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Year 3 - Psychiatry (DP) > Depression and Mood Disorders > Flashcards

Flashcards in Depression and Mood Disorders Deck (246)
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1

What are the risk factors for adult mental illness?

Childhood abuse
Neglect

2

What are the 8 parts of a mental state exam?

Appearance
Behaviour
Speech
Mood/Affect
Thought (form and content [inc. delusions])
Perception
Cognition
Insight

3

What important schooling aspects are important in a social history?

Academic performance
Behaviour
Friends

4

What are important employment aspects are important in a social history?

Jobs:
- Performance
- Sick leave
Reasons for unemployment

5

What important aspects of relationships are important in a social history?

Length
Details
Reasons for breakup
Children
Sexual history

6

What is a forensic history?

Criminal offences

7

What are some aspects of assessing general appearance in a mental state exam?

Age
Physique/Build
Dress (Any evidence of self-neglect?)
Effort with appearance
Tattoos
Signs of physical ill-health
Posture
Facial expression
Physical features of alcoholism or drug abuse

8

What are some aspects of assessing behavour in a mental state exam?

Describe what they're doing (Appropriate for situation?)
Psychomotor agitation/retardation:
- Unintentional and purposeless motions
- Stems from mentail tension and anxiety
Eye contact
Attitude/Raport

9

What are some aspects of assessing quality of speech in a mental state exam?

Clarity
Volume

10

What are some aspects of assessing of rate of speech in a mental state exam?

Pressure
Poverty

11

What are some aspects of assessing quantity of speech in a mental state exam?

Too much/little
Spontaneous
Sudden silences

12

How do we describe mood in a mental state exam?

Objective description
Subjective description

13

How is mood usually described in a mental state exam?

In patient's own words

14

What is afferent?

The experience of feeling or emotion

15

What parameters can aid in the labelling of afferent?

Appropriateness
Intensity
Range/Reactivity/Mobility

16

What are the two types of appropriateness in the assessment of affect in a mental state exam?

Congruent (appropriate for emotion in context)
Incongruent (inappropriate)

17

What can a bland affect on describing a distressing situation indicate?

Schizophrenia

18

What can a blunted intensity in the assessment of affect in a mental state exam?

Schizophrenia
Depression
PTSD

19

What can a heightened intensity in the assessment of affect in a mental state exam?

Mania

20

What can an exaggerated intensity in the assessment of affect in a mental state exam?

Personality disorder

21

How can the mobility of affect be described in a mental state exam?

Restricted
Labile
Reactive

22

What is passive suicidality?

Thoughts of life not worth living

23

What is active suicidality?

Thoughts of wanting to self-harm/die with methods and plans

24

How can thought form be inferred in a mental state exam?

Speech
Patient's description

25

What is flight of ideas (thought form)?

High tempo thoughts
Words associated inappropriately due to:
- Their meaning
- Rhyme
Speech loses aim and patient wanders from theme
Jump from topics to topic with recognisable links:
- Rhyming
- Puns
- Environmental distractions

26

What is poverty of thought?

Global reduction in quantity of thought

27

What are the features of a formal thought disorder?

Evidence in patient's writing/speech that there is abnormal thought linking
Disturbance in:
- Organisation
- Control
- Processing
NOT a content abnormality
ie. Thought A -> Thought B

28

What is thought blocking? In what condition is it seen in?

Speech suddenly interrupted by silence
Schizophrenia

29

A patient talks freely but vaguely. Speech is muddled, illogical, difficult to follow and cannot be clarified. A lot is said but no information is gathered.

Loosening of associations

30

What is tangential thinking?

Wandering from topic and never returning to it
Patient doesn't provide the info requested
ie. Thought A -> F -> C

31

What is circumstantiality?

Inability to answer a question without giving excessive and unnecessary detail
Patient will eventually answer
ie. Thought A -> Thought A1 -> Thought A2 -> Thought A

32

What are neologisms?

Patient makes up a new word or phrase using existing words or phrases in a bizarre way

33

What are though preoccupations?

Thought content that are not fixed, false or intrusive
BUT have an undue prominence in patient's mind

34

What are overvalued ideas?

