Psychofarm Final Review

Front 1

What are the positive symptoms of schizophrenia? (2)

Back 1

Hallucinations & delusions; thought disorders

Front 2

What is one possible biochemical explanation for the positive sx of SZ?

Back 2

Excess of dopamine -- either too much is released or too many receptors?

Front 3

What are the negative symptoms of SZ? (4 A's + 1)

Back 3

affective flattening; apathy; social withdrawal; anhedonia; alogia (poverty of speech)

Front 4

What are 2 possible explanations for the existence of neg sx in SZ?

Back 4

Neuronal damage (loss of nerve cells for variety of reasons, maybe genetically programmed); Glutamate deficit

Front 5

What is the "dopamine hypothesis"?

Back 5

SZ involves a functional excess of DA. BUT other NTs are involved so SZ is not just the opposite of Parkinson's.

Front 6

What is the support for the DA Hypothesis? (2)

Back 6

DA blockade is correated with clinical potency (i.e., block the receptors & Sxs improve); use of stimulants that increase DA can induce SZ-like psychosis

Front 7

What are the neurological deficits in SZ that are associated with negative symptoms? (6)

Back 7

enlarged ventricles; seasonality effect (viral insult midtrimester when limbic system develops); prefrontal cortex - thalamic - cerebellar connections are disturbed; GLU disturbance; white matter disturbance; anterior cingulate dysfx

Front 8

How do you deal with neurological deficits?

Back 8

Can only treat the symptoms; can't treat the underlying causes

Front 9

What are the indications for administering antipsychotics? (6)

Back 9

SZ, acute mania (esp if BPI, Borderline PD, Tourette's, drug induced psychosis, "preventing" SZ (conversial theory by McGlashon)

Front 10

What are the indications for administering antipsychotics? (6)

Back 10

SZ, acute mania (esp if BPI, Borderline PD, Tourette's, drug induced psychosis, "preventing" SZ (conversial theory by McGlashon)

Front 11

What are the major dopamine pathways, and what do they affect? (4)

Back 11

Mesolimbic (emotion), mesocortical (cognition), nigrostriatal (movement), tuberoinfundibular (hormones)

Front 12

name 2 traditional antipsychotics

Back 12

Haldol (haloperidol) and Thorazine (chlorpromazine)

Front 13

What is the mesolimbic DA pathway?

Back 13

From midbrain to nucleus accumbens

Front 14

What is the mechanism of the traditional antipsychotics, and what do they effect?

Back 14

They block the DA-2 receptors; this treats positive symptoms.

Front 15

What is the mesocortical DA pathway?

Back 15

From midbrain to cortex

Front 16

What is the nigrostriatal DA pathway?

Back 16

Form Substantia nigra to striatum

Front 17

What is the tuberoinfundibular DA pathway?

Back 17

From hypothalamus to pituitary

Front 18

What are the possible motor side effects from the traditional antipsychotics? (3)

Back 18

EPS (Parkinsonian SEs: shuffle, stooped posture, drooling, slow motor systems, hard to initiate movement); Dystonias (sustained muscle contractions); TD (Tardive Dyskinesia)

Front 19

What is TD (Tardive Dyskinesia)?

Back 19

abnormal involuntary movements of face, tongue, that can spread to shoulders, neck & torso

Front 20

What causes motor side effects in SZ?

Back 20

Imbalance of DA and ACH: need correct amount of each

Front 21

What is onset of TD? Who gets it the worst?

Back 21

Slow onset (usu after 2 years on meds); elderly

Front 22

What often prompts TD to appear?

Back 22

Reduction in dose of meds

Front 23

Rate of TD?

Back 23

4% in first 5 years on meds

Front 24

What causes TD?

Back 24

Denervation supersensitivity (excess DA, little Ach): D2 receptors used to being blocked, if less med then receptors are oversensitive to DA since not used to being exposed to so much

Front 25

How treat TD?

Back 25

can be irreversible; there is no fully effective treatment. Prevention is the key: should monitor for SX every 6 months.

Front 26

What meds are associated with TD?

Back 26

All antipsychotics, but more frequent with the typicals than the atypicals

Front 27

What is Neuroleptic Malignant Syndrome (NMS)? What is rate of occurance, and onset?

