Psychiatry Flashcards
1
Q
Class of drug - Lithium
A
Mood stabiliser
2
Q
Indication - Lithium
A
- acute mania / hypo mania (good evidence)
- prophylaxis in bipolar disorder
- bipolar depression
- treatment resistant depression
3
Q
Suicide risk - Lithium
A
Reduces risk of both attempted and completed suicide by 80%
4
Q
Therapeutic range - Lithium
A
0.4-1.2 mmol / litre
(some recommend up to 1.0 mmol/litre).
Blood samples should be taken 12 hours after the dose.
5
Q
Side effects - Lithium
A
- GI upset
- Fine tremor
- Polyuria
- Polydipsia
- Metallic taste in mouth
- Weight gain
- Oedema
6
Q
Toxicity symptoms - Lithium
A
- Diarrhoea
- Coarse tremor
- Ataxia
- Dysarthria (slurred speech)
- Nystagmus
- Confusion
- Convulsions
7
Q
Toxicity level - Lithium
A
> 1.5 mmol/litre
If >2.5 mmol/litre emergency treatment including haemodialysis is required.
8
Q
Causes of toxicity - Lithium
A
- dehydration
- diuretics
- NSAIDs
- calcium channel blockers
9
Q
Contraindications - Lithium
A
- Addison’s disease
- Heart disease
- Renal disease
10
Q
Monitoring requirements - Lithium
A
- Lithium level (initially weekly, thereafter every 12 weeks)
- U&Es (6 months)
- Thyroid function test (6 months)
11
Q
Pregnancy - Lithium
A
Teratogen - increased risk of major heart malformations (6%).
- majority are ASD and VSD
- Ebstein’s anomaly (abnormality of tricuspid valve) increased from 0.00005% to 0.1% with exposure in first trimester.
12
Q
Indication - Valporate
A
- acute mania / hypo-mania
- prophylaxis in bipolar disorder (weaker evidence than lithium)
13
Q
Preparations - Valporate
A
- sodium valporate
- semi-sodium (Depakote)
14
Q
Pregnancy - Valporate
A
Known to be teratogenic
- congenital malformation 8-10%
- neural tube defect 3%
- low verbal IQ - 30%
- autism 6%
- valporate syndrome 6%
15
Q
Pregnancy advice - Valporate
A
- withdraw gradually before conception
- not prescribed to patients with child-bearing potential unless ‘pregnancy prevention programme’ is followed.
16
Q
Indications - Lamotrigine
A
- bipolar depression
- prophylaxis in bipolar disorder (limited evidence)
- augmentation of antidepressants in treatment-resistant depression
17
Q
Side effects - Lamotrigine
A
Generally well tolerated. Dose needs to be titrated due to concerns with Stevens-Johnson Syndrome developing.
18
Q
Pregnancy - Lamotrigine
A
The least teratogenic mood stabiliser. Possibly increased risk of cleft lip / palate with first-trimester exposure.
19
Q
Mechanism of action - Carbamazepine
A
Blocks voltage dependent sodium channels.
20
Q
Indications - Carbamazepine
A
- acute mania / hypomania (weaker evidence than lithium or valporate)
- prophylaxis in bipolar disorder (weak evidence)
- bipolar depression
21
Q
Indication - anti-psychotic
A
- psychosis
- mood disorder
- anxiety disorders
- insomnia
- rapid tranquillisation
- nausea and vomiting
- hiccups
- tics including Tourette’s syndrome
22
Q
Examples of typical anti-psychotics
A
- chlorpromazine
- fluphenazine
- flupentixol
- haloperidol
- pipithiazine
- sulpiride
- trifluoperazine
- zuclopenthixol
23
Q
Neurological side effects of typical anti-psychotics
A
- neuroleptic malignant syndrome
- seizure threshold lowered
- sedation
- extrapyramidal side effects
24
Q
List the extra pyramidal side effects
A
- Akathisia
- Parkinsonism
- Acute Dystonia
- Tardive dyskinesia
25
Define akathisia
Subjective feelings of restlessness, often associated with objective signs (pacing, rocking, repeatedly crossing legs).
26
Define Parkinsonism
Tremor, rigidity and bradykinesia. Usually develops after several days to weeks.
27
Define acute dystonia
Involuntary muscle spasms which produce briefly sustained abnormal postures. Usually within 48 hours of initiation.
