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Pharmacy > Chapter 4: Mental health disorders > Flashcards

Chapter 4: Mental health disorders Flashcards

1
Q

Name and explain the 4 dopamine pathways in the brain.

A
  1. Mesocortical pathway: regulates cognition, memory, decision making
  2. Mesolimbic pathway: regulates pleasure, addiction, reward
  3. Nigrostriatal pathway:
    regulates sensory, movement
  4. Tuberoinfundibular pathway: regulates prolactin levels.
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2
Q

Describe dopamine activity levels in a schizophrenic patient

A
  1. Underactivity in the mesocortical pathway –> Negative symptoms (Social withdrawal, apathy, poor hygiene).
  2. Overactivity of the mesolimbic pathway –> Positive symptoms (hallucinations, delusions, dis organised speech and thoughts).
  3. D2 antagonism in nigrostriatal pathway –> extrpyramidal symptoms (Parkinsonism, tremor, tardive dyskinesia, akathesia, dystonia).
  4. D2 antagonism in tuberoinfundibular pathway –> hyperprolactinaemia (menstrual disturbances, galactorrhoea, breast enlargement, sexual dysfunction).
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3
Q

List the symptoms of schizophrenia

A

Positive symptoms:
• Hallucinations
• Delusions
• Dis-organised speech and thoughts

Negative symptoms:
• Social Withdrawal
• Apathy
• Loss of motivation in activities

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4
Q

What route are antispsychotics often given in an emergency situation?

A

Intramuscular injections

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5
Q

Are normal intramuscular anti psychotic injections the same as intramuscular anti-psychotic depot preparations?

A

NO (this is very important to note).

Intramuscular anti-psychotic depot preparations are long acting and are administered every 1-4 weeks by intramuscular injection to aid compliance when compliance with oral therapy is unreliable. other normal anti-psychotic IM injections are short acting and used for emergencies

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6
Q

Why should a prescription specify a certain dose for both IM and oral route? Why should IM route be lower than the oral route?

When else should you consider lowering an IM dose?

A

The IM route avoids the first pass effect Oral route dose does not. Hence oral doses should be higher.

If the patient is very active. This is because there is increased blood flow to the muscles which considerably increases rate of absorption.

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7
Q

How often should the dose of anti-psychotics for emergency use be reviewed?

A

Every day

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8
Q

What is the time frame that a patient should receive an anti-psychotic drug at optimum dose for before it is deemed ineffective?

A

4-6 weeks

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9
Q

Why should prescribing more than one anti-psychotic at a time be avoided except in certain circumstances for e.g. clozapine augmentation or when changing medication during titration?

A

Due to risks of ADRs such as extra pyramidal symptoms, QT prolongation and sudden cardiac death.

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10
Q

What drug should be offered if schizophrenia is not controlled despite the sequential use of at-least 2 different anti-psychotic (one of which including a 2nd generation drug).

A

Clozapine.

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11
Q

How long must you wait before the addition of a second anti psychotic to augment clozapine?

A

8-10 weeks.

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12
Q

Describe the 1st generation typical antipsychotics

A
  • Acts predominantly by blocking dopamine D2 receptors in the brain.
  • Not selective for any of the 4 dopamine pathways in the brain hence causes a range of s.es particularly extrapyramidal symptoms and elevated prolactin than 2nd generation.
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13
Q

Which generation antipsychotics have more occurrences of extra-pyramidal symptoms and prolatinaemia ?

A

1 st generation

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14
Q

List all 1st generation anti-psychotics

A

Phenothiazines
• Chlorpromazine
• Levomepromazine
• Promazine

• Pericyazine

  • Fluphenazine
  • Perphenazine
  • Prochlorperazine
  • Trifluoperazine

Butyrophenones
• Benperidol
• Haloperidol

Thioxanthene
• Flupentixol
• Zuclopenthixol

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15
Q

Which antipsychotics are the MOST sedating?

A

chlorpromazine
levopromazine
promazine

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16
Q

Which antipsychotics are least sedating?

A 
fluphenazine 
perphenzine 
trifluoperazine 
Prochlorperazine 
haloperidol 
benperidol 
pimozide ? 
sulpiride ?
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17
Q

Which antipsychotics is associated with the most extrapyramidal side effects?

A 
fluphenazine 
perphenzine 
trifluoperazine 
Prochlorperazine 
haloperidol 
benperidol
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18
Q

Which anti-psychotics are associated with the least amount of extra-pyramidal side effects?

