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Year 4 Psychiatry > Psychiatric Pharmacology > Flashcards

Psychiatric Pharmacology Flashcards

1
Q

What is the rationale behind SSRIs?

A

Selective Serotonin Reuptake Inhibitors

Deficiency in serotonergic activity in depressed patients

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2
Q

Give three indications for commencing SSRIs

A
  • Mild to Moderate depression where low intensity psychosocial interventions have not helped
  • Patients with subthreshold depression
  • Mod to Severe depression with concomitant high intensity psychological intervention
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3
Q

Describe the efficacy of SSRIs

A

Same efficacy as TCAs
Fewer Anti-muscarinic Side Effects
Less Cardiotoxic

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4
Q

What is the SSRI licensed for Major Depression?

A

Paroxetine

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5
Q

What is the SSRI licensed for Bulimia Nervosa?

A

Fluoxetine

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6
Q

Name two contraindications to SSRIs

A

Children (unless seen by psychiatrist)

Mania

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7
Q

Name two instances in which SSRIs should be cautioned

A

Epilepsy

Suicidal Ideation

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8
Q

Name two DDIs of SSRIs

A

Some platelet interference

NSAIDs
Warfarin/Heparin

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9
Q

Name three side effects of SSRIs

A

Decreased alertness
Suicidal feelings
Dyspepsia

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10
Q

Name four causes of Serotonin Syndrome

A
  • Drug is started too high/Dose escalated
  • Addition of another serotinergic
  • Replacement of antidepressants without long enough clearance period
  • SSRI and MAOI
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11
Q

How does Serotonin Syndrome present?

A

Neuromuscular Hyperactivity
Autonomic Dysfunction (tachycardia, hyperthermia, shivering)
Altered mental state

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12
Q

How is Serotonin Syndrome managed?

A

Withdrawal of medication

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13
Q

State three pieces of advice that should be given to patients when starting SSRIs

A

May take a few weeks to work
Must stop if they develop a rash
After remission of symptoms, needs to be continued for another 4-6 months

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14
Q

When should patients on SSRIs be reviewed

A

After 1-2 weeks of starting

After 4-8 weeks to determine response

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15
Q

What is the first line SSRI for children?

A

Fluoxetine

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16
Q

What is the first line SSRI for patients post MI?

A

Sertraline

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17
Q

What is the max dose of Fluoxetine, Sertraline, Citalopram and Paroxetine?

A

Fluoxetine - 60mg
Sertraline - 200mg
Citalopram - 40mg
Paroxetine - 50mg

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18
Q

How should SSRIs be withdrawn?

A

Reduce dose gradually over a four week period

Any abrupt stop - Discontinuation Syndrome (restlessness, problems sleeping, sweating)

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19
Q

Which SSRI commonly causes weight gain?

A

Paroxetine

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20
Q

Give three indications for SNRIs

A

Major depressive disorder
Anxiety Disorder
OCD

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21
Q

When should SNRIs be taken?

A

Recommend to take in the morning as can cause insomnia in some patients if taken at night

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22
Q

Name two contraindications to SNRIs

A

If they have taken MAOI in the past two weeks

NSAIDs

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23
Q

Name three general Side Effects

A

Loss of Appetite
Increased suicidal thoughts
Sexual Dysfunction (Low libido, anorgasmia)

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24
Q

How should SNRIs be withdrawn?

A

Slowly taper to avoid discontinuation syndrome

This is common with Venlafaxine due to short half life

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25
Q

Name an indication and contraindication for Venlafaxine as a choice of SNRI

A

Good for Geriatrics

CI - High Arrhythmic Risk, Uncontrolled Htn

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26
Q

Give an advantage and disadvantage to Duloxetine as a choice of SNRI

A

Effective for physical depression symptoms

Can’t break capsules due to instability in stomach

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27
Q

Name three populations unsuitable to take Mirtazepine as a choice of SNRI

A

Elderly
Hypertensive
Urinary retention

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28
Q

Name two SE of Mirtazepine

A

Weight Gain

Sedative

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29
Q

What is the mechanism of action of TCAs? Give two examples

A

Blocks Serotonin and Noradrenaline reuptake (first generation as opposed to SNRIs)
Amitryptyline, Imipramine

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30
Q

Name three indications for TCAs

A

Depression
Anxiety
Chronic Bed Wetting

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31
Q

Describe some interactions of TCAs

A

CYP450

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32
Q

TCAs can cause weight gain and colnvulsions. Give three other categories of side effects

A

Antimuscarinic
Antihistaminic
Antiadrenergic

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33
Q

Name two cautions and two contraindications for TCAs

A

Caution: Epilepsy, Cardiac Disease
Contraindication: Mania, Recent MI

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34
Q

How quickly does a TCA overdose become apparent?

