1
Q
What are the core symptoms of depression diagnosis?
A
- Persistent low mood and/or Feeling down, depressed or hopeless
- Loss of interest or pleasure
- Need a number of symptoms (emotional , physical and behavioural) and functional impairment to be present
2
Q
What is the duration of symptoms required for diagnosis?
A
- 2 weeks minimum
3
Q
What are the 3 types of severity of depression and what are the diagnosis using DSM-5 classification?
A
- Mild: minimum number of symptoms (5+ of 9) with mild functional impairment
- Moderate depression: More symptoms and/or more functional impairment
- Severe depression: Most symptoms present with marked functional impairment
4
Q
How is mild depression treated?
A
- Lifestyle changes and counselling
5
Q
How is moderate/severe depression treated?
A
- Lifestyle changes, counselling, talking therapies pharmacotherapy (using meds) (generic SSRI), non-drug treatments (ECT: medical procedure where small electric currents are passed through the brain to intentionally trigger a brief seizure)
6
Q
What environmental factors can cause depression?
A
- Stress - early life (adverse childhood exprience) and on-going (psychological/physical)
- Drugs/alcohol
- Medicines (steroids)
- Physical health conditions (CVD)
- Co-morbid psychiatric and neurodevelopmental conditions
7
Q
What is the Pathology of depression?
A
- Uncertain
- Some patients have increased cortisol levels
- Some have structural brain changes (older/chronic disease)
- Some have functional brain changes
- Effective drugs suggest deficit in monoamine neurotransmission (5-HT)(NE), (DA).
8
Q
What are some other symptoms of depression of the DSM-5 classification?
A
- Weight loss/gain
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feeling worthless or excessive or inapropriate guilt
- Decreased concentration
- Thoughts of death/ suicide
9
Q
What should be asked about the core symptoms of depression?
A
- During the last month have you often been bothered by feeling down, depressed or hopeless
- Do you have little interest or pleasure in doing things
10
Q
Why use depression questionnaires?
A
- Helpful in detecting depression and assessing severity, but shouldnt be used alone to determine presence of depression which needs treatment
11
Q
What are the 3 recommended questionnaires which are validated for use in primary care?
A
- PHQ (Patient health questionnaire 9)
- HADS (Hospital anxiety and depression scale)
- BDI -II (Back depression inventory 11)
12
Q
What is Subthreshold depression and persistent subthreshold depressive symptoms?
A
- At least 2 but less than 5 symptoms of depression
- Subthreshold symptoms for more days then not for at least 2 years, which is not the consequence of partially resolved major depression. Not severe enough to meet full diagnostic criteria
13
Q
A
14
Q
What is seasonal affective disorder (SAD)?
A
Episodes of depression that recur annually at the same time each year with remission in between
15
Q
What are three complications of depression?
A
- Exacerbation of the pain, disability, and distress associated with a range of physical diseases.
- Reduced quality of life for the person and their families.
- Increased morbidity and mortality.
16
Q
What are 4 depression risks a person should be assessed and managed for?
A
- The risk of suicide.
- Any factors which may affect the development, course and severity of depression.
- Any safeguarding concerns for children or vulnerable adults in their care.
- Comorbid conditions associated with depression.
17
Q
9 questions from DSM-V for depression diagnosis
A
- Depressed mood most of the day
- Diminesh interest or pleasure in all or most activities
- Significant unintentional weight loss or gain
- Insomnia or too much sleeping
- Agitation or psychomotor retardation noticed by others
- Fatigue or loss of energy
- Fellings of worthlessness or excessive guilt
- Diminshed ability to think or concentrate, or indecisiveness
- Recurrent thought of death.
18
Q
What are 5 comorbidities that may be an underlying cause of depression?
A
- Alcohol/substance misuse
- Anxiety
- Psychotic symptoms
- Eating disorder
- Dementia
19
Q
Mild-to-moderate depression management
A
- Offer low-intensity psychosocial interventions (such as individual guided self-help, computerized cognitive behavioural therapy (CCBT) or a structured group-based physical activity programme).
- Antidepressants should not be used routinely, but may be used for people with a history of depression, persistent subthreshold symptoms, or a concomitant chronic physical health problem.
20
Q
Moderate or severe depression
A
- Offer a combo of antidepressant and a high-intensity psychological intervention (such as individual CBT, interpersonal therapy, behavioural activation, or couples therapy).
- For a first episode , SSRI such as citalopram, fluoxetine, paroxetine, or sertraline should be offered.
- For a recurrent episode, an antidepressant that has previously elicited a good response should be offered
21
Q
Which SSRI is preferred to moderate to severe depression and what should also be considered with SSRI?
A
- Sertraline as it has lower risk of drug interactions
- Consider gastroprotection in older people who are taking NSAIDs like aspirin
22
Q
What are considerations for starting an antidepressant?
