Psychiatric Medications

metabolic syndrome

(hyperglycemia, insulin resistance, dyslipidemia), and weight gain. -Increased abdominal circumference -Increased blood glucose -Increased triglycerides -Elevated blood pressure -newer antipsychotics SDAs→ can lead to this --Some meds will cause the pt to gain 50-100 lbs

use of Lamotrigine (Lamictal)

(mood stabilizer- antimania) - used often in clinical practice -Anticonvulsant: Maintenance of Bipolar. Helpful in Bipolar II cycling. -Helpful for *depressive symptoms* -Risk of rash and SJS

use of Temazepam (Restoril)

-Insomnia

examples of SARIs (Serotonin 2 antagonist/reuptake inhibitor)

-Trazodone (Desyrel) -Nefazodone (Serzone)

what are SNRIs

-Class: Nonselective inhibitor of serotonin, norepinephrine, and dopamine. -Works faster than SSRI (don't pick for anxiety because it makes them more anxious at first) -example is Venlafaxine (Effexor)

use of Nefazodone (Serzone)

-SARI (Serotonin 2 antagonist/reuptake inhibitor) -Depression and relapse prevention in MDD. Also helps with PTSD and Panic disorder -Only used after other agents fail. Black box warning for liver toxicity

use of Trazodone (Desyrel)

-SARI (Serotonin 2 antagonist/reuptake inhibitor) -Depression indication. Also helps with insomnia --More beneficial for insomnia

use of Chlordiazepoxide (Librium)

-Acute Alcohol withdrawal

esketamine spray

-newer option -For tx resistant depression

extrapyramidal symptoms

-*Terminology Relating to Antipsychotic Medications* -Includes 4 categories: akathisia, acute dystonia, parkinsonism, and Tardive Dyskinesia.

safety and proper use of benzos

-10% of the population use one of these each year. -Fairly Safe and effective when used properly -Along with antidepressant. --Slow taper off 5-10% per week -Have to be VERY cautious using these meds --Should be as cautious with these as you are with opioids

neuroleptic malignant syndrome

-*Rare, life threatening condition*. Fever, muscular rigidity, altered Mental Status, autonomic dysfunction (HTN, tachypnea, diaphoresis, incontinence). --Antipsychotics pose this risk (Most commonly with DRAs). --Drugs that induce dopamine-2 receptor blockade can cause NMS. --Risk increases with *dehydration, high dose, rapid increase, concomitant use of lithium* (in setting of dehydration) --Usually starts weeks after starting treatment. Can be a rapid physical decline over 3-7 days. --Treat with *ICU support, dantrolene, bromocriptine*

tx of chronic depression

Should remain treated for several years. SSRI's are well tolerated

MOA of SSRI's and SE

-1st line treatment -- if one doesn't work, try another in the category -Effective through the selective inhibition of serontonin reuptake (little effect on dopamine and norepinephrine) --Tell the patient it will take weeks to reach maximum effect. Side effects: -Adverse sexual side effects (will most likely stay long term), weight gain, headaches, nervousness, agitation, sleep changes, GI symptom's, rash -- Nausea, sleep issues, agitation - will go away (need to wait it out) -DONT STOP ABRUPTLY -Suicide: SSRI's reduce the risk of suicide, however patients with suicidal thoughts should be monitored closely the first few weeks of therapy

indication for TCAs and examples

-2nd line treatment for depression. Previously 1st line treatment -Nortriptyline: Pamelor -- Less side effects -Amitriptyline (Elavil) -- More side effects than others -Desipramine (Norpramin): -- Less sedating than other -Doxepin (Sinequan) -- Less side effects -- Good antihistamine properties, helps with sedation, pain, and sleep

atypical antipsychotics used for acute mania in bipolar

-Abilify, Zyprexa, Risperdal, Seroquel, Geodon (clinical practice) -Zyprexa and Abilify are approved for maintenance of bipolar disorder

SSRI discontinuation syndrome

-Abrupt discontinuation of an SSRI. Dizziness, weakness, nausea, headache, rebound depression, anxiety, insomnia, poor concentration, irritability, agitation, upper respiratory symptoms, paresthesias, and migraine like symptoms. -Starts after 6 weeks of treatment and usually resolves in 3 weeks. -Prozac less common. Prozac can be used to treat discontinuation syndrome --Has the longest half life - if they stop it is the easiest to come off of and have the body tolerate

treatment of acute anxiety vs chronic anxiety

-Acute anxiety: *Benzodiazepines work well*. --There is a high potential for tolerance, dependence and abuse. --Sedative, anxiolytic, anticonvulsant and muscle relaxant -Chronic anxiety: Benzodiazepines (usually Buspirone) --Can be used for long-term treatment of GAD and panic disorder --*Should be on Antidepressant also* --SSRI's and SNRI's --Can increase anxiety upon starting (Takes a long time for these to work- can be only benzo in the meantime but have to make sure they know its short-term) -Ongoing anxiety→ better treated with antidepressant

use of Diazepam (Valium)

