Psychiatric Cases-wrap up Flashcards
Case A: 41-yo F with depression
Important things to note
- MUST differentiate b/w chronic (chronic depressive episode) vs situational depression(i.e. Acute loss of a family member)
- 80% of ppl who receive tx for depression will improve
- Medication tx can take 4-6 weeks to become effective,
- BUT improvement is often seen within the first week
- Antidepressants are NON-habit forming
- Tx for 4-9 months after full remission and then graded discontinuation is possible
- Cont medication indefinitely for recurrent depression
SSRIs: list Ex’s
Selective serotonin reuptake inhibitors
–Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft)
SSRIs: MOA
selectively inhibits serotonin reuptake (i.e. increasing serotonergic activity).
SNRIs: list Exs
Serotonin-norepinephrine reuptake inhibitors
SNRIs- Desvenlafaxine (pristiq), Duloxetine (Cymbalta), Venlafaxine (Effexor)
SNRIs: MOA
Inhibits NE, Serotonin, and dopamine reuptake.
Tricyclics: list ex
-TCAs are particularly useful for _________ depression
Amitriptyline (Elavil)
**melancholic
Tetracyclic: list ex
Bupropion (wellbutrin)–CAN be first line
Wellbutrin MOA
Bupropion MOA: inhibits neuronal uptake of NE and dopamine. Exact mech of smoking cessation is unknown.
MAOIs- list Exs
Monoamine oxidase inhibitor
–Isocarbozid (Marplan), Penelzine (Nardil)
list other examples of antidepressants.
Mirtazapine (Remeron), Trazodone (Desyrel) –> GOOD for concurrent insomnia/anxiety
What drugs are good for tx resistant depression?
Aripiprazole (Abilify) and Quetiapine (Seroquel) –
list Indicators for an antidepressant
Depression Anxiety Pain Premenstrual dysphoric disorder Smoking cessation Eating disorders
How to chose an antidepressant?
Indication Cost Availability Drug interactions Patient age and gender
First line: SSRI or SNRI
-list reasons why?
inexpensive, ease of use, tolerability and safety
Although SSRIs are of one pharmacologic class, they are not of one chemical class. Therefore, failure to respond to one SSRI does not reliably predict failure to respond to others.
TCA and MAOI are now second or third line- because?
potential lethal overdose, need titration, serious drug interactions, adverse effects
Adverse Effects SSRI:
-serotonic activity=
nausea, GI upset, Diarrhea, diminished sexual function (decreased interest, delayed orgasm, diminished arousal), headaches, weight gain
Adverse Effects SSRI:
-discontinuation syndrome=
sudden discontinuation –> dizziness and paresthesia
SNRI and tricyclic adverse reactions
Serotonergic adverse effects
& Noradrenergic effects
CNS activation,
List ex’s of noradrenergic effects
increased BP, increased heart rate
Describe CNS activation
insomnia, anxiety, agitation
TCA- list ex’s of anticholinergic effects
dry mouth, constipation, urinary retention, blurred vision, confusion
Discontinuation syndrome for SNRI and TCAs: (list S/E)
cholinergic rebound and flulike symptoms
MAOIs: list adverse effects
**Orthostatic hypotension and weight gain, highest rates of sexual effects
What are some of the CAUTION points you need to be aware of when prescribing an antidepressant:
- Suicide attempts are common
- OD is most common method (especially with TCAs)
- A 1500 mg dose of amitriptyline (less than 7 days) is enough to be lethal
- Drug interaction
(have conversation with pt: in a small % of pts that start an antidepressant get suicidal, call the PCP asap and d/c med)
Managing SE’s:
GI distress: ?
Sedation?
GI Distress: Take after meals
Sedation: Take at HS, most SSRIs are less sedating (Prozac)
Managing SE’s:
Agitation and insomnia?
Sexual dysfunction?
Agitation and Insomnia: Switch to a more sedating options (Remeron, Celexa, Effexor)
Sexual Dysfunction: Less w/ Wellbutrin, Remeron, consider a PDE-5
Managing SE’s:
- anxiety?
