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TPX Neuro, Psych, & Sub abuse > Week 3: Bipolar, Anxiety > Flashcards

Week 3: Bipolar, Anxiety Flashcards

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1
Q

What is Bipolar disorder

A

Cyclic mental illness with recurrent mood episodes that occur over a persons lifetime.

symptoms, course, severity and response to treatment

differ among individuals

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2
Q

Patho of bipolar disorder

A

caused by genetic factors, environmental triggers, and the dysregulation of neurotransmitters and second messenger systems in the brain

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3
Q

Etiology of bipolar disorder

A

caused by genetic factors, environmental triggers, and the dysregulation of neurotransmitters and second messenger systems in the brain

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4
Q

Key features of bipolar spectrum disorders

A

hx of mania or hypomania

dx includes dysthymia, persistent depressive disorder, cyclothymia, drugs induced hypomania and recurrent unipolar depression.

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5
Q

Bipolar 1 disorder

A

manic episode +/- major depressive or hypomanic episode (may be mixed)

MUST HAV A MANIC EPISODE

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6
Q

Bipolar 2 disorder

A

major depressive episode +hypomanic episode

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7
Q

common Characteristics of BD

A

<25 y.o

family hx of bipolar disorder

increased sleeping/ napping

increased appetite/ weight

psychomotor retardation

atypical depression (mood liability, irritability, agitation, racing thoughts, psychotic features, pathological guilt

co-occuring substance abuse

4A’S: ANXIOUS
ANGER
AGGITATION
lack of ATTENTION

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8
Q

Mania vs hypomanic

A

mania: >1 week of period of abnormal and persistent elevated mood, often leading to hospitalization

hypomania: at least 4 days of abnormal and persistent elevated mood, usually doesn’t lead to hospitalization

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9
Q

Challenges in dx

A

must rule out organic causes of mania or depression

accuracy in dx is key and requires excellent hx

mania may b confused with ADHD related dirosers

depression may appear to be unipolar

not the result of a substance (of abuse or prescribed)

execution if under antipdepressent trent: can be dx with mania or hypo

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10
Q

rapid cycling

A

> 4 episodes per year, often with key feature of frequent and severe episodes of depression

more freq. in women

poor prognosis, may require combo therapy

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11
Q

Goals of therapy for BD treatment

A

rapid control over behavioral sx, sleep restoration and mood stabilization

chance and maintain levels function

complete remission and prevent future episodes

optimize the chance for successful drug therapy such as increase adherence and reduce ADR and DI include pt therapy selection

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12
Q

General treatment approach for BD and non pharm

A

pharm:
must be individualized
must be specific to the episode patient is currently experiencing
should include for both PHARM AND NON pharm treatment

non pharm: address environmental factors
sleep
diet
exercise
psychoeducation, psychotherapy

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13
Q

List of FDA approved agents for BPD acute mani and mixed episode

A

lithium, valproate

carbamezapine ir+er

aripiprazole
asenapine
caripraszine
olanzipine
quetiapine
risperidone
ziprasidone

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14
Q

list of FDA approved agents for BPD maintenance

A

lithium

lamotrigine

aripiprazole

olanzipine

quetiapine

risperidone

ziprasidone (adjunct Li/VPA)

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15
Q

list of FDA approved medications for acute depression monotherapy

A

cariprazine
lurasidone
olanzipine (with fluoxetine)
quetiapine

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16
Q

General pharm BPD treatment guidelines

A

once dx with BPD, pt should remain on mood stabilizer(term used for some of meds to treat BPD) for their lifetime

augmentation meds should be added onto mood stabilizer during acute episodes, then withdrawn when clinically appropriate

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17
Q

LAI FDA approved for BPD

A

ARIPIPRAZOLE (ABILIFY MAINTENA) NOT aristatda: maintnace of BP1

RISPERIDONE (Risperdal Consta NOT perseris: monotherapy or adjunctive therapy to lithium or valproate for maintenance tretment of BP1

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18
Q

General treatment guidelines for acute manic and mixed episodes

A

General treatment to use Lithium, VPA, or SGA

Monotherapy and combo therapy are both first line treatments for acute mania. Choice depends on rapidity of response needed, hx of partial response to monotherapy, or severity of mania

D/C antidepressants of possible

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19
Q

treatment options for acute manic and mixed episodes

A

monotherapy:
LI, VPA or SGA (aripiprazole, asenapine, risperidone, , cariprazine)

