Depression and Anxiety

Question 1

two examples of TCAs

Answer 1

1. amitriptylline

2. imipramine

Question 2

SSRIs

Answer 2

1. fluoxetine

2. citalopram

Question 3

SNRIs

Answer 3

1. venlafaxine

2. duloxetine

Question 4

what is an atypical antidepressant

Answer 4

buproprion-NE and Dopamine reuptake inhib

Question 5

Buproprion pros

Answer 5

against weight gain and smoking

Question 6

Buproprion cons

Answer 6

epileptogenic

Question 7

Cheese/Tyramine effect

Answer 7

MAOI however, which irreversibly inhibits MAO Type A, results in prevention of NE breakdown/degradation, hence accumulation of NE. MAO-A inhibition also prevents breakdown of tyramine (tyramine ingested in forms of cheese). Tyramine (sympathomimetic agent) increases the release of NE. The combination can result in large accumulation of NE release with vasoconstriction and BP elevation, presenting with hypertensive crisis. Stop MAOI, treat with IV nitrates and beta-blocker (labetalol).

Question 8

What do TCAs block?

Answer 8

1. NE
2. Serotonin
3. Histamine
4. Alpha-1-adrenergic
5. Muscarinic cholinergic
6. Voltage sensitive sodium channels

Question 9

TCAs adverse effects:

Answer 9

anticholinergic: confusion, urinary retention, blurred vision, dry mouth, constipation, tachycardia
antihistamine: weight gain, sedation

alpha blocking: postural hypotension

Question 10

In which 4 conditions are TCAs contraindicated?

Answer 10

MI
Arrhythmia
closed angle glaucoma
BPH

Question 11

which TCA is safest in pregnancy and can be used in elderly

Answer 11

amitryptilline

Question 12

which TCA is used for enuresis

Answer 12

imipramine

Question 13

Toxic effects of TCAs

Answer 13

cardiotoxic: sinus tachycardia (due to anticholinergic effect, worsened by hypotension);

refractory hypotension (alpha-1 adrenergic receptor blockade with decreased peripheral resistance,

impaired sodium input resulting in impaired myocardial contractility thus contributing to hypotension and decreased cardiac output);

cardiac conduction abnormalities (due to inhibition of fast sodium channels, delayed AV conduction, risk of arrythmias)

CNS toxicity – delirium, lethargy, seizures, coma (inhibition of fast sodium channels in the CNS, antagonism of GABA A receptors, antihistaminic effects)

Question 14

which SSRI also blocks NE reuptake?

Answer 14

Fluoxetine

Question 15

SSRI side effects

Answer 15

sexual dysfunction

BUT

no anticholinergic, no antihistamine or cardiac effects

NB CAN POTENTIATE SUIDICIDAL THOUGHTS IN CHILDREN/TEENS SO CHOOSE A TCA FOR THIS AGE GROUP

SSRIs block serotonin uptake in platelets, thus increased risk of bleeding; warfarin and SSRI’s contra-indicated

safe in early preg

Question 16

Serotonin syndrome

Answer 16

•Neuromuscular hyperactivity:
–tremor, sustained clonus (pathognomonic; mostly if high doses of SSRI’s used, if other serotonergic agents used), hyperreflexia, rigidity
•Altered mental state:
–agitation, confusion
•Autonomic hyperactivity
–fever, sweating, tachycardia, tachypnoea, diarrhoea

e.g. serotonergics - tramadol; linezolid, St. John’s Wort
Treat – stop the drug; benzodiazepines, treat symptomatically

Question 17

which drug releases NE and serotonin into the synaptic cleft?

Answer 17

mianserin

Question 18

Mianserin

Answer 18

tetracyclic antidepressants, alpha 2 antagonists. Not a SSRI, not a TCA.
Unlike the tricyclic antidepressants, it does not prevent peripheral reuptake of NE, but releases 5-HT and NE into the synaptic cleft.

Free of anticholinergic side-effects (useful in patients with prostatic enlargement; closed-angle glaucoma), not cardiotoxic, no risk of OD.

Potentially anti-histaminic side-effect with sedation; and weightgain.

Serious risk of neutropenia and agranulocytosis

Question 19

Venlafaxine

Answer 19

Venlafaxine – SNRI – at lower doses only has serotonin reuptake inhibition; at higher doses has NE reuptake inhibition (not the case with duloxetine, which has uptake inhibition of both at low and high doses). Thus, at lower doses, acts as SSRI. Problem with venlafaxine – discontinuation/withdrawal syndrome; follows interruption/reduction/discontinuation of drug. Can present with paresthesiae, ataxia/dizzyness, lethargy, insomnia, anxiety, agitation. Consider drug only when patient poorly responsive to others.

SNRIs are a bit more difficult to manage, withdrawal

Question 20

BPMD meds

Answer 20

1. Lithium
2. Anticonvulsants: sodium valproate, carbamezapine
3. lamotrigine-rash

Question 21

Lithium toxicity

Answer 21

Nephrotoxic
neurotoxic
thyrotoxic

Question 22

adverse effects lithium

Answer 22

neutrophilia,
weight gain,
polydipsia and polyuria,
not teratogenic

don’t use with NSAIDS, ACE I, thiazide diuretics

Question 23

treatment anxiety

Answer 23

benzodiazepines

Question 24

treatment serotonin syndrome

Answer 24

benzodiazepines