Psychiatric drugs

Question 1

Which SSRI is considered to be the best ‘all-round’?

Answer 1

Escitalopram

Question 2

What kind of drug is mirtazapine?

What does it promote?

Answer 2

Noradrenergic and Selective Serotonin Antidepressant

Promotes sleep and weight gain

Often used if an SSRI has initially been trialed and seen to be ineffective

Question 3

Which type of antidepressant is ‘usually’ first line?

Answer 3

SSRIs

Question 4

How long should you wait when trialling a new antidepressant in a patient before you consider it to be unresponsive?

Answer 4

2-6 weeks to take effect, so wait for at least 6 weeks

Question 5

How long should a patient take an antidepressant?

Answer 5

First episode - continue for 6-12 months after full resolution of symptoms

Second episode - continue to use for 12-24 months after recurrence

Third episode onwards - lifelong if possible

Question 6

What type of medication is first line in a patient with an acute episode of mania?

Answer 6

An antipsychotic - olanzapine, quetiapine or respiradone

Question 7

How long should benzodiazepines be used for?

Answer 7

BZDs are useful for symptom control in an acute setting, but shouldn’t be used for any longer than 2 weeks

Question 8

Should antidepressants be used in a patient with acute bipolar depression?

What type of medication is first line in these patients?

Answer 8

Not alone - should always be prescribed with an antimanic drug

Should also be avoided in people that have had a recent hypomanic episode, or a history of rapid cycling

Antipsychotics are first line - quetiapine, olanzapine or lurasidone (also lithium or sodium valproate)

Question 9

What type of medication is the mainstay of treatment in maintenance of bipolar disoders?

Answer 9

Mood stabilisers (lithium, anticonvulsants, antipsychotics)

Lithium is the GOLD STANDARD

Lamotrigine if the patient is primarily dealing with depression

Sodium valproate if the patient is primarily dealing with mania/hypomania

Question 10

Regarding electroconvulsive therapy, is bilateral or unilateral more commonly used?

What are some of the contraindications to ECT?

Answer 10

Bilateral is more commonly performed as it is easier to do and acts quicker, however it is more likely to result in cognitive problems

Contraindications

• Relative
  
  • angina
  • congesitve heart failure
  • pulmonary disease
  • osteoporosis
  • pregnancy
• Absolute
  
  • recent MI or stroke
  • intracranial mass
  • phaeochromocytoma

Question 11

Name some SSRIs

What are some of the side effects associated with SSRIs?

Answer 11

Fluoxetine, Citalopram, Escitalopram, Sertraline, Paroxetine

Side effects

• GI upsent
• anxiety
• agitation
• insomnia (so should be taken in the morning)
• sexual dysfunction
• discontinuation effects (worst with paroxetine)
• increased risk of GI bleeding if used alongside NSAIDs

Question 12

Name some tricyclic antidepressants

What are some of the side effects associated with TCAs?

Answer 12

Amitriptyline, Clomipramine, Imipramine, Lofepramine

Side effects

• potentially cardiotoxic in overdose
• sedation (so take at night)
• confusion
• dizziness
• antimuscarinic effects e.g. dry mouth, dry eyes, blurred vision etc.
• sexual dysfunction

Question 13

Name some SNRIs

What are some of the side effects associated with SNRIs?

Answer 13

Venlafaxine, Duloxetine

NB - mirtazapine used in combination with venlafaxine is an extremely effective treatment (California rocket fuel)

Side effects

• as with SSRIs, although higher risk with SNRIs
• hypertension
• like SSRIs, SNRIs can cause insomnia and so should be taken in the morning

Question 14

Name some monoamine oxidase inhibitors

What are some of the side effects associated with MAOIs?

Answer 14

Phenelzine, Moclobemide (reversible), Isocarboxazid

Very effective but only used in resistant depression due to dietary and medication restrictions. Also need to be taken 3 times a day

Side effects

• risk of hypertensive crisis if foods like wine or cheese (high levels of tyramine) are consumed - headaches, SoB, nosebleed, anxiety, arrhythmias, seizures, death
• postural hypotension
• drowsiness and tiredness
• insomnia
• nausea
• constipation

Question 15

Uh oh, that patient taking MAOIs has just eaten a whole wheel of brie! He’s going into hypertensive crisis!!

What medication is used to treat this?

Answer 15

Phentolamine infusion (competitively blocks alpha adrenergic receptors leading to muscle relaxation and vascular dilatation)

Can also use Chlorpromazine, another alpha-1 blocker, along with sublingual GTN spray

Question 16

What’s worth noting about Moclobemide compared to the other MAOIs?

Answer 16

Moclobemide is reversible (less effective, but less side effects)

Question 17

Which dopamine receptors are predominantly targeted by antipsychotics?

Answer 17

Dopamine D2 receptors - antipsychotics block dopaminergic transmission in the mesolimbic pathway

Question 18

Name some typical antipsychotics

What are some of the associated side effects of typical antipsychotics?

Answer 18

Haloperidol, Chlorpromazine, Zuclopentixol, Flupentixol, Sulpiride

Side effects

• EPSEs (due to nigrostriatal pathway being affected)
  
  • Oculogyric crisis
  • ​Parkinsonism
  • acute dystonia
  • akathisia (mental and/or motor restlessness)
  • tardive dyskinesia (stiff, jerky movements of the face, mouth and body)
• sedation
• dizziness
• QT prolongation
• hyperprolactinaemia
• Neuroleptic malignant syndrome

Question 19

Name some atypical antipsychotics

What are some of the side effects associated with atypicals?

Answer 19

Quetiapine, Olanzapine, Amisulpiride, Paliperidone, Clozapine

Side effects

• sedation
• weight gain
• Metabolic syndrome - abdo obesity, high BP, high glucose etc.
• constipation
• QT prolongation
• NB - Clozapine is also associated with agranulocytosis and myocarditis/cardiomyopathy