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Psychiatry > Psychopharmacology > Flashcards

Psychopharmacology Flashcards

1
Q

Antidepressants

A
  • Increase serotonin (5HT) and/or noradrenaline (NA)
  • Different antidepressants vary in:
    • Effect on 5HT or NA
    • Effects on other receptors
    • Half-life, interactions and toxicity
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2
Q

Selective Serotonin Reuptake Inhibitors (SSRIs)

A
  • Fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram
  • Usually 1st line
  • Side effects:
    • Gastrointestinal
      • Common: Nausea, appetite loss, dry mouth, diarrhoea, constipation, dyspepsia.
      • Uncommon: vomiting, weight loss.
    • CNS
      • Common: insomnia, dizziness, anxiety, fatigue, tremor and somnolence.
      • Uncommon: EPS, seizures and mania.
    • Other
      • Common: sweating, delayed orgasm and anorgasmia.
      • Uncommon: hyponatraemia and alopaecia.
  • Fluoxetine has longest half-life and least discontinuation
  • Sertraline used in people with lots of comorbidities
  • Paroxetine has gretest risk of discontinuation, used in OCD
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3
Q

Noradrenaline Reuptake Inhibitors (NARIs)

A
  • Reboxetine
  • Action - NA
  • Less effective
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4
Q

Tricyclic antidepressants (TCAs)

A
  • Block 5HT and NA (as well as lots of other receptors)
  • Very effective
  • Lots of side effects
  • Overdose dangerous and can cause seizures, coma and arrthymias
  • SRI - depression lifts
  • NRI - depression lifts
  • H1 inserted - weight gain, drowsiness
  • α inserted - dizziness, low BP
  • M1 inserted - constipation, dry mouth, blurred vision, drowsiness
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5
Q

Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs)

A
  • Venlafaxine, Duloxetine
  • Better tolerated than TCAs
  • Possibly more effective than SSRIs for severe depression
  • Used 2nd/3rd line
  • Prominent side effect - sexual dysfuction
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6
Q

Noradrenaline and specific antidepressants (NaSSAs)

A
  • Mirtazepine
  • Blocks α 2 receptors - Increases 5-HT release
  • Blocks 5-HT2 and 3 receptors - anxiolytic effect
  • Blocks H1 receptors - Sedation, Weight gain
  • Relatively safe in overdose
  • Used 2nd/3rd line
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7
Q

Monoamine Oxidase Inhibitors (MAOIs)

A
  • Inhibit monoamine oxidase
    • A - NA, 5HT, DA, Tyramine
    • B - DA, Tyramine, others
  • Phenelzine, isocarboxazid, tranylcypromine (PIT) - inhibit MAOA and B irreversibly
  • Moclobemide - inhibits MAOA reversibly
  • Tyramine in the diet is a potential releaser of NA - NA broken down by MAOA in the brain and gut, if MAOA is inhibited then tyramine can lead to a hypertensive crisis
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8
Q

Antipsychotics

A
  • D2 + 5HT2a + HAM antagonism
  • Dopamine receptor antagonism can effect 4 brain pathways:
    • Mesolimbic (positive symptoms and reward - blockage causes anhedonia etc)
    • Mesocortical (deficiency in dopamine leads to negative symptoms - worsen cognition)
    • Nigrostriatal (extrapyramidal effects - Parkinsonism and tardive dyskinesia)
    • Tuberoinfundibular (prolactin - galactorrhoea, infetility)
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9
Q

Types of antipsychotics

A
  • Typical/1st generation - mainly D2
    • Chlorpromazine
    • Flupentixol (Depixol)
    • Haloperidol
    • Sulpride
    • Zuclopenthixol (Clopixol)
  • Atypicals/2nd generation (QOAARC) - mixed D2 and 5HT2A effect so less EPSE and hyperprolactinaemia, more metabolic syndrome
    • Quetiaprine
    • Olanzapine
    • Amisulpiride
    • Aripiprazole
    • Risperidone
    • Clozapine (can cause agranulocytosis - fatal)
  • Clozapine levels go up when patient stops smoking and side effects include sialorrhoea, seizures, myocarditis, agranulocytosis, sedation, constipation and sudden hyperglycaemia
  • Monitoring includes weight, BP, ECG, glucose/HbA1c, lipids and remind patient to wear sunscreen
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10
Q

Lithium

A
  • Multiple mechanisms
  • Narrow therapeutic index - monitor levels every 3 months
  • Renal and thyroid dysfunction
    • Renal function + TFTs 6 monthly, calcium annually
  • Sudden discontinuation has 50% risk of mania
  • Teratogenic - Ebstein’s anomaly
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11
Q

Valproate (mood stabiliser)

A
  • Multiple actions (including GABA)
  • Not for women of child bearing potential - Teratogenicity (neural tube defects)
  • Side effects include nausea, tiredness, weight gain, hair loss with curly regrowth
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12
Q

Carbamazepine (mood stabiliser)

A
  • Na channel blocker
  • Side effects include nausea, headaches, dizziness, dry mouth, low WCC, raised LFT
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13
Q

Lamotrigrine (mood stabiliser)

A
  • Slow dose titration
  • Risk of SJS
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14
Q

Hypnotics/Anxiolytics

A
  • Benzodiazepines
    • GABA
    • Diazepam, lorazepam, temazepam (-zepam)
    • Tolerance after >4 weeks
  • Z-drugs
    • GABA
    • Zopiclone, zolpidem
  • Pregabalin - Ca channels
  • Buspirone - 5HT1A agonist
  • Propranolol, atenolol – beta blocker
  • Antidepressants
  • Sedative antipsychotics
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15
Q

