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Psychiatry Studying > Guidelines > Flashcards

Guidelines Flashcards

1
Q

What is the criteria for Level 1 Evidence?

A

Meta-analysis with narrow confidence intervals and/or 2 or more RCTs with adequate sample size, preferably placebo controlled

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2
Q

What is the criteria for Level 2 Evidence?

A

Meta-analysis with wide confidence intervals and/or 1 or more RCTs with adequate sample size

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3
Q

What is the criteria for Level 3 Evidence?

A

Small-sample RCTs or nonrandomized, controlled prospective studies or case series or high-quality retrospective studies

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4
Q

What is the criteria for Level 4 Evidence?

A

Expert opinion/consensus

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5
Q

According to CANMAT, how does a recommendation become first line?

A

Level 1 or Level 2 Evidence, plus clinical support

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6
Q

According to CANMAT, how does a recommendation become second line?

A

Level 3 Evidence or higher, plus clinical support

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7
Q

According to CANMAT, how does a recommendation become third line?

A

Level 4 Evidence or higher, plus clinical support

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8
Q

According to CANMAT Depression Guidelines (2016), what medications are first line?

(Long answer)

A

Remember - SSRIs, SNRIs, NDRI, “MMAV”

  • All SSRIs
    • Escitalopram
    • Citalopram
    • Fluoxetine
    • Fluvoxamine
    • Paroxetine
    • Sertraline
  • All SNRIs (minus Levomilnacipran)
    • Duloxetine
    • Venlafaxine
    • Desvenlafaxine
    • Milnacipran
  • NDRI
    • Bupropion
  • a2-Adrenergic agonist; 5-HT2 antagonist
    • Mirtazapine
    • Mianserin
  • 2 Others
    • Agomelatine (MT1 and MT2 agonist; 5-HT2 antagonist)
    • Vortioxetine (Serotonin reuptake inhibitor; 5-HT1A agonist; 5-HT1B partial

agonist; 5-HT1D, 5-HT3A, and 5-HT7 antagonist)

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9
Q

According to CANMAT Depression Guidelines (2016), what medications are second line?

A

Remember: TCAs, Quetiapine, LevoM, MAOS, and “dones”

  • TCAs
    • Amitriptyline, domipramine, desipramine, nortriptyline, etc
  • Quetiapine
  • Levomilnacipran (SNRI)
  • Moclobemide (Reversible Inhibitor of MAO-A)
  • Selegeline (Irreversible Inhibitor of MAO-B)
  • Trazodone (Serotonin reuptake inhibitor; 5-HT2 antagonist)
  • Vilazodone (Serotonin reuptake inhibitor; 5-HT1A partial agonist)
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10
Q

According to CANMAT Depression Guidelines (2016), what medications are third line?

A
  • Irreversible MAOs
    • Phenelzine
    • Tranylcypromine
  • Reboxetine (Noradrenaline reuptake inhibitor)
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11
Q

According to CANMAT, what factors should you consider in selecting an antidepressant?

A
  • Patient Factors
    • Clinical Features
    • Comorbid Conditions
    • Response and Side Effects during previous trials
    • Patient Preference
  • Medication Factors
    • Comparative efficacy
    • Side Effects /Comparative Tolerabilty
    • Potential Interactions
    • Ease of use
    • Cost and availability
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12
Q

According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with anxious distress?

A
  • Use antidepressant with efficacy in GAD
  • No difference between SSRI, SNRI, Bupropion
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13
Q

According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with catatonia?

A

Benzodiazepenes

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14
Q

According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with melancholic features?

A

No antidepressants have demonstrated efficacy

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15
Q

According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with atypical features?

A

No antidepressants showed superiority

(Older studies found MAOs >TCAs)

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16
Q

According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with psychotic features?

A

Use antidepressant and antipsychotic co-treatment

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17
Q

According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with mixed features?

A

Lurasidone

Ziprasidone

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18
Q

According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with seasonal pattern?

A

No antidepressants have demonstrated superiority

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19
Q

According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with cognitive dysfunction?

A

Vortioxetine (level 1)

SSRIs

Bupropion

Duloxetine

Moclobemide

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20
Q

According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with sleep disturbance?

A

Agomelatine

Mirtazpine

Trazodone

Quetiapine

(Weigh against potential for side effects)

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21
Q

According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with somatic symptoms?

A

Pain

  • Duloxetine - Level 1
  • Other SNRIs - Level 2

Fatigue

  • Bupropion - Level 1
  • SSRIs - Level 2

Low Energy

  • Duloxetine - Level 2
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22
Q

What are risk factors to consider longer term (2 years or longer) maintenance treatment with antidepressants?

A
  • Frequent, recurrent episodes
  • Severe episodes (psychosis, severe impairment, suicidality)
  • Chronic episodes
  • Presence of comorbid psychiatric or other medical conditions
  • Presence of residual symptoms
  • Difficult-to-treat episodes
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23
Q

After you have selected and initiated a first line antidepressant, how long do you wait to determine whether there is early improvement?

A

2-4 weeks

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24
Q

You have started an antidepressant, and there is early improvement after 2-4 weeks. What do you do next?

A

Keep patient on treatment for 6-8 weeks, then reassess

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25
Q

You have started an antidepressant that showed some early improvement after 4 weeks. 8 weeks later, patient has full symptom remission. How long do you keep them on treatment?

A
  • 6-9 months
  • 2 years or longer if risk factors for recurrence
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26
Q

You have started a first line antidepressant. After 4 weeks, there is no early improvement. What is your next step?

A
  • Consider Factors for switch vs adjunct
    • Depending on tolerability, first optimize by increasing dose
    • Switch to antidepressant with superior efficacy OR
    • Add an adjunctive medication
    • After failure of 1 or more antidepressants, consider switching to second or thrid line agent
  • For early treatment resistance, consider adjunct use of psychological and neurostimulation treatments
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27
Q

According to CANMAT, what are first line recommendations for adjunctive medications for nonresponse or partial response to an antidepressant?

A

Aripiprazole

Quetiapine

Risperidone

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28
Q

According to CANMAT, what are second line recommendations for adjunctive medications for nonresponse or partial response to an antidepressant?

A

Brexpiprazole

Bupropion

Lithium

Mirtazapine

Mianserin

Modafinil

Olanzapine

Triiodothyronine (T3)

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29
Q

According to CANMAT, what are third line recommendations for adjunctive medications for nonresponse or partial response to an antidepressant?

A
  • Other antidepressants
  • Other stimulants
  • TCAs
  • Ziprasidone
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30
Q

According to CANMAT, what is an experimental recommendation for adjunctive treatment for nonresponse or partial response to an antidepressant?

A

Ketamine

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31
Q

What are factors to consider in choosing between switching to another antidepressant monotherapy or adding an adjunctive medication?

