Psychiatric Drugs & Management Flashcards

1
Q

Give examples of predisposing factors for mental illness.

A

“inclined”

BIOLOGICAL = genetics, gender, head injury

PSYCHOLOGICAL = personality type, conflict

SOCIAL = role, isolation, gender

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2
Q

Give examples of precipitating factors for mental illness.

A

“catalyst”

BIOLOGICAL = drug use, head injury

PSYCHOLOGICAL = traumatic life experience, coping style

SOCIAL = poverty, isolation

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3
Q

Give examples of perpetuating factors for mental illness.

A

“make something continue”

BIOLOGICAL = non-compliance with medication, drug abuse

PSYCHOLOGICAL = hopelessness

SOCIAL = social network, work, family

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4
Q

What are the diagnostic requirements of depression?

A

2 week history of at least 2 of the core symptoms:

  • low mood
  • anhedonia
  • decreased energy

2/3 of the core symptoms indicates mild/moderate depression
3/3 of the core symptoms indicates major depression

The no. of secondary symptoms also indicates the severity:

  • decreased appetite
  • sleep disturbance
  • hopelessness
  • reduced libido
  • reduced concentration
  • irritability
  • self harm/suicidal ideas/acts
  • can have psychotic symptoms
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5
Q

Outline the pathophysiology of depression.

A

Hypothesis 1: deficiency of monoamine neurotransmitters (noradrenaline and serotonin)

Hypothesis 2: abnormality in receptors for monoamine transmission (depletion of neurotransmitter —> up-regulation of post-synaptic receptors)

Hypothesis 3: deficiency in molecular functioning distal to the post-synaptic receptor

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6
Q

Outline the pharmacological options for depression. How long are these usually indicated for?

A

MAO inhibitors

MAO uptake inhibitors: non-selective noradrenaline AND serotonin or selective noradrenaline OR serotonin

  • non-selective = pure (SNRIs) or with additional actions (TCAs)
  • selective = noradreline (NARIs) or serotonin (SSRIs)

Other e.g. mirtazepine

First-line pharmacological treatment for depression is indicated for at least 1yr before cessation

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7
Q

Give some examples of SSRIs. Describe the pharmacodynamics and ADRs associated with their use. When are they indicated?

A

e.g. fluoxetine (Prozac), citalopram (most selective), paroxetine (most potent), sertraline

First-line treatment for moderate to severe depression (along with CBT)

Pharmacodynamics:

  • almost completely absorbed from the gut
  • long elimination half lives (OD)
  • metabolised in liver
  • max benefit in 4-6wks (WARN ABOUT!)
  • reasonably safe in overdose (if taken on their own)
ADRs: 
COMMON = 
- anorexia 
- nausea 
- diarrhoea 
RARE = 
- precipitation of mania due to increasing mood (lowest risk of all anti-depressants) 
- increased suicidal ideation within 3 days (?increased motivation/concentration/energy) 
- tremor 
- extrapyramidal symptoms
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8
Q

Give some examples of TCAs. Describe their pharmacokinetics and pharmacodynamics. Give some examples of ADRs associated with their use.

A

e.g. amitryptiline (neuropathic nerve pain), imipramine, clomipramine (OCD), lofepramine

Pharmacokinetics (highly toxic, multiple ADRs):

  • inhibition of noradrenaline uptake —> sympathomimetics ADRs
  • muscarinic cholinoceptor blockade —> anticholinergic ADRs
  • alpha-1-adrenoceptor blockade —> sympatholytic ADRs

Pharmacodynamics:

  • lipid soluble
  • absorbed from gut
  • long half life
  • metabolised in liver

ADRs:

  • CNS = sedation, impairment of psychomotor performance, lowering of seizure threshold, hyporeflexia
  • ANS = reduction in glandular secretions, eye accommodation block, constipation, pupil constriction, hypothermia
  • CVS = tachycardia, postural hypotension, impair myocardial contractility (put on cardiac monitor)
  • GI = constipation
  • metabolic acidosis
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9
Q

Give some examples of SNRIs. When are they indicated? Describe their pharmacokinetics and pharmacodynamics. Give some examples of ADRs associated with their use.

A

e.g. duloxetine, venlafaxine

Second or third-line treatment for depression

Pharmacokinetics:

  • low dose = serotonergic actions
  • high dose = noradrenergic actions

Pharmacodynamics:
- short half life (may be withdrawal syndrome on discontinuation)

ADRs: same as with SSRIs:
COMMON = 
- anorexia 
- nausea 
- diarrhoea 
RARE = 
- precipitation of mania due to increasing mood (increased risk compared with SSRIs)
- increased suicidal ideation within 3 days (?increased motivation/concentration/energy) 
- tremor 
- extrapyramidal symptoms
ADDITIONAL (SNRI-specific) = 
- sleep disturbance 
- hypertension 
- dry mouth 
- hyponatraemia
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10
Q

Give examples of ADRs associated with MAO inhibitors. What dietary considerations are there when using them?

