Psych Case Wrap-Up (Jaynstein) (Midterm) Flashcards
1
Q
When evaluating a Pt for depression what do you need to differentiate?
A
Differentiate between chronic depression and situational depression
2
Q
When starting antidepressants how long does it typically take to see improvment?
A
Improvement may be experienced within the first week, but usually takes 4-6 weeks before the full effect is seen. Before trying a new med make sure to give a full 4-6 week trial.
3
Q
How long after full remission of depression should the Pt continue to take their antidepressants?
A
4-9 months after full remission, then graded discontinuation. If recurrent depression may need to take meds indefinitely.
4
Q
What percentage of Pts who receive treatment for depression will experience improvement?
A
80%
5
Q
Are antidepressants habit forming?
A
No
6
Q
What class of antidepressants are the most commonly prescribed?
A
SSRI
7
Q
SSRI means what?
A
Selective Serotonin Reuptake Inhibitor
8
Q
Name some common SSRIs
A
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
9
Q
What is a SNRI?
A
Serotonin-norepinephrine Reuptake Inhibitor. Antidepressants that modulate two neurotransmitters.
10
Q
Name some common SNRIs
A
- Desvenlafaxine (Pristiq)
- Duloxetine (Cymbalta)
- Venlafaxine (Effexor)
11
Q
Which classes of antidepressants are considered first line?
A
SSRIs and SNRIs
12
Q
Amitriptyline (Elavil) and other TCAs are particularly good at treating which kind of depression?
A
Melancholic depression
13
Q
What is one use, outside of depression, for Buproprion (Wellbutrin)?
A
Smoking cessation
14
Q
Mirtazapine (Remeron) and Trazodone (Desyrel) are useful in Pts with?
A
Concurrent insomina/anxiety
15
Q
When should Aripiprazole (Abilify) and Quetiapine (Seroquel) be considered?
A
In cases of resistant depression (failed trial of SSRI and/or SNRI)
16
Q
If a Pt does not respond to one SSRI should you move to a different class of antidepressants?
A
No, failing one SSRI does not mean other SSRIs won’t work. Try a few different SSRIs before switching classes.
17
Q
Common indications for antidepressant therapy?
A
- Depression
- Anxiety
- Chronic pain
- Premenstrual dysphoric disorder (PMDD)
- Smoking cessation
- Eating disorders
18
Q
Is it okay to initiate antidepressant therapy on a Pts first presentation to the office for depression?
A
Yes!! It is likely if they are presenting with a concern for depression that they have been dealing with it for a while and have tried non-pharmacologic treatments like stress reduction.
19
Q
What should you consider when choosing an antidepressant?
A
- Indication
- Cost (SSRIs tend to be very cheap)
- Availability
- Drug interactions
- Patient age and gender
20
Q
Why are SSRIs and SNRIs first line?
A
- Inexpensive
- Easy to use
- Lower S/E compared to TCAs and MAOIs
- Safe
21
Q
Which antidepressants are second and third line? Why?
A
TCAs and MAOIs
- Potential lethal overdose
- Need titration
- Serious drug interactions
- Many S/E
22
Q
Common adverse effects of SSRIs
A
- Nausea
- GI upset
- Diarrhea
- Diminished sexual function
- Decreased interest
- Delayed orgasm
- Diminished arousal
- Headaches
- Weight gain
- Discontinuation syndrome:
- Sudden discontinuation can lead to dizziness and paresthesias
- Can make Pt feel shitty but is not lethal
- Recommended to do slow taper when discontinuing SSRI
23
Q
SNRI and TCA adverse reactions
A
- Same as SSRIs
- Noradrenergic effects
- Increased BP
- Tachycardia
- CNS activation
- Insomnia
- Anxiety
- Agitation
- Anticholinergic (TCAs)
- Dry mouth
- Constipation
- Urinary retention
- Blurred vision
- Confusion
- Discontinuation syndrome
- Cholinergic rebound
- Flu-like symptoms
24
Q
MAOI adverse effects
A
- Orthostatic hypotension
- Weight gain
- Highest rates of sexual dysfunction
25
Sadly suicide attempts are common in depressed Pts. When during the course of their treatment are they most common?
During initiation of antidepressants and during discontinuation of antidepressants
26
Which antidepressant class is the most common to OD on during a suicide attempt?
TCAs
A 1500 mg dose of amitriptyline (less than a week's worth) is enough to be fatal.
27
Options to manage the following S/E of antidepressants
* GI distress:
* Sedation:
* Agitation and insomnia:
* Sexual dysfunction:
* Anxiety/Panic:
* Orthostatic hypotension:
* GI distress: Take after meals
* Sedation: Take at HS (most SSRIs such as Prozac are less sedating)
* Agitation and insomnia: Switch to a more sedating option (Remeron, Celexa, Effexor)
* Sexual dysfunction: Switch to medication with a low sexual S/E profile such as Wellbutrin or Remeron. Consider prescribing a PDE-5 in addition to the antidepressant
* Anxiety/Panic: Paxil, Remeron, Effexor, and TCAs are helpful in reducing anxiety. Try to avoid benzos!
