Psychiatric Flashcards
1
Q
What % of pts who receive tx for depression will improve
A
80%
2
Q
Depression:∙
Rx tx can take __-__ wks to become fully effective, but improvement is often experienced w/in __ wk(s)
A
4-6wks
1wk
3
Q
Are antidepressants habit forming?
A
nope
4
Q
Tx time for antidepressants after full remission?
A
4-9mo
5
Q
T/F: you can do graded discontinuance for antidepressants in recurrent depression
A
nope
continuous rx indefinitely
6
Q
6 indications for antidepressant use
A
∙Depression
∙Anxiety
∙Chronic Pain
∙Premenstrual dysphoric disorder (PMDD)
can be just around menses, 1wk
∙Smoking cessation (Welbutrin)
∙Eating disorders
7
Q
How to chose an antidepressant (5)
A
∙Indication
∙Cost
∙Availability
∙Drug interactions
always run interactions in epocrates prior to start
∙Patient age and gender
8
Q
First line Rx classes for depression?
A
SSRI & SNRI
9
Q
5 reasons why TCA & MAOI are not 1st line for depression?
A
potential lethal OD
need titration
serious DDI
adverse effects
narrow therapeutic window
TCA’s are bad…
10
Q
Can you use St John’s Wort or SAMe in patients currently taking a serotonergic agent?
A
HELL NO
11
Q
T/F: St John’s wort has lots of DDIs
A
Yes
Its a potent inducer of CYP450
12
Q
SSRI MOA and 5 common ones
A
Selective serotonin reuptake inhibitors
“zo pro pro, PaCe”
Zoloft
Prozac
Lexapro
Paxil
Celexa
13
Q
SNRI MOA and 3 common ones
A
Serotonin-NE reuptake inhibitors
“Pristine Cymbal Effects”
Pristiq
Cymbalta
Effexor
14
Q
SSRI or SNRI:
Anxiety?
A
Both
15
Q
SSRI or SNRI:
Depression tx
A
SNRI>SSRI.
SSRI still good
16
Q
SSRI or SNRI:
More s/e?
A
SNRI
17
Q
Tx for Melancholic Depression
A
TCA:Amitriptyline
these pts are also at higher risk of SI
18
Q
Tetracyclic Rx for depression
A
Welbutrin
19
Q
T/F: Welbutrin can be first line for depression?
A
yes
20
Q
MOA of Welbutrin?
A
NE-D2 receptor antagonist
21
Q
2 Tx for Depression with Insomnia/Anxiety?
A
Mirtazapine (Remeron)
Trazodone (Desyrel)
22
Q
2 Tx for Resistant Depression
A
“Able to see the light”
Aripiprazole (Abilify) and Quetiapine (Seroquel)
23
Q
Why should seroquel NEVER be 1st line for depression?
A
Can develop acute psychosis
24
Q
MAOI MOA and 2 Rx
A
Monoamine oxidase inhibitor
Isocarbozid (Marplan), Penelzine (Nardil)
25
Can Marplan or Nardil ever be 1st line depression Rx?
Nope
26
SSRI:
What are 5 serotonic activity effects?
weight gain
Nausea
Diarrhea
GI upset
Diminished sexual function
HA
27
SSRI:
What are the 2 s/e of Discontinuation syndrome?
sudden discontinuation
→ dizziness and paresthesia
28
Will discontinuation syndrome in SSRI/SNRI cause deadly w/d?
nope
29
What are the 2 groupings of adverse effects from SNRIs?
Serotonergic adverse effects
Noradrenergic effects:
HTN
Tachy
CNS activation: insomnia, anxiety, agitation
30
What is the D/Csyndrome like for SNRI & TCA (2)?
Cholinergic rebound
FLS
31
TCA: Adverse effects
Anticholinergic:
dry mouth
constipation
urinary retention
blurred vision
confusion
32
MAOI: Adverse effects (2)
Higher effects of what?
Orthostatic hypotension
wt gain
higher rates of sexual effects
33
D/C syndrome of TCA?
cholinergic rebound
FLS
34
Are suicide attempts common in depression?
yes
35
What is the MCC of SI in depression?
OD (esp TCA)
36
___ dose of ___ (<__days) is lethal
1500mg
Amitriptyline
<7d
37
Managing S/E:
GI Distress?
Take after meals
38
Managing S/E:
Sedation?
Take at HS, most SSRIs are less sedating (Prozac)
39
Managing S/E:
Agitation and Insomnia:
"Causes Rapid Eye"
Switch to a more sedating options (Remeron, Celexa, Effexor)
40
Managing S/E:
Sexual Dysfunction:
Less with Wellbutrin, Remeron, consider a PDE-5 (Sildenafil)
41
Managing S/E:
Anxiety/Panic:
Avoid what drug class?
