Exam 2 Flashcards
what is biological psychiatry
psychiatry that aims to understand mental illness in terms of the biological function of the nervous system
what is transcultural psychiatry
psychiatry concerned with cultural and ethnic context of mental illness
true or false: if a diagnosis is made, pharmacotherapy should be offered
false, pharmacotherapy may not always be needed, other things like counselling, nutrition, exercise ect may be all that is needed
how might family history affect the prescribing of medication
a strong family history may encourage earlier use of medication
should level of distress be used as an indicator for starting medication
no, not by itself. Patients often only present when they are in most distress but this alone is not an indication for medication
is level of dysfunction and indication to start medication
yes. Level of dysfunction is a strong indicator for when to start medicaiton
what is the therapeutic objective for pharmacotherapy
improve function and minimize symptoms
what should you consider if there is no drug to target the primary symptoms?
then drug therapy is probably not indicated and you should consider non pharmacological options
what are the 4 classes of psychotropic medications
anti-anxiety
antidepressants
mood stabalizers
anti-psychotics
what is a multimodal approach to pharmacotherapy
using more than one class to target more than one pathway to improve symptom profile and function
true or false: for most people, monotherapy is enough
true
what are the excitatory neurotransmitters (5)
Acetylcholine
Dopamine
Epinephrine
Norephinephrine
Glutamate
what are the inhibitory neurotransmitters
GABA
Serotonin
what neurotransmitter is related to anxiety, depression, and ADHD
GABA
what neurotransmitter is related to alzheimers and myasthenia gravis
Acetylcholine
what neurotransmitter is related to depression, anger control, OCD, and suicide
serotonin
what neurotransmitter is related to parkinsons, schizophrenia, and addiction
dopamine
what neurotransmitter is related to brain trauma, autoimmune diseases, encephalopathies, epilepsy, and alzheimers
Glutamate
low levels of dopamine are associated with what
parkinsons, addiction, anhedonia, fatigue, cognitive impairment, problems with executive function, ADHD, impulsivity
excess levels of dopamine are associated with what
schizophrenia, anxiety, hypervigilance, paranoia, hallucinations
low levels of serotonin are associated with what
depression, anger control, OCD, suicide
what neurotransmitter counteracts epi and norepi
serotonin
what neurotransmitter is implicated in migraines
serotonin
what is the relationship between serotonin and GABA
serotonin enhances GABA, so inhibiting reuptake of serotonin can prolong the calming effects of GABA
what is a deficiency in serotonin related to
depressed mood, anxiety, panic, phobias, OCD, irritability, changes in eating, memory and learning problems, cardiovascular function, temperature regulation
what is a way to naturally increase serotonin
vigorous exercise
what is the primary role of serotonin
mood, emotions, appetite, sleep
what is the primary role of dopamine
pleasure center of the brain
what is the primary role of acetylcholin
somatic nervous system
what is associated with a loss of acetylcholine
alzheimers
which neurotransmitter is associated with movement, skeletal muscles and muscle tone
acetylcholine
what is the main role of epinephrine
energy and emergency system in SNS
what neurotransmitted is connected to the formation of memories associated with stress
epinephrine
what neurotransmitter is synthesized by tyrosine (amino acid found in meats, dairy, nuts, and eggs)
norepi
what neurotransmitter helps with concentration and motivation, increases BP and HR and releases glucose stores
norepi
what is a deficiency in norepi associated with
depressed mood, fatigue, psychomotor retardation, impaired attention, slow memory
what is an excess of norepi associated with
hypomania, mania, anxiety, irritability, nightmares, muscle cramping
what neurotransmitter generated calm and relaxation
GABA
GABA deficiency is associated with what
anxiety disorders, poor impulse control
what is the most widespread neurotransmitter in the brain
L-glutamate
what two neurotransmitters, working in tandem, are called the speed control mechanisms of the brain
GABA and norepi
what is the role of L-glutamate
involved in memory and learning
what are the 3 phases of treatment
acute phase = 0-3 months
continuation phase = 4-9 months
maintenance phase = years
why is aggressive treatment upon onset best for treating mental health disorders
the longer a disorder is not treated or undertreated, the more difficult it is to go into remission
what are the main side effects of benzos
drowsiness, dizziness, decreased alertness and concentration, impairment of motor coordination
how do benzos work
potentiate GABA which produces emotional relaxation
what is the half life of benzos
14-80 hours, longer in the elderlu
how do barbiturates work
enhance effects of GABA
what are side effects of barbiturates
profound CNS depression, dizziness, light headedness, memory and attention impairement
why are barbiturates rarely prescribed anymore
they have a narrow therapuetic index so even small overdoses can cause death
how do TCAs work
inhibit reuptake of norepi and serotonin, block histamine receptors
what things are improved with TCA use
improved sleep, concentration, attention, and memory
why are TCAs more dangerous than some other options
narrow therapeutic index and can be toxic in certain people causing fatality
why are SSRIs and SNRIs better than benzos for long term anxiety treatment
