Psychopharmacology

Question 1

What is the first line antidepressant type?

Answer 1

Selective Serotonin Reuptake Inhibitor (SSRI) e.g. fluoxetine, sertraline, citalopram

Question 2

Which SSRI will be best to offer if you are worried about poor compliance?

Answer 2

Fluoxetine - longest half life, have to take fewer pills per day

Question 3

Which SSRI is a good choice if a patient has hepatic or renal impairment?

Answer 3

Citalopram - but beware QT prolongation

Question 4

What are some common side effects with SSRIs?

Answer 4

N+V, insomnia, sexual dysfunction (anorgasmia), headache, loss of apetite, diarrhoea, restlessness.

Question 5

What are some rarer but important side effects with SSRIs?

Answer 5

Thoughts of harming self (increased risk of suicide in initial phase of treatment), hyponatraemia, serotonin syndrome, GI bleeds.

Question 6

When is the best time to take SSRIs?

Answer 6

In the morning as they can make it harder to fall asleep

Question 7

How long does it take before antidepressants have their effects on raising mood?

Answer 7

4-6 weeks, so wait this long before deeming ineffective

Question 8

How long should a patient be on antidepressants for?

Answer 8

For 6-9 months following recovery.

If multiple episodes of depression, they should be on it for 2 years

Question 9

What potentially beneficial side effects does mirtazapine have?

Answer 9

Sedation and appetite stimulant (weight gain)

Question 10

Which less commonly used antidepressant drug class is most dangerous in overdose?

Answer 10

Tricyclic antidepressants

Question 11

What additional tests may someone starting on venlafaxine need?

Answer 11

ECG - can prolong QT interval

BP - can cause hypotension

Question 12

Which SSRI is thought to be safest for breastfeeding women?

Answer 12

Sertraline

Question 13

How long is the onset of action of the tranquilizing effect, side effects, and anti-psychotic effects of antipyschotic drugs?

Answer 13

Tranquilizing effect: hours
Side effects: hours to days
Anti-psychotic effect: days to weeks

Question 14

What is the primary mode of action of antipsychotics?

Answer 14

Dopamine receptor antagonists - particularly D2

Question 15

What tests are required before starting someone on an antipsychotic?

Answer 15

Bloods - FBC, U+Es, LFTs, HbA1c, glucose, prolactin, lipids, cholesterol
Physical - ECG, weight, blood pressure, HR. (Some APs are prone to QTc prolongation

Question 16

Which side effects are more common with first generation antipsychotics?

Answer 16

Extrapyramidal side effects such as (acute) dystonia, akithesia, tardive dyskinesia, parkinsonism. Also get hyperprolactinaemia causing sexual dysfunction, gynaecomastia, galactorrhoea, amenorrhoea.

Question 17

How may acute dystonia present?

Answer 17

Torticollis
Occulogyric crisis
Opisthotonus

Question 18

What medication can help to reduce symptoms of dystonia and akithesia following Antipsychotic therapy?

Answer 18

Procyclidine

Question 19

Which side effects are more common with second generation antipsychotics?

Answer 19

Metabolic side effects such as weight gain, hyperglycaemia, dyslipidaemia

Question 20

What side effects of both generations of antipsychotics should you be aware of?

Answer 20

Lowered seizure threshold, QTc prolongation.

Question 21

What is, generally, considered the first line antipsychotic?

Answer 21

Olanzapine

Question 22

Which side effect is common with olanzapine that may make it intolerable?

Answer 22

Weight gain

Question 23

Which anitpsychotic is thought to have the least effect on weight changes and is therefore preferential for some patients?

Answer 23

Aripiprazole

Question 24

When should a patient be considered for clozapine (a more effective antipsychotic therapy)?

Answer 24

After no response to full trials of 2+ other antipsychotics.

Question 25

What risk is there to the fetus if the mother is taking risperidone during pregnancy?

Answer 25

Slightly elevated risk of congenital heart defects

Question 26

What risk is there to the fetus if the mother is taking an SSRI (particularly paroxetine) during pregnancy?

Answer 26

Slightly elevated risk of persistent pulmonary hypertension of the newborn

Question 27

What risk is there to the fetus if the mother is taking Lithium during pregnancy?

Answer 27

Teratogenic: Risk of Ebstein's anomaly (abnormal tricuspid valve) and other, more minor heart defects

Question 28

What are some important side effects of clozapine?

Answer 28

AGRANULOCYTOSIS, myocarditis, weight gain, hypersalivation, seizures, sleepiness

Question 29

How often should a patient on clozapine have blood tests?

Answer 29

Weekly FBCs for first 18 weeks to check for agranulocytosis then fortnighlty up to 1 year then monthly

Question 30

What are the features of neuroleptic malignant syndrome?

Answer 30

Fever, sweating, confusion, racing heart beat, muscle stiffness, difficulty moving

Question 31

What is the therapeutic window for lithium?

Answer 31

Narrow at 0.4-1.0

Question 32

How is lithium excreted?

Answer 32

Via the kidneys, and is therefore dependent on renal function, fluid intake and sodium intake

Question 33

When should blood lithium levels be monitored?

Answer 33

12 hours after the last dose

Question 34

What baseline investigations should a patient have before starting lithium?

Answer 34

Physical exam and weight. Bloods: U+Es, TFTs, Calcium, eGFR ECG Pregnancy test (if a woman of childbearing age)

Question 35

How frequent is the monitoring of a patient on lithium?

Answer 35

``` Monitor blood Lithium levels every 3 months once a steady dose has been achieved. U+Es every 3 months TFTs every 6 months Calcium and creatinine every 12 months Regular weight and ECG monitoring ```

Question 36

What are some early side effects of lithium?

Answer 36

Fine tremor, metallic taste, N+V, dry mouth, polyuria, polydipsia

Question 37

What are some late side effects of lithium?

Answer 37

Hypothyroidism, weight gain, diabetes insipidus, ataxia, arrhythmias, dysarthria

Question 38

At what level will lithium be toxic?

Answer 38

When blood levels reach >= 1.5 mmol/L

Question 39

What are the signs and symptoms of lithium toxicity?

Answer 39

Early: Blurred vision, anorexia, N+V, diarrhoea, coarse tremor, ataxia, dysarthria Late: Confusion, renal failure, delirium, fits, coma, death

Question 40

What may precipitate lithium toxicity?

Answer 40

Concurrent use of nephrotoxic drugs (esp. thiazide diuretics, NSAIDs, ACE-is), renal failure, dehydration, UTI.

Question 41

How is lithium toxicity managed?

Answer 41

Medical emergency. | Stop lithium. Aggressive fluid therapy and consider dialysis. Treat underlying cause.

Question 42

What are some important side effects of valproate?

Answer 42

Gastric irritation, dose-related tremor, thrombocytopenia, hair loss with curly regrowth

Question 43

Which antipsychotic is most likely to reduce seizure threshold?

Answer 43

Clozapine