A

Consider SWITCHING when

  • It is the first antidepressant trial
  • Poorly tolerated side effects to initial
  • No response (<25% improvement) to initial
  • you have more time to wait for a response (less severe, less impairment)
  • Pt prefers to switch

Consider adjunctive when

  • there have been 2 or more antidepressants tried
  • Initial antidepressant is well tolerated
  • There is partial response (>25% improvement) to initial AD
  • There are specific residual symptoms or side effects to the initial antidepressant that can be targeted.
  • There is less time to wait for a response (more severe, more functional impairment).
  • Patient prefers to add on another medication
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32
Q

What does CANMAT say about managing persistent and chronic depression (PDD)?

A
  • SSRIs similar in efficacy to TCAs but better tolerated
  • atients with repeated treatment failures and a chronic course of depression may require a chronic disease management approach (i.e., with less emphasis on remission of symptoms and cure, greater emphasis on improving func- tioning and quality of life, and greater use of psychotherapeutic and nonmedication treatments)
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33
Q

What are first line psychological treatments for acute and maintenance treatment of MDD?

A

CBT

IPT

Behavioural Activation

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34
Q

What are second line psychological treatments for acute and maintenance treatment of MDD?

A

Mindfulness Based CBT (MCBT)

Cognitive Behavioural Analysis System of Psychotherapy (CBASP)

Problem-Solving Therapy (PST)

Short Term Psychodynamic Psychotherapy (STPP)

Telephone delivered CBT and IPT

Internet and computer assisted therapy

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35
Q

What are third lline psychological treatments for acute and maintenance treatment of MDD?

A

Long term psychodynamic

Acceptance and Commitment Therapy (ACT)

Videoconferenced Psychotherapy

Motivational Interviewing (MI)

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36
Q

What is the impact of comorbid anxiety on psychological treatments in MDD?

A
  • Anxiety likely doesn’t complicate or reduce response to tx
  • CBT more beneficial than other psychological treatments
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37
Q

What is the impact of comorbid substance abuse on psychological treatments in MDD?

A
  • CBT improves both depression and substance abuse symptoms
  • Integrated treatment is effective but with small effect size
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38
Q

What is the impact of comorbid personality disorders on psychological treatments in MDD?

A
  • PDs have negative impact on depression outcomes
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39
Q

What is the impact of comorbid ADHD on psychological treatments in MDD?

A

CBT for ADHD helps both disorders, as adjunct to medications

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40
Q

What is the impact of comorbid HIV on psychological treatments in MDD?

A

CBT effective, mostly in group

IPT may be effective but limited studies

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41
Q

What is the impact of comorbid Parkinson’s Disease on psychological treatments in MDD?

A

CBT effective for reducing depressive symptoms

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42
Q

Which neurostimulation technique(s) are first line treatments for MDD?

A

rTMS

ECT (in some situations)

*both in acute and maintenance

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43
Q

Which neurostimulation technique(s) are second line treatment for MDD?

A

ECT (if no specific indication making it first line)

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44
Q

Which neurostimulation technique(s) are third line treatments for MDD?

A

Transcranial Direct Current Stimulation (tDCS)

Vagus Nerve Stimulation (VNS)

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45
Q

What is the first line reccommendation for rTMS stimulation protocols?

A

High frequency rTMS to left DLPFC (>10Hz)

Low frequency rTMA to right DLPFC (<1Hz)

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46
Q

How is rTMS delivered?

A
  • Powerful (1-2.5 Tesla) focused magnetic field impulses to induce electrical currents in neural tissue, vis inductor coil placed on scalp
  • Usually delivered by tech or nurse, under MD supervision
  • no anaesthesia required
  • 1x daily, 5 x/week
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47
Q

How many sessions are required for rTMS?

A
  • Initial course until remission is achieved, up to 20 sessions
  • Extend course up to 30 sessions in responders who haven’t achieved remission
  • Use rTMS PRN to maintain response
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48
Q

How does rTMS compare to ECT?

A
  • ECT more effective
  • rTMS should be considered prior to ECT, as pts who did not respond to ECT are unlikely to respond to TMS
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49
Q

What are the clinical indications for ECT as a first-line treatment for MDD?

A
  • Acute SI
  • Psychotic Features
  • Treatment Resistant Depression
  • Repeated med intolerance
  • Catatonic Features
  • Prior good response to ECT
  • Rapidly deteriorating physical status
  • During pregnancy, for any of the above indications
  • Patient preference
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50
Q

What are absolute contraindications to ECT?

A

There are none

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51
Q

Which conditions may be associated with an increased safety risk for ECT?

A
  • Space occupying lesion
  • Increased ICP
  • recent MI
  • recent cerebral hemmorhage
  • unstable vascular anaeurysm/malformation
  • Pheochromocytoma
  • Class 4 or 5 anasthesia risk
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52
Q

What are absolute contraindications to rtMS?

A
  • Metallic hardware anywhere in the head (except the mouth)
  • Eg. cochlear implants, brain stimulators or electrodes, aneurysm clips
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53
Q

What are relative contraindications to rtMS?

A

Cardiac Pacemaker

Implantable defibrillator

Hx Epilepsy

Presence of brain lesion

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54
Q

What are the first line recommendatiosn for delivery of ECT?

A

Brief Pulse, Right unilateral (5-6x sz threshold)

Brief Pulse, Bifrontal (at 1.5-2 x sz threshold)

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55
Q

How many treatments are required for ECT?

A

Index Course ranges from 6-15

Delivered 2-3x per week

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56
Q

How effective is ECT as a treatment for MDD?

A

70-80%

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57
Q

When are ECT relapse rates the highest?

A

In first 6 months post ECT (37.7%)

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58
Q

What is the mortality rate for ECT?

A

1 death/73,440 treatments

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59
Q

What are most common adverse effects of ECT?

A

Headache

Muscle Soreness

Nausea

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60
Q

What type of cognitive side effects are seen in ECT?

A
  • transient disorientation
  • retrograde amneia
  • anterograde amneisa

But MILD and short term

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61
Q

What factors are associated with higher rates of short term adverse cognitive effects of ECT? (vs those associated with lower rates)

A
  • Bitemporal electrode placement vs bifrontal or nilateral
  • Brief pulse width vs ultrabrief pulse
  • suprathreshold stimulation vs lower elctrical dose
  • Treatment 3x/week vs 2x/week
  • Use of lithium vs lower dose or discontinuing lithium
  • Use of high doses anaesthetic agent vs lower doses
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62
Q

What are first line complementary and alternative treatments in MDD?

A

Light Therapy (Seasonal MDD)

Exercise (Mild to Moderate MDD)

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63
Q

What are reccommendations for exercise as treatment for MDD?

A

30 mins of supervised moderate intensity exercise at least 3x/week for minimm 9 weeks

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64
Q

What are second line reccommendations for physicial and meditative treatments of depression?