Aversive drugs

A
  • Disulfiram (Antabuse) - aldehyde dehydrogenase inhibitor (alcohol > acetaldehyde (↑) > acetate)
  • Acamprosate - alcohol cravings
  • Opiate antagonists - Nalmefene – alcohol (reduced enjoyment), Naltrexone – opiate abuse
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16
Q

Cognitive enhancers

A
  • Acetylcholinesterase (AChE) Inhibitors
    • Increase ACh
    • Donepezil, Galantamine, Rivastigmine
  • NMDA antagonists (neuroprotective)
    • Memantine
17
Q

Stimulants

A
  • ADHD, Narcolepsy
  • Action – increase DA and/or NA
  • Methylphenidate and Dexamfetamine
    • DA and NA RI
  • Atomoxetine – NA RI
  • Modafinil – DA and NA releaser
18
Q

Electroconvulsive Therapy (ECT)

A
  • Seizure – improves mood and psychotic symptoms
  • One of the safest treatments
  • Least side effects
  • Fastest acting – life saving
  • Indications
    • Severe depression
    • Suicidal ideation, psychomotor retardation
    • Catatonia
    • Treatment resistant psychosis
  • No absolute contraindications
  • Usually twice a week, up to 12 sessions
  • Patient needs to give consent or 2nd opinion from MWC
  • Risks are mainly from anaesthetic, dentition, headache, muscle pains, vomiting and long-term memory can be affected
19
Q

Psychosurgery

A
  • Lobotomy – not done anymore
  • Anterior cingulotomy (targets anterior cingulate cortex – part of limbic system)
  • Treatment resistant mood disorder
  • Treatment resistant OCD
  • Other treatments
    • Transcranial Magnetic Stimulations (TMS)
    • Vagal Nerve Stimulation (VNS)
20
Q

Adverse affects of antipsychotics

A
  • Movement disorders
    • Acute dystonia ( <10%) - Involuntary contraction of skeletal muscle. e.g. torticollis or oculogyric crisis. More commonly younger males, neuroleptic naïve.
    • Pseudo-parkinsonism (<40%) - Tremor, rigidity and hypokinesia. Dopamine blockade of nigro-striatal pathways implicated aetiologically.
    • Akathisia(<30%) - Characterised by motor restlsssness , a subjective feeling of tension and an inability to tolerate inactivity which gives rise to restless movement.
    • Tardive dyskinesia(<30%) - Late onset hyperkinetic, involuntary movements. Involves face, lips, tongue, jaw and neck, but which involve the trunck, arms and hands. Most common syndrome is the BLM syndrome (Bucco-linguo-masticatory Triad). Most importantly may be irreversible in 30% cases. Aetiology appears to be the increase in sensitivity of Dopamine receptors through up regulation from chronic blockade.
  • Autonomic effects
    • Anti-adrenergic - Postural Hypotension,
    • ECG changes (QTC prolongation) with subsequent cardiac dysrythmias such as Torsade des pointes.
    • Sexual dysfunction – ejaculatory failure.
    • Anti-cholinergic Effects- dry mouth, blurring of vision, constipation, difficulty with micturition and urinary retention.
  • Neuroleptic Malignant Syndrome (NMS). – is a potentially fatal condition that produces muscle rigidity, extreme EPS, severely elevated body temperature, hypertension, and tachycardia. If untreated can cause respiratory failure and cardiovascular collapse. Rare.
  • Convulsant Activity – antipsychotics especially of the phenothiazine class (eg. Chlorpromazine) can lower seizure threshold. Individuals with established Epilepsy can show an increase in fit frequency.
  • Pigmentation – possibly due to catalytic effect of ultraviolet light acting upon melatonin in presence of phenothiazines. Melanin therefore deposited in the skin.
  • Metabolic Effects
    • Weight gain – Class effect with Clozapine and Olanzapine showing greatest propensity to weight gain.
    • Linked to Diabetes.
    • Multiple mechanisms include Serotonergic (5HT2C) subtype antagonism and anti-histaminic binding properties and interfrence with the Leptin system.
    • Hyperprolactinaemia through Tuberoinfundibular Dopamine pathway blockade in the pituaitary.
    • Effects are reduced libido, sexual dysfunction through impotence in males, menstrual irregularites and lactation in non-pregnant females.
  • Hypersensitivity Reactions
    • Cholestatic Jaundice – frequently due to phenothiazine class but all antipsychotics can cause transaminase changes in liver.
    • Skin Reactions – Photosensitivity rashes and sunburns can occur in addition to urticarial or eczematous rashes.
21
Q

Adverse effects of Lithium

A
  • Nausea
  • Vomiting
  • Diarrhoea
  • Metallic taste in the mouth
  • Cognitive “Dulling”
  • Tremor
  • Muscle weakness
  • Weight Gain
  • Hypothyroidism
  • Hyperparathyoidism
  • Renal Tubular Necrosis - Renal Failure
  • Nephrogenic Diabetes Insipidus
  • Toxicity (tremor, nausea, vomiting and dizziness to ataxia, dysarthria, drowsiness, coma, fits and death)
22
Q

Clinical features of serotonin syndrome

A
  • Neurological : Myoclonus. nystagmus, headache, tremor, rigidity and seizures
  • Mental state : irritability, confusion, agitation, hypomania, coma.
  • Other : Hyperpyrexia, sweating, diarrhoea, cardiac arrhythmias, death.

NB: some of these symptoms resemble Neuroleptic Malignant Syndrome (NMS)

Psychiatry (22 decks)

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