Psych & Behavioral Disorders Flashcards by Dana Pocasangre

Monitoring concerns of SSRIs

any drug to drug interactions- other CYP450 drugs, warfarin, any drug that prolongs QT intervals (bc SSRIs do as well), use caution in angina pts, mindful of pregnant women
caution in elderly pts

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Other agents besides stimulants and non stimulants that could be used for ADHD

selective alpha-2 agonists (clonidine)
tricyclic antidepressants (amitriptilyine)
bupropion -welbutrin (anti-depressant)- may be moderately effective but lowers seizure threshold

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When to prescribe benzos

acute and short-term use in treatment of panic attacks

particularly those associated with generalized anxiety disorder and alcohol withdrawal

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What 3 drugs are in the SNRI class

Effexor (venlafaxine)- also used for hot flashes, menopause in women who cannot take hormones
Cymbalta (duloxetine)
Savella (milnacipran)- also used for fibromyalgia and neuropathic pain

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Somatic effects of anxiety

tachycardia, palpitations, increased BP, hyperventilation, tremor, sweating, GI -n/v/d

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Contraindications for stimulants

history of schizophrenia or other psychosis

symptoms of anxiety, tension, agitation

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Side effects of Strattera

**BLACK BOX –Possibility of SI- screen/closely monitor
Liver damage can occur but rare- increased LFTs can be seen in the 1st month
Effect is not always immediate

Common s/e:
GI discomfort, appetite decrease, mood swings, increased BP
RARE:
Liver injury, mania, agitation and/or mood swings

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Major side effects of SSRIs

nausea, loose stools
sexual dysfunction
weight gain- how will this effect pts mental state

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Side effects of Clonidine

hypotension
dry mouth
over sedation
*Rebound hypertension if abruptly stopped: ALWAYS TAPER

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Black-box warning of SSRIs

must assess pt for depression/SI

increase in SI in users age 24 and under

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Adverse effects of benzos

excessive sedation
respiratory depression
increase tolerance/physiologic dependance

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When should a non stimulant be used for ADHD

can be less effective but used if pt doesn’t want to use stimulant or has a history of substance abuse

ex. Stattera - less potential for abuse

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Preferred method of treatment for ADHD

Stimulants

start low and increase slowly until s/s resolve

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Symptoms of serotonin syndrome

Rigidity
Hyperthermia
Autonomic instability
Tremors
Confusion
Delirium
Coma

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Serotonergic anxiolytics- Buspirone (Wellbutrin)- what is is used for

approved for treatment of anxiety
chemically similar to haldol
no extrapyramidal syndromes
little risk of dependency
no effect on GABA system so it cannot be used for benzodiazepines withdrawal

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Two most popular class of stimulants and drug names

Methylphenidate- Ritalin SR/LA , concerta, methylin, daytrana, metadate, Focalin/Focalin SR

Amphetamine Salts- Adderall

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Wellbutrin (bupropion) MOA and use

weak inhibitor of neuronal uptake of dopamine, norepinephrine, and serotonin
helpful for smoking cessation
can be used for extended periods

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Clonidine- class and use

Alpha-2 agonist
good mood stabilizer Especially for kids also approved for ADHD
effective non stimulant alternative to Strattera
capable of controlling tics
Long acting seems to work better than SA

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MAOIs example

Nardil (phenelzine)- not used so much anymore, decreases metabolic inactivation of catecholamines, multiple side effects and interactions with drugs/food

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Short acting Benzos
intermediate
Long acting benzos

short acting- Ativan (lorazapam), Xanax (alprazolam), serax (oxazepam)
intermediate acting- valium (diazepam)
Long acting- klonopin (clonazepam), librium

What to discuss concerning cardiac risk in pts before starting stimulant

get thorough cardiac h&p including family and personal
- arrhythmias, premature heart disease, sudden death
normal vital signs
pt having any CP, palpitations, syncope (esp with exercise), fainting or SOB w/ exercise
YES to any –requires an EKG

ADHD diagnostic criteria

must be consistent at least 6 months
must be present in more than one setting
must have existed before 12 years of age
must show clear impairment in functioning
no longer disqualified by comorbid diagnosis (autism)

