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1
Q

What are the indications of ECT?

A

Severe or treatment resistant MDD or bipolar disorder

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2
Q

What is the efficacy (%) for ECT?

A

80%

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3
Q

What is the procedure for ECT?

A

Electrical current passes thru the brain, causing a seizure

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4
Q

What is used prior to ECT treatment?

A

General anesthesia and a muscle relaxant

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5
Q

What are the SE of ECT?

A

Confusion

Possible memory deficits

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6
Q

What are the relative contraindications for ECT?

A

H/p treatment resistance, need for rapid treatment response, and severity of illness

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7
Q

What are the NTI medications?

A

Li

CBZ

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8
Q

Which medications increase suicidality?

A

Mood stabilizers except Li

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9
Q

What is the MOA of Li?

A

Alter cation transport
Neurotransmitter reuptake
Effects of send messenger systems

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10
Q

Which drugs have an MOA of VSSCa?

A

VPA
CBZ
OxCBZ
Lamictal

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11
Q

What is topiramates MOA?

A

Interferes with both Ca and Ca channels

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12
Q

What is pregabalin/gabapentin’s MOA?

A

Alpha-2-delta ligands

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13
Q

What is keppra’s MOA?

A

Inhibition of N-type Ca channels

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14
Q

What are the WD sx of benzos?

A 
Anxiety
Agitation
Insomnia
Restlessness
Muscle tension
Irritability
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15
Q

What are the WD sx of TCAs?

A

Cholinergic rebound

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16
Q

What are the WD sx of SSRIs?

A

Fatigue, lethargy, flu-like sx, dizziness, n/d, HA

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17
Q

What are the WD sx of paxil?

A

Cholinergic rebound

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18
Q

What are the WD sx of duloxetine?

A

Severe WD reported

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19
Q

What are FGA MOAs?

A

Block D2 receptors

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20
Q

What are SGA MOA?

A

Blocks D2 receptors

Selective modifying effects of 5HT2A antagonism

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21
Q

What is the first line treatment of MDD?

A

SSRI
SNRI
Mirtazapine
Bupropion

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22
Q

What is the first line treatment of bipolar mania?

A

Li
BPA
SGAs
Consider 2 drug combo if severe

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23
Q

What is the first line treatment of bipolar depression?

A

Li
Lamictal
Quetiapine
VPA

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24
Q

What is the first line treatment of mixed bipolar depression?

