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Psychiatry > Drugs for mood disorder > Flashcards

Drugs for mood disorder Flashcards

1
Q

Conditions that one should be aware of for prescribing antidepressants

A

Renal/hepatic impairment

Coronary artery disease - avoid TCAs

Epilepsy - lowered seizure threshold

Bipolar - mania

GI bleeding/NSAIDs - avoid fluoxetine, sertraline, paroxetine

MAO-I/Lithium + SSRI –> serotonin syndrome

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2
Q

Alternative antidepressants for GI bleeding

A

Prescribe gastroprotection (PPI, antihistamine) w/ SSRI

Alternatively use mirtazapine or nortriptyline

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3
Q

Effect of medication on suicide risk

A

Li –> lower suicide risk

SSRI may initially raise suicide risk in young patients, need regular f/u + management plan

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4
Q

Effectiveness of antidepressant therapy

A

65-75% of patients (STAR*D trial)

1/3, 1/3, 16%

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5
Q

Monoamine theory of depression

A

Depression is caused by reduction in monoamines (5-HT, NA, DA)

Antidepressants raise monoamines (resisted by autoreceptor feedback) –> raise BDNF postsynaptically –> neurogenesis/new synaptic connections (explains lag)

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6
Q

Examples of SSRIs

A

Citalopram

Fluoxetine

Paroxetine

Sertraline

Fluvoxamine

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7
Q

Common side effects of SSRIs

A

Nausea

Agitation (esp younger patients)

Insomnia

Sexual dysfunction

Postural hypotension

P450 inhibition –> check drug interactions

Discontinuation syndrome (rare but well-characterised)

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8
Q

Examples of SNRIs

A

Venlafaxine

Duloxetine

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9
Q

Anti-depressants with half-life <24h

A

Paroxetine

Fluvoxamine

SNRIs e.g. venlafaxine

NDRIs (e.g. buproprion)

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10
Q

Mechanism of action of tricyclic antidepressants

A

Serotonin + noardrenaline + melatonin presynaptic transporter inhibition

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11
Q

Examples of TCAs

A

Nortriptyline

Amitryptiline

Clomipramine

Imipramine

Amoxapine

Doxepin

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12
Q

Examples of MAO-Is

A

Moclobemide (reversible)

Phenelzine (non-reversible)

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13
Q

Common interaction of MAO-I

A

Tyramine (wine, cheese, chocolate) or sympathomimetic drugs (e.g. decongestants) –> flushing + hypertensive crisis

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14
Q

Drug class of bupropion

A

Noradrenaline dopamine reuptake inhibitor (NDRI)

Also used for smoking cessation

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15
Q

Drug class of mirtazapine

A

NAergic and specific serotonin antagonist (NaSSA)

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16
Q

Mechanism of action of NaSSA

A

Blocks negative feedback –> increase NA and 5-HT release

NA and serotonergic specific antidepressnt

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17
Q

Short-term side effects of SSRIs

A

Dry mouth

Postural hypotension

GI disturbance

Insomnia

Tremor

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18
Q

Long-term side effects of SSRIs

A

Platelet dysf(x)

Sexual dysf(x)

Hyponatraemia

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19
Q

SSRI side effects in pregnancy

A

Increased risk of post-partum haemmorhage

Increased risk of persistent pulmonary hypoplasia (3 per 1000)

Withdrawal symptoms in baby –> increase length of hospital stay but not permanent

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20
Q

TCA contraindications

A

Neuro: Epilepsy, glaucoma

Psych: Suicidality (dangerous in OD)

Cardiovascular: Recent MI, heart block, arrhythmia, ischaemic heart disease

Endocrine: Prostatism, diabetes (use caution)

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21
Q

TCA toxicity

A

Prolonged QT, tachyarrhythmias

Seizures

Serotonin syndrome

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22
Q

Common side effects of TCAs

A

Anticholinergic: ++ (esp dry mouth/eyes, urinary retention/constipation)

Antihistaminergic: +++ (esp sedation, weight gain, advice on driving/machinery)

Cardiac: ++ (toxicity)

Metabolic/neuro: +

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23
Q

MAO-I mode of action

A

Inhibit MAO –> prevent breakdown of monoamines in presynaptic terminal + synaptic cleft –> raise levels

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24
Q

MAO-I indications

A

Third-line treatment, for atypical depression

Evidence of lower efficacy

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25
Q

Common side effects of MAO-Is

A

Postural hypotension

Weight gain

Insomnia

Ankle oedema

Sexual dysfunction

26
Q

Preferred antidepressant class for cardiac pts

A

SSRIs (beware antiplatelet drugs)

27
Q

Antidepressant class if sexual dysf(x) is an issue

A

Bupropion, mirtazapine

28
Q

Seratonin syndrome features

A

Autonomic: Shivering, sweating, hyperthermia,

Cardiac: vasoconstriction/hypertension, tachycardia

GI: nausea/diarrhoea

Neuro: Headache, agitation, confusion, hallucinations

Muscular: Myoclonus, clonus, hyperreflexia, tremor

29
Q

Management of serotonin syndrome

A

Fluids: Cause of mortality

Temperature control: cooling blankets, antipyretics

Muscle relaxant: Lorazepam

30
Q

Rare but dangerous complication of mirtazapine

A

Agranulocytosis

Look for sore throat, stomatitis, fever, other infx acccompanied by neutropaenia

31
Q

Distinguishing NMS from SS

A

NMS:

