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RRCCPA Pharmacotherapeutics > Psych Case Wrap-Up (Jaynstein) (Midterm) > Flashcards

Psych Case Wrap-Up (Jaynstein) (Midterm) Flashcards

1
Q

When evaluating a Pt for depression what do you need to differentiate?

A

Differentiate between chronic depression and situational depression

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2
Q

When starting antidepressants how long does it typically take to see improvment?

A

Improvement may be experienced within the first week, but usually takes 4-6 weeks before the full effect is seen. Before trying a new med make sure to give a full 4-6 week trial.

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3
Q

How long after full remission of depression should the Pt continue to take their antidepressants?

A

4-9 months after full remission, then graded discontinuation. If recurrent depression may need to take meds indefinitely.

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4
Q

What percentage of Pts who receive treatment for depression will experience improvement?

A

80%

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5
Q

Are antidepressants habit forming?

A

No

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6
Q

What class of antidepressants are the most commonly prescribed?

A

SSRI

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7
Q

SSRI means what?

A

Selective Serotonin Reuptake Inhibitor

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8
Q

Name some common SSRIs

A
  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Fluoxetine (Prozac)
  • Paroxetine (Paxil)
  • Sertraline (Zoloft)
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9
Q

What is a SNRI?

A

Serotonin-norepinephrine Reuptake Inhibitor. Antidepressants that modulate two neurotransmitters.

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10
Q

Name some common SNRIs

A
  • Desvenlafaxine (Pristiq)
  • Duloxetine (Cymbalta)
  • Venlafaxine (Effexor)
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11
Q

Which classes of antidepressants are considered first line?

A

SSRIs and SNRIs

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12
Q

Amitriptyline (Elavil) and other TCAs are particularly good at treating which kind of depression?

A

Melancholic depression

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13
Q

What is one use, outside of depression, for Buproprion (Wellbutrin)?

A

Smoking cessation

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14
Q

Mirtazapine (Remeron) and Trazodone (Desyrel) are useful in Pts with?

A

Concurrent insomina/anxiety

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15
Q

When should Aripiprazole (Abilify) and Quetiapine (Seroquel) be considered?

A

In cases of resistant depression (failed trial of SSRI and/or SNRI)

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16
Q

If a Pt does not respond to one SSRI should you move to a different class of antidepressants?

A

No, failing one SSRI does not mean other SSRIs won’t work. Try a few different SSRIs before switching classes.

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17
Q

Common indications for antidepressant therapy?

A
  • Depression
  • Anxiety
  • Chronic pain
  • Premenstrual dysphoric disorder (PMDD)
  • Smoking cessation
  • Eating disorders
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18
Q

Is it okay to initiate antidepressant therapy on a Pts first presentation to the office for depression?

A

Yes!! It is likely if they are presenting with a concern for depression that they have been dealing with it for a while and have tried non-pharmacologic treatments like stress reduction.

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19
Q

What should you consider when choosing an antidepressant?

A
  • Indication
  • Cost (SSRIs tend to be very cheap)
  • Availability
  • Drug interactions
  • Patient age and gender
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20
Q

Why are SSRIs and SNRIs first line?

A
  • Inexpensive
  • Easy to use
  • Lower S/E compared to TCAs and MAOIs
  • Safe
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21
Q

Which antidepressants are second and third line? Why?

A

TCAs and MAOIs

  • Potential lethal overdose
  • Need titration
  • Serious drug interactions
  • Many S/E
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22
Q

Common adverse effects of SSRIs

A
  • Nausea
  • GI upset
  • Diarrhea
  • Diminished sexual function
    • Decreased interest
    • Delayed orgasm
    • Diminished arousal
  • Headaches
  • Weight gain
  • Discontinuation syndrome:
    • Sudden discontinuation can lead to dizziness and paresthesias
    • Can make Pt feel shitty but is not lethal
    • Recommended to do slow taper when discontinuing SSRI
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23
Q

SNRI and TCA adverse reactions

A
  • Same as SSRIs
  • Noradrenergic effects
    • Increased BP
    • Tachycardia
  • CNS activation
    • Insomnia
    • Anxiety
    • Agitation
  • Anticholinergic (TCAs)
    • Dry mouth
    • Constipation
    • Urinary retention
    • Blurred vision
    • Confusion
  • Discontinuation syndrome
    • Cholinergic rebound
    • Flu-like symptoms
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24
Q

MAOI adverse effects

A
  • Orthostatic hypotension
  • Weight gain
  • Highest rates of sexual dysfunction
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25
Q

Sadly suicide attempts are common in depressed Pts. When during the course of their treatment are they most common?

