Day 1 - Psych Part 1 Mood, Anxiety Flashcards
Neurotransmitter changes: (1) Anxiety disorders (2) Depression (3) Mania (4) Alzheimer’s (5) Huntington’s (6) Schizophrenia (7) Parkinson’s disease
(1) Inc. NE, Dec. Serotonin & GABA (2) Dec. NE, Dopamine, & Serotonin (3) Inc. NE & Serotonin (4) Dec. ACh (not give anticholinergics) (5) Dec. ACh & GABA (think: Choreiform) (6) Inc. Dopamine (7) Dec. Dopamine, Inc. ACh
Pathological grief/bereavement criteria
(1) Depression criteria met for at least 2 weeks, after first 2 months following loss (2) Generalized feelings of hopelessness/helplessness/worthlessness/guilt (3) Suicideal ideation (4) Distressing feelings not diminish intensity by 6 mo. (5) Inability to move on, trust others, & re-engage in life by 6 mo.
Med conditions assoc. w/ severe depression
(1) Hypothyroidism (2) Hyperparathyroidism (3) Parkinson’s disease (4) Stroke, especially ACA (5) CNS Neoplasms (6) Pancreatic cancer
Meds known for causing sx of depression
(1) Sedatives - Alcohol, Benzos, Antihistamines (2) Stimulant withdrawal (3) Methyldopa (antihypertensive, used in pregnancy) (4) 1st gen. antipsychotics (e.g., Haloperidol) (5) Metoclopramide/Perchlorperazine (6) Glucocorticoids (steroids - mania, insomnia, also) (7) Insufficient thyroid replacement, causing hypothyroidism (8) Alpha-Interferon (tx viral hepatitis, depression is contraindication)
Suicidal risk factors - scale used
SAD PERSONS: (1) Sex (men) (2) Age (younger than 19, older than 45) (3) Depression (4) Prior attempts (5) Ethanol (6) Rational thought process (psychotic/irrational) (7) Support lacking (8) Organized plan (9) No spouse (10) Sickness; Also schizophrenia & owning hand gun
Sx of atypical depression; Meds
Hypersomnia, psychomotor retardation, hyperphagia (& weight gain), hypersensitivity to rejection; MAO Inhibitors work better than TCAs, SSRIs also work
Cause & 1st line tx for seasonal affective disorder
Depression in winter months, lack of exposure to light; Tx w/ light phototherapy; SSRIs & bupropion may also be useful
Name antidepressants in following categories: (1) SSRIs (2) TCAs (3) MAO Inhibitors (4) NDRI (5) SNRI (6) Tetracyclics
(1) Fluoxetine, Fluvoxamine, Sertraline, Paroxetine, Citalopram, Escitalopram (2) Imipramine, Amitriptyline, Desipramine, Nortriptyline, Clomipramine, Doxepin (3) Phenelzine, Selegiline, Tranylcypromine (4) Bupropion (5) Venlafaxine, Duloxetine, Milnacipran, Nefazodone (SARI?) (6) Mirtazipine, Trazodone
Drugs not taken w/ SSRIs due to risk of serotonin syndrome
(1) Other SSRIs (2) SNRIs (3) MAOIs (4) St. John’s wort (5) Tryptophan (6) Drugs - cocaine, amphetamine, ecstasy (7) L-Dopa/Dopamine
Serotonin syndrome p/w
Mental status changes: anxiety, agitation, delirium, restlessness, disorientation; Autonomic excitation: diaphoresis, tachycardia, hypertension, vomiting, hyperthermia, diarrhea; Neuromuscular hyperactivity - tremor, rigidity, hyperreflexia; Ocular clonus (slow continuous horizontal eye movements), Spontaneous or inducible clonus at ankle, Babinski b/l
Serotonin syndrome Tx
D/c serotonin agents; Supportive care, normal vital signs, Sedate w/ benzos; High temp - sedation, intubation, & mechanical cooling; Paralysis relieves hyperthermia (caused by muscle movement); No need for antipyretics; If agitation despite Benzos, use Serotonin antagonist (i.e., Cyproheptadine); After resolution, assess need to resume serotinergic agent
Serotonin withdrawal syndrome p/w; Worse offenders; Tx
Dizziness, nausea, fautigue, muscle ache, chills, irritability; Paroxetine & Venlafaxine; Switch to SSRIs w/ long half-life, like Fluoxetine
Name SNRIs generic (brands only FYI); For those not used for tx of depression, give use
