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Psychopharmacology Flashcards

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1
Q

What are the indications for antidepressants?

A

Unipolar and bipolar depression
Organic mood disorders
Schizoaffective disorder
Anxiety disorders including OCD, panic, social phobia, PTSD

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2
Q

What is the time frame of delay for antidepressants to control symptoms?

A

2-4 weeks

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3
Q

What are the guidelines for prophylactic antidepressant use?

A

First episode continue for 6mth to a year
Second episode continue for 2 years
Third episode disucuss life long

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4
Q

What are the different classes of antidepressants?

A

Tricyclics (TCAs)
Monoamine Oxidase Inhibitors (MAOIs)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)
Novel antidepressants

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5
Q

What are the possible adverse affects of TCAs?

A

Antihistaminic, anticholinergic, antiadrenergic (low BP, constipation, arrhythmia)
Lethal in overdose
QT lengthening

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6
Q

What is the chemical composition of tertiary TCAs?

A

Tertiary amine side chains
Side chains prone to cross react with other types of receptors leading to more side effects
Have active metabolites

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7
Q

What is the main pharmacological action of secondary TCAs?

A

Block noradrenaline

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8
Q

What are some examples of secondary TCAs?

A

Desipramine, notrtriptyline

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9
Q

What is the pharmacological action of MAOIs?

A

Bind irreversibly to monoamine oxidase thereby preventing inactivation of amines such as norepinephrine, dopamine and serotonin leading to increased synaptic levels

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10
Q

What are some of the side effects of MAOIs?

A 
Orthostatic hypotension 
Weight gain
Dry mouth
Sedation
Sexual dysfunction 
Sleep disturbance
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11
Q

What is the cheese reaction?

A

Hypertensive crisis can develop when MAOI’s are taken with tyramine-rich foods or sympathomimetics

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12
Q

What is serotonin syndrome?

A

Can develop if take MAOI with meds that increase serotonin or have sympathomimetic actions

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13
Q

What are the symptoms of serotonin syndrome?

A 
Abdominal pain 
Diarrhoea
Sweats 
Tachycardia 
HTN 
Myoclonus 
Irritability 
Delirium
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14
Q

How can serotonin syndrome be avoided?

A

Wait 2 weeks before switching from an SSRI to an MAOI

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15
Q

What is the main function of SSRIs?

A

Block the presynaptic serotonin reuptake

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16
Q

What are the side effects of SSRIs?

A 
GI upset
Sexual dysfunction (30%+!), 
Anxiety, 
Restlessness, 
Nervousness, 
Insomnia, 
Fatigue or sedation,
Dizziness
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17
Q

What is activation syndrome?

A

Cause increased serotonin. Cab be distressing for patient

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18
Q

What are the symptoms of activation syndrome?

A

Nausea
Increased anxiety
Panic
Agitation

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19
Q

What are the symptoms of discontinuation syndrome?

A

Agitation
Nausea
Disequilibrium
Dysphoria

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20
Q

What are the pros of paroxetine?

A 
Short half life with no active metabolite means no build-up (which is good if hypomania develops)
Sedating properties (dose at night) offers good initial relief from anxiety and insomnia
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21
Q

What are the cons of paroxetine?

A

Sedating, wt gain, more anticholinergic effects

Likely to cause a discontinuation syndrome

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22
Q

What are the pros of sertraline?

A

Very weak P450 interactions (only slight CYP2D6)
Short half life with lower build-up of metabolites
Less sedating when compared to paroxetine

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23
Q

What are the cons of sertraline?

A

Max absorption requires a full stomach

Increased number of GI adverse drug reactions

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24
Q

What are the pros of fluoxetine?

