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1
Q

What are the indications of ECT?

A

Severe or treatment resistant MDD or bipolar disorder

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2
Q

What is the efficacy (%) for ECT?

A

80%

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3
Q

What is the procedure for ECT?

A

Electrical current passes thru the brain, causing a seizure

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4
Q

What is used prior to ECT treatment?

A

General anesthesia and a muscle relaxant

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5
Q

What are the SE of ECT?

A

Confusion

Possible memory deficits

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6
Q

What are the relative contraindications for ECT?

A

H/p treatment resistance, need for rapid treatment response, and severity of illness

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7
Q

What are the NTI medications?

A

Li

CBZ

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8
Q

Which medications increase suicidality?

A

Mood stabilizers except Li

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9
Q

What is the MOA of Li?

A

Alter cation transport
Neurotransmitter reuptake
Effects of send messenger systems

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10
Q

Which drugs have an MOA of VSSCa?

A

VPA
CBZ
OxCBZ
Lamictal

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11
Q

What is topiramates MOA?

A

Interferes with both Ca and Ca channels

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12
Q

What is pregabalin/gabapentin’s MOA?

A

Alpha-2-delta ligands

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13
Q

What is keppra’s MOA?

A

Inhibition of N-type Ca channels

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14
Q

What are the WD sx of benzos?

A 
Anxiety
Agitation
Insomnia
Restlessness
Muscle tension
Irritability
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15
Q

What are the WD sx of TCAs?

A

Cholinergic rebound

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16
Q

What are the WD sx of SSRIs?

A

Fatigue, lethargy, flu-like sx, dizziness, n/d, HA

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17
Q

What are the WD sx of paxil?

A

Cholinergic rebound

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18
Q

What are the WD sx of duloxetine?

A

Severe WD reported

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19
Q

What are FGA MOAs?

A

Block D2 receptors

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20
Q

What are SGA MOA?

A

Blocks D2 receptors

Selective modifying effects of 5HT2A antagonism

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21
Q

What is the first line treatment of MDD?

A

SSRI
SNRI
Mirtazapine
Bupropion

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22
Q

What is the first line treatment of bipolar mania?

A

Li
BPA
SGAs
Consider 2 drug combo if severe

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23
Q

What is the first line treatment of bipolar depression?

A

Li
Lamictal
Quetiapine
VPA

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24
Q

What is the first line treatment of mixed bipolar depression?

A

CBZ
VPA
Olanz

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25
Q

What is the first line treatment of GAD?

A

SSRI

SNRI

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26
Q

What is the first line treatment of panic disorder?

A

SSRI
SNRI
CBT

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27
Q

What is the first line treatment of OCD?

A

CBT AND SSRIs

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28
Q

What is the first line treatment of PTSD?

A

SSRI (relieves core PTSD sx)

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29
Q

What is the first line treatment of psych emergencies?

A

APX for acute agitation
Haldol used most often
SGAs

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30
Q

What is the first line treatment of schizophrenia?

A

SGA

DA

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31
Q

What is the first line treatment of ASD?

A

Non-pharm

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32
Q

What is the first line treatment of personality disorders?

A

Psychotherapy

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33
Q

How do we adjust MDD therapy for partial response

A

Ensure optimized dose

Can switch or augment (Li gold standard for augmentation)

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34
Q

What medications can worsen/cause depression

A 
Clonidine
OCS
Steroids
AEDs
APX
Varenicline
Benzo
EtOH
Opioids
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35
Q

What are the augmentation strategies for MDD?

A

Li gold stand.

Augmentation is best when there is a response seen

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36
Q

What is the DOT for MDD?

A

At least 12 months with 1st episode
12-36 months for patients w/ recurrent and/or severe MDD
Potentially indefinite

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37
Q

What are the screening tools for bipolar?

A

MDQ - Bipolar disorder

PHQ9 - Depression

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38
Q

What is the DSM-5 criteria for MDD?

A

5+ sx during the same 2 week period (must have at least decreased interest/low mood)
SIG E CAPSL

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39
Q

What does SIG E CAPSL stand for?

A 
Sleep 
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicidal thoughts
Low mood
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40
Q

What is the DSM-5 criteria for Persistent depressive disorder?

