Psychopharmacology Flashcards
Indications for supportive psychotherapy
- Adjustment disorders
- Acute emotional crises
- When a long-lasting “cure” is not expected, but improved functioning is hoped for (as in chronic schizophrenia, for example)
Indications for insight-oritented psychotherapy
- Treatment of anxiety and depression in all of their forms
- Somatoform and dissociative disorders
- Personality disorders
- Neuroses
- Chronic effects of psychosocial trauma
Goal of supportive psychotherapy
To form a close therapeutic alliance with the patient and help to define current problems, consider and implement possible solutions
Goal of insight psychotherapy
Recognize transference/countertransference feelings as they occur, uncover unconscious wishes and defenses that may have caused the patient to behave in a maladaptive manner
Substitution therapy
Form of behavioral modification therapy that is aimed at replacing an undesirable behavior with a desirable one
Ex, replace smoking with chewing gum
Types of “talk therapy”
Individual psychotherapy
Behavior modification therapy
Cognitive therapy
Social therapy (therapy as a group of similar patients, family, couple, etc)
Indications for ECT
- Depression that is unresponsive to medication
- Depression that is severe and acutely life-threatening (unrelenting, serious suicidal ideation, patient will not eat/drink, etc)
- Severe, unrelenting mania (less common)
What is the single most effective treatment for severe major depressive disorder?
ECT
Side effects of ECT
- Postictal state (brief)
- Possible retrograde memory loss
- Headache, nausea
- Muscle stiffness
- Very small to nonexistent risk of long-term cognitive impairment
Contraindications to ECT
- Elevated ICP
- Space-occupying lesion in the brain
- Recent MI (< 3 months since event)
- Severe arterial hypertension
Note that pregnancy is NOT a contraindication to ECT.
Transcranial magnetic stimulation
Similar idea to ECT, but not inducing a seizure
Must be used repetitively (generally daily, 5x/week, 4-6 weeks). For this reason it is usually called “repetitive” TMS, or rTMS.
Side effects of rTMS
- Syncope
- Twitching/tingling of facial musculature
- Scalp discomfort at site of treatment
- Headache
- Rarely, hearing loss, seizure
- Rarely may induce a manic episode in those with bipolar disorder
Tricyclic antidepressants
SSRIs and SNRIs
MAOis
Miscellaneous antidepressants
Mood stabilizers
1st generation antipsychotics
2nd generation antipsychotics
Nonbenzodiazepines
Stimulants
Treating antipsychotic-induced dystonias
Anticholinergics (or 1st generation antihistamines with anticholinergic properties) are used for this indication:
Bantropine, biperiden, diphenylhydramine, trihexyphenidyl
Treating antipsychotic-induced akithisias
Remember, akithisias = motor restlessness
Propranolol or benzodiazepines are useful for this indication
Medications used to treat parkinsonian side effects of antipsychotics
Amantadine and/or levodopa are typically used
Important side effect of chronic quetiapine use
Cataracts may develop
Slit-lamp exam when starting chronic use and q6 month are recommended
Possible acute side effect of trazodone
Priapism
Treat with intra-corporal injection of epinephrine. This is a medical emergency.
What is the single most imporant side effect of buproprion?
Lowering the seizure threshold
Important side effects of clozapine
Agranulocytosis – frequent monitoring of leukocyte count is necessary
Anticholinergic effects
Like all antipsychotics, possibility of NMS
Treatment for life-threatening lithium toxicity
Dialysis
Treatment of benzodiazepine overdose
Flumenazil
A benzodiazepine antagonist
Treatment for excessive daytime sleepiness in shift workers
Modafinil
Just like narcolepsy!
Amoxapine - loxapine relationship
The tricyclic antidepressant amoxapine also happens to be a metabolite of the antipsychotic loxapine
Due to their structural similarity, amoxapine can also cause some extrapyramidal symptoms, making it unique among the tricyclics
Serotonin syndrome symptoms in order of appearance
- Diarrhea
- Restlessness
- Extreme agitation
- Hyperreflexia and autonomic instability
- Myoclonus, seizure, hyperthermia, rigidity, delirium
- Coma, death
Most common side effects of SSRIs
Sexual dysfunction
GI disturbance
Foods containing tyramine
Red wine
Aged cheese
Liver
Smoked foods
Use buproprion in patients with ___
Avoid buproprion in patients with ___
Use buproprion in patients with smoking history
Avoid buproprion in patients with eating disorders, seizures
Who can’t use valproate as a mood stabilizer?
Women of child-bearing age
Benzo withdrawal looks a lot like ___
Benzo withdrawal looks a lot like alcohol withdrawal
Which makes sense. Both GABA antagonists.
ehat is ths crap?
i dunno
Main drug specific side effect of olanzapine
Atypical antipsychotic (serotonin-dopamine antagonist)
Somnolence
All tricyclics end with:
- -yline
- -amine
Exception: amoxapine
Notable side effects of all tricyclics
- Anticholinergic effects
- Orthostatic hypotension and/or tachycardia
- QT prolongation
- Weight gain
Side effects of venlafaxine
“Activating SNRI” that may worsen anxiety
Poor choice for insomnia.
