Psychopharmacology

Question 1

Examples of SSRIs

Answer 1

sertraline, fluoxetine, paroxetine, citalopram, escitalopram

FLUOXETINE in UNDER 18

Question 2

Indications for SSRIs

Answer 2

depression, anxiety, OCD, bulimia nervosa

Question 3

SSRIs MOA

Answer 3

inhibit the reuptake of serotonin from presynaptic serotonin pumps

Question 4

Side effects of SSRIs

Answer 4

GI symptoms, anxiety/agitation, insomnia, sweating, sex (anorgasmia)

Associated with:

• Increased suicidality,
• cytochrome-mediated interactions (fluoxetine)

Can cause hyponatraemia

Question 5

SSRI withdrawal Sx

Answer 5

dizziness, headache, tremor, agitation, GI issues ~
esp paroxetine and sertraline

Question 6

MOAI

Answer 6

Inhibit the enzymes: Monoamine oxidase A + B

Indicated for use in depression

Question 7

MOAI SE

Answer 7

• Overdose
• TYRAMINE CHEESE REACTION (hypertensive crisis)

Question 8

SNRIs

Answer 8

Venelafaxine, Duloxetine

• indicated for depression and anxiety

Question 9

SNRI MOA

Answer 9

Presynaptic blockade of both noradrenaline and serotonin reuptake pumps
(in high doses also blocks dopamine reuptake);

low effects on muscarinic,
histaminergic and alpha-adrenergic receptors

Question 10

SNRIs SE

Answer 10

dizziness, dry mouth, constipation, hot flushes (muscarinic?)

Question 11

NaSSAs

Answer 11

Noradrenergic and Specific Serotonergic Antidepressants

• Mirtazapine

Indicated for use in: depression, anxiety (off license)

Question 12

NaSSAs (Mirtazapine) MOA

Answer 12

presynaptic alpha2 blockage -> increased noradrenaline and
serotonin from presynaptic neurons;

histamine antagonist

Question 13

Mirtazapine (NaSSA) SE

Answer 13

• SEDATION + Wight gain (from histamine blocking)
• Headache
• Postural hypotension
• Dizziness
• Tremor

Question 14

Tricyclics

Answer 14

AMITRYPTYLINE

Indicated in:

• Depression
• Anxiety
• OCD
• Chronic pain (lower dose)
• Nocturnal enuresis

Question 15

Tricyclic MOA

Answer 15

blockade of both noradrenaline and serotonin reuptake pumps (alsodopamine to a small extent).

Muscarinic, histaminergic, alpha-adrenergic

Question 16

When are tricyclics contraindicated

Answer 16

• IHD
• Arrhythmias
• Severe liver disease
• RIsk of OVERDOSE

Question 17

Tricyclic SE

Answer 17

Remember: Triple A

• Anticholinergic
  - Dry mouth; constipation; blurred vision; urinary retention
• Antiadrenergic
  - Postural hypotension
• Antihistaminergic
  - Sedation + weight gain

+ CARDIAC -> LONG QT; HEART BLOCK; ARRHYTHMIAS; PALPITATIONS

Question 18

Lithium indications

Answer 18

• MANIA (acute and prophylaxis)
• Tx RESISTANT depression
• Agression + Impulsivity
• MOOD STABILISATION

Question 19

What monitoring is required for lithium

Answer 19

• Pre starting BASELINE:
  - FBC, U+E, Ca2+, PO4^3-, TFTs, ECG, PREGNANCY
• WEEKLY BLOODS till levels stable -> then 3 MONTHLY
  - Including renal + TFTs

Question 20

What is the theraputic index range of lithium

Answer 20

0.5. - 1

1.5-2 = toxicity

> 2 = severly toxic

Question 21

Lithium SE

Answer 21

• Polyuria, Polydipsia
• Weight gain
• Oedema
• Fine tremor -> coarse when more serious

QT ECG changes
Arrhythmias
Nystagmus
Dysarthria
Brisk reflexes
Impaired consiousness
TERATOGENIC (Ebstein’s abnormality of tricuspid)

Question 22

Which meds is it inadvisiable to have alongside lithium

Answer 22

NSAIDs, ACEi and Duiretics (anything that alters kidney function)

