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
How do NSRI's work?
The same way as SSRI's but by binding to noradrenaline re-uptake receptors as well
26
What other symptom are NSRI's indicated for besides depression?
Neuropathic pain
27
In what way do the side-effects differ from those of SSRI's?
Have a greater potential for sedation, nausea and sexual dysfunction
28
What are the two NSRI's?
Duloxetine Venlafaxine
29
What is the dose range for duloxetine?
60 - 120mg
30
What is the dose range for venlafaxine?
75 - 375mg
31
Why is venlafaxine generally better than duloxetine?
More efficacious Can go to a higher dose
32
When can high dose duloxetine be problematic?
Heart disease
33
What must be done regularly in patients on venlafaxine at doses higher than 225mg?
Blood pressure monitoring
34
What class does mirtazapine belong to?
A unique class
35
How does mirtazapine work?
By acting as a 5HT-2 and 5HT-3 antagonist
36
Through what pathway does mirtazapine exert it’s main side effect of sedation?
H1 (histamine) activity
37
What are the two major side effects of mirtazapine?
Sedation and weight gain
38
Are the side-effects of mirtazapine always negative?
No - can be used to therapeutic advantage
39
Are tricyclics antidepressants commonly used?
Not as a first line treatment
40
When are tricyclics antidepressants usually used?
In patient’s who do not respond to SSRI’s
41
What are some newer tricyclics antidepressants?
Lofepramine and nortriptyline
42
What is an older tricyclic antidepressant?
Amitriptyline
43
What sort of side-effects can tricyclic antidepressants have?
Muscarinic and histamine
44
Why must caution be taken when prescribing tricyclic antidepressants?
They can be fatal in an overdose
45
How can tricyclic antidepressants cause death?
QTc prolongation and arrhythmias
46
What other condition can tricyclic antidepressants be used to treat?
Neuropathic pain
47
What does MAOI stand for?
Monoamine oxidase inhibitor
48
What are the two types of MAOI?
MAOI-A and MAOI-B
49
What pathway do MAOI-A’s work more on?
Serotonin
50
What pathways do MAOI-B’s work more on?
Dopamine
51
What type of depression are MAOI’s more useful in?
Atypical depression
52
What other way can MAOIs be categorised?
Reversible and irreversible
53
Which category of MAOI’s (reversible or irreversible) are more dangerous?
Irreversible
54
What are two examples irreversible MAOI’s?
Phenelzine Isocarboxazid
55
What are two examples of reversible MAOI’s?
Moclobamide Tranylcypromine
56
Why must MAOI’s be prescribe with caution?
Potential for dangerous interactions with other drugs Potential for tyramine reaction Requires a wash-out period before changing to another antidepressant
57
What can a tyramine reaction lead to?
Hypertensive crisis
58
What foods should be avoided to prevent a tyramine crisis?
Cheese Picked meats Wine Other tyramine products
59
How long must the wash-out period be when switching from an MAOI?
Up to 6 weeks
60
What is vortioxetine?
A new type of antidepressant?
61
How does vortioxetine exert its effects?
By having all sorts of serotonergic activity
62
What is the most common side-effect of vortioxetine?
Nausea
63
When deciding which antidepressant to use what should be considered?
What has been used before and was it effective/tolerated? Are there comorbidities that also need to be addressed?
64
What comorbidities can be addressed when treating depression?
Weight loss Insomnia Neuropathic pain
65
What should be used to treat new depression with no previous treatment?
SSRI | With an exception
66
What is the exception to using an SSRI for treating previously untreated depression?
In major weight loss or sleep difficulty
67
What should be used instead of an SSRI if its use is contraindicated in new depression?
Mirtazapine
68
When treating depression, if a drug has no benefit at a typical dose, should it be increased?
No
69
When treating depression, if a drug has no benefit at a typical dose, what should be done?
Switch to a different antidepressant
70
When treating depression, if a drug has only partial benefit at a typical dose, should it be increased?
Yes
71
When treating anxiety, if an antidepressant has no benefit at a typical dose, should it be increased?
Consider as an option
72
Should an antidepressant be switched immediately if it has significant side-effects within a couple of week?
Not always, these can get better
73
When should antidepressants be switched if they’re causing significant side-effects in the first couple of weeks?
If they cause a big problem for the patient
74
What is discontinuation syndrome?
A syndrome occurring upon discontinuation of antidepressants that is characterised by: Sweating Shakes Agitation Insomnia Headaches Irritability Nausea and vomiting Paraesthesia Clonus
75
What is the severity of discontinuation syndrome influenced by?
Half-life
76
What antidepressants are the trickiest to stop?
Paroxetine and venlafaxine
77
What methods can be used to ease discontinuation of antidepressants?
Alternate days of taking and not taking Snap tablets in half Switch to fluoxetine and then reduce that instead
78
What is serotonin syndrome?
A potentially life threatening condition with a very vague presentation with three groups of symptoms
79
What are the three groups of symptoms seen in serotonin syndrome?
Cognitive Autonomic Somatic
80
What are the cognitive symptoms of serotonin syndrome?
Headaches Agitation Hypomania Confusions Coma
81
What are the autonomic symptoms of serotonin syndrome?
Shivering Sweating Hyperthermia Tachycardia Nausea and diarrhoea
82
What are the somatic symptoms of serotonin syndrome?
