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3RD YEAR SYSTEMS: Psychiatry > Anti-depressants and Anxiolytics > Flashcards

Anti-depressants and Anxiolytics Flashcards

1
Q

How long after you start someone on an anti-depressant before it starts to be effective and symptoms start to improve?

A

2 - 4 weeks

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2
Q

What are the 5 main classes of anti-depressants?

A
  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Serotonin/Noradrenaline (dual) Reuptake Inhibitors (SNRIs)
  • Tricyclics (TCAs)
  • Monoamine Oxidase Inhibitors (MAOIs)
  • Novel anti-depressants
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3
Q

Which class of anti-depressants tend to be 1st line in treatment of depression?

A

Selective Serotonin Reuptake Inhibitors (SSRIs)

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4
Q

What is the common treatment regime/progression of treatment for someone with depression?

A
  1. Start them on an SSRI
  2. If no improvement is seen after a trial of adequate length (at least 2 months) and adequate dose then you tend to switch them to another class of anti-depressant.
  3. If again there is no improvement, you then add an adjunctive.
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5
Q

Tricyclics:

  1. Are these well tolerated?
  2. What are their main side effects?
A
  1. These are often very effective but the side effects are usually unacceptable for most people. TCAs are toxic – even a week supply could cause an overdose. CV effects = can cause QT lengthening even at a therapeutic serum.
  2. They have anti-histaminic and anti-cholinergic effects which cause the following side effects:-
    • Anti-histaminic => weight gain, sleepy
    • Anti-cholinergic => dry mouth, blurred vision
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6
Q

Names of common TCAs

A
  • Amitriptyline
  • Nortriptyline
  • Protriptyline
  • Imipramine
  • Desipramine
  • Clomipramine
  • Doxepin
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7
Q

How do Tricyclics work?

A

TCAs work by hitting quite a lot of receptors, as a result they increase serotonin, dopamine and noradrenaline.

Different TCAs hit these receptors in slightly different ways.

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8
Q

What are the 2 subclasses of Tricyclics?

A

Tertiary TCAs - essentially ‘dirtier drugs’ – lots of amine side chains which are prone to cross reacting with other types of receptors which leads to more side effects. Examples of tertiary TCAs include Imipramine, amitriptyline, doxepin, clomipramine. They also have active metabolites (when they are broken down in the body) including desipramine and nortriptyline.

Secondary TCAs - these are often the active metabolites of the tertiary amines / TCAs. They primarily block noradrenaline. Side effects are the same as tertiary TCAs but are generally less severe. Examples of secondary TCAs include Desipramine, nortriptyline.

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9
Q

How do Monoamine Oxidase Inhibitors (MAOIs) work?

A

These do the same things as TCAs but in a slightly different way.

MAOIs bind irreversibly to monoamine oxidase which prevents the inactivation of amines such as norepinephrine, dopamine and serotonin (so they are always activated) leading to increased synaptic levels. They are very effective for resistant depression.

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10
Q

What are the side effects associated with MAOIs?

A
  • Orthostatic hypotension
  • Weight gain
  • Dry mouth
  • Sedation
  • Sexual dysfunction
  • Sleep disturbance
  • Cheese reaction – Patients on these may need to alter their diet
  • Serotonin syndrome
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11
Q

Describe the ‘cheese reaction’ side effect of MAOIs

A

This is a reaction caused by eating Tyramine-rich foods whilst on MAOI medication. Tyramine-rich foods include:- aged cheese, beer on tap, red wine, soy sauce, flava beans etc (the tyramine content increases as foods age)

Tyramine affects your blood pressure. It is regulated and broken down by the MAO enzyme and so when on MAOI medication, you cannot break down the tyramine and this can cause a hypertensive crisis or potentially death.

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12
Q

What is Serotonin syndrome?

A
  • Serotonin syndrome is a potentially fatal but rare condition.
  • It develops if there are excess serotonin levels – this can happen if you take MAOI with meds that increase serotonin or have sympathomimetic actions.
  • Also if you are using a combination of anti-depressants or SSIs at a high dose.
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13
Q

How do SSRIs work?

A
  • SSRIs block pre-synaptic serotonin reuptake so increase the level of serotonin available.
  • Used for both depression and anxiety.
  • They are relatively safe – very little risk of cardiotoxicity in overdose.
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14
Q

What are the side effects of SSRIs?

A

They have side effects but they are more tolerable!

  • GI upset
  • Sexual dysfunction in up to 30% of people
  • Anxiety
  • Restlessness
  • Nervousness
  • Insomnia
  • Fatigue
  • Sedation
  • Dizziness
  • Activation or discontiunation syndrome can be an issue!
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15
Q

What is activation syndrome and discontinuation syndrome?

A
  • Activation syndrome – caused by an increase in serotonin. Tends to last 2-10 days. Can feel sick, nauseous, increased anxiety, panic and agitation.
  • Discontinuation syndrome - happens if you stop SSRIs suddenly. Causes things like agitation, nausea, imbalance (dizziness, vertigo, light headedness) and dysphoria (a state of unease or generalized dissatisfaction with life).
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16
Q

How might you get around/avoid discontinuation syndrome?

A

Discontinuation syndrome is more common with drugs that have a shorter half life so to get around discontinuation syndrome you could swap the patient onto an SSRI such as Fluoxetine (Prozac) that has a longer half-life.

