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Psychiatry Exam 1 > Antidepressants, Mood Stabilizers, and Meds to tx Anxiety > Flashcards

Antidepressants, Mood Stabilizers, and Meds to tx Anxiety Flashcards

1
Q

Considerations in anxiety tx

A

Lowest dose possible and increase (Start low go slow), avoid bupropion, maybe add benzos w/ end point in mind

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2
Q

Risk factors for MDE recurrence

A
  • Persistence of subthreshold symptoms
  • Severity of episode
  • Earlier age of onset
  • Presence of additional psychiatric diagnosis
  • Presence of chronic medical diagnosis
  • Family history of psych disorder
  • Persistent sleep disturbance
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3
Q

Withdrawal symptoms of antidepressants

A

Dizziness, nausea, paresthesias, anxiety, insomnia (prevent by tapering over 2-4wks)

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4
Q

Black box warning on antidepressants

A

> Suicide risk for children, adolescents, and young adults
= suicide risk for 24yrs+
< suicide risk for 65 yrs +

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5
Q

Antidepressants in pregnancy (and exception to rule!)

A

All SSRIs are category C (except Paroxetine – D bc risk of cardiac malformations); later use may incrase risk of persistent pulmonary hypertension and use to delivery may result in neonatal w/drawal

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6
Q

SSRIs (6)

A
  • Citalopram
  • Escitalopram
  • Fluoxetine
  • Fluvoxamine
  • Paroxetine
  • Sertraline
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7
Q

SNRIs (4)

A
  • Desvenlafaxine
  • Duloxetine
  • Levominalcipran
  • Venlafaxine
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8
Q

TCAs (10)

A
  • Amitryptyline
  • Clomipramine
  • Desipramine
  • Doxepin
  • Imipramine
  • Nortriptyline
  • Amoxapine
  • Marpotiline
  • Protriptyline
  • Trimipramine
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9
Q

MAOIs (4)

A
  • Isocarboxasid
  • Phenelzine
  • Selegiline
  • Tranylcypromine
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10
Q

SSRI MOA

A

Selectively inhibit 5HT reuptake (no other interaxns)

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11
Q

SSRI uses/Metabolism

A

1st line in depressive and anxiety disorders (QD dosing, metabolized by liver – danger in fluvoxamine for drugs w/ therapeutic indices, fluox/parox w/ opiates)

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12
Q

SSRI w/ long t1/2

A

Fluoextine

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13
Q

Side effects of SSRIs

A

GI: NVD (dose dependent), exacerbation of tension headache, some agents activation/insomnia (e.g. fluoxetine – start low dose, take in morning, use sleep med), some agents sedation (paroxetine – give at bedtime), decreased libido/erectile and ejaculatory dysfxn; delayed orgasm or inorgasmia; weight changes (paroxetine)

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14
Q

SNRI MOA

A

Inhibit reuptake of serotonin and NE (lack of interaxn w/ other receptors)

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15
Q

SNRI uses

A

Pain, depression etc.

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16
Q

SNRI SEs

A

NV, sexual dysfxn, activation, addition of NE –> HTN

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17
Q

Bupropion MOA

A

Weak NDRI (NE and DA reuptake inhibitor)

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18
Q

Uses of bupropion

A

Smoking cessation, depression (improve sexual fxn); no weight gain

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19
Q

SEs/CIs of bupropion

A

SE: seizure risk (CI in BN and AN, electrolyte imbalances)

Not good w/ anxiety

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20
Q

Mirtazipine MOA

A

NE and specific 5HT antidepressant (NOT a RI); antihistiminergic effects

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21
Q

Mirtazipine SEs

A

Sedation, weight gain (2o to antihistamine)

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22
Q

Vilazadone MOA

A

SSRI and partial 5HT1A agonist

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23
Q

Vilazadone SEs

A

More GI effects than SSRI, but less sexual side effects

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24
Q

Trazodone MOA

A

Weak SSRI, 5HT2r blocker

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25
Q

Trazodone uses

A

Not usually antidepressant, more often for insomnia

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26
Q

Trazodone SEs

A

Orthostatic hypotension, priapism

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27
Q

Vortioxetine MOA

A

SSRI, 5HT1A agonist, 5HT1b partial agonist, other 5HT antagonist

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28
Q

Vortioextine advantage

A

Advantage for pts w cognitive complaints

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29
Q

TCA MOA

A

Predominantly NE antidepressants secondary to inhibition of NE RI and some SSRI; also antagonize alpha1-adrenergic receptors, histamine receptors, and muscarinic Ach receptors

