Chapter: Psych Conditions Flashcards
Depression
What are some of the key factors involved in depression, and which neurotransmitter is often considered most significant for regulating mood?
The causes of depression are complex and involve genetic, biological, and environmental factors. Neurotransmitters such as serotonin (5-HT), glutamate, acetylcholine (ACh), dopamine (DA), norepinephrine (NE), and epinephrine (Epi) are implicated. Among these, serotonin may play a pivotal role in regulating mood. Additionally, certain medications can contribute to or exacerbate depression.
Depression
What assessment tools are commonly used for diagnosing depression?
Diagnosing and treating depression presents challenges as brain chemical imbalances cannot be directly measured. Diagnosis relies on symptom assessment according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), while the HDRS (Ham-D) scale is the most widely used depression assessment scale. Patients rate their depression symptoms on a numerical scale, with the total score indicating the presence or absence of depression.
Depression
DSM-5 Criteria
At least 5 of the following symptoms during the
same two week period (must include depressed
mood or diminished interest/pleasure):
Depression
Medications That Can Worsen Depression
Depression
Depression in Pregnancy and Postpartum Depression: What are the considerations for women on antidepressants when planning pregnancy, and how does untreated depression during pregnancy and postpartum depression impact maternal and fetal health, according to ACOG guidelines?
When planning pregnancy, women on antidepressants may consider tapering off if their depression is mild and they’ve been symptom-free for six months, but in severe cases, continued medication may be necessary. Depression during pregnancy, if untreated, can lead to adverse outcomes, including premature birth and low birth weight. ACOG guidelines suggest starting with psychotherapy for mild depression during pregnancy, with medication as a second option if needed, considering the risks versus benefits.
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Drug treatment during pregnancy poses risks for both mother and baby, requiring careful consideration of individual risk versus benefit. SSRIs are commonly prescribed, except for paroxetine, due to potential cardiac effects. However, there’s a warning about SSRIs and the risk of persistent pulmonary hypertension of the newborn (PPHN).
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Postpartum depression, often missed or undertreated, can harm the mother, baby, and family. Drug safety during breastfeeding is crucial. SSRIs or tricyclics are commonly favored, except for doxepin. Brexanolone (Zulresso), an FDA-approved C-IV drug for postpartum depression, is administered via continuous IV infusion over 60 hours but may lead to excessive sedation.
Depression
Antidepressant Safety?: What precautions should be taken when prescribing oral nonselective monoamine oxidase inhibitors (MAO inhibitors) ? Additionally, how should healthcare providers approach discontinuation of antidepressants to mitigate withdrawal symptoms?
Due to safety concerns, oral nonselective monoamine oxidase inhibitors (MAO inhibitors) like phenelzine, tranylcypromine, and isocarboxazid are reserved for patients unresponsive to other treatments. Serotonin syndrome, a potentially severe condition, can arise from the interaction of multiple antidepressants/ serotonergic medications, including SSRIs/SNRIs, tricyclic antidepressants, and others. The risk is heightened when combining MAO inhibitors with other serotonergic drugs, particularly at higher doses. Symptoms of serotonin syndrome range from nausea and dizziness to hallucinations and tachycardia, muscle rigidity.
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When discontinuing antidepressants, a gradual tapering over several weeks is generally recommended to mitigate withdrawal symptoms, which may include anxiety, agitation, and flu-like sensations. An exception is fluoxetine which self tapers b/c of it’s long half life!
Depression
Antidepressants: BOXED WARNINGS & MEDGUIDES
All antidepressants come with a boxed warning about the potential for increased suicidal thoughts or actions in certain age groups, particularly children, teenagers, or young adults, especially at the start of treatment or when dosage is adjusted. Additionally, MedGuides are mandated for all antidepressants.
Depression
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI): MOA, C/I, Warnings, SEs, Notes
- MOA: increase 5-HT by inhibiting its reuptake in the neuronal synapse. They weakly affect NE and DA.
- C/I: Do not use with MAO inhibitors (including linezolid)
- Warnings: QT prolongation, SIADH/hyponatremia, fall risk (Beer’s)
- SEs: Sexual side effects - decrease libido, ejec dysfunction, Somnolence, insomnia, nausea, dry mouth, diaphoresis (dose-related), weakness, tremor, dizziness, HA
- Notes: - Most activating is fluoxetine; take dose in AM; Most sedating is paroxetine take in PM; Sertraline is preferred in patients with cardiac risk!
