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Dr. Kamran Mehmood
(Clinical Fellow North Bristol NHS Trust UK)

50 yr Old Male.
had MI 6 months ago.
Down recently and not as active as used to be
works in a warehouse
Your Diagnosis is Moderate Depression
Sertraline or Venlafaxine?
Used in Moderate to severe depression.
Common S/E: Nausea, Constipation, Anorexia.
Drowsiness, Dizziness, Dry mouth, Insomnia,

Depression and Anxiety co-exist in patients with CVD

DO NOT start venlafaxine or TCA in patients with
recent MI.
45 year old Female with Mild Depression.
Had CBT based self help for last three
months but does not feel better. What
would you do next?
1. Venlafaxine
2. Citalopram
3. Dosulepin
Venlafaxine: Not 1st line

Citalopram: SSRI, Fewer side effects. 1st line

in Mild Depression

Dosulepin: TCA. Increased Cardiac Risks

35 year old female presented a few months ago with 1st
episode of Depression. Was started on Citalopram 20mg/day
by another GP taking since 8 months. Symptoms resolved 6
months ago. Patient now wants to stop taking medicine.
What would you do?

1. Stop Citalopram
2. Change Citalopram to Fluoxetine
3. Gradually reduce the dose and then stop.
Start low and go slow

Reduce antidepressants over at least 4 weeks to

avoid discontinuation symptoms
Discontinuation symptoms of
More with Paroxetine (Why?)
Less with Fluoxetine

Worsening or labile mood

Discontinuation symptoms of TCA

GI symptoms (NVD, Abdominal pain)

Flu like symptoms
Anxiety, Agitation.
Fatigue, sleep disturbances (Nightmares)
Movement disorders (Akathisia)
40 year old Female, Bipolar. On Lithium, symptoms stable for
Now presented with 2 day history of D & V. O/E Mild dehydration
confusion and Ataxic gait. What will you do?

1. Stool culture and Oral rehydration fluids

2. Review lithium dose and review patient in one week
3. Stop lithium immediately and refer to acute care.
Lithium Toxicity
>1.5 mmol/L
Risk group: Elderly, Impaired renal function,
dehydrated, Drugs causing sodium depletion, drugs
reducing lithium excretion.
V/D, Coarse tremors (mostly hands), muscle weakness,
lack of coordination, Ataxia, Slurred speech, Blurred
vision, lethargy, Confusion, Seizures.
Lithium Side effects:
Fine tremors
Dry Mouth
Altered taste sensation
Increased thirst
Increased frequency of urination
Mild Nausea
Weight gain
ECG changes, Goitre, Hyperparathyroidism, Hypothyroidism,
Monitoring patients on Lithium
Baseline weight
FBC, U&E, eGFR, corrected calcium, Thyroid function.

Baseline investigations before starting treatment and then

every 6 months.

NICE: Lithium levels every 3 months for 1st year and 6

monthly afterwards. (3 monthly if last plasma lithium level
0.8mmol or greater)
40 yr old Female, known GAD, had worsening
symptoms 3 weeks ago for which short course of
Diazepam was started. She is much calmer now.
Continue Diazepam or not?
1. Continue for further 3 weeks
2. Refer to Psychological therapy
3. Start Venlafaxine
4. Start Beta Blocker
NICE Guidelines:

Do not Give Benzodiazepines for more

than 2 to 4 weeks in GAD
42 yr old Female with Fibromyaligia. Pain worse at night
which keeps her awake. She has moderate depression. There
are no Contraindications for Antidepressants so you start her
on Amitriptyline. What should you tell her?

1. Dry Mouth
2. Regular Blood tests to check the level of Drugs
3. May keep awake at night
Side effecsts of TCA
Cardiac Arrhythmias and Heart Block
Anticholinergic Symptoms (dry mouth, difficulty in voiding,
postural hypotension, precipitation of Glaucoma)
Mood and sleep disturbance
Confused states
Fine tremors/headache
Skin rashes
Mild Cholestatic Jaundice
35 year old Male with Schizophrenia. On Antipsychotic since
3 months and cetirizine for hay fever, also finished a course
of Fluclox for skin infection a week ago. Went for sunbathing
over weekend has, now has rash near arms and chest. Most
likely cause of rash?

1. Cetrizine
2. Chlorpromazine
3. Flucloxacillin
1st Generation - Phenothiazines: (Blocks D2 receptors, Non
Selective for any dopamine pathway)
Group 1: Chlorpromazine (Photosensitive Rash),
Levomepromazine, Promazine. All are sedative with
moderate antimuscarinic and extrapyramidal side effects
Group 2: Pericyazine, Pipotiazine. Fewer extrapyramidal side
Group 3: Fluphenazine, prochlorperazine. Less sedative,
more extrapyramidal side effects.
2nd Generation Olanzapine, Clozapine, Quetiapine Less EP
symptoms. High risk of metabolic adverse effects
25 year old male with Schizophernia brought in by
mother. Started taking Flupentixol 2 weeks ago. Now
has 1 day history of confusion, 2 episodes of
incontinence. O/E: confused, drowsy, Temp 38
degrees, HR 110/min, BP 160/100mmHg

Neuroleptic Malignant Syndrome
Rare usually in early stage of treatment
Most common with 1st generation antipsychotics
Hyperthermia, fluctuating consciousness, muscle
rigidity, tachycardia, labile BP, sweating, incontinence
and Raised CPK levels.

Tx: Supportive.
Withdraw drug, rehydrate and benzodiazepine.
35 year old female taking Lorazepam 1mg 6 times a
day for 2 years. Initially started to manage anxiety.
Symptomless now. What should be done?
1. Stop Lorazepam Immediately
2. Switch to Pregabalin
3. Switch from Lorazepam to Diazepam before
initiating Benzo withdrawal.
Benzodiazepine Withdrawal:
Short Acting Benzodiazepines (Lorazepam, Oxizepam)
preferred in hepatic impairment but risk of
withdrawal is more (insomnia, anxiety, convulsions)

Long Acting Benzodiazepines (Diazepam, Alprazolam,

Chlordiazepoxide, Clobazam) Withdrawal symptoms
usually take a longer time to set in after stopping up
to 3 weeks.
28 year old female, Bipolar, well for past 2 yrs, pregnancy is
confirmed. Currently stable and not on treatment. Which of
the following is safest if she needs treatment during

1. Carbamezapine
2. Valproate
3. Lithium
4. Antipsychotics
Pregnancy and Psychotropic
Valproate Stop, fetal malformation
Carbamezapine Discuss stopping, risk of FM
If already taking Lamotrigine Check levels frequently
and into post natal period, Risk of cleft palate. Should
not routinely be prescribed in pregnancy
Lithium: Check levels every 4 weeks then weekly from
36th week. Stop during labour and check levels 12
hours after last dose.
65 year old female with episodes of dizziness since
starting Citalopram 20mg/day 3 weeks ago. Symptoms
start when standing up from sitting or when gets out
of bed in morning. BP 138/80 on sitting and 120/65
on standing Mood has improved. What will you do?
1. Continue on current dose
2. Decrease Citalopram and review in two weeks
3. Stop Citalopram
Key Points
Lithium and Antipsychotics Life threatening side effects
When starting any psychotropic drug inform about side
Review regularly
Patients taking SSRI and NSAIDS/Aspirin are at increased risk
of UGI bleed. Consider alternative antidepressant and PPI
Herbal Mood enhancers like St. Johns Wort may interact
with other medicine (Enzyme inducer, OCP, Anticoagulation
drugs, Antiepileptic drugs) Active ingredient vary.
Thank you