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Psycho-Pharmacology Flashcards

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1
Q

What are indications for anti-depressants?

A

Unipolar and bipolar depression
Organic mood disorders
Schizoaffective disorder
Anxiety disorders

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2
Q

How long is typical delay between achievement of therapeutic dose and symptom improvement in anti-depressants?

A

2-4 weeks

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3
Q

How should you use prophylaxis for depression?

A

First episode continue for 6 months
Second episode continue for 2 years
Third episode discuss life long

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4
Q

Examples of tertiary TCAs?

A

Imipramine
Amitriptyline
Doxepin
Clomipramine

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5
Q

Side effects of TCAs?

A

Anti-cholinergic, Anti-adrenergic
Anti-histaminic
QT lengthening

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6
Q

Examples of secondary TCAs?

A

Desipramine, nortriptyline

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7
Q

Do secondary or tertiary TCAs generally have worse side effects?

A

Tertiary

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8
Q

How do Monoamine Oxidase inhibitors (MAOIs) work?

A

Bind irreversibly to MAO preventing inactivation of amines (noradrenaline, dopamine and serotonin) leading to increased synaptic levels

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9
Q

What are MAOIs effective for?

A

Resistant depression

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10
Q

What are the side effects of MAOIs?

A

Orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction and sleep disturbance

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11
Q

Types of anti-depressants?

A 
TCAs 
Monoamine Oxidase inhibitors
Selective serotonin inhibitors
Serotonin/noreadrenaline reuptake inhibitors
Novel antidepressants
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12
Q

What can develop when MAOIs are taken with tyramine rich foods or sympathomimetics? (cheese reaction)

A

Hypertensive crisis

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13
Q

What can develop if MAOIs taken with medications that increase serotonin?

A

Serotonin syndrome
Sx - abdominal pain, diarrhoea, sweats, tachycardia, HTN, myoclonus
Can lead to hyperpyrexia, cardio shock and death

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14
Q

How can you avoid serotonin syndrome?

A

Wait 2 weeks before switching from SSRI to MAOI

Exception is fluoxetine where wait 5 weeks

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15
Q

How do selective serotonin reuptake inhibitors work? (SSRIs)

A

Block presynaptic serotonin reuptake

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16
Q

What can SSRIs be used to treat?

A

Anxiety and depressive symptoms

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17
Q

What are the most common general side effects of SSRIs?

A

GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia, fatigue, dizziness

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18
Q

What is discontinuation syndrome with SSRIs?

A

Agitation, nausea, disequilibrium and dysphoria

More common in shorter half life drugs

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19
Q

What is activation syndrome?

A

Caused by increased serotonin
Nausea, increased anxiety, panic and agitation
Typically last 2-10 days

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20
Q

What are the Pros and cons of Paroxetine? And what type of drug?

A

SSRI
Pros: short half life, no build up. Sedating properties offer good initial relief
Cons: Sedating, weight gain, anti-cholinergic effects. Likely to cause a discontinuation syndrome

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21
Q

What are the Pros and cons of Sertraline? And what type of drug?

A

SSRI
Pros: weak P450 interactions, short half-life, less sedating than paroxetine
Cons: Max absorption needs full stomach.Increased number GI ADRs

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22
Q

What are the Pros and cons of Fluoxetine? And what type of drug?

A

SSRI
Pros: long half life, good for non-compliance issues, can use to taper off SSRI
Cons: Metabolite build up, P45- interactions, initial anxiety and insomnia increase. More likely to induce mania

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23
Q

What are the Pros and cons of Ciralopram? And what type of drug?

A

SSRI
Pros: few D-D, intermediate half life
Cons: Dose-dependent QT interval prolongation. Cam be sedating, GI side effects

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24
Q

What is the benefit of Escitalopram over ciralopram?

