Psychotherapeutics Flashcards
Do first or second generation antipsychotics work better in the treatment of schizophrenia?
They work the same
Pros and cons of first gen antipsychotics
Pros = cheaper
Cons = EPS
Pros and cons of second gen antipsychotics
Pros = no EPS
cons = more expensive, metabolic effects that put the patient at risk for CV events and death
Which receptors do 1st gen antipsychotics work on?
D2
Also can interact with ACh, histamine, and NE receptors
Which receptors do 2nd gen antipsychotics work on?
D1, D2, D4, 5-HT
Also can interact with a1, histamine, and M receptors
How long does it take for schizophrenia symptom improvement upon initiation of pharmacological therapy?
2-4 weeks
Full effect: months
Adverse effects of FGAs
EPS!!!
neuroleptic malignant syndrome
Anti cholinergic effects
Orthostatic hypotension
Hyperprolactinemia
Seizures
Sexual dysfunction
Dysrhythmias
What are EPS?
Movement disorders due to drug effects on the extrapyramidal motor system
List 4 types of EPS
pseudoparkinsonism
Acute dystopia
Akathisia
Tardive dyskinesia
Which category of EPS does not have a treatment?
Tardive dyskinesias
How are 3/4 of EPS treated?
Anticholinergics
Amantadine
Beta blockers
Benzodiazepines
Mechanism of neuroleptic malignant syndrome?
DA receptor blockade from antipsychotic medications
S/s neuroleptic malignant syndrome
Rigidity
Sudden high fever
Sweating
ANS instability —> BP changes/dysrhythmias
Seizures, coma
Treatment for neuroleptic malignant syndrome
Withdraw antipsychotic med
Possibly switch to SGA
Supportive care (resp, hemodynamics)
What can NMS also look like?
Serotonin syndrome (from drugs that increase 5-HT)
Major adverse of haloperidol?
Earlier EPS
QT prolongation
What is the potency of haloperidol?
High
What are the major adverse effects of phenothiazine?
Sedation
Orthostatic hypotension
Anticholinergic effects
QT prolongation
Lower incidence of EPS
What are the three metabolic adverse effects of SGA that can result in CV events?
DM
Weight gain
HLD
Schizophrenia relapse while on pharmacological therapy is most likely to occur because of ______.
Nonadherence
How long is the pharmacological treatment of schizophrenia?
Indefinite
Neurotransmitters hypothesized to be involved in depression?
Norepi
Serotonin
When initiating antidepressant therapy, how long until drug effects are at plateau?
Up to 3m
Pharmacological antidepressant therapy should be combined with:
Psychotherapy
Antidepressants have a black box warning because:
Early in treatment, depression/suicidal ideation can increase
List 4 classes of antidepressants
SSRIs
SNRIs
TCAs
MAOIs
Mechanism of SSRIs
Inhibit reputake of 5-HT = increased concentration in neuronal synapse
Which is the safest antidepressant class?
SSRIs
List some SSRIs
Fluoxetine
Citalopram
Escitalopram
Paroxetine
Sertaline
(Others)
Adverse effects of SSRIs
Nausea
Agitation/insomnia
Sexual dysfunction
Weight gain
Serotonin syndrome
Major drug interactions with SSRIs
Other drugs that increase serotonin (MAOIs, SNRIs, TCAs, analgesics, triptans) = serotonin syndrome
Other drugs that inhibit platelet aggregation (antiplatelets) = increased bleeding risk
Mechanism of SNRIs
Inhibit reuptake of 5-HT and NE = increased concentration on neuronal synapse
Adverse effects of SNRIs
Same as SSRIs
+ HTN
List some SNRIs
Venlafaxine
Duloxetine
(Others)
Mechanism of TCAs:
As an antidepressant, they inhibit 5-HT and NE reuptake = increased concentration in neuronal synapse
Not selective tho, so also impact H, M, and various other receptors
List some TCAs
Amitriptyline
Clomioramine
(Others)
Adverse effects of TCAs
Commonly due to H & M receptor interaction
- orthostatic hypotension
- anticholinergic effects
- sedation
- cardiac toxicity (dyrhythmias, HB)
- seizures
- SI
Major reasons for drug interactions with TCAS:
- HTN risk (MAOIs, sympathomimetics)
- CNS depression (additive with other agents)
Mechanism of MAOIs
Inhibit monoamine oxidase = decreased metabolism of NE, 5-HT, DA, tyramine
Antidepressant = increased NE and 5-HT availability
Duration of effect of MAOIs
2 weeks
(Since irreversible inhibition of MAO)
List some MAOI inhibitors used for depression
Isocarboxazid
Phenelzine
Tranycypromine
Are nonselective MAOI or MAO-B inhibitors used for treatment of depression?
