Guidelines Flashcards
(254 cards)
1
Q
What is the criteria for Level 1 Evidence?
A
Meta-analysis with narrow confidence intervals and/or 2 or more RCTs with adequate sample size, preferably placebo controlled
2
Q
What is the criteria for Level 2 Evidence?
A
Meta-analysis with wide confidence intervals and/or 1 or more RCTs with adequate sample size
3
Q
What is the criteria for Level 3 Evidence?
A
Small-sample RCTs or nonrandomized, controlled prospective studies or case series or high-quality retrospective studies
4
Q
What is the criteria for Level 4 Evidence?
A
Expert opinion/consensus
5
Q
According to CANMAT, how does a recommendation become first line?
A
Level 1 or Level 2 Evidence, plus clinical support
6
Q
According to CANMAT, how does a recommendation become second line?
A
Level 3 Evidence or higher, plus clinical support
7
Q
According to CANMAT, how does a recommendation become third line?
A
Level 4 Evidence or higher, plus clinical support
8
Q
According to CANMAT Depression Guidelines (2016), what medications are first line?
(Long answer)
A
Remember - SSRIs, SNRIs, NDRI, “MMAV”
- All SSRIs
- Escitalopram
- Citalopram
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Sertraline
- All SNRIs (minus Levomilnacipran)
- Duloxetine
- Venlafaxine
- Desvenlafaxine
- Milnacipran
- NDRI
- Bupropion
- a2-Adrenergic agonist; 5-HT2 antagonist
- Mirtazapine
- Mianserin
- 2 Others
- Agomelatine (MT1 and MT2 agonist; 5-HT2 antagonist)
- Vortioxetine (Serotonin reuptake inhibitor; 5-HT1A agonist; 5-HT1B partial
agonist; 5-HT1D, 5-HT3A, and 5-HT7 antagonist)
9
Q
According to CANMAT Depression Guidelines (2016), what medications are second line?
A
Remember: TCAs, Quetiapine, LevoM, MAOS, and “dones”
- TCAs
- Amitriptyline, domipramine, desipramine, nortriptyline, etc
- Quetiapine
- Levomilnacipran (SNRI)
- Moclobemide (Reversible Inhibitor of MAO-A)
- Selegeline (Irreversible Inhibitor of MAO-B)
- Trazodone (Serotonin reuptake inhibitor; 5-HT2 antagonist)
- Vilazodone (Serotonin reuptake inhibitor; 5-HT1A partial agonist)
10
Q
According to CANMAT Depression Guidelines (2016), what medications are third line?
A
- Irreversible MAOs
- Phenelzine
- Tranylcypromine
- Reboxetine (Noradrenaline reuptake inhibitor)
11
Q
According to CANMAT, what factors should you consider in selecting an antidepressant?
A
- Patient Factors
- Clinical Features
- Comorbid Conditions
- Response and Side Effects during previous trials
- Patient Preference
- Medication Factors
- Comparative efficacy
- Side Effects /Comparative Tolerabilty
- Potential Interactions
- Ease of use
- Cost and availability
12
Q
According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with anxious distress?
A
- Use antidepressant with efficacy in GAD
- No difference between SSRI, SNRI, Bupropion
13
Q
According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with catatonia?
A
Benzodiazepenes
14
Q
According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with melancholic features?
A
No antidepressants have demonstrated efficacy
15
Q
According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with atypical features?
A
No antidepressants showed superiority
(Older studies found MAOs >TCAs)
16
Q
According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with psychotic features?
A
Use antidepressant and antipsychotic co-treatment
17
Q
According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with mixed features?
A
Lurasidone
Ziprasidone
18
Q
According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with seasonal pattern?
A
No antidepressants have demonstrated superiority
19
Q
According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with cognitive dysfunction?
A
Vortioxetine (level 1)
SSRIs
Bupropion
Duloxetine
Moclobemide
20
Q
According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with sleep disturbance?
A
Agomelatine
Mirtazpine
Trazodone
Quetiapine
(Weigh against potential for side effects)
21
Q
According to CANMAT Depression Guidelines (2016), what are the reccommendations for MDD with somatic symptoms?
A
Pain
- Duloxetine - Level 1
- Other SNRIs - Level 2
Fatigue
- Bupropion - Level 1
- SSRIs - Level 2
Low Energy
- Duloxetine - Level 2
22
Q
What are risk factors to consider longer term (2 years or longer) maintenance treatment with antidepressants?
A
- Frequent, recurrent episodes
- Severe episodes (psychosis, severe impairment, suicidality)
- Chronic episodes
- Presence of comorbid psychiatric or other medical conditions
- Presence of residual symptoms
- Difficult-to-treat episodes
23
Q
After you have selected and initiated a first line antidepressant, how long do you wait to determine whether there is early improvement?
A
2-4 weeks
24
Q
You have started an antidepressant, and there is early improvement after 2-4 weeks. What do you do next?
A
Keep patient on treatment for 6-8 weeks, then reassess
25
You have started an antidepressant that showed some early improvement after 4 weeks. 8 weeks later, patient has full symptom remission. How long do you keep them on treatment?
* 6-9 months
* 2 years or longer if risk factors for recurrence
26
You have started a first line antidepressant. After 4 weeks, there is no early improvement. What is your next step?
* Consider Factors for switch vs adjunct
* Depending on tolerability, first optimize by increasing dose
* Switch to antidepressant with superior efficacy OR
* Add an adjunctive medication
* After failure of 1 or more antidepressants, consider switching to second or thrid line agent
* For early treatment resistance, consider adjunct use of psychological and neurostimulation treatments
27
According to CANMAT, what are first line recommendations for adjunctive medications for nonresponse or partial response to an antidepressant?
Aripiprazole
Quetiapine
Risperidone
28
According to CANMAT, what are second line recommendations for adjunctive medications for nonresponse or partial response to an antidepressant?
Brexpiprazole
Bupropion
Lithium
Mirtazapine
Mianserin
Modafinil
Olanzapine
Triiodothyronine (T3)
29
According to CANMAT, what are third line recommendations for adjunctive medications for nonresponse or partial response to an antidepressant?
* Other antidepressants
* Other stimulants
* TCAs
* Ziprasidone
30
According to CANMAT, what is an experimental recommendation for adjunctive treatment for nonresponse or partial response to an antidepressant?
Ketamine
31
What are factors to consider in choosing between switching to another antidepressant monotherapy or adding an adjunctive medication?
