What are the psychological symptoms?
- low self esteem
- worry and anxiety
- suicidal thoughts
What are the physical symptoms?
- lack of energy
- changes in weight and appetite
- insomnia
What is normally first line for depression?
SSRIs
Why are SSRIs preferred over TCAs?
less sedating, less antimuscarainic, less epileptogenic, less cardiotoxic
How long do SSRIs take to work?
- at least 2 weeks
- wait at least 4 weeks before deeming them effective
What are the lengths of maintenance doses for SSRIs?
- 6 months after remission
- 12 months in generalised anxiety disorder
- 2 years in recurrent depression
What are guidelines for treating depression?
- 1st line = SSRI
- 2nd line = Increase dose, try different SSRI or mirtazapine. Lofepramine (TCA) can also be used)
- 3rd line = add in another class or an augmenting agent (lithium or antipsychotic)
What are the side effects of antidepressants?
- hyponatraeima - drowsiness, confusion, convulsions
- serotonin syndrome
- suicidal ideation
What are the main symptoms of serotonin syndrome (overdose)?
- neuromuscular - tremor, myoclonus, muscle rigidity
- altered mental state - agitation, confusion, mania
- autonomic dysfunction - labile BP, urination, diarrhoea, hyperthermia, tachycardia
Why is there a washout period before switching to a different class of antidepressant?
to avoid serotonin syndrome
How long should you wait before switching antidepressants?
- MAOIs = 2 weeks. Moclobemide doesn’t require wash out period
- SSRIs = 1 week. Sertraline 2 weeks. Fluoxetine 5 weeks.
- TCAs = 1-2 weeks. Clomipramine 3 weeks
What are the symptoms of antidepressant withdrawal?
GI upset, anxiety, influenza-like symptoms, sleep disturbance
Which is the only antidepressant licensed for children?
fluoxetine
Which SSRIs can cause QT prolongation?
citalopram, escitalopram
What are the side effects of SSRIs?
- GI disturbance
- Appetite or weight change
- Serotonin syndrome
- Hypersensitivity reaction - hyponatraemia, rash
- Increased bleeding risk
- QT prolongation - citalopram
- Seizure threshold lowered
- Movement disorder
What are the interactions of SSRIs?
- Inhibitors - increase cp
- NSAIDs, Aspirin, anticoags, anti-platelets - bleeding risk
- Drugs that prolong QT
- Drugs that increase risk of serotonin syndrome - e.g. sumatriptan
- Drugs that induce hyponatraemia
What are the side effects?
- Cardiotoxic - prolonged qt, heart block, htn
- antimuscarinic - dry mouth, blurred vision, constipation, urinary retention
- sedation
What are the interactions?
- Inducers - reduced cp
- Inhibitors - increased cp
- drugs that induce hyponatraemia
- drugs that prolong QT interval
- antihypertensives - increase risk of hypotension
- increased antimuscaranic effects
- increased risk of serotonin syndrome
What are some irreversible MAOIs?
phenelzine, isocarboxazid, tranylcypromine
What is the reversible MAOI?
moclobemide (short acting)
What are the side effects of MAOIs?
- Hepatotoxicity
- postural hypotension
- potential hypertensive crisis - interacts with sympathomimetics, dopaminergic drugs, tcas
What food should patients avoid if taking MAOIs?
Foods containing tyramine = strong cheese, cured/smoked meat and fish, beer, overripe fruit, broad beans, tofu
