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Flashcards in Mental Health Deck (21):
1

ANTIDEPRESSANTS
TCAs

examples

ADRs

Cautions

Pregnancy

nonselective norepinephrine-serotonin reuptake inhibitors

amitriptyline, nortriptyline, imimpramine

diaphoresis, anticholinergic effects, orthostatic hypotension, sedation, drowsiness (act on histamine- drowsiness, weight gain)

Overdose can be fatal
Contraindicated: CV, glaucoma, prostatic hypertrophy, urinary incontinence, seizure disorders

C

2

TCAs continued
do not prescribe with

do not

baseline

maois

d/c abruptly, titrate both ways

EKG
assess suicidality

3

TCAs (older) nnsri

MAOIS (older)

SSRIs

SNRIS

Amitriptyline, nortriptyline, impiramine
Deoxepin, desipramine, clomipramine

Nardil, Marplan, Parnate

Fluoxetine, Paroxetine, Sertraline, Fluvoxamine, Citalopram, Escitalopram

Venlafaxine, deluoxetine, milnacipran, desvenlafaxine

4

MAOIs

ADRs

pregnancy

metabolism

Nardil marplan parnate

tyramine (toxicity- htn) orthostatic hypotension, HA, insomnia, diarrhea

C

major liver, cyp

tyramine- restrict 14 days after dc or other drugs (SSRIs SNRIs)

5

Pros cons older agents antidepressants

Older:
pro- effective, more effective at psychotic/melancholic depression, MAOIS for atypical depression, experienced, strong lit, cost effective, known therapeutic window
cons- delay in onset, SE- nonselsective, dietary restrictions, toxic, lethal in overdose

6

SSRIs
Half life

Metabolism

Which for OCD

ADR

Pregnancy

elderly

slow absorption, half life 21-26 hours except fluoxetine 1-3 days

major first pass, liver metabolism

fluvoxamine

CNS, GI, sexual dysfunction
RENAL/HEPATIC impairment

B/C- avoid in 1st and last (sertraline used without adverse consequences)

elderly half dose recommended




7

SSRIs cont.

Never give more than

Initial SE

Celexa- think....

lexapro-

4 weeks

nausea, lightheaded sedation muscle restlessness sleep disturbance- minor and transient

celexa- qtc prolongation, >60 or concurrent use (cimetidine, omeprazole)

lexapro- active metabolite citalopram no QTC

8

SSRIs

prozac

other- luvox, paxil, zoloft

Serotonin syndrome

Withdrawal syndrome

prozac- weekly dose available

Serotonin syndrome- fatal (n/d, chills, sweating, hyperthermia, hypertension, jerking, agitation, confusion) - adequate titration (5 half lives per dose decrease), do not combine with serotonergic agents

Withdrawal- shorter half life drugs (paxil, zoloft, celexa, escialopram) can show withdrawal after one missed - nausea, dizziness, pareshesia (all require gradual tapering except prozac)

9

SNRIs
Nefazadone

Duloxetine- not approved for

Do not give these to

Interactions

Pregnancy

nefazadone- bb liver toxity, failure, not recommended

cymbalta not approved for children

do not give to glaucoma

quinolones (metabolized by liver)

C- effexor did not increase incidence

10

SNRI

ADRs

Used in

Watch

headache, somnolence, dizziness, insomnia, fatigue dry mouth, constipation, orto, increase bg, urinary retntion

major depression

Watch patients with liver disease, electrolyte imbalance in elderly

11

SNRIs continued

effexor

effexor- discontinuation symptoms if dosed miss

cymbalta- more potent, monitor liver

pristiq- active metabolite of effexor, renal dosing

12

Other antidepressants

Wellbutrin

Remeron

Trazadone

wellbutrin- Dop and Norep, can cause anxiety, psychosis and seizures, can improve sexual function

Remeron- weight gain good for elderly, NE serotonin

Trazadone- take with food, sleep

13

Pros cons newer agents

pro- effective, broad indications, high TI, improved compliance, tolerance, some once a day dosing

cons- expensive, sexual dysfunction, less efficacious for endogenous and psychotic depression, "poop" out problem except effexor, less drug monitoring

14

BENZODIAZEPINES
GABA
Short-
Intermediate-
Long-

contraindicated in

ADR

short- Clorazepate, Halazepam, Prazepam

intermediate- xanax, ativan, serax, librium

long- valium, klonopin

pregnancy, lactation, children < 6 , hepatic/renal disease, geriatric caution

ADR- CNS depression mainly- cardiac repsp depression excessive sedation

15

Non benzo gaba

Not used for

Up to ___ weeks for max effect

Contraindicated in

Preganncy

Buspar - seretonergic anxiolytics- take with food

Panic disorder

6 weeks

Renal, hepatic

B

16

ANTIPSYCHOTICS
warning

Typical-effective at ___ symptoms, ADRs

Examples

Contraindicated in

increased mortality in elderly patietns with dementia-related pscyhosis

Typical- phenothiazine and nonphenothiazine- effective at reducing positive symptoms

ADRs- EPS (antihistamines, antiparkinsons, anticholinergics given to counteract) NMS, sedation, reduction seizure threshold, sexual dysfunction

Ex: Haldol, fluphenazine (high potency) chlorpromazine and thiroidazine (low potency)

Contraindicated in: narrow angle glaucoma, bone marrow depression, severe liver CV disease

17

Atypical

Effects
Less

ADRs

Caution in

Pregnancy

block serotonin and inhibit release of dopamine

Positive and negative
Less risk EPS TD

Weight gain, seizures, hyperprolactinemia, dizziness, ortho, tachycardia, sleep distrubance, constipation

hepatic or renal

C

18

Atypicals continued

Clozapine- risk for

clozapine- fatal agranulocytosis- registration required- weekly or biweekly- monitor 4 weeks after dc

19

Bipolar

Lithium- pregnancy, children, interactions

Valproic acid- used for, pregnancy, highly?, ADRs, interactions

C, do not give to <12

Nsaids, diuretics (increase NA excretion increase lithium levels)

Valproic- for acute mania and prevention, D, highly protein bound, ADR- GI CNS alopecia, interactions- protein bound so displaced by carbamezapine and warfarin THERAPEUTIC MONITORING 50-100

20

MOOD STABILIZERS

Third line tx for

Examples

Pregnancy

ADRS

3rd line tx: bipolar

Ex: Lamictal, Gabapentin, Topamax

C

somnolence, dizziness, ataxia, fatigue
lamictal/topamax- SJ

21

BIPOLAR DISORDER
1st generation antisychotics

2nd generation

1st- before lithium were mainstay, manage agitation and psychosis in acute mania, many se, less expensive, category C

2nd- monotherapy or in combo with mood stabilizers, antidepressant and mood stabilizing (treat both poles)