{"id":37206,"date":"2026-07-04T07:46:53","date_gmt":"2026-07-04T02:16:53","guid":{"rendered":"https:\/\/atsixty.com\/?p=37206"},"modified":"2026-07-04T07:46:53","modified_gmt":"2026-07-04T02:16:53","slug":"psychopharmacology-i-antidepressants-mood-stabilisers","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/morning-rounds\/psychopharmacology-i-antidepressants-mood-stabilisers\/","title":{"rendered":"Psychopharmacology I \u2014 Antidepressants & Mood Stabilisers"},"content":{"rendered":"\n\n\n\n\nMorning Rounds · Psychiatry · Psychopharmacology I<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#psy04 *,#psy04 *::before,#psy04 *::after{box-sizing:border-box;margin:0;padding:0}\n#psy04{\n --py:#34547A;\n --py-light:#4A6B95;\n --py-pale:#E8EEF5;\n --py-dark:#243C56;\n 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.mr-ring-in{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#psy04 .mr-ring-pct{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--py)}\n#psy04 .mr-ring-sub{font-size:0.54rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:0.06em}\n#psy04 .mr-score-title{font-family:'Playfair Display',serif;font-size:1.15rem;font-weight:700;color:var(--ink);margin-bottom:4px}\n#psy04 .mr-score-net{font-size:0.9rem;color:var(--py);font-weight:600;margin-bottom:4px}\n#psy04 .mr-verdict{font-size:0.83rem;color:var(--ink-soft);font-style:italic;margin-bottom:18px;padding:0 12px}\n#psy04 .mr-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap}\n#psy04 .mr-band{padding:5px 13px;border-radius:16px;font-size:0.78rem;font-weight:600}\n#psy04 .mr-band-c{background:var(--correct-bg);color:var(--correct)}\n#psy04 .mr-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#psy04 .mr-band-s{background:var(--py-pale);color:var(--py)}\n#psy04 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--py);color:var(--py);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#psy04 .mr-retry:hover{background:var(--py);color:#EEF3FA}\n@media(max-width:480px){#psy04 .mr-title{font-size:1.4rem}#psy04 .mr-num{font-size:1.7rem}#psy04 .mr-stem{font-size:0.9rem}#psy04 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<div id=\"psy04\">\n\n <div class=\"mr-header\">\n <div class=\"mr-eyebrow\">Morning Rounds · Psychiatry Series · Round 04<\/div>\n <div class=\"mr-title\">\n Psychopharmacology I —<br><em>Antidepressants & Mood Stabilisers<\/em>\n <\/div>\n <div class=\"mr-subtitle\">Five cases · SSRIs, MAOIs, lithium, valproate & TCA overdose · Trust your instinct<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Cases<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"mr-sentinel\" id=\"psy04-sentinel\"><\/div>\n\n <div class=\"mr-progress\" id=\"psy04-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"psy04-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n <div id=\"psy04-cases\"><\/div>\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"psy04-submit\">Submit for Debrief<\/button>\n <\/div>\n <div class=\"mr-score\" id=\"psy04-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"psy04-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"psy04-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"psy04-net\"><\/div>\n <div class=\"mr-verdict\" id=\"psy04-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"psy04-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"psy04-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"psy04-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"psy04-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n <\/div>\n\n<\/div><!-- end #psy04 -->\n\n<script>\n(function () {\n 'use strict';\n\n var NS = 'psy04';\n var TOTAL = 5;\n var MAX = 20;\n var LTRS = ['A','B','C','D'];\n\n var QS = [{\"id\": 1, \"tag\": \"SSRI Rationale & Elderly Hyponatraemia\", \"stem\": \"Why are SSRIs generally preferred as first-line pharmacotherapy for major depression over older antidepressant classes, and what is a clinically important side effect to monitor for in an elderly patient?\", \"correct\": \"SSRIs have a safer profile than TCAs or MAOIs, especially in overdose; in elderly patients, watch specifically for SIADH-related hyponatraemia.\", \"opts\": [\"SSRIs have a safer profile than TCAs or MAOIs, especially in overdose; in elderly patients, watch specifically for SIADH-related hyponatraemia.\", \"SSRIs are considered free of any clinically significant side effects relative to TCAs or MAOIs, eliminating any monitoring need in elderly patients.\", \"SSRIs are preferred for raising dopamine more selectively than TCAs do, with anticholinergic toxicity as the main elderly-specific concern.\", \"SSRIs are preferred mainly for faster onset than TCAs, reaching full effect within days, with sedation as the main elderly-specific concern.\"], \"exp\": \"SSRIs' selective serotonin reuptake inhibition gives them a much safer profile than TCAs (cardiotoxicity in overdose) or MAOIs (dietary restrictions, hypertensive crisis risk), making them first-line. In elderly patients specifically, SSRI-induced hyponatraemia via SIADH is a well-recognised, clinically important risk requiring monitoring, alongside the more common GI and sexual side effects.<br><br>SSRIs are not side-effect-free, and ongoing monitoring (including for hyponatraemia and fall risk) remains relevant in elderly patients. Their mechanism is serotonin reuptake inhibition, not dopaminergic, and the key elderly risk is electrolyte, not anticholinergic. And SSRIs, like other antidepressants, generally take 2–4 weeks for full therapeutic effect, not days, with hyponatraemia — not sedation — being the specifically flagged elderly risk.\", \"imgId\": null}, {\"id\": 2, \"tag\": \"SSRI-to-MAOI Switch: Washout Period\", \"stem\": \"A patient on fluoxetine wishes to switch to an MAOI due to inadequate response. What washout consideration is essential before starting the MAOI, and why?\", \"correct\": \"A roughly five-week washout is needed after fluoxetine specifically, since its long-acting metabolite risks serotonin syndrome with an MAOI.\", \"opts\": [\"A roughly five-week washout is needed after fluoxetine specifically, since its long-acting metabolite risks serotonin syndrome with an MAOI.\", \"No washout is needed at all between an SSRI and an MAOI, since the two classes act through entirely separate, non-overlapping neurotransmitter pathways.\", \"A 24-hour washout is sufficient regardless of which SSRI was used, since this briefly clears any meaningful serotonergic activity beforehand.\", \"The washout mainly prevents tyramine-related hypertensive crisis, which is the primary mechanism of concern in this SSRI-to-MAOI switch.\"], \"exp\": \"Fluoxetine's active metabolite, norfluoxetine, has an unusually long half-life, so a roughly 5-week washout is recommended specifically after fluoxetine before starting an MAOI — longer than the ~2-week washout typical for other SSRIs — to avoid combining residual serotonergic activity with an MAOI's serotonin-potentiating effect, which can precipitate serotonin syndrome.<br><br>SSRIs and MAOIs both increase synaptic serotonin through different mechanisms, so their effects are additive, not independent — a washout is necessary. A 24-hour washout is far too short, particularly for fluoxetine given its long-acting metabolite. And while MAOIs do carry a separate tyramine-related hypertensive crisis risk tied to diet, the specific concern driving the SSRI-to-MAOI washout is serotonin syndrome, not tyramine interaction.\", \"imgId\": null}, {\"id\": 3, \"tag\": \"Lithium Toxicity, Monitoring & Teratogenicity\", \"stem\": \"A patient on long-term lithium for bipolar disorder presents with coarse tremor, ataxia, confusion, and vomiting. What is the most likely explanation, what should be checked, and what teratogenic risk is relevant if she becomes pregnant?\", \"correct\": \"Likely lithium toxicity from reduced clearance; check a serum level urgently — pregnancy risk includes fetal cardiac defects like Ebstein's.\", \"opts\": [\"Likely lithium toxicity from reduced clearance; check a serum level urgently — pregnancy risk includes fetal cardiac defects like Ebstein's.\", \"This represents simply lithium's normal, fully expected side-effect profile at standard maintenance doses, needing no urgent serum level check.\", \"Likely lithium toxicity, but the relevant pregnancy risk is neural tube defects rather than any cardiac malformation in the fetus.\", \"Unrelated to lithium and likely an acute psychiatric relapse instead, making a serum lithium level an unhelpful investigation here.\"], \"exp\": \"Lithium toxicity classically presents with coarse tremor (vs the fine tremor of therapeutic levels), ataxia, confusion, and GI symptoms — exactly this picture — often precipitated by reduced clearance from dehydration, renal impairment, or interacting drugs (NSAIDs, ACE inhibitors, thiazide diuretics). A serum lithium level is the key investigation. In pregnancy, lithium is specifically associated with fetal cardiac malformations, notably Ebstein's anomaly.