Psychiatry Flashcards

Question

Atypical Antipsychotics- controls ____ SX? Effects which NTs? Risk for EPS?

Answer 1

- Aid in controlling negative symptoms as well as positive - Have indirect effect on serotonin as well as dopamine - Less extrapyramidal syndrome (EPS)

Answer 2

-Less risk of EPS -More risk of hematological effects (agranulocytosis) -Sedation Olanzapine: anticholinergic effects *Caution in elders: increases mortality *All are pregnancy Category C, except clozapine (Category B) Clozapine: high-risk agranulocytosis, weekly CBC (stop if WBC is less than 3500)

Answer 3

-Depends on patient and cause of psychosis -Delirium: haloperidol, risperidone Start low -Agitated dementia, but off label Risperidone 0.5–1.5 mg/day -Elders First generation: greater risk EPS Second generation: increased CV events and death

Answer 4

Schizophrenia Ziprasidone (Geodon) or aripiprazole (Abilify) Second generation, less EPS, less metabolic SEs Mania (bipolar) Consult for aripipazole (Abilify) and mood stabilizer (lithium or valproic acid)

Answer 5

* *Clozapine: use should be reserved for severe schizophrenia * Can cause fatal agranulocytosis * Both patients and provider need to be registered * Need a baseline CBC before starting and then up to 4 weeks once drug is discontinued * Need to assess for leukopenia, fever, chills, lethargy * Agranulocytosis is fatal within 24 to 72 hours

Answer 6

- Baseline labs: CBC, LFT, EKG * *Weekly WBC if on Clozapine - Stigma of psychiatric illness and ADEs - For patients on short-term antipsychotics for treatment of vomiting, there is a risk of acute dystonia - Education: medication risks/benefits and side effects * Always forewarn patients and their family members of potential side effects to maintain trust.

Answer 7

Managing SE and EPS - Akathisa: BBs may be helpful - Parkinsonian S&S - Rx with benztropine (Cogentin) - Diphenhydramine (Benadryl), antihistamine with anticholinergic properties - Amantidine (Symmetrel), a dopamine agonist - Discontinuing mediation

Answer 8

=Mood: a pervasive and sustained emotion that, in the extreme, markedly affects the person's perception of the world and the ability to adequately function in society =Mood disorders: when a mood disturbance is combined with associated symptoms that impair the individual's ability to function -True prevalence unknown -Peak: age 25 to 44 and may be increasing in prevalence

Answer 9

Predisposing factors: family history (first-degree relatives are up to three times more likely), female gender

Answer 10

Diagnosis of depression: mood, anhedonia, significant with weight loss or gain, insomnia or hypersomnia, increased or decreased activity

Answer 11

Depressive disorders - Major or minor depressive disorder - Dysthymia - Seasonal affective disorder

Answer 12

Bipolar disorders | =Associated with depression and mania or hypomania

Answer 13

- Symptoms of depression reflect changes in brain monoamine neurotransmitters: NE, serotonin (5-HT), and dopamine (DA) - Initial episodes of depression are more likely to be associated with major life events

Answer 14

Theories regarding etiology: NE, DA, 5-HT 1) Biologic amine hypothesis Depression caused by insufficient amounts of monoamine neurotransmitters or receptor dysfunction: Mostly NE, but also serotonin, and dopamine 2) Permissive hypothesis Low levels of serotonin permit depressive state 3) Dysregulation hypothesis Erratic levels of neurotransmitters 5-HT* or NE link hypothesis

Answer 15

1) Serotonin reuptake inhibitor or 5HT1A receptor partial agonist: Vilazodone (Viibryd) 2) Serotonin reuptake inhibitors (SSRIs) 3) Serotonin-norepinephrine reuptake inhibitors (SNRIs) Venlafaxine (Effexor) Desvenlafaxine (Pristique) Duloxetine (Cymbalta): also neuropathic pain Milnacipran (Savella): fibromyalgia 4) Mixed reuptake and neuroreceptor antagonists (Tricyclics: TCAs) Amitriptyline (Elavil) 5) Monoamine oxidase inhibitors (MAOIs) Phenelzine (Nardil) Decreases metabolic inactivation of catecholamines Many side effects and drug-to-drug interactions 6) Serotonin receptor antagonists Mirtazapine (Remeron), trazodone, and nefazodone Antidepressant and antianxiety: alpha-2 antagonist Fewer side effects than tricyclics 7) Aminoketone: bupropion (Wellbutrin) Weak inhibitor of neuronal uptake of dopamine, NE, and serotonin 8) Atypical antipsychotics Abilify

