Management of mood disorders

Question 1

What is usually the 1st line drug for the treatment of depression ?

Answer 1

SSRI - but not always need to take into consideration the patients co-morbidities etc

Question 2

What is a good question to always ask when deciding anti-depressant treatment for the patient ?

Answer 2

What they used last time and if it worked ?

Question 3

How long do anti-depressants take to work ?

Answer 3

Usually 2-6weeks

Question 4

When would you consider ECT in treatment of depression ?

Answer 4

If needing a quicker response e.g. suicide risk etc

Question 5

What are some of the other treatment options in depression besides anti-depressants ?

Answer 5

• ECT
• CBT
• IPT
• CBASP
• lifestyle changes
• meaningful activity
• stress reduction
• routine (especially sleep)

Question 6

In psychotic depression what drugs can be combined to treat this ?

Which drug should be continued ?

Answer 6

• Anti-depressants and anti-psychotics
• The anti-depressant is the drug which should then be continued long-term

Question 7

What is a rare risk of the use of anti-depressant drugs in young people ?

Answer 7

Can rarely cause agitation and lead to suicide in young people

Question 8

What is none response to an anti-depressant defined as ?

Answer 8

No response or inadequate response after six weeks at the maximum BNF dose or highest tolerated dose

Question 9

How long should anti-depressant medication be continued for in the treatment of depression?

Answer 9

1. Continue treatment for 6-12 months after full resolution of symptoms
2. after a first episode, 12-24 months for a recurrence,
3. after third episode should continue indefinitely if willing

Question 10

What is the mainstay of treatment of bipolar disorder ?

Answer 10

lithium, anticonvulsants (lamotrigine and carbamazepine), antipsychotics

Question 11

Why are anti-depressants not usually used in the treatment of bipolar (considering they often get depressive episodes)?

Answer 11

Antidepressants can cause switching to mania/hypomania or mood instability. Even if they don’t cause elevated mood they are not as effective as mood stabilisers for bipolar depression.

Question 12

What drug is good for the treatment of bipolar depression?

Answer 12

Lamotrigine

Question 13

What drug is good for the treatment of mania/hypomania ?

Answer 13

Volproate semisodium

Question 14

What drugs are good for the treatment of both elevated and depressed states in bipolar disorder ?

Answer 14

Lithium and anti-psychotics

Note lithium is more the maintenance therapy and is the 1st line treatment for that

Question 15

What can be given to a patient with bipolar disorder if compliance is poor or they are unwilling to take oral medication?

Answer 15

IM antipsychotics can be given every 2-4 weeks

Question 16

Anti-depressants are not usually used in the treatment of depressive episodes of bipolar but when would they be considered and what anti-depressant would you use 1st line?

Answer 16

severe depressive episodes

1st line = SSRI’s

Question 17

What are the different types of SSRI’s available?

Answer 17

Fluoxetine, sertraline, citalopram, escitalopram, paroxetine

Question 18

What are the main side effects someone may experience when taking an SSRI?

Answer 18

• GI upset (diarrhoea & vomiting)
• anxiety (worsened)
• agitation
• insomnia
• sexual dysfunction - delayed orgasm
• Hyponatremia in older patients.
• Transient increase in self-harm / suicidal ideation in <25 years (mainly teenagers)

Question 19

When should SSRI’s be taken to reduce the risk of insomnia caused by them?

Answer 19

In the morning

Question 20

What are some of the symptoms people may experience when discontinuing trearment with SSRI’s and which SSRI is associated worse symptoms ?

Answer 20

• GI upset, anxiety, agitation, insomnia, myoclonus
• So taper the dose over a few weeks
• Paroxetine is associated with the worse symptoms so is rarely used

Question 21

When taking with what class of drug is there an increased risk of GI bleeds when on an SSRI?

Answer 21

NSAID’s

Question 22

If someone has cardiac problems and needs to be put on an SSRI which SSRI is safest ?

Answer 22

Sertraline

Question 23

Which SSRI is safest to use in epilepsy ?

Answer 23

Citalopram

Question 24

Which SSRI is associated with long QT syndrome ?

Answer 24

Citalopram

Question 25

Which is the most effective SSRI?

Answer 25

Fluoxetine

Question 26

Give some examples of tricyclic anti-depressants

Answer 26

Amitriptyline, clomipramine, imipramine, lofepramine, dosulepin.

Question 27

What are the common side effects of tricyclic anti-depressants and what is the important one you need to be wary about ?

Answer 27

* sedation * weight gain * confusion * anticholinergic effects - blurred vision, dry mouth, constipation, urinary retention * sexual dysfunction * postural hypotension, tachycardia ## Footnote **Rarely cardiac arrhythmias**

Question 28

Who are tricyclics avoided in ?

Answer 28

* Cardiac problems, * Older people * Suicidal intent (cardiac toxicity in OD - overdose)

Question 29

What is the main Noradrenergic and Specific Serotonergic Antidepressant (NaSSA)?

Answer 29

Mirtazapine

Question 30

When is mirtazapine usually used ?

Answer 30

Often used when SSRI hasn’t worked (2nd line)

Question 31

When may mirtazipine be used 1st line over an SSRI?

Answer 31

* if patient has insomnia and/or poor appetite, it also has a good effect in reducing anxiety * SSRI would make their insomnia worse * Has a higher sedative effect at a lower dose compared to higher (weird)

Question 32

What can mirtazapine often be used inconjuction with ?

Answer 32

SSRI or venlafaxine (SNRI)

Question 33

What are the side effects of mirtazapine ?

Answer 33

* Main ones are - **Sedating**, causes **hunger/weight gain** (both may be advantage or disadvantage) - could be good if someone with anorexia needs an anti-depressant * Other side effects: constipation, dizziness, falls, dry mouth, unusual/vivid dreams. Rarely blood dyscrasias (haematological problems e.g. lower platelets), seizures.

Question 34

What situations must you be careful with mirtazapine use ?

Answer 34

* It causes GI upset with alcohol so need to avoid alcohol when on it * and be careful when combining with other sedating agents

Question 35

What is serotonin syndrome ?

Answer 35

It is a potentially fatal condition triggered by too much nerve cell activity.

Question 36

List the causes of serotonin syndrome

Answer 36

* monoamine oxidase inhibitors * SSRIs * ecstasy * amphetamines * st johns wart

Question 37

What are the clinical features of serotonin syndrome ?

Answer 37

* Neuromuscular excitation (e.g. hyperreflexia, myoclonus, rigidity) * Autonomic nervous system excitation (e.g. hyperthermia) * Altered mental state - confusion ==\> coma ==\> death May initially appear like someone youd exepect to be on ectasy e.g. buzzing etc

Question 38

What is the management of serotonin syndrome ?

Answer 38

* supportive including IV fluids * benzodiazepines * more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine