Pharmacological Treatment of mood and affective disorders

Question 1

What are examples of SSRIs?

Answer 1

Citalopram, sertraline, fluoxetine

Question 2

What are SSRIs first line Tx for?

Answer 2

Depression

Question 3

What are the side effects of SSRIs?

Answer 3

Nausea, anxiety, weight gain, diarrhoea, insomnia, sexual dysfunction

Question 4

Tricyclic antidepressants example?

Answer 4

Amitriptyline

Question 5

What are the side effects of tricyclic antidepressants?

Answer 5

Anticholinergic SE (postural hypotension, blurred vision, urinary retention, constipation, dry mouth, weight gain)

Question 6

Why do you have to be especially careful when prescribing tricyclic antidepressants?

Answer 6

They are cardio-toxic and so are easily overdosed on

Question 7

What does SNRIs stand for

Answer 7

Serotonin and Noradrenaline reuptake inhibitors

Question 8

examples of SNRIs

Answer 8

Venlafaxine, Duloxetine

Question 9

SE of SNRis?

Answer 9

Nausea, sexual dysfunction, headache, insomnia, anxiety, sweating, dose related increased BP

Question 10

What does MAOIs stand for

Answer 10

Phenelzine, Isocarboxazid

Question 11

side effects of MAOIs?

Answer 11

dietary restrictions, drug interactions, postural hypotension, dizziness, constipation, insomnia, drowsiness, nausea, diarrhoea, dry mouth

Question 12

What is Mirtazapine?

Answer 12

ANTIDEPRESSANT - Presynaptic alpha2-adrenoreceptor antagonist which increases central noradrenergic and serotonergic neurotransmission.

Question 13

What are side effects of mirtazapine?

Answer 13

• Drowsiness
• Agitation
• Anxiety
• Arthralgia
• Confusion
• Nausea and vomiting
• Weight gain

Question 14

Why is it important to have regular reviews of patients when first starting them on anti-depressants?

Answer 14

as it can increase suicidal ideation during the first few weeks, as it may give them the motivation to attempt suicide before it starts to increase their mood.

Question 15

How long does it take to start to see the effects of antidepressants?

Answer 15

3-6 weeks

Question 16

When do the side effects kick in with regards to antidepressants?

Answer 16

instantly

Question 17

When should antidepressants be stopped?

Answer 17

Not until 6 months after remission

Question 18

What are red flags of antidepressants?

Answer 18

• Serotonin Syndrome
• Hyponatraemia  SSRIs usually in older adults
• GI bleeding  SSRIs
• Discontinuation symptoms if stop antidepressants too abruptly

Question 19

What are examples of mood stabilisers?

Answer 19

lithium, valproate, lamotrigine, carbamazepine

Question 20

When is lithium indicated?

Answer 20

BAD, schizoaffective disorder, used to prevent mania more than depressive episodes in bipolar, best evidence to prevent acute episodes in bipolar

Question 21

What is a big side effect with use of lithium?

Answer 21

Lithium toxicity

Question 22

What is the normal level of lithium and what is it when toxic?

Answer 22

Normal level =0.4-1 mmol/L, Toxicity = >1.5mmol/L

Question 23

What are symptoms of lithium toxicity?

Answer 23

• Nausea
• Vomiting
• Diarrhoea
• Confusion
• Excessive sleeping
• Seizures
• Monoclonic jerk
• Coarse tremor

Question 24

Management of lithium toxicity?

Answer 24

STOP Lithium and rehydrate, potentially haemodialysis

Question 25

When is valproate indicated?

Answer 25

prevent mania more than depressive episodes

Question 26

When is lamotrigine indicated?

Answer 26

Prevent depressive episodes only

Question 27

When is carbamazepine indicated?

Answer 27

Only used if good response to it and tried after lithium and valproate

Question 28

What is serotonin syndrome or serotonin toxicity?

Answer 28

is a potentially life-threatening drug-induced condition caused by too much serotonin in the synapses of the brain.

Question 29

Why does it usually occur?

Answer 29

Most cases involve two drugs that increase serotonin in different ways or an overdose of one serotonin-elevating drug. e.g. SSRis and SNRIs or MAOIs

Question 30

What drugs are implicated in serotonin syndrome?

Answer 30

Antidepressants: SSRI, SNRI, TCA, MAOI, St John’s wort, lithium.
Analgesics: tramadol, pethidine, fentanyl, dextromethorphan (in OTC cough remedies).
Antiemetics: odansetron, metoclopramide.
Recreational: cocaine, MDMA, amfetamine, LSD.
Others: eg, linezolid, tryptophan, buspirone, methylthioninium chloride (methylene blue)

Question 31

What are the characteristic symptoms of serotonin syndrome?

Answer 31

Characteristic triad:
Autonomic hyperactivity
Neuromuscular abnormality
Mental status changes

Question 32

What autonomic disturbance may be seen in serotonin syndrome?

Answer 32

Hypertension.
Tachycardia.
Hyperthermia.
Hyperactive bowel sounds.
Mydriasis.
Excessive sweating.

Question 33

What neuromuscular abnormalities may be seen in serotonin syndrome?

Answer 33

Tremor.
Clonus - inducible or spontaneous.
Ocular clonus.
Hypertonicity.
Hyperreflexia (this symptom can be masked if there is severe muscle rigidity)

Question 34

What mental state changes may be seen in serotonin syndrome?

Answer 34

Anxiety.
Agitation.
Confusion.
Coma.

Question 35

Mx of serotonin syndrome?

Answer 35

Removal of offending agents or interacting drugs
Mild: usually resolve within 24 hours of discontinuation (those drugs with longer half lives may take longer e.g. fluoxetine)
Moderate: should have cardiovascular and thermal disturbances corrected and receive 5-HT2A antagonists such as cyproheptadine
Severe: need aggressive treatment and intensive care with early sedation, neuromuscular paralysis and ventilatory support.