Psycho-Pharmacology Flashcards
How long do antidepressants take to kick in?
3-4 weeks
How long do anti-psychotics take to kick in?
up to 6 weeks
Indications for antidepressants
Unipolar and bipolar depression organic mood disorders schizoaffective disorder anxiety disorders including OCD Panic social phobia PTSD premenstrual dysphoric disorder impulsivity associated with personality disorders
How long would you try an antidepressant for if no improvement is seen and you switch to another antidepressant or augment with another agent?
At least two months
4 types of antidepressant drugs
Tricyclics (TCA)
Monoamine Oxidase Inhibitor (MOIs)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)
Novel antidepressants
Side effects of TCAs
VERY HIGH SIDE EFFECT PROFILE antihistaminic anticholinergic antiadrenergic QT lengthening
How much of TCA would it take for an overdose?
LETHAL in overdose
even a one week supply can be lethal
Side effects of tertiary TCAs
antihistaminic (sedation and weight gain)
Anticholintergic (dry mouth, dry eyes, constipation, memory deficits and potentially delirium)
antiadrenergic (orthostatic hypotension, sedation, sexual dysfunction)
What do tertiary TCAs predominately act on?
Serotonin Receptors
Examples of tertiary TCAs
Imipramine
Amytriptyline
Doxepin
Clomipramine
Side effects of secondary TCAs
Same as TCAs but generally less severe
Examples of secondary TCAs
Desipramine
Noritriptyline
What would be used to treat depression
Start with SSRI then switch
to SNRI
What are monoamine oxidase inhibitors (MAOIs) very effective for?
Depression
Side effects of MAOIs
orthrostatic hypotension weight gain dry mouth sedation Sexual dysfunction sleep disturbance
What reaction can occur with MAOIS?
Cheese reaction - hypertensive crisis when MAIOs are taken with tyramine rich foods or symphatomimetics
What syndrome can develop if MAOIs are taken with meds that increase serotonin or have sympahtetomimetic actions?
Serotonin syndrome
What do SSRIs do?
Block the presynaptic serotonin reuptake
What does SSRI treat?
Both depressive and anxiety symptoms
Side effects of SSRI
GI upset Sexual dysfunction (30+) anxiety restlessness nervousness insomnia fatigue or sedation dizziness
How toxic are SSRIs?
Pretty untoxic
Stopping SSRIs can give what?
A discontinuation syndrome with agitation, nausea, disequilibrium and dysphoria - but only lasts 1 week
3 examples of SSRIs
Paroxetine
Sertraline
Fluoxetine (Prozac)
What do SNRIs do?
Inhibit both serotonin and noradrenergic reuptake like TCAs but without antihistamine, antiadrenic or anticholingergic side effects
What are SNRIs used for?
Depression
Anxiety
Neuropathic pain
Examples of SNRIs
Venlafaxine
Duloxetine
Examples of novel antidepressants
Mirtazapine
Burproprion
How to treat if treatment resistance
Combination of antidepressants e.g. SSRI or SNRI with Mirtazepine
Adjunctive treatment with lithium
Adjunctive treatment with atypical antipsychotic e.g. quetiapine
ECT
How to treat depression
Start with SSRI
then if need to switch to SNRI
What is treatment prophylaxis?
Once better, keep on medication for a period of time so do not become unwell again
Treatment prophylaxis for a first episode
Keep on current dosage for 6 months - 1 year once better
Treatment prophylaxis for second episode
Keep on current doseage for 2 years
Treatment prophylaxis for third episode
Keep on current doseage for however long it takes e.g. possibly 3 years
Indications for mood stabilisers
Bipolar
Cyclothymia
Schizoaffective
Classes of mood stabilisers
Lithium
Anticonvulsants
Antipsychotics
What is the only medication to reduce the suicide rate
lithium
Factors predicting a positive response to lithium
Prior long term response
Family member with good response
Classic pure mania
Mania is followed by depression
Before start lithium, what do you do?
U and Es
TSH
Pregnancy test
Who is not meant to use lithium?
Women of childbearing age
Side effects of lithium
GI distress - reduced appetite - nausea vomiting - diarrhoea Thyroid abnormalities Non significant leucocytosis Polyuria/polydipsia secondary to ADH antagonism Hair loss acne reduces seizure threshold cognitive slowing intention tremor
Examples of anticonvulsants
Valproic acid
Carbamazepine
Lamotrigine
Valproic acid has a positive response in….
Rapid cycling patients (F>M)
Comorbid substance issues
Mixed patients
Paitents with co morbid anxiety disorders
Valproic acid vs Lithium
valproic acid as effective as lithium in mania prophylaxis
valproic acid is not as effective as lithium in depression prophylaxis
better tolerated than lithium
Before starting valproic acid, what needs to be done?
Pregnancy test
Baseline LFTs
FBC
start folic acid supplement in women
Side effects of valproic acid
Thrombocytopenia and platelet dysfunction Nausea Vomiting Weight gain Sedation tremor increased risk of neural tube defect hair loss
What is carbamazepine first line for?
Acute mania
mania prophylaxis
Who is indicated for carbamazepine?
Rapid cyclers
Mixed patients
What should be done before carbamazepine is started?
LFTs
FBC
ECG
Side effects of carbamazepine
rash - MOST COMMON nausea, vomiting, diarrhoea sedation, dizziness, ataxia, confusion AV conduction delays Water retention resulting in hyponatraemia DRUG DRUG INTERACTIONS
Side effects of Lamotrigine
nausea vomiting sedation dizziness ataxia confusion steven johnstones syndrome Toxic epidermal necrolysis
Indications for antipyschotics
Schizophrenia
Schizoaffective disorder
Bipolar disorder (when psychotic symptoms and/or mood stabilisation)
Psychotic depression
augmenting agents in treatment with resistant anxiety disorders
What is the typical antipsychotic do?
D2 dopamine receptor antagonists
Examples of antipsychotics
Risperidone Olanzapine Quetiapine Aripiprazole Clozapine
S/Es of olanzapine
Weight gain Hypertriglyceraemia Hypercholesteraemia Hyperglycaemia Hyperprolactinaemia Abnormal LFTs
S/Es of clozapine
Agranulocytosis (required bloods every 6 months)
Seizures
Sedation
Weight gain
Abnormal LFTs
Hypertriglycaemia,glycermia,cholesteraemia
What is clozapine reserved for?
Treatment resistant patients (due to side effect profile)
S/Es of antipsychotics
Tardive dyskinesia
- involuntary muscle movements
Neuroleptic malignant syndrome
Extrapyramidal S/Es
Presentation of neuroepileptic malignant syndrome
Severe muscle rigidity Fever Altered mental status Autonomic instability Elevated WBC Elevated LFTs and CPK
Examples of extrapyramidal S/Es of antipsychotics
Acute dystonia
Parkinson syndrome
Akathisia
What are anxiolytics used to treat?
Panic disorder Generalised anxiety Substance related disorders and their withdrawal Insomnias Parasomnias
Example of an anxiolytic
Buspirone
What are benzodiazepines used to treat?
Insomnia
Parasomnias
Anxiety
CNS depressant withdrawal protocols
S/Es of benzodiazepines
Somnolence Cognitive deficits Amnesia Disinhibition Tolerance DEPENDENCE
Definition of somnolence
Strong desire for sleep, and sleeping for long periods when do so
