Psychopharmacotherapy

Question 1

Name drugs in the tricyclic/tetracyclic class

Answer 1

Amitriptyline, Doxepin, Imipramine, Glomipramine, Trimipramine, Desipramine (2), Nortriptyline (2), Protriptyline (2*), and amoxapine (tetracyclic)

Question 2

What are the side effects of Tricyclic/Tetracyclic Medications?

Answer 2

Anticholinergic: dry mouth, blurry vision, urinary retention, constipation
Sedation (3* > 2*; risk of fall in elderly patients)
Alpha-adrenergic blockade, causing hypotension
Tachycardia
Prolongation of QT (cardiac arrhythmias)
Weight gain (antihistamine effect)

Question 3

OCD responds specifically to which TCA?

Answer 3

clomipramine (3*)

Question 4

What is the mechanism of action for TCAs?

Answer 4

increase the level of monoamines in the synapse by reducing the uptake of NE and 5HT

Question 5

Which laboratory values distinguish Neuroleptic Malignant Syndrome from Serotonin Syndrome?

Answer 5

elevations in creatine kinase, liver function tests (lactate dehydrogenase, aspartate transaminase), and white blood cell count, coupled with a low serum iron level, distinguishes NMS from SS

Question 6

Which TCA may cause extrapyramidal syndrome and NMS?

Answer 6

amoxapine (metabolite of loxapine)

Question 7

What are the side effects of SSRIs and SNRIs?

Answer 7

agitation, akathisia (inner restlessness), panic, insomnia, diarrhea, GI distress, headache, sexual dysfunction (delayed ejaculation/impotence (M), norgasmia (F)

Question 8

Name SSRIs

Name SNRIs

Answer 8

SSRIs: fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram

SNRIs: venlafaxine

SSNRI: duloxetine

Question 9

Which SSRI has “possibly fewer sexual side effects”?

Answer 9

citalopram

Question 10

To avoid serotonin syndrome, an SSRI should be continued at least __ weeks before starting a MAOI

Answer 10

5

Question 11

Name MAOIs

Answer 11

phenelzine, isocarboxazid, selegiline, tranylcypromine

Question 12

What are side effects of MAOIs? What should be avoided during their administration?

Answer 12

side effects: orthostatic hypotension, somnolence, weight gain

should never be coadministered with SSRIs, cheese, fermented or aged foods, or liver (tyramine–>hypertensive crisis)

Question 13

What type of depression can MAOIs be helpful in?

Answer 13

depression with atypical features (overating, oversleeping, irritability)

Question 14

Trazodone can lead to which infamous side effect?

Answer 14

priapism in males

Question 15

Mirtazapine is used to treat _________________. It’s mechanism of action is:

Answer 15

depression. It acts as an antagonist at central pre-synaptic alpha(2)-receptors, inhibiting negative feedback to the presynaptic nerve and causing an increase in NE release and increase in serotonin release in those synapses. Also acts as a 5HT2 and 5HT3 antagonist, which leads to less interference with sexual function, nausea, diarrhea

Question 16

Priapism caused by trazodone can be treated by

Answer 16

injecting epinephrine into the head of the penis

Question 17

What is the mechanism for orthostatic hypotension caused by TCA/heterocyclic antidepressants?

Answer 17

alpha-adrenergic blockade

Question 18

Name MAOIs

Answer 18

phenelzine, isocarboxazid, selegiline, tranylcypromine

Question 19

Which mood stabilizer, used in treating bipolar disorder, can lead to teratogenic neural tube disorder?

Answer 19

valproic acid

Question 20

Akathisia can be treated with

Answer 20

propanolol

Question 21

Acute lithium toxicity/overdose manifests as:

Answer 21

seizures, coma

Question 22

Serotonin syndrome is characterized by (in order of appearance):

Answer 22

diarrhea, restlessness, extreme agitation, hyperreflexia, autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, and death

Question 23

Side effects of lithium:

Answer 23

tremor, polyuria/DI, acne, hypothyroidism, cardiac dysrhythmias, weight gain, edema, leukocytosis

Question 24

What is neuroleptic malignant syndrome caused by? What are its characteristics?

Answer 24

can be caused at any time by an antipsychotic agent

features: 1) movement disorder (muscle rigidity, dystonia, agitation)
2) autonomic symptoms (high fever, sweating, tachycardia, hypertension). CPK and WBC usually high

Treatment is mostly supportive (hydration and cooling) but can include medication with dantrolene and/or bromocriptine.