Psychopharmacology

Question 1

What is important to establish before prescribing a medication for psychiatric problem?

Answer 1

Diagnosis

target symptoms - monitor therapy response

Question 2

How to select the agent and dose

Answer 2

acceptable side effect profile
lowest effective dose
been on medication before which worked
PMH

Question 3

Indications for anti-depressants

Answer 3

unipolar and bipolar depression
organic mood disorders
schizoaffective disorder
anxiety disorders - OCD, panic, social phobia, PTSD

Question 4

How long is the delay after therapeutic dose is achieved and symptoms improving?

Answer 4

3-6 weeks

Question 5

If no improvement after 2 months of adequate dose what should be done?

Answer 5

switch to another antidepressant or augment with another agent

Question 6

Classifications of antidepressants

Answer 6

TCAs
MAOIs
SSRIs
SNRIs
Novel antidepressants

Question 7

3 potentially unacceptable side effect profile of TCAs

Answer 7

anticholinergic
antihistaminic
antiandrenergic

Question 8

Caution with prescribing even a weeks dose of TCAs

Answer 8

lethal in overdose

can cause QT lengthening

Question 9

Why do TCAs have the 3 side effect profile?

Answer 9

tertiary side chains cross react with other types of receptors

Question 10

antihistaminic side effects

Answer 10

sedation and weight gain

Question 11

anticholinergic side effects

Answer 11

dry mouth
dry eyes
constipation
memory deficits and delirium

Question 12

Anti adrenergic side effects

Answer 12

orthostatic hypotension
sedation
sexual dysfunction

Question 13

tertiary TCAs receptors

Answer 13

predominantly serotonin

Question 14

Examples of tertiary TCAs

Answer 14

imipramine
amitriptyline
clomipramine

Question 15

Where do secondary TCAs arise from?

Answer 15

metabolites of tertiary TCAs

Question 16

primary action of secondary TCAs

Answer 16

block noradrenaline

Question 17

Examples of secondary TCAs

Answer 17

desipramine

nortriptyline

Question 18

How do MAOIs work?

Answer 18

bind irreversibly, preventing inactivation of amines eg Norepinephrine, dopamine and serotonin

Question 19

What are MAOI’s very effective for?

Answer 19

depression

Question 20

Side effects of MAOIs

Answer 20

orthostatic hypotension 
weight gain 
dry mouth 
sedation 
sexual dysfunction 
sleep disturbance

Question 21

Hypertensive crisis occurs with which meds and when?

Answer 21

MAOIs
taken with tyramine rich foods or sympathomimetics
cheese reaction

Question 22

Serotonin syndrome occurs with which meds and when?

Answer 22

MAOI and meds that increase serotonin or sympathomimetics

Question 23

Serotonin syndrome symptoms

Answer 23

abdominal pain 
diarrhoea
sweats 
tachycardia 
HTN 
myoclonus 
irritability 
delirium 
death

Question 24

How to avoid serotonin syndrome

Answer 24

wait 2 weeks before SSRI –> MAOI (fluoxetine is 5 weeks)

Question 25

How do SSRIs work?

Answer 25

block presynaptic serotonin reuptake

Question 26

Side effects of SSRIs

Answer 26

``` GI upset sexual dysfunction * anxiety restlessness nervousness insomnia fatigue or sedation dizziness ```

Question 27

What do SSRIs treat?

Answer 27

anxiety and depression

Question 28

Discontinuation syndrome of SSRIs

Answer 28

agitation nausea dysphoria

Question 29

Name some SSRIs

Answer 29

``` paroxetine sertraline fluoxetine citalopram escitalopram fluvoxamine ```

Question 30

How o SNRIs work?

Answer 30

block both serotonin and noradrenergic reuptake like TCAs

Question 31

Positives of SNRIs compared to TCAs

Answer 31

no anti cholinergic, histaminic or adrenergic side effects

Question 32

SNRIs uses

Answer 32

depression anxiety neuropathic pain

Question 33

Examples of SNRIs

Answer 33

venlafaxine | duloxetine

Question 34

Mirtazapine

Answer 34

5HT2 and 5HT3 receptor antagonist

Question 35

Buproprion

Answer 35

good as augmenting agent

Question 36

How to combat treatment resistance with antidepressants

Answer 36

combo eg SSRI/SNRI with mirtazapine adjunctive with lithium adjunctive with atypical antipsychotic eg olanzapine ECT

Question 37

Indications for mood stabilisers

Answer 37

bipolar cyclothymia schizoaffective

Question 38

Classes of mood stabilisers

Answer 38

lithium anticonvulsants antipsychotics

Question 39

Only medication to reduce suicide rate

Answer 39

lithium

Question 40

Factors predicting positive response to lithium

Answer 40

prior long term response of family member good response classic pure mania mania followed by depression