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20
Q

General 1st line Treatment for acute major depressive episodes

A

Acute: BP1: LI, lamotrigine, quetiapine (IR&ER), lurasidone

acute BP-II: quetiapine (IR&ER)

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21
Q

agents NOT recommended for treatment of acute mania in BPD

A

gabapentin, topiramate, lamotrigine, verapamil, tigabine

combos: risperidone+carbamezapine, olanizpine +carbamezapine

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22
Q

agents NOT recommended for TREATMENT of acuteacutedepressive episode

A

gabapentin, aripiprazole, ziprazidone. A and z can worsen depression

combos: adjunctive ziprasidone, adjunctive levetiracetam (keppra)

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23
Q

agents NOT recommended for BPD maintenance

A

gabapentin, topiramate, or antidepressants

or adjunct fluphenthixol

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24
Q

Anticonvulsants approved for Bipolar

Valproate

indication:
MOA:
AE:
DDI:
CI:
Monitoring:

A

indication: first line treatment for both acute mania(fda approved) and ppx (non fda approved) for recurrent manic and depressive episodes
*also indicated for use in rapid cycling and mixed states

MOA:–
AE: dose related gi, TREMOR, AND SEDATION, PROLINGED BLEEDING, dose dependent Alopecia(reversible), weight gain,

DDI:
CI:
Monitoring:
BBW:panreatitis and/or liver toxicity, hepatotoxicity, urea disorders: educate pts to report flu like symptoms, gi pain, yellowing of skin, dark urine. intervene if LFTs 3x baseline.

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25
Q

Lithium use in bipolar disorder

indication:
MOA:
Adverse reactions:
DDI:
contraindicated
monitoring:

A

indication: euphoric mania (not for rapid cyclers or mixed states)

MOA:
Adverse reactions:
a: long term effects on kidneys polydipsia and polyuria w. or w.o nephrogenic diabetes insidious (NDI), AKI, CKD3 reported also
b. dose related CNS effects
c.muscle weakness
d.cardiac effects
e. decrease thyroid hormone synthesis

contraindications: severe cardiac or renal disease

DDI:NSAIDS, ace-I, arbs, diuretics, CCB, d/c lithium 2 days before and after electro convulsive therapy, caffeine

monitoring:
renal function (SCr, BUN)
baseline PE
CBC w. differential (reversible leukocytosis)
FG, lipids-weight, waist circumference
thyroid function test
serum electrolytes
dermatologic (acne)
lithium levels every 3 months

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26
Q

Considerations for Lithium in use for bipolar disorder

when can it be used?

what are the side/long term effects?

what do you have to monitor for?

what are interactions?

A

when can it be used?
First line for acute mania, acute bipolar depression and maintenance in BPI and BPII. NOT for rapid cycling or mixed states. decreases suicide significantly

how to be used?
900-2400mg/kg/day.
give with food
must maintain good hydration
onset for mania 6-10 days and full effect in 3 weeks, >4 weeks for depression

what are the side/long term effects?
*polydipsia nd polyuria w. or w.o NDI, AKI,or ckd
*GI or cns EFFECTS(dose related worst at peak
*muscle weekness and lethargy
*cardiac effects
*decreased thyroid hormone synthesis
Floppy baby syndrome

what do you have to monitor for?
*lithium levels: 0.6-1.2 mEq/L : 1.0-1.2 for acute mood episodes. >1.5mEq/L is toxic (if it is below range and drug still working, no need to increase dose). TDM 8-12 hrs after last dose, at Css.
*Renal function:containdicated in severe renal disease
*cardiac function: ci in severe cardiac disease
*thyroif function
*cbc w. differential
*FG, fasting glucose, waist circumference (metabolic)
*may unmask brigade syndrome(fast irrgefular heart beat)

what are interactions?
ACE-I, ARBs, NSAIDS, diuretics, blood dyscrasia w. clozapine d/c, ehanced neurotoxicity with electroconvulsive therapy, Methyl-xanthines like caffeine, etc.

