PH3113 - Psychiatric Disease and its Pharmacology 3 Flashcards
What are the side effects of SSRIs?
Nausea
Anorexia
Insomnia
Loss of libido
Interactions with other drugs
- NSAIDs
- increased GI bleeding
- prescribe gastroprotective drug
- omeprazole
What is Buspirone?
5-HT(1A) partial agonist licenced for short-term use in anxiety
- same mechanism as SSRIs
- effective in GAD
- less effective than benzodiazepines
- safer in terms of tolerance
Side effects
- nausea
- dizziness
Does not cause
- sedation
- tolerance
- withdrawal
NOT RECOMMENDED BY NICE
- can be used off label as intermediate option
What is propranolol?
treat anxiety
- useful for physical symptoms
- palpitations
- tremor
- sweating
- shortness of breath
Do not have sufficient evidence to support their inclusion in NICE guidelines
Small studies indicate giving propranolol immediately after a traumatic event may prevent emerging PTSD
- breaks the cycle of panic but no effect on underlying cause
How many levels of sleep are there?
4 stages
- 75% Non-REM sleep
- slow wave sleep
- stages 1 - 3
- 25% REM sleep
- rapid eye movement
- associated with dreaming
- stage 4
How does sleep take place on a neurological level?
Neurones in the ventrolateral pre-optic nucleus (VLPO) of the hypothalamus are GABAergic
- switching on the neurones in the VLPO may initiate sleep by inhibiting midbrain areas that control wakefulness
Give examples of sleep disorders?
Insomnia
- difficulty in getting to sleep or staying asleep long enough to feel refreshed the next morning
Sleep apnoea
- abnormal breathing pattern in sleep
Restless leg syndrome
- Wilis Ekbom disease
REM sleep behaviour disorder
- acting out of dream that are
- vivid
- intense
- violent
Narcolepsy
- extreme sleepiness and tendency to fall asleep suddenly during the day
What is insomnia?
Reflects a disturbance of arousal and/or sleep systems in the brain
- insomnia can be caused by any factor which
- increases activity in arousal systems or
- decreases activity in sleep systems
What are the causes of insomnia?
Recreational drugs
- caffeine
- nicotine
- alcohol
- cannabis
Medicinal drugs
- anti-convulsants
- anti-psychotics
- beta-blockers
- SSRIs
- Mono-amine oxidase inhibitors
- MAOIs
- steroids
- decongestants
- alpha-agonists
- alpha-antagonists
- narcotic analgesics
Drug withdrawal
- CNS depressants
- alcohol
- anxiolytics
- hypnotics
Physiological
- diet
- late night exercise
- shift work
- night work
- evening work
Environmental
- noise
- bright lights
- extremes of temperature
Medical conditions
- psychological
- anxiety
- depression
- grief
- stress
- non-psychological
- chronic pain
- gastric reflux
- asthma
- sleep apnoea
What are the types of insomnia?
Primary insomnia
- insomnia not attributable to a medical psychiatric or environmental cause
Secondary insomnia
- insomnia secondary to another condition
Transient
- 2 - 3 days
- caused by changes in routine
- change in time zone
- alteration of shift work
Short term
- < 3 weeks
- may result from temporary environmental stress
Chronic insomnia
- > 3 weeks
- usually secondary to other conditions
What is the treatment for insomnia?
Non-drug treatment
- lifestyle changes
- CBT
Hypnotics
- benzodiazepines
- benzodiazepine-like drugs
- melatonin
The cause of the insomnia should be established and the underlying factors should be treated
- hypnotics should be used only for short periods of time
What lifestyle changes should be employed to treat insomnia?
Establishing fixed times for going to bed and waking up
Trying to relax before going to bed
Maintaining a comfortable sleeping environment
Avoid napping during the day
Avoiding caffeine, nicotine and alcohol late at night
Avoiding exercise within four hours of bedtime
Avoiding eating a heavy meal late at night
Avoiding watching or checking the clock throughout the night
Using the bedroom mainly for sleep if possible
How do benzodiazepines treat insomnia?
Decrease the time taken to get to sleep
In individuals who habitually sleep < 6hours, they increase duration of sleep
Short acting benzodiazepines recommended for insomnia
- maximum 2 - 4 hours
Should only be used when it is severe, disabling, or causing the patient extreme distress
What are benzodiazepine-like drugs?
Z-hypnotics
- zaleplon
- zoplicone
- zolpidem
Short acting
- half life < 8 hours
- no hangover effect
- natural wake up
Lack anxiolytic effects
- don’t treat anxiety
Bind to GABA(A) in a similar way to benzodiazepines
- preferentially to alpha-1 subtype
- only sedating
What is zopiclone?
Hypnotic effects similar to benzodiazepines and similar potential for adverse effects
- tolerance
- dependence
- withdrawal effects
Psychiatric reactions have been reported shortly after the first dose
- hallucinations
- nightmares
No CD regulations
- may cause less alteration of sleep stages
What is melatonin?
Hormone produced by the pineal gland
- regulates the circadian rhythm of sleep
Released once it becomes dark
- continues until first light of day
Decreases with age
Melatonin promotes sleep initiation and resets circadian clock
Prolonged release melatonin available for primary insomnia in over 55 year olds
- can be used for up to 3 weeks
