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*Psychiatry > Psycho-pharmacology I > Flashcards

Psycho-pharmacology I Flashcards

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1
Q

What are the indications for antidepressants?

A 
Unipolar/bipolar depression
Organic mood disorders 
Schizoeffective disorder
Anxiety disorders 
Impulsivity associated with personality disorders
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2
Q

What delay is associated with antidepressants?

A

3-6 weeks after therapeutic dose achieved

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3
Q

When are antidepressants changed post-usage?

A

At least 2 months trial period

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4
Q

What are the main classes of antidepressants?

A 
Tricyclics
Monoamine Oxidase inhibitors
SSRIs
SNRIs
Novel antidepressants
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5
Q

What are the side effects associated with Tricyclic antidepressants?

A 
Antihistaminic
Anticholinergic 
Antiadrenergic
QT lengthening
Lethal in overdose
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6
Q

What are tertiary TCAs?

A

Tertiary amine side chains

Worsen side effects (antihistaminic, anticholinergic, antiadrenergic)

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7
Q

What are antihistaminic side effects?

A

Sedation

Weight gain

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8
Q

What are anticholinergic side effects?

A

Dry eyes, mouth
Constipation
Memory deficits
Delirium

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9
Q

What are antiadrenergic side effects?

A

Orthostatic hypotension
Sedation
Sexual dysfunction

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10
Q

Tertiary TCAs act on what?

A

Serotonin receptors

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11
Q

Give an 2 examples of tertiary TCAs?

A

Imipramine
Amitriptyline
Doxepin
Clomipramine

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12
Q

What are the active metabolites of tertiary TCAs?

A

Desipramine

Nortriptyline

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13
Q

What are secondary TCAs?

A

Metabolites of tertiary TCAs

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14
Q

How do secondary TCAs work?

A

Block noradrenaline

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15
Q

Give 2 examples of secondary TCAs?

A

Desipramine

Nortriptyline

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16
Q

What side effects are associated with secondary TCAs?

A

Same as tertiary TCAs (but less severe)

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17
Q

How do Monoamine Oxidase inhibitors work?

A

Bind irreversibly to monoamine oxidase, prevent inactivation of amines:
Norepinephrine, dopamine, serotonin (increasing levels)

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18
Q

What side effects are associated with Monoamine Oxidase inhibitors?

A 
Orthostatic hypotension
Weight gain
Dry mouth
Sedation
Sexual dysfunction
Sleep disturbance
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19
Q

What risks are associated with Monoamine Oxidase inhibitors?

A

Hypertensive crisis when taken with tyramine rich foods or sympathomimetics
Serotonin syndrome

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20
Q

Serotonin syndrome is associated with which antidepressants?

A

Monoamine Oxidase inhibitors taken with Serotonin increasing drugs/sympathomimetics

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21
Q

What are the symptoms of serotonin syndrome?

A 
Abdominal pain
Diarrhoea 
Sweats
Tachycardia
HTN
Myoclonus 
Irritability
Delirium
Hyperpyrexia
Cardiovascular shock
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22
Q

How do SSRIs work?

A

Prevent presynaptic serotonin reuptake

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23
Q

SSRIs are used in the treatment of what?

A

Anxiety

Depression

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24
Q

What side effects are associated with SSRIs?