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27
Q

Valproate Considerations

A

indications: fda approved for acute manic and mixed episodes

BBW: pancreatitis and/or liver toxicity and urea disorders

formulations approved:
depakote , depakote ER,
Stavzor

dose related gi, tremor (can give bb to reduce)
sedation (give @hs)
dose related alopecia
weight gain
prolonged bleeding

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28
Q

Lamotrigine Considerations for use in bipolar disorder

A

anticonvulsant

FDA approved for maintenance therapy and acute depression

dose escalation must be low and slow to decrease risk of SJS

Cause less drowsiness than Other agents

When combined w. Valproate , lamotrigine dose must be halved

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29
Q

Carbamezapine considerations for use in BP

A

only FDA approved formulation is ER formulation (Equetro)

dose can be increased rapidly for inpt.

used for acute manic episodes: onset for mani is 7days. not used for maintenance. also sed after 1st line agents

CI: can cause neutropenia( bone marrow suppression) leukopenia, hematologist disease, agranulocytosis, patients with positive HLA

careful combo use with valproate because valproate can increase levels (also in lamotrigine

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30
Q

Considerations for antipsychotics as adjunctive therapy

A

SGA may be good for certain episodes, not all

FGA good for acute mania

use in combo w. lithium or valproate for acute or mixed

injectable APS good option for pts. with poor adherence

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31
Q

Considerations for antidepressants as adjunctive therapy

A

only used as add on therapy

do not use in bipolar disorder alone . may result in switch to mania if in depressed phase

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32
Q

Considerations for benzons as adjunctive therapy in BPD

A

high potency agents like clonazepam or lorazepam can be used during acute mania/ agitation or anxious features/ restore sleep

adjustt to response and adverse events

used short term

avoid in pts with substance use

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33
Q

bipolar treatment considerations in pregnancy

A

divalproex: can cause neural tube defects. avoid as 1st line in women who may become pregnant

carbamezapine: increased risk of spina bifida. avoid during pregnancy

lamotrigine: lower levels during pregnancy

lithium: increased doses during pregnancy, use care upon delivery. increased risk of abnormal tricuspid valve.

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34
Q

If psychosis is present during a bipolar episode, what agents to use

A

use an APS along with an agent to treat bipolar. an APS must be present

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35
Q

Lithium interactions effects

A

NSAIDS: increase Li lives

ACE/ARBs: increase Li levels

diuretics: increase Li levels

Methyl Xanthines(i.e caffeine): decrease Li levels

36
Q

what is anxiety

A

an emotional state commonly caused by the perception of real or percieved danger

normal anxiety is an appropriate adaptive response

if excessive, can result in significant disability

37
Q

treatment goal of generalized anxiety disorder

A

remission with minimal or anxiety symptoms and no functional impairment

38
Q

what are the agents of choice for GAD managemeent?

A

antidepressants.

takes atleast 8-12 weeks to take effect. much slower response than when using these agents for depression

39
Q

key features of GAD

A

excessive difficult to control anxiety and worry about multiple events or activities

SS of restlnessneds or feeling on the edge or tension

psychological SS: excessive anxiety
worries that arre out of control
feeling on edge

physical symptoms: restlness
fatigue
muscle tension
sleep disturbances
irritability

impairment:
socially
accupationally
poor coping skills

40
Q

key features of panic disorder

A

recurrent expected panic attacks, in absense of triggers . persistent concerns about additinoal panic attacks and/or maladaptive change in behavior related to attacks

41
Q

key features of agoraphobia

A

markes unreasonable fear or anxiety about a specific situation , which is activdely avoided due to thoughts that escape may be difficult and fear resulting in panic symptoms

42
Q

key features ofspecific phobia

A

marked unreasonable fear or anxiety about a specific object or situation (flying spiders, recieving injection)

43
Q

key features of social anxiety disorder

A

marked. excessive unreasonable fear of anxiety about social situations in which there may beb scrutiny by others, which is actively avoided

44
Q

drugs that induce anxiety

A

anticonvulsants: carbamezapine, phenytoin

antidepressants: buproprion, SSRI, TCA

anti-HTN: clonidine and felodipine

abx: quinolones, isoniazid

bronchodilators: albuterol, theophylline

corticosteroids: prednisone

dopamine agonists: amantadine, levedopa

herbal agents: ginseng, ephedra, ma huang

illicit substances: cocaine, ectasy, THC

stimulants: methylphenydate, caffeine, nicotine

toxicity: anticholinergics, digoxin

withdrawal: includes sedatives

45
Q

dx for GAD

A

persistent symptoms for most days for at least 6 mo. and worry is unrealistic or excesive about a number of events or activities

gradual onset w. avergae onset @age21

women more likely than men

46
Q

Goals of therpay for GAD

A

long term: remission, prevent occurance
acute: decrease severyity and duration of symptoms, increase function

at all times: decrease ADR, increace adherance

non pharm:
CMT, psychoeducation
avoid stimulants and alcohol

47
Q

GAD pharm treatment

A

antidepressents: treatment of choice

APS and antihistimaines: high incidence of ADR and toxicity,

48
Q

1st line GAD treatment

A

FDA approved
SSRI’s
*Escitalopram (Lexapro)
*Paroxetine (Paxil)