A

Extremely toxic

ADRs:

  • postural hypotension
  • weakness
  • dizziness
  • headache
  • fatigue
  • agitation
  • anxiety
  • weight gain
  • impotence

Cannot eat certain foods e.g. cheese

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11
Q

Define psychosis. What conditions can have psychosis as a symptom?

A

Lack of contact with reality

Encompasses hallucinations and delusions

Seen in:

  • paranoid schizophrenia
  • mania
  • severe depression with psychosis
  • organic syndromes
  • delusional disorders
  • delirium
  • dementia
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12
Q

Contrast hallucinations and delusions.

A

HALLUCINATION = perception in the absence of an external stimulus

DELUSION = fixed false belief that is out of keeping with someone’s culture or religious beliefs

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13
Q

Outline the prevalence of paranoid schizophrenia. What are the signs and symptoms?

A

PREVALENCE = 1% in general population

  • 10%+ risk with one parent with paranoid schizophrenia
  • 50%+ risk with both parents with paranoid schizophrenia
  • 10% will kill themselves
  • die 20yrs younger than the general population (without considering increased suicidal risk)

S&S:

  • disturbances of thinking
  • auditory hallucinations (hear voices OUTSIDE head)
  • persecutory delusions
  • unusual speech (thought disorder)
  • behavioural changes
  • lack of insight
  • apathy
  • asocial
  • self-neglect
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14
Q

What is the pathophysiology of paranoid schizophrenia?

A

DOPAMINE:

  • dopamine antagonists (D2) usually the best treatment for schizophrenia but do not treat the negative symptoms (apathy, asocial, self-neglect)
  • some evidence of increased dopamine function in schizophrenics
  • amphetamine causes symptoms similar to positive symptoms of schizophrenia (hallucinations, delusions)
  • changes in dopamine function may be a response to long-term treatment

SEROTONIN:

  • implicated in behaviours disturbed in schizophrenia (perception, attention, mood, aggression, sexual drive, appetite, motor behaviours, sleep)
  • most anti-psychotic drugs are 5-HT antagonists (e.g. clozapine)
  • precursors of 5-HT exacerbate schizophrenia (e.g. tryptophan)

GLUTAMATE:

  • PCP (non-competitive NMDA-type glutamate receptor antagonist) induces symptoms very similar to schizophrenia
  • post-mortem studies show increased cortical glutamate receptors of increased binding of glutamate receptor ligands
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15
Q

What are the different dopamine pathways in the brain? How are they involved in schizophrenia?

A

MESOLIMBIC: emotional response and behaviour
(dramatic therapeutic action of dopamine on positive psychotic symptoms)

MESOCORTICAL: arousal and mood
(enhanced negative and cognitive psychotic symptoms)

TUBEROINFUNDIBULAR (hypothalamus and pituitary gland) —> hyperprolactinaemia (lactation, infertility, sexual dysfunction)

NIGROSTRIATAL:

  • Parkinson’s disease
  • extrapyramidal side-effects
  • tardive dyskinesia
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16
Q

What is tardive dyskinesia?

A

Mostly irreversible neurological disorder of involuntary movements caused by long-term use of anti-psychotic or neuroleptic drugs

  • rapid movement of arms/legs
  • tongue protrusion
  • grimacing
  • rapid eye blinking
  • lip smacking/pursing/puckering

Unaware of movements unless looking in the mirror

17
Q

How effective is the treatment for schizophrenia?

A

25% dead/unimproved and hospitalised or institutionalised (more community-based care)

25% fully recovered

25% improved and relatively independent

25% improved but need support

18
Q

Give some examples of typical anti-psychotics indicated for schizophrenia. Describe their pharmacokinetics. Give examples of ADRs associated with their use.

A

e.g. haloperidol (sedating; safe in emergency), chlorpromazine

Pharmacokinetics:

  • dopamine receptor blockade
  • anticholinergic blockade
  • alpha-adrenergic blockade
  • antihistamine

ADRs:

  • extrapyramidal = Parkinsonism, acute dystonia, tardive dyskinesia, akathisia
  • neuroleptic malignant syndrome
  • postural hypotension
  • weight gain
  • endocrine e.g. prolactinaemia
  • pigmentation

Overdose:

  • CNS depression
  • cardiac toxicity (lengthened QT interval)
  • risk of sudden death
19
Q

Define akathisia.