Depression
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI): Medications (brand/ generic)
- Citalopram (Celexa): 40mg/day max (20mg if +60 y/o)
- Escitalopram (Lexapro): 20mg/day max (10mg if +60 y/o)
- Fluoxetine (Prozac)
- Paroxetine (Paxil, Brisdelle used for vasomotor symp d/t menopause)
- Sertraline (Zoloft)
Depression
SSRI DDI
- To prevent serotonin syndrome or hypertensive crisis: Allow a two-week washout period between MAO inhibitors and SSRIs, except for fluoxetine, which requires a five-week washout due to its long half-life. Avoid initiation in patients receiving linezolid or IV methylene blue to mitigate the risk of serotonin syndrome.
- QT prolongation most consistently noted with citalopram and escitalopram - avoid with other QT prolong drugs
- Increase bleed risk when used with AC and NSAIDs
- Fluoxetine, paroxetine and fluvoxamine are CYP2D6 inhibitors Do nto use with tamoxifen!
Depression
SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI): MOA, C/I, Warning, SEs
- MOA: SNRIs work similarly to SSRIs by inhibiting the reuptake of serotonin (5-HT) in the neuronal synapse. Additionally, they inhibit the reuptake of norepinephrine (NE), leading to differences in indications and side effect profiles compared to SSRIs.
- C/I: Do Not use with MOA Inhibitor
- Warnings: SIADH/hyponatremia , fall risk (BEERS). Bleed risk (additional to SNRI)
- SEs:Similar to SSRls (d/t decrease 5-HT reuptake); Side effects due to increase NE: increase HR, dilated pupils, dry mouth, excessive sweating and constipation, increased BP
SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI): Medication (brand/ generic)
- Venlafaxine (Effexor XR)
- Duloxetine (Cymbalta)
- Desvenlafaxine (Pristiq)
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Similar DDI as SSRI
Depression
TRICYCLICS: MOA, C/I, SEs
- MOA: Inhibit the reuptake of norepinephrine (NE) and serotonin (5-HT). They also block acetylcholine (ACh) and histamine receptors, contributing to their side effect profile. TCAs are divided into two main categories: secondary amines, which are relatively selective for NE, and tertiary amines, which can be more effective but have a worse side effect profile.
- C/I: Do not use with MAO inhibitors, linezolid, IV methylene blue
- SEs:
CARDIOTOXICITY: QT prolongation with overdose, Orthostasis,, tachycardia
ANTICHOLINERGIC: Dry mouth, blurred vision, urinary retention, constipation, vivid dreams, weight gain (Tertiary amines have more anticholinergic effects)
Depression
Tricyclics: Tertiary Amines VS. Secondary Amines
1. Tertiary: Amitriptyline; Doxepin - for depression, all are generic but Silenor is for insomnia
**2. Secondary: ** Nortriptyline (Pamelor)
Depression
DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITOR: Bupropion (Wellbutrin SR,
Wellbutrin XL) - Dosing, C/I, SEs
- Dosing: Do not exceed 450 mg/Day
- C/I: Seizure disorder; history of anorexia/bulimia, abrupt discontinuation of ethanol or sedatives; do not use with MAO inhibitors, linezolid, IV methylene blue, or other forms of buproprion
- SEs: Dry mouth, CNS stimulation (insomnia, restlessness, insomnia), tremors/seizures, weight loss
Depression
MONOAMINE OXIDASE INHIBITORS: Drugs, MOA, Warnings
Drugs: lsocarboxazid (Marplan); Phenelzine (Nardil); Tranylcypromine (Parnate)
- MOA: MAO inhibitors block the enzyme monoamine oxidase, which breaks down neurotransmitters like serotonin (5-HT), norepinephrine (NE), epinephrine (Epi), and dopamine (DA). Sudden increases in these neurotransmitters can lead to hypertensive crisis and death.
- Warnings: Not commonly used, but watch for drug-drug and drug-food interactions- if missed
could be fatal! Hypertensive crisis or serotonin syndrome can occur when taken with TCAs, SSRl, many other drugs and tyramine-rich food!!
