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301 Cards in this Set
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define psychosis
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mental disorder with or without organic damage
-loss of contact with reality |
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before diagnosisin psychosis, rule out what?
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DEMENTIA
D-drugs(cocaine, amp) E-electrolyte imbalance M-Metabolic dysfxn-hyperglycemia E-ears/eyes disturbances N-nutrition def-thiamine T-Traumatic brain injury/tumor I-Infection(UTI, neurpsphillis) A-AIDS |
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overall prevalance of all psychotic disorders?
shizo? |
4% total
1% |
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psychosis diagnosis
male:female ratio age of onset for each? |
in diagnosis its equiv.
onset-men early adulthood female-late adulthood |
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etiology of schizophrenia
theories |
multi-factorial
developmental theory neurodegenerative genetic predisposition |
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developmental theory
define |
cell migration abnormality(2nd trimester)
low birth weight, hypoxia |
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whats the most accepted theory for schizo today
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neurodegenerative-progressive deteriotion->just like alzheimers-once 1st break never really the same again
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mechs of schizo
-mesolimbic normal function? problem with schizo |
nml-arousal, memory, motivational memory
problem-increase in DA(+symptoms) |
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mechs of schizo
-mesocortical normal function? problem with schizo |
Cortical-Cognition,Communication
problem-decrease in DA (- symptoms) |
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mechs of schizo
-nigrostriatal normal function? |
nml-EPS, movement
fxn in schizo-whered med A/E occur |
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mechs of schizo
-tuberoinfundlbular normal function? problem with schizo |
nml-regulates prolactin release
pblm-where med induced A/E occur |
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1st gen FGAs
mesolimbic? mesocorical? nigrostriatal? TFB? |
decrease DA in ALL systems
MC-dec DA(may worsen) NS- increaes EPS TFB-increases prolactin |
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2nd gen FGAs
mesolimbic? mesocorical? nigrostriatal? TFB? |
ML-some dec. in DA
MC-inc DA & dec 5HT2 NS-some dec in DA-less EPS TFB-less proctainemia |
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whats the % of genetic predispostion if u have 1st degree relative with shizo
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10%
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diagnostic criteria for schizo-name of model + criteria
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DSMIV-TR
2 or more of symptoms for >1 month + social/occup dysfxn +rule out DEMENTIA |
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symptoms of schizo which u need 2 of?
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delusions
hallucinations disorganized speech catatonic behav-stiff, flat effect negative symptoms |
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define delusion
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its a fixed false believe
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define hallucination
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preception in absence of stimulus
can only be of 5 senses auditory most common |
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duration of symptoms
-schizo? 0shizophreniform? |
shizo- >=30 days
form- >=2 weeks, <6 months |
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types of schizo
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paranoid
disorganized undifferentiated |
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DESCRIBE
paranoid schizo- disorganized- undiff |
paranoid-most common in younger males
disorg-lower fxning undiff-lowest fxning - 1)catatonic-stiff/mute -2)-residual-had +symptoms, now only - symptoms |
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symptoms of schizo
positive? |
unusual thought(delusion)
hallucinations suspicousness |
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symptoms of schizo
negative |
affective flattening
apathy anhedonia avolition alogia |
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symptoms of schizo
cognitive |
impaired attention/working memory
-due to low DA in mesolimbic |
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define
anhedonia avolition alogia |
anhedonia-lack of pleasure
avolition-no desire,motivation alogia-poverty of speech, one word answers |
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comprehensive elements of care
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meds
supportive cognitive/psychosocial therapies housing financial/vocational support |
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shizophrenia
goals of theraphy? |
prevent deteroriation of social functioning w/i first 5 years
minimize S/E realistically treat target symptoms |
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target symptoms
most resonsive to least responsive |
most
combativness/agitation tension/hyperactive hallucinations sleep social skills delusions judgment insight |
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1st antipyshotic created when?
