General Psychiatry Flashcards
Pseudoparkinsonism Treatment
Symptoms such as bradykinesia, rigidity, tremor, or akinesia
lower or change med
oral anticholinergic agents such as diphenhydramine, trihexyphenidyl, and benztropine
Dystonia Treatment
Symptoms such as torticollis, laryngospasm, and oculogyric crisis.
Intramuscular anticholinergics
oral anticholinergics to prevent in high-risk pts
Akathisia Treatment
Somatic restlessness and inability to stay still or calm
lower or change med
propranolol (lipophilic b-blocker): first line
benzodiazepines: second line
Agents with serotonin-2 activity:
Mirtazapine (most evidence)
Trazodone
Cyproheptadine
Tardive dyskinesia Treatment
Symptoms such as abnormal involuntary movements
usually involves the orofacial muscles and is often insidious
tardive dyskinesia is often irreversible
switch to clozapine
Treat with Valbenazine (Ingrezza) or deutetrabenazine (Austedo)
Neuroleptic malignant syndrome Treatment
Stop the agent and give supportive therapy
Bromocriptine and dantrolene have been used with varying success.
Do not reinitiate antipsychotics until at least 14 days after resolution of NMS symptoms
Hyperprolactinemia with Antipsychotics
High risk in FGA
Risperidone and paliperidone have the highest risk for the SGAs
Aripiprazole can lower prolactin concentrations
QTc prolongation with Antipsychotics
Of the FGAs highest with chlorpromazine, intravenous haloperidol, and thioridazine
Of the SGAs clozapine, ziprasidone, and iloperidone
Seizures with Antipsychotics
Lower the seizure threshold
Highest risk with Chlorpromazine, cariprazine, and clozapine
Lowest risk with Aripiprazole, fluphenazine, haloperidol, pimozide, risperidone, thioridazine, and trifluoperazine
SSRIs
Selectively inhibit the reuptake of serotonin into the presynaptic neuron and desensitize the presynaptic serotonin autoreceptor, resulting in increased serotonin concentrations
AE:
Have been associate with EPS
Hyponatremia
Withdrawal syndrome
Modest bleeding risk
Venlafaxine
SNRI
Dose related effect on norepinephrine
Doses less than 150mg/day is only a serotonin reuptake inhibitor
Can increase BP
Duloxetine
SNR
Also approved for diabetic peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain
Do not use in hepatic insufficiency (liver toxicity), end-stage renal disease requiring dialysis, or sever renal impartment
Desvenlafaxine
SNRI
An active metabolite of venlafaxine. Benefits over the parent drug are limited.
Because it bypasses CYP metabolism, it may be advantageous in patients with hepatic insufficiency or those taking major 2D6 inducers or inhibitors
Can increase BP and cause OH
Lemomilnaciparn
SNRI
Only approved for depression not fibromyalgia
Not recommended in end-stage renal disease
Renal dosing
Can increase HR, cause palpitations, and OH
Milnaciparn
SNRI
only approved for fibromyalgia
Vilazodone (Viibryd)
an SSRI with partial agonist at the serotonin-1A receptor (mixed)
Lower risk of sexual dysfunction
Do not use in seizure disorder
Can cause acute pancreatitis and sleep paralysis rarely
Vortioxetine (Trintellix)
An SSRI, but its pharmacologic profile differs from other SSRIs (mixed)
has additional agonist activity at the serotonin-1A receptor, partial agonist activity at the serotonin-1B receptor, and antagonistic activity at the serotonin-3, serotonin-1D, and serotonin-7 receptors
Improves cognitive function
Lower risk of sexual dysfunction
Trazodone (Desyrel)
A serotonin reuptake inhibitor that also blocks serotonin-2A receptors (mixed)
Can cause OH and sedation
Often used for insomnia but at lower doses
Risk of priapism
Nefazodone (Serzone)
a serotonin-2A antagonist like trazodone, but it also blocks the reuptake of serotonin and norepinephrine (mixed)
Lower risk of sexual dysfunction
Low risk for OH
BID dosing
Liver toxicity (Monitor LFT)
Mirtazapine (Remeron)
an antagonist of presynaptic α2 -autoreceptors and heteroreceptors, which results in an increase in norepinephrine and serotonin release in the synapse (mixed)
minimal to no sexual dysfunction
no nausea or GI disturbances
causes weight gain
Bupropion (Aplenzin, Forfivo, Wellbutrin)
an inhibitor of dopamine and norepinephrine reuptake with minimal effects on serotonin
increased risk of seizures
common adverse effects include insomnia, anxiety, irritability, headache, and decreased appetite
may improve sexual function
off-label ADHD
Antidepressants for Generalized anxiety disorder
escitalopram
paroxetine [IR and CR]
sertraline
duloxetine
venlafaxine XR
Antidepressants for Panic disorder
All SSRIs and venlafaxine XR
Antidepressants for Social anxiety
paroxetine [IR and CR]
sertraline
escitalopram
fluvoxamine [IR and CR]
venlafaxine XR
Antidepressants for OCD
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
Antidepressants for PTSD
sertraline
paroxetine
fluoxetine
venlafaxine XR
Eszopiclone (Lunesta)
GABAA agonist whose half-life is 6 hours; thus, morning effects can result if it is taken late in the night
can be used for chronic insomnia.
Patients should be counseled to use caution when driving or performing activities that require alertness, particularly with the 2- to 3-mg doses
should be taken immediately before bed and when the patient will be in bed for at least 7–8 hours
can cause a metallic taste in the mouth.
Zaleplon (Sonata)
nonbenzodiazepine sedative-hypnotic modulates the GABAA receptor complex
For patients with sleep maintenance problems, it may not last as long
has a shorter half-life (about 1 hour) and may cause fewer problems in the morning, especially if given late
shortens onset to sleep but does not prolong sleep time or number of awakenings
indicated only for short-term treatment of insomnia and has been used in trials for up to 5 weeks
Zolpidem (Ambien)
nonbenzodiazepine sedative-hypnotic modulates the GABAA receptor complex
Compared with benzodiazepines, zolpidem lacks anticonvulsant action, muscle-relaxant properties, and respiratory depressant effect
lower risk of tolerance and withdrawal
avoided in obstructive sleep apnea
good choice for patients in whom benzodiazepines should be avoided
Indications vary by dosage form:
-All are indicated to decrease sleep latency
-The CR for sleep maintenance and longer-term therapy
-The sublingual tablet formulation Intermezzo prn for patients who have difficulty falling back to sleep as long as 4 hours or more remain.
Lower doses for women and alder adults
lemborexant (Dayvigo)
Orexin (OX1 and OX2) Receptor Antagonists
decreases sleep latency and promote sleep maintenance
It should be taken with at least 7 hours of remaining sleep
It is metabolized by 3A4, and use should be avoided in patients taking either inducers or inhibitors of 3A4
Time to onset may be delayed if taken with food
contraindicated in patients with concomitant narcolepsy
suvorexant (Belsomra)
Orexin (OX1 and OX2) Receptor Antagonists
decreases sleep latency and promote sleep maintenance
should be taken within 30 minutes of bedtime and with at least 7 hours of sleep time
It is metabolized by 3A4, and the dose must be decreased in patients taking concomitant 3A4 inhibitors
contraindicated in patients with concomitant narcolepsy
Doxepin (Silenor)
A TCA indicated for impaired sleep maintenance
Doses used are lower than for depression
Chances for morning effects are high because of the long half-life of both doxepin and its active metabolite, nordoxepin.
Ramelteon (Rozerem)
Melatonin agonist (no activity at the GABA or benzodiazepine receptor)
Duration is 2–5 hours
no dependence or tolerance, and it can be used long term for chronic insomnia
primarily metabolized by 1A2, but inducers and inhibitors of 2C9 and 3A4 can also affect it
should be avoided in patients with severe sleep apnea
Naltrexone for Alcohol Abuse
can also be used chronically and reduces cravings
If used, it should be combined with CBT
Monitor LFTs and do not use in hepatic impairment
Tablet and Injection available
Acamprosate
Alcohol Abuse
structural analog of GABA that also reduces cravings
Evidence regarding efficacy is more mixed than with naltrexone.
Safe to use in hepatic impairment
Renally dosed and should not be used if crcl <30
Warning for suicidal ideation and should not be used in patients that are actively suicidal
Disulfiram
Alcohol Abuse
considered aversion therapy
associated with hepatotoxicity
should be avoided in patients with severe myocardial disease
should not be combined with metronidazole because of an increased risk of encephalopathy
Patients should also be counseled to avoid alcohol-containing items, particularly medications and certain mouthwashes, because of the risk of adverse effects
Naltrexone for substance abuse
ER injectable is usually preferred because of better adherence
The ER injectable is part of a REMS education program. Patients must be counseled on the following points:
-Risk of increased opioid sensitivity and opioid overdose
-Risk of severe reactions at the injection site
-Risk of liver injury, including liver damage or hepatitis
-Therapeutic effects of opioid medications taken for pain, cough and cold, or diarrhea may not be felt by the patient
The patient must be completely off opioids for 7–10 days before naltrexone is administered (14 days if taking methadone or buprenorphine).