A

Depression sx not meeting full MDD for at least 2 years

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41
Q

What is the DSM-5 criteria for hypomania?

A

3+ GIDDINES sx

4+ days

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42
Q

What does GIDDINES stand for?

A 
Grandiose; increased self esteem
Increased activity
Decreased judgement
Distractibility; flight of ideas
Irritability
Need less sleep
Elevated mood
Speedy talking or thoughts
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43
Q

What is the DSM-5 criteria for mania?

A

3+ GIDDINES sx

1+ week

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44
Q

What is the DSM-5 criteria for cyclothymic disorder?

A

At least 2 years w/hypomanic and depressive sx

More than 2 months at a time; present > 1/2 the time

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45
Q

What is the DSM-5 criteria for mixed bipolar disorder?

A

Patient with both mania and depression simultaneously

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46
Q

What is the DSM-5 criteria for GAD?

A

More days than not for at least 6 months
Difficult to control the worry
3+ sx: arousal, fatigue, trouble, concentrating, irritable, tension, insomnia

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47
Q

What is the DSM-5 criteria for social anxiety disorder?

A

A marked and persistent fear of one or more social or performance situations
Fear of humiliation/embarrassment
Lasts 6+ months

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48
Q

What is the DSM-5 criteria for panic disorder?

A

Panic attack sx for > 1 month or >1 sx:
Persistent concern
Worry about consequences
Behavioral change

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49
Q

What is the DSM-5 criteria for OCD-PD?

A

Recurrent and persistent thoughts with attempts to ignore or suppress, followed by repetitive behaviors aimed at preventing or reducing stress
Obsessions/compulsions are time consuming (take more than 1 hour a day) or cause clinically significant distress or impairment

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50
Q

What is the DSM-5 criteria for PTSD?

A

Event is experienced, patient re-experiences the event as memories, dreams or flashbacks, which causes anxiety like sx
Pt uses avoidance of external reminders
Leads to negative alterations in mood and cognition
Pt will go on to have persistent sx of arousal and hyperactivity (outbursts, hypervigilance, startle response, insomnia)
Duration = lasts longer than 1 month, and causes clinically significant distress/impairment

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51
Q

What is the DSM-5 criteria for sleep disorders?

A

1+ complaints of:
Difficulty initiating sleep
Maintaining sleep
Awakenings with inability to return to sleep

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52
Q

What is the DSM-5 criteria for SUD?

A

2+ sx w/in a 12month period
Large amounts of substance over a longer period than intended
Desire/unsuccessful efforts to cut down/control use
Time spent in activities necessary to obtain, use and/or recover from its effects
Cravings
Repeated failures to fulfill major obligations at work, school or home
Continued use despite having persistent or recurrent social or interpersonal problems
Tolerance
WD

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53
Q

What is the DSM-5 criteria for schizophrenia?

A 
2+ for a significant portion of time during a 1 month period: one of the sx must be 1-3
Delusions
Hallucinations
Disorganized speech
Grossly disorganized catatonic behavior
Negative sx
6+ months with at least 1 month of active phase sx
Significantly impaired functioning
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54
Q

What is the DSM-5 criteria for ASD?

A

Persistent deficits in social communication and social interaction (social-emotional reciprocity, nonverbal communicative behaviors, relationship)
Restricted, repetitive patterns of behavior (repetitive movements, adherence to routines, restricted fixated interests, response to sensory input)
Must impair function
Present in the early developmental period
Sx may be masked by learned strategies

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55
Q

What is the DSM-5 criteria for personality disorder?

A

Enduring pattern, deviates markedly from cultural expectations
s+ sx: cognition, affectivity, interpersonal functioning, impulse control
Inflexible and pervasive, stable, long duration - presented in adolescence or early adulthood

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56
Q

What is borderline PD?

A

Instability in interpersonal relationships, self-image, and affects and marked impulsivity

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57
Q

What is narcissistic PD?

A

Grandiosity, need for admiration, and lack of empathy

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58
Q

What is OCD-PD

A

Pre-occupation with orderliness, perfectionism and control

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59
Q

What are the 1st line options for acute bipolar mania?

