Psychopharmacology: anxiety + mood disorders Flashcards
What is the predominant biochemical theory for depression?
monoamine hypothesis of depression - lack of serotonergic and noradrenergic activity in the brain can cause symptoms of depression
What are the 5 grades of depression set by NICE?
sub-threshold
mild
moderate
severe
complex
Depression key presenting symptoms
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
Non-pharmacological treatments for depression
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
4 main stages of drug treatment for depression
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
Name some classes of antidepressants
tricyclic antidepressants (TCAs)
selective serotonin reuptake inhibitors (SSRIs)
serotonin noradrenaline reuptake inhibitors (SNRIs)
noradrenaline and specific serotoninergic antidepressant (NaSSA)
monoamine oxidase inhibitors (MAOIs)
Name some tricyclic antidepressants
amitriptyline
imipramine
dosulepin
clomipramine
lofepramine
trimipramine
Tricyclic antidepressants MOA
block reuptake of noradrenaline and serotonin
Tricyclic antidepressants side effects
GI upsets, dry mouth, blurred vision, constipation, urinary retention, postural hypotension, cardiac arrhythmias, sedation, confusion, memory problems
Name some SSRIs
citalopram
sertraline
fluoxetine
paroxetine
fluvoxamine
escitalopram
SSRIs MOA
increases the level of serotonin in the synapse by blocking the reuptake pump
SSRIs common side effects
GI upset
anxiety symptoms (initially)
Name some SNRIs
venlafaxine
duloxetine
Who can’t take SNRIs?
contraindicated in people with cardiovascular risk factors
SNRIs common side effects
nausea
headache
dry mouth
sweating
Name a NaSSA?
mirtazapine
NaSSA (mirtazapine) MOA
enhances the action of noradrenaline and serotonin in the synapse
Mirtazapine side effects
sedation
increase in appetite
dizziness
dry mouth
Name some MAOIs
phenelzine
isocarboxazid
tranylcypromine
moclobemide
MOAIs MOA
inhibit (either reversibly or irreversibly) monoamine oxidase enzymes to prevent the breakdown of monoamine neurotransmitters
What dietary restrictions are in place for patients on MAOIs and why is this?
avoid food or drinks that contain tyramine (including alcohol) because this can cause a very large sudden increase in blood pressure (hypertensive crisis)
What foods contain tyramine?
cheese
liver
yoghurt
marmite
oxo
bovril
yeast
dried sausage eg. pepperoni
beer, lager, wine
How should antidepressants be dosed?
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
Signs and symptoms of serotonin syndrome
restlessness
sweating
tremor
shivering
muscular rigidity
confusion
convulsions
death
Name some anxiety disorders
generalised anxiety disorder
obsessive compulsive disorder
post-traumatic stress disorder
panic disorder
phobic anxiety disorders
Anxiety disorders pathophysiology
in the CNS, the major mediators of the symptoms of anxiety disorders appear to be noradrenaline, serotonin, dopamine and GABA
Short term pharmacological treatment of anxiety disorder
benzodiazepines
beta blockers eg. propranolol
antihistamines eg. hydroxyzine
antipsychotics
Long term pharmacological treatment of anxiety disorder
antidepressants (eg. SSRIs, TCAs, MAOIs, venlafaxine, mirtazapine)
buspirone
pregabalin
When are benzodiazepines useful in anxiety?
up to 4 weeks when symptoms are severe (disabling)
long term use risks tolerance and dependence
Symptoms of benzodiazepine withdrawal
mild - restlessness, tremor, agitation
severe - depression, convulsions, psychosis
When are antipsychotics used in anxiety disorder?
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
When are beta blockers (propranolol) used in anxiety disorder?
primarily for specific physical symptoms and reducing the vicious cycle of feeling more anxious, become tremulous and tachycardic, fuelling the anxiety
First line pharmacological treatment for GAD
SSRI (eg. paroxetine)
First line pharmacological treatment for PTSD
SSRI eg. sertraline
needs long term treatment as relapse is common
avoid benzodiazepines as can be counter-productive
OCD pharmacological treatment principles
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
