Anxiolytics and anti-depressants

Question 1

The Limbic system

Answer 1

our moods and emotions are controlled by a loose grouping of different regions of the brain
hypothalamus: maintains homeostasis and motivational drives
amygdala: recognises and responds to emotions.
hippocampus:allows long-term storage of experiences and memory.
nucleus accumbens: involved in reward and pleasure.
cingulate cortex: registers pleasant and painful stimuli, also involved in aggression.
prefrontal cortex: deals with decision making and the expression of mood.

Question 2

SERT inhibitors

Answer 2

Tricyclic antidepressants:
- Desipramine
- Imipramine 
Selective serotonin re-uptake inhibitors:
- Sertraline
- Citalopram
- Fluoxetine (Prozac)
SERT inhibitors/5-HT releasers:
- Fenfluramine
- Methylenedioxymethamphetamine (MDMA, “E”)

Question 3

Where is serotonin found?

Answer 3

9 main clusters that lie near the midline of the brain stem

Question 4

Dopamine deficiency of Parkinson’s

Answer 4

loss of dopamine from neurons in the substantia nigra of the mid brain

Question 5

What are the 2 mood disorders?

Answer 5

major (unipolar) depression
bipolar depression
triad of symptoms for depression:
- low/depressed mood
- anhedonia (inability to feel pleasure)
- decreased energy/fatigue

Question 6

What are the symptoms of mania?

Answer 6

elation, talkativeness, creativity, fullness of energy and confidence

Question 7

Fight or flight reaction to stress

Answer 7

1. Stress causes the hypothalamus to produce corticotropin-releasing hormone (CRH).
2. CRH activates the sympathetic nervous system and acts as a signal to the pituitary gland to produce adrenocorticotrophic hormone (ACTH), which in turn signals the adrenal gland to secrete cortisol.
3. These cause the physiological changes necessary for a heightened response to stress.
4. Cortisol also feeds back on glucocorticoid receptors in the hypothalamus and hippocampus

Question 8

Treatment of depression

Answer 8

counselling
psychotherapy eg. CBT
MAOI's
Tricyclic drugs
SSR'Is
3rd generation anti-depressants
mood stabilizers
ECT - anaesthesia and muscle relaxants must be givem

Question 9

Monoamine oxidase inhibitors

Answer 9

eg. Phenelzine - treatment of bipolar and depression
Tranylcypromine - treatment of severe depression
- adverse effects:
hypertensive crisis, foods high in tyramine increase BP, Tryptophan supplements or other psychoactive drugs should be avoided as risk of “serotonin syndrome”, weight gain, oedema, sexual dysfunction and sedation
- contraindications:
impaired renal or hepatic function, hypertension, pregnant or lactating women

Question 10

Tricyclic anti-depressants

Answer 10

eg. Imipramine - treatment of depression
Amitriptyline - treatment of depression
Doxepin - depression and anxiety
- adverse affects:
weight gain, sexual dysfunction, inhibition of liver enzymes, adrenergic effects (avoid with coronary instability), antihistaminergic effects (sedation, avoid other CNS depressants), anticholinergic effects (headache)

Question 11

Selective Serotonin re-uptake inhibitors

Answer 11

eg. Fluoxetine - depression and OCD
Paraxetine - depression and panic disorders
Sertraline - depression and panic dosorders
Citalopram - depression
- adverse effects:
sexual dysfunction, dependence and withdrawal, drug interactions eg. Benzo’s, Warfarin
- contraindications:
patients with history of mania

Question 12

Miscellaneous next generation antidepressants

Answer 12

eg, Buroprion - depression

Venlafaxine - depression

Question 13

Mood stabilisers

Answer 13

eg. Lithium carbonate - prophylaxis and acute mania
Lithium citrate - prophylaxis and acute mania
Carbamazepine - mania, epilepsy
Valproate - mania, epilepsy
-adverse effects:
dizziness, headache, confusion, cardiac dysrhythmias, nephrotoxicity
- contraindications:
patients with renal dysfunction, leukaemia,
dehydration or sodium depletion

Question 14

Anxiety disorders

Answer 14

Generalised anxiety disorder
Panic disorders
Phobias
Post-traumatic stress
OCD
treated with anxiolytics

Question 15

Sedative hypnotics

Answer 15

eg. Thiopental - prep for surgery
Seconbarbital - insomnia, anxiety and acute agitation
Phenobarbital - insomnia, anxiety and seizures
Zolpidem - insomnia
- adverse effects
avoid other CNS depressants, check for suicidal tendencies, drowsiness/hangover effect, tolerance/dependence - seizure on withdrawal
- contraindications:
children under 18, pregnancy/nursing mothers

Question 16

Benzodiazepines

Answer 16

eg. Diazepam - anxiety and seizures
Alprazolam - anxiety and panic disorders
Temazepam - short term treatment of insomnia
Lorazepam - anxiety, status epilepticus, pre-op sedation, amnesia
do not cause over-sedation and tolerance
- adverse effects:
avoid CNS depressants, anticholinergic effects (dry mouth, headache)
DATE RAPE DRUG
- contraindications:
renal and hepatic dysfunction, glaucoma, pregnancy and lactation

Question 17

Non-benzodiazepines

Answer 17

eg. Buspirone - anxiety, depression co-therapy
- adverse effects:
avoid other CNS depressants, never take with MAOI’s, anticholinergic effects (dizziness, headache, dry mouth)

Question 18

Schizophrenia

Answer 18

“Positive” symptoms – hallucinations, delusions, bizarre thoughts
“Negative” symptoms – social withdrawal, flattened mood, apathy
patients unable to separate real from unreal experiences
behaviour often bizarre and inappropriate

Question 19

3 types of schizophrenia

Answer 19

Disorganised schizophrenia:
- dis-organised, thought disorder; flattened mood
- difficult to understand - speech may be incomprehensible
Paranoid schizophrenia
- experience hallucinations and delusions, but not the other symptoms
Catatonic schizophrenia
- psychmotor disturbances, e.g. catatonic stupor and waxy flexibility

Question 20

Typical Antipyschotics/neuroleptics

Answer 20

eg. Chlorpromazine - psychosis and schizophrenia, behavioural problems in children
Fluphenazine - psychosis and schizophrenia
Haloperidol - psychosis and severe behavioural problems
Loxapine - mood disorders and schizophrenia
sopamine receptor antagonists
- adverse effects:
parkinsonism (tremor), sedation, hypotension, do not take with other CNS depressants, anti-anti-hypertensives
- contraindications:
CV disease, bone marrow depression, liver/thyroid disfunction, Parkinson’s

Question 21

Atypical antipsychotics

Answer 21

eg. Clozapine, Amisulpride, Risperidone, Olanzepine - schizophrenia
- adverse effects:
risk of neuroleptic malignancy syndrome, avoid other CNS depressants, photo-sensitivity, GI distress, weight gain