Answer 16

1) Serotonin reuptake inhibitor or 5HT1A receptor partial agonist: Vilazodone (Viibryd)

Answer 17

- Zoloft (sertraline) - Paxil (paroxetine) - Celexa (citalopram) - Lexapro (escitalopram) - Luvox (fluvoxamine) - Prozac (fluoxetine)

Answer 18

3) Serotonin-norepinephrine reuptake inhibitors (SNRIs) Venlafaxine (Effexor) Desvenlafaxine (Pristique) Duloxetine (Cymbalta): also neuropathic pain Milnacipran (Savella): fibromyalgia

Answer 19

4) Mixed reuptake and neuroreceptor antagonists (Tricyclics: TCAs) Amitriptyline (Elavil)

Answer 20

5) Monoamine oxidase inhibitors (MAOIs) Phenelzine (Nardil) Decreases metabolic inactivation of catecholamines Many side effects and drug-to-drug interactions

Answer 21

6) Serotonin receptor antagonists Mirtazapine (Remeron), trazodone, and nefazodone Antidepressant and antianxiety: alpha-2 antagonist Fewer side effects than tricyclics

Answer 22

Aminoketone: bupropion (Wellbutrin) | Weak inhibitor of neuronal uptake of dopamine, NE, and serotonin

Answer 23

Actions - Potently and selectively inhibit the serotonin uptake pump on presynaptic neuron - Increase concentration of 5-HT in synapse by inhibiting reuptake, weak effect on NE and dopamine reuptake

Answer 24

Indications - Often first choice in antidepressants - Treatment of anxiety disorders and anxiety complicating depression - Obsessive compulsive disorder (OCD)

Answer 25

Effexor: serotonin and norepinephrine reuptake inhibitor Venlafaxine (Effexor) Actions: dose-dependent sequential effects on the uptake pumps for serotonin and norepinephrine At lower doses: primarily an SSRI At higher doses: produces norepinephrine reuptake Indications: equivalent of adding an NSRI to an SSRI for augmented effects

Answer 26

``` -Distribution Wide Vd Extensive protein binding -Metabolism *Interference with CYP 450 system -Excretion: renal -Half-lives vary Fluoxetine: longest half-life (4–6 days) Norfluoxetine: half-life (7–10 days) Fluvoxamine: shortest half-life (15–26 hours) ```

Answer 27

Major side effects -Nausea and loose stools Mediated by 5-HT3 agonism -Sexual dysfunction: male and female anorgasmia and decreased libido Mediated by indirect serotonin agonism and occurs in dose-dependent fashion with all SSRIs and venlafaxine -Weight gain **Sexual dysfunction and weight gain are common reasons for discontinuation of SSRIs

Answer 28

``` Serotonin syndrome -Increased risk with high dose and combining 5-HT reuptake inhibitors, MAOIs, and St. John's wort, or antiemetics Rigidity Hyperthermia Autonomic instability Myoclonus Confusion Delirium Coma *Especially problematic in the elderly ```

Answer 29

-Aschenbrenner-patients with history of seizure disorder are at increased risk for seizures with SSRIs

Answer 30

-Withdrawal syndrome: depressive symptoms or mania -Withdrawal symptoms = FLUSH Flu-like, fatigue, myalgia, loose stools, and nausea Lightheadedness and dizziness Uneasiness and restlessness Sleep and sensory disturbances Headache -Symptoms remit within 24 hours or restarting SSRI -Risk factors: time on drug, potency of drug, and half-life

Answer 31

-Assess for depression, suicidal ideation Since 2007, black-box warning in patients

Answer 32

-Often associated with depression and psychiatric illness -May be acute, transient, situational or chronic, persistent, and/or psychologic Apprehension and reduced concentration Fatigue and insomnia Somatic (sympathomimetic) Tachycardia, palpitations, and increased blood pressure (BP) Hyperventilation, tremor, sweating, and GI issues

Answer 33

BZDs: sedative-hypnotics - Can result in: central nervous system (CNS) depression, decrease in activity, moderate excitement, depression of respiratory and vasomotor centers in CNS - Actions: sedation, hypnosis, decreased anxiety, muscle relaxation, anterograde amnesia (useful in surgery and procedures), anticonvulsant activity - Relief of anxiety primarily related to CNS depression (causing sedation, depressing respiratory and vasomotors centers in CNS)

