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Psychiatry > Psychopharmacology 1 > Flashcards

Psychopharmacology 1 Flashcards

1
Q

List the indications for prescribing antidepressants

A

Unipolar/bipolar depression, organic mood disorders, schizoaffective disorder, anxiety disorders including OCD, panic, social phobia and PTSD

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2
Q

How long does it typically take for antidepressants to start improving symptoms?

A

3-6 weeks

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3
Q

Name the classifications of antidepressant medications

A
  • Tricyclics
  • Monoamine Oxidase Inhibitors (MAOIs)
  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)
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4
Q

What are the drawbacks of TCAs?

A
  • Potentially unacceptable side effect profile
  • Lethal in overdose
  • Can cause QT lengthening
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5
Q

Describe the mechanism of tertiary TCAs

A
  • They have amine side chains with can react with a variety of receptors
  • Acts predominantly on serotonin receptors
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6
Q

List the possible side effects of TCAs

A
  • Anti-histaminic: sedation and weight gain
  • Anti-cholinergic: dry mouth, dry eyes, constipation, memory deficits and delirium
  • Anti-adrenergic: orthostatic hypotension, sedation and sexual function
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7
Q

Give four examples of tertiary TCAs

A

Imipramine, amitryptyline, doxepin and chlomipramine

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8
Q

Describe the features of secondary TCAs

A
  • Often metabolites of tertiary amines
  • Primarily block noradrenaline
  • Side effects are the same as tertiary TCAs but generally less severe
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9
Q

Give two examples of secondary TCAs

A

Desipramine and nortriptyline

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10
Q

Describe the mechanism of monoamine oxidase inhibitors

A

They bind irreversibly to monoamine oxidase thereby preventing inactivation of amines (noradrenaline, dopamine and serotonin etc.) to increase synaptic levels

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11
Q

List the possible side effects of monoamine oxidase inhibitors

A

Orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction and sleep disturbance

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12
Q

What is the potential dangerous consequence of monoamine oxidase inhibitors and what causes it?

A

Hypertensive crisis - caused by taking MAOIs with tyramine rich foods (cheese, wine etc.)

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13
Q

Name the cause of serotonin syndrome and how it presents

A
  • MAOIs being taken alongside meds that increase serotonin or have sympathomimetic actions
  • Abdominal pain, diarrhoea, sweats, tachycardia, HTN, myoclonus, irritability and delirium
  • Can lead to hyperpyrexia, CVS shock and death
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14
Q

Describe the mechanism of selective serotonin reuptake inhibitors and the indications for use

A
  • Block the presynaptic serotonin reuptake

- Anxiety and depression

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15
Q

List the most common side effects of SSRIs

A

GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia, fatigue/sedation and dizziness

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16
Q

What can happen if an SSRI is stopped suddenly?

A

-Discontinuation syndrome: agitation, nausea, disequilibrium and dysphoria

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17
Q

What are the pros and cons of Paroxetine?

A
  • Pros: short half life and sedation properties (good for anxiety and insomnia)
  • Cons: significant CYP2D6 inhibition, sedation, weight gain, anticholinergic effects and likely to cause discontinuation syndrome
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18
Q

What are the pros and cons of sertraline?

A
  • Pros: weak P450 interactions, short half life and less sedating compared to paroxetine
  • Cons: max absorption requires a full stomach and there is an increased number of GI adverse drug reactions
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19
Q

What are the pros and cons of fluoxetine (prozac)?

A

Pros

  • Long half life (decreased incidence of discontinuation syndrome)
  • Initially activating so may provide increased energy

Cons

  • Long half life may cause active metabolite to build up
  • Significant P450 interactions (not a good choice in patients on multiple meds)
  • Initial activation may increase anxiety and insomnia
  • More likely to induce mania than other SSRIs
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20
Q

What are the pros and cons of citalopram?

A

Pros

  • Low inhibition of P450 enzymes so fewer drug interactions
  • Intermediate half life

Cons

  • Dose dependant QT interval prolongation (>40 mg not recommended)
  • Can be sedating
  • GI side effects
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21
Q

What are the pros and cones of escitalopram?

