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1

LITHIUM

USES

  • Lithium is the drug of choice for controlling acute manic episodes in patients with bipolar disorders AND for long-term prophylaxis for against recurrence for mania and/or depression. Gotta stabilize that mood fam.
  • Reduced euphoria, hyperactivity, BUT does not cause sedation.

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LITHIUM 

DANGER

  • DANGER DANGER: Because lithium is excreted by the kidneys, watch out for patients who have renal problems! If ya can’t piss it out, we in trouble.
  • Dehydration will cause lithium retention , so increase fluids!
  • Taking diuretics and drinking alcohol increases your serum lithium levels

3

LITHIUM 

LEVELS

  • Maintenance (What we should keep it around): 0.4 - 1.0 mEq/L
  • What dose should we give: 900 to 1200 mg
  • TOXICITY: Lithium levels must be kept under 1.5 mEq/L, levels above this can produce significant toxicity.
  • So make sure, you gotta draw lithium blood levels to see how your body handles it!

4

LITHIUM 

SIDE EFFECTS

  • GI effects such as nausea, vomiting, abdominal bloating, and diarrhea. 
  • Tremor (Produce fine hand tremor)
  • POLYURIA - You piss alot, like a bunch. Some patients almost 3 L a day.
  • Renal Toxicity (Assess kidney function before treatment
  • Goiter & Hypothyroidism
  • Teratogenesis
  • Use in lactation (Lithium goes into breast milk. So no no lithium guys)
  • Rare chance of leukocytosis. 

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LITHIUM 

TOXICITIES TABLE

6

SIDE EFFECTS OF 

MOOD-STABILIZERS

(ANTI-CONVULSANTS)

  • Anticonvulsant medications also are used as mood stabilizers. 
  • DANGER WILL ROBINSON, DANGER! Life-threatening side effect is Stevens-Johnson Syndrome (SJS), a severe rash which can affect the trunk OR mucous membranes can occur with anticonvulsants, esp. lamotrigine (Lamictal). Advance dose VERY SLOWLY:

 

  • Patient needs regular blood draws to measure therapeutic levels.  Can cause weight gain, sleepiness, N&V.  May increase the risk of suicidal thoughts.
  •  
  • -Hives, a rash, fever, or swollen glands.
  • -Signs of Stevens-Johnson syndrome, which causes dangerous sores on the mucous membranes of the mouth, nose, genitals, and eyelids.
  • -Confusion.
  • -Slurred speech.
  • -Nausea, vomiting, and diarrhea.
  • -Trembling.
  • -Increased thirst and increased need to urinate.
  • -Weight gain in the first few months of use.
  • -Drowsiness.

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WHICH NEUROTRANSMITTERS

ARE AFFECTED BY 

WHICH FAMILIES 

OF ANTIDEPRESSANTS (SSRIs, SNRIs)

  • SSRI’s (Guys its in the name!!) - Selective SEROTONIN reuptake inhibitors
  • SNRI’s - SEROTONIN and NOREPINEPHRINE reuptake inhibitors
  • NDRI’s- NOREPINEPHRINE and DOPAMINE reuptake inhibitors
  • Monoamine Oxidase Inhibitors (TRICK QUESTION), it doesn’t affect a neurotransmitter directly. Monoamine oxidase is an enzyme responsible for breaking down the three (Serotonin, Norepinephrine, and Dopamine). SO by inhibiting the enzyme, we increase the levels of all three! Tho its a bad medication lol...

8

EPS and Metabolic Syndrome

Which drugs are they associated with

  • EPS (Extrapyramidal Symptoms): rigidity, persistent muscle spasms, tremors, restlessness .  Parkinsonianism is another type of EPS.
     
  • Metabolic Syndrome: significant weight gain, increased blood sugar, increased triglycerides . This increases risk for CVD and diabetes .  Some people get gynecomastia & galactorrhea. Patient’s weight, glucose levels, prolactin levels and lipid levels should be monitored regularly.

