psychopharmacology Flashcards
indications of SSRIs
- moderate/severe depressive episodes (all SSRIs)
- dysthymia
- GAD (paroxetine)
- chronic pain
- schizoaffective disorder
- OCD
- panic disorder (citalopram, escitalporam, paroxetine)
- social phobia (escitalopram, paroxetine)
- PTSD (paroxetine, sertraline)
- impulsivity associated w personality disorders
when do we deem no imporvement w antidepressants
at least 2 months
antidepressant classifications
TCAs - tricyclic antidepressants
MAOIs - monoamine oxidase inhibitors
SSRIs - selective seotonin
SNRIs
what are TCAs
indications
imipramine, amitryptilline
lethal in overdose
QT prolongation and arrhytmias
indications
- depressive illness, nocturnal enuresis in children, neuropathic pain
SEs of TCAs
CIs
sedation, weight gain - antoihistaminc - anticholinergic - SLUDGE OPPOSITE - antiadrenergic - orthostatic hypotension, libido confusion/delirium gynaecomastia/galactorrhoea
CIs - recent MI, arryhthmias, mania, sever liver disease, agranulocytosis
MAOIs
indications
inhibit monoamine oxidase A and B present at nerve terminals
irreversible - phenelzine, isocarboxide
reversible - moclobemide - good for atypical depression
indications
- third line for depression or treatment resistant depression
- social phobia
TYRAMINE CHEESE REACTION
hypertensive crisis - tyramine reaction
avoid certain foods such as peas, wine, processed meats as they contain high amounts of tyramine - high MAOIS inhibitor increase tyramine increase catecholamines leading to HTN crisis - CVS events ie stroke
clinical features
- headache, palpitations, fever, convulsions, coma
serotonin syndrome
SEs of MAOIs
CVS - OH, arrhythmias
neuropsychiatric - drowsy/insomnia, headache
GI - increased appetite, weight gain
libido, dry mouth
hepatic - increased LFTs
hypertensive reaction with tyramine containing foods
SSRis
which one is used post MI
in children and adolescents
block reuptake of serotonin
sertraline
fluoxetine
SEs of SSRIs
SEs - GI upset - GI bleeding - PPI libido anxiety restlessness nervousness insomnia fatigue sedation dizziness
what is discontinuation syndrome and its effects
when you stop SSRIs
restlessness
problems sleeping
unsteadiness
sweating
abdominal symptoms
altered sensations (for example electric shock sensations in the head)
altered feelings (for example irritability, anxiety or confusion).
cons of paroxetine
sign CYP2D6 inhibition sedating weight gain more AntoACH effects discouraged during pregnancy likely to cause discontinuation syndrome
pros of sertraline
very weak p45o INTERACTIONS and only slight CYP2D6
short half life w lower build up of metabolites
less sedating
safest in cardiac disease
cons of sertraline
max absoprtion requires a full stomach
Increase number of GI adverse drug interactions
pros of fluoxetine
long half life. less incidence of discontinuation
activating NOT SEDATION
cons of fluoxetine
long half life and active metabolite build up
significant P450 interactions
intiial activation - increase anxiety ad insomnia
more likely to induce mania
pros and cons of citalopram
PROS
low inhibition of P450 enzymes so fewer drug-drug interaction
what is SNRIs
inhibit both serotonin and noradrenergic reuptake but WO antihistamine
pros fo venlafaxine
minimla drug interactions
short half life ad fast renal clearance
cons of venlafaxine
can increase diastolic BP
sig nausea
Bad discontinuation syndrome - taper recommeded after 2 weeks of administation DUE TO ITS LONG HALF L
casue QT prolongation
sex
duloxetine pros and cons
helps w physcial Sx of depressionie headaches, pain
