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Year 3 - Mental Health > Antidepressants and Antipsychotics > Flashcards

Antidepressants and Antipsychotics Flashcards

1
Q

What are some common effects of adrenergic receptor agonism?

A

Sweating

Tremor

Headaches

Nausea

Dizziness

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2
Q

What are some common effects of muscarinic receptor agonism?

A

Dry mouth + thirst (+dysphagia)

Urinary retention/difficulty urinating

Hot and flushed skin

Dry skin

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3
Q

What are some common effects of histamine receptor agonism?

A

Dry mouth

Drowsiness

Dizziness

N+V

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4
Q

What neurotransmitter system do most anti-depressants act on?

A

Serotonin

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5
Q

What do most serotonin related anti-depressants aim to do?

A

Increase serotonin activity at post-synaptic receptors

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6
Q

How long can it take for most anti-depressants to begin working?

A

2-3 weeks

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7
Q

What is the most commonly used type of anti-depressant?

A

SSRI’s (Selective serotonin re-uptake inhibitors)

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8
Q

What are some other types of ant-depressant’s?

A

NSRI’s (noradrenaline and serotonin re-uptake inhibitors)

Mirtazapine

Tricyclics

MAOI’s (Mono-amine oxidase inhibitors)

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9
Q

How doe SSRI’s exert their effects?

A

By increasing serotonin activity at post-synaptic receptors

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10
Q

How do SSRI’s increase serotonin activity?

A

Reducing the pre-synaptic re-uptake of serotonin after its release

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11
Q

What does the reduction of the pre-synaptic re-uptake of serotonin result in?

A

More serotonin sitting in the nerve junction

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12
Q

Other than increased serotonin in the nerve junction, what effect do SSRI’s have on the nerve junction?

A

Down regulates post-synaptic serotonin receptors

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13
Q

What are some common side-effects of SSRI’s?

A 
Restlessness and agitation on initiation
Nausea/GI disturbances
Headaches
Weight changes
Sexual dysfunction

Bleeding and suicidal ideation (less common and usually age related)

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14
Q

What are some examples of SSRI’s?

A

Sertraline

Citalopram

Escitalopram

Fluoxetine

Paroxetine

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15
Q

What is the dose range for sertraline?

A

50 - 200mg

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16
Q

In the context of what group of non-psychiatric conditions is sertaline considered the safest?

A

Cardiac disease

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17
Q

What is the dose range for citalopram?

A

20 - 40mg

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18
Q

What is the dose range for escitalopram?

A

10 - 20mg

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19
Q

What must be considered when prescribing citalopram/escitalopram?

A

QTc prolongation

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20
Q

What is the dose range for fluoxetine?

A

20 - 60mg

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21
Q

What must be considered when switching from fluoxetine?

A

Serotonin syndrome

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22
Q

What is the dose range for paroxetine?

A

20 - 60mg

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23
Q

What must be considered when stopping paroxetine?

A

Discontinuation syndrome

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24
Q

What does NSRI stand for?

A

Noradrenaline and serotonin re-uptake inhibitors

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25
Q

How do NSRI’s work?

A

The same way as SSRI’s but by binding to noradrenaline re-uptake receptors as well

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26
Q

What other symptom are NSRI’s indicated for besides depression?

A

Neuropathic pain

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27
Q

In what way do the side-effects differ from those of SSRI’s?

A

Have a greater potential for sedation, nausea and sexual dysfunction

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28
Q

What are the two NSRI’s?

A

Duloxetine

Venlafaxine

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29
Q

What is the dose range for duloxetine?

A

60 - 120mg

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30
Q

What is the dose range for venlafaxine?

A

75 - 375mg

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31
Q

Why is venlafaxine generally better than duloxetine?

A

More efficacious

Can go to a higher dose

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32
Q

When can high dose duloxetine be problematic?

A

Heart disease

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33
Q

What must be done regularly in patients on venlafaxine at doses higher than 225mg?

A

Blood pressure monitoring

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34
Q

What class does mirtazapine belong to?

A

A unique class

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35
Q

How does mirtazapine work?

A

By acting as a 5HT-2 and 5HT-3 antagonist

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36
Q

Through what pathway does mirtazapine exert it’s main side effect of sedation?

A

H1 (histamine) activity

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37
Q

What are the two major side effects of mirtazapine?

A

Sedation and weight gain

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38
Q

Are the side-effects of mirtazapine always negative?

A

No - can be used to therapeutic advantage

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39
Q

Are tricyclics antidepressants commonly used?

A

Not as a first line treatment

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40
Q

When are tricyclics antidepressants usually used?

A

In patient’s who do not respond to SSRI’s

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41
Q

What are some newer tricyclics antidepressants?

A

Lofepramine and nortriptyline

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42
Q

What is an older tricyclic antidepressant?

A

Amitriptyline

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43
Q

What sort of side-effects can tricyclic antidepressants have?

A

Muscarinic and histamine

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44
Q

Why must caution be taken when prescribing tricyclic antidepressants?

A

They can be fatal in an overdose

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45
Q

How can tricyclic antidepressants cause death?