Chlorpromazine (Thorazine)
Low Potency FGA
High risk of anticholinergic effects, sedation, and OH
Moderate risk of EPS
Loxapine (Adasuve, Loxitane)
Intermediate Potency FGA
Moderate risk for of anticholinergic effects, sedation, OH, and EPS
Perphenazine (Trilafon)
Intermediate Potency FGA
Moderate risk for of anticholinergic effects, sedation, OH, and EPS
Trifluoperazine (Stelazine)
Intermediate Potency FGA
Moderate risk for anticholinergic effects and EPS
Low risk for Sedation and OH
Fluphenazine (Prolixin)
High Potency FGA
High risk of EPS
Low risk for anticholinergic effects, sedation, and OH
Haloperidol (Haldol)
High Potency FGA
High risk of EPS
Low risk for anticholinergic effects, sedation, and OH
Pimozide (Orap)
High Potency FGA
High risk of EPS
Low risk for anticholinergic effects, sedation, and OH
Thiothixene (Navane)
High Potency FGA
High risk of EPS
Low risk for anticholinergic effects, sedation, and OH
FGAs with highest risk of weight gain
clozapine
olanzapine
FGAs with highest risk of glucose abnormalities
clozapine
olanzapine
FGAs with the highest risk of dislipidemia
clozapine
olanzapine
quetiapine
FGAs with highest risk of anticholinergic effects
clozapine
FGAs with highest risk of sedation
clozapine
quetiapine
FGAs with highest risk of OH
clozapine
iloperidone
FGAs with the lowest risk of Weight gain
Aripiprazole
Brexpiprazole
Lumateprerone
Lurasidone
Ziprasidone
FGAs with the lowest risk of glucose abnormalities
Aripiprazole
Brexpiprazole
Cariprazine
Paliperidone
Ziprasidone
FGAs with the lowest risk of dyslipidemia
Aripiprazole
Cariprazine
Iloperidone
Risperidone
Ziprasidone
FGAs with the lowest risk of anticholinergic effects
Aripiprazole
Asenapine
Brexpiprazole
Iloperidone
Lumateperone
Lurasidone
Paliperidone
Risperidone
Ziprasidone
FGAs with the lowest risk of sedation
Aripiprazole
Iloperidone
Lumateperone
Lurasidone
Paliperidone
FGAs with the lowest risk of OH
Aripiprazole
Brexpiprazole
Lumateperone
Lurasidone
FGAs with the lowest risk of Akathisia (EPS)
Clozapine
Iloperidone
Quetiapine
FGAs with the lowest risk of Parkinsonism
Aripiprazole
Asenapine
Brexpiprazole
Cariprzine
Clozapine
Iloperidone
Quetiapine
Ziprasidone
Tricyclic Antidepressants
TCAs block serotonin and norepinephrine uptake
adverse effects limit use
cause orthostasis, sedation, and anticholinergic effects, and sexual dysfunction
cardiotoxic in overdose so avoid in suicidal patients
Monoamine Oxidase Inhibitors
irreversibly block the enzyme responsible for the breakdown of certain neurotransmitters, such as norepinephrine
avoid foods high in tyramine (e.g., aged cheese, preserved meats, wine, beer) due to risk of hypertensive crisis
lots of drug interaction
2 weeks wash out when changing between antidepressant and MAOI (except for fluoxetine, in which case the waiting period should be 5–6 weeks, and vortioxetine is 3 weeks) to avoid serotonin toxicity
Selegiline (MAO-B inhibitor) is available in a patch formulation for depression.
Bipolar I
one or more manic or mixed episodes
major depressive episodes are not necessary for the diagnosis, most patients have depressive episodes
Bipolar I Treatment
Lithium is the gold standard (depression and mania)
Divalproex/valproic acid (for rapid cycling but not for depression)
Carbamazepine (acute mania and maintenance)
Lamotrigine (for maintenance but not acute mania due to titration)
All SGAs have received FDA approval for use in acute mania or mixed episodes except for brexpiprazole, clozapine, iloperidone, lumateperone, and lurasidone
Lorazepam or diazepam is often used in the acute setting only
Bipolar II
Chronic disorder marked by one or more major depressive episodes, accompanied by at least one hypomanic episode
depressive phase more debilitating
Bipolar II Treatment
Lithium is a first-line agent, but it may not achieve remission as monotherapy and takes time to relieve symptoms
Quetiapine is preferred for acute symptom treatment
Lurasidone can also be used
Lamotrigine is a reasonable alternative for longer-term symptom control, but because of its slow titration schedule, it is not useful in the acute setting
Antidepressants are used more commonly but should be used with caution, and never as monotherapy. Olanzapine and fluoxetine may thus be an option
Cyclothymic Bipolar disorder
Several periods of hypomania and mild depression, none of which meet the criteria for mania or major depressive episode
Rapid cycling Bipolar
At least four episodes of mania, hypomania, or depression in 1 year with 2 months between episodes or a switch to the opposite polarity
