Pharmacological Treatments of Affective and Anxiety Disorders Flashcards by Michael Gray

How do antidepressants work?

Don’t fully know
Main neurotransmitters are serotonin and noradrenaline and are increased
Circuit between amygdala, frontal lobe and hypothalamus lights up, indicated important pathway

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How good is response rate?

60-70%

NNT 3

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What does nnt mean?

Number needed to treat

NNT3 means give to 3 to treat 1

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How are antidepressants usually introduced?

Selection based on past history of response, side effect profile and comorbidities
If no improvement is seen after a trial of at least 2 months then change needed

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How might antidepressant treatment change if ineffective after trial?

Dose
Switch to different antidepressant
Augment with another agent
Usually refer to psychiatry if 2 medications make no difference

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What are some side effects of TCAs?

Weight gain
Sleepy
Dry mouth
Blurred vision

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How do TCAs work?

Increasing serotonin, dopamine and noradrenaline

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What are some drawbacks of TCAs?

Lethal in OD

Even 1 weeks supply can kill

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How might TCAs affect the heart?

QT lengthening

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What kind of TCAs are “dirtier”?

Tertiary
Tertiary amine side chains cross react with more receptors causing more side effects
Amitriptyline
Doxepin
Clomipramine

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How do secondary TCAs usually work?

Block noradrenaline
Desipramine
Nortriptyline

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How does monoamine oxidase inhibitors work?

Bind irreversibly to monoamine oxidase

Prevents inactivation of amines like norepinephrine, dopamine and serotonin

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What kind of depression is particularly responsive to MAOIs?

Resistant depression

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What are some side effects of MAOIs?

Orthostatic hypotension
Weight gain
Dry mouth
Sedation
Sexual dysfunction
Sleep disturbance

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What is Cheese Reaction?

MAOIs taken with tyramine rich food like cheese can result in hypertensive crisis as tyramine isn’t broken down properly

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What is serotonin syndrome?

If MAOIs taken with other meds that increase serotonin
Abdominal pain
Diarrhoea
Sweats
Tachycardia
HTN
Pyrexia
Death

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How do SSRIs work?

Block presynaptic serotonin reuptake

Treat both anxiety and depressive symptoms

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What are some side effects of SSRIs?

GI upset
Sexual dysfunction
Anxiety
Restlessness
Nervousness
Insomnia
Fatigue
Sedation
Dizziness

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What is sertraline?

SSRI

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What are some consequences of sudden withdrawal of SSRIs?

Discontinuation syndrome
Agitation
Nausea
Disequlibrium
Dysphoria

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What is a drawback of the short half life of some SSRIs like sertraline?

Symptoms can return quite quickly if medication is missed

Discontinuation syndrome

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What is activation syndrome?

Increase in serotonin leading to nausea, increased anxiety, panic, agitation
Typically last 2-10 days
WARN PATIENTS

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What is a good option of an SSRI with longer half life?

Fluoxetine

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What are some pros for sertraline?

Less drug interactions
Short half life
Activation can help retardation
Easy to stage changes in dose
Less sedating

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What are some cons of sertraline?

Max absorption requires full stomach | More GI adverse drug reactions

What are some pros of fluoxetine (prozac)?

Longer half life Helps with discontinuation syndrome Helps compliance

What are some drawbacks of sertraline?

Long half life may lead to build up More adverse drug reactions Initial activation may increase anxiety More likely to induce mania

What are SNRIs?

Serotonin/Norepinephrine reuptake inhibitors Inhibit both serotonin and noradrenergic reuptake Venlafaxine

What are some pros of SNRIs?

Less antiadrenergic and anticholinergic side effects of TCAs | Short half life

What are SNRIs used for?

Depression Anxiety Neuropathic pain

What are some drawbacks of venlafaxine?

``` Raised BP Nausea Discontinuation syndrome Prolonged QT Sexual dysfunction ```

What are some pros of duloxetine?

Treats some physical symptoms of depression | Less likely to raise BP

What are some drawbacks for duloxetine?

Some interactions in liver | Active ingredient not stable in stomach so can't break capsule

What is mirtazipine?

Novel antidepressant

What is mirtazapine used for?

Good augmentation for SSRIs as different mechanism | Sedative so can be useful in substance abuse

What are some side effects of mirtazapine?

Increased cholesterol Weight gain Very sedating

What is a significant contraindication for TCAs?

Previous suicide attempts

What are some options to overcome treatment resistance?

