CNS Meds: Depression & Psychosis Flashcards
Describe the 4 treatment modalities for depression
- pharmacotherapy
- Cognitive behavioral therapy
- Electroconvulsive therapy (ECT)
when drugs & psychotherapy have not worked - Vagus nerve stimulation
only after treatment with at least 4 drugs has failed
Name 6 examples of SSRIs
- Paxil – Paroxetine
- Celexa – Citalopram
- Prozac – Fluoxetine
- Zoloft – Sertraline
- Luvox – Fluvoxamine
- Lexapro – Escitalopram
What are the indications of SSRIs?
Depression
Other mental disorders: OCD, PTSD, social anxiety disorder, panic disorder, eating disorder
PMS
Enuresis (involuntary urination)
Recognize the time that selective serotonin reuptake inhibitors (SSRIs) take to show their effects
Effects take 10-21 days
Specify 2 precautions that patients on SSRIs must take
- If they want to stop taking the medication, they should wean gradually.
- Take SSRIs with food at bedtime!
- We want to minimize anticholinergic effects (dry mouth, constipation, urinary retention, dilated pupils, blurred vision, increased HR)
- Take at bedtime unless sleep is disturbed
List 9 side effects of selective serotonin reuptake inhibitors (SSRIs)
- insomnia
- anxiety
- nervousness
- headache
- weight gain
- nausea
- GI distress
- dry mouth
- sexual dysfunction
Describe serotonin syndrome and identify the clinical features of serotonin syndrome
It is a rare adverse effect of SSRIs due to autonomic “instability”
Can be life threatening
Sweating, agitation, confusion, hyperreflexia, fever, tremor hallucination, seizures, coma
Name 2 alternative antidepressant drugs to SSRIs
- SNRIs (serotonin-norepinephrine)
Venlafaxine – Effexor - NDRIs (norepinephrine-dopamine)
Bupropion – Wellbutrin
***Bupropion is also used for smoking cessation!
Describe the mechanism of action of tricyclic antidepressants (TCAs)
TCAs block the neuronal reuptake of 2 monoamine transmitters:
NE and serotonin
Name 5 examples of TCAs
Amitriptyline – Elavil
Imipramine – Tofranil
Clomipramine – Anafranil
Nortriptyline – Aventyl
Amoxapine –Asendin
List 2 indications of TCAs
Depression
***Chronic pain: fibromyalgia, migraine, severe depression
TCAs can have sedative/hypnotic effect
List 10 side effects of tricyclic antidepressants (TCAs)
Sedation & Confusion
Orthostatic hypotension
Arrhythmias, cardiac toxicity
Weight gain
Anti-cholinergic effect
**especially for the elderly
**Take at bedtime to minimize side effects
Name 4 examples of monoamine oxidase inhibitors (MAOIs)
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Selegiline (Emsam)
Tips to remember:
“Take Pride in Shanghai” lol
List 3 examples of monoamine neurotransmitters
Norepinephrine
Serotonin
Dopamine
Discuss the effect of a patient consuming tyramine-rich foods while being treated with a monoamine oxidase inhibitor (MAOI)
MAOIs inhibit monoamine oxidase, so the body cannot get rid itself of excess NE
–> Raised level of NE
–> Hypertensive crisis (life-threatening increase in BP)
List the classic examples of tyramine-rich foods
Tyramine is commonly found in foods that are aged
- cheese
- smoked fish
- tofu
- protein extracts
- sauerkraut
- miso
There are more!!!
List 3 drug classes that are likely to lead to serotonin syndrome
SSRIs
MAOIs
MDMA (phenylethylamines)
List 2 drug interactions that will also cause serotonin syndrome
combine MAOIs with:
- opioids like meperidine
- tricyclic antidepressants (TCA)
List 4 indications of monoamine oxidase inhibitors (MAOIs)
- Depression
- Bulimia nervosa (eating disorder)
- Obsession-compulsive disorder
- Panic attacks
We do not see MAOIs often in practice, but MAOIs can work effectively for some patients with depression.
Recall the disorders for which mood stabilizers are indicated
They are often used in bipolar disorder, borderline personality disorder (Luka Yamano!!) , and schizophrenia.