- Ortho hypotension?
Anxiety/Panic: Options include Paxil, Remeron, Effexor, TCAs (try to avoid BDZs)
Orthostatic HYPOTN: hydration, education on mvt
Discontinuation of antidepressants:
- withdrawal is typically ___
- Reduce med over ___ weeks
- mild – but tapering off is recommended
- -Reduce over 4 weeks – slower if symptomatic
OTC’s: St. John’s Wort and SAMe
-benefit?
Both have demonstrated some benefit for treating depression
St. John’s Wort and SAMe:
BOTH should not be used in Pts also taking _____
a serotonergic agent (SSRI or SNRI)
St. John’s Wort is a potent inducer of ______
CYP 450 –> LOTS of interactions
Antipsychotics Agents reduce psychotic sx in ______
schizophrenia, bipolar, psychotic depression, senile psychosis and drug-induced psychosis
Antipsychotics Agents:
- mood and sleep effects?
- Improve mood, reduce anxiety
- Decrease sleep disorders
Case completion for CASE A: Pt meets dx criteria for MDD—initiate tx TODAY-– Medication therapy + Psychotherapy
-Pt tried Paxil in the past (SSRI), Pt is concerned for weight gain
what medication would you like to prescribe her now?
-Prozac 20 mg QD, Zoloft 50 mg QD, Lexapro 10 mg QD– all can be titrated up. STOP st johns wort. F/u in 4 weeks
Although schiz. Can occur at any age, the avrg age of onset tends to be:
in late teens to early 20’s for men, abd late 20s to early 30s for women. It is UNCOMMON for schizophrenia to be dx in a person younger than 12 yo or older than 40
Schizophrenia can be treated-–about 1/2 of Pts can be fully independent with aggressive tx and compliance
First Generation (typical) antipsychotic agents (FGA): list Ex’s of Phenothiazines and S/E
Chlorpromazine (Thorazine)
–Sedation, weight gain, tardive dyskinesia
First Generation (typical) antipsychotic agents (FGA): list Ex’s of Thioxanthenes
Thiothixene (Navane)
–High potency, medium extrapyriamidal toxicity, medium sedative and hypotensive action
First Generation (typical) antipsychotic agents (FGA): list Ex’s of Butyrophenones
Haloperidol/droperidol (Haldol)
–High level of EPS, high potency, WIDELY USED
Best used for acute, short-term symptom control
FGA are options for schizophrenia – but ____ are more recommended
second generation antipsychotic agents
Extrapyramidal Symptoms:
Dystonia=
continuous spasm and muscle contractions
Extrapyramidal Symptoms:
Akasthisia=
motor restlessness
Extrapyramidal Symptoms:
Parkinsonism=
Tardive dyskinesia=
Parkinsonism- irregular, jerky movements
Tardive dyskinesia- involuntary muscle movements in lower face and distal extremities
Extrapyramidal Symptoms: others?
Bradykinesia-Slow movements
-Tremors
Second Generation (atypical) antipsychotic agents are regarded as first line tx because ______
they have a lower risk for EPS, minimal risk for tardive dyskinesia, and a lower incidence of cognitive impairment than FGA.
1st line agent (2nd gen):
Quetiapine=
S/E?
Dosing?
Quetiapine – (Seroquel and Seroquel XR) –
***Wt gain!
-Initiate the immediate release formulation of quetiapine at 25 mg twice daily, 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.
1st line agent (2nd gen atypical) antipsychotic agent: Risperidone= S/E? dosing? FDA approval?
Risperidone (Resperdal) – inexpensive, long and short acting options, less EPS Sxs – but risk increases with dosage, wt gain
- Initiate risperidone at 1–2 mg/day and titrate to 2–6 mg/day for the treatment of schizophrenia
- Risperidone is also approved by the FDA for **monotherapy or adjunctive treatment of acute manic or mixed episodes associated with bipolar I disorder, and irritability associated with autistic disorder.