A

Movement disorder characterised by feeling of inner restlessness and a compelling need to be in constant motion

e.g. rocking, marching on the spot, crossing and uncrossing legs

20
Q

What is neuroleptic malignant syndrome?

A

Neurological disorder most often caused by adverse reaction to neuroleptic or anti-psychotic drugs

S&S:

  • severe rigidity = shuffling gait, dysphagia, dyspnoea
  • hyperthermia
  • autonomic lability
  • confusion
  • fluctuating consciousness

EMERGENCY!!! (10% mortality)

Treatment = withdraw anti-psychotics and supportive treatment

21
Q

Give examples of atypical anti-psychotics. When are they indicated? Describe their dosing regimen. Give some examples of ADRs associated with their use.

A

e.g. olanzapine, risperidone, quetiapine, clozapine (most powerful, used for treatment resistant schizophrenia)

First-line treatment for schizophrenia

Given OD; different preparations available e.g. PO, short-acting (days) or long-acting (weeks) depot injections (if they refuse to take medications - Mental Health Act or poor adherence)

ADRs:

  • extrapyramidal symptoms (less so than typical anti-psychotics)
  • significant weight gain (esp. olanzapine) by affecting satiety centre —> diabetes, hypercholesterolaemia
  • prolactinaemia (esp. risperidone)
  • sedation
  • agranulocytosis causing neutropenia (clozapine); frequent FBCs req.
  • QT lengthening (risperidone)
  • lowered seizure threshold (risperidone)
22
Q

What are the general actions of anti-psychotics and their approximate timelines?

A
Sedations (hrs) 
Tranquilisation (hrs) 
Anti-psychotic (days-wks) 
Activating effect (removal of negative symptoms) (wks) 
Extra-pyramidal symptoms (hrs-days)
23
Q

What are the signs and symptoms of anxiety disorders? How can anxiety disorders present?

A

Situational (phobias) or continuous (GAD)

  • fear out of proportion to situation
  • avoidance
  • fear of dying/going crazy
  • light-headedness
  • shortness of breath
  • hot and cold flushes
  • nausea
  • palpitations
  • numbness
  • pins and needles
24
Q

Outline the treatment options for anxiety disorders.

A

First-line: non-pharmacological treatments e.g. CBT, exposure and response therapy (phobias)

Treat co-existent disorders

Pharmacology:

  • anti-depressants (serotonin and noradrenaline)
  • anxiolytics (GABA)
  • anti-psychotics
25
Q

Give some examples of benzodiazepines. Describe their pharmacokinetics and pharmacodynamics. Give examples of ADRs associated with their use.

A

e.g. diazepam, lorazepam

Pharmacokinetics:

  • high affinity agonists at GABA-BZ receptor complex —> anxiolytic, hypnotic, anticonvulsant effects
  • tolerance (give short-term, one-off doses to prevent e.g. less than 2wks)
  • dependence —> withdrawal (insomnia, agitation, anxiety)

Pharmacodynamics:

  • oral bioavailability (~30-90min)
  • highly lipid soluble (rapid CNS diffusion)
  • renal excretion
  • long half life
ADRs:
COMMON = 
- drowsiness 
- dizziness 
- psychomotor impairment 
OCCASIONAL = 
- dry mouth 
- blurred vision 
- GI disturbances 
- ataxia 
- headache 
- hypotension 
RARE = 
- amnesia 
- restlessness 
- rash 

+ cleft lip/palate in pregnancy
+ resp. depression and feeding difficulties in newborn

Overdose: resp. depression (reversed by flumazenil; shorter half life than benzos so multiple doses may be required)

note: flumazenil lowers seizure threshold

26
Q

What is bipolar disorder characterised by?

A

Episodes of depression and (hypo)mania

27
Q

Define mania. What are the signs and symptoms of mania?

A

Elevated mood, physical and mental over-activity, self-important ideas

Minimum of 1wk

S&S:

  • feeling of unusually excited, happy, optimistic, irritable
  • overactive
  • poor concentration/short attention span
  • poor sleep
  • rapid speech (jump from one idea to another)
  • poor judgement
  • increased interest in sex
  • psychosis (hallucinations, grandiose delusions)
28
Q

What are the pharmacological treatment options for bipolar disorder?

