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Psychiatry > Pharmacological Treatments of Affective and Anxiety Disorders > Flashcards

Pharmacological Treatments of Affective and Anxiety Disorders Flashcards

1
Q

How do antidepressants work?

A

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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2
Q

How good is response rate?

A

60-70%

NNT 3

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3
Q

What does nnt mean?

A

Number needed to treat

NNT3 means give to 3 to treat 1

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4
Q

How are antidepressants usually introduced?

A

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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5
Q

How might antidepressant treatment change if ineffective after trial?

A

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

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6
Q

What are some side effects of TCAs?

A

Weight gain
Sleepy
Dry mouth
Blurred vision

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7
Q

How do TCAs work?

A

Increasing serotonin, dopamine and noradrenaline

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8
Q

What are some drawbacks of TCAs?

A

Lethal in OD

Even 1 weeks supply can kill

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9
Q

How might TCAs affect the heart?

A

QT lengthening

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10
Q

What kind of TCAs are “dirtier”?

A 
Tertiary
Tertiary amine side chains cross react with more receptors causing more side effects
Amitriptyline
Doxepin
Clomipramine
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11
Q

How do secondary TCAs usually work?

A

Block noradrenaline
Desipramine
Nortriptyline

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12
Q

How does monoamine oxidase inhibitors work?

A

Bind irreversibly to monoamine oxidase

Prevents inactivation of amines like norepinephrine, dopamine and serotonin

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13
Q

What kind of depression is particularly responsive to MAOIs?

A

Resistant depression

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14
Q

What are some side effects of MAOIs?

A 
Orthostatic hypotension
Weight gain
Dry mouth
Sedation
Sexual dysfunction
Sleep disturbance
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15
Q

What is Cheese Reaction?

A

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

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16
Q

What is serotonin syndrome?

A 
If MAOIs taken with other meds that increase serotonin
Abdominal pain
Diarrhoea
Sweats
Tachycardia
HTN
Pyrexia
Death
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17
Q

How do SSRIs work?

A

Block presynaptic serotonin reuptake

Treat both anxiety and depressive symptoms

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18
Q

What are some side effects of SSRIs?

A 
GI upset
Sexual dysfunction
Anxiety
Restlessness
Nervousness
Insomnia
Fatigue
Sedation
Dizziness
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19
Q

What is sertraline?

A

SSRI

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20
Q

What are some consequences of sudden withdrawal of SSRIs?

A 
Discontinuation syndrome
Agitation
Nausea
Disequlibrium
Dysphoria
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21
Q

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

A

Symptoms can return quite quickly if medication is missed

Discontinuation syndrome

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22
Q

What is activation syndrome?

A

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

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23
Q

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

A

Fluoxetine

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24
Q

What are some pros for sertraline?

A 
Less drug interactions
Short half life
Activation can help retardation
Easy to stage changes in dose
Less sedating
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25
Q

What are some cons of sertraline?

A

Max absorption requires full stomach

More GI adverse drug reactions

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26
Q

What are some pros of fluoxetine (prozac)?

A

Longer half life
Helps with discontinuation syndrome
Helps compliance

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27
Q

What are some drawbacks of sertraline?

A

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

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28
Q

What are SNRIs?

A

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

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29
Q

What are some pros of SNRIs?

A

Less antiadrenergic and anticholinergic side effects of TCAs

Short half life

30
Q

What are SNRIs used for?

A

Depression
Anxiety
Neuropathic pain

31
Q

What are some drawbacks of venlafaxine?

A 
Raised BP
Nausea
Discontinuation syndrome
Prolonged QT
Sexual dysfunction
32
Q

What are some pros of duloxetine?

A

Treats some physical symptoms of depression

Less likely to raise BP

33
Q

What are some drawbacks for duloxetine?

A

Some interactions in liver

Active ingredient not stable in stomach so can’t break capsule

34
Q

What is mirtazipine?

A

Novel antidepressant

35
Q

What is mirtazapine used for?