``` Start on SSRI Move to SNRI Add mirtazapine Adjunctive lithium Adjunctive atypical antipsychotic like quetiapine or aripiprazole ECT ```

What are some considerations for treating anxiety?

Serotonergic treatment preferable | Avoid symptomatic relief like diazepam

When are mood stabilisers indicated?

Bipolar disorder Cyclothymia Schizoaffective disorder

What are some different classes of mood stabilisers?

Lithium Anticonvulsants Antipsychotics

Which medication is the only which reduced suicide rates?

Lithium

How is lithium used?

Reduces suicide rate in bipolar affective disorder | Effective in long-term prophylaxis for mania and depressive episodes

What might predispose to good lithium response?

Prior long-term response for patient or family member | Classic pure mania or if mania followed by depression

What are some tests to do before starting lithium and why?

U&E and TSH and pregnancy in women | Affects renal function and can affect thyroid function

Why should a patient get a pregnancy test before starting on lithium?

Associated with Ebstein's anomaly in first trimester | 20x greater risk

What are some side effects of lithium?

``` Reduced appetite Nausea Diarrhoea Hypothyroid Leukocytosis Polyuria/polydypsia Renal fibrosis leading to renal failure Hair loss Acne Reduces seizure threshold ```

Why might lithium not be good for epileptics?

Reduces seizure threshold

What are some consequences of lithium toxicity?

``` Vomiting Diarrhoea Ataxia Dizziness Slurred speech Nystagmus Blurred vision Clonic limb movements Convulsions Delirium Syncope Oliguria Renal failure ```

What is valproic acid?

Anticonvulsant

What is valproic acid good for?

``` Mania prophylaxis Rapid cycling patients Comorbid substance issues Mixed patients Comorbid anxiety Better tolerated than lithium ```

Why is valproic acid avoided in child bearing age?

Neural tube defects

What are some tests to do before starting valproic acid?

LFTs FBC Pregnancy

What are some side effects of valproic acid?

``` Thrombocytopenia Platelet dysfunction Nausea/vomiting Weight gain Sedation Tremor Hair loss ```

What is carbamazepine used for?

First line agent for acute mania and mania prophylaxis

What are some tests to be done before starting carbamazepine?

FBC LFTs ECG

What are some carbamazepine side effects?

``` Rash Nausea, vomiting, diarrhoea Sedation, dizziness, ataxia, confusion AV conduction delays Aplastic anaemia Water retention ```

Why is ECG required before starting carbamazepine?

Risk of AV conduction delay

How does carbamazepine cause water retention?

Vasopressin-like effect | Can result in hyponatremia

What is lamotrigine used for?

Neuropathic pain | Bipolar depression

What are some serious side effects of lamotrigine?

Steven Johnstone syndrome (serious rash less common with slow titration)

What would be a good med for manic episodes with alcohol abuse?

Depakote (anticonvulsant) | Rapid cycler

Is LFT rising in anticonvulsants concerning?

No Pretty common Unless its excessive (3x) you can just monitor

What would be most likely treatment for a violent, sexually disinhibited patient brought in by police for detention?

IM meds with sedation Antipsychotic (olanzapine) and benzodiazepine (lorazepam) Mood stabiliser once condition stable

How are phobias managed?

CBT/exposure therapy Benzodiazepines in short-term crisis SSRI antidepressants may help

How are panic disorders managed?

CBT Add SSRI if CBT response inadequate TCA like clomipramine or imipramine may be tried after 3 months

What is the first choice drug to treat GAD if requested or indicated?

Sertraline | SNRI like venlafaxine or duloxetine if sertraline fails

What is the first line treatment for OCD?

CBT

What is the second line treatment for OCD?

SSRI antidepressants

What is the best treatment for PTSD?

Trauma-focussed CBT

Pharmacological Treatments of Affective and Anxiety Disorders Flashcards

(70 cards)