* Orthostatic hypotension: Good hydration, education on getting up safely from rest
28
When tapering off antidepressants how long should you do it for?
Taper off over the course of 4 weeks, if Pt experiences withdrawal symptoms slow down the taper.
29
Which OTCs have been demonstrated to have some benefit in the treatment of depression?
St. John's Wort and SAMe
30
St. John's Wort and SAMe should not be used in which Pts?
Pts currently taking serotonergic agents. If planning to start an SSRI or SNRI ensure the patient is not taking St. John's Wort or SAMe.
31
St. John's Wort is a potent inducer of what?
CYP 450. Can lead to lots of interactions
32
When treating depression the best outcomes are found with?
Medication therapy + Psychotherapy
33
If a Pt shows some improvement on an SSRI but isn't to the level they would like to be after 4-6 weeks what should you do?
Titrate up on the dose of the SSRI (up to max dose) before switching to a different med.
34
At what age does schizophrenia tend to appear?
* Can occur at any age
* Typically late teens to early 20's for men
* Typically late 20's to early 30's for women
* Uncommon to be diagnosed in a person younger than 12 or older than 40
35
With aggressive treatment and medication compliance what percentage of schizophrenics can live fully independent lives?
About 50%
36
Antipsychotic agents reduce psychotic symptoms in which disorders?
* Schizophrenia
* Bipolar
* Psychotic depression
* Senile psychosis
* Drug-induced psychosis
37
As well as reducing psychotic symptoms antipsychotic agents also?
* Improve mood
* Reduce anxiety
* Decrease sleep disorders
38
Common first-generation (typical) antipsychotic agents (FGA) and their effects
* Phenothiazines
* Chlorpromazine (Thorazine)
* Sedation, weight gain, tardive dyskinesia
* Thioxanthenes
* Thiothixene (Navane)
* High potency, medium extrapyramidal toxicity, medium sedation, hypotension
* Butyrophenones
* Haloperidol/droperidol (Haldol)
* High levels of extrapyramidal symptoms, high potency, widely used
39
Do first or second-generation antipsychotic agents have more side effects?
First generation
40
Are first or second-generation antipsychotic agents preferred in the treatment of schizophrenia?
Second-generation antipsychotic agents are preferred. First-generation antipsychotic agents can also treat schizophrenia if 2nd gen antipsychotic agents fail.
41
Of the FGAs which is best used for acute treatment of psychotic symptoms?
Haldol
42
What are extrapyramidal symptoms?
* Dystonia
* Continous spasm and muscle contractions
* Akathisia
* Motor restlessness
* Parkinsonism
* Irregular, jerky movements
* Tardive dyskinesia
* Involuntary muscle movements in the lower face and distal extremities
* Bradykinesia
* Slow movements
* Tremors
43
Common Second-generation (atypical) antipsychotic agents (SGA)
* Quetiapine (Seroquel and Seroquel XR)
* Risperidone (Risperdal)
* Ziprasidone (Geodon)
* Paliperidone (Invega)
* Aripiprizole (Abilify)
* Clozapin (Clozaril)
* Olanzapine (Zyprexa)
Any of these are appropriate for the treatment of schizophrenia
44
Why are SGAs considered the first line in the treatment of schizophrenia over FGAs?
Lower risk for EPS, minimal risk for tardive dyskinesia, and lower incidence of cognitive impairment
45
Treatment regimen for schizophrenia with Quetiapine (Seroquel). and common S/E.
* Initiate the IR formulation at 25 mg BID, followed by a dose titration of 25-50 mg/day in divided doses daily until reaching the target dose of 300-400 mg/day by day 4.
* Can cause significant weight gain
46
Treatment regimen for schizophrenia with Risperidone (Risperdal), and common S/E.
* Initiate at 1-2 mg/day and titrate to 2-6 mg/day
* Fewer EPS than other antipsychotic agents but risk increases with dosage
* Weight gain
47
Risperdal is FDA approved for the treatment of schizophrenia, what other disorders is it approved to treat?
* Monotherapy or adjunctive treatment of acute manic or mixed episodes in Bipolar I
* Irritability associated with autistic disorder
48
Treatment regimen for schizophrenia with Zi[rasidone (Geodon), and common S/E.
* 20 mg BID with food, can be titrated up to a max of 80mg BID
* Less weight gain than other SGAs
* Caution in Pts with CVD and prolonged QTc
49
Treatment regimen for schizophrenia with Paliperidone (Invega) and common S/E.
* Reccomened dose is 6 mg QAM. Can be increased by 3 mg/day every 5 days to a max of 12 mg/day.
