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PAS - CLIN MED 2 > PSYCH 3 > Flashcards

PSYCH 3 Flashcards

1
Q

major depressive disorder

MEDS: ALL MEDS generally take 4-6 weeks to fully work  problem for individuals who are suicidal; problem with compliance because patient may stop taking medication because they aren’t feeling better
• _____ (SSRI) GOLD STANDARD
o First choice in treating depression
o Mechanism of action: inhibition of uptake of serotonin – _____ serotonin in brain
o Do not use with _____ (monoamine oxidase inhibitors)  can cause _____ (too much serotonin)
 Can occur in patients taking multiple drugs that increase serotonin levels (ex. SSRI and MAOIs)
 Initially causes _____, restlessness, confusion, _____, diaphoresis, tremor, _____
 Can progress to hyperthermia, _____, rhabdomyolysis, renal failure, _____, coma, death
 Treat patients by STOPPING all suspected medications and START on serotonin antagonist (_____)
 Wait at least 2 weeks before switching a patient from SSRI to MAOI switching because they are not responding to the SSRI (5-6 weeks with Fluoxetine (Prozac) due to long ½ life)
o Side effects: _____, sedation, weight gain, _____ (common), hyponatremia (rare, but can occur especially in elderly), rebound anxiety
o Can cause symptoms when patient withdraws (dizziness, fatigue)
o Safer than some other antidepressants if overdose occurs
o Although chemically, structural differences are minimal, patients often respond differently (side effects and efficacy) to different SSRIs
 Types: Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Citalopram (Celexa), Escitalopram (Lexapro), Fluvoxamine (Luvox) only FDA approved for OCD

A 
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
increase
MAOIs
SEROTONIN SYNDROME
lethargy
flushing
myoclonus
hypertonicity
seizures
cyproheptadine
nausea
sexual dysfunction
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2
Q

MDD

• _____ (TCA’S) NOT FIRST LINE, USED WITH OTHER COMORBIDITES THAT CAN BE TREATED WITH A TCA
o Mechanism of action: mostly _____ uptake inhibition
o Side effects: _____, sedation, weight gain, orthostatic hypotension, _____ effects, sexual dysfunction
o Toxicity: 2 week supply is lethal – don’t use in suicidal patients
o Not generally first line for MDD due to toxicity and side effects; often selected if patient has other factors (insomnia, chronic pain, migraines)
o Types:
 Amitriptyline (Elavil) – useful in chronic pain, migraines, insomnia
 Imipramine (Tofranil) – enuresis, panic disorder
 Clomipramine (Anafranil) – OCD
 Doxepin (Sinequan) – insomnia, chronic pain, possible behaviors in elderly dementia patients
 Nortriptyline (Pamelor) – chronic pain, causes less orthostasis
 Desipramine – less anticholinergic effects, less sedation

A

TRICYCLIC ANTIDEPRESSANTS
NE
anticholinergic
cardiovascular

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3
Q

MDD

• _____ (MAOIS)
o Mechanism of action: inhibits MAO (the breakdown enzyme for _____) for 5HT, NE, and dopamine
o Side effects: _____, dizziness, _____, peripheral edema
o Drug interactions: not to be used with serotonergic drugs (remember, may cause serotonin syndrome)
o No tyramine containing foods (red wine, cheese, chicken liver, cured meats)  can cause hypertensive crisis
o Often effective in depression with “atypical features”: hypersomnia, increased appetite and weight gain, heavy feelings in the extremities, increased sensitivity to personal rejection
o Types: Phenelzine (Nardil), Tranylcypromine (Parnate), Isocarboxazid (Marplan)