A

Li
VPA
SGA
Consider 2 drug combo if severe

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60
Q

What drugs are recommended for bipolar disorder with comorbid anxiety?

A

Gabapentin or quetiapine

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61
Q

What is used for PTSD augmentation?

A

Prazosin (nightmares and flashbacks)

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62
Q

What is the 1st line treatment for PTSD?

A

SSRIs (treat core sx)

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63
Q

For what disorders are SSRIs 1st line treatment?

A

GAD
Panic
PTSD
OCD

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64
Q

What is SSRI place in anxiety disorders?

A

Generally first line

Start lower doses

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65
Q

What is the role of APX in treatment of anxiety?

A

3rd line

Quetiapine is most studied

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66
Q

What are common SSRI SE?

A

Insomnia
Wt gain
Jitteriness/anxiety
GI sx

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67
Q

When do we use augmentation in OCD?

A

3rd line

Duloxetine, phenelzine, trancypromine, tramadol

68
Q

What disorders does benzos treat?

A

GAD

Panic disorder

69
Q

When are benzos used in GAD?

A

2nd line therapy
Short term until SSRI works
4 wks or less

70
Q

When are benzos used in Panic disorder?

A

2nd line or

Adjunctive (short term < 8 weeks) can lead to a more rapid response to SSRI

71
Q

What are the NMRBAs?

A

Zolpidem
Zaleplon
Eszopiclone

72
Q

What is IR zolpidem used for?

A

Sleep onset PRN

73
Q

What is the Zolpidem CR used for?

A

Sleep onset and/or maintenance

74
Q

What is the zolpidem SL used for?

A

Sleep onset and/or frequent awakenings

75
Q

How can zaleplon be taken?

A

At sleep onset, and again if 4 hours of sleep remaining

76
Q

What is zaleplon used for?

A

Sleep onset and/or (2nd dose for frequent awakening)

77
Q

What is eszopiclone used for?

A

Sleep onset and/or maintenance up to 6 months

78
Q

What is the DORA?

79
Q

What is belsomra used for?

A

Onset and maintenance

80
Q

What is a M1+M2 agonist?

A

Ramelteon (Rozerm)

81
Q

When is ramelteon taken?

A

30 minutes before HS

82
Q

What drugs are safe for elderly for sleep?

A

Rozerem
Belsomra
Mirtazapine

83
Q

What TCA is used for sleep?

A

Doxepin at low doses

84
Q

What drug may be beneficial elderly sleep disorders?

A

Mirtazapine

85
Q

What type of treatments are essential for SAD/SUD recovery?

A

Psychosocial

86
Q

What are evidence based psychosocial treatments?

A 
CBT
Motivational enhancement therapy
Behavioral therapies
12-step facilitation
Psychodynamic therapy/interpersonal therapy
Self-help manuals
Behavioral self-control
Case management
Group, marital, and family therapies
87
Q

What is the pharmacists role in reducing SAD/SUD?

A

Recognize signs of use/abuse
Provide patient, provider and community education
Become informed regarding substances of abuse and “hot” or trendy substances of abuse
Communicate with local pharmacists and provider regarding local trends and issues
Join the local SA prevention task force
Join the NCCSR system

88
Q

What are the RFs for SUD?

A

Genetic predisposition
Personality traits like high impulsivity or sensation seeking
Co-occurring psychiatric disorders
Males, younger adults, single individuals, unemployed
Having deceased parents
Exposure to substance - earlier age, stronger risk
Stressful external environment

89
Q

What are the treatments for SUD (amphetamine) WD?

A

Supportive care
IV hydration
BP/HR management
Benzos for agitation, anxiety or seizures

90
Q

What are the treatments for SUD (opioids) WD?

A

Clonidine - has been found to help with n/v/d, cramps and sweating

91
Q

What drugs are the treatment for benzo overdoses?

A

Benzos:
Fluphenazine (antidote)
Flumazenil

92
Q

What are APX that are abused?

A

Quetiapine

93
Q

What are anticonvulsants that are abused?

A

Gaba
Pregaba
CBZ

94
Q

What are antidepressants that are abused?

A

Bupropion
Venlafaxine
Fluox

95
Q

What is an antihypertensive that is abused?

