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Psychpharmacology - Coggle Diagram
Psychpharmacology
Antidepressants
Mechanism of Action
All increase monoamine levels within synaptic clefts in relevant parts of brain
MAOI: Inhibit monoamine oxidase, reduce destruction of monoamines
TCAs, SSRI, SNRI, NDRI: Block reuptake of monoamines into presynaptic neurons
NASSA: Block presynaptic a2-adrenergic receptors, thus increasing release of norepinephrine secondarily serotonin into synaptic cleft
Share delay between onset of treatment and the onset of response
Clinical effects include antidepressants action but also development of tolerance to the acute side effects of antidepressant drugs
Side Effects
MAOI
Avoid tyramine containing foods
RIMA
No drug-drug or drug-food interaction like the MAOI's, Nausea, headaches
TCA
Antihistamine - Weight gain, and sedation
Anticholinergic - NaSSA, NDRI
Anti-alpha adrenergic - dizziness, orthostatic hypotension
Blockade of fast sodium channels - Prolongation of QTc
SSRI
THE NEW AGE
Tremor, Headaches, euphoria, nervousness, endocrine, weight changes, anorgasmia, Gastrointestinal Upset, Excretions
SNRI
DAD SINGS
Diastolic Blood pressure increases, Anorexia, Dry Mouth, Sexual, Insomnia, Nervousness, Gastrointestinal Disturbance, Sweating (can be effective in treating pain)
NDRI
Seizures, headache, hypertension, Agitation and Anticholinergic, Rash, Emesis, decrease appetite weight loss, sleep disruption,
Can combine with SSRI with resistant depression: More tremors sleep disruption, agitation (effect on sns), no sexual side effects
SARI
Orthostatic hypotension, sedation
NASSA
Weight, gain, drowsiness, Antiemetic
Hypertensive Crisis
Norepinepherine is most closely linked with control of BP, Tyramine can also cause release of NE
SSRI Discontinuation Syndrome
FINISH Syndrome
Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbances, Hyperarousal
Treatment
Add low dose fluoxetine to reduce symptoms
Serotonin Syndrome
HARMED
Hyperthermia, Agitation, Rigidity, increased reflexes, Myoclonus, Encephalopathy, Diaphoresis
Diagnosis
Using hunter criteria
Serotonin Agent used + one of the following
Spontaneous clonus, inducible clonus, ocular clonus, tremor and hyperreflexia, hypertonia
Choice of Intial Therapy
First line
Psychotherapy
Moderate to severe depression
Medication is indicated
Psychotic dperession
Either combination antipsychotic + antidepressant or ECT
Starting antidepressants
Start withreuptake inhibitor (SSRI, SNRI, NDRI) or mirtazapine (Not TCA or MAOI)
Start at lowest dose
increase every 5 half lives until end points
Intolerable side effects, full response, maximum dose
How to make a choice
Symptom profile, side effects, pt preference, cost, History of response, comorbidities, drug-drug interactions
Goals of Treatmetn
Remission of symptoms, maintaining improvement,
Neurotransmitter Systems
Monoamine neurotransmitters are involved in mood disorders
Norepinepherine
Most of the cell bodies for noradrenergic neurons are ion locus ceruleus
Prominent noradrenergic involvement in SNS (Pain), CNS pain pathways, and brainstem cardiovascular centre
Dopamine
Dopaminergic cell bopdies in substantia nigra
Key for modulation of reward, cognition, sleep and movmenet
Serotonin
Located in the raphe nucleus
Prominent descending serotonergic spinal cord projections and 5HT3 receptors in the GI system
Bipolar Disorder
Mood stabilizer
Treat either : acute bipolar depression, acute mania, maintenance
Lithium
Mechanism Of action
Unknown although ITP is implicated
Involved in second messenger leading to: Increasing GABA, reducing glutamate, stabilizing catecholamine, blocking hormone effect
Side effects
Lethargy, insipidis, Tremor/Teratogen, Hypothyroid, Increased weight, Vomiting, nausea, Misc (EKG changes, acne, hair loss)
Toxicity
Narrow Therapeutic index
Anything that affects water/electrolyte imbalance can contribute to Li toxicity
Increased by NSAIDS, thiazide diuretics, ACEI, tetracyclines, anticonvulsants
Decreased by caffeine, salt, osmotic diuretics, Carbonic Anhydrase inhibitors
Work Up
Lytes, BUN, Cr, TSH, beta hCG, EKG, look at metabolic baseline, Personal and FHx
Monitoring
Every five days, until steady state reached, then every 3-6 months
Repeat kidney functions, TSH, ECG every 6-12 months
BMI, every 3 months
Valproic Acid
Indications
First line for acute mania, and second line for acute bipolar depression
For bipolar mania and for maintenance phase
Side Effects
Acute Side effects
STUN
Sedation, tremor, Unsteadiness, Nausea
Long term side effects
Acne, hair loss, weight gain, edema, Blood dyscrasias, Liver function, reproductive changes
Monitoring
Initial,
CBC< serum every 2-4 days till steady state, Personal + FHx of obesity, dyslipidemia, HT
Ongoing
Repeat monthyl tests for 6 months, then every 6 months until symptoms develop
Lamotrigine
Indications
Bipolar depression (Bipolar 1 and 2)
First line maintenance for bipolar depression
Side effects
Rash, Activation, Spaced out, Steven Johnson Syndrome, Headache
Titration
Start with 25-50 mg/d, increase eery 2 weeks by 25-50 mg, maintenance dose of 100 mg twice daily