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Psychopharm > Psychopharm Cases > Flashcards

Psychopharm Cases Flashcards

1
Q

How far into the diagnosis process can you start treating psychosis?

A

Can start treating psychosis even before you have a diagnosis

  • want to restores functioning
  • relieve functioning
  • make sure person has capacity to participate in future medical decisions
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2
Q

Drugs that can induce psychosis

A
  • cocaine
  • MJ
  • PCP (NMDA blocker)
  • K2
  • amphetamines (due to surge of DA, NE)
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3
Q

Mechanism of cocaine activity

A

Cocaine = NE/DA/5HT2 reuptake inhibitor

=sympathomimetic

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4
Q

Mechanism of PCP activity

A

NMDA (glutamate) receptor blocker

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5
Q

Mechanism by which stimulants treat ADHD

A

D2 increase in the mesocortical tract

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6
Q

For agitation: use Haldol or Chlorpromazine

A

Asking high vs. low potency typical antipsychotic

-use Haldol (good for agitation)

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7
Q

Describe the mechanism by which congentin treats EPS

A

EPS can be seen as an imbalance btwn dopaminergic and cholinergic neurons

-decreasing cholinergic increases the dopaminergic => congentin increases the DA tone in the nigrostriatal pathway

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8
Q

Why is it so critical to monitor pts on antipsychotics for akithesia?

A

B/c big risk factor for suicide

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9
Q

Treatmetn for akithesia

A
  • Beta-blocker (but watch out for bronchoconstriction)

- sometimes anticholinergisc or benzos

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10
Q

Mechanism of tardive dyskinesia

A

Due to upregulation of the DA receptors over time

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11
Q

What is the risk of depot antipsychotics?

A

If NMS is induced, you can’t stop the offending agent! So require long term very careful monitoring

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12
Q

Typical monitoring schedule for pt on clozapine

A
  • every week for first 6 months
  • every 2 weeks for next 6 mo
  • then every month after that
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13
Q

Bromocriptine

(a) mechanism
(b) indications

A

Bromocriptine

(a) Dopamine agonist
(b) used in Parkinsons, also in hyperprolactinemia b/c DA and prolactin have reverse feedback mechanisms

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14
Q

Which antipsychotic causes the most hyperprolactinemia

A

Risperidone (even more than Haldol)

-not known why

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15
Q

How to keep someone on Risperidone despite hyperprolactinemia?

A

Add a bit of aripiprazole (has some partial D2 agonism) => aripiprazole will kick the Risperidol in the tuberoinfundibular tract off the receptor to decrease prolactin release => decrease sexual dysfuntion

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16
Q

Physostigmine

A

Physostigmine = cholinesterase inhibitor

-give for anti-cholinergic (ex: benadryl, TCA) overdose

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17
Q

Atropine

A

Anti-cholinergic

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18
Q

2 ways to judge a suicide attempt

A

(1) lethality of mechanism
ex: gun vs. cutting w/ plastic knife

(2) Intent to die
ex: at home alone or in public

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19
Q

Describe the cardiotoxicity of TCAs

A

Cardiotoxicity is due to the anticholinergic effect: increases AV node conduction => increases arrhythmia risk

-prolongs QTC => increased risk of Torsades (type of VT that => sudden cardiac death)

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20
Q

Biggest risk factors for SA

A

-previous attempts

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21
Q

Contraindication for antidepressants

A

Bipolar disorder!!!

Need to monitor carefully for subthreshold hypomanic symptoms

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22
Q

Describe the effects of 5HT on

(a) 5HT1A
(b) 5HT2A
(c) 5HT2C

A

5HT receptors

(a) More serotonin at 5HT1A is what creates the antidepressant/anxiolytic effects
(b) 5HT2 and 5HT2C => anxiety, agitation, akithesia, sexual side effects

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23
Q

How may SSRIs contribute to akithesia?

A

Extra 5HT causes decreased DA release => akithesia

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24
Q

Why side effects of SSRIs may decrease after the first few weeks

A

5HT2A receptors downregulate more than 5HT1A receptors

25
Q

Dose dependent effects of SNRIs

A
  • Venlafaxine doesn’t becoming N until decently high dose

- Desvenlafaxine becomes SN at low doses

26
Q

What may you add as as adjunct to SNRI/SSRIs for depression

A

Mertazapine b/c it has a different mechanism => can be added w/ synergistic effect

27
Q

Effect of SSRIs on hemoregulation

A

Platelets also have 5HTT => SSRIs cause platelets to be less active => increased risk for GI, surgical etc bleeding

28
Q

Explain basic approach to antidepressant therapy for basic depression

A

Start on SSRI

(a) if partial response- increase dose
(b) if at max dose- stick w/ it (max effect at 1-2 mo) and add
- psychotherapy
- buproprion
- mirtazapine if having trouble sleeping
- thyroid hormone

29
Q

3 things proven to decrease suicidality

A
  • lithium
  • clozapine
  • ECT
30
Q

Miosis vs. mydriasis

A

Miosis = pinpoint pupils

Mydriasis = huge pupils

31
Q

Miosis vs. mydriasis

(a) trazodone
(b) opioid overdose
(c) stimulants
(d) SSRI/SNRI
(e) Mirtazapine
(f) opiate withdrawal
(g) antipsychotics
(h) anticholinergics
(i) cocaine intoxication

