Psych Flashcards
What is the DSM-5 criteria for depression diagnosis?
At least 5 of the following (must include 1 ) during the same 2 week period:
1) Mood depressed
2) Sleep inc/dec
3) Interest/pleasure diminished*
4) Guilt/feelings of worthlessness
5) Energy dec
6) Concentration dec
7) Appetite inc/dec
8) Psychomotor agitation/retardation
9) Suicidal ideation
Drugs that can cause/worsen depression
Atomoxetine
Indomethacin
Efavirenz
Rilpivirine
Beta blockers
Hormonal OC
Steroids
Antidepressants (boxed warning)
BZDs
Natural products used for depression
St John’s Wort
Valerian
5-HTP
SAMe
What is a suitable drug trial period for antidepressants?
4-8 weeks
What is the DOC for depression in pregnancy?
SSRIs (except parotexine)
They do have a warning for pulmonary HTN in newborn but are still preferred
What is the DOC for postpartum depression?
SSRI or TCAs (except doxepin)
Symptoms of serotonin syndrome
Severe nausea, dizziness, HA, diarrhea, agitation, tachycardia, hallucinations, muscle rigidity
Which antidepressant does not need to be tapered when discontinuing therapy?
Fluoxetine (self tapers with long half life)
What boxed warning do all antidepressants have?
Increased suicidal thoughts/actions in some children, teens, and young adults
MedGuides are required
MOA for SSRIs
Increase 5-HT by inhibiting its reuptake in the neuronal synapse
Examples of SSRIs
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Fluvoxamine
Key points for SSRIs
Citalopram max dose 20 mg and escitalopram 10 mg in pts >60 yo
Warnings for QT prolongation, SIADH, bleeding
SE: sexual dysfunction, somnolence, insomnia, nausea, dry mouth, diaphoresis, tremor, dizziness, HA
Most activating SSRI
Fluoxetine
Most sedating SSRI
Paroxetine
Which SSRI is preferred in pts with cardiac risk?
Sertraline
Which SSRIs/SNRIs are CYP2D6 inhibitors?
Fluoxetine
Paroxetine
Fluvoxamine
Duloxetine
Which SSRI has the highest risk of QT prolongation?
Citalopram
How long of a washout is required between MAOi and SSRI/SNRI/TCA/bupropion use?
2 weeks
Can cause serotonin syndrome or hypertensive crisis
Key points for vilazodone (Viibryd)
SSRI + 5-HT1A partial agonist
Take with food
Less sexual SE than SSRIs/SNRIs
Key points for vortioxetine (Trintellix)
SSRI + 5-HT3 antagonist + 5-HT1A agonist
Can cause constipation
Must half dose when used with CYP2D6 inhibitors
Examples of SNRIs
Venlafaxine (Effexor)
Duloxetine (Cymbalta)
Desvenlafaxine (Pristiq)
Levomilnacipan (Fetzima)
SNRI MOA
Inhibit reuptake of 5-HT and NE
Key points for SNRIs
Similar SE to SSRIs plus increased HR, dilated pupils, excessive sweating, constipation
Increased BP can occur with all SNRIs, esp with high dose venlafaxine
Examples of TCAs
Tertiary amines:
Amitripyline (Elavil)
Doxepin
Clomipramine (Anafranil)
Imipramine (Tofranil)
Secondary amines:
Nortriptyline (Pamelor)
Desipramine (Norpramin)
Key points for TCAs
QT prolongation w/ OD
Orthostasis
Anticholinergic SE (dry mouth, blurred vision, urinary retention, constipation)
Can cause weight gain
On Beer’s list
Tertiary amines have increased anticholinergic SE and weight gain
What enzyme are TCAs metabolized via?
CYP2D6
Key points for bupropion (Wellbutrin)
CI w/ hx of seizures, anorexia/bulimia
SE: Dry mouth, CNS stimulation, tremors/seizures, weight loss
Max XL dose = 450 mg/day
Max SR dose = 200 mg/dose
Examples of MAOi
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Selegiline (MAO-B selective)
MAOi MOA
Inhibit monoamine oxidase which is responsible for the breakdown of catecholamines (5-HT, NE, Epi, DA)
Key points for MAOi
CI w/ CVD, hepatic disease, severe renal disease, pheochromocytoma
Many DDIs and food interactions - can be fatal if missed
SE: Anticholinergic, orthostasis, sedation, sexual dysfunction
Max dose for most is around 60 mg/day
What foods are CI with MAOi?
Tyramine-rich foods (increase NE): aged cheese, pickled herring, yeast, air-dried meats, sauerkraut, soy sauce, fava beans, wine/beer
Anything smoked, pickled, aged, or fermented
How long of a washout is required between fluoxetine and MAOi use?
5 weeks
Key points for mirtazapine (Remeron)
Tetracyclic antidepressant
SE: sedation, increased appetite, weight gain, anticholineric effects, QT prolongation
Key points for trazodone
Inhibits 5-HT reuptake, blocks H1 and a1 receptors
SE: sedation (used more for sleep), sexual dysfunction (pripism), additive QT risk
Sleep dosing much lower than depression dosing
What is the major toxicity of nefazodone?