-All anxiety disorders -More for muscle relaxing agent

MOA and SE profile of antidepresssants

-All increase the levels of neurotransmitters: Serotonin, Norepinephrine, Dopamine -Side Effect Profile --Less effects than other classes of antidepressants

features of diazepam (valium)- use, onset, SE

-Anxiety/generalized, alcohol withdrawal, muscle spasm, tonic-clonic seizures -1st benzo and still commonly used -Fast onset of action -Side Effects: decreased cognition, fever, constipation, sedation, increased salivation, bradycardia, respiratory depression --More likely ones: respiratory depression, decreased cognition and sedation --Pt education: tell them to take it on a day off and see how their body reacts to it

use of Carbamazepine (Tegretol) and SE

-Bipolar I acute mania (mood stabilizer- antimania) -Side Effects: *rash*, N/V, weight gain, diplopia, *SJS, Toxic epidermal Necrolysis* (Rare) -SEDATION is problematic -Not FDA approved for bipolar maintenance, but often seen

thorough history for antidepressant selection

-Bipolar disorder: treatment with antidepressant alone can induce mania (very impulse, grandiose actions, poor judgement) -Suicidal ideation -Suicide or overdose attempt -Psychosis -Lifelong treatment for the chronically depressed. -25% relapse in 2 months after discontinuation. -Often need adjunctive or additional medication

The P450 enzyme with the most variation in different people is the ________ , which ....

-CYP2D6 -processes many antidepressants and antipsychotic medications.

examples of Mood Stabilizers: Antimania Drugs

-Carbamazepine (Tegretol) -Lamotrigine (Lamictal) -Oxcarbazepine (Trileptal) -Atypical antipsychotic: Abilify, Zyprexa, Risperdal, Seroquel, Geodon (clinical practice)

special consideration of children and elderly

-Children: Small dosage and increase until clinical effects are seen. Children may metabolize drugs more quickly. -- Increased risk of suicidal ideation with children --Be careful with SSRIs: May realize the child actually has ADHD or bipolar d/o and they are manic -Elderly: Small dosages (start with half-dose) - problems with polypharmacy

features of Buspirone (BuSpar)- use, onset, SE

-Chronic Anxiety, GAD -Slow onset. 7-10 days. -Side effects: Minimal: dizziness, headache, nausea -Less likely to build a tolerance. -Can be used long term -Right now there are shortages (sometimes can only get 5 mg- usual dose is 30 mg) --Will have to take 3-4 times a day: may be difficult to remember

classes of antipsychotic drugs

-Class: Serotonin-dopamine antagonists (SDA's, atypical antipsychotic drugs) --Safer. Less EPS. Occupy less D2 receptors --*Atypical antipsychotics are 1st line treatment* --Cause METABOLIC SYNDROME -Class: Dopamine receptor antagonists (typical antipsychotics) --Block Dopamine receptors --1st generation (older), but second line tx --Cause parkinsonism, atonic dystonic rxn, tardive dyskinesia

Anxiolytics and Hypnotics: Dependence and withdrawal symptoms

-Concern with long-term use is the development of dependence. Especially the high potency agents. -Discontinuation of benzo' s can result in symptom recurrence and rebound, (anxiety, insomnia, sensitivity to light/sound, tachycardia, mild systolic HTN, tremor, seizure), also withdrawal symptoms

general cause of serotonin syndrome

-Consequence of excess serotonergic activity at serotonin receptors. Neurologic, autonomic, and neuromuscular changes -Rare. SSRI with an MAOI can raise plasma concentration to toxic levels and produce a serotonin syndrome. Can be fatal. 3 of the underlined for diagnosis

warnings and labs prior to giving Nortriptyline: Pamelor

-DO NOT USE POST MI -CANNOT BE USED WITH MAOI -Order EKG prior to starting and use in caution in patient with cardiovascular disease --EKG during treatment --CBC to monitor neutrophils --Can order a TCA level --Monitor glucose: can increase or decrease --*Monitor weight*: increase is common

Six Ds to optimize psychotropic drug therapy

-Diagnosis: target specific symptoms so the drug response can be objectively assessed -Drug Selection: consider medical treatment and drug-drug interactions. Past and family history. Side effect profile -Dosage: need to give an adequate therapeutic trial period and adequate dosing -Duration: therapeutic trials are usually *4-6 weeks for antidepressants, antipsychotics, and mood stabilizing drugs*. Anxiolytic and stimulant drugs often see benefits within hours -Discontinuation: discontinuation syndrome commonly occurs when the medication is stopped. Short half life are most prone. Tapering off medication. -- I.e. with drugs such as Paxil- can get very sick if stopped abruptly -Dialogue: Inform about side effects. Reason for the medication.