A

During initiation of antidepressants and during discontinuation of antidepressants

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26
Q

Which antidepressant class is the most common to OD on during a suicide attempt?

A

TCAs

A 1500 mg dose of amitriptyline (less than a week’s worth) is enough to be fatal.

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27
Q

Options to manage the following S/E of antidepressants

  • GI distress:
  • Sedation:
  • Agitation and insomnia:
  • Sexual dysfunction:
  • Anxiety/Panic:
  • Orthostatic hypotension:
A
  • GI distress: Take after meals
  • Sedation: Take at HS (most SSRIs such as Prozac are less sedating)
  • Agitation and insomnia: Switch to a more sedating option (Remeron, Celexa, Effexor)
  • Sexual dysfunction: Switch to medication with a low sexual S/E profile such as Wellbutrin or Remeron. Consider prescribing a PDE-5 in addition to the antidepressant
  • Anxiety/Panic: Paxil, Remeron, Effexor, and TCAs are helpful in reducing anxiety. Try to avoid benzos!
  • Orthostatic hypotension: Good hydration, education on getting up safely from rest
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28
Q

When tapering off antidepressants how long should you do it for?

A

Taper off over the course of 4 weeks, if Pt experiences withdrawal symptoms slow down the taper.

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29
Q

Which OTCs have been demonstrated to have some benefit in the treatment of depression?

A

St. John’s Wort and SAMe

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30
Q

St. John’s Wort and SAMe should not be used in which Pts?

A

Pts currently taking serotonergic agents. If planning to start an SSRI or SNRI ensure the patient is not taking St. John’s Wort or SAMe.

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31
Q

St. John’s Wort is a potent inducer of what?

A

CYP 450. Can lead to lots of interactions

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32
Q

When treating depression the best outcomes are found with?

A

Medication therapy + Psychotherapy

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33
Q

If a Pt shows some improvement on an SSRI but isn’t to the level they would like to be after 4-6 weeks what should you do?

A

Titrate up on the dose of the SSRI (up to max dose) before switching to a different med.

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34
Q

At what age does schizophrenia tend to appear?

A
  • Can occur at any age
  • Typically late teens to early 20’s for men
  • Typically late 20’s to early 30’s for women
  • Uncommon to be diagnosed in a person younger than 12 or older than 40
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35
Q

With aggressive treatment and medication compliance what percentage of schizophrenics can live fully independent lives?

A

About 50%

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36
Q

Antipsychotic agents reduce psychotic symptoms in which disorders?

A
  • Schizophrenia
  • Bipolar
  • Psychotic depression
  • Senile psychosis
  • Drug-induced psychosis
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37
Q

As well as reducing psychotic symptoms antipsychotic agents also?

A
  • Improve mood
  • Reduce anxiety
  • Decrease sleep disorders
38
Q

Common first-generation (typical) antipsychotic agents (FGA) and their effects

A
  • Phenothiazines
    • Chlorpromazine (Thorazine)
      • Sedation, weight gain, tardive dyskinesia
  • Thioxanthenes
    • Thiothixene (Navane)
      • High potency, medium extrapyramidal toxicity, medium sedation, hypotension
  • Butyrophenones
    • Haloperidol/droperidol (Haldol)
      • High levels of extrapyramidal symptoms, high potency, widely used
39
Q

Do first or second-generation antipsychotic agents have more side effects?

A

First generation

40
Q

Are first or second-generation antipsychotic agents preferred in the treatment of schizophrenia?

A

Second-generation antipsychotic agents are preferred. First-generation antipsychotic agents can also treat schizophrenia if 2nd gen antipsychotic agents fail.

41
Q

Of the FGAs which is best used for acute treatment of psychotic symptoms?

42
Q

What are extrapyramidal symptoms?

