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Psychiatry > Antidepressants > Flashcards

Antidepressants Flashcards

1
Q

What are the causes of depression?

A
  • Originally thought that low levels of serotonin was the cause.
  • Now not so clear but likely reduction in serotonin receptors in hippocampus.
    • Would help explain why SSRI takes so long to work.
  • Many studies show people with depression having what is assumed to be normal levels of serotonin.
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2
Q

Describe the action of Mono Amine Oxidase Inhibitors.

Give examples of these drugs and list the side effects.

A
  • Inhibit the activity of MAO enzymes.
  • They were the first class of antidepressants developed.
  • MAO breaks down norepinephrine / serotonin and dopamine.
  • Inhibiting MAO increases level of all three transmitters.
  • Examples:
    • Phenelzine
    • Selegilline - also used in Parkinsons (helps control symptoms)
    • Tranylcypromine
  • Side effects:
    • Weakness
    • Dizziness
    • Headache
    • Fatigue
    • Weight gain
    • Impotence
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3
Q

What are the interactions with MAOIs?

A
  • Should not be used in combination with SSRI / Tricyclic as well as some analgesics such as morphine / tramadol as they will increase serotonin to potentially dangerous levels causing confsion, hypertension, tremor, coma, and possibly death i.e. neuroplastic malignant syndrome.
  • Foods high in tyramine may also cause ahypertensive crisis:
    • Cheese
    • Certain meats such as venison
    • Alcohol
    • Some green vegetables i.e.broad beans
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4
Q

Describe the action of reversible MAOIs.

A
  • Moclobeminde:
    • Reported to act by reversible inhibition of MAO type A.
    • Therefore called RIMA.
    • Tyramine has less of an effect (fewer interactions).
    • Short acting so medications can be changed with only one week washout period.
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5
Q

What is the mechanism of action of tricyclic antidepressants?

A
  • Act by inhibiting re-uptake of norepinephrine and serotonin by blocking the transporters responsible for re-uptake of these neurotransmitters.
  • Increasing concentration of neurotransmitters in the synapses and triggering further neurotransmission.
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6
Q

What are the uses of tricyclic antidepressants?

A
  • Depression
  • Anxiety
  • Chronic pain (i.e. fibromyalgia, reflex sympathetic dystrophy
  • syndrome)
  • IBS
  • Neuralgia
  • OCD
  • Nocturnalenuresis
  • PTSD
  • The main ones!
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7
Q

In which condition should tricyclic antidepressants be used with extreme caution?

A

Tricyclics should be used with caution in cardiovascular disease due to risk of arrythmias.

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8
Q

What are the side effects of tricyclic antidepressants?

A
  • Tricyclics should be used with caution in cardiovascular disease due to risk of arrythmias.
  • Tricyclics have antimuscarinic activity that blocks activity of the muscarinic acetylcholine receptor and so reduce intestinal mobility.
  • They can induce bradycardia followed by tachycardia, reduce bronchial secretions, urinary retention, dry mouth and confusion.
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9
Q

Give examples of tricyclic antidepressants?

Which is the most common (first line in Fife)?

A
  • Amitriptyline - most common and first line in Fife.
  • Clomipramine
  • Imipramine
  • Lofepramine
  • Nortriptyline
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10
Q

What are the concerns about prescribing tricyclic antidepressants?

A

Tricyclics are very dangerous in overdose so beware of how much you prescribe for a patient and use with caution in patients at high risk of suicide.

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11
Q

Describe the mechanism of action of Selective Serotonin Re-Uptake Inhibitors (SSRIs).

A
  • Believed to work by increasing levels of neurotransmitter serotonin by limiting its re- absorption and pure SSRI have only a weak affinity for norepinephrine and dopamine transmitters.
  • Serotonin receptors are know as 5- hydroxytryptamine (5-HT).
  • They are, therefore, cleaner with generally fewer side effects and better tolerated by patients.
  • 5-HT receptors are found in the peripheral and central nervous systems mediating both excitatory and inhibitory neurotransmission.
  • These receptors modulate the release of many neurotransmitters
    • GABA
    • Dopamine
    • Epinephrine
    • Norepinephrine
    • Acetylcholine
  • They influence aggression, anxiety, cognition, learning memory, mood and sleep.
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12
Q

What are the uses of SSRIs?

