Vol 1

Question 1

Foods to avoid for MAO-I

Answer 1

Avoid tyramine
- dried, aged, smoked, fermented, spoiled, improperly spoiled meat, poultry, fish
- broad bean pods
- aged cheeses, yogurt (processed, cottage, ricotta OK)
- tap and nonpasteurized beers (can/bottled OK)
- Marmite, sauerkraut
- Soy products/tofu

Question 2

When should antidepressant maintenance become indefinite?

Answer 2

• particularly severe episode (i.e. suicidality)
• remission from 3 episodes of major depression

Question 3

Why avoid tyramine with MAO-Is?

Answer 3

• MAO-A destroys NE
• Tyramine increases release of NE
• MAO-I stops destruction of NE –> risk of dangerously high BP

Question 4

Brain changes in depression

Answer 4

frontal-limbic function disconnection; hippocampal volume loss is greater with longer periods of untreated depression

Question 5

Dangerous HTN combos w MAO-Is (adrenergic stimulation)

Answer 5

• decongestants (phenylephrine, ephedrine, ma huang, pseudoephedrine, phenylpropanolamine)
• stimulants (amphetamine, methylphenidate)
• antidepressants with norepi reuptake inhibition (TCAs, NRI, SNRIs, NDRIs)
• appetite suppression w norepi reuptake inhibition (phentermine)

Question 6

Potentially lethal MAOI combos –> hyperthermia/serotonin syndrome (SERT inhibition)

Answer 6

• Antidepressants (SSRIs, SNRIs, TCA esp clomipramine)
• Other TCA (cyclobenzaprine, carbamazepine)
• Appetite suppressants w SERT inhibition (sibutramine)
• Opioids (dextromethorphan, meperidine, tramadol, methadone, prpoxyphene)

Question 7

Psychotic pt with partial response on valproate can benefit from lamotrigine augmentation but valproate affects plasma levels of lamotrigine. How to titrate?

Answer 7

valproate incr plasma levels of lamotrigine –> titration schedule of lamotrigine should be halved

Question 8

Actively ill & psychotic while on ziprasidone (geodon) 80mg AM 160mg PM & vapropate (depakote) 1500mg PM. What next?

Answer 8

Start clozapine for this treatment-resistant case; If only partial improvement, augment with lamotrigine (titrate half bc on vaproate)

Question 9

What are the negative sx of schizophrenia?

Answer 9

Dysfunctions of
- communication = alogia
- affect = blunted affect
- socialization = asociality
- capacity for pleasure = anhedonia
- motivation = avolition

Question 10

Best tx for schizophrenia with negative sx per Stahl 2010

Answer 10

Ziprasidone, standard dose of 80-160mg/d - superior to low dose ziprasidone and haloperidol in enhancing # of pts in remission long term

Question 11

What do neg sx in schizophrenia predict?

Answer 11

Worse
- QoL
- social functioning
- interpersonal relationships
- work performance
- overall outcome

Question 12

Cannabis in general population

Answer 12

incr risk of psychotic sx

Question 13

Cannabis in pts with psychotic dx

Answer 13

• negative effect on illness course
• causes more and earlier relapses
• more frequent hospitalization
• poorer psychosocial functioning
• loss of brain tissue 2x rate compared to those who don’t use cannabis

Question 14

Why do patients with psychosis use cannabis?

Answer 14

• enhancement of positive affect
• social acceptance
• coping with negative affect/sx

Question 15

How to treat aggression in Alzheimer’s Dz?

Answer 15

(1) identify and address reversible precipitants of behaviors (i.e. pain, nicotine withdrawal, med SE, medical neurological or psych conditions; environmental triggers)
(2) SSRI, eg citalopram
(3) some rationale and anecdotal evidence for beta-blocker, valproate, gabapentin, selegiline
(4) try low dose atypical antipsychotic like risperdal

Question 16

Biggest worry about starting antipsychotic in Alzheimer’s Dz

Answer 16

Black box warning (likely over-interpreted); worsening of Parkinsonian sxs and complications if pt actually has Lewy Body dementia (in which case, use quetiapine or clozapine)

Question 17

Black box warning for antipsychotics in elderly with alzheimer’s

Answer 17

Incr risk of cardiovascular events and death

Question 18

Paroxetine & Thioridazine

Answer 18

paroxetine is irreversible CYP2D6 and may incr blood lvls of thioridazine, increasing chance for QTc prolongation

Question 19

Paroxetine & aspirin

Answer 19

paroxetine’s effect on incr bleeding time may pharmacodynamically interact with aspirin causing bleeding disorder of varying effects

Question 20

Paroxetine & HCTZ

Answer 20

pharmacodynamic interaction with natiuretics can cause significant hypoNa, esp in elderly with chronic use of paroxetine

Question 21

Chief metabolic pathway for carbamazepine

Answer 21

CYP3A4

Question 22

SSRIs FDA-approved for treating PTSD

Answer 22

Paroxetine & Sertraline (although VA also supports use of venlafaxine & fluoxetine)

Question 23

Med approved for both ADHD and binge eating disorder

Answer 23

Lisdexamfetamine dimesylate

Question 25

Psychopharm for mood and personality disorders (ie BPD and bipolar)

Answer 25

lamotrigine, lamictal, and atypical antipsychotic (ie ziprasidone) triple combo can be helpful; antidepressants can be destabilizing

Question 26

first line pharmrx for PTSD, which ones FDA-approved?

Answer 26

SSRIS; SNRIs; paroxetine and sertraline

Question 27

approved for ADHD with some evidence for use in oppositional and inattentive/hyperactive sxs of ADHD (but not approved for ODD)

Answer 27

Guanfacine

Question 28

ADHD neurotransmitter disturbance

Answer 28

low DA and NE signals and/or high noise in the PFC

Question 29

ADHD - theoretically only low in NE, treat with?

Answer 29

alpha 2A agonist that selectively enhances NE like guanfacine XR

Question 30

ADHD & ODD neurotransmitters?

Answer 30

hypothetically VERY LOW NE signals and low DA signals in VMPFC (ventromedial), thus augment a stimulant with guanfacine

Question 31

Where is problem solving and executive functioning regulated?

Answer 31

Dorsolateral prefrontal cortex

Question 32

an agent with Sigma one properties that work for both OCD and delusional/psychotic disorders

Answer 32

fluvoxamine

Question 33

consider doing this if patient on both abilify and risperdal

Answer 33

Abilify has higher D2R affinity and is only a partial agonist so can theoretically interfere with risperdal effects