Psycho-Pharmacology Flashcards
What are indications for anti-depressants?
Unipolar and bipolar depression
Organic mood disorders
Schizoaffective disorder
Anxiety disorders
How long is typical delay between achievement of therapeutic dose and symptom improvement in anti-depressants?
2-4 weeks
How should you use prophylaxis for depression?
First episode continue for 6 months
Second episode continue for 2 years
Third episode discuss life long
Examples of tertiary TCAs?
Imipramine
Amitriptyline
Doxepin
Clomipramine
Side effects of TCAs?
Anti-cholinergic, Anti-adrenergic
Anti-histaminic
QT lengthening
Examples of secondary TCAs?
Desipramine, nortriptyline
Do secondary or tertiary TCAs generally have worse side effects?
Tertiary
How do Monoamine Oxidase inhibitors (MAOIs) work?
Bind irreversibly to MAO preventing inactivation of amines (noradrenaline, dopamine and serotonin) leading to increased synaptic levels
What are MAOIs effective for?
Resistant depression
What are the side effects of MAOIs?
Orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction and sleep disturbance
Types of anti-depressants?
TCAs Monoamine Oxidase inhibitors Selective serotonin inhibitors Serotonin/noreadrenaline reuptake inhibitors Novel antidepressants
What can develop when MAOIs are taken with tyramine rich foods or sympathomimetics? (cheese reaction)
Hypertensive crisis
What can develop if MAOIs taken with medications that increase serotonin?
Serotonin syndrome
Sx - abdominal pain, diarrhoea, sweats, tachycardia, HTN, myoclonus
Can lead to hyperpyrexia, cardio shock and death
How can you avoid serotonin syndrome?
Wait 2 weeks before switching from SSRI to MAOI
Exception is fluoxetine where wait 5 weeks
How do selective serotonin reuptake inhibitors work? (SSRIs)
Block presynaptic serotonin reuptake
What can SSRIs be used to treat?
Anxiety and depressive symptoms
What are the most common general side effects of SSRIs?
GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia, fatigue, dizziness
What is discontinuation syndrome with SSRIs?
Agitation, nausea, disequilibrium and dysphoria
More common in shorter half life drugs
What is activation syndrome?
Caused by increased serotonin
Nausea, increased anxiety, panic and agitation
Typically last 2-10 days
What are the Pros and cons of Paroxetine? And what type of drug?
SSRI
Pros: short half life, no build up. Sedating properties offer good initial relief
Cons: Sedating, weight gain, anti-cholinergic effects. Likely to cause a discontinuation syndrome
What are the Pros and cons of Sertraline? And what type of drug?
SSRI
Pros: weak P450 interactions, short half-life, less sedating than paroxetine
Cons: Max absorption needs full stomach.Increased number GI ADRs
What are the Pros and cons of Fluoxetine? And what type of drug?
SSRI
Pros: long half life, good for non-compliance issues, can use to taper off SSRI
Cons: Metabolite build up, P45- interactions, initial anxiety and insomnia increase. More likely to induce mania
What are the Pros and cons of Ciralopram? And what type of drug?
SSRI
Pros: few D-D, intermediate half life
Cons: Dose-dependent QT interval prolongation. Cam be sedating, GI side effects
What is the benefit of Escitalopram over ciralopram?
More effective in acute response and remission
What are the Pros and cons of fluvoxamine? And what type of drug?
SSRI
Pros: shortest 1/2 life, some analgesic properties
Cons: shortest 1/2life, GI distress, headaches, sedation, weakness. Strong inhibitor of some P450
How do seritonin/noradrenaline reuptake inhibitors work? (SNRIs)
Inhibit serotonin and noradrenergic reuptake like TCAs without their side effects
What are SNRIs used for?
Depression, anxiety
Possibly neuropathic pain
What are the Pros and cons of Venlafaxine? And what type of drug?
SNRI
Pros: minimal d-d and little P450, short half life and fast renal clearance
Cons: increase in DBP, nausea, discontinuation syndrome, sexual side effects
What are the Pros and cons of Duloxetine? And what type of drug?
SNRI
Pros: far less BP increase
Cons: P450 effects, active ingredient not stable in stomach
What are the Pros and cons of Mirtazapine? And what type of drug?
Novel antidepressant
Pros:good augmentation to SSRIs, hypnotic at lower doses
Cons: Increase cholesterol, sedating, weight gain
What are the Pros and cons of Buproprion? And what type of drug?
Novel antidepressant
Pros: Augmenting agent No weight gain, sexual side effects sedation or cardiac interaction, second line ADHD agent
Cons: may increase seizure risk (avoid TBI, anorexia, bulimia. Not anxiety Rx. Abuse potential due to psychosis
How could you treat treatment resistant depression?
Combination of antidepressants
Adjunctive treatment with lithium
Adjunctive treatment with atypical antipsychotic
ECT
What are indications for mood stabilisers?
Bipolar, cyclothymia, schizoaffective
What are the classes of mood stabilisers?
Lithium
Anticonvulsants
Antipsychotics
What is the only medication to reduce suicide rate?
Lithium
What is lithium useful for prophylactically?
Mania and depressive episodes
What are factors predicting a positive repose to lithium?
Prior long term response or family member with good response
Classic pure mania
Mania followed by depression
What do you need to check before starting lithium?
Baseline U&E and TSH
Pregnancy test
What do you need to monitor with lithium?
Steady state achieved after 5 days - check 12 hours after last dose
Level 3 months once stable Goal blood level between 0.6-1.2
TSH and creatinine 6 months
What are lithium side effects?