NRIs – nortriptyline and desipramine
SRIs – comipramine

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30
Q

TCA uses

A

Depression (not 1st line), pain syndromes (migraines, neuropathy), enuresis

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31
Q

TCA SEs/DDIs/OD

A

Cardiac problems – tachycardia, flattened T waves, prolonged QT, depressed ST (baseline EKG)
DDI – avoid similar SE profiles (M, alpha1, H); OD at 5x therapeutic dose (cardiotoxic and seizures)

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32
Q

MAOI MOA

A

Inhibit breakdown of amine neurotransmitters by inhibiting MAO A (5HT, NE, DA, tyramine) and MAO B (pehnylethylamine, DA, tyramine) – irreversible and nonselective

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33
Q

MAOI Uses

A

Atypical depression (not first line)

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34
Q

MAO Considerations/SEs

A

Edema, insomnia, orthostatic hypotension, sexual dysfxn, weight gain

Dietary restriction (tyramine –> hypertensive crisis)

DDIs w/ other 5HT meds –> serotonin syndrome

35
Q

Hypertensive crisis characteristics and tx

A

Diastolic BP > 120mmHg, tx w/ phentolamine (alpha antagonist), can be fatal

other characteristics:

  • Occipital HA which may radiate forward
  • Palpitations
  • Neck stiffening
  • NV
  • Sweating w/ w/o fever
  • Dilated pupils/photophobia
  • Tachy/bradycardia w/ w/o chest pain
36
Q

Medication restrictions to prevent hypertensive crisis

A

Adrenergic stimulation
Decongestants: phenylephrine, ephedrine, pseudoephedrine, phenylpropoanolamine-mine
Stimulants: amphetamines, methylphenidate, modafinil
Appetite suppressants w/ NRI: Sibutramine, phentermine
Antidepressants w/ NRI: TCAs, SNRIs, Bupropion

37
Q

Serotonin syndrome symptoms

A

Potentially life threatening rxn from too much 5HT

Can cause:

  • Autonomic instability
  • Confusion
  • Hallucinations
  • Hyperthermia
  • Hypertonicity
  • Myoclonus
  • Nausea
  • Seizures
  • Tremors
  • Coma/death
38
Q

Serotinergic Meds

A 
Antidepressants: SSRIs, SNRIs, TCAs (other tricyclic structures -- cyclobenzaprine, carbamazepine)
Triptants
Appetite suppressants (sibutramine)
Opioids: Destromethorphan, meperidine, tramadol, mehtadone, propoxyphene
39
Q

Other tx for depressive disorders

A

Light therapy (esp for seasonal)
Ketamine (but not sustainable and expensive)
ECT (good for resistant to tx or acute suicidality, general anesthesia causes most risk –> induce seizure, effective for 70% of those who don’t respond to meds; CIs: recent MI, space occupying/hemorrhagic cranial lesion, SE: memory problems)
TMS (for tx resistant pts, electrical current depolarizes neurons, 1hr QD x wks, patient awake, headache as SE)

40
Q

Lithium MOA

A

Post synaptically at GPCRs – depletion of PIP (indicated for all BPAD phases)

41
Q

Li pharmacokinetics

A

95% excreted unchanged by kidney

42
Q

Li toxicity symptoms/concentrations

A

> 1.2 mEq/L: Nausea, tremor, diarrhea, ataxia
1.5 mEq/L: Seizure
2.0 mEq/L: Acute renal failure
2.5mEq/L: Coma/death

43
Q

What increases Li levels?

A

Nsaids, Calcium channel blockers, ACE inhibitors, Thiazide diuretics, dehydration, decreased kidney fxn, low Na diet

44
Q

What decreases Li levels?

A

Pregnancy, high Na diet, theophylline, caffiene, lack of adherence

45
Q

Li Nuisance SEs (12)

A
  • Acne
  • Benign leukocytosis
  • Cognitive difficulties
  • Edema
  • GI distress
  • Hair loss
  • Incoordination
  • Polydypsia, polyuria
  • Psoriasis
  • Sedation
  • Tremor
  • Wt gain
46
Q

Li Medically serious SEs (4)

A
  • Hypothyroidism
  • Irreversible kidney disease
  • SA node blockade
  • Sick sinus syndrome
47
Q

