Depression Flashcards
(25 cards)
What are the treatment options for depression? What are the lines of treatment?
1st line: SSRIs
2nd: increase SSRI dose, switch to a different SSRI, switch to mirtazapine
3rd: add a different class - TCAs, SNRI (venlafaxine - for severe depression), moclobemide
3rd: augmenting agent - lithium, antipsychotic
irreversible MAOIs: specialist supervision
Which TCAs have the most antimuscarinic effects, highest risk of liver toxicity, toxic in overdose?
imipramine: antimuscarinic (M/M)
lofepramine: liver toxicity (L/L)
dosulepin: toxic in overdose
What are the types of MAOIs?
PIT: irreversible
phenelzine
isocarboxazid
tranylcypromine
moclobemide: reversible
Which SSRIs are good for
- children
- CVD
Which SSRI
- has the greatest risk of withdrawal reaction
- causes QT prolongation
children: fluoxetine
CVD: sertraline
greatest risk of withdrawal reaction: paroxetine
QT prolongation: citalopram, escitalopram
How long does it take antidepressants to work? When can you switch? How often should they be reviewed? How long are they used for?
takes upto 4 weeks to see effects
can be changed after 4 weeks (6 weeks for elderly)
review within 2 weeks, 2-4 weeks to see response to treatment
review after 1 week: if at risk of suicide or who are aged 18 to 25 years
take for at least 6 months (12 months in elderly) after remission, 12 months in GAD, 2 years in recurrent depression
What are the benefits of SSRIs over TCAs?
less sedation
fewer antimuscarinic side effects
fewer cardiotoxic side effects
safer in overdose
better tolerated
What are the side effects of SSRIs?
hyponatraemia
suicidal behaviour: especially at the beginning of treatment
GAS
GI disturbances: nausea, vomiting
appetite or weight disturbance
serotonin syndrome
What are the symptoms of hyponatreamia?
3C’s of hyponatraemia: coma, convulsions, confusion
SALTLOSS
stupor/coma
anorexia
lethargy
tendon reflexes - decreased
limp muscles - weakness
orthostatic/postural hypotension
seizures/headaches
stomach cramps
What medications can cause serotonin syndrome?
SSRIs
TCAs
MAOIs
triptans
tramadol
lithium
linezolid
ondansetron
What are the symptoms of serotonin syndrome?
NAA: withdraw
neuromuscular hyperactivity: tremor, muscle rigidity, myoclonus
autonomic dysfunction: hyperthermia, tachycardia, pallor, sweating, labile BP
altered mental state: agitation, confusion, mania
What are the less sedating TCAs?
NIL
nortriptyline
imipramine
lofepramine
When are SSRIs and TCAs CI?
manic phase in bipolar disorder
What are antimuscarinic side effects?
anorexia
blurred vision
constipation, confusion
dry mouth
urinary retention
What are the symptoms of TCA overdose?
dry mouth
hypotension
hypothermia
convulsions
arrhythmias
dilated pupils
urinary retention
coma
What is withdrawal reaction with antidepressants?
withdraw reactions occur within 5 days of stopping
higher risk if suddenly stopped after >8 weeks of taking it
reduce dose gradually over 4 weeks or more
highest risk with paroxetine and venlafaxine
What are the risks associated with SSRIs?
increased bleeding risk
QT prolongation
lowered seizure threshold
movement disorders and dyskinesia
What are the main drug interactions for SSRIs?
increased bleeding his: NSAIDs, aspirin anti platelets, anticoagulants
increased risk of QT prolongation: macrolides, amiodarone, mefloquine, chloroquine, lithium, antipsychotics
hypokalaemia (leads to TDP): theophylline, beta agonists, diuretics, corticosteroids
What are the main drug interactions for TCAs?
increased risk of hypotension: antihypertensives, SGLT2i, dopaminergic, sildenafil
increased muscarinic effects: antipsychotics, atropine, oxybutynin, tolterodine
What are the main points of MAOIs?
MAOOI
massive hypertensive crisis risk
avoid tyramine
OTC meds: pseudoephedrine, avoid during + 14 days after
other antidepressants: serotonin syndrome
increased suicide risk
can cause hepatotoxicity in hepatic impairment
What are the main interactions for MAOIs?
hypertensive crises: pseudoephedrine, adrenaline (avoid during + 14 days after), levodopa, MAObIs, TCAs
tranylcypromine + clomipramine
What are the main food interactions for MAOIs?
food containing tyramine: mature cheese, wine pickled herring, game, meat sticks, yeast extracts, fermented soya bean products
avoid alcohol/de-alcoholised (low alcohol) drinks
avoid stale or ‘going off’ food: eat only fresh food
When should MAOIs be discontinued?
risk of postural hypotension and hypertensive responses
- discontinue if palpitations or frequent headaches occur
Can MAOIs be used in pregnancy?
avoid: risk of neonatal malformation
What is the MHRA warning for SSRIs/SNRIs?
small increased risk of postpartum haemorrhage when used in the month before delivery
