Mental health Flashcards
What are the indications of SSRI’s and provide examples?
1) Depression (1st line)
2) GAD/Panic disorders
3) OCD
-Citalopram, Sertraline, Fluoxetine
What is the mechanism of action of SSRI’s?
Selective serotonin reuptake inhibitors inhibit serotonin reuptake.
Why use SSRI’s over TCA’s?
SSRI’s are generally preferred as they have fewer adverse effects and less dangerous in overdose than TCA’s.
What are the important side effects of prescribing SSRI’s and SNRI’s?
- Weight disturbance (loss or gain)
- Insomnia
- Sexual dysfunction
- Hyponatraemia in the elderly
- Citalopram specifically can prolong QT interval, predisposing to arrhythmias
- Suicidal thoughts and behaviour increased, just use with caution
- GI upset (nausea, vomiting, pain, diarrhoea)
- At high doses can cause serotonin syndrome (triad of altered consciousness level, neuromuscular abnormalities and autonomic hyperactivity), but this usually responds to treatment withdrawal.
What is serotonin syndrome? What other medication can increase the risk of it?
At high doses of SSRI’s can cause serotonin syndrome (triad of altered consciousness level, neuromuscular abnormalities and autonomic hyperactivity), but this usually responds to treatment withdrawal of SSRI’s.
-Other antidepressants such as MAOI, have the same effect, so when used simultaneously with SSRI’s can increase risk of serotonin syndrome.
What happens when antidepressants are stopped?
-Discontinuation syndrome occurs with symptoms such as GI upset, diarrhoea, dizziness, headache, insomnia, tremor. So antidepressants need to be gradually tapered down before being withdrawn completely
What are interactions of SSRI’s?
- Do not combine with MAOI/triptans as can increase chance of serotonin syndrome
- Do not combine with Antipsychotics as can prolong QT interval, predisposing to arrhythmias
- If using with NSAIDS co-prescribe PPI as NSAID and SSRI can cause GI bleeding.
What are MAOI’s and action?
Monoamine oxidase inhibitors inhibit monoamine oxidase A. These are typically used for atypical depression.
What are CI of SSRI’s and SNRI’s?
- prolonged QT interval
- young people.
- mania, may actually worsen symptoms of bipolar or uncover a manic episode
What are SNRI’s?
Serotonin-noradrenaline reuptake inhibitors inhibit uptake of serotonin and noradrenaline.
What are indications of TCA’s and examples?
1) Depression (2nd line)
2) Anxiety/panic disorders
3) OCD
4) Neuropathic pain in MS
Examples: Amitriptyline
What is the mechanism of action of TCA’s?
-Tricyclic antidepressants inhibit reuptake of serotonin and noradrenaline. Also blocks wide array of receptors e.g. muscarinics, histamine, adrenergic, dopamine
What are adverse effects of TCA’s?
- Blockage of histamine and adrenergic receptors can cause sedation and hypotension
- Cardiac effects can cause ST elevation and QT interval prolongation
- cause sexual dysfunction
- DANGEROUS in overdose causing convulsions, arrhythmias
- Sudden withdrawal can cause GI upset, insomnia
What are CI of TCA’s?
- Arrhythmias
- Recent MI
- Pts with high risk of overdose
What are indications of Mirtazapine?
1)Antidepressant for major depression, can be given to patients with depression whereby sedation or increased oral intake is needed
What are side effects of mirtazapine?
-Associated with increased appetite, weight gain
-sedation
So can be given to patients with depression whereby sedation or increased oral intake is needed.
What are indications of Benzodiazepines?
1) Seizures (1st line) - lorazepam
2) Alcohol withdrawal (1st line) - chlordiazepoxide/diazepam
3) Short treatment for insomnia - temazepam
4) Short term treatment for anxiety disorders - temazepam
5) Sedation for acute mania or psychosis
What is the mechanism of action of Benzodiazepines?
Benzodiazepines facilitate and enhance binding of GABA to the GABAA receptor.
What are the side effects of Benzodiazepines?
- Can cause dose-dependent drowsiness, coma and sedation. Important to warn pts about potential dangers of drowsiness when driving.
- Risk of substance dependence with prolonged use
- Sudden withdrawal can cause withdrawal symptoms
What are the warnings of Benzodiazepines?
- Use with caution in pts with chronic respiratory disease (COPD, sleep apnoea) as may depress respiration.