name? 1statypical? |
typical-chlorpromazine in 50's-60's
atypical-clozapine |
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treatment guidelines for shizophrenia
summary? |
TIMA-texas med algorithm
use atypicals first clozapine for refractory pts |
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steps in initial tx of psychosis
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1 Target symptoms
2 select med regards to comorbities and pt tolerability 3Duration 3-4wks, if not effective, switch |
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T or F
SGAs have more efficacy than the FGAs |
False
no difference in efficacy |
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schizophrenia
tx for how long? realpse %? |
tx for 5 years-lifetime
high-20-30% |
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schizo
refractory tx |
clozapine-gold standard
combo atypical/typical high dose antipsychotic |
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limitations of typicals
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resistant positive sympt-40-60% no response/lil
neg symp-less likely to respond S/E-EPS, sedation, orthostatis |
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FGAs MOA
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D2 blockade-need 60-65%of receptor blockade for efficacy
>77% d2 block=EPS |
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describe binding
FGAs SGAa |
F-slow on, slow off-tightly bound=more EPS
S-fast on, fast off-loose bound=less EPS |
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Shcizo
all meds are compared to? |
(chlorpromazine)thorazine 100mg
=prolixin(fluphenazine)2mg =haloperidol 2mg |
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typicals S/E
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inc prolacin
weight gain QT prolongation CNS-EPS, sedation sexual dysfxn photosensitive, blue skin |
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Typicals Endocrine S/E
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elevated prolactin-galactorrhea, gynecomastia
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MOA of prolactinemia
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med decreases DA, DA inhibits prolactin=high prolacin
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prolactin sequellae
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from long term prolactinemia
-osteroprosis -fertility issues -CV disease |
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typicals endocrine S/E
weight gain possible mechs |
antihsitamine effects
anticholinergic-so ppl drink sugary drinks block of 5HTc receptor |
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%increase in weight from baseline tahts considered clinically sig
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7%
not based on anything, just random number |
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typicals
CV S/E |
orthostatic hypotension-alpha block, inhib relflex vasoconstriction
-usually low potency FGA |
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typicals
CV S/E |
QTc prlongation
mesoridazine-BBW** thioridazine so recc ECG in elderly,high risk |
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typicals
ANS S/E manage how? |
Anticholinergic
-usually low potency manage-inc fluids, chew gum increase fiber in take exercise |
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FGAs
CNS S/E |
dystonia
akathasia psudeoparkinsons tardive dyskinesia neuroleptic malignant syndrome |
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dystonia
-define? -whos at risk? -tx? |
abnormal muscle tonicity(acute)
-young pts, male, highdose/potency pts tx-B52's -benadryl 50 IM benztropine 2 IM lorazepam 1-2mg IM |
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mech os dystonia
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FGAs dec DA, which causes high ACH=muscle stiffness
usually 24-72H of changing dose or starting haldol |
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akathisa
-define? mech? -tx? |
inner restlessness, cant sit still
mech-unknown tx-lower dose/switch propanolol 30-120 BID benzo:lorazpam 1mg BID |
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what NOT to give for akasthia pts?
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NO anti-ACH!!!
will worsen it |
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psudeoparkinsons and FGAs
incidence %? signs? |
30% incidence
PCAT-posture, cogwheel, akinesia, tremors |
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FGAs
puseodparkinsons Tx |
anticholinergics
-benztropine(cogentin) 1-2mg BID -benadryl 25-50 TID Amantadine-increase DA-but inc psychosis switch med to atypical |
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FGAs
Tardive Dyskinesa -define? symptoms |
abnormal involuntary movement with chronic use >6months FGAs
symp-think joker 8% cases are irreversible |
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Risk factors for TD
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long term use FGAs
>65 YOA high PANSS rating female organic brain damage comborbities-HTN,diabetes |
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TX of TD
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clozapine
Vit E?-free rad may cause TD Botulin Toxin-paralize |
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FGAs
neuroleptic malignant syndrome how severe? mech? |
1% of pts
most severe high death rate 40% mech-disrupt thermoreg process 4 cardinal symptoms |
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what are 4 cardinal symptoms of NMS
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body temp > 38C, 100.4F
altered mental status autonomic dyfxn-HTN,tachycardina muscle rigidty+pain |
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Tx of NMS
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stop med
supportive-fluids,APAP Bromocriptine dantrolene DO NOT rechallenge-use atypical |
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FGAs
dermatologic effects |
phenothiazines-inc photosensitivity (chlorpromazine)
blue-gray/purplish discoloration |
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summary of typicals AE
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low potency- high sedation, anticholinergic, CV but low EPS
High potency-low sedation, low anticholinergic, CV but VERY HIGH EPS |
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low potency FGAs
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chlorpromazine(thorazine)
thioridazine(mellaril) |
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high potency FGAa
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haloperidol, fluphenazine(prolixin), trifleoperazine(stelazine)
loxapine(loxitane) |
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Is there any difference btwn FGA and SGA effectiveness?
1 exception? |
no
exception-clozapine-more effective in refractory |
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SGA mech of action
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antag of D2 and antag of 5HT2a
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aripipazole
MOA |
D2 partial agonist
5HT1A-partial agonist 5HT2A-partial antagonist |
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starting doses
aripiprazole olanzapine |
15mg/day
abilify zyprexa |
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starting doses
quetiapine ziprasidone |
seroquel-150
geodone-80 |
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starting doses
risperidone paliperidone ER Clozapine |
risperdal 2
invega-6 clozaril-12.5-25 |
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active target doses( low-high)
aripiprazole olanzapine quetapine risperadone |
abilify-15, 30
zyprexa 10, 30 seroquel- 400, 800 Risperdal- 2, 9 |
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active target doses( low-high)
ziprasidone paliperadone clozapine |
geodon 80, 180
invega 6, 15 clozaril 300, 900 |
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if off clozapine for > 48H must do what?
