
- SSRI. Do not give benzodiazepines except short term in a crisis
- OCD
- SSRIs
- PTSD
- Poor evidence for drug treatments
Pregabalin for Anxiety
- Dose for GAD – 150mg-600mg daily in divided doses
- Use lower doses in older adults
- Renally cleared therefore dose reductions needed in renal
impairment - Binds to an auxiliary subunit of voltage gated calcium channels in the
CNS, reducing excitability - Side effects; sedation, constipation, confusion, euphoria, blurred
vision, weight gain - Drug of abuse – now a controlled drug
Benzodiazepines
- Work by increasing the effects of the inhibitory transmitter GABA
- Can be used short term in crisis for anxiety spectrum disorders but
should not be the mainstay of treatment. - Efficacy reduces with long term treatment due to tolerance
- Regular review due to risk of addiction and abuse
Mixed anxiety and depression
Symptoms of both with equal
intensity
* Treat as per depression
* Often depression lifts first and
patients become more anxious
* CBT can be effective for both
anxiety and depression
