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Psychiatry > Practical Psychopharmacology (Antidepressants and Mood Stabilisers) > Flashcards

Practical Psychopharmacology (Antidepressants and Mood Stabilisers) Flashcards

1
Q

Common side effects of SSRIs

A

Headache, GI disturbance (nausea, diarrhoea/ constipation), sleep disturbance/ vivid dreams, sexual dysfunction, suicidal ideation

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2
Q

Contraindications for SSRIs

A

History of hyponatraemia or predisposition to GI bleeds

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3
Q

Duration of tx with SSRIs

A

For depressive episode: once well, should continue on the same dose for 6-12 months

For recurrent depression (significant risk of relapse): up to 2 years

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4
Q

Normal response time for antidepressant therapy

A

Usually seen within 2-4 weeks. At least 4 weeks at an effective dose is needed before determining that the patient has failed to respond

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5
Q

Liscenced SSRI for depression in children

A

Fluoxetine

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6
Q

Side effects of tricyclic antidepressants

A
  • Cardiotoxic- (QT prolongation, ST elevation, AV block) Particularly problematic in suicidal patients
  • Anti-cholinergic/ muscarinic effects: dry mouth, blurred vision, constipation, urinary retention
  • Anti-hitaminergic effects: sedation, hypotension, weight gain
  • Lethal at overdose and cause discontinuation syndrome
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7
Q

Monoamine oxidase inhibitors (MAOIs) mechanism of action and cheese reaction

A
  • Increase the availability of 5HT and NA in the synapse (older drugs are irreversible), newwer ones are reversible (RIMAs)
  • Tyramine Interation= cheese reaction- pts need a special low tyramine diet- hypertensive crisis occurs when taking MAOIs and eating food such as cheese high in tyramine
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8
Q

What causes discontinuation syndrome and what are its symptoms

A

Can occur in all antidepressant groups especially in SSRIs and venlafaxine: these are NOT THE SAME AS WITHDRAWAL, since antidepressants are not addictive.

Can include GI symptoms, flu-like symptoms, anxiety, trouble sleeping, headache

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9
Q

What is refractory depression and what are its treatment options

A

​Depression which is not responsive to treatment

  1. Must check medication adherence in a non-accusatory manner, then optimise dose and side effect profile
  2. Switch antidepressant, initially to an alternative SSRI
  3. Switch to an alternative antidepressant class e.g Mirtazapine, venlafaxine, TCA
  4. If all this fails, this is now ‘refractory depression’- try combinations such as addition of an SSRI or augment with lithium or another antipsychotic
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10
Q

What is serotonin syndrome, and what is the triad of symptoms that characterise it?

A

A medical emergency which occurs when excessive serotonin in the synapses the brain, the incidence is <1%, presents as a TIAD of:

  1. Altered mental state: agitation confusion, coma
  2. Neuromuscular changes: hallmark features is myoclonus, hypertonia, hyper reflexia, tremor
  3. Autonomic dysfunction: tachycardia, HTN, mydriasis (dilated pupils)
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11
Q

Risk factors for the development of seretonin syndrome

A

Antidepressant use, combination antidepressant, overdose of antidepressants, lithium, ECT, opiates, concurrent use of an SSRI and St John’s Wort- a psychoactive plant

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12
Q

Complications of seretonin syndrome

A

DIC, rhabdomyolysis, RF, metabolic acidosis, seizures

(treatment involves stopping the antidepressant and giving supportive therapy)

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13
Q

Examples of SSRIs

A

Setraline, Citalopram, Fluoxetine, Escitalopram, Paroxetine

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14
Q

Drug class and side effects of Mirtazapine

A

Noradrenergic and specific seretonergic antidepressant (NaSSA)

SEs: Increased appetite (useful if malnourished), weight gain, sedation, dry mouth, headache, dizziness

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15
Q

Drug class and side effects of Venlafaxine and Duloxetine

A

Seretonin-Noradrenaline re-uptake inhibitors

SEs: similair to SSRIs, need to monitor BP

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16
Q

Examples of TCAs

A

Amitriptyline, Imipramine

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17
Q

Example and side effects of a RIMA

A

Moclobemide

SEs: cheese reaction

18
Q

Drug class and side effects of Trazodone

A

Seretonin antagonist and reuptake inhibitor (SARI)

SEs: sedation, arrhythmia, hypotension, priapism

19
Q

Example and uses of a noradrenaline and dopamine reuptake inhibitor

A

Bupropion- liscenced to help smoking cessation in the UK

20
Q

Reboxetine drug class and advantages

A

A selective noradrenaline reuptake inhibitor (NRI)

Less likely to cause sexual dysfunction

21
Q

Example of a melatonin agonist and serotonin agonist

A

Agomelatine

22
Q

Drug class and side effect profile of Vortioxetine

A

Serotonin modulator and stimulator

Has a good side effect profile: GI effects, dizziness and skin reactions

23
Q

How is lithium used in the treatment of mental healh disorders?

