Mental Health Disorders (Aside From Schizophrenia) Flashcards by Nicholas Walker

Schizophrenia diagnostic criteria

Both Positive and Negative Symptoms

At least 2 or more of the following symptoms: Delusions, Hallucinations, Disorganized speech, grossly disorganized/catatonic behavior, negative symptoms.

At least ONE of the symptoms must include Delusions, Hallucinations, or Disorganized speech

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Regardless of antipsychotic use, schizophrenia patients are at greater risk of which two comorbidities than the general population

Diabetes (1.5-2x) More likely

Diabetes Family Hx = 6x more likely

Cardiovascular risk
(Smoking 5x more likely, 1/2, 1/4 less likely to exercise, 8x more likely obese, 4x more likely to drink)

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Factors of patient-centered treatment plan for schizophrenia

Pharmacotherapy

Side effects

Community integration (adaptive functioning)

Prevent relapse/rehospitalization

Patients goals/aspirations

Family/support system

Adherence

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List some non-pharma treatment for schizophrenia

Pharmacotherapy is NECESSARY

Education, Cognitive Therapy, Living skills, social skills, education, work/employment, housing, financial support

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Aripiprazole, Asenapine, Brexipiparozole, Cariprazine, Clorazapine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperadone, ziprasidone

Are all classified as what?

Atypical, Newer, 2nd or 3rd Generation

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Chlorpromazine, Thioridazine, Fluphenazine, Haloperidol, Perphenazine, Loxapine, Droperidol

Are all classified as which type of med?

Typical, Classic, 1st Generation

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What are the SEVEN medication therapy goals in schizophrenia

Consider Patient Goals of Therapy
Reduce/Eliminate Symptoms
Absence of Symptoms Not Realistic
Minimize Adverse Drug Reactions
Prevent Relapse
Maximize quality of life and adaptive Function
Prevent Hospitalization

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Which population when treated with antipsychotic drugs are at an increased risk of death?

Elderly patients

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Drug induced psychoses is for those who

Go on to develop long term symptoms despite sobriety

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Psychoses associated with dementia or delirium and drug induced psychoses fall under which category

Antipsychotic USES/indications

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Why were “available formulations” marked as very important

It is important to consider patients adherence, how they are willing and how they can take a med, extended release, long acting injectables, inhaled, tab/capsule, etc.

With behavioral schizophrenic issues, it is important

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What factors should be considered when INITIATING antipsychotic therapy for schizophrenia

Start low, go slow (rapid titration = side effects = adherence issues)

Taper slowly if switching meds (withdrawal = nausea/headache)

Dose based on severity (Acute psychosis - may titrate more quickly)

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After 2 antipsychotic trials, _____ is recommended. Why is this drug notable.

(He thinks more than two.)

After 2 antipsychotic trials, clozapine is recommended. (Lots of side effects)

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What is the time frame and effects for Medication response time

Week 1: Less Agitation, Fewer Hallucinations (Medicated Cooperation)

Week 2-4: Improved: Socialization, Self-Care/Hygiene, Mood, Improved hallucinations/delusions

‘Week4-6: Improved thought disorder, decreased hallucinations/delusions, conversation more appropriate, reduced agitation

Persistent Symptoms: Look like improved judgement, inappropriate affect, fixed delusions/hallucinations

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Response is considered ___% improvement,ent in symptoms from baseline (often seen within TWO WEEK of therapy.

Improvement of at least 50% by ___-___ weeks

20% improvement in 2 weeks

50% in 4-6 weeks

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What are some examples of Extrapyramidal Symptoms (EPS)

What drugs are associated with LOWER risk of EPS

Dose related pseudoparkinsonism
Akathisia
Dystopia
Tardive Dyskinesia
Neuroleptic Malignant Syndrome

Lower risk with clozapine, quetiapine, and iloperidone

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A schizo patient on anti-psychotics has developed cogwheel rigidity, tremor at rest, shuffling gait.

Dx and treatment?

Dx = Parkinsonism

Treatment
1st: lower dose
Also, amantadine, anticholinergics (bentropin or trihexyphendyl) could switch antipsychotic

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A patient on aripiprazole (similar to brexpiprazole and lurasidone) now is showing restlessness, excessive movements, inability to sit still. Family suggest psychosis or anxiety.