A

Pros

  • Low overall inhibition of P450 enzymes
  • Intermediate half life
  • More effective than citalopram in acute response and remission

Cons

  • Does dependent QT interval prolongation with doses of 10-30mg daily
  • Nausea, headaches
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22
Q

What are the pros and cons of fluvoxamine?

A

Pros

  • Shortest half life
  • Found to possess some analgesic properties

Cons

  • Shortest half life
  • GI distress, headaches, sedation and weakness
  • Strong inhibitor of CYP1A2 and CYP2C19
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23
Q

What are the benefits of serotonin/noradrenaline reuptake inhibitors?

A

-Inhibit both serotonin and noradrenergic reuptake but without the antihistamine, antiadrenergic or anticholinergic side effects that TCAs have

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24
Q

What are the indications for SNRIs?

A

Depression, anxiety and neuropathic pain

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25
Q

Give the common examples of SNRIs

A

Venlafaxine, duloxetine

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26
Q

What are the pros and cons of venlafaxine?

A

Pros

  • Minimal drug interactions and P450 activity
  • Short half life and fast renal clearance

Cons

  • Can cause an increase in diastolic BP
  • May cause significant nausea
  • Can cause a bad discontinuation syndrome (taper recommended)
  • QT prolongation
  • Sexual side effects in >30%
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27
Q

What are the pros and cons of duloxetine?

A

Pros

  • Data may suggest efficacy for the physical symptoms of depression
  • Less BP increase compared to venlafaxine

Cons

  • CYP2D6 and CYP1A2
  • Cannot break capsule - active ingredient is not stable within the stomach
  • Higher drop out rate (in pooled analysis)
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28
Q

What are the pros and cons of mirtazapine?

A

Pros

  • Different mechanism of action may provide good augmentation strategy to SSRIs
  • Can be utilised as a hypnotic at lower doses

Cons

  • Increases serum cholesterol and triglycerides in some patients
  • Very sedating at lower doses
  • Associated with weight gain
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29
Q

What are the pros and cons of buproprion?

A

Pros

  • Good for use as an augmenting agent
  • No weight gain, sexual side effects etc.
  • Low induction of mania
  • Second line ADHD agent

Cons

  • May increase seizure risk
  • Should be avoided in patients with traumatic brain injury, bulimia and anorexia
  • Does not treat anxiety
  • Has abuse potential
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30
Q

What are the management options for treatment resistant depression?

A
  • Combination of antidepressants e.g. SSRI or SNRI with Mirtazepine
  • Adjunctive treatment with lithium
  • Adjunctive treatment with an atypical antipsychotic e,g, quetapaine, olanzapine or aripiprazole
  • ECT
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31
Q

Name the commonly used SSRIs

A

Paroxetine, sertraline, fluoxetine, citalopram, escitalopram, fluvoxamine

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32
Q

What are the indications for mood stabilisers?

A

Bipolar disorder, cyclothymia and schizoaffective

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33
Q

What are the classes of mood stabilisers?

A

Lithium, anticonvulsants and antipsychotics

34
Q

What are the benefits of using lithium?

A
  • Only medication to reduce suicide rate

- Effective in long term prophylaxis of both mania and depressive episodes

35
Q

Which factors predict a positive response to lithium?

A
  • Prior long term response or family member with good response
  • Classic pure mania
  • Mania is followed by depression
36
Q

What should be done before starting a patient on lithium?

A
  • Baseline U&Es and TSH

- Pregnancy test

37
Q

What should be done after starting a patient on lithium?

A
  • Check levels 12 hrs after day 5 dose
  • Check q 3months and TSH and creatinine levels at 6 months
  • Blood level should be between 0.6-1.2
38
Q

What are the potential side effects of lithium?

A

Reduced appetite, nausea/vomiting, diarrhoea, thyroid abnormalities, nonsignificant leukocytosis, polyuria/polydipsia secondary to ADH antagonism, hair loss, acne, reduced seizure threshold, cognitive slowing and intention tremor

39
Q

Describe the features of mild, moderate and severe lithium toxicity

A
  • Mild (1.5-2.0): vomiting, diarrhoea, ataxia, dizziness, slurred speech and nystagmus
  • Moderate (2.0-2.5): Nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium and syncope
  • Severe (>2.5): generalised convulsions, oliguria and renal failure
40
Q

Name the commonly used anticonvulsants

A

Valproic acid (Depakote), carbamazepine, lamotrigine

41
Q

What are the benefits and downsides to using valproic acid?