A

Within the first hour due to easy absorption from small intestine

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35
Q

Name five effects of TCA overdose

A 
Confusion
Hypotension
Syncope
Hypo ventilations
Decreased/Absent bowel sounds
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36
Q

How is TCA overdose managed?

A

IV Sodium Bicarbonate

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37
Q

Name the two types of MAOI

A

Irreversible - Phenelzine, Isocarboxazid

Reversible - Moclobamide (MAOI- A selective)

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38
Q

Name three indications for MAOI

A

3rd line for depression
Social Phobia
Panic Disorder

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39
Q

Name some interactions of MAOI

A

Lethal - SSRIs, TCA

May potentiate cigarette effects

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40
Q

How should MAOI be stopped?

A

Withdrawn over a four week period with a two week washout

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41
Q

Name three side effects of MAOI

A

Orthostatic Hypotension
Dry Mouth
Anorgasmia

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42
Q

What is a Hypertensive Crisis with MAOI?

A

Excess tyramine causes release of Norepinephrine (causing continuous vasoconstriction)
Avoid tyramine rich foods (Alcohol, cheese, fermented foods)

Not required with Moclobamide

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43
Q

When are Antipsychotics required?

A

Any psychiatric conditions where patient has Delusions and/or Hallucinations

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44
Q

Describe the four dopamine pathways in the CNS

A

Mesolimbic - too much dopamine in psychosis
Mesocortical - too little dopamine in psychosis
Nigrostriatal - Dopamine dependent movement
Tuberoinfundibular - the pathway that can result in hyperprolactinaemia

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45
Q

What is the MOA of typical antipsychotics?

A

D2 Receptor Antagonists

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46
Q

Name the three types of typical antipsychotics and give an example of each

A

High Potency - Haloperidol
Mid Potency - Perphenazine
Low Potency - Chlorpromazine

High potency has much higher risk of Extra Pyramidal SE than Low Potency

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47
Q

Name three side effects of Haloperidol

A

Akathisia
Parkinsonism
Dystonia

All EPS

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48
Q

Name three contraindications to Haloperidol

A

Acute stroke
Severe intoxication
Known cardiac disease

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49
Q

How would an overdose of Haloperidol present?

A

Often just severe forms of the classical side effects

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50
Q

How is a Haloperidol overdose managed?

A

Activated charcoal if within first hour
Monitor for Long QT
Ropinorole/Bromocriptine for EPS

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51
Q

What should be monitored with Haloperidol?

A

BMI
BP
Fasting BGC

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52
Q

Name three SE to Chlorpromazine

A

Dose dependent increase in seizure risk
Weight Gain
Sedation

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53
Q

Name two interactions of Chlorpromazine

A

Decreased absorption if full stomach/alcohol

Can inhibit own metabolism as it is a CYP2D6 substrate AND inhibitor

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54
Q

What is the MOA of a Atypical Antipsychotics?

A

Serotonin Dopamine 2 Antagonists

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55
Q

Name three effects more likely with Atypical Antipsychotics (than typical)

A

Metabolic Syndrome
Weight Gain
T2DM

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56
Q

How long should Atypical Antipsychotics be continued for?

A

Up to 5 years

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57
Q

If stopping antipsychotics, how long should they be tapered over?

A

3 months

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58
Q

Describe three side effects of Risperidone

A

Hyperprolactinaemia
Weight Gain
In doses over 6mg it functions more like a typical - Extrapyramidal

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59
Q

Describe three side effects of Olanzepine

A

Weight Gain
Hyperprolactinaemia
Hypertriglyceridaemia

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60
Q

How are the effects of Olanzepine monitored?

A

Fasting BGC at baseline
Then every 4-6 monthly
Then yearly

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61
Q

Depot administration is not an option for Quetiapine. Give three side effects

A

Weight Gain
Orthostatic Hypotension
Metabolic Syndrome

62
Q

Name the Atypical Antipsychotic that is NOT KNOWN to cause Metabolic Syndrome

A

Aripiprazole

Because it’s a partial agonist

63
Q

Clozapine is an Atypical Antipsychotic with severe SE. When is it used?

