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Psychiatric Medicine > Psychopharmacology > Flashcards

Psychopharmacology Flashcards

1
Q

What are antidepressants generally used for?

A
  • Unipolar and bipolar depression
  • Organic mood disorders
  • Schizoaffective disorder
  • Anxiety disorders including OCD, panic, social phobia
  • PTSD
  • Premenstrual dysphoric disorder
  • Impulsivity associated with personality disorders
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2
Q

What is the mechanism of action of Tricyclic antidepressants?

A

Monoamine (serotonin and noradrenaline) reuptake is blocked by the TCAs which antagonise the amine transporter, resulting in a greater monoamine concentration in the synapse

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3
Q

What are examples of TCAs?

A
  • Amitriptyline
  • Clomipramine
  • Nortriptyline
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4
Q

When are TCA’s indicated for use?

A
  • Depression
  • Anxiety disorder
  • Neuropathy
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5
Q

What are common side effects of TCA’s?

A
  • Anti-cholinergic effects - dry mouth, blurred vision, constuipation, hypotension, urinary retention
  • Arrhythmias/Heart block
  • Hyponatraemia - due to SIADH
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6
Q

What is the mechanism of action of monoamine oxidase inhibitors?

A

Amine neurotransmitters (e.g. 5HT, catecholamines, dopamine) are broken down to inactive metabolites by the enzyme monoamine oxidase (MAO), of which two isoforms exist, in nerve terminals:

  • MAOA - found principally in the gut and liver
  • MAOB - found in the brain

MAO inhibitors prevent breakdown of amine neurotransmitters by irreversibly binding with the enzyme

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7
Q

When are monoamine oxidase inhibitors used?

A
  • Resistant depression
  • Parkinson’s Disease
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8
Q

What are side effects of MAOI’s?

A
  • Orthostatic hypotension
  • Weight gain
  • Dry mouth
  • 3 S’s - Sedation, Sexual dysfunction, Sleep disturbance
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9
Q

What is the mechanism of action of SSRI’s?

A

Serotonin is a monoamine neurotransmitter with a role in regulation of mood. SSRIs selectively inhibit the reuptake of the monoamine serotonin (5-HT) within the synapse. The prolongation of the presence of serotonin in the synapse causes an upregulation of its effects on the postsynaptic neuron.

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11
Q

What are examples of SSRI’s?

A
  • Citalopram
  • Fluoxetine
  • Paroxetine
  • Sertraline
  • Paroxetine
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12
Q

What is a specific adverse reaction that can occur with MAOI’s?

A

Tyramine (cheese) reaction - Tyramine in foodstuffs is not broken down by bound MAOA and enters circulation causing dangerous hypertension due to its sympathomimetic effect

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13
Q

When are SSRI’s indicated for use?

A
  • Depressive illness
  • Panic disorder
  • Obsessive compulsive disorder
  • Anxiety disorders
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14
Q

What problem can occur when MAOI’s are taken in combination with medications which increase serotonin?

A

Serotonin syndrome

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15
Q

What is serotonin syndrome?

A

A group of symptoms that may occur following use of certain serotonergic medications or drugs:

  • Abdo pain/diarrhoea
  • Sweats
  • Tachycardia
  • HTN
  • Myoclonus
  • Irritability
  • Delerium

Can lead to hyperpyrexia, CVS shock and death

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16
Q

When starting someone on SSRI’s, what do you have to warn them about?

A

Activation and discontinuation syndromes

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17
Q

What symptoms occur in activation syndrome that is caused by SSRI’s?

A
  • Nausea
  • Increased anxiety, panic and agitation
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18
Q

How long does activation syndrome last in patients who have been started on SSRI’s?

A

2-10 days

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19
Q

What are the symptoms associated with discontinuation syndrome with SSRI use?

A
  • Agitation
  • Nausea
  • Disequilibrium
  • Dysphoria

More common with drugs with shorter half-life

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20
Q

What are the most common side effects associated with SSRI’s?

A
  • GI upset
  • Sexual dysfunction
  • Anxiety
  • Restlessness
  • Nervousness
  • Insomnia
  • Fatigue
  • Sedation
  • Dizziness
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21
Q

What can occur when SSRI’s are used in combination with other drugs that increase seratonin levels?

A

Seratonin syndrome

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22
Q

What drugs of abuse can in increase the risk of serotonin syndrome developing if used with SSRI’s?

A
  • Amphetamines
  • Cocaine
  • LSD
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23
Q

Why does fluoxetine have a lower risk of discontinuation syndrome than other SSRI’s?

A

Longer half-life

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24
Q

What is the mechanism of action of serotonin/noradrenaline reuptake inhibitors?

A

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

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25
Q

What are the indications for SNRI use?

A
  • Depression
  • Anxiety
  • Sometimes neuropathic pain
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26
Q

What are the typical (first generation) antipsychotic medications?

A
  • Haloperidol
  • Chlorpromazine
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27
Q

What are the indications for Antipsychotic medications?

A
  • Acute mania
  • Acute psychosis
  • Chronic schizophrenia
  • Sedation in acute confusional states
  • Premedication before general anaesthesia
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28
Q

How do antipsychotic medications act?