28
Define tardive dyskinesia
Abnormal involuntary hyperkinetic movements. Potentially irreversible. Abnormal movements include abnormal tongue movements (fly catching, Bon-Bon sign), pouting/smacking of lips, chewing, head nodding, grimacing, rocking movements.
29
Which anti psychotics are more likely to increase the risk of metabolic syndrome?
Olanzapine and Clozapine
30
What is the metabolic syndrome?
- central obesity
- insulin resistance
- impaired glucose regulation
- hypertension
- raised triglycerides
- raised LDL cholesterol and / or low HDL cholesterol
31
Incidence neuroleptic malignant syndrome
0.07-0.2% per year with a mortality of 5-20%.
| Most frequently occurs when initiating an anti psychotic.
32
Symptoms of neuroleptic malignant syndrome
- hyperthermia
- muscle rigidity
- confusion
- tachycardia
- hyper / hypotension
- tremor
- raised creatine kinase
- metabolic acidosis (low pH)
33
Neuroleptic malignant syndrome - immediate management.
Treat as medical emergency and stop all antipsychotics immediately
34
Atypical antipsychotics that can be given as a depot
- Risperidone
- Olanzapine
- Aripiprazole
35
Typical anti psychotics as depot
- haloperidol
- flupentixol
- zuclopenthixol
- fluphenazine
36
Atypical anti psychotics examples
- Aripiprazole
- Amisulpride
- Olanzapine
- Quetiapine
- Risperidone
- Clozapine
37
Atypical anti-psychotics mode of action
D2 antagonism +/- 5-HT receptor antagonism
38
Aripiprazole mode of action
Partial dopamine agonist. A partial agonist limits the maximum response.
39
Aripiprazole side effects
- nausea
- restlessness
- insomnia
- may initially exacerbate psychosis
- least weight gain
- minimal metabolic effect
40
Olanzapine side effects
- sedation (major)
- weight gain (major)
- raised triglycerides
- pro-glycaemic
- dizziness
- anticholinergic side effects
41
Clozapine mode of action
D4 blockade in addition to other sites
42
Clozapine - serious side effects
- myocarditis / cardiomyopathy
- orthostatic hypotension
- agranulocytosis
43
Clozapine - other side effects
- sedation (serious)
- weight gain (serious)
- raised triglycerides
- pro-glycemic
- hypersalivation
- reduced seizure threshold
44
Risperidone side effects (depot)
- sedation
- weight gain
- hyper prolactinaemia
- sexual dysfunction
- EPSE
45
Quetiapine side effects
- sedation
- weight gain
- possible QT prolongation
- less metabolic disturbance than Olanzapine
46
SSRI examples
- fluoxetine
- paroxetine
- citalopram
- sertraline
- fluvoxamine
- escitalopram
47
SSRI initiation side effects
- exacerbation of anxiety
48
SSRI side effects
- nausea
- insomnia
- apathy and fatigue
- diarrhoea
- dizziness
- sweating
- akathesia (restless)
- sexual dysfunction
49
Paroxetine side effect (specific)
Cardiac defects with first trimester exposure
50
SNRIs examples
Venlafaxine
| Duloxetine
51
TCAs examples
- amitriptyline
- imipramine
- clomipramine
- dosulepin
- lofepramine
52
TCA side effects
Antimuscarinic side effects (dry mouth, blurred vision, urinary retention and constipation)
```
Sedation
Weight gain
Dizziness
Hypotension
Delirium
```
53
MAOI examples
- phenelzine
- tranylcypromine
- isocarboxazid
- moclobemide (reversible MAOI)
54
MAOI side effects
- dry mouth
- nausea
- diarrhoea or constipation
- headache
- sleep disturbance
- postural hypotension
Significant reaction with tyramine containing food.
55
What is the reaction between MAOIs and tyramine
Tyramine rich foods - cheese, red wine, beer and liver.
Hypertensive crisis
Tachycardia
Cardiac arrhythmia
Cerebrovascular accident (stroke)
Antidote - alpha blocker such as prazosin
56
What is serotonin syndrome
Excess serotonin in brain may result from combining medication or adding St. John’s wort.
- hyper reflexia
- hyperthermia
- sweating (diaphoresis)
- tachycardia
- muscle rigidity
- disorientation progressing to delirium
57
Mirtazapine (NaSSA)
Significant sedation and / or weight gain on relatively low doses.
58
Discontinuation of anti depressants reactions
- dizziness
- numbness
- tingling
- nausea
- vomiting
- headache
- sweating
- anxiety
- sleep disturbance
- strange dreams
- electric shock like sensations