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restart dose at 12.5
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SGAs half lives
abilify zyprexa seroquel risperdal geodon clozaril invega |
abilify-48H so qd
zyrexa-20-70H, QD Seroquel-7H, TID Risperdal-3-24H Geodon-4-10H Clozaril 8-12H, BID Invega-23H,QD |
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potent 2D6 Inhib
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Prozac
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CYP2D6 drugs
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abilify, risperdal, invega
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what must be done while taking geodon
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MUST take with FOOD
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NEW SGAs
asenapine(saphris) dosage form? |
its 5mgSL, no eating for 10 mins after dose
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NEW SGAs
iloperidone(fanapt) |
may tk 2 weeks to increase dose cuz of Orthostatis, CV problems
1mg/bid, then up it 1 mg qd till 12-24mg/day |
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NEW SGAs
paliperidone palmitate(susenna) |
injectable
234mgIM day1, 156 wk later, and 117 IM monthly |
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NEW SGAs
olanzapine ER(relprevv) |
watch for 3H-pt may get post delerium sedation syndrom
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whats gold standard for refractory schizo
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clozapine
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clozapine
target dose? |
300-600mg/day
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clozapines BBW
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agranulocytosis
seizure disorder >600mg increases cardiac collapse myocarditis |
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SGA precautions
-metabolic syndrome |
requires at least 3
1-waist circum male>40in, female >35in 2-fasting triglyc >150 3fasting HDL m<40, f<50 4BP>130/85 5Fasting BG >110 |
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SGAs class adverse effects
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movement disorders-EPS, TD-more EPS with risperdal
increase in Stroke:BBW -most cases-risperdal>6mg orthostatis-quetapine,risperdal |
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metabolic monitoring parameters for psychosis
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ADA+Mt Sinai guidelines
baseline-check all metabolic syndrome things 12 weeks-everything but family history |
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FGAs + SGAs
most/least weight gain |
least-geodon, prolixin, abilify
most-zyprexa, cloazaril |
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SGAs
specific A/E and management abilify zyprexa seroquel risperdal geodon |
abilify-akathesia-give in AM with food
zyprexa-weight gain-watch wt/TG seroquel-sedation,cataracts-give HS risperdal-EPS,prolactin geodon-QTprolong-baseline ECG |
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what contrindicated in risperdal theraphy
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pts with pituitary tumors-causes hyperprolactinemia
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CATIE trial-
CUtLass study- |
catie-deals with effectivness of intervention
cutlass-cost utility of drug |
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catie study objectives
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which is more effective FGAs or SGAs
double blind study, by NIMH not drug companies |
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catie results
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olanazpine best-lowest DC rate, but high tolerability-A/E
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CATIE conclusions
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high discontinuation-74% before 18months
no diff in atypicals and perphenazine used low dose perphanzine which ahs low EPS-kinda biased |
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CUtLass study results
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FGAs have increase in QOL
cheaper meds per year |
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scales
AIMS HAMD PANSS YBOCS |
AIMS-EPS
HAMD-depression PANSS-anti-pyschotics YBOCS-OCD |
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define
Bipolar 1 bipolar 2 |
1-presence of mania and depression
2-depression + hypomania |
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define
cyclothymia |
2 years of cycling of depressive sytmptoms and hypomania
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comorbities of bipolarness
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depression-50%
anxiety-50% substance abuse-65% |
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whos at higher risk of BPD?
men or woman? age of onset? |
both have same risk
adolescence: 15 to 24 YOA may take 5-10 yrs to diagnose |
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BPD is leading cause of
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chronic disability worldwide
costs 45 billion in US |
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etiology of BPD
genetic %? |
genetic-90% have relative with mood disorder
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etiology of BPD
non genetic factors |
head truama
dysreg of aminoacid transmitters sensitization +kindling theory |
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whats sensitization + kindling theory
|
recurrence causes behavioral sensitivity=mood cycling
more episodes=less trigger treshhold needed for mood elevation |
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neurochemical theories of BPD
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permissive serotonin hypothesis-5HT low-role in modulating DA release
catecholine hypothesis-inc DA+NE during severe mania GABA def. theory-GABA inhib DA + NE |
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secondary causes of mania
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no sleep
acute stress-family death meds-cocaine, steroids, opiate withdrawl, SSRI, TCA, SNRI |
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criteria for manic episode
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abnormally and elevated expansive, or irritable mood for least 1 week...+ 3 or more symptoms
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symptoms of hypomania/mania
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DIGFAST
D-distractibility-unfocused Insomnia Grandiosity- inflated self esteem Flight of ideas-mind races Activity increased- + goal directed activities Speech pressured-very talkative Thoughtlessness-risky |
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describe hypomania
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high self esteem
increased creativity+work ability low need for sleep NOT impair functioning |
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describe mania
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grandiosity
flight of ideas symptoms interfere with social/work functions |
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describe delirious or psychotic mania
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overally active
hostile destruction of property hallucinations delusions severe mania |
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describe acute mania
|
impulsive
dangerous to self + others usually agitated/psychosis require hospitalization requires rapid tx-IM antipysotics |
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acute mania within 3 weeks
drugs to tx? |
lithium
chlorpromazine depakote/carbamazepine olanzapine, risperidone, quetapine, aripiprazole, ziprasidone, asenapine |
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bipolar maintence > 3 wks
drugs to tx? |
lithium
LOAQ-lamotrigine, olanzapine, aripiprazole, quetapine |
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acute depression BPD
drugs to tx? |
quetapine
olanzapine + fluoxetine |
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TIMA algorithm for mania/hyopmania
STAGE1- |
monotheraphy
Li depakote abilify seroquel risperdal ziprasidone |
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TIMA algorithm for mania/hyopmania
STAGE2 |
2 drug combo
LI, DVP, or atypical(but not 2 atyps) NOT abilify,clozapine |
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TIMA algorithm for MIXED or dysphoric mania/hypoania
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DVP or abilify, risperidone, or ziprasidone
NOT LITHIUM! |
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TIMA algorithm for mania/hyopmania
STAGE4 |
ECT + Clozapine
ECT+ (Li + DVP) ECT + (atypical +CBZ, OXC) |
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summary of APA guidelines
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1st line-monotheraphy of Li, valproate or antipsychotic
more severe pt-Li or valproate + antipsycotic SGAs >FGAs cuz of benign S/E-! |
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brand name soda with mood stabalizer in it?