A

Long half-life so decreased incidence of discontinuation syndromes. Good for pts with medication noncompliance issues
Initially activating so may provide increased energy
Secondary to long half life, can give one 20mg tab to taper someone off SSRI when trying to prevent SSRI Discontinuation Syndrome

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25
What are the cons of fluoxetine?
Long half life and active metabolite may build up (e.g. not a good choice in patients with hepatic illness) Significant P450 interactions so this may not be a good choice in pts already on a number of meds Initial activation may increase anxiety and insomnia More likely to induce mania than some of the other SSRIs
26
What are the pros of citalopram?
Low inhibition of P450 enzymes so fewer drug-drug interactions Intermediate ½ life
27
What are the cons of citalopram?
Dose-dependent QT interval prolongation with doses of 10-30mg daily- due to this risk doses of >40mg/day not recommended! Can be sedating (has mild antagonism at H1 histamine receptor) GI side effects (less than sertraline)
28
What are the pros of escitalopram?
Low overall inhibition of P450s enzymes so fewer drug-drug interactions Intermediate 1/2 life More effective than Citalopram in acute response and remission
29
What are the cons of escitalopram?
Dose-dependent QT interval prolongation with doses of 10-30mg daily Nausea, headache
30
What are the pros of fluvoxamine?
Shortest ½ life | Found to possess some analgesic properties
31
What are the pros of fluvoxamine?
Shortest ½ life GI distress, headaches, sedation, weakness Strong inhibitor of CYP1A2 and CYP2C19
32
How do SNRIs work?
Inhibit both serotonin and noradrenergic reuptake like the TCAS but without the antihistamine, antiadrenergic or anticholinergic side effects
33
What are SNRIs most commonly used to treat?
Depression Anxiety Neuropathic pain
34
What are the pros of venlafaxine?
Minimal drug interactions and almost no P450 activity | Short half life and fast renal clearance avoids build-up (good for geriatric populations)
35
What are the cons for venlafaxine?
Can cause a 10-15 mmHG dose dependent increase in diastolic BP. May cause significant nausea, primarily with immediate-release (IR) tabs Can cause a bad discontinuation syndrome, and taper recommended after 2 weeks of administration Noted to cause QT prolongation Sexual side effects in >30%
36
What are the pros of duloxetine?
Some data to suggest efficacy for the physical symptoms of depression Thus far less BP increase as compared to venlafaxine, however this may change in time
37
What are the cons of duloxetine?
CYP2D6 and CYP1A2 inhibitor Cannot break capsule, as active ingredient not stable within the stomach In pooled analysis had higher drop out rate
38
What are the pros of mertazapine?
Different mechanism of action may provide a good augmentation strategy to SSRIs. Is a 5HT2 and 5HT3 receptor antagonist Can be utilized as a hypnotic at lower doses secondary to antihistaminic effects
39
What are the cons of mertazapine?
Increases serum cholesterol by 20% in 15% of patients and triglycerides in 6% of patients Very sedating at lower doses. At doses 30mg and above it can become activating and require change of administration time to the morning. Associated with weight gain (particularly at doses below 45mg
40
What are the pros of buproprion?
Good for use as an augmenting agent Mechanism of action likely reuptake inhibition of dopamine and norepinephrine No weight gain, sexual side effects, sedation or cardiac interactions Low induction of mania Is a second line ADHD agent so consider if patient has a co-occurring diagnosis
41
What are the cons of buproprion?
May increase seizure risk at high doses (450mg+) and should avoid in patients with Traumatic Brain Injury, bulimia and anorexia. Does not treat anxiety unlike many other antidepressants and can actually cause anxiety, agitation and insomnia Has abuse potential because can induce psychotic sx at high doses
42
What are the indications for mood stabilisers?
Bipolar Cyclothymia Schizoaffective
43
How must lithium be used?
Get baseline U&E and TSH Must get pregnancy test from female Once stable check levels every 3 months Check creatinine and TSH every 6 months
44
What are the side effects of lithium?
