Venlafaxine (Effexor) Duloxetine (Cymbalta) Can worsen acute narrow-angle glaucoma Avoid with glaucoma

Amitriptyline (Elavil) Nortriptyline (Pamelor) Doxepin (Sinequan) AEs= Anticholinergic effects Category X Caution with elderly “SADCUB”: Sedation, Anorexia, Dry mouth, Confusion, Constipation, Urinary Retention, BPH Do not combine SSRIs with MAOI (↑ risk of serotonin syndrome)

diarrhea, dry mouth, metallic taste in the mouth Check blood levels

NOT 1st line depression Postherpetic neuralgia Stress urinary incontinence Chronic pain

TCAs Amitriptyline (Elavil) Nortriptyline (Norpramin)

Psych Flashcards by katie gazda

High levels of serotonin,. Introduction of a new drug in the system. Drug interactions. Recent increase in dose

Presentation: Acute with rapid progression
Signs and symptoms: high fever, muscular rigidity, mental status changes,
hyperreflexia/clonus, uncontrolled shivering, mydriasis (dilated pupils)
⚠WARNING⚠: Highest risk when combining two drugs that both block serotonin (SSRIs,
MAOIs, TCAs, triptans, tryptophan). Wait 2 weeks if switching drugs

Serotonin syndrome

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Atypical Antipsychotics
AEs/ Warnings

Olanzapine (Zyprexa)
Risperidone (Risperdal)
Quetiapine (Seroquel)

Obesity, DM II,
hyperlipidemia, metabolic
syndrome,
hypothyroidism.

Weight gain (monitor BMI) Q 3
months

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Anticonvulsants?
AEs/ Warnings

Lamotrigine (Lamictal)
Carbamazepine (Tegretol)- also used to tx 5th CN trigeminal neuralgia
Valproate (Depakote)

Steven-Johnson Syndrome
(Lamictal) -> ER

Patient education: monitor for sings of Steven-Johnson (rashes).

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SSRIs?
AEs and warnings

Sertraline (Zoloft)
Paroxetine (Paxil)
Citalopram (Celexa)
Escitalopram (Lexapro)
Anxiety
Insomnia
Sexual side effects
Serotonin syndrome
Black Box Warning: suicidal ideation
<24yrs age
Do not discontinue Paxil abruptly

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SNRIs
AEs/ Warnings

Venlafaxine (Effexor)
Duloxetine (Cymbalta)

Can worsen acute
narrow-angle glaucoma
* Avoid with glaucoma

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Typical Antipsychotics
AEs/ Warnings

Haloperidol (Haldol)

↑lipids/triglycerides
Malignant neuroleptic syndrome

Monitor: glucose, lipids
Black Box Warning: elderly=death

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Atypical Antidepressants
AEs/ Warnings

Bupropion (Wellbutrin)
Zyban for smoking cessation

AE= Seizures
* Contraindicated with anorexia, bulimia, hx seizures

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TCAs
AEs/ Warnings

Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Doxepin (Sinequan)

AEs=
* Anticholinergic effects
* Category X

Caution with elderly “SADCUB”:
Sedation, Anorexia, Dry mouth,
Confusion, Constipation, Urinary
Retention, BPH
Do not combine SSRIs with MAOI (↑
risk of serotonin syndrome)

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Lithium
AEs/ Warning

diarrhea, dry mouth,
metallic taste in the mouth

Check blood levels

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Best SSRI for non-compliant pts (longest ½ life)

Fluoxetine (Prozac)

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SSRI with fewer drug interactions

Citalopram

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SSRI with shortest 1/2 life. ED

Paxil

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Avoid with anorexia or thin elderly (↓
appetite)

SSRIs

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can cause mania in bipolar pts

SSRIs

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1st line for
* Major depression
* OCD
* GAD
* Panic disorder
* Social anxiety disorder

SSRIs
* Sertraline (Zoloft)
* Paroxetine (Paxil)
* Citalopram (Celexa)
* Escitalopram (Lexapro)

1st like tx for elderly, start low and slow (fewer SE). Assess
compliance and effects 2 weeks after initiating tx. Must wait 4-8 weeks before changing med.

