Psychopharmacology Flashcards
Describe the difference between “relapse” and “recurrence” in the ocntext of depressive illness
- Relapse - in the acute (6-12 week) or continuation (4-9 month) phase
- Recurrence - in the maintenance (1+ year) phase
Describe how you might base the decision of duration of antidepressant therapy for patient with depressive illness
- 1st episode - 6-12 months tapering
- 2 episodes in 5 years - 3 years maintenance
- 3+ episodes in 5 years - 5 years maintenance
- Psychosis/suicidality - long-term treatment
If you thinking about commencing an antipsychotic drug, what investigations would you do before writing the script?
- Side-effect of most anti-psychotics is weight gain
- BMI, BP, fasting glucose, lipid profile, LFT, UEC, FBE
Which atypical antipsychotics have less risk of weight gain?
- Risperidone, aripiprazole (some others)
Describe the onset and efficacy of antidepressant drugs.
- Slow onset (2-4 weeks)
- Response rates of 70-80% (more effective in moderate-severe depression)
- No difference between members of the same class
What are some of the symptoms of a severe (biological/melancholic) depression?
Early morning awakening, diurnal variation, psychomotor retardation
What are some of the common side effects of SSRIs?
- Headache, dizziness, nausea, loose stools, constipation, somnolence and insomnia, sweating, dry mouth, tremor, anxiety, restlessness, sexual dysfunction
- Sertraline and escitalopram are the best tolerated by patients
What are some of the side effects of dual-acting SSRI/SNRIs?
- Serotonin effects: headache, dizziness, nausea, loose stools, constipation, somnolence and insomnia, sweating, dry mouth, tremor, anxiety, restlessness, sexual dysfunction
- Noradrenergic effects: hyponatraemia, palpitations, tachycardia, seizures
What are the symptoms of benzodiazepine withdrawal syndrome?
- Anxiety, irritability, insomnia, palpitations, hypersensitivity to sensory stimuli, nausea, headache, tremor, sweating)
- Reducing spontaneously within 1 to 4 weeks of stopping the benzodiazepine
Outline the treatment of generalised anziety disorder
- Psychotherapy
- Pharmacotherapy
- SSRI or venlafaxine
- MAOI or buspirone
- Diazepam
What are some of the adverse effects of benzodiazepines?
- Disinhibition, psychomotor/cognitive impairment, withdrawal phenomena, rebound insomnia
List some first generation antipsychotics. What is the broad mechanism of action of these? What are the undesirable side-effects?
- Chlorpromazine, flupenthixol, fluphenazine, haloperidol, zuclopenthixol
- B-blockade (mostly DA-ergic)
- Hyperprolactinaemia, extrapyramidal effects, weight gain, hyperglycaemia
List some second generation antipsychotics. What is the broad mechanism of action? What are some of the undesirable side-effects?
- Amisulpride, aripiprazole, asenapine, clozapine, olanzapine, paliperidone, quetiapine, risperadone, sertindole, ziprasidone
- B-blockade (DA-ergic as well but more selective just to basal ganglia)
- Dyslipidaemia, hyperglycaemia, weight gain
- Autonomics (orthostatic hypotension, sedation)
What antipsychotics are more likely to weight gain and cardiometabolic derangements? Which would you consider swapping to?
- Clozapine, olanzapine, paliperi/risperidone
- Aripiprazole, asenapine
What are some of the indications for lithium?
- Bipolar disorder and unipolar depression prophylaxis, hypomanic episodes, augmentation of antidepressant drugs (psychiatrist only), schizoaffective and schizophrenia
What are some of the complications of lithium use? With this in mind, what tests should you order before and during treatment?
- TFTs, UEC, urinalysis, creatinine clearance, FBE, ECG, with repeated TSH, creatinine)
- While taking - trough levels
- Memory problems, thirst, polyuria, tremor, drowsiness, weight gain, metallic taste, sexual problems
- Renal toxicity, hypothyroidism or NT goitre, T1 pregnancy complications, diabetes insipidus
What are the signs/symptoms of lithium toxicity? What can trigger it?
- Lithium toxicity - N+V progressing through ataxia, dysarthria to stupor/coma/seizures
- Fine tremor and hyperreflexia progresses to paralysis, rigidity, CV collapse, renal failure
- Can be triggered by dehydration, NSAIDs, ACEIs
What are some of the side-effects of valproate use?
- Side-effects - sedation and hyperneuro effects, GI disturbance, alopecia, PCOS, hyperinsulin/androgen/lipidaemia, hepatotoxicity, pancreatitis
List some pharmacological agents that can trigger Stevens-Johnson’s syndrome
- Carbamazepine, lamotrigine, topiramate, barbiturates, fluoxetine, some NSAIDs
What tends to distinguish atypical antipsychotics from typical antipsychotics?
- Decreased incidence of extrapyramidal symptoms
- Potential effectiveness in negative syndromes and cognitive domains
- Better tolerabilility and therefore compliance
- No difference in efficacy in treating positive symptoms
Which drugs in particular should raise suspicion of serotonin syndrome?
- SSRI/SNRI
- MAOIs
- TCAs
- Lithium
- Champix
Which symptoms of schizophrenia do atypical antipsychotics work best for? Clozapine?
- Positive symptoms
- Positive AND negative
What are some of the possible consequences of clozapine therapy?
- Metabolic syndrome: hypertension, hyperlipidaemia, impaired glucose tolerance, central obesity
- Myocarditis (eosinophilic)
- Agranulocytosis
What monitoring is required for clozapine therapy?
- LFTs, lipids, BMI, BP, ECG, FBE, echo
- FBE - weekly for 18 weekly then monthly
- Lipids/ECG/echo 6/12ly
What kind of myocarditis can clozapine cause? What does smoking do to serum levels?
- Eosinophilic
- Decreases (enzyme inducing)