A

Exercise (Moderate to Severe MDD)

Light therapy (non-seasonal mild to moderate MDD)

Yoga (Mild to moderate MDD)

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65
Q

What is a first line natural health product as treatment for depression?

A

St. John’s Wort (Mild to Moderate)

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66
Q

What are second line natural health products as treatment for depression?

A

St. John’s Wort (moderate to severe MDD)

Omega 3

SAM-e

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67
Q

According to CANMAT, what is first line treatment of MDD in children and youth?

A

CBT

IPT

Internet-based psychotherapy (milder severity, if in-person not possible)

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68
Q

According to CANMAT, what is first line treatment of MDD in children and youth?

A

Fluoxetine (Level 1)

Escitalopram, sertraline, citalopram (Level 2)

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69
Q

According to CANMAT, what is third line treatment of MDD in children and youth?

A

Venlafaxine

TCA

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70
Q

According to CANMAT, what is true about suicide prevention in children and youth?

  1. CBT for suicide prevention combined with pharmacotherapy resulted in greatest improvements in depressed youth who had recently attempted suicide
  2. CBT alone resulted in greatest improvements in depressed youth who had recently attempted suicide
  3. Pharmacotherapy alone resulted in greatest improvements in depressed youth who had recently attempted suicide
  4. CBT + pharmacotherapy = pharmacotherapy alone resulted in improvements in depressed youth who had recently attempted suicide
A

CBT for suicide prevention combined with pharmacotherapy resulted in greatest improvements in depressed youth who had recently attempted suicide

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71
Q

According to CANMAT, what is the evidence of paroxetine in treating children and youth with depression?

A

Paroxetine has not shown efficacy in this age group

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72
Q

What precautions should one take in prescribing citalopram in children?

A
  • Children with long QT should not be treated with citalopram
  • Children with congenital heart disease or hepatic impairment sould be treated with caution
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73
Q

When would you choose pharmacotherapy before a trial of psychotherapy in children?

A
  • If psychotherapy not accessivle, acceptable, or effective in moderate MDD
  • In more severe cases of depression
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74
Q

Hoq frequently should children be monitored after initiating treatment with an antidepressant?

A
  • Weekly for first 4 weeks
  • Then visits every 2 weeks for a month
  • Then after 12 weeks to monitor adverse events/SI
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75
Q

When starting antidepressant in youth, how do you dose?

A
  • Start at low end of therapeutic range
  • Continue at least 4 weeks before considering dose increase
  • If 12 weeks of adequate dosing, and pt shows only partial response, switch
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76
Q

How long should children with MDD be treated with pharmacotherapy?

A
  • 12 months if severe or 2 episodes
  • Otherwise, 6-12 months
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77
Q

Which antidepressants has Health Canada approved under the age of 18?

A

None!

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78
Q

What is the warning associated with use of antidepressants in patients 24 and younger?

A

Black Box Warning, increased suicidal thoughts/behaviours

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79
Q

Maternal/Perinatal Depression is associated with the following poor outcomes accoridng to CANMAT:

A
  • Poor obstetrical outcomes
  • SGA
  • NICU
  • Increased rates neonatal complications
  • impairment in bonding
  • infant sleep difficulties
  • developmental delay
  • cognitive, behavioural, emotional problems in offspring
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80
Q

What is first line treatment of mild to moderate MDD during pregnancy according to CANMAT?

A

CBT

IPT

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81
Q

What is second line treatment of mild to moderate MDD in pregnancy according to CANMAT?

A

Citalopram

Escitalopram

Sertraline

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82
Q

What is first line treatment of severe MDD in pregnancy according to CANMAT?

A

Citalopram

Escitalopram

Sertraline

(either alone, or in combo with CBT/IPT. Psychotehrapy monotherapy NOT reccommended)

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83
Q

What is second line treatment of severe MDD in pregnancy according to CANMAT?

A

Buproprion

Desvenlafaxine

Duloxetine

Fluoxetine

Fluvoxamine

Mirtazapine

TCAs

Venlafaxine

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84
Q

What “line” of reccommendation is ECT in severe/psychotic/tx resistant MDD in pregnancy AND breastfeeding?

A

Third Line

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85
Q

Which antidepressants have the lowest RID (relative infant dose) and milk to plasma ratios?

A

Setraline

Fluvoxamine

Paroxetine

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86
Q

What is second line treatment of Mild to Moderate Postpartum Depression During Breastfeeding?

A

Citalopram

Escitalopram

Setraline

Combo of the above + CBT/IPT

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87
Q

What is first line treatment of severe Postpartum Depression During Breastfeeding?

A

Citalopram

Escitalopram

Setraline

Combo above + CBT/IPT

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88
Q

What is second line treatment of severe Postpartum Depression During Breastfeeding?

A

Fluoxetine

Fluvoxamine

Paroxetine

TCAs (except doxepin - v high rate of passage into breast milk)

Bupropion

Desvenlafaxine

Duloxetine

Mirtazapine

Venlafaxine

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89
Q

What is the first line reccommendation for treatment of perimenopausal depression?

A

Desvenlafaxine

CBT

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90
Q

What is the second line reccommendation for treatment of perimenopausal depression?

A

Trasndermal Estradiol (level 2)

Citalopram (Level 3)

Duloxetine

Escitalopram

Mirtazapine

Quetiapine XR

Venlafaxine XR

Fluoxetine (Level 4)

Nortriptyline

Paroxetine

Sertraline

Omega 3

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91
Q

What is the first line reccommendation for treatment of late life depression according to CANMAT?

A

Duloxetine (level 1)

Mirtazapine

Nortriptyline

Bupropion (Level 2)

Citalopram

Escitalopram

Desvenlafaxine

Duloxetine

Sertraline

Venlafaxine

Vortioxetine

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92
Q

What is the second line reccommendation for treatment of late life depression according to CANMAT?

A
  • Switch to
    • Notriptyline
    • Moclobemide
    • Phenelzine
    • Quetiapine
    • Trazodone
    • Bupropion
  • Combine with
    • Aripiprazole
    • Lithium
    • Methyphenidate
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93
Q

According to Katzman, what is the role of benzos in anxiety disorders?

A

May be useful as adjunct early in tx

In acute crises

Or wiating for onset of efficacy of SSRIs/antidepressants

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94
Q

According to Katzman, in anxiety disorders, how long does it take for pharmacological treatment to be effective?

A

2-8 weeks in onset of symptom relief

Full response in 12 weeks or longer

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95
Q

According to Katzman, how long should therapy continue for?

A

Longer term therapy associated with continued symptom improvement and relapse prevention

Therapy shoul dbe continued 12-24 months for most patients

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96
Q

According to Katzman, how should medications be dosed in anxiety disroders?

A

Initiate at low doses

Titrate to reccommended dosage at 1-2wk intervals over 4-6 weeks

Once therapeutic range achieved, improvement in next 4-8 weeks

F/u at 2 wk intervals for first 6 wks, then monthly

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97
Q

According to Katzman what objective scales can be used to assess a patient’s progress?

A

Clinical Global Impression (CGI) scale

Hamilton Anxiety Rating Scale (HARS)

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98
Q

According to Katzman in panic disorder, what is true about the effectiveness of CBT vs medications?

A

CBT was significantly favored over medications for the treatment of panic disorder in a meta-analysis

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99
Q

According to Katzman in Panic Disorder, what type of CBT techniques had the most consistent evidence of efficacy?

A

Exposure

Cognitive restructuring

Other CBT techniques

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100
Q

According to Katzman in panic disorder, what is true about combination psychotherapy + pharmacotherapy with antidepressants?

A

Superior to CBT or pharmacotherapy alone during acute treatment and while meds continued

After terminatin of therapy, combined therapy was MORE effective than pharmacotherapy alone and AS effective as psychotherapy

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101
Q

According to Katzman in Panic Disorder, what are first line reccommendations for pharmacotherapy?

A
  • SSRIs
    • Citalopram
    • Escitalopram
    • Fluoxetine
    • Fluovoxamine
    • Paroxetine
    • Sertraline
  • Venlafaxine
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102
Q

According to Katzman in Panic Disorder, what are second line reccommendations for pharmacotherapy?

A
  • Benzos
    • Alprazolam
    • Clonzaepam
    • Diazepam
    • Lorazepam
  • TCAs
    • Clomipramine
    • Imipramine
  • Other antidepressants
    • Mirtazapine
    • reboxetine
103
Q

According to Katzman in Panic Disorder, what are first line reccommendations for adjunctive pharmacotherapy?

A

None

104
Q

According to Katzman in Panic Disorder, what are second line reccommendations for adjunctive pharmacotherapy?

A

Alprazolam

Clonazepam

105
Q

According to Katzman in Panic Disorder, what is NOT reccommended for pharmacotherapy?

A

Buspirone

Propranolol

Trazodone

Tiagabine

106
Q

What is an acceptable appraoch to initial treatment of panic disorder?

A

Pharmacotherapy

CBT

CBT + Pharmacotherapy

107
Q

According to Katzman, what type of psychological treatment is recommended in all phobias?

A

Exposure

108
Q

According to Katzman, what type of psychological treatment is recommended in phobia of heights, flying, spiders, claustrophobia?

A

Virtual Reality exposure

109
Q

According to Katzman, what type of psychological treatment is recommended in phobias of spiders, flying, small animals?

A

Computer-based self help

110
Q

According to Katzman, what type of psychological treatment is recommended in blood-injection-inury phobia?

A

Applied muscle tension

(Exposure + muscle tension exercises)

111
Q

According to Katzman, what is the role of medication in treating specific phobias?

A

Pharmacotherapy is generally unproven, and thus not a recommended treatment for most cases

112
Q

What are principles of treating social Anxiety Disorder according to Katzman?

A

CBt/exposure therapy alone are effective first line options

CBT = pharmacotherapy in acute treatment

Gains achieved through CBT persist longer than pharmacotherapy

(Note that CBT + pharm combo not better than CBT alone)

113
Q

What is the gold standard for psychological treatment of social anxiety disorder?

A

CBT

Cognitive - restructuring, challenging maladaptive thoughts

Behaviour - exposure

114
Q

According to Katzman, what is first line pharmacological treatment of Social Anxiety Disorder?

A
  • SSRIs
    • Escitalopram
    • Fuvoxamine
    • Paroxetine
    • Sertraline
  • Pregabalin
  • Venlafaxine
115
Q

According to Katzman, what is second line pharmacological treatment of Social Anxiety Disorder?

A
  • Citalopram
  • Benzos
    • Alprazolam
    • Bromazepam
    • Clonazepam
  • Gabapentin
  • Phenelzine
116
Q

According to Katzman, what is first line adjunctive pharmacological treatment of Social Anxiety Disorder?

A

None

117
Q

What are principles of treating GAD according to Katzman?

A

CBT effective first line option

= Effective to pharmacotherapy

No evidence for routine combo of CBT + meds

(But when pt tries psychotherapy and doesnt respond, try meds and vice versa)

118
Q

According to Katzman, what is first line pharmacological treatment of GAD?

A
  • SSRIs
    • Escitalopram
    • Paroxetine
    • Sertraline
  • SNRIs
    • Venlafaxine
    • Duloxetine
  • Pregabalin
119
Q

According to Katzman, what is second line pharmacological treatment of GAD?

A
  • Benzos
    • Alprazolam
    • Bromazepam
    • Diazepam
    • Lorazepam
  • Bupropion
  • Buspirone
  • Vortioxetine
  • Imipramine
  • Quetiapine XR
  • Hydroxyzine

*Usually consider benzos first, for short term use. Reserve bupropion for later. Quetiapine should be reserved for those who can’t tolerate antidepressants or benzos

120
Q

According to Katzman, what is first line Adjunctive pharmacological treatment of GAD?

A

None

121
Q

According to Katzman, what is second line Adjunctive pharmacological treatment of GAD?

A

Pregabalin

122
Q

According to Katzman, what is reccommended for psychological therapies for anxiety in the elderly?

A

Relaxation Training

CBT

Supportive Therapy

CT

123
Q

According to Katzman, what is third line Adjunctive pharmacological treatment of GAD?

A

Aripiprazole

Olanzapine

Quetiapine

Risperidone

124
Q

According to Katzman, in treating OCD, what is the approach to treating OCD?

A

CBT (ERP) is effective first line options

CBT = or > pharmacotherapy

CBT + meds > meds alone (but NOT better than CBT alone)

125
Q

According to Katzman, in OCD, what psychotherapy has been shown to be more efficacious than ERP?

A

Danger Idea Reduction Therapy (DIRT)

( tx specifically designed to address fear of contaimination with infectious diseases, using cognitive intervention that includes no direct exposure)

126
Q

According to Katzman, what is first line recommendation for pharmacotherapy in OCD?

A

Escitalopram

Fluoxetine

Paroxetine

Sertraline

Fluvoxamine

127
Q

According to Katzman, what is second line recommendation for pharmacotherapy in OCD?

A

Citalopram

Clomipramine

Venlafaxine

Mirtazapine

128
Q

According to Katzman, what is first line adjunct recommendation for pharmacotherapy in OCD?

A

Aripiprazole

Risperidone

129
Q

According to Katzman, what is second line adjunct recommendation for pharmacotherapy in OCD?

A

Memantine

Quetiapine

Topiramate

130
Q

What is the role of early intervention for prevention of PTSD?

A
  • Evidence doesn’s upport widespread intervention eg debriefing
  • Screening and treating appropriate individuals may be preferred
    • TF-CBT for ASD, PTSD to prevent chronic PTSD
131
Q

What does psychological treatment for PTSD typically entail?

A
  • Education about disorder and treatment
  • Exposure to cues related to traumatic event
  • Types of CBT
    • TF-CBT
    • EMDR
    • PE (Prolonged Exposure)
    • Stress Management Therapy
    • ICBT (internet based CBT)
    • VRE (virtual reality exposure)
132
Q

According to Katzman, what is the general appraoch to selecting a medication for anxiety in someone with another comorbid psychiatric disorder?

A

Consider therapies that are effective in both disorders

133
Q

According to Katzman, what are first line recommendations for pharmacotherapy for core symptoms of PTSD?

A

Fluoxetine

Paroxetine

Sertraline

Venlafaxine

134
Q

According to Katzman, what are second line recommendations for pharmacotherapy for core symptoms of PTSD?

A

Fluvoxamine

Mirtazapine

Phenelzine

135
Q

According to Katzman, what are second line adjunctive recommendations for pharmacotherapy for core symptoms of PTSD?

A

olanzapine

risperidone

eszopiclone

136
Q

According to Katzman, what are first line adjunctive recommendations for pharmacotherapy for core symptoms of PTSD?

A

None

137
Q

According to Katzman, if antidepressant treatment is indicated for an anxiety disorder in a lactating person, which medications are preferred?

A

Sertraline

Paroxetine

138
Q

In children with anxiety disorders, according to Katzman, what are the principles of treatment?

A
  • Psychological treatments are generally preferred
  • If warranted consider combination
  • COMBO psychological and pharmacological >/= either alone
  • SSRI generally preferred
139
Q

According to Katzman, which medications have evidence for GAD in the elderly?

A

Pregabalin (mono or adj)

Duloxetine

Venlafaxine

Citalopram/Escitalopram

Setraline

Fluvoxamine

Mirtazapine (when used in depression, may have anxiolytic effects)

140
Q

According to Katzman, which medications have evidence for treatment of panic disorder in elderly?

A

Paroxetine

Escitalopram

Fluvoxamine

141
Q

According to Katzman, which medications have evidence for treatment of OCD in elderly?

A

Fluvoxamine

142
Q

According to Katzman, which medications should be considered for patients with an anxiety/related disorder and comorbid MDD?

A
  • Antidepressants (SSRIs/SNRIs) as first line treatment
  • Quetiapine has efficacy as monotherapy in both MDD and GAD, MDD w/ anxiety
  • Aripiprazole augmentation, risperidone monotherapy may reduce como symptoms
143
Q

According to Katzman, what are reccommendations for psychotherapy for anxiety in the elderly?

A
  • Evidence for
    • Relaxation Trianing
    • CBT
    • Supportive Therapy
    • CT
  • Specifically,
    • CBT = GAD, panic
    • Exposure +/- CBT = PTSD, phobias
  • Psychotherapy as effective as pharmacotherapy in elderly
144
Q

According to Katzman, which medications have evidence for comorbid bipolar disorder/psychosis + anxiety?

A
  • Lithium, olanzapine, lamotrigine
  • Atypical AP
  • Adjunctive valproate and gabapentin for panic
145
Q

According to Katzman, what is the pharmacological approach to treating comorbid ADHD + anxiety?

A
  • Stimulants may help anxiety symptoms by treating ADHD
  • Atomoxetine can improve ADHD, anxiety (mostly SAD) and depressive symptoms
  • Atomoxetine + amphetamine improve anxiety in pts with ADHD and GAD refractory to antidepressant alone
146
Q

According to CANMAT 2018 for bipolar, what psychological interventions are reccommended for acute mania?

A

None

147
Q

According to CANMAT 2018 for bipolar, what psychological interventions are reccommended for maintenance?

A
  • 1st line
    • Psychoeducation
  • 2nd line
    • CBT
    • Family Focused Therapy
  • 3rd line
    • IPSRT
    • Peer Support

* as maintenance, adjunctive treatment options

148
Q
A
149
Q

According to CANMAT Bipolar 2018, which medications are reccommended first-line for treatment of acute mania? (monotherapies)

A

Lithium

Quetiapine

Divalproex

Asenapine

Aripiprazole

Paliperidone (>6mg)

Risperidone

Cariprazine

150
Q

According to CANMAT Bipolar 2018, which medications are reccommended first-line for treatment of acute mania? (combination therapies)

A

Quetiapine + Li/DVP

Aripiprazole + Li/DVP

Asenapine + Li/DVP

Risperidone + Li/DVP

151
Q

According to CANMAT Bipolar 2018, which medications are recommended second-line for treatment of acute mania?

A

Olanzapine

Carbamazepine

OLZ + Li/DVP

Lithium + DVP

Ziprasidone

Haloperidol

ECT

152
Q

According to CANMAT Bipolar 2018, in treating acute mania, what are considerations in choosing between monotherapy or combination therapy?

A
  • For all patients, tx should be initiated with first line monotherapy OR combination
  • Typically combination treatments have higher efficacy
  • Combination therapy is associated with more adverse effects than monotherapy
  • Consider past use, safety and tolerabilty, clinical features, and patient preference
153
Q

According to CANMAT Bipolar 2018, if there is no response to a first line anti manic agent at optimal doses, what is the next step?

A

Try another first line agent

Add on an additional first line agent (except NOT for paliperidone/ziprasidone)

Use second and third line only if many trials of first line agents unsiccessful

154
Q

According to CANMAT Bipolar 2018, what is the role of ECT in treating bipolar mania?

A

Second line option

Up to 80% show clinical improvement

Brief pulse therapy 2-3x per week

Bifrontal >bitemporal

155
Q

According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with features of

  • classical grandiose mania, or
  • few episodes of illness, or
  • mania-depression-euthymia course, or
  • Family history of BD, or
  • Family history of lithium response?
A

Lithium > Divalproex

156
Q

According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with features of classical and dysphoric mania?

A

DVP = Lithium

157
Q

According to CANMAT Bipolar 2018, which medications are reccommended in acute mania, with features of

  • Multiple prior episodes
  • Predominant irritable or dysphoric mood
  • Comorbid substance use
  • History of Head Trauma
A

DVP > Lithium

(but use ++ caution if prescribing in women of childbearing potential)

158
Q

According to CANMAT Bipolar 2018, which clinical features may respond favourably to carbamazepine?

A

Hx of head trauma

Como anxiety, substance use

Schizoaffective presentations with mood-incongruent delusions

No hx of BD in first degree relatives

159
Q

According to CANMAT Bipolar 2018, which clinical features may respond favourably to a combination therapy of Lithium and DVP?

A

When response is needed faster

“At risk” patients

Prev hx of partial acute response to monotherapy

Severe manic episodes

160
Q

According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with features of anxious distress?

A

DVP

Quetiapine

Olanzapine

Carbamazepine

161
Q

According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with mixed features?

A

DVP

Atypicals (asenapine, aripiprazole, olanzapine, ziprasidone)

Often combination therapy required

162
Q

According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with psychotic features?

A

Li/DVP + Atypical

  • may be more effective than other first line combinations for mood incongruent features, but overallno superiority of any first line agent/combo
163
Q

According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with features of rapid cycling?

A

Follow maintenance recommendations

No superiority of any first line tx in treating manic symptoms with rapid cycling course

164
Q

According to CANMAT Bipolar 2018, which medications are reccommended in acute mania, with features of seasonal pattern?

A

No evidence for superiority of any agents

165
Q

According to CANMAT Bipolar 2018, what psychosocial interventions can be recommended for acute bipolar depression?

A

No first line recommendations

Can choose between CBT, FFT, and IPSRT (Level 3) based on indiivdual strengths and needs

ALWAYS offer psychoeducation in BD

166
Q
A
167
Q

According to CANMAT Bipolar 2018, which medications are reccommended for acute bipolar 1 depression, first line?

A

Quetiapine

Lurasidone + Li/DVP

Lithium

Lamotrigine

Lurasidone

Lamotrigine Adjunctive

168
Q

According to CANMAT Bipolar 2018, which medications are reccommended for acute bipolar 1 depression, second line?

A

DVP

SSRIs/Bupropion (adj)

ECT

Cariprazine

OLZ-Fluoxetine

169
Q

According to CANMAT Bipolar 2018, when initiating treatment for bipolar depression, when should early improvement be noticed?

A

2 weeks

170
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, what are considerations in whether to switch or add adjunctive treatment?

A

Switch overall preferred to add-on to limit polypharm

Use rational polypharmacy via add-ons

Consider switching classes if antidepressnat ineffective

Overlap and taper

Go to second-line only if all first line options have been tried and failed

171
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, when should ECT be considered?

A

Second line

Tx refractory patients

When rapid response is needed (catatonia, psychotic, very suicidal)

172
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, what is notably not recommended as treatment?

A

Aripiprazole

Antidepressant monotherapy

Ziprasidone

173
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited when there is a need for rapid response?

A

Quetiapine

Lurasidone

ECT (second line)

174
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for patients with previous response to current treatment?

A

Adjunctive treatment

175
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for features of anxious distress?

A

Quetiapine

Olanzapine-Fluoxetine

Lurasidone

176
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for mixed features?

A

Combination Therapies

Olanzapine Fluoxetine

Asenapine

Lurasidone

* avoid antidepressants

177
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for melancholic features?

A

No specific studies

ECT may be very effective

178
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for atypical features?

A

Some evidence for tranylcypromine

*but risk of switch, so ONLY use with Li, DVP, or Atypical

179
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for psychotic features?

A

ECT

Antipsychotics

180
Q

According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for features of rapid cycling?

A

(Consider thyroid, antidepressants, substance use)

Not great evidence, but the following have comparable maintenance efficacy:

Li

DVP

Olanzapine

Quetiapine

181
Q

According to CANMAT Bipolar 2018, for bipolar 1 maintenance treatment, what are first line treatments?

A

Lithium

Quetiapine

Divalproex

Lamotrigine

Asenapine

Quetiapine + Li/DVP

Aripiprazole + Li/DVP

Aripiprazole

Aripiprazole IM, monthly

182
Q

According to CANMAT Bipolar 2018, for bipolar 1 maintenance treatment, what are second line treatments?

A

Olanzapine

Risperidone LAI

RIsperidone LAI adj

Carbamazepine

Paliperidone (>6mg)

Lurasidone + Li/DVP

Ziprasidone + Li/DVP

183
Q

According to CANMAT Bipolar 2018, for acute bipolar 2 depression, what are first line treatment recommendations?

A

Quetiapine

184
Q

According to CANMAT Bipolar 2018, for acute bipolar 2 depression, what are second line treatment recommendations?

A

Lithium

Lamotrigine

Bupropion (adj)

ECT

Sertraline

Venlafaxine

185
Q

According to CANMAT Bipolar 2018, for bipolar 2 maintenance, what are first line treatment recommendations?

A

Quetiapine

Lithium

Lamotrigine

186
Q

According to CANMAT Bipolar 2018, for bipolar 2 maintenance, what are second line treatment recommendations?

A

Venlafaxine

187
Q

According to CANMAT Bipolar 2018, for hypomania, what are treatment recommendations?

A

No great evidence exists

Clinical experience suggests that all anti-manic meds are efficacious in hypomania

If hypomania is frequent, severe, impairing, consider Li, DVP, AP and maybe N-Ac

188
Q

According to CANMAT Bipolar 2018, for Bipolar II depression, what are first line treatment recommendations?

A

Quetiapine

189
Q

According to CANMAT Bipolar 2018, for Bipolar II depression, what are second line treatment recommendations?

A

Lithium

Lamotrigine

Bupropion

Sertraline

Venlafaxine

ECT

190
Q

According to CANMAT Bipolar 2018, for Bipolar II maintenance, what are first line treatment recommendations?

A

Quetiapine

Lithium

Lamotrigine

191
Q

According to CANMAT Bipolar 2018, for Bipolar II maintenance, what are second line treatment recommendations?

A

Venlafaxine

192
Q

Teratogencity of Mediciations Used in Bipolar Disorder. Memorize this.

A
193
Q

According to CANMAT Bipolar 2018, for pregnant people, what is the best approach to treatment of BAD in first trimester?

A

Psychological strategies preferred over medications in first trimester

When meds are necessary, preference should be given to monotherapy and lowest effective dose

194
Q

According to CANMAT Bipolar 2018, what are risks associated with divalproex in pregnancy?

A

Should be avoided due to risks of NTD (5%)

higher incidences of congenital abnormalities

striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts

195
Q

According to CANMAT Bipolar 2018, in later pregnancy, what are considerations in dosing?

A

Pts may require higher doses of meds towards end of pregnancy because:

Changes in physiology in 2nd and early 3rd trim

Increased plasma volume

Increased hepatice activity

Increased renal clearance

196
Q

According to CANMAT Bipolar 2018, which medications have evidence in tretaing postpartum mania?

A

Antipsychotics

Benzos

Lithium

197
Q

According to CANMAT Bipolar 2018, which medications have evidence in treating postpartum bipolar depression?

A

Quetiapine

198
Q

According to CANMAT Bipolar 2018, what approach should be taken in treating postpartum mood episodes in general?

A

Hierarchies for non-postpartum mood episodes should be followed

But consider breastfeeding safety if applicable

199
Q

According to CANMAT Bipolar 2018, what should be considered when counselling a patient with bipolar disorder about breastfeeding in the postpartum period?

A

Counselling about early recognition of drug toxicity

Olanzapine and quetiapine may be preferred because of relatively lower infant dosages

Impact of meds may be lower if med is taken after feeding times

Consider replacing/supplemeting with formula to limit sleep disruption

Partners do night feeding by bottle

In women wiith postpartum psychosis/mania, breatsfeeding may be too unsafe if motehr is disorganized

200
Q

What did STEP-BD say about mood episodes in menopause?

A

Increased rates of depressive, but not manic episodes

201
Q

According to CANMAT Bipolar 2018, what are general principles in pharmacological management of children with BD?

A

General principles from adults apply

Elevated risk for CVD complications, so RFs should be assessed and intervention as necessary

Children more susceptible to metabolic side effects

Polypharmacy should be very judiciously used

202
Q

According to CANMAT Bipolar 2018, which medications are considered first line in treating mania in children?

A

Lithium

Risperidone

Aripiprazole

Asenapine

Quetiapine

203
Q

According to CANMAT Bipolar 2018, which medications are considered second line in treating mania in children?

A

Olanzapine

Ziprasidone

Quetiapine adjunct

204
Q

According to CANMAT Bipolar 2018, which medications are considered first line in treating bipolar depression in children?

A

Lurasidone

205
Q

According to CANMAT Bipolar 2018, which medications are considered second line in treating bipoalr depression in children?

A

Lithium

Lamotrigine

206
Q

According to CANMAT Bipolar 2018, which medications are considered first line in bipolar maintenance in children?

A

Aripiprazole

Lithium

Divalproex

207
Q

According to CANMAT Bipolar 2018, what can be used in treating comorbid ADHD in a youth with BD?

A

Stimulants in stable/euthymic youth taking optimal doses of anti manic meds

Mixed amphetamine salts and methylphenidate

(Theoretical risk of converting to mania with atomoxetine)

208
Q

According to CANMAT Bipolar 2018, what considerations should you make in treating comorbid subsatnce use in child with BD?

A

Treat concurrently

Li may be effective for reducing substance use in this pop

FFT

N-AC possibly (esp re cannabis)

209
Q

According to CANMAT Bipolar 2018, what is true of medical comorbidities of older adults with BD?

A

3-4x more med comos

Metabolic syndrome,HTN, DM, CVD

Reduction of life expectancy of 10-15 y

Assessment of older adults with BD should inlcude through physical and neuro inv

Coordinate with other care providers

Inlcude smoking cessation

210
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological management of acute mania in older adults?

A

First Line - Li or DVP (lower doses may be effective)

Second Line - Quetiapine

211
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological management of acute bipolar depression in older adults?

A

First Line - Quetiapine and Lurasidone

Second Line - Li, Lamotrigine

212
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological management of bipoalr maintenance in older adults?

A

Choice should be based on what was effective in acute stage

Li, DVP, Lamotrigine have geriatric efficacy data

213
Q

According to CANMAT Bipolar 2018, what are the most common comorbid psychiatric disorders with BD?

A

SUD (33%-45% of people with BD)

Anxiety Disorders (24-56%)

Personality Disorders (42%)

Impulse Control Disorders (10-20%)

214
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid Alcohol use disorder and BD?

A

Combo of Li + DVP is only tx that meets Levl 2

Li - use with caution bc of potential electrolye imbalance

Anticovulsants - LFTs and lipase levels before initiating

Agents for primary AUD (naltrexone, disulfriam, gabapentin, not acamprosate) may have some benefit in BD (Level 4)

215
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid cannabis use disorder and BD?

A

Li/DVP level 3

20% of ppl with BD will have cannabis disorder

Cannabis use disorder assocaited with younger age, mixed episode/polarity, presence of psychotic features, comorbid SUDs

216
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid cocaine use disorder and BD?

A

Citicholine adj (Level 2)

Li, DVP, Quetiapine, Risperidone, Bupropion (Lvls 3 & 4)

No great evidence here

217
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid opioid use disorder and BD?

A

Methadone (Level 3)

But evidence not great

218
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid other/miscellaneous substance use disorder and BD?

A

OLZ

Aripiprazole

219
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid GAD/Panic Disorder and BD?

A

Quetiapine (level 2)

In pts who are euthymic and treated with lithium, Lamotrigine or OLZ may be helpful (3)

OLZ + Fluoxetine (3)

Gabapentin (4)

220
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid OCD and BD?

A

Mood stabilizers and atypical AP may be adequate to resolve comorbid OCD and BD

Antidepressants might be necessary for some patients

If antidepressants are used, SSRIs preferred, and prophylactic anti-manic agents should be optimised before antidepressant started

Potential benefits of Li, anticonvulsants, OLZ, risperidone, quetiapine, aripiprazole

221
Q

According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid personality disorder and BD?

A

DVP and Li (Lvl 3, 4)

Psychoeducation

DBT

222
Q

Accoridng to CANMAT Bipolar 2018, what are baseline investigations that should be done in a patient with BD?

A

CBC

Fasting Glucose

Fasting Lipids

CBC - Platelets

Electrolytes and Calcium

Liver enzymes

Serum bilirubin

PTT

Urinalysis, Urine tox

Creatinine. eGFR, 24H cr clearance if hx of renal disease

TSH

ECG if >40 or otehr indication

Preg test if relevant

Prolactin

223
Q

According to CANMAT Bipolar 2018, for patients on maintenance therapy with lithium, what does ongoing monitoring include?

A

Levels should be done at trough (12h after last dose)

2 consecutive levels should be established in tx range during acute phase (0.8-1.2mEQ/L; 0.4-0.8 in older adults in acute; maintenance 0.6-1 sufficient)

Then q 3-6 months or more frequently if indicated

Thyroid, Renal Fx, Ca q6months

224
Q

According to CANMAT Bipolar 2018, for patients on maintenance therapy with Divalproex, what does ongoing monitoring include?

A

Levels should be done at trough (12h after last dose)

2 consecutive levels should be established in tx range during acute phase (Target 35-700mM/L in acute phase)

Then q 3-6 months or more frequently if indicated (and 3-5 days after dose adj)

Menstrual hx, Haem profile, LFTs at 3-6 mth intervals in first year

225
Q

According to CANMAT Bipolar 2018, for patients on maintenance therapy with carbamazepine, what does ongoing monitoring include?

A

Levels should be done at trough (12h after last dose); q6-12 months

To ensure levels not in toxic range; as there is no est relationship between efficacy and serum levels

Serum levels of all psyschotropics should be monitored bevause of interactions

Routinely educate about skin rashes (SJS and TEN)

HLA-B1502 allele testing in genetically at risk pops for high risk for SJS/TEN (Han Chinese, Asian ancestry)

226
Q

According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause weight gain?

A

OLZ

CLozapine

Risperidone

Quetiapine

Gabapentin

DVP

Lithium

227
Q

According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause GI symptoms?