Unreasonable, sustained beliefs that are held with less than delusional intensity

35

Give an example of an overvalued idea?

Hypochondriasis

36

What are obsessions?

Undesired, unpleasant intrusive thoughts that cannot be suppressed

37

What is a delusion?

A fixed, false belief.
Inappropriate to the patient's socio-economic background
Firmly held in the face of:
- Logical argument OR
- Evidence to the contrary
Not modified by experience or reason
Usually very individualised or of great personal significance

38

Where do most delusions originate from?

Often an attempt to explain an anomalous experience as hallucinations

39

What are grandiose delusions?

Belief that one is very powerful or even a God

40

What are nihilistic/cotard delusions?

False belief that one does not exist or has died

41

What are bizarre delusions?

Beliefs that are clearly impossible
Not understood by peers and don't derive from life experiences

42

What is a delusion of reference?

Insignificant events/objects have great personal significance

43

What are delusions of control? What else can they be called?

External forces controlling oneself
Passivity

44

What are the four main features in assessing perception in a mental state exam?

Derealisation/Depersonalisation:
- Perception that surroundings/self aren't real
Deja vu
Illusions
Hallucinations

45

What do second person auditory hallucinations indicate?

Psychotic depression

46

What do third person auditory hallucinations indicate?

Schizophrenia

47

How can we assess attention and concentration (cognition)?

Serial sevens (count down from 100 in sevens)
Digit span (give number sequence - ask to recall)

48

How else can we assess cognition?

Orientation (time/place/person)
Memory
Calculation
Language (name objects)
Visuospatial functioning (copy a diagram/clock face)
Executive functioning:
- Ask what x and y have in common

49

What are some clues that a patient's cognition is impaired?

Unable to recall purpose of interview
Vague about:
- Time
- How they came to arrive at interview
Discussing past events/dead relatives as if current

50

How many points are in the Addenbrookes Cognitive Examination?

100

51

How many points are in the Montreal Cognitive Assessment?

30

52

What can insight be divided into in terms of the mental state exam?

The four As:
- Awareness of one's own symptoms
- Attribution of symptoms to appropriate mental disorder
- Appraisal/Analysis of consequences of symptoms
- Acceptance of treatment

53

What is anautognosia?

Absence of awareness of ones own symptoms

54

What is dysautoagnosia?

Absence of attribution of symptoms to an appropriate mental disorder

55

How is early morning wakening described?

Waking >= 2 hours before expected/normal time

56

What is stupor?

Absence of relational functions

57

What is anhedonia?

Loss of enjoyment/pleasure

58

What is appearance and behaviour like in depression?

Reduced facial expression
'Furrowed' brown
Reduced eye contact
Limited gesturing
Difficult rapport

59

What is speech like in depression?

Reduced rate, volume, intonation
Lowered pitch
Increased speech latency
Limited content (short, brief answers)

60

What is a patient's mood like in depression?

'Flat'

61

What is a patient's affect like in depression?

Depressed
Reduced range
Limited reactivity:
- Doesn't respond/react to changes in subject/context/emotion

62

How is thought form affected in depressive moods?

Flow of thought:
- Slow and pondering
- Might be absent

63

How is thought content affected in depressive moods?

Negative, self-accusatory, guilt
Delusions may occur:
- Guilt
- Poverty
- Nihilism
- Hypochondriasis

64

What other symptoms tend to be presence alongside paranoia in psychosis?

Persecutory ideas/delusions
Altered perceptions
Lost insight

65

What types of auditory hallucinations can be present in depressive states?

2nd person and derogatory

66

What cognitive deficits are typically present in depressive states?

Working memory
Attention
Planning

67

How is insight affected in depression?

Typically preserved

68

In what conditions is insight often absent?

Schizophrenia
Mania

69

What do patients experiencing depression often attribute their symptoms to?

Sins
Physical illness
Personal failing and weakness

70

What is the lifetime prevalence of depression?

14-18% in lifetime

71

How many cases of depression become chronic?

20%

72

How does DSM-5 classify depressive disorders?