  • Slow onset
  • Slow progression
  • Lead pipe rigidity
  • Bradkinetic activity (cf clonus, tremors)
32
Q

Prevalence of antidepressant discontinuation syndrome

A

30%

33
Q

Timecourse of antidepressant discontinuation syndrome

A

Abrupt onset (2-5d after withdrawal) + short duration of symptoms (1d -3 weeks), usually self-limiting

34
Q

Risk factors for antidepressant discontinuation syndrome

A

Personal: Young age, Hx of discontinuation

Medication: Short half-life (e.g. paroxetine), high dose, duration <8wk, variable compliance

35
Q

Symptoms of discontinuation syndrome

A

SD GASS

Sensory: Paraesthesia, visual disturbance

Disequilibrium: Light-headedness, dizziness

both of the above less common with TCAs

GI: nausea + vomiting, diarrhoea

Affective: Irritability, low mood

Sleep: Insomnia, nightmares

Somatic: Flu-like symptoms, fatigue + headache

36
Q

Proposed mechanism of action of litihium

A

Substitute for many cations–>??

Effect on membrane electrophysiology

Gene expression –> neuroprotective

Effect on 2nd messenger systems (e.g. lower inositol levels)

37
Q

Drug interactions for Lithium

A

Cardiovascular: Anti-arrhtyhmics, anti-hypertensives

Analgesics esp NSAIDs

Psychiatric: Antipsychotics, antidepressants, antiepileptics

Antacids

38
Q

Workup before starting Lithium

A

Weight

U+Es + Ca, eGFR

TFTs

ECG

FBC

Advise commitment >=2y necessary

39
Q

Lithium level monitoring

A

1w after starting Li

1w after every dose change, weekly until stable levels

Every 3mo Li levels + TFTs/renal f(x)/ECG/BMI/U+E (incl. Ca)

40
Q

Common side effects of Lithium

A

Early: Metallic taste, dry mouth, thirst, polyuria, fine tremor, cognitive problems

Late: Weight gain + sedation, psoriasis, hair loss

41
Q

Rarer but more dangerous side effects of lithium

A

Hypothyroidism (1/20)

CKD (1/10 reversible, 1% irreversible)

Slowed cardiac conduction leading to arrhythmias (contraindicated in heart failure/sick sinus)

42
Q

Risk of congenital anomalies in Li pregnancies compared to normal

A

4-12% vs 2-4%

43
Q

Signs of Li toxicity

A

Early: Coarse tremor, diarrhoea (often bloody), dehydration, lethargy, N+V

Late: Ataxia, slurred speech, muscle hypertonicity/fasciculations, confusion/delirium

44
Q

Management of Li toxicity

A

Education: Stay hydrated + eat enough salt esp on hot days

Dose modification: + level monitoring

Emergency: Isotonic saline resuscitation to force diuresis

45
Q

Psychiatric indications for valproate

A

Acute mania

Depressive episode of bipolar alongside antidepressant

Bipolar prophylaxis (unlicensed)

46
Q

Mechanism of action of valproate

A

Increase GABAergic availability

47
Q

Absolute contraindication for valproate

A

Females of child-bearing age

48
Q

Common side effects of valproate

A

GI disturbance

Sedation, headache

Ataxia, tremor

Thrombocytopaenia –> manage bleeding risk esp before surgery

49
Q

Rarer but more serious side effects of valproate

A

Pancreatitis

Hepatotoxicity

Agranulocytosis

50
Q

Psychiatric indications for lamotrigine

A

Prophylaxis for bipolar disorder, prevents depressive episodes

51
Q

Mechanism of action of lamotrigine

A

Inhibits voltage-gated Na channels, reduces glutamate release

52
Q

Common side effects for lamotrigine

A

N+V

Sleepiness/insomnia

Visual + cerebellar dysf(x)

53
Q

Rarer but more dangerous side effects of lamotrigine

A

Rash (3-5%) - stop at first sign due to risk of SJS/TEN

Hepatotoxicity

Blood dyscrasias

54
Q

Timing of TCA and SSRI medication

A

SSRI: morning as activating

TCA: night as sedating (avoid in people who need to drive/use heavymachinery esp in the early morning)

55
Q

Antidepressant class of choice for post-MI depression

A

SSRIs, antiplatelet effect may be protective against CV risk

56
Q

Monitoring antidepressants

A

Every 1-2 weeks

Screen for hyponatraemia, SE profile, suicidality, serotonin syndrome

57
Q

Monitoring for valproate

A

LFTs

58
Q

Mood stabilisers for Li-resistant bipolar

A

Lamotrigine

Sodium valproate

Carbamazepine (less effective)

59
Q

Common side effects of SNRIs

A

Hypertension

60
Q

Common side effects of mirtazapine

A

Antiemetic, antipruritic, sedating

Oversedation, hyperphagia

Psychiatry (20 decks)

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