Psych pharmacology and treatments

Question 1

what are the different types of SSRI?

Answer 1

• Citalopram
• Escitalopram
• Fluoxetine
• Paroxetine
• Sertraline

Question 2

what can SSRIs be used for?

Answer 2

first line treatment for depression
post traumatic stress disorder
OCD

Question 3

what SSRI is useful post MI?

Answer 3

Sertraline

Question 4

what SSRI is the one of choice in children and adolescents?

Answer 4

Fluoxetine

Question 5

what are the side effects of SSRIs?

Answer 5

• most common is GI symptoms
• increased risk of GI bleeding, if patient is taking NSAIDs and SSRI a PPI should also be prescribed
• citalopram can cause a dose-dependent QT interval prolongation
• insomnia, increased anxiety and irritability
• sexual side effects - ED
• nausea, vomiting and diarrhoea
• hyponatraemia (SIADH)

Question 6

what drugs do SSRIs interact with?

Answer 6

NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin: GI problems
triptans: avoid SSRIs
monoamine oxidase inhibitors (MAOIs) - risk of serotonin syndrome

Question 7

how long should a patient take an SSRI after remission?

Answer 7

at least 6 months to reduce the risk of relapse

Question 8

how should patients stop taking SSRIs?

Answer 8

gradually over a 4 week period
(not necessary with fluoxetine)
paroxetine has higher incidence of discontinuation symptoms

Question 9

what symptoms should make you stop taking SSRI?

Answer 9

increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia

Question 10

can women take SSRI during pregnancy?

Answer 10

• BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
• Use during the first trimester gives a small increased risk of congenital heart defects
• Use during the third trimester can result in persistent pulmonary hypertension of the newborn
• Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Question 11

what are SNRIs?

Answer 11

serotonin-norepinephrine reuptake Inhibitor

Venlafaxine
desvenlafaxine
duloxetine

Question 12

what can SNRI be used for?

Answer 12

depression
anxiety
panic disorder
effective in reducing pain associated with fibromyalgia and pain caused by neuropathy

Question 13

what are the side effects of SNRIs?

Answer 13

same as SSRI

may increase blood pressure and heart rate

Question 14

what are TCAs?

Answer 14

tricyclic antidepressants
amitriptyline
clomipramine
imipramine

Question 15

what can TCAs be used for?

Answer 15

depression
can also be used in migraine prevention and treatment of neuropathic pain
insomnia

Question 16

what are the side effects of TCAs?

Answer 16

hypotension 
dizziness 
sedation 
blurred vision 
dry mouth 
constipation 
urinary retention 
cardiac conduction abnormalities 
cardiotoxicity and QT prolongation

Question 17

what are MAOIs?

Answer 17

Monoamine oxidase inhibitors

two types A and B
(type a preferentially metabolises serotonin)
(type B preferentially metabolised dopamine)

Isocarboxazid
phenelzine

selegiline (specifically type B - good for Parkinson’s)

Question 18

what are MAOIs used for?

Answer 18

depression

Question 19

what are the the side effects of MAOIs?

Answer 19

drug drug interactions
drug food interactions - avoid tyramine rich food (cheese, cured or smoked meats/fish, some overripe fruits) as they can cause hypertensive crisis and potentially a stoke

other side effects include dry mouth, nausea, diarrhoea, constipation, headache, drowsiness, insomnia

Question 20

how should SSRIs be monitored?

Answer 20

MONITOR 1-2 weeks (after 1 week if under 30/increased risk of suicide) after starting - agitation and SUICIDAL IDEATION initially - since have more energy but mood hasn’t improved yet

*requires 2-4 weeks to become effective

Question 21

what is serotonin syndrome?

Answer 21

too much serotonin = restless, fever, tremor, myoclonus, confusion, fits

Question 22

what is a contraindication to SNRIs?

Answer 22

chronic alcoholic liver

Question 23

what is an atypical antidepressant and when is it indicated?

Answer 23

• Mirtazapine

- Indicated for depression where sedation or increased oral intake is desirable also indicated for PTSD

Question 24

what are the side effects of mirtazapine ?

Answer 24

weight gain and sedation

Question 25

when is lithium used?

Answer 25

- Acute treatment of mania - Bipolar relapse prevention - Treatment resistant depression

Question 26

why does lithium need monitoring? | how is it monitored?

Answer 26

because it is very toxic and has very narrow therapeutic window (avoid in those who have risk of suicide) TFT - hypothyroid can manifest 6-18 months after FBC pregnancy test kidney function test s

Question 27

what are the side effects of lithium?