A

QTc prolongation and arrhythmias

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46
Q

What other condition can tricyclic antidepressants be used to treat?

A

Neuropathic pain

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47
Q

What does MAOI stand for?

A

Monoamine oxidase inhibitor

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48
Q

What are the two types of MAOI?

A

MAOI-A and MAOI-B

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49
Q

What pathway do MAOI-A’s work more on?

A

Serotonin

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50
Q

What pathways do MAOI-B’s work more on?

A

Dopamine

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51
Q

What type of depression are MAOI’s more useful in?

A

Atypical depression

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52
Q

What other way can MAOIs be categorised?

A

Reversible and irreversible

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53
Q

Which category of MAOI’s (reversible or irreversible) are more dangerous?

A

Irreversible

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54
Q

What are two examples irreversible MAOI’s?

A

Phenelzine

Isocarboxazid

55
Q

What are two examples of reversible MAOI’s?

A

Moclobamide

Tranylcypromine

56
Q

Why must MAOI’s be prescribe with caution?

A

Potential for dangerous interactions with other drugs

Potential for tyramine reaction

Requires a wash-out period before changing to another antidepressant

57
Q

What can a tyramine reaction lead to?

A

Hypertensive crisis

58
Q

What foods should be avoided to prevent a tyramine crisis?

A

Cheese

Picked meats

Wine

Other tyramine products

59
Q

How long must the wash-out period be when switching from an MAOI?

A

Up to 6 weeks

60
Q

What is vortioxetine?

A

A new type of antidepressant?

61
Q

How does vortioxetine exert its effects?

A

By having all sorts of serotonergic activity

62
Q

What is the most common side-effect of vortioxetine?

63
Q

When deciding which antidepressant to use what should be considered?

A

What has been used before and was it effective/tolerated?

Are there comorbidities that also need to be addressed?

64
Q

What comorbidities can be addressed when treating depression?

A

Weight loss

Insomnia

Neuropathic pain

65
Q

What should be used to treat new depression with no previous treatment?

A

SSRI

With an exception

66
Q

What is the exception to using an SSRI for treating previously untreated depression?

A

In major weight loss or sleep difficulty

67
Q

What should be used instead of an SSRI if its use is contraindicated in new depression?

A

Mirtazapine

68
Q

When treating depression, if a drug has no benefit at a typical dose, should it be increased?

69
Q

When treating depression, if a drug has no benefit at a typical dose, what should be done?

A

Switch to a different antidepressant

70
Q

When treating depression, if a drug has only partial benefit at a typical dose, should it be increased?

71
Q

When treating anxiety, if an antidepressant has no benefit at a typical dose, should it be increased?

A

Consider as an option

72
Q

Should an antidepressant be switched immediately if it has significant side-effects within a couple of week?

A

Not always, these can get better

73
Q

When should antidepressants be switched if they’re causing significant side-effects in the first couple of weeks?

A

If they cause a big problem for the patient

74
Q

What is discontinuation syndrome?

A

A syndrome occurring upon discontinuation of antidepressants that is characterised by:

Sweating

Shakes

Agitation

Insomnia

Headaches

Irritability

Nausea and vomiting

Paraesthesia

Clonus

75
Q

What is the severity of discontinuation syndrome influenced by?

76
Q

What antidepressants are the trickiest to stop?

A

Paroxetine and venlafaxine

77
Q

What methods can be used to ease discontinuation of antidepressants?

A

Alternate days of taking and not taking

Snap tablets in half

Switch to fluoxetine and then reduce that instead

78
Q

What is serotonin syndrome?

A

A potentially life threatening condition with a very vague presentation with three groups of symptoms

79
Q

What are the three groups of symptoms seen in serotonin syndrome?

A

Cognitive

Autonomic

Somatic

80
Q

What are the cognitive symptoms of serotonin syndrome?

A

Headaches

Agitation

Hypomania

Confusions

Coma

81
Q

What are the autonomic symptoms of serotonin syndrome?

A

Shivering

Sweating

Hyperthermia

Tachycardia

Nausea and diarrhoea

82
Q

What are the somatic symptoms of serotonin syndrome?

A

Myoclonus

Hyper-reflexia

Tremor

83
Q

What causes serotonin syndrome?

A

Occurs sometimes in the use of drugs affecting the serotonin system and causing excessive serotonin

84
Q

How is serotonin syndrome treated?

A

Supportively with fluids and monitoring

85
Q

What is another name for antipsychotics?

A

Neuroleptics

86
Q

What do all current antipsychotics do?

A

Reduce the level of dopamine activity at D2 receptors

87
Q

What are the targeted dopaminergic pathways in antipsychotic mechanism?

A

Mesocortical

Mesolimbic

88
Q

What pathways are not meant for targeting (but often are) in antipsychotic mechanism?

A

Nigrostriatal

Tuberoinfundibular

89
Q

What is the nigrostriatal pathway involved in?

90
Q

Deficiency of dopamine in the nigrostriatal pathway occurs in what non-psychiatric condition?

A

Parkinson’s Disease

91
Q

What is the tuberoinfundibular pathway involved in?

