Depression

Question 1

Goal of antidepressants

Answer 1

Target psychomotor and physiological changes e.g. loss of appetite and sleep disturbances
Improvement in sleep- usually first benefit of therapy
Used for moderate to severe depression, in addition to dysthymia (lower grade chronic depression)

Question 2

ECT (electroconvulsive treatment)

Answer 2

Can be used in severe depression if 2 week onset of antidepressant therapy would may result in harm for the patient

Question 3

First line for depression

Answer 3

SSRIs

Better tolerated
Safer in overdose
In patients with unstable angina or those who have had a recent MI- sertraline found to be safe

Question 4

TCAs

Answer 4

Similar efficacy to SSRIs
More likely to be discontinued due to side effects: sedating, anti-muscarinic SE and cardiotoxic
Toxicity in overdose

Question 5

MAOIs

Answer 5

Avoid tyramine-rich foods

Question 6

How long to wait before considering switching antidepressant?

Answer 6

4 weeks (6 weeks in the elderly)

Question 7

Following remission, how long should treatment be continued for?

Answer 7

At the same dose for at least 6 months (12 months in elderly)
If they have a history of recurrent depression, they should receive maintenance therapy for at least 2 years.

Question 8

Hyponatraemia

Answer 8

Most common with SSRIs than with other antidepressants

Should be considered in all patients who develop drowsiness, confusion or convulsions while taking an antidepressant

Question 9

Suicidal thoughts and behaviour

Answer 9

Children, young adults and those with a history of suicidal behaviour are particularly at risk

Question 10

Symptoms of serotonin syndrome

Answer 10

NEUROMUSCULAR HYPERACTIVITY: tremor, hyperreflexia, clonus, myoclonus, rigidity

AUTONOMIC DYSFUNCTION: tachycardia, blood pressure changes, hyperthermia, shivering, diarrhoea

ALTERED MENTAL STATE: agitation, confusion, mania

Question 11

Failure to respond

Answer 11

FTR to initial SSRI treatment- increase in dose, switch to a different SSRI or mirtazapine.

Other 2nd lines are lofepramine, moclobemide, reboxetine. Other TCAs and venlafaxine should only be considered in severe depression and MAOIs should only be initiated by specialists.

Question 12

Management of acute anxiety

Answer 12

Benzodiazepine or busiprone hydrochloride

For chronic (longer than 4 weeks duration) may be suitable to use an antidepressant.

Question 13

Treatment of Generalised Anxiety Disorder

Answer 13

SSRI- escitalopram, paroxetine
SNRI- Duloxetine, venlafaxine
If these are not tolerated, pregabalin can be considered.

Question 14

Treating panic disorder, OCD, PTSD and phobic states such as social anxiety disorder

Answer 14

1st line- SSRIs
2nd line in panic disorder (unlicensed)- clomipramine hydrochloride or imipramine hydrochloride

Moclobemide- can be used in social anxiety disorder

Question 15

Sedative tricyclic antidepressants

Answer 15

Amitriptyline
Clomipramine
Dosulepin
Doxepin
Mianserin
Trazodone
Trimipramine

Question 16

Less sedative tricyclic antidepressants

Answer 16

Imipramine
Lofepramine
Nortriptyline

Question 17

Lofepramine

Answer 17

Lowest incidence of side effects
Less dangerous in overdose
But hepatic toxicity

Question 18

Imipramine

Answer 18

More antimuscarinic side effects than other TCAs

Question 19

Most dangerous in overdose

Answer 19

Amitriptyline and dosulepin

Question 20

Administration of TCAs

Answer 20

Long half life so only once at night administration is required

Question 21

TCAs and children

Answer 21

Studies show that TCAs are not effective for treating depression in children

Question 22

STOPP criteria for TCAs in the elderly

Answer 22

Those with dementia, narrow angle glaucoma, cardiac conduction abnormalities, prostatism or history of urinary retention

Question 23

Stimulant action of MAOIs

Answer 23

Tranylcypromine has a greater stimulant action than phenelzine or isocarboxazid so is more likely to cause a hypertensive crisis.

