Which medications may trigger anxiety?
- Salbutamol
- Theophylline
- Corticosteroids
- Anti-Depressants
- Caffeine
What is the difference between mania and hypomania?
- Both terms relate to abnormally elevated mood or irritability
- Mania → there is severe functional impairment or psychotic symptoms for > 7 days
- Hypomania → describes decreased or increased function for > 4 days
N.B. from an exam point of view the key differentiation is psychotic symptoms
- e.g. delusions of grandeur or auditory hallucinations which suggest mania
What medical consideration need to be made in a patient with Bipolar Disorder?
2-3 times increased ↑ risk of ⟶
- Diabetes
- Cardiovascular Disease
- COPD
What is avolition?
Poor Motivation
You review a patient who has been taking citalopram for the past two years to treat depression. He has felt well now for the past year and you agree a plan to stop the antidepressant. How should the citalopram be stopped?
Withdraw gradually over the next 4 weeks
*Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine due to its longer half-life). Paroxetine has a higher incidence of discontinuation symptoms.*
What is a potential adverse effect of Citalopram?
PROLONGED QT INTERVAL
- Citalopram* → SSRI
- Advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation
- Should not be used in those with →
- congenital long QT syndrome
- known pre-existing QT interval prolongation
- in combination with other medicines that prolong the QT interval
- The maximum daily dose →
- 40 mg for adults
- 20 mg > 65 years old
- 20 mg for those w hepatic impairment
What are some potential drug interactions/considerations when prescribing an SSRI?
- NSAIDs → NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
- Warfarin/Heparin → NICE guidelines recommend avoiding SSRIs and considering mirtazapine
- Aspirin → see above (avoid)
- Triptans → avoid SSRIs
What advice would you give regarding SSRI use in pregnancy?
- BNF says to weigh up benefits & risk when deciding whether to use in pregnancy.
- Use during the 1st trimester gives a small increased risk of congenital heart defects
- Use during the 3rd trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the 1st trimester
What are 2 examples of Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs)?
- Venlaflaxine
- Duloxetine
What are the common side effects of TCAs?
- Drowsiness
- Dry Mouth
- Blurred Vision
- Constipation
- Urinary Retention
Which are the more sedative VS less sedative TCAs?
More Sedative
- Amitriptyline
- Clomipramine
- Dosulepin
- Trazodone
Less Sedative
- Imipramine
- Lofepramine
- Nortriptyline
What are the uses and contra-indications of TCAs?
Used less commonly now for depression due to their side-effects and toxicity in overdose
They are however used widely in the treatment of NEUROPATHIC PAIN (where smaller doses are typically required)
- Low-Dose Amitriptyline →
- neuropathic pain
- prophylaxis of headache → tension and migraine
- Lofepramine has a lower incidence of toxicity in overdose
N.B. Amitriptyline and Dosulepin (Dothiepin) are considered the most DANGEROUS in overdose
Which drug is associated with a reduced seizure threshold?
Clozapine
A 35-year-old man with schizophrenia has been on clozapine for 5 years, and has been well controlled and stable that time. However, at his most recent check-up, the clozapine levels were found to be above toxicity threshold, and his dose had to reduced.
Which of the following is most likely to cause a rise in clozapine blood levels?
Smoking Cessation
- Smoking cessation can cause a significant rise in clozapine levels, and so it should be discussed with a psychiatrist before stopping smoking*
- Starting smoking, or smoking more, can reduce clozapine levels*