Hepatotoxicity
What medications can be used as augmentation for depression (in combo with an antidepressant)?
Buspirone
Aripiprazole
Olanzepine
Quentiapine
Lithium
What are examples of EPS?
Dystonias, akathisia, Parkinsonism, tardive dyskinesias
What are examples of negative symptoms associated with schizophrenia?
Lack of emotion/apathy
Social withdrawal
Loss of motivation/avolition
Lack of speech/alogia
loss of interest in activities
Poor hygiene
What are examples of positive symptoms associated with schizophrenia?
Hallucinations
Delusions
Disorganized thinking/behavior
Difficulty paying attention
What medications/drug can cause psychotic symptoms?
Anticholinergics
Dextromethorphan
Dopamine agonists
Stimulants
Interferons
Steroids
Cannabis
Cocaine
LSD
PCP
Which medications are 1st line for the treatment of schizophrenia?
Second-generation antipsychotics
What is the primary difference between 1st and 2nd gen antipsychotics?
1st gen have a higher incidence of EPS
Olanzapine should not be given with what medication due to risk of sedation/resp depression?
Benzodiazepines
What boxed warning is present on all antipsychotics?
Increased risk of mortality when used for dementia-related psychosis in elderly patients (due to CV complications and infection)
1st gen antipsychotic MOA
Blocks dopamine-2 (D2) receptors, minimal serotonin blockade
Examples of 1st gen antipsychotics
Low potency: chlorpromazine, thioridazine
Mid potency: loxapine, perphenazine
High potency: haloperidol, fluphenazine, thiothixene, trifluoperazine
Key points for 1st gen antipsychotics
Warnings for QTc prolongation, orthostasis/falls, anticholinergic effects, CNS depression, EPS, hyperprolactinemia, neuroleptic malignant syndrome (NMS)
Lower potency = high sedation, low EPS
Higher potency = low sedation, high EPS
What drug class can be given to avoid/limit painful dystonic reactions associated with EPS?
Anticholinergics (benztropine, diphenhydramine)
Examples of second generation antipsychotics
Aripiprazole (Abilify)
Clozapine (Clozaril)
Lurasidone (Latuda)
Olanzapine (Zyprexa)
Paliperdone (Invega)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
(There’s more but these are bold)
SE for aripiprazole
Akathisia
Can be activating or sedating
Key points for clozapine
Warnings for neutropenia, myocarditis, cardiomyopathy, seizures
SE: agranulocytosis, seizures, constipation, metabolic syndrome (weight gain), hypersalivation
Prescribers and pharmacies must be REMS certified
To start, ANC must be > 1500
Stop if ANC <1000
Only used last line
SE for lurasidone
Somnolence, EPS (dystonias), nausea
Risk of metabolic syndrome (lower than other SGAs)
CI with strong CYP3A4 inducers/inhibitors
SE for olanzapine
Somnolence, metabolic syndrome
Sedation and delirium are possible with injection - must be monitored for 3 hrs post injection
2nd gen antipsychotics MOA
Blocks dopamine (D2) and serotonin (5-HT1A) receptors
SE for paliperidone
Increased prolactin
EPS (esp at high doses)
Metabolic syndrome
QT prolongation
Available as LA injection (monthly, q3 months, and q6 months)
Key points for quetiapine
SE: Somnolence, metabolic syndrome
Low EPS risk - used for psychosis in Parkinsons
For XR: take at night w/o food
SE for risperidone
Increased prolactin
EPS (esp at high doses)
QT prolongation
Metabolic syndrome
SE for ziprasidone
QT prolongation
Must take w/ food
Which antipsychotic medications may want to be avoided in patients with CVD or DM?
2nd gen antipsychotics
Metabolic syndrome can cause increased weight, cholesterol, TG, and BG
Which 1st gen antipsychotic has the highest risk of QT prolongation?
Thioridazine
Has a boxed warning
Which medications are approved for the treatment of tardive dyskinesia?
VMAT2 inhibitors
- Valbenazine (Ingrezza)
- Deutetrabenazine (Austedo)
What is neuroleptic malignant syndrome (NMS)?
A medical emergency caused by D2 blockade
Rare but can be lethal
S/S: hyperthermia, extreme muscle rigidity, mental status change, tachycardia, tachypnea, elevated CK and WBC
What 3 drugs are utilized in the treatment of NMS?
BZDs
Dantrolene
Dopamine agonist (bromocriptine)
also stop the antipsychotic causing it
Bipolar I
Characterized by mania that significantly impairs social/work functioning (psychosis, delusions) or requires hospitalization
Bipolar II
Characterized by hypomania - does not affect social/work functioning or require hospitalization
First line treatment options for manic episodes (BPD)
Valproate or lithium +/- an antipsychotic
First line treatment options for depressive episodes (BPD)
Antipsychotics
Can add on lithium, valproate, or lamotrigine if needed
Which BPD meds should be avoided in pregnancy?
Valproare, lithium, and carbamazepine
Which meds are preferred in pregnancy for BPD?