GI distress including reduced appetite, nausea/vomiting, diarrhea Thyroid abnormalities Nonsignificant leukocytosis Polyuria/polydypsia secondary to ADH antagonism. In a small number of patients can cause interstitial renal fibrosis. Hair loss, acne Reduces seizure threshold, cognitive slowing, intention tremor
45
What would mild levels of lithium toxicity cause?
``` Vomiting Diarrhea Ataxia Dizziness Slurred speech Nystagmus ```
46
What would moderate levels of lithium toxicity cause?
``` Nausea Vomiting Anorexia Blurred vision Clonic limb movements Convulsions Delirium Syncope ```
47
What would severe levels of lithium toxicity cause?
Generalised convulsions Oliguria Renal failure
48
How must valproic acid be used?
LFTS, pregnancy test and FBC
49
What are the side effects of valproic acid?
Thrombocytopenia and platelet dysfunction Nausea, vomiting, weight gain Sedation, tremor Increased risk of neural tube defect 1-2% vs 0.14-0.2% in general population secondary to reduction in folic acid Hair loss
50
What is carbamazepine used to treat?
Acute mania and mania prophylaxis
51
How must carbamazepine be used?
LFT, FBC and ECG before starting
52
What are the side effects of carbamazepine?
Rash- most common SE seen Nausea, vomiting, diarrhea Sedation, dizziness, ataxia, confusion AV conduction delays Aplastic anemia and agranulocytosis (<0.002%) Water retention due to vasopressin-like effect which can result in hyponatremia Drug-drug interactions
53
How should lamotrigine be used?
LFTs before starting Start with 25mg daily for 2 weeks Increase to 50mg for 2 weeks Increase to 100mg
54
What are the side effects of lamotrigine?
``` Nausea/vomiting Sedation Dizziness Ataxia Confusion Toxic epidermal necrolysis Stevens Johnson's syndrome ```
55
What are the indications for antipyschotics?
Schizophrenia Schizoaffective disorder Bipolar disorder- for mood stabilization and/or when psychotic features are present, psychotic depression, augmenting agent in treatment resistant anxiety disorders
56
What are the key pathways that are affected by dopamine in the brain?
Mesocortical Mesolimbic Nigrostriatal Tuberoinfundibular
57
What are the side effects of respiridone?
Increased extrapyramidal side effects Hyperprolactinaemia Weight gain Sedation
58
What are the side effects of olanzapine?
Weight gain Hypertriglyceridemia, hypercholesterolemia, hyperglycemia Abnormal LFTs Hyperprolactinaemia
59
What are the side effects of quetiapine?
Abnormal LFTs Weight gain Hypertriglyceridemia, hypercholesterolemia, hyperglycemia Orthostatic hypotension
60
What are the pros of aripiprazole?
Low EPS Low sedation No QT prolongation
61
What are the cons of clozapine?
Associated with agranulocytosis (0.5-2%) and therefore requires weekly blood draws x 6 months, then Q- 2weeks x 6 months Increased risk of seizures Associated with the most sedation, weight gain and abnormal LFT’s Increased risk of hypertriglyceridemia, hypercholesterolemia, hyperglycemia, including nonketotic hyperosmolar coma and death with and/or without weight gain
62
What is tar dive dyskinesia?
Involuntary muscle movements that may not resolve with drug discontinuation
63
What is neuroleptic malignant syndrome?
Characterized by severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC, CPK and lfts. Potentially fatal
64
What are extrapyramidal side effects (EPS)?
Acute dystonia Parkinson syndrome Akathisia
65
What can be taken to manage EPS?
Anticholinergics (benzotropine, trihexyphenidyl, diphenhydramine) Amantadine Beta blockers (propanolol)
66
What are anxiolytics used to treat?
Panic disorders Generalised anxiety disorder Substance-Related disorder
67
What are the pros of busprione?
Good augmentation strategy- Mechanism of action is 5HT1A agonist. It works independent of endogenous release of serotonin. No sedation
68
What are the cons of buspirone?
Takes around 2 weeks before patients notice results. Will not reduce anxiety in patients that are used to taking BZDs because there is no sedation effect to “take the edge off.
69
What are benzodiazepines used to treat?
Insomnia Parasomnias Anxiety disorders
70
What are the side effects of benzodiazepines?
``` Somnolence Cognitive deficits Amnesia Disinhibition Tolerance Dependence ```

Psychiatry (17 decks)

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