Psychiatric - Mental Health

Question 1

Depression
first line medications

Answer 1

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

Question 2

Why do people stop taking their depression medications? What can be added to help?

Answer 2

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

Question 3

Depression
herbal supplement

Answer 3

St. John’s Wart
- do not use anything with serotonin in addition
- serotonin syndrome s/s
shivering
seizure
shaking
tremors
tachycardia
agitation

Question 4

SNRI side effects

Answer 4

GI issues
- diarrhea will go away on its own, but increase fiber

Question 5

Selective serotonin reuptake inhibitors SSRI
SSRI

Answer 5

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

Question 6

Suicidal Ideation = safety alert

Answer 6

• straight forward do they have a plan and how they will do it
• black box warning on antidepressants
• 72 hold possibly

Question 7

• SSRI to avoid with elderly
• tricyclic antidepressants to avoid with the elderly

Answer 7

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

Question 8

Antidepressants safe in elderly

Answer 8

SSRI
- sertraline (Zoloft)
- escitalopram (Lexapro)

Question 9

Patient is experiencing fatigue

Answer 9

order iron and thyroid panel (D)

Increasing fatigue is not an expected finding with escitalopram (Lexapro)

Question 10

Which SSRI is most sedating?

Answer 10

paroxetine (Paxil)

Question 11

Which SSRI to avoid with anxiety?

Answer 11

fluoxetine (Prozac) due to jitteriness side effect

Question 12

Serotonin and norepinephrine reuptake inhibitors
SNRI

Answer 12

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

Question 13

Duloxetine (Cymbalta) SNRI

Answer 13

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

Question 14

Atypical antipsychotics
Examples and Assessments

Answer 14

• 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

Question 15

Haloperidol (Haldol)

Answer 15

first-generation antipsychotic
schizophrenia
Tourette syndrome

weight gain
elevations in triglycerides
fasting plasma glucose
metabolic syndrome
tardive dyskinesia
QT prolongation

Question 16

Bipolar Disorder
s/s
tx and side effects

Answer 16

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

Question 17

Post Traumatic Stress Disorder
s/s
tx

Answer 17

nightmares, hypervigilence (assessing threat around you), startle response, flashbacks, insomnia

SSRI
escitalopram (Lexapro) or fluoxetine (Prozac)

Question 18

Seasonal Affective Disorder

Answer 18

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

Question 19

CYP34A enzyme

Answer 19

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

Question 20

CYP2C19 enzyme

Answer 20

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

Question 21

Tricyclic Antidepressants

Answer 21

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)

Answer 21

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).

Question 22

Monoamine oxidase inhibitors
MAOIs
- tyramine & grapefruit juice = NO!

Answer 22

• 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