Avoid SSRIs within 14 days from
MAOIs (serotonin syndrome)

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NOT 1st line depression
Postherpetic neuralgia
Stress urinary
incontinence
Chronic pain

TCAs

Amitriptyline (Elavil)
Nortriptyline (Norpramin)

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main SE of TCAs . Who should not take

Sedation
Avoid with patients with
hx of suicide (can hoard
pills and overdose)

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1st line tx for Depression and Neuropathic pain

SE?

SNRIs
* Duloxetine (Cymbalta)
* Venlafaxine (Effexor)
* Desvenlafaxine (Pristiq)

Nausea
Anticholinergic effects
Excessive sweating

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Not first line for anything. Have anticholinergic effects .

MAOIs
* Phenelzine (Nardil)
* Tranylcypromine
(Pernate)

Rarely used due to serious food/drug interaction (↑ tyramine content)

Do NOT combine with MAOI, SSRI, TCA
Wait 2 weeks when switching to another group

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1st line for Anxiety, Panic disorder, insomnia

Benzos
* Diazepam (Valium): for severe alcohol withdrawal/seizures
* Midazolam (Versed)
* Alprazolam (Xanax)
* Lorazepam (Ativan)
* Diazepam (Valium)
* Clonazepam (Klonopin)

AEs for Benzos. Warnings

Drowsiness, Confusion, Slurred speech

Avoid long acting in the elderly: Valium, Librium. Restoril, Klonopin

Do NOT discontinue abruptly= seizures

Chronic use of antipsychotics cause

Pill rolling, shuffling gain, bradykinesia.

Extrapyramidal symptoms from antipsychotics

Akinesia (inability to initiate movement), Akathisia (strong inner feeling to move, unable to stay still), Bradykinesia
(sower movements), tardive dyskinesia (involuntary movements such as lip smacking, tongue, face, trunk and extremities).

SSRIs with fewer drug interactions. May prolong QT interval.

Better for Elderly: citalopram (Celexa) and escitalopram (Lexapro)

↑ Risk of bleeding when taken with blood thinners (NSAIDS, Coumadin, Jantoven)

SSRIs

↑ risk of suicidal thinking and behavior in children, adolescents, young adults; the risk is increased in young adults ages 18-24 years during initial treatment (first 1-2 months). Assess for suicidal thinking after 2 weeks of initiating therapy.

SSRIs

used for sexual dysfunction caused by SSRIs.

Wellbutrin

Avoid long acting in the elderly: Valium, Librium. Restoril, Klonopin

Benzos

Cause: Rare, life-threatening reaction from typical (1st generation) and atypical (2nd generation) antipsychotics. Following initiation of a new therapy or recent increase in dose. These drugs affect the dopaminergic system of the brain. Signs and symptoms: acute very high fever, muscular rigidity, mental status changes, tachypnea, elevated HR fluctuating BP, urinary incontinence

Malignant Neuroleptic Syndrome

Cause: dysfunction of the neurotransmitter serotonin and norepinephrine. Strong genetic component. Symptoms: Depressed mood, tearful, anhedonia (↓ interest or pleasure in activities) , ↓energy, insomnia, guilt, ↓concentration, suicide, weight changes, agitation. Other causes: hypothyroidism, anemia, autoimmune disorders, V12 deficiency. ⚠WARNING⚠: Assess for suicidal and/or homicidal ideation or plan. “Baker Act” means of providing mental health emergency services. * Refer to psychiatric hospital, call 911, police. * While in crisis, patient can’t drive self.

Depression

Labs to check with depression

CBC, CMP, TSH, B12 level, toxicology screen… -You want to r/o anemia, DM, hypothyroidism, Addison’s, B12 anemia.

Alcohol level >______% is illegal for driving.

0.08

CAGE TEST

CAGE TEST C Need to cut down? A Annoyed with comments on drinking? G Guilty about drinking? E Need early drink in the AM?