"Treat Every Panic Real"
Paxil, Remeron, Effexor, TCAs
(try to avoid BDZs)
42
Managing S/E:
Orthostatic HYPOTN:
hydrate, educate on mvt
43
Managing S/E:
Wt gain:
"Prevents weight change"
cymbalta, Prozac, Welbutrin
44
D/C
Is the w/d bad?
taper? how?
No
WD typically mild
taper is recommended
↓ over 4wks– slower if symptomatic
45
D/C Taper for SNRI?
do a slower taper with the SNRI
(↓ Q2wks, plan to be done in 6-8wks)
could also crossover to another Drug
46
Best combo for MDD tx?
Medication therapy + Psychotherapy (CBT)
47
Is it common for schizophrenia to be diagnosed in a person younger than 12 or older than 40.
Nope
48
Can schizophrenia be treated?
yes
49
1/2 of schizophrenia pts can be fully independent with what 2 things?
aggressive tx & compliance
50
Antiphsychotics do what 3 things for schizophrenia?
↑ mood
↓ anxiety
↓ sleep disorders
51
When are FGA best used?
acute
short-term symptom control
52
Wy are FGA not 1st line for schizo (3)?
EPS
TD
cognitive impairment
53
3 drug classes of FGA
Phenothiazines – Chlorpromazine (Thorazine)
Thioxanthenes – Thiothixene (Navane)
Butyrophenones – Haloperidol/droperidol (Haldol)
54
Which FGA class has wt gain, sedation & TD?
Phenothiazines – Chlorpromazine (Thorazine)
55
Which FGA class has high potency, medium EPS, medium sedative & hypotension?
Thioxanthenes – Thiothixene (Navane)
56
Which FGA class has high levels of EPS & high potency & is widely used?
Butyrophenones – Haloperidol/droperidol (Haldol)
57
EPS:
Dystonia-
continuous spasm and muscle contractions
58
EPS:
Akathisia-
motor restlessness
59
EPS:
Parkinsonism-
irregular, jerky movements
60
EPS:
Tardive dyskinesia-
involuntary muscle movements in lower and distal extremities
61
EPS:
Bradykinesia-
Slow movements
Tremors
62
What drug class is 1st line tx for Schizophrenia?Why?
SGA
lower risk EPS
minima risk TD
lower incidence of cognitive impairment
63
7 drugs choices for SGA?
Quetiapine – (Seroquel & Seroquel XR)
Risperidone (Resperdal)
Ziprasidone (Geodon)
Paliperidone (Invega)
Aripiprazole (Abilify)
Clozapin
Olanzapine (Zyprexa)
64
SGA:
Which 2 rx causes wt gain?
Seroquel
Risperdal
65
SGA:
Which rx causes EPS with an increase in dosage?
Rsiperdal
66
SGA:
Which rx is an active metabolite of risperdal?
Invega
67
SGA:
Which rx is inexpensive, comes in long & sort acting options?
Risperdal
68
SGA:
Which Rx is FDA approved monotherapy or adjunctive tx of acute manic or mixed episodes assoc w/ bipolar I disorder, and irritability associated with autistic disorder.
Risperdal
69
SGA:
Which Rx should be used with caution in CVD and prolonged QTc
Geodon
70
SGA:
Which 2 rx cause less wt gain?
Geodon & Abilify
71
Why do we only use clozapin for refractory pts?
severe risk of neutropenia
72
SGA:
Which rx is NOT recommended as 1st line?
Zyprexa
73
3 things to consider with schizo drug choice
Adverse effects/efficacy
comorbids
cost
74
What dose works for schizophrenia?
lowest possible effective dose
75
Are divided daily doses hard for this pop? (schizo)?
yes
76
Schizo:
___ = compliance
Simplification
77
3 acute options for schizo
Zyprexa – IM/ODT
Haldol – IV
Benzo’s
78
SGA should be given an adequate trial for at least__-__weeks at a therapeutic dose.
6–8 weeks at a therapeutic dose.
**6-8wks after you get pt to right dose
79
7 SE we need to know for SGA?
wt gain
hyperglycemia
DM
HLD
DKA
Coma
Death
80
Schizo:
Must distinguish b/w __ and _
drug-induced psychosis and schizophrenia
81
Schizo:
to dx, must see ____ when they are not under _____.
new psychotic features
Haldol or other drugs.
82
MDD:
Differentiate b/w ___ or ____ Depression
Chronic
Situational
83
Short term ETOH w/d goals (5)
Most important goal?
*Control acute symptoms of alcohol withdrawal
**Prevent progression to delirium tremens
*Prevent future ETOH WD Sz
*Correct electrolyte imbalances (K+ and Mg2+)
*Start THIAMINE prophylaxis to prevent Wernicke’s encephalopathy
84
T/F: If a pt has a ETOH WD Sz, will prob sz again in future
true
85
DT sx and onset:
Delirium & tremors! & AMS
onset 3-5 (10) days post, lasts 2-3 days
86
Long term goals of ETOH WD (4)
*Enroll patient in a program to help him stop drinking
-followed by long-term abstinence control
*W/U for liver dz (LFTs)→ prevent further progress
*Treat and manage other comorbidities
87
Prophylaxis Tx for Wernickes encephalopathy
THIAMINE
88
What is the TOC for ETOH & WD sz?