Major Depressive Disorder
Persistent Depressive Disorder

73

How are mood disorders as defined by ICD-10?

F30 - Manic episode
F31 - Bipolar affective disorder
F32 - Depressive episode
F33 - Recurrent depressive disorder
F34 - Persistent mood disorders
F38 - Unspecified mood disorder

74

How are depressive episodes defined by ICD-10?

F32.0 - Mild depressive episode
F32.1 - Moderate depressive episode
F32.2 - Severe depressive episode without psychosis
F32.3 - Severe depressive episode with psychosis
F32.8 - Other depressive episodes
F32.9 - Depressive episode, unspecified

75

What are the diagnostic features of a depressive illness?

Must be clearly abnormal for individual concerned
It must persist
Should interfere with normal function significantly

76

What are general criteria for depression?

Depressive episode lasting >= 2 weeks
No hypomanic/manic symptoms at any point

77

What are the core features of depression (criterion B)?

At least 2 of the 3 following present:
1. Depressed mood:
- To an abnormal degree
- Present for most of day; almost every day
- Largely uninfluenced by circumstances
- Sustained for at least 2 weeks
2. Loss of interest/pleasure in normally fun activities
3. Decreased energy or increased fatiguability

78

The following are additional features of depression (criterion C):
1. Loss of self-confidence/esteem
2. Unreasonable feelings of self-reproach/excessive guilt
3. Recurrent thoughts of death/suicide or suicidal behaviour
4. Diminished ability to think/concentrare
5. Change in psychomotor activity
6. Sleep disturbance
7. Change in appetite (weight change)

At least 4

79

What rating scales can be used to assess the severity of depression?

Hamilton Rating Scale for Depression
Montgomery-Asperg Depression Rating Scale
Beck Depression Inventory

80

How is a moderate depressive episode defined by the F32.0 criteria?

At least 2 of the 3 symptoms in criterion B
Criterion C symptoms:
- Enough present to give total of >= 6

81

How is a severe depressive episode defined by the F32.0 criteria?

All 3 symptoms from criterion B
Criterion C symptoms:
- Enough present to give total of >= 8

82

How can we define a somatic syndrome?

Four of the following present:
- Loss of interest in usually pleasurable activities
- Loss of emotional reactions to emotional events
- Early morning waking
- Depression worse in the morning
- Objective evidence of psychomotor retardation
- Marked loss of appetite
- Weight loss (>=5% in last month)
- Loss of libido

83

What do the following define:
1. Mood reactivity
2. Two or more of the following:
- Significant weight gain/increased appetite
- Hypersomnia
- Leaden paralysis (heavy feeling in arms/legs)
- Interpersonal rejection resulting in social/occupational impairment

Atypical depression

84

What is Cotard's Syndrome?

A type of psychotic depression

85

What are the features of Cotard's Syndrome?

Often nihilistic delusions

86

In what populations is Cotard's Syndrome more common?

Elderly

87

What is the median number of lifetime episodes in major depressive disorder?

4

88

What is the mean age of onset of major depressive disorder?

27 years

89

What are the five Rs of depression? At what periods do they occur?

Response (acute phase - within 12 weeks)
Remission (at beginning of continuation; 4-9 months)
Recovery (maintenance stage - after 1 year)
Relapse (symptoms again during acute/continuation)
Recurrence (more symptoms after recovery)

90

How does DSM-V classify Bipolar disorders?

Bipolar:
- I
- II
Cyclothymic disorder

91

How does ICD-10 classify Bipolar disorders?

Hypomania
Mania with psychotic features
Mania without psychotic features

92

How is Bipolar I defined by DSM-V?

Has to meet criteria for mania
Represents 'classic' form of manic-depressive psychosis

93

How is Bipolar II defined by DSM-V?

Current/past hypomania AND current/past depression
No mania

94

What is the most common kind of Bipolar disorder (in terms of DSM-V classification)?

Bipolar II

95

What is Bipolar II.5 in terms of DSM-V?

Depressions superimposed on cyclothymic temperament

96

How is Cyclothymic disorder described in the context of DSM-V?

