Psychopharmacological Treatments of Affective and Anxiety Disorders

Question 1

How long after starting antidepressants does the patient start to notice an effect?

Answer 1

2-4wks

Question 2

If a patient is on antidepressants, how long do they have to trial a drug for without changes before changing the type?

Answer 2

2 months

Question 3

Which conditions may be treated with antidepressants

Answer 3

Unipolar and bipolar depression
Organic mood disorders
Schizoaffective disorder
Anxiety disorders including OCD, panic, social phobia
PTSD

Question 4

List some of the different antidepressant types.

Answer 4

Selective Serotonin Reuptake Inhibitors (SSRIs)
Tricyclics (TCAs)
Monoamine Oxidase Inhibitors (MAOIs)
Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)

Question 5

How do SSRI’s work?

Answer 5

Block presynpatic seratonin reuptake

Question 6

Which conditions do SSRI’s treat?

Answer 6

Anxiety
Depression

Question 8

Side effects of SSRIs?

Answer 8

GI upset
Sexual dysfunction
Anxiety
Restlessness
Nervousness
Insomnia
Fatigue or sedation
Dizziness

Question 9

What is important to note about starting SSRIs?

Answer 9

Symptoms get worse before they get better
Typically for 2-10 days

This is due to a thing called activation syndrome. Can cause nausea and anxiousness.

Question 10

Which change may be seen on ECG in a patient taking tricyclics?

Answer 10

QT lengthening

Question 11

What are the two types of tricyclics?

Answer 11

Secondary
Tertiary

Question 12

Which type of antidepressant is lethal in overdose?

Answer 12

Tricyclics

Question 13

Which antidepressant is rarely used but very effective for resistant depression?

Answer 13

Monoamine Oxidase Inhibitors (MAOIs)

Question 14

Side effects of Monoamine Oxidase Inhibitors (MAOIs)?

Answer 14

Hypotension
Sleep disturbance
Sexual dysfunction
Sedation
Dry mouth

Question 15

Monoamine Oxidase Inhibitors (MAOIs) can cause a hypertensive crisis when taken with foods rich in what?

Answer 15

Tyramine

->cheese

Question 16

Symptoms of serotonin syndrome?

Answer 16

Abdominal pain, diarrhea, sweats, tachycardia, HTN, myoclonus, irritability, delirium. Can lead to hyperpyrexia, cardiovascular shock and death

Question 17

How do you reduce risks of serotonin syndrome>

Answer 17

Wait 2 weeks before switching from an SSRI to an MAOI

Question 18

When are Serotonin/Norepinephrine reuptake inhibitors (SNRIs) used?

Answer 18

Anxiety
Depression
Possibly neuropathic pain

Question 20

How do Serotonin/Norepinephrine reuptake inhibitors (SNRIs) work?

Answer 20

Inhibit both serotonin and noradrenergic reuptake like the TCAS but without the antihistamine, antiadrenergic or anticholinergic side effects

Question 21

List some Serotonin/Norepinephrine reuptake inhibitors (SNRIs).

Answer 21

Venlafaxine
Duloxetine
Vortioxetine

Question 22

List some SSRIs.

Answer 22

Fluoxetine (Prozac)
Sertraline

Question 23

List some tricyclics.

Answer 23

Amitriptyline
Clomipramine
Imipramine
Lofepramine
Nortriptyline

Question 24

Susie has a depressive episode with no history of hypomania or mania. She has depressed mood, not eating, psychomotor retardation and poor sleep with early morning wakening. What agent would you like to use for her?
Establish dx: Major depressive disorder
Target symptoms: depression, poor appetite, psychomotor retardation and insomnia

Medication?

Answer 24

SSRI

so either Citalopram, Fluoxetine or Sertraline.