FOR ANTIPSYCHOTICS!!! 

  • First Gen Antipsychs: Causes EPS
  • Second Gen Antipsychs: Metabolic syndrome AND a little bit of EPS as well!!

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CLOZAPINE

TOXIC EFFECTS

Agranulocytosis

(Must be in registry for it) Make sure neutrophil count above 1500 

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LITHIUM

TOXIC EFFECTS

DEATH - GAME OVER

convulsions, oliguria.

TOXIC to kidneys and thyroid

11

ANTIPSYCHOTICS 

TOXIC EFFECTS

all antipsychotic medications was determined, that death rates are higher for elderly people with dementia when taking this medication

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FGA 

FIRST GENERATION ANTIPSYCHOTICS 

TOXIC LEVELS

Extrapyramidal Symtoms (EPS)-rigidity, persistent muscle spasms, tremors, restlessness  

especially Tardive Dyskinesia - causes repetitive, involuntary movements, such as grimacing and eye blinking (Give Cogentin!)

13

SGA

SECOND GENERATION ANTIPSYCHOTICS 

TOXIC LEVELS

Metabolic Syndrom: significant weight gain, increased blood sugar, increased triglycerides . This increases risk for CVD and diabetes .

Extrapyramidal Symtoms (EPS): rigidity, persistent muscle spasms, tremors, restlessness  

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SSRI

SELECTIVE SEROTONIC REUPTAKE INHIBITOR 

TOXIC LEVELS

Celexa (Citalopram) : Can cause cardiac problems above 40 mg daily dose 

15

ANTIDEPRESSANT 

TOXIC LEVELS

Serotonin syndrome 

  • Agitation or restlessness
  • Confusion
  • Rapid heart rate and high blood pressure
  • Dilated pupils
  • Loss of muscle coordination or twitching muscles
  • Muscle rigidity
  • Heavy sweating
  • Diarrhea

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MONOAMINE OXIDASE INHIBITOR (MAOI) 

TOXIC LEVELS

  • Mixing MAOIs with other antidepressants or  tyramine foods can cause a hypertensive crisis which can lead to stroke .
  • Foods and medicines that contain high levels of tyramine are dangerous for people taking MAOIs . Tyramine is found in some wines, and pickles, smoked meats & cheeses, draft beers.
  • This makes me sad, i love my beer and cheese :(

17

TRI-CYCLIC ANTIDEPRESSANTS (TCA) 

TOXIC LEVELS

 

Can cause cardiac problems in older individuals. 

18

ANTICONVULSANT MEDS 

TOXIC LEVELS

DANGER WILL ROBINSON, DANGER!!

 

Steven-Johnsons syndrome (Eww bad bad) 

19

BENZODIAZEPINE 

TOXIC LEVELS

Very addictive, can cause that crack addiction 

20

BENZODIAZEPINE

like drugs (Z-drugs) 

TOXIC LEVELS

Cause sleep sex, driving, and sleepy eating!

21

BENZODIAZEPINE

Benzos are anti-anxiety drugs!!

Benzos promote GABA in the brain. These bad boys work fast and well for anxiety BUT they are physically addictive and cause psychological dependence. 

Tolerance can develop quickly. You can get addicted even  if you only take them a few times per week.  It can take weeks, months or years to detox from them. 

SE: They can cause death from respiratory depression when combined with alcohol or opiods.   Other possible side effects include: Drowsiness, dizziness, upset stomach, blurred vision,  headache, confusion. 

Can be used on inpatient psych units for alcohol detox, catatonia and as take-down meds.  Patients should not be discharged with them.

DO NOT USE WITH ALCOHOL OR OPIOIDS (and any cns depressants). You. WIll. Die.

BENZOS only really differ from each other by its potency! Like Xanax is 10 times more potent than valium! Its crazy!!!

