Depression

Question 1

first line antidepressant?

Answer 1

1. mirtazapine
2. SSRI
3. SNRI
4. bupropion

Question 2

non-pharm for depression?

Answer 2

sleep hygiene
psychotherapy
neurostimulation (ECT, rTMS) - reserve for severe depression

Question 3

what is considered adequate trial?

Answer 3

adequate dose + adequate duration (4-8w)

Question 4

why is there a delayed response?

Answer 4

due to gradual downregulation of pre-synpatic autoreceptors in synapse, which in turn facilitate neurotransmitter release

Question 5

how long does it take for physical sx (eg sleep & appetite) to improve?

Answer 5

1-2 weeks

Question 6

how long does it take for mood sxs to improve?

Answer 6

longer, 4-8 weeks

Question 7

how long should anti-depressants be continued for?

Answer 7

another 4-9 months after acute treatment (total 6-12 months)

Question 8

why does anti-depressants take so long to have an effect?

Answer 8

inhibition of pre-synpatic autoreceptors take a long time
inhibit pre-synaptic autoreceptors –> inhibit release of neurotransmitted

Question 9

most antidepressants have short half life, which anti-depressants have long half life?

Answer 9

fluoxetine, vortioxetine

Question 10

what TCAs are there?

Answer 10

Amitriptyline –> Nortriptyline
Imipramine –> Desipramine
Dothiepin (Dosulepin)
Clomipramine

Question 11

MOA of TCA

Answer 11

Blocks reuptake of NE & 5HT.
Anticholinergic
H1 & alpha-adrenergic antagonism

Question 12

SE of TCA

Answer 12

GI & sexual dysfunction,
Anticholinergic, Sedation,
Weight gain , Orthostatic, BP
Arrhythmias, Seizure,
Fatal on overdoses

Question 13

what SSRI are there?

Answer 13

Fluoxetine –>Norfluoxetine
Fluvoxamine
Escitalopram/Citalopram
Sertraline
Paroxetine

Question 14

MOA for SSRI?

Answer 14

Blocks reuptake of 5HT
selectively.

Question 15

side effects of SSRI?

Answer 15

GI & sexual dysfunction.
Headache, transient nervousness during initiation
Insomnia: Fluoxetine
Hyponatremia (SIADH)
Bleeding risk; EPSE

Question 16

which SSRI is the most anticholinergic, sedating, increase weight & short half life (withdrawal)?

Answer 16

paroxetine

Question 17

which cause QTc prolongation at high dose in elderly

Answer 17

escitalopram, citalopram

Question 18

what NaSSA are there?

Answer 18

mirtazapine

Question 19

side effects of NaSSA

Answer 19

Somnolence, increase appetite,
weight gain

Question 19

MOA of mirtazapine

Answer 19

alpha- 2 adrenoceptor antagonist
increase 5HT & NE
5HT2&3, H1 antagonism

Question 20

what are mirtazapine good for?

Answer 20

Reverse GI & sexual SE of SSRI/SNRI.

Question 21

what are NDRI?

Answer 21

bupropion

Question 22

MOA of bupropion

Answer 22

Blocks reuptake of NE & DA

Question 23

SE of bupropion

Answer 23

Seizure,
Insomnia, Psychosis
Not suitable for eating d/o.

Question 24

what benefit of brupropion

Answer 24

decrease sexual SE of SSRI/SNRI Smoking cessation aid

Question 25

what MAOi are there

Answer 25

moclobemide

Question 26

MOA of mocloblemide

Answer 26

Reversible MAOI A (RIMA)

Question 27

adjunct treatment for MDD (antipsychotic)

Answer 27

aripiparazole, brexpiparazole, quetapine XR

Question 28

what PRN hypnotics for adjunctive treatment for MDD?

Answer 28

benzodiazepines, z-hypnotics (zopiclone, zolpidem), antihistamine (hydroxyzine)

Question 29

dose of fluoxetine?

Answer 29

20mg OM, max 80mg

Question 30

dose of mirtazapine?

Answer 30

15-45mg, max 45mg

Question 31

can you combine MAOi & SSRI?

Answer 31

no, need wash out period when switching

Question 32

precautions in elderly?

Answer 32

avcoid TCAs

Question 33

mandatory counselling for

Answer 33

suicidality

Question 34

which antidepressant suitable for underweight?

Answer 34

mirtazapine

Question 35

which antidepressent suitable for chronic pain/neuropathy?

Answer 35

duloxetine

Question 36

which anti-depressants has fewer CYP interactions?

Answer 36

mirtazapine, escitalopram, venlaflazine, desvenlafazine, vortioxetine

Question 37

what is antidepressants discontinuoation syndrome?

Answer 37

due to abruptly stopping treatment esp paroxetine, venlaflaxine (short t1/2)

Question 38

presentation of antidepressants discontinuation syndrome?

Answer 38

FINISH Flu like symptoms (lethargy, fatigue, headache, achiness, Insomnia (with vivid dreams or Nausea (sometimes vomiting), Imbalance (dizziness, vertigo, light headedness), Sensory disturbances (“burning,” “tingling,”, “electric like” sensations) Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness).

Question 39

how to avoid Antidepressants Discontinuation Syndrome

Answer 39

gradual tapering