Question 41

before starting lithium

Answer 41

U+E, TSH | pregnancy test - ebsteins

Question 42

monitoring lithium

Answer 42

TSH and creatinine

Question 43

Goal blood level for lithium

Answer 43

0.6-1.2

Question 44

Lithium side effects

Answer 44

GI distress - low appetite, vomiting, diarrhoea thyroid abnormalities polyuria/polydipsia hair loss and acne

Question 45

Symptoms of lithium toxicity

Answer 45

vomit, diarrhoea, convulsions, renal failure, blurred vision, syncope

Question 46

Valproic acid compared to lithium

Answer 46

as effective in mania prophylaxis but not depression prophylaxis better tolerated

Question 47

Factors predicting positive response to valproic acid

Answer 47

rapid cycling patient - F co morbid substance issue mixed patients comorbid anxiety disorder

Question 48

Before starting valproic acid

Answer 48

LFT pregnancy test FBC folic acid supplement in women

Question 49

monitoring valproic acid

Answer 49

LFT and CBC

Question 50

Goal blood level valproic acid

Answer 50

50-125

Question 51

Valproic acid side effects

Answer 51

thrombocytopenia nausea, weight gain sedation, tremor NTD

Question 52

What is carbamazepine first line for?

Answer 52

acute mania and mania prophylaxis

Question 53

Who is carbamazepine indicated for?

Answer 53

rapid cyclers | mixed patients

Question 54

Before starting carbamazepine

Answer 54

LFT, FBC, ECG

Question 55

Monitoring carbamazepine

Answer 55

CBC and LFT

Question 56

Why must you check and adjust carbamazepine levels at a month?

Answer 56

induces own metabolism

Question 57

carbamazepine side effects

Answer 57

RASH | nausea, vomit, sedation, ataxia, water retention, drug-drug interactions

Question 58

Lamotrigine side effects

Answer 58

N&V, sedation, TEN, SJS - stop if any rash | blood dyscriasis

Question 59

What does valproic acid do to lamotrigine?

Answer 59

increases/doubles levels

Question 60

Indication for antipsychotics

Answer 60

schizophrenia schizoaffective bipolar - mood stabilisation/psychotic psychotic depression

Question 61

4 dopamine pathways in brain

Answer 61

mesocortical mesolimbic nigrostriatal tuberoinfindibular

Question 62

mesocortical

Answer 62

brain stem to cortex negative symptoms too little dopamine

Question 63

mesolimbic

Answer 63

dopaminergic cell bodies in brainstem to limbic system positive symptoms too much dopamine

Question 64

nigrostriatal

Answer 64

dopaminergic cell bodies in substantia nigra to basal ganglia movement regulation

Question 65

Dopamine effect on Ach

Answer 65

suppression

Question 66

Dopamine hypoactivity

Answer 66

parkinsonian movements

Question 67

Tuberoinfindibular

Answer 67

hypothalamus to ant.pit.

Question 68

Dopamine effect on prolactin

Answer 68

inhibits release

Question 69

Blocking dopamine in tuberoinfindibular pathway

Answer 69

hyperprolactinaemia | gynaecomastia, galactorrhoea

Question 70

Typical antipsychotics class

Answer 70

D2 dopamine receptor antagonists

Question 71

High potency typical antipsychotics

Answer 71

bind with high affinity | extrapyramidal side effects

Question 72

Low potency typical antipsychotics

Answer 72

less affinity for 2 interact with non dopaminergic receptors anticholinergic effects

Question 73

How atypical antipsychotics work

Answer 73

serotonin-dopamine 2 antagonists

Question 74

Why are atypical antipsychotics atypical?

Answer 74

affect dopamine and serotonin neurotransmission in 4 key brain dopamine pathways

Question 75

Examples of atypical antipsychotics

Answer 75

``` risperidone olanzapine Seroquel apiprazole clozapine ```

Question 76

What is clozapine associated with?

Answer 76

agranulocytosis - weekly blood draws

Question 77

Antipsychotic adverse effects

Answer 77

tardive dyskinesia neuroleptic malignant syndrome EPS

Question 78

Agents for EPS

Answer 78

anticholinergics dopamine facilitators beta blockers

Question 79

Atypical antipsychotics before starting

Answer 79

fasting lipid profile fasting blood sugar LFT CBC

Question 80

Anxiolytic use

Answer 80

panic disorder GAD substance related insomnia

Question 81

Using anxiolytics to treat anxiety

Answer 81

used with SSRI or SNRI

Question 82

Anxiolytics

Answer 82

BZD | buspirone

Question 83

BZD side effects

Answer 83

``` somnolence amnesia cognitive deficits disinhibition tolerance dependence ```