96
Q

What OTC agents are abused?

A

Robitussin DM
Sudafed
Coricidin H
Loperamide

97
Q

What uncommon drug classes are abused?

A 
APX
Anticonvulsants
Antidepressants
Antihistamines/antiemetics
Antihypertensives
PDE5 inhibitors
OTCs
98
Q

How do we treat agitation/aggression?

A 
APX = preferred for agitation
Haloperidol most common
Loxapine (CI in lung dz)
Olanzapine
SGA for agitation - risperidone, olanzapine, quetiapine
Benzos
99
Q

What is the SAFEST approach?

A

Spacing - maintain distance
Appearance - maintain empathetic appearance
Focus - watch the person
Exchange - delay by calm, continuous talk
Stabilization - get control of the situation
Treatment -

100
Q

What is the therapy plan for patients with SI?

A 
1-800-273-TALK
Ask them about suicide
Treatment specific disorder
Limit use of potentially
Pts should be treating in a setting that is least restrictive and most likely to be safe and effective
101
Q

What is the non-pharm treatment for aggression and agitation

A

SAFEST approach

102
Q

What are RFs for suicidal thoughts?

A 
MI
Pst hospital DC
Age 10-24 and 90+
Males
Unmarried
Caucasians
Sexual orientation
Occupation (physicians/veterans)
103
Q

What is agitation?

A

Unpleasant emotional state of extreme arousal

104
Q

What is delirium?

A

Change in cognitions
Disturbance of consciousness
Onset of hours to days

105
Q

What is psychosis

A

Delusions and hallucinations or perceptual disturbances

106
Q

What is SI

A

Thoughts of serving as the agent of one’s own death

May vary in seriousness depending on th specificity of suicide plans and the degree of suicidal intent

107
Q

What is the presentation of delirium?

A 
Change in cognition
Disturbance of consciousness
Temporal course
Psychomotor agitation
Sleep-wake reversals
Irritability
Anxiety
Emotional lability
Hypersensitivity to light/sounds
108
Q

What meds should be avoided in SI?

A

All mood stabilizers except Li

TCAs

109
Q

What are SE of FGA?

A

EPS
NMS
Haloperidol = QTc prolongation

110
Q

What are the sx of EPS?

A

Dystonia
Akathisia
Pseudoparkinsonism
Tardive dyskinesia

111
Q

What is NMS?

A

Neuroleptic malignant syndrome
Lead pipe rigidity
Fever
Leukocytosis

112
Q

What are SE for all SGAs?

A

Wt gain
DM
Dyslipidemia

113
Q

When is clozapine CI?

A

Seizures

Agranulocytosis

114
Q

What are special SE to clozapine?

A

Orthostatic hypotension
Drooling
Anticholinergic effects

115
Q

What is the most efficacious APX?

A

Clozapine - not used d/t SE

116
Q

What is special about quetiapine compared to other APX?

A

No EPS/prolactin elevation

117
Q

When is quetiapine preferred in PD?

A

Can’t afford pimvanserin

118
Q

Which SGA is available SL?

119
Q

What drug is asenapine chemically related to?

A

Mirtazapine

120
Q

What is the SE of risperidone?

A

Increased prolactin (more than other APX)

121
Q

What is a dose-dependent SE of risperidone?

122
Q

What is the active metabolite of risperidone?

A

Paliperidone

123
Q

What drugs have a long acting injectable?

A

Risperidone and Paliperidone

Aripiprazole

124
Q

What is the primary EPS sx associated with ziprasidone?

125
Q

How should ziprasidone be taken?

A

With 500 cals of food

126
Q

What is a SE of iloperidone?

A

QTc prolongation

Orthostatic hypotension

127
Q

What are the clinical pearls for lurasidone?

A

Considered to be one of the least impacting QTc
Renally dosed
Major 3A4 substrate
Take with food

128
Q

What is a SE of aripiprazole?

A

Activating

129
Q

What are pearls for aripiprazole?

A

Relatively nonsedating APX
Reduced EPS
3A4, 2D6 metabolite

130
Q

Which SGA have little effect on wt gain, lipids, BG?

A

Lurasidone

Aripiprazole

131
Q

Which drug is not used with a CrCl < 30?