- Cycles of hypomania/depression over at least 2 years
- Never asymptomatic for more than 2 months during those 2 years
- No major depression/mania
- No schizoaffective disorder
- Not explained by drugs.alcohol
- Symptoms impair functioning

97

What is Bipolar III?

'Psuedo-unipolar'
Hypomania ONLY after use of antidepressants for depression

98

What is Bipolar IV?

Depressions arising from a hyperthymic temperament

99

How is Bipolar Affective Disorder described in ICD-10?

Characterised by >=2 episodes in which mood and activity are significantly disturbed:
- Hypomania/Mania and sometimes depression
- Repeated hypomania or mania ONLY
- 1st episode of (hypo)mania -> Not depression

100

How does ICD-10 describe a hypomanic episode?

1. Mood is elevated/irritable
- To an abnormal degree
- Sustained for >=4 consecutive days
2. >=3 of the following; interfering with daily living:
- Increased activity/restlessness
- Increased talkativeness
- Difficulty concentrating or distractability
- Reduced need for sleep
- Increased sexual energy
- Mild spending sprees

101

How does ICD-10 describe a manic episode?

1. Mood predominantly elevated/expansive/irritable:
- Definitely abnormal
- Prominent change sustained for >=1 week
- Or prominent change requiring hospital admission
2. >=3 of the following (>=4 if only irritable) resulting in severe interference:
- Restlessness
- Pressure of speech
- Flight of thoughts
- Disinhibition
- Reduced need for sleep
- Grandiosity/Increased self-esteem
- Distractability
- Reckless behaviour without appreciating risk
- Marked sexual energy/indiscretions

102

What is F30.1?

Mania without psychotic symptoms
Perceptual disorders may occur:
- Subacute hyperacusis
- Appreciations of colours as very vivid

103

What is F30.2?

Mania with psychotic symptoms

104

What delusions or hallucinations must not occur in F30.2?

Those listed as Typical Schizophrenic:
- No bizarre delusions
- No 3rd person/running commentary hallucinations

105

What are the commonest delusions in mania with psychotic symptoms?

Grandiose
Self-referential
Erotic
Persecutory

106

When does bipolar disorder tend to onset?

Late teens/early 20s

107

If there is a family history of bipolar disorder, how does this affect onset of bipolar disorder?

Earlier
Precipitated by lower levels of stress

108

Bipolar disorder that onsets after 60 years of age is often associated with what?

Treatment resistance
Progressive decline in functioning
Underlying organic cause

109

What gene is associated with Schizophrenia?

DISC2

110

What genes are associated with Schizoaffective disorders?

NRG1
G72
G30

111

What gene is associated with bipolar disorder?

ANK3

112

What is the most common mood disturbance in bipolar disturbance?

Depression (30-50%)

113

What ICD-10 range defines eating disorders?

F50-F59

114

What is F50.0?

Anorexia nervosa

115

What is F50.1?

Atypical anorexia nervosa

116

What is F50.2?

Bulimia nervosa

117

What are the four features of anorexia nervosa?

1. Weight loss (lack of weight gain in kids):
- Weight =<15% below normal for age and height
2. Weight loss in self-induced by fatty-food avoidance
3. Self-perception of being too fat (intrusive dread of fatness)
4. Widespread endocrine disorder:
- Involves hypothalamic-pituitary-gonadal axis
- Amenorrhoea in females (vaginal bleed while on HRT/COC)
- Loss of libido and potency in males

118

How can pre-pubertal onset of anorexia nervosa affect development?

Growth ceases
In girls:
- Breasts do not develop
- Primary amenorrhoea
In girls:
- Genitals remain juvenile

119

On recovery of pre-pubertal anorexia nervosa, what can occur?

Puberty usually completed normally
Menarche is late

120

What are the DSM-V subtypes of anorexia nervosa?

Restricting
Binge-eating/Purging

121

What are the four ICD-10 criteria for Bulimia Nervosa?