Consider SWITCHING when
* It is the first antidepressant trial
* Poorly tolerated side effects to initial
* No response (\<25% improvement) to initial
* you have more time to wait for a response (less severe, less impairment)
* Pt prefers to switch
Consider adjunctive when
* there have been 2 or more antidepressants tried
* Initial antidepressant is well tolerated
* There is partial response (\>25% improvement) to initial AD
* There are specific residual symptoms or side effects to the initial antidepressant that can be targeted.
* There is less time to wait for a response (more severe, more functional impairment).
* Patient prefers to add on another medication
32
What does CANMAT say about managing persistent and chronic depression (PDD)?
* SSRIs similar in efficacy to TCAs but better tolerated
* atients with repeated treatment failures and a chronic course of depression may require a chronic disease management approach (i.e., with less emphasis on remission of symptoms and cure, greater emphasis on improving func- tioning and quality of life, and greater use of psychotherapeutic and nonmedication treatments)
33
What are first line psychological treatments for acute and maintenance treatment of MDD?
CBT
IPT
Behavioural Activation
34
What are second line psychological treatments for acute and maintenance treatment of MDD?
Mindfulness Based CBT (MCBT)
Cognitive Behavioural Analysis System of Psychotherapy (CBASP)
Problem-Solving Therapy (PST)
Short Term Psychodynamic Psychotherapy (STPP)
Telephone delivered CBT and IPT
Internet and computer assisted therapy
35
What are third lline psychological treatments for acute and maintenance treatment of MDD?
Long term psychodynamic
Acceptance and Commitment Therapy (ACT)
Videoconferenced Psychotherapy
Motivational Interviewing (MI)
36
What is the impact of comorbid anxiety on psychological treatments in MDD?
* Anxiety likely doesn't complicate or reduce response to tx
* CBT more beneficial than other psychological treatments
37
What is the impact of comorbid substance abuse on psychological treatments in MDD?
* CBT improves both depression and substance abuse symptoms
* Integrated treatment is effective but with small effect size
38
What is the impact of comorbid personality disorders on psychological treatments in MDD?
* PDs have negative impact on depression outcomes
39
What is the impact of comorbid ADHD on psychological treatments in MDD?
CBT for ADHD helps both disorders, as adjunct to medications
40
What is the impact of comorbid HIV on psychological treatments in MDD?
CBT effective, mostly in group
IPT may be effective but limited studies
41
What is the impact of comorbid Parkinson's Disease on psychological treatments in MDD?
CBT effective for reducing depressive symptoms
42
Which neurostimulation technique(s) are first line treatments for MDD?
rTMS
ECT (in some situations)
\*both in acute and maintenance
43
Which neurostimulation technique(s) are second line treatment for MDD?
ECT (if no specific indication making it first line)
44
Which neurostimulation technique(s) are third line treatments for MDD?
Transcranial Direct Current Stimulation (tDCS)
Vagus Nerve Stimulation (VNS)
45
What is the first line reccommendation for rTMS stimulation protocols?
High frequency rTMS to left DLPFC (\>10Hz)
Low frequency rTMA to right DLPFC (\<1Hz)
46
How is rTMS delivered?
* Powerful (1-2.5 Tesla) focused magnetic field impulses to induce electrical currents in neural tissue, vis inductor coil placed on scalp
* Usually delivered by tech or nurse, under MD supervision
* no anaesthesia required
* 1x daily, 5 x/week
47
How many sessions are required for rTMS?
* Initial course until remission is achieved, up to 20 sessions
* Extend course up to 30 sessions in responders who haven't achieved remission
* Use rTMS PRN to maintain response
48
How does rTMS compare to ECT?
* ECT more effective
* rTMS should be considered prior to ECT, as pts who did not respond to ECT are unlikely to respond to TMS
49
What are the clinical indications for ECT as a first-line treatment for MDD?
* Acute SI
* Psychotic Features
* Treatment Resistant Depression
* Repeated med intolerance
* Catatonic Features
* Prior good response to ECT
* Rapidly deteriorating physical status
* During pregnancy, for any of the above indications
* Patient preference
50
What are absolute contraindications to ECT?
There are none
51
Which conditions may be associated with an increased safety risk for ECT?
* Space occupying lesion
* Increased ICP
* recent MI
* recent cerebral hemmorhage
* unstable vascular anaeurysm/malformation
* Pheochromocytoma
* Class 4 or 5 anasthesia risk
52
What are absolute contraindications to rtMS?
* Metallic hardware anywhere in the head (except the mouth)
* Eg. cochlear implants, brain stimulators or electrodes, aneurysm clips
53
What are relative contraindications to rtMS?
Cardiac Pacemaker
Implantable defibrillator
Hx Epilepsy
Presence of brain lesion
54
What are the first line recommendatiosn for delivery of ECT?
Brief Pulse, Right unilateral (5-6x sz threshold)
Brief Pulse, Bifrontal (at 1.5-2 x sz threshold)
55
How many treatments are required for ECT?
Index Course ranges from 6-15
Delivered 2-3x per week
56
How effective is ECT as a treatment for MDD?
70-80%
57
When are ECT relapse rates the highest?
In first 6 months post ECT (37.7%)
58
What is the mortality rate for ECT?
1 death/73,440 treatments
59
What are most common adverse effects of ECT?
Headache
Muscle Soreness
Nausea
60
What type of cognitive side effects are seen in ECT?
* transient disorientation
* retrograde amneia
* anterograde amneisa
But MILD and short term
61
What factors are associated with higher rates of short term adverse cognitive effects of ECT? (vs those associated with lower rates)
* Bitemporal electrode placement vs bifrontal or nilateral
* Brief pulse width vs ultrabrief pulse
* suprathreshold stimulation vs lower elctrical dose
* Treatment 3x/week vs 2x/week
* Use of lithium vs lower dose or discontinuing lithium
* Use of high doses anaesthetic agent vs lower doses
62
What are first line complementary and alternative treatments in MDD?
Light Therapy (Seasonal MDD)
Exercise (Mild to Moderate MDD)
63
What are reccommendations for exercise as treatment for MDD?
30 mins of supervised moderate intensity exercise at least 3x/week for minimm 9 weeks
64
What are second line reccommendations for physicial and meditative treatments of depression?
Exercise (Moderate to Severe MDD)
Light therapy (non-seasonal mild to moderate MDD)
Yoga (Mild to moderate MDD)
65
What is a first line natural health product as treatment for depression?