A
  • They are the most widely prescribed antidepressants
  • Uses:
    • Depression
    • Anxiety
    • OCD
    • Panic disorder
    • PTSD
    • Eating disorders
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13
Q

What are the side-effects of SSRIs?

A
  • Sexual: dysfunction and reduced libido.
  • Cardiac: some, especially citalopram, to be used with caution as can cause QT interval prolongation therefore dose dependant with citalopram.
  • Bleeding: affects anticoagulants (i.e. warfarin and aspirin) and also increased risk of GI bleeds.
  • Suicide: possible increased risk of suicide especially in children and adolescents.
  • Overdose: safer than other antidepressants
  • Epilepsy: may reduce fit threshold
  • Others include:
    • Nausea
    • Rash
    • Muscle aches
    • Insomnia
    • Sweating
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14
Q

Describe the toxicity of SSRIs when used in overdose.

A
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15
Q

What is Duloxetine?

What are its uses and side effects?

A
  • SNRI (serotonin norepinephrine uptake inhibitor).
  • Uses:
    • Depression​
    • Neuropathic pain (diabetes, fibromyalgia)
    • Stress urinary incontinence
  • Side effects:
    • ​Nausea
    • Insomnia
    • Dizziness
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16
Q

What is mirtazapine?

What are its uses and side effects?

A
  • A presynaptic alpha2-adrenoreceptor antagonist. Also a noradrenergic and specific serotonergic antidepressant NaSSA.
  • Uses:
    • ​Depression
    • Anxiety
    • PTSD
  • Side effects:
    • ​Low dose causes drowsiness so best taken at night
    • Higher dose more stimulant effect
17
Q

What is venlafaxine?

What are its uses and side effects?

A
  • Serotonin-norepinephrine re-uptake inhibitor (SNRI).
  • Uses:
    • ​Major Depressive Disorder
    • Anxiety
    • Panic
    • Social phobia
    • Metabolized in the body into desvenlafaxine (by cytochrome P206 isoenzyme in the liver)
    • Often used in treatment of resistant depression
18
Q

Give examples of other drugs with antidepressant properties.

A
  • Antipsychotics such as risperidone.
  • Lithium used in bipolar/mania mood stabilization possible adverse affects on kidney and thyroid function.
19
Q

Describe how antidepressants work for pain.

A
  • Can be used to treat nerve damage or abnormal nerve function (neuropathic) and some muscle pains.
  • Direct effect on the mechanisms of the pain, and not through any effect on mood.
  • Tricyclics work by blocking the re-uptake of Noradrenaline and Serotonin (5-HT) into the nerve endings and increasing their levels in the pain control pathways.
  • Their benefit arises: by their direct effect on pain, and also through beneficial effects on sleep.
20
Q

What are the antidepressants commonly used for pain?

A
  • Commonly used antidepressants:
    • Amitriptyline
    • Nortriptyline
    • Duloxetine
  • Duloxetine is also licensed for diabetic neuropathy
21
Q

Describe drug-induced QT prolongation.

A
  • Prolongation of the QT interval can lead to a life threatening arrhythmia known as torsades de pointes.
  • Recent warnings have highlighted the risk of QT prolongation with citalopram.
  • Use of more than one drug that prolongs the QT interval increases the risk of torsades de pointes and ventricular arrhythmia.
22
Q

Which drugs can cause drug-induced QT prolongation?

A
23
Q

Which patients are at greater risk of drug-induced QT prolongation?

A
  • People who have more risk factors for QTc prolongation than the general population are particularly vulnerable to drug-induced LQTS.
    • Major psychiatric disorders
    • Cardiovascular disease
    • The elderly
    • Women

Psychiatry (5 decks)

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