Depression
MAO Inhibitor DDI
MAO inhibitors can’t be taken with drugs or foods that boost levels of neurotransmitters like serotonin, norepinephrine, dopamine, or epinephrine to avoid dangerous complications like hypertensive crisis, serotonin syndrome, or psychosis. Drugs to avoid include SSRIs, SNRIs, TCAs, lithium, tramadol, and certain others. Foods high in tyramine, like aged cheese, pickled herring, and some wines, should also be avoided. Similarly, medications like ephedrine, bupropion, and certain ADHD drugs should not be taken with MAO inhibitors.
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Keep this in mind!
- To prevent serotonin syndrome or hypertensive crisis: Allow a two-week washout period between MAO inhibitors and SSRIs, except for fluoxetine, which requires a five-week washout due to its long half-life
Depression
Selecting the best antidepressant based on comorbidities: Cardiac/ QT Risk
- Sertraline preferred
- Do not choose a QT-prolonging drug/dose (e.g., high doses of citalopram or escitalopram)
- Watch for additive QT effects when SSRls, SNRls, TCAs, mirtazapine or trazodone are used with other QT-prolonging drugs
Depression
Selecting the best antidepressant based on comorbidities: Smoker
Bupropion SR is FDA-approved for smoking cessation
Depression
Selecting the best antidepressant based on comorbidities: Peripheral Neuropathy + pain
Consider Duloxetine
Depression
Selecting the best antidepressant based on comorbidities: Seizure disorder or at risk for seizures (bulimia/anorexia, recent
alcohol or sedative withdrawal)
Do not use Buproprion
Depression
Selecting the best antidepressant based on comorbidities: Pregnant
- Do not use paroxetine
- Mild-to -moderate depression: psychotherapy is first-line.
- Severe depression: certain SSRls are first-line (e.g., citalopram, escitalopram, fluoxetine, sertraline)
Depression
Selecting the best antidepressant based on comorbidities: Daytime Sedation/ Insomnia
- Do not take a sedating drug early in the day (take it at night!) (e.g., paroxetine, mirtazapine, trazodone)
- Activating medications taken in the morning are preferred (e.g., fluoxetine , bupropion)
Depression
Selecting the best antidepressant based on comorbidities: Sexual Dysfunction
- High risk with SSRls and SNRls
- Lower risk with bupropion and mirtazapine
Depression
Treatment Resistant Depression… What to do?
The American Psych Association (APA) state patient should recieve a 4-8 week trial of medication at theraputic dose before concluding that drug does not work! But if it really doesn’t work…consider below
- change to new antidepressant
- increase the current antidepressant dose
- Use a combo antidepressant with different MOA
- Augment with buspirone or low dose atypical antipsychotic (Aripiprazole (Abilify), Olanzapine + Fluoxetine (Symbyax), Quetiapine (Seroquel)
- Augment with lithium
SCHIZOPHRENIA/ PSYCHOSIS
What are the key features and challenges associated with schizophrenia, and how is its diagnosis typically determined according to psychiatric guidelines?
Schizophrenia is a chronic, severe, and disabling thought disorder that occurs in approximately 1% of all societies.
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Common symptoms of schizophrenia encompass hallucinations (sensing something that is not present, such as imaginary voices), delusions (belief in something real that is not true), and disorganized thinking or behavior, leading to an inability to focus attention and communicate organized thoughts.
Treatment adherence is crucial but often challenging to achieve due to patients’ lack of insight into their illness. Schizophrenia is associated with a high suicide rate and typically begins to manifest symptoms in young adulthood.
Diagnosis is primarily based on behavioral observation (both negative and positive signs) rather than laboratory tests, with criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).
SCHIZOPHRENIA/ PSYCHOSIS
DSM -5 DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA
SCHIZOPHRENIA/ PSYCHOSIS
List of Medication/ Recreational Drugs That Can Cause
Psychotic Symp
SCHIZOPHRENIA/ PSYCHOSIS
DRUG TREATMENT: General info on antipsychotic
Antipsychotics primarily block dopamine receptors, with newer ones also targeting serotonin and other receptors. While effective in treating positive symptoms like hallucinations and delusions, they can exacerbate negative symptoms like lack of motivation.
