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M3 Psychiatry > Final Exam > Flashcards

Final Exam Flashcards

1
Q

SSRI stands for

A

selective serotonin reuptake inhibitor

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2
Q

Fluoxetine half life

A

1 week

Longest of SSRIs

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3
Q

What is discontinuation syndrome and what medications commonly cause it?

A

caused by stopping a short half life SSRI/SNRIs abruptly

Meds: Paroxetine, Fluvoxamine, Venlafaxine

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4
Q

What combination can cause serotonin syndrome

A

SSRI and MAOI used together

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5
Q

Most likely SSRI to cause weight gain

A

Paroxetine

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6
Q

What is the required washout period to switch from an MAOI to an SSRI?

A

2 weeks

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7
Q

What is the relationship between escitalopram and citalopram?

A

escitalopram is the S-enantiomer of citalopram

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8
Q

What is the common side effect to all SSRIs?

A

sexual side effects

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9
Q

SNRI stands for

A

serotonin norepinephrine reuptake inhibitor

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10
Q

What is the metabolite of venlafaxine?

A

desvenlafaxine

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11
Q

MOA of venlafaxine

A

blocks reuptake of serotonin at all doses, blocks dopamine at very high doses

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12
Q

Preferred use for duloxetine

A

Painful symptoms of depression, diabetic neuropathy pain, chronic pain (MSK, fibromyalgia, GAD, MDD)

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13
Q

What is “poop-out” syndrome?

A

decreased response to medication after initial response, seen with SSRI’s and SNRI’s
medical term: antidepressant treatment tachyphylaxis = progressive or acute tolerance development after chronic administration of SSRI/SNRI

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14
Q

Risk associated with SNRI use for bipolar patients

A

inducing mania

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15
Q

Venlafaxine effects

A 
Helps with hot flashes/flushing in perimenopausal women
Increases BP (dose dependent)
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16
Q

Major NDRI drug

A

Bupropion

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17
Q

MOA of Bupropion

A

Inhibits reuptake of norepinephrine and dopamine

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18
Q

Use of bupropion

A

Treats cravings from nicotine dependence
Antidepressant
May be useful for treating children with ADHD

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19
Q

Benefit of using bupropion as antidepressant

A

No sexual dysfunction effects, no effect on weight gain

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20
Q

Risks associated with bupropion

A

Lowers seizure threshold, significantly at high doses

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21
Q

Compare efficacy of bupropion to SSRI/SNRI for GAD treatment

A

Bupropion is less effective than SSRI/SNRIs for GAD treatment

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22
Q

Onset of action for bupropion

A

2-4 weeks

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23
Q

Mirtazepine MOA

A

pre-synaptic alpha 2 adrenergic antagonist increases release of NE and 5HT into the synaptic cleft, also blocks postsynaptic H1

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24
Q

Benefits of mirtazepine over SSRI/SNRI

A

decreased GI side effects due to specific 5HT3 antagonism

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25
Q

Side effects of mirtazepine

A

weight gain (F>M)

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26
Q

Combination of mirtazepine and MAOI can cause

A

Serotonin syndrome

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27
Q

Onset of action for insomnia and anxiety effects of mirtazepine

A

Immediate

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28
Q

Mirtazepine effect on CYP450

A

No effect

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29
Q

TCA mechanism

A

inhibits reuptake of 5HT and NE

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30
Q

TCA side effects

A

Anticholinergic effects: blurred vision, urinary hesitancy, dry mouth, constipation

Alpha1 adrenergic effects: dizziness, sedation, hypotension

Histamine effects: sedation, weight gain

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31
Q

Metabolite of amitriptyline

A

Nortriptyline (secondary amine) is metabolite of amitriptyline (tertiary amine)

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32
Q

Metabolite of imipramine

A

Desipramine (secondary amine) is the metabolite of imipramine (tertiary amine)

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33
Q

Gender differences in TCA antidepressant efficacy

A

TCAs may be more effective than SSRI’s for treating depression in men

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34
Q

TCA concentration is increased by

A

medications that inhibit CYP450 2D6 including fluoxetine, paroxetine, bupropion, duloxetine

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35
Q

Risk associated with TCA OD

A

Cardiac arrhythmia risk due to blockade of fast sodium channels

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36
Q

Lithium is approved for treatment of

A

acute manic episodes, maintenance therapy for bipolar disorder

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37
Q

Unique benefit of lithium

A

Decreases suicide risk

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38
Q

When should Li blood levels be drawn?

