Psychiatry Flashcards
Selective serotonin reuptake inhibitors (SSRIs)
An adequate trial is considered 4-6 weeks SA: headache, GI disturbance, sexual dysfunction, increased bleeding (2/2 platelet dysfunction), increased risk of peptic ulcers (avoid NSAIDs)
Venlafaxine (Effexor)
SNRI SA: diaphoresis, increased BP Not the best for hypertensive patients
Duloxetine (Cymbalta)
SNRI FDA approved for pain
Mirtazapine (Remeron)
Alpha2-adrenergic receptor antagonist Good for the elderly, increases appetite, sedating
Tricyclic antidepressants (TCAs)
SA: sedation, weight gain, orthostatic hypotension, anticholinergic effects, prolonged QT interval Most lethal in overdose –> arrythmias
Monoamine oxidase inhibitors (MAOIs)
Used for refractory depression SA: hypertensive crisis when used with sympathomimetics or ingestion of tyramine-rich foods (wine, beer, aged cheeses, liver, smoked meats), orthostatic hypotension, serotonin syndrome if combined with other serotonergic drugs
Lithium
Mood stabilizer
Indicated for bipolar I
Reduces suicide risk
SA: weight gain, tremor, GI disturbance, fatigue, arrhythmias, seizures, goiter/hypothyroidism, leukocytosis, nephrogenic DI, polydipsia, alopecia, metallic taste
Avoid in renal disease, heart disease, hyponatremia, diuretic use, pregnancy (a/w Ebstein anomaly)
Check creatinine and TFTs before starting
Carbamazepine
Sodium channel blocker
Indicated for bipolar I, esp. rapid cycling or mixed features
Valproic acid
Sodium channel blocker, inhibits GABA transaminase increaseing GABA concentration
Indicated for bipolar I, esp. rapid cycling or mixed features
Avoid in liver disease
Monitor for thrombocytopenia
Sertraline (Zoloft)
SSRI Good for atypical depression and MDD with psychotic features FDA approved for PTSD
Citalopram (Celexa)
SSRI FDA approved for MDD Good for depression in the elderly and for behavioral issues related to dementia Prolongs QTc
Prazosin
Alpha1-receptor antagonist Indicated for nightmares and hypervigilance a/w PTSD
Escitalopram (Lexapro)
SSRI Best tolerated SSRI FDA approved for MDD and GAD
Melatonin
Indicated for circadian rhythm sleep disorders
Pramipexole
Dopamine agonist Indicated for Parkinson disease and restless leg syndrome
Quetiapine (Seroquel)
Atypical antipsychotic SA: sedating Adjunct for depression
Modafinil
Nonamphetamine Indicated for narcolepsy
Risperidone
Atypical antipsychotic
SA: hyperprolactinemia (sexual dysfunction, gynecomastia in men, amenorrhea, glactorrhea)
Aripiprazole (Abilify)
Atypical antipsychotic
More weight neutral
Good adjunct for depression
SA: akathisia
Clozapine (Clozaril)
Atypical antipsychotic
SA: agranulocytosis, seizures, myocarditis, orthostatic hypotension
Very effective but reserved for patients who have failed at least 2 antipsychotic trials as need to regularly monitor CBC
Olanzapine
Atypical antipsychotic
SA: weight gain
Paliperidone (Invega)
Atypical antipsychotic Metabolite of risperidone
Lurasidone (Latuda)
Atypical antipsychotic Adjunct for bipolar, minimal effect on QTc
Ziprasidone
Atypical antipsychotic
SA: prolongs QTc
Minimal effect on weight
Treatment for acute mania
Antipsychotics (quick onset) Lithium Valproate
Lamotrigine
Anticonvulsant Indicated for bipolar depressive episodes SA: Stevens-Johnson syndrome
fTreatments for extrapyramidal symptoms
Acute dystonia –> benzotropine or diphenhydramine (IM)
Akathisia –> reduction of antipsychotic dose + beta-blocker or benzodiazepine
Parkinsonism –> benzotropine or amantadine
Tardive dyskinesia –> no definitely treatment but clozapine may help
The first three are caused by acute D2 blockade but tardive dyskinesia is associted with chronic antipsychotic use which causes upregulation of dopamine receptors