A

CBZ
VPA
Olanz

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25
What is the first line treatment of GAD?
SSRI | SNRI
26
What is the first line treatment of panic disorder?
SSRI SNRI CBT
27
What is the first line treatment of OCD?
CBT AND SSRIs
28
What is the first line treatment of PTSD?
SSRI (relieves core PTSD sx)
29
What is the first line treatment of psych emergencies?
APX for acute agitation Haldol used most often SGAs
30
What is the first line treatment of schizophrenia?
SGA | DA
31
What is the first line treatment of ASD?
Non-pharm
32
What is the first line treatment of personality disorders?
Psychotherapy
33
How do we adjust MDD therapy for partial response
Ensure optimized dose | Can switch or augment (Li gold standard for augmentation)
34
What medications can worsen/cause depression
``` Clonidine OCS Steroids AEDs APX Varenicline Benzo EtOH Opioids ```
35
What are the augmentation strategies for MDD?
Li gold stand. | Augmentation is best when there is a response seen
36
What is the DOT for MDD?
At least 12 months with 1st episode 12-36 months for patients w/ recurrent and/or severe MDD Potentially indefinite
37
What are the screening tools for bipolar?
MDQ - Bipolar disorder | PHQ9 - Depression
38
What is the DSM-5 criteria for MDD?
5+ sx during the same 2 week period (must have at least decreased interest/low mood) SIG E CAPSL
39
What does SIG E CAPSL stand for?
``` Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicidal thoughts Low mood ```
40
What is the DSM-5 criteria for Persistent depressive disorder?
Depression sx not meeting full MDD for at least 2 years
41
What is the DSM-5 criteria for hypomania?
3+ GIDDINES sx | 4+ days
42
What does GIDDINES stand for?
``` Grandiose; increased self esteem Increased activity Decreased judgement Distractibility; flight of ideas Irritability Need less sleep Elevated mood Speedy talking or thoughts ```
43
What is the DSM-5 criteria for mania?
3+ GIDDINES sx | 1+ week
44
What is the DSM-5 criteria for cyclothymic disorder?
At least 2 years w/hypomanic and depressive sx | More than 2 months at a time; present > 1/2 the time
45
What is the DSM-5 criteria for mixed bipolar disorder?
Patient with both mania and depression simultaneously
46
What is the DSM-5 criteria for GAD?
More days than not for at least 6 months Difficult to control the worry 3+ sx: arousal, fatigue, trouble, concentrating, irritable, tension, insomnia
47
What is the DSM-5 criteria for social anxiety disorder?
A marked and persistent fear of one or more social or performance situations Fear of humiliation/embarrassment Lasts 6+ months
48
What is the DSM-5 criteria for panic disorder?
Panic attack sx for > 1 month or >1 sx: Persistent concern Worry about consequences Behavioral change
49
What is the DSM-5 criteria for OCD-PD?
Recurrent and persistent thoughts with attempts to ignore or suppress, followed by repetitive behaviors aimed at preventing or reducing stress Obsessions/compulsions are time consuming (take more than 1 hour a day) or cause clinically significant distress or impairment
50
What is the DSM-5 criteria for PTSD?
Event is experienced, patient re-experiences the event as memories, dreams or flashbacks, which causes anxiety like sx Pt uses avoidance of external reminders Leads to negative alterations in mood and cognition Pt will go on to have persistent sx of arousal and hyperactivity (outbursts, hypervigilance, startle response, insomnia) Duration = lasts longer than 1 month, and causes clinically significant distress/impairment
51
What is the DSM-5 criteria for sleep disorders?
1+ complaints of: Difficulty initiating sleep Maintaining sleep Awakenings with inability to return to sleep
52
What is the DSM-5 criteria for SUD?
2+ sx w/in a 12month period Large amounts of substance over a longer period than intended Desire/unsuccessful efforts to cut down/control use Time spent in activities necessary to obtain, use and/or recover from its effects Cravings Repeated failures to fulfill major obligations at work, school or home Continued use despite having persistent or recurrent social or interpersonal problems Tolerance WD
53
What is the DSM-5 criteria for schizophrenia?
``` 2+ for a significant portion of time during a 1 month period: one of the sx must be 1-3 Delusions Hallucinations Disorganized speech Grossly disorganized catatonic behavior Negative sx 6+ months with at least 1 month of active phase sx Significantly impaired functioning ```
54
What is the DSM-5 criteria for ASD?
Persistent deficits in social communication and social interaction (social-emotional reciprocity, nonverbal communicative behaviors, relationship) Restricted, repetitive patterns of behavior (repetitive movements, adherence to routines, restricted fixated interests, response to sensory input) Must impair function Present in the early developmental period Sx may be masked by learned strategies
55
What is the DSM-5 criteria for personality disorder?
Enduring pattern, deviates markedly from cultural expectations s+ sx: cognition, affectivity, interpersonal functioning, impulse control Inflexible and pervasive, stable, long duration - presented in adolescence or early adulthood
56
What is borderline PD?
Instability in interpersonal relationships, self-image, and affects and marked impulsivity
57
What is narcissistic PD?