Question 24

Hepatotoxicity in MAOIs

Answer 24

Isocarboxazid and phenelzine are more likely to cause hepatotoxicity than tranylcypromine.

Question 25

Patients who are said to respond best to MAOIs

Answer 25

Phobic patients and depressed patients with atypical, hypochondriacal or hysterical features

Question 26

Response to MAOI treatment

Answer 26

May take up to 5 weeks

Question 27

How long after stopping MAOI treatment can treatment with other antidepressants be commenced?

Answer 27

2 weeks | 3 weeks if starting clomipramine or imipramine

Question 28

How long after stopping an MAOI can another be started?

Answer 28

2 weeks (then start at a reduced dose)

Question 29

How long after stopping a TCA can an MAOI be started?

Answer 29

At least 7-14 days (3 weeks in the case of clomipramine or imipramine)

Question 30

How long after stopping an SSRI can an MAOI be started?

Answer 30

``` 1 week (At least 5 weeks in the case of fluoxetine) ```

Question 31

Flupentixol (thixanthene)

Answer 31

Antidepressant properties at low doses | Also used for the treatment of psychoses

Question 32

Vortioxetine

Answer 32

Recommended in patients who have responded inadequately to 2 antidepressants within the current episode

Question 33

Tryptophan

Answer 33

Treatment-resistant depression Withold treatment if patient experiences any symptoms of eosinophilia myalgia syndrome (EMS) until the possibility of EMS is excluded.

Question 34

Agomelatine

Answer 34

Liver function tests

Question 35

Monoamine oxidase inhibitors

Answer 35

Risk of postural hypotension and hypertensive episodes- monitor BP

Question 36

MAOI withdrawal symptoms

Answer 36

``` Agitation Irritability Ataxia Movement disorders Insomnia Drowsiness Vivid dreams Cognitive impairment Slowed speech ```

Question 37

How long within stopping antidepressants can withdrawal symptoms present?

Answer 37

5 days

Question 38

When is risk of developing withdrawal to antidepressants highest?

Answer 38

If they have been taking for longer than 8 weeks

Question 39

How long does the danger of interaction between MAOIs and tyramine-rich foods last for after discontinuation?

Answer 39

2 weeks Avoid alcoholic or low alcohol drinks in addition to food that may be going off or stale

Question 40

Moclobemide

Answer 40

Claimed to cause less potentiation of tyramine than other traditional irreversible MAOIs such as phenelzine, tranylcypromine and isocarboxazid but should still avoid consuming lots of mature cheese, yeast extracts and fermented soya bean products, etc.

Question 41

Contraindications of SSRIs

Answer 41

Poorly controlled epilepsy | If patient enters the manic phase

Question 42

Sexual dysfunction with SSRIs and SNRIs

Answer 42

May persist even after treatment has stopped.

Question 43

SSRI withdrawal symptoms

Answer 43

``` GI disturbances Headache Anxiety Electric shock sensation in the head, neck, spine Tinnitus Sleep disturbances Fatigue Influenza-like symptoms Sweating ```

Question 44

Citalopram/escitalopram oral drops

Answer 44

Can be mixed with water, orange juice or apple juice before taking

Question 45

SSRIs

Answer 45

Counsel on effect on driving and skilled tasks

Question 46

Paroxetine and venlafaxine

Answer 46

Associated with higher risk of withdrawal symptoms

Question 47

Duloxetine in pregnancy

Answer 47

Avoid if stress urinary incontinence but if not, use only if potential benefit outweighs risk

Question 48

Contraindication to venlafaxine

Answer 48

Uncontrolled hypertension

Question 49

Trazodone

Answer 49

Serotonin uptake inhibitor

Question 50

Amitriptyline

Answer 50

Associated with a higher rate of fatality with overdose Treatment should be stopped if patient enters manic phase TCAs should be prescribed in limited quantities at one time due to the potential cardiogenic and epileptogenic effects in overdose. Max 2 weeks of 75mg daily should be considered for patients at increased risk of suicide.

Question 51

TCA overdose symptoms

Answer 51

``` Dry mouth Coma Hypotension Hypothermia Hyperreflexia Convulsions Respiratory failure Arrhythmias Dilated pupils and urinary retention ```