What is the dx, treatment, and concern?

Akathisia (associated with aripiprazole)

Worry: Risk of suicidal ideation

Treatment:
1. Lower the dose
2. Switch to different antipsychotic
3. Add a benzo, or add propranolol

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A patient on comes into the ER with an odd and painful seizing of the head/neck/limbs.

What is the dx and treatment?

What would you discharge the patient with to prevent it happening again?

Dx: Acute Dystonia

Manage with:
1. Anticholinergic (diphenhydramine, benztropine, trihexyphendyl)
2. IM for acute use
3. Oral used long term, minimize dose possibly

Discharge: Benztropine for long-term use.

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A patient comes into the ER with involuntary choreiform movements of the tongue, lower face and jaw, and extremities.They have schizophrenia and have been using Haloperdol for 8 years now to manage.

Dx?

Cause?

Important counseling?

Management?

Dx: Tardive Dyskinesia
Cause: Risk with FGA’s (haloperdol)
Counseling: IRREVERSIBLE in most cases.
Management: VMAT2 (Deutetrabenazine and balbenzine > tetrabenzine

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A patient in the ER has schizophrenia, started a new anti-psychotic medication 3 days ago, and is having sx of fever, muscle rigidity, altered mental status, and autonomic instability.

Dx?
Cause?
Counseling Points?
Management?

Dx: Neuroleptic Malignant Syndrome (NMS)
Cause: High risk within 10 days of new med
Counseling: Risk for Rhabdomyolysis, Acute Renal Failure, Cardiac Arrhythmia
Management:
1. D/C Drug
2. Support and HYDRATION
3. Treat with Bromocriptine (PO_, DANTROLENE (IV_, or amantadine (PO)

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QTc-prolongation, OH, Tachycardia, Lowered seizure threshold, anticholinergic, insomnia, tremor, sedation are ALL categorized as what?

Anti-Psychotic adverse effects to consider (watch comorbidities)

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Med rec on schizo who has concerns with metabolic health.

Non-Pharma Recommendations?
Medication Recommendations?

Non-Pharma: Increase Activity, Decrease Calories

Pharma: maybe switch to different med

Low risk: asenapine, iloperidone
Lower Risk: Aripiprazole, brexpiprazole, cariprazine
Lowest Risk: Lurasidone, ziprasidone

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A patient is experiencing EPS while on Risperidone.

What med would you ideally switch to?

Aripiprazole is likely the best option. (LEAST AE’s)

Could also consider: lumateperone, iloperidone, clozapine (maybe), cariprazone, brexpiprazole.

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Patient comes in complaining of increased sedations since starting olanzapine for the schizophrenia. What meds would you consider switching to?

Aripiprazole (Least AE’s.) Also could consider: lumateperone, haloperidol, fluphenazine. All similar to Aripiprazole in decreased sedation.

A patient with severely low blood pressure, and a history of orthostatic hypotention comes into. They were prescribed olanzapine, and since have experienced increased OH. What would you switch the Olanzapine for?

Best: Aripiprazole Others (Decreased OH risk): Fluphenazine, Haloperidol, Brexpiprazole, Cariprazone, Lumateperone, Lurasidone.

A patient with new dx for schizophrenia needs to start antipsychotic meds. The patient is severely obese with a very high BMI Which meds would be contraindicated in this patient?

Most contraindicated: Clozapine, olanzapine Next (Not Ideal): Chlorpromazine, Asenapine, Iloperidone, Lurasidone, Quetiapine, Risperidone

A patient with uncontrolled diabetes, has now been diagnosed with schizophrenia. They have uncontrolled, high blood glucose What meds are contraindicated in this patient

Most (Do not use): Clozapine, Olanzapine Avoid: Chlorpromazine, Asenapine, Iloperidone, Lurasidone, Quetiapine, Risperidone

A patient has been newly diagnosed with schizophrenia. The patient has a history of QTc issues. Which meds would be contraindicated in this patient.

Most (Do not use): Chlorpromazine, Thioridazine, Haloperidol, Quetiapine, Ziprasidone Avoid: Clozapine, Iloperidone,Olanzapine, Risperidone

You are starting a patient on Aripiprazole for new onset schizophrenia. You work at Walmart and counsel them. What do you say to patient

1. FDA Warning (Monitor Impulse Control, gambling, binge eating.) 2. Weight Gain 3. Caution if HTN 4. AE: GI, Akathisia, Insomnia, Anxiety

A patient returns to your clinic. You have tried aripiprazole and olanzapine in this patient to manage schizophrenia. They are depressed (suicidal) as nothing helps. What would you recommend next. Why?

Clozapine APA recommends clozapine in treatment-resistant schizophrenia. Clozapine superiority in suicidal behavior Very Effective

A patient has failed 2 psych meds, and now is being treated with Clozapine. They are otherwise healthy aside from being schizophrenic What monitoring is recommended? How should it be initiated? What are some AE’s?

AE: Secdation, Drooling, Weight Gain. Monitoring: REMS (CBC, ANC, NEUTROPHIL WEEKLY - MONTHLY MONITORING. Initiation: START LOW GO SLOW. Minimize seizure, OH, sedation, and CV risk.

A patient has been started on Clozapine after multiple failed psych meds for their schizophrenia treatment. They have a history of smoking, and report they are attempting to quit. How should you address smoking cessation?

Smoking reduces clozapine levels via CYP1A2 induction. Not the nicotine that does it. Counsel on cessation progress; emphasize that you cannot be on clozapine effectively while smoking.

Olanzapine primary AE’s are? Contraindicated in?

Sedation. Weight Gain. Dry Mouth. Consitpation. High Metabolic Risk. Narrow-Angle Glaucoma

Risperidone is the most “_____” of the atypicals. What are Risperidone’s notable AE’s?

Risperidone is the most typical of the atypicals. Highest rate of elevated PROLACTIN levels (GYNECOMASTIA NIPPLES) Risk for AKATHISIA

This drug is… Metabolite of Resperidon but shows LESS EPS than risperidone. Only comes in osmotic delivery system; so you cannot split/crush tablet.

Paliperidone

What critical side effects are shown in Paliperidone (Invega)

Prolactin/Gynecomastia (Tested) Orthostatic Hypotension. Headache. Dose-Dependent Akathisia & EPS. Insomnia. Can’t swallow pill = can’t take.

Characteristics of Quetiapine: AE’s: Dosing Range: (Histaminergic, Serotonergic, Antagonism) (Bipolar Depression, Psychosis/Mania) Which doses are for which dx?

AE: Sedation, Orthostatic Hypotension, Dizziness, Dry mouth headache, WEIGHT GAIN (TEST HIGH METABOLIC RISK) Dosing: <150mg histaminergic 150mg-300mg: serotonergic (MDD augmentation) >300mg: D2 antagonism (TEST - SCHIZOPHRENIC DOSE) 300mg-600mg: bipolar depression >600mg: psychosis/mania.

Why is dosing especially important for quetiapine?

Receptor occupancy changes based on dose. Important to remember when dosing for schizophrenia.

Ziprasidone has some important counseling points. What are they

Ziprasidone 1. Give caps with >500 calories of food (bioavailability decreased by about 60% if unwed due to poor absorption. 2. Qtr prolongation 3. Low weight gain Dosage 20-80mg bid. Use with caution in hepatic impairment and use IM with caution renal impairment.

A patient\

AE’s of Lurasidone (Laguna?) counseling points?

1. AKATHISINA 2. Weight neutral, low weight gain risk, somnolence, dose-related creatinine increase. 3. Adminster with food >350. Increase AUC and Cmax.

Which medication would be viable in an NPO patient? Why?

Asenapine (Saphris). Available as patch

Which medication is same as aripiprazole except less akathisia

Brexpiprazole (Rexulti) 1. D2 partial agonist 2. Brand name only

Which drug was referred to as a “great drug, with insurance issues?” That could be resolved by PA.

Cariprazine (Vraylar) Low risk of weight gain, well tolerated, D3 and D2 partial agonist. Long half life, brand name

Iloperidone (fanpapt) if seen on test what do we do?

It is not the answer.

