Week 4 - Antidepressants & mood stabilisers

Question 1

What characterises depression? Give examples

Answer 1

Emotional and biological symptoms including:

Emotional
Misery/apathy
Guilt
Low SE
Loss of motivation

Biological
Disturbances in appetite, energy, sleep, libido and psychomotor function

Question 2

What are some causes of depression?

Answer 2

Genes
Abuse/neglect
Prolonged excessive stress/trauma
Adverse social circumstances
General medical conditions - hypothyroidism
Substances

Postnatal is a thing

Question 3

What is life time incidence of depression?

Answer 3

20%

Question 4

What’s the rate of recurrence following a single episode?

Answer 4

50%

Question 5

WHat is the suicidal behaviour incidence in patients with depression?

Answer 5

10-15%

Question 6

What is bipolar disorder characterised by?

Answer 6

Destabilisation of mood - depressive and manic episodes

Question 7

WHat is mania?

Answer 7

Episodes of pathologically elevated or irritable mood of at least a week
Symptoms include:
Increased sustained elation and energy, less need to sleep, reduced judgement

Question 8

WHat are some monoamines that affect mood?

Answer 8

Serotonin (5-HT), noradrenaline, dopamine, ,acetylcholine, glutamate and GABA

Question 9

What are the main pharamcological targets for depression?

Answer 9

Serotonin and noradrenaline

Question 10

What are first line AD drugs?

Answer 10

SSRIs, including paroxetine and fluoxetine

Noradrenaline reuptake inhibitors - reboxetine

Question 11

Which two drugs are reserved for psychiatrists?

Answer 11

Tricyclic antidepressants

Monoamine oxidase inhibitors

Question 12

What does NA alpha2 signalling mechanism?

Answer 12

Lowering cAMP

Question 13

What is 5-HT1A,B signalling mechanisms?

Answer 13

Reduces cAMP

Question 14

What is the action of TCAs of monoamine transporters?

Answer 14

Act as reversible negative allosteric modulators on axon nerve terminals and dendrites, reducing monoamine transporter affinity for monoamine neurotransmitters - AKA NA and serotonin

Question 15

Elevation of what leads to alleviation of depression?

Answer 15

Elevation of brain derived neurotrophic factor

Question 16

How do you elevate brain derived neurotrophic factor

Answer 16

This is delayed from taking antidepressants, but increases transcription factor for BDNF via upregulation of cAMP pathway

Question 17

What are the antidep drugs that increase CREB and BDNF?

Answer 17

• SNRIs (NA + Serotonin)
• SSRIs
• NRIs
• NDRI

Question 18

What is a major theory of Mirtazapine success in depression?

Answer 18

Causes an immediate increase in synaptic levels of serotonin and noradrenaline by inhibiting inhibitory mechanisms on NA and serotonin nerve terminals

Question 19

What does CREB do?

Answer 19

Increases BDNF gene expression

Question 20

How does environment cause depression?

Answer 20

Trauma/abuse reduces neuronal plasticity in key areas of the brain –> antidepressants can restore this

Question 21

What are TCAs and MAOIs reserved for?

Answer 21

Severe depression and now response to newer and safer antidepressants

Question 22

What do you have to avoid in MAOIs?

Answer 22

HAve to avoid certain foods with tyramine i.e. soft cheeses, or sympathomimetic drugs because the MAOIs prevent tyramine from being inactivated in the gut –> hypertensive crisis

Question 23

why are SSRIs safer than TCAs?

Answer 23

They have higher therapeutic indices because they lack the affinity for muscarinic receptors and don’t impair cardiac conduction like TCAs do

Question 24

WHat should SSRIs never be combined with? WHy?

Answer 24

MAOI or RIMA

–> leads to serotonin syndrome, which can lead to fatalities

Question 25

What are SSRI side effects?

Answer 25

- GIT - nausea, anorexia, diarrhoea - CNS - insomnia, anxiety, restlessness - Sexual - decreased libido and sexual enjoyment - Increased suicidal ideation can occur at the start

Question 26

What is the main cause of SSRI side effects?