Venlafaxine (Effexor), Desvenlafaxine (Pristiq), Duloxetine (Cymbalta), Nefazodone (Serzone), Milnacipran (Savella) - fibromyalgia only, Sibutramine (Meridia) - weight loss only
Eval. prior to TCAs in children
Screen PMH for heart disease, palpitations, syncope, and near-syncope (since TCAs can cause arrhythmias); FH for sudden death prior to age 40, long QT syndrome, arrhythmias, hypertrophic cardiomyopathy; EKG prior to initiation & again once optimized
Sx of TCA overdose
Cardiotoxicity (tachycardia, hypotension, conduction abnormalities); CNS toxicity (sedation, obtundation, coma, seizures); Anticholinergic (mydriasis, xerostomia, ileus, urinary retention, dementia/confusion)
Best TCA for elderly & why
Nortriptyline (over amitriptyline), since less anticholinergic side effects
TCA overdose mgt
ABCs; Activated charcoal, Continuous cardiac monitoring for at least 6 hrs, Frequent neuro checks, EKG, Electrolytes, TCA level, Gastric lavage in acute phase, IVF if hypotension; Most important - prolong QRS give sodium bicarb & if seizures give Benzos (maybe Barbs or Propofol - NOT phenytoin for toxin induced seizures)
Foods w/ tyramine; Assoc. conditions
Fermented, aged, smoked, pickled, spoiled; Cheese, beers, wine, miso soup, avocados, brown bananas, etc. ; MAOi hypertensive crisis & migraine
Bupropion contraind in which pt pops
Lower threshold of seizure, so avoided in pts w/ eating disorders (anorexia/bulimia), history of seizure disorder, & any other seizure risk (MAOi in last 14 days, withdrawing from alcohol or sedatives like benzos)
ECT indications
(1) Severe depression refractory to antidepressants (2) Depression w/ sychotic feat. (3) Severe suicidality (4) Depression w/ catatonic stupor (5) Depression w/ food refusal, leading to nutritional deficiency (6) Situations where rapid antidepressant response required (7) Previous good response to ECT (8) Medical conditions prevent use of antidepressants (e.g., elderly on lots of meds) (9) Bipolar disorder or mania (10) Schizophrenia psychosis
s/e of Lithium use in tx of bipolar disorder
(1) CNS depression & tremor (2) Thyroid changes (hypo/hyper, or goiter with euthyroid) (3) Nephrogenic DI (reversible w/ discontinuation - polydipsia, polyuria) (4) GI - n/v, diarrhea, metallic taste changes, weight gain
Tx for nephrogenic DI 2/2 Li toxicity
Hydrochlorothiazide & Amiloride (added for Li, closing Na channels)
Depression mgt in pt with bipolar disorder
Mild: Li or Lamotrigine alone; Moderate: second mood stabilizer (Lamotrigine) or atypical antipsychotic (Olanazipine, Risperidone, or Quetiapine); Lamotrigine has significant drug intx w/ Valproic acid and Lamotrigine; Adding antidepressant to mood stabilizer not shown to be effective; Severe depression - try other mood stabilizers or ETC
Dx criteria for adjustment disorder w/ depressed mood
(1) Clinically significant behavioral or emotional reactions causing significant distress or social/occupational impairment (2) Sx develop in response to identifiable psychosocial stressor, other than bereavement (3) Sx begin w/i 3 mo. of stressor (4) Sx disappear w/i 6 months of disapperance of stressor
MDD vs. Adjustment disorder w/ depressed mood
Adjustment disorder w/ depressed mood occurs w/i 3 mo. of identifiable stressor & disappears within 6 mo. of disappearance of stressor; Not meet MDD criteria
Acute stress disorder v. PTSD
Acute stress disorder: sx last less than 4 weeks; PTSD: sx lasting longer than 6 mo.
Tx for PTSD
Psychotherapy & SSRIs first-line; Other antidepressants may be used; Benzos avoided; Mood stabilizers; Alpha blockers improves nightmares; Atypical antipsychotics if refractory to other therapies