A

Lithium is the gold standard mood stabiliser used in BPAD, schizoaffective disorder and severe or refractory depression

24
Q

Therapeutic range of lithium

A

0.4-1.0mmol/L

(narrow therapeutic range) would worry about lithium toxicity above this range and the treatment being ineffective below this. Requires regular monitoring (potentially fatal above 2mmol/L)

25
Q

Complications of lithium treatment

A

Arrhythmia, CKD, Hypothyroidism, also teratogenic so should be avoided in pregnancy unless the mother is at significant risk.

26
Q

Common adverse effects of lithium

A

Fine tremor, mild GI upset, ‘metallic taste’ in mouth, sedation

27
Q

Effects of persistently elevated lithium levels

A
  • Renal disease
    • Polyuria and polydipsia (can cause DI)
    • CKD
  • Hypothyroidism
  • Weight gain
  • Persistent tremor
  • T wave flattening on ECG
  • Mild cognitive impairment
  • Change in hair texture
  • Mild leucocytosis
28
Q

Symptoms of lithium toxicity (>1.5mmol/L)

A
  • Coarse tremor
  • Marked GI upset
  • Ataxia
  • Dysarthria
  • Impaired conciousness
  • Epileptic seizures
  • Nystagmus
  • Renal failure
29
Q

What checks should be done before commencing a patient on lithium treatment?

A

FBC, U&Es, calcium, TFTs, ECG and initially lithium levels will be monitored weekly

30
Q

What maintenance monitoring should be done for patients on lithium

A
  • 6 monthly bloods including FBC, U&Es, calcium, TFTs, ECG
  • 3 monthly lithium levels
  • Also need to safety net: advice to stay hydrated, come back if GI symptoms or febrile illness
31
Q

Which drugs increase the risk of lithium toxicity?

A
32
Q

Risks associated with stopping lithium treatment suddenly

A

Increased risk of manic episodes

33
Q

Examples of antipsychotic drugs and their uses

A

Olanzipine, Risperidone, Quitiapine

Rapidly effective for both acute mania and prophylaxis against mania

Must be aware of risk of developing dyslipidaemia and metabolic syndrome when using olanzipine

34
Q

Examples of Anticonvulsant medication

A

Sodium Valproate, Carbamazepine, Lamotrigine

35
Q

Indications and side effects of Sodium Valproate

A
  • Used for acute mania and prophylaxis, but not to be used in women of childbearing age- risk of developmental disorders and congenital malformations.
  • Can also cause PCOS
  • GI upset (nausea, vomiting, dyspepsia, diarrhoea), tremor, sedation, weight gain, curly/loss hair, ankle swelling FBC abnormalities (leucopenia, thrombocytopenia), abnormal LFTS
36
Q

Indications and side effects of carbamazepine

A
  • A strong CYP450 inhibitor which is uncommmonly used for prophylaxis against mania
  • SEs: Nausea and vomiting, blurred vision, ataxia/, fatigue, hepatic failure, antidiuretic effect (hyponatraemia), FBC abnormalities (leucopenia, thrombocytopenia), skin rashes, abnormal LFTS
37
Q

Indications and side effects of Lamotrigine

A
  • Used for prophyaxis and in dipolar depression
  • Side effects: Nausea and vomiting, rash, headache, sedation, insomnia, aggression
  • Rarely causes STEVENS JOHNSON syndrome (epidermal necrolysis)
38
Q

Management of acute mania

A
  • IF first episode: Antipsychotics (+lithium if ineffective on its own), may stop antidepressant
  • IF already on stabiliser: optimise dose then add antipsychotic
  • May add adjunctive benzo
39
Q

Long term management of mania

A
  • Lithium
  • Or/in addition use valproate/olanzapine
40
Q

Management of bipolar depression

A
  • Limited evidence but don’t use SSRIs alone- add antipsychotic or mood stabiliser
41
Q

Why shoul antidepressants be avoided in rapid cyclinf bipolar disorder

A

They should only be prescribed if the patient is also taking an antipsychotic or anti-manic agent, because of the risk of triggering a manic episode. This would best be done with the advice of the Mental Health Team. Fluoxetine is the only SSRI recommended by NICE for use in Bipolar Affective Disorder

Psychiatry (15 decks)

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