A
  • Dystonia
    • Continous spasm and muscle contractions
  • Akathisia
    • Motor restlessness
  • Parkinsonism
    • Irregular, jerky movements
  • Tardive dyskinesia
    • Involuntary muscle movements in the lower face and distal extremities
  • Bradykinesia
    • Slow movements
  • Tremors
43
Q

Common Second-generation (atypical) antipsychotic agents (SGA)

A
  • Quetiapine (Seroquel and Seroquel XR)
  • Risperidone (Risperdal)
  • Ziprasidone (Geodon)
  • Paliperidone (Invega)
  • Aripiprizole (Abilify)
  • Clozapin (Clozaril)
  • Olanzapine (Zyprexa)

Any of these are appropriate for the treatment of schizophrenia

44
Q

Why are SGAs considered the first line in the treatment of schizophrenia over FGAs?

A

Lower risk for EPS, minimal risk for tardive dyskinesia, and lower incidence of cognitive impairment

45
Q

Treatment regimen for schizophrenia with Quetiapine (Seroquel). and common S/E.

A
  • Initiate the IR formulation at 25 mg BID, followed by a dose titration of 25-50 mg/day in divided doses daily until reaching the target dose of 300-400 mg/day by day 4.
  • Can cause significant weight gain
46
Q

Treatment regimen for schizophrenia with Risperidone (Risperdal), and common S/E.

A
  • Initiate at 1-2 mg/day and titrate to 2-6 mg/day
  • Fewer EPS than other antipsychotic agents but risk increases with dosage
  • Weight gain
47
Q

Risperdal is FDA approved for the treatment of schizophrenia, what other disorders is it approved to treat?

A
  • Monotherapy or adjunctive treatment of acute manic or mixed episodes in Bipolar I
  • Irritability associated with autistic disorder
48
Q

Treatment regimen for schizophrenia with Zi[rasidone (Geodon), and common S/E.

A
  • 20 mg BID with food, can be titrated up to a max of 80mg BID
  • Less weight gain than other SGAs
  • Caution in Pts with CVD and prolonged QTc
49
Q

Treatment regimen for schizophrenia with Paliperidone (Invega) and common S/E.

A
  • Reccomened dose is 6 mg QAM. Can be increased by 3 mg/day every 5 days to a max of 12 mg/day.
  • Is the active metabolite of Risperidone and has the same S/E profile
50
Q

Treatment regimen for schizophrenia with Aripiprazole (Abilify) and common S/E.

A
  • The initial dose is 10-15 mg QD. Can titrate up to max 30 mg/day. Should not increase dosage before 2 week when steady state is reached
  • Weight gain
51
Q

Of the SGAs which ones are not indicated as first-line meds in the treatment of schizophrenia?

A
  • Clozapine (Clozaril)
    • Severe risk of neutropenia
    • Reserved for refractory Pts
  • Olanzapine (Zyprexa)
    • Commonly prescribed however guidelines do not recommend as a first-line agent.
52
Q

What should you consider when choosing which medication to treat schizophrenia?

A
  • Adverse effects
  • Efficacy
  • Comorbidities
  • Cost
53
Q

Which meds are options for the treatment of an acute psychotic break?

A
  • Zyprexa (IM/ODT(Orally disintegrating tablet))
  • Haldol (IV)
  • Benzo’s such as Lorazepam (Ativan)
54
Q

How long should an SGA at a therapeutic dose be trialed for?

A

At least 6-8 weeks

55
Q

Common S/E of SGAs

A
  • Weight gain
  • Hyperglycemia
  • Diabetes mellitus
  • Hyperlipidemia

Hyperglycemia, ketoacidosis, coma, and death have been reported with SGAs

56
Q

Typical workup for someone presenting with their first acute psychotic episode due to schizophrenia

A
  • Distinguish between drug-induced psychosis and schizophrenia
  • Provide an acute antipsychotic in order to have Pt completely evaluated
  • Admit as new-onset schizophrenia for a full psychiatric evaluation
  • SGA should be chosen as first-line
57
Q

Is alcohol withdrawal deadly?