22

CLOZARIL (CLOZAPINE)

Clozapine (Clozaril) can sometimes cause life-threatening agranulocytosis.

People who take clozapine must get their white blood cell counts ( esp. ANC or absolute neutrophiil count) checked every week or two.  Patients must be in a “Clozapine Registry” in order to receive the medication.

Clozapine is potentially helpful for people who do not respond to other antipsychotic medications .

Important blood draws and levels

Because risk of agranulocytosis, make sure to monitor both WBC and ANC

IF WBC below 3000/ mm3 - STOP treatment

IF ANC below 1500/ mm3 - STOP treatment

Dangerous side effect is agranulocytosis

METABOLIC SYNDROME and EPS as well!!

23

WHAT IS

ANXIETY

Anxiety and depression are often two sides of the same coin

A feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome. BASICALLY me before every exam

24

GAD (Generalized Anxiety Disorders)

Experiences excessive or unreasonable worry or apprehension.

  • Patients have great difficulty controlling their anxiety. You basically worry about everything- Help
  • Medications: Include Benzos (SHORT TERM ONLY!), Busiprone, and Antidepressants for long term care (SSRI or SNRI)

25

PANIC DISORDER

Pt. who have recurrent panic attacks or worried about having panic attacks

A panic attack is an abrupt surge of intense fear or discomfort that peaks at 10 mins. (FEELS like you having a heart attack)

Medications: SSRI and SNRI’s. Benzo’s to immediately reduce somatic symptoms until the antidepressants start working (So short term!)

26

AGORAPHOBIA

Agoraphobia - Anxiety triggered by real life situations or anticipated exposure such as open areas, small areas, public transportations 

Can start panic like symptoms

Social phobia-Fear of social or performance situations in which embarrassment may occur, such as public speaking, going to parties.

Specific phobias
            - Animal type: snakes, insects, etc. (childhood onset)
            - Natural environment type: heights, water, storms (childhood onset)
            - Blood, injection, injury type (familial, strong vasovagal reaction)
            - Situational type: airplanes, elevator (bimodal peaks in childhood & in 20’s)
            - Other: fear of choking, vomiting, illness

 

Medications: ALL PHOBIAS TREAT WITH SSRIS. Can give clonidine or propranolol before social situations. Also, cognitive behavioral therapy and systematic desensitization really helps :)

27

OCD

OBSESSVIE COMPULSIVE DISORDER

A common, chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that he or she feels the urge to repeat over and over.

Compulsions are rituals or repetitive behaviors that MUST be done for that individual to function. 

MEDS:

SSRIs such as

fluoxetine (Prozac) 

sertraline (Zoloft) 

fluvoxamine (Luvox)

paroxetine (paxil)

28

PTSD

(Post traumatic stress disorder) 

A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. This is usually associated with War vets or sexual trauma. 

First line treatment for PTSD: SSRIs

Paroxetine, sertraline and fluoxetine

Secondline treatmetns: Tricyclic antidepressants and monoamine oxidase inhibitors

Trazadone to help sleep. Benzo’s for short term anxiety (Risk of dependence). Can give clonidine or propranolol. Finally, atypical antipsychotics such as olanzapine, risperidone, and quetiapine.

 

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OVERALL TREATMENT

for anxiety disorders

  • Behavioral therapies: systematic desensitization
  • Medication: SSRIs, benzodiazepines (ADDICTIVE), buspirone, hydroxyzine
  • Psychotherapy & Psychoanalysis
  • Hypnosis
  • Cognitive Behavioral Therapy
  • Benzo’s are a dirty band aid, I guess they good for use. But they will cause problems later

30

BIPOLAR DISORDER

  • Bipolar I: Manic & depressed symptoms are present   Most patients are depressed most of the time (More common in men)
  • Bipolar II: Hypomania and depression (more common in females)
  • Cyclothymic Disorder: The “lite” version of Bipolar II