Increases BP at high doses – poor choice for hypertension
Great for patients who need an activating antidepressant
How long of a window should there be between stopping an SSRI/SNRI and starting a MAOi
5 weeks
To prevent serotonin syndrome
Side effects of all SSRIs or SNRIs
Akathisia, anxiety, agitation
Diarrhea/GI upset
Sexual dysfunction
Risk of serotonin syndrome
May increase suicidal thoughts/behaviors
Main drug specific side effect of these SSRIs:
Sertraline
Paroxetine
Fluvoxamine
Citalopram
- Sertraline: Diarrhea
- Paroxetine: Anticholinergic effects
- Fluvoxamine: Nausea/vomiting
- Citalopram: Less sexual side effects than other SSRIs
Mood stabilizers with high risk of neural tube defect in pregnant patients
- Valproate
- Divalproex
Drug specific side effect of Thioridazine
Retinitis pigmentosa
A form of degenerative retinopathy. Characterized by “pigment clumps” in the retina. Images shown.
Technically all antipsythotics can cause this, but it is usually associated with this one
Main drug specific side effect of Ziprasidone
QT prolongation
An atypical antipsycbotic
Only four MAOis you need to know
Phenelzine
Isocarboxazid
Selegiline
Trancylcypromine
If it ends in any of these, it is either a 1st or 2nd generation antipsychotic:
- -zine / -azine
- -apine
- -done / -idone
Why might a TCA be a poor therapeutic choice for a patient with MDD with suicidality?
Because you can OD on it!
TCA toxicity causes potentially fatal cardiac arrhythmias
Buproprion side effect profile
- Reduced seizure threshold
- Tachycardia w/ possible arrhythmias
- Insomnia
- Activating side effects like jitteriness
- Also helps with smoking cessation!
- Weight loss
Effects of mirtazapine
- Effective in treating both depression and anxiety
- Encourages appetite
- Helps induce sleep/to treat insomnia
Best SNRI for the purpose of treating neuropathic pain
Duloxetine
Only two atypical antipsychotics that can be used in an acute setting (fast acting)
Olanzapine
Ziprazidone
Final active metabolite of benzodiazepines
Oxazepam
If someone is delirious, you cannot . . .
. . . comment on psychosis or mood
You have to treat the delirium before you can evaluate these.
Benzos at a low dose can induce ___ rather than ___
Benzos at a low dose can induce disinhibition rather than sedation
Antidepressant rule of 6’s
- It takes 6 weeks to see efficacy
- Stay on it for 6 months at an effective dose before trialing off
- If changing medications, allow for a 6 week washout period
Most common SSRIs
(Es)citalopram
Sertraline
Fluoxetine
Paroxetine
Most common SNRIs
(Des)venlafaxine
Duloxetine
Buproprion cannot be used in ___
Buproprion cannot be used in bulimia
Since they are high risk for seizures
Serotonin modulators
Mirtazepine (SE: orexogenic)
Trazodone (SE: sleep aid, may cause priapism)
More used for their side effects than as primary antidepressants.
TCA’s that don’t end in “-tryptyline”
Imipramine
Doxepin
3 C’s of the TCAs
- Convulsions (increased risk of seizure)
- Cardiotoxicity (predispose to arrhythmias, prolong QT interval)
- Coma (altered mental status)
Patient with a history of depression has a hypertensive crisis after attending a wine and cheese party. What antidepressant are they taking?
One of the MAOis, either phenylzine or selegiline.
Lines of therapy for bipolar
1st line: Li or valproate
2nd line: Quetiapine or Li/valproate + quetiapine or lamotrigine
3rd line / almost never: Carbamazepine
Only FDA approved medication for pediatric depression
Fluoxetine
SSRI with the most cardiac effects
(Es)citalopram
QTc prolongation
What SSRI is contraindicated in pregnancy?
Paroxetine
Lithium toxicity
Lithium toxicity results in an altered mental status, dysarthria, decreased muscle strength, and a coarse tremor.
It happens in the case of overdose OR dehydration.
Treat w/ hemodialysis.
Fluphenazine
1st generation antipsychotic belonging to the Phenothiazine subgroup
Fluphenazine in particular can cause impaired thermoregulation (hyper or hypothermia)
Patients on fluphenazine who are likely to be exposed to extreme temperatures should be monitored
If a patient who smokes is already willing and motivated to quit. . .
. . . there is no additional benefit to motivational interviewing
Start buproprion if there is no contraindication. Otherwise, start varenicline.
Antidepressant discontinuation syndrome
Caused by abrupt cessation of antidepressant drugs without appropriate tapering
Onsets in 1-4 days
Sx include: headache, depressed mood, fatigue, insomnia, nausea, sensory disturbances, irritability, ataxia, tremor, and myalgia
Paroxetine discontinuation has an increased risk of antidepressant discontinuation syndrome.