Li Teratogenicity

A

Ebsteins anomaly assc w/ 1st trimester use

48
Q

Li Labs Before Tx

A

Kidney fxn, CBC, electrolytes, thyroid fxn panel, pregnancy test

49
Q

Li Labs during Tx

A

Kidney fxn, CBC, thyroid fxn panel, pregnancy test

50
Q

Valproic Acid MOA

A

Increases GABA in brain

51
Q

Valproic Acid Indications

A

Acute mania and maintenance

52
Q

Valproic Acid PKs

A

Extensively liver metabolized (DDIS), highly protein bound (interaxn w protein bound meds like coumadin, digitalis), onset of effect 5-7d

53
Q

Valproic Acid Common SEs

A
  • Benign hepatic transaminase elevations
  • Benign leukopenia and thrombocytopenia
  • GI distress
  • Hair loss
  • Osteoporosis
  • Sedation
  • Tremor
  • Wt gain
54
Q

Valproic Acid Serious but rare SEs

A
  • Agranulocytosis
  • Hemorrhagic pancreatitis
  • Hepatic tox (Hx of liver dysfxn increases risk)
55
Q

Valproic Acid unique to women SEs

A
  • Polycystic ovarian syndrome

- Neural tube defects (in uterus)

56
Q

Valproic Acid Labs before Tx

A

CBC, LFTs, PLTs, pregnancy

57
Q

Valproic Acid Labs during Tx

A

CBC, LFTs, PLTs, Val level

58
Q

Carbmazepine MOA

A

Inhibits voltage dependent presynaptic Na channels

59
Q

Carbamazepine Indications

A

Acute mania and maintenance

60
Q

Carbamazepine PK

A

Metabolized by liver (DDIs), induces its own metabolism

61
Q

Carbamazepine SEs (Common and less frequent)

A

Common: fatigue, nausea, neurological symptoms (diplopia, blurred vision, ataxis)
Less frequent: Mild leukopenia and thrombocytopenia, mild LFT increase, skin rash

62
Q

Carbamazepine serious (rare) SEs and teratogenicity

A
  • Agranulocytosis
  • Aplastic anemia
  • Thrombocytopenia
  • Hepatic failure
  • Pancreatitis
  • SJS (don’t combine w/ lamotrigine)
  • Teratogenicity: NTD
63
Q

Carbamazepine Labs

A

CBC, PLTs, LFTs, Carb level

64
Q

Lamotrigine MOA

A

Inhibits Glu and voltage-gated Na channels

65
Q

Lamotrigine Indications

A

Maintenance of BPAD and bipolar depression

66
Q

What drugs influence Lamotrigine conc?

A

Depakote INCREASES

Caramazepine DECREASES

67
Q

Lamotrigine common SEs

A
  • Headache
  • INfxn
  • Nausea
  • Xerostomia
68
Q

Lamotrigine rare (serious) SEs

A
  • SJS
69
Q

BPAD Antipsychotic Indications

A

For acute mania and BPAD depression

70
Q

Benzodiazepine BPAD Indications

A

Adjunct for acute mania, agitation, insomnia

71
Q

Anxiety Tx

A

1st line – SSRIs

All others efficacious except bupropion

72
Q

OCD Tx

A

Serotonergic agent at high dose (SSRI or clomipramine)

73
Q

Benzodiazepine MOA

A

Binds benzo receptor –> enhances GABA activity –> more Cl flow

74
Q

Benzo common properties (6)

A
  • Amenestic
  • Anticonvulsant
  • Anxiolytic
  • Hypnotic
  • Muscle relaxation
  • Tolerance/dependence
75
Q

Benzo Rapid onset

A

Diazepam

76
Q

Benzo intermediate onset (4)

A

Alprazolam, Chlordiazepoxide, Clonazepam, Lorazepam

77
Q

Benzo SEs

A
  • Sedation
  • Cognitive probs and falls (elderly)
  • Decreased respiration (bad w/ preexisting pulmonary dysfxn)
  • Memory problems (anterograde amnesia)
78
Q

Glucoronidated only benzos (3)

A

Lorazepam, oxazepam, temazepam

79
Q

Teratogenic effects of benzos

A

Cleft palate in 1st trimester

80
Q

Propanolol psych indications

A

Social anxiety disorder/social phobia

81
Q

Propanolol actions in anxiety

A

Reduces peripheral manifestations (tachycardia, tremor, sweating)

82
Q

Buspirone MOA

A

5HT1a agonist

83
Q

Busipirone Indications

A

GAD only (not 1st line), qd

84
Q

Busipirone SEs

A
  • Dizziness most common
  • Drowsiness
  • Nervousness
  • Headache
  • GI upset
  • Serotonin syndrome

Psychiatry Exam 1 (9 decks)

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