A

5d after starting/changing dose to confirm therapeutic levels
Should be trough levels (12 hours after previous dose)

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39
Q

Maintenance treatment levels for Li

A

0.6-0.8 mEq/L

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40
Q

How is Li toxicity > 4 mEq treated

A

dialysis

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41
Q

What conditions can increase risk for Li toxicity?

A

Renal impairment
Sodium depletion
Dehydration

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42
Q

Labs 1-2x/year for patients on Li

A

Li level, TSH, BUN/Cr

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43
Q

Labs before starting Li

A

TSH, BUN/Cr, Pregnancy

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44
Q

Li risk during pregnancy

A

Ebstein’s anomaly from exposure during first trimester

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45
Q

Li can cause tremor, which can be exacerbated or improved by what substances?

A

Tremor exacerbated by caffeine, improved by propranolol

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46
Q

Divalproex sodium (Valproic acid) is approved for treating

A

Antiepileptic approved for treatment of bipolar mania, migraine prophylaxis

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47
Q

Labs before starting valproic acid

A

LFT, platelets and pregnancy test

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48
Q

Risks associated with valproic acid treatment

A

Hepatotoxicity in children <2y
Spina bifida from exposure during first trimester
Aspirin + valproate increases risk of thrombocytopenia

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49
Q

Difference between depakene and depakote

A

Fewer GI side effects associated with depakote due to enteric coating

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50
Q

Interaction between valproate and lamotrigine

A

Valproate doubles lamotrigine concentration

When used in combination, dose of lamotrigine should be halved

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51
Q

Trough levels for valproate are drawn

A

19 hours after last dose

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52
Q

Carbamazepine is approved to treat

A

acute manic or mixed episodes of bipolar I disorder

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53
Q

Unique metabolism feature of carbamazepine

A

Autoinduction - half life decreases to less than 50% of initial because it is substrate and inducer of CYP3A4

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54
Q

Interaction between carbamazepine and oral contraceptives

A

CYP induction decreases concentration of oral contraceptives, increasing risk for pregnancy

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55
Q

Side effects of carbamazepine

A

Agranulocytosis, aplastic anemia
Hyponatremia
Hepatotoxicity

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56
Q

Regular labs for carbamazepine

A

Blood levels, platelets, CBC, LFT

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57
Q

Oxcarbazepine

A

similar to carbamazepine but not FDA approved for bipolar treatment

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58
Q

Lamotrigine is indicated for

A

maintenance of bipolar disorder, bipolar depression, but NOT acute mania

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59
Q

Medications approved for maintenance treatment of bipolar disorder

A

Lithium, lamotrigine, quetiapine, olanzapine, and aripiprazole

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60
Q

Medications approved for treating bipolar depression

A

Lamotrigine, quetiapine, lithium, olanzapine/fluoxetine and lurasidone

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61
Q

Medications indicated for treatment of acute mania

A

Lithium, divalproex, carbamazepine, quetiapine, ziprasidone and asenapine

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62
Q

Side effects of lamotrigine

A

Benign rash, severe rash, SJS

No risk for weight gain or sedation

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63
Q

DDI between lamotrigine and divalproex

A

divalproex doubles lamotrigine level, need to halve lamotrigine dose to keep at therapeutic level and prevent possible SJS

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64
Q

MOA of lamotrigine

A

Blocks sodium channels

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65
Q

What was the first antipsychotic medication?

