Depression

Question 1

What are the three severities of depression?

Answer 1

Mild
Moderate
Severe

Question 2

Depression is more common when in the presence of what other things?

Answer 2

Physical disease
Excessive and chronic alcohol misuse
Social stresses
Interpersonal difficulties
Lack of social support

Question 3

Name the three main types of antidepressant.

Answer 3

Tricyclic antidepressants
Selective serotonin reuptake inhibitors
Monoamine oxidase inhibitors

Question 4

What are the characteristic features of depression?

Answer 4

Low mood
Early morning wakening
Lethargic
Anhedonia
Feelings of guilt

Question 5

How long do features of depression need to have been persisting for it to be classed as depression?

Answer 5

2 weeks

Question 6

What is the most effective treatment for depression?

Answer 6

Combination of cognitive behavioural therapy and an antidepressant

Question 7

What things can determine the choice of antidepressant prescribed?

Answer 7

Side effects (either positive or negative for patient)
Co-morbid illness
Interactions

Question 8

How do SSRIs work?

Answer 8

Inhibit reuptake of serotonin within synapse, therefore prolonging its effects

Question 9

Name the SSRIs.

Answer 9

Citalopram
Escitalopram
Fluvoxamine
Fluoxetine
Sertraline
Paroxetine

Question 10

What are the common side effects of SSRIs?

Answer 10

Nausea
GI disturbances
Dry mouth
Insomnia
Loss of libido

Question 11

Why are SSRIs preferred over TCAs? (in terms of side effects)

Answer 11

SSRIs have no anti-cholingeric side effects

Question 12

Why are SSRIs not prescribed to under 18s?

Answer 12

Studies have shown there to be a higher risk factor for the development of suicidal/self harm ideation in under 18s taking SSRIs

Question 13

What is serotonin syndrome?

Answer 13

A toxic hyperserotonergic state

Question 14

What is serotonin syndrome caused by?

Answer 14

Ingestion of two or more drugs that increase serotonin levels, e.g. SSRIs combined with MAOIs, dopaminergic drugs or TCAs

Question 15

What are some symptoms of serotonin syndrome?

Answer 15

Agitation
Confusion
Tremor
Diarrhoea
Tachycardia
Hypertension
Hyperthermia

Question 16

How can you reduce the effect of insomnia caused by SSRIs?

Answer 16

Advise to take in morning

Question 17

What are some adverse effects of SSRIs?

Answer 17

Hyponatraemia
GI bleeding
Serotonin syndrome
QT prolongation

Question 18

Why are patients gradually reduced off SSRIs instead of just being stopped?

Answer 18

Sudden stopping can lead to withdrawal syndrome

Question 19

Why should care be taken when giving SSRIs to epileptics?

Answer 19

SSRIS lower the seizure threshold

Question 20

What are the characteristics of withdrawal syndrome

Answer 20

Shivering
Dizziness
Anxiety
Headache
Nausea
'Electric shocks'

Question 21

Name some tricyclic antidepressants.

Answer 21

Imipramine
Amitriptyline
Lofepramine
Nortriptyline
Clomipramine

Question 22

How do TCAs work?

Answer 22

Potentiate actions of monoamines (serotonin and noradrenaline) by inhibiting reuptake into nerve terminals

Question 23

What are the oldest antidepressants and therefore have the most evidence for them?

Answer 23

MAOIs

Question 24

What are the antimuscarinic effects of TCAs?

Answer 24

Dry mouth
Constipation
Tremor
Blurred vision
Urinary retention

Question 25

What cardiovascular side effects can TCAs cause?

Answer 25

QT prolongation Arrhythmias Postural hypotension

Question 26

Why is it not wise to prescribe TCAs to patients with suicidal thoughts?

Answer 26

TCAs are toxic in overdose

Question 27

What are some side effects of TCAs?

Answer 27

Weight gain Sedation Confusion Motor incoordination

Question 28

Why do TCAs have cardiovascular side effects?

Answer 28

Block the alpha1-adrenoreceptor

Question 29

What are the contraindications of prescribing TCAs?

Answer 29

Prostatism Narrow angle glaucoma Recent MI Heart block

Question 30

In which patients should you be cautious to prescribe TCAs?

Answer 30

Those with: Ischaemic heart disease Epilepsy

Question 31

What kind of drugs can TCAs interact with?

