Treatment of Mood Disorders Flashcards by Megan Rose

When should antidepressants be considered for a patient with depressive symptoms?

Moderate or severe depression
Mild depression that has not responded to lifestyle measures/low intensity psychosocial intervention
Mild depression with a history of moderate/severe depression

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What is the first line management for depression?

If mild/moderate:
An antidepressant (normally an SSRI) OR
High intensity psychological intervention:
- CBT
- IPT (interpersonal therapy)

If moderate/severe:
–> combine above treatments

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Which factors should be taken into account when choosing an antidepressant?

Anticipated side effects
Potential interactions with other medications or physical illness
Previous antidepressants tried by the patients and their efficacy

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How should a patient be monitored when starting an antidepressant?

If not at risk of suicide:
- check up two weeks after starting
If increased risk of suicide or < 30 years old:
- check up after 1 week

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What should be considered if an antidepressant isn’t working?

Compliance
Is the diagnosis correct?
Substance misuse
Physical illness
Address other predisposing, precipitating and prolonging factors

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How long should an antidepressant be taken with no improvement, before you consider increasing the dose or swapping to another drug?

4-6 weeks

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What can be done if an antidepressant isn’t working?

Increase dose
Swap
Combine - most commonly SSRI/SNRI plus mirtazapine

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How long should a patient take an antidepressant for in order to prevent relapse?

If first episode –> at least 6 months after full recovery without reducing dose

If second episode or more –> at least 1-2 years after full recovery without reducing dose

Some may require lifelong treatment

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Which neurotransmitters are involved in development of depression?

Functional deficit of monoamine transmitters

–> in particular serotonin (5-HT) and noradrenaline

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What are the different classes of antidepressants available?

Monoamine oxidase inhibitors
Monoamine reuptake inhibitors:
- tricyclics
- non-selective reuptake inhibitors (NSRIs)
- selective serotonin reuptake inhibitors (SSRIs)
- noradrenaline reuptake inhibitors
Atypical drugs (post-synaptic effects)

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What is the mode of action of monoamine oxidase inhibitors and give two examples?

Inhibitors of MAO-A and B

Phenelzine (irreversible)
Moclobemide (reversible)

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What are the side effects of monoamine oxidase inhibitors?

Hypertensive crisis (‘cheese reaction’) - must have restricted diet
Potentiates the effects of other drugs e.g. barbiturates
Insomnia
Drowsiness
Postural hypotension
Peripheral oedema

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How do TCAs work?

Block the reuptake of monoamines (NA and 5-HT) into presynaptic terminals

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Give 4 examples of TCAs?

Imipramine
Clomipramine
Dosulepin
Amitriptyline
Lofepramine

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What are the common side effects of TCAs?

Anticholinergic:
- blurred vision
- dry mouth
- constipation
- urinary retention 
Sedation
Weight gain
Postural hypotension
Tachycardia
Arrhythmias
Cardiotoxic in overdose

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How do SSRIs work?

Selectively inhibit reuptake of serotonin from the synaptic cleft

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Give 5 examples of SSRIs

Fluoxetine
Citalopram/Escitalopram
Sertraline
Paroxetine

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What are the common side effects of SSRIs?

GI upset
Headache
Worsened anxiety
Transient increase in suicidal ideation in <25 years
Sweating
Insomnia/vivid dreams
Sexual dysfunction
Hyponatraemia (in elderly)
Discontinuation effects
Increase risk of GI bleeding if taken with NSAIDs

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What is the mode of action of SNRIs and give two examples?

Block reuptake of NA + 5HT into the presynaptic terminals

Venlafaxine
Duloxetine

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What is the mode of action of mirtazepine?

Blocks alpha-2, 5-HT2 and 5-HT3 receptors

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What are the side effects of mirtazepine?

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Weight gain
Sedation
Constipation
Dizziness
Falls 
Dry mouth
GI upset when taken with alcohol
Unusual/vivid dreams
Rare: blood dyscrasias, seizures

What is the advantage of taking mitrazepine with an SSRI?

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Mirtazepine can block the serotenergic side effects of SSRI

Which antidepressants have the greatest risk of discontinuation symptoms?

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Venlafaxine + paroxetine

shorter half life

Which antidepressants have the greatest toxicity in overdose?

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Venlafaxine + TCAs

–> caution if suicidal

How should antidepressants be discontinued?