Grandiosity, need for admiration, and lack of empathy
58
What is OCD-PD
Pre-occupation with orderliness, perfectionism and control
59
What are the 1st line options for acute bipolar mania?
Li VPA SGA Consider 2 drug combo if severe
60
What drugs are recommended for bipolar disorder with comorbid anxiety?
Gabapentin or quetiapine
61
What is used for PTSD augmentation?
Prazosin (nightmares and flashbacks)
62
What is the 1st line treatment for PTSD?
SSRIs (treat core sx)
63
For what disorders are SSRIs 1st line treatment?
GAD Panic PTSD OCD
64
What is SSRI place in anxiety disorders?
Generally first line | Start lower doses
65
What is the role of APX in treatment of anxiety?
3rd line | Quetiapine is most studied
66
What are common SSRI SE?
Insomnia Wt gain Jitteriness/anxiety GI sx
67
When do we use augmentation in OCD?
3rd line | Duloxetine, phenelzine, trancypromine, tramadol
68
What disorders does benzos treat?
GAD | Panic disorder
69
When are benzos used in GAD?
2nd line therapy Short term until SSRI works 4 wks or less
70
When are benzos used in Panic disorder?
2nd line or | Adjunctive (short term < 8 weeks) can lead to a more rapid response to SSRI
71
What are the NMRBAs?
Zolpidem Zaleplon Eszopiclone
72
What is IR zolpidem used for?
Sleep onset PRN
73
What is the Zolpidem CR used for?
Sleep onset and/or maintenance
74
What is the zolpidem SL used for?
Sleep onset and/or frequent awakenings
75
How can zaleplon be taken?
At sleep onset, and again if 4 hours of sleep remaining
76
What is zaleplon used for?
Sleep onset and/or (2nd dose for frequent awakening)
77
What is eszopiclone used for?
Sleep onset and/or maintenance up to 6 months
78
What is the DORA?
Belsomra
79
What is belsomra used for?
Onset and maintenance
80
What is a M1+M2 agonist?
Ramelteon (Rozerm)
81
When is ramelteon taken?
30 minutes before HS
82
What drugs are safe for elderly for sleep?
Rozerem Belsomra Mirtazapine
83
What TCA is used for sleep?
Doxepin at low doses
84
What drug may be beneficial elderly sleep disorders?
Mirtazapine
85
What type of treatments are essential for SAD/SUD recovery?
Psychosocial
86
What are evidence based psychosocial treatments?
``` CBT Motivational enhancement therapy Behavioral therapies 12-step facilitation Psychodynamic therapy/interpersonal therapy Self-help manuals Behavioral self-control Case management Group, marital, and family therapies ```
87
What is the pharmacists role in reducing SAD/SUD?
Recognize signs of use/abuse Provide patient, provider and community education Become informed regarding substances of abuse and "hot" or trendy substances of abuse Communicate with local pharmacists and provider regarding local trends and issues Join the local SA prevention task force Join the NCCSR system
88
What are the RFs for SUD?
Genetic predisposition Personality traits like high impulsivity or sensation seeking Co-occurring psychiatric disorders Males, younger adults, single individuals, unemployed Having deceased parents Exposure to substance - earlier age, stronger risk Stressful external environment
89
What are the treatments for SUD (amphetamine) WD?
Supportive care IV hydration BP/HR management Benzos for agitation, anxiety or seizures
90
What are the treatments for SUD (opioids) WD?
Clonidine - has been found to help with n/v/d, cramps and sweating
91
What drugs are the treatment for benzo overdoses?
Benzos: Fluphenazine (antidote) Flumazenil
92
What are APX that are abused?
Quetiapine
93
What are anticonvulsants that are abused?
Gaba Pregaba CBZ
94
What are antidepressants that are abused?
Bupropion Venlafaxine Fluox
95
What is an antihypertensive that is abused?
Clonidine
96
What OTC agents are abused?
Robitussin DM Sudafed Coricidin H Loperamide
97
What uncommon drug classes are abused?
``` APX Anticonvulsants Antidepressants Antihistamines/antiemetics Antihypertensives PDE5 inhibitors OTCs ```
98
How do we treat agitation/aggression?
``` APX = preferred for agitation Haloperidol most common Loxapine (CI in lung dz) Olanzapine SGA for agitation - risperidone, olanzapine, quetiapine Benzos ```
99
What is the SAFEST approach?
Spacing - maintain distance Appearance - maintain empathetic appearance Focus - watch the person Exchange - delay by calm, continuous talk Stabilization - get control of the situation Treatment -
100
What is the therapy plan for patients with SI?
``` 1-800-273-TALK Ask them about suicide Treatment specific disorder Limit use of potentially Pts should be treating in a setting that is least restrictive and most likely to be safe and effective ```
101
What is the non-pharm treatment for aggression and agitation
SAFEST approach
102
What are RFs for suicidal thoughts?
``` MI Pst hospital DC Age 10-24 and 90+ Males Unmarried Caucasians Sexual orientation Occupation (physicians/veterans) ```
103
What is agitation?
Unpleasant emotional state of extreme arousal
104
What is delirium?
Change in cognitions Disturbance of consciousness Onset of hours to days
105
What is psychosis
Delusions and hallucinations or perceptual disturbances
106
What is SI
Thoughts of serving as the agent of one's own death | May vary in seriousness depending on th specificity of suicide plans and the degree of suicidal intent
107
What is the presentation of delirium?
