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Psychopharmacology Flashcards

1
Q

What important things do you need to keep in mind when choosing medications to treat mental illnesses?

A

Choosing an agent with acceptable side effects at lowest effective dose
Avoiding DDIs

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2
Q

What is the response rate to antidepressants?

A

40%

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3
Q

What conditions may you treat with antidepressants?

A

Unipolar and bipolar depression, organic mood disorders, schizoaffective disorder, anxiety disorders (OCD, social phobia, panic), PTSD etc.

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4
Q

What must you warn your patients of when starting them on antidepressants?

A

That they take 2-4 weeks to reach their therapeutic dose (when their symptoms will improve)

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5
Q

Why would you start someone on prophylactic antidepressants?

A

To reduce relapse and likelihood of another episode

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6
Q

After someone first episode of depression how long should you keep them on antidepressants for?

A

6m - 1y

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7
Q

After someone second episode of depression how long should you keep them on antidepressants for?

A

2y

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8
Q

After someone third episode of depression how long should you keep them on antidepressants for?

A

Consider life long

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9
Q

In treating depression, with an antidepressant, if no improvement is seen in ____ time then either ______ or ________

A

If no improvement is seen in within 2 months, either switch to another antidepressant or augment with another agent

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10
Q

What are the different types of antidepressants?

A

SSRIs - selective serotonin reuptake inhibitors
SNRIs - serotonin/noradrenaline reuptake inhibitors
MAOIs - monoamine oxidase inhibitors
TCAs - tricyclics
Novel antidepressants

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11
Q

What is the biggest issue with TCAs?

A

Lethal in OD - DON’T GIVE TO SUICIDAL PATIENT

Unacceptable side effects - antihistaminic, anticholingeric and antiadrenergic side effects

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12
Q

What side effects are associated with TCAs?

A

Antihistaminic - sedation, wt gain
Anticholingeric - dry mouth, eyes, constipation, memory deficits, delirium
Antiadrenergic - orthostatic hypotension, sedation, sexual dysfunction

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13
Q

How do tertiary TCAs work?

A

Act on serotonin receptors

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14
Q

What are examples of tertiary TCAs?

A

Amitriptyline
Imipramine
Doxepin

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15
Q

What are secondary TCAs?

A

Metabolites of tertiary amines

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16
Q

How do secondary TCAs work?

A

Block noradrenaline

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17
Q

What are the SEs of secondary TCAs?

A

Like tertiary TCAs but not as bad

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18
Q

Give examples of secondary TCAs

A

Desipramine, nortriptyline

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19
Q

How do MAOIs work?

A

Bind irreversibly to monoamine oxidase which prevents inactivation of amines, e.g. noradrenaline, dopamine and serotonin –> higher synaptic levels

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20
Q

What are the SEs for MAOIs?

A

Orthostatic hypotension, wt gain, dry mouth, sedation, sexual dysfunction, sleep disturbance

Cheese reaction when taken with tyramine rich foods

Serotonin syndrome if taken with meds increasing serotonin/have symathomimetic actions

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21
Q

What are the symptoms of serotonin syndrome?

A

Abdominal pain, diarrhoea, sweats, tachycardia, hypotension, myoclonus, irritability, delirium hyperprexia, CV shock and death

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22
Q

What must you do if you are switching from an SSRI to a MAOI?

A

Wait 2 weeks or 5 weeks if fluoxetine (longer half life)

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23
Q

What is used for first line treatment of depression?

A

SSRIs

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24
Q

How do SSRIs work?