Answer 31

``` Those with sedative effect, e.g. Alcohol Opioids Sedative anti-histamines Anxiolytics Those that prolong QT interval, eg. Amiodarone Catecholamines, eg adrenaline ```

Question 32

How does venlafaxine work?

Answer 32

Potent blocker of serotonin reuptake, with some action on noradrenaline reuptake

Question 33

In which individuals should venlafaxine not be prescribed?

Answer 33

Those with uncontrolled hypertension | Those prone to cardiac arrhythmias

Question 34

How do MAOIs work?

Answer 34

Irreversibly inhibit intracellular enzymes monoamine oxidase A and B, leading to increase of noradrenaline, dopamine and serotonin in the brain

Question 35

What should be avoided when taking MAOIs?

Answer 35

Foods rich in tyramine, e.g. mature cheese, pickled herring, yeast extracts

Question 36

In someone diagnosed with depression what should they be advised to stop doing?

Answer 36

Drinking alcohol | Taking depressive drugs, e.g. steroids

Question 37

What are examples of MAOIs?

Answer 37

``` Phenelzine Isocarboxazid Isoniazid Tranylcypromine Moclobemide ```

Question 38

What does monoamine oxidase A have a preference to?

Answer 38

Serotonin

Question 39

What does monoamine oxidase B have a preference to?

Answer 39

Phenylethylamine | Dopamine

Question 40

What are some adverse effects of MAOIs?

Answer 40

Postural hypotension Atropine-like effects Weight gain CNS stimulation (insomnia, restlessness, hallucinations)

Question 41

How long can MAOIs stay in the body after they are stopped?

Answer 41

Up to 3 weeks

Question 42

What type of drug can MAOIs interact with?

Answer 42

Ephedrine-containing drugs, e.g. OTC cough and cold medications, other antidepressants

Question 43

How does mirtazapine act?

Answer 43

Antagonises presynaptic alpha2-adrenoreceptors, enhancing release of serotonin and noradrenaline Also blocks H1-receptors

Question 44

What kind of drug is trazodone?

Answer 44

A tetracyclic antidepressant

Question 45

How does trazodone work?

Answer 45

Blocks 5-HT(2a) and 5-HT(2c) receptors, blocking serotonin reuptake

Question 46

What are the side effects of mirtazapine and trazodone?

Answer 46

Sedative effect | Risk of increased appetite (therefore weight gain)

Question 47

Why are mirtazapine and trazodone less dangerous in overdose than TCAs?

Answer 47

Fewer autonomic side effects, so are less cardiotoxic

Question 48

How does duloxetine work?

Answer 48

Inhibits both noradrenaline and serotonin reuptake

Question 49

When is venlafaxine used?

Answer 49

In severe cases of depression

Question 50

When is duloxetine used?

Answer 50

Major depressive disorder | Can be used to treat urinary incontinence and diabetic neuropathy

Question 51

What is the first line treatment for depression in someone post-MI?

Answer 51

Sertraline

Question 52

Which TCA has the least anticholinergic activity?

Answer 52

Lofepramine

Question 53

What are the two subtypes of benzodiazepines?

Answer 53

Hypnotics | Anxiolytics

Question 54

What are hypnotic BZDs used to treat?

Answer 54

Insomnia

Question 55

Name some hypnotic BZDs.

Answer 55

``` Temazepam Nitrazepam Zopiclone Zopidem Zaleplon ```

Question 56

What are anxiolytic BZDs used to treat?

Answer 56

Anxiety

Question 57

Name some anxiolytic BZDs.

Answer 57

Diazepam Chlordiazepoxide Lorazepam Oxazepam

Question 58

How do BZDs work?

Answer 58

Agonists that bind to site on GABAa receptor, enhancing inhibitory effect of GABA by opening chloride channels

Question 59

Why should BZDs not be taken with alcohol?

Answer 59

Danger of overdosing, due to both affecting same receptor (BZDs indirectly, alcohol directly)

Question 60

What are some adverse effects of BZDs?

Answer 60

``` Drowsiness Falls Impairment judgement and dexterity Forgetfulness Confusion Irritability Aggression ```

Question 61

What are BZDs usually indicated for?

Answer 61

Short-term relief of severe, disabling anxiety or insomnia