Depression

how long does it take to see an effect and when do you monitor

take 4 weeks to see effect

review within 2 weeks to check symptoms and side effects

1 week if 18 to 25 years due to suicide risk

takes minimum 6 months after remission

What would you advise patients about if they abruptly stop antidepressants

Withdrawal symptoms

traetemtn for moderate to severe depression

first line SSRI

if limited response you can: incraese dose, switch to another SSRI or diff class

Treatment for severe depression

Electro convulsive therapy

which class of antidepressants are dangerous in overdose

TCAs

which TCA has the best sfatey profile

Lofepramine

SSRI considerations

if unstable angina/ recent MI use sertraline

do not use in uncontrolled epilepsy

Don’t give in manic phase bipolar

highest risk of qt prolongation with citalopram/ escitalopram

avoid sertraline in severe hepatic impairment

SSRI SEs

SQASH SIBS

Suicidal thought

Qt prolongation

Appetite changes

Seizures

Hepatic impairment

Sexual dysfunction

Insomnia

Bleeding (GI)

Serotonin syndrome

SSRI interactions

serotonin syndrome- if used with st johns wort, SNRIs, opioids, triptans

QT prolongation- lithium, antiarrhythmica, TCAs

Incraesed bleeding risk- anticoagulants, NSAIDs, antiplatelts

hyponatremia- carbomazepine

reduce seizure threshold- antiepileptics

CYP450 enzymes inhibitors/inducers as they’re cleared by this inhibitor e.g. grapefruit juice

Fluoxetine/ Paroxetine decrease tamoxifen concs

what is serotonin syndrome

altered mental status - agitation/ anxiety/ excitement

neuromuscular abnormalities- tremors/ msucle rigidity

autonomic hyperactivity- tachy, flushed skin, vomiting, diarrhoea

what drugs increase risk of serotonin syndrome

SSRIs, MAOIs, TCAs, Opioids, Linezolid, Metoclopramide, ondansetron, sumatriptan, bupropion, buspirone, st johns wort

What are the TCAs which are sedating and less sedating

TCAs e.g. amitriptyline, clomipramine, imipramine, lofepramine, nortryiptyline, dosulepin (not rxed anymore)

sedating oens= better for anxious pts amitriptyline, clomipramine, dozepin, trazadone

less sedating= better for withdrawn pts imipramine, lofepramine, nortriptyline

Which TCAs the worst in overdose

Amitriptyline and doselupin

TCA side effects

headche

tremors

constipation

dry mouth

sexual dysfucntion

blurred vsion

weight gain

QT prolonagtion / hypotension in toxicity

TCA interactions

Serotonin syndomre: SNRIs, opioids, st johns wort, triptans, tramadol

increase BP when given with phenylephrine

sedative effects- alcohol, barbituates, benzos

QT prolongation- lithium, antiarrhythmics

cyp450 iducers/inhibitors

FATAL intercation WITH MAO- Ai Tranylcypromine and clomipramide

MAO-A inhibitord SEs and intercations

e.g. isocarboxazide, meclobemide, phenelzine, tranylcypromine

avoid abrupt withdrawl

tranycypromine-hypertensive crisis

isocarboxazide and phenelzine= hepatotoxicty

avoid alcohol and tyramine rich foods (causes hypertension)

Phenylephrine + MAO-Is = hypertensive crisis

what are the MAO-A i washout periods

dont start antidepressants for 2 weeks after treatemnt with MAOIs

OR 3 weeks for clomipramine/ imipramine

dont start an MAOI until

2 weeks after previous MAOi

1-2 weeks after TCA

1 week after SSRI or 5 weeks for fluoxetine