Depression and bipolar Flashcards by Erin Tarrant

What are the main risk factors for depression

Genetics
anxiety
physical illness
drugs
gender –> women more likely

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What are the risk factors for recurrent depression

Onset after 60
Family history
poor symptom control
history of frequent episodes

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What are some drugs that are known to induce depression

Antipsychotics
steroids
benzodiazapines
NSAIDs
Cardio drugs
parkinson drug withdrawal

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What are some emotional symptoms of depression

Sadness
anxiety
feeling low
feeling hopeless
guilt
lack of enjoyment from anything

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What are some physical symptoms of depression

Fatigue
sexual dysfunction
headaches
insomnia
weight changes

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What are some cognitve symptoms of depression

Hard to concentrate
Hard to decision make
Struggle to think of words
decreased judgement

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What are the 2 diagnostic criteria used

DSM-IV
ICD-10

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What is the DSM-IV criteria for a depression diagnosis

1 key symptom + minimum 5 symptoms

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What is the ICD-10 criteria for a depression diagnosis

2 key symptoms + 4 symptoms

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What are the key symptoms for a depression diagnosis

Persistent low mood or sadness
Loss of interst/pleasure
lack of energy

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What other medical conditions can present similarly to depression

Bipolar –> have lows
Generalised anxiety disorder
Dementia
schizophrenia
illness

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What medication do we treat GAD with

SSRIs
pregabalin
Buspirone

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Give examples of low intensity psychosocial inteventions

Guided self help
CBT
Being active

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Give some examples of high intensity psychosocial interventions

Counselling
CBT
relaxation
anxiety therapy

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What non-pharmacological interventions are appropriate for severe depression

Electroconvulsive therapy
Transcranial magnetic stimulation
High intensity psychosocial interventions

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When should we give antidepressants in mild depression?

Past history of moderate/ severe depression
subhold depressive symptoms >2years
Depression persists after non-pharmacological interventions

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What antidepressants are difficult to get to a good therapeutic dose?

TCAs

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Why are TCAs associated with lots of S/E

Impacts on autonomic control and gives antimuscarinic S/E

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What are some common S/E with TCAs

Anti-muscarinic
postural hypotension –> work on vasomotor centre
sedation
QT interval prolongation

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What drugs are associated with QT prlongation

Methotrexate
lithium
TCAs
antipsychotics

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What would we give a patient with psychotic depression

Antidepressant + antipsychotic
+
psychological therapy

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What antipsychotic medications can we give in combination with antidepressants

Aripiprazole
Olanzapine
Quetiapine
Risperidone

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What are the first line antidepressant treatments for depression

SSRIs
SNRIs

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What is a second line SSRI

Paroxetine

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What medication is used in bipolar depression

Lithium

What food must you avoid with MAO inhibitors

Tyramine containing foods ie. cheese and marmite, yeast products

What are second line anti-depressants

MAO inhibitors TCAs

Give examples of SSRIs

Sertraline citalopram fluoxetine

Give examples of SNRIs

Duloxetine venalfaxine

Give examples of TCAs

Clomipramine amitriptyline doxepin

What type of drug is zopiclone

Non benzodiazapine hypnoic/ sedative

When would we use zopiclone

Insomnia

What is required when switching antidepressants

Wean off the first one Slowly titrate up the new drug

What is the only licensed antidepressan tfor children and adolescents

Fluoxetine

What dosage of fluoxetine should be used first line in children

10mg/d slowly titrated

What is licensed in children for OCD

Sertraline

What drug should not be used at all in u18s

Citalopram

What anti-depressant should you avoid in pregnancy

Paroxatine

What antidepressants are the best to use in the elderly

SSRIs

What are the symptoms of seretonin syndrome

Tremor tachycardia blood pressure changes agitation confusion

What is commonly seen as a side effect in the elderly on antidepressants due to inapproproiate release of ADH

Hyponatraemia low sodium levels

How do we treat acute anxiety

Benzodiazepine

What is a risk of SSRIs in the elderly

Hyponatraemia GI bleeding Postural hypotension

What antidepressant is recommended in cardiac disease

SSRIs

Who should you not prescribe SSRIs to

In manic phase of bipolar QT prolongation history of GI bleeding severe hepatic impairment poorly controlled epilepsy

What must you monitor if prescriibng SSRIs in cardiac disease

Antiplatelet activity due to increased risk of bleeds check if theyre on any anti-coagulants

What SSRIs are contraindicated in QT interval prolongation

Citalopram Escitalopram

If someone has severe liver disease, what drugs should you avoid

Anything that causes sedation or constipation

Why cant diazepam be used in the elderly

slow metabolism ad accumulation increased risk of falls due to sedative effect

What wouldnt you sell OTC with SSRIs due to risk of GI bleeds

NSAIDs

What are some signs of SSRI withdrawal sundrome

Sleep disturbances Irritability Confusion fatigue and general feeling unwell Instability