A

Block presynaptic reuptake of serotonin

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25
What are the SEs of SSRIs?
GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia, fatigue, sedation, dizziness Activation syndrome Discontinuation syndrome
26
What is activation syndrome?
For the first 2-10 days of starting SSRIs feel more anxious, agitated, nauseated and panicked
27
What is discontinuation syndrome?
On completing SSRI course, feel agitated, nauseated, dysphoric
28
What are the main pros and cons of paroxetine?
Sedating, wt gain
29
What are the main pros and cons of sertraline?
GI SEs | Less sedating
30
What are the main pros and cons of fluoxetine?
``` Can be used in u18s P450 interactions (avoid in those on lots of drugs) Avoid in hepatic illness ```
31
What are the main pros and cons of citalopram/escitalopram?
Fewer DDIs QT lengthening Sedating, GI SEs
32
What are the main pros and cons of fluvoxamine?
GI SEs, side effects, sedation, weakness Inhibits liver enzymes Analgesic
33
How do SNRIs work?
Inhibit both serotonin and noradrenaline uptake
34
What can SNRIs be used for?
Depression, anxiety, neuropathic pain
35
What is second line treatment for depression?
SNRIs
36
What are the two SNRIs?
Venlafaxine | Duloxetine
37
What are examples of SSRIs?
``` Fluoxetine Paroxetine Sertraline Citalopram/escitalopram Fluvoxamine ```
38
What are the main pros and cons of venlafaxine?
``` Minimal DDIs Increases diastolic BP Nausea QT prolongation Sexual SEs ```
39
What are the main pros and cons of duloxetine?
Used for stress incontinence and neuropathic pain as well
40
What are the two novel antidepressants?
Mitrazapine | Buproprion
41
What are the main pros and cons of mitrazapine?
Increases serum cholesterol Very sedation Wt gain
42
How does mirtazapine work?
5HT2 and 5HT3 receptor antagonist
43
What are the main pros and cons of buproprion?
May induce seizure risk in those with traumatic brain injury, bulimia, anorexia Doesn't treat anxiety May cause psychosis
44
How do you treat treatment resistant depression?
Combine SSRI or SNRI with mirtazapine Augment with lithium or atypical antipsychotic ECT
45
What is ECT?
Electroconvulsive therapy | Stimulate an epileptic seizure under GA and muscle relaxant
46
What are SEs of ECT?
Memory loss and headache
47
What are indications for mood stabilisers?
Bipolar, cyclothymia, schizoaffective disorders
48
What are positive factors predicting a good response to lithium?
Previous good response Positive response of family member Classic pure mania Mania followed by depression (where mania is first episode)
49
What must you do before starting lithium treatment?
Get baseline U&Es and TSH as kidneys and thyroid gland are affected by lithium use
50
What abnormality can result from lithium use during pregnancy?
Ebstein's abnormality (heart defect) in first trimester
51
How does the body get rid of lithium?
Not metabolised by liver | Excreted by kidney
52
What must you ensure to do with lithium use?
Do regular blood tests to ensure lithium level is between 0.6-1.2
53
What are side effects of lithium use?
GI SEs - reduced appetite, N/V, diarrhoea Hypothyroidism Non-specific leucocytosis Polyuria/polydipsia (due to ADH antagonism) Hair loss, acne Reduced seizure threshold, cognitive slowing, intention tremor
54
What happens if blood levels of lithium are between 1.5 and 2?
Vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus
55
What happens if blood levels of lithium are between 2 and 2.5?
Nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope
56
What happens if blood levels of lithium are over 2.5?
Generalised convulsions, renal failure, oliguria, death
57
What must patients on lithium be aware of?
Illness/dehydration can cause lithium levels to increase --> lithium toxicity
58
What is the classification of lithium toxicity?
Mild - 1.5-2 Moderate - 2-2.5 severe >2.5
59
What are factors predicting a good response to valproic acid treatment?
Rapid cycling patients Comorbid substance misuse Mixed patients Patients with cormorbid anxiety
60
What must you do before you start someone on sodium valproate?
LFTs, FBC, pregnancy test
61
Why must sodium valproate be avoided in woman of childbearing age?
Causes neural tube defects
62
What is the target level of sodium valproate?
50-125 but generally more on response rather than blood level
63
What are the side effects of sodium valproate?
Thrombocytopenia, platelet dysfunction N/V, wt gain Sedation, tremor, hair loss
64
When might you use carbamazepine?
First line for acute mania and mania prophylaxis | Indicated for rapid cyclers/mixed patients
65
What must you do before starting someone on carbamazepine?
FBC, LFTs, ECG
66
What SEs are associated with carbamazepine?
``` Rash - most common N/V, diarrhoea Sedation, dizziness, ataxia, confusion AV conduction delays Aplastic anaemia, agranulocystosis Water retention due to vasopressin like effect which can lead to hyponatraemia DDIs ```