Myoclonus Hyper-reflexia Tremor
83
What causes serotonin syndrome?
Occurs sometimes in the use of drugs affecting the serotonin system and causing excessive serotonin
84
How is serotonin syndrome treated?
Supportively with fluids and monitoring
85
What is another name for antipsychotics?
Neuroleptics
86
What do all current antipsychotics do?
Reduce the level of dopamine activity at D2 receptors
87
What are the targeted dopaminergic pathways in antipsychotic mechanism?
Mesocortical Mesolimbic
88
What pathways are not meant for targeting (but often are) in antipsychotic mechanism?
Nigrostriatal Tuberoinfundibular
89
What is the nigrostriatal pathway involved in?
Movement
90
Deficiency of dopamine in the nigrostriatal pathway occurs in what non-psychiatric condition?
Parkinson’s Disease
91
What is the tuberoinfundibular pathway involved in?
HPA axis
92
What do all antipsychotics have the potential to cause?
Sedation Extrapyramidal side-effects (EPSE’s) Weight gain QTc prolongation
93
What can all antipsychotics cause acutely?
Dystonia - including oculogyric crisis
94
What are the two main groups of antipsychotics?
Typical Atypical
95
What are typical antipsychotics?
Older drugs that are more likely to cause extrapyramidal side-effects Tend to bind more to muscarinic and histamines receptors
96
Other than dopamine, what other system do atypical antipsychotics tend to affect?
Serotonin
97
What are some typical antipsychotics?
Haloperidol Flupenthixol Zuclopenthixol Chlorpromazine Sulpride
98
What are some atypical antipsychotics?
Clozapine Olanzapine Risperidone Quetiapine Amisulpride Aripiprazole
99
What is another name for atypical antipsychotics?
Second generation antipsychotics
100
What side-effects are typical antipsychotics more likely to cause?
EPSE’s Dizziness Sexual dysfunction
101
What are some EPSE’s?
Bradykinesia Muscle stiffness Tremor Tardive dyskinesia Akathisia
102
What is akathisia?
Inner feeling of restlessness - particularly affects the legs, can also present as rocking back and forth or pacing
103
What side-effects are atypical antipsychotics more likely to cause?
Weight gain Dyslipidaemia Diabetes
104
What types of monitoring must patients on antipsychotics undergo?
Baseline Weekly Three monthly Yearly
105
What are some baseline observations taken before prescribing antipsychotics?
FBC Lipids LFT HbA1C Weight ECG Blood pressure and pulse
106
What weekly observations must a patient on antipsychotics undergo?
Weight
107
What three monthly observations must a patient on antipsychotics undergo?
FBC Lipids LFT HbA1C Weight ECG Blood pressure and pulse
108
What yearly observations must a patient on antipsychotics undergo?
FBC Lipids LFT HbA1C Weight ECG Blood pressure and pulse
109
What was the first atypical antipsychotic?
Clozapine
110
What receptors does clozapine act as an antagonist at?
D2 5HT-2
111
What is special about clozapine?
The most efficacious antipsychotic
112
How long can it take for clozapine to exert its full effects?
Months
113
When should clozapine be used to treat schizophrenia?
When two other antipsychotics have not worked
114
What does clozapine have significant potential to cause?
Agranulocytosis (severe leukopenia) Gastrointestinal hypomobility
115
What must be done to avoid agranulocytosis in clozapine use?
Close FBC monitoring. Weekly for first 18 weeks, then fortnightly then monthly
116
What can gastrointestinal hypomobility cause?
Constipation Potentially fatal bowel obstruction
117
What are some other side-effects of clozapine?
Hypersalivation Urinary incontinence
118
How should clozapine dosage be increased?
Titrated slowly over two weeks with monitoring of vital signs
119
Why should vital signs be monitored when titration clozapine upwards?
Due to the potential for autonomic dysregulation
120
What is neuroleptic malignant syndrome?
A rare life threatening reaction to antipsychotics
121
What are the symptoms of neuroleptic malignant syndrome?
Fever Confusion Muscle rigidity Sweating Autonomic instability
122
What usually causes death in neuroleptic malignant syndrome?
Rhabdomyolysis Renal failure Seizures
123
What are the risk factors for neuroleptic malignant syndrome?
High potency dopamine antagonists (typical antipsychotics) in antipsychotic naive High doses Young men
124
What is the treatment for neuroleptic malignant syndrome?
Emergency referral to A & E Stop antipsychotic Fluid resuscitation Reduce temperature
125
What are anticholinergics used for in psychiatry?
To treat the EPSE’s of antipsychotics
126
What quality of dopamine and acetylcholine is important in the nigrostriatal pathway?
The ratio between the two
127
What happens if there is too much acetylcholine in relation to dopamine?
Get EPSE’s
128
As antipsychotics aim to reduce dopamine activity, dopamine cannot be increased (or will reverse antipsychotic treatment). So how are EPSE’s treated?
By simultaneously reducing acetylcholine activity to restore the normal ratio
129
What is the most commonly used drug for treating EPSE’s?
Procyclidine
130
What does procyclidine have the potential for?
Misuse
131
What are two other anticholinergics?
Benzatropine Trihexphenidyl
132
What are anticholinergics not effective at treating?
Tardive dyskinesia
133
What effect can anticholinergics have on tardive dyskinesia?
Exacerbation