A

pericyazine
pimozide?
sulpiride ?

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19
Q

Which antipsychotic causes QT prolongation?

A

Haloperidol

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20
Q

Describe the 2nd generation atypical anti-psychotics

A

blocks dopamine 1-4 receptors
Has a more distinct clinical profile in regards to s.es
Has more metabolic s.es (weight gain, diabetes, dyslipidaemia).
May be more effective at treating negative symptoms.

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21
Q

List 2nd generation antipsychotic drugs

A 
COAARQ
clozapine 
olanzapine 
risperidone 
amisulpiride 
aripripazole 
quetiapine
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22
Q

What is the most effective antipsychotic ?

A

Clozapine

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23
Q

When is clozapine prescribed?

A

When 2 or more antipsychotics have been tried (inlc 2nd gen) for at least 6-8 weeks each.

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24
Q

Can a patient continue taking the next dose of clozapine as normal if 2 days have been missed?

A

No patient must SPEAK to the doctor/specialist and they will need to re-initiate it.

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25
Q

Clozapine causes an increased risk of agranulocytosis. which other drugs cause agranulocytosis?

A 
Antipsychotics (clozapine)
Cytotoxic drugs (methotrexate)
Antimalarials (quinine) 
Aminosalicylates (sulfasalazine)
Any other drugs that cause bone marrow suppresion
26
Q

What are the top Side effects of clozapine?

A
  1. Myocarditis and cardiomyopathy
    Persistent tachycardia in the first 2 months
    Stop clozapine permanently if it occurs.
    (rapid heart rate, abnormal rhthyms, sob, ankle swelling)
  2. Agranulocytosis and neutropenia
    monitoring for leucocyte blood count every week for 18 weeks, then every 2 weeks for a year, then monthly onwards.
    (chills, fever, weakness, sore throat).
  3. Gastro-intestinal obstruction
    Intestinal peristalsis impaired = constipation, paralytic ileus.
    Advice patient to report constipation immediately before taking next dose.
27
Q

What patient counselling needs to be offered to those on chlorpromazine

A 
Very sedating (can cause drowsiness esp drivers). 
contact sensitization: avoid direct sunlight
28
Q

Which anti psychotics cause QT prolongation?

A 
Haloperidol 
Clozapine 
Pimozide 
Risperidone 
Fluphenazine 
thioridiazine (not licensed in uk?)
29
Q

Hyper salivation associated with clozapine can be treated with what?

A

Hyoscine hydrobromide

30
Q

What monitoring is required for patients on antipsychotics?

A

Weight: Measure at the start of therapy, then weekly for the first 6 weeks, at 12 weeks, at 1 year, and then yearly.

Fasting blood glucose, HbA1c, and blood lipid concentrations: measure at baseline, at 12 weeks, at 1 year, and then yearly.

Prolactin concentrations measure at baseline, 6 months and then yearly.

Before initiating antipsychotic drugs, an ECG may be required, particularly if physical examination identifies cardiovascular risk factors (e.g., high blood pressure), if there is a personal history of CVD, or if the patient is being admitted as an inpatient.

Blood pressure monitoring is advised before starting therapy, at 12 weeks, at 1 year and then yearly during treatment and dose titration of antipsychotic drugs.

Expert sources advise to monitor full blood count, urea and electrolytes, and liver function tests at the start of therapy with antipsychotic drugs, and then yearly thereafter.

31
Q

What are the side effects of anti-psychotics?

A
  1. Extrapyramidal symptoms
  2. Hyperprolactinaemia
  3. Sexual dysfunction
  4. Cardiovascular side effects
  5. Hyperglycaemia
  6. Weight gain
  7. Hypotension
  8. Neuroleptic malignant syndrome
  9. Blood dyscarsias
  10. Antimuscarinic s/es
  11. Photosensitivity
  12. Jaundice (including cholestatic)
32
Q

Most depot preparations often end in ‘decanoate’ true or false?

A

True

33
Q

Can a patient with hepatic impairment take chlorpromazine?

A

Manufacturer advises caution in severe hepatic failure (increased risk of accumulation).

34
Q

Can a patient with renal impairment take chlorpromazine what are the dose adjustments that need to be done?

A

Start with small doses in severe renal impairment because of increased cerebral sensitivity.

35
Q

When chlorpromazine is injected intramuscularly what are the monitoring requirements?

