Psychopharmacology Flashcards
State some common side effects from adrenergic/noradrenergic drugs
- Sweating
- Tremor
- Nausea
- Headaches
- Dizziness
State some common side effects from muscarinic (ACh) drugs
- Dry mouth / thirst
- Dry skin
- Hot / flushed skin
- Urinary retention
- Difficulty swallowing
State some common side effects from histamine drugs
- Dry mouth
- Drowsiness
- Dizziness
- N&V
State main mechanism of action of most antidepressants
Act on serotonin activity, aim to increase activity at postsynaptic receptors
Explain the mechanism of action of selective serotonin reuptake inhibitor (SSRI) drugs
Increase serotonin activity
- Reduces reuptake of serotonin at the presynaptic membrane
- More serotonin remains in the synapse
- Leads to a downregulation of serotonin receptions on the postsynaptic membrane
State some common side effects of selective serotonin reuptake inhibitor (SSRI) drugs = STRESS
Sweating
Tremor
Rash
Extrapyramidal side effects (uncommon)
Sexual dysfunction
Somnolence = drowsiness
- Restlessness
- GI disturbance e.g. nausea, diarrhoea/constipation
- Headache
- Bleeding
- Hypomania
- Suicidal ideation
State how long antidepressants take to:
1. Start to have an effect
2. Substantial benefit
- Start to have an effect in 1 week
- Substantial benefit by weeks 4-6
List some examples of selective serotonin reuptake inhibitor (SSRI) drugs
- Sertraline
- Citalopram
- Fluoxetine
- Paroxetine
State the safest SSRI drug to use in cardiac disease
Sertraline
State the main side effect of Citalopram to be concerned about
QT prolongation
State the main side effect of Fluoxetine to be concerned about
Serotonin syndrome (occurs when switching to another drug and there is a cross over as Fluoxetine has a long t1/2)
State the main side effect of Paroxetine to be concerned about
Discontinuation syndrome (occurs when suddenly stopping SSRI, due to short t1/2)
Outline how SSRIs (selective serotonin reuptake inhibitors) are different to SNRIs (serotonin and NA reuptake inhibitors)
SSRIs block serotonin reuptake receptors on presynaptic membrane
SNRIs act in a similar way, but ALSO block noradrenaline reuptake receptors as well
State some side effects for serotonin and NA reuptake inhibitors (SNRIs)
- GI disturbance e.g. nausea
- Headache
- Dry mouth
- Hypertension
- Sexual dysfunction
List 2 examples of serotonin and NA reuptake inhibitors (SNRIs)
- Duloxetine
- Venlafaxine
(can be used for neuropathic pain)
State the target receptors for Mirtazapine (class of its own)
Serotonin receptor (5HT receptor) antagonist - acts at 5HT-2 and 5HT-3 receptors
Also strong histamine activity (at H1 receptors) = sedation
State the main 2 side effects of Mirtazapine (class of its own)
- Sedation
- Weight gain
only drug where side effects don’t reduce by reducing dosage of drug
List some examples of tricyclic antidepressants (TCAs)
- Amitriptyline (older)
- Nortriptyline (newer)
- Lofepramine (newer)
Used at lower doses for neuropathic pain
State some side effects of tricyclic antidepressants (TCAs)
Muscarinic effects:
- Dry mouth / thirst
- Nausea
- Urinary retention
- Dry / flushed skin
- Difficulty swallowing
Histaminic effects:
- Dry mouth
- Sedation
- Dizziness
- N&V
Outline the fatal side effect from tricyclic antidepressant (TCA) overdose
- QT prolongation
- Arrhythmias
For monoamine oxidase inhibitors (MAOi) - state the amino acid it can react with and what it can lead to
Tyramine
- Tyramine reaction can lead to a hypertensive crisis
Tyramine products: cheese, wine, pickled meats
State the new antidepressant which can be used for difficult to treat cognitive symptoms
Vortioexetine
For the following scenarios, suggest which antidepressant to consider:
- New case with no previous treatment
- Depression with major weight loss
- Depression with major sleep difficulty
- Depression with neuropathic pain
New case with no previous treatment = SSRI
Depression with major weight loss = Mirtazapine
