Depression

Question 1

what are the core symptoms of depression?

Answer 1

• Low mood

- Loss of pleasure – stop doing things that you used to enjoy

Question 2

what are the other symptoms of depression?

Answer 2

Fatigue/loss of energy

• Worthlessness, guilt – small incidence that happened in the past
• Recurrent thoughts of death, suicidal thoughts, suicide attempts
• Reduced ability to think or concentrate, indecisiveness
• Psychomotor agitation or retardation
• Insomnia/hypersomnia
• Weight loss or gain

Question 3

when do you start the treatment for depression?

Answer 3

• moderate or severe depression
• a past history of moderate or severe depression
• subthreshold depressive symptoms present for at least 2 years
• subthreshold depressive symptoms or mild depression persisting after other interventions
• mild depression when you have tried everything for a few years and were not helpful you would move onto pharmacological interventions

Question 4

how do you approach the treatment for depression?

Answer 4

• Balance guidelines and patient factors
• Allergies, co-morbidities, concurrent medications
• Tolerance/acceptability of side effects
• Patient preference
• Keep it simple
• Patient counselling

Question 5

what are the differnt types of treatment for depression?

Answer 5

• SSRIs
• SNRIs
• Mirtazapine
• Tricyclics (and related)
• MAOIs
• Reboxetine
• Agomelatine
• Vortioxetine

Question 6

what are examples of SSRI’s?

Answer 6

• Sertraline, Citalopram, Fluoxetine, Escitalopram, Paroxetine, Fluvoxamine

Question 7

when would you use an SSRI?

Answer 7

• First line choice

- if it doesn’t work NICE suggest swapping to another

Question 8

what are the side effects of SSRIs?

Answer 8

• Initial agitation, anxiety
– need to warn a patient of this so they aren’t surprised if this does happen
• GI side effects, hyponatraemia (low sodium, especially in the elderly)
- QT prolongation

Question 9

what are the risk of SSRIs?

Answer 9

• Bleeding risk
– avoid using with NSAIDS/anticoagulants  GI bleeds, may need omeprazole if wanting to give SSRI and aspirin
– Effect of platelets

Question 10

what are examples of SNRIs?

Answer 10

Venlafaxine, Duloxetine

Question 11

what issues may you have with SNRIs?

Answer 11

• Blood pressure –

o Venlafaxine contra-indicated in uncontrolled hypertension

Question 12

what is mirtazapine?

Answer 12

• Considered to be a better tolerated antidepressant (newer)
• Side effects to note –
o Sedation – this might help if the patient is not sleeping very well
o , weight gain – might help if patient is easting very well

Question 13

what are examples of tricyclics?

Answer 13

• Amitriptyline, Clomipramine, Nortriptyline, Lofepramine, Dosulepin

Question 14

what are the side effects of tricyclics?

Answer 14

• Antimuscarinic side effects
o Constipation, urine retention, blood pressure, hypotension, sedation, falls, blurred vision (elderly AVOID)
• Cardiotoxicity – don’t use post MI

Question 15

what are the risks of tricyclics?

Answer 15

• Risk in overdose – if patient has suicide risk do NOT give and if you had to would only give 7 days. Dangerous in overdose, due to cardiotoxicity

Question 16

what are examples of MAOIs?

Answer 16

• Phenelzine, Tranylcypromine, Isocarboxazid

Question 17

what is monoamine oxidase needed for?

Answer 17

• Monoamine oxidase is needed to break down tyramine, when you inhibit this it means you build them up to toxic levels and this may cause bleeds on brain.

Question 18

what are strict rules of MAOIs?

Answer 18

• Strict dietary requirements – risk of hypertensive crisis

Question 19

what is agomelatine?

Answer 19

• Novel target - Melatonergic agonist – works on melatonin
• Hepatotoxicity risk –
o cases of liver injury, including fatal hepatic failure, reported post-marketing.
• LFT monitoring – baseline, 3 weeks, 6 weeks, 3 months, 6 months
o People don’t want to do this so it is not well adhered

Question 20

what is vortioxetine?

Answer 20

• Serotonin based
• Recommended by NICE as an option for treating depression in adults who have not responded to 2 antidepressants in the current episode.
• 3rd line treatment

Question 21

how do you chose the anitdepressant?

Answer 21

• Monotherapy first – SSRI, or better tolerated newer antidepressant.
• Switch if needed.
• Then, less well tolerated, older antidepressants.
• Before changing due to lack of effect, check:
- how long has the patient been taking the antidepressant
- have they been taking it regularly? ? Right time of time, every day?
• If changing due to side effects, think:
- which options would be better tolerated? has the side effect been stopping them do things within there life and has it had time to go away
• If switching – how can this be done safely? reduce down gradually? Leave a gap?? Use mawdsley interactions to see if this is needed. Check reference to be able to do this safely

Question 22

what happens if there is no improvement?

Answer 22

• Time to improvement?
o 4 week trial based that you saw an effect but you may see change within 1-2 weeks.
o 1-2 weeks are when you will get the most side effects but these should fade out
o This may be longer in the elderly – 6 weeks
• Check compliance
• Increase dose
o If there was a slight improvement but not a major response you could change there dose
• Consider changing treatment – switching monotherapies
o Sometimes patients don’t want to increase dose they just want to change to a new one
• Some improvement by 4 weeks, continue for another 2 – 4 weeks. Can consider switching if response inadequate, patient experiencing side effects, or patient prefers to.

Question 23

what is said about st.john worts and depression?

Answer 23

• Not recommended in depression.
• Not because it doesn’t work
• This is because we don’t have a regulatory body for this so when you buy It you don’t know dose, amount you are getting
• It alos have a lot of interactions
• Different potencies, potential for serious interactions.
• Efficacy?

Question 24

when should you stop treatment?

Answer 24

• Continue for at least 6 months’ after remission
o People often don’t follow up on this
o Do this to prevent relapse
o If history of depression we could increase this to 2-5 years or even for life to prevent relapse
o We usually keep using them for elderly as if they relapse it usually causes multiple health concerns to prevent this happening (physical harm)
o Use the dose that they took from when they had the episode