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Psychiatry > Psychopharmacology > Flashcards

Psychopharmacology Flashcards

1
Q

What are the indications for antidepressants?

A

Unipolar and bipolar depression
Organic mood disorders
Schizoaffective disorder
Anxiety disorders including OCD, panic, social phobia, PTSD

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2
Q

What is the time frame of delay for antidepressants to control symptoms?

A

2-4 weeks

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3
Q

What are the guidelines for prophylactic antidepressant use?

A

First episode continue for 6mth to a year
Second episode continue for 2 years
Third episode disucuss life long

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4
Q

What are the different classes of antidepressants?

A

Tricyclics (TCAs)
Monoamine Oxidase Inhibitors (MAOIs)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)
Novel antidepressants

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5
Q

What are the possible adverse affects of TCAs?

A

Antihistaminic, anticholinergic, antiadrenergic (low BP, constipation, arrhythmia)
Lethal in overdose
QT lengthening

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6
Q

What is the chemical composition of tertiary TCAs?

A

Tertiary amine side chains
Side chains prone to cross react with other types of receptors leading to more side effects
Have active metabolites

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7
Q

What is the main pharmacological action of secondary TCAs?

A

Block noradrenaline

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8
Q

What are some examples of secondary TCAs?

A

Desipramine, notrtriptyline

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9
Q

What is the pharmacological action of MAOIs?

A

Bind irreversibly to monoamine oxidase thereby preventing inactivation of amines such as norepinephrine, dopamine and serotonin leading to increased synaptic levels

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10
Q

What are some of the side effects of MAOIs?

A 
Orthostatic hypotension 
Weight gain
Dry mouth
Sedation
Sexual dysfunction 
Sleep disturbance
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11
Q

What is the cheese reaction?

A

Hypertensive crisis can develop when MAOI’s are taken with tyramine-rich foods or sympathomimetics

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12
Q

What is serotonin syndrome?

A

Can develop if take MAOI with meds that increase serotonin or have sympathomimetic actions

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13
Q

What are the symptoms of serotonin syndrome?

A 
Abdominal pain 
Diarrhoea
Sweats 
Tachycardia 
HTN 
Myoclonus 
Irritability 
Delirium
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14
Q

How can serotonin syndrome be avoided?

A

Wait 2 weeks before switching from an SSRI to an MAOI

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15
Q

What is the main function of SSRIs?

A

Block the presynaptic serotonin reuptake

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16
Q

What are the side effects of SSRIs?

A 
GI upset
Sexual dysfunction (30%+!), 
Anxiety, 
Restlessness, 
Nervousness, 
Insomnia, 
Fatigue or sedation,
Dizziness
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17
Q

What is activation syndrome?

A

Cause increased serotonin. Cab be distressing for patient

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18
Q

What are the symptoms of activation syndrome?

A

Nausea
Increased anxiety
Panic
Agitation

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19
Q

What are the symptoms of discontinuation syndrome?

A

Agitation
Nausea
Disequilibrium
Dysphoria

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20
Q

What are the pros of paroxetine?

A 
Short half life with no active metabolite means no build-up (which is good if hypomania develops)
Sedating properties (dose at night) offers good initial relief from anxiety and insomnia
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21
Q

What are the cons of paroxetine?

A

Sedating, wt gain, more anticholinergic effects

Likely to cause a discontinuation syndrome

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22
Q

What are the pros of sertraline?

A

Very weak P450 interactions (only slight CYP2D6)
Short half life with lower build-up of metabolites
Less sedating when compared to paroxetine

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23
Q

What are the cons of sertraline?

A

Max absorption requires a full stomach

Increased number of GI adverse drug reactions

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24
Q

What are the pros of fluoxetine?

A

Long half-life so decreased incidence of discontinuation syndromes. Good for pts with medication noncompliance issues
Initially activating so may provide increased energy
Secondary to long half life, can give one 20mg tab to taper someone off SSRI when trying to prevent SSRI Discontinuation Syndrome

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25
Q

What are the cons of fluoxetine?

A

Long half life and active metabolite may build up (e.g. not a good choice in patients with hepatic illness)
Significant P450 interactions so this may not be a good choice in pts already on a number of meds
Initial activation may increase anxiety and insomnia
More likely to induce mania than some of the other SSRIs

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26
Q

What are the pros of citalopram?