Question 25

Bob is a 55 year old diabetic man with mild hypertnesion and painful diabetic neuropathy who has had previous depressive episodes and one suicide attempt. He meets criteria currently for a major depressive episode with some anxiety. He has been treated with paroxetine, sertraline and mirtazepine. His depression was improved slightly with each of these meds but never remitted. What would you like to treat him with?

Answer 25

Has already tried two SRRIs so best choice would be Duloxetine as targets neuropathic pain, depression and anxiety

Question 26

What is the treatment for treatment resistant depression?

Answer 26

1. Combo of antidepressants e.g. SSRI or SNRI with Mirtazapine 2. Adjunctive treatment with lithium 3. Adjunctive treatment with atypical antipsychotic e.g. Quetiapine, Olanzapine or Aripiprazole

Question 27

What are the treatment options for treatment resistant anxiety?

Answer 27

1. High dose SSRI first 2. Combination of antidepressants e.g. SSRI or SNRI with Mirtazapine 3.Adjunctive treatment with atypical antipsychotic e.g. Quetiapine, Olanzapine or risperidone 4. Adjunctive treatment with Pregabalin or buspirone

Question 28

Why is diazepam not good for treatment resistant anxiety?

Answer 28

Does not treat underlying cause

Question 29

Prophylaxis is important for antidepressant medication. After one episode of depression, how long should the patient continue their meds?

Answer 29

6mths-1yr

Question 30

Prophylaxis is important for antidepressant medication. After two episodes of depression, how long should the patient continue their meds?

Answer 30

2yrs

Question 31

Prophylaxis is important for antidepressant medication. After three episodes of depression, how long should the patient continue their meds?

Answer 31

Lifelong ->generally well tolerated so okay to take long-term

Question 32

What are some of the conditions treated with mood stabilisers?

Answer 32

Bipolar Cyclothymia Schizoaffective,

Question 33

What are some of the types of mood stabilisers?

Answer 33

Lithium Anticonvulsants Antipsychotics

Question 34

What is the only medication that reduces suicide rate?

Answer 34

Lithium

Question 36

What are some of the factors which predict a good response to lithium treatment?

Answer 36

Prior long-term response or family member with good response Classic pure mania Mania is followed by depression

Question 37

What is lithium effective in the prophylaxis of?

Answer 37

Both mania and depressive episodes of bipolar affective disorder

Question 38

What tests need to be done before commencing someone on lithium?

Answer 38

Baseline U&Es and TSH Pregnancy test in females

Question 39

Side effects of lithium?

Answer 39

GI upset e.g. reduced appetite, nausea/vomiting, diarrhoea Thyroid abnormalities Hair loss Acne Polyuria/polydipsia

Question 40

Valproic acid, an anticonvulsant, is as effective as Lithium in mania prophylaxis but is not as effective in depression prophylaxis. It is better tolerated than lithium. What are some of the factors which predict a good response?

Answer 40

Rapid cycling patients (females>males) Comorbid substance issues Mixed patients Patients with comorbid anxiety disorders

Question 41

Which tests need to be done before starting a patient on Valproic acid?

Answer 41

LFTs Pregnancy test FBC

Question 42

Why should Valproic acid be avoided completely in women of child bearing age?

Answer 42

Can cause neural tube defects

Question 43

Side effects of Valproic acid?

Answer 43

Thrombocytopenia and platelet dysfunction Nausea, vomiting, weight gain Sedation, tremor Increased risk of neural tube defect Hair loss

Question 44

What is the first line agent for acute mania and mania prophylaxis?

Answer 44

Carbamazepine (Tegretol)

Question 45

Lithium can be toxic. What are some of the symptoms of mild lithium toxicity?

Answer 45

Vomiting Diarrhoea Ataxia Dizziness Slurred speech Nystagmus

Question 46

Lithium can be toxic. What are some of the symptoms of moderate lithium toxicity?

Answer 46

Nausea Vomiting Anorexia Blurred vision Clonic limb movements Convulsions Delirium Syncope

Question 47

Lithium can be toxic. What are some of the symptoms of severe lithium toxicity?