* Is the active metabolite of Risperidone and has the same S/E profile
50
Treatment regimen for schizophrenia with Aripiprazole (Abilify) and common S/E.
* The initial dose is 10-15 mg QD. Can titrate up to max 30 mg/day. Should not increase dosage before 2 week when steady state is reached
* Weight gain
51
Of the SGAs which ones are **not** indicated as first-line meds in the treatment of schizophrenia?
* Clozapine (Clozaril)
* Severe risk of neutropenia
* Reserved for refractory Pts
* Olanzapine (Zyprexa)
* Commonly prescribed however guidelines do not recommend as a first-line agent.
52
What should you consider when choosing which medication to treat schizophrenia?
* Adverse effects
* Efficacy
* Comorbidities
* Cost
53
Which meds are options for the treatment of an acute psychotic break?
* Zyprexa (IM/ODT(Orally disintegrating tablet))
* Haldol (IV)
* Benzo's such as Lorazepam (Ativan)
54
How long should an SGA at a therapeutic dose be trialed for?
At least 6-8 weeks
55
Common S/E of SGAs
* Weight gain
* Hyperglycemia
* Diabetes mellitus
* Hyperlipidemia
Hyperglycemia, ketoacidosis, coma, and death have been reported with SGAs
56
Typical workup for someone presenting with their first acute psychotic episode due to schizophrenia
* Distinguish between drug-induced psychosis and schizophrenia
* Provide an acute antipsychotic in order to have Pt completely evaluated
* Admit as new-onset schizophrenia for a full psychiatric evaluation
* SGA should be chosen as first-line
57
Is alcohol withdrawal deadly?
It can be!! Same with Benzo withdrawal
58
Short term goals in the treatment of alcohol withdrawal
* Control acute symptoms of alcohol withdrawal
* Prevent progression to delirium tremens
* AMS
* Onset 3-10 days following last drink
* Lasts 2-3 days
* Prevent alcohol withdrawal seizures
* Correct electrolyte imbalances
* Potassium
* Magnesium
* Start prophylaxis to prevent Wernicke's encephalopathy
59
If a Pt has an alcohol withdrawal seizure are they more or less likely to have seizures during future episodes of alcohol withdrawal?
More likley
60
Long term goals in the treatment of alcohol withdrawal
* Long-term abstinence control
* Enrollment in a program to help combat drinking
* Work up potential liver disease/prevent further progression of liver disease
* Treat and manage comorbidities
61
Which medication class is the treatment of choice for both alcohol withdrawal and withdrawal seizures?
Benzodiazepines
All benzodiazepines appear equally efficacious in reducing signs and symptoms of withdrawal
62
Name some long-acting benzo's and their use in alcohol withdrawal
* Diazepam (Valium)
* Chlordiazepoxide (Librium)
* Used in preventing seizures and symptom control
Clinical monitoring is required as they are metabolized by the liver, increasing the risk of toxicity.
63
Name some short-acting benzo's used in alcohol withdrawal treatment
* Lorazepam (Ativan)
* Oxazepam
Less affected by liver dysfunction and less toxic to the liver and have fewer residual sedative effects compared to long-acting benzo's
64
All benzo's used in the treatment of alcohol withdrawal should be?
Front-loaded
65
Dosage for lorazepam (Ativan) in treating alcohol withdrawal symptoms? For alcohol withdrawal seizures?
* Alcohol withdrawal symptoms
* 2-4 mg PO/IV Q 4-6 hours
* Alcohol withdrawal seizures
* 4 mg IV may be repeated
66
Dosage for diazepam (Valium) in treating alcohol withdrawal symptoms? For alcohol withdrawal seizures?
* Alcohol withdrawal symptoms
* 5 mg PO Q6 hours
* Alcohol withdrawal seizures
* 5-10 mg Q 10 minutes for 30 mg total
67
Dosage for Chlordiazepoxide (Librium) in treating alcohol withdrawal symptoms? For alcohol withdrawal seizures?
* Alcohol withdrawal symptoms
* 50-100 mg PO
* Alcohol withdrawal seizures
* Not indicated
68
Non-benzodiazepine options for the treatment of alcohol withdrawal
* Barbituates
* Phenobarbitol
* Has been shown to be safer than benzo's, some ERs are using pheno over benzo's
* Alpha-Agonists
* Clonidine
* Can be added to the benzo treatment, should not be used as monotherapy. Has been shown to decrease symptoms in Pts experiencing mild-to-moderate alcohol withdrawal.
* Short-term benefit of helping lower BP and HR.
69
Which other medications should be added to the treatment of alcohol withdrawal on top of benzo's?
* Thiamine 500 mg IV
* Home taper for three days
* Folate
* Home multivitamin PO QD
Both help reduce the risk of developing Wernicke's encephalopathy and progression to delirium tremens
70
When is the risk of alcohol withdrawal seizures greatest?