A

Chlorpromazine

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66
Q

2 major categories of typical antipsychotics

A

high potency and low potency

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67
Q

Available haloperidol formulations

A

PO, IM, and IV

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68
Q

Use of haloperidol

A

Agitated psychotic patients

Can also treat Tourette’s syndrome

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69
Q

Typical antipsychotics available in IM forms given every 2-4 weeks

A

Haloperidol and fluphenazine

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70
Q

Medications to counter EPS effects of FGAs

A

trihexyphenidyl, benztropine, and diphenhydramine

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71
Q

Low potency antipsychotics act on what receptors

A

anticholinergic, antihistaminic and anti alpha1

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72
Q

Typical antipsychotic used more often as an anti-emetic

A

Prochlorperazine

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73
Q

Treatment for intractable hiccups

A

Chlorpromazine

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74
Q

Typical antipsychotic with highest risk of dose dependent QTc prolongation

A

Thioridazine

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75
Q

Most efficacious antipsychotic

A

Clozapine

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76
Q

Quetiapine use

A

Psychosis in lewy body dementia and Parkinson’s disease

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77
Q

Quetiapine has a low risk for this side effect

A

EPS

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78
Q

Atypical antipsychotics most likely to cause sedation and metabolic syndrome

A

Olanzapine and clozapine

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79
Q

Metabolically neutral SGAs

A

Lurasidone, asenapine, ziprasidone and aripiprazole

80
Q

SGA with highest risk of QTc prolongation

A

Ziprasidone

81
Q

Aripiprazole MOA and common side effect

A

Partial dopamine agonist, commonly causes akathisia

82
Q

What is tardive dyskinesia?

A

repetitive, involuntary, purposeless movements, often of the face

83
Q

Indication for abruptly stopping clozapine

A

WBC is <2,000 or ANC <1,000, indicating agranulocytosis

84
Q

Paradoxical side effects of clozapine

A

dry mouth and excess salivation

85
Q

Metabolic syndrome labs/tests

A

glucose, lipids, weight, waist circumference

86
Q

What is dystonia

A

Muscle rigidity

87
Q

What is an oculogyric crisis?

A

dystonic reaction resulting in involuntary upward deviation of the eyes

88
Q

Side effect associated with alpha 1 adrenergic antagonism

A

Dose dependent orthostatic hypotension

89
Q

Risk of using antipsychotics in early dementia patients

A

Sudden death

90
Q

D2 blockade in the tuberoinfundibular tract can cause this side effect

A

Elevated PRL leading to gynecomastia

91
Q

MOA of SGAs

A

D2 and 5HT2A antagonism

92
Q

D2 occupancy required for antipsychotic effect

A

> 60% blockade

93
Q

D2 occupancy causing side effects

A

> 80% blockade causes increased PRL and EPS

94
Q

NMS is caused by

A

Excess D2 blockade

95
Q

Tract associated with positive symptoms of schizophrenia

A

Mesolimbic pathway

96
Q

Tract associated with negative symptoms of schizophrenia

A

Mesocortical pathway

97
Q

Anti-emetics that can cause EPS or TD

A

Prochlorperazine, metoclopramide, droperidol, promethazine

98
Q

Effect of smoking in schizophrenics

A

Cigarette smoke induces metabolism of antipsychotic medications, thus reducing levels
Also increases risk for CV disease

99
Q

Lab that correlates with severity of NMS

A

Creatine kinase

100
Q

Antipsychotics approved to treat bipolar depression

A

Olanzapine/Fluoxetine
Lurasidone
Quetiapine

101
Q

Active metabolite of risperidone

A

Paliperidone

102
Q

Demographic at greatest risk for dystonia from antipsychotics

A

Young males

103
Q

First sign of NMS

A

mental status change (followed by rigidity, hyperthermia and autonomic instability)

104
Q

Ratio of depression to mania in bipolar I patients

A

Depressed 2x more than manic

105
Q

Gender differences for bipolar risk

A

Same in men and women

106
Q

Ratio of depression to hypomania in bipolar II

A

Depressed 15x more than hypomanic

107
Q

Which gender more likely to have first mood disturbance be manic

A

Men

108
Q

Risk of future manic episode following a first episode mania

A

85%

109
Q

Risk of bipolar disorder if identical twin has been diagnosed

A

70%

110
Q

Difference in peak age onset of bipolar I and II

A

II onset mid 20s

I onset 18y

111
Q

Which side of family history is more important for bipolar risk

A

Maternal side

112
Q

After the first MDD mood disturbance, what is the risk of future episodes?

A

risk of future episodes is 50% (after 2 episodes, 70%; after 3 episodes, >90%)

113
Q

With each episode of mania, what happens to episode duration and interepisode interval?

A

Duration increases and interval decreases

-spend more time in manic state

114
Q

Average lifetime manic episodes without pharmacologic intervention

A

9-10 episodes

115
Q

Percent of bipolar patients that end lives in suicide

A

16%

116
Q

First sign of new manic episode

A

decreased need for sleep

117
Q

Mania is first episode, followed by depression how often?

A

60% mania –> depression

40% depression–> mania

118
Q

Avoid depakote treatment for these patients

A

Liver disease

119
Q

Can you rapidly load depakote?

