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Psychiatry week 1 > Management of mood disorders > Flashcards

Management of mood disorders Flashcards

1
Q

What are the 2 main SNRI’s (seritonin and noradrenaline reuptake inhibitors) and when are they commonly used?

A
  • Venlafaxine and duloxetine
  • Commonly used when SSRI and/or mirtazapine haven’t worked (3rd line)
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2
Q

What are the potnetial side effects caised by SNRI’s?

A
  • Same as SSRI’s - GI upset, anxiety, agitation, insomnia, myoclonus, and get discontinuation symptoms just like in SSRI’s (managed the same way by tapering off instead of just stopping instantly)
  • Also hypertension, cardiac arrhythmias
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3
Q

When monotherapy for depression hasn’t worked, which combination of anti-depressants is particularly effective ?

A

Venlafaxine is excellent in combination with mirtazapine (california rocket fuel)

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4
Q

What anti-depressant can also be used for bladder instability or neuropathic pain ?

A

Duloxetine

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5
Q

Give examples of MAOI’s (monooxamine oxidase inhibitors) and when are they used ?

A
  • Irreversible MAOIs: phenelzine, tranylcypromine, isocarboxazid
  • Reversible MAOI: moclobemide (less side effects, less effective)

Only use in treatment resistant depression due to dietary and medication restrictions. Rarely used in bipolar due to high risk of switching to mania.

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6
Q

What are the side effects/problems of MAOI’s and which side effect is the key one to look out for ?

A

postural hypotension, insomnia, nausea, tiredness, constipation, perioheral oedema.

Rarely hypertensive crisis, hepatic impairment, seizures,

Need to take it 3 times daily so not great for adherence

Hypertensive crisis .

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7
Q

What type of foods should you avoid which can precipitate hypertensive crisis in someone on a MAOI and what symptoms might suggest a hypertensive crisis ?

A

High tyramine foods​ - cheese, meat, alcohol

Symptoms of hypertensive crisis: headache, SOB, nosebleed, anxiety. Can lead to arrhythmias, stroke, seizures, death

treat with phentolamine infusion for the crisis

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8
Q

List some of the drug interactions of MAOI’s

A

: SSRIs/SNRIs, tryptophan, tricyclics, mirtazapine, phenylephrine, some opioids, dextromethorphan

basically interacts with a lot of drugs esp some of the other anti-depressants hence its not used often

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9
Q

What is the main Serotonin 2 antagonist/reuptake inhibitors (SARI) and when is it used ?

A

Trazodone

Used for when sedation is needed or to argument other anti-depressants (think it sounds like tramadol so causes sedation)

often used in the elderly to sedate and reduce agitation

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10
Q

What are some of the other side effects of SAIR?

A

GI upset, dizziness, sedation, tiredness, headache, hypotension/syncope, incoordination, oedema, blurred vision, priapism

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11
Q

What is the most effective treatment of bipolar disorder ?

A

Lithium carbonate

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12
Q

What are some of the side effects of lithium carbonate ?

A
  • GI upset
  • dry mouth/strnage taste
  • feeling of weakness/shakiness
  • sedation
  • weight gain
  • fine tremor
  • polydipsia, polyuria (think DM, this is excessive thrist and urination)
  • ankle swelling
  • renal impairment
  • cardiac arrhythmias
  • hypothyroidism
  • hypoparathyroidism
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13
Q

What is the main side effect you are worried about in lithium use and ==> what drug interactions do you need to be careful with ?

A

Renal impairment

NSAID’s, ACEi, ARB’s and diuretics (think simply the drugs it interacts with are also drugs which affect the kidneys)

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14
Q

What monitoring is required when on lithium carbonate ?

A
  1. Prior to initiation: U+E, TFTs, ECG,
  2. During initiation: lithium level and U+E weekly sample taken 12hrs after dose is given until lithium level stable within therapeutic range
  3. Every 3 months: lithium level and U+E
  4. Every 6 months: TFTs (hypothyroidism is usually treated with levothyroxine rather than stopping lithium)
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15
Q

What are the signs of lithium toxicity and how is it treated ?