``` Change in cognition Disturbance of consciousness Temporal course Psychomotor agitation Sleep-wake reversals Irritability Anxiety Emotional lability Hypersensitivity to light/sounds ```
108
What meds should be avoided in SI?
All mood stabilizers except Li | TCAs
109
What are SE of FGA?
EPS NMS Haloperidol = QTc prolongation
110
What are the sx of EPS?
Dystonia Akathisia Pseudoparkinsonism Tardive dyskinesia
111
What is NMS?
Neuroleptic malignant syndrome Lead pipe rigidity Fever Leukocytosis
112
What are SE for all SGAs?
Wt gain DM Dyslipidemia
113
When is clozapine CI?
Seizures | Agranulocytosis
114
What are special SE to clozapine?
Orthostatic hypotension Drooling Anticholinergic effects
115
What is the most efficacious APX?
Clozapine - not used d/t SE
116
What is special about quetiapine compared to other APX?
No EPS/prolactin elevation
117
When is quetiapine preferred in PD?
Can't afford pimvanserin
118
Which SGA is available SL?
Asenapine
119
What drug is asenapine chemically related to?
Mirtazapine
120
What is the SE of risperidone?
Increased prolactin (more than other APX)
121
What is a dose-dependent SE of risperidone?
EPS
122
What is the active metabolite of risperidone?
Paliperidone
123
What drugs have a long acting injectable?
Risperidone and Paliperidone | Aripiprazole
124
What is the primary EPS sx associated with ziprasidone?
Akathisia
125
How should ziprasidone be taken?
With 500 cals of food
126
What is a SE of iloperidone?
QTc prolongation | Orthostatic hypotension
127
What are the clinical pearls for lurasidone?
Considered to be one of the least impacting QTc Renally dosed Major 3A4 substrate Take with food
128
What is a SE of aripiprazole?
Activating
129
What are pearls for aripiprazole?
Relatively nonsedating APX Reduced EPS 3A4, 2D6 metabolite
130
Which SGA have little effect on wt gain, lipids, BG?
Lurasidone | Aripiprazole
131
Which drug is not used with a CrCl < 30?
Cariprazine
132
What is the only FDA approved agent for PD psychosis?
Primvanserin
133
Which antidepressants can use direct switching?
SSRI -> SSRI SSRI -> SNRI SNRI -> SNRI
134
Which drugs require a 2 week lag period?
MAOI -> anything | anything -> MAOI
135
Which drug requires a 5 week lag period when changing to an MAOI?
Fluoextine
136
What drugs are used in movement disorders?
FGA
137
How do we augment therapy for MDD remaining sx?
Augment with an antidepressant from a different pharmacologic class Augment with a different "psychotropic" agent Augmentation is a better strategy when response is seen
138
How do we adjust MDD therapy?
Ensure adequate trial (4-8 weeks) at an appropriate (target) dose
139
How do we adjust therapy for non-response in GAD?
Try another agent
140
How do we adjust therapy for partial-response in GAD?
Continue therapy, titrate to target dose, re-evaluate later
141
How do we switch APX?
Cross-taper over weeks
142
If a patient has a personality disorder with depression and anxiety, how is it treated?
SSRIs (HD)
143
If a patient has a personality d/o with impulsivity, aggression, mood instability, anxiety, anger or cognition/perception problems, how is it treated?
APX (Low dose)
144
What drug class do we avoid in personality disorders
Benzos
145
What SGAs are approved for children with ASD?
Risperidone (5+) | Aripiprazole (6+)
146
What is the pharmacists role in the treatment for ASD?
Counsel patients and families appropriately | Show compassion, empathy, and kindness
147
What drugs does smoking decrease?
``` Asenapine Clozapine Olanzapine Haldol Ziprasidone Duloxetine ```
148
What are the positive sx of schizophrenia?
``` Delusion Hallucination Disorganized speech Disorganized behavior Catatonic ```
149
What is the treatment for resistant schizophrenia
Clozapine
150
What is the order of drugs (most to least) for metabolic AEs?
Cloz=Olan>Quet>>>Arip
151
Is there ever a reason for APX polypharm?
Yes sometimes
152
What is the 1st line treatment of schizophrenia?
SGA | DA
153
What is the 2nd line treatment of schizophrenia?
Try another SGA
154
What is the DOT of schizophrenia?
At least 12 months, but usually life long
155
What are negative sx of schizophrenia?
``` Alogia Affective blunting Asociality Anhedonia Avolition Cognitive sx Affective/mood Aggressive sx ```
156
What is the treatment of NMS?
Remove offending agent Hydration Dantrolene Bromocriptene
157
What is the treatment of acute dystonia?
Remove offending agent Anticholinergics Benzo
158
What is the treatment of akathisia?
Remove offending agent Anticholinergic Propranolol
159
What is the treatment of pseudoparkinsonism?
Removal of offending agent Anticholinergics Amantadine
160
What is the treatment of tardive dyskinesia?
Removal of offending agent | VMAT-2 inhibitors
161
What are the dopaminergic pathways?
``` Mesolimbic = positive Mesocortical = negative Nigrostriatal = EPS Tuberoinfundibular = increase prolactin levels/ hyperprolactinemia ```
162
What are the starting doses of SSRIs?
``` Lexapro: 10 Fluox: 20 Paxil: 20 Celexa: 20 Zoloft: 50 Fluvox: 50 ```
163
What are the usual doses of SSRIs?
``` Lexapro: 10-20 Fluox: 20-60 Paxil: 20-60 Celexa: 20-40 Zoloft: 50-200 Fluvox: 100-300 ```
164
What are the starting doses of SNRIs?
Effexor: 37.5-75 Pristiq: 50 Duloxetine: 30-60
165
What are the usual doses of SNRIs?
Effexor: 75-375 Pristiq: 50-100 Duloxetine: 60-120

Psych (9 decks)

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