|
7up-had lithium in 1920's
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Li
used for? MOA? |
12 + up for acute mania/ BP maint
MOA-presynaptic mod of release + synthesis of NE + 5HT no role in DA=not for psychosis |
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Li pharmacokinetics
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D-not protein bound
M-not metab-100% renally eliminated t1/2-24H but usually BID/TID |
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always order Li in what units to reduce med erros?
|
mEq or ml
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Li dosing for acute mania?
|
8 mEq TID or 15 mg/kg
300mg BID |
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target lithium plasma levels?
|
.6-1.2 mEq/L
get before fist morning dose and least 8-12H after evening dose SS-3 to 5 days, so wait till then acute-1 or 2 times weekly, then monthly chronic-3 to 6 months, at least annually |
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Lithium level corresponds to A/E
<1.5 |
mild or transient
GI upset mild polyuria muscle fatigue |
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Lithium level corresponds to A/E
1.5-2.5 |
moderate
tremor/twitching slurred speech vertigo sedation lethargy hyperreflexia |
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Lithium level corresponds to A/E
>2,5 |
severe-emergency need dialysis
seizures, stupor, coma, CV collapse, death |
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Li A/E
|
granulocytosis-inc in WBC
hypothroidism ECG changes-brady, twave inversions activation tremor-not @ rest acne weight gain psoriasis activation |
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Li
what to give as addon |
levothyroxine-causes hypothroidism
maybe propanolol for tremor |
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Li
preg category? C/I during? what does it cause? |
preg cat D
C/I during 1st trimester causes ebsteins anomoly yet its still DOC for preg+bipolar |
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what is ebsteins anomoly
|
from Li
abnormal displacement of tricuspid valve in to right ventricle |
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Li monitoring parameters
baseline |
think about S/E
baseline- ECG CBC Electrolytes-Na + K Scr + BUN T3, T4, TSH preg urinalysis |
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Li monitoring parameters
1 month later |
repeat, after stablemonitor electrolytes, renal and thyroid fxn
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Li drug Intnxs
|
thiazides: HCTZ-increases Li 30%-toxic
at proximal-increased reabs of Na+Li distal-inc excretion of Na |
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what increases Li conc
|
LANT
Loops ACEI NSAIDS Thiazides |
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what decreases Li conc
|
salt
theophyline |
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SSRIs and SNRIs + Li have risk of?
|
5HT syndrome
|
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Li clinical evidence
|
equally effective in preventing both manic and depressive episodes
1 month for full response |
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indications for poor Li response?
|
rapid cycling > 4 episodes per year
atypical features-cause Li has no effect on DA |
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Li pt counselling
|
baseline labs + F/U Q 3 months(stable pt)
onset of action-initial 10-14 days full-1 month keep hydrated to prevent toxicity |
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Valproate
indicated uses? MOA |
acute mania
seizure disorder migraines MOA-regulates GABA synthesis,release,uptake normalizes Na + Ca |
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when switching from DR or reg Depakote, to ER you must do what
|
increase daily dose by 10-20%
|
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valproate PK
|
abs-liquid faster than tablet
distrib-90% protein bound |
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valproate
metab? half life? interactions? |
metab-hepatic
t1/2-5-20H inxn-2C19 substrate 2C9,2D6, 3A4 inhibitor |
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valproate
acute mania doses |
20-30mg/kg/day
max 60 mg/kg/day target-50-125mcg/ml 12 H after dose, 3-5 days after starting tx |
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what are the valproate levels that correlate with a decrease in manic symptoms
|
>94 mcg/ml
but the higer the amt the more SE |
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Valproate SE
Acute |
N/V
mild hand tremor sedation increase in liver enzymes-monitor AST/ALT |
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Valproate SE
chronic |
BBW-pancreatitis
-hepatotoxicity thrombocytopenia hyperammonemia-fatigue weight gain polystitic ovary syndrome alopecia |
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valproate
preg cat? not recc when? what odes it cause |
preg cat D
NOT recc in 1st trimester renal tube defects-spina bifida folic acid 4mg/day may decrease defects |
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valproate interactions
Carbamazepin? phenytoin lamotrgine risperdal |
valproate increases CBZ
valpro increaes PHT PHT also increases VP Valpro increases LAM risperdal increases Valp |
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|
if on lamotrigine(lamictal) and valproate, monitor for
|
rash-->steven-johnson syndrome
decrease LAM dose by 50% |
|
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valproate monitoring parameters
|
baseline- CBC-platelets
hepatic enzymes-AST fasting glucose fasting lipid panel weight |
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valproate
baselinelabs and periodic labs draw when? onset of action |
6-12 months
onset 3 to 5 days |
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Valproate clinical evidence
as effective as? indicators of positive response? |
as effective as Li for acute mania
+response-mixed mania, rapid cycling >4/year organic mental disorder(trauma) |