CONS
CYPD26 and CYP1A2 inhibitor
cannot break capsule as active ingredient not stable within the stomach
mitrazapine pros
atypical antidepressant
noradrenaline and specific serotonin antidepressant receptor
5HT2 and 5HT3 recepetor antagonist
hypnotic at lower dose
CONS
increased appetite and weight gain
SSRIs drug interactions
taking NSAIDs increase GI bleeding so if given co-prescribe PPI
warfarin/heparin - consider mitrazapine instead
triptan drugs for migraine - increased risk of serotonin syndrome
MAOIs - increased risk of serotonin syndrome
if taking heprain aspirin warfarin what can be prescribed for depression
mitrazapine
inidcations for mood stabilisers
bipolar
cyclothymia
schizoaffective
augmentation in treatment resistant depression
classes of
lithium
anticonvulsants
antipsychotics
indications of lithium
- first line prophylaxis for bipolar disorder
- moderate to severe mania
- augmentation of a n antidepressant
reduces aggression and suicidality
plasma levels
renal toxicity and hypothyroidism
lithium toxicity
interaction w other drugs
Li SEs
GI distress - reduced appetite, N/V, diarrhoea Leucocytosis Impaired renal function Tremor(fine)/ teratogenic/ thirst Hypothyroidism/ hair loss Increased weight/ fluid retention Urine (polyuria) Metallic taste
TOXICITY Tremor (coarse) Oliguric renal failure ataXia Increased reflexes Convulsions/coma/consciousness
Li toxicity
mild -> 1.5-2.0 - vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus
moderate -> 2.0-2.6 - NV, anorexia, blurred vision, clinic limb movements, convulsions, delirum, syncope
sever ->
>2.5 generalised convulsions, oliguria, renal failure
drug int w lithium
ACE i
AII inhi
diuretics - thiazide
NSAIDs
valproate
indications
SEs
mania, hypomania, bipolar depression
SEs
GI disturbances
Very fat Aggression LFTs Platelets low (thrombocytopenia) Reversible hair loss Oedema (peripheral Ataxia Tremor/Tiredness/Teratogenic Emesis
CIs
pregnancy - NT defects spina bifida
hepatic dysfunction
porphyria
Before FBC LFTs PT pregnancy weight/BMI
LFTs and PT first 6 months
LFTs FBC weight again after 6 months and then annually
continupous monitoring FBC, LFT- 6 months
SEs NV weight gain sedation tremor hair loss
teratogen - not to be used in CBAG
carbamzepine
SEs
prophylaxis of bipolar disorder 3RD LINE
alcohol withdrawal
U&Es FBC LFTs Baseline weight monitor 6 monthly
SEs GI disturbances rash - dermatits dizzy hyponatraemia blood disorders
monitoring
WCC after a week
LFTs and U&Es
CI
COCP
lamortrigine
bipolar depression
before starting
FBC, LFTs, U&Es
titration medication
SEs GI distubrances SJS/TEN headache tremor NV sedation diz ataxia
typical antipsychotic
adverse effects
esp with elderly
examples
administration
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
- > Extrapyramidal side-effects
- > hyperprolactinaemia
elderly
increases risk of stroke and VTE
Haloperidol
Chlopromazine
depot
rapid tranquilisationb
low potency - low affinity interact w nondopaminergic
cardiotoxic, anticholinergic - sedation, hypotensionchlorpromazine
atypcial antipsychotics
adverse effects
Act on a variety of receptors (D2, D3, D4, 5-HT)
- Extrapyramidal side-effects
- hyperprolactinaemia less common
Metabolic effects
rispieridone, planzapine, clozapine
risperidone
tabs, IM depot, rapidly dissolving
less sedating tha olanzapine
high potency
increased extrapyramidal SEs
induce hyperprolactinaemia
weight gain and sedation
DOSE DEPENDENT
olanzapine
rabs
IM immediate release
fasting blood glucose
- after one month’s Mx
- every 4-6 months
weight gain