Lithium is renally excreted

Question 23

Sodium valproate

Answer 23

Indicated as: MOOD STABILISER, ANTICONVULSANT, for Migraine prophylaxis

Question 24

Sodium valproate SE

Answer 24

weight gain, dizziness, hair loss, n+v, tremor, deranged LFTs

TERATOGENIC

Question 25

Benzodiazepines

Answer 25

- **lorazepam (short acting)**, - diazepam (longer acting), - midazolam, - **chlordiazepoxide**

Question 26

Benzodiazepams indications

Answer 26

- **anxiety (short term in extreme cases only)**, - mania, psychosis, - alcohol withdrawal, - insomnia, - acute agitation/aggression, - epilepsy, - acute back pain

Question 27

Benzodiazepine MOA

Answer 27

bind to GABA receptor -> neuronal inhibition

Question 28

Benzodiazepine SE

Answer 28

- Addiction - Resp / CNS DEPRESSANT EFFECTS (so can't take any other cns depressants at same time) - avoid in neuro / severe resp disease

Question 29

Methylphenidate

Answer 29

**ADHD** MOA: Dopamine + Noradrenaline reuptake - Modified slow realse OR fast relaease

Question 30

Methylphenidate SE

Answer 30

anxiety, increased BP, arrhythmias, appetite loss

Question 31

Acetylecholinesterase Inhib

Answer 31

- DONEPEZIL, RIVASTIGMINE, Galantamine for MILD-MOD ALZHEIMER'S

Question 32

AChE Inhib SE

Answer 32

- Fatigue - GI issues - BRADYCARDIA - Need to check BASLINE ECG + PR before starting

Question 33

Z-drugs

Answer 33

SLEEPING PILLS etc ZOPICLONE - Stimulate GABA receptor - RIsk of Dependancy - Careful in neuro / resp disease

Question 34

Antipsychotics indications

Answer 34

- PSYCHOSIS - MANIA - Depresssion - Refractory anxiety - PTSD - Behavioural challenges in dementia - Tourettes - Rapid tranquilisation

Question 35

Antipsychotics SE

Answer 35

- ANTICHOLINERGIC - ANTIHISTAMINERGIC - ANTI-ALPHA ADRENERGIC - Lower seizure thershold - QT PROLONGATION Extrapyramidal (more common in typical APs): - Parkinsonism - Acute dystonia - Tradive dyskinesia after years (permenant)

Question 36

MOA of Typical Antipsychotics + examples

Answer 36

ANTAGONISE D2 RECEPTORS - involved in: - Mesolimbic (delusions / hallucinations) - Mesocortical (Negative Sx) - Substantia Nigra (Movement - blocking -> Extrapyramidal SE) - Tuberoinfundibular (blocks dopamine inhib of pit gland -> prolactin secretion -> improved sexual function + libido) - Chemoreceptor trigger zone (N+V) HALOPERIDOL (injectable), CHLORPROMAZINE, FLUPENTIXOL

Question 37

MOA of Atypical antipsychotics + examples

Answer 37

BLOCKS 5HT2 receptor -> METABOLIC SE (weight gain, impaired glycaemic control, lipid elevation) E.g. RISPERIDONE, OLANZEPINE, CLOZAPINE, Quetiapine, Aripiprazole (these can be given IM)

Question 38

When is clozapine used and why is it not commonly used

Answer 38

Tx RESISTANT SCHIZOPHRENIA Has lots of SE: - Hypersalivation - Constipation - Myocarditis - Cardiomyopathy - **NEUTROPENIA + AGRANULOCYOTOSIS**

Question 39

Methadone

Answer 39

- Used as oral substitution therapy in addictions * Opiate receptor agonist * Risk of respiratory depression

Question 40

Buprenorphine

Answer 40

* Oral substitution in opiate dependence * Partial opiate receptor agonist * Patient needs to be in state of withdrawal before starting or will cause withdrawal

Question 41

Examples of liver enzyme inducing drugs

Answer 41

- Rifampicin - Phenytoin - Carbamazepine - St John's Wort - Chronic alcohol use Important as more at risk from paracetamol overdose