A
  • As effective as lithium in mania prophylaxis
  • Better tolerated than lithium
  • Not as effective in depression prophylaxis
42
Q

Which factors predict a positive response to valproic acid?

A
  • Rapid cycling patients (females > males)
  • Comorbid substance issues
  • Mixed patients
  • Comorbid anxiety disorders
43
Q

What needs done before and after starting a patient on valproic acid?

A
  • Before: LFTs, pregnancy test and FBC
  • After: Folic acid supplement in women and monitoring
  • Monitoring: check 12hrs after dose on day 4/5 and repeat FBC and LFTs
  • Target level: 50-125
44
Q

What are the potential side effects of valproic acid?

A

Thrombocytopenia, platelet dysfunction, nausea, vomiting, weight gain, sedation, tremor, increased risk of neural tube defect and hair loss

45
Q

What are the indications for carbamazepine?

A
  • First line for acute mania and mania prophylaxis

- Indicated for rapid cyclers and mixed patients

46
Q

What should be done before and after starting a patient on carbamazepine?

A
  • Before: LFTs, FBC and ECG
  • Monitoring: check levels 12 hrs after day 5 dose and repeat FBC and LFTs
  • Target Levels: 4-12mcg/ml
  • Check level and adjust does after 1 month (induces own metabolism)
47
Q

What are the potential side effects of carbamazepine?

A

Rash, nausea, vomiting, diarrhoea, sedation, dizziness, ataxia, confusion, AV conduction delays, aplastic anaemia, agranlulocytosis, water retention leading to hyponatremia and drug-drug interactions

48
Q

List the drugs which can increase carbamazepine levels/toxicity?

A

Acetazolamide, cimetidine, clozapine, diltiazem, INH, fluvoxamine, fluoxetine, erythromycin, clarithromycin, fluconazole, itraconazole, metronidazole, propoxyphene, verapamil and ketoconazole

49
Q

Which drugs decrease carbamazepine levels?

A

Neuroleptics, barbiturates, phenytoin and TCAs

50
Q

Which drugs can carbamazepine increase the metabolism of?

A

Oestrogen, progesterone, warfarin, methadone, antidepressants, antipsychotics, BZDs, immunosuppressants and theophylline etc.

51
Q

What are the potential side effects of lamotrigine?

A

Nausea, vomiting, sedation, dizziness, ataxia, confusion, toxic epidermal necrolysis and Steven Johnson’s syndrome and blood dyscrasias

52
Q

What are the indications for the use of antipsychotics?

A

Schizophrenia, schizoaffective disorder, bipolar disorder (for mood stabilisation and/or any psychotic features), psychotic depression and as an augmenting agent in treatment resistant anxiety disorders

53
Q

Where does the mesocortical pathway run and why is it relevant to psychotic patients?

A
  • Projects from the ventral tegmentum (brain stem) to the cerebral cortex)
  • Where negative symptoms and cognitive disorders (lack of executive function) arise: too little dopamine is the problem
54
Q

Where does the mesolimbic pathway run and why is it relevant to psychotic patients?

A
  • Projects from the dopaminergic cell bodies in the ventral tegmentum to the limbic system
  • Where the positive symptoms come from (hallucinations, delusions and thought disorders): too much dopamine
55
Q

Where does the nigrostriatal pathway run and why is it relevant to ?

A
  • Projects from the dopaminergic cell bodies in the substantia nigra to the basal ganglia
  • Involved in movement regulation
  • Dopamine hypoactivity causes: parkinsonian movements e.g. rigidity, bradykinesia, tremors, akathisia and dystonia
56
Q

Where does the tuberoinfundibular pathway run and why is it relevant?

A
  • Projects from the hypothalamus to the anterior pituitary
  • Dopamine regulates prolactin release
  • Blocking dopamine in this pathway will predispose the patient to hyperprolactinaemia (gynaecomastia/ galactorrhoea/ decreased libido/ menstrual dysfunction)
57
Q

How do high potency typical antipsychotics work?