St. John's Wort (Mild to Moderate)
66
What are second line natural health products as treatment for depression?
St. John's Wort (moderate to severe MDD)
Omega 3
SAM-e
67
According to CANMAT, what is first line treatment of MDD in children and youth?
CBT
IPT
Internet-based psychotherapy (milder severity, if in-person not possible)
68
According to CANMAT, what is first line treatment of MDD in children and youth?
Fluoxetine (Level 1)
Escitalopram, sertraline, citalopram (Level 2)
69
According to CANMAT, what is third line treatment of MDD in children and youth?
Venlafaxine
TCA
70
According to CANMAT, what is true about suicide prevention in children and youth?
1. CBT for suicide prevention combined with pharmacotherapy resulted in greatest improvements in depressed youth who had recently attempted suicide
2. CBT alone resulted in greatest improvements in depressed youth who had recently attempted suicide
3. Pharmacotherapy alone resulted in greatest improvements in depressed youth who had recently attempted suicide
4. CBT + pharmacotherapy = pharmacotherapy alone resulted in improvements in depressed youth who had recently attempted suicide
CBT for suicide prevention combined with pharmacotherapy resulted in greatest improvements in depressed youth who had recently attempted suicide
71
According to CANMAT, what is the evidence of paroxetine in treating children and youth with depression?
Paroxetine has not shown efficacy in this age group
72
What precautions should one take in prescribing citalopram in children?
* Children with long QT should not be treated with citalopram
* Children with congenital heart disease or hepatic impairment sould be treated with caution
73
When would you choose pharmacotherapy before a trial of psychotherapy in children?
* If psychotherapy not accessivle, acceptable, or effective in moderate MDD
* In more severe cases of depression
74
Hoq frequently should children be monitored after initiating treatment with an antidepressant?
* Weekly for first 4 weeks
* Then visits every 2 weeks for a month
* Then after 12 weeks to monitor adverse events/SI
75
When starting antidepressant in youth, how do you dose?
* Start at low end of therapeutic range
* Continue at least 4 weeks before considering dose increase
* If 12 weeks of adequate dosing, and pt shows only partial response, switch
76
How long should children with MDD be treated with pharmacotherapy?
* 12 months if severe or 2 episodes
* Otherwise, 6-12 months
77
Which antidepressants has Health Canada approved under the age of 18?
None!
78
What is the warning associated with use of antidepressants in patients 24 and younger?
Black Box Warning, increased suicidal thoughts/behaviours
79
Maternal/Perinatal Depression is associated with the following poor outcomes accoridng to CANMAT:
* Poor obstetrical outcomes
* SGA
* NICU
* Increased rates neonatal complications
* impairment in bonding
* infant sleep difficulties
* developmental delay
* cognitive, behavioural, emotional problems in offspring
80
What is first line treatment of mild to moderate MDD during pregnancy according to CANMAT?
CBT
IPT
81
What is second line treatment of mild to moderate MDD in pregnancy according to CANMAT?
Citalopram
Escitalopram
Sertraline
82
What is first line treatment of severe MDD in pregnancy according to CANMAT?
Citalopram
Escitalopram
Sertraline
(either alone, or in combo with CBT/IPT. Psychotehrapy monotherapy NOT reccommended)
83
What is second line treatment of severe MDD in pregnancy according to CANMAT?
Buproprion
Desvenlafaxine
Duloxetine
Fluoxetine
Fluvoxamine
Mirtazapine
TCAs
Venlafaxine
84
What "line" of reccommendation is ECT in severe/psychotic/tx resistant MDD in pregnancy AND breastfeeding?
Third Line
85
Which antidepressants have the lowest RID (relative infant dose) and milk to plasma ratios?
Setraline
Fluvoxamine
Paroxetine
86
What is second line treatment of Mild to Moderate Postpartum Depression During Breastfeeding?
Citalopram
Escitalopram
Setraline
Combo of the above + CBT/IPT
87
What is first line treatment of severe Postpartum Depression During Breastfeeding?
Citalopram
Escitalopram
Setraline
Combo above + CBT/IPT
88
What is second line treatment of severe Postpartum Depression During Breastfeeding?
Fluoxetine
Fluvoxamine
Paroxetine
TCAs (except doxepin - v high rate of passage into breast milk)
Bupropion
Desvenlafaxine
Duloxetine
Mirtazapine
Venlafaxine
89
What is the first line reccommendation for treatment of perimenopausal depression?
Desvenlafaxine
CBT
90
What is the second line reccommendation for treatment of perimenopausal depression?
Trasndermal Estradiol (level 2)
Citalopram (Level 3)
Duloxetine
Escitalopram
Mirtazapine
Quetiapine XR
Venlafaxine XR
Fluoxetine (Level 4)
Nortriptyline
Paroxetine
Sertraline
Omega 3
91
What is the first line reccommendation for treatment of late life depression according to CANMAT?
Duloxetine (level 1)
Mirtazapine
Nortriptyline
Bupropion (Level 2)
Citalopram
Escitalopram
Desvenlafaxine
Duloxetine
Sertraline
Venlafaxine
Vortioxetine
92
What is the second line reccommendation for treatment of late life depression according to CANMAT?
* Switch to
* Notriptyline
* Moclobemide
* Phenelzine
* Quetiapine
* Trazodone
* Bupropion
* Combine with
* Aripiprazole
* Lithium
* Methyphenidate
93
According to Katzman, what is the role of benzos in anxiety disorders?
May be useful as adjunct early in tx
In acute crises
Or wiating for onset of efficacy of SSRIs/antidepressants
94
According to Katzman, in anxiety disorders, how long does it take for pharmacological treatment to be effective?
2-8 weeks in onset of symptom relief
Full response in 12 weeks or longer
95
According to Katzman, how long should therapy continue for?
Longer term therapy associated with continued symptom improvement and relapse prevention
Therapy shoul dbe continued 12-24 months for most patients
96
According to Katzman, how should medications be dosed in anxiety disroders?
Initiate at low doses
Titrate to reccommended dosage at 1-2wk intervals over 4-6 weeks
Once therapeutic range achieved, improvement in next 4-8 weeks
F/u at 2 wk intervals for first 6 wks, then monthly
97
According to Katzman what objective scales can be used to assess a patient's progress?
Clinical Global Impression (CGI) scale
Hamilton Anxiety Rating Scale (HARS)
98
According to Katzman in panic disorder, what is true about the effectiveness of CBT vs medications?