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T or F
valproate there is evidence for maintence and is used in clinical practice |
F
no evidence, but is used in clinical practice |
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Carbamazepine
indicated for? MOA |
for acute mania
MOA-modulates Na and Ca regulates GABA |
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CBZ recc dose
target levels for BPD |
200 BID, max 1600 perday
no est. target level epilepsy-usually 4-12 mcg/ml |
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which is better in BPD
SGAs or FGAs |
equally effective in acute mania except clozapine
diff is in SE |
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SGA dosing in BPD
starting + target(low-high) aripiprazole |
15
15-45 |
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SGA dosing in BPD
starting + target(low-high) olanzepine |
15
10-30 |
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SGA dosing in BPD
starting + target(low-high) quetipine |
100-150
300-800 |
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SGA dosing in BPD
starting + target(low-high) risperdal |
2
2-6 |
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SGA dosing in BPD
starting + target(low-high) ziprasidone |
80
80-180 |
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SGA dosing in BPD
starting + target(low-high) asenapine |
10-20
10-20 |
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most common cause of metabolic syndrom
|
clozapine
olanzapine |
|
|
consider risk of weight gain in SGA pts when?
|
pts BMI>25
need intervention unless BMI <18.5 interventions-weight management switching meds to abilify, geodon adjunct med-metformin |
|
|
highest 3 meds that cause weight gain in adults
kids |
adults-clozapine, olanzapine, risperidone
kids-olanzepine, risperidone, quetiapine (clozapine does NOT increase weight in kids) |
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BP depressive episodes last how long
|
exceed duration and frequency than manic episodes
|
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BP depression meds
which is better? dose of the drug |
lamotrigine better than Li
doses at 50-200mg |
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which drug is better for mania, Li or Lamictal
|
Li
|
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major depression
prevalent more in men or women? |
women-but may be misleading-guys tough it out-and show it as anger so misdiagnosed
|
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depression
genetics |
1/5-3x common in 1st degree relatives
identical twins>fraternal |
|
|
depression episodes
1st episode- 2nd episode- 3rd episode- |
after 1st 50% have another
2nd-70%have another 3rd-90% have another episode may spontaneously resolve with 6-24 months |
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chronic illness that may cause depression
|
CNS-accident, stroke, trauma
CV-CHF, MI Autoimmune-diabetes endocrine-hypothroid anemia, malnutriotn |
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meds associated with depressive symptoms
|
NSAIDS
sulfonamides clonidine, propanolol Benzos, ethanol corticosteroid, progesterone, accutane cancer meds, pesticides |
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majoe depressive episode criteria
|
5 symptomsmostly every day x 2 weeks + change from previous functioning
at least 1 must be depressed mood or anhedonia |
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depression symptoms for clinical diagnosis
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SIGECAPS
Sleep-inc or dec Interests-dec Guilt-inc Energy-dec Concentration-dec Appetite-inc or dec Psychomotor Suicidal thought-feeling worthless |
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T or F
Asking someone if they have suidical thoughts does will cause a person to be more likely to commit suidicde |
F
asking shows u care-and you will prolly prevent it |
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Rating instruments
HAM-D BDI MMSE |
HAMD-by clinitian
BDI-by pt the higher the score-more dpressed for above MMSE-if other 2 scores are really bad-shows other chronic dieases |
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nonpharmacological theraphy for depression
|
psychotheraphy
light response-seasonal affective disorder ECT-90%effective-tx refractive depression |
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depression meds
max efficacy seen when |
4-8weeks
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depression
txing 1st episode- txting 2nd- txting 3rd |
1st-need 1 yr of tx
2nd-need 2 years 3rd-lifetime of tx |
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proposed mechs for depression(theories)
|
biogenic-amine-
receptor-sensitivity cortisol |
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biogenic-amine theory
|
deficit of 5HT and/or NE in synaptic cleft
doesnt explain why it takes 4-8weeks to see effects with antidepress |
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receptor-sensitivity
|
dysregulation in the sensitivites of receptors
explains the time-lag of tx |
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cortisol theory
|
over stim of cortisol-leadss to dysreg of DA + 5HT receptors+decreases binding to those receptors in prescence of 2 much cortisol
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TCAs MOA
|
inhib PREsynaptically reuptake of NE + 5HT
considered an SNRI |
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TCA drugs
tertiary amines |
amitriptyline
imipramine doxepin trimipramine |
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TCA drugs
secondary amines |
nortriptyline
desipramine protriptyline |
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TCA tertiary amine
starting dose? MD? |
50-75
MD 100-300 |
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TCAs secondary amines
SD? MD? |
25
200 MD protriptylline is exception |
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amitriptyline breaks down into?
