Psychopharmacological Treatments of Affective and Anxiety Disorders Flashcards
How long after starting antidepressants does the patient start to notice an effect?
2-4wks
If a patient is on antidepressants, how long do they have to trial a drug for without changes before changing the type?
2 months
Which conditions may be treated with antidepressants
Unipolar and bipolar depression
Organic mood disorders
Schizoaffective disorder
Anxiety disorders including OCD, panic, social phobia
PTSD
List some of the different antidepressant types.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Tricyclics (TCAs)
Monoamine Oxidase Inhibitors (MAOIs)
Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)
How do SSRI’s work?
Block presynpatic seratonin reuptake
Which conditions do SSRI’s treat?
Anxiety
Depression
Side effects of SSRIs?
GI upset
Sexual dysfunction
Anxiety
Restlessness
Nervousness
Insomnia
Fatigue or sedation
Dizziness
What is important to note about starting SSRIs?
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.
Which change may be seen on ECG in a patient taking tricyclics?
QT lengthening
What are the two types of tricyclics?
Secondary
Tertiary
Which type of antidepressant is lethal in overdose?
Tricyclics
Which antidepressant is rarely used but very effective for resistant depression?
Monoamine Oxidase Inhibitors (MAOIs)
Side effects of Monoamine Oxidase Inhibitors (MAOIs)?
Hypotension
Sleep disturbance
Sexual dysfunction
Sedation
Dry mouth
Monoamine Oxidase Inhibitors (MAOIs) can cause a hypertensive crisis when taken with foods rich in what?
Tyramine
->cheese
Symptoms of serotonin syndrome?
Abdominal pain, diarrhea, sweats, tachycardia, HTN, myoclonus, irritability, delirium. Can lead to hyperpyrexia, cardiovascular shock and death
How do you reduce risks of serotonin syndrome>
Wait 2 weeks before switching from an SSRI to an MAOI
When are Serotonin/Norepinephrine reuptake inhibitors (SNRIs) used?
Anxiety
Depression
Possibly neuropathic pain
How do Serotonin/Norepinephrine reuptake inhibitors (SNRIs) work?
Inhibit both serotonin and noradrenergic reuptake like the TCAS but without the antihistamine, antiadrenergic or anticholinergic side effects
List some Serotonin/Norepinephrine reuptake inhibitors (SNRIs).
Venlafaxine
Duloxetine
Vortioxetine
List some SSRIs.
Fluoxetine (Prozac)
Sertraline
List some tricyclics.
Amitriptyline
Clomipramine
Imipramine
Lofepramine
Nortriptyline
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?
SSRI
so either Citalopram, Fluoxetine or Sertraline.
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?
Has already tried two SRRIs so best choice would be Duloxetine as targets neuropathic pain, depression and anxiety
What is the treatment for treatment resistant depression?
- Combo of antidepressants e.g. SSRI or SNRI with Mirtazapine
- Adjunctive treatment with lithium
- Adjunctive treatment with atypical antipsychotic e.g. Quetiapine, Olanzapine or Aripiprazole
What are the treatment options for treatment resistant anxiety?
- High dose SSRI first
- Combination of antidepressants e.g. SSRI or SNRI with Mirtazapine
3.Adjunctive treatment with atypical antipsychotic e.g. Quetiapine, Olanzapine or risperidone
- Adjunctive treatment with Pregabalin or buspirone
Why is diazepam not good for treatment resistant anxiety?
Does not treat underlying cause
Prophylaxis is important for antidepressant medication.
After one episode of depression, how long should the patient continue their meds?
6mths-1yr
Prophylaxis is important for antidepressant medication.
After two episodes of depression, how long should the patient continue their meds?
2yrs
Prophylaxis is important for antidepressant medication.
After three episodes of depression, how long should the patient continue their meds?
Lifelong
->generally well tolerated so okay to take long-term
What are some of the conditions treated with mood stabilisers?