CBT was significantly favored over medications for the treatment of panic disorder in a meta-analysis
99
According to Katzman in Panic Disorder, what type of CBT techniques had the most consistent evidence of efficacy?
Exposure
Cognitive restructuring
Other CBT techniques
100
According to Katzman in panic disorder, what is true about combination psychotherapy + pharmacotherapy with antidepressants?
Superior to CBT or pharmacotherapy alone during acute treatment and while meds continued
After terminatin of therapy, combined therapy was MORE effective than pharmacotherapy alone and AS effective as psychotherapy
101
According to Katzman in Panic Disorder, what are first line reccommendations for pharmacotherapy?
* SSRIs
* Citalopram
* Escitalopram
* Fluoxetine
* Fluovoxamine
* Paroxetine
* Sertraline
* Venlafaxine
102
According to Katzman in Panic Disorder, what are second line reccommendations for pharmacotherapy?
* Benzos
* Alprazolam
* Clonzaepam
* Diazepam
* Lorazepam
* TCAs
* Clomipramine
* Imipramine
* Other antidepressants
* Mirtazapine
* reboxetine
103
According to Katzman in Panic Disorder, what are first line reccommendations for adjunctive pharmacotherapy?
None
104
According to Katzman in Panic Disorder, what are second line reccommendations for adjunctive pharmacotherapy?
Alprazolam
Clonazepam
105
According to Katzman in Panic Disorder, what is NOT reccommended for pharmacotherapy?
Buspirone
Propranolol
Trazodone
Tiagabine
106
What is an acceptable appraoch to initial treatment of panic disorder?
Pharmacotherapy
CBT
CBT + Pharmacotherapy
107
According to Katzman, what type of psychological treatment is recommended in all phobias?
Exposure
108
According to Katzman, what type of psychological treatment is recommended in phobia of heights, flying, spiders, claustrophobia?
Virtual Reality exposure
109
According to Katzman, what type of psychological treatment is recommended in phobias of spiders, flying, small animals?
Computer-based self help
110
According to Katzman, what type of psychological treatment is recommended in blood-injection-inury phobia?
Applied muscle tension
| (Exposure + muscle tension exercises)
111
According to Katzman, what is the role of medication in treating specific phobias?
Pharmacotherapy is generally unproven, and thus not a recommended treatment for most cases
112
What are principles of treating social Anxiety Disorder according to Katzman?
CBt/exposure therapy alone are effective first line options
CBT = pharmacotherapy in acute treatment
Gains achieved through CBT persist longer than pharmacotherapy
(Note that CBT + pharm combo not better than CBT alone)
113
What is the gold standard for psychological treatment of social anxiety disorder?
CBT
Cognitive - restructuring, challenging maladaptive thoughts
Behaviour - exposure
114
According to Katzman, what is first line pharmacological treatment of Social Anxiety Disorder?
* SSRIs
* Escitalopram
* Fuvoxamine
* Paroxetine
* Sertraline
* Pregabalin
* Venlafaxine
115
According to Katzman, what is second line pharmacological treatment of Social Anxiety Disorder?
* Citalopram
* Benzos
* Alprazolam
* Bromazepam
* Clonazepam
* Gabapentin
* Phenelzine
116
According to Katzman, what is first line adjunctive pharmacological treatment of Social Anxiety Disorder?
None
117
What are principles of treating GAD according to Katzman?
CBT effective first line option
= Effective to pharmacotherapy
No evidence for routine combo of CBT + meds
(But when pt tries psychotherapy and doesnt respond, try meds and vice versa)
118
According to Katzman, what is first line pharmacological treatment of GAD?
* SSRIs
* Escitalopram
* Paroxetine
* Sertraline
* SNRIs
* Venlafaxine
* Duloxetine
* Pregabalin
119
According to Katzman, what is second line pharmacological treatment of GAD?
* Benzos
* Alprazolam
* Bromazepam
* Diazepam
* Lorazepam
* Bupropion
* Buspirone
* Vortioxetine
* Imipramine
* Quetiapine XR
* Hydroxyzine
\*Usually consider benzos first, for short term use. Reserve bupropion for later. Quetiapine should be reserved for those who can't tolerate antidepressants or benzos
120
According to Katzman, what is first line Adjunctive pharmacological treatment of GAD?
None
121
According to Katzman, what is second line Adjunctive pharmacological treatment of GAD?
Pregabalin
122
According to Katzman, what is reccommended for psychological therapies for anxiety in the elderly?
Relaxation Training
CBT
Supportive Therapy
CT
123
According to Katzman, what is third line Adjunctive pharmacological treatment of GAD?
Aripiprazole
Olanzapine
Quetiapine
Risperidone
124
According to Katzman, in treating OCD, what is the approach to treating OCD?
CBT (ERP) is effective first line options
CBT **=** *or* **\>** pharmacotherapy
CBT + meds \> meds alone (but NOT better than CBT alone)
125
According to Katzman, in OCD, what psychotherapy has been shown to be more efficacious than ERP?
Danger Idea Reduction Therapy (DIRT)
( tx specifically designed to address fear of contaimination with infectious diseases, using cognitive intervention that includes no direct exposure)
126
According to Katzman, what is first line recommendation for pharmacotherapy in OCD?
Escitalopram
Fluoxetine
Paroxetine
Sertraline
Fluvoxamine
127
According to Katzman, what is second line recommendation for pharmacotherapy in OCD?
Citalopram
Clomipramine
Venlafaxine
Mirtazapine
128
According to Katzman, what is first line adjunct recommendation for pharmacotherapy in OCD?
Aripiprazole
Risperidone
129
According to Katzman, what is second line adjunct recommendation for pharmacotherapy in OCD?
Memantine
Quetiapine
Topiramate
130
What is the role of early intervention for prevention of PTSD?
* Evidence doesn's upport widespread intervention eg debriefing
* Screening and treating appropriate individuals may be preferred
* TF-CBT for ASD, PTSD to prevent chronic PTSD
131
What does psychological treatment for PTSD typically entail?
* Education about disorder and treatment
* Exposure to cues related to traumatic event
* Types of CBT
* TF-CBT
* EMDR
* PE (Prolonged Exposure)
* Stress Management Therapy
* ICBT (internet based CBT)
* VRE (virtual reality exposure)
132
According to Katzman, what is the general appraoch to selecting a medication for anxiety in someone with another comorbid psychiatric disorder?