A

It can be!! Same with Benzo withdrawal

58
Q

Short term goals in the treatment of alcohol withdrawal

A
  • Control acute symptoms of alcohol withdrawal
  • Prevent progression to delirium tremens
    • AMS
    • Onset 3-10 days following last drink
    • Lasts 2-3 days
  • Prevent alcohol withdrawal seizures
  • Correct electrolyte imbalances
    • Potassium
    • Magnesium
  • Start prophylaxis to prevent Wernicke’s encephalopathy
59
Q

If a Pt has an alcohol withdrawal seizure are they more or less likely to have seizures during future episodes of alcohol withdrawal?

A

More likley

60
Q

Long term goals in the treatment of alcohol withdrawal

A
  • Long-term abstinence control
  • Enrollment in a program to help combat drinking
  • Work up potential liver disease/prevent further progression of liver disease
  • Treat and manage comorbidities
61
Q

Which medication class is the treatment of choice for both alcohol withdrawal and withdrawal seizures?

A

Benzodiazepines

All benzodiazepines appear equally efficacious in reducing signs and symptoms of withdrawal

62
Q

Name some long-acting benzo’s and their use in alcohol withdrawal

A
  • Diazepam (Valium)
  • Chlordiazepoxide (Librium)
  • Used in preventing seizures and symptom control

Clinical monitoring is required as they are metabolized by the liver, increasing the risk of toxicity.

63
Q

Name some short-acting benzo’s used in alcohol withdrawal treatment

A
  • Lorazepam (Ativan)
  • Oxazepam

Less affected by liver dysfunction and less toxic to the liver and have fewer residual sedative effects compared to long-acting benzo’s

64
Q

All benzo’s used in the treatment of alcohol withdrawal should be?

A

Front-loaded

65
Q

Dosage for lorazepam (Ativan) in treating alcohol withdrawal symptoms? For alcohol withdrawal seizures?

A
  • Alcohol withdrawal symptoms
    • 2-4 mg PO/IV Q 4-6 hours
  • Alcohol withdrawal seizures
    • 4 mg IV may be repeated
66
Q

Dosage for diazepam (Valium) in treating alcohol withdrawal symptoms? For alcohol withdrawal seizures?

A
  • Alcohol withdrawal symptoms
    • 5 mg PO Q6 hours
  • Alcohol withdrawal seizures
    • 5-10 mg Q 10 minutes for 30 mg total
67
Q

Dosage for Chlordiazepoxide (Librium) in treating alcohol withdrawal symptoms? For alcohol withdrawal seizures?

A
  • Alcohol withdrawal symptoms
    • 50-100 mg PO
  • Alcohol withdrawal seizures
    • Not indicated
68
Q

Non-benzodiazepine options for the treatment of alcohol withdrawal

A
  • Barbituates
    • Phenobarbitol
      • Has been shown to be safer than benzo’s, some ERs are using pheno over benzo’s
  • Alpha-Agonists
    • Clonidine
      • Can be added to the benzo treatment, should not be used as monotherapy. Has been shown to decrease symptoms in Pts experiencing mild-to-moderate alcohol withdrawal.
      • Short-term benefit of helping lower BP and HR.
69
Q

Which other medications should be added to the treatment of alcohol withdrawal on top of benzo’s?

A
  • Thiamine 500 mg IV
    • Home taper for three days
  • Folate
    • Home multivitamin PO QD

Both help reduce the risk of developing Wernicke’s encephalopathy and progression to delirium tremens

70
Q

When is the risk of alcohol withdrawal seizures greatest?

A

6-72 hours after cessation of alcohol

71
Q

What are the stages of alcohol withdrawal and when do they occur? (this is based off Jaynstein’s slides)

A
  • Stage 1 (0-8 hours after the last drink)
    • Anxiety, insomnia, nausea, abdominal pain
  • Stage 2 (1-3 days after last drink)
    • HTN, hyperthermia
  • Stage 3 (3 days-1 week after last drink)
    • Hallucinations, fever, agitation, possible seizures
72
Q

What does CIWA stand for and what does it measure?

A
  • Clinical institute withdrawal assessment
  • Scoring system to gauge the severity of alcohol withdrawal
    • Score 0-67

Don’t need to memorize the scoring criteria

73
Q

If a Pt is in alcohol withdrawal is deemed safe enough to go through withdrawals at home which benzo is the safest to use?

A

Librium 50-100 mg PO TID or QID. Have strict instructions on when to return to ED.

73
Q

If a Pt states that they have no interest in quitting drinking, and plan to go home and drink after being discharged can you D/C them?