Answer 34

- Indications: for acute and short-term use in treatment of panic attacks, generalized anxiety disorder (GAD), insomnia, and EtOH (ethanol) withdrawal - BZDs can also be abused in date rape flunitrazepam Rohypnol)

Answer 35

-Short acting: no accumulation, less daytime sedation with nighttime dose, increased anterograde amnesia. Increased frequency of dosing, rebound insomnia, interdose rebound. Ativan (lorazepam), Xanax (alprazolam), Serax (oxazepam) -Intermediate acting: Valium (diazepam) -Long acting: less frequent dosing, no interdose rebound, less severe withdrawal. Risk of accumulation and of next-day sedation. Klonopin (clonazepam), Librium (chlordiazepoxide) High potency: short acting and more withdrawal symptoms Low potency: increased duration, more rapid onset of action, and more abuse risk

Answer 36

- Bind to molecular components of the gamma-aminobutyric acid (GABAA) receptors in the neuronal membranes in the CNS - GABAA is an amino acid and a major inhibitory neurotransmitter - GABAA receptor is an integral membrane chloride channel and mediates most of the rapid, neuroinhibitory transmission in the CNS - Potentiate GABA-ergic inhibition at all levels of the CNS leads to decreased firing rate of critical neurons in many regions of the brain - BZDs increase the amount of chloride current generated by GABAA receptor activation, potentiating the effects of GABA throughout the nervous system

Answer 37

-Distribution: all have high lipid solubility, protein binding is not clinically significant: 0–98% -Metabolism: classified according to half-life, which depends on rate of metabolic transformation -Extensive hepatic metabolism Phase I (3A4, 2C19) and II (glucuronidation) Active metabolites -Excretion: renal Most BZDs are completely absorbed and rapidly distributed to CNS. There is redistribution of drug from tissues to plasma (prolonged elimination).

Answer 38

- Excessive sedation: dizziness, lethargy, and ataxia - Respiratory depression: can be fatal in OD, but usually only in a patient with underlying pulmonary dysfunction or in combination with other CNS/respiratory depressants (EtOH)

Answer 39

Tolerance: decreased responsiveness to the drug following repeated exposure Cross tolerance occurs with alcohol Physiologic dependence: altered physical state that requires continuous drug administration to prevent withdrawal symptoms. May include increased anxiety, insomnia, CNS excitability that can progress to convulsions. Severity of withdrawal symptoms depends on individual drugs and size of dose. Half-life also affects withdrawal. Longer half-life results in self-tapering.

Answer 40

- Caution elders | - Pregnancy Category C or D

Answer 41

``` -Monitor for side effects Excessive sedation -Monitor for escalating use Patient education -Do not use alcohol or other CNS depressants (kava-kava). -Do not increase prescribed doses. -Slowly taper the drug after prolonged use. -Use caution with driving. ```

Answer 42

-The only BZD antagonist available for clinical use currently blocks many of the actions of BZDs but does not antagonize CNS effects of other sedative hypnotics, opioids, ethanol, or general anesthetics. Antagonist Flumazenil (Romazicon) Parenteral: 0.1 mg/ml IV -Antagonism of BZD-induced respiratory depression is less predictable. -All BZDs have a longer half-life than flumazenil (0.7–1.3 hours) and require several doses. -Adverse effects: agitation, dizziness, nausea, severe abstinence syndrome in dependent patients -Seizures and cardiac arrhythmias in patients who have ingested BZDs with tricyclics

Answer 43

``` -Hypnotic, nonbenzodiazepine Zolpidem (Ambien) Eszopicione (Lunesta) -Serotonin receptor antagonists Trazedone, Remeron -Tricyclics Elavil ```

Answer 44

- Must be present for more than 6 months and in more than one setting - Needs to have been present before 12 years of age - Requires obvious difficulty with job, school, or social setting - Changes in DSM-5 criteria allows for autistic patients to be diagnosed with ADHD

Answer 45

Inattention, Hyperactivity, Impulsivity,

Answer 46

- Genetics - Pre- and postnatal factors (e.g., cigarette smoking) - Environmental factors - Changes in the brain: shows in frontal, parietal, and temporal lobes - Abnormal dopamine uptake - Abnormal norepinephrine production

Answer 47

Combination of - Environmental modification (school, work) - Behavioral modification - Medication