A

MONOAMINE OXIDASE INHIBITORS
neurotransmitters
hypotension
insomnia

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4
Q

MDD

• OTHER NEUROTRANSMITTER REUPTAKE INHIBITOR MEDICATIONS

o _____ (SNRIS)
 Side effects: similar to SSRIs, but can have more _____ & constipation
 Types:
• Venlafaxine (Effexor) – MDD, GAD, neuropathic pain
• Duloxetine (Cymbalta) – MDD, neuropathic pain, fibromyalgia
o NOREPINEPHRINE-DOPAMINE REUPTAKE INHIBITORS – _____ (WELLBUTRIN)
 Used to treat MDD, adjunctive in adult ADHD, smoking cessation
 Side effects: increased risk of seizures and _____ at higher doses
 LESS _____ side effects
 Contraindicated in patients with seizures, eating disorders, or patients currently on MAOI
o SEROTONIN RECEPTOR ANTAGONISTS
 Often used as an adjunctive therapy in MDD, when starting an SSRI to treat _____ until depression improves
 Side effects: nausea, dizziness, orthostatic hypotension, cardiac arrhythmias, sedation, and _____
 Types:
• Trazodone (Desyrel) – useful in MDD, particularly with insomnia
o ALPHA-ADRENERGIC RECEPTOR ANTAGONISTS – MIRTAZAPINE (REMERON)
 Useful in _____ patients with _____, weight loss, insomnia
 Side effects: sedation, weight gain, dizziness, tremor, dry mouth, constipation
 Less sexual side effects than SSRIs, fewer drug interactions

A 
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS
dry mouth
BUPROPION
psychosis
sexual
insomnia 
priapism
elderly
depression
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5
Q

MDD

PSYCHOTHERAPY
• Can be used alone or in conjunction with medications to treat MDD
• Cognitive-behavioral therapy (CBT), interpersonal therapy, problem-solving therapy, family/couples therapy

ELECTROCONVULSIVE THERAPY (short term cognitive defects)
• Used for patients who are _____ or cannot _____ medications, or in patients who need _____ reduction of depressive symptoms (suicide risk)
• 6-12 treatments administered over several week period  often have immediate symptom reduction
• Retrograde and anterograde _____ common  cannot remember what happened before or after
• Transient side effects include headache, nausea, muscle aches

A 
refractory
tolerate
rapid
suicide
amnesia
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6
Q

persistent depressive disorder

  • Course tends to be more indolent, less severe, but less likely to resolve than MDD
  • Combination of _____ and _____ more efficacious than either alone
  • Treat with similar meds to MDD (SSRIs, TCAs, MAOIs)
A

psychotherapy

pharmacotherapy

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7
Q

premenstrual jdysporic disorder

  • _____ first line  can dose daily, or only during the luteal phase (start taking SSRI at about day 10)
  • OCPs may help reduce symptoms
A

SSRIs

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8
Q

disruptive mood regulation disorder (DMDD)

  • Because of the new nature of this disorder, no established protocols for treatment
  • Psychotherapy, including _____ for parents considered first line
  • Medications to treat underlying depression/anxiety (SSRIs) or ADHD (_____)
A

therapy

stimulants

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9
Q

bipolar disorder

• SUMMARY:
1. _____ FIRST (_____ OR LAMOTRIGINE/LAMICTAL)
2. _____ only added late in therapy for treatment resistant depression
o _____ associated with highest rates of mood cycling
o Only approved combo for an episode of Major Depression in BP Disorder: mood stabilizer plus the atypical antipsychotic _____ (Zyprexa) and anti-depressant _____ (Prozac)

A 
MOOD STABILIZER
lithium 
Antidepressants
SSRIs
olanzapine
fluoxetine
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10
Q

cyclothymic disorder

  • _____
  • Therapy
A

Mood stabilizers

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11
Q

major depressive disorder with psychotic features

  • Need to treat BOTH depressive AND psychotic symptoms
  • Consider hospital admission (mandatory for suicidal ideation)
  • 2 tx options: medication or electroconvulsive therapy
    o COMBOS med therapy:
     _____ 5mg @ hs WITH _____ 50 mg qd
     Or _____ with an SSRI
     Antipsychotic w/ TCAs = less favorable
    • side effects are oppressive and not well tolerated
    o _____ therapy
     May be first line tx in this disorder – esp in catatonia
     Most effective tx for psychosis plus depression
A