A

All are dopamine receptor type 2 antagonists. This is the most likely explanation for their sedative / tranquilizing effect. The antipsychotic effect is probably an adaptive response to the antidopaminergic actions.

The atypical antipsychotic drugs have greater effects on other receptors than the dopamine receptor (including 5HT2 receptor, histamine receptor).

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29
Q

Which class of antipsychotic medications are more at risk of causing extra-pyramidal side effects?

A

1st generation (typical) antipsychotics - due to their greater action on dopamine receptors

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30
Q

What is important to bear in mind about antipsychotics in terms of side effects?

A

The greater the sedative level of the drug, the less extrapyramidal or anticholinergic side effects there are

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31
Q

What are the main atypical (second generation) antipsychotic medications?

A
  • Respiradone
  • Olanzapine
  • Quitiepine
  • Aripiprazole
  • Clozapine
32
Q

What side effects are seen with antipsychotic use?

A
  • Extra-pyramidal side effects
  • Anti-cholinergic side effects
  • Hyperprolactinaemia
  • Hyperglycaemia
  • Temp regulation interference
  • Venous thromboembolism
  • Prolonged QT interval
33
Q

What are extra-pyramidal side effects?

A

Drug-induced movement disorders that include acute and tardive symptoms:

  • Parkinsonian symptoms
  • Dystonia (abnormal face and body movements) and dyskinesia
  • Akasthisia (restlessness)
  • Tardive dyskinesia
34
Q

What are anti-cholinergic side effects?

A
  • Dry mouth
  • Blurred vision
  • Difficulty passing urine/retention
  • Constipation
  • Hypotension
  • Rare - Ileus, Glaucoma
35
Q

What is dyskinesia?

A

https://www.youtube.com/watch?v=IR1K7HW6KZ0

The impairment of voluntary motor activity by superimposed involuntary motor activity

36
Q

What is akasthisia?

A

https://www.youtube.com/watch?v=pSXzuCNlI6Q

A subjective sense of uncomfortable desire to move, relieved by movement of the affected part. Often a side effect of neuroleptic drugs

37
Q

What is tardive dyskinesia?

A

A movement disorder associated with long-term treatment with neuroleptic drugs. Characterised by abnormal movements, especially of the mouth and tongue such as lip smacking, sucking and puckering. It can also involve other parts of the body with chore-athetoid movements of the finger, toes and writhing movements of the trunk. They tend to increase when the patient is aroused and are typically absent when they are asleep. In some cases it is irreversible.

https://www.youtube.com/watch?v=W_3bbpFjI68

38
Q

What are the side effects associated with respiradone?

A
  • Increased risk of EPSE
  • Most likely to induce hyperprolactinaemia
  • Weight gain
  • Sedation
39
Q

What side effects are associated with Olanzapine?

A
  • Weight gain - can be as much as 30-50lbs
  • Hypertriglyceridemia, hypercholesterolemia, hyperglycemia - even without weight gain
  • Hyperprolactinemia - less than risperidone
  • Abnormal LFT’s - 2% of all patients
40
Q

What are the side effects of Quitiepine?

A
  • Abnormal LFT’s - 6% of all patients
  • Weight gain - though less than seen with olanzapine
  • Hypertriglyceridemia, hypercholesterolemia, hyperglycemia - however less than olanzapine
  • Orthostatic hypotension
41
Q

Which antipsychotic is most likely to cause orthostatic hypotension?

A

Quitiepine

42
Q

What are the side-effects of clozapine?

A
  • Agranulocytosis
  • Increased risk of seizures - especially if combined with lithium
  • Sedation
  • Weight gain
  • Abnormal LFT’s
  • Hypertriglyceridemia, hypercholesterolemia, hyperglycemia
  • Nonketotic hyperosmolar coma and death
  • Neutropenia
  • Idiopathic hyperthermia
  • Hypersalivation
43
Q

Which atypical antipsychotic is the most sedative?

A

Clozapine

44
Q

Which antipsychotics cause abnormal LFT’s?

A
  • Quitiepine
  • Olanzipine
  • Clozapine
45
Q

Which atypical antipsychotics cause weight gain?

A

All except Aripirazole

46
Q

What is neuroleptic malignant syndrome?

A

A rare, but life-threatening, idiosyncratic reaction to neuroleptic/antipsychotic medications. Characterised by:

  • Severe muscle rigidity
  • Fever
  • Altered mental status
  • Autonomic instability
  • Elevated WBC
47
Q

What is the mechanism of action of benzodiazepines?

A

Potentiation of GABA neurotransmission

48
Q

What are examples of benzodiazepines?

A
  • Diazepam
  • Lorazepam
  • Midazolam
  • Temazepam
49
Q

When are benzodiazepines indicated for use?

A
  • Seizure termination - particularly prolonged/status epilepticus - CHECK SIGN GUIDELINES
  • Severe panic disorders if resistant to antidepressants*
  • Anxiety disorders - short term use only
  • Insomnia - short term use only
  • Alcohol withdrawal
  • Perioperative sedation
50
Q

What are the side effects of benzodiazepines?