imipramine breaks down into |
nortiptyline
desipramine |
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protriptyilline
dose? |
vivactyl-not sedating
MD 15-60mg |
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TCA S/E
|
anticholinergic-mostly tertiary-can't see, pee, spit, or shit
antihistaminic-tertiary-sedation, weight gain |
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TCA S/E continued
|
lower seizure threshold
CV-arrhytmias, CI with 1 or 2 heart block |
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T or F
All antidepressents lower the seizure threshold which one is CI in seizures |
T
buproprion is CI |
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MAOIs
MOA types |
inhib MAO-irreversible
reduces breakdown of DA, 5HT, and NE Type A-alimentary(GI) type B-brain |
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which antidepressant can be given with MAOIs
|
should NEVER be given with another antidepressent
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MAOIs
drug and dose |
selegilline patch(Emsam)
for type B at low doses 6mg/day initial 6,9,12 mg/day range |
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MAOIs
dietary restrictions for 6mg and 9/12mg |
6mg-no dietary restriction
9/12mg- selectivity lost, must follow restrictions |
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2 week rule
exception? |
just for MAOIs
-must wait when DCing other drug and starting MAOIs and visa versa prozac is exception |
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if going from MAOI to prozac wait how long?
if going from prozac to MAOI how long to wait? |
2 weeks
4 weeks |
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MAOI drug/food interaction causes
|
serotonin syndrome from antidepressents
hypertensive crisis-tyramine containing foods-its when BP >180/120 |
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tx serotonin syndrome how?
tx hypertensive crisis how? |
SS-supportive care/fluids
HC-cyproheptadine in severe cases |
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tyramine containing foods
|
red wine, cheese, smoked/aged meats, yeasts
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SSRIs MOA
dosing |
inhib reuptake of serotonin
dose-increase q 1-2 weeks- taper off slowly |
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SSRI
drugs? |
prozac(fluoxetine)
zoloft(sertraline) paxil(paroxetine) citalopram(celexa) escitalopram(lexapro) fluvoxamine(luvox) |
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fluoxetine
dose? interaction SE |
intial 5-20mg/day
range 20-80 2D6 interaction SE-most is insomnia, sex dysfxn |
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fluoxetine
metabolite? tapering ? |
active metab-norfluoxetine
only SSRI that can be stoped without tappering |
|
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sertraline
initial dose/range? S/E |
25-50mg/d
50-200 mg/d low interactions SE/-DIARRHEA, sex dysfunction, |
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paroxetine
dosing? interactions? SE |
5-20mg/d
range 20-60mg/d potent 2D6 interaction>prozac S/E-most sedating, same SE as prozac preg Cat D |
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1st BBW for suicide
which drug |
paxil
|
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citalopram
dosing? SE |
10-20mg/d inital
20-40mg d range SE-middle of road-less activating, not as sedating |
|
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Escitalopram
dosing (1/2 of celexa) conversion ration of celexa to lexapro |
5-10MG/d
5-20 2:1 celexa 10=lexapro 5 |
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most activating SSRI
|
prozac, zoloft
|
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most drug interactions of SSRIs
|
prozac and paxil
|
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|
least drug interactions of SSRIs
|
celexa, lexapro, and zoloft
|
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fluvoxamine(luvox0
indicated for? dose? interactions |
for anxiety-not depression
intial 50mg/d range 50-300 interactions-1A2,3A4massive warfarin,benzos,BB |
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vilazodone(Viibryd)
class? MOA? dose? S/E |
modified SSRI
selective serotonin reuptake inhib, partial 5HT1A agonist 10mg/d 20-40 range take with food for max absp A/E-insomnia, but less sex dysfxn |
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SNRIs
drugs |
venlafaxine(effexor)
desvenlafaxine(pristiq) duloxetine(cymbalta) |
|
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venlafaxine
MOA dose? |
5HT, NE>DA reuptake inhibitor....as incr dose NE>5HT
initial dose-75mg/d, range 75-375mg/d |
|
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pros vs cons of effexor
|
-not cardiotoxic like TCAs
-at high doses(300) increases BP by 5 |
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Pristiq
MOA doses drug interactions |
desvenlafaxine
5HT>NE>DA reuptake inhib-more NE selective than effexor 50mg/day range 50-400 less 2D6 interactions than effexor good for alcholics-no hepatic metab |
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pristiq
why is there 100mg |
no one knows
starting is 50 and maint is 50, if after 2 weeks it doesnt work..wont work at all! |
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cymbalta(duloxetine)
MOA dosing SE |
5HT and NE reuptake inhib
intial 20 BID, range-40-60 SE-sexual dysfn, dec appetite |
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cymbalta
also approved for? kinetics? |
approved for fibromyalgia
short t1/2 must taper off-rebound depression |
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buproppion
whats class? MOA? dose |
aminoketone
MOA-weak DA + NE reuptake inhib dose-150mg/d, range 150-450mg/d |
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wellbutrin
S/E whats good about it |
S/E-increases risk of seizures, hand tremor
if 5HT based depression-this wont help good cause-no weight gain, no sexual dysfxn |
|
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tetracyclic
drug? MOA dose |
mirtazapine(remeron)
MOA-alpha2 recp antag-postsynapt block of 5HT2 and 3 receptors 15mg/d, range 15-45mg/d |
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mirtazapine
form? S/E |
has ODT form
sedation(low doses), inc appetite, inc weight, used for HIV +anorexia less insomnia and sexual dysfxn than other SSRIs |
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nefazodone(serzone)
class? MOA? INTERACTION |
triazolopyridine
5HT>>NE reuptake, 5HT2 antag hepatic toxic |
|
|
trazodone
class? dose? SE |
triazolopyridine
weak 5HT reuptake inhib, 5HT2 antag up to 600mg/d for sleep-50-200mg/d SE-priapism/sedation |
|
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trazodone
most used for |
sleep-but if you go higher than 150 it acts like a antidepressent and not sleep
|
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|
augmented strategies for depression
|
lithium
liothyronine-T3-less SE than lithium buspirone ECT-resistant pts |
|
|
whats in california rocket fuel?