Haldol
Zoloft
Atypical antipsychotic
Electro-convulsant

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12
Q

manic episode with psychotic features

  • Use an _____
    o Often need a _____ at same time
  • When acute episode is controlled  withdraw antipsychotic and continue mood stabilizer
A

anti-psychotic

mood-stabilizer

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13
Q

oppositional defiant disorder

  • Individual and family counseling
  • Treat comorbid disorders
  • _____ can help the child learn to manage anger, improve problem-solving ability, develop techniques to delay impulsive responses, and improve social interactions.
  • School based and parental management training
A

CBT

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14
Q

intermittent explosive disorder

MEDS: none are FDA approved

  • SSRI (_____) and antiepileptic (oxcarbazepine)  appear effective
  • Other SSRIs, mood stabilizers (ex. lithium, carbamazepine), and beta blockers  role is unclear
  • _____-generation antipsychotics (ex. risperidone) used to dampen aggressive impulses in other clinical populations (Alzheimer’s Disease) may be helpful
  • NO BENZOS  cause behavioral disinhibition
  • Medication to treat aggressive impulses

PSYCHOTHERAPY:
- CBT – identify and diffuse triggers

A

fluoxetine

Second

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15
Q

conduct disorder

  • Vary depending on the age of the child, symptom severity, comorbid disorders, family supports, and the child’s intellectual and social assets
  • Individual and family _____ to detention center or group home
  • Parental management training
  • Medication for comorbidities  ADHD, etc.
    o _____ carbonate, psychostimulants, haloperidol, and _____-generation antipsychotics are used “off-label”
A

therapy
Lithium
second

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16
Q

pyromania

  • Treatment is challenging
  • Treat co-morbid disorders
  • No clear role for medication in pyromania
  • Family _____ can be helpful in the broader issue of family dysfunction
  • _____ patient about the dangerousness and significance of the fire setting
  • Patient also need to learn alternative ways of coping with stressful situations to decrease reliance on fire setting as an outlet
A

therapy

Educate

17
Q

kleptomania

  • _____ and _____ used off label
  • Treat comorbid disorders
  • CBT to steer individual away from stealing or avoid cues
  • If arrested for shoplifting, processing through the legal system may help to curb impulses
  • Probation or self-imposed ban on shopping (seldom sustainable)
A

SSRIs

naltrexone

18
Q

somatic symptom disorder

  • Symptoms tend to wax and wane, reoccur during stressful periods
  • Patients should have regularly scheduled visits with same _____
  • Minimize _____ work-ups
  • Patients may resist psychiatric treatment/referral!!!
A

PCP

unnecessary

19
Q

illness anxiety disorder

  • Regularly scheduled visits with one _____
  • Referral for _____
  • Treatment for comorbid depression or anxiety
A

PCP

CBT

20
Q

conversion disorder

  • CBT
  • _____
  • Patients may spontaneously recover, although tend to reoccur
A

Physical therapy

21
Q

factitious disorder

  • All medical providers need to collaborate to avoid _____ treatments or work-up
  • Patients are very _____ to treatment!
A

unnecessary

resistant

22
Q

TREATMENT [of Psychosis]

