Pharmacological Treatments of Affective and Anxiety Disorders

Question 1

What are some conditions that can be treated by antidepressants?

Answer 1

Unipolar and bipolar depression
Organic mood disorders
Schizoaffective disorder

Anxiety disorders (OCD, social phobia, PTSD)
Premenstrual dysphoric disorder
Personality disorders

Question 2

How do antidepressants work?

Answer 2

Increase levels of serotonin and noradrenaline in the brain

Increasing these neurotransmitters changes receptors in the brain which is why there isnt an immediate response

Question 3

How long is the delay before symptoms improve when taking antidepressants?

Answer 3

Lecture slides say 2-4 weeks

Heard 7-14 days in the tutorial though

Question 4

What are some common side effects associated with tricyclic antidepressants?

Answer 4

Antihistaminic:
Weight Gain
Sleepiness

Anticholinergic:
Dry Mouth
Blurred Vision

Question 5

How do TCA’s work?

Answer 5

Work by increasing serotonin, dopamine and noradrenaline

Question 6

What are some of the negatives of TCA’s?

Answer 6

Lethal in overdose (even a weeks supply can cause death)

Cause QT lengthening even at therapeutic level

High side effect profile

Question 7

Would you prescribe a secondary or a tertiary TCA if you had the choice? Why?

Answer 7

Secondary

The added side chains in tertiary tend to be more reactive and result in greater side effects

Question 8

How do monoamine oxidase inhibitors work?

Answer 8

Bind irreversibly to monoamine oxidase which prevents the inactivation of amines such as norepinephrine, dopamine and serotonin

Increases their synaptic levels

Question 9

When do monoamine oxidase inhibitors tend to get prescribed?

Answer 9

Treatment resistant depression

Question 10

What are some of the side effects of monoamine oxidase inhibitors?

Answer 10

• Orthostatic hypotension (sudden drop in blood pressure when you stand from a seated position)
• Weight gain
• Dry mouth
• Sedation
• Sexual dysfunction
• Sleep disturbance

Question 11

What is the cheese reaction?

Answer 11

When monoamine oxidase inhibitors are taken with tyramine rich foods or sympathomimetics they can cause hypertensive crisis

Cheese, red wine, processed meats all rich in tyramine

Question 12

What brings about serotonin syndrome? What is serotonin syndrome characterized by?

Answer 12

Caused by taking monoamine oxidase inhibitors with meds that increase serotonin or have sympathomimetic actions

Characterized by abdominal pain, diarrhoea, sweats, tachycardia, HTN, myoclonus, irratibility, delerium. Can lead to cardiovascular shock and death

Question 13

How do selective serotonin reuptake inhibitors (SSRI’s) work? What symptoms are they most suited to?

Answer 13

Block the presynaptic reuptake of serotonin

Treat both anxiety and depressive symptoms

Question 14

What are some of the side effects of SSRI’s?

Answer 14

GI upset 
Sexual dysfunction
anxiety, nervousness 
insomnia, restlessness
fatigue or sedation
nausea

Question 15

If you stop taking SSRI’s abruptly what are you at risk of?

Answer 15

Discontinuation syndrome

Agitation, nausea, disequilibrium and dysphria

Question 16

If a patient starts taking SSRI’s what may be seen in the first week or so? What symptoms might you expect?

Answer 16

Activation syndrome

Nausea, anxiety, panic and agitation

Should only last 2-10 days

Question 17

What are some examples of SSRI’s?

Answer 17

Sertraline

Fluoxetine (Prozac)

Question 18

How do SNRI’s work? (serotonin / noradrenaline reuptake inhibitors)

Answer 18

Inhibit both serotonin and noradrenaline uptake but without the antihistaminic / antiadrenergic and anticholinergic side effects of TCA’s

Question 19

When are serotonin / noradrenaline reuptake inhibitors used?

Answer 19

Used for depression, anxiety and potentially neuropathic pain

Question 20

What are the conditions that may require treatment with mood stabilizers?

Answer 20

Bipolar disorder

Cyclothymia

Schizoaffective disorders

Question 21

What are the main classes of mood stabilizers?

Answer 21

Lithium

Anticonvulsants

Antipsychotics

Question 22

What is the only medication shown to drop suicide rates in bipolar affective disorder?

Answer 22

Lithium

Drops suicide rates by about 15 percent

Prior long term response or family member with good response predicts good response

Question 23

What is lithium used for?

Answer 23

prophylaxis of both mania and depressive episodes in bipolar affective disorder

Question 24

In order to prescribe lithium what tests are needed?

Answer 24

Baseline U&E and TSH

Pregnancy tests (Ebsteins anomaly)

Question 25

How do you ensure lithium is being administered in the proper amount?

Answer 25

Steady state should be achieved within 5 days, check 12 hours after last dose

Once stable check level at 3 months (aiming for blood level 0.6-1.2)

Check TSH and creatinine at 6 months

Question 26

What are some of the potential side effects of lithium?

Answer 26

GI distress: reduced appetite, nausea / vomiting / diarrhoea

Thyroid abnormalities (and hair loss / acne)

Nonsignificant leukocytosis

Polyuria and polydipsia (secondary to ADH antagonism, can cause interstitial renal fibrosis in small minority)

Reduces seizure threshold, cognitive slowing, intention tremor

Question 27

What are some signs of lithium toxicity? How high blood levels is too high?

Answer 27

Vomiting, diarrhoea, nystagmus slurred speech
Blurred vision, convulsions, delerium, oliguria and renal failure if severe

1.5-2.0 - mild, 2.0-2.5 - moderate, >2.5 severe

Question 28

What are the main anticonvulsants?

Answer 28

Valproic Acid

Carbamezapine

Lamotrigine

Question 29

What is valproic acid useful for treating? What is an advantage of it?

Answer 29

Effective as lithium in prohylaxis of mania, but not as effective for depression

Usually better tolerated than lithium

Question 30

What tests are needed before valproic acid is started? What is the target range?

Answer 30

FBC

LFT’s

Pregnancy (neural tube defects - avoid drug in women of child bearing age)

Target range is: 50-125

Question 31

What are some of the potential side effects of valproic acid?

Answer 31

Thrombocytopenia and platelet dysfunction

Nausea, vomiting, weight gain

Sedation, tremor

Reduction in folic acid which can cause neural tube defects in fetus

Hair loss

Question 32

What is carbamezapine used for?

Answer 32

Acute mania treatment

Mania prophylaxis

Question 33

What tests are needed before carbamezapine is started? What is the target blood level?

Answer 33

LFTs

FBC

ECG

Target: 4-12 mcg/mL. Need to check level and redose at about a month because it induces its own metabolism, gets metabolized quicker

Question 34

What are some of the potential side effects of carbamezapine?

Answer 34

Rash (common)

Nausea, vomiting, diarrhoea

Water retention due to vasopressin like effect

Atrioventricular conduction delays

Commonly involved in drug interactions

Question 35

What is lamotrigine used to treat?

Answer 35

Used to treat bipolar depression and neuropathic / chronic pain

Question 36

What tests are needed before lamotrigine is started? How do you ensure a proper level of the drug is administered?

Answer 36

Liver function tests

Titration: start with 25mg for 2 weeks, then 50mg for 2 weeks, then 100mg (faster titration results in rash often)

If the patient stops the drug for 5 or more days might need to start at 25mg again

Question 37

What are some of the potential side effects of lamotrigine?

Answer 37

Nausea / vomiting

Sedation, ataxia, dizziness and confusion

Toxic epidermal necrolysis / Steven Johnsons Syndrome (be wary of rash)

Blood Diseases