Consider therapies that are effective in both disorders
133
According to Katzman, what are first line recommendations for pharmacotherapy for core symptoms of PTSD?
Fluoxetine
Paroxetine
Sertraline
Venlafaxine
134
According to Katzman, what are second line recommendations for pharmacotherapy for core symptoms of PTSD?
Fluvoxamine
Mirtazapine
Phenelzine
135
According to Katzman, what are second line adjunctive recommendations for pharmacotherapy for core symptoms of PTSD?
olanzapine
risperidone
eszopiclone
136
According to Katzman, what are first line adjunctive recommendations for pharmacotherapy for core symptoms of PTSD?
None
137
According to Katzman, if antidepressant treatment is indicated for an anxiety disorder in a lactating person, which medications are preferred?
Sertraline
Paroxetine
138
In children with anxiety disorders, according to Katzman, what are the principles of treatment?
* Psychological treatments are generally preferred
* If warranted consider combination
* COMBO psychological and pharmacological \>/= either alone
* SSRI generally preferred
139
According to Katzman, which medications have evidence for GAD in the elderly?
Pregabalin (mono or adj)
Duloxetine
Venlafaxine
Citalopram/Escitalopram
Setraline
Fluvoxamine
Mirtazapine (when used in depression, may have anxiolytic effects)
140
According to Katzman, which medications have evidence for treatment of panic disorder in elderly?
Paroxetine
Escitalopram
Fluvoxamine
141
According to Katzman, which medications have evidence for treatment of OCD in elderly?
Fluvoxamine
142
According to Katzman, which medications should be considered for patients with an anxiety/related disorder and comorbid MDD?
* Antidepressants (SSRIs/SNRIs) as first line treatment
* Quetiapine has efficacy as monotherapy in both MDD and GAD, MDD w/ anxiety
* Aripiprazole augmentation, risperidone monotherapy may reduce como symptoms
143
According to Katzman, what are reccommendations for psychotherapy for anxiety in the elderly?
* Evidence for
* Relaxation Trianing
* CBT
* Supportive Therapy
* CT
* Specifically,
* CBT = GAD, panic
* Exposure +/- CBT = PTSD, phobias
* Psychotherapy as effective as pharmacotherapy in elderly
144
According to Katzman, which medications have evidence for comorbid bipolar disorder/psychosis + anxiety?
* Lithium, olanzapine, lamotrigine
* Atypical AP
* Adjunctive valproate and gabapentin for panic
145
According to Katzman, what is the pharmacological approach to treating comorbid ADHD + anxiety?
* Stimulants may help anxiety symptoms by treating ADHD
* Atomoxetine can improve ADHD, anxiety (mostly SAD) and depressive symptoms
* Atomoxetine + amphetamine improve anxiety in pts with ADHD and GAD refractory to antidepressant alone
146
According to CANMAT 2018 for bipolar, what psychological interventions are reccommended for acute mania?
None
147
According to CANMAT 2018 for bipolar, what psychological interventions are reccommended for maintenance?
* 1st line
* Psychoeducation
* 2nd line
* CBT
* Family Focused Therapy
* 3rd line
* IPSRT
* Peer Support
\* as maintenance, adjunctive treatment options
148
149
According to CANMAT Bipolar 2018, which medications are reccommended first-line for treatment of acute mania? (monotherapies)
Lithium
Quetiapine
Divalproex
Asenapine
Aripiprazole
Paliperidone (\>6mg)
Risperidone
Cariprazine
150
According to CANMAT Bipolar 2018, which medications are reccommended first-line for treatment of acute mania? (combination therapies)
Quetiapine + Li/DVP
Aripiprazole + Li/DVP
Asenapine + Li/DVP
Risperidone + Li/DVP
151
According to CANMAT Bipolar 2018, which medications are recommended second-line for treatment of acute mania?
Olanzapine
Carbamazepine
OLZ + Li/DVP
Lithium + DVP
Ziprasidone
Haloperidol
ECT
152
According to CANMAT Bipolar 2018, in treating acute mania, what are considerations in choosing between monotherapy or combination therapy?
* For all patients, tx should be initiated with first line monotherapy OR combination
* Typically combination treatments have higher efficacy
* Combination therapy is associated with more adverse effects than monotherapy
* Consider past use, safety and tolerabilty, clinical features, and patient preference
153
According to CANMAT Bipolar 2018, if there is no response to a first line anti manic agent at optimal doses, what is the next step?
Try another first line agent
Add on an additional first line agent (except NOT for paliperidone/ziprasidone)
Use second and third line only if many trials of first line agents unsiccessful
154
According to CANMAT Bipolar 2018, what is the role of ECT in treating bipolar mania?
Second line option
Up to 80% show clinical improvement
Brief pulse therapy 2-3x per week
Bifrontal \>bitemporal
155
According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with features of
* classical grandiose mania, or
* few episodes of illness, or
* mania-depression-euthymia course, or
* Family history of BD, or
* Family history of lithium response?
Lithium \> Divalproex
156
According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with features of classical and dysphoric mania?
DVP = Lithium
157
According to CANMAT Bipolar 2018, which medications are reccommended in acute mania, with features of
* Multiple prior episodes
* Predominant irritable or dysphoric mood
* Comorbid substance use
* History of Head Trauma
DVP \> Lithium
(but use ++ caution if prescribing in women of childbearing potential)
158
According to CANMAT Bipolar 2018, which clinical features may respond favourably to carbamazepine?
Hx of head trauma
Como anxiety, substance use
Schizoaffective presentations with mood-incongruent delusions
No hx of BD in first degree relatives
159
According to CANMAT Bipolar 2018, which clinical features may respond favourably to a combination therapy of Lithium and DVP?
When response is needed faster
"At risk" patients
Prev hx of partial acute response to monotherapy
Severe manic episodes
160
According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with features of anxious distress?
DVP
Quetiapine
Olanzapine
Carbamazepine
161
According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with mixed features?
DVP
Atypicals (asenapine, aripiprazole, olanzapine, ziprasidone)
Often combination therapy required
162
According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with psychotic features?
Li/DVP + Atypical
- may be more effective than other first line combinations for mood incongruent features, but overallno superiority of any first line agent/combo
163
According to CANMAT Bipolar 2018, which medications are reccommended acute mania, with features of rapid cycling?
Follow maintenance recommendations
No superiority of any first line tx in treating manic symptoms with rapid cycling course
164
According to CANMAT Bipolar 2018, which medications are reccommended in acute mania, with features of seasonal pattern?