A

Cariprazine

132
Q

What is the only FDA approved agent for PD psychosis?

A

Primvanserin

133
Q

Which antidepressants can use direct switching?

A

SSRI -> SSRI
SSRI -> SNRI
SNRI -> SNRI

134
Q

Which drugs require a 2 week lag period?

A

MAOI -> anything

anything -> MAOI

135
Q

Which drug requires a 5 week lag period when changing to an MAOI?

A

Fluoextine

136
Q

What drugs are used in movement disorders?

137
Q

How do we augment therapy for MDD remaining sx?

A

Augment with an antidepressant from a different pharmacologic class
Augment with a different “psychotropic” agent
Augmentation is a better strategy when response is seen

138
Q

How do we adjust MDD therapy?

A

Ensure adequate trial (4-8 weeks) at an appropriate (target) dose

139
Q

How do we adjust therapy for non-response in GAD?

A

Try another agent

140
Q

How do we adjust therapy for partial-response in GAD?

A

Continue therapy, titrate to target dose, re-evaluate later

141
Q

How do we switch APX?

A

Cross-taper over weeks

142
Q

If a patient has a personality disorder with depression and anxiety, how is it treated?

A

SSRIs (HD)

143
Q

If a patient has a personality d/o with impulsivity, aggression, mood instability, anxiety, anger or cognition/perception problems, how is it treated?

A

APX (Low dose)

144
Q

What drug class do we avoid in personality disorders

145
Q

What SGAs are approved for children with ASD?

A

Risperidone (5+)

Aripiprazole (6+)

146
Q

What is the pharmacists role in the treatment for ASD?

A

Counsel patients and families appropriately

Show compassion, empathy, and kindness

147
Q

What drugs does smoking decrease?

A 
Asenapine
Clozapine
Olanzapine
Haldol
Ziprasidone
Duloxetine
148
Q

What are the positive sx of schizophrenia?

A 
Delusion
Hallucination
Disorganized speech
Disorganized behavior
Catatonic
149
Q

What is the treatment for resistant schizophrenia

150
Q

What is the order of drugs (most to least) for metabolic AEs?

A

Cloz=Olan>Quet»>Arip

151
Q

Is there ever a reason for APX polypharm?

A

Yes sometimes

152
Q

What is the 1st line treatment of schizophrenia?

153
Q

What is the 2nd line treatment of schizophrenia?

A

Try another SGA

154
Q

What is the DOT of schizophrenia?

A

At least 12 months, but usually life long

155
Q

What are negative sx of schizophrenia?

A 
Alogia
Affective blunting
Asociality
Anhedonia
Avolition
Cognitive sx
Affective/mood
Aggressive sx
156
Q

What is the treatment of NMS?

A

Remove offending agent
Hydration
Dantrolene
Bromocriptene

157
Q

What is the treatment of acute dystonia?

A

Remove offending agent
Anticholinergics
Benzo

158
Q

What is the treatment of akathisia?

A

Remove offending agent
Anticholinergic
Propranolol

159
Q

What is the treatment of pseudoparkinsonism?

A

Removal of offending agent
Anticholinergics
Amantadine

160
Q

What is the treatment of tardive dyskinesia?

A

Removal of offending agent

VMAT-2 inhibitors

161
Q

What are the dopaminergic pathways?

A 
Mesolimbic = positive
Mesocortical = negative
Nigrostriatal = EPS
Tuberoinfundibular = increase prolactin levels/ hyperprolactinemia
162
Q

What are the starting doses of SSRIs?

A 
Lexapro: 10
Fluox: 20
Paxil: 20
Celexa: 20
Zoloft: 50
Fluvox: 50
163
Q

What are the usual doses of SSRIs?

A 
Lexapro: 10-20
Fluox: 20-60
Paxil: 20-60
Celexa: 20-40
Zoloft: 50-200
Fluvox: 100-300
164
Q

What are the starting doses of SNRIs?

A

Effexor: 37.5-75
Pristiq: 50
Duloxetine: 30-60

165
Q

What are the usual doses of SNRIs?

A

Effexor: 75-375
Pristiq: 50-100
Duloxetine: 60-120

Psych (9 decks)

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