hypertriglyceridaemia, hypercholestrolemia, hyperglycaemia
hyperprolcatinaemia
trasaminitis
quetiapine
tab
cause transaminitis
good in bipolar
weight gain, hypertriglyceridaemia, hypercholestrolemia, hyperglycaemia
cause orthostatic hypotension
aripiprazole
regular tabs, IM formulation, depot form
partial agonist
low extrapyramidal SEs
no QT prolongation
low sedation
CYPD26 (Fluoxetine and paroxetine) and 3A4 (carbamezepine and ketoconazole) interactions - adjust dose POTENTIAL INTOLERABILITY DUE TO AKATHISIA/ACTIVATION
Clozapine
special monitoring
side effects
reserved for Mx resistant pts
ass w granulocytosis - weekly bloods for 18 weeks, fortnightly for one year and then monthly
fasting blood glucose
after one months and then every 4-6 months
weight gain excessive salivation agranulocytosis neutropenia myocarditis arrhythmias constipation urinary incintineve increased seizures sedation transaminitis dyspepsia
hypertriglyceridaemia, hypercholestrolemia, hyperglycaemia
extrapyramidal SEs of
PAD-T
-> Parkinsonism -weeks or months
-> Akathisia (severe restlessness) - first months
- > Dystonia
- sustained muscle contraction (e.g. torticollis, oculogyric crisis)
- may be managed with procyclidine - within days
-> Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, most common is chewing and pouting of jaw)
Mx - tetrabenazine
LATE ONSET (years)
anxiolytics
anxiety disorders
benzodiazepines
insomina, parasomnias, anxiety
bind to GABA, reduce the excitability of neurones
CNS depressant withdrawal protocols ex. ETOH withdrawal
SEs somnolence congitive deficits ANTEROGRADE AMNESIA - memory recall and creation of new memories is significantly impaired disinhibition tolerance dependence
respiratory deprression - FLUMAZENIL
drugs used in ADHD
methyphenidate
- inhibit DA and NA reuptake : increasing DA and NA levels in the synaptic cleft
above stimulants
drugs used in ADHD
methyphenidate
- inhibit DA and NA reuptake : increasing DA and NA levels in the synaptic cleft
above stimulants
DA - abuse potential
atomoxetine - NA
increase Na LEVELS IN SYNAPITC CLEFT
atypical antipsychotics are first line where
schizophrenia
adverse effects of atypical for antipsychotics
weight gain
clozapine is associated with agranulocytosis (see below)
hyperprolactinaemia
risks of elderly ppl using antipsychotics
increased risk of stroke
increased risk of venous thromboembolism
adverse effects of clozapine
agranulocytosis (1%), neutropaenia (3%)
reduced seizure threshold - can induce seizures in up to 3% of patients
constipation
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
what might increase clozapine
smoking
SEs of antipsychotics
antimuscarinic cant see, cant pee, cant spit, cant shit - blurred vision - urinary retention - dry mouth - constipation
- tremor
anithistaminergic - sedation
- weight gain
anti-adrenergic
- postural hypotension
- tachycardia
- ejaculatory failure
endocrine/metabolic
- raised prolactin - sexual dys, reuced bone mineral, mestrual disturbances, breast enlargement
- –> may result in galactorrhoea
- impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
- reduced seizure threshold (greater with atypicals)
Prolonged QT interval (particularly haloperidol)
discontinuation Sx of SSRIs
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
SSRIs and pregnancy
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
during breastfeeding - paroxetine and sertraline
before starting antipsychotic what is measured
- weight or BMI
- pulse
- blood pressure
- fasting blood glucose or glycosylated haemoglobin (HbA1c)
- blood lipid profile.