No evidence for superiority of any agents
165
According to CANMAT Bipolar 2018, what psychosocial interventions can be recommended for acute bipolar depression?
No first line recommendations
Can choose between CBT, FFT, and IPSRT (Level 3) based on indiivdual strengths and needs
ALWAYS offer psychoeducation in BD
166
167
According to CANMAT Bipolar 2018, which medications are reccommended for acute bipolar 1 depression, first line?
Quetiapine
Lurasidone + Li/DVP
Lithium
Lamotrigine
Lurasidone
Lamotrigine Adjunctive
168
According to CANMAT Bipolar 2018, which medications are reccommended for acute bipolar 1 depression, second line?
DVP
SSRIs/Bupropion (adj)
ECT
Cariprazine
OLZ-Fluoxetine
169
According to CANMAT Bipolar 2018, when initiating treatment for bipolar depression, when should early improvement be noticed?
2 weeks
170
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, what are considerations in whether to switch or add adjunctive treatment?
Switch overall preferred to add-on to limit polypharm
Use rational polypharmacy via add-ons
Consider switching classes if antidepressnat ineffective
Overlap and taper
Go to second-line only if all first line options have been tried and failed
171
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, when should ECT be considered?
Second line
Tx refractory patients
When rapid response is needed (catatonia, psychotic, very suicidal)
172
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, what is notably not recommended as treatment?
Aripiprazole
Antidepressant monotherapy
Ziprasidone
173
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited when there is a need for rapid response?
Quetiapine
Lurasidone
ECT (second line)
174
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for patients with previous response to current treatment?
Adjunctive treatment
175
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for features of anxious distress?
Quetiapine
Olanzapine-Fluoxetine
Lurasidone
176
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for mixed features?
Combination Therapies
Olanzapine Fluoxetine
Asenapine
Lurasidone
\* avoid antidepressants
177
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for melancholic features?
No specific studies
ECT may be very effective
178
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for atypical features?
Some evidence for tranylcypromine
\*but risk of switch, so ONLY use with Li, DVP, or Atypical
179
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for psychotic features?
ECT
Antipsychotics
180
According to CANMAT Bipolar 2018, for bipolar 1 depression treatment, which treatments are best suited for features of rapid cycling?
(Consider thyroid, antidepressants, substance use)
Not great evidence, but the following have comparable maintenance efficacy:
Li
DVP
Olanzapine
Quetiapine
181
According to CANMAT Bipolar 2018, for bipolar 1 maintenance treatment, what are first line treatments?
Lithium
Quetiapine
Divalproex
Lamotrigine
Asenapine
Quetiapine + Li/DVP
Aripiprazole + Li/DVP
Aripiprazole
Aripiprazole IM, monthly
182
According to CANMAT Bipolar 2018, for bipolar 1 maintenance treatment, what are second line treatments?
Olanzapine
Risperidone LAI
RIsperidone LAI adj
Carbamazepine
Paliperidone (\>6mg)
Lurasidone + Li/DVP
Ziprasidone + Li/DVP
183
According to CANMAT Bipolar 2018, for acute bipolar 2 depression, what are first line treatment recommendations?
Quetiapine
184
According to CANMAT Bipolar 2018, for acute bipolar 2 depression, what are second line treatment recommendations?
Lithium
Lamotrigine
Bupropion (adj)
ECT
Sertraline
Venlafaxine
185
According to CANMAT Bipolar 2018, for bipolar 2 maintenance, what are first line treatment recommendations?
Quetiapine
Lithium
Lamotrigine
186
According to CANMAT Bipolar 2018, for bipolar 2 maintenance, what are second line treatment recommendations?
Venlafaxine
187
According to CANMAT Bipolar 2018, for hypomania, what are treatment recommendations?
No great evidence exists
Clinical experience suggests that all anti-manic meds are efficacious in hypomania
If hypomania is frequent, severe, impairing, consider Li, DVP, AP and maybe N-Ac
188
According to CANMAT Bipolar 2018, for Bipolar II depression, what are first line treatment recommendations?
Quetiapine
189
According to CANMAT Bipolar 2018, for Bipolar II depression, what are second line treatment recommendations?
Lithium
Lamotrigine
Bupropion
Sertraline
Venlafaxine
ECT
190
According to CANMAT Bipolar 2018, for Bipolar II maintenance, what are first line treatment recommendations?
Quetiapine
Lithium
Lamotrigine
191
According to CANMAT Bipolar 2018, for Bipolar II maintenance, what are second line treatment recommendations?
Venlafaxine
192
Teratogencity of Mediciations Used in Bipolar Disorder. Memorize this.
193
According to CANMAT Bipolar 2018, for pregnant people, what is the best approach to treatment of BAD in first trimester?
Psychological strategies preferred over medications in first trimester
When meds are necessary, preference should be given to monotherapy and lowest effective dose
194
According to CANMAT Bipolar 2018, what are risks associated with divalproex in pregnancy?
Should be avoided due to risks of NTD (5%)
higher incidences of congenital abnormalities
striking degrees of neurodevelopmental delay in children at 3y, loss of 9 IQ pts
195
According to CANMAT Bipolar 2018, in later pregnancy, what are considerations in dosing?
Pts may require higher doses of meds towards end of pregnancy because:
Changes in physiology in 2nd and early 3rd trim
Increased plasma volume
Increased hepatice activity
Increased renal clearance
196
According to CANMAT Bipolar 2018, which medications have evidence in tretaing postpartum mania?
Antipsychotics
Benzos
Lithium
197
According to CANMAT Bipolar 2018, which medications have evidence in treating postpartum bipolar depression?
Quetiapine
198
According to CANMAT Bipolar 2018, what approach should be taken in treating postpartum mood episodes in general?
Hierarchies for non-postpartum mood episodes should be followed
But consider breastfeeding safety if applicable
199
According to CANMAT Bipolar 2018, what should be considered when counselling a patient with bipolar disorder about breastfeeding in the postpartum period?
Counselling about early recognition of drug toxicity
Olanzapine and quetiapine may be preferred because of relatively lower infant dosages
Impact of meds may be lower if med is taken after feeding times
Consider replacing/supplemeting with formula to limit sleep disruption
Partners do night feeding by bottle
In women wiith postpartum psychosis/mania, breatsfeeding may be too unsafe if motehr is disorganized
200
What did STEP-BD say about mood episodes in menopause?