not sedating, not addictiong and less dangerous
what are some down sides to using SSRI and SNRI for anxiety instead of using benzo
less effect for decreasing somatic effects and more side effects than benso
when would alpha adrenergic blockers (usually used for HTN and urinary retention) be used in mental health
can reduce sleep disturbances caused by excess norepi
used for nightmares in PTSD
Why are MAOIs infrequently prescribed and when might you use them
high reactivity with food and other medications but may be prescribed for refractory depression. Should be prescribed by psychiatrists
what neurotransmitters of TCAs effect
norepi and serotonin
what class is prazosin and what is it used for
alpha adrenergic blocker
for nightmares from PTSD
what are the side effects of prazosin
drowsiness, fatigue, headache, nausea, palpitations, nasal congestion, edema
what is the first dose phenomenon with prazosin
may cause a sudden drop in BP after first dose or increase dose which can cause fainting so best to take at night
what are first line options for GAD
any SSRI, SNRIs (venlafaxine)
what are first line treatment for panic attacks
any SSRI, long acting benzo, imipramine, lorazepam, alpazolam
what are first line options for treating social anxiety disorder
fluoxetine, paroxetine, venlafaxine, inderal, despiramine
what are first line options for treating acute stress disorder
lorazepam, zopiclone (for sleep), amitriptyline (for sleep) atarax
what are first line options for treating PTSD
sertaline, paroxetine, fluoxetine, prazosin (for nightmares)
when treating PTSD why would mirtazepine be prescribed? why would trazedone?
mirtazepine for rumination, trazedone for sleep
any SSRI except ___ would be first line treatment for OCS
citalopram and escitalopram
true or false: TCAs have the same efficacy as SSRIs for treating GAD
true and TCAs also improve sleep and promote deep sleep
what are the most effective SSRIs for social anxiety disorder
fluoexetine, fluvoxamine, parocetine
if a patient with social anxiety disorder also has somatic symptoms such as blushing and sweating, what medication can be tried
Inderal (beta blocker) - used as a PRN dose
what are the two main approaches to treated acute stress disorder
improving sleep or help during the day
what medication can be used to help with sleep in acute stress disorder
zopiclone, TCA like amitriptyline, hydroxyzine
what medications can be used to help patients during the day with acute stress disorder
short acting benzos for crisis or longer acting benzo like clonazepam or diazepam
when is melatonin especially helpful
in the elderly and for time zone changes as there is no tolerance development
what neurotransmitters are implicated with PTSD
excess norepi, reduced serotonin, reduced GABA, reduced dopamine
why should PTSD be treated as early as possible
long standing PTSD may not respond to medication as well as those who are treated early on
what is first and second line treatment for PTSD
first line is SSRI or SNRI
second line is TCA
what neurotransmitter is implicated in nightmares from PTSD
thought to occur from elevated norepu
how does prazosin work for PTSD nightmares
crosses blood brain barrier and dampens the effects of norepi
how long does it take for prazosin to start working
can take several weeks but usually effective within a few days
what other conditions might be improved if a patient is put on prazosin
HTN and urinary retention
what are the most common SE of prazosin
headache and dizziness
why might mirtazepine be used for PTSD
less sexual side effects than SSRI and SNRI and especially useful for enhancing sleep in PTSD
true or false: trazadone can be used as an adjunct in PTSD treatment but should not be used as monotherapy
true
what is first line treatment for OCD
SSRI and the TCA clomipramine
when treating OCD with an SSRI, how long should you wait before switching to another medication or add another drug
at least 12 weeks
if after 12 weeks of treatment for OCD with an SSRI, there is still incomplete response, what is the next step
do not withdraw the SSRI but add another agent like atypical anti-psychotic (risperidone) or anti-convulsant (topiramate)
what are the most common side effects of most anxiety medications and what education should you provide
most will include dizziness, dry mouth, and nausea
educate that usually will resolve after a couple of weeks
why is the question “how are you feeling” not an effective way to measure response to medication
not specific and does not assess symptom improvement
why do you not want to abruptly stop Inderal (beta blocker) and how long should you wean it for
can cause sympathetic overactivity causing HTN and rebound symptoms
wean slowly over 6-10 days
current typical antidepressants act on what neurotransmitters and about how many people are resistant to the treatment
act on serotonin and/or norepi
about 1/3 of people are resistant to treatment
how might ketamine be used in the treatment of depression
at low doses, it gives a rapid response to treatment resitant depression without sedative side effects but can produce euphoric side effects
how does stress affect neurons
causes neuronal atrophy in everyone, even if mild, which could have wide spread consequences
what are some ways to help prevent neuronal atrophy from stress
good coping, social supports, exercise
what non pharmacological method has been shown to have the biggest effect on enhancing synaptic connections and neuronal function
exercise
depression is thought to be from a decrease in one of the main monoamines which include:
serotonin, norepi, dopamine
what amino acid makes serotonin? norepi?
