Pharmacological Treatments of Affective and Anxiety Disorders

Question 1

What are the classes of anti-depressants?

Answer 1

Tricyclics 
MAOIs
SSRIs
SNRIs
Novel antidepressants

Question 2

What are the side effects of tricyclics?

Answer 2

• Antihistaminic
• Anticholinergic: dry mouth, increased heart rate, light sensitivity
• Antiadrenergic
• QT prolongation
• Lethal in overdose

Question 3

Do tertiary tricyclics have more or less side effects than normal tricyclics?

Answer 3

More side effects

Question 4

What are examples of tertiary tricyclics?

Answer 4

Imipramine
Amitriptyline
Doxepin
Clomipramine

Question 5

What is the action of secondary tricyclics?

Answer 5

Block noradrenaline

Question 6

Do secondary tricyclics have more or less side effects than tertiary tricyclics?

Answer 6

Same but less severe

Question 7

What are examples of secondary tricyclics?

Answer 7

Desipramine

Nortriptyline

Question 8

What class of antidepressant is good for resistant depression?

Answer 8

MAOIs. Occasionally for treatment resistant depression and sleep disturbance.

Question 9

What is the action of MAOIs?

Answer 9

Bind irreversibly to MAO, preventing inactivation of amines such as norepinephrine, dopamine and serotonin, leading to increased synaptic levels.

Question 10

Main side effects of MAOIs?

Answer 10

Weight gain, dry mouth, sexual dysfunction, sedation, postural hypotension and sleep disturbance.

Cheese reaction: foods rich in tyramine or sympathomimetics

Question 11

What class of antidepressant can treat both depression and anxiety?

Answer 11

SSRIs

Question 12

What are the benefits of SSRIs?

Answer 12

Very little risk in overdose

Question 13

What is the action of SSRIs?

Answer 13

Block presynaptic serotonin reuptake

Question 14

Main side effects of SSRIs?

Answer 14

Anxiety, restlessness, nervousness, insomnia, fatigue, sedation, sexual dysfunction

Question 15

What are examples of SSRIs?

Answer 15

Sertraline

Fluoxetine

Question 16

Pros and cons of Sertraline?

Answer 16

Pros: Less sedating when compared to paroxetine, short half-life with a build-up of metabolites

Cons: Full stomach for max absorption, increased number of GI adverse reactions

Question 17

Pros and cons of fluoxetine?

Answer 17

Pros: Long half-life so decreased incidence of discontinuation syndromes (non-compliant patients)

Cons: Long half-life so build-up active metabolite (hepatic illness), significant P450 interactions (polypharmacy), activation syndrome, mania.

Question 18

What treats depression, anxiety and possibly neuropathic pain?

Answer 18

SNRIs

Question 19

What is the action of SNRIs?

Answer 19

Inhibit serotonin and noradrenergic reuptake like TCAs, but without bad side effects

Question 20

What are examples of SNRIs?

Answer 20

Venlafaxine

Duloxetine

Question 21

Pros and cons of Venlafaxine?

Answer 21

Pros: Minimal drug interactions, a short half-life, fast renal clearance.

Cons: Increase diastolic BP, nausea, continuation syndrome and QT prolongation.

Question 22

Pros and cons of Duloxetine?

Answer 22

Pros: physical symptoms of depression, less increase in BP.

Cons: Active ingredient not stable in stomach.

Question 23

What is an example of novel antidepressants?

Answer 23

Mirtrazapine

Question 24

Pros and cons of Mirtrazapine?

Answer 24

Pros: Good augmentation strategy to SSRIs, hypnotic at lower doses secondary to antihistaminic effects.

Cons: 20% increased serum cholesterol, sedation and weight gain at low doses.

Question 25

Management of treatment resistant depression?

Answer 25

Antidepressant with - Mirtazapine - Atypical antipsychotic (quetiapine, olanzapine, aripiprazole) - Lithium - ECT

Question 26

What class of drug do you use for bipolar, cyclothymia, schizoaffective disorder?

Answer 26

Mood stabiliser

Question 27

First line for bipolar?

Answer 27

Lithium

Question 28

Factors predicting positive response to lithium?

Answer 28

- Prior long term response or family member with good response - Classic pure mania - Mania follower by depression

Question 29

What to check before starting patients on lithium?

Answer 29

U&E, TSH, pregnancy

Question 30

Side effects of lithium

Answer 30

* Thyroid * Interstitial renal fibrosis * Polyuria/polydipsia * Hair loss * CNS symptoms (seizure, tremor) * Acne * GI distress * Nonsignificant leukocytosis

Question 31

What is mild lithium toxicity?

Answer 31

1.5-2, vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus

Question 32

What is moderate lithium toxicity?

Answer 32

2-2.5 vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus nausea.

Question 33

What is severe lithium toxicity?

Answer 33

>2.5 generalised convulsions, oliguria and renal failure

Question 34

What are examples of anticonvulsants?

Answer 34

Valproic acid Carbamazepine Lamotrigine

Question 35

Valproic acid: what to check and main side effects?