Depression with major sleep difficulty = Mirtazapine
Depression with neuropathic pain = SNRI
Outline the rough pathway / order for trying antidepressants
SSRI first
- If no effect, try different SSRI
- No effect, switch to SNRI (Venlafaxine or Duloxetine)
- Mirtazapine
Outline when discontinuation syndrome happens and list some symptoms
Can happen if antidepressant medication is stopped, especially suddenly
- Sweating
- Tremor
- Agitation / irritability
- Insomnia
- Headaches
- N&V
- Paraesthesia
- Clonus
State the SSRI drug and SNRI drug which have the highest risk of discontinuation syndrome and why
- Paroxetine (SSRI)
- Venlafaxine (SNRI)
Short t1/2
List some symptoms of serotonin syndrome, including:
- Cognitive
- Autonomic
- Somatic
Cognitive:
- Hypomania
- Confusion
- Agitation
- Coma
Autonomic:
- Sweating
- Hyperthermia
- Nausea
- Diarrhoea
Somatic:
- Headache
- Myoclonus (muscle jerking)
- Tremor
- Hyperreflexia
Briefly state why serotonin syndrome occurs and how is treated
Caused by abrupt increase in serotonin, can occur if started on a high dose or switching one antidepressant to another which creates a cross over
Generally supportive management
- Stop/reduce offending drug
- Fluids
- Monitoring
- May consider stopping/changing dose
State how antipsychotic drugs aim to work
Reduce level of dopamine activity
- Act at D2 receptors
- Target dopaminergic pathways
State the 4 dopaminergic brain pathways and which ones are the target for anti-pscyhotics
Targets:
- Mesocortical
- Mesolimbic
Unwanted effects:
- Nigrostriatal
- HPA axis (tuberoinfundibular)
State some generic side effects of antipsychotics
- Sedation
- Extrapyramidal side effects
- Weight gain
State the difference between typical and atypical antipsychotics,
- Pharmacological target
- Tolerability
- Likely side effects
Typical = older
- High affinity to block D2/D3 receptors in the brain = reduce Dopamine transmission
- Less tolerable
Likely side effects
- Extrapyramidal side effects e.g. tardive dyskinesia
- High prolactin
Atypical = newer
- Target serotonin receptors more
- More tolerable
Likely side effects
- Metabolic syndrome (diabetes and weight gain)
- Stroke in elderly
List the typical and atypical antipsychotics
ALL D2 receptor antagonists except Aripiprazole
Typical = older
- Haloperidol
- Chlorpromazine
- Flupenthixol
- Zuclopenthixol
- Sulpiride
Atypical = newer
- Clozapine
- Olanzapine
- Quetiapine
- Risperidone
- Aripiprazole D2 partial agonist
- Amisulpride
Efficacy is similar
State some extrapyramidal side effect features
- Akathisia (urge to move)
- Dystonia (muscle contractions/spasms)
- Parkinsonisms (tremor and/or rigidity, bradykinesia)
- Tardive dyskinesia
State the frequency of monitoring required for antipsychotics and what should be monitored
Frequency:
- Baseline
- 3 months after starting treatment
- Then yearly
Monitoring:
- Weekly weights
- FBC, lipids, LFTs, HbA1c, ECG, blood pressure and pulse
Outline some main side effects of atypical antipsychotics and also typical antipsychotics
Atypical antipsychotics:
- Weight gain and hypergylcamia (metabolic syndrome)
- QT prolongation
- Lesser risk of extrapyramidal side effects e.g. rigidity, tremor
Typical antipsychotics:
- Extrapyramidal side effects e.g. rigidity, tremor
- Tardive dyskinesia
- Weight gain
- Constipation
- Dizziness / drowsiness
- Dry mouth
- Gynaecomastia
- Hyperglycaemia
For both: risk of neuroleptic malignant syndrome
Outline neuroleptic malignant syndrome (including which drugs cause it) and including symptoms of the syndrome
Rare life threatening reaction in patients taking antipsychotics
Onset of symptoms in first 10 days after starting/changing treatment
Symptoms (like malignant hyperthermia):
- Fever
- Autonomic instability e.g. tachycardia
- Sweating
- Muscle rigidity
- Confusion
Death usually occurs due to:
- rhabdomyolysis
- renal failure
- seizures
State some risk factors for developing neuroleptic malignant syndrome