1st line agent (2nd gen atypical) antipsychotic agent:
Ziprasidone=
S/E?
dosage?
Ziprasidone (Geodon) – less wt gain, caution in **CVD and prolonged QTc
-Initial dosage for the treatment of schizophrenia is 20 mg twice daily with food, which can be titrated upward based on an individual patient basis to a maximum of 80 mg twice daily
1st line agent (2nd gen atypical) antipsychotic agent:
Paliperidone=
Aripiprazole=
a lower risk for EPS, minimal risk for tardive dyskinesia, and a lower incidence of cognitive impairment than FGA.
- -Paliperidone (Invega) - active metabolite of risperidone and in essence has the same side effect profile as risperidone.
- Recommended dose for the treatment of schizophrenia is 6 mg once daily administered in the morning. The dose can be increased by 3 mg/day every 5 days as clinically needed to a maximum of 12 mg/day.
- -Aripiprazole (Abilify) – less wt gain, generic, multiple preparations (ODT, liquid)
- Initial dose for the treatment of schizophrenia is 10–15 mg once daily titrated up to 30 mg/day if clinically needed. Dosage increases should not be made before 2 weeks when steady state is reached
2nd gen atypical) antipsychotic agent:
-Clozapine is reserved for _____ patients
-Olanzapine=
Clozapin – severe risk of neutropenia; reserved for refractory pts. **can cause agranulocytosis!!!
Olanzapine (Zyprexa) – commonly prescribed; guidelines do not recommend as a first line agent
Dosage Schedules for antipsychotics
- Divided daily doses
- Titration to effective dose
- Low end of dose should be tried for several weeks
- After the effective daily dose has been discovered dose can be given once daily (typically at night)
Simplification= > compliance
**Acute tx options (antipsychotic agents)
- Zyprexa(olanzipine) – IM/ODT
- Haldol – IV/IM
- Benzo’s (ativan)
SGA should be given an adequate trial for at least ____ weeks at a therapeutic dose.
6–8
S/E of SGA:
Weight gain, hyperglycemia, diabetes mellitus, and hyperlipidemia),9 hyperglycemia, ketoacidosis, coma, and death have been reported with SGA.
Short Term steps for Pt in alcohol withdrawal
Control acute symptoms of alcohol withdrawal
Prevent progression to delirium tremens
Prevent future alcohol withdrawal seizures
Correct electrolyte imbalances (potassium and magnesium)
Start prophylaxis to prevent Wernicke’s encephalopathy
Long Term steps for Pt in alcohol withdrawal
Enroll patient in a program to help him stop drinking, followed by long-term abstinence control
Work up potential liver disease to prevent further progression.
Treat and manage other comorbidities
Case completion for boy with schizophrenia
- MUST distinguish b/w drug induced psychosis and schizophrenia
- Provide and acute antipsychotic in order to have the pt completely evaluated
- admit Pts w/ new onset schizophrenia
- SGAs should be chosen as **first line
what is the treatment of choice for alcohol withdrawal and withdrawal seizures?
- *benzos
- All benzodiazepines appear equally efficacious in reducing signs and symptoms of withdrawal
- All benzo’s used for acute alcohol withdrawal should be front-loaded
List Long acting benzos
diazepam and chloradiazepoxide–> preventing withdrawal seizures and symptom control
***Clinical monitoring is required – increased toxicity risk – metabolized by the liver
List ex’s of short-acting benzos
lorazepam and oxazepam–>
less affected by liver dysfunction and have fewer residual sedative effects
Short term effects of alc withdrawal
- when does AMS occur?
- Sx last?
AMS, onset 3-10 days after cessation of alcohol, symptoms can last 2-3 days
Tx of alc withdrawal: med and dose
lorazepam 2–4 mg PO/IV Q 4–6 H
Valium (diazepam) 5mg PO Q6hrs
Librium 50-100 mg
Tx of seizures 2/2 alc withdrawal:
lorazepam 4 mg IV may repeat
Valium 5-10mg IV q 10min 30mg total
What medication has been shown to decrease symptoms in patients experiencing mild-to-moderate alcohol withdrawal. In the short term, it should also help lower the patient’s BP and heart ?