A

Lithium

Anti-epileptics

  • sodium valproate for extreme manias
  • carbamazepine for rapid cycling
  • lamotrigine for bipolar depression

Anti-psychotics for bipolar depression or psychosis in bipolar disorder

29
Q

Describe the pharmacokinetics and pharmacodynamics of lithium. When is it indicated? What monitoring is required? Give some examples of ADRs associated with lithium.

A

Pharmacokinetics: acts on-

  • electrolytes and channels
  • 5-HT
  • secondary messenger systems

Reduces suicidality

Pharmacodynamics:

  • renal excretion (potentially nephrotoxic)
  • OD slow release
  • take 12hrs after last dose (narrow therapeutic window)

Indications:

  • prophylaxis for mania and depression in bipolar disorder
  • augmentation of anti-depressants in unipolar depression

Monitoring:

  • levels need to be monitored at least 3/month
  • check renal and thyroid function before starting and every 6 months

ADRs:

  • memory problems
  • thirst
  • polyuria
  • tremor
  • drowsiness
  • weight gain
  • hypothyroidism
  • hair loss
  • rashes
  • nephrotoxicity

Overdose:

  • vomiting and diarrhoea (increases conc. of lithium)
  • coarse tremor
  • dysarthria
  • cognitive impairment
  • restlessness
  • agitation
  • confusion
  • ataxia
  • coma
  • death

Treatment for overdose:

  • supportive
  • anti-convulsants
  • increase fluid intake/IV fluids
  • haemodialysis may be necessary
30
Q

Outline the pharmacological treatment for dementia.

A

ACH-ase inhibitors

NMDA antagonists

31
Q

Give some examples of anticholinesterase inhibitors indicated for dementia. When are they indicated? Give some examples of ADRs associated with their use.

A

e.g. donepezil, galantamine, rivastigmine

Indicated for mild to moderate dementia to reduce progression of symptoms (extra year at home)

ADRs:

  • N&V, vomiting, anorexia, diarrhoea
  • fatigue, insomnia, headache
  • bradycardia (measure pulse before initiating treatment)
  • worsening of COPD
  • gastric/duodenal ulcers
32
Q

Give an example of a NMDA antagonist indicated for dementia. Give some examples of ADRs associated with its use.

A

Memantine

Indicated for moderate to severe dementia

ADRs:

  • hypertension
  • dyspnoea
  • headache
  • dizziness
  • drowsiness
33
Q

In general, what are the actions of CNS drugs?

A

Neurotransmitter receptor agonists and antagonists

Regulatory enzyme inhibitors (involved in the production or destruction of neurotransmitters)

34
Q

How can a confused or delirious violent psychiatric patient be managed?

A

Call security to restrain

Small dose PO/IV haloperidol (quick acting typical anti-psychotic which causes sedation)

Manage cause e.g. UTI

\+ give visible clock 
\+ give light room 
\+ give music 
\+ keep sleep pattern constant 
\+ talk to (de-escalation)
\+ include family/friends/carers 

SEDATIVES MAKE WORSE!!!

35
Q

Define delirium. Give some examples of causes.

A

State of mental confusion which fluctuates/acute disturbance of consciousness (differentiates from dementia)

DELIRIUMS = 
Drugs
Electrolyte disturbance/Environmental change 
Low O2, Little hearing/seeing 
Infection
Retention (urine/faeces)
Ictal state
Underhydration/nutrition
Metabolic e.g. diabetes, Na+ abnormalities 
Subdural haematoma
36
Q

How can the severity of depression be assessed?

A

1-10 mood rating

Beck’s depression inventory (American pop.)

SAD PERSONS score (determine action needed):
Sex (1 point for male) 
Age (1 point if younger than 20yrs or older than 44yrs)
Depression (1 point)
Previous attempt (1 point)
Ethanol abuse (1 point) 
Rational thinking loss (1 point)
Social support lacking (1 point) 
Organised Plan (1 point for lethal plan) 
No spouse (1 point) 
Sickness (1 point for chronic, debilitating, severe conditions) 

PHQ-9

  1. Little interest or pleasure in doing things (anhedonia)
  2. Feeling down, depressed, or hopeless
  3. Trouble falling or staying asleep/sleeping too much
  4. Feeling tired or having little energy
  5. Poor appetite/overeating
  6. Feeling bad about yourself/failure/let yourself or family down
  7. Trouble concentrating on things e.g. reading newspaper, watching TV
  8. Moving or speaking so slowly that other people could have noticed/so fidgety or restless that you have been moving a lot more than usual
  9. Thoughts that you would be better off dead

Suicidal ideation:

  • ?access to methods
  • ?planned in detail (non-compulsive)
  • what did you expect to happen? (hospitalisation v.s. death)
  • ?long-term planning