List two types of mood stabilizers
- Lithium
- Anticonvulsants – treat epilepsy but can also act as mood stabilizers
Describe how lithium benefits patients with bipolar disorder
We use lithium to treat acute mania OR prevent future mania/depression
Recall how long lithium might take to exert a therapeutic effect
Onset of the effects to kick in: 5 - 7 days
Peak: 2-3 weeks after
Describe characteristics of borderline personality disorder and explain the role of lithium in the treatment
Borderline personality disorder: characterized by mood swings, impulsiveness, and intense fear of abandonment (getting alone)
The therapeutic ranges for lithium therapy
Normal: 0.6 - 1.2 mEq/L
Toxic: greater than 1.5 mEq/L
Can cause death: greater than 2.5 mEq/L
Describe mild, moderate, and severe signs of lithium toxicity
Mild: nausea, vomiting, and fatigue
Moderate: confusion, agitation, delirium,
Severe: coma, seizures
Explain how a low serum sodium level can affect lithium levels
Low serum Na can increase the risk of Li toxicity
(kidney wants to hold on Na –> body cannot distinguish Na and Li –> Li is also retained)
Risk factors for low Na
Diet, diarrhea, and diuretics
Review 7 common side effects of Li early in the treatment
GI distress
Since Li can mess up electrolyte balance of the body, it can cause:
fatigue
headache, muscle weakness, confusion, memory impairment
polyuria & thirst (Li blocks the effect of ADH)
List the classic side effects associated with chronic lithium therapy
- May cause degenerative changes to the kidney
- May cause goiter OR hypothyroidism
Recall common indications for antipsychotic medications
Used mostly in:
Schizophrenia (primary use)
Bipolar disorder (in manic phase)
Delusional disorders, depressive psychoses, and drug-induced psychoses
*** Note: psychosis = a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality.
Identify which age group should not be administered antipsychotics
Antipsychotics should not be used to treat dementia-related psychoses in the elderly (as they increase the risk of mortality)
Differentiate between 1st- and 2nd-generation antipsychotic medications
1st: “conventional antipsychotics”
2nd: “atypical antipsychotics”
equally effective but differ in side effects
List 3 common 1st-generation antipsychotics (FGAs)
Chlorpromazine
Fluphenazine
Haloperidol
Recall how FGAs are classified
classified by potency (=the size of the daily dose needed)
Low: chlorpromazine
Medium: fluphenazine
High: haloperidol
Describe why FGAs have a higher risk of causing extrapyramidal symptoms (EPS)
FGA blocks dopamine receptors in the CNS
–> could develop motor issues
(just like Parkinson’s patients do not have enough dopamine)
Note: EPS are often IRREVERSIBLE !!!
List 4 examples of EPS
Early reactions (first 3)
1. Dystonia (twisting movement, may respond to anticholinergic medications like benztropine)
2. Parkinsonism
3. Akathisia (motor restlessness)
More common with high potent drug!
Late reactions
4. Tardive dyskinesia (abnormal movement of face and limbs)
List common other side effects associated with chlorpromazine and haloperidol
Chlorpromazine and haloperidol can cause prolonged QT interval.
They can also mess up hormonal balance –> galactorrhea, gynecomastia (men develop breast) and mensural irregularities.
Describe the signs and symptoms of neuroleptic malignant syndrome (NMS)
Life-threatening adverse effects of FGAs:
- rigidity (back is arched = opisthotonos)
- high fever
- abnormal BP, cardiac dysrhythmias)
List medications used to counteract the effects of NMS
Dantrolene: relaxant for rigidity and high fever
Bromocriptine: dopamine receptor agonist to relieve CNS toxicity
List 3 commonly used 2nd-generation antipsychotics (SGAs)
Clozapine
Olanzapine
Risperidone
**moderately block dopamine and strongly block serotonin receptors –> low risk of EPS
Review slide 18 for FGA vs SGA side effects difference!
Describe how SGAs may affect metabolism
SGAs can cause metabolic problems like weight gain, diabetes, and dyslipidemia –> increase cardiovascular risk
List a concerning side effect of clozapine that makes it a less-optimal SGA choice compared with other SGAs
Clozapine has a unique risk: agranulocytosis (low WBC count)
–> could lead to sepsis