Bipolar
Cyclothymia
Schizoaffective,
What are some of the types of mood stabilisers?
Lithium
Anticonvulsants
Antipsychotics
What is the only medication that reduces suicide rate?
Lithium
What are some of the factors which predict a good response to lithium treatment?
Prior long-term response or family member with good response
Classic pure mania
Mania is followed by depression
What is lithium effective in the prophylaxis of?
Both mania and depressive episodes of bipolar affective disorder
What tests need to be done before commencing someone on lithium?
Baseline U&Es and TSH
Pregnancy test in females
Side effects of lithium?
GI upset e.g. reduced appetite, nausea/vomiting, diarrhoea
Thyroid abnormalities
Hair loss
Acne
Polyuria/polydipsia
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?
Rapid cycling patients (females>males)
Comorbid substance issues
Mixed patients
Patients with comorbid anxiety disorders
Which tests need to be done before starting a patient on Valproic acid?
LFTs
Pregnancy test
FBC
Why should Valproic acid be avoided completely in women of child bearing age?
Can cause neural tube defects
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 the first line agent for acute mania and mania prophylaxis?
Carbamazepine (Tegretol)
Lithium can be toxic.
What are some of the symptoms of mild lithium toxicity?
Vomiting
Diarrhoea
Ataxia
Dizziness
Slurred speech
Nystagmus
Lithium can be toxic.
What are some of the symptoms of moderate lithium toxicity?
Nausea
Vomiting
Anorexia
Blurred vision
Clonic limb movements
Convulsions
Delirium
Syncope
Lithium can be toxic.
What are some of the symptoms of severe lithium toxicity?
Generalized convulsions
Oliguria
Renal failure
Before starting a patient on Carbamazepine (Tegretol), which tests need to be done?
Baseline liver function tests, FBC and an ECG
Side effects of Carbamazepine (Tegretol)?
Rash- most common SE seen
Nausea, vomiting, diarrhea
Sedation, dizziness, ataxia, confusion
AV conduction delays
Aplastic anemia and agranulocytosis
Water retention
Drug-drug interactions
Lamotrigine ( Lamictal) is another type of anticonvulsant. What can it also be used for?
Neuropathic / chronic pain
Tests before starting Lamotrigine ( Lamictal)?
LFTs
Side effects of Lamotrigine ( Lamictal)?
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.
If a patient on
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?
Lithium
->likely over child bearing age but check pregnancy test beforehand.
Conditions which are treated with antipsychotics?
Schizophrenia
Schizoaffective disorder
Bipolar disorder- for mood stabilization and/or when psychotic features are present
Psychotic depression
Augmenting agent in treatment resistant anxiety disorders
Adverse effects of antipsychotics?
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
What are there reduced levels of in Parkinson’s?
Dopamine
What are the two types of antipsychotic drugs?
Typicals
Atypicals
Give some examples of typical antipsychotic drugs?
Fluphenazine, Haloperidol, Pimozide.
Give some examples of atypical antipsychotic drugs.
SDAs:
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Aripiprazole (Abilify)
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?
Clozapine
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?
Fasting lipid profile
Fasting blood sugar
Lfts
WBC
Which conditions are anxiolytics used to treat?
Panic disorder
Generalized Anxiety disorder
Substance-related disorders and their withdrawal Insomnias and parasomnias
Which other drugs are anxiolytics combined with to treat anxiety?
SSRIS or SNRIs
List some anxiolytics drugs.
Buspirone (Buspar)
Benzodiazapines
As well as anxiety, which other conditions can Benzodiazapines treat?
Insomnia and parainsomia
Side effects of Benzodiazapines?
Somnolence- drowsiness or strong desire to fall asleep
Cognitive deficits
Amnesia
Disinhibition
Tolerance
Dependence
What is the most common psychotic symptom>
Lack of insight
->bad as this means patients often don’t take their medications as they don’t realise they are ill.