dosing/guidelines and adverse effects of lithium

-Dosing and guidelines: --Initial work up: PE, serum creatinine, electrolytes, thyroid function, CBC, ECG, Pregnancy test. --Need *regular blood work with serum creatinine* → can go into *renal failure* and need to d/c --ALWAYS order lithium levels -Precautions and adverse effects: --30% significant effects: gastric distress, weight gain, tremor, fatigue, mild cognitive impairment, sexual side effects, sedation, hypothyroidism, tremor --Life threatening SE: renal dysfunction, arrhythmias, sick sinus syndrome, bradycardia

examples of SSNRIs

-Duloxetine (Cymbalta) -Desvenlafaxine (Pristiq)

tx of depression in children

-FDA warning about increased risk of suicide in children and adolescents -SE's: GI, insomnia, psychosis

Ingrezza™ (valbenazine)

-First FDA approved drug for the treatment of tardive dyskinesia (i.e. older person that has been on haldol for a good portion of their life, will mostly have tardive dyskinesia) --Adverse effect associated with the use of some antipsychotic medications characterized by involuntary movements of the jaw, lips, and tongue or extremities -Was approved without a black box warning for depression or suicide -Adverse effects associated with valbenazine include sleepiness (fatigue) and QT prolongation.

benzodiazepine antagonist

-Flumazenil (Romazicon) - reversal agent -Can reverse the effects of Benzo' s

tx of depression during and after pregnancy

-Fluoxetine is not associated with increased perinatal complications. -All are Cat. C except *Paxil Cat. D*

use of Buspirone (BuSpar)

-GAD, Chronic Anxiety --Not addictive - can be used longer term without problems --The safest benzo

commonly used DRAs

-Haloperidol (Haldol) - used often in adult psych -Perphenazine (Trilafon) -Chlorpromazine (Thorazine) - used often in adult psych -Prochlorperazine (Compazine) -- Can be used for nausea -Thioridazine (Mellaril)- not ideal but effective

short term tx of acute psychotic episodes (not on exam)

-Haloperidol (Haldol): -IM works in 30 mins - pretty potent -- can give another dose or give a Benzo -other options for atypical antipsychotics in schizophrenia and bipolar disorder -- Olanzapine (Zyprexa) -- Ziprasidone (Geodon) -- Aripiprazole (Abilify)

important things to monitor with olanzapine (Zyprexa)

-Higher dosing occasional extrapyramidal effects. Metabolic syndrome. Weight gain (significant 30-100) --Some pts take in the evening because it helps them sleep

important things to monitor with ziprasidone (Geodon)

-If taken with food the absorption increases twofold. Bruxism, dystonia, somnolence side effects. --Less likely to cause weight gain, NEEDS food --Teeth grinding and dystonia are major effects

use and SE of Vilazodone Hcl (Viibryd)

-Indicated for the treatment of major depressive disorder Initially studies show less side effects. -Side effects include diarrhea and nausea. -There are less reports of sexual side effects and less reports of weight gain. -Some of the mechanism of action is related to the selective inhibition of the serotonin reuptake and partial agonist at 5HT receptors. -Dosed daily and reaches the maximum dose in 2 weeks

indication and features/warnings of Fetzima (levomilnacipran)

-Indication for major depressive disorder (MDD) -Recently FDA approval (2013) -Serotonin-norepinephrine reuptake inhibitor (SNRI) --Seems is like it is more of an NSRI, the drug's uptake inhibition of norepinephrine is more potent than its serotonin inhibition. -Not seen much because pt needs to fail other med classes before rxed this one

use and SE of mirtazapine (Remeron)

-Likely to enhance noradrenergic and serotonergic neurotransmission. -Treatment of MDD. Works well when added to SSRI. --middle aged older patients: Causes weight gain and makes you tired (preferred in pts who are depressed and losing weight etc) -Lacks the anticholinergic effects of TCA and GI, sexual side effects of SSRI's. Rarely lethal in Overdose --Tx Depression and anxiety -Rarely used because of the side effects --Can help to decrease anxiety --Agranulocytosis can occur --Cautioned use in patients with Cardiovascular disease --Liver and renal impairment slows clearance of drug, dose low --Increased Cholesterol and Triglycerides

warnings/precautions and SE of Fetzima (levomilnacipran)

-Many warnings and precautions: Seizure disorders, history of mania, hypomania, bipolar disorder, pre-existing hypertension, cardio or cerebrovascular disease or tachyarrhythmias, narrow angle glaucoma. -Side effects: Nausea, constipation, hyperhidrosis, erectile dysfunction, tachycardia, vomiