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Clin Mgt 2 DM & Psych > GAD, ADD, Depression > Flashcards

GAD, ADD, Depression Flashcards

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1
Q

Dx GAD

A

Excessive anxiety/worry more days than not x6 months + ≥3:

  • Restlessness
  • Easily fatigued
  • Difficulty concentrating
  • Difficulty falling/staying asleep
  • Irritability
  • Muscle tension
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2
Q

pathophys of GAD

A

Decreased GABA receptor density. Inc glutamate

Decreased 5-HT

CO2 serum concentration sensitivity (panic)

Increased amygdala activity

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3
Q

tx of acute phase anxiety

A

Start SSRIs, TCAs

+/-BZD if necessary

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4
Q

pphx anxiety tx

A

SSRIs, SNRIs

buspirone

pregabalin

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5
Q

name first and second line tx for anxiety

tx timelines

A

SSRIs for 12 weeks then switch to another for at least 6 mos.

  • Fluoxetine may have best response and remission outcomes.
  • Sertraline best tolerability outcomes.

Venlafaxine second line (dose 75mg or less)

  • Venlafaxine and paroxetine may have worst comparative outcomes.
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6
Q

SSRIs for GAD w/

best response and remission outcomes.

best tolerability outcomes.

may have worst comparative outcomes.

A

Fluoxetine may have best response and remission outcomes.

Sertraline best tolerability outcomes.

Venlafaxine and paroxetine may have worst comparative outcomes.

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7
Q

Indication & MOI of Buspirone

advantages & disadvantages

A

indicated for GAD

5HT1A partial agonist

Advantages:

  • Almost as effective as benzos for GAD
  • No sedation, cognitive impairment, respiratory depression, dependence or withdrawal
  • Lacks abuse potential

Disadvantages:

  • Onset of effect ~2 weeks, but can take 6 weeks for full effect (similar to the antidepressants)
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8
Q

name an antiepiletic to consider w/ GAD

A

Pregabalin

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9
Q

Name the atypical antipsychotic you could use in GAD (unlikely)

A

Quetiapine –> monotherapy may be beneficial in non refractory GAD

greater discontinuations.

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10
Q

define panic attack

A

Period of intense fear in which 4 of the following symptoms develop abruptly and reached a peak within minutes.

  • Palpitations
  • Sweating
  • Trembling
  • Shortness of breath or smothering
  • Feeling of choking
  • Chest pain
  • Nausea
  • Dizzy or lightheadedness
  • Chills or heat sensations
  • Paresthesias
  • Derealization or depersonalization
  • Fear of losing control
  • Fear of dying – peaks at 10-15mins and disappears in 30 mins
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11
Q

define panic disorder

A

YOU CHANGE YOUR LIFE

At least one of the attacks has been followed by 1 month of one of the following

  • Persistent concern about having additional attacks
  • Worry about the implication of the attack
  • Significant change in behavior related to the attacks
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12
Q

first line for panic disorder

A

Antidepressants - high dose

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13
Q

how to dose SSRIs for pt with panic disorder

A

Need to start low and increase dose slowly – takes a while to get to therapeutic dose

  • SSRIs can precipitate a panic attack if initially dosed too high.
  • Goal dose is at high end of dosing range.

treat for at least 8 weeks (and probably 12).

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14
Q

name drugs to consider for a pt w/ panic attacks

A

SSRIs and SNRIs

TCAs

BZDs for the first 4-6 weeks of treatment only.

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15
Q

what type of benzos are indicated for panic attacks

A

Alprazolam

lorazepam

High potency, short acting

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16
Q

type of BZD indicated for GAD vs Panic disorders

A

GAD - low potency, low acting

Panic - High potency, short acting (Alprazolam, lorazepam.)

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17
Q

what is the most common comorbidity assoc w/ GAD & PD

A

MDD

At least half of GAD patients will develop MDD.

30-60% of Panic patients will develop MDD.

