Psychiatry Pharmacology

Question 1

What is the NICE guidelines for treatment of mild-moderate depression?

Answer 1

Individual guided self-help based on CBT principles
Computerised CBT
A structured group physical activity programme
Do not use antidepressants routinely in mild depression as risk-benefit ratio is poor

Question 2

What is the NICE guidelines for treatment of moderate - severe depression?

Answer 2

Combination of antidepressants and high intensity psychological intervention (e.g., CBT or Interpersonal therapy (IPT))

Question 3

What are the biopsychosocial approaches to treatment in all severity of depression?

Answer 3

Psychoeducation
Addressing social issues
Physical exercise
Sleep hygeine
Address co-existing substance misuse issues
Ensure no underlying physical health issues

Question 4

What is the drug treatment algorithm for depression?

Answer 4

1) SSRI 🡪
2) second SSRI 🡪
3) drug from class other than SSRI e.g. SNRI or mirtazapine 🡪
4) combination antidepressant (e.g. SSRI+mirtazapine, mirtazapine + venlafaxine) 🡪
5) augmentation (e.g. antipsychotics such as quetiapine, lithium) 🡪
6) Consider alternative augmentation agent not used (e.g. TCA, MAOIs)

Question 5

Define treatment resistance?

Answer 5

Defined when an individual has not shown adequate response to adequate dose to two different antidepressants for adequate duration (e.g. usually 6 weeks)

Question 6

What are the types of antidepressants?

Answer 6

SSRIs
SNRIs
NaSSA
TCA
MAO-i

Question 7

Mechanism of action of SSRIs

Answer 7

• Inhibits the serotonin reuptake transporter on the presynaptic membrane
• This prevents re-uptake and subsequent degradation of serotonin from the synaptic cleft
• Prolonged presence of serotonin in the synaptic cleft leads to prolonged neuronal activity
• SSRIs therefore restore the concentration of serotonin to normal levels

Question 8

Examples of SSRIs

Answer 8

Citalopram
Fluoxetine (often first line in CAHMS)
Sertraline (first line in GAD)
Paroxetine

Question 9

Indications of SSRIs

Answer 9

depression, anxiety, OCD, eating disorders, PTSD, social anxiety

Question 10

Side effects of SSRIs

Answer 10

GI disturbance, headache, insomnia, sexual side effects, increased anxiety/suicidality initially, increased risk of bleeding

Question 11

Contraindications when using SSRIs

Answer 11

Caution in patients with poorly controlled epilepsy

Discontinue SSRIs if the patient enters a manic phase

Question 12

Cautions when using SSRIs

Answer 12

Increase suicidal thoughts and ideation in first two weeks

Can precipitate a manic phase in bipolar disorder

Question 13

What are the important alarm bell signs that you should look out for in a patient taking SSRIs

Answer 13

• Hyponatraemia,
• GI bleeding,
• Serotonin syndrome : neuromuscular hyperactivity (tremor, hyperreflexia, clonus, myoclonus, rigidity)
• Autonomic dysfunction (tachycardia, BP changes, hyperthermia, diaphoresis, shivering, diarrhoea)
• Altered mental state (agitation, confusion, mania)

Question 14

Risks when using SSRIs

Answer 14

Contraindicated if they have had a manic episode and cannot use with a MAO-i

Be careful with citalopram as can prolong the QT interval

Serotonin syndrome

Question 15

Name three interactions of SSRIs

Answer 15

• Alcohol (increased sedative effect)
• NSAIDs (increased risk of bleeding - co prescribe PPI)
• Antiepileptics (SSRIs lower the seizure threshold)
• Beta blockers
• Lithium
• Methadone
• Smoking
• Warfarin
• Theophylline
• MAOIs - SSRIs should not be started until 2 weeks of stopping an MAOI, MAOIs should not be started until 7-14 days after stopping an SSRI.
• Risk of serotonin syndrome

Question 16

How do you monitor SSRIs

Answer 16

Monitor for side effects - esp in the first two weeks as suicidal ideation increases

If confusion or falls occur check U&Es for a serum sodium concentration (rule out hyponatraemia)