67
Apart from as a mood stabiliser and anticonvulsant, what can lamotrigine be used for?
Neuropathic/chronic pain
68
What must you check before you start lamotrigine?
LFTs
69
What are the side effects of lamotrigine?
N/V Sedation, dizziness, ataxia, confusion TEN/SJS ANY RASH - STOP RX IMMEDIATELY
70
Apart from lithium, sodium valproate, carbamazepine and lamotrigine what else can be used as mood stabilisers?
Antipsychotics (e.g. risperidone or quetiapine) Tend to use antipsychotics with someone who has been detained with really bad mania and then use mood stabilisers after for prophylaxis
71
If well enough and first episode of mania what should you give?
Lithium
72
If really unwell and first episode of mania what should you give?
Antipsychotic
73
What is an average starting dose of lithium?
800mg nocte
74
What are indications for use of antipsychotics?
Schizophrenia, schizoaffective disorder, bipolar disorder (for mood stabilisation/when psychotic features present), psychotic depression
75
What is the mesocortical pathway?
Dopaminergic neurons fire from VTA to cortex | In schizophrenia there is reduced dopaminergic firing over the mesocortical pathway --> negative symptoms
76
What is the mesolimbic pathway?
Dopaminergic neurons firing from the VTA to the nucleus accumbens (limbic system) In schizophrenia there is too much dopamine in this pathway --> positive symptoms
77
What is the nigrostriatal pathway?
Normally responsible for co-ordination of movement Dopaminergic neurons project from the substantia nigra to the basal ganglia Treatment in schizophrenia reduces dopamine in this pathway which may lead to EPS
78
What is the tuberoinfindibular pathway?
Dopaminergic neurons fire from the hypothalamus to the anterior pituitary Antipsychotics decrease dopamine firing from this pathway --> increased prolactin NB - increased prolactin leads to galactorrhoea and reduced FSH (leading to amenorrhoea)
79
How do the typical antipsychotics work?
D2 dopamine receptor antagonists
80
What are examples of typicals?
Fluphenazine, haloperidol
81
What side effects are common from typicals?
Typicals are also anti-HAM (histamine, alpha, muscarinic) meaning they lead to sedation, weight gain, hypotension, sexual dysfunction, dry mouth, visual problems etc. And extrapyramidal side effects & neuroepileptic malignant syndrome
82
How do the atypicals work?
Serotonin and dopamine 2 antagonists
83
What is the main difference in the atypicals and typicals?
Atypicals tend not to cause EPS but cause more weight gain, cholesterol raising and diabetes mellitus
84
What are the various routes of administration of antipsychotics?
Tablets, IM, rapidly dissolving
85
What is the issue with risperidone?
More likely to cause hyperprolactinaemia | Acts like typical >6mg
86
Give examples of typicals
Risperidone, olanzapine, aripiprazole, quetiapine, clozapine
87
What is the issue with olanzapine?
May cause irregular LFTs
88
What are the issues with quetiapine?
Most likely to cause orthostatic hypotension | Only available as a tablet
89
When should you use clozapine and why?
Treatment resistance only due to side effects Agranulocytosis means that those on clozapine must have FBC checks Also increased risk of seizures
90
How long does it tend to take for an antipsychotic to start working?
6 weeks
91
When is someone considered as treatment resistant?
When they have not responded to 2 antipsychotics (1 of which should be an atypical)
92
What are the movement disorders associated with antipsychotic use (the extrapyramidal symptoms)?
Tardive dyskinesia Parkinsonsim Dystonia Akathesia
93
What is tardive dyskinesia?
Involuntary movements of the lips, tongue, neck e.g. lip smacking
94
What is parkinsonism?
Symptoms exactly same as Parkinson's disease | Cogwheel rigidity, resting tremor, shuffling gait etc.
95
What is akathisia?
Restlessness, pacing, taping etc.
96
What is dystonia?
Sustained muscle contraction
97
How do you treat EPS?
Anticholingerics (e.g. benzotropine) Dopamine facilitators, e.g. amantadine Beta blockers for akathisia (e.g. propranolol)
98
What are anxiolytics used to treat?
Panic disorder, GAD, substance related disorders, insomnias, parasomnias Usually used in combo with SSRIs/SNRIs
99
What are the two anxiolytics we need to know about?
Buspirone and benzodiazepines
100
How does buspirone work?
5HT1A agonist Takes around 2 weeks to work!!
101
What are the side effects of benzodiazepines?
Somnolence, cognitive defects, amnesia, disinhibition, tolerance, dependence
102
Why would you try to avoid benzos?
They work very quickly, but after about 10 days their effect wears off where as fluoxetine starts working then

Psychiatry (26 decks)

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