SNRI’s
*Duloxetine(Cymbalta)
*venlafaxine XR

NON FDA APPROVED:
SSRI:sertraline
AntiEpileptic: Pregablin

49
Q

general Antidepressant treatment considerations for GAD

A

lag time of 2-4 weeks OR LONGER b4 any antianxiety effects

efficacy can take 8-12 weeks

start low and go slow, with gradual taper

response to treatnment described as improved, partial response after 4-6 weeks. if partial response, confirm adequacy of trial and consider augmentation, or switch AD

after adequate trial , continue for atleast 1 year

50
Q

SSRI considerations

A

BBW: increased risk of suicide in ppl </=24 y.o

discontinuation syndrome

abnormal bleeding due to 5HT reuptake on patelets

hyponatremia

seretonin syndrome:SS: BASICALLY-HYPERACTIVITY

agitation
restlessness
confusion
diarrhea
sweating
tachycardia
HTN
dilated pupild
loss of muscle coordination
muscle rigidity

can occur if taking multiple agents with serotonin

such as…
triptan migraine agents
pain medication such as fentanyl and tramadol
nausea products such as zofran(ondansetron) and reglan(metoclopramide)
Busprione
Linezolid
Ritonavir

avoid drugs that impair the metabolism of serotonin

potential cognitive and motor impairment.

degrees of Qtc prolongation

require caution/ dose modifications with hepatic impairment

51
Q

SNRI consideration

A

BBW: increased risk of suicide in ppl </=24 y.o

abnormal bleeding due to 5HT reuptake on platelets

potential for increased activation of mania

elevated BP
hyponatremia and seretonin syndrome

discontinuation syndrome

tend to be more energy boosting than any other AD

52
Q

considerations for antihistamine use in GAD

A

hydroxyzine FDA approved
second line agent
beers list

53
Q

considerations for APS use in GAD

A

BBW: increased risk of death in use in elderly w. dementia related psychosis: NOT for elderly pts who are being treated long term for another idnicatino like schizophrenia

quetiapine second line agent

ziprasidone not recommended

54
Q

considerations fo rAED use in GAD

A

not a confirmed BBW, but increased risk of suicidal thoughts

55
Q

conditions/comorbidities with anxieties and recommendations

A

sleep disturbance:
evaluate and mange causes
more sedating agants such as pregablin or hydroxyzine

elderly pts:
consider sertraline or escitalopram, beers list

neuropathic pain: consider pregablin

56
Q

benzodiazepine considerations for use in GAD

A

provide rapid releif of symptoms 2-3 weeks. NOT EFFECTIVE for depression

long term use asocitaed w. phsyical and mental dependence

ci: allergy to bxd, hx of substance use, myasthenia gravis, severe hepatic disease, resp. disease, narrow angle glaucoma

BBW: ins=creased risk of death when used in combo with opiates. ALSO risk of abuse, misuse, and addiction

risk of rebond anxiety w. quick d/c

inceeased risk of seizures after d/c from high dose benzo and use of AED

d/c taper example:
25% [er week reduction until 50%, then decrease dose by 1/8 q4-7 days

fo rtherapy >8 weeks taper over 2-3 weeks

for therapy >6mo. taper over 4-8 weeks. if greater than 1 year, over 2-4 MONTHS

elderly ptsa increased risk of falls b/c of increased conc.

57
Q

FDA approved BZds for anxiety and considerations

A

CLAD

Clorazepate: needs acid

Lorazepam: Over the liver (OTL), less lipophilic, longer duration of action

Alprazolam (Xanax):HIGH POTENCY. available as ODT

Diazepam: euphoria, misuse, more lipophilic, faster rate of absorption and short duration of action

58
Q

Panic disorder

A

a series of unexpected, spontaneous attacks of intense terifying fear

attack is followed by at least 1 month of having persistent fear

attack last 20-30 min but highest intensity in first 10 min

59
Q

nic disorder symptoms

A

psycho:
fear of losing control
fear of going crazy
fear of dying
depersonalization
de-realization

phsyical: gi distress

chestpain/ disocmforrt

chills/hot flashes

dizziness

palpitations

sob

trembling

shaking
sweating

60
Q

panic disorder (agoraphobia)