Answer 47

Generalized convulsions Oliguria Renal failure

Question 48

Before starting a patient on Carbamazepine (Tegretol), which tests need to be done?

Answer 48

Baseline liver function tests, FBC and an ECG

Question 49

Side effects of Carbamazepine (Tegretol)?

Answer 49

Rash- most common SE seen Nausea, vomiting, diarrhea Sedation, dizziness, ataxia, confusion AV conduction delays Aplastic anemia and agranulocytosis Water retention Drug-drug interactions

Question 50

Lamotrigine ( Lamictal) is another type of anticonvulsant. What can it also be used for?

Answer 50

Neuropathic / chronic pain

Question 51

Tests before starting Lamotrigine ( Lamictal)?

Answer 51

LFTs

Question 52

Side effects of Lamotrigine ( Lamictal)?

Answer 52

Necrotising fasciitis Nausea/vomiting Sedation, dizziness, ataxia and confusion Stevens Johnson's Syndrome. -> The character/severity of the rash is not a good predictor of severity of reaction. Therefore, if ANY rash develops, discontinue use immediately.

Question 53

If a patient on

Question 54

47 yo woman hospitalized with her first episode of mania. She has no previous history of a depressive episode. She has no drug or ETOH history and has no medical issues. What medication would you like to start?

Answer 54

Lithium ->likely over child bearing age but check pregnancy test beforehand.

Question 55

Conditions which are treated with antipsychotics?

Answer 55

Schizophrenia Schizoaffective disorder Bipolar disorder- for mood stabilization and/or when psychotic features are present Psychotic depression Augmenting agent in treatment resistant anxiety disorders

Question 56

Adverse effects of antipsychotics?

Answer 56

Tardive Dyskinesia (TD)-involuntary muscle movements that may not resolve with drug discontinuation Neuroleptic Malignant Syndrome (NMS): Characterized by severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC, CPK and LFTs. Extrapyramidal side effects (EPS): Acute dystonia, Parkinson syndrome, Akathisia be aware increased risk of suicide

Question 57

What are there reduced levels of in Parkinson's?

Answer 57

Dopamine

Question 58

What are the two types of antipsychotic drugs?

Answer 58

Typicals Atypicals

Question 61

Give some examples of typical antipsychotic drugs?

Answer 61

Fluphenazine, Haloperidol, Pimozide.

Question 62

Give some examples of atypical antipsychotic drugs.

Answer 62

SDAs: Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Aripiprazole (Abilify)

Question 63

Schizophrenia is a chronic illness Roughly 1/3 don’t respond to first line treatment Treatment resistance defined as poor response to 2 first line antipsychotics at at adequate dose for 8 weeks What is used in this case?

Answer 63

Clozapine

Question 64

21 yo AA male with symptoms consistent with schizophrenia is admitted because of profound psychotic sx. He is treatment naïve. You plan to start an antipsychotic- what baseline blood work would you obtain?

Answer 64

Fasting lipid profile Fasting blood sugar Lfts WBC

Question 65

Which conditions are anxiolytics used to treat?

Answer 65

Panic disorder Generalized Anxiety disorder Substance-related disorders and their withdrawal Insomnias and parasomnias

Question 66

Which other drugs are anxiolytics combined with to treat anxiety?

Answer 66

SSRIS or SNRIs

Question 67

List some anxiolytics drugs.

Answer 67

Buspirone (Buspar) Benzodiazapines

Question 68

As well as anxiety, which other conditions can Benzodiazapines treat?

Answer 68

Insomnia and parainsomia

Question 69

Side effects of Benzodiazapines?

Answer 69

Somnolence- drowsiness or strong desire to fall asleep Cognitive deficits Amnesia Disinhibition Tolerance Dependence

Question 70

What is the most common psychotic symptom>

Answer 70

Lack of insight ->bad as this means patients often don't take their medications as they don't realise they are ill.