A

Treatment resistant Schizophrenia

64
Q

Name four SE of Clozapine

A

Hypersalivation
Incontinence
Increased Seizure Risk
Sedation

65
Q

How is Clozapine monitored?

A

Weekly blood draws for 5 months
Fortnightly blood draws for 6 months
Then monthly

66
Q

Name three general SE for Atypical Antipsychotics

A

Tardive Dyskinesia (involuntary muscle movement)
Neuroleptic Malignant Syndrome
Extrapyramidal SE

67
Q

Give three indications for commencing a Mood Stabiliser

A

Bipolar
Augmenting resistant depression
Schizoaffective

68
Q

What is the first line mood stabilisers for BPAD?

69
Q

Name five bloods that should be done before commencing Lithium treatment

A 
FBC
U&Es
TFTs
eGFR
Pregnancy
70
Q

How should Lithium therapy be monitored?

A
  • Lithium levels should be checked 12 hours after first dose, and then 3 monthly (therapeutic range is 0.4-1)
  • 6 monthly U and Es
  • Yearly TFTs
71
Q

Give three SE of Lithium Therapy

A

GI distress
Metallic Taste
Fine tremor

72
Q

Give three contraindications to a Lithium Therapy

A

Renal Failure
Pregnancy
Breast Feeding

73
Q

Describe the effects of Lithium Toxicity

A

Mild (1.5-2) - Ataxia, Dizziness, Coarse Tremor

Severe (>2.5) - Generalised Convulsions, Dysuria, Renal Failure

74
Q

What could you advise the patient about avoiding Lithium Toxicity?

A

Stay hydrated

75
Q

Describe the proposed MOA of Valproate

A

Inhibits GABA breakdown

76
Q

Give three indications for use of Valproate

A 
BPAD prophylaxis (Second line)
Rapid Cycling (+ Lithium)
Mania
77
Q

What should be measured prior to commencing Valproate?

78
Q

How should Valproate therapy be monitored?

A

6 monthly FBC and LFTs

79
Q

Name three SE of Valproate

A

Weight Gain
Tremor
Teratogenic

80
Q

Describe the proposed MOA of Carbamazepine

A

Blocks voltage gated sodium channels (preventing repetitive firing)
Reduces glutamate release

81
Q

How is Carbemazepine therapy monitored?

A

6 monthly FBC and LFTs

82
Q

Give three SE of Carbemazepine

A

Rash
Hyponatraemia
Nausea and Vomiting

83
Q

Describe the proposed MOA of Lamotrigine

A

Inhibits presynaptic sodium and potassium channels, reducing action potentials

84
Q

What should be measured before commencing Lamotrigine therapy?

A

LFTs
FBC
U and Es

85
Q

How should Lamotrigine therapy be initiated?

A

Start at 25mg for 2/52
Increase slowly up to 100mg

If stopped for >5d, need to restart at 25mg

86
Q

Lamotrigine is the drug of choice in child bearing age as it is NOT teratogenic. However, give three other SE

A

Sedation
Headache
Steven Johnson Syndrome

87
Q

Name 5 Anxiolytics

A 
Benzodiazepines
Pregabalin
Buspirone
Propranolol
Zopiclone
88
Q

What is the MOA of Benzodiazepines?

A

GABA Potentiators

89
Q

Name three SE of Benzodiazepines

A

Somnolence
Amnesia
Disinhibition

90
Q

Overdose of Benzodiazpeones causes respiratory depression, what is the antidote?

A

Flumazenil

91
Q

Name two short acting and two long acting Benzodiazepines

A

Short acting - Lorazepam, Midazolam

Long acting - Diazepam, Chlordiazepoxide

92
Q

What is the MOA of Pregabalin?

A

Glutamate, Noradrenaline and Substance P inhibitor

93
Q

Other than being an Anxiolytic, what other actions can Pregabalin have?

A

Epilepsy control

Pain control

94
Q

Give three SE of Pregabalin

A

Headache
Dizziness
Sleepiness

95
Q

Buspirone is a Non Sedating Anxiolytic. What is it’s MOA?

A

Serotonin 5HT1A receptor agonist

96
Q

Give three contraindications to Buspirone

A

Metabolic Acidosis
MAO Inhibitors
Severely compromised liver/renal function

97
Q

What can be used as long term management for Anxiety?