A

Depends, if they are unstable you shouldn’t D/C them. If they are stable and plan to go home and drink it’s okay to D/C as continuing drinking is safer than going through alcohol withdrawal. A weird concept I know, but you can’t stop someone who isn’t ready to quit.

74
Q

Which alcohol cessation medication should never be given to an intoxicated Pt or a Pt who plans to continue to drink?

A
  • Disulfiram (Antabuse)
75
Q

Which Pt is Disulfiram (Antabuse) most successful in?

A
  • A Pt who has already gone through alcohol withdrawal and who is motivated to stay sober
76
Q

Which Pts is it safer to have them continue drinking rather than quit “cold turkey”

A
  • Pts who do not have a definitive plan on how to safely stop drinking. Alcohol withdrawal can be deadly, it takes a multidiscipline approach to come up with a plan to help a Pt stop drinking, survive alcohol withdrawal, and maintain abstinence from alcohol.
77
Q

Which medications are associated with insomnia?

A
  • CNS stimulants
    • D-amphetamine
    • Methylphenidate
  • BP drugs
    • Alpha and Beta-blockers
  • Respiratory medications
    • Albuterol
    • Theophylline
  • Decongestants
    • Phenylephrine
    • Pseudoephedrine
  • Hormones
    • Corticosteroids
  • Other substances
    • Alcohol
    • Nicotene
    • Cocaine
78
Q

What lifestyle changes can you advise a Pt to make to help reduce insomnia?

A
  • Stimulus control
    • Avoid Alcohol
    • Avoid Caffeine
  • Environment
    • Dark rooms
    • Quiet
    • Decrease pre-sleep activity (such as screen time before bed)
    • Bedroom only used for sleep and sex
  • Behavioral therapy
    • Sleep hygiene
    • Sleep restriction therapy
    • Relaxation
    • CBT
79
Q

Even though they are not FDA regulated what OTC supplements may help with sleep?

A
  • Valerian root
  • Kava-kava
  • Melatonin
  • Passionflower
  • Skullcap
  • Lavender
  • Hops
  • Tryptophan
80
Q

Many OTC sleep medications are in which classes?

A

Antihistamine or anticholinergic

81
Q

Common OTC sleep medications

A
  • Benadryl
  • Tylenol PM
    • Just Tylenol and Benadryl, just have Pt take Benadryl unless they have pain
  • Sleep-Eze
  • Doxylamine (Unisom)
82
Q

What are some common undesirable side effects of OTC sleep medications?

A
  • May be habit-forming
    • Should be used PRN, not every night
  • Vivid dreams
  • Next day “hangover”
83
Q

Which antidepressants are used in the treatment of insomnia?

A
  • Doxepin
  • Trazodone
84
Q

Which benzodiazepines are used in the treatment of insomnia?

A
  • Lorazepam (Ativan)
  • Clonzepam (Klonopin)
  • Alprazolam (Xanax)
  • Trizolam (Halcion)*
  • Estazolam (ProSom)*
  • Temazepam (Restoril)*

These should not be first-line meds as they are highly addictive

*slightly safer benzo’s that are appropriate for everyday use

All benzo’s are category X in pregnancy

85
Q

Benzodiazepines and Z-drugs act on which receptors?

A

GABAa receptors

86
Q

What are two common Z-drugs for insomnia?

A
  • Zolpidem (Ambien)
  • Eszopiclone (Lunesta)
87
Q

What is the predominant inhibitory neurotransmitter?

A

Gamma-aminobutyric acid (GABA)

88
Q

Which medications for insomnia are safe in pregnancy?

A
  • Doxylamine (Unisom)
  • Zolpidem (Ambien)
89
Q

General approach to treating insomnia

A
  • Everyone gets lifestyle and sleep hygiene education
  • It is reasonable to start with melatonin
  • OTC medications for PRN insomnia
  • Benzo’s for situational insomnia
    • Limit to 2 weeks or less
  • Non-benzos (Z-drugs) for long-term insomnia
  • Antidepressant for co-morbid depression, anxiety, mania
90
Q

These flashcards only covered the wrap-up powerpoint. What else should you do?

A

Have a beer and re-read all the cases

RRCCPA Pharmacotherapeutics (11 decks)

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