<br><br>Coarse tremor, ataxia, confusion, and vomiting together are signs of toxicity, not an expected benign profile at therapeutic levels. The teratogenic risk specifically linked to lithium is cardiac, not neural tube defects (which are more classically linked to valproate). And given the medication history and classic symptom cluster, lithium toxicity is the most likely explanation, making a lithium level a necessary investigation.\", \"imgId\": null}, {\"id\": 4, \"tag\": \"Valproate vs. Lamotrigine in Bipolar Maintenance\", \"stem\": \"Two patients with Bipolar I disorder need maintenance therapy: one has predominantly manic episodes, the other predominantly depressive episodes. One is a woman of reproductive age planning future pregnancy. How should mood-stabiliser choice be guided, and what teratogenicity consideration applies?\", \"correct\": \"Valproate suits manic-predominant maintenance, lamotrigine suits depressive-predominant; valproate carries the higher teratogenic risk.\", \"opts\": [\"Valproate suits manic-predominant maintenance, lamotrigine suits depressive-predominant; valproate carries the higher teratogenic risk.\", \"Valproate and lamotrigine are fully interchangeable for both polarities, with neither carrying greater teratogenic risk in pregnancy.\", \"Lamotrigine suits acute mania due to rapid onset, while valproate is reserved mainly for depressive-predominant maintenance therapy.\", \"Valproate and lamotrigine carry similar teratogenic risk, both linked mainly to cardiac rather than neural tube defects in the fetus.\"], \"exp\": \"Valproate has strong efficacy for acute mania and manic-predominant maintenance, while lamotrigine is comparatively more effective at preventing depressive relapses, making the choice polarity-dependent. Teratogenicity differs meaningfully too: valproate carries a well-established high risk of neural tube defects and reduced IQ, considerably greater than lamotrigine's lower-risk profile, which is why valproate is generally avoided in women of reproductive age when alternatives exist.<br><br>These two drugs are not interchangeable — their relative strengths differ by mood polarity. Lamotrigine's onset is gradual (slow titration to avoid Stevens-Johnson syndrome) and it is not preferred for acute mania — the third option reverses both drugs' polarity-specific strengths. And valproate's major teratogenic concern is neural tube defects, not cardiac malformations, with a notably higher risk than lamotrigine.\", \"imgId\": null}, {\"id\": 5, \"tag\": \"TCA Overdose: Cardiotoxicity & Sodium Bicarbonate\", \"stem\": \"A patient presents after intentional ingestion of a large quantity of amitriptyline. ECG shows QRS widening beyond 100ms. What is the primary concern, and what is the most appropriate immediate management?\", \"correct\": \"QRS widening reflects sodium-channel blockade; IV sodium bicarbonate is the priority, narrowing the QRS and reducing arrhythmia risk.\", \"opts\": [\"QRS widening reflects sodium-channel blockade; IV sodium bicarbonate is the priority, narrowing the QRS and reducing arrhythmia risk.\", \"QRS widening here is considered a benign, incidental ECG finding needing no specific intervention beyond supportive care and observation.\", \"The primary concern is anticholinergic delirium, treated first-line with physostigmine; QRS widening is a separate, unrelated finding.\", \"IV calcium gluconate is the priority, since QRS widening in TCA overdose reflects a calcium-channel-mediated mechanism, as in CCB toxicity.\"], \"exp\": \"TCA cardiotoxicity arises from cardiac sodium channel blockade, with QRS widening (>100ms) being a key marker of arrhythmia and seizure risk. Sodium bicarbonate is the cornerstone treatment — it increases extracellular sodium concentration and serum pH, both of which counteract the sodium channel blockade and narrow the QRS complex.<br><br>QRS widening in this context is not benign — it's a marker of significant toxicity requiring active intervention. Physostigmine is generally avoided in TCA overdose due to risk of worsening cardiotoxicity and seizures, and it does not address the sodium-channel-mediated QRS widening, which remains the primary concern. 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