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18
Q

•Highest risk of admission due to OD in Medicaid patients when compared to other BZDs.

A

Alprazolam

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19
Q

name fast onset BZDs

A
  • Triazolam
  • Alprazolam
  • Loprazolam
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20
Q

what drug would you give to a pt who is tapering off BZD and feeling withdrawl si/sx?

A

Pregabalin

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21
Q

describe how to taper BZDs

A

Empower patient.

  • Most research has been done in median age > 60 yo
  • offer to anyone >64 or to anyone prescribed for >4wks

_Slow reduction 3-6 month_s with decreases of 1/8 to 1/4 dose qweek/q2week/monthly dose

Along with initiation of an SSRI/SNRI for anxiety maintenance (if appropriate)

Melatonin for sleep*

Pregabalin with withdrawal/anxiety symptoms**

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22
Q

who should we offer BZD tapering to

A

over 64 or

anyone prescribed for >4wks

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23
Q

si/sx of protracted BZD withdrawl

A

May last for up to a year after drug cessation

  • Anxiety
  • Insomnia
  • Depression

Weakness, muscle pain, tremor, irritable bowel

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24
Q

signs of rapid BZD withdrawl

A

Tremors

Anxiety

Perceptual disturbances

Dysphoria

Psychosis

Seizures

Insomnia

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25
Q

explain role of atypical antipsychotics in GAD and PD

A

For panic disorder:

  • NO monotherapy –> adjunct to SSRIs.

For GAD: NOT RECOMMENDED

  • atypicals shown to have more side effects with little benefit when added to SSRIs-
  • Quetiapine monotherapy has positive efficacy data but poor tolerability
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26
Q

name other adjuct tx for anxiet & PD

A

Hydroxyzine

propranolol

clonidine

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27
Q

describe neurobiology of ADD

A

Blocking NE alpha2 receptors results in ADHD like behavior.

  • Dysfunction in prefrontal-striatal neural circuits
  • Reductions in synaptic DA, –> enhanced DA reuptake & i_ncreased catabolism_.
  • Low prefrontal cortex NE.

P50 suppression deficiency.

  • Deficiency in the ability to suppress reaction to an auditory stimuli.

Delayed brain maturation.

28
Q

describe delayed brain maturation in ADD

A

Delayed Cortical thickness & surface area.

Approximately a 2-3 year delay in children.

  • 18 yo the differences not significant.
29
Q

list 2 office questionaires to help dx ADD

A

ADHD-RS

SNAP-IV

30
Q

name notable findings on ADHD-RS

A
  1. Fidgets with hands or feet or squirms in seat.
  2. Does not seem to listen when spoken to directly.
  3. Is “on the go” or acts as if “driven by a motor.”
  4. Talks excessively.
31
Q

name notable findings in the SNAP-IV

A

LETI

  1. Often does not seem to listen when spoken to directly
  2. Often loses temper
  3. Often is excitable, impulsive
  4. Often is irritable
32
Q

MOI of stimulats used to tx ADD

A

methylphenidate: block the reuptake of dopamine and norepinephrine.

  • dexmethylphenidate has less NE effects potentially resulting in better tolerability.

amphetamines: Also inhibits MAO and may have direct stimulatory effects on alpha and beta receptors.

INC DA

33
Q

what ADD meds are you concerned as they are metabolized through 2D6 pathway

which is not?

A

dextroamphetamine/ mixed amphetamine salts/ lisdexamfetamine

Atomoxetine

methylphenidate is NOT!

34
Q

what med should you never give to someone w/ ADD & a tic disorder

A

dextroamphetamine/ mixed amphetamine salts/ lisdexamfetamine

35
Q

med of choice for ADD + anxiety sx

A

atomoxetine

36
Q

med of choice ADD + SUD

A

atomoxetine

37
Q

MOI of Atomoxetine

indication??

A

blocks the reuptake of NE.

  • This results in benefits on both alpha 2 receptors and small increases in DA

Not as good as stimulant

ADD

38
Q

Useful adjunct to stimulants.

A

Guanfacine

39
Q

MOI of Guanfacine

A

Alpha 2 agonist –> This results in strengthening the relevant connections for attention.

  • Compared to DA enhancement which weakens irrelevant connections.
  • Lower NE –> reduce BP
40
Q

adverse effects of Guanfacine

A

Decrease in BP and pulse

sedation/somnolence/fatigue

41
Q

____, compared to guanfacine, is less specific and will stimulate alpha __, __ and __ receptors resulting

A

Clonidine, compared to guanfacine, is less specific and will stimulate alpha 2a, b and c receptors resulting

42
Q

adverse effects of clonidine

A

in more sedation & greater decrease in BP.

shorter half life requiring increased frequency in dosing.

43
Q

which stimulant is better to give someone w/ ADD + seizure

A

methylphenidate

44
Q

define MDE

A

5 or more of the below symptoms for 2 weeks and which cause significant impairment in social, academic and occupational functioning.

  • –*depressed mood
  • –*lack of enjoyment in pleasurable activities
  • –changes in weight
  • –changes in sleep
  • –psychomotor agitation or retardation
  • –fatigue or lack of energy
  • –feelings of worthlessness or excessive guilt
  • –decreased concentration
  • –thoughts of suicide
45
Q

define persistent depressive disorder

A

Depressed mood for _more days than not for a_t least 2 years. _+ 2 o_r more of the following:

  • -poor appetite or overeating
  • -insomnia or hypersomnia
  • -low energy or fatigue
  • -low self-esteem
  • -poor concentration or difficulty making decisions
  • -feelings of hopelessness
46
Q

what disorder is important to r/o when evaluating a depressed pt

what should tou ask them

A

bipolar

any mania??

47
Q

define

beravement

adjustment disorder

A
  • Bereavement - depressive symptoms which occur after the loss of a loved one.
  • Adjustment disorder - development of emotional and/or behavioral symptoms within 3 months after an identifiable stressor.
48
Q

T/F

in tx depression: All classes are equally efficacious

A

TRUE

49
Q

in depression:

____the most useful when considering tolerability, efficacy and benefits.

_____ and____ had slightly better efficacy than the other reviewed antidepressants.1

A
  • Sertraline the most useful when considering tolerability, efficacy and benefits.
  • Escitalopram and mirtazapine had slightly better efficacy than the other reviewed antidepressants.1
50
Q

what are the serotonin targets we want to agonize/antagonize in tx depresion

A

5-HT1a agonism

5-HT2 antagonism

  • seems to lower anxiety and promote the 5-HT1a agonistic effect.
51
Q

list steps to follow in regards to Nonresponse to initial antidepressant

A
  1. 4-8 weeks of treatment. <25% reduction in sx then inc dose
  2. If no response then switch to another antidepressant. (different type
  3. After 2 trials then consider the patient to be treatment resistant.
  4. Switching to a third antidepressant monotherapy. (SSRI –> SSRI –> SNRI)
  5. add adjuvant non antidepressive (esketamine, atypical, lithium)
  6. COMBO therapy –> (SSR+ Bup or SSRI/SNRI + mirtazapine)
52
Q

name approriate combo therapy for depression

what pt would you use each combo w/??

A

SSRI along with bupropion. –> ↑ dopamine (NE)

  • Drowsy all day / no energy

SSRI or SNRI with mirtazapine. –> ↑ serotonin & NE through alpha 2 blockade

  • Can’t fall asleep – (hypnotic)
53
Q

Combining an SSRI, SNRI or TCA with an___ is not recommended.

A

Combining an SSRI, SNRI or TCA with an MAOI is not recommended.

