Depression Flashcards
(42 cards)
Definition of depression?
Core symptoms for at least 2 weeks not secondary to the effects of drug/alcohol misuse, organic illness or bereavement
Sub-types of depression?
Post-natal depression
Atypical depression
Pre-menstrual dysphoric disorder
Seasonal affective disorder
Organic causes of depression?
Endocrine - addisons, cushings, hypothyroidism
Metabolic - Fe/B12/folate deficiency, Hypercalcarmia, hypomagnesia
Neurological - alzheimer’s, HD, epilepsy, MS, IC tumours, parkinson’s
Drugs - L-dopa, steroids, B-blockers, digoxin
Illicit drugs - cocaine, amphetamines, opioids, alcohol
Delirium - UTIs, infection
ICD-10 criteria for severity of depression?
Mild = 2 core, 2 other Moderate = 2 core, 3 other Severe = 3 core, 4 other
ICD-10 core symptoms?
Anhedonia
Low energy/fatigued (Anergy)
Low mood
Other ICD-10 symptoms?
Guilt Reduced appetite Reduced libido Reduced confidence (Low self-esteem) Disturbed sleep Reduced Concentration Suicidal thoughts
Indirect presentation of depression?
Mostly somatic presentations: headache, Gi disturbance, weight change, chronic pain syndrome
What is pseudo-dementia?
A cognitive impairment (confusion, memory loss, decline in normal function) as result of a lack of motivation and mood disturbances
What is first line SSRI treatment for depression?
Citalopram and fluoxetine = 1st line
Biological management ladder for depression
- SSRI
- Increase dose of SSRI –> switch SSRI
- 2nd line drugs SNRI (venlafaxine), TCA, MOA-I
- Augmentation with lithium or another class NASSA (mirtazapine)
- ECT (severe refractory depression)
Common SSRI side effects?
Blurred vision, dizziness, dry mouth, sweaty, headaches
GI: GI upset, nausea, loss of appetite, bleeds
Head: headache, agitated/restless, insomnia
Loss of libido/erectile dysfunction
Hyponatremia (anorexia, nausea, malaise –> headache, confusion, seizures) - can occur in other A/D medication
Prolonged QTc
NB. milder than TCAs, worse than SNRI but less toxic and reduced risk of OD
May feel worse/anxious in first couple of weeks
What is serotonin syndrome?
A common complication of anti-depressants (SSRI, TCA, MAO-I, st johns wort) that result in an increase in 5HT
–> fever, restlessness, tremor –> arrhythmias, confusion, seizures
What is occurs in treatment withdrawal?
Occurs within 5 days of stopping anti-depressant
Mild and self limiting - restlessness, mood changes, sleep disturbance, unsteadiness, sweating
Most severe in venlafaxine and paroxetine
What is ECT?
Inducing seizures under GA x 2 weekly for 12 weeks
70-80% response
S.E. = headache, nausea, muscle pain, memory loss
What should you check if antidepressants are not working?
Compliance
Enough time?
Alcohol and other depressant drugs?
Perpetuating factors
When would sertraline or paroxetine be used as first line treatment for depression?
Sertraline - post MI
Paroxetine - post natal depression
Contraindications for SSRIs?
Manic episode (increase in 5HT exacerbates symptoms) Epilepsy and peptic ulcer - risk of S.E.
How can Gi disturbance/bleeds be limited when SSRIs are used?
PPI
Also give PPI when using NSAIDS
Drug interactions of SSRIs
Increased cardiotoxicity with TCA/MAO-i - never combine!
NSAIDS - increased risk of GI bleed (prescribe PPI if required)
Warfarin/heparin/aspirin –> bleeds (prescribe mirtazapine instead)
Sensible starting dose of SSRI e.g. citalopram?
20mg (increase as required)
Max dose of citalopram = 40mg (due to QTc prolongation
20mg in elderly and hepatic impairment)
What drugs can be given second line for depression?
SNRIs e.g. venlafaxine
NARI e.g. Reboxetine
Tricyclics (2nd/3rd line) e.g. amitriptyline
Indications for SSRIs and SNRIs?
Depression
Anxiety
Panic disorder
OCD
Contraindications for SNRI?
Elderly
Do not give with TCA/MAO-i
Caution in hepatic/renal impairment and CVD
S.E. of SNRI?
Similar to SSRI + HTN
Increased risk of withdrawal symptoms