A

being in atleats 2 situations or places where escape is difficult

cause pts. to avoid situations

61
Q

pharm treatment for PD

A

treatment of choice: antidepressants

62
Q

PD ctreatment considerations

A

start low and go slow with dosing
(up to 1/2 of doses used for depression, esp, with SSR and SNRI

antidepresssant therapy may take 8-12 weeks to see full efficacy

63
Q

1st lines PD agents

A

FDA APPROVED
SSRI
fluoxetine
paroxetine
sertraline

SNRI:
venlafaxineXR

NON FDA approved
citalopram
escitalopram
fluvoxamine

64
Q

not recommended agents in PD

A

buspirone (due to slow onset of action)
propanolol
tiagbine
trazadone

65
Q

goals of therapy of PD

A

same as GAD

long term: remission, prevent occurance
acute: decrease severyity and duration of symptoms, increase function

at all times: decrease ADR, increace adherance

non pharm:
CMT, psychoeducation
avoid stimulants and alcohol

66
Q

considerations for benzos in panic disorders

A

can be used as a first step if there is an urgency and no delay in relief is possible

high potency bzd are preffered such as alprazolam and clonazepam, but lorazepam and diazepam can also be used

67
Q

alterniative drug therapies fo r PD

A

buspirone, trazadone, buprorpion, , APS, beta blockers and antihistamines shown to be INEFFECTIVE

buspirone has NO antidepressant effects

68
Q

treatment fo PD in special populations

A

edlerdy: less and fewer intense attacks

children: tend to have fear of dying and agoraphobia

in general SSRI best choice

69
Q

PD: Specific phobia

A

persistent fear of object or situation

70
Q

treatment of PD: specific phobia

A

unresponsive to drug therapy

highlighy response to CBT

71
Q

PD: social anxiety disorder

A

intense fear by intense, irrational and persistent fear of being scrutinized or judged in social settings or performance situations

72
Q

etiology of SAD

A

mean age is mid teend

SAD higher in women

mean age 20 year course

73
Q

dx of PD:SAD

A

ADULTS <18 Y.O. SS for atleast 6 mo to meet dx criteria

feers: judged by others
embarassed
humiliated

addressing group of ppl

eating or writing infront of tohers

interacting with authority

speaking in public

talking to strangers

use of public facilities

74
Q

goals of therapy PD:SAD

A

long term: remission, prevent occurance
acute: decrease severyity and duration of symptoms, increase function

at all times: decrease ADR, increace adherance

non pharm:
CMT, psychoeducation
avoid stimulants and alcohol

75
Q

first line options for SAD treatment

A

antidepressants

76
Q

1st line SAD options

A

FDA approved:
SSRI:
*paroxetine
Sertraline

SNRI
Venlafaxine

non FDA approved
escitalopram
fluvoaxamine

77
Q

not recommended in PD-SAD

A

busprinone, atenelol, levetiracetam, quetiapine, propanalol (only if symptoms are present)

78
Q

considerations for special population for SAD treatment:

A

elderly: pk/pd changes, organ function, increased risk of falls and sensitivity etc.

children: cbt is a good treatment option..

pregnancy: do not use paroxetine:

79
Q

PTSD treatment considerations

A

non pharm theapy options are best… such as cbt and eye movement desensitization

SSRI’s and venlafaxine first line pharm treatment options

BENZOS are not recommended

prazosin and clonidine for PTSD related nightmares

80
Q

PTSD first line treatments

A

FDA Approved
ssri: paroxetine
serttraline

WSNRI:
venlafaxine

non fda approved:
fluoxetine

81
Q

PTSD epidemiology

A

exposure to a traumatic event

response to event must incude intense horror, fear, or feelings of helplessness

pt must have one intrusion symptom, 1 avoidance, and 2 symptoms of negartive alterations in cognition

must cause significant distress or impairment of dysfunction

82
Q

benzo diazepine treatment in PTSD

A

DO NOT GIVE BENZOS

can impair cbt effectiveness

83
Q

augmentation therapy for ptsd

A

for pts with persistant symptoms

84
Q

OCD tratment

A

SSRI treatment of choice alone or with CBT

augmentation of ssri w. low dose APS may be helpful

non pharm:
cbt
exposure

85
Q

first line agents for OCD

A

fluoxetine (prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline(Zoloft)

TPX Neuro, Psych, & Sub abuse (7 decks)

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