Neuroleptic malignant syndrome
Characterized by fever/hyperthermia, autonomic instability (tachycardia, labile BP, tachypnea, diaphoresis), muscle rigidity (lead-pipe), AMS, elevated CK
Causes: antipsychotics, antiemetics, antiparkinson medication withdrawal
Tx: stop the antipsychotic, supportive care (hydration, cooling), dantrolene or bromocriptine
Haloperidol
Typical antipsychotic, high potentcy SA: dystonia, akathisia, parkinsonism, tardive dyskinesia
Serotonin syndrome
S&S: autonomic instability, AMS, hyperreflexia, myoclonus, increased bowel sounds
Tx: stop medication, benzos for clonus, CCB for HTN, cyproheptadine
Associated with drug-drug interactions with serotonergic activity (e.g. SSRIs, MAOIs, linezolid)
Buspirone
Anxiolytic 5-HT1A agonist
Indicated for generalized anxiety disorder
Not effective in treating acute anxiety due to slow onset of action
Clomipramine
TCA (most serotonin selective) Can be used to treat obsessive-compulsive disorder but not first line
Chlorpromazine
Typical antipsychotic
SA: corneal deposits
Fluphenazine
Typical antipsychotic, high potentcy
Perphenazine
Typical antipsychotic
Atypical antipsychotics
Serotonin (5-HT2) and dopamine (D4 > D2) antagonists SA: HTN, hyperglycemia, weight gain, HLD
What are the weight neutral atypical antipsychotics?
Aripiprazole Ziprasidone
Which antipsychotics are good adjuncts for depression?
Aripiprazole Quetiapine
Fluoxetine (Prozac)
SSRI
Only SSRI FDA approved for bulimia
Indicated for MDD, OCD, bulimia
Alprazolam
Short-acting benzodiazepine Can cause seizures following abrupt discontinuation
Paroxetine (Paxil)
SSRI FDA approved for PTSD Inhibits it’s own metabolism Short half-life –> requires taper
Risk factors for obstructive sleep apnea
STOP BANG Snoring Tiredness during the day Observed apnea Pressure of blood BMI > 35 Age > 50 Neck circumference > 16 Gender of male
Fluvoxamine (Luvox)
SSRI FDA approved for OCD and social phobia Interacts with nicotine
Desvenlafaxine (Pristiq)
SNRI Active metabolite of venlafaxine
Duloxetine (Cymbalta)
SNRI
Serotonin discontinuation syndrome
S&S: dizziness, fatigue, headache, nausea, “electric like” shocks Highest risk is paroxetine
What medication is contraindicated in eating disorders?
Bupropion because it lowers the seizure threshold
Diagnostic tests for alcohol use disorder?
MCV –> macrocytosis GGT AST > ALT (not specific) Blood alcohol level (high levels without evidence of intoxication = tolerance) High HDL, low LDL (not specific)
Buprenorphine
Opioid receptor partial agonist Used to treat opioid addiction
Methadone
Mu-opioid agonist
Used to help with opioid detox in people with opioid dependence (has a long half-life so suppresses cravings and withdrawal symptoms ≥ 24 hours)
Disulfiram
Inhibits aldehyde dehydrogenase –> patient feels ill if ethanol consumed
Used to treat alcoholism in high-functioning alcoholics who desire long-term abstinence
Treatment of catatonia
Benzodiazepines and/or ECT Avoid antipsychotics
Lorazepam
Benzodiazepine
Chlordiazepoxide
Very long-acting benzodiazepine
Avoid in liver disease
Bupropion
Norepinephrine and dopamine reuptake inhibitor (NDRI)
Often added when partial response to SSRI or sexual side effects from SSRIs
Can also aid in smoking cessation
Avoid in patients with bulimia or seizures
Nortryptyline
TCA
Tranylcypromine
MAOI
Indicated for treatment-resistant or atypical depression
Flumazenil
Bensodiazepine antagonist Used to treat overdose
Amitryptyline (Elavil)
TCA
Most anticholinergic
What medications are good for treating the depressed stage of bipolar disorder?
