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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
Dose dependent effects of SNRIs
- Venlafaxine doesn't becoming N until decently high dose | - Desvenlafaxine becomes SN at low doses
26
What may you add as as adjunct to SNRI/SSRIs for depression
Mertazapine b/c it has a different mechanism => can be added w/ synergistic effect
27
Effect of SSRIs on hemoregulation
Platelets also have 5HTT => SSRIs cause platelets to be less active => increased risk for GI, surgical etc bleeding
28
Explain basic approach to antidepressant therapy for basic depression
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
3 things proven to decrease suicidality
- lithium - clozapine - ECT
30
Miosis vs. mydriasis
Miosis = pinpoint pupils Mydriasis = huge pupils
31
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
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
Mechanism by which opiate OD => pupil change
Opiate OD => miosis (pinpoint pupils) due to loss of sympathetic activity to the ciliary ganglion => parasympathetics work uninhibited
33
3 main clinical signs of serotonin syndrome
clonus, tremor, diarrhea
34
Pharmacologic treatment for (a) serotonin syndrome (b) NMS
pharmacologic tx for (a) serotonin syndrome = benzos (b) NMS - benzos - bromocriptine (DA agonist) - dantriline (CCB) for rigidity
35
Clinical signs of alcohol withdrawal
-hypertension, tachycardia, tremor
36
Differentiate the 3 benzos used in alcohol withdrawal
(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
Goal of benzo use during alcohol withdrawal
- keep vitals stable | - keep pt resting but arousable
38
Medication to treat opiate withdrawal
Clonidine (alpha agonist) directly targets the withdrawal -opiates (sympathomimetic) => alpha receptors downregulate
39
Signs of MJ overdose
- can cause psychosis - hyperphagia - conjunctiva injection
40
Signs of MJ withdrawal
No such thing...MJ doesn't cause withdrawal
41
CV risks of cocaine overdose
Cocaine-induced MI | -increased inotropy increases myocyte oxygen demand
42
Psychiatric risks of cocaine overdose
-mood and psychotic symptoms
43
Best way to treat bipolar manic episode
- 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
Drugs for bipolar maintenance
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
Drugs for bipolar depressive episode
-NOT depakote- does little for depression (1) Lithium + lamotrigine - atypicals - carbamazepine
46
What to look for on ECG of pt on lithium
Bradycardia -T wave flattening (which is benign)
47
What to look for on CBC of pt on lithium
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
Clinical signs of lithium toxicity
- tremors | - renal failure
49
Major classes of drug interactions w/ lithium
- thiazide diuretics - ACEi - NSAIDs
50
What to look for on CBC of pt on valproic acid
- thrombocytopenia | - aplastic anemia (pancytopenia)
51
What to monitor on BMP for pt on valproic acid
Ammonia level | -valproic acid can cause hyperammonium => delirium
52
Ideal lithium serum level in (a) acute mania (b) bipolar maintenance
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
Common side effects of lithium
- GI irritation - cognitive blurring - weight gain - polyuria, polydipsia
54
When can benzo intoxication be lethal?
When combined w/ EtOH or opiates
55
What determines the (a) half life of a benzo (b) time to onset of a benzo
Benzo (a) half life (duration of action) depends on active metabolites (b) time to onset depends on its lipid solubility
56
Name 4 short acting benzos
Short acting benzos: - aprazolam (Xanax) - lorazepam (Ativan) - oxtazepam (Serax) - temazepam (restoril)
57
Name 3 long acting benzos
Long acting benzos: - clonazepam (klonopin) - diazepam (valium) - chlordiazepoxide (librium)
58
California rocket fuel
Velafaxine (SNRI) + Mirtazapine (NaSSA)

Psychopharm (10 decks)

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