- Use lower doses for elderly, their more susceptible to side effects leading to falls
What is the antagonist for Benzodiazepines?
-Flumazenil can reverse effects of benzodiazepines
What is the mechanism of action and types of antipsychotics?
- First generation (typical) are D2 (dopamine) receptor antagonist
- Second generation atypical antipsychotics act on a variety of receptors.
What are the indications of antipsychotics?
1) Schizophrenia - Haloperidol (first generation antipsychotic)
2) Bipolar disorder
3) Severe psychomotor agitation that is causing dangerous, impulsive, violent behaviour (calms patients)
4) Depression or mania with psychotic features
What are extrapyramidal side effects and which drug associated with?
Commonly in first generation typical antipsychotics e.g. haloperidol, blocking dopamine pathway can cause extrapyramidal effects (movement abnormalities e.g.
- parkinsonism (bradykinesia which is slowing of movements)
- dystonia (muscle spasms)
- akathisia (severe restlessness)
- tardive dyskinesia (involuntary movements of head, limbs, trunk)
Other side effects are include impaired glucose tolerance, prolonged qt intervals, hyperprolactinaemia.
What are warnings of antipsychotics?
- Elderly start at lower doses, as more susceptible to the side effects
- Avoid in pts with dementia, can cause stroke or death
- Avoid in pts with Parkinson’s disease due to extrapyramidal effects.
What are examples of mood stabilizers and what do they do?
- Lithium
- Anti-epileptics e.g. Valproate, Carbamazepine, Lamotrigine
Mood stabilizers help reduce mood swings and prevent manic and depressive episodes
What are indications of Lithium?
1) Acute mania
2) Prophylaxis of bipolar disorders (prevents relapse), if lithium CI give carbamazepine
What are important drug interactions for lithium?
-Avoid use of diuretics (thiazides), NSAIDSs and ACE inhibitors as these can increase lithium levels.
Investigations needed prior to initiating treatment with mood stabilisers?
Mood stabilizers e.g., lithium
Prior to initiating therapy
- FBC
- U + E
- Calcium - check for hypercalcaemia
- Thyroid function
- Pregnancy test (women of childbearing age)
- ECG (cardiac disease)
What are adverse effects of Lithium?
- Teratogenicity
- Cardiac: T wave flattening or inversion
- Polydipsia, polyuria, weight gain, oedema
- Fine tremor
- Impaired renal function
- Hypernatraemia
- Hyperparathyroidism can result in hypercalcaemia (kidney stones)
- FBC
- U + E
- Calcium
- Thyroid function
- Pregnancy test (women of childbearing age)
- ECG (cardiac disease)
How is lithium monitored?
Weekly after starting treatment until stable for 2 consecutive weeks. Then monitor every 3 months. Monitor renal function.
What is the warning of Valproate?
-Avoid in women of childbearing age due to teratogenicity.
Which of these is not a contraindication of SSRI use?
- mania
- suicidal thoughts
- epilepsy
- prolonged QT interval
Can be used with caution if pt with depression has suicidal thoughts, regular monitoring.
What are side effects of atypical antipsychotics?
Examples: olanzapine and clozapine
- Polyuria and polydipsia leads to diabetes
- Weight gain
- Clozapine causes agranulocytosis (reduced number of WBC called neutrophils)
What is the antidepressant of choice for young adults and children?
Fluoxetine
What are the adverse effects of atypical antipsychotics e.g. clozapine, olanzapine?
Commonly in second generation antipsychotics e.g. clozapine, metabolic disturbances
- obesity
- diabetes mellitus
- hypercholesterolaemia
- dyslipidaemia
Other side effects are prolongation of QT intervals causing arrhythmias, sexual dysfunction.
Why is lithium monitoring required?
Can cause lithium toxicity.
- Can cause thyroid dysfunction.
- Nephrotoxicity. Lithium is excreted by kidneys, so clearance of lithium decreased in pts with renal impairment and sodium depletion so requires lithium monitoring.
What are the CI for lithium use?
- Addisons disease - lithium block action of fludrocortisone (drug used to replace aldosterone)
- Cardiac disease associated with rhythm disorders
- Significant renal impairment
- Untreated hypothyroidism
- Pregnant
What length of time to withdraw SSRI to prevent discontinuation syndrome?
Over 1 month, antidepressants need to be gradually tapered down before being withdrawn completely