Labs to check for alcoholism

AST & ALT elevated with alcoholism. If AST > ALT (2:1 ratio) = alcoholic hepatitis. Macrocytic anemia.

sudden onset of confusion, delusions, transient auditory, tactile, or visual hallucinations; tachycardia, HTN, disturbed psychomotor behavior, grand mal seizures.

Acute Delirium Tremens

TX for Acute Delirium Tremens

1. Benzos (Librium, Valium), antipsychotics if needed (Haldol). a. Disulfiram (Antabuse) causes N&V, Naltrexone (Vivitrol) to ↓ cravings. 2. Multivitamin replacement (thiamine, folate, high calorie diet). 3. Avoid prescribing addictive drugs due to potential abuse.

complication from chronic alcohol abuse. Neurological disorder including hypotension, visual impairment, coma. S&S: confusion, ataxia, stupor, coma, and hypotension. Tx: high dose parenteral vitamins, including thiamine and B1.

Korsakoff’s Syndrome (Wernicke-Korsakoff Syndrome):

amnesia caused by chronic thiamine deficiency due to chronic alcoholism. Causes problems with learning, retaining, and remembering information. S&S: disorientation, attention deficit, visual impairment.

Korsakoff’s Amnesic Syndrome

12-week course, advise to quit smoking 1-4 weeks from starting tx. May cause sedation (impair driving, operating machinery

Varenicline (Chantix)

1st line tx for insomnia

sleep hygiene

Complementary/Alter native Tx for Insomnia - Avoid mixing with alcohol. Tranquilizers, hypnotics= will ↑ sedation.

Kava-kava

Complementary/Alter native Tx for Insomnia - Sedating, also used for anxiety

Valerian Root

Must have at least 1 manic period lasting more than one week. Mania: ↑energy/activity, racing thoughts, increased talkativeness, grandiosity, less need for sleep, disinhibition, euphoria, poor impulse control. Should have at least 3: irritable or aggressiveness, lack of need for sleep, higher than normal self-esteem, lack of attention, inability to concentrate or make decisions.

Bipolar Type 1

Must have at least one hypomanic period as well as severe depressive period that lasts at least 14 days. Hypomania (like mania but milder). Depression: feeling sad, hopeless, forgetfulness, inability to concentrate, sleeping more than usual, weigh changes, eating habits changes, no interest in activities, slow thinking, thoughts of suicide. Higher risk of suicide

Bipolar Type 2

A mental health condition that is characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities. Difficulty with concentration and memory may also be present. Onset 16-30 years of age. S&S: psychotic symptoms include delusions and paranoia, hallucinations such as auditory, flat affect, poor social skills, poor executive function. ⚠WARNING⚠ : antipsychotics such as Haldol can prolong QT intervals (EKG needed), and can cause fatal arrythmia called “torsade de pointes”

Schizophrenia

Patients experience flashbacks, nightmares, intrusive thoughts, avoidance of reminders of trauma, sleep disturbance, and hypervigilance. Causes: war, sexual assault, MI, stroke, ICU stays. * Higher risk of depression, anxiety, antisocial disorder, substance abuse. * PTSD checklist (PCL-5), a 20 item self-report measure. * Pharmacology: paroxetine (Paxil), sertraline (Zoloft)

PTSD

An irrational preoccupation with an intense fear of gaining weight along with distorted perception of body shape and weight. Behavior is secretive, perfectionist, and self-absorbed. Severe restriction of food intake (including binge eating and purging), weight loss with BMI <18.5, lanugo, amenorrhea for at least 3 months. May purge (dental enamel loss), use of laxatives, vomit, excessive daily exercise. Complications: osteopenia/osteoporosis (from amenorrhea & ↓ estrogen), peripheral edema (from ↓ albumin & ↓ protein), cardiac complications (electrolyte imbalance).

Anorexia Nervosa

Which drug classification is contraindicated with anorexia?

Atypical Antidepressants