Back 27

NMS = fever, sweating, muscle rigidity; potentially fatal. 1 - 2% with high potency typical antipsychotics (esp if high dose). Onset is 3 - 9 days of tx w/rapid progression similar to allergy.

Front 28

What is treatment for Neuroleptic Malignant Syndrome?

Back 28

Early detection and treat symptoms with DA agonists and hydrate

Front 29

What do 2nd generation atypical antipsychotics act on? What is the purpose of them?

Back 29

They block 5HT receptors (and sometimes D2 receptors as well). They help reduce negative symptoms.

Front 30

Why use 2Gen atypicals?

Back 30

Have better efficacy in TX-resistant SZ; Have different Ses (weight gain, blood sugar and metabolic problems)

Front 31

How do the 2nd Gen atypicals work?

Back 31

Block Dx to decrease positive sxs and block 5HT to decrease negative sxs

Front 32

clozapine

Back 32

Clozaril - atypical

Front 33

risperidone

Back 33

Risperdal - atypical

Front 34

olanzapine

Back 34

Zyprexa - atypical

Front 35

aripiprazole

Back 35

Abilify - atypical

Front 36

Who gets depot drug administration?

Back 36

non compliant; outpatients (more in Europe than US); Not for acute tx

Front 37

What is danger in depot drug administration?

Back 37

patient needs must come first: can't use it as a chemical straight-jacket at board and care homes

Front 38

Put the 6 atypicals in order from least weight gain to most

Back 38

Abilify, Geodon, Risperal & Seroquel, Zyprexa, Clozaril

Front 39

chlorpromazine

Back 39

Thorazine - typical

Front 40

haloperidol

Back 40

Haldol - typial

Front 41

What health condition is Zyprexa associated with?

Back 41

diabetes

Front 42

How do you monitor for adherence in clients? (5)

Back 42

patient interview by clinician; interview family member/caregiver; blood levels; electonic monitoring; communication/web-based monitoring systme

Front 43

What are some reasons for nonadherence to antipsychotic meds?

Back 43

Medication not working; Side Fx; complex dosing; paranoia; substance abuse; impaired insight; med not valued by family/caregiver; can't refill/other access issues

Front 44

How can you enhance adherence to antipsychotic meds?

Back 44

simplify regimen; use alternative formulation (oral wafer, injection); involve family - caregiver; tailored interventions that directly target adherence (counseling; psychoed; peer support)

Front 45

With SZ, what is relative efficacy of meds only, family tx + meds, social skills training + meds, all 3?

Back 45

drugs only - least adherence; all 3 - most adherence; meds plus family tx or meds plus soc skills training are both about equal, in middle

Front 46

Discuss prodromal treatment of SZ

Back 46

Treat with Zyprexa based on early symptoms (for DSM need 6 months of symptoms). Considered especially if have 1st degree relatives w/SZ

Front 47

What percentage of diagnosed SZ people also have substance abuse?

Back 47

57%
(47% have ETOH problem)

Front 48

pros and cons of using Clozaril?

Back 48

For tx-resistant SZ (esp disorganized type); Txs neg sxs; fewer motor SEs; can cause agranulocytosis so need blood monitoring wkly/biwkly; highest weight gain of 2G meds

Front 49

pros and cons of Risperdal?

Back 49

more EPS than others; SEs are agitation, insomnia, wt gain;less effective than Clozaril on pos sxs

Front 50

Pros and cons of Zyprexa?

Back 50

more effective than others for cts w/mild sxs; low EPS; least orthostatic HPT; inc risk of diabetes; inc liver enzymes

Front 51

pros and cons of Seroquel

Back 51

low EPS; high rate of sedation; orthostatic HP; medium rate of wt gain; must take 2x/day

Front 52

Which dx has highest rate in kids? what rate is it in population?

Back 52

ADHD -- 5%

Front 53

What is one unintended consequence of medicating kids for ADHD?

Back 53

Many of the 10 million prescriptions written are "diverted" (non-medical use of stimulant).

Front 54

What are prescription trends in ped population? (# of scrips, problem w/that & possible response)?

