Psych & Behavioral Disorders Flashcards
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
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
When to prescribe benzos
acute and short-term use in treatment of panic attacks
particularly those associated with generalized anxiety disorder and alcohol withdrawal
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
Somatic effects of anxiety
tachycardia, palpitations, increased BP, hyperventilation, tremor, sweating, GI -n/v/d
Contraindications for stimulants
history of schizophrenia or other psychosis
symptoms of anxiety, tension, agitation
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
Major side effects of SSRIs
nausea, loose stools
sexual dysfunction
weight gain- how will this effect pts mental state
Side effects of Clonidine
hypotension
dry mouth
over sedation
*Rebound hypertension if abruptly stopped: ALWAYS TAPER
Black-box warning of SSRIs
must assess pt for depression/SI
increase in SI in users age 24 and under
Adverse effects of benzos
excessive sedation
respiratory depression
increase tolerance/physiologic dependance
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
Preferred method of treatment for ADHD
Stimulants
start low and increase slowly until s/s resolve
Symptoms of serotonin syndrome
Rigidity Hyperthermia Autonomic instability Tremors Confusion Delirium Coma
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
Two most popular class of stimulants and drug names
Methylphenidate- Ritalin SR/LA , concerta, methylin, daytrana, metadate, Focalin/Focalin SR
Amphetamine Salts- Adderall
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
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
MAOIs example
Nardil (phenelzine)- not used so much anymore, decreases metabolic inactivation of catecholamines, multiple side effects and interactions with drugs/food
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