A

Low inhibition of P450 enzymes so fewer drug-drug interactions
Intermediate ½ life

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27
Q

What are the cons of citalopram?

A

Dose-dependent QT interval prolongation with doses of 10-30mg daily- due to this risk doses of >40mg/day not recommended!
Can be sedating (has mild antagonism at H1 histamine receptor)
GI side effects (less than sertraline)

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28
Q

What are the pros of escitalopram?

A

Low overall inhibition of P450s enzymes so fewer drug-drug interactions
Intermediate 1/2 life
More effective than Citalopram in acute response and remission

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29
Q

What are the cons of escitalopram?

A

Dose-dependent QT interval prolongation with doses of 10-30mg daily
Nausea, headache

30
Q

What are the pros of fluvoxamine?

A

Shortest ½ life

Found to possess some analgesic properties

31
Q

What are the pros of fluvoxamine?

A

Shortest ½ life
GI distress, headaches, sedation, weakness
Strong inhibitor of CYP1A2 and CYP2C19

32
Q

How do SNRIs work?

A

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

33
Q

What are SNRIs most commonly used to treat?

A

Depression
Anxiety
Neuropathic pain

34
Q

What are the pros of venlafaxine?

A

Minimal drug interactions and almost no P450 activity

Short half life and fast renal clearance avoids build-up (good for geriatric populations)

35
Q

What are the cons for venlafaxine?

A

Can cause a 10-15 mmHG dose dependent increase in diastolic BP.
May cause significant nausea, primarily with immediate-release (IR) tabs
Can cause a bad discontinuation syndrome, and taper recommended after 2 weeks of administration
Noted to cause QT prolongation
Sexual side effects in >30%

36
Q

What are the pros of duloxetine?

A

Some data to suggest efficacy for the physical symptoms of depression
Thus far less BP increase as compared to venlafaxine, however this may change in time

37
Q

What are the cons of duloxetine?

A

CYP2D6 and CYP1A2 inhibitor
Cannot break capsule, as active ingredient not stable within the stomach
In pooled analysis had higher drop out rate

38
Q

What are the pros of mertazapine?

A

Different mechanism of action may provide a good augmentation strategy to SSRIs. Is a 5HT2 and 5HT3 receptor antagonist
Can be utilized as a hypnotic at lower doses secondary to antihistaminic effects

39
Q

What are the cons of mertazapine?

A

Increases serum cholesterol by 20% in 15% of patients and triglycerides in 6% of patients
Very sedating at lower doses. At doses 30mg and above it can become activating and require change of administration time to the morning.
Associated with weight gain (particularly at doses below 45mg

40
Q

What are the pros of buproprion?

A

Good for use as an augmenting agent
Mechanism of action likely reuptake inhibition of dopamine and norepinephrine
No weight gain, sexual side effects, sedation or cardiac interactions
Low induction of mania
Is a second line ADHD agent so consider if patient has a co-occurring diagnosis

41
Q

What are the cons of buproprion?

A

May increase seizure risk at high doses (450mg+) and should avoid in patients with Traumatic Brain Injury, bulimia and anorexia.
Does not treat anxiety unlike many other antidepressants and can actually cause anxiety, agitation and insomnia
Has abuse potential because can induce psychotic sx at high doses

42
Q

What are the indications for mood stabilisers?

A

Bipolar
Cyclothymia
Schizoaffective

43
Q

How must lithium be used?

A

Get baseline U&E and TSH
Must get pregnancy test from female
Once stable check levels every 3 months
Check creatinine and TSH every 6 months

44
Q

What are the side effects of lithium?

A

GI distress including reduced appetite, nausea/vomiting, diarrhea
Thyroid abnormalities
Nonsignificant leukocytosis
Polyuria/polydypsia secondary to ADH antagonism. In a small number of patients can cause interstitial renal fibrosis.
Hair loss, acne
Reduces seizure threshold, cognitive slowing, intention tremor

45
Q

What would mild levels of lithium toxicity cause?

A 
Vomiting
Diarrhea
Ataxia
Dizziness
Slurred speech
Nystagmus
46
Q

What would moderate levels of lithium toxicity cause?