54
Q

post partum depression

first line

second line

third line

A

First line: psychotherapy

Second line Pharm:

  • Citalopram
  • escitalopram
  • sertraline

Third Line: Brexanolone IV

  • Acts as allopregnanolone
  • Neuroactive steroid that drops dramatically after childbirth
  • Has positive GABAA modulatory effects (pass out)
55
Q

name Non-Prescription Strategies for post partum dep

A
  • SAMe
  • Folic Acid
56
Q

Non-Pharmacologic Therapies for dep

A

Electroconvulsive Therapy (ECT).

Repetitive Transcranial Magnetic Stimulation (rTMS). – noninvasive

Deep Brain Stimulation (DBS). - used for Parkinson’s Disease.

Vagus Nerve Stimulation (VNS). - used for seizure disorder.

57
Q

tx follow up algorithm for starting pt on antidepresant s

A

Meet with pt after 10-14 days –> assess tolerability and safety/suicidal thoughts. –> Kids every week

Meet in 4 weeks to assess efficacy. –> Should be feeling better

Meet _2-4 weeks later to measure maximal respons_e

  • (6-8 weeks of a therapeutic dose).

Meet e_very month for next 4-9 months_ during continuation phase. (up to 1 year)

  • if more then 2 episodes take medication forever
57
Q

Patient Education Message for antidep

A
  • Take medication daily (as prescribed).
  • Antidepressants need to be taken 2-4 weeks before noticeable effects will occur.
  • Patients need to continue taking the antidepressant even if they start to feel better.
  • Patients should not stop taking the antidepressant without talking to a clinician.
  • Patients should be given specific instructions on how to resolve questions regarding their treatment (e.g. a contact person/case manager)
58
Q

tx depression in kids

A
  • Fluoxetine – >8 y/o (FIRST LINE)
  • Escitalopram — >12 y/o (SECOND LINE)
  • Venlafaxine after 2 failed attempts
59
Q

tx dep in pregnancy & BF

A

PREGNANCY: No med preferred

  • If need med – fluoxetine
  • Bupropion – useful but does not help w/ anxiety

BREASFEEDING

  • Sertraline & paroxetine negligible in milk
60
Q

if prescribing atypical antipsychotic which would you choose bc of least side effects and least likely to cause movement disorder?

A

Aripiprazole

61
Q

Aripiprazole is used in what case?

A

Adjunct/ add-on therapy for refractory depression (+SSRI or SNRI)

62
Q

name adjuctive meds you can add on for depression

A

Selegiline transdermal patch

Esketamine – nasal inhalation

Brexanolone

Atypical antipsychotics:

  • Aripiprazole – fewer side effects
  • Olanzapine w/ fluoxetine
  • Quetiapine
63
Q

indication & adverse effects

Brexanolone

A

PPD

LOC/sedation/syncope (DEC O2)

64
Q

indication / MOI / Adverse effects:

Esketamine

A

add-on for depression

MOI

  • NMDA glutamate receptor antagonist
  • Block reuptake of serotonin, NE, & DA
  • 5-HT 1 agonist
  • Opiate receptor agonist (mild)

Adverse Effects

  • Dissociation - outer body experience (buzzed)
  • INC HR/BP
65
Q

indication / MOI / adverse effects

Selegiline transdermal patch

A

adjuct for depression

MOI: CNS (selective) monoaminoxidase inhibitors (MAOI)

  • Works in the CNS but does not affect GI located monoamine oxidase (MO).
  • Avoidance of GI located (MO) allows the GI tract to still break down dietary tyramine before it is allowed into the blood stream.

Adverse Effects:

  • Hypertensive crisis at high doses 2° to ­ GI tyramine absorption (dietary restrictions)
  • Too much DA (bc too much tyramine)
  • Skin irritation
  • Xerostomia
  • Diarrhea
66
Q

what drug Mimics allopregnanolone (positive GABA effects)

A

Brexanolone

PPD

Clin Mgt 2 DM & Psych (3 decks)

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