A
  • Warning signs: GI upset, blurred vision, coarse tremor, ataxia, drowsiness
  • Severe toxicity: confusion, loss of consciousness, seizures, coma, death

Treatment: stop lithium, IV fluids, monitor renal function, may need dialysis in severe cases

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16
Q

When may semisodium valproate be used and what is its mechanism of action?

A

in bipolar mania/hypomania

Blocks voltage sensitive sodium channels, increases levels of GABA

17
Q

What are the side effects of semisodium valproate and who should it be avoided ?

A

Sedation, tremor, dizziness, GI upset, tiredness, weight gain. Rarely hepatotoxicity, pancreatitis, increase in suicidal behaviour

should be avoided in women of childbearing age because its teratogenic

18
Q

When is lamotrigine used (apart for in epilepsy) and how does it work?

It is an anti-convulsant btw

A

Used in the treatment and prophylaxis of bipolar depression

Blocks voltage sensitive sodium channels

19
Q

What are the potential side effects of lamotrigine and what is the main side effect you need to be worried about ?

A
  • Rash (10%), GI upset,
  • insomnia,
  • dizziness,
  • ataxia,
  • tiredness.
  • Rarely Stevens Johnson syndrome (SJS), blood dyscrasias.

Patients advised to see a doctor ASAP if they get a rash incase of SJS

20
Q

Give examples of atypical anti-psychotics and what they can be used to treat?

A

Olanzapine, risperidone, quetiapine, amisulpride, paliperidone, clozapine (not licensed for mood disorders), aripiprazole

Treatment and prophylaxis of both manic/hypomanic and depressed mood states in bipolar disorder. Combine with an antidepressant in psychotic unipolar depression

(typical psychotics can be used to treat the exact same stuff)

21
Q

What are some of the side effects which atypical anti-psychotics can cause?

A

Sedation, weight gain (mainly mediated through increased hunger), metabolic syndrome (leading to diabetes), EPSE (extra-pyramidal side effects), constipation, QTc prolongation, neuroleptic malignant syndrome.

If EPSE most common in Aripiprazole use out of these drugs

22
Q

What are the additional side effects specific to clozapine ?

A
  • Agrnaulocytosis & Neutropaenia - weekly FBC needed
  • Reduced seizure threshold - can induce seizures in up to 3% of patients
  • constipation
  • myocarditis: a baseline ECG should be taken before starting treatment
  • hypersalivation
23
Q

Give some examples of typical anti-psychotics and there mechanism of action

A

Haloperidol, chlorpromazine, zuclopentixol, flupentixol, sulpiride,

Main action is dopamine 2 receptor blockade

24
Q

What are some of the side effects of typical anti-psychotics ?

A
  • EPSE, sedation, dizziness, QTc prolongation, hyperprolactinaemia, neuroleptic malignant syndrome
  • Note typicals used less often than atypicals
25
Q

Go over this table for the side effects of psychiatric drugs

A
26
Q

List the features of EPSE

A
  • Parkinsonism - including falls, tremor etc
  • Tardive dyskinesia - stiff jerky movements of the face & body
  • Akathesia (hard to stay still)
  • Orofacial dyskinesia (involuntary repetitive movement of the mouth & face)
  • Acute dystonia (involuntary contractions of muscles of extremities, face, neck etc)
27
Q

What are the clinical features of neuroleptic malignant syndrome ?

A
  • Pyrexia
  • Autonomic instability - swining BP, HR etc
  • Increasing muscle tone - eventually can lead to rhabdomyolisis ==> acute renal failure
  • Agitated delirium with confusion
28
Q

What is neuroleptic malignant syndrome and what is it caused by ?

A

A rare but dangerous condition seen in patients taking antipsychotic medication. It carries a mortality of up to 10% and can also occur with atypical antipsychotics. It may also occur with dopaminergic drugs (such as levodopa) for Parkinson’s disease, usually when the drug is suddenly stopped or the dose reduced.

29
Q

What is the management of neuroleptic malignant syndrome ?

A
  • Stop antipsychotic + IV fluids to prevent renal failure
  • Dantrolene may be useful in selected cases
  • Bromocriptine, dopamine agonist, may also be used

Psychiatry week 1 (12 decks)

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