1. Recurrent overeating:
- >=2 times a week over >=3 months
- Lots of food in a short period of time#2.
2. Preoccupation with eating and cravings
3. Counteracting the fattening effects by >=1 of:
- Self induced vomiting
- Self induced purging
- Alternating periods of starvation (use of appetite suppressants/thyroid hormones/diuretics or abandoning insulin in diabetics)
4. Self-perception of being too fat

122

In terms of DSM-V, how many associated features must occur alongside binge episodes to diagnose a binge eating disorder?

>=3

123

What are some high risk indicative behavioural features for anorexia?

Feeding problems
Reduced BMI
Social difficulties

124

What are some high risk indicative psychobiological features for anorexia?

Reduced reward and increased threat
Sensitivity
Social cognition problems
Cognitive rigidity

125

What are some prodromal features of anorexia?

Coping:
- Avoidance
- Perfectionism
Compulsivity
Anxiety

126

What can indicate a severe enduring anorexia?

Social isolation
Impaired physical and mental QoL
Habits not goal-directed
Threat sensitivity
Reduced social cognition

127

What are some high risk indications for bulimia?

Robust feeding
Increased BMI
Increased reward sensitivity
Reduced response inhibition for food

128

What is the Standardised Mortality Ratio?

Ratio between number of deaths in a study population and the number of deaths that would be expected?

129

What is the Standardised Mortality Ratio for anorexia?

5.86

130

What is the Standardised Mortality Ratio for bulimia?

1.93

131

What causes refeeding syndrome?

Depletion of already inadequate stores of nutrients:
- Magnesium
- Potassium
- Phosphate

132

What is a low-moderate risk BMI?

17.5-16

133

What is a moderate risk BMI?

16-15

134

What is a high risk BMI?

14.9-13

135

What is a very high risk BMI?

<13

136

What do the BMA Guidelines for consenting to treatment say a patient should be able to do?

- Understand in simple language what the treatment is, its purpose and nature and why its propose
- Understand its benefits, risks and alternatives
- Understand broadly the consequences of no therapy
- Retain info long enough to weigh up options and make a decision

137

What is the purpose of the Adults with Incapacity (Scotland) Act 2000?

Provides guidance for safeguarding the welfare/finances of adults who lack capacity:
- Mental illness
- Learning disability
- Inability to communicate

138

How does the Adults with Incapacity Act define an adult?

Aged >=16 year

139

What is Part 6 of the Adults with Incapacity Act?

Welfare/Financial Guardianship:
- Authorises a person to make a decision which the patient can't

140

What is Part 5 of the Adults with Incapacity Act?

Medical treatment

141

When is a person not deemed to have a mental disorder and so won't be treated as such?

Promiscuity
Sexual deviancy
Alcohol/Drug abuse
Acting as no prudent person would

142

What does Section 47 prohibit?

Use of force unless immediately necessary and only for as long as is necessary

143

What article of the European Convention on Human Rights protects against arbitrary detention?

Article 5

144

When would Emergency Detention be used under the Mental Health Act?

If there is need for an urgent assessment of the patient's condition when they post a risk to themselves or others

145

Who can authorise Emergency Detention under the Mental Health Act?

Any doctor
(Preferably under guidance by a mental health officer)

146

How long can a person be detained under an Emergency Detention under the Mental Health Act?

72 hours maximum

147

Does Emergency Detention under the Mental Health Act allowed the patient to be treated against their will?

No

148

When would Short-Term Detention be used under the Mental Health Act?

When it is deemed that the patient requires admission to hospital to prevent injury to themselves or others
AND
That there is a need for the provision of medical treatment

149

Who can authorise Short-Term Detention under the Mental Health Act?

Recommended by a psychiatrist and agreed by a mental health officer

150

How long can a person be detained under Short-Term Detention under the Mental Health Act?

28 days

151

Does Short-Term Detention under the Mental Health Act allowed the patient to be treated against their will?

Yes

152

When would a Compulsory Treatment Order be used under the Mental Health Act?

The patient has a mental disorder in which treatment:
- Would prevent it worsening OR
- Alleviate symptoms/effects
AND
If the patient wasn't treated there would be risk to:
- Health/safety/welfare of patient
- Safety/welfare of others

153

How can a Compulsory Treatment Order be approved?