who created it |
Wellbutrin(Da+NE)+ SSRI(5HT)
-like MAOI but no hypertensive crisis -steven stahl created it |
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1st line for depression
when to use SNRI or wellbutrin |
SSRI
when pt has failed 2 SSRIs |
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transient SE last how long in antidepressents?
50% stop taking med swhen? |
lasts 2 weeks
50% stop taking within these 2 weeks-let them know they subside |
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anxiety
acivation of |
sympathetic
flight or fight increased HR, BP, RR |
|
|
anxiety
problematic when? |
occurs despite any real/serious threat
excessively long, and intense DISRUPTS DAILY LIFE its normal human behavior |
|
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Anxiety
risk factors |
female
single, low SES, young adult, enviornmental |
|
|
generalized anxiety disorder
define |
constant anxiety for more days than not, and for at least 6 months
cause distress indaily life |
|
|
major depression and anxiety share what percentage of similaralities
|
60% or more
|
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|
gen. anxiety disorder
diagnosis criteria |
at least 3 of the following symptoms
-restlnessness difficult concentrating irritable muscle tension disturbed sleep poor coping |
|
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generalized anxiety disorder
epidemology |
majority have another pschiatric disorder
>60% have major depressive disorder |
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G.A.D.
pathophys |
abnormality in nonadrenergic + CCK fxn
benzo+5HT system dysfxn-GABA-a receptor decreased alpha2 receptor-NE overactivity |
|
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Social Anxiety
define |
intense and/or constand fear in a social situation(supermarkets)
person acknowledges fear is excessive |
|
|
social anxiety
symptoms? |
fear severely interfers with daily life
blushing muscle twitching stuttering |
|
|
social anxiety
considered? 2 subtypes |
a phobic disorder
subtypes-generalized and nongeneralized more common in females |
|
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social anxiety
risk factors |
young ppl
lower SES single |
|
|
social anxiety patho
gen nongen |
gen-involve noradrenergic system-fight or flight
nongen-involves dopaminergic and serotonergic dysfxn |
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panic disorder
diagnosis criteria |
at least 2 unexpected attacks with at least 4 symptoms-abruptly peak within 10mins
|
|
|
panic disorder
symptoms |
palpitations
sweating shaking chest pain(SOB) N/V-GI disturbances fear of going crazy numbness chills or hotness |
|
|
2 different types of panic disorder
|
agoraphobia-fear of open spaces(marketplaces)
-avoid situation, endure with distress, require a friend without agoraphobia- |
|
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panic disorder
epidemiology |
onset-late teen/early adulthood
women 2/3x>males >50%have major depressive episode very low rate of remission |
|
|
panic disorder
pathophys |
dysregulated firing in amygdala-hypothalamus and locus ceruleus
abnormalities in benzo receptors, nonadrenergic, serotonergic, and CCK heredity-CO2 hypersensitivity=passingout |
|
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OCD
presence of |
obsessions or compulsions
|
|
|
define obsession
|
recurrent and persistent ideas not about real life problems, causes anxiety
|
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|
define compulsion
|
repetitive and intentional physical manifestation to reduce anxiety
|
|
|
obsession examples
compulsion examples |
obs-contamination, symmetry, religous, sexual, agressive
com-cleaning, arranging symmetry, counting, checking, hoarding |
|
|
OCD
describe person |
attempts to ignore ideas
believes obsessions are senseless at sompoint knows its excessive and unreasonable cause marked distress/time consuming for >1H daily |
|
|
OCD epidemiology
onset? comorbidties? |
onset -adolesnce to early adulthood
tic disorders about 25% 12% have panic disorders 60% exp panic attacks |
|
|
OCD
pathophys |
serotonergic dysfxn