Answer 48

``` Medication -First line: long-acting medications Stimulants Nonstimulants -Other FDA-approved medications Clonidine Guanfacine -Non-FDA-approved medications (due to side effects) Modafinil Bupropion ```

Answer 49

Consequences are well documented in the literature. - Poor school success - Difficulty with friendships - Increased conflict with parents - Increased risk-taking behaviors - Increased rates of substance abuse - Increased injuries - Increased motor vehicle accidents

Answer 50

-DSM criteria need to be met -For children, the parent and teacher need to complete a validated tool for diagnosis Conners scale Vanderbilt scale Others -For adults Conners adult scale Brown attention deficit disorder scale Others

Answer 51

- Start with a low dose and then slowly titrate up until symptoms are controlled with minimal side effects - Choose between short-acting and long-acting medications - Use alternative forms of medication for people that cannot swallow pills

Answer 52

-Preferred medications for ADHD are mixed amphetamine salts and methylphenidate (stimulants) due to best safety profile and effect

Answer 53

- Mixed amphetamine salts: Adderall and Adderall XR - Methylphenidate: Concerta, Methylin, Daytrana, Ritalin, Ritalin SR, Ritalin LA, and Metadate - Dextroamphetamine: Dexedrine and Dexedrine Spansules - Lisdexamfetamine: Vyvanse - Dexmethylphenidate: Focalin and Focalin SR - Dexamfetamine sulfate: Dexamed (Kohne Pharma) is approved in Europe and is the cousin to Adderall XR

Answer 54

- For all children who are to initiate medication for ADHD, perform a careful cardiac history and physical: - Personal history of cardiac symptoms - Family history of cardiac problems, especially arrhythmias, sudden death, or death at a young age from a cardiac cause - Vital signs - Cardiac physical exam * *Obtain an EKG if there is any history of chest pain, palpitations, syncope, or shortness of breath during exercise. * *For children with tic disorders, manage carefully or see them in collaboration with a specialist if you need to prescribe a stimulant.

Answer 55

- History of schizophrenia or other psychosis - Prominent symptoms of anxiety, tension, and agitation - History of drug abuse by the patient, family, or friends

Answer 56

-Short-acting medications Typical dosing in the past: two short-acting tablets, one in the morning and one at lunch Still in use (fewer night time symptoms) -Long-acting medications More expensive Have the benefit of only dosing once daily Eliminate any stigmatization of taking a pill at lunch **Both can be used in conjunction as long as the maximum daily dose is not exceeded.

Answer 57

``` -Short acting Methylin or Ritalin Initiate at 5 mg (max dose 60 mg/day) Duration of 3–5 hours -Long acting Concerta 18–72 mg/day Duration of 12 hours Methyl ER 10–60 mg Duration of 8 hours Ritalin LA 20–60 mg Duration of 6–8 hours Metadate CD 20–60 mg Duration of 6–8 hours Daytrana (patch form) 10–30 mg, wear for 9 hours Duration of 11–12 hours ```

Answer 58

-Mixed amphetamine salts Adderall SA: 2.5–40 mg; duration 6 hours Adderall XR: 5–40 mg; duration 10 hours -Dextroamphetamine Dexedrine/Dextrostat: 3.5–40 mg; duration 4–6 hours Dexedrine Spansules: 5–40 mg; duration ≥6 hours **Not preferred due to increased side effect panel and risk of addiction -Lisdexamfetamine Vyvanse: 2–70 mg/day; duration 10–12 hours Prodrug of dextroamphetamine Lysine bound to dexamfetamine, cleaved in intestine to activate **Lower abuse potential due to activation method -Dexmethylphenidate Focalin: 2.5–20 mg; duration 3–5 hours Focalin XR: 5–30 mg/day; duration 8–12 hours Enantiomer of methylphenidate

Answer 59

- Delay in sleep onset - Anorexia and suppressed appetite - Worsening of tics (uncertain) - Headaches - Abdominal pain - Increased blood pressure - Skin irritation (with Daytrana)

Answer 60

- Growth deceleration - Blood dyscrasias - Fearfulness - Depressive episodes - Hallucinations and confusion - Problems with seizures - Rebound effect (with short-acting medications) - Priapism

Answer 61

- It is preferred to try three different stimulants prior to trying a nonstimulant medication. - Children and adolescents may require higher doses of stimulants than adults because of their higher metabolism. - Start low and increase the dose each week, monitoring closely for effectiveness and side effects. - Stimulants may bring out underlying psychosis.