GI distress
Thyroid abnormalities
Nonsignificant leukocytosis
Polyuria/polydipsia secondary to ADH antagonism
Hair loss, acne
Reduces seizure threshold, cognitive slowing, intention tremor
Is valproic acid more effective for mania or depression prophylaxis?
Mania
What factors predict a positive response in valproic acid?
Rapid cycling patients F>M
Comorbid substance issues
Mixed patients
Patients with comorbid anxiety disorders
Is lithium or valproic acid better tolerated?
Valproic acid
What should be measured before starting valproic acid?
Base line LFTs
Pregnancy test
FBC
Why should valproic acid be avoided in woman of child bearing age?
Neural tube defects
What is the monitoring for valproic acid?
Steady state achieved after 4-5 days, check 12
hours after last dose and repeat FBC and LFTs
Goal target between 50 and 125
What are valproic acid side effects?
Thrombocytopenia and platelet dysfunction
N+V, weight gain
Sedation, tremor
Hair loss
What is use for carbamazepine and what patients is it indicated in?
First line agent for acute mania and mania prophylaxis
Indicated for rapid cyclers and mixed patients
What should be done before starting carbamazepine?
Baseline LFTs
FBC
ECG
What monitoring should be done with carbamazepine?
Steady state after 5 days - 12 hours after last dose
Repeat FBC and LFTs
Goal 4-12mcg/ml
Need to check level and adjust dosing after around a month as induces own metabolism
What are side effects of carbamazepine?
Rash N+V, diarrhoea Sedation, dizziness, ataxia, confusion AV conduction delays Water retention due to vasopressin like effect --> hyponatremia D-D
What tests need to be done before lamotrigine?
Baseline LFTs
What is the procedure for initiation/titration of lamotrigine?
Start 25mg daily for 2 weeks then increase to 50mg for 2 weeks then 100mg if patient stops med for >/=5 days then must start 25mg again
Side effects of lamotrigine?
N+V
Sedation, dizziness, ataxia and confusion
Toxic epidermal necrolysis and stevens johnson’s syndrome - IF any rash develops discontinue use immediately
VPA increases lamotrigine levels as dose sertraline
Indications for antipsychotic use?
Schizophrenia, schizoaffective disorder
Bipolar for mood stabilisation and/or psychotic features
Psychotic depression
Augmenting agent in treatment resistant anxiety disorders
What are the key pathways affected by dopamine in the bra
Mesocortical (negative symptoms and cognitive disorders, too little dopamine)
Mesolimbic (positive symptoms, too much dopamine)
Nigrostriatal (movement regulation)
Tuberoinfundibular (blocking dopamine here –> hyperprolactinaemia)
What are typical antipyschotics?
D2 dopamine receptor antagonist (high affinity)
Higher risk of extrapyramidal sid effects
What are examples of high potency typical antipsychotics?
Fluphenazine
Haloperidol
Pimozide
What are examples and side effects of low potency typicals?
Cardiotoxic and anticholinergic - sedation, hypotension
Chlorpromazine
Thioridazine
What are antipsychotic atypicals?
Serotonin dopamine 2 antagonists
Affect dopamine and serotonin in four key dopamine pathways in brain
About risperidone?
Regular tabs, IM and rapidly dissolving tablet
More like typical at doses > 6mg
Increased extrapyramidal side effects
Most likely atypical to induce hyperprolactinaemia
S/E of weight gain and sedation
About onlazapine?
Regular tabs, immediate release IM, rapidly dissolving tab, demo form
Weight gain
Hypertriglyceridaemia and hypercholesterolaemia, hyperglycaemia
About quetiapine?
Regular tablet form only Abnormal LFTS(6%) Weight gain less than onlazapine Same hypers as onlaxapine but less Orthostatic hypotension
About ariprazole?
Regular tabs, immediate release IM and depo
D2 partial antagonist
LOW EPS, no QT, low sedation
Interactions with other psychiatric meds (fluoxetine and paroxetine and carbamazepine)
No weight gain
About clozapine?
Regular tablet
Reserved for treatment resistant
Weekly blood draws x 6 months then Q- 2weeks x 6months
Increased risk of seizures (esp + lithium)
Most sedation, weight gain and abnormal LFTs)
What are indications for anxiolytics?
Panic disorder, generalised anxiety, substance related and withdrawal, insomnias and paraomnias
Agents for extrapyramidal side effects?
Anticholinergics (benztropine) Dopamine facilitators (amantadine) Beta bockers (propranolol)
About buspirone?
Pros: good augmentation and no sedation
Cons: 2 weeks till patient notices results. Wont reduces anxiety in patient used to taking BZDs
About benzodiazepines?
Treat insomnia, parasomnias and anxiety
CNS depressant withdrawal protocols
S/E somnolence, conginitve deficits, amnesia, disinhibition, tolerance, dependence
What would you use in a treatment naive patient with depression first line?
SSRI
What are some less sedating SSRIs?
Citalopram
Fluoxetine
Sertraline
What are some anti-depressantsassociated with weight gain?
Paroxetine
Mirtazapine
When would you move on to a duel reuptake inhibitor in a depression patient?
No remission with two SSRIs or a novel agent
What would you discuss in a women of child bearing age when prescribing lithium?
Contraception methods
What is a rapid cycler?
4 or more depressive or manic episodes per year
What increase in LFTs on anticonvulsants would warrant considering changes in therapy?
More than triple baseline