A
  • They are D2 dopamine receptor antagonists

- They bind to the D2 receptor with high affinity

58
Q

Give 3 examples of high potency typical antipsychotics

A
  • Fluphenazine
  • Haloperidol
  • Pimozide
59
Q

How do low potency typical antipsychotics work?

A

-They have less affinity for the D2 receptors but tend to interact with nondopaminergic receptors (has more cardiotoxic and anticholinergic adverse effects)

60
Q

What are the potential side effects

A

Sedation and hypotension

61
Q

Give two examples of low potency typical antipsychotics

A
  • Chlorpromazine

- Thioridazine

62
Q

How do atypical antipsychotics work?

A
  • They are serotonin-dopamine 2 antagonists
  • They are atypical in the way they affect dopamine and serotonin neurotransmission in the four key dopamine pathways in the brain
63
Q

In which forms is risperidone (risperdal) available in?

A

Regular tabs, IM depot and rapidly dissolving tablet

64
Q

What happens when the dose of risperidone is greater than 6mg?

A

It functions more like a typical antipsychotic

65
Q

What are the downsides to using risperidone?

A
  • Side effects: extra pyramidal
  • Most likely to induce hyperprolactinaemia
  • Causes weight gain and sedation
66
Q

Which forms is Olanzapine (zyprexa) available in?

A

Regular tabs, immediate release IM, rapidly dissolving tablets and depo form

67
Q

What are the downsides to using olanzapine (zyprexa)?

A
  • Weight gain
  • Hypertriglyceridemia, hypercholesterolemia and hyperglycaemia
  • May cause hyperprolactinemia
  • May cause abnormal LFTs
68
Q

What are the downsides to using quetiapine (seroquel)?

A
  • May cause abnormal LFTs
  • May be associated with weight gain
  • May cause hypertriglyceridemia, hypercholesterolemia and hyperglycaemia
  • Most likely to cause orthostatic hypotension
69
Q

How does aripiprazole (abilify) work?

A

It is a partial D2 agonist

70
Q

What are the benefits of using aripiprazole?

A
  • Low EPS
  • No QT prolongation
  • Low sedation
  • Not associated with weight gain
71
Q

What are the downsides to using ariprazole?

A
  • CYP2D6 (fluoxetine and paroxetine) and 3A4 (carbamazepine and ketoconazole_ interactions - recommended to adjust the dosing
  • Potential intolerability due to akathisia/activation
72
Q

When is clozapine used?

A

For treatment resistant patients

73
Q

What are the downsides to using clozapine?

A
  • Associated with agranulocytosis
  • Increased risk of seizures
  • Associated with the most sedation, weight gain and abnormal LFTs
  • Increased risk of hypertriglyceridemia, hypercholesterolemia, hyperglycemia, including nonketotic hyperosmolar coma and death with and/or without weight gain
74
Q

List the possible anti-psychotic adverse effects

A
  • Tardive dyskinesia (involuntary muscle movements)
  • Neuroleptic Malignant Syndrome: severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC, CPK and LFTs -potentially fatal
  • Extrapyramidal side effects: acute dystonia, Parkinson syndrome and akathisia
75
Q

How can EPS be managed?

A
  • Anticholinergics e.g. benztropine
  • Dopamine facilitators e.g. amatadine
  • Beta blockers e.g. propranolol
  • Watch for other meds with anticholinergic activity
76
Q

Which baseline drugs should be done before starting someone on an anti-psychotic?

A
  • Fasting lipid profile
  • Fasting blood sugar
  • LFTs
  • FBC
77
Q

What are the indications for anxiolytics?

A

Panic disorder, generalised anxiety disorder, substance related disorders + their withdrawal, insomnias and parasomnias

78
Q

What are the pros and cons of buspirone (buspar)?

A
  • Pros: good augmentation strategy and no sedation
  • Cons: takes roughly 2 weeks before patients notice the results and does not reduce anxiety in patients that are used to BZDs
79
Q

Give examples of anxiolytics

A

Buspirone

80
Q

What are the indications for benzodiazapines?

A
  • Insomnia, parasomnias and anxiety disorders

- CNS depressant withdrawal protocols

81
Q

List the side effects/cons of using benzodiazapines

A
  • Somnolence
  • Cognitive deficits
  • Amnesia
  • Disinhibition
  • Tolerance
  • Dependence

Psychiatry (16 decks)

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