A 
Sexual dysfunction
GI upset
Anxiety
Restless/Nervous
Insomnia
Sedation
Discontinuation syndrome
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25
What is discontinuation syndrome?
``` Effects of stopping SSRIs Agitation Nausea Disequilibrium Dysphoria ```
26
What are the advantages of Sertraline?
Weak P450 interactions Short half life Slow metabolite build up Less sedating than paroxetine
27
What are the disadvantages of Sertraline?
Requires full stomach for absorption | Increased GI ADRs
28
What are the advantages of Fluoxetine?
Long half life (reduced risk discontinuation syndrome) Increased energy Can be given to taper off SSRI use
29
What are the disadvantages of Fluoxetine?
Active metabolite may build up (risk in hepatic illness) P450 interactions Initial anxiety and insomnia Risk of mania over other SSRIs
30
Name 3 commonly used SSRIs?
``` Paroxetine Sertaline Fluoxetine Citalopram Escitalopram Fluvoxamine ```
31
How do SNRIs work?
Inhibit Serotonin AND Noradrenergic reuptake | Without antihist/adrenergic/cholinergic sides
32
SNRIs are used for what?
Depression Anxiety Neuropathic pain
33
Name 2 commonly used SNRIs?
Venlafaxine | Duloxetine
34
What are the advantages of Venlafaxine?
Minimal drug interactions Short half life Fast renal clearance
35
What are the disadvantages of Venlafaxine?
``` Can cause 10-15mmHg dose dependent BP increase Nausea (IR tabs) Bad discontinuation syndrome QT prolongation Sexual side effects ```
36
What are the advantages of Duloxetine?
Efficacy for physical symptoms of depression | Less BP increase than Venlafaxine
37
What are the disadvantages of Duloxetine?
CYP2D6 and CYP1A2 inhibitor | Active ingredient not stable in stomach (cannot break capsule)
38
Name 2 commonly used Novel antidepressants?
Mirtazepine | Buproprion
39
What are the advantages of Mirtazepine?
Different mechanism to SSRIs | Hypnotic at lower doses (antihistaminic)
40
What are the disadvantages of Mirtazepine?
Increased Cholesterol and triglycerides Very sedating at low doses Weight gain at low doses
41
What are the advantages of Buproprion?
``` Augmenting agent Inhibits dopamine + norepinephrine No weight gain, sexual sides Low mania 2nd line for ADHD ```
42
What are the disadvantages of Buproprion?
Seizure risk Avoid in TBI, bulimia, anorexia Can cause anxiety, agitation and insomnia Psychotic at high doses
43
How can resistance to antidepressants be managed?
Combination of antidepressants Add lithium Add atypical antipsychotic
44
What atypical antipsychotics may be used to aid in antidepressant resistance?
Quetiapine Olanzapine Aripiprazole
45
What are the indications for the use of mood stabilisers?
Bipolar Cyclothymia Schizoeffective disorder
46
What are the classes of mood stabilisers?
Lithium Anticonvulsants Antipsychotics
47
What are the indications for lithium?
Patient at risk of suicide | Long-term mania and depressive episodes
48
What are the factors predicting a positive response to lithium?
FH of good response Prior long-term response Classic pure mania Mania followed by depression
49
Outline the use of Lithium
``` Baseline U+E and TSH Pregnancy test Monitor until steady state achieved Check TSH and creatinine 3 and 6mo, Thyroid function Blood level between 0.6 and 1.2 ```
50
Lithium use during pregnancy is associated with what?
Ebstein's anomaly
51
What are the side effects of lithium use?
``` GI distress, reduced appetite Thyroid abnormalities Nonsignificant leukocytosis Polyuria (can cause interstitial renal fibrosis) Hair loss Acne Reduced seizure threshold ```
52
What are the levels of Lithium toxicity?
Mild - 1.5-2 Moderate - 2-2.5 Severe - >2.5
53
What are the symptoms of mild lithium toxicity?
``` Vomiting Diarrhoea Dizziness Ataxia Nystagmus ```
54
What are the symptoms of moderate lithium toxicity?
``` N+V Anorexia Blurred vision Clonus Convulsions Delirium Syncope ```
55
What are the symptoms of severe lithium toxicity?
Convulsions Oliguria Renal failure
56
What are the main groups of anticonvulsants?
Valproic acid Carbamazepine Lamotrigine
57
What factors predict a positive response to Valproic acid?
``` Rapid cycling patients Female Comorbid substance abuse Mixed patients Comorbid anxiety disorders ```
58
What is the first line agent for acute mania/mania prophylaxis?
Carbamazepine
59
When is Carbamazepine indicated?
Acute mania Mania prophylaxis Rapid cycling/mixed patients
60
Outline the use of Carbamazepine?
Before: LFTs, FBC, ECG Monitor: steady state, repeat FBC, LFTs Target: 4-12mcg/ml Check after a month
61
What side effects are associated with use of Carbamazepine?
``` Rash N+V, Diarrhoea Sedation Dizziness, ataxia AV conduction delay Drug-drug interactions Hyponatremia ```
62
What side effects are associated with Lamotrigine?
N+V Sedation, dizziness TEN/SJS
63
What are the indications for discontinuing Lamotrigine use?