92
Q

What do all antipsychotics have the potential to cause?

A

Sedation

Extrapyramidal side-effects (EPSE’s)

Weight gain

QTc prolongation

93
Q

What can all antipsychotics cause acutely?

A

Dystonia - including oculogyric crisis

94
Q

What are the two main groups of antipsychotics?

A

Typical

Atypical

95
Q

What are typical antipsychotics?

A

Older drugs that are more likely to cause extrapyramidal side-effects

Tend to bind more to muscarinic and histamines receptors

96
Q

Other than dopamine, what other system do atypical antipsychotics tend to affect?

97
Q

What are some typical antipsychotics?

A

Haloperidol

Flupenthixol

Zuclopenthixol

Chlorpromazine

Sulpride

98
Q

What are some atypical antipsychotics?

A

Clozapine

Olanzapine

Risperidone

Quetiapine

Amisulpride

Aripiprazole

99
Q

What is another name for atypical antipsychotics?

A

Second generation antipsychotics

100
Q

What side-effects are typical antipsychotics more likely to cause?

A

EPSE’s

Dizziness

Sexual dysfunction

101
Q

What are some EPSE’s?

A

Bradykinesia

Muscle stiffness

Tremor

Tardive dyskinesia

Akathisia

102
Q

What is akathisia?

A

Inner feeling of restlessness - particularly affects the legs, can also present as rocking back and forth or pacing

103
Q

What side-effects are atypical antipsychotics more likely to cause?

A

Weight gain

Dyslipidaemia

Diabetes

104
Q

What types of monitoring must patients on antipsychotics undergo?

A

Baseline

Weekly

Three monthly

Yearly

105
Q

What are some baseline observations taken before prescribing antipsychotics?

A

FBC

Lipids

LFT

HbA1C

Weight

ECG

Blood pressure and pulse

106
Q

What weekly observations must a patient on antipsychotics undergo?

107
Q

What three monthly observations must a patient on antipsychotics undergo?

A

FBC

Lipids

LFT

HbA1C

Weight

ECG

Blood pressure and pulse

108
Q

What yearly observations must a patient on antipsychotics undergo?

A

FBC

Lipids

LFT

HbA1C

Weight

ECG

Blood pressure and pulse

109
Q

What was the first atypical antipsychotic?

110
Q

What receptors does clozapine act as an antagonist at?

111
Q

What is special about clozapine?

A

The most efficacious antipsychotic

112
Q

How long can it take for clozapine to exert its full effects?

113
Q

When should clozapine be used to treat schizophrenia?

A

When two other antipsychotics have not worked

114
Q

What does clozapine have significant potential to cause?

A

Agranulocytosis (severe leukopenia)

Gastrointestinal hypomobility

115
Q

What must be done to avoid agranulocytosis in clozapine use?

A

Close FBC monitoring.

Weekly for first 18 weeks, then fortnightly then monthly

116
Q

What can gastrointestinal hypomobility cause?

A

Constipation

Potentially fatal bowel obstruction

117
Q

What are some other side-effects of clozapine?

A

Hypersalivation

Urinary incontinence

118
Q

How should clozapine dosage be increased?

A

Titrated slowly over two weeks with monitoring of vital signs

119
Q

Why should vital signs be monitored when titration clozapine upwards?

A

Due to the potential for autonomic dysregulation

120
Q

What is neuroleptic malignant syndrome?

A

A rare life threatening reaction to antipsychotics

121
Q

What are the symptoms of neuroleptic malignant syndrome?

A

Fever

Confusion

Muscle rigidity

Sweating

Autonomic instability

122
Q

What usually causes death in neuroleptic malignant syndrome?

A

Rhabdomyolysis

Renal failure

Seizures

123
Q

What are the risk factors for neuroleptic malignant syndrome?

A

High potency dopamine antagonists (typical antipsychotics) in antipsychotic naive

High doses

Young men

124
Q

What is the treatment for neuroleptic malignant syndrome?

A

Emergency referral to A & E

Stop antipsychotic

Fluid resuscitation

Reduce temperature

125
Q

What are anticholinergics used for in psychiatry?

A

To treat the EPSE’s of antipsychotics

126
Q

What quality of dopamine and acetylcholine is important in the nigrostriatal pathway?

A

The ratio between the two

127
Q

What happens if there is too much acetylcholine in relation to dopamine?

A

Get EPSE’s

128
Q

As antipsychotics aim to reduce dopamine activity, dopamine cannot be increased (or will reverse antipsychotic treatment). So how are EPSE’s treated?

A

By simultaneously reducing acetylcholine activity to restore the normal ratio

129
Q

What is the most commonly used drug for treating EPSE’s?

A

Procyclidine

130
Q

What does procyclidine have the potential for?

131
Q

What are two other anticholinergics?

A

Benzatropine

Trihexphenidyl

132
Q

What are anticholinergics not effective at treating?

A

Tardive dyskinesia

133
Q

What effect can anticholinergics have on tardive dyskinesia?

A

Exacerbation

Year 3 - Mental Health (12 decks)

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