Psychopharmacology - Part 2

Question 1

What are the indications for mood stabilizers?

Answer 1

Bipolar, cyclothymia and schizoaffective disorder

Question 2

What are the classes of mood stabilizers?

Answer 2

Lithium
Anticonvulsants
Antipsychotics

Question 3

Describe lithium

Answer 3

Only medication to reduce suicide rate
Effective long term prophylaxis of both mania and depressive episodes
Positive factors - FH with good response, classic pure mania and mania following depression

Question 4

What is checked before starting lithium?

Answer 4

Get baseline U+Es and TSH
Check pregnancy - first trimester is associated with Ebstein’s anomaly

Question 5

What is the monitoring on lithium?

Answer 5

Steady state achieved after 5 days
Once stable check 3 months and TSH + creatinine 6 months
Goal is 0.6-1.2

Question 6

What are the lithium side effects?

Answer 6

GI distress - reduced appetite, N/V and diarrhoea
Thyroid abnormalities
Polyuria/ polydipsia secondary to ADH antagonism
Hair loss and acne
Reduced seizure threshold, cognitive slowing and intention tremor

Question 7

What are mild levels of lithium toxicity?

Answer 7

1.5 - 2
Vomiting, diarrhoea, ataxia, dizziness, slurred speech and nystagmus

Question 8

What is moderate lithium toxicity?

Answer 8

2-2.5
N/V, anorexia, blurred vision, clonic limb movements, convulsant, delirium and syncope

Question 9

What is severe lithium toxicity?

Answer 9

> 2.5
Generalised convulsions, oliguria and renal failure

Question 10

Describe valproic acid (Depakote) - anticonvulsant

Answer 10

Effective as lithium in mania prophylaxis but not in depression
Positive response - rapid cycling patients, comorbid substance issues, mixed patients and comorbid anxiety disorders
Better tolerated than lithium

Question 11

What is checked in valproic acid?

Answer 11

LFTS, pregnancy test and FBC
Avoid in women of child bearing age - neural tube defects
Goal is between 50-125

Question 12

What are side effects of valproic acid?

Answer 12

Thrombocytopenia and platelet dysfunction
N/V, weight gain, sedation, tremor and hair loss

Question 13

When is carbamazepine (Tegretol) used - anticonvulsant?

Answer 13

First line agent for acute mania and mania prophylaxis
Indicated for rapid cycles and mixed patients

Question 14

What is checked before going on carbamazepine?

Answer 14

Baseline LFTS, FBC and ECG
Target is 4-12mcg/ml
Need to check level and adjust dosing after a month because induces own metabolism

Question 15

What are the side effects f carbamazepine?

Answer 15

Rash, N/V, diarrhoea, sedation, dizziness, ataxia, confusion, AV conduction delays, aplastic anaemia, agranulocytosis and water retention
Drug - drug interaction

Question 16

Describe lamotrigine (Lamictal) - anticonvulsant

Answer 16

Also use for neuropathic/ chronic pain
Baseline LFTS before starting
Start on 25mg for 2 weeks then 50mg for 2 weeks when 100mg (rash if too fast) and if stopped then have to start again

Question 17

What are the side effects of lamotrigine?

Answer 17

N/V, sedation, dizziness, ataxia and confusion
Severe - toxic epidermal necrolysis and SJS
Blood dyscrasias
Drug interactions - VPA and sertraline

Question 18

What are the indications for antipsychotics?

Answer 18

Schizophrenia, schizoaffective disorder, bipolar for mood stabilization or psychotic features and psychotic depression

Question 19

Describe typical antipsychotics

Answer 19

D2 dopamine receptor antagonists
High potency bind to D2 receptor in high affinity - higher risk of extrapyramidal side effects
Fluphenazine, Haloperidol and Pimozide

Question 20

Describe low potency typical antipsychotics

Answer 20

Have less affinity for the D2 receptors but tend to interact with non-dopaminergic receptors - more cardiotoxic and anticholinergic effects (sedation and hypotension)
Chlorpromazine and Thioridazine

Question 21

What are the adverse effects of antipsychotics?

Answer 21

Tardive dyskinesia - involuntary muscle movements that may not resolve
Neuroleptic malignant syndrome
Extrapyramidal side effects - Acute dystonia and Parkinson’s
Akathisia

Question 22

What are the symptoms in neuroleptic malignant syndrome?

Answer 22

Severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC and CPK

Question 23

What are agents for extrapyramidal symptoms?

Answer 23

Anticholinergics - benztropine, trihexyphenidyl and procyclidine (watch for side effects esp. with TCAs)
BB for akathisia

Question 24

Describe antipsychotics atypicals

Answer 24

Serotonin dopamine 2 antagonists
Tend to effect dopamine 1,3,4 and 5 so less EPS
Atypical in the way they affect dopamine and serotonin neurotransmission

Question 25

Describe risperidone (Risperdal) - antipsychotic

Answer 25

Regular tablets, IM and rapidly dissolving tablet Function more like a typical at doses greater than 6mg Increased EPS Weight gain and sedation Atypical to induce hyperprolactinemia

Question 26

Describe olanzapine (Zyprexa) - antipsychotic

Answer 26

Regular tablets, IM, rapidly dissolving tablet and depo form Weight gain, hypertriglyceridemia, hypercholesterolemia, hyperprolactinemia and hyperglycaemia May cause abnormal LFTs

Question 27

Describe Quetiapine (Seroquel) - antipsychotic

Answer 27

Regular tablet May cause abnormal LFTs Weight gain, hypertriglyceridemia, hypercholesterolemia and hyperglycaemia Orthostatic hypotension

Question 28

Describe Aripiprazole (Abilify) - antipsychotic

Answer 28

Regular tablets, immediate release IM and depo form Unique mechanism of action as D2 partial agonist Low EPS, no QT prolongation, low sedation and low weight gain

Question 29

Describe Lurasidone - antipsychotic

Answer 29

Newer Similar side effects to aripiprazole Potential weight gain and increased rate akathisia

Question 30

Describe treatment resistance for schizophrenia

Answer 30

Poor prognosis to 2 first line antipsychotics at adequate dose for 8 weeks Clozapine used in this case

Question 31

When is clozapine used?

Answer 31

Treatment resistant patients as side effect profile Regular tablet form

Question 32

What are the side effects of clozapine?

Answer 32

Agranulocytosis, seizures, sedation, weight gain, abnormal LFTs, hypertriglyceridemia, hypercholesterolemia, hyperglycaemia, non-ketotic hyperosmolar coma and death

Question 33

Describe prophylaxis in psychotic disorder

Answer 33

Relapse more commonly due to non-compliance

Question 34

Describe anxiolytics

Answer 34

Used to treat panic disorder, generalised anxiety disorder (in combo. with SSRIs and SNRIs), substance related disorder and their withdrawal, insomnias and parasomnias

Question 35

What are the pros of buspirone - anxiolytics?

Answer 35

Good augmentation strategy in anxiety 5HT1A agonist No sedation

Question 36

What are the cons of buspirone?

Answer 36

Takes about 2 weeks before notice results Will not reduce anxiety in patients that are used to taking BZDs as no sedation effect

Question 37

Describe benzodiazapines

Answer 37

Used to treat insomnia, parasomnias and anxiety disorders Also in CNS depressant withdrawal protocols

Question 38

What are the side effects of benzodiazepines?

Answer 38

Somnolence, cognitive deficits, amnesia, disinhibition, tolerance and dependence