A

Good augmentation for SSRIs as different mechanism

Sedative so can be useful in substance abuse

36
Q

What are some side effects of mirtazapine?

A

Increased cholesterol
Weight gain
Very sedating

37
Q

What is a significant contraindication for TCAs?

A

Previous suicide attempts

38
Q

What are some options to overcome treatment resistance?

A 
Start on SSRI
Move to SNRI
Add mirtazapine
Adjunctive lithium
Adjunctive atypical antipsychotic like quetiapine or aripiprazole
ECT
39
Q

What are some considerations for treating anxiety?

A

Serotonergic treatment preferable

Avoid symptomatic relief like diazepam

40
Q

When are mood stabilisers indicated?

A

Bipolar disorder
Cyclothymia
Schizoaffective disorder

41
Q

What are some different classes of mood stabilisers?

A

Lithium
Anticonvulsants
Antipsychotics

42
Q

Which medication is the only which reduced suicide rates?

A

Lithium

43
Q

How is lithium used?

A

Reduces suicide rate in bipolar affective disorder

Effective in long-term prophylaxis for mania and depressive episodes

44
Q

What might predispose to good lithium response?

A

Prior long-term response for patient or family member

Classic pure mania or if mania followed by depression

45
Q

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

A

U&E and TSH and pregnancy in women

Affects renal function and can affect thyroid function

46
Q

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

A

Associated with Ebstein’s anomaly in first trimester

20x greater risk

47
Q

What are some side effects of lithium?

A 
Reduced appetite
Nausea
Diarrhoea
Hypothyroid
Leukocytosis
Polyuria/polydypsia
Renal fibrosis leading to renal failure
Hair loss
Acne
Reduces seizure threshold
48
Q

Why might lithium not be good for epileptics?

A

Reduces seizure threshold

49
Q

What are some consequences of lithium toxicity?

A 
Vomiting
Diarrhoea
Ataxia
Dizziness
Slurred speech
Nystagmus
Blurred vision
Clonic limb movements
Convulsions
Delirium
Syncope
Oliguria
Renal failure
50
Q

What is valproic acid?

A

Anticonvulsant

51
Q

What is valproic acid good for?

A 
Mania prophylaxis
Rapid cycling patients
Comorbid substance issues
Mixed patients
Comorbid anxiety
Better tolerated than lithium
52
Q

Why is valproic acid avoided in child bearing age?

A

Neural tube defects

53
Q

What are some tests to do before starting valproic acid?

A

LFTs
FBC
Pregnancy

54
Q

What are some side effects of valproic acid?

A 
Thrombocytopenia
Platelet dysfunction
Nausea/vomiting
Weight gain
Sedation
Tremor
Hair loss
55
Q

What is carbamazepine used for?

A

First line agent for acute mania and mania prophylaxis

56
Q

What are some tests to be done before starting carbamazepine?

A

FBC
LFTs
ECG

57
Q

What are some carbamazepine side effects?

A 
Rash
Nausea, vomiting, diarrhoea
Sedation, dizziness, ataxia, confusion
AV conduction delays
Aplastic anaemia
Water retention
58
Q

Why is ECG required before starting carbamazepine?

A

Risk of AV conduction delay

59
Q

How does carbamazepine cause water retention?

A

Vasopressin-like effect

Can result in hyponatremia

60
Q

What is lamotrigine used for?

A

Neuropathic pain

Bipolar depression

61
Q

What are some serious side effects of lamotrigine?

A

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

62
Q

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

A

Depakote (anticonvulsant)

Rapid cycler

63
Q

Is LFT rising in anticonvulsants concerning?

A

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

64
Q

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

A

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

65
Q

How are phobias managed?

A

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

66
Q

How are panic disorders managed?

A

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

67
Q

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

A

Sertraline

SNRI like venlafaxine or duloxetine if sertraline fails

68
Q

What is the first line treatment for OCD?

A

CBT

69
Q

What is the second line treatment for OCD?

A

SSRI antidepressants

70
Q

What is the best treatment for PTSD?

A

Trauma-focussed CBT

Psychiatry (18 decks)

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