Increased rates of depressive, but not manic episodes
201
According to CANMAT Bipolar 2018, what are general principles in pharmacological management of children with BD?
General principles from adults apply
Elevated risk for CVD complications, so RFs should be assessed and intervention as necessary
Children more susceptible to metabolic side effects
Polypharmacy should be very judiciously used
202
According to CANMAT Bipolar 2018, which medications are considered first line in treating mania in children?
Lithium
Risperidone
Aripiprazole
Asenapine
Quetiapine
203
According to CANMAT Bipolar 2018, which medications are considered second line in treating mania in children?
Olanzapine
Ziprasidone
Quetiapine adjunct
204
According to CANMAT Bipolar 2018, which medications are considered first line in treating bipolar depression in children?
Lurasidone
205
According to CANMAT Bipolar 2018, which medications are considered second line in treating bipoalr depression in children?
Lithium
Lamotrigine
206
According to CANMAT Bipolar 2018, which medications are considered first line in bipolar maintenance in children?
Aripiprazole
Lithium
Divalproex
207
According to CANMAT Bipolar 2018, what can be used in treating comorbid ADHD in a youth with BD?
Stimulants in stable/euthymic youth taking optimal doses of anti manic meds
Mixed amphetamine salts and methylphenidate
(Theoretical risk of converting to mania with atomoxetine)
208
According to CANMAT Bipolar 2018, what considerations should you make in treating comorbid subsatnce use in child with BD?
Treat concurrently
Li may be effective for reducing substance use in this pop
FFT
N-AC possibly (esp re cannabis)
209
According to CANMAT Bipolar 2018, what is true of medical comorbidities of older adults with BD?
3-4x more med comos
Metabolic syndrome,HTN, DM, CVD
Reduction of life expectancy of 10-15 y
Assessment of older adults with BD should inlcude through physical and neuro inv
Coordinate with other care providers
Inlcude smoking cessation
210
According to CANMAT Bipolar 2018, what is recommended pharmacological management of acute mania in older adults?
First Line - Li or DVP (lower doses may be effective)
Second Line - Quetiapine
211
According to CANMAT Bipolar 2018, what is recommended pharmacological management of acute bipolar depression in older adults?
First Line - Quetiapine and Lurasidone
Second Line - Li, Lamotrigine
212
According to CANMAT Bipolar 2018, what is recommended pharmacological management of bipoalr maintenance in older adults?
Choice should be based on what was effective in acute stage
Li, DVP, Lamotrigine have geriatric efficacy data
213
According to CANMAT Bipolar 2018, what are the most common comorbid psychiatric disorders with BD?
SUD (33%-45% of people with BD)
Anxiety Disorders (24-56%)
Personality Disorders (42%)
Impulse Control Disorders (10-20%)
214
According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid Alcohol use disorder and BD?
Combo of Li + DVP is only tx that meets Levl 2
Li - use with caution bc of potential electrolye imbalance
Anticovulsants - LFTs and lipase levels before initiating
Agents for primary AUD (naltrexone, disulfriam, gabapentin, _not acamprosate_) may have some benefit in BD (Level 4)
215
According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid cannabis use disorder and BD?
Li/DVP level 3
20% of ppl with BD will have cannabis disorder
Cannabis use disorder assocaited with younger age, mixed episode/polarity, presence of psychotic features, comorbid SUDs
216
According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid cocaine use disorder and BD?
Citicholine adj (Level 2)
Li, DVP, Quetiapine, Risperidone, Bupropion (Lvls 3 & 4)
No great evidence here
217
According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid opioid use disorder and BD?
Methadone (Level 3)
But evidence not great
218
According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid other/miscellaneous substance use disorder and BD?
OLZ
Aripiprazole
219
According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid GAD/Panic Disorder and BD?
Quetiapine (level 2)
In pts who are euthymic and treated with lithium, Lamotrigine or OLZ may be helpful (3)
OLZ + Fluoxetine (3)
Gabapentin (4)
220
According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid OCD and BD?
Mood stabilizers and atypical AP may be adequate to resolve comorbid OCD and BD
Antidepressants might be necessary for some patients
If antidepressants are used, SSRIs preferred, and prophylactic anti-manic agents should be optimised before antidepressant started
Potential benefits of Li, anticonvulsants, OLZ, risperidone, quetiapine, aripiprazole
221
According to CANMAT Bipolar 2018, what is recommended pharmacological approach to treating comorbid personality disorder and BD?
DVP and Li (Lvl 3, 4)
Psychoeducation
DBT
222
Accoridng to CANMAT Bipolar 2018, what are baseline investigations that should be done in a patient with BD?
CBC
Fasting Glucose
Fasting Lipids
CBC - Platelets
Electrolytes and Calcium
Liver enzymes
Serum bilirubin
PTT
Urinalysis, Urine tox
Creatinine. eGFR, 24H cr clearance if hx of renal disease
TSH
ECG if \>40 or otehr indication
Preg test if relevant
Prolactin
223
According to CANMAT Bipolar 2018, for patients on maintenance therapy with lithium, what does ongoing monitoring include?
Levels should be done at **trough (12h** after last dose)
**2 consecutive levels** should be established in tx range during acute phase (**0.8-1.2**mEQ/L; **0.4-0.8** in older adults in acute; maintenance **0.6-1** sufficient)
Then **q 3-6 months** or more frequently if indicated
Thyroid, Renal Fx, Ca q6months
224
According to CANMAT Bipolar 2018, for patients on maintenance therapy with Divalproex, what does ongoing monitoring include?
Levels should be done at trough (12h after last dose)
2 consecutive levels should be established in tx range during acute phase (Target 35-700mM/L in acute phase)
Then q 3-6 months or more frequently if indicated (and 3-5 days after dose adj)
Menstrual hx, Haem profile, LFTs at 3-6 mth intervals in first year
225
According to CANMAT Bipolar 2018, for patients on maintenance therapy with carbamazepine, what does ongoing monitoring include?
Levels should be done at trough (12h after last dose); q6-12 months
To ensure levels not in toxic range; as there is no est relationship between efficacy and serum levels
Serum levels of all psyschotropics should be monitored bevause of interactions
Routinely educate about skin rashes (SJS and TEN)
HLA-B1502 allele testing in genetically at risk pops for high risk for SJS/TEN (Han Chinese, Asian ancestry)
226
According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause weight gain?
OLZ
CLozapine
Risperidone
Quetiapine
Gabapentin
DVP
Lithium
227
According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause GI symptoms?
