Wk 9 Antipsychotic's

Question 1

schizophrenia

Answer 1

US lifetime prev is ~1%

lifetime prev of suicide is ~10%

Question 2

risk if 2nd degree relative has schizophrenia

Answer 2

~3%

Question 3

risk if 1st degree relative has schizophrenia

Answer 3

~10%

Question 4

Risk if both parents have schizophrenia

Answer 4

~40%

Question 5

monozygotic twin risk for schizophrenia

Answer 5

~48%

Question 6

schizophrenia presentation

Answer 6

NOT “split personality”
chronic disorganization of thought and affect
pharmacotherapy is mainstay of treatment
psychosocial rehab is mainstay of non-drug tx

Question 7

acute psychotic episodes of schizophrenia

Answer 7

auditory hallucinations (esp voices) 
delusions (fixed false beliefs) 
ideas of influence (external forces control their actions)

Question 8

symptom classification of schizophrenia

Answer 8

positive (most obvious/dramatic), negative (functional impairment) and cognitive

Question 9

original “dopamine hypothesis”

Answer 9

acue psychotic episodes inc dopamine neurotransmission

results in hypersensitivity to stimuli

Question 10

newer “dysregulation hypothesis”

Answer 10

since inhibitor neurons are modulated by dopamine, 5-HT, Act and NE, these become targets for new agents

Question 11

first generation antipsychotics

Answer 11

dopamine antagonism was found to be the mode of action (esp D2)
MOA characterizes “typical” antipsychotics
dec presynaptic release of dopamine
not typically first line
used before SGA if chronically ill pt had previously satisfactory response

Question 12

neuroleptic

Answer 12

AP drugs with prominent D2-dopamine rec antagonism

“typical” antipsychotics, first generation antipsychotics

Question 13

traditional equivalent doses of Fluphenazine and Haloperidol

Answer 13

2 mg, but also have long-acting depot injection formulations available (highly potent)

Question 14

FGA >60% D2 blockade

Answer 14

clinical response

Question 15

FGA > 70% D2 blockade

Answer 15

hyperprolactinemia

Question 16

FGA >80% D2 blockade

Answer 16

inc risk of extrapyramidal symptoms

Question 17

incidence of death from FGA

Answer 17

~0.015%/yr

Question 18

most likely FGA to cause QT prolongation

Answer 18

Thioridazine

Question 19

least likely FGA to cause QT prolongation

Answer 19

Haloperidol

Question 20

early neuro adverse effects of FGA

Answer 20

acute dystonia (1-5 days = max risk)
akathisia (5-60 days, usual tx for agitation is to give more drug but not in this case)
Parkinsonism (5-30 days)

Question 21

late neuro adverse effects of FGA

Answer 21

neuroleptic malignant syndrome (weeks, 10% mortality, antiparkinson agents not effective) 
tardive dyskinesia (months-yrs of tx)
perioral tremor (rabbit syndrome, months-yrs)

Question 22

neuroleptic malignant syndrome

Answer 22

more common in pt’s on high potency or depot FGAs, dehydrated or exhausted pt’s

Question 23

neuroleptic malignant syndrome tx

Answer 23

discount antipsychotic

use only SGAs for re challenge post-NMS

Question 24

only SGA to fulfill all criteria

Answer 24

clozapine

Question 25

additional SGA therapeutic mechanisms

Answer 25

D1, D4 antagonism | NE, 5-HT antagonism

Question 26

early SGAs

Answer 26

``` greatly reduced risk of tar dive dyskinesia esp good for - symptoms sig less relapse than with FGAs 25% relapse rate with Risperidone 40% relapse rate with haloperidol ```

Question 27

3 phases of tx in schizo

Answer 27

acute, stabilization and maintenance phase

Question 28

tx of first (acute) psychotic episode

Answer 28

initial goal is to calm agitated pt immediate tx improves long term outcome most psychiatrist rx SGA (NOT CLOZAPINE) (dec anger and anxiety usually in 24-48 hrs) near max improvement seen by 6-8 wks suicide risk inc's as other symptoms improve!!!!!

Question 29

pharm algorithm stage 1

Answer 29

only for pt's with FIRST schizo episode | SGAs considered 1st line

Question 30

pharm algorithm stage 2

Answer 30

chronically ill pt recently started on AP or new onset pt with poor response to stage 1 mono therapy with FGA or SGA (not clozapine) chose different AP than stage 1

Question 31

pharm algorithm stage 3

Answer 31

switch to clozapine inc efficacy for suicidal behavior consider earlier in suicidal pt

Question 32

pharm algorithm stage 4

Answer 32

cont clozapine | add an additional AP (combo AP therapy)

Question 33

pharm algorithm stage 5

Answer 33

trial of mono therapy AP | use FGA or SGA not previously used

Question 34

pharm algorithm stage 6

Answer 34

consider combo therapy | when switching to APs: overlap 2nd agent for 1-2 weeks then taper and DC 1st agent

Question 35

combination

Answer 35

involves using 2 AP simultaneously

Question 36

augmentation

Answer 36

addition of a non-AP drug to an AP

Question 37

augmentation agents

Answer 37

mood stabilizers, SSRIs, BB's (anti aggressive effect)

Question 38

combo therapy steps 4-6

Answer 38

multiple MOAs combo trials should be time-limited (12 wks) if no improvement, taper 1 med then D/C a series of mono therapies is preferred over AP combinations

Question 39

maintenance tx

Answer 39

1st presentations may respond sooner meds may red symptoms, but are not curative all symptoms may not abate prevents relapse (18-32% on drug vs 60-80% on placebo) cont at least 12 months past remission

Question 40

long-acting depot injectable APs

Answer 40

recommended in unreliable pt's not used as 1st line look for SE as a cause of nonadherence

Question 41

haloperidol deconate

Answer 41

use 10-15 x PO dose round dose up to nearest 50 mg give dose via deep IM injection q month overlap with PO haloperidol for 1st month

Question 42

risperidone

Answer 42

only SGA depot, needs reconstitution

Question 43

bipolar 1 vs 2

Answer 43

mania, usually requiring hospitalization (classic) vs hypomania (major depression + hypomania) need to r/o amphetamine abuse and pheochromocytoma

Question 44

bipolar dx

Answer 44

previously called manic-depression one of most distinctive syndromes in psychiatry unique hallmark of illness is mania (different from pt's usual behavior) single manic episode sufficient for dx

Question 45

S/S's of bipolar dx

Answer 45

elevated mood, overactivity, lack of need for sleep and inc optimism

Question 46

types of bipolar disorder

Answer 46

one mamic episode, alternating episodes and mania every few yrs

Question 47

rapid cyclers

Answer 47

patient with >4 manic or depressive cycles/yr

Question 48

genetic risk of bipolar dx

Answer 48

~50% of pt's have family hx | ~10% in siblings of affected pt's

Question 49

tx of acute mania

Answer 49

medical ER! non tx endangers: marriage, job, pt's life AP drugs effective rapid drug onset may be lifesaving (think short acting injectables!!) newer "atypical" Abs are effective in compliant pt's

Question 50

bipolar depression

Answer 50

depressive episode responds to SSRIs, TCAs and MAOIs Antidepressants may induce switch from depression to mania!!! (don't use antidepressants in pt's with hx of dangerous mania episodes)

Question 51

lithium

Answer 51

collect trough samples just prior to next dose | recently found this prophylactically is much more effective than valproate for suicide prevention