- Young male
- High doses
- High potency drugs in antipsychotic naive patients
List some investigations to consider in a patient with neuroleptic malignant syndrome
- FBC (leukocytosis / infection)
- Creatine Kinase (markedly elevated)
- U&Es (renal function)
- LFTs (liver function)
Outline some basic management steps for neuroleptic malignant syndrome
- Emergency referral to A&E
- Stop antipsychotics / causative medication
- Fluid resuscitation
- Benzodiazepine for behavioural disturbance
- Oxygen if necessary
- Cool temp with cooling blankets
Rhabdomyolysis - fluids and sodium bicarbonate
Relax muscles: Dantrolene or Lorazepam
Outline the difference in presentation between neuroleptic malignant syndrome and serotonin syndrome
NMS is very similar to serotonin syndrome, but the main difference is that serotonin syndrome is associated with serotoninergic medications
Both present with hyperthermia, autonomic dysregulation and altered mental status
State a drug that can be used to treat extrapyramidal side effects of antipsychotic drugs (except tardive dyskinesia)
Procyclidine (anticholinergic)
Briefly explain acute dystonia and how to manage it
- Sustained and painful muscular spasms
- Can occur after antipsychotics
Management:
- Stop antipsychotic immediately, could restart later on
- IM Procyclidine (anticholinergic) and continue for 1-2 days after, consider long term
State what drug class Clozapine belongs to and roughly how it works
Antipsychotic
D2 and 5HT-2 antagonist (both dopamine and serotonin receptor blocker)
State the main risks of Clozapine and how they are mitigated against
- Agranulocytosis
- Weekly / fortnightly / monthly FBC monitoring at clinic - Bowel obstruction / toxic megacolon (untreated constipation)
Also
- Hypersalivation
- Urinary incontinence
Dose titrated very slowly over 2 weeks and monitor for autonomic dysregulation (postural hypotension)
State the required monitoring for Clozapine (antipsychotic)
FBC - weekly for first 18 weeks (risk of agranulocytosis, esp. neutrophils)
Then 2 times a month for up to a year
After a year, can be done monthly
Also monitor risk of constipation (ask about symptoms)
Briefly explain how agranulocytosis secondary to Clozapine is treated
- STOP CLOZAPINE
- Stop other bone marrow suppressing drugs e.g. Sodium Valproate
- Avoid other antipsychotics where possible
- Contact consultant haematologist
- Avoid sources of infection
- May use Lithium or G-CSF
State the 2 antidepressants that are safest in pregnancy
Sertraline
Fluoxetine
Some TCAs e.g. Amitriptyline
Should be used with caution, at the lowest effective dose
State the 2 antidepressants that are safest in breastfeeding
Sertraline
Paroxetine
Should be used with caution, at the lowest effective dose
State drug classes that be used in the management of anxiety
- Beta blockers
- Antidepressants
- Benzodiazepines
- Pregabalin
State indications for use of Benzodiazepines
- Delirium tremens
- Alcohol detoxification
- Acute psychosis (sedation)
- Violent behaviour
Advised against:
- Insomnia (short term)
- Anxiety (short term)
Outline the management steps for delirium tremens
Benzodiazepines: Oral Lorazepam
(if unable, offer it as IV or offer Haloperidol)
State 2 most commonly used Benzodiazepines in anxiety and how they work
- Diazepam
- Lorazepam
Potentiate GABA receptors and reduce excitability of GABA neurones
- Allosteric modulators which change structure of GABA receptors and makes GABA more potent when it binds (more inhibition)
State 1 example of a short acting benzodiazepines and 2 examples of long acting benzodiazepines
Short acting: Lorazepam (< 12 hours)
Long acting: Diazepam (< 12 hours)
Explain the potential paradoxical disinhibition in use of Benzodiazepines
Paradoxical disinhibition can occasionally occur in Benzodiazepine use
- Commonly occurs if low dose of drug is used
- Inhibition of frontotemporal lobe without inhibition of amygdala = erratic behaviour
