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Psychiatry > Drugs for mood disorder > Flashcards

Drugs for mood disorder Flashcards

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1
Q

Conditions that one should be aware of for prescribing antidepressants

A

Renal/hepatic impairment

Coronary artery disease - avoid TCAs

Epilepsy - lowered seizure threshold

Bipolar - mania

GI bleeding/NSAIDs - avoid fluoxetine, sertraline, paroxetine

MAO-I/Lithium + SSRI –> serotonin syndrome

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2
Q

Alternative antidepressants for GI bleeding

A

Prescribe gastroprotection (PPI, antihistamine) w/ SSRI

Alternatively use mirtazapine or nortriptyline

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3
Q

Effect of medication on suicide risk

A

Li –> lower suicide risk

SSRI may initially raise suicide risk in young patients, need regular f/u + management plan

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4
Q

Effectiveness of antidepressant therapy

A

65-75% of patients (STAR*D trial)

1/3, 1/3, 16%

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5
Q

Monoamine theory of depression

A

Depression is caused by reduction in monoamines (5-HT, NA, DA)

Antidepressants raise monoamines (resisted by autoreceptor feedback) –> raise BDNF postsynaptically –> neurogenesis/new synaptic connections (explains lag)

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6
Q

Examples of SSRIs

A

Citalopram

Fluoxetine

Paroxetine

Sertraline

Fluvoxamine

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7
Q

Common side effects of SSRIs

A

Nausea

Agitation (esp younger patients)

Insomnia

Sexual dysfunction

Postural hypotension

P450 inhibition –> check drug interactions

Discontinuation syndrome (rare but well-characterised)

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8
Q

Examples of SNRIs

A

Venlafaxine

Duloxetine

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9
Q

Anti-depressants with half-life <24h

A

Paroxetine

Fluvoxamine

SNRIs e.g. venlafaxine

NDRIs (e.g. buproprion)

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10
Q

Mechanism of action of tricyclic antidepressants

A

Serotonin + noardrenaline + melatonin presynaptic transporter inhibition

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11
Q

Examples of TCAs

A

Nortriptyline

Amitryptiline

Clomipramine

Imipramine

Amoxapine

Doxepin

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12
Q

Examples of MAO-Is

A

Moclobemide (reversible)

Phenelzine (non-reversible)

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13
Q

Common interaction of MAO-I

A

Tyramine (wine, cheese, chocolate) or sympathomimetic drugs (e.g. decongestants) –> flushing + hypertensive crisis

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14
Q

Drug class of bupropion

A

Noradrenaline dopamine reuptake inhibitor (NDRI)

Also used for smoking cessation

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15
Q

Drug class of mirtazapine

A

NAergic and specific serotonin antagonist (NaSSA)

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16
Q

Mechanism of action of NaSSA

A

Blocks negative feedback –> increase NA and 5-HT release

NA and serotonergic specific antidepressnt

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17
Q

Short-term side effects of SSRIs

A

Dry mouth

Postural hypotension

GI disturbance

Insomnia

Tremor

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18
Q

Long-term side effects of SSRIs

A

Platelet dysf(x)

Sexual dysf(x)

Hyponatraemia

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19
Q

SSRI side effects in pregnancy

A

Increased risk of post-partum haemmorhage

Increased risk of persistent pulmonary hypoplasia (3 per 1000)

Withdrawal symptoms in baby –> increase length of hospital stay but not permanent

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20
Q

TCA contraindications

A

Neuro: Epilepsy, glaucoma

Psych: Suicidality (dangerous in OD)

Cardiovascular: Recent MI, heart block, arrhythmia, ischaemic heart disease

Endocrine: Prostatism, diabetes (use caution)

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21
Q

TCA toxicity

A

Prolonged QT, tachyarrhythmias

Seizures

Serotonin syndrome

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22
Q

Common side effects of TCAs

A

Anticholinergic: ++ (esp dry mouth/eyes, urinary retention/constipation)

Antihistaminergic: +++ (esp sedation, weight gain, advice on driving/machinery)

Cardiac: ++ (toxicity)

Metabolic/neuro: +

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23
Q

MAO-I mode of action

A

Inhibit MAO –> prevent breakdown of monoamines in presynaptic terminal + synaptic cleft –> raise levels