Answer 35

LFT, pregnancy Side effects include thrombocytopaenia and platelet dysfunction, nausea, vomiting, weight gain, sedation, tremor, hair loss.

Question 36

Carbamazepine: what to check and main side effects?

Answer 36

FBC, ECG Rash, nausea, vomiting, diarrhoea, sedation, ataxia, confusion, AV conduction delays, aplastic anaemia and agranulocytosis

Question 37

Lamotrigine: what to check and main side effects?

Answer 37

LFT Nausea, vomiting, sedation, dizziness, ataxia and confusion. Toxic epidermal necrosis (if rash stop immediately), blood dyscrasias

Question 38

What are rapid cycler and mixed patients?

Answer 38

Rapid cycler: many bipolar episodes in a year Mixed patients: Depression and mania at the same time

Question 39

What is the first line agent for acute mania and mania prophylaxis in rapid cycler and mixed patients?

Answer 39

Carbamazepine

Question 40

What class of drug do you use for schizophrenia, schizoaffective disorder, bipolar disorder, psychotic depression?

Answer 40

Antipsychotics

Question 41

What are the different dopamine pathways?

Answer 41

Mesocortical Mesolimbic Nigrostriatal Tuberoinfundibular

Question 42

What symptoms does the mesocortical pathway give rise to?

Answer 42

Negative symptoms and | cognitive disorders arise. Problem here for a psychotic patient is too little dopamine

Question 43

What symptoms does the mesoclimbic pathway give rise to?

Answer 43

Positive symptoms come from here. Too much dopamine

Question 44

What symptoms does the nigrostriatal pathway give rise to?

Answer 44

Involved in movement | regulation. Dopamine hypoactivity --> Parkinsonian movements

Question 45

What symptoms does the tuberoinfundibular pathway give rise to?

Answer 45

Blocking dopamine in this pathway will predispose to hyperprolactinaemia

Question 46

What is the action of typical antipsychotics?

Answer 46

D2 receptor antagonists

Question 47

What are the main side effects of typical antipsychotics?

Answer 47

Higher risk extrapyramidal side effects. Cardiotoxic and anticholinergic adverse effects including sedation and hypotension.

Question 48

What are the examples of typical antipsychotics?

Answer 48

Fluphenazine, haloperidol, pimozide, chlorpromazine, thioridazine.

Question 49

What is the action of atypical antipsychotics?

Answer 49

Serotonin-dopamine 2 agonists.

Question 50

What is the difference between atypical and typical antipsychotics?

Answer 50

Atypicals affect dopamine and serotonin in the four key dopamine pathways in the brain, so they differ in side effect profiles.

Question 51

What are the examples of atypical antipsychotics?

Answer 51

Risperidone, Olanzapine, Quetiapine, Aripiprazole, Clozapine

Question 52

What are the main side effects of risperidone?

Answer 52

Extrapyramidal side effects Prolactinaemia Weight gain Sedation.

Question 53

What are the main side effects of olanzapine?

Answer 53

Prolactinaemia | Abnormal LFTs

Question 54

What are the main side effects of quetiapine?

Answer 54

``` Abnormal LFTs Weight gain Cholesterolaemia Glycaemia Triglyceridaemia Orthostatic hypotension ```

Question 55

What are the main side effects of aripiprazole?

Answer 55

Extrapyramidal side effects No QT prolongation Akathisia/activation Not really sedation or weight gain.

Question 56

What are the main side effects of clozapine?

Answer 56

``` Used for treatment resistant patients Agranulocytosis Lowers seizure threshold, Most sedation + weight gain Abnormal LFTs Triglyceridaemia Cholesterolaemia Glycaemia Coma ```

Question 57

What is an important principle of schizophrenia prophylaxis?

Answer 57

Keep the patient on treatment as far as possible, to prevent relapse and cognitive decline.

Question 58

What are the main antipsychotic adverse effects?

Answer 58

Tardive dyskinesia Neuroleptic malignant syndrome Elevated WBC, CPK, LFTs Extrapyramidal side effects

Question 59

What are extrapyramidal side effects?

Answer 59

Acute dystonia, Parkinson syndrome, akathisia

Question 60

If a patient comes in showing signs of extrapyramidal side effects, what can you use to treat?

Answer 60

Benztropine Trihexyphenidyl Diphenhydramine Amantidine Propranolol Diazepam

Question 61

What are anxiolytics used to treat?

Answer 61

Panic disorder, GAD, substance misuse, withdrawal, insomnia, parasomnias

Question 62

What are examples of anxiolytics?

Answer 62

Busiprone | Benzodiazepines

Question 63

What are the pros of busiprone?

Answer 63

Good augmentation strategy. Independent of endogenous release of serotonin. No sedation

Question 64

What are the cons of busiprone?

Answer 64

Effect takes around 2 weeks. Less efficacious in patients used to BZDs

Question 65

What are the pros of benzodiazepines ?

Answer 65

Very effective, used as acute short-term treatment.

Question 66

What are the cons of benzodiazepines ?

Answer 66

- Somnolence - Cognitive defects - Amnesia - Disinhibition - Tolerance - Dependence (potential for misuse)