Psychopharmacology

Question 1

List some indications for antidepressant use

Answer 1

Unipolar and bipolar depression,
Organic mood disorders,
Schizoaffective disorder,
Anxiety disorders (OCD, panic, social phobia, PTSD, premenstrual dysphoric disorder, impulsivity associated with personality disorders.)

Question 2

How long is the typical delay between therapeutic dose and symptom improvement?

Answer 2

3-6 weeks

Question 3

How long should you wait before either switching to another antidepressant/augmenting due to no improvement?

Answer 3

At least 2 months

Question 4

List some classifications of antidepressants?

Answer 4

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

Question 5

What are some of the side effects of TCAs?

Answer 5

• Antihistaminic (Sedation, Weight gain)
• Anticholinergic (Dry mouth, dry eyes, constipation etc)
• Antiadrenergic (Othostatic hypotension, sexual dysfunction)
• Lethal in overdose
• QT lengthening

Question 6

List some examples of tertiary TCAs

Answer 6

Imipramine
Amitriptyline
Doxepin
Clompiramine

Question 7

List some examples of secondary TCAs

Answer 7

Desipramine

Notrtriptyline

Question 8

List some side effects of MAOIs

Answer 8

Orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction and sleep disturbance

Hypertensive reaction with tyramine-rich foods (Cheese reaction!)

Question 9

What symptoms may take place in serotonin syndrome?

Answer 9

Abdominal pain
Diarrhoea
Sweating
Tachycardia
Hypertension
Myoclonus
Irritability
Delirium
Hyperpyrexia
Shock
Death

(Need to wait 2 weeks before switching from SSRI to MAOI)

Question 10

List some common side effects of SSRIs

Answer 10

GI upset
Sexual dysfunction
Nervousness
Insomnia
Fatigue
Sedation
Dizziness
Discontinutation syndrome (Agitation, nausea, disequilibrium, dysphoria)

Question 11

List some examples of SSRIs

Answer 11

Paroxetine
Sertraline
Fluoxetine
Citalopram
Escitalopram
Fluvoxamine

Question 12

Which SSRI may be good for patients with noncompliance issues?

Answer 12

Fluoxetine

Question 13

List some examples of SNRIs

Answer 13

Venlafaxine

Duloxetine

Question 14

What SNRI may be useful for physical symptoms of depression?

Answer 14

Duloxetine

Also for neuropathic pain!

Question 15

List some examples of novel antidepressants

Answer 15

Mirtazapine

Buproprion

Question 16

What can be used in treatment resistant depression?

Answer 16

• Combination - eg SSRI/SNRI + Mirtazepine
• Adjunctive lithium
• Adjunctive atypical antipsychotic (eg Quetipaine)
• ECT

Question 17

List some indications for mood stabiliser use?

Answer 17

• Bipolar
• Cyclothymia
• Scizoaffective

Question 18

List some classes of mood stabiliser

Answer 18

Lithium
Anticonvulsants
Antipsychotics

Question 19

What is the only medication to reduce suicide rate?

Answer 19

Lithium

Question 20

What factors predict good response rate to lithium?

Answer 20

• Prior long-term response or family member with good response
• Classic pure mania
• Mania is followed by depression

Question 21

What things need to be checked before commencing lithium?

Answer 21

• Baseline U+E
• TSH
• Check pregnancy test in women (Ebstein’s anomaly risk)

Question 22

How often do lithium levels need checked after steady state is achieved?

Answer 22

Every 3 months

Question 23

List some potential side effects of lithium

Answer 23

• GI distress - reduced appetite, nausea/vomiting, diarrhoea
• Thyroid abnormalities
• Nonsignificant leukocytosis
• Polyuria/polydypsia secondary to ADH antagonism.
• Hair loss, acne
• Reduces seizure threshold, cognitive slowing, intention tremor

Question 24

What are the effects of lithium toxicity

Answer 24

Mild (1.5-2.0) - Vomiting, diarrhoea, dizziness, slurred speech, nystagmus

Moderate (2-2.5) - +Blurred vision, clonic limb movements, convulsions, delirium

Severe - + generalised convulsions, oliguria, renal failure

Question 25

What is the therapeutic range of lithium?

Answer 25

0.6-1.2

Question 26

List some examples of anticonvulsants?

Answer 26

Vaproic acid (Depakote) Carbamazepine Lamotrigine

Question 27

What things need to be checked before commencing valproic acid?

Answer 27

Baseline LFTs Pregnancy test FBC

Question 28

What are some side effects of valproic acid?

Answer 28

- Thrombocytopenia and platelet dysfunction - Nausea, vomiting, weight gain - Sedation, tremor - Neural tube defect - Hair loss

Question 29

What things need to be checked before commencing carbamazepine?

Answer 29

Baseline LFTs FBC ECG

Question 30

What are some common side effects of carbamazepine?

Answer 30

- Rash - Nausea, vomiting, diarrhoea - Sedation, dizziness, ataxia, confusion - AV conduction delays - Aplastic anemia and agranulocytosis - Water retention -> Hyponatremia

Question 31

What are some common side effects of lamotrigine?

Answer 31

-Nausea/vomiting -Sedation, dizziness, ataxia, confusion -Toxic epidermal necrolysis -Stevens Johnson's syndrome etc

Question 32

List some antipsychotic drugs that may be used in bipolar disroder

Answer 32

- Aripiprazole - Risperidone - Quetiapine - Olanzapine

Question 33

What are some indications for antipsychotics?

Answer 33

- Schizophrenia - Schizoaffective disorder - Bipolar disorder for mood stabilisation - Psychotic depression - Treatment resistant anxiety disorders

Question 34

What key pathways are affected by dopamine in the brain?

Answer 34

- Mesocortical - Mesolimbic - Nigrostriatal - Tuberoinfundibular

Question 35

What pathway in the brain is responsible for negative symptoms in schizophrenia?

Answer 35

Mesocortical pathway

Question 36

What pathway in the brain is responsible for positive symptoms in schizophrenia?

Answer 36

Mesolimbic pathway

Question 37

What receptors do typical antipsychotics act on?

Answer 37

D2 dopamine receptor (Antagonists)

Question 38

List some examples of typical antipsychotics

Answer 38

``` Fluphenazine Haloperidol Pimozide Chlorpromazine Thioridazine ```

Question 39

What receptors do atypical antipsychotics act on?

Answer 39

Serotonin-dopamine 2 antagonists

Question 40

List some examples of atypical antipsychotics

Answer 40

``` Risperidone Olanzepine Quetiapine Aripiprazole Clozapine ```

Question 41

List some adverse effects of antipsychotic medications

Answer 41

- Tardve dyskinesia - Extrapyramidal side effects (Acute dystonia, Parkinsonisms, Akathisia) - Neuroleptic Maligant Syndrome

Question 42

What agents may be used to counter extrapyramidal side effects?

Answer 42

- Anticholinergics (Benztropine, trihexyphenidyl, diphenhydramine) - Dopamine facilitators (Amantadine) - Beta-bockers (Propanolol)

Question 43

What are some indications for anxiolytics?

Answer 43

- Panic disorder - Generalised anxiety disorder - Substance-related disorders

Question 44

List some examples of anxiolytics

Answer 44

Buspirone | Benzodiazpines

Question 45

When may bezodiazepine be used?

Answer 45

- Insomnia, parasomnias, anxiety disorders | - CNS depressant withdrawal

Question 46

What are some side effects of benzodiazapines?

Answer 46

``` Somnolence Cognitive deficits Amnesia Disinhibition Tolerance Dependence ```