A mental health officer must apply to a Tribunal
The application should have:
- Two medical recommendations
- Plan of care (detailing care and treatment proposed)

154

Who is allowed to object to anything under the Compulsory Treatment Order?

The patient
The patient's named person
The patient's primary carer

155

Are patient's upon which a Compulsory Treatment Order has been enforced allowed to be detained in hospital?

Not initially
There will be specifications in the order where detention can be authorised

156

How long can a Compulsory Treatment Order last?

6 months initially
Can be extended for another 6 months
Then for another 12 months

157

Under what age does a person categorically have no consent?

If =<12 years

158

When might children younger than 16 have capacity?

They understand nature/purpose/consequences of intervention
They understand consequences of not having treatment

159

If a child, deemed competent by a doctor, consents to treatment that their parents do not consent to, can the parents overrule the decision?

No.

160

If a child, deemed competent by a doctor, does not consent to treatment that their parents do consent to, can the parents overrule the decision? What can they do?

No.
Can potentially apply for a court order

161

If a child, deemed competent by a doctor, does not consent to treatment that you, as their physician deem life-saving, what should you do?

Discuss with MDT
Legal advice might be useful - a court order may be required

162

If parents of a child who is not competent (younger than 12 or cannot understand fully the procedure) do not consent to treatment that physicians deem beneficial to the child's survival or QoL, what should you do?

MDT discussion
Legal advice
Court order

163

What antidepressants are deemed NA-selective?

Maprotiline
Protriptyline
Nortriptyline

164

What antidepressants are deemed non-selective?

Amitriptyline and Imipramine (1:1 ratio)
Clomipramine

165

What antidepressants are deemed serotonin-selective?

Venlafaxine
Paroxetine
Sertraline
Fluoxetine
Citalopram

166

What class of drugs do Phenelzine, Isocarboxazid and Tranylcypromine belong to?

MAOI

167

What type of drug is Moclobemide?

Reversible Inhibitor of MonoAmine oxidase A (RIMA)

168

Give some examples of TCAs

Amitriptyline
Clomipramine
Imipramine
Nortriptyline
Dosulepin

169

Give some examples of SSRIs

Fluoxetine
Paroxetine
(Es)Citalopram
Sertraline
Fluvoxamine

170

Give some examples of SNRIs

Venlafaxine
Duloxetine

171

What type of drug is Reboxetine?

NARI

172

What type of drug is Mirtazapine?

An atypical antidepressant with NA and specific serotenergic activity (NASSA)

173

What systems function to mediate seeking and approach behaviours (including pleasure)?

Ascending DA systems (mesolimbic/cortical)
Ventral striatum

174

What is the dorsal striatum important for?

Movement

175

What is the amygdala important for?

Conditioning and learning

176

What is the function of the anterior cingulate?

Attention
Conflict
Response selection

177

What part of the brain is responsible for relative reward preference and rule learning?

Orbitofrontal cortex

178

What systems function to promote survival in event of threat?

Ascending serotonin systems
NA transmitters
Central nucleus of amygdala
Hippocampus
Ventroanterior and medial hypothalamus
Periaqueductal grey matter

179

What do MAOIs prevent?

The action of monoamine oxidase which breaks down:
- DA
- NA
- Serotonin

180

How do TCA work?

Act at presynaptic membrane to prevent serotonin and NA reuptake

181

In dopamine transmission, how is dopamine produced?

Tyrosine -> Levodopa -> DA

182

What effect do amphetamines and MPP+ have on the DA transporter and dopamine?

Compete with DNA for reuptake
Force DA out of presynaptic vesicles, resulting in their release into synapse

183

What effect do cocaine, GBR 12935, WIN 35,428 and RTI-121 have on the DA transporter?

Bind to receptor and inhibit DA reuptake

184

How is NA produced in a noradrenergic neurone?

Tyrosine -> L-DOPA -> DA (cytoplasm) -> DA (vesicle) -> NA

185

How does amphetamine affect the NA transporter (NET)?

Substrate
Reverses direction of neurotransmitter
Increases synaptic NA

186

What drugs inhibit the NA transporter?

Cocaine
Nisoxetine
Reboxetine

187

How is serotonin produced in a serotonergic neurone?

