psychopharmacology

Question 1

what are pros and cons of TCAs ?

Answer 1

pros - very effective

cons - antihistaminic (weight gain, sedation), anticholinergic, antiadrenergic(hypotension, sexual dysfunction) side effects
lethal in overdose
can cause QT lengthening

Question 2

what is the action of tertiary TCAs ?

Answer 2

serotonin receptor agonists

Question 3

what are secondary TCAs and what is their action ?

Answer 3

metabolites of tertiary amines
block noradrenaline
less severe side effects

nortriptyline, desipramine

Question 4

how do MAOIs work ?

Answer 4

bind to monoamine oxidase, prevent inactivation of amines such as norepinephrine, dopamine, serotonin - leads to increased synaptic levels

Question 5

what are side effects of MAOIs ?

Answer 5

tyramine crisis - hypertensive crisis
orthostatic hypotension
weight gain
dry mouth
sedation
sexual dysfunction
sleep disturbance

Question 6

what is serotonin syndrome ?

Answer 6

if taking MAOIs with meds that increase serotonin

abdo pain
diarrhoea
sweats
tachycardia, HTN
myoclonus
irritability 
delirium

hyperpyrexia, shock, death

Question 7

how do you avoid serotonin syndrome ?

Answer 7

wait 2 weeks before switching from SSRI to MAOI

except fluoxetine wait 5 weeks

Question 8

what are examples of MAOIs ?

Answer 8

selegeline

rasagiline

Question 9

how do SSRIs work ?

Answer 9

block presynaptic serotonin uptake

Question 10

what are common side effects with SSRIs ?

Answer 10

GI upset
sexual dysfunction
anxiety
restlessness
nervousness
insomnia
fatigue
sedation
dizziness

Question 11

what are symptoms of discontinuation syndrome ?

Answer 11

agitation
nausea
disequilibrium
dysphoria

Question 12

what are pros and cons of paroxetine ?

Answer 12

pros - short half life, sedating - take at night, good initial

cons - weight gain, sedating, discontinuation syndrome

Question 13

what are pros and cons of sertraline ?

Answer 13

pros - weak drug interaction, short h/l

cons - need full stomach, GI ADR

Question 14

what are pros and cons of fluoxetine ?

Answer 14

pros - less discontinuation, initial activating

cons - bad for liver, ADR, initial anxiety, induce mania

Question 15

what are pros and cons of citalopram ?

Answer 15

pros - few ADR

cons - QT prolongation, sedating, GI

Question 16

what are pros and cons of escitalopram ?

Answer 16

pros - low ADR

cons - QT prolongation, nausea, headache

Question 17

what are pros and cons of fluvoxamine ?

Answer 17

pros - analgesic, shortest h/l

cons - GI, headache, sedation, weakness, ADR

Question 18

how do SNRIs work ?

Answer 18

inhibit both serotonin and noradrenergic reuptake like TCA but less side effects

Question 19

what are pros and cons with venlafaxine ?

Answer 19

pros - low ADR, fast renal clearance

cons - HTN, nausea, discontinuation syndrome, sexual side effect, QT prolongation

Question 20

what are pros and cons of duloxetine ?

Answer 20

pros - physical depression

cons- ADR, high drop out rate

Question 21

what are pros and cons of mirtazapine ?

Answer 21

pros - augmented with SSRI - 5HT receptor antagonist

cons - increase cholesterol, sedating, weight gain

Question 22

what are pros and cons of buproprion ?

Answer 22

pros - augmenting, little side effects, 2nd line ADHD

cons- seizure risk avoid in brain things, no anxiety treatment, psychotic - abuse potential

Question 23

how do you manage treatment resistance ?

Answer 23

combo SSRI/SNRI with mirtazapine
+lithium
+atypical antipsychotic
ECT

Question 24

what factors predict +ve response to lithium ?

Answer 24

prior long term/ FHx good response
classic pure mania
mania followed by depression

Question 25

what needs to be done before starting lithium ?

Answer 25

baseline U+E, TSH

pregnancy test

Question 26

how do you monitor someone on lithium ?

Answer 26

check after 5 days, 12 hours after dose
once stable check 3 months + TSH, creatinine,
then 6 months
goal 0.6-1.2

Question 27

what are side effects of lithium ?

Answer 27

GI distress - N+V, diarrhoea
thyroid abnormalities
leukocytosis
polyuria 
hair loss, acne
reduced seizure threshold, cognitive slowing

Question 28

what are symptoms of lithium toxicity ?

Answer 28

mid 1.5-2.0 - vomiting, diarrhoea, ataxia, dizziness, slurred speech

moderate 2-2.5 - N+V, anorexia, blurred vision, clonic movement, seizure, delirium, syncope

severe >2.5 - seizures, oliguria, renal failure

Question 29

what factors predict positive response to valproic acid ?

Answer 29

rapid cycling patients
comorbid substance abuse
mixed patients
anxiety

Question 30

what needs done before starting valproic acid ?

Answer 30

baseline LFTs
pregnancy test
FBC
start folic acid in women

Question 31

how is valproic acid monitored ?

Answer 31

steady after 4/5 days, 12 hours after dose
repeat FBC, LFT

target 50-125

Question 32

what are side effects of valproic acid ?

Answer 32

thrombocytopenia 
N+V
weight gain
sedation
tremor
hair loss

neural tube defect

Question 33

what needs done before starting carbamazepine ?

Answer 33

baseline LFT, FBC, ECG

Question 34

how is carbamazepine monitored ?

Answer 34

steady 5 days + 12 hours
FBC, LFTs

4-12 mcg/ml

check after 1 month

Question 35

what are side effects of carbamazepine ?

Answer 35

rash
N+V+D
sedation
dizziness, ataxia, confusion
AV conduction delay
anaemia, agranulocytosis
water retention 
ADR - lots

Question 36

what are side effects of lamotrigine ?

Answer 36

N+V
sedation, dizzy, ataxic, confusion
TEN, SJS - discontinue if rash

Question 37

what drugs increase lamotrigine ?

Answer 37

VPA