Psychopharmacy

Question 1

When are antidepressants indicated?

Answer 1

Unipolar and bipolar depression, 
Mood disorders, 
Schizoaffective disorder, 
Anxiety disorders, 
PTSD

Question 2

How long does it take to see the affects of antidepressants work?

Answer 2

3-6 weeks

Question 3

What are the classifications of antidepressants?

Answer 3

Tricyclics,
Monamine oxidase inhibitors,
Selective serotonin reuptake inhibitors,
Serotonin/ noradrenaline reuptake inhibitors,
Novel antidepressants

Question 4

Cons of TCAs

Answer 4

Lethal in overdose,
Side effects- antihistaminic, anticholinergic, antiadrenergic,
Can cause QT lengthening

Question 5

Examples of side effects causes by tertiary TCAs

Answer 5

Antihistaminic (sedation and weight gain),
Anticholinergic (dry mouth, dry eyes, constipation, memory deficits, delirium)
Antiadrenergic (orthostatic hypotension, sedation, sexual dysfunction)

Question 6

What receptors do tertiary TCAs mainly act on?

Answer 6

Serotonin receptors

Question 7

Name some examples of tertiary TCAs

Answer 7

Imipramine,
Amitriptyline,
Doxxepin,
Clomipramine

Question 8

What receptor do secondary TCAs act on?

Answer 8

Noradrenaline

Question 9

Examples of secondary TCAs

Answer 9

Desipramine,

Notriptyline

Question 10

How do monoamine oxidase inhibitors work?

Answer 10

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

Question 11

Side effects of monoamine oxidase inhibitors?

Answer 11

Orthostatic hypotension, 
Weight gain, 
Dry mouth, 
Sedation, 
Sexual dysfunction, 
Sleep disturbance,
Cheese reaction

Question 12

What is the cheese reaction?

Answer 12

A hypertensive crisis that can develop when MAOI’s are taken with tyramine-rich food or sympathomimetics (red wine, cheese, processed meats, beans)

Question 13

What is serotonin syndrome

Answer 13

A condition that can develop if MAOI is taken with meds that increase serotonin or have sympathomimetic actions

Question 14

Serotonin syndrome symptoms?

Answer 14

Abdominal pain, 
Diarrhoea, 
Sweats, 
Tachycardia, 
Hypertension, 
Myoclonus, 
Irritability, 
Delirium,
Hyperperexia, 
Cardiovascular shock and death

Question 15

How to avoid serotonin syndrome?

Answer 15

Wait 2 weeks before switching from an SSRI to an MAOI

And wait 5 weeks if swapping from fluoxetine

Question 16

How do selective serotonin reuptake inhibitors (SSRIs) work?

Answer 16

Block the presynaptic serotonin reuptake

Question 17

Side effects of SSRIs

Answer 17

GI upset, 
Sexual dysfunction,
Anxiety,
Restlessness, 
Nervousness, 
Insomnia, 
Fatigue, 
Sedation, 
Dizziness

Question 18

Pro of SSRIs

Answer 18

Little risk of overdose

Question 19

Examples of SSRIs

Answer 19

Paroxetine, 
Sertraline (common GI SE)
Fluoxetine (aka prozac, has a long half life),
Citlopram (common sedating and GI SE),
Escitalopram,
Fluvoxamine

Question 20

How do serotonin/ norepinephrine reuptake inhibitors (SNRIs) work?

Answer 20

Inhibit serotonin and noradrenergic reuptake like the TCAs but without side effects

Question 21

Examples of serotonin/norepinephrine reuptake inhibitors

Answer 21

Venlafaxine (short half life, can cause a 10-15mmHG increase in diastolic BP),
Duloxetine

Question 22

Novel antidepressants examples?

Answer 22

Mirtazapine (increases serum cholesterol, very sedating, weight gain),
Buproprion (can increase seizure risk, anxiety, agitation, insomnia)

Question 23

Best 1st line treatement for depression?

Answer 23

SSRI

Citalopram, fluoxetine, sertraline best choices

Question 24

Which SSRI have a higher chance of sedation and weight gain as side effects?

Answer 24

Paroxetine,

Mitrzapine

Question 25

How long should you keep people on antidepressants after they feel better?

Answer 25

After 1st episode- 6 months, After 2nd episode- 2 years, After 3rd episode- lifelong

Question 26

Indications for mood stabilisers?

Answer 26

Bipolar, Cyclothymia, Schizoaffective

Question 27

Classes of mood stabilisers?

Answer 27

Lithium, Anticonvulsants, Antipsychotics

Question 28

Factors predicting positive response to lithium?

Answer 28

Prior long term response, family member with good response, Classic pure mania, Mania followed by depression

Question 29

What should you check before starting lithium?

Answer 29

U&Es, TSH, Pregnancy test (associated with Epstein’s anomaly in 1st trimester)

Question 30

How to monitor lithium?

Answer 30

Steady state achieved after 5 days, Check 12 hours after last dose, Once stable check every 3 months and TSH and creatinine every 6 months

Question 31

Lithium blood level goal?

Answer 31

0.6-1.2

Question 32

Most common lithium side effects?

Answer 32

GI distress - reduced appetite, - n/v - diarrhoea

Question 33

Other lithium side effects?

Answer 33

``` Thyroid abnormalities, No significant leukocytosis, Polyuria/ polydypsia, Hair loss, Acne, Reduces seizure threshold, Cognitive slowing, Intention tremor ```

Question 34

Lithium toxicity levels

Answer 34

Mild- 1.5-2.0 Moderate- 2.0-2.5 Severe- >2.5

Question 35

Mild lithium toxicity signs?

Answer 35

``` Vomiting, Diarrhoea, Ataxia, Dizziness, Slurred speech, Nystagmus ```

Question 36

Moderate lithium toxicity signs?

Answer 36

``` N/v, Anorexia, Blurred vision, Clonic limb movements, Convulsions, Delirium, Syncope ```

Question 37

Severe lithium toxicity signs

Answer 37

Generalised convulsions, Oliguria, Renal failure

Question 38

Examples of anticonvulsants

Answer 38

Valproic acid, Carbamazepine, Lamotrigine

Question 39

Factors predicting a positive response from valproic acid

Answer 39

Rapid cycling patients, Comorbidities substance issues, Mixed patients, Patients with comorbidities anxiety disorders

Question 40

Tests to do before commencing valproic acid?

Answer 40

Baseline liver function tests, Pregnancy test, FBC

Question 41

Goal blood level of valproic acid?

Answer 41

50-125

Question 42

Valproic acid side effects

Answer 42

``` Thrombocytopenia, Platelet dysfunction, N/v, Weight gain, Sedation, Tremor, Increased risk of neural tube defect, Hair loss ```

Question 43

When is carbamazepine prescribed?

Answer 43

First line agent for acute mania and mania prophylaxis

Question 44

Carbamazepine side effects?

Answer 44

``` Rash, N/v, Diarrhoea, Sedation, Dizziness, Ataxia, Confusion, AV conduction delays, Aplastic anaemia and agranulocytosis, Water retention, Rug-drug interactions ```

Question 45

Drugs that can increase carbamazepine levels/ toxicity?

Answer 45

``` Acetazolamiode, Cimetidine, Diltiazem, Fluvoxamine, Fluoxetine, Clarithromycin, Fluconazole, Metronidazole, Verapamil ```

Question 46

Side effects of lamotrigine

Answer 46

N/v, Sedation, dizziness, ataxia, confusion, TENS and SJS