Lamotrigine
Lurasidone (limited, only used for BP depression)
Key points for lithium
Therapeutic range = 0.6-1.2 mEq/L (trough)
- >1.5: ataxia, tremor vomiting
- >2.5: CNS depression, seizure, coma, arrhythmia
SE: serotonin syndrome, cognitive effects, cogwheel rigidity, tremor, thirst, polyuria/polydipsia, weight gain, hypothyroidism
Take w/ food to decrease nausea
Renally cleared - levels increase with salt loss (ACE/ARBs/diuretics) and NSAIDs; decrease with increased salt, caffeine, theophylline
Which neurotransmitter does lithium primarily effect?
Glutamate
Equivalence between lithium citrate and lithium carbonate
5 mL (8 mEq) lithium citrate syrup = 300 mg lithium carbonate
First line treatment for ADHD for children ages 4-5 yo
Behavior management/classroom intervention
Which non-stimulant medications can be used for the treatment of ADHD?
Atomoxetine (strattera)
Guanfacine ER (Intuniv
Clonidine ER (Kapvay)
SE for stimulants
Tachycardia, HTN, CV events, pripism, psychosis (mania), increased seizure risk, loss of appetite (can decrease growth in children), serotonin syndrome, insomnia, irritability
Avoid w/ MAOi’s
Which drug is the active isomer of methylphenidate
Dexmethylphenidate (Focalin)
Examples of stimulants
Methylphenidate (Ritalin, Concerta, Daytrana)
Dexmethylphenidate (Focalin)
Dextroamphetamine/amphetamine (Adderall)
Lisdexamfetamine (Vyvanse)
What is special about Vyvanse’s formulation?
Prodrug
Low abuse potential, must be hydrolyzed in the blood so the “rush” is muted if the drug is injected/snorted
Key points for atomoxetine
Avoid with MAOi’s
Can cause hepatotoxicity (rare, within 120 days)
Same SE as stimulants
Metabolized via CYP2D6
Do not open capsule - eye irritant
Key points for clonidine ER and guanfacine ER
Alpha 2a agonists
Dose-dependent CV effects, sedation, and drowsiness
Must be tapered, can cause rebound HTN
SE: Dry mouth, somnolence, fatigue, dizziness, constipation, bradycardia, hypotension
Caution with other CNS depressants
Drugs that can cause anxiety
Albuterol
Antipsychotics
Bupropion
Caffeine/theophylline
Decongestants
Levothyroxine (OD)
Steroids
Stimulants
What meds are 1st line for anxiety?
SSRIs, SNRIs
What meds are 2nd line for anxiety?
Buspirone
TCAs (amitriptylline, nortriptylline)
Hydroxyzine
Pregabalin/gabapentin (not FDA approved)
Key points for buspirone
CI w/ MAOi’s
SE: serotonin syndrome, dizziness, drowsiness
No potential for abuse/misuse, tolerance, or psychological dependence
CYP3A4 substrate
Which BZDs are preferred in elderly patients or pts with liver impairment?
LOT - undergo glucuronidation
Lorazepam
Oxazepam
Temazepam
BZD MOA
Enhances GABA (inhibitory NT) –> causes CNS depression
Which BZD is preferred for sleep?
Temazepam
Which BZDs are preferred for anxiety?
Long half life, less risk of abuse
Clonazepam, lorazepam, diazepam
Which drug is the antidote to BZDs?
Flumazenil
Which BZDs are metabolized via CYP3A4?
Alprazolam
Diazepam
Clonazepam
Chlordiazepoxide
Clorazepate
Definition of insomnia
Symptoms at least 3x per week for at least 3 months
Which drugs can worsen insomnia?
Donepezil
Alcohol
Antiretrovirals
Aripiprazole
Atomoxetine
Bupropion
Caffeine
Decongestants
Diuretics (nocturia)
Steroids
Stimulants
Chantix
Drugs that help fall asleep only
Ramelteon
Zaleplon
Drugs that help stay asleep only
Doxepin
Suvorexant
Drugs that help fall asleep and stay asleep
Eszopiclone
Zolpidem
Examples of non-BZD hypnotics
Eszopiclone (Lunesta)
Zolpidem (Ambien)
Zaleplon (Sonata)
Key points for hypnotics
Warnings for next-day CNS depression and abuse potential
CI w/ complex sleep behavior (sleep walking/driving/etc.)
SE: somnolence, dizziness, ataxia, HA, parasomnias
Do not take w/ large or fatty meal or alcohol
Caution with CYP3A4 inhibitors
Examples of orexin receptor antagonists
Lamborexant (DayVigo)
Suvorexant (Belsomra)
Examples of melatonin receptor agonists
Ramelteon
Tasimelteon
(Not controlled substances)
Which medications are used in the treatment of restless leg syndrome (RLS)?
Pramipexole (Mirapex) - IR
Ropinirol (Requip) - IR
Rotigotine (Neupro) - patch
Taken 1-3 hrs before bedtime
Which meds are used in the treatment of narcolepsy?
Modafinil (Provigil)
Armodafinil (Nuvigil)
Sodium oxybate (Xyrem) - date rape drug, have REMS program