A

Miosis (pinpoint pupils) vs. mydriasis (dilated pupils)

(a) trazodone => miosis
(b) opioid overdose => pinpoint pupils
(c) stimulants => mydriasis
(d) SSRI/SNRI => mydriasis
(e) Mirtazapine => miosis
(f) opiate withdrawal => mydriasis
(g) antipsychotics => miosis
(h) anticholinergics => mydriasis
(i) cocaine (sympathomimetic => mydriasis

32
Q

Mechanism by which opiate OD => pupil change

A

Opiate OD => miosis (pinpoint pupils)

due to loss of sympathetic activity to the ciliary ganglion => parasympathetics work uninhibited

33
Q

3 main clinical signs of serotonin syndrome

A

clonus, tremor, diarrhea

34
Q

Pharmacologic treatment for

(a) serotonin syndrome
(b) NMS

A

pharmacologic tx for

(a) serotonin syndrome = benzos

(b) NMS
- benzos
- bromocriptine (DA agonist)
- dantriline (CCB) for rigidity

35
Q

Clinical signs of alcohol withdrawal

A

-hypertension, tachycardia, tremor

36
Q

Differentiate the 3 benzos used in alcohol withdrawal

A

(1) Lorazepam
- safest if there’s liver dysfxn, but not long acting

(2) Chlordiazeproxide (librium)
(3) Diazepam (valium)
- advantage that they’re longer acting
- but be careful b/c they have active metabolites

37
Q

Goal of benzo use during alcohol withdrawal

A
  • keep vitals stable

- keep pt resting but arousable

38
Q

Medication to treat opiate withdrawal

A

Clonidine (alpha agonist) directly targets the withdrawal

-opiates (sympathomimetic) => alpha receptors downregulate

39
Q

Signs of MJ overdose

A
  • can cause psychosis
  • hyperphagia
  • conjunctiva injection
40
Q

Signs of MJ withdrawal

A

No such thing…MJ doesn’t cause withdrawal

41
Q

CV risks of cocaine overdose

A

Cocaine-induced MI

-increased inotropy increases myocyte oxygen demand

42
Q

Psychiatric risks of cocaine overdose

A

-mood and psychotic symptoms

43
Q

Best way to treat bipolar manic episode

A
  • Can use Depakote alone (good for mania and works quickly)
  • Can’t use lithium in isolation for acute mania (takes 1-2 weeks to have effect) => use Li + benzo or atypical

distant 3rd choice = carbamazepine

44
Q

Drugs for bipolar maintenance

A

Aka how to avoid mania btwn episodes

  • lithium: slower acting tho so if used acutely add another
  • depakote: faster acting than lithium, good for manic (but not depressive) bipolar
    adjuncts: atypicals, carbamazepine
45
Q

Drugs for bipolar depressive episode

A

-NOT depakote- does little for depression

(1) Lithium + lamotrigine
- atypicals
- carbamazepine

46
Q

What to look for on ECG of pt on lithium

A

Bradycardia

-T wave flattening (which is benign)

47
Q

What to look for on CBC of pt on lithium

A

Benign leukocytosis

-b/c of margination: WBCs acucmulate to the edge of the vessel => get higher white count when take blood from edge of vessel

48
Q

Clinical signs of lithium toxicity

A
  • tremors

- renal failure

49
Q

Major classes of drug interactions w/ lithium

A
  • thiazide diuretics
  • ACEi
  • NSAIDs
50
Q

What to look for on CBC of pt on valproic acid

A
  • thrombocytopenia

- aplastic anemia (pancytopenia)

51
Q

What to monitor on BMP for pt on valproic acid

A

Ammonia level

-valproic acid can cause hyperammonium => delirium

52
Q

Ideal lithium serum level in

(a) acute mania
(b) bipolar maintenance

A

Ideal serum lithium level

(a) acute mania: .8-1.2
(b) bipolar maintenance .5-1.0

-and for some ppl even w/in that range might be too high, so close monitoring required

53
Q

Common side effects of lithium

A
  • GI irritation
  • cognitive blurring
  • weight gain
  • polyuria, polydipsia
54
Q

When can benzo intoxication be lethal?

A

When combined w/ EtOH or opiates

55
Q

What determines the

(a) half life of a benzo
(b) time to onset of a benzo

A

Benzo

(a) half life (duration of action) depends on active metabolites
(b) time to onset depends on its lipid solubility

56
Q

Name 4 short acting benzos

A

Short acting benzos:

  • aprazolam (Xanax)
  • lorazepam (Ativan)
  • oxtazepam (Serax)
  • temazepam (restoril)
57
Q

Name 3 long acting benzos

A

Long acting benzos:

  • clonazepam (klonopin)
  • diazepam (valium)
  • chlordiazepoxide (librium)
58
Q

California rocket fuel

A

Velafaxine (SNRI) + Mirtazapine (NaSSA)

Psychopharm (10 decks)

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