serotonin - tryptophan
norepi - tyrosine
what are side effects of abrupt withdrawal of an SSRI
headache, n/v, agitation, sleep disturbancs
which antidepressant class may also reduce pain from fibromyalgia
SNRI
what are common SE of TCAs
orthostatic HoTN, dizziness, sedation, anticholinergic effects
what antidepressant may also be used to prevent migraines and neuropathic pain
amitriptyline
why are MAOIs a last choice for treatment of depression
high incidence of interaction with other drugs and any foods containing tyramine which can cause HTN crisis and stroke
what is the best class of medication to use if the primary concern in MDD is hopelessness
SNRI
what is the best medication to use if the primary concern in MDD is lack of energy and fatigue
fluoxetine, bupropion, venlafaxine because they are all activator
what is the best medication to use if the primary concern in MDD is insomnia
fluvoxamine, mirtazapine, TCAs
what medication is the best studied and safest to use for MDD in younger people
fluoxetine (prozac)
what is the best medication for MDD in older adults? which one should be avoided?
citalopram is best for older adults
avoid paroxetine
for people with migraines, what MDD drugs should be avoided
buproprion and SSRIs as they may interact with triptans and cause serotonin syndrome
are SSRIs safe to use in pregnant and breastfeeding mothers
yes
when should bupropion be avoided
hyperactivity disorder, eating disorders, alcoholism, bipolar, seizures, psychotic disorders, personality disorders
when should TCAs be avoided
cardiac arrhythmias
elderly with fall risk
obsesity
BPH
urinary retention
bipolar
a patient treated for MDD has resolution of all other symptoms but still has fatigue. What does this mean?
incomplete response
what is refractory MDD and what should you do
when a client cannot achieve remission even after several trials of medication combos
refer to psychiatrist
what is relapse
remission lasting less than 6 months
what are some risk factors for relapse and recurrence
incomplete treatment
nonadherence
stopping before at least 2 years of treatment
situational barriers
unrecognized comorbidities
treated during crisis but only brought back to baseline
substance use
what is tachyphylaxis
tolerance to SSRIs, inital response with symptoms returning around 6 months
what should you do for a patient wth tachyphylaxis
rule out nonadherence
then increase dose or decrease dose
then add another drug
then consult psychiatry
what class of medication is most likely to have tachyphylaxis
SSRI
what is SSRI discontinuance syndrome
abrupt withdrawal from SSRI, more common with short to medium half life SSRIs
when would you expect symptoms of SSRI discontinuance symptoms to start and how long would they last
within 2-5 days and lasts 1-2 weeks but can occur over a prolonged time
what are the main symptoms of SSRI discontinuance symptoms
main are n/v/d, fatigue and headaches
can also include light headedness, poor appetite, diaphoresis, chills, treamors, altered sensations, muscle and joint aches, sleep disturbances
which SSRI is most likely to cause SSRI discontinuance syndrome
paroxetine
true or false: gradual tapering prevents SSRI discontinuance syndrom
false
what SNRI is most likely to cause withdrawal if stopped abruptly
velafaxine
what are the symptoms of SNRI withdrawal? or they more or less severe than SSRI withdrawal
dizziness, flu like symptoms, anxiety
usually more severe than SSRI withdrawal
how might you differentiate withdrawal symptoms from relapse symptoms for SSRIs
withdrawal symptoms usually have an early onset while relapse is usually gradual
what is rebound phenomena
a rapid return and worsening of patients original symptoms
what is treatment for discontinuance syndrom
reassruance and support, reinstating the same or another drug may only postpone or aggrevate the problem
what is serotonin syndrom
a potentially fatal condition caused by excess serotonin
what is the triad of symptoms for serotonin syndrome
symptoms seen where serotonin concentrations are the highest: neuromuscular, autonomic, and GI
what characterizes serotonin syndrome
mental status changes, neuromuscular hyperactivity and autonomic instability
what are some proserotonergic drugs that may interact with SSRIs
MAOIs
TACs
Trazadone
Mirtazapine
Bupropion
SNRIs
Norepi-dopamine reuptake inhibitors
Lithium
Opioids
Linezolid
Amphetamines and stimulinats
St. Johns Wort
Ginseng
how long should the wash out period be between stopping an SSRI and starting another serotonergic medication
usually 2-3 weeks, longer for elderly
5 weeks for fluoexetine
what is the diagnostic criteria for serotonin syndrome
symptoms coincide with addition of serotoniergic agent or increased dose
at least 3 symptoms: agitation, ataxia, diaphoresis, diarrhea, hyperreflexia, mental status change, myoclonus, shivering, tremor, hyperthermia
what are some complications of serotonin syndrome
seizures
arrythmia
rhabdo
DIC
renal failure
resp failure
death
what MDD medication is contraindicated in patients with congenital long QT sydrome
citalopram
when does serotonin syndrome start, how long does it last, and when do most fatalities occur
starts within 2-8 hours of ingestion, if asymptomptomatic for 6-8 hours unlikely to require further treatment, most fatalities occur within first 24 hours
what is the role of St. Johns Wort in MDD and what should you be aware of
helpful for mild to moderate depression
do not use with SSRIs for risk of serotonin syndrome
why should you follow up with young adults and adolescents within the first week of starting SSRI therapy
highest risk of suicide during this time
why are mood stabilizers a priority for treating bipolar
high risk of suicide
true or false: bipolar should be managed by or in partnership with a psychiatrist
true
how long should treatment last after a first presentation of bipolar?