- ECG - monitoring esp for haloperidol and MANDATORY FOR PIMOZIDE
Monitoring antipsychotic drug Mx
FBC, U&Es and LFTs - annually
- pulse and blood pressure after each dose change
- weight or BMI weekly repeat at 3, 6 months and then yearly
HbA1c, lipid profile, Glucose - repeat at 3, 6 months and yearly
- prolactin - at 6 months then yearly
- ECG - drug/dose change and yearly
- response to treatment, including changes in symptoms and behaviour
- side effects and their impact on physical health and functioning
- the emergence of movement disorders
- adherence
clinical features
Ix
Mx
of NMS
- hyperthermia
- muscle rigidity
- confusion
- fluctuating consciousness
- autonomic instability
- tachycardia
- fluctuating BP
Ix
- increase in CK
- FBC
- LFTs deranged
Mx
- stop antipsychotic
- IV fluids for renal failure
- cooling
- dantrolene (muscle relaxant)
- bromocriptine - dopamine agonist
complications
- PE
- renal failure
- shock
what is depot antipsychotic
- long acting, slow release given IM every 1-4 weeks
- typical antipscychotic - flupentixol, fluphenazine
atypical - aripiprazole
why should chlorpromazine be avoided in the elderly
increases death
what are anxiolytics and hypnotics
licensed for anxiety disorders
hypnotics induce sleep
examples of anxiolytics
benzodiazepines barbituates buspirone beta-blockers antipsychotics
examples of hypnotics
benzodiazepines
low dose amitriptyline
Z drugs - zopiclone, zolpidem, zaleplon
examples of benzos
Which of the following benzodiazepines do you think would present the largest problem in terms of withdrawal?
MOA
long acting (>24 hours) - diazepam, chlordiazepoxide
short acting (<12 hours) - lorazepam, midazolam
lorazepam 0 short half life
increase GAB
indications of benzodiazepines
what is the usual recommended maximum duration of treatment?
how to discontinue long term use benzodiazepines
- insomnia
- anxiety disorders - panic/phobia
- delirium terens adn alcohol detoxicification
- acute psychosis
- violent behaviour
2-4 weeks
Reduce the dose in steps of 1/8th of the daily dose every fortnight
SEs of benzodiazepines
- drowsiness/light headed
- confusion + ataxia
- amnesia
- dependence
- paradoxical increase in aggression
- muscle weakness
- respiratory depression
aim of cbt
initially to help individuals to identify and challenge their automatic negative thoughts and then to modify any abnormal underlying core beliefs.
what is operant conditioning
states that behaviour is reinforced if it has positive consequences for the individual, and it prevents any negative consequences.
what is relaxation training
This is particularly useful for those with stress-related and anxiety disorders. Here, the patient is asked to use techniques causing muscle relaxation during times of stress or anxiety. The patient also learns to put themselves in situations that they find relaxing, such as walking in the fields.
Systemic desensitization
This is often used for phobic anxiety disorders. In this therapy, an individual is gradually exposed to a hierarchy of anxiety-producing situations
flooding
Unlike systemic desensitization, flooding therapy involves the patient rapidly being exposed to the phobic object without any attempt to reduce anxiety beforehand. They are required to continue exposure until the associated anxiety diminishes. It is not a technique commonly used.
ERP
his therapy can be used for a variety of anxiety disorders but is particularly useful for OCD and phobias. Patients are repeatedly exposed to the situation which causes them anxiety (e.g. exposure to dirt) and are prevented from performing the compulsive actions which lessens that anxiety (e.g. washing their hands). After initial anxiety on exposure, the levels of anxiety gradually habituate and decline
behavioural activation
This therapy is used for depressive illness. The rationale behind it is that patients avoid doing certain things as they feel they will not enjoy them or fear failure in completing them. Behavioural activation involves making realistic and achievable plans to carry out activities and then gradually increasing the amount of activity.
indications
rationale
aim
mode of delivery
of psychodynamic
Dissociative disorders, somatoform disorders, psychosexual disorders, certain
personality disorders, chronic dysthymia, recurrent depression.
It is based upon the idea that childhood experiences, past unresolved conflicts and previous relationships significantly influence an individual’s current situation. It is based on psychoanalytic principles.
he unconscious is explored using free association (the client says whatever comes
to their mind) and the therapist then interprets these statements. Conflicts and defence mechanisms (e.g. denial, projection) are explored and the client subsequently develops insight in order to change their maladaptive behaviour.