A
- Consider suicide risk and toxicity in overdose.
- Explain that symptoms of anxiety may initially worsen.
- Explain that antidepressants take time to work.(2-4 weeks)
- Explain that antidepressants should be continued for at least 6 months following remission of symptoms, as this greatly reduces the risk of relapse
23
Q
What 4 things should be discussed in a follow up review when on SSRI and when should this be arranged with no suicide risk?
A
- response to treatment
- need for further management
- adverse effects
- compliance issues
- arrange an initial interview after 2 weeks, Review regularly thereafter — for example, every 2–4 weeks for the first 3 months and if the response to treatment is good, longer review intervals can be considered.
24
Q
What should happen if they need necessary admission but person declines?
A
- Compulsory admission may be arranged under sections of the Mental Health Act.
25
6 things to consider when deciding an antidepressant
- Preference
- Toxicity in overdose
- The adverse effect profile — for example, sedation, sexual adverse effects, weight gain.
- Any associated psychiatric disorder or concurrent medical illness or condition.
- Potential for drug interactions
26
Give advice about guided self-help groups, support groups and other local and national resources. Guided self-help may include:
- Self-help leaflets or books, using cognitive behavioural therapy principles.
- Self-help computer programmes or the internet.
- Exercise sessions (three each week for up to 1 hour), for 10–12 weeks.
27
Are antidepressants addictive?
No, but discontinuation symptoms experienced in one third of people.
- If you stop abruptly or miss doses you get these symptoms
28
Name some discontinuation symptoms
- restlessness
- problems sleeping,
- unsteadiness,
- sweating,
- abdominal symptoms,
- altered sensations (for example electric shock sensations in the head), or altered feelings (irritability, anxiety, confusion).
29
How can come antidepressants affect driving?
- Potentially have sedating effects, and may affect the person’s ability to drive. Most affect during 1st month
30
What can you not use during antidepressants?
- St John’s wort: reduces its effectiveness
31
For people at an increased risk of suicide, or people aged under 30 years (depression review)
- Arrange an initial review within 1 week.
- Review frequently thereafter until the risk is no longer considered clinically important.
32
What is bipolar disorder?
- A serious long-term mental illness, which is usually characterized by episodic depressed and elated moods, and increased activity (hypomania or mania).
33
What are The most important complications of bipolar disorder
- Suicide and deliberate self-harm
34
What are Consequences of acute episodes of bipolar?
- Financial difficulties from overspending.
- Traumatic injuries and accidents.
- Sexually transmitted infections and unplanned pregnancy from disinhibition and increased libido.
- Damage to reputation, income and occupation, and relationships.
- Self-neglect, exhaustion, and dehydration.
- Exploitation by others.
- Alcohol and substance misuse.
- Harm to others.
35
If a person has suspected bipolar disorder
- Should be referred for specialist mental health assessment, management, and follow-up. A risk assessment should be done to determine the urgency of referral.
36
During the acute phase, people who have been newly diagnosed with bipolar disorder may be offered the following drug treatments:
- A therapeutic trial of an oral antipsychotic (haloperidol, olanzapine, quetiapine, or risperidone).
37
If the first antipsychotic is not tolerated or not effective, (bipolar) and If a second-line antipsychotic is not effective, (bipolar)
- a second antipsychotic (from one of the four antipsychotics listed above) is usually offered
- lithium may be added, or if this is not suitable, sodium valproate may be added instead (unless the person is a pre-menopausal female).
Antidepressant medication is usually tapered and discontinued if the person develops mania while taking an antidepressant.
38
For the treatment of bipolar options include:
Quetiapine alone, or
Fluoxetine combined with olanzapine, or
Olanzapine alone, or
Lamotrigine alone.
39
Four weeks after the acute episode has resolved, the secondary care team will usually discuss the long-term management plan.
To prevent relapses, the person is usually offered a choice to:
- Continue their current treatment for mania, or
- Start long-term treatment with lithium to prevent relapses, or
- If lithium is not effective, valproate may be added to lithium treatment.
- If lithium is poorly tolerated, valproate alone or olanzapine alone may be considered.
40
Psychological therapies may also be offered for bipolar which ones?
- People with bipolar depression may be offered a psychological intervention that has been specially developed for bipolar depression.
- Alternatively, a high-intensity psychological intervention used to treat depression (for example cognitive behavioural therapy) may be offered.
41
What would secondary care normally do to monitor bipolar?
- Monitor the person’s physical health, mental health, and the effects of antipsychotic drug treatment for at least the first 12 months, or until the person’s condition has stabilized.
- Encourage the person to make a lasting power of attorney: trusted person can express their view
- Write a care plan with the person and/or their carer (with a copy sent to the primary care team) that defines the roles of primary and secondary care (see below).