Answer 62

=Noradrenergic reuptake inhibitor First nonstimulant to be approved by the FDA for ADHD treatment Dosing 0.5 mg/kg/day to initiate, titrate up to 1.2 mg/kg/day Max dose is 100 mg/day or 1.4 mg/kg/day Can dose BID if 24-hour coverage is needed **No immediate effect: can take weeks, like antidepressants

Answer 63

- Metabolized by cytochrome P450: 2D6-interaction with fluoxetine, paroxetine, and quinidine - Contraindicated in narrow-angle glaucoma, within 2 weeks of an MAO inhibitor - Caution required with hypertension, tachycardia, cardiovascular, or cerebrovascular disease - Caution also required with concurrent albuterol use * **Black-box warning for possibility of suicidal ideation when initiating - Screen for thoughts about self-harm or increasing agitation - Can cause severe liver damage

Answer 64

Common side effects - GI discomfort and vomiting - Fatigue - Anorexia - Dizziness - Mood swings - Increase in blood pressure and heart rate

Answer 65

Rare side effects - Hypersensitivity reactions - Agitation - Liver damage - Mania

Answer 66

=alpha-2 agonist -Effectively reduces aggression and hyperactivity -May have some effects on tics as well Usual dosing Short-acting clonidine 0.05 mg qhs–0.4 mg/24 hours Long-acting clonidine (Kapvay) 0.1–0.4 mg/24 hours Duration of 10–12 hours **Should not be discontinued abruptly: always taper **Rebound hypertension can occur with abrupt withdrawal *Lost favor due to "slowing" effect in children (slowed too much) *Back in favor in ER form

Answer 67

- Hypotension - Dry mouth - Dizziness - Drowsiness and fatigue - Constipation - Anorexia - Arrhythmias - Depression

Answer 68

``` =alpha-2 agonist Short-acting version: Tenex 0.5–4 mg/day in divided doses Long-acting version: Intuniv 0.1–0.4 mg/day (QD–BID) Duration of 10–12 hours * Less sedating than clonidine * Being used a lot more recently! ```

Answer 69

- Drowsiness - Dizziness - Insomnia - GI issues - Hypotension - Fainting

Answer 70

- Used for hypersomnia in adults - Common side effects: headache, insomnia, and anorexia - During testing: showed improved ADHD scores, but weight loss was common - Also associated with Stevens–Johnson rash

Answer 71

-Noradrenergic effect -Benefits with ADHD (from adult data) Dosage Starting at 75 mg/day Given BID, typically 75–300 mg/day Available forms Tablets of 75 mg and 100 mg Sustained release (SR) tablets of 100 mg, 150 mg, and 200 mg Extended release (XL) tablets of 150 mg and 300 mg -Side effects Similar to those for clonidine Activation can occur -Seizures are rare (0.4%) and are even less likely with SR and XL forms -Anorexia, agitation, depression, or self-injury

Answer 72

- While at the discretion of the prescriber, once every 1–3 months is usual - Include blood pressure, weight, heart rate, and side effect review - Assess target goals - Adjust the medication as needed - Collaborate/refer if needed - Maintain contact with school

Answer 73

Higher risk if - Caucasian - Member of a fraternity or sorority - GPA is low - Medication taken is immediate release - Multiple ADHD symptoms

Answer 74

- Screen all families and patients for substance use/abuse - Prescribe extended release stimulants: Vyvanse (popular) - Alternatively, use nonstimulant medications - Follow patients and your prescriptions carefully

Answer 75

-20% concurrence of ADHD and tic disorders -50% of patients with Tourette's will have ADHD In the past, stimulants contraindicated in patients with tic disorders (biochemical relationship) Not supported by evidence!

Answer 76

If your patient with ADHD develops tics 1) Stop the stimulant, with a retrial in a few weeks: monitor symptoms 2) If tolerates a short-acting stimulant, change to long acting 3) Change the stimulant 4) If that fails, change to a nonstimulant (e.g., atomoxetine) 5) Or use a stimulant combined with an Alpha-2 agonist 6) Rarely, an atypical antipsychotic is prescribed

Answer 77

For all patients -Screen for depression, anxiety, psychosis, and aggression first -Multimodal therapy will likely be needed For anxiety disorders -Strattera is better -Stimulant, with SSRI for anxiety

Psychiatry Flashcards

(103 cards)