Depression + Antidepressants

Question 1

What are the depressive symptoms?

Answer 1

Depressed mood
Loss of interest
Weight loss/gain
Insomnia
Agitation
Fatigue
Feeling worthless
Decreased concentration
Thoughts of death/suicide

Question 2

What is mild depression?

Answer 2

Minimum of 5 symptoms
Mild functional impairment

Question 3

What is moderate depression?

Answer 3

More symptoms
More functional impairment

Question 4

What is severe depression?

Answer 4

Most symptoms present
Marked functional impairment

Question 5

What is aetiology of depression?

Answer 5

Stress - early-life + on-going
Drugs/alcohol
Medicines
Genetics - more likely if relation has it

Question 6

What is the pathology of depression?

Answer 6

UNCERTAIN
BUT increased cortisol levels

Question 7

How do you treat mild depression?

Answer 7

Lifestyle changes
Counselling

Question 8

How do you treat moderate/severe depression?

Answer 8

Lifestyle changes
Counselling
Pharmacotherapy
Non-drug treatments

Question 9

What is Iproniazid?

Answer 9

Inhibits monoamine oxidase

Question 10

What is Imipramine?

Answer 10

Inhibits reuptake of 5-HT + noradrenaline

Question 11

Describe the biochemistry of 5-HT terminal

Answer 11

Activity of TPH determine synthesis rate
Activity of MAO determines breakdown
Synthesis + breakdown determine vesicular content
Content of vesicles determines amount of 5-HT released per AP
Firing activity determines release rate
Transporter activity determines reuptake rate
Release + reuptake determine level + duration of 5-HT in synaptic cleft + activation of receptors

Question 12

What does the inhibition of MAO do?

Answer 12

Increased neurotransmitter in vesicles
Increased release per impulse

Question 13

What does the inhibition of reuptake do?

Answer 13

Increased duration + concentration of 5-HT/NA in synaptic cleft

Question 14

What targets metabolism?

Answer 14

MAO inhibitors

Question 15

What targets the reuptake?

Answer 15

TCAs
SSRIs
NARIs = noradrenaline reuptake inhibitors
SNRIs

Question 16

What does MAOa target the most?

Answer 16

5-HT>NA>DA

Question 17

What does MAOb target the most?

Answer 17

DA>NA>5-HT

Question 18

What are the MAOa drugs?

Answer 18

Clorgyline
Moclobemide

Question 19

What are the MAOb drugs?

Answer 19

Selegiline

Question 20

What are the MAOa+b drugs?

Answer 20

Pargyline
Iproniazid
Tranylcypromine

Question 21

What are the interactions for MOA inhibitors?

Answer 21

Interaction with foods
Serotonin syndrome = interact with other serotonergic drugs

Question 22

What is the patient advice for MOA inhibitors?

Answer 22

Avoid certain foods
Avoid OTC cold remedies + drugs of abuse
Do NOT take any other antidepressants

Question 23

What is the main problem with MOA inhibitors?

Answer 23

Irreversible enzyme inhibitors
= their effects outlast the clearance of the drug
= take around 6 weeks for enzyme protein turnover

Question 24

What are the side effects of TCAs/SSRIs/SNRIs?

Answer 24

GI disturbance
Sexual dysfunction
Dry mouth

Question 25

What are the TCAs side effects?

Answer 25

Sedation Hypotension Weight gain Dry mouth Urinary retention

Question 26

What is the problem with antidepressants?

Answer 26

Delayed action (4-8 weeks)

Question 27

What is the 1st line treatment for depression?

Answer 27

SSRI eg. Sertraline, Citalopram

Question 28

What do you need to do with SSRIs?

Answer 28

Low dose first THEN increase if tolerated BUT must be safe

Question 29

What to do if there is a poor response to treatment?

Answer 29

Ensure positive lifestyle changes Increase dose - BUT safe Switch antidepressant Additional drug Additional non-drug therapy = CBT therapy Other drug treatments = transcranial magnetic stimulation (TMS)

Question 30

Why is TCAs NOT 1st line?

Answer 30

More side effects More dangerous in overdose

Question 31

Why is SNRIs NOT 1st line?

Answer 31

More efficacious in treatment of resistant depression BUT less well tolerated

Question 32

Why is MAO inhibitors NOT 1ST line?

Answer 32

Effective BUT difficult to take

Question 33

What can happen of you come off antidepressants suddenly?

Answer 33

Withdrawal symptoms Associate with relapse

Question 34

Why do you come off antidepressants?

Answer 34

Depression is episodic + recurrent Discontinuation associated with relapse

Question 35

What are the withdrawal symptoms?

Answer 35

Flu-like symptoms Nausea Anxiety Electric shocks Difficulty sleeping

Question 36

How do you avoid discontinuation syndrome for long half life drugs? eg. Fluoxetine

Answer 36

Gradually decrease amount of tablets = plasma levels fall very slowly

Question 37

How do you avoid discontinuation syndrome for short half life drugs? eg. Paroxetine

Answer 37

Switch to fluoxetine Reduce doses slowly over several weeks Treat symptoms -eg. constipation