Tryptophan -> 5-Hydroxytrytophan -> Serotonin

188

How does amphetamine and MDMA affect the serotonin transporter?

Substrates
Competitive reuptake inhibiton

189

What drugs inhibit the serotonin transporter?

Cocaine
Fluoxetine
Paroxetine
Sertraline

190

What are the mechanisms by which amphetamine and MDMA increase synaptic concentrations of DA/NA/5-HT?

VMAT2 inhibitors:
- Reduce their transport in vesicles by forcing them out of the vesicles
- Increase concentration in presynaptic neurone
TAAR1 agonists:
- Trigger protein kinases A and C
- Phosphorylate DAT/NET/SERT
- Reverse transport direction
- Increas concentration in synaptic cleft

191

What enzyme converts tryptophan to 5-hydroxytryptophan?

Tryptophan hydroxylase

192

What enzyme converts 5-hydroxytryptophan to serotonin?

Aromatic-L-amino acid decarboxylase

193

What serotonin receptors are targeted by anti-depressants?

5-HT1a
5-HT2a
5-HT2b
5-HT2c
5-HT3
5-HT6
5-HT7

194

What drugs target 5-HT1b and 5-HT1d?

Migraine medications (eg. Triptans)

195

What serotonin receptor is targeted by anti-emetics?

5-HT3

196

What serotonin receptor has GI pro-kinetic effects and what is it used to treat?

5-HT4
IBS and chronic constipation

197

On what receptor do fluoxetine and paroxetine at on?

5-HT2 (a-c)

198

On what receptors does Amitroptyline act on?

5-HT6
5-HT7

199

How long do SSRIs take to have effect? At this time, what are the levels of 5-HT like in the synaptic cleft?

2-3 weeks
Normal

200

What circuits are indicated in SSRI use?

Limbic-cortical

201

What type of receptors are 5-HT1a receptors?

Inhibitory autoreceptors

202

Upon acute antidepressant treatment, what happens in the synapse?

5-HT reuptake is inhibited
Increased [5-HT] in cleft
Stimulates 5-HT1a receptors to inhibit presynaptic firing

203

What does chronic occupancy of the 5-HT1a receptor cause?

Desensitise it
Return to normal firing
Facilitates serotenergic transmission in presence of reuptake blockade

204

What is wrong with the serotenergic system in depression?

Dysregulation in transmission
(Serotonin is not low)

205

Why are SSRIs typically first line?

Almost all can be started at a therapeutic dose
Usually good tolerance
Relatively safe in overdose

206

Why do SSRIs interact with other drugs?

Inhibit CYP450

207

What are some side effects of SSRIs?

Sexual dysfunction:
- Via DA blockade +/or serotonin activation
GI side effects (nausea, constipation, diarrhoea)
Short-term anxiety
Increased risk of self-harm in first few weeks in young people (=<25 years)

208

What drugs can cause reversal of an SSRI?

5-HT2 antagonists
Partial 5-HT1a agonists (eg. Trazodone)

209

When might an SSRI be avoided?

Agitated depression
Intolerable GI effects
On warfarin (SSRIs can potentiate bleeding)
If on AEDs

210

When is citalopram specifically avoided?

With another medication that may prolong QT
If diagnosed with long QT
If cardiac disease
If on antipsychotics
If on amitriptyline (for neuropathic pain)

211

What drug for depression may be preferred in breastfeeding? (This is also the second choice SSRI in all with depression)

Sertraline

212

What is the typical dosing regime for fluoxetine?

20mg/day PO initially
Increased after 3-4 weeks if necessary
Max 60mg/day PO

213

What is the typical dosing regime for sertraline?

50mg/day PO initially
Increased by 50mg increments at intervals of at least one week
Max 200mg/day PO

214

What monitoring may be needed in high does TCA therapy and why?

ECG
QT lengthening

215

What are the side effects of TCAs?

Constipation
Dry mouth
Blurred vision
Effects on cardiac function
Postural hypotension:
- Failure of peripheral orthostatic reflexes

216

What does MAO A metabolise?