  • Adequate trial of meds: 4-6 weeks of FULL DOSE of antipsychotic medication
    o _____ = Conventional antipsychotics that block D2 (dopamine) receptors
     More effective at treating the _____ symptoms of psychosis (versus negative)
     Side effects:
     _____ symptoms (EPS)
    • More common with high-potency ___ gen antipsychotics (can become perm)
    • Dystonia = spasms of face, neck, and tongue (stick out tongue)
    • _____ = tremor, rigidity, bradykinesia
    • Akathisia = feeling of restlessness, need to keep moving
    _____ symptoms
    • Dry mouth, constipation, blurred vision, hyperthermia
     _____ syndrome
    • More common in ___ gen antipsychotics
    • ↑ BP, ↑ blood sugar, weight gain esp in the abdomen  causes dyslipidemia
     tardive dyskinesias
    • More common in ___ gen antipsychotics
    • Choreoathetoid movements in face, tongue, head (
    • Can become permanent even with drug discontinuation
     _____ Syndrome
    • More common in ___ gen meds
    • Change in mental status, autonomic instability (high fever, labile BP, tachycardia, diaphoresis), lead-pipe rigidity, elevated CPK levels, leukocytosis, metabolic acidosis
    • Medical emergency, must STOP all psych meds
     OTHER
    • Prolonged QTc interval
    • Hyperprolactinemia
    • Fatigue
    • Sexual Dysfunction
    • Rashes, photosensitivity
A 
NEUROLEPTICS
positive
extrapyramidal
1st
Parkinsonism
anticholinergic
metabolic
2nd
1st
Neuroleptic Malignant
1st
23
Q

1) _____ (Mellaril): Indicated for schizophrenia unresponsive to (preferably 2) other antipsychotic drugs.
• Start: 50-100 mg tid; increase gradually to max 800 mg qd in 2-4 divided doses
• Get EKG levels at baseline; monitor for _____, low EPS symptoms, high _____, high anticholinergic effects, high orthostatic hypotension
2) _____ (Haldol): low cost
• High _____ symptoms, lower sedation, low anticholinergics, low orthostasis
• 5-20 mg common  Can give as single dosage @ hs

  • **PROPHYLACTIC OR DRUGS USED TO TREAT EPS SYMPTOMS (side effect)
    1) Benztropine (Cogentin) = anticholinergic  useful for acute EPS, dystonia, prophylaxis
    2) _____ (Benadryl) = antihistamine
    3) Amantadine (Symmetrel) = Dopamine facilitator  used in patients who can’t tolerate anticholinergic sxs
    4) Propranolol (Inderal) = useful for akathisia
A 
Thioridazine
QT elongation
sedation
Haloperidol
EPS
Diphenhydramine
24
Q

***ATYPICAL NEUROLEPTICS
1) _____ (Clozaril) - for refractory Schizophrenia
• 12.5 mg 1-2 times qd; increase by 25-50 mg qd to 300-450 mg divided doses by end of 2 weeks
o When reducing, titrate down over 2 weeks
• Monitor _____ and diff before, weekly for first 6 months, and for 4 weeks after drug discontinued
• Monitor for hyperglycemia
• Agranulocytosis – can occur in 1-2% of cases (fatal in 1/10,000)
o Clozapine may only be dispensed in 1 ek supplies
o Pharmacist must have confirmation that WBC is within acceptable range for the week
o Cost per year: ~$10,000.
2) _____ (Risperdal) = for psychosis
• Initially, 2mg for 1 day  then 4 mg for 1 d, then 6 mg
o Usual range: 4-8 mg
• _____, rare EPS, slight sedation
3) Quetiapine (Seroquel) = for schizophrenia
• Initially 25 mg bid  increase daily  Day 4 dose should be 300-400 mg qd in divided doses
• Do _____ exam initially and every 6 months
• Low incidence of EPS, low incidence of sedation, orthostatic hypotension
4) Olanzapine (Zyprexa) = for psychosis
• Initially 5-10 mg qd (Max 20 mg qd)
• Low EPS, higher _____, orthostatic hypotension (esp w/ antihypertensives)
• Potentiated with fluvoxamine

***ADJUNCTIVE AGENTS
 If pt. responds to antipsychotics but remains agitated:
• _____ (Ativan) 1 mg tid
• Propranolol (Inderal) 20 mg tid good for restlessness (akathisia) or marked tremor
 Lithium carbonate, valproate and carbamazepine
• Reduce impulsive and aggressive behavior, hyperactivity or mood swings
 Antidepressants for depression
 ECT for depression or catatonia

A 
Clozapine
WBC
Risperidone
Orthostatic hypotension
eye
sedation
Lorazepam

PAS - CLIN MED 2 (8 decks)

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