A

Yes, response seen within 3 days

Dose: multiply weight x 10

120
Q

Response rate for lithium treatment in bipolar patients with euphoric mood, FHx of illness, and/or few lifetime episodes

A

70%

121
Q

What is the rule of thirds?

A

With Li or depakote monotherapy, 1/3 respond well, 1/3 partially respond, and 1/3 respond poorly

122
Q

Preferred treatment for severe acute mania

A

Li + antipsychotic

Depakote + antipsychotic

123
Q

At what point is maintenance treatment always indicated

A

After 2 manic episodes

124
Q

What decreases risk of conversion to mania when stopping Lithium?

A

Gradually discontinuing over months instead of abruptly stopping

125
Q

Is Aripiprazole useful for bipolar depression?

A

No, but it is for MDD

126
Q

Classes of medicine with increased switch rate and increase in number of rapid cycling cases

A

TCA’s and SNRI’s

127
Q

Lowest risk antidepressant for causing switch to manic episode

A

Bupropion

128
Q

What is anosognosia?

A

Lack of insight, patients do not recognize they are ill

129
Q

Positive symptoms of schizophrenia

A

Delusions, hallucinations, disorganized thinking

130
Q

Cognitive symptoms of schizophrenia

A

SMART - impaired speed, memory, attention, reading, and tact

131
Q

What is catatonia?

A

Motor inhibition including stupor, waxy flexibility, mutism, negativism, stereotypy, and echolalia

132
Q

Gender differences of schizophrenia symptoms

A

Males more likely to have negative symptoms, resulting in a more severe course. Men usually have earlier onset. Females have second peak of onset >40y

133
Q

Negative symptoms of schizophrenia

A

alogia, affective flattening, avolition, anhedonia

134
Q

Schizophreniform disorder

A

Schizophrenia A criteria met for a duration between 1 and 6 months

135
Q

Diagnosis of schizophrenia requires these conditions to be ruled out

A

other psychotic disorders, developmental disorders, medical or neurological illness, substance abuse, medication induced, personality disorders, and mood disorders

136
Q

Common symptom of schizophrenia and MDD

A

Anhedonia

137
Q

What are hypnopompic hallucinations?

A

hallucinations only when waking up from sleeping

138
Q

Course of negative symptoms during schizophrenia

A

present early in the illness, worsen during active periods and do not respond well to antipsychotic medications

139
Q

Social effects of schizophrenia

A

Limited social contact, only 30-40% married, only 33% are able ot live independently

140
Q

What percent of schizophrenics experience only a single active episode?

A

10%

141
Q

What feature predates many schizophrenic psychotic episodes?

A

Prodrome seen 85% of the time, functional decline

142
Q

Life expectancy of schizophrenics compared to normal

A

25 years less due to CV disease

143
Q

How are relapses into active phase schizophrenia prevented?

A

Continuous antipsychotic treatment

144
Q

Most common reason for hospitalization in schizophrenics

A

psychosis/active phase of illness

145
Q

If antipsychotic not working at 2 weeks, then …

A

unlikely to work by 4 weeks

*Exception - clozapine

146
Q

Dosage difference for first break of active psychosis

A

Lower dose due to greater sensitivity to medication side effects

147
Q

Effect of using lowest effective dose

A

Increase risk of relapse

148
Q

2 medications proven to decrease suicide risk

A

Lithium and clozapine

149
Q

Indication for clozapine

A

persistence of positive symptoms, failure of > 2 antipsychotic trials, comorbid substance abuse and recurrent suicidality/violence

150
Q

What is akathisia

A

Subjective sense of restlessness

151
Q

Treatment of choice for akathisia

A

propranolol (can also use amantadine, lorazepam, clonidine, or mirtazapine)

152
Q

Why are patients less likely to complain of EPS from low potency FGAs?

A

Side effects can mask the EPS symptoms

153
Q

Most common outcome of TD

A

Symptoms remain static/unchanged

154
Q

Treatment of choice for TD

A

Clozapine

50% show symptom reduction

155
Q

What demographic is at highest risk for TD from FGAs?