Gradually reduce dose over 4 weeks (or longer)

Which discontinuation symptoms may occur if an antidepressant is stopped abruptly?

``` Restlessness Problems sleeping Unsteadiness Sweating Abdominal symptoms Altered sensations (e.g. electric shock sensations in head) Irritability, anxiety or confusion ```

When should you consider admitting a patient with depression?

If significant risk of suicide, self harm or self neglect

When should ECT be considered for depression?

Severe, life threatening depression | - when a rapid response is required or when other treatments have failed

What are the contraindication for ECT?

Absolute: - recent MI (last 3 months) - recent CVA - intracranial mass lesion - pheochromocytoma Relative: - angina - HF - severe pulmonary disease - severe osteoporosis - pregnancy

Which antidepressants are considered the 'top 4' and why?

Escitalopram - probably the best all round SSRI Sertraline - good CV safety profile and allows easy dose titration Mirtazepine - promotes sleep and appetite/weight gain Venlafaxine - higher rates of adverse effects but may be more effective

What are the principles of treatment in bipolar disorder?

``` Acute treatment of symptoms: - reduce mood in mania - raise mood in depression Long term treatment (prophylaxis): - to stabilise mood ```

What are the principles for treating acute mania?

Maximise antimanic dose if patient already on maintenance treatment Discontinue antidepressants Combination therapy may be required Likely require admission if manic

Which drugs are used to treat acute mania?

Antipsychotic first line: - olanzapine, quetiapine or rispiridone Other options: - lithium, carbamazepine, ECT Oral if possible, but IM may be required Benzos can be used symptomatically for agitation, insomnia etc

What are the principles for treating acute bipolar depression?

Never prescribe antidepressant without an antimanic drug Avoid antidepressants if recent manic/hypomanic episode or history of rapid cycling SSRIs (particularly fluoxetine) preferable choice

Which drugs can be prescribed to treat acute bipolar depression?

Antipsychotic first line --> quetiapine or olanzapine Antidepressant alongside antipsychotic, lithium or valproate: - FLUOXETINE Lamotrigine can be used but takes time to titrate ECT Lithium

What are the options for bipolar maintenance therapy?

``` Lithium is gold standard Other options: - antipsychotics - lamotrigine (if primarily depression) - valproate (if primarily manic) - carbamazepine ```

How is lithium therapy monitored?

12 hour post dose blood levels (narrow therapeutic index)

What are the side effects of lithium carbonate?

``` Dry mouth/strange taste Polydipsia and polyuria Tremor Hypothyroidism Long term reduced renal function Ankle swelling Nephrogenic diabetes insipidus Weight gain ```

What are the features of lithium toxicity?

``` Vomiting Diarrhoea Ataxia + coarse tremor Drowsiness/altered consciousness Convulsions Coma ```

What are the main side effects associated with valproate and carbamazepine?

``` Drowsiness Ataxia CV effects Induces liver enzymes Teratogenicity (valproate) ```

Why do you need to warn patients about a rash with lamotrigine?

Small risk of Steven-Johnson syndrome

Which antipsychotics might be used as mood stabilisers?

Quetiapine Aripiprazole Olanzapine Lurasidone

Which tests need to be done prior to starting lithium therapy?

``` BMI U+Es including calcium eGFR TFTs FBC ECG if CV disease or risk factors ```

What needs to be monitored in a patient taking lithium?

Plasma lithium level + U+Es every 3 months | Every 6 months: - BMI - TFTs more often if abnormalities

What is the management of depression in children?

CBT first (before considering medication) Antidepressants: - fluoxetine first line - sertraline or citalopram

Which SSRI is good if cardiac problems?

Sertraline

Which SSRI is safest in epilepsy?

Citalopram

Which patients should TCAs be avoided in?

Cardiac problems Suicidal intent Older people

Which foods need to be avoided if taking a MAOI?

``` Cheese Red wine Fermented meats Marmite, Bovril Caffeine Broad beans Soy, tofu ...etc ```

What are the symptoms of a hypertensive crisis?

``` Headache SOB Nosebleeds Anxiety --> arrhythmias, stroke, seizure, death ```

How is a hypertensive crisis treated?

Phentolamine infusion

What are some of the drug interactions with lithium?

NSAIDs ACE inhibitors ARBs Diuretics (thiazide worse than loop)

Treatment of Mood Disorders Flashcards

(52 cards)