Back 54

# of scrips doubled form 1987 to 1996; lack of reliable research; Congress wants meds tested in ped pop.

Front 55

Pediatric vs. adult pharmacokinetics?

Back 55

small size means more sensitive to meds; faster metabolism means drugs break down more quickly (so need higher dose); lack of exposure to meds means more sensitive than adults

Front 56

How should MD deal with different pharmacokinetics in ped pop?

Back 56

Adjust dose by body weight. Keep increased rate of metabolism in mind when dosing.

Front 57

DSM diagnostic criteria for ADHD?

Back 57

1. either inattention or hperactivity/impulsivity for at least 6 months that is maladaptive and not developmentally appropriate. 2) Sxs caused impairment before age 7. 3) Impairment in 2+ settings. 4) Clear evidence of clinically sig. impairment 5)Not due to other condition such as PDD, SZ, Mood D/O, etc.

Front 58

Causes of ADHD?

Back 58

Probably a bio basis since risk factors include low birth weight, birth trauma, TBI, in utero drug exposure, heavy metal poisoning, vitamin deficiency

Front 59

Evidence for probably genetic component to ADHD?

Back 59

Study shows increased incidence of abnormal repetitions in DNA of D4 receptors. Study shows higher concordance of disease in MZ vs. DZ twins.

Front 60

Why treat ADHD w/stimulants?

Back 60

Seems paradoxical but stimulants help pts focus. Ritalin increases DA in different areas.Inc in mesocortical path may help attn and concentration. Also increases NE which causes SEs.

Front 61

What are pharmacological txs for ADHD?

Back 61

Stimulants: methylphenidate (most common); dextroamphetamine; other amphetamines.
NON stimulants: atomxetine (Strattera - officially an anti-D but not usu taken for that. slightly lower efficacy than the stimulants)

Front 62

Ritalin

Back 62

methylphenidate

Front 63

Other brands/versions for the same compound that forms Ritalin?

Back 63

Concerta & Metadate(sustained release versions); Daytrana (patch)

Front 64

Dexedrine

Back 64

dextroamphetamine

Front 65

Adderall

Back 65

d- and l-amphetamine

Front 66

Provigil

Back 66

modafinil

Front 67

Sparlon

Back 67

modafinil

Front 68

What is efficacy of Ritalin? What are positive effects of Ritalin?

Back 68

about 70% efficacy
It improves attention span & decreases activity level. It helps with irritability, daydreaming, anxiety and nail biting.

Front 69

What are neg side effects of Ritalin?

Back 69

Appetite loss (usu s/t issue); insomnia (give early in day); headache (medicate & usu wear off).

Front 70

What are long term effects of Ritalin on neuronal development?

Back 70

We don't know.

Front 71

What are contraindications for Ritalin and other stimulants?

Back 71

Heart problems. BP problems. ADHD drugs have black box warnings about possibility of sudden death at normal doses for child/adoles w/heart conditions. Also even if no hx of psychosis, inc risk of psychotic/manic SXs.

Front 72

Are kids over-medicated with Ritalin?

Back 72

One study showed 1/2 of kids taking stims were never diagnosed with ADHD; took stims 3+ yrs; showed increased risk of muscle tics.
One study indicated that LOWER doses may be effective ttx.

Front 73

What non-stim meds are prescribed for ADHD?

Back 73

Strattera (atomoxetine - antiDep med)
Alpha2 NE agonists (clonidine/Catapres, guanfacine/Tenex) - BP drugs that block NE uptake & can work for hyperactivity.
Antidepressants (SSRIs and MAOIs) - not used much

Front 74

What prescribe Strattera vs. Ritalin?

Back 74

Similar efficacy, but lower rates of insomnia & appetite loss

Front 75

Discuss preschoolers and ADHD medication.

Back 75

Large increase in scrips.
Study: <20% of those w/signif behax probs received meds. Of these 50% had ADHD; rest had speech/lang d/o's, in utero drug exposure, etc. Most were male & MediCaid. Many had hx of abuse, neglect, foster placements. SO...both under and over medicated

Front 76

Discuss diversion of Ritalin in HS and in college

Back 76

study: HS - 2.4% report using (more are abusing than are using appropriately)
study: college - 5.3% using nonmedically for both studying and rec. More intranasal than oral use. Part of the issue is unfair competition.

