A patient you are looking after is started on imipramine for depression.
Which combination of side effects is most likely to be seen in a patient taking this class of antidepressants?
Correct Answer E: These antimuscarinic side-effects are more common with imipramine than other types of tricyclic antidepressants.
Tricyclic antidepressants:
Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side effects and toxicity in overdose. They are however used widely in the treatment of neuropathic pain, where smaller doses are typically required.
Common side-effects:
Choice of tricyclic:
*Trazodone is technically a 'tricyclic-related antidepressant'
Which one of the following statements regarding post-partum mental health problems is NOT true?
Correct Answer A: Post-natal depression is seen in around 10% of women.
Post-partum mental health problems:
Post-partum mental health problems range from the 'baby-blues' to puerperal psychosis:
*Paroxetine is recommended by SIGN because of the low milk/plasma ratio.
**Fluoxetine is best avoided due to a long half-life.
A 65-year-old female with a history of ischaemic heart disease is noted to be depressed following a recent myocardial infarction.
What would be the most appropriate antidepressant to start?
Correct Answer E: Sertraline is the preferred antidepressant following a myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants.
Depression: selective serotonin reuptake inhibitors:
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression:
Adverse effects:
Interactions:
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks.
For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms:
A 35-year-old man with a history of schizophrenia is brought to the Emergency Department by worried friends due to drowsiness. On examination he is generally rigid. A diagnosis of neuroleptic malignant syndrome is suspected.
Each one of the following is a feature of neuroleptic malignant syndrome, except:
Correct Answer D: Neuroleptic malignant syndrome is typically seen in patients who have just commenced treatment. Renal failure may occur secondary to rhabdomyolysis.
Neuroleptic malignant syndrome:
Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients taking antipsychotic medication. It carries a mortality of up to 10% and can also occur with atypical antipsychotics.
Features:
A raised creatine kinase is present in most cases. A leukocytosis may also be seen.
Management:
A 64-year-old woman presents as she is feeling down and sleeping poorly. After speaking to the patient and using a validated symptom measure you decide she has moderate depression. She has a past history of cerebrovascular disease and currently takes aspirin, ramipril and simvastatin.
What is the most appropriate course of action?
Correct Answer C: There is an increased incidence of gastrointestinal bleeding when aspirin / NSAIDs are combined with selective serotonin reuptake inhibitors. This patient should therefore also be offered a proton pump inhibitor such as lansoprazole. It would be inappropriate to stop aspirin in a patient with a history of cerebrovascular disease.
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