**Alpha agonist–>Clonidine can be safely added to this patient’s acute treatment regimen
Another medication that can be used for acute alc withdrawal?
Barbs: phenobarbital
What are 2 other meds (supplements) that must be added to the Pt’s regimen (pt with alcohol withdrawal) in order to reduce complications?
Thiamine 500 mg IV–>Home taper for three days
Folate –>Home Multivitamin PO daily
Alc Withdrawal symptoms:
seizure risk is GREATEST at ____ hours
6-72 hours **
Clinical Institute w/D assessment (CIWA):
describe this scoring system
Scoring systmen to gage severity of alc w/d. Score 0-67.
-always safer to admit alc withdrawal pts then to send them home
Home treatment for alc w/d pt
-who can you give antabuse to?
Alcohol withdrawal can be deadly!
- Multidisciplinary approach:
- Benzo’s for home?
- Librium 50-100mg PO TID or QID
- Cessation medications – Disulfiram (Antabuse)–>NEVER GIVE TO SOMEONE WHO IS INTOXICATED
- Unwanted effects appear 10-30 mins after alcohol consumption
- Only works if patient is motivated to stay sober
Medications assoc. with insomnia: list
CNS Stimulants: D-amphetamine, Methyphenidrate
BP drugs: alpha and **beta blockers
Respiratory meds: albuterol and theophyline
Decongestants: Phenylephrine, Pseudoephedrine
Hormones: Corticosteroids
Other substances: alcohol, nicotine, cocaine
Case completion for alc w/d pt:
- admit this Pt, benzo or barb load, correct electrolytes if necessary, give thiamine and folate
- Home- hemodynamically stable, definitive f/u plan and resources
- It’s safer for Pts to continue drinking, then to go home w/out definitive plan
Approach to insomnia:
Lifestyle changes–>
Stimulus Control–> avoid alcohol, caffeine (ie recommend no caffeine after noon)
Environment –> dark room, quiet, decrease pre-sleep activity
Behavioral therapy –> sleep hygiene, sleep restriction therapy, relaxation, CBT
Approach to insomnia:
-dietary supplements that are NOT FDA regulated: (Ex’s)
Valerian Kava-Kava Melatonin Passion flower Skullcap Lavender Hops
Tryptophan
Approach to insomnia:
list ex’s of OTC meds
Many are antihistamine or anticholinergic agents
Benadryl, Tylenol PM, Sleep-Eze, doxylamine (Unisom)
- Many work well – ***may be habit forming
- Undesirable S/E include vivid dreams and next day “hang over”
these meds should NOT be taken every night
Insomnia Medications:
antidepressant ex’s
Doxepin and Trazodone
Insomnia Medications:
benzo ex’s
lorazepam, clonazepam, alprazolam, Triazolam (Halcion), Estazolam (ProSom), Temazepam (Restoril)
**All pregnancy X
these meds all act on GABA alpha receptors
Insomnia Medications:
non benzos
- **zolpidem (ambien),
- *-Eszopiclone (lunesta)
Doxylamine in pregnancy
Ambien also safe
Insomnia Medications:
what is the predominate MOA of these meds?
Gamma aminobutyric acid (GABA) – predominate inhibitory neurotransmitter
Approach to Insomnia: general steps
- every patient receives ________
- what medication is reasonable to start with?
- PRN insomnia tx?
-Situational insomnia tx?
vs
long-term insomnia tx?
- **Everyone gets lifestyle and sleep hygiene education
- It is reasonable to start with melatonin
-OTC medications for PRN insomnia
Benzos – for situational insomnia (try to limit to 2 weeks)
Non-benzos – for long-term insomnia
-Antidepressant for co-morbid depression, anxiety, mania