17
Q

Name 2 commonly used SSRIs

A
  • Sertraline
  • Fluoxetine
18
Q

Pros and cons of Sertraline (SSRI)

A

Pros

  • Doesn’t tend to react with other drugs
  • Has a shorter half life with lower build up of metabolites meaning fewer side effects

Cons

  • Max absorption requires a full stomach and so you have to take it with a meal or just after eating
19
Q

Pros and cons of Fluoxetine (prozax) (SSRI)

A

Pros

  • Longer half-life is good for prevention of discontinuation syndrome. And also, for those patients with poor compliance.

Cons

  • Has more drug interactions than Sertraline
  • Longer half-life and active metabolite build up - not food in patients with hepatic illness
  • More likely to induce mania than other SSRIs
20
Q

How do Serotonin/ Norepinephrine reuptake Inhibitors (SNRIs) work?

A

This is a dual action anti-depressant which works to inhibit both serotonin and noradrenergic reuptake (similar job to TCAs) but with fewer side effects.

Used for depression, anxiety and possibly neuropathic pain.

21
Q

Name 2 commonly used SNRIs

A
  • Venlafaxine
  • Duloxetine
22
Q

Pros and cons of commonly used SNRIs

A
  • Venlafaxine
    • Pros – minimal drug interactions and almost no P450 activity. Short half-life and fast renal clearance avoids build up (good for geriatric population)
    • Cons – can cause increase in diastolic BP (quite common), can get similar activation and discontinuation syndromes with this too, sexual dysfunction
  • Duloxetine
    • Pros – doesn’t increase BP in most cases
    • Cons – some drug reactions
23
Q

Name 1 common Novel anti-depressant (newer drugs)

A

Mitrazapine

24
Q

Pros and cons of Mitrazapine

A

Pros – slightly different action compared with SSRIs as it affects different serotonin receptors so it can provide a good augmentation strategy to SSRIs (combination)

Cons – The main problems associated with this drug is weight gain and an increase in serum cholesterol! (very common). Very sedating at lower doses - drug users tend to like this medication due to its sedative nature.

25
Q

If a patient’s depression becomes ‘treatment resistant’ what should you do? i.e what adjunctives are available?

A
  • 1st go to – combination of antidepressants. You may start the patient on one drug and then swap it but if neither work then do combination.
  • Next you could add lithium
  • Or you could add an atypical antipsychotic e.g Quetipaine, Olanzapine, or Aripiprazole
  • Electroconvulsive therapy
26
Q

What would you then do once you get someone better to prevent relapse resistance in the future?

A

You need to give prophylaxis medication.

  • If it was their first relapse - prophylaxis for 6 months-1 year
  • If it was their second relapse - prophylaxis for 2 years
  • After a third episode - life-long prophylaxis
27
Q

Which drugs are commonly used to treat Anxiety?

A

SSRIs or SNRIs

We try to avoid symptomatic relief from things such as diazepam because that doesn’t treat the underlying cause of the anxiety.

28
Q

Does adjunctive therapy work in treating anxiety?

A

No evidence for lithium but combining an SSRI or SNRI with an anti-psychotic such as risperidone or quetiapine has proven effective

29
Q

What is the normal step-wise management for someone with Generalised Anxiety Disorder / Panic disorder?

A

Step 1 - identify and assess, education about GAD and treatment options. Active monitoring.

Step 2 - low-intensity psychological interventions i.e written or electronic self-help materials or education groups

Step 3 - Choice of a high-intensity psychological intervention (CBT/applied relaxation) or a drug treatment

Step 4 - Highly specialist treatment, such as complex drug and/or psychological treatment regimens; input from
multi-agency teams, crisis services, day hospitals or inpatient care

30
Q

Which medication is commonly used to treat Anxiety in primary care?

A
  1. SSRIs tend to be 1st line - consider offering Sertraline first because it is the most cost-effective
  2. If sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI) - n.b there is a greater side effect profile with these + an increased risk of suicidal thinking so need to monitor
  3. If these are ineffective then offer Pregabalin (an anti-epileptic)
31
Q
  1. What are Benzodiazepines?
  2. When are they used/prescribed?
  3. Give examples of some different types of benzodiazepines
A
  1. They are anti-anxiety (anxiolytic) medication
  2. Reserve for short-term use only e.g particularly severe period of anxiety, emergency sedation or withdrawal states - helps get patient safely through alcohol withdrawal especially if they are in delirium tremens (acute confusional state – sweating, fits and seizures)
  3. Diazepam and Alprazolam (Xanax)
32
Q

Side effects of Benzodiazepines? (5)

A
  • Somnolence
  • Cognitive deficits
  • Amnesia
  • Disinhibition
  • Tolerance and dependence - regularly abused substance in drug using population – tolerance increases so they need more and then dependence develops. It also becomes less effective, so they take more.
33
Q

What treatment is offered to those who have had an overdose on benzodiazepines?

A

Flumazenil

34
Q

Dementia drugs

A

Acetylcholinesterase inhibitors - rivastigmine, memantine - parkinsonism, agranulocytosis, agitation

NMDA receptor antagonists - memantine, dizziness, constipation, headache

3RD YEAR SYSTEMS: Psychiatry (15 decks)

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