Psychoanalysis is an intense therapy that usually involves between one and five 50-minute sessions per week, possibly for a number of years. This is a much longer duration than in CBT.
what is transference
The patient re-experiences the strong emotions from early important relationships, in their relationship with the therapist. When the current emotions are positive it is said to be positive transference and vice versa for negative emotions.
what is counter transference
The therapist is affected by powerful emotions felt by the patient during therapy and reflects what the patient is feeling.
what is psyhcoeducatoin
delivery of information to people in order to help them understand and cope with their mental illness.
1) the name and nature of their illness; 2) likely causes of the illness, in their particular case; 3) what the health services can do to help them; and 4) what they can do to help themselves (self-help)
counselling
form of relieving distress and is undertaken by means of active dialogue between the counsellor and the client.
Behaviour and emotional life are shaped by previous experience, the current environment, and the relationships that individuals have.
what is Interpersonal therapy (IPT)
depression and eating disorders.
deals with four interpersonal problems (grief at the loss of relationships, role disputes within relationships, managing changes in relationships and interpersonal deficits) which may be causing difficulty in initiating or maintaining relationships.
what is EMDR
access and process traumatic memories with the goal of emotionally resolving them.
PTSD
client recalling emotionally traumatic material while focusing on an external stimulus
Antidotes to paracetamol opiates benzodiazepines warfarin beta-blockers TCAs organophosphates
paracetamol - N-acetylcysteine opiates - naloxone benzodiazepines - flumazenil warfarin - vitamin K beta-blockers - Glucagon TCAs - sodium carbonate organophosphates - atropine
Activated charcoal: for the majority of drugs taken in overdose, early
use of activated charcoal (within one hour of ingestion) can prevent or reduce absorption of the drug.
TOXBASE can be viewed for information on rarer poisons.
define suicide
attempted suicide
risk assessment
Suicide: A fatal act of self-harm initiated with the intention of ending one’s own life.
Attempted suicide: The act of intentionally trying to take one’s own life with the primary aim of
dying, but failing to succeed in this endeavour.
Risk assessment: In a psychiatric context, it is assessing the risk of self-harm, suicide and/or risk to others.
clinical RFs for suicide
History of DSH or attempted suicide
The rate of suicide in people who have self-harmed increases and is 50–100 times greater than in the general population.
Psychiatric illness
Including depression, schizophrenia, substance misuse, alcohol abuse and personality disorder.
Childhood abuse
History of childhood sexual or physical abuse.
Family history
Family history of suicide or suicide attempt in first-degree relatives increases the risk.
Medical illness
Physically disabling, painful or terminal illness.
socio-demographic RFs of suicide
Male gender
Males are 3x more likely than females. Male suicide attempts are more likely to be violent and therefore successful.
Age
Highest in the age group 40 to 44 in men.
Employment and financial status
Those unemployed and who have low socioeconomic status are at higher risk.
Occupation
Vets, doctors, nurses and farmers are at higher risk of suicide.
Access to lethal means
The most lethal means of suicide are firearms, followed by hanging, strangling, and suffocation.
Social support
Low social support, living alone, institutionalized, e.g. prisons, soldiers.
Marital status
Those that are single, widowed, seperated or divorced.
Recent life crisis
e.g. Bereavement, family breakdown.
clinical features of a suicidal pt
Preoccupation with death
Sense of isolation and withdrawal from society.
Emotional distance from others.
Distraction and lack of pleasure: Often are ‘in their own world’ and suffer from anhedonia.
Focus on the past: They dwell on past losses and defeats and anticipate no future; they voice the notion of Beck’s cognitive triad that the world would be better off without them.
Feelings of hopelessness and helplessness.
Ix for suicide
Questionnaires - Tool for Assessment of Suicide Risk (TASR), Beck Suicide Intent Scale.
individual suicide prevention strategies
Detect and treat psychiatric disorders.