A

More effective in acute response and remission

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25
What are the Pros and cons of fluvoxamine? And what type of drug?
SSRI Pros: shortest 1/2 life, some analgesic properties Cons: shortest 1/2life, GI distress, headaches, sedation, weakness. Strong inhibitor of some P450
26
How do seritonin/noradrenaline reuptake inhibitors work? (SNRIs)
Inhibit serotonin and noradrenergic reuptake like TCAs without their side effects
27
What are SNRIs used for?
Depression, anxiety | Possibly neuropathic pain
28
What are the Pros and cons of Venlafaxine? And what type of drug?
SNRI Pros: minimal d-d and little P450, short half life and fast renal clearance Cons: increase in DBP, nausea, discontinuation syndrome, sexual side effects
29
What are the Pros and cons of Duloxetine? And what type of drug?
SNRI Pros: far less BP increase Cons: P450 effects, active ingredient not stable in stomach
30
What are the Pros and cons of Mirtazapine? And what type of drug?
Novel antidepressant Pros:good augmentation to SSRIs, hypnotic at lower doses Cons: Increase cholesterol, sedating, weight gain
31
What are the Pros and cons of Buproprion? And what type of drug?
Novel antidepressant Pros: Augmenting agent No weight gain, sexual side effects sedation or cardiac interaction, second line ADHD agent Cons: may increase seizure risk (avoid TBI, anorexia, bulimia. Not anxiety Rx. Abuse potential due to psychosis
32
How could you treat treatment resistant depression?
Combination of antidepressants Adjunctive treatment with lithium Adjunctive treatment with atypical antipsychotic ECT
33
What are indications for mood stabilisers?
Bipolar, cyclothymia, schizoaffective
34
What are the classes of mood stabilisers?
Lithium Anticonvulsants Antipsychotics
35
What is the only medication to reduce suicide rate?
Lithium
36
What is lithium useful for prophylactically?
Mania and depressive episodes
37
What are factors predicting a positive repose to lithium?
Prior long term response or family member with good response Classic pure mania Mania followed by depression
38
What do you need to check before starting lithium?
Baseline U&E and TSH | Pregnancy test
39
What do you need to monitor with lithium?
Steady state achieved after 5 days - check 12 hours after last dose Level 3 months once stable Goal blood level between 0.6-1.2 TSH and creatinine 6 months
40
What are lithium side effects?
GI distress Thyroid abnormalities Nonsignificant leukocytosis Polyuria/polydipsia secondary to ADH antagonism Hair loss, acne Reduces seizure threshold, cognitive slowing, intention tremor
41
Is valproic acid more effective for mania or depression prophylaxis?
Mania
42
What factors predict a positive response in valproic acid?
Rapid cycling patients F>M Comorbid substance issues Mixed patients Patients with comorbid anxiety disorders
43
Is lithium or valproic acid better tolerated?
Valproic acid
44
What should be measured before starting valproic acid?
Base line LFTs Pregnancy test FBC
45
Why should valproic acid be avoided in woman of child bearing age?
Neural tube defects
46
What is the monitoring for valproic acid?
Steady state achieved after 4-5 days, check 12 hours after last dose and repeat FBC and LFTs Goal target between 50 and 125
47
What are valproic acid side effects?
Thrombocytopenia and platelet dysfunction N+V, weight gain Sedation, tremor Hair loss
48
What is use for carbamazepine and what patients is it indicated in?
First line agent for acute mania and mania prophylaxis | Indicated for rapid cyclers and mixed patients
49
What should be done before starting carbamazepine?
Baseline LFTs FBC ECG
50
What monitoring should be done with carbamazepine?
Steady state after 5 days - 12 hours after last dose Repeat FBC and LFTs Goal 4-12mcg/ml Need to check level and adjust dosing after around a month as induces own metabolism
51
What are side effects of carbamazepine?