A

The elderly (50% risk)

156
Q

SGAs least likely to cause EPS

A

Clozapine and Quetiapine

157
Q

Aripiprazole unique features

A

long half life and low risk of metabolic syndrome, high risk of akathisia, partial agonist

158
Q

SGAs available in long acting injectable forms

A

Risperidone and paliperidone

159
Q

Ziprasidone risks

A

Need to take with food

QTc prolongation risk

160
Q

CATIE study found that Olanzapine

A

has the best compliance rates among SGAs

161
Q

Mild side effects of clozapine

A

sialorrhea, weight gain, sedation, anticholinergic effects, myocarditis, and a lower seizure threshold

162
Q

How long does a urine test stay positive after smoking marijuana?

A

4 days

163
Q

Adverse effects of marijuana

A

Psychosis, anxiety/panic attacks, memory loss, amotivation, disorientation, unsteady coordination, altered perception, decreased consciousness
10% of users become dependent

164
Q

What is dronabinol?

A

A synthetic cannabinoid agonist used to treat anorexia and weight loss in AIDS patients, nausea/vomiting in chemo patients

165
Q

Clinical effects of marijuana

A

Anti-inflammatory, anti-convulsant, anti-emetic

166
Q

What is the most common illicit drug used worldwide?

A

Marijuana

167
Q

What are the common medications used for cessation of cigarette smoking?

A

Bupropion
Verenicline
Nortriptyline
Clonidine

168
Q

Success rate for smoking cessation without ever relapsing

A

5%

169
Q

It is unusual for individuals to start smoking after what age?

A

21 years old

170
Q

Describe the course of nicotine withdrawal

A

Begins within 24h of cessation and peaks at day 2-3, lasts about 2-3 weeks

171
Q

What chemical mediates rewarding effects associated with addiction?

A

Opioids mediate rewarding effects by enhancing midbrain release of dopamine

172
Q

Disulfiram MOA

A

Inhibits breakdown leading to buildup of acetaldehyde and negative reinforcement of alcohol abuse

173
Q

Naltrexone MOA and use for alcohol dependence

A

Mu receptor antagonist
Monthly depot injections
Most effective for treating cravings

174
Q

Social/moderate drinkers have this many drinks per day

A

Men 2 or fewer

Women 1 or fewer

175
Q

How does tolerance affect positive reinforcement

A

Tolerance leads to lack of positive reinforcement

176
Q

How does negative reinforcement affect alcohol dependence

A

Individuals keep drinking to stave off negative effects of alcohol

177
Q

Labs that indicate ongoing heavy drinking

A

GGT, CDT

*MCV not valuable due to long half life of RBCs

178
Q

Comorbid disorders of alcohol use disorder

A

Bipolar disorder, schizophrenia, antisocial personality disorder

179
Q

Risk for using inhalants

A

Sudden death due to cardiac arrhythmia

180
Q

PCP

A

anesthetic agent produces feelings of separation from mind and body, detected in urine up to 8 days after use
Can cause nystagmus, decreased pain response, and violent behavior

181
Q

How long can opioids be detected in UDS after using?

A

12-36h

182
Q

Medical conditions IV opiate users are at risk for

A

hepatitis, TB, bacterial endocarditis

183
Q

Opiate withdrawal symptoms

A

Dilated pupils, dysphoria, N/V, muscle aches, lacrimation/rhinorrhea, piloerection, fever and sweating

184
Q

How is opioid intoxication diagnosed

A

Administration of naloxone stops symptoms

185
Q

What is suboxone

A

Naloxone + buprenorphine

186
Q

Drug most commonly involved in ER visits

A

Cocaine

187
Q

Most rapid onset of action from cocaine is via this route

A

Smoking and injecting

188
Q

What is a speedball?

A

Combination of cocaine and heroin

189
Q

Neurotransmitters increased by cocaine

A

Glutamate and dopamine

190
Q

How can PCP intoxication be distinguished from stimulant intoxication?

A

UDS

PCP may cause vertical nystagmus

191
Q

Sign of stimulant withdrawal

A

Bradycardia

192
Q

Disorders associated with caffeine use

A

Sleep disorder, anxiety

193
Q

Disorders associated with marijuana use

A

Anxiety disorders, sleep disorders, psychotic disorders

194
Q

Disorders associated with PCP use

A

Psychotic disorders, anxiety disorders, delirium and mood disorders

195
Q

Disorders associated with opioid use

A

Sleep disorders, sexual dysfunction, delirium, and depressive disorders

196
Q

Disorders associated with cocaine use

A

sexual dysfunction, delirium and psychotic disorders

197
Q

Disorders associated with stimulant use

A

anxiety, OCD, sleep and mood disorders

M3 Psychiatry (1 decks)

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