6-72 hours after cessation of alcohol
71
What are the stages of alcohol withdrawal and when do they occur? (this is based off Jaynstein's slides)
* Stage 1 (0-8 hours after the last drink)
* Anxiety, insomnia, nausea, abdominal pain
* Stage 2 (1-3 days after last drink)
* HTN, hyperthermia
* Stage 3 (3 days-1 week after last drink)
* Hallucinations, fever, agitation, possible seizures
72
What does CIWA stand for and what does it measure?
* Clinical institute withdrawal assessment
* Scoring system to gauge the severity of alcohol withdrawal
* Score 0-67
Don't need to memorize the scoring criteria
73
If a Pt is in alcohol withdrawal is deemed safe enough to go through withdrawals at home which benzo is the safest to use?
Librium 50-100 mg PO TID or QID. Have strict instructions on when to return to ED.
73
If a Pt states that they have no interest in quitting drinking, and plan to go home and drink after being discharged can you D/C them?
Depends, if they are unstable you shouldn't D/C them. If they are stable and plan to go home and drink it's okay to D/C as continuing drinking is safer than going through alcohol withdrawal. A weird concept I know, but you can't stop someone who isn't ready to quit.
74
Which alcohol cessation medication should never be given to an intoxicated Pt or a Pt who plans to continue to drink?
* Disulfiram (Antabuse)
75
Which Pt is Disulfiram (Antabuse) most successful in?
* A Pt who has already gone through alcohol withdrawal and who is motivated to stay sober
76
Which Pts is it safer to have them continue drinking rather than quit “cold turkey”
* Pts who do not have a definitive plan on how to safely stop drinking. Alcohol withdrawal can be deadly, it takes a multidiscipline approach to come up with a plan to help a Pt stop drinking, survive alcohol withdrawal, and maintain abstinence from alcohol.
77
Which medications are associated with insomnia?
* CNS stimulants
* D-amphetamine
* Methylphenidate
* BP drugs
* Alpha and Beta-blockers
* Respiratory medications
* Albuterol
* Theophylline
* Decongestants
* Phenylephrine
* Pseudoephedrine
* Hormones
* Corticosteroids
* Other substances
* Alcohol
* Nicotene
* Cocaine
78
What lifestyle changes can you advise a Pt to make to help reduce insomnia?
* Stimulus control
* Avoid Alcohol
* Avoid Caffeine
* Environment
* Dark rooms
* Quiet
* Decrease pre-sleep activity (such as screen time before bed)
* Bedroom only used for sleep and sex
* Behavioral therapy
* Sleep hygiene
* Sleep restriction therapy
* Relaxation
* CBT
79
Even though they are not FDA regulated what OTC supplements may help with sleep?
* Valerian root
* Kava-kava
* Melatonin
* Passionflower
* Skullcap
* Lavender
* Hops
* Tryptophan
80
Many OTC sleep medications are in which classes?
Antihistamine or anticholinergic
81
Common OTC sleep medications
* Benadryl
* Tylenol PM
* Just Tylenol and Benadryl, just have Pt take Benadryl unless they have pain
* Sleep-Eze
* Doxylamine (Unisom)
82
What are some common undesirable side effects of OTC sleep medications?
* May be habit-forming
* Should be used PRN, not every night
* Vivid dreams
* Next day “hangover”
83
Which antidepressants are used in the treatment of insomnia?
* Doxepin
* Trazodone
84
Which benzodiazepines are used in the treatment of insomnia?
* Lorazepam (Ativan)
* Clonzepam (Klonopin)
* Alprazolam (Xanax)
* Trizolam (Halcion)\*
* Estazolam (ProSom)\*
* Temazepam (Restoril)\*
These should not be first-line meds as they are highly addictive
\*slightly safer benzo's that are appropriate for everyday use
All benzo's are category X in pregnancy
85
Benzodiazepines and Z-drugs act on which receptors?
GABAa receptors
86
What are two common Z-drugs for insomnia?
* Zolpidem (Ambien)
* Eszopiclone (Lunesta)
87
What is the predominant inhibitory neurotransmitter?
Gamma-aminobutyric acid (GABA)
88
Which medications for insomnia are safe in pregnancy?
* Doxylamine (Unisom)
* Zolpidem (Ambien)
89
General approach to treating insomnia
* Everyone gets lifestyle and sleep hygiene education
* It is reasonable to start with melatonin
* OTC medications for PRN insomnia
* Benzo's for situational insomnia
* Limit to 2 weeks or less
* Non-benzos (Z-drugs) for long-term insomnia
* Antidepressant for co-morbid depression, anxiety, mania
90
These flashcards only covered the wrap-up powerpoint. What else should you do?
Have a beer and re-read all the cases
