Psych Pharmacology - Antidepressants

Question 1

First line treatment for uncomplicated depression?

Answer 1

SSRI (e.g. escitalopram 10-20mg) or agomelatine (25-50mg)

Question 2

Rx Depression w anxiousness

Answer 2

less activating SSRI e.g. escitalopram 10-20mg or agomelatine 25-50mg. Consider NASA or TCA if severe

Question 3

Rx Depression w psychosis

Answer 3

SNRI (duloxetine 30-60 mg) combine with antipsychotic (2nd gen e.g. quetiapine 300-750mg or olanzapine 5-20mg)

Question 4

Rx Generalised anxiety disorder

Answer 4

SSRI w more sedation (agomelatine/citalopram/sertraline/paroxetine)

Question 5

Rx Panic Disorder

Answer 5

SSRI w more sedation + anxiolytic in first 1-2 weeks to avoid panic attacks

Question 6

Rx Obsessive-compulsive disorder

Answer 6

SSRI

Question 7

The “more activating” antidepressants

Answer 7

FLU-RE-VEN-DES-BUP
fluoxetine 20-40mg, reboxetine 8-12 mg
venlafaxine 75-300mg, desvenlafaxine 50-200mg
bupropion 150-450mg

Question 8

The “less activating” antidepressants

Answer 8

agomelatine 25-50mg
other SSRIs (citalo-/escitalopram, paroxetine, sertraline)
NASA mirtazepine 30-45mg
SNRI duloxetine 30-60mg

Question 9

Directions for use of antidepressants and general advice

Answer 9

Take after meals to avoid GIT upset
Can aggravate restless leg syndrome (Rx pramipexole-D2 agonist)
Cease or tell Doctor if experiencing side effects

Question 10

Why should you be suspicious of patients with no side effects to medication?

Answer 10

• May not be compliant with meds

- May be fast metabolisers or be inducing CYP450s

Question 11

What is the relationship between antidepressants and risk of suicide?

Answer 11

WARNING: Increased risk of suicide in the 1-2weeks post-commencement of treatment (improving motivation and energy levels may also raise impulsivity for suicide before they are more well)

Question 12

What is the side effect profile of SSRIs?

Answer 12

5 SAD (S S S S SAD)

• Serotonin syndrome
• Sleep disturbance (Sedation/insomnia)
• Sexual dysfunction
• Sodium (SIADH)
• Suicidality

Others: Anticholinergic SE (SLUD)
Dizziness/diarrhoea/and other GIT

Question 13

What are the treatment priorities of Serotonin Syndrome

Answer 13

Cease Serotonergic medication (usually resolves in 24 hours unless long acting drugs are implicated)
Supportive care (IV fluids, cardiac monitoring)
Sedation with BZDs (IV diazepam 5-10mg)
If severe with hyperthermia - muscle relaxants and intubation

Question 14

What are serious side effects of clozapine? How do you monitor?

Answer 14

Agranulocytosis and neutropenia
-Weekly FBE for 18 weeks then monthly

Myocarditis and cardiomyopathy

• Baseline troponin I, CRP, ECG, and Echo
• repeat bloods weekly for first month of treatment