SSRI withdrawl symptoms

FLUSH
Flu-like 
Lightheaded or dizzy
Uneasiness or restlessness
Sleepiness or sensory distubrances
Headaches

s/s stop within 24 hours after starting SSRI back up
MUST reduce SSRI gradually

First Choice for ADHD

Stimulants

First choice among antidepressants- class and drug names

``` SSRI's -- Zoloft (sertraline) Paxil (paroxetine) celexa (citalopram) Lexapro (escitalopram) Luvox (fluvoxamine) Prozac (fluoxetine)- oldest SSRI- very useful ```

pharmadynamics of SSRIs

widely distributed highly protein bound metabolism: interferes with CP450 enzymes (beware of interactions with other meds) renal excretion

MOA of benzodiazepines

bind to the molecular components of GABA alpha receptors in the CNS neuronal membranes - potentiates GABA-ergic inhibition at all levels of CNS-- firing rate of critical neurons is decreased in many regions of the brain best used intermittently, in low doses

Mixed retake and neuroreceptor antagonist (tricyclic)

Elavil (amitriptyline)

Benzo antagonist for overdose

Romazicon IV

SSRIs MOA

potently and selectively inhibit serotonin uptake pump on the presynaptic neuron increase concentration of 5HT in synapse by inhibiting reuptake weak effect on dopamine, norepinephrine reuptake

What questions should be asked of patients before starting a stimulant for ADHD

cardiac history tic disorders Substance abuse history

What is trazodone used for

antidepressant/antianxiety is an alpha-2 antagonist has fewer side effects than tricyclics

Pharmacodynamics of benzos

high fat solubility highly protein bound metabolism: extensively through liver, active metabolites excretion: renal system

Things to know about Strattera

Norepinephrine reuptake inhibitor Metabolized by CYP450 (watch drug interactions) caution in pts with HTN, tachycardia, cardiovascular or cerebrovascular disease can take weeks to take effect

Domains of adults with ADHD

Inattention- staying on task, organizing/prioritizing, time management Impulsivity- unwise speech and behavoirs Hyperactivity (restlessness)- talking to much, interrupting Emotional dysregulation- mood lability, irritability, anger outbursts, low frustration tolerance

Which 2 drugs make up the serotonin receptor antagonists

Remeron (mirtazapine) and Oleptro (trazodone)

How long does it take for SSRIs to reach full therapeutic strength

2 weeks

What are some indications for SSRI use

effective in treating anxiety that sometimes complicates depression as well as anxiety disorder itself (citalopram) very useful in treating obsessive compulsive disorder

Which SSRI is indicated for age 8 and up for major depression

Prozac (fluoxetine) - oldest SSRI and still very useful

Action of benzodiazepines

``` sedation hypnosis decreased anxiety muscle relaxation amnesia anticonvulsant activity nausea relief depression of respiratory drive ```

Patients w/ ADHD need to understand that other issues need to be addressed separately such as...

``` ADHD meds won't help: anxiety ODD learning disabilities mood disorders (depression, bipolar) substance use disorder ```

Guanfacine- class and use

Alpha-2 agonist Tenex SA or Intuniv LA less sedating than clonidine side effects same as clonidine (hypotension, dry mouth, over sedation)

Guidelines for use of benzos

use cautiously with elders NEVER use in pregnancy monitor for escalating use educate: avoid alcohol, kava-kava, slowly taper off, do not drive while using

Side effects of buspirone

``` dry mouth lightheadedness headache insomnia interaction with MAO inhibitors or SSRIs- may potential serotonin syndrome ``` dose TID

First FDA-approved non stimulant

Strattera (Atomoxetine)

Half lives of fluoxetine and fluvoxamine

Prozac (fluoxetine)- 4-6 days | Luvox (fluvoxamine) - 15-26 hours

Causes of serotonin syndrome

Interaction of SSRI with certain cardiac meds dosage is too high interaction with MAOI interaction with St. John's wort- always ask about herbal sups

rare side effects of stimulants

``` delay in sleep onset anorexia induce tics headaches abdominal pain increased BP skin irritation (with daytrana) rebound effects ```

Strattera contraindications

patients with glaucoma or taking MAO inhibitors | cannot be used concurrently with albuterol