Psychopharmacology Flashcards
Susie has a depressive episode with no history of hypomania or mania. She has depressed mood, not eating, psychomotor retardation and poor sleep with early morning wakening. What agent would you like to use for her?
Establish dx: Major depressive disorder
Target symptoms: depression, poor appetite, psychomotor retardation and insomnia
what medications would you avoid
Less desirable choices include Paroxetine and Mirtazapine because of sedation and wt gain.
Not a duel reuptake inhibitors because she is treatment naïve.
Not a TCA because of side effects
Susie has a depressive episode with no history of hypomania or mania. She has depressed mood, not eating, psychomotor retardation and poor sleep with early morning wakening. What agent would you like to use for her?
Establish dx: Major depressive disorder
Target symptoms: depression, poor appetite, psychomotor retardation and insomnia
what medications would you reccomend
For a treatment naive patient start with an SSRI.
Using the side effect profile as a guide select an SSRI that is less sedating. Good choices would be Citalopram, Fluoxetine or Sertraline.
ob is a 55 year old diabetic man with mild hypertnesion and painful diabetic neuropathy who has had previous depressive episodes and one suicide attempt. He meets criteria currently for a major depressive episode with some anxiety. He has been treated with paroxetine, sertraline and mirtazepine. His depression was improved slightly with each of these meds but never remitted. What would you like to treat him with?
Establish dx: Major depressive disorder with anxious features
Target symptoms: depressive sx, anxiety and possibly his neuropathic pain
Assuming he received adequate trials previously would move on to a duel reuptake inhibitor as he had not achieved remission with two SSRIS or a novel agent.
Given his mild HT would not choose Venlafaxine. TCA’s can help with neuropathic pain and depression however not a good choice given the SE profile and lethality in overdose. Duloxetine is a good choice since it has an indication for neuropathic pain, depression and anxiety. Three birds with one stone!!
how would you treat treatment resistant depression
Combination of antidepressants eg SSRI or SNRI with Mirtazepine
Adjunctive treatment with Lithium
Adjunctive treatment with atypical antipsychotic eg Quetipaine, Olanzapine or Aripiprazole
If interested look up STAR D study
ECT!!
how would you treat treatment resistant anxiety
High dose SSRI first
Combination of antidepressants eg SSRI or SNRI with Mirtazepine
Adjunctive treatment with atypical antipsychotic eg Quetiapine, Olanzapine or Risperidone
Adjunctive treatment with Pregabalin or buspirone
Diazepam does not treat underlying cause!! Avoid
47 yo woman hospitalized with her first episode of mania. She has no previous history of a depressive episode. She has no drug or ETOH history and has no medical issues. What medication would you like to start?
Given her first presentation was a manic episode statistically she will do better on lithium. Likely over child bearing age.
Make sure to check a pregnancy test, serum creatinine and TSH prior to initiation of treatment.
Discuss with her what she will use for birth control and document this discussion.
You start her at 800mg nocte (average starting dose) and when she comes to see you in one week she is complaining about stomach irritation and some diarrhea. What do you think is going on and what should you do?
GI irritation including diarrhea is common particularly early in treatment. Encourage pt to drink adequate fluid, leave at current dose and see if side effects resolve.
27 yo male is admitted secondary to a manic episode. In reviewing his history you find he has 5 to 6 manic or depressive episodes a year. He has also struggled on and off with ETOH abuse. What medication would you like to start?
Valproic acid would be a good choice because pt is a rapid cycler (4 or more depressive or manic episodes/year) and because of comorbid ETOH abuse.
You start 250mg BD and titrate to 500mg BD. His depakote level is 70. You check his lfts and compared to baseline
Schizophrenia is a chronic illness
Roughly 1/3 don’t respond to first line treatment
Treatment resistance defined as poor response to 2 first line antipsychotics at at adequate dose for 8 weeks
Clozapine used in this case
21 yo AA male with symptoms consistent with schizophrenia is admitted because of profound psychotic sx. He is treatment naïve. You plan to start an antipsychotic- what baseline blood work would you obtain?
Many atypical antipsychotics can cause dyslipidemia, abnormal LFT’s and elevated blood sugars and there is a class risk of diabetes unrelated to weight gain so you need the following:
Fasting lipid profile
Fasting blood sugar
Lfts
WBC
His labs come back as follows:
Mildly elevated choleerol and glusose
Lfts, WBC Normal
What agent would you like to start?
Pt has mildly elevated total cholesterol and a low HDL for his age. Would not choose Olanzapine or Quetiapine given risk of dyslipidemia. Risperidone, Lurasidone or Aripiprazole are good choices.
You start Risperidone and titrate to 3mg BID (high average dose)
He starts to complain that he “feels uncomfortable in my skin like I can’t sit still”. What is likely going on and what are you going to do about it?
He is likely experiencing akathisia. This is not uncommon with Risperidone. Given he was very ill reducing the dose may not be the best choice so likely treat with an propranolol or diazepam. You need to treat akathisia because it is associated with an increase risk for suicide!
