Psychiatry - Drugs

Question 1

Dopamine Hypothesis

Answer 1

Mesolimbic (too much D2) - positive symptoms

Mesocortical (too little D2) - negative symptoms

Tuberofundibular - endocrine/metabolic SE

Nigrostriatal - EPSE

Question 2

EPSE

Answer 2

Acute dystonia

• Painful spastic contraction
• Give procyclidine

Akathesia

• Restlessness and distress
• Procyclidine/propanolol

Parkinsonism

• Tremor, rigidty and bradykinesia
• Anticholinergics

Tardive dyskinesia

• Involuntary, repeatitive movements
• Tongue, lips face
• Irreversible, anticholinergics make it worse

Question 3

Neuroleptic Malignant Syndrome

Answer 3

Within 10 days on initiation

• Severe rigidity
• Temp >38 degrees
• Fluctuating consciousness
• Autonomic instability

Question 4

Depot

Answer 4

1st generation and Risperidone

2-8 weeks, deep IM injection

Increased compliance and bioavailability
Decrease abuse/toxicity

Question 5

1st Generation - MOA

Answer 5

Decrease D2 in all 4 pathways

Question 6

1st Generation - Indications

Answer 6

Schizophrenia
Acute mania
Psychosis

Question 7

1st Generation - Side Effects

Answer 7

Tuberoinfundibular

• Prolactinaemia
• Galactorrhoea, menstual disturbance

Acetylcholine
- Can’t spit can’t see can’t poo can’t pee

Adrenaline/noradrenaline

• Postural hypotension
• Sexual dysfunction

Histamine

• Sedation
• Weight gain

Question 8

Achetylcholine Side Effects

Answer 8

• Dry mouth
• Blurred vision
• Urinary retention
• Constipation

Question 9

2nd Generation - MOA

Answer 9

Decreased action on Nigrostriatal = decreased EPSE

Increased on other e.g. adrenergic/histamine = weight gain

Question 10

2nd Generation - Indications

Answer 10

First line in schizophrenia

Clozapine = Treatment resistant schizophrenia

Question 11

Clozapine - Indications

Answer 11

Treatment resistant schizophrenia

• 2 or more other antipsychotics tried
• At full dose for 6 months
• With no effect (not stopped due to side effects)

Question 12

Clozapine - Side Effects

Answer 12

Neutropenia and agranulocytosis

Question 13

Clozapine - Monitoring

Answer 13

• Weekly FBC etc for 18 weeks
• 2 weekly for first year
• 4 weekly after that

Withdraw if leucocytes <3000 or neutrophils <1500

Question 14

2nd Generation - Side Effects

Answer 14

Weight gain, 
dizziness, 
T2DM, 
postural hypotension, 
hyperlipidaemia

Question 15

Quetipine/Zotepine - Side Effects

Answer 15

QT prolongation

No Ach side effects

Question 16

2nd Generation - Baseline Monitoring

Answer 16

Bloods
- FBC, UEs, LFTs, HbA1c, Glucose, prolactin, lipids, cholesterol

Physical
- Weight, BP, HR

ECG

• Hx CV/Smoker
• On quetipine or zotepine

Question 17

Lithium - Indications

Answer 17

BAD prophylaxis
Recurrent/resistant depression

Use for >3 years
- Poor compliance = rebound mania (hard to treat)

Question 18

Lithium Side Effects - Early

Answer 18

Fatigue
Drowsiness
Fine Tremor
Weight gain
Polydipsia 
Polyuria

Question 19

Lithium Side Effects - Late

Answer 19

Thryoid problems
Renal failure
CVD

Question 20

Lithium Toxicity

Answer 20

Mild Drowsiness, ataxia, coarse tremore

Severe:
Convulsions, collapse

Question 21

Lithium Monitoring - Bloods

Answer 21

Lithium levels checked 12 hours post dose.

3-5 days for the first few weeks until stable, then 3-4 monthly levels

Check kidney and thyroid function too

Question 22

Lithium - Baseline Monitoring

Answer 22

Weight
Renal function
TFTs
Pregnancy Test
ECG

Question 23

SSRIs - MOA and examples

Answer 23

Inhibit re-uptake of serotonin at the synaptic cleft

• Fluoxetine
• Sertraline
• Paroxetine
• Citalopram
• Escitalopram
• Fluvoxamine

Question 24

SSRIs - Side effects

Answer 24

Very Common

• GI Disturbance
• Insomnia (do not take at night)
• Sexual disturbance

Common

• Headache
• Decreased appetite
• Restlessness

Rare

• Rash
• Thoughts of self harm

Question 25

SSRIs - Counselling

Answer 25

How? - One tablet each day in the morning Effect - By week 2, definitely by week 8 Duration - 12 months to prevent relapse Stopping - Wean off Overdose - Not toxic

Question 26

SNRIs - MOA and Examples

Answer 26

Inhibit reuptake of serotonin and noradrenaline - Venlafaxine - Duloxetine

Question 27

SNRIs - Indication

Answer 27

Treatment resistant depression - increased efficacy and rapid onset GAD

Question 28

SNRIs - Side effects

Answer 28

Nausea, headache, sleepiness, dizziness Cardiotoxic - avoid in heart disease/hypertension

Question 29

SNRIs - Monitoring

Answer 29

ECG and BP before starting

Question 30

Tricyclic Antidepressant - MOA and Examples

Answer 30

Inhibit reuptake of noradrenaline and serotonin - Amitriptyline - Imipramine - Lofepramine (not toxic in overdose)

Question 31

TCAs - Indications

Answer 31

Imipramine - non sedating Amitriptyline - sedating Clomipramine - use in OCD

Question 32

TCAs - Side Effects

Answer 32

Ach side effects Histamine Cardiotoxic (avoid in MI/heart block) Neurotoxic - delirium etc.

Question 33

TCA - Overdose + Antidote

Answer 33

Very toxic Increased HR, dilated pupils, low GCS, palpable bladder, seizures, arrythmias Give Sodium Bicarbonate

Question 34

NASSA - MOA and Example

Answer 34

Noradrenaline and Serotonin Specific Antidepressant Mirtazapine Severe depression, especially if poor sleep/diet

Question 35

NASSA - Side Effects

Answer 35

Sedation Weight gain Dry mouth Dizziness SAFE IN OVERDOSE

Question 36

NARI - MOA and Example

Answer 36

Noradrenaline Re-uptake inhibitor Reboxetine Severe depression

Question 37

NARI - Side Effects

Answer 37

Nausea, anorexia, sweating, dizziness, postural hypotension SAFE IN OVERDOSE

Question 38

Risperidone - Side Effects

Answer 38

Low BP Restlessness Headache Sexual dysfunction

Question 39

Olanzapine - Side Effects

Answer 39

Weight gain Sedation Constipation

Question 40

SSRIs - Side Effects

Answer 40

N+V Dizziness Dry mouth Sexual dysfunction Increased suicidal thoughts

Question 41

Mirtazapine - Side Effects

Answer 41

Weight gain Sedation Dizziness Dry Mouth

Question 42

Venlafaxine - Side Effects

Answer 42

NOT in CVD N+V Dizziness Headache