M5 study guide

Question 1

Tricyclic antidepressants

Answer 1

-E.g. Amitriptyline, Clomipramine, Desipramine, Doexpin
-use of these drugs have greatly declined
-2nd line drug
-MOA: block neuronal reuptake of two monoamine transmitters at the CNS intensifying their effects
-Major adverse effects: sedation, orthostatic hypotension, and anticholinergic effects, cardiac toxicity, lower seizure threshold
-Overdose can be life-threatening
-More dangerous and less well tolerated

Question 2

MAO inhibitors

Answer 2

-E.g. Isocarboxazid, Phenelzine, Selegiline, Tranylcypromine
-More hazardous, typically 3rd choice
-MOA: immediatley inactivates MAO in the synapse cause increased prolongation of NE, 5HT, and dopamine
-Greatest concern: Hypertensive crisis-triggered by eating foods rich in Tyramine
-Many drug interactions- avoid all drugs not approved by provider- HTN crisis with indirect-acting sympathomimetics
-SSRIs and serotonergic drugs can cause serotonin syndrome
-DRUG OF CHOICE FOR ATYPICAL DEPRESSION
-Most administered PO, Ensam (Selegiline) given transdermal (risk of HTN crisis is less w/ transdermal admin)—-AVOID drug-drug interactions by taking other meds not prescribed

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Question 3

SSRIs

Answer 3

-E.g. Citalopram, Escitalopram, Fluoxetine, Sertraline, Vortioxetine
-Most commonly prescribed, safer, more tolerated
-1st drug choice
-MOA: Selectively block neuronal reuptake of serotonin, more serotonin stays present
-DO NOT block reuptake of dopamine and norepinephrine
-Adverse effects: sexual dysfunction, weight gain, serotonin syndrome
-Like all other antidepressants, monitor for suicidality when treatment is initiated
-MUST TAPER-abrupt discontinuation can cause dizziness

Question 4

Adverse drug-drug interactions and treatment in patients taking MAO inhibitors

Answer 4

-Avoid all drugs, prescription or OTC, unless approved by DR
-AVOID Combo of TCA-MAOI-can cause severe HTN
-MAOI-SSRIs increase risk for serotonin syndrome–treatment includes discontinue drug, monitor and will resolve spontaneously.
-Antihypertensives- combined use of MAOI can lead to excessive lowering of blood pressure
-DO NOT TAKE W/ TEGRETOL OR TRILEPTAL

Question 5

Teaching for those taking MAOI

Answer 5

-Patients should be informed about symptoms of HTN crisis (headache, tachycardia, palpitations, N/V, Sweating) -instruct to seek immediate medical attention if experiencing those symptoms-can lead to stroke and death
-Dietary restrictions: tyramine, caffeine, phenylethylamine–all can precipitate HTN in pts taking MAOIs—AVOID
-NO DRUGS OTHER THAN THOSE PRESCRIBED BY PROVIDER

Question 6

Etiology of depression

Answer 6

-Most common psychiatric diagnosis
-understood to be caused by a deficiency of Monoamine neurotransmitters (serotonin and NE) in the brain
-depressed mood and loss of pleasure in usual activities
-Symptoms: insomnia/hypersomnia, anorexia/weight gain, mental slowing, loss of concentration, feeling of guilt, worthlessness, helplessness, suicidal ideation
Diagnosis: symptoms most of the day, nearly everyday for 2 weeks

Question 7

Steps in treating someone with Major Depression

Answer 7

-Pharmacotherapy
-depression specific psychotherapy
-somatic therapis-yoga
-electroconvulsive therapy
-rule out non psychiatric causes of depression prior to starting drug therapy-make sure its not a symptom of another illness. E.g. thyroid disorder

Question 8

Options for those w/ Major Depression who are considered non responders

Answer 8

-increase the dose
-try a different drug in the same class
-try a different class
-add an atypical antidepressant

Question 9

Nontraditional treatments for major depression

Answer 9

Somatic therapy
Electroconvulsive therapy

Question 10

Current treatments for GAD. Note any potential for abuse

Answer 10

-SSRI + SNRI= first line treatment for GAD
Can also use buspirone
-GAD can be treated with non drug therapy including supportive therapy, cognitive behavioral therapy, biofeedback, and relaxation training
-2nd line BZD- pts taking BZD carry some abuse potential especially that that abuse w/ ETOH
-Benzos act rapidly, good for a PRN for immediate relief
-potential for abuse by taking benzos since onset of relief is rapid
-avoid pregnancy/lactation-crosses placenta
-caution w/ active metabolites

Question 11

Treatments/drug classes and important teaching points for medications used in those w/ BD

Answer 11

Commonly treated w/ 3 major groups: mood stabilizers, antipsychotics, and antidepressants

Question 12

Mood stabilizers

Answer 12

-Relieve symptoms during manic and depressive episodes, prevent recurrence of these episodes, also they DO NOT worsen symptoms of mania or depression
E.g. Lithium and Valproate