State some side effects for Benzodiazepines
- Drowsiness (next day)
- Light-headedness (next day)
- Confusion
- Ataxia
- Amnesia
- Dependence
- Muscle weakness
- Respiratory depression
Outline how Pregabalin works for anxiety
- Binds to voltage gated Ca channels and alters threshold potential
- Makes Ca channels harder to stimulate
= reduces neuronal activity
State 2 side effects of Pregabalin
- Weight gain
- Sedation
State the 2 classes of hypnotics (sleeping tablets) that can be used and a two examples of each
Benzodiazepines:
- Temazepam
- Lormetazepam
Non-benzodiazepines (z-drugs):
- Zopiclone
- Zolpidem
State 3 types of mood stabilisers and examples of drug names
- Lithium (own class)
- Anticonvulsants
- Carbamazepine
- Lamotrigine
- Sodium valproate - Antipsychotics
- Haloperidol
- Olanzapine
- Quetiapine
- Risperidone
suState Lithium monitoring frequency, including what is monitored
Monitor Lithium levels, U&Es and thyroid levels
Lithium levels:
- Every week until therapeutic level is stable for a month
- Once stable, 3 monthly monitoring
U&Es:
- Every 6 months
Thyroid function:
- Every 12 months
State 2 long term complications of Lithium to be aware of
- Hypothyroidism (reversible - should resolve on stopping Lithium)
- Renal impairment (irreversible)
List some side effects of Lithium AND symptoms of Lithium toxicity ‘TOXIC’
Side effects:
- Metallic taste / dry mouth
- GI disturbance
- FINE tremor
- Excessive thirst and urination
- Weight gain
- Thyroid dysfunction
Symptoms of toxicity:
- Tremor (coarse)
- Oliguric renal failure
- AtaXia
- Increased reflexes
- Convulsions / coma / reduced consciousness
List 3 medications that can increase Lithium levels in the body (through nephrotoxic effects)
- NSAIDs
- ACEi
- Loop diuretics
Outline the management steps for Lithium toxicity (>1mmol/L)
No specific antidote to lithium toxicity.
Supportive treatment
- Regularly check Lithium levels every 6–12 hours
- May require diuresis, or peritoneal dialysis haemodialysis if very high levels
State how long antipsychotics should be used for after a psychotic episode
Continue antipsychotics for at least 1-2 years after a psychotic episode
Some recommend use for 5 year after to prevent relapse
State the antipsychotics that CAN be give orally and as a depot (and those that can only be given orally)
Oral and depot:
- Haloperidol (short acting IM and depot)
- Chlorpromazine
- Olanzapine
- Risperidone
- Aripiprazole
Just oral:
- Quetiapine
- Clozapine
State the first line atypical antipsychotic that can be used to treat bipolar disorder
Quetiapine
Can use other atypical or typical antipsychotics
State some anticonvulsants that can be used for bipolar disorder treatment
- Sodium valproate
- Carbamazepine
- Lamotrigine (risk Stevens Johnson syndrome)
State some side effects of anticonvulsants used for bipolar disorder treatment
- Weight gain
- Sedation
- Risk of thrombocytopenia
- Lamotrigine: additional risk Stevens Johnson syndrome
State 3 drugs used in the treatment of ADHD
Stimulants:
- Methylphenidate
- Dextroamphetamine
SNRI:
- Atomoxetine
State the advantages of SSRIs compared to TCAs
- SSRIs generally have slightly less adverse effects
- SSRIs are associated with lower rates of anticholinergic side effects, weight gain and sedation, compared to TCAs
State the disadvantages of SSRIs compared to TCAs
- SSRIs appear to be slightly less efficacious, compared to TCAs
- SSRIs are less good for treating neuropathic pain, compared to TCAs
State the purpose of rapid tranquillisation and some associated risks
Purpose:
- Emergency measure
- Used to quickly calm a person down and reduce the risk of further violence / harm to themselves and others
- Not intended to treat
underlying mental illness or induce sleep or unconsciousness, but to
promote a calmer state
Risks:
- Hypotension
- Loss of consciousness / airway obstruction
- Cardiac arrest
- Seizures
- Coma / death
- Neuroleptic malignant syndrome
What is psychotherapy?