& 2 reasons why?
Barbituates
Less risk of respiratory depression
longer half-life
89
What is the DOC for ETOH & WD sz?
Why?
Phenobarbitol
does not cause a high
90
__ are DOC if your ETOH pt is actively seizing
Benzos
91
T/F: All benzodiazepines seem equally efficacious in reducing signs and symptoms of ETOH withdrawal
true
92
Which Benzo class needs clinical monitoring?
Long acting
(Diazepam (valium) & Chloradiazepoxide (Librium))
93
Which Benzo class prevents w/d sz and sx control?
Long acting
diazepam (valium) & chloradiazepoxide (Librium)
94
Which benzo class has increased toxicity risk (liver metabolism)
Long acting
diazepam (valium) & chloradiazepoxide (Librium)
95
Which benzo class has less affected by liver dysfunction & ↓ sedative effects
Short acting (lorazepam and oxazepam)
96
Which benzo can be used outpt?
Librium (long acting)
97
Which 2 ETOH wd Rx do not cause a high?
Phenobarbitol
Librium
98
Benzos:
3 Rx for WD
Lorazepam 2–4 mg PO/IV Q 4–6 H
Valium 5mg PO Q6hrs
Librium 50-100mg
99
Benzos:
2 Rx for Sz
Lorazepam 4 mg IV may repeat
Valium 5-10mg IV q 10min 30mg total
100
Clonidine? for ETOH w/d?
Alpha – Agonists can be safely added. ↓ sx
In the short term, ↓BP & HR
101
What 2 necessary tx are added to ETOH WD Tx?
THIAMINE
FOLATE
102
When is sz risk highest?
6-72hrs
103
T/F: Librium can be done at home
true
all other benzos at home-risky
104
Disulfram (Antabuse)
Can you use w/an intoicated pt?
NEVER GIVE TO SOMEONE WHO IS INTOXICATED
only works if pt is motivated to stay sober
105
What to do with ETOH W?D pt w/hx of Sz & high risk? (might have had sz)?
Admit this patient, barb load, correct (e-)
if necessary, give thiamine and folate
Home – hemodynamically stable, definitive f/u plan and resources
106
When can admitted etoh wd pt go home?
hemodynamically stable, definitive f/u plan and resources
107
T/F: It is safer for patients to continue drinking that stop without a definitive plan
true
108
What are the e- imbalances of ETOH misuse?
K+
Mg2+
109
Meds assoc w/Insomnia:
CNS stimulants
D-amphetamine
Methylphenidine
110
Meds assoc w/Insomnia:
BP drugs
alpha & BB
111
Meds assoc w/Insomnia:
Resp rx
Albuterol
Theophylline
112
Meds assoc w/Insomnia:
Decongestants
Phenylephrine
Pseudoephedrine
113
Meds assoc w/Insomnia:
Hormones
Corticosteroids
114
Meds assoc w/Insomnia:
Others substances
Alcohol
Narcotics
Cocaine
115
Approach to insomnia (4)
∙ Lifestyle
∙ Stimulus Control → avoid alcohol, caffeine
∙ Environment→ dark room, quiet, decrease pre-sleep activity
∙ Behavioral therapy→ sleep hygiene, sleep restriction therapy, relaxation, CBT
116
Dietary Supplements for insomnia
Valerian Root
Kava-Kava
Melatonin
Passion flower
Skullcap
Lavender
Hops
Tryptophan
117
T/F: Dietary supplements for insomnia are FDA regulated
false
118
T/F: Many OTC rx for insomnia are antihistamine or anticholinergic
true
119
5 OTC Rx for insomnia
Benadryl
Tylenol PM
Sleep-Eze
doxylamine (Unisom)
Hydroxazine
120
2 undesirable effects from OTC rx for insomnia
vivid dreams
hangover
121
2 rx classes that act on ___ to promote sleep
GABA
Antidepressants
Benzos
122
Is a benzo a good idea for sleep?
hell no
123
Antidepressants for sleep?
Doxepin
Trazodone
124
T/F:Doxepin, Trazodone & benzos are category x
truee
125
Non benzo rx for insomnia
do they work well?
Ambien
Lunesta
YES
126
predominate inhibitory neurotransmitter for sleep
GAB
127
Insomnia:
Everyone should do __ & ___
lifestyle change ad sleep hygiene
128
max timeline for benzos for insomnia
2wks
129
T/F: when chosing insomnia rx, you can use an antidepressant for co-morbid depression, anxiety, mania
True
130
Is it reasonable to start insomnia tx with melatonin?
yes!