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24
Q

MAO-I indications

A

Third-line treatment, for atypical depression

Evidence of lower efficacy

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25
Common side effects of MAO-Is
Postural hypotension Weight gain Insomnia Ankle oedema Sexual dysfunction
26
Preferred antidepressant class for cardiac pts
SSRIs (beware antiplatelet drugs)
27
Antidepressant class if sexual dysf(x) is an issue
Bupropion, mirtazapine
28
Seratonin syndrome features
**Autonomic:** Shivering, sweating, hyperthermia, **Cardiac:** vasoconstriction/hypertension, tachycardia **GI:** nausea/diarrhoea **Neuro:** Headache, agitation, confusion, hallucinations **Muscular:** Myoclonus, clonus, hyperreflexia, tremor
29
Management of serotonin syndrome
**Fluids:** Cause of mortality **Temperature control:** cooling blankets, antipyretics **Muscle relaxant:** Lorazepam
30
Rare but dangerous complication of mirtazapine
Agranulocytosis Look for sore throat, stomatitis, fever, other infx acccompanied by neutropaenia
31
Distinguishing NMS from SS
NMS: * Slow onset * Slow progression * Lead pipe rigidity * Bradkinetic activity (cf clonus, tremors)
32
Prevalence of antidepressant discontinuation syndrome
30%
33
Timecourse of antidepressant discontinuation syndrome
Abrupt onset (2-5d after withdrawal) + short duration of symptoms (1d -3 weeks), usually self-limiting
34
Risk factors for antidepressant discontinuation syndrome
**Personal:** Young age, Hx of discontinuation **Medication:** Short half-life (e.g. paroxetine), high dose, duration \<8wk, variable compliance
35
Symptoms of discontinuation syndrome
SD GASS **Sensory:** Paraesthesia, visual disturbance **Disequilibrium:** Light-headedness, dizziness *both of the above less common with TCAs* **GI:** nausea + vomiting, diarrhoea **Affective:** Irritability, low mood **Sleep:** Insomnia, nightmares **Somatic:** Flu-like symptoms, fatigue + headache
36
Proposed mechanism of action of litihium
Substitute for many cations--\>?? Effect on membrane electrophysiology Gene expression --\> neuroprotective Effect on 2nd messenger systems (e.g. lower inositol levels)
37
Drug interactions for Lithium
**Cardiovascular:** Anti-arrhtyhmics, anti-hypertensives **Analgesics** esp NSAIDs **Psychiatric:** Antipsychotics, antidepressants, antiepileptics Antacids
38
Workup before starting Lithium
Weight U+Es + Ca, eGFR TFTs ECG FBC Advise commitment \>=2y necessary
39
Lithium level monitoring
1w after starting Li 1w after every dose change, weekly until stable levels Every 3mo Li levels + TFTs/renal f(x)/ECG/BMI/U+E (incl. Ca)
40
Common side effects of Lithium
**Early:** Metallic taste, dry mouth, thirst, polyuria, fine tremor, cognitive problems **Late:** Weight gain + sedation, psoriasis, hair loss
41
Rarer but more dangerous side effects of lithium
Hypothyroidism (1/20) CKD (1/10 reversible, 1% irreversible) Slowed cardiac conduction leading to arrhythmias (contraindicated in heart failure/sick sinus)
42
Risk of congenital anomalies in Li pregnancies compared to normal
4-12% vs 2-4%
43
Signs of Li toxicity
**Early:** Coarse tremor, diarrhoea (often bloody), dehydration, lethargy, N+V **Late:** Ataxia, slurred speech, muscle hypertonicity/fasciculations, confusion/delirium
44
Management of Li toxicity
**Education:** Stay hydrated + eat enough salt esp on hot days **Dose modification:** + level monitoring **Emergency:** Isotonic saline resuscitation to force diuresis
45
Psychiatric indications for valproate
Acute mania Depressive episode of bipolar alongside antidepressant Bipolar prophylaxis (unlicensed)
46
Mechanism of action of valproate
Increase GABAergic availability
47
Absolute contraindication for valproate
Females of child-bearing age
48
Common side effects of valproate
GI disturbance Sedation, headache Ataxia, tremor Thrombocytopaenia --\> manage bleeding risk esp before surgery
49
Rarer but more serious side effects of valproate
Pancreatitis Hepatotoxicity Agranulocytosis
50
Psychiatric indications for lamotrigine
Prophylaxis for bipolar disorder, prevents depressive episodes
51
Mechanism of action of lamotrigine
Inhibits voltage-gated Na channels, reduces glutamate release
52
Common side effects for lamotrigine
N+V Sleepiness/insomnia Visual + cerebellar dysf(x)
53
Rarer but more dangerous side effects of lamotrigine
Rash (3-5%) - stop at first sign due to risk of SJS/TEN Hepatotoxicity Blood dyscrasias
54
Timing of TCA and SSRI medication
SSRI: morning as activating TCA: night as sedating (avoid in people who need to drive/use heavymachinery esp in the early morning)
55
Antidepressant class of choice for post-MI depression
SSRIs, antiplatelet effect may be protective against CV risk
56
Monitoring antidepressants
Every 1-2 weeks Screen for hyponatraemia, SE profile, suicidality, serotonin syndrome
57
Monitoring for valproate
LFTs
58
Mood stabilisers for Li-resistant bipolar
Lamotrigine Sodium valproate Carbamazepine (less effective)
59
Common side effects of SNRIs
Hypertension
60
Common side effects of mirtazapine
Antiemetic, antipruritic, sedating Oversedation, hyperphagia

Psychiatry (20 decks)

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