A 
Nausea
Vomiting
Anorexia
Blurred vision
Clonic limb movements
Convulsions
Delirium
Syncope
47
Q

What would severe levels of lithium toxicity cause?

A

Generalised convulsions
Oliguria
Renal failure

48
Q

How must valproic acid be used?

A

LFTS, pregnancy test and FBC

49
Q

What are the side effects of valproic acid?

A

Thrombocytopenia and platelet dysfunction
Nausea, vomiting, weight gain
Sedation, tremor
Increased risk of neural tube defect 1-2% vs 0.14-0.2% in general population secondary to reduction in folic acid
Hair loss

50
Q

What is carbamazepine used to treat?

A

Acute mania and mania prophylaxis

51
Q

How must carbamazepine be used?

A

LFT, FBC and ECG before starting

52
Q

What are the side effects of carbamazepine?

A

Rash- most common SE seen
Nausea, vomiting, diarrhea
Sedation, dizziness, ataxia, confusion
AV conduction delays
Aplastic anemia and agranulocytosis (<0.002%)
Water retention due to vasopressin-like effect which can result in hyponatremia
Drug-drug interactions

53
Q

How should lamotrigine be used?

A

LFTs before starting
Start with 25mg daily for 2 weeks
Increase to 50mg for 2 weeks
Increase to 100mg

54
Q

What are the side effects of lamotrigine?

A 
Nausea/vomiting
Sedation 
Dizziness 
Ataxia 
Confusion 
Toxic epidermal necrolysis 
Stevens Johnson's syndrome
55
Q

What are the indications for antipyschotics?

A

Schizophrenia
Schizoaffective disorder
Bipolar disorder- for mood stabilization and/or when psychotic features are present, psychotic depression, augmenting agent in treatment resistant anxiety disorders

56
Q

What are the key pathways that are affected by dopamine in the brain?

A

Mesocortical
Mesolimbic
Nigrostriatal
Tuberoinfundibular

57
Q

What are the side effects of respiridone?

A

Increased extrapyramidal side effects
Hyperprolactinaemia
Weight gain
Sedation

58
Q

What are the side effects of olanzapine?

A

Weight gain
Hypertriglyceridemia, hypercholesterolemia, hyperglycemia
Abnormal LFTs
Hyperprolactinaemia

59
Q

What are the side effects of quetiapine?

A

Abnormal LFTs
Weight gain
Hypertriglyceridemia, hypercholesterolemia, hyperglycemia
Orthostatic hypotension

60
Q

What are the pros of aripiprazole?

A

Low EPS
Low sedation
No QT prolongation

61
Q

What are the cons of clozapine?

A

Associated with agranulocytosis (0.5-2%) and therefore requires weekly blood draws x 6 months, then Q- 2weeks x 6 months
Increased risk of seizures
Associated with the most sedation, weight gain and abnormal LFT’s
Increased risk of hypertriglyceridemia, hypercholesterolemia, hyperglycemia, including nonketotic hyperosmolar coma and death with and/or without weight gain

62
Q

What is tar dive dyskinesia?

A

Involuntary muscle movements that may not resolve with drug discontinuation

63
Q

What is neuroleptic malignant syndrome?

A

Characterized by severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC, CPK and lfts. Potentially fatal

64
Q

What are extrapyramidal side effects (EPS)?

A

Acute dystonia
Parkinson syndrome
Akathisia

65
Q

What can be taken to manage EPS?

A

Anticholinergics (benzotropine, trihexyphenidyl, diphenhydramine)
Amantadine
Beta blockers (propanolol)

66
Q

What are anxiolytics used to treat?

A

Panic disorders
Generalised anxiety disorder
Substance-Related disorder

67
Q

What are the pros of busprione?

A

Good augmentation strategy- Mechanism of action is 5HT1A agonist. It works independent of endogenous release of serotonin.
No sedation

68
Q

What are the cons of buspirone?

A

Takes around 2 weeks before patients notice results.
Will not reduce anxiety in patients that are used to taking BZDs because there is no sedation effect to “take the edge off.

69
Q

What are benzodiazepines used to treat?

A

Insomnia
Parasomnias
Anxiety disorders

70
Q

What are the side effects of benzodiazepines?

A 
Somnolence
Cognitive deficits
Amnesia
Disinhibition
Tolerance
Dependence

Psychiatry (17 decks)

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