98
Q

What is the first line medication for ADHD? What is it’s MOA?

A

Methylphenidate/Ritalin

Increases dopamine and noradrenaline in synaptic cleft

99
Q

Give three SE of Ritalin

A

Difficulty sleeping
Decreased Appetite
Anxiety

100
Q

When is Ritalin Contraindicated?

A

MAOI
Tics
Glaucoma

101
Q

Other than Ritalin, name two other drugs used in ADHD

A

Amphetamines

Atomoxetine

102
Q

Give four SE of Amphetamines

A

Raynaud
ED
Difficulty Urinating
Increased Alertness

103
Q

What is the MOA of Atomoxetine?

A

Inhibits Noradrenaline reuptake

104
Q

Give two contraindications for Atomoxetine

A

Symptomatic Cardiac Disease

Phaeochromocytoma

105
Q

What are Hypnotics? How are they different to Sedatives?

A

Psychoactive drug whose primary function is to increase sleep

Different to sedatives: Sedatives calm or relieve anxiety

106
Q

Give four examples of Hypnotic Drugs

A

Barbiturates
Benzodiazepines
Zopiclone
Melatonin

107
Q

What is the MOA of Zopiclone?

A

GABA receptor Agonist

Reduces amount of time in REM

108
Q

Give three SE of Zopiclone

A

Metallic taste
Nausea
Dizziness

109
Q

Describe the options for electrode placement in ECT

A

Bitemporal (4cm above midline between tragus and outer eye)
Bifrontal
Unilateral (both on non dominant hemisphere)

110
Q

Describe the physical principles of ECT

A
  • Small electrical current passed through the brain of an anaesthetised patient with a muscle relaxant
  • Voltage causes neurone firing to be recurrent and synchronous
  • Induces neuroplastic changes faster and more powerfully than antidepressants
111
Q

How often is ECT administered?

A

Generally 6-12 sessions in total

Roughly two a week

112
Q

Describe the indication for ECT in terms of depression

A

Recommended against routine use, but when other treatments have failed
Can use maintenance ECT - patient continues to have ECT at a reduced frequency, alongside meds to maintain remission

113
Q

Describe the indication for ECT in terms of psychoses

A

Recommended for a prolonged or severe manic episode

114
Q

Describe the indication for ECT in terms of catatonia

A

Recommended as Catatonia is often the final common pathway for severe mental illness

115
Q

The higher the voltage above the seizure threshold, the more efficacious. Give an example of a drug that increases the seizure threshold, and one that decreases it.

A

Increased by Anaesthetics

Decreased by Antipsychotics

116
Q

After a full medical examination, what anaesthetic is used for ECT?

A

Short acting barbiturate anaesthetics such as Methohexitone Sodium

117
Q

Give three contraindications to ECT

A

Status Epilepticus
MI less than 3 months ago
Raised ICP

118
Q

What is the most common complication of ECT?

A

Cardiac complications
Bigeminy and SVT
The presence of arrhythmias pre ECT predicts the outcome post ECT

119
Q

Other than cardiac, give four other potential complications of ECT

A

Dental Fractures
Aspiration Pneumonitis
Peripheral Nerve Palsies
Anterograde/Retrograde Amnesia

120
Q

What is Neuroleptic Malignant Syndrome?

A

Disorder characterised by hyperthermia, muscle rigidity, autonomic dysfunction and depressed/fluctuating levels of arousal over 24-72 hours

121
Q

Describe the aetiology of Neuroleptic Malignant Syndrome

A
  • Sudden and marked Dopamine receptor blockade India Nigrostriatal/Hypothalamic/Mesocortical and Mesolimbic pathways
  • Common with typical antipsychotics such as Haloperidol
  • Leads to impaired thermoregulation in hypothalamus and basal ganglia
122
Q

Give two differentials for Neuroleptic Malignant Syndrome

A

Phaeochromocytoma

Thyrotoxicosis

123
Q

Using the mnemonic FEVER, describe the clinical features of Neuroleptic Malignant Syndrome

A

Fever (higher than 40 degrees Celsius in 40% of patients)
Elevated Enzymes (Creatine Kinase)
Vital Sign Instability (Tachycardia, Elevated/Labile BP, Postural Hypotension)
Encephalopathy
Rigidity

124
Q

How would you investigate Neuroleptic Malignant Syndrome?