Urgent hospitilization under the Mental Health Act.
Involvement of the Crisis Resolution and home treatment team.
population level suicide prevention strategies
Public education and discussion.
Reducing access to means of suicide, e.g. encouraging patients to dispose of unwanted tablets, safer prescribing, safety rails at high places.
Easy, rapid access to psychiatric care or support groups, e.g. Samaritans (who provide emergency 24 hour support).
Decreasing societal stressors, e.g. unemployment and domestic violence.
- reducing substance misuse
what is ECT
small electrical current through the brain with a view to inducing a modified epileptic seizure which is therapeutic.
Indications of ECT
ECT’ (Euphoric Catatonic Tearful):
1. Prolonged or severe mania (Euphoric).
2. Catatonia(Catatonic).
3. Severe depression (Tearful):
Treatment-resistant depression.
Suicidal ideation or serious risk to others.
Life-threatening depression, e.g. when the patient refuses to eat or drink.
NOTE: (1) Severe depression is the most common indication for the use of ECT.
consent for ECT
ECT is a procedure where written, informed consent is vital.
For patients detained under the Mental Health Act, an independent second opinion must be obtained to determine suitability for ECT.
Short term side effects of ECT
PC DAMS
Peripheral Nerve palsies
Cardiac arrhythmias, Confusion
Dental and oral trauma
Anaesthetic risks laryngospasm, sore throat, N+V
Muscular aches and headaches
Short-term memory impairment, Status epilepticus
NOTE: ECT may precipitate a manic episode in patients with bipolar affective disorder.
long term side effects OF ECT
Anterograde and retrograde amnesia – the deficit is greater in those who receive bilateral ECT versus unilateral ECT.
Contraindications of ECT
MI (<3 months ago), Major unstable fracture.
Aneurysm (cerebral).
Raised ICP, e.g. intracranial bleed, space-occupying lesion (the only absolute contraindication).
Stroke <1 month ago, a history of Status epilepticus, Severe anaesthetic risk (e.g. severe cardiovascular or respiratory disease).
NOTE: The risks associated with ECT may be enhanced during pregnancy, in older people, and in children. Therefore clinicians should exercise particular caution in these groups.
which antipsychotic does not cause weight gain and safe in cardiac pts
aripiprazole
what is community treatment order
This can be used to specify conditions to which the patient is subject to on discharge, and the patient may be recalled to hospital if the conditions are not met. For example, if the patient does not comply with their medication in the community, they can be recalled to hospital regardless of whether they would otherwise currently meet the required criteria for detention under a Section of the Mental Health Act – This means clinicians needn’t wait for the patient to relapse and become risky before re-admitting them to hospital, thus avoiding relapses and possible consequences of relapses.
advantage of a depot
Paliperidone is a depot version of Risperidone. This is not a medication which Mr S has previously tried or had adverse reactions to.
- Paliperidone does not require oral medication (Risperidone) to be taken during initiation, so is a good choice in a patient who is currently refusing all oral medications. It is initiated through loading doses of IM injections (Day 1 and Day 8 of treatment, then monthly thereafter).
- If a patient remains stable for at least four months on the monthly dose of IM Paliperidone, they can instead be given a formulation which only requires administration every 3 months.
role of pregablin
• Binds to voltage gated calcium channels in neurones
• Increases extra-cellular amounts of the enzyme responsible for
synthesis of GABA and therefore increases GABA concentrations in
the brain
• Reduces neuronal activity (i.e. is a CNS depressant)
• Used in anxiety, neuropathic pain and epilepsy
• Less potential for misuse and dependence (and tolerance) than
benzodiazepines – but still misused – nickname “Budweisers”
• BNF says short term use – often used indefinitely
• Causes sedation and can cause weight gain
what do you do when with SSRI before commencing ECT
reduce the dose of SSRI and maybe increase it at the end of ECT