``` Rash N+V, diarrhoea Sedation, dizziness, ataxia, confusion AV conduction delays Water retention due to vasopressin like effect --> hyponatremia D-D ```
52
What tests need to be done before lamotrigine?
Baseline LFTs
53
What is the procedure for initiation/titration of lamotrigine?
Start 25mg daily for 2 weeks then increase to 50mg for 2 weeks then 100mg if patient stops med for >/=5 days then must start 25mg again
54
Side effects of lamotrigine?
N+V Sedation, dizziness, ataxia and confusion Toxic epidermal necrolysis and stevens johnson's syndrome - IF any rash develops discontinue use immediately VPA increases lamotrigine levels as dose sertraline
55
Indications for antipsychotic use?
Schizophrenia, schizoaffective disorder Bipolar for mood stabilisation and/or psychotic features Psychotic depression Augmenting agent in treatment resistant anxiety disorders
56
What are the key pathways affected by dopamine in the bra
Mesocortical (negative symptoms and cognitive disorders, too little dopamine) Mesolimbic (positive symptoms, too much dopamine) Nigrostriatal (movement regulation) Tuberoinfundibular (blocking dopamine here --> hyperprolactinaemia)
57
What are typical antipyschotics?
D2 dopamine receptor antagonist (high affinity) | Higher risk of extrapyramidal sid effects
58
What are examples of high potency typical antipsychotics?
Fluphenazine Haloperidol Pimozide
59
What are examples and side effects of low potency typicals?
Cardiotoxic and anticholinergic - sedation, hypotension Chlorpromazine Thioridazine
60
What are antipsychotic atypicals?
Serotonin dopamine 2 antagonists | Affect dopamine and serotonin in four key dopamine pathways in brain
61
About risperidone?
Regular tabs, IM and rapidly dissolving tablet More like typical at doses > 6mg Increased extrapyramidal side effects Most likely atypical to induce hyperprolactinaemia S/E of weight gain and sedation
62
About onlazapine?
Regular tabs, immediate release IM, rapidly dissolving tab, demo form Weight gain Hypertriglyceridaemia and hypercholesterolaemia, hyperglycaemia
63
About quetiapine?
``` Regular tablet form only Abnormal LFTS(6%) Weight gain less than onlazapine Same hypers as onlaxapine but less Orthostatic hypotension ```
64
About ariprazole?
Regular tabs, immediate release IM and depo D2 partial antagonist LOW EPS, no QT, low sedation Interactions with other psychiatric meds (fluoxetine and paroxetine and carbamazepine) No weight gain
65
About clozapine?
Regular tablet Reserved for treatment resistant Weekly blood draws x 6 months then Q- 2weeks x 6months Increased risk of seizures (esp + lithium) Most sedation, weight gain and abnormal LFTs)
66
What are indications for anxiolytics?
Panic disorder, generalised anxiety, substance related and withdrawal, insomnias and paraomnias
67
Agents for extrapyramidal side effects?
``` Anticholinergics (benztropine) Dopamine facilitators (amantadine) Beta bockers (propranolol) ```
68
About buspirone?
Pros: good augmentation and no sedation Cons: 2 weeks till patient notices results. Wont reduces anxiety in patient used to taking BZDs
69
About benzodiazepines?
Treat insomnia, parasomnias and anxiety CNS depressant withdrawal protocols S/E somnolence, conginitve deficits, amnesia, disinhibition, tolerance, dependence
70
What would you use in a treatment naive patient with depression first line?
SSRI
71
What are some less sedating SSRIs?
Citalopram Fluoxetine Sertraline
72
What are some anti-depressantsassociated with weight gain?
Paroxetine | Mirtazapine
73
When would you move on to a duel reuptake inhibitor in a depression patient?
No remission with two SSRIs or a novel agent
74
What would you discuss in a women of child bearing age when prescribing lithium?
Contraception methods
75
What is a rapid cycler?
4 or more depressive or manic episodes per year
76
What increase in LFTs on anticonvulsants would warrant considering changes in therapy?
More than triple baseline

Psychiatry (13 decks)

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