What are some short life anti-depressants

Venalfaxine paroxatine duloxetine

What is the worst antidepressant in overdose

TCAs

What causes anxiety

Abnormal regulation of the fear response

What circuits are heightened in anxiety disorders

Amygdala

What drug can be used for situational anxiety

Propranolol

What channels do gabapentin/pregabalin affect

NaV CaV

What are the symptoms of anxiety

Apprehension GI distubrances Nausea palpitations cant concentrate

What is the MOA for lithium

Enters Na+ channels accumulates within the cells intefere with kinase activation inhibits GSK3 so cant phosphorylate downstream pathways that cause bipolar

What are the 2 neurotransmitters involved in the monoamine theory

5-HT Noradrenaline

What receptors do 5-HT target

5-HT1a

What receptors does noradrenaline target

Alpha-2

What causes the degradation of monoamines in the synapse

MAO-A

What happens to serotonin and noradrenaline in the synapse in depression

Decrease due to degradation

What happens when 5HT and NA levels are decreased in the brain

Cant stop the BAD gene transcription INCREASE neuronal apoptosis DECREASE neurogenesis Changes in neuroplasticity

Decrease the sequence in cortisol release

Hypothalamic neurons CRF --> hypothalamus ACTH --> pituitary Cortisol --> Adrenal cortex

What causes an increase in cortisol release

Stress

What does an increase in cortisol cause

Neuronal apoptosis

What neurons are lost in depression

Astrocytes oligodenrodytes GABAnergic

What is BDNF

Brain derived neurotropic factor

What does BDNF do

stimulated neuron growth

What is the receptor for BDNF

TrkB

What does a decrease in BDNF cause

Decrease in neurogenesis

What does an increase in glutamate cause in depression

Neuronal apoptosis

What inflammatory cyrokines are associated with depression

IL-2, IFN-gamma

Summarise the 4 contributing physiological factors for depression

1) Decreased 5-HT, NA in synaptic clef 2) Increased glutamate and NDMA excitation 3) Increased cortisol release 4) Inflammatory cytokines --> IL-2, IFN-gamma

What is the drug target for SSRIs

SERT transporter

What transporter family is SERT associated with

SLC6

Summarise the structure of the SERT transporter

12 intracellular domains

What cotransporter does SERT use

Na+

What are SSRIs MOA

Prevent reuptake of 5-HT into pre synaptic terminal via SERT transporters increase 5-HT levels in synapse

What is the transporter for NA

NET

How can NA affect 5-HT release

Activate alpha-1 receptors and encourage 5-HT release

What type of inhibitors are Mao

Irreversible non-competitive inhibitors

Where are structual changes to the brain associated with depression mnost likely to be

Hippocampus Pre-frontal cortex

What is TCA MOA

Inhibit SERT and NET

What are the symptopms of depression in bipolar

Helplessness lack of enjoyment fatigue low mood anxiety

What are the symptopms of mania in bipolar

Euphoria Grandeur Bonld 'darish' appearance lack of sleep needed Risky behaviour --> dont care about consequences flight of ideas

What does a diagnosis of bipolar I mean

1 manic episode and major depressive episodes or mania alone

What are the symptoms that differe mania from hypomania

Mania includes psychotic symptoms such as hallucinations, paranoia, delusions

What does a diagnosis of bipolar II mean

Hypomania episode

What does a diagnosis of bipolar III mean

Recurrent mixed states of mania and depression

What diagnostic criteria is used for bipolar

DMS-IV ICD-10

What is the first step to look for treatment wise if a patient comes in with mania

Take them off any antidepressants

Give examples of antipsychotics

Aripiprazole Quietiapine Olanzapine

What is the most commonly used mood stabiliser

Lithium

What is the best mood stabiliser if the patient is in a current state of mania

Quetiapine due to it being an antipsychotic

What can we give a patient who is experience insomnia

Zopiclone

What is the MOA of lithium

Increases seretonin Decreases dopamine

Give some contraindications for lithium

Cardiac disease Low sodium levels addisons disease pregnancy / breast feeding QT interval prolongation or on drugs that cause it already

What do we need to monitor BEFORE we start lithium

ECG --> check QT interval Renal function --> excreted by kidneys Thyroid function --> hypothyroidism can cause low mood BMI U&Es FBC

How often do you need to monitor plasma levels on lithium

Every 3 months in first year

What is starting dose of lithium

Elderly 200mg Adult 400mg

What are some of the side effects of lithium

Fine hand tremor Increased thirst / urine output Weight gain

What are the signs of lithium toxicity

Severe tremor Slurring words confusion muscle weakness

What drugs cause an INCREASE in lithium levels

anti-hypertensives --> ACEi, ARB, diuretics, aldesterone antagonists SSRIs NSAIDs

How long should lithium be withdrawed

at least 4 weeks

Depression and bipolar Flashcards

(107 cards)