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Second-generation antipsychotics are preferred/ first line due to lower extrapyramidal symptoms, but first-generation antipsychotics may still be used, especially if patients are stabilized on them. Both types (more so FGA) carry risks of EPS, including tardive dyskinesia, which can be irreversible and requires discontinuation of the causative drug.
SCHIZOPHRENIA/ PSYCHOSIS
Boxed Warnings for All Antipsychotics
Antipsychotics should not be used to manage agitation in elderly individuals with dementia-related psychosis due to increased mortality risks, particularly cardiovascular issues and infections. Some antipsychotics also elevate the risk of stroke in dementia patients, and all carry warnings for falls.
SCHIZOPHRENIA/ PSYCHOSIS
First Generation Antipsychotic: List the Drugs and it’s potency
Low Potency: Chlorpromazine, Thioridazine
Mid Potency: Loxapine, Perphenazine
High Potency: Haloperidol (Haldol), Fluphenazine, others
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Sedation and EPS: lower potency drugs have hgiher sedation and lower EPS, and higher potency drugs have lower sedation and higher EPS (all cause sedation and EPS)
SCHIZOPHRENIA/ PSYCHOSIS
Treatment Consideration for people with different issues:
4. Nonadherence or homeless
Choose a long-acting injection
Bipolar Disorder
Diagnostic Criteria (Mania) - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria are used to diagnose bipolar disorders. A toxicology screen should be done prior to starting treatment to rule out druginduced mania.
Bipolar Disorder
Lithium (Lithobid): DDI
ADHD
Diagnostic Citeria: The DSM-5 diagnostic criteria for ADHD is based on an assessment of the primary symptoms, inattention and/or hyperactivity and impulsivity as described in answer
ADHD
Treatment of ADHD: Guidelines
Anxiety Disorders: Background, non-drug treatment; drugs that can cause anxiety
Occasional anxiety in the general population arises from challenging situations at work, home, or school, with symptoms like fear, worry, and physical discomfort. These symptoms typically resolve when the stressor is removed. Anxiety disorders, however, involve chronic and severe symptoms causing distress, affecting daily functioning and relationships. Major types include generalized anxiety disorder (GAD), panic disorder (PD), and social anxiety disorder (SAD), with OCD and PTSD categorized separately in the DSM-5. OCD falls under “obsessive-compulsive and related disorders,” while PTSD is classified under “trauma and stressor-related disorders.”
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Lifestyle changes such as increased physical activity, community involvement, and stress-reducing activities like yoga and meditation can improve symptoms of anxiety. Cognitive Behavioral Therapy (CBT) involves exploring thought patterns with a trained clinician, incorporating problem-solving and relaxation techniques.
Anxiety Disorder
Benzodiazepines:What are the considerations and risks associated with the use of benzodiazepines (BZDs) in the treatment of anxiety, particularly regarding their effectiveness, potential for addiction, and appropriateness for elderly patients?
Benzodiazepines (BZDs) enhance the inhibitory neurotransmitter GABA in the CNS, providing rapid relief for symptoms of anxiety, but not addressing underlying causes. They are useful for short-term treatment of acute anxiety disrupting daily life. However, long-term use can lead to addiction and tolerance, necessitating careful tapering to prevent withdrawal symptoms. Should only be used for 1-2 weeks then D/C. if used for a long time..need taper off. In elderly +65 y/o (Beer’s) BZDs are potentially inappropriate due to a high risk of confusion, falls, and paradoxical reactions. If prescribed, lower-risk options like lorazepam, oxazepam, or temazepam are preferred.
Insomnia
Drugs that can worsen insomnia
Guideline Recommendations for Chronic Insomnia
For long-term use, non-benzodiazepines are preferred over benzodiazepines due to lower risk of physical dependence and fewer daytime cognitive effects. Treatment duration should be minimized and the lowest effective dose used. OTC first-generation antihistamines like diphenhydramine or doxylamine can help short-term but aren’t recommended for chronic insomnia. Benzodiazepines may be used short-term if there’s no history of substance abuse or concurrent opioid use. However, they’re considered potentially inappropriate for those aged 65 and older, with lorazepam, oxazepam, and temazepam preferred in the elderly. Lemborexant (Dayvigo), an orexin receptor antagonist, is a recent FDA-approved treatment for adult insomnia.