Systematic use of a relationship between a patient and a therapist to produce changes in feelings, thoughts and behaviour (as opposed to physical and social methods)
List some qualities that make a patient a good candidate for psychotherapy
- Takes responsibility for resolution of their difficulties
- Psychologically minded
- Patients are able to verbalise their problems
Outline the management steps for Wernicke’s encephalopathy
Offer prophylactic oral thiamine to those at risk e.g. dependent drinkers
Mainstay treatment:
- IV Thiamine for a minimum of 5 days
- Oral thiamine should continue after parenteral therapy
State some common side effects of Haloperidol and Chlorpromazine (same)
- Hypotension
- Constipation
- Dry mouth
- Drowsiness
- Insomnia
- Blurred vision
List some indications for antipsychotic medications
First line for Schizophrenia (and other conditions where psychosis can present)
- Schizoaffective disorder
- Drug-induced psychosis
- Acute mania
- Major depressive disorder with psychosis
- Delusional disorder
- Severe agitation
- EUPD (if psychotic symptoms are present)
List some indications for mood stabiliser medications
First line: bipolar affective disorder
- Acute manic episode (if atypical antipsychotic ineffective)
- Depression (adjunct only)
Outline the role of mood stablisers
- Help to stabilise mood
- Reduce incidence of hypomania/mania and depressive symptoms
- Most effective for bipolar disorder
State some common side effects of mood stabilisers e.g. Lithium = LITHIUM
Low WCC
Impaired renal function
Tremor / teratogenic
Hypothyroidism / hair loss
Increased weight / fluid retention
Urine increased
Metallic taste
Briefly explain the concept of cognitive behavioural therapy (CBT)
- Based on idea that disorder is influenced by the patient’s thoughts and feelings
- Explores the interaction between thoughts, feelings and behaviours
- Aims to identify and challenge automatic negative thoughts
Suggest some conditions for which CBT psychotherapy can be used
Mood:
- Mild to moderate depression
- Bipolar disorder
Neurotic:
- Anxiety disorders e.g. GAD, PTSD, OCD
Psychotic:
- Psychosis disorders
- Schizophrenia
Other:
- Eating disorders
- Substance misuse
- Chronic medical conditions e.g. chronic fatigue syndrome
State the concept behind behaviour therapies
Based on learning theory, especially operant conditioning (behaviours are reinforced if positive consequences)
List 2 examples of behavioural therapies and state what conditions they are used in
Exposure and response prevention = in phobias and OCD
Systemic desensitisation = in phobias
Briefly explain the concept of psychodynamic therapy
- Based on concept that childhood experiences / unresolved conflicts / previous relationships significantly influence a current situation
- Uses free association (patient says whatever they want) and therapist interprets these statements
- Huge emphasis on relationship between patient and therapist
- Explores conflicts and defence mechanisms and development of insight
Suggest some conditions for which psychodynamic therapy can be used
- Recurrent depression (chronic dysthymia)
- Dissociative disorders
- Somatoform disorders
- Psychosexual disorders
- Some personality disorders
Briefly explain the concepts of transference and counter-transference in psychodynamic therapy
Transference - patient experiences strong emotions from early important relationships, which is reflected within their relationship with the therapist
Counter-transference - therapist is affected by powerful emotions from the patient and reflects what the patient is feeling
Outline the concept of family (systemic) therapy
- Involves family members being seen together (family system)
- Focusses on family system’s ability to help family problems and individual mental illness
- Corrects any impaired communication or dysfunctional relationships
Suggest some conditions for which family (systemic) therapy can be used
Paediatric disorders:
- Eating disorders
- Conduct disorder
Adult disorders:
- Bipolar affective disorder
- Schizophrenia
- Depression
State how dialectical behavioural therapy is used in emotionally unstable (borderline) personality disorder
- Uses components of CBT
- GROUP skills training
- Provides individuals with alternative coping strategies (other than self-harm) to deal with emotional instability
State the first line medication for ADHD
Methylphenidate or Dexamfetamine/Lisdexamfetamine
List some side effects of the stimulants used to treat ADHD (Methylphenidate or Dexamfetamine/Lisdexamfetamine)
- Stunted growth
- Tachycardia, arrythmias or hypertension
- Tics
- Sexual dysfunction (Atomoxetine)
- Seizures
- Worsening of behaviour
- Stimulant misuse
State the management of acute dystonia
Treatment centres re-balancing disrupted dopaminergic-cholinergic levels
- Discontinuation of the offending agent
- IV anticholinergic drugs e.g. Diphenhydramine and Benztropine
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