A

Li, DVP

(Take at bedtime, take with food, use slow release forms when available)

228
Q

According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause renal toxicity?

A

Lithium! (LiNDI, ATN)

CKD Risk Factors - long term use, higher plasma levels, multiple daily doses, other renal meds, somatic illness, older age, incidents of Li toxicity

Also very narrow therapeutic window, so intox is a ocmplication, and can lead to reduced eGFR

229
Q

According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause heamatological effects?

A

Clozapine - Baeline haem profile, be enrolled in clozapine monitoring pgm, weekly then 2-4 weeks

CBZ - maybe RF for leukopenia

230
Q

According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause CVD?

A

Lithium (QT, T wave)

Risperidone, OLZ, Ziprasidone, Asenapine (arrhythmias, QTC, ect)

Clozapine

231
Q

According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause metabolic syndrome?

A

Atypicals - mostly OLZ, clozapine, quetiapine, risperidone

Aripiprazole, Ziprasidone, Asenapine, Luasidone

All pts on atypicals shoudl be monitored for blood glucose, lipid profiles,

232
Q

According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause sedation?

A

DVP

Atypicals

233
Q

According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause cognitive side effects?

A

Lithium

Anticonvulsants (except lamotrigine)

234
Q

According to CADDRA 2020, what are first line pharmacological treatments for ADHD?

A
  • Amphetamine-Based Stimulants
    • Mixed Amphetamine Salts (Adderall XR) (12-14h)
    • Lisdexamphetamine (Vyvanse) ~14h
  • Methylphenidate
    • Biphentin ~12h
    • Concerta ~12h
    • Foquest ~16h
235
Q

According to CADDRA 2020, what are second line pharmacological treatments for ADHD?

A
  • Amphetamine-Based Stimulants
    • Dextroamphetamine (Dexedrine) ~4h
  • Methylphenidate
    • Methylphenidate SA (Ritalin) ~3-4h
  • Non-stimulant SNRI
    • Atomoxetine (up to 24h) 0.5mg/kg
  • Non-stimulant a-2a adrenergic receptor agonist
    • Guanfacine XR up to 24h
236
Q

According to the Canada Schizophrenia Guidelines, in first-episode psychosis, what is recommended as first line treatment?

A

Antipsychotics

237
Q

According to the Canada Schizophrenia Guidelines, in first-episode psychosis, how should antipsychotic be selected?

A

Choice should be made by patient and physician (and caregiver) together

No established superiority between FGAs and SGAs in FEP

Decision making should be guided by side effect profile

238
Q

According to the Canada Schizophrenia Guidelines, in first-episode psychosis, how long should a medication trial be?

A

After initiated, continue for at least 2 weeks unless there are sig tolerability issues

(much of AP effect should be seen in first several weeks)

If poor response, assess med adherence and substance use

Optimize Dose

If no response after 4 weeks despite dose optimization, change AP

If partial response, R/A after 8 weeks

239
Q

According to the Canada Schizophrenia Guidelines, in first-episode psychosis, what is the recommended duration of maintenance treatment?

A

18 months

240
Q

According to the Canada Schizophrenia Guidelines, in acute exacerbation, after an increase or change in antipsychotic, how long should medication be continued?

A

4 weeks unless significant tolerability issues, if no improvement, switch

Where partial repsonse is seen after 4 weeks, R/A in 8 weeks

241
Q

According to the Canada Schizophrenia Guidelines, in relapse prevention and maintenance treatment, what is the recommended dosing?

A

Low to moderate dosing

CPZ 300-400mg daily

Risperidone 4-6mg daily

Olanzapine 20mg - 30mg daily

Abilify 30 - 45mg daily

242
Q

According to the Canada Schizophrenia Guidelines, in relapse prevention and maintenance treatment, what is the recommended duration of treatment?

A

Following resolution of positive symptoms of an acute psychotic episode

Maintenance tx with antipsychotic medications for “2 and possibly up to 5 years or longer”

243
Q

According to the Canada Schizophrenia Guidelines, in relapse prevention and maintenance treatment, what is the recommendation for oral or depot antipsychotics?

A

Patients should be given choice in keeping with their preference

Not just for nonadherence

(unless circumstances don’t allow this option, eg CTO)

244
Q

According to the Canada Schizophrenia Guidelines, what is the definition of treatment resistant schizoprhenia?

A

Non-responsiveness is the lack of satisfactory clinical response (<20% improvement in symptoms), despite treatment with appropriate courses of at least two marketed chemically-unrelated antipsychotic drugs.

245
Q

According to the Canada Schizophrenia Guidelines, in treatment-resistant schizophrenia (TRS), what should be recommended?

A

Clozapine

246
Q

According to the Canada Schizophrenia Guidelines, what is the definition of clozapine-resistant schizophrenia?

A

At least 8, but preferably 12 weeks at a dose of _>_400mg/day

Documentation of adherence

Plasma levels at least once (>350 if OD dosing, >25 if BID dosing)

Persistence of >2 pos symptoms with at least mdoerate severity, or single pos symptoms iwth severe severity

If all of the above met, “clozapine-resistant schizophrenia” specifier should be added

247
Q

According to the Canada Schizophrenia Guidelines, in clozapine-resistant schizophrenia, what is the treatment recommendation?

A

There isn’t one.

No intervention has demonstrated enough effect

Adjunct therapies, ECT may be useful

248
Q

According to the Canada Schizophrenia Guidelines, in patients with aggression and hostility, what is the treatment recommendation?

A
  • Based on Pt Preference, past experience, side effect profile, current meds
  • If TRS + aggression/hostility, trial of clozapine indicated
249
Q

According to the Canada Schizophrenia Guidelines, in comorbid depressive disorder, what is the treatment recommendation?

A

Individuals who meet criteria for depressive disorder should be treated according to relevant clinical practice guidelines for depression, including the use of antidepressants.

250
Q

According to the Canada Schizophrenia Guidelines, in youth with first episode of psychosis, what is the first step in management?

A

Early Identification

Urgent referral to specialist mental health service/EPI

251
Q

According to the Canada Schizophrenia Guidelines, in youth with first episode of psychosis, what is the first step in treatment?

A

Offer antipsychotic medication + psychological/psychosocial interventions

(should not be started in primary care, unless consultation with a CA Psychiatrist)

252
Q
A
253
Q

According to the Canada Schizophrenia Guidelines, in youth with first episode of psychosis, how should choice of antipsychotic be made?

A

Jointly with young person/parents/HCPs

Likely benefits and side effects (metabolic, extrapyramidal, cardio, hormonal, other)

254
Q

According to the Canada Schizophrenia Guidelines, in youth with first episode of psychosis when starting or changing antipsychotics, when is EKG indicated?

A
  • specified in Health Canada drug database

Psychiatry Studying (11 decks)

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