at least 6 months but ideally 1 year
what is the annual monitoring recommended for people with bipolar
weight, BMI, nutritional status
BP, pusle, CV risk
fasting glucose or A1C
liver and renal
Thryoid and calcium if on lithium
what is first line therapy for acute depressive phase of bipolar and acute mania
lithium
what class of drug is lithium
mood stabilizer
what is the therapeutic trough levels for lithium
0.4-0.9
can lithium be taken during pregnancy or breastfeeding
no
what are the SE of lithium
n/v, fine tremor, dry mouth, headaches and drowsinesss
what monitoring is recommended for lithium
levels weekly X3 then at 12 weeks another lithium level and renal levels
what are toxicity symptoms of lithium
n/v/d, confusion, stupor, ataxia, muscle weakness, polyuria, polydipsia, arrythmias, seizures
what are the anticonvulsants used for bipolar
valproate and lamotragine
what should patients on valproate be made aware of
requires stable nutritional intake, must avoid alcohol, take with food but not milk
can valproate be stopped abruptly
no, taper slowly to prevent seizures
what anticonvulsant may be used as monotherapy for bipolar during the maintenance phase
lamotragine
what bipolar medication carries a risk of serius rash including steven johnson? what should a patient do if they develop a rash?
lamotragine
should discontinue immediatley and seek medical care
what are the side effects of lamotragine
n/v, dizziness, ataxia, tremor (common)
why are atypical antipsychotics used in bipolar
to abort psychosis and help stabalize mood
what are the atypical antipsychotics used in bipolar
risperidone
olanzapine
quetiapine
what is the main disadvantage of using atypical antipsychotics
weight gain is common and may precipitate DM and hyperlipidemia
what are extrapyramidal symptoms and what class of medications may cause them
dystonia, akathisia, parkinsonism, tardive dyskinesia
may be caused by atypical antipsychotics
what should you do if a bipolar patient is experiencing EPS from their medicatioin
consult with psychiatry as changes to dose or meds should be done by them
the first episode of psychosis often appears between the age of ______ and there is a high risk of _____ after the first episode
15-25
suicide
what neurotransmitter plays a key role in psychotic disorders
dopamine
which atypical antipsychotic may cause angranular cytosis and so requires periodic blood cell monitoring
cloazpine
atypical or typical antipsychotics are preferred for dysphoria and suicidal behavior
atypical
atypical or typical antipsychotics are preferred for substance abuse and cognitive problems
atypical
atpyical or typical antipsychotics are preferred for aggressive behavior and agitation
typical
atypical or typical antipsychotics are preferred for excitability and insomnia
typical
what are the main side effects of antipsychotics
weight gain
hyperglycemia
EPS
anticholinergic effects
sexual side effects
CVS risk
prolactin elevation
all antipsychotics are rated ____ for pregnancy
category C
true or false: patients who do not have symptoms but are at high risk of having psychosis should have antipsychotics started
false, do not start medication in an attempt to prevent or due to elevated risk
what two treatments are recommended for psychosis
oral antipsychotics and psychological treatments like CBT or family intervention
true or false: counselling is a valid alternative to CBT for treating pyschosis
false, CBT is much more effective and counselling should not routinely be recommended
what investigations should be done at 12 weeks, 1 year, and then annually for people on antipsychotics
weight, BP, A1C or fasting glucose, lipids, and prolactin
true or false: adherence therapy and skills training should be routinely offered to those with psychotic disorders
false
true or false: art therapy may be a helpful adjunct for people with psychotic disorders
true