42
What are some pharmaceutical considerations for lithium?
- Always prescribe lithium by brand name as preparations vary widely in bioavailability.
- Initial adverse effects of lithium therapy include nausea, diarrhoea, vertigo, muscle weakness, and a ‘dazed’ feeling.
- These effects often resolve with continued therapy. Fine hand tremors, polyuria, and polydipsia may persist.
43
What are long term adverse effects of lithium?
- hypothyroidism
- hyperthyroidism
- hyperparathyroidism
- nephrotoxicity
- renal tumours
- rhabdyolysus
44
Because of lithium’s narrow therapeutic index, interactions with other drugs can be very important. The most commonly encountered interactions are with:
- Diuretics
- NSAiDs
- Haloperidol
- Carbamazepine
- Antidepressants
- ACE inhibitors
- Drugs that prolong QT interval
- Drugs that cause hypokalemia
45
Lithium levels monitoring
-1.Lithium levels are normally measured one week after starting treatment.
2.One week after every dose change, and weekly until the levels are stable.
3.Once levels are stable, levels are usually measured every 3 months.
Lithium levels should be measured 12 hours post-dose.
46
Valproate metabolism (increased levels) is increased by what meds?
- Valproate is highly protein-bound (up to 94%), is metabolized by the liver, so drugs that inhibit CYP450 enzymes (for example erythromycin, fluoxetine, and cimetidine) can increase valproate levels.
47
Valproate can increase the plasma levels of some drugs…
- Valproate can increase the plasma levels of some drugs, possibly by inhibition of their metabolism (for example tricyclic antidepressants, particularly clomipramine).
48
When should Valproate not be prescribed?
Not be prescribed to female children, female adolescents, women of childbearing potential, or pregnant women to treat bipolar disorder unless the illness is very severe and there is no effective alternative option. (MHRA)
49
Valproate can cause blood disorders what are the symptoms?
- any unexplained bleeding, bruising, purpura, sore throat, fever, or malaise that occurs during treatment
50
Before starting valproate treatment (4)
1. A full blood count, baseline liver function tests (LFTs), and body weight or body mass index (BMI) are usually measured.
Advise the person and their carers how to recognize the signs and symptoms of:
2.Blood disorders
3.Liver disorders
4.Pancreatitis
Inform them that they should seek immediate medical help if these develop.
51
Liver disorders symptoms
- sudden onset of weakness,
- malaise,
- anorexia
- lethargy,
- oedema, and drowsiness [which are sometimes associated with repeated vomiting and abdominal pain], and jaundice
52
Pancreatitis symptoms
abdominal pain, nausea, and vomiting
53
What are adverse effects of antipsychotics?
- Extrapyramidal symptoms
• Weight gain
• Dyslipidaemia
• Hyperprolactinaemia
• Sedation
54
The following interactions are common to all antipsychotics: Drugs with a sedative action
- Drugs with a sedative action (such as alcohol, analgesics, tricyclic antidepressants, and sedating antihistamines) will enhance the sedative effects of antipsychotics.
55
The following interactions are common to all antipsychotics: Drugs with a hypotensive effect
- Drugs with a hypotensive effect (for example antihypertensives) will enhance the hypotensive effect of antipsychotics.
56
The following interactions are common to all antipsychotics: Diuretics
- Diuretics may cause hypokalaemia, which may increase the risk of arrhythmias; monitor potassium levels in people taking diuretics.
57
How is treatment resistant / difficult to treat depression?
- Add second antidepressant (SSRI + atypical), augmentation (antipsychotic, lithium)
58
What is Iproniazid and Imipramine?
- Anti TB med and inhibits monoamine oxidase (inhibits causing euphoria and increased energy)
- Analogue of antipsychotic chlorpromazine = inhibits reuptake of 5-HT/noradrenaline (relieves depressive symptoms)
59
What do MAO inhibitor and neurotransmitter reuptake inhibitor essentially do?
- Increase post-synaptic receptor activity
60
What determines breakdown of 5HT and the vesicular content?
- Monoamine oxidase
- Synthesis and breakdown. This determines the amount of 5HT released per action potential
61
What determines the release rate of 5HT and reuptake rate and?
- Firing activity
- Transporter activity
- The release and reuptake rate determines The level and duration of 5-HT in synaptic clef and cation of receptor.
62
What does MAO inhibitor do?
- Inhibits monoamine oxidase
- Increase neurotransmitter in the vesicle
- Increases neurotransmitter release per impulse
63
What are some reuptake inhibitor drugs?
- TCA
- SSRIs
- NARIs : noradrenaline reuptake inhibitors
- SNRIs
64
The MAO A subtype of monoamine oxidase has the highest affinity to what monoamine?