Question 13

Lithium

Answer 13

-antimanic effects can begin in 5-7 days but full effects not until 2-3 wks
-short half life, high toxicity, very low therapeutic index
-check lithium levels frequently
-Pt teaching: no NSAIDS, it is terotogen-birth control, clear all meds w/ prescriber
-Lithium toxicity can occur when Na level are low, monitor in dehydration and if taking diuretics
-DO NOT TAKE NSAIDS OR ANTICHOLINERGICS

Question 14

Valproate (Depakote)

Answer 14

-first antiseizure drug approved for BPD
-works faster, more desirbale side effect profile compares to lithium, safer
-does not reduce risk for suicide and does NOT decrease risk for recurrence

Question 15

Antipsychoticsin the setting of bipolar disorder

Answer 15

-given to help control symptoms during severe manic episodes
-usually in combo with mood stabilizer
-2nd generation antipsychotics are preferred

Question 16

Antidepressants in the setting of bipolar disorder

Answer 16

-given during depressive episode
-always used in combo w/ mood stabilizer to avoid causing mania
-SSRIs can be used
-Avoid TCAs as they increase manic episodes

Question 17

What med class can be added to BPD treatment to help w/ insomnia, anxiety, and agitation

Answer 17

Benzodiazepines

Question 18

Treatment for managing acute delirium. Describe contraindications if any.

Answer 18

-Haloperidol-member of the butyrophenone family, high potency agent. Early extrapyramidal reactions occur, also can cause prolonged QT interval causing serious dysrhythmias, especially when given IV or at high doses
-Chlorpromazine-low potency agent
-Clozapine-can cause agranulocytosis, orthostatic hypotension, dry mouth, blurry vision, urinary retention, constipation, tachycardia. Clozapine can cause weight gain, diabetes, dyslipidemia
-Treat hyperactive delerium- no FDA drug approved
-Choose a med like haldol-QTC monitoring
-Supportive care

Question 19

EPS pathophysiology

Answer 19

-All first generation antipsychotic medications (FGAs) produce a strong blockade of dopamine in the CNS
-Resulting in serious movement disorders, known as EPS
-Movement disorders resulting from effects of FGAs which act on the extrapyramidal motor system
-Although the exact cause is unknown, it is thought to be related to D2 receptors

Question 20

Which population should BZD be avoided

Answer 20

-Avoid in patients with respiratory disorders
-COPD-benzos may worsen hypoventilation
-OSA- may exacerbate apneic episodes
-Snoring patient-benzos may convert partial airway obstruction into OSA
-Old people bitch

Question 21

Indications for treatment with: SSRI and BZD

Answer 21

-SSRIs- most commonly prescribed antidepressant
-BZD- treatment of anxiety, insomnia, and seizure disorder

Question 22

Side effects/ clusters of side effect symptoms that may be seen in those being treated with psychotherapeutic drugs

Answer 22

-Side effects: most troubling side effects are EPS-especially tardive dyskinesia
-acute dystonia
-parkinsonism
-akathisia
-NMS-worse possible side effect
-anticholinergic effects
-orthostatic hypotension
-sedation
-seizures
-sexual dysfunction
-neuroendocrine effects
-agranulocytosis
-severe dysrhythmias

Question 23

Non pharm treatment for insomnia

Answer 23

-melatonin-a hormone that helps regulate the circadian clock
-sleep hygeine, CBT, relaxation therapy, multicomponent therapy

Question 24

Neuroleptic Malignant Syndrome (NMS)

Answer 24

-Very rare, 4% die
-most of the drugs that cause NMS are antipsychotic drugs. First generation (typical) and 2nd generation (atypical)
-Symptoms: rigidity, very high temps may exceed 41 degrees C, sweating, autonomic instability manifested as dysrhythmias and fluctuations in BP
-LOC may rise and fall-can appear confused or mute, seizures and coma may develop
-Hyperthermia should be controlled w/ cooling blankets + antipyretics
-Treatment consists of supportive measures, drug therapy, and immediate withdrawal of antipsychotic meds
-Hydration w/ fluids
-Benzos can help relieve anxiety and reduce BP
-2 meds may be helpful: bromocriptine(dopamine receptor antagonist) and dantrolene (direct acting muscle relaxant)
-wait 2 weeks before resuming treatment, use lowest effective dose

Question 25

Serotonin Syndrome

Answer 25

-Occurs 2-72 hours after treatment onset
-Symptoms: AMS, confusion, disorientation, anxiety, hallucinations, poor concentration, incoordination, myoclonus, hyperflexia, excessive sweating, tremor, fever
-symptoms resolve spontaneously after discontinuing drug
-IVF, cooling blanket for treating
-Figure out if patient is taking MAOI + SSRI
-MAOI + other drugs–increase risk
-“mad as a hatter, red as a heat, dry as a bone”

Question 26

Techniques to assist w/ patient adherence to the prescribed regimen of atypical antidepressants

Answer 26

-atypical antidepressants (2nd generation)
-Clozapine-first SGA, most effective drug for scizizophrenia
-Monitor CBC regularly to assess for life-threatening agranulocytosis
-Evaluate for improvement of psychotic symptoms