NA
5-HT
Tyramine

217

What does MAO B metabolise?

DA
Tyramine
Phenylethylamine

218

When are MAOI used?

3rd or 4th line
Often in atypical depression

219

What are side effects of MAOI therapy?

Flushing
Headache
Hypertension
CVA (rarely)

220

Why do MAOIs cause their side effects?

Tyramine is usually inactivated in the gut
Since it remains active, NA is released

221

What can cause hypersensitive crises with MAOI therapy?

Tyramine-containing foods:
- Cheese
- Yoghurts
- Meat
- Alcohol
Drugs:
- Sympathomimetics (OTC cold remedies)
- Pethidine

222

How can the side effects of MAOIs be treated?

Alpha-blockade:
- Phentolamine
- Chlorpromazine

223

What side effects can some antidepressants (eg. Paroxetine) cause?

Extrapyramidal (due to effects on DA):
- Tremor
- Dystonia
- Akathisia
- Tardive dyskinesia

224

Give an example of an antipsychotic that may be an antidepressant at a low dose.

Flupentixol

225

What drug acts as a benzodiazepine receptor inverse agonist on the GABAa receptor complex?

FG-7142

226

What drug acts as a benzodiazepine receptor antagonist on the GABAa receptor complex?

Flumazenil

227

What drug acts as a benzodiazepine receptor agonist on the GABAa receptor complex?

Diazepam

228

When is a benzodiazepine receptor antagonist used?

Reversal of sedative effects benzodiazepine
OR
Treatment of benzodiazepine overdose

229

What effect does Picrotoxin have on the GABAa receptor?

Binds to the picrotoxin site:
- Channel blocker
- Stimulant and convulsant effects

230

What other sites (and hence drugs) are on the GABAa receptor (apart from BZD and GAPA sites)? What effects do these have?

Barbituate site
Steroid site
Positive allosteric modulators:
- Indirectly affects agonist or inverse agonist action

231

What type of receptor is GABAa?

Ligand-gate ion channel

232

What drugs act as GABAa receptor agonists?

Ethanol
Benzodiazepines
Propofol
Anaesthetics

233

What drug acts as a GABAa receptor antagonist?

Flumazenil

234

What type of receptor is GABAb?

GPCR

235

What drugs act as GABAb receptor agonists?

Baclofen
Propofol

236

What anticonvulsants act as mood stabilisers?

Carbamazepine
Valproate
Lamotrigine

237

What second generation antipsychotics can be used as mood stabilisers?

Olanzapine
Risperidone
Aripiprazole
Quetiapine

238

What other drugs can be used as mood stabiliers?

Lithium carbonate (citrate)
Nimodipine (calcium channel blocker)

239

How does lamotrigine work?

Blocking sodium channels
Doesn't work directly via GABA:
- Reduces excitability and cell firing

240

How many lithium work?

Inhibition of 5-HT autoreceptors
Increase in anti-apoptotic factor Bcl-2
Inhibition of glycogen synthase kinase-3 (GSK-3)
Depletion of inositol
Up-regulation of glutamate reuptake

241

How do true/1st generation antipsychotics work?

Related to D2 receptor affinity

242

What circuit results in the desired effect of true/1st generation antipsychotics?

DA blockade in the mesolimbic circuits

243

What causes the adverse effects of true/1st generation antipsychotics?

DA blockade in nigrostriatal pathway:
- Movement disorders
DA blockade in the tubero-infundibular pathway:
- Hyperprolactinaemia

244

What are the three mechanisms of action of 2nd generation antipsychotics?

1. Increased D2 receptor-binding affinity:
- Increased antipsychotic effectiveness
2. Increased 5-HT2c and a receptor-binding affinities:
- Increased antipsychotic efficacy
3. Increased 5-HT1a binding affinity:
- Reduced antipsychotic efficacy

245

What does structural imagine in bipolar disorder show?

Reduced grey matter volume in Brodmann Area 24 (anterior cingulate gyrus)

246

What does functional imaging in bipolar disorder show?

Increased metabolism in amygdala:
- Correlates with outcome
Reduced metabolism:
- OfC
- Medial ventral pfC