Answer 26

Over stimulation of some serotonin receptors | Tolerance ends up reducing side effects

Question 27

When do the antidep and anti-anx effects of SSRIs kick in?

Answer 27

2-4 weeks

Question 28

What are SSRI indications?

Answer 28

``` Depression OCDs Social phobia Panic disorders GAD ADD PTSD Eating disorders ```

Question 29

What are the most commonly prescribed AD drugs?

Answer 29

SSRIs

Question 30

What is Venlafaxine?

Answer 30

An SNRI - serotonin and noradrenaline reuptake inhibtors

Question 31

How does Venlafaxine activity change with dose?

Answer 31

At lower doses, blocks more serotonin reuptake. | At higher doses, mostly NA

Question 32

What are side effects of Venlafaxine?

Answer 32

Nausea, anorexia, constipation, secual dysfunction, hypertension

Question 33

WHat is Venlafaxine very good for?

Answer 33

Depressed patients with anxiety | May be good for chronic pain

Question 34

What does Mirtazapine do?

Answer 34

It's an NaSSA - antagonises alpha a adrenoceptors, histamine 1 receptors and serotonin receptors

Question 35

What would you use Mirtazapine?

Answer 35

Depressed individuals requiring sedation | Alternative to SSRIs if insomnia or seual dysfunction are problematic

Question 36

What are Mirtazapine side effects?

Answer 36

Dizziness, weight gain, drowsiness, dry mouth, constipation

Question 37

What is Bupropion used for and why?

Answer 37

Smoking cessation It's a weak NA and dopamine reuptake inhibitor - good for smoking cessation because blocks dopamine reuptake at the dopamine transporters, which mitigates some cravings in a minimal way to avoid addiction

Question 38

Which patients would bupropion be good for with depression?

Answer 38

It's activation - godo for patients with low energy and who are prone to fatigue

Question 39

What's the main problem with bupropion?

Answer 39

Seizures | --> less likely with slow release bupropion

Question 40

What are contraindications of bupropion?

Answer 40

Seizure history Anorexia Bipolar Insomnia

Question 41

What does lithium do?

Answer 41

Neuro-protective action - promotes neuroplasticity Mood stabilising Significant anti-suicide action

Question 42

What's the main 2 problems with lithium?

Answer 42

Low therapeutic index for toxicity | Big weight gain

Question 43

What are SEs of lithium?

Answer 43

Nausea, thirst, polyuria, hypothyroidism, weight gain, diarrhoea, tremor, weakness and mental confusion

Question 44

Which organ does lithium effect?

Answer 44

Kidney function - prolongued lithium treatment may cayse serious tubular damage

Question 45

WHat would you use for bipolar after lithium?

Answer 45

Anti-convulsant mood stabilisers | Atypical antipsychotics

Question 46

What are first line treatment for acute mania?

Answer 46

Lithium, valproate, atypical antipsychotics

Question 47

What's first line treatment for bipolar depression?

Answer 47

Lithium, sodium valproate, quetiapine and lamotrigine

Question 48

What do you need to be aware of in pregnancy with bipolar treatment?

Answer 48

Lithium and anticonvulsant mood stabilisers can increase the chance of foetal malformation

Question 49

WHen can you conclude antidep isn't working?

Answer 49

4-6 weeks

Question 50

When do you discontinue antidepressant medications?

Answer 50

After 4-9 months, gradually If on multiple episodes, can consider 2-5 ears Severe = rest of lives

Question 51

What are 1st line ADs for MDD?

Answer 51

SSRIs - sertraline SNRIs - venlafaxine Mirtazapine - NaSSa

Question 52

What are 2nd line ASs for MDD?

Answer 52

Moclobemide Reboxetine Agomelatine

Question 53

What is last resort in MDD treatment?

Answer 53

Electroconvulsive therapy - who are resistant to antidep medications

Question 54

Which medication combination is really good for bipolar depression?

Answer 54

Fluoxetine - olanzapine

Question 55

WHat should you try for mild-moderate depression?

Answer 55

Psychotherapy, exercise and lifestyle modifications

Question 56

What should you monitor after AD initiation in patients under 25 particularly?

Answer 56

Anxiety Agitation Suicidal ideation