Treatments Week 3 Flashcards
SUD and Bipolar
Lithium, Valproate, and Carbamezepine
CBT also effective in both disorders. Integrated group therapy has best outcomes.
Schizophrenia
Domamine antaonists: Haloperidol/Fluphenazine
Serotonin/DA antagonists: Clozaril (clozapine), risperidone, etc.
Naltrexone for alcohol dependence and Schizophrenia
GAD and Alcohol SUD
Buspirone
Social Anxiety Disorder and Alcohol SUD
Paroxetine (Small study)
PTSD and SUD
Group therapy integrating CBT for SUD and PTSD. Emphasis on seeking safety.
Sertraline helpful for cluster 1 ( early onset PTSD late onset SUD) Neutral for cluster 2 and contraindicated cluster 3 (early onset/severe SUD, and later-onset PTSD)
ADHD and SUD
No controlled trials
Conventional wisdom is to avoid psychostimulants.
Methylphenidate
First line for ADHD. Mildest
Short acting = Ritalin
Long acting = concerta
Risks: Cardiovascular; Anxiety/Depression; Pschosis/Mania (very rare)
Dextroamphetamine Sulfate (Dexedrine)
Other First line for ADHD. More potent amphetamine w/ 2-6 hour half life.
Risks: Cardiovascular; Anxiety/Depression; Pschosis/Mania (very rare)
Amphetamine and Dextroamphetamine (Adderall)
Potent and longest acting. Works by stimulating DA release and blocking reuptake.
Indications: ADHD, treatment resistant MDD adjunct, lethargy, trouble concentrating, poor motivation
Side effects: activation, anxiety
dangerous - dependence, arrythmias, psyfdchosis/Mania (very rare)
Atomoxetine (strattera)
Selective NE reuptake inhibitor. Second line for ADHD. First line for ADHD and Anxiety
A.E. = nausea, agitation
SSRIs
First line depression. Also used vs. anxiety disorders. Fluoxetine, Sertraline, etc.
Mechanism. Selectively block 5HT reuptake.
Safe
60% respond but only 30% remission. (50% of people get 50% better according to Baldes)
Most common side effect is sexual dysfunction (60-70%) along with GI, agitation/sedation
Other dangerous side effects: platelet dysfunction, drug interactions (CYP2D6), seizure, serotonin syndrome, suicide (questionable)
- Can be effectively augmented with 3 drugs:
1. ) Buspirone (Anxiolytic)
2. ) Mirtazapine (atypical antidepressant)
3. ) Buproprion (atypical antidepressant)
Mirtazapine (Remeron)
Blocks 5HT2 and 5HT3 (gut = anti-emetic) and alpha-2 autoreceptor antagonist. Net effect is increased synaptic NE and 5HT.
Indications: MDD, anxiety disorders
Side effects: sedation, weight gain (ideal use is in small elderly people who struggle to sleep.
Less sexual dysfunciton than SSRIs (13%)
Also can be used as cheaper version of Ondansetron (zofran)
SNRI
Block 5HT and NE (i.e. venlafaxine)
More energy/agitation, but still has sexual dysfunction.
Better for anxiety + depression according to Dr. Schultz.
(Baldes thinks slightly more effective.)
Most common side effect is sexual dysfunction (60-70%) along with GI, agitation/sedation. Hypertension, tachycardia. Discontinuation syndrome (must taper –> can be very dangerous.)
Other dangerous side effects: platelet dysfunction, drug interactions (CYP2D6), seizure, serotonin syndrome, suicide (questionable)
Buproprion
(Wellbutrin)
NE and DA specific blocker. Little to no sexual side effects.
Less help with anxiety except in smokers
Efficacy: Useful mostly as adjunct for residual symptoms.
Side effects: headache, hypertension, irritability, increased anxiety.
Dangerous = drug interactions CYP2D6 inhibitor, and seizures
Special uses: smoking cessation, ADHD, Reversal of sexual side effects.
Buspirone
Anxiolytic. Partial agonist of 5HT; less sexual side effects. Mild/moderate control of 5HT
Placebo effect/ mild effect. Rarely works for patients who have used benzos in the past.
Tricyclics
Imipramine
Mechanism: “shotgun drugs” increase synaptic 5HT and NE
Indications: MDD, anxiety, chronic (neuropathic) pain, fibromyalgia, and insomnia.
More efficacious than SSRIs or SNRIs. 80% respond with more side effects.
Side effects: Dry mouth, sedation, constipation.
Dangerous: drug interactions (CYP2D6, seizure, arrthymias, and lethal in overdose (one week prescriptions).
Exposure therapy
Education about common reactions to trauma, breathing retraining, and repeated exposure to the past trauma in graduated doses.
The goal is for the traumatic event to be remembered without anxiety or panic resulting
Cognitive Therapy
Separating the intrusive thoughts from the associated anxiety they produce
Stress Inoculation Training
Variant of exposure therapy that teaches client to relax.
Monoamine oxidase inhibitors
Archetypal agent: phynelzine
Mechanism: Inhibit MAO thus increase synaptic serotoning, NE, and DA.
Indications: MDD (treatment resistant), anxiety
Efficacy: More efficacious than SSRIs and SNRIs, or TCAs
Side effects: sedation, weight gain
Dangerous - med interactions, food interactions (tyramine), hypertensive crisis, and serotonin syndrome.
Aripiprazole
Abilify. Atypical Antipsychotic that is the best in its class for antidepressant usage.
Mechanism: block post synaptic 5HT and partial agonist of post synaptic DA receptor. (different than other atypical antipsychotics!
Indications: Schizophrenia, bipolar, MDD (treatment resistant adjunct)
Efficacy: useful in combination of SSRI or SNRI
Side effects: sedation, weight gain, parkinsonian side effects.
Lithium
Mechanism: enhance 5HT neurotransmission?
Indications: Bipolar, treament resistant MDD adjunct, mood stabilizer
Efficacy: Useful in combination with SSRI and SNRI (Baldes yes other guy no)
Side effects: sedation, weight gain, tremor
dangerous - toxicity (thiazide diuretics increase levels)
Thyroid hormone (cytomel/triiodothyronine)
Mechanism: stimulate gene transcription
Indications: treatments resistant MDD adjunct; mood instability
Efficacy: Useful in combination with SSRI or SNRI (Baldes yes, other guy no)
Side effects: activation
Dangerous: hyperthyroidism (monitor levels)
Ketamine
NMDA receptor antagonist. Increases BDNF to enhance neurogenesis
Indications: MDD -treatment resistant and severe (experimental), anesthesia
Efficacy: highly effective, very rapid onset
Side effects: sedation
dangerous - hallucinations, dissociation
Electroconvulsive Therapy
Very effective for severe depressionl, refractory mania, and catatonia. Can be life saving, but stigmatized currently (biggest hurry)
Causes massive neurotransmitter release
Transcranial magnetic stimulation
Stimulates dorsolater PFC. Not covered by insuarance
Deep brain stimulation
Surgical implantation of simulator in the subcallosal cingulate gyrus.
Growing evidence indicating this for refractory depression