ANY Rash
64
What drugs increase lamotrigine use?
VPA | Sertraline
65
What antipsychotics are indicated for Bipolar disorder?
Aripiprazole Risperdone Quetiapine Olanzapine
66
How do anticonvulsants affect liver function?
LFT increase expected | No change unless >3x change
67
What are the indications for antipsychotics?
``` Schizophrenia Schizoaffective disorder Bipolar (mood stabilisation or for psychotic features) Psychotic depression Augmenting agent (anxiety) ```
68
What pathways in the brain are affected by dopamine?
Mesocortical Mesolimbic Nigrostriatal Tuberoinfundibular
69
Outline the mesocortical pathway and its role in psychosis?
Brain stem to the cerebral cortex Causes negative symptoms and cognitive disorders Psychosis is related to too little dopamine here
70
Outline the mesolimbic pathway and its role in psychosis?
Dopaminergic cell bodies in ventral tegmentum to limbic system Positive symptoms Psychosis is related to too much dopamine here
71
What are positive symptoms?
Hallucinations Delusions Thought disorders
72
Outline the nigrostriatal pathway and its role in psychosis?
Dopaminergic cell bodies in substantia nigra to basal ganglia Involved in movement Dopamine hypoactivity can cause parkinsonian movements, akathisia, dystonia
73
How does dopamine affect acetylcholine?
Dopamine suppresses acetylcholine activity
74
Outline the tuberoinfundibular pathway and its role in psychosis?
Hypothalamus to anterior pituitary | Blocking dopamine to TI pathway predisposes patient to hyperprolactinaemia
75
How does dopamine affect prolactin release?
Dopamine release inhibits prolactin release
76
What are the symptoms of hyperprolactinaemia?
Gynaecomastia Galactorrhea Decreased libido Menstrual dysfunction
77
How do high potency typical antipsychotics affect dopamine?
D2 dopamine receptor antagonists | Bind to D2 receptors with high affinity.
78
High potency typical antipsychotics increase the risk of what?
Extrapyramidal side effects
79
Give 2 examples of typical antipsychotics?
Fluphenazine Haloperidol Pimozide
80
How do low potency typical antipsychotics affect dopamine?
Less affinity for D2 receptors Interact with non-dopaminergic receptors Cardiotoxic + anticholinergic ADRs
81
How do Atypical antipsychotics work?
Serotonin-dopamine 2 antagonists | Affect dopamine AND serotonin in 4 pathyways
82
What side effects are associated with Risperidone?
Extrapyramidal Hyperprolactinaemia Weight gain Sedation
83
What side effects are associated with antipsychotics?
Tardive Dyskenesia Neuroleptic Malignant syndrome Extrapyramidal side effects
84
What is tardive dyskinesia?
Involuntary muscle movements | may not resolve with drug discontinuation
85
What is Neuroleptic Malignant syndrome?
``` Severe muscle rigity Fever Altered mental state Autonomic instability Elevated WBC, CBK, LFTs ```
86
What are Extrapyramidal side effects?
Acute Dystonia Parkinson syndrome Akathisia
87
What agents treat extrapyramidal side effects?
Anticholinergics Dopamine facilitators Beta blockers
88
What are the indications for anxiolytics?
``` Panic disorder Generalised anxiety disorder Substance related/withdrawal Insomnias Parasomnias ```
89
What are the indications for benzodiazepines?
``` Insomnia Parasomnia Anxiety disorders CNS depressant withdrawals Acute sedation ```
90
What side effects are associated with benzodiazepines?
``` Somnolence Cognitive deficits Amnesia Disinhibitions Tolerance Dependence ```
91
What are the pros and cons of buspirone?
``` Pro: No sedation Con: 2 week to take effect Will not work on patients used to benzodiazepines ```
92
What are the main Anxiolytics?
Buspirone | Benzodiazepines
93
Name 2 atypical antipsychotics?
``` Risperidone Olanzapine Quetiapine Clozapine Aripiprazole ```
94
What antidepressants are associated with hypertensive crisis?
MAOIs and tyramine rich foods/sympathomimetics
95
What foods are rich in tyramine?
Cheese Red wine Processed meat Beans
96
How long after 1st, 2nd and 3rd incidences of depression should a patient be on antidepressants?
1st - 6 months 2nd - 2 years 3rd - lifelong
97
What are the side effects of low-potency antipsychotics?
Cardiotoxic | Anticholinergic effects - sedation, hypotension
98
How are first line drugs for schizophenia chosen?
Choose based on a drugs side effect profile for first line
99
What is the rule of efficacy for antipsychotics?
1/3 Very effective 1/3 reasonably effective 1/3 inaffective
100
How is clozapine use managed?
Check bloods continuously though use to monitor for agranulocytosis
101
What is seen before a psychosis relapse?
Loss of compliance Lack of insight May need to use mental health act
102
How is akathisia as a side effect managed?
(Reduce dose if possible) Benzodiazepine Propanalol

*Psychiatry (18 decks)

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