A patient comes in with a new onset of leukopenia and neutropenia. The patient started a new schizo med 2 weeks ago. What med and why

Lumateperone (Caplyta) Can cause Leukopenia and Neutropenia within first 3-4 weeks.

Which drug has the LOWEST incidence rate across all antipsychotics?

Lumateperone (Caplyta)

What is the regular dosing and renal dosing of lumateperone (caplyta)

42mg qd Renal 21mg qd

Which medications learned in schizophrenia meds are associated with sedation? (5 of them) How do we manage sedation issues?

1. Clozapine 2. Chlorpromazine 3. Thioridazine 4. Olanzapine 5. Quetiapine Manage: Lower dose, change to bedtime dosing, switch to less sedating med (aripiprazole, lurasidone)

medications are known to have highest risk for Orthostatic Hypotension? (6 meds) How do we manage OH if problem?

1. Clozapine 2. Olanzapine 3. Chlorpromazine 4. Thioridazine 5. Risperidone 6. Quetiapine Manage: Decrease/divide dose, switch to med with less antiadrenergic effect

Which medications are associated with anticholinergic effect? (5 meds) Management?

1. Clozapine 2. Chlorpromazine 3. Thioridazine 4. Olanzapine 5. Quetiapine (high doses) Manage: Lower or avoid doses

Which meds associated with highest risk of hyperprolactinemia? Manage?

1. Risperidone 2. Paliperidone 3. Any FGA Manage: Switch antipsychotics, to partial agonist.

Which meds are associated with high risk of Extrapyramidal Effects?

Haloperidol FGAs Manage: Lower dose, switch to low risk agent (clozapine, quetiapine, iloperidone, anticholinergic meds)

Which meds have high risk for Akathisia (3 meds?) Manage?

1. Aripiprazole 2. Brexpiprazole 3. Lurasidone Manage: dose reduction, addition of benzo/b-blocker (b&b), switch to lower agent

Which meds have high risk for QTc prolongation? (4) Manage?

1. Thioridazone 2. Ziprasidone 3. iloperidone 4. Haloperidol Manage: Avoid other QTc prolonging meds, monitor ECG, switch meds.

Which meds are high risk for weight gain, metabolic syndrome, diabetes, hyperlipidemia? (3 meds) MANAGE?

1. Clozapine 2. Olanzapine 3. Quetiapine Manage: Monitor/manage comorbid, switch to aripiprazole/ziprasidone

You have a highly suicidal patient with schizophrenia. The number one goal is to reduce suicidality. What med?

Clozapine. Reduced suicidality.

Which 3 meds are > than other SGA’s on more outcomes?

Clozapine Olanzapine Risperidone

A patient has issues with adherence. What would you recommend

LAIA. Improved adherence.

Which LAIA requires use of FDA REMS program? Why?

Olanzapine (Zyprexa) injection. Risk of post-injection delirium/sedation syndrome. Must be given in healthcare facility and observed for 3 hours post injection

1. Which FGA have immediate response? 2. Which FGA have long acting? 3. Which SGA have immediate response? 4. Which SGA is long acting?

1. Haloperidol, Chlorpromazine, Fluphenazine 2. Haloperidol Fluphenazine 3. Ziprasidone, Olanzapine 4. Aripiprazole, Risperidone, Paliperidone, Olanzapine: risk for sedation and delirium in first fees hours.

Which disease Confusion, Fast onset, Change from baseline awareness and attention, fluctuates, medical emergency, non-Pharma treatment, antipsychotic treatment risk, benzo risk

Delirium.

Goals of acute agitation treatment

1. Calm without excessive sedation 2. Early treatment underlying psychosis 3. Minimize treatment AE’s Calm > Sedate > Antipsychotic

1st line for acute management agitation?

Lorazepam 1-4mg PO or IM every 1-2 hours. Haloperidol/Olanzapine/Ziprasidone injection acute psychosis

In acute agitation, which two meds specifically should not be given together?

Olanzapine IM + Benzo Excessive sedation and cardiorespiratory depression

Which med requires WBC and ANC monitoring

Clorazil

What should be considered in FGA and SGA meds in elderly?

BBW: increased risk of death when used in elderly patients with dementia.