Front 77

Is ADHD a gateway drug?

Back 77

Meta-analysis of previous studiesn shows medically appropr stim users have LOWER subsequent rate of SA

Front 78

How do you medicate a child with ADHD who also has tics (since stim use can increase tics)?

Back 78

Prescribe methylphenidate AND clonidine (hypertensive) for: increased attentiveness & on task behavior; decreased crying, frustraiton, restlessness, excitability & impulsiveness

Front 79

What is tx for pediatric depression?

Back 79

First try CBT or behavioral tx. Then add SSRI (Prozac, Paxil, Zoloft, Celexa)

Front 80

Discuss adolescent depression and use of SSRIs

Back 80

There is increased risk of suicidality, potentially, so there is a black box warning about it (which caused 20% decrease in # of scrips). Have to weigh this against increased risk of suicide from UNTREATED depression. If do prescribe it, need psychoed for ct and ct's family re: careful monitoring of suicidality

Front 81

What is medication tx for Eating Disorders?

Back 81

SSRIS not useful typically in underweight anorexics, though often used anyway. May reduce meal anxiety to help w/relapse prevention. Some support for SSRI use w/bulimics.

Front 82

Discuss Tourette's and pediatric population

Back 82

very rare. Have rapid physical or vocal tics that are very difficult to resist. 75% also have obsessive behaviors. Meds: clonidine, Prozac. Last resort: antipsychotics for tics (slow down motor responses). Hypothesis is too much GLU creates excesive DA

Front 83

Why is it important to consider gender when prescribing psychotropics?

Back 83

2/3 of scrips are for women. Women have more neg f/x than men. Women's cyclical hormonal changes effect some med's levels in blood (PMS fluid retention may effect water sol meds; drug absorbtion rates may change after menopause; have differential rate of absorption of "basic" vs acidic meds vs. men, etc.)

Front 84

What are the gender differences in absorption of ETOH?

Back 84

Women have less ability to metabolize ETOH vs. men so get more effect from less ETOH compared to them.

Front 85

How can you treat PMDD?

Back 85

Lifestyle interventions (diet & exercise, which are 25% effective) and meds (more common). Diet: freq, bal meals w/carbs; low caffeine, nicotine, ETOH, salt; inc exercise to reduce stress & renew energy, reduce fluid retention, inc endorphins. Hormonal tx (estrogen, progesterone); non-scrip agents (cohosh, vit A & E); tx sxs w/diuretics, etc.; SSRIs, anti-anxiety BZ

Front 86

What is Sarafem and what is it used for?

Back 86

it's essentially fluoxetine, and is marketed to women for PMDD. How can something with a half life of 7 days be effective when prescribed for s/t use (less than 7 days)? Ineffective at best, and pathologizing womenhood at worst.

Front 87

discuss pregnancy and psychotropics

Back 87

have to balance risk to fetus and mother vs. risks of not treating the condition.
placenta is not a barrier to psychotropics.
1st trimester-highest risk to developing organx
maternal toxicity does not = fetal toxicity

Front 88

What are possible neg effects of use of meds during pregnancy? (3)

Back 88

teratogenic fx - physical malform's from meds like valproate, thalidomide, etc.
toxic fx at birth - withdrawal syndrome (seizures, irritability, feeding difficulties, etc.), low birth weight
behavioral teratogenesis - longer term, possibly perm problems (IQ effects, learning diffs, ADHD, etc.)

Front 89

Does taking birth control pills have any effect on incidence of depression in women?

Back 89

Probably increases incidence depending on type of hormone used, age of woman, etc.

Front 90

Discuss post partum mental illness.

Back 90

13% of women experience PPD (with or w/out prior hx; for 1/3 this is first occurence).
Highest risk of incidence is first 5 weeks after birth
High risk of relapse of bipolar DO and MDD in post partum period (up to 50%)

Front 91

Discuss mood stabilizers and pregnancy

Back 91

Lithium: best choice but can cause cardiace malformations; avoid in 1st trimester
Tegretal: can cause digital malformations, neural tube defects (spina bifida)
Valproate: can cause neural tube defects, craniofacial defects, spina bifida