A

Patients should be supine; BP should be monitored for 30mins after injection

36
Q
  1. Can chlorpromazine tablets be crushed?
A

NO

37
Q
  1. What are the handling and storage recommendations of chlorpromazine?
A

HCPs should avoid direct contact with chlorpromazine and solutions should be handled with care, tablets cannot be crushed.

38
Q

What formulations are chlorpromazine available as?

A

Tablets, Sol for inj, Oral sol

39
Q

Can flupentixol be used by pregnant women?

A

Avoid unless benefits outweighs the risk

40
Q

Can flupentixol be used during breast-feeding?

A

Avoid- Flupentixol is present in breast milk

41
Q

Can a patient with hepatic impairment take flupentixol?

A

Manufacturer advises caution- monitor serum drug concentration.

42
Q

Can a patient with renal impairment take flupentixol?

A

Manufacturer advises caution. Dose adjustments will need to be carried out. Start will small doses of antipsychotic drugs in severe renal impairment because of increased cerebral sensitivity.

43
Q

What time of day should flupentixol not be taken and why?

A

Although drowsiness may occur, it can also have an alerting effect so should not be taken in the evening

44
Q

What formulations is flupentixol available as?

A

Tablets

45
Q

Prochlorperazine is used for the treatment of acute migraine but is not licensed for it.

Which formulations of prochlorperazine is not licensed for use in children?

A
  • Injections
  • Buccastem MR tabs
  • Avoid oral route in children under 10kg –> CNS depression, comatose states, phaeochromocytoma
46
Q
  1. What formulations are available for prochlorperazine?
A

Tablets
Sol for inj
Buccal tabs
Oral solution

47
Q
  1. Which antipsychotic is recommended to be avoided in hepatic impairment?
A

Prochlorperazine

48
Q
  1. How would you advice a patient taking buccal tablets to use the medication?
A

The tablets should be placed high between upper lip and gum and be left to dissolve.

49
Q

Which antipsychotic does not affect blood pressure to the same extent as the others do hence BP monitoring is not mandatory for?

A

Amisulpride, aripiprazole

• Formulations: Tabs, Oral sol

50
Q

What is the first line of treatment for depression?

A

SSRIs

51
Q

List the main groups of antidepressants

A

SSRIs
Tricyclic antidepressants
Monoamine oxidase

52
Q

Give examples of SSRIs

A 
Sertraline
escitalopram
citalopram
paroxetine
fluoxetine
fluvoxamine
53
Q

Give examples of tricyclic antidepressants

A 
amitriptyline
clomipramine 
dosulepin 
doxepin
mianserin 
trazodone
trimipramine 
imipramine 
lofepramine
nortriptyline
54
Q

give examples of monoamine oxidase inhibitors

A
  • Tranylcypromine
  • Phenelzine
  • Selegiline
  • Isocarboxazid
  • Moclobemide
55
Q

Why are SSRIs the recommended first line of treatment for depression?

A

• Well tolerated
• Safer in overdose
• Less sedating
• Fewer antimuscuranic and cardiotoxic
effects than tricyclic antidepressants.
• Patients with unstable angina or recent MI –> sertraline

56
Q

What are the symptoms of overdose of SSRIs?

A

N&V, Agitation , nystagmus, drowsiness, sinus tachcardia

57
Q

Is it safe for pregnant women to take SSRIs?

A

Avoid if possible unless benefits outweighs the risk. There is a risk of congenital heart defects when taken during early pregnancy (1st trimester). if used during the 3rd trimester there is a risk of neonatal withdrawal symptom symptoms and persistent pulmonary hypertension in the new borns.

58
Q

Patients on antidepressants should not stop medication abruptly. If they do what could be the possible side effects of abrupt treatment cessation?

A 
GI disturbances 
Headache, fatigue,
Anxiety 
Tinnitus 
electric shock sensation in the head 
Sleep distubances.
59
Q

How should SSRIs be withdrawed?

A

dose should be tapered gradually over about 4 weeks or longer if withdrawal symptoms emerge (6 months in people who have been on long term maintenance treatment).

60
Q

Which SSRI should be avoided during prengnacy ?

A

Paroxetine

61
Q

Which SSRI should be avoided during breastfeeding?

A

Escitalopram, fluoxetine, fluvoxamine, sertraline

62
Q

Which SSRI dose should be reduced if the patinet has an eGFR of <30ml/min/1.73m2

A

paroxetine

Pharmacy (6 decks)

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