Li, DVP
(Take at bedtime, take with food, use slow release forms when available)
228
According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause renal toxicity?
Lithium! (LiNDI, ATN)
CKD Risk Factors - long term use, higher plasma levels, multiple daily doses, other renal meds, somatic illness, older age, incidents of Li toxicity
Also very narrow therapeutic window, so intox is a ocmplication, and can lead to reduced eGFR
229
According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause heamatological effects?
Clozapine - Baeline haem profile, be enrolled in clozapine monitoring pgm, weekly then 2-4 weeks
CBZ - maybe RF for leukopenia
230
According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause CVD?
Lithium (QT, T wave)
Risperidone, OLZ, Ziprasidone, Asenapine (arrhythmias, QTC, ect)
Clozapine
231
According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause metabolic syndrome?
Atypicals - mostly OLZ, clozapine, quetiapine, risperidone
Aripiprazole, Ziprasidone, Asenapine, Luasidone
All pts on atypicals shoudl be monitored for blood glucose, lipid profiles,
232
According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause sedation?
DVP
Atypicals
233
According to CANMAT 2018, which medication used in the treatment for BD are most likely to cause cognitive side effects?
Lithium
Anticonvulsants (except lamotrigine)
234
According to CADDRA 2020, what are first line pharmacological treatments for ADHD?
* Amphetamine-Based Stimulants
* Mixed Amphetamine Salts (Adderall XR) (12-14h)
* Lisdexamphetamine (Vyvanse) ~14h
* Methylphenidate
* Biphentin ~12h
* Concerta ~12h
* Foquest ~16h
235
According to CADDRA 2020, what are second line pharmacological treatments for ADHD?
* Amphetamine-Based Stimulants
* Dextroamphetamine (Dexedrine) ~4h
* Methylphenidate
* Methylphenidate SA (Ritalin) ~3-4h
* Non-stimulant SNRI
* Atomoxetine (up to 24h) 0.5mg/kg
* Non-stimulant a-2a adrenergic receptor agonist
* Guanfacine XR up to 24h
236
According to the Canada Schizophrenia Guidelines, in first-episode psychosis, what is recommended as first line treatment?
Antipsychotics
237
According to the Canada Schizophrenia Guidelines, in first-episode psychosis, how should antipsychotic be selected?
Choice should be made by patient and physician (and caregiver) together
No established superiority between FGAs and SGAs in FEP
Decision making should be guided by side effect profile
238
According to the Canada Schizophrenia Guidelines, in first-episode psychosis, how long should a medication trial be?
After initiated, continue for at least 2 weeks unless there are sig tolerability issues
(much of AP effect should be seen in first several weeks)
If poor response, assess med adherence and substance use
Optimize Dose
If no response after 4 weeks despite dose optimization, change AP
If partial response, R/A after 8 weeks
239
According to the Canada Schizophrenia Guidelines, in first-episode psychosis, what is the recommended duration of maintenance treatment?
18 months
240
According to the Canada Schizophrenia Guidelines, in acute exacerbation, after an increase or change in antipsychotic, how long should medication be continued?
4 weeks unless significant tolerability issues, if no improvement, switch
Where partial repsonse is seen after 4 weeks, R/A in 8 weeks
241
According to the Canada Schizophrenia Guidelines, in relapse prevention and maintenance treatment, what is the recommended dosing?
Low to moderate dosing
CPZ 300-400mg daily
Risperidone 4-6mg daily
Olanzapine 20mg - 30mg daily
Abilify 30 - 45mg daily
242
According to the Canada Schizophrenia Guidelines, in relapse prevention and maintenance treatment, what is the recommended duration of treatment?
Following resolution of positive symptoms of an acute psychotic episode
Maintenance tx with antipsychotic medications for "2 and possibly up to 5 years or longer"
243
According to the Canada Schizophrenia Guidelines, in relapse prevention and maintenance treatment, what is the recommendation for oral or depot antipsychotics?
Patients should be given choice in keeping with their preference
Not just for nonadherence
(unless circumstances don't allow this option, eg CTO)
244
According to the Canada Schizophrenia Guidelines, what is the definition of treatment resistant schizoprhenia?
Non-responsiveness is the lack of satisfactory clinical response (\<20% improvement in symptoms), despite treatment with appropriate courses of at least two marketed chemically-unrelated antipsychotic drugs.
245
According to the Canada Schizophrenia Guidelines, in treatment-resistant schizophrenia (TRS), what should be recommended?
Clozapine
246
According to the Canada Schizophrenia Guidelines, what is the definition of clozapine-resistant schizophrenia?
At least 8, but preferably 12 weeks at a dose of _\>_400mg/day
Documentation of adherence
Plasma levels at least once (\>350 if OD dosing, \>25 if BID dosing)
Persistence of \>2 pos symptoms with at least mdoerate severity, or single pos symptoms iwth severe severity
If all of the above met, "clozapine-resistant schizophrenia" specifier should be added
247
According to the Canada Schizophrenia Guidelines, in clozapine-resistant schizophrenia, what is the treatment recommendation?
There isn't one.
No intervention has demonstrated enough effect
Adjunct therapies, ECT may be useful
248
According to the Canada Schizophrenia Guidelines, in patients with aggression and hostility, what is the treatment recommendation?
- Based on Pt Preference, past experience, side effect profile, current meds
- If TRS + aggression/hostility, trial of clozapine indicated
249
According to the Canada Schizophrenia Guidelines, in comorbid depressive disorder, what is the treatment recommendation?
Individuals who meet criteria for depressive disorder should be treated according to relevant clinical practice guidelines for depression, including the use of antidepressants.
250
According to the Canada Schizophrenia Guidelines, in youth with first episode of psychosis, what is the first step in management?
Early Identification
Urgent referral to specialist mental health service/EPI
251
According to the Canada Schizophrenia Guidelines, in youth with first episode of psychosis, what is the first step in treatment?
Offer antipsychotic medication + psychological/psychosocial interventions
(should not be started in primary care, unless consultation with a CA Psychiatrist)
252
253
According to the Canada Schizophrenia Guidelines, in youth with first episode of psychosis, how should choice of antipsychotic be made?
Jointly with young person/parents/HCPs
Likely benefits and side effects (metabolic, extrapyramidal, cardio, hormonal, other)
254
According to the Canada Schizophrenia Guidelines, in youth with first episode of psychosis when starting or changing antipsychotics, when is EKG indicated?
* specified in Health Canada drug database