Atypical antipsychotics quetiapine and lurasidone
Treatment for treatment-resistant or severe bipolar?
Lithium or valproate + atypial antipsychotic (quetiapine)
Trazodone
Serotonin agonist and reuptake inhibitor Sedating SA: priapism
Doxepin
TCA
Imipramine
TCA
Trimipramine
TCA
Desipramine
TCA Least antichoinergic
Isocaroxazid
MAOI
Selegiline
MAOI, selectively MAO-B
MAO-B preferentially metabolizes dopamine over norepinephrine and serotoin so inhibition increases the availability of dopamine
Indicated for treatment-resistant or atypical depression, Parkinsons
Moclobemide
MAOI
Pirlindole
MAOI
Treating an MAOI-induced hypertensive crisis?
Stop medication, IV nitroprusside, clonidine
In which psychiatric disorders is pharmacology the first line treatment?
ADHD Schizophrenia Bipolar disorder
Narcolepsy
≥ 3x/week for 3 months of excessive daytime sleepiness, hypnagogic hallucinations (on falling asleep), sleep paralysis, cataplexy (emotionally triggered loss of muscle tone)
May see decreased hypocretin-1 (orexin) in CSF
Tx: stimulants in the daytime (amphetamines, modafinil), sodium oxybate (GHB) at night
Schizophrenia timeline
< 1 month: brief psychotic disorder
1-6 months: schizophreniform disorder
> 6 months: schizophrenia
Schizoid vs. schizotypal vs. schizoaffective
Schizoid: voluntary social withdrawal, content with isolation
Schizotypal: eccentric, odd/magical beliefs
Schizoaffective: schizophrenia + bipolar or depressive mood disorder
Stress disorders timeline
3 days - 1 month: acute stress disorder
> 1 month: PTSD
Sleep terror disorder vs. nightmares
Sleep terror disorder: occur during non-REM sleep, no memory or arousal
Nightmares: occur during REM sleep, memory of scary dream
Methylphenidate
Increases catecholamines (especially norepinephrine and dopamine) at the synaptic cleft
Indicated for ADHD, narcolepsy, and appetite control
Bipolar disorder with psychotic features vs. Schizoaffective disorder
In bipolar disorder with psychotic features, psychotic symptoms occur exclusively during mood episodes
In schizoaffective disorder, delusions or hallucinations are present in the absense of major depressive or manic episodes
Bipolar I vs. bipolar II
Bipolar I: at least one manic episode, depressive episode not required
Bipolar II: at least one hypomanic episode + at least one major depressive episode
Manic episode: symptoms more severe, last at least 1 week or required hospitalization, marked impairement, may have psychotic features
Hypomanic episode: less severe symptoms, ≥ 4 consecutive days, less severe impairement, no psychotic features
Rett syndrome
X-linked disorder (MECP2 gene) seen almost exclusively in girls
Regression characterized by loss of development, loss of verbal abilities, intellectual disability, ataxia, stereotyped hand-wringing, deceleration of head growth
Apparent around ages 1-4
Strongest predictive factor for suicide?
Previous suicide attempts
Phenelzine
MAOI
Indicated for treatment-resistant or atypical depression
What characterizes atypical depression?
Mood reactivity (feeling better in response to positive events)
Leaden paralysis
Reaction sensitivity
Tourette disorder vs. tic disorder
Tourette disorder: ≥ 1 year of motor + vocal tics (don’t have to be concurrent)
Tic disorder: ≥ 1 year of motor or vocal tics but not both
Bulimia nervosa vs. binge-eating disorder
Bulimia nervosa: compensatory behaviors, excessive worry about body shape and weight
Binge-eating disorder: no compensatory behaviors
