Antidepressants and mood stabilisers Flashcards
What is the usual first line tx for depression?
SSRIs
How long do antidepressants take to work?
2-6 weeks
Why should you start antidepressants at a low does and titrate up?
avoid initiation side effects
What is the treatment for psychotic depression?
antidepressants and antipsychotics
What should be looked for in younger patients starting on antidepressants?
can cause agitation leading to suicidal behaviour
What should be the dosing in the elderly?
lower- usually half normal adult dose
How long should treatment be continued after full resolution of symptoms after a first episode?
6-12 months
How long should treatment be continued after full resolution after a recurrence?
12-24 months
After a thrid epsidoe of depression how long should treatment be continued?
indefinitely
What is the mainstay of treatment with bipolar disorder?
mood stabilisers- lithium; anticonvulsants; antipsychotics
What drug is good for bipolar depression?
lamotrigine
What drug is good for mania/hypomania?
valproate
What drugs are good for both elevated and depressed states?
lithium and antipsychotics
When are antidepressants useful in bipolar?
short term for severe depressive episodes- generally avoid
What happens if antidepressants are used in bipolar?
cause switching to mania or mood instability; not effective as mood stabilisers
When are depot IM antipsychotics given?
if compliance is poor or patient unwilling to take oral
Give examples of SSRIs?
fluoxetine; sertraline; citalopram; escitalopram; paroxetine
What are the SE of SSRIs?
GI upset; anxiety; agitation; insomnia; sexual dysfunction; hyponatraemia
When should SSRIs be taken and why?
in the morning to reduce insomnia
What SSRI has the worst discontinuation symptoms?
paroxetine
What are the discontinuation SE of SSRI?
GI upset; anxiety; agitation; insomnia; myoclonus
What SSRI is safest in cardiac problems?
sertraline
What SSRI is safest in epilepsy?
citalopram
What cardiac SE is citalopram associated with?
long QTc
Why are tricyclic antidepressants not first line?
cardiac SE and dangerous in OD
What are the SE of TCAs?
sedation; confusion; dizziness; antimuscarinic effects; sexual dysfunction; cardiac arrthymias
What TCA has a lower cardiac risk?
lofepramine
When should TCAs be taken? Why?
at night as cause sedation
What patients should TCAs be avoided in?
cardiac problems; older people; suicidal intent
What type of antidepressant is mirtazapine?
noadrenergic and speciic serotonergic
When would mirtazapine be first line?
if patient has insomnia or poor appetite
What can mirtazapine be used in combination with?
SSRIs or venlafaxine
What are the SE of mirtazapine?
sedation; hunger/weight gain; constipation; dizziness; falls; dry mouth; unusual/vivid dreams; blood dyscrasias; seizures
When should mirtazapine be taken and why?
at night due to sedation
What happens if mirtazapine is taken with alcohol?
GI upset
Give examples of SNRIs?
venlafaxine and dulozetine
What is duloxetine used for other than depression?
neuropathic pain and bladder instability
What are the SE of SNRIs?
same as SSRIs; HT; cardiac arrhythmias
When should SNRIs be taken?
in the morning to avoid insomina
Give examples of irreversible MAOIs?
phenelzine; tranylcypromine; isocarboxazid
Give examples of reversible MAOIs?
moclobemide
When are MAOIs used?
treatment resistant depression
Why are MAOIs only used in tratment resistant depression?
dietary and medication restriction
What are the monoamine neurotransmitters?
norepinephrin; serotonin; dopamine
What are the SE of monoamine oxidase inhibitors?
postural hypotension; drowsiness; insomnia; nausea; tiredness; constipation; hypertensive crisis; hepatic impairment; seizures
Why are there difficulties with compliance in MAOIs?
three times daily dosing
What does the aminoacid tyramine do?
potent releaser of norepinephrine
What are the symptoms of a hypertensive crisis?
HA; SOB; nosebleed; anxiety; arrhythmias; stroke; seizures; death
What are high tyramine foods?
cheese; alcoholic drinks; dried meats; stock cubes; soy; tofu; pate; marmite; caffeine
How is a hypertensive crisis treated?
phentolamine infusion
Give an example of a serotonin antagonist/reuptake inhibitor?
trazodone
What are the SE of trazodone?
GI upset; dizziness; sedation; tiredness; HA; hypotension; incoordination; oedema; blurred vision; priapism
What is the most effective treatment for bipolar?
lithium
What are the SE of lithium?
GI upset; dry mouth; feeling of weakness; sedation; weight gain; fine tremor; polydipsia; polyuria; ankle swelling; renal impairment; cardiac arrhythmias; hypothyroidism hypoparathyroidism
When should lithium be taken?
at night due to sedation
What are th drug interactions of lithium?
NSAIDs; ACEIs; ARBs; diuretics
What tests should be done prior to commencing lithium?
U&Es; TFTs; ECG
What tests should be done during initiation of lithium tx?
lithium level (12 hours after last dose) and U&Es every 5 days
What should be done every 3 months on lithium?
lithium level and U&Es
What should be checked every 6 months on lithium?
TFTs
What are the warning signs of lithium toxicity?
GI upset; blurred vision; coarse tremor; ataxia; drowsiness
What are the signso f severe lithium toxicity?
confusion; LOC; seizures; coma; death
What are the causes of lithium toxicity?
increased dose; dehydration (physical illness; lack of fluid intake; alchohol; hot weather; exercise); drug interactions; reduction in salt intake
What is the treatment for lithium toxicity?
stop lithium; IV fluids; monitor renal function
What is the action sodium valproate?
blocks voltage sensitive sodium channels; increses levels of GABA
What are the SE of sodium valproate?
sedation; tremor; dizziness; GI upset; tiredness; weight gain; hepatotoxicity; pancreatitis; increase in suicidal behaviour; tertogenic
What should be chekced before starting sodium valproate?
platelets and LFTs
What is the action of lamotrigine?
blocks voltage sensitive sodium channels
What are the SE of lamotrigine?
rash; GI upset; insomnia; sedation; dizziness; ataxia; tiredness; SJS; blood dyscrasias
How should lamotrigine be started to reduce risk of rash and SJS?
titrate slowly over 6 weeks
What are the SE of atypical antipsychotics?
sedation; weight gain; metabolic syndrome; extrapyramidal symptoms; constipation; QTc prolongation; neuroleptic malignant syndrome
What are the SE of aripiprazole?
insomnia; GI upset; agitation; akathisia; orthostatic hypotension; headache; constipation
Give examples of atypical antipsychotics?
olanzapine; risperidone; quetiapine; amisulpride; paliperidone; clozapine; aripiprazole
Give examples of typical antipsychotics?
haloperidol; chlorpromazine;
What is the main action of typical antipsychotics?
dopamine 2 receptor blockade
What are the SE of typical antipyschotics?
extrapyramidal symptoms; sedation; dizziness; QT prolongation; hyperprolacintaemia; neuoleptic malignant syndrome; tardive dyskinesia; akathisia