Answer 27

leucocytosis early side effects - fine tremor, dry mouth, metallic taste, mild diuresis, sick Late - weight gain, hypothyroidism, hypokalaemia, oedema, teratogenic, diabetes insupidus * LITHIUM * Level - 0.6-1 mmol/L, Leukocytosis * Insipidus - Nephrogenic Diabetes (Increase ADH) • Tremors - mild (ok), coarse? (TOXICITY) * Hydration - Dry mouth, diarrhoea, thirsty * Increased - GI, Skin, memory problems * Under active thyroid (decreased TSH) * Metallic taste, mum beware - Ebstein anoma

Question 28

when does lithium toxicity occur? what can it be caused by what are the symptoms and how is it managed?

Answer 28

• Occurs when levels are GREATER than 1.0-1.5mmol/L • Can be caused by: - Fluid depletion (vomiting, diarrhoea, dehydration) - Changes in salt level in diet - Reduced renal function - Certain medications e.g. diuretics, NSAIDs, blood pressure medication - Change in brand of lithium • Onset usually sudden • Symptoms: - Coarse tremor, hyperreflexia, seizures, heart block - Muscle weakness, ataxia, coma - Dysarthria, dysphasia • Management: - STOP LITHIUM & TREAT cause - Give fluids - Haemodialysis (if severe)

Question 29

what can antipsychotics be used for?

Answer 29

- Relieve positive symptoms i.e. hallucinations, thought disorder, delusions - Treat schizophrenia - Control acute mania - Provide rapid tranquillisation - Treat psychotic depression

Question 30

what can antipsychotics not do?

Answer 30

- Relieve negative symptoms i.e. blunted emotions, apathy - Change personalities apart from clozapine

Question 31

before starting antipsychotics what tests need to be performed?

Answer 31

- Bloods - FBC, U&E, LFT, lipids, BM, cholesterol, prolactin - Physical - weight, BP, pulse - ECG - Risk of prolonged QT syndrome/arrhythmias

Question 32

what are some first generation/typical anti-psychotic?

Answer 32

Haloperidol | Chlorpromazine

Question 33

what are the side effects of first generation antipsychotics?

Answer 33

worsening negative symptoms extrapyramidal side effects (acute dystonic reaction, Parkinsonism, akathisia, tardive dyskinesia (involuntary, repetitive body movements)) anticholinergic side effects - dry mouth, constipation, blurred vision, urinary retention antiadrenergic - postural HTN antihistaminergic - sedation and weight gain prolactinaemia and gynocomastia in men

Question 34

what are some examples of second generation/atypical antipsychotics?

Answer 34

Olanzapine, Clozapine, Risperidone, Quetiapine

Question 35

what are the side effects of 2nd gen antipsychotics?

Answer 35

* Metabolic - weight gain, hyperglycaemia and dyslipidemia | * Hyperprolactinaemia

Question 36

when is clozapine used?

Answer 36

in treatment resistant schizophrenia | used when 2 other treatments have networked

Question 37

what are the side effects of clozapine?

Answer 37

Agranulocytosis (bone marrow suppression) neutropenia, myocarditis, cardiomyopathy, constipation) * requires regular blood test for neutropenia * staring/stoping smoking can alter the drug metabolism

Question 38

what is the neuroleptic malignant syndrome?

Answer 38

Rare life threatening reaction to antipsychotics (both typical and atypical) Carries a mortality of 10% More common in young male patients Features: • Onset usually in first 10 days of treatment or after increasing dose • Pyrexia, rigidity, tachycardia • Severe motor/mental/autonomic dysfunction • Increased sweating, dysphagia, urinary incontinence • Raised creatine kinase in most cases - AKI (secondary to rhabdomyolysis) may develop in severe cases

Question 39

how is neuroleptic malignant syndrome managed?

Answer 39

stop antipsychotic IV fluids to prevent renal failure Bromocriptine may be used

Question 40

what can sodium valproate be used for?

Answer 40

epilepsy acute mania bipolar

Question 41

what are the side effects of sodium valproate?

Answer 41

``` VALPROATE: • Vomiting • Ataxia • Liver toxicity • Pancreatitis • Tremor • Extra weight-gain ```

Question 42

what can carbamazepine be used for?

Answer 42

epilepsy | 2nd line for bipolar prophylaxis

Question 43

what are some examples of anxiolytics and hypnotics?

Answer 43

Benzodiazepines e.g. Diazepam and ‘z’ drugs (zopiclone, zolpiden, zaleplon)

Question 44

what are the side effects of anxiolytics and hypnotics? | and how is an overdose managed?

Answer 44

- ALL result in TOLERANCE, DEPENDENCE and WITHDRAWAL - When used in combination with alcohol can become addictive - Respiratory depression when used with alcohol or opiates - Overdose management: • Flumazenil - an antagonist of benzodiazepine receptor -> reverses effects