Nonselective
Adverse effects of MAOIs
CNS stim
Orthostatic hypotension
Others same as SSRIs
Major causes of drug interactions with MAOIs
- Severe HTN with any other drug that increases NE or causes hypertension
- Serotonin syndrome risk with any other drug that increases 5-HT
Food element that should be avoided while on MAOIs
Tyramine
What is the risk with tyramine when on a MAOI
Excessive NE release = HTN, HA, tachycardia/MI
Can be deadly
List some tyramine containing foods
Aged cheeses
Cured meats
Processed meats
Fermented or pickled foods
Some sauces (soy sauce)
Fava beans
Alcoholic beverages
(Others)
List some atypical antidepressants
Bupropion
Mirtazapine
Esketamine
(Others)
List mood stabilizers used in the treatment of bipolar disorder
Lithium
Valproate
Carbamazepine
Which antipsychotics are used in bipolar disorder
Second gen
Specific PK considerations with lithium
- rapid 1/2 life = multiple doses per day
- narrow therapeutic index = drug levels must be monitored
S/s mild lithium toxicity (to educate patients)
Fine tremor
GI disturbances
Polyuria & polydipsia
Agitation
Confusion/delirium
S/s severe lithium toxicity
Tremors
Delirium
Seizures
QT prolongation
Renal failure
Coma
Death
Goal range in lithium treatment
0.4-1mEq/L
Mechanism of action of benzodiazepines
Potentiation of GABA
(I.e. utilizes the GABA that the body has)
Why does ceiling effect occur with benzodiazepines?
Because they potentiate endogenous GABA, they don’t agonize the receptor on their own
Adverse effects of benzodiazepines
CNS depression
Anterograde amnesia
Teratogenic
Mechanism of action of benzodiazepine like drugs
Agonize GABA receptor
List some benzodiazepine like drugs
Zolpidem
Zaleplon
Eszipiclone
What is the difference between zalpeplon and zolpidem
Zaleplon has a rapid onset but short duration, so only helpful for falling asleep
Zolpidem has a longer duration so helpful also for staying asleep
How does ramelteon work
Agonizes melatonin receptor (15x more potent than melatonin itself)
Which sleep aid isn’t a controlled substance
Ramelteon (melatonin agonist)
How does suvorexant work?
Antagonizes the effects of orexin, resulting in decreased wakefulness
Major difference between barbiturates and benzodiazepines
Barbiturates agonize GABA receptor directly, thus there is no ceiling effect to CNS and respiratory depression
Adverse effects of barbiturates
Severe resp depression (death)
Sedation (can be used as a general anesthetic)
CYP450 induction
Tolerance & physical dependence
Drugs used in anxiety
SSRIs
SNRIs
Buspirone
Benzodiazepines
Mechanism of action of buspirone
Not we’ll known, but likely binds 5-HT receptors
Adverse effects of buspirone
Minimal
Dizziness
Nausea
HA
First line drugs for ADHD
CNS stimulants
Adverse effect of all CNS stimulants
Seizures
Types of CNS stimulants
Amphetamines
Methylphenidate/dexmethylphenidate
Methylxanthines
Modafinil
Mechanism of action of amphetamines
Stimulate release of NE & DA, inhibit some of their reuptake
Adverse effects of amphetamines
Insomnia, restlessness, euphoria
Appetite suppression
Tachycardia, vasocontriction (can lead to dysrhythmias, HTN)
How do methylxanthines work
Block adenosine receptor = cAMP accumulation
Which schedule drug is methylphenidate
II
Adverse effects of methylxanthines
Decreased fatigue
Tremors, insomnia
Cardiac stimulation
CNS vasoconstriction
Bronchodilation
How does modafinil work
Unclear
Influences sleep/wake cycles
Adverse effects of modafinil
Minimal, just avoid in pregnancy
