Psychopharmacology: anxiety + mood disorders

Question 1

What is the predominant biochemical theory for depression?

Answer 1

monoamine hypothesis of depression - lack of serotonergic and noradrenergic activity in the brain can cause symptoms of depression

Question 2

What are the 5 grades of depression set by NICE?

Answer 2

sub-threshold
mild
moderate
severe
complex

Question 3

Depression key presenting symptoms

Answer 3

poor sleep
anxiety
mood varying throughout the day
altered appetite
tiredness, slowness, loss of energy
feeling depressed or agitated
loss of interest in previously enjoyed activities
feelings of worthlessness/guilt
poor memory
recurrent thoughts of death or suicide

Question 4

Non-pharmacological treatments for depression

Answer 4

social support
guided self-help
being active
counselling
psychological therapies (CBT, relaxation therapy, mindfulness)
general support and advice eg. on financial matters, to reduce stress

Question 5

4 main stages of drug treatment for depression

Answer 5

1) symptom control - moderate/severe = antidepressant trial for 6 weeks, continue for 12 weeks if some response

2) continuation - for at least 6 months to prevent relapse

3) relapse prevention - for those with risk factors keep on antidepressant longer (2nd episode = 1-2 years, 3rd episode = 5 years +)

4) discontinuation - slow reduction

Question 6

Name some classes of antidepressants

Answer 6

tricyclic antidepressants (TCAs)
selective serotonin reuptake inhibitors (SSRIs)
serotonin noradrenaline reuptake inhibitors (SNRIs)
noradrenaline and specific serotoninergic antidepressant (NaSSA)
monoamine oxidase inhibitors (MAOIs)

Question 7

Name some tricyclic antidepressants

Answer 7

amitriptyline
imipramine
dosulepin
clomipramine
lofepramine
trimipramine

Question 8

Tricyclic antidepressants MOA

Answer 8

block reuptake of noradrenaline and serotonin

Question 9

Tricyclic antidepressants side effects

Answer 9

GI upsets, dry mouth, blurred vision, constipation, urinary retention, postural hypotension, cardiac arrhythmias, sedation, confusion, memory problems

Question 10

Name some SSRIs

Answer 10

citalopram
sertraline
fluoxetine
paroxetine
fluvoxamine
escitalopram

Question 11

SSRIs MOA

Answer 11

increases the level of serotonin in the synapse by blocking the reuptake pump

Question 12

SSRIs common side effects

Answer 12

GI upset
anxiety symptoms (initially)

Question 13

Name some SNRIs

Answer 13

venlafaxine
duloxetine

Question 14

Who can’t take SNRIs?

Answer 14

contraindicated in people with cardiovascular risk factors

Question 15

SNRIs common side effects

Answer 15

nausea
headache
dry mouth
sweating

Question 16

Name a NaSSA?

Answer 16

mirtazapine

Question 17

NaSSA (mirtazapine) MOA

Answer 17

enhances the action of noradrenaline and serotonin in the synapse

Question 18

Mirtazapine side effects

Answer 18

sedation
increase in appetite
dizziness
dry mouth

Question 19

Name some MAOIs

Answer 19

phenelzine
isocarboxazid
tranylcypromine
moclobemide

Question 20

MOAIs MOA

Answer 20

inhibit (either reversibly or irreversibly) monoamine oxidase enzymes to prevent the breakdown of monoamine neurotransmitters

Question 21

What dietary restrictions are in place for patients on MAOIs and why is this?

Answer 21

avoid food or drinks that contain tyramine (including alcohol) because this can cause a very large sudden increase in blood pressure (hypertensive crisis)

Question 22

What foods contain tyramine?

Answer 22

cheese
liver
yoghurt
marmite
oxo
bovril
yeast
dried sausage eg. pepperoni
beer, lager, wine

Question 23

How should antidepressants be dosed?

Answer 23

most antidepressants are more tolerable if started at lower initial dose (half the standard) and increased to target dose over days or weeks

exception is mirtazapine - start at 30mg/day as it is less sedating at this dose than at lower doses

Question 24

Signs and symptoms of serotonin syndrome

Answer 24

restlessness
sweating
tremor
shivering
muscular rigidity
confusion
convulsions
death

Question 25

Name some anxiety disorders

Answer 25

generalised anxiety disorder
obsessive compulsive disorder
post-traumatic stress disorder
panic disorder
phobic anxiety disorders

Question 26

Anxiety disorders pathophysiology

Answer 26

in the CNS, the major mediators of the symptoms of anxiety disorders appear to be noradrenaline, serotonin, dopamine and GABA

Question 27

Short term pharmacological treatment of anxiety disorder

Answer 27

benzodiazepines
beta blockers eg. propranolol
antihistamines eg. hydroxyzine
antipsychotics

Question 28

Long term pharmacological treatment of anxiety disorder

Answer 28

antidepressants (eg. SSRIs, TCAs, MAOIs, venlafaxine, mirtazapine)
buspirone
pregabalin

Question 29

When are benzodiazepines useful in anxiety?

Answer 29

up to 4 weeks when symptoms are severe (disabling)
long term use risks tolerance and dependence

Question 30

Symptoms of benzodiazepine withdrawal

Answer 30

mild - restlessness, tremor, agitation
severe - depression, convulsions, psychosis

Question 31

When are antipsychotics used in anxiety disorder?

Answer 31

frequently used for tranquilising effects
used in acute inpatient environment if a patient is extremely anxious and agitated and is causing harm to themselves or others

Question 32

When are beta blockers (propranolol) used in anxiety disorder?

Answer 32

primarily for specific physical symptoms and reducing the vicious cycle of feeling more anxious, become tremulous and tachycardic, fuelling the anxiety

Question 33

First line pharmacological treatment for GAD

Answer 33

SSRI (eg. paroxetine)

Question 34

First line pharmacological treatment for PTSD

Answer 34

SSRI eg. sertraline
needs long term treatment as relapse is common
avoid benzodiazepines as can be counter-productive

Question 35

OCD pharmacological treatment principles

Answer 35

only central serotonin enhancers are effective - SSRIs/clomipramine

daily dose usually needs to be very high

should see improvements on maximum tolerated dose by 3 months

stay on drug for minimum 1-2 years as relapse is common in discontinuation

gradual discontinuation over several months