- Serotonin > Noradrenaline > Dopamine
- (Serotonin highest affinity)
65
The MAO B subtype of monoamine oxidase has the highest affinity to what monoamine
- Dopamine > Noradrenaline > Serotonin
- (Dopamine highest affinity)
66
What are MAO A inhibitors/ MAO A and B inhibitors used for? And What are MAO B inhibitors used for?
- Depression treatment
- Parkinson’s disease
67
What are MAO A inhibitors examples?
- Clorgyline
- Moclobemide
68
MAO A and B inhibitors examples
- Tranylcypromine
- Iproniazid
- Pargyline
69
MAO B inhibitors examples
- Selegiline
- A at higher doses
70
What are problematic interactions with MAO inhibitors?
- ‘Cheese reaction’ – avoid certain foods
- Avoid cold remedies and rec drugs
- Serotonin syndrome – interaction with other ‘serotonergic drugs’
71
‘Cheese reaction’ and MAO inhibitors
- MAO part of cytochrome P450 enzyme, so responsible for breaking down tyramine and other amines.
- MOA inhibitors cause amine levels to increase.
-Increases BP (alpha-1 vasoconstriction)
-Provoke hypertensive crisis
72
Irreversible blockade of enzymes through MAO inhibitors.
MAOI can bind to enzyme irreversible, so effects outlast clearance of the drug (drug not present in plasma levels).
New enzymes required to synthesis (6 weeks)
73
Name some TCA and NARI?
- Amitrytiline, desipramine, clomipramine
- Reboxetine
74
What differs in reuptake inhibitors? (3)
- 5-HT/NA selectivity
- Other pharmacology
- Half-life
75
5-HT/NA selectivity of reuptake inhibitors
The relative potency of the 5-HT and NA transporters for different drugs varies
TAC- small difference
SSRIs- big difference
SNRIs- small difference
76
How are TACs non-selective and ‘dirty’?
Small difference. Because at the doses taken they attach to other receptors (e.g. H1, NA alpha 1 and mACh)
77
How are SSRIs selective and ‘clean’?
Big gap for affinity for 5-HT transporter and affinity for other receptors. So at the doses taken not going to be blocking other unwanted receptors.
78
How are SNRIs non-selective and ‘clean’?
Small gap but do not have affinity for other unwanted receptors.
79
What is blocking of histamine H1 receptor associated with? (side effects) and What is blocking of 5-HT transporter associated with? (side effects)
- Sedation (sleepy and weight gain)
- Sexual defunction and GI disturbances
80
What is blocking of NA alpha 1 receptor associated with? (side effects) AND What is blocking of mACh (muscarinic acetylcholine receptor associated with? (side effects) AND What is blocking of NA transporter associated with? (side effects)
- Postural hypotension
- Dry mouth, urinary retention, and constipation
- Anxiety
81
82
First line drug treatment for depression
- SSRI- sertraline, citalopram
- Low dose and titrate up
83
Lifestyle changes for depression
- Dec drug/alcohol/stress
- Inc social and physical activity
84
Why is SSRI first line?
Well tolerated and few side effects
85
TCAs effectiveness and side effects
- More side effects (but sedation may be useful for insomnia)
- More dangerous in overdose
86
SNRIs effectiveness and side effects and MAOIs effectiveness and side effects
- More efficacious in treatment for depression, but less well tolerated
- Effective but difficult to take
87
88
What SSRI has a long half-life?
- Fluoxetine, so couple weeks to clear out
89
Discontinuation of antidepressants management
- Switch to fluoxetine due to long half life. Reduce dose slowly.
- Treat symptoms
90
What are some discontiuation symptoms?
- Flu-like symptoms
- Nausea
- Anxiety
- ‘Electric shocks’
- Difficulty sleeping
91
What SSRI has a short half-life?
- Paroxetine (Seroxat)/venlafaxine
Stage 3 - Case 2 (Central Nervous System)
flashcards
Decks in class (9)
# Cards
-
Lecture 1 & 2: Pathophysiology and Pharmacology of Schizophrenia And Case Study36
-
Lecture 3 & 4: Anxiety And Insomina Pathiophysiology, Pharmacology & Pharmaceutical Care41
-
Lecture 5 & 6: Parkinsons Disease Pathophysiology, Pharmacology And Pharmaceutical Care37
-
Lecture 7 & 8: Depression: Pathophysiology & Pharmacology & Pharmaceutical Care Of Affective Disorders91
-
Lecture 9: Pathophysiology And Pharmacology Of Dementia39
-
Lecture 10 & 11: Epilepsy: Pathophysiology And Pharmacology & Pharmaceutical Care61
-
Lecture 12: Pharmacological principles of addiction0
-
Lecture 14 & 15: Alcohol brief intervention & nicotine smoking cessation16
-
Lecture 16: Pharmaceutics/Pharmacokinetics: Neurology0
