Psych Flashcards
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
Atypical Antipsychotics
AEs/ Warnings
Olanzapine (Zyprexa)
Risperidone (Risperdal)
Quetiapine (Seroquel)
Obesity, DM II,
hyperlipidemia, metabolic
syndrome,
hypothyroidism.
Weight gain (monitor BMI) Q 3
months
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).
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
SNRIs
AEs/ Warnings
- Venlafaxine (Effexor)
- Duloxetine (Cymbalta)
Can worsen acute
narrow-angle glaucoma
* Avoid with glaucoma
Typical Antipsychotics
AEs/ Warnings
Haloperidol (Haldol)
↑lipids/triglycerides
Malignant neuroleptic syndrome
Monitor: glucose, lipids
Black Box Warning: elderly=death
Atypical Antidepressants
AEs/ Warnings
Bupropion (Wellbutrin)
Zyban for smoking cessation
AE= Seizures
* Contraindicated with anorexia, bulimia, hx seizures
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)
Lithium
AEs/ Warning
diarrhea, dry mouth,
metallic taste in the mouth
- Check blood levels
Best SSRI for non-compliant pts (longest ½ life)
Fluoxetine (Prozac)
SSRI with fewer drug interactions
Citalopram
SSRI with shortest 1/2 life. ED
Paxil
Avoid with anorexia or thin elderly (↓
appetite)
SSRIs
can cause mania in bipolar pts
SSRIs
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)
- NOT 1st line depression
- Postherpetic neuralgia
- Stress urinary
incontinence - Chronic pain
TCAs
- Amitriptyline (Elavil)
- Nortriptyline (Norpramin)
main SE of TCAs . Who should not take
Sedation
Avoid with patients with
hx of suicide (can hoard
pills and overdose)
1st line tx for Depression and Neuropathic pain
SE?
SNRIs
* Duloxetine (Cymbalta)
* Venlafaxine (Effexor)
* Desvenlafaxine (Pristiq)
- Nausea
- Anticholinergic effects
- Excessive sweating
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
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
- Benzos (Librium, Valium), antipsychotics if needed (Haldol).
a. Disulfiram (Antabuse) causes N&V, Naltrexone (Vivitrol) to ↓ cravings. - Multivitamin replacement (thiamine, folate, high calorie diet).
- 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