A

TOLERANCE/DEPENDENCE - long term use

  • Drowsiness
  • In-coordination
  • Muscle weakness
  • Dizziness
  • Confusion
51
Q

Why do extra-pyramidal side effects occur?

A

Occur as a result of D2 receptor blockade in the nigrostriatal pathway and are more likely to be associated with high potency antipsychotics (70-80% D2 occupation) which have little anticholinergic action, such as the piperazine phenothiazines and the butyrophenones

52
Q

What can occur as a result of hyperprolactinaemia?

A
  • Galactorrhea.
  • Menstrual irregularities.
  • Sexual dysfunction.
  • Osteoporosis.
  • Increased risk breast cancer.
53
Q

What are the commonly used mood stabilisers?

A
  • Lithium
  • Anticonvulsants
    • Valproic acid
    • Carbemazepine
    • Lamotrigine
54
Q

What is the mechanism of action of lithium?

A

The mechanism of action of lithium is unknown. It may include alterations in transmembrane ion flux and / or reduction in phosphatidylinositide turnover, which lead to mood stabilization.

55
Q

What are the indications for use of lithium?

A
  • Treatment and prophylaxis of mania
  • Bipolar disorder
  • Recurrent depression
  • Aggressive or self-mutilating behaviour (rarely used)
56
Q

What are the side effects of lithium?

A
  • Gastro intestinal disturbance
  • Fine tremor
  • ADH antagonism + tubulointerstitial damage -> nephrogenic diabetes insipidus
  • Weight gain and oedema
  • Exacerbation of psoriasis
  • Goitre and thyroid dysfunction
  • Reduced seizure threshold
  • Toxicity
57
Q

What are signs of lithium intoxication?

A
  • Vomiting, diarrhea
  • Ataxia
  • Dizziness
  • Slurred speech
  • Nystagmus
58
Q

What signs/symptoms would indicate severe lithium toxicity?

A
  • Hyper-reflexia
  • Convulsions
  • Psychosis
  • Syncope
  • Renal insufficiency
59
Q

What is the blood level that is aimed for when using lithium?

A

0.6-1.2

60
Q

When considering starting lithium, what should you do first?

A
  • Baseline U+E and TSH
  • Pregnancy test in woman
61
Q

How long does it take for lithium to reach a steady state after first dose?

A

5 days

62
Q

How often should lithium levels be checked once steady state is established?

A

3 months

63
Q

When should you recheck U+E’s, creatinine and TSH?

A

6 months

64
Q

What is the mechanism of action of sodium valproate/valproic acid?

A

Three separate methods:

  • Increasing the amount of GABA in the brain
  • Blocking Sodium Channels
  • Blocking Calcium Channels

It increases the amount of GABA in the brain by inhibiting the enzyme GABA Transaminase, which normally breaks down GABA.

By blocking both sodium and calcium channels, Valproate prevents the depolarisation/firing of neurones

65
Q

What are the side effects of sodium valproate/valrpoic acid?

A
  • SEVERE - sudden onset of liver failure, acute pancreatitis and severe thrombocytopenia.
  • Nausea and vomiting
  • Diarrhoea
  • Weight gain
  • Oedema
  • Hallucinations
66
Q

When giving sodium valproate/valproic acid, what baseline tests should you do?

A
  • LFTs
  • Pregnancy test
  • FBC
67
Q

When is carbemazepine indicated for use?

A
  • Acute mania
  • Mania prophylaxis
68
Q

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

A

Carbemazepine

69
Q

What is the mechanism of action of carbemazepine?

A

Carbamazepine acts by binding to the sodium channels of neuronal membranes and prevents the influx of sodium into the cell which normally leads to an action potential. By preventing depolarisation of these neurones, there is not the repeated “firing” of action potentials that is responsible for epileptic seizures.

70
Q

What are the side effects of carbemazepine use?

A
  • Skin conditions
  • SIADH
  • Nausea and vomiting
  • Dry mouth
  • Peripheral Oedema, weight gain
  • Dizziness
  • Drowsiness and fatigue
  • Headache
  • Abnormal LFTs
  • AV conduction delays
71
Q

What serious skin conditions can occur with the use of carbemazepine and lamotrigine?

A
  • SJS
  • Toxic Epidermal Necrolysis
72
Q

What baseline measurements should you take before starting someone on carbemazepine?

A
  • FBC
  • LFTs
  • ECG
73
Q

What is the mechanism of action of lamotrigine?

A

Acts as a sodium channel blocker, to reduce the influx of sodium ions into neurones, and therefore reduced action potentials. This effectively stops the neurones from repetitively “firing” and therefore prevents seizures.

74
Q

What are the side effects of lamotrigine?

A
  • Rashes
  • Nausea, vomiting and diarrhoea
  • Somnolence or insomnia
  • Headache
  • Dizziness
  • Blurred vision or diplopia
  • Ataxia
  • Skin conditions
  • Haematological abnormalities

Psychiatric Medicine (16 decks)

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