hyperactivity in frontal love and basal ganglia-emotional system decreased white matter small pituitary gland |
|
|
excess cortisol leads to
too littler cortisol leads to |
lots=depression
little=aggression |
|
|
PTSD
define |
acute distress from everely traumatic event
avoidance of stimuli of event or nubing of general responsivness |
|
|
PTSD
diagnosis criteria |
symptoms of increased arousal which indlude 2 symptoms
disturbance occur at least 1 month and cause impairment in daily life |
|
|
PTSD
symptoms |
sleep difficulties
irritable/anger outburst cognitive difficulties hypervigilant exaggerated startle response |
|
|
whats the most common cause of PTSD
|
sudden unexpected loss of a loved one
|
|
|
PTSD
pathophys |
altered noradrenergic, serotonergic, glutaminergic, and neuroendocrine fxn
reduced hippocampal volume increased sensitivity in hypothalamus,pituitary, and adrenal system |
|
|
anxiety
describe what occurs,receptors SSRI tx |
low serotoin so post synaptic term upreg, but once a surge occurs of serotonin too much rushes in cause of all the open doors
SSRIs will increast amt of fee serotonin to slowly downreg post synaptic channels |
|
|
SSRIS in anxiety do what short term
|
will accutally increase anxiety-so start low and go slow but eventually be a higher dose than depression(8-12wks)
|
|
|
generalized anxiety disorder
drugs for tx |
1st line-SSRIs
effexor TCAs benzos buspirone hydroxyzine |
|
|
G.A.D.
how do you give the drugs |
ALL MEDS Schedules, not PRN
takes 12-16 wks for response |
|
|
GAD
SSRI tx adv vs disadv |
ADV-low risk in suicide pt, good for mixed pt(depression+anxiety)
Disadv-serotonin syndrome if OD, early activation, disrupts sleep |
|
|
GAD
effexor tx adv vs disad |
ad-good for depression + anxiety
disadv-delayed onset, ealy activation |
|
|
GAD
TCAs |
minmizes activation-sedating
increased risk of suicide |
|
|
GAD
benzos |
hit benzo receptor on post synaptic GABA-a neuron-hyperpolarizes
|
|
|
3 benzos not metabolized
|
LOTe-ok for hepatic disease pts
lorazepam oxazepam temazepam |
|
|
GAD
benzos adv vs disadv |
adv0good for insomnia, fast onset
disadv-sedation, withdrawl+dependence |
|
|
benzo OD use?
|
flumazenil-thought this didnt really work??
|
|
|
GAD
buspirone |
5-HT1a partial agonist
increases DA |
|
|
GAD
busiprone adv vs disadv |
adv-no abuse potential
disadv-doesn't really work if benzo doesnt work don't even try this |
|
|
GAD
hydroxyzine |
H1 blocker-anticholinergic like benadryl
|
|
|
social anxiety
drugs to tx |
SSRIs
effexor benzos buspirone BB Gabapentin MAOIs NO TCAS, NO hydroxyzine |
|
|
Social Anxiety
1st line how long to tx for |
SSRIs
tx for 1 yr after 1st episode and effects first seen |
|
|
Social Anxiety
benzos busiprone |
can be used PRN if stressful event is anticipated
busiprone-must be scheduled |
|
|
benzos can be scheduled when?
|
panic attack or social anxiety being txted with SSRIs-will cause an increase in activation so u can schedule benzo for 2 weeks, then PRN
|
|
|
Social Anxiety
BB adv vs disadv |
propanolol 10-20mg
atenolol 25mg PRN adv-dec manifestations-sweating d-not much data on it |
|
|
T or F
Benzos>BB in social anxiety |
true
benzos are proven |
|
|
social anxiety
gabapentin MAOIS |
gaba-questionable
MAOIs-scheduled, last resort**, many food restrictions, decreases symptoms quick |
|
|
Panic Disorder
drugs |
SSRIs-1st line
TCAs MAOIs Benzos |
|
|
panic disorder
SSRIs |
early activation
block PA, but not anticipatory anxiety |
|
|
panic disorder
TCAs MAOIs |
t-imipramine most common
M-last line, rare |
|
|
Panic Disorder
benzos |
alprazolam-FDA approved, effective for anticipatory anxiety
|
|
|
Panic disorder
scheduled drugs scheduled/PRN |
SSRIs
TCAs MAOIs both scheduled/prn-benzos....scheduled is for unplanned, PRN is for planned(anticipatory) |
|
|
OCD
drugs |
SSRIs-1st line, much higher doses-fluoxetine 80-120mg
TCAs-2nd line cuz SE |
|
|
OCD combo drugs
|
SSRI+antipsychotics-for delusions/halucination
SSRI+depakote/lithium for manic attacks-abnormal impulses |
|
|
PTSD
drugs |
SSRIs-sertraline/fluoxetine
TCAs- MAOIs-last line |
|
|
OCD+PTSD
benzos |
NONE-USELESS!!!
|
|
|
new SGA for psychosis
lurasidone(latuda) DOSE? |
40-80mg daily
|
