Psych 5 Flashcards
1
Q
Depot antipsychotics
A
- Long acting formulation, only some anti-psychotics available
- Can be given 1-4 weekly, monthly and 3 monthly
- Advantages: useful in non-compliant patients, useful if struggle to take oral
- Disadvantages: plasma level maintained for long time (ADR, interactions), unable to switch antipsychotics quickly
2
Q
Neuromalignant syndrome
A
- Body temperature rises rapidly and it can be fatal in 1-3 days
- Symptoms: Fever, Diaphoresis (sweating), rigidity, confusion, fluctuating consciousness, fluctuating BP, tachycardia, elevated creatine kinase, altered LFT
- More common in first generation but second generation antipsychotics can also cause, as well as antidepressants (SSRI, lithium)
- Combination of antipsychotic and SSRI increases risk
- Risk factors: drug increase or reduction, abrupt withdrawal of anticholingeric, psychosis, organic brain disease, alcoholism, parkinsons, if agitated and in need of restraint/seclusion
3
Q
Diagnosing and treating Neuroepileptic Malignant syndrome
A
- Diagnostic test: no specific test, CK >1000, AST/ALT
- Withdraw antipsychotics, lithium, antidepressant for at least 5 days. Begin with small dose and increase slowly
- Monitor temp, pulse, BP
- Use benzodiazepine- im lorazepam
- Correct any dehydration and hyperpyrexia
- In hospital: rehydration, Bromocriptine and dantrolene (muscle relaxant)
4
Q
Lithium
A
- Class of drug: mood stabiliser, anti-manic drugs
- Mechanism of action: mimics sodium, modulates dopaminergic and serotonergic transmission
- Licensed indications: acute manic or hypomanic episodes, adjunct in treatment resistant depression, prophylaxis bipolar affective disorder. Control of aggressive behaviour or intentional self harm
5
Q
Antipsychotics: management of sexual side effects
A
- Switch to low risk antidepressant= mirtazapine, vortioxetine, agomelatine
- Dose reduction
- In men sildenafil/tadalafil help
- Other medication: Buspropion, transdermal testosterone
6
Q
Clozapine
A
- An atypical antipsychotic indicated if failure of 2 other antipsychotic medications (treatment resistant)
- Side effects: agranulocytosis, neutropenia, reduced seizure threshold, constipation, slurred speech
- Patients should have weekly FBC for the first 18 weeks of treatment then fortnightly for a year and then monthly
- Blood lipids and weight should be measured at baseline, every 3 months for the first year, and then yearly.
- Fasting blood glucose should be tested at baseline, after one months’ treatment, then every 4–6 months.
7
Q
Depressive disorder: pharmacological management
A
- First line – SSRI eg Sertraline, Escitalopram. explain that antidepressants might take 4-6 weeks to be effective. Increases risk of suicide first 2 weeks – need to follow up weekly if risk is high or support form CPN/with patient’s consent, carer to monitor mental state
- If no response 2-4 weeks, increase dose if tolerated. If not tolerated consider switching to different class of antidepressant
- Second line – different class of antidepressants – SNRI, NaSSA
- If no response, reassess diagnosis & severity of illness. Check compliance & adverse effects
- Augment – Lithium, Antipsychotic
- Duration of treatment: depends on individual. Continue treatment until patient has returned to premorbid level plus 6 months thereafter to prevent relapse.
8
Q
Tricyclic antidepressants (TCA’s)
A
- g. amitriptyline, lofepramine, clomipramine
- Inhibit 5-HT and NA uptake which Produces therapeutic effect
- Block of M1, H1, alpha1 receptors produces side effects= causes sedation, postural hypotension and anticholingeric side effects (dry mouth, constipation, urinary retention, blurred vison), long QT syndrome
- Contraindicated in previous heart disease, BPH
- Poorly tolerated and toxic in overdose
- In depression Lofepramine is second line, Clomipramine second line for OCD
9
Q
Selective Serotonin Reuptake Inhibitor (SSRI)
A
- For example: fluoxetine, paroxetine, sertraline, citalopram
- Inhibits 5-HT uptake: produces therapeutic benefit against depression, OCD, panic, anxiety
- Side effects: nausea, early increased anxiety, sexual dysfunction, QT prolongation, hyponatraemia. GI symptoms most common side effects
- Well tolerated and good first line treatment
10
Q
Serotonin syndrome
A
- Potentially life threatening condition due to increased serotonergic activity in the CNS
- Either starting SSRI or drug interaction i.e. SSRI+Tramadol
- Triad of: mental status changes, autonomic hyperactivity and neuromuscular abnormalities
- Clinical diagnosis and stop SSRI
11
Q
Serotonin and Noradrenaline Reuptake Inhibitor (SNRI)
A
- e.g. venlafaxine, duloxetine
- Inhibit 5-HT and NA uptake: Produces therapeutic effect, Produces side effects similar to SSRI
- Better tolerated than TCAs and probably more effective than SSRIs for severe depression therefore good second/third line treatment
- Side effects: nausea, insomnia, tachycardia, agitation
12
Q
Noradrenaline and Serotonin Selective Antagonist (NaSSA)
A
- e.g. mirtazepine
- Modulate norepinephrine and serotonin levels
- Used if want weight gain or sedative effect
- Possibly more potent than SSRIs plus lacks sexual side effects. Can cause marked weight gain and sedation. Used second line
13
Q
5-HT2 antagonist
A
- e.g. Trazodone
- Similar potency to other antidepressants but often added to SSRI’s or SNRI’s at low doses to provide sedation
- Rare side effect of priapism
14
Q
Monoamine Oxidase inhibitor
A
- Traditional e.g. phenelzine, tranylcypromine
- Food & drug interaction: builds up tyramine, cheese, wine, chocolate, salami
- RIMA (sub class) e.g. moclobemide
- Increase levels of 5-HT, NA (and dopamine - traditionals)
- Third/fourth line treatments for severe and/or atypical depression
15
Q
NICE: antidepressants
A
- SSRI first line: If not effective – an alternate SSRI.
- Reasonable alternatives = mirtazepine, but consider moclobemide, reboxetine, lofepramine. Venlafaxine or an older TCA for severe depression
- Vortioxetine as third line agent
- Esketamine for treatment resistant depression (Decision pending)
16
Q
SSRI and pregnancy
A
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Avoid paroxetine
17
Q
Types of SSRI’s
A
- Sertraline is used post MI
- Caution with SSRI in children and adolescents. Fluoxetine is the antidepressant of choice
- Citalopram associated with QT elongation
- SSRI and NSAID need a PPI
- Avoid with: warfarin/heparin, aspirin, triptans, MAOI
- When stopping SSRI reduce over 4 weeks
18
Q
When to prescribe antidepressants
A
- Antidepressants are a first line treatment for: moderate and severe MDD in adults, Sub-threshold depression that has persisted for 2 years or more.
- Antidepressants are an option for mild MDD especially if: there is a history of moderate to severe recurrent depression. The depression has persisted for more than 2–3 months
- Antidepressants are not a first line treatment for short duration sub-threshold depression in adults but consider if: there is a prior history of moderate to severe recurrent depression. The depression persists for more than 2–3 months