A

Bloods (Creatine Kinase, FBC, U and Es, Drug Titre)
Urinary Myoglobin
ABG

125
Q

Name four management options for Neuroleptic Malignant Syndrome

A

Hydration
Active Cooling
IV Benzodiazepines
Bromocriptine (Dopamine Agonist)

126
Q

Name three reasons Thiamine is reduced in Wernicke’s Encephalopathy

A

Inadequate nutritional Thiamine intake
Decreased GI absorption of Thiamine
Impaired Thiamine utilisation in cells

127
Q

What is the triad of Wernickes Encephalopathy?

A

Ataxia
Ophthalmoplegia
Confusion

128
Q

Name five bloods you would do to investigate Wernicke’s Encephalopathy

A 
FBC
LFTs
Thiamine (Low)
Pyruvate (High)
ABG
129
Q

How would you manage Wernicke’s Encephalopathy?

A

Thiamine (Oral/IV/IM) plus Vitamin B Complex/Multivitamins

130
Q

When should prophylactic Thiamine be given?

A

If they are malnourished (50g/day)

If they have decompensated Liver Disease

131
Q

What is the main complication of Wernicke’s Encephalopathy?

A

Korsakoff’s Syndrome (Permanent memory features of Confabulation and Amnesia etc)

132
Q

What is Delirium Tremens?

A

A disorder of acute alcohol withdrawal

133
Q

Symptoms normally begin 24-72 hours after cease of Alcohol a Consumption. Give four clinical features of Delirium Tremens

A

Hallucinations
Confusion
Delusions
Severe Agitation

134
Q

Give three risk factors which puts a patient more at risk of Delirium Tremens during alcohol withdrawal

A

Co-Existing medical condition
Older age
Abnormal liver function

135
Q

Give four managements of Delirium Tremens

A

A to E
Treat any Hypoglycaemia
Benzodiazepine Sedation
Start Pabrinex (likely to have coexisting Wernicke’s)

136
Q

What is Acute Dystonia?

A

Reversible Extrapyramidal effects that can occur after admin of a neuroleptic drug

137
Q

Describe the aetiology of Acute Dystonia

A

Drug induced alteration of Dopaminergic/Cholinergic balance in Basal Ganglia
D2 receptor blockade leads to excess cholinergic output

138
Q

Mental Status and Vital Signs are usually unaffected in Acute Dystonia. Give three clinical features

A

Oculogyric Crisis (fixed deviation of eyes in one direction)
Protrusion of tongue
Trismus (lock jaw)

139
Q

Name three potential medications for Acute Dystonia

A

Anticholinergics - Benztropine
Antihistamine - Diphenhydramine
Benzodiazepines

140
Q

When does Lithium Toxicity occur?

A

Safe levels are 0.4-1 mEq/l

Toxicity occurs at >1.5, severe at >2 and >3 is a medical emergency

141
Q

Give three features of Mild to Moderate Lithium Toxicity

A

Diarrhoea
Vomiting
Stomach Pain

142
Q

Give three features of Severe Lithium Toxicity

A

Seizures
Agitation
Slurred Speech

143
Q

Describe the three types of Lithium Toxicity

A

Acute - Too much lithium at once (accidentally or on purpose)
Chronic - Too much lithium daily over a long period of time (affected by dehydration, kidney problems)
Acute on Chronic - Can happen if you take too much for a long time, then suddenly take more

144
Q

Name three investigations for Lithium Toxicity

A

ECG
Bloods (U and Es, Glucose)
Lithium levels (Urine or Blood)

145
Q

How would you treat Mild Lithium Toxicity?

A

Normally goes away on its own

Drink extra fluids and monitor

146
Q

How would you treat Moderate to Severe Lithium Toxicity?

A

If taken in last hour - Gastric Lavage/Activated Charcoal
IV fluids
Haemodialysis

147
Q

What drug commonly causes Agranulocytosis (<500/cm2)?

148
Q

What are three granulocytes?

A

Neutrophils
Eosinophils
Basophils

149
Q

How should Clozapine induced Agranulocytosis be avoided?

A

WBC monitoring carried out weekly for the first 18 months

150
Q

How is Clozapine Induced agranulocytosis managed?

A

Stop drug and treat and infections

151
Q

What kind of seizure does ECT induce?

A

Generalised Tonic Clonic

Year 4 Psychiatry (12 decks)

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