Psychiatric - Mental Health Flashcards
Depression
first line medications
Selective serotonin reuptake inhibitors SSRI
Serotonin and norepinephrine reuptake inhibitors SNRI
Takes 4-6 weeks before they start working, increase the dose if it does not work, check thyroid levels and underlying causes
We keep patients on it for at least six months
Why do people stop taking their depression medications? What can be added to help?
sexual dysfunction
weight gain
*side effects of SSRIs and SNRIs
Bupropion (Wellbutrin) (A) is a norepinephrine and dopamine reuptake inhibitor that is used for treating depression. It is also prescribed in conjunction with selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) to reduce the occurrence of sexual side effects.
Lowers seizure threshold = no Wellbutrin
Depression
herbal supplement
St. John’s Wart
- do not use anything with serotonin in addition
- serotonin syndrome s/s
shivering
seizure
shaking
tremors
tachycardia
agitation
SNRI side effects
GI issues
- diarrhea will go away on its own, but increase fiber
Selective serotonin reuptake inhibitors SSRI
SSRI
serotonin affects mood
paroxetine (Paxil): OCD, off label for premenstrual disorders/menopause
escitalopram (Lexapro): generalized anxiety, quick onset
sertraline (Zoloft): overall safe profile, good choice for elderly
fluoxetine (Prozac): bullimia (weight neutral), may feel jittery
first line tx for OCD , PTSD, anxiety
Suicidal Ideation = safety alert
- straight forward do they have a plan and how they will do it
- black box warning on antidepressants
- 72 hold possibly
- SSRI to avoid with elderly
- tricyclic antidepressants to avoid with the elderly
SSRIs to avoid
- fluoxetine (prozac) due to its long half life
- Vilazodone (Viibryd) can cause hyponatremia in elderly patients
Tricyclic Antidepressants
- Amitriptyline, Nortriptyline (Pamelor), Trimipramine (etc.) due to its anticholinergic side effects
Antidepressants safe in elderly
SSRI
- sertraline (Zoloft)
- escitalopram (Lexapro)
Patient is experiencing fatigue
order iron and thyroid panel (D)
Increasing fatigue is not an expected finding with escitalopram (Lexapro)
Which SSRI is most sedating?
paroxetine (Paxil)
Which SSRI to avoid with anxiety?
fluoxetine (Prozac) due to jitteriness side effect
Serotonin and norepinephrine reuptake inhibitors
SNRI
blocks serotonin and norepinephrine
created to be more effective than SSRI, but no evidence of this yet
duloxetine (Cymbalta)
venlafaxine (Effexor)
sexual dysfunction
weight gain
hypertension
Duloxetine (Cymbalta) SNRI
major depressive disorder in adults
generalized anxiety disorder in adolescents
fibromyalgia
No tests are required prior to starting duloxetine in healthy individuals
- avoided for uncontrolled HTN as it can increase blood pressure
-serotonin syndrome when combined with sumatriptan (Imitrex) - avoided in patients with hepatic impairments such as hepatitis B
Atypical antipsychotics
Examples and Assessments
- refractory depression
- olanzapine (Zyprexa)
- quetiapine (Seroquil)
- risperidone (Risperdal)
Assess
- lipid profile / hyperlipidemia
- assess weight / weight gain
- blood glucose / hyperglycemia
Galactorrhea: milk production from the breast unrelated to pregnancy or lactation
tardive dyskinesia
Haloperidol (Haldol)
first-generation antipsychotic
schizophrenia
Tourette syndrome
weight gain
elevations in triglycerides
fasting plasma glucose
metabolic syndrome
tardive dyskinesia
QT prolongation
Bipolar Disorder
s/s
tx and side effects
Manic: not sleeping, making impulse purchases, excited
Depressed: cannot get out of bed, unable to complete daily activities
Treated with lithium / Lithobid as a mood stabilizer (how much sodium movies through nerve/muscle cells) - narrow therapeutic range (0.6-1.2) if greater than 2 g = toxicity
- avoid grapefruit
- no pregnancy
- side effects: affects thyroid hypothyroidism (can occur when on long term - may grow goiter), weight gain, nausea, altered sodium levels
Post Traumatic Stress Disorder
s/s
tx
nightmares, hypervigilence (assessing threat around you), startle response, flashbacks, insomnia
SSRI
escitalopram (Lexapro) or fluoxetine (Prozac)
Seasonal Affective Disorder
Affects patient’s Arcadian rhythm and puts them into a depressed state
First-line treatment for major depressive disorder, with seasonal pattern includes:
- antidepressant - selective serotonin reuptake inhibitor sertraline (Zoloft)
- bright light therapy
- psychotherapy, such as cognitive behavioral therapy (CBT)
- daily walks outside, even on cloudy days
- aerobic exercise
CYP34A enzyme
CYP3A4 is the main human enzyme responsible for phase I metabolism of dietary compounds, prescribed drugs and xenobiotics, steroid hormones, and bile acids
- cannot give with St. John’s wart with antidepressants b/c it can be neurotoxic, cause serotonin syndrome
CYP2C19 enzyme
CYP2C19 processes (metabolizes) medicine to remove them from the body - people can be poor, rapid, or ultra-rapid metabolizers
metabolizes numerous commonly used drugs including citalopram, clomipramine, clopidogrel, diazepam, omeprazole, S-mephenytoin, and biguanides
Asian population may not have this and cannot metabolize pain medications such as tramadol, codeine
Tricyclic Antidepressants
increase norepinephrine and serotonin and decreasing acetylcholine
- TRIPTYLINE
- example amitriptyline (no longer sold under brand name Elvil)
weight gain
cardiac history - slow cardiac conduction - obtain EKG
anticholinergic effects
Easy to overdose (5x to be dangerous)
Duloxetine (Cymbalta) is approved for treatment of major depressive disorder in adults as well as fibromyalgia. There are no known significant interactions with gabapentin (Neurontin) (C).
Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SNRI). Dosages typically range from 20–60 mg per day, though doses up to 120 mg per day may be seen in some cases. No tests are required prior to starting duloxetine in healthy individuals, though blood pressure should be evaluated and monitored at regular intervals while using this medication, as SNRIs have the potential to increase blood pressure.
Why are the other choices incorrect?
Duloxetine is approved for the treatment of generalized anxiety disorder in adolescents, though it is not approved for depression in this population. Duloxetine also has the potential to increase the risk for serotonin syndrome when combined with sumatriptan (Imitrex) (A). Duloxetine should be avoided in patients with hepatic impairments such as hepatitis B (B). SNRIs such as duloxetine have the potential to increase blood pressure and thus should be avoided in those with uncontrolled hypertension (D).
Monoamine oxidase inhibitors
MAOIs
- tyramine & grapefruit juice = NO!
- inhibits monamine oxidase that removes serotonin, dopamine, and norepinephrine
3rd line treatment for refractory or atypical depression
- cannot prescribe with other antidepressants d/t serotonin syndrome
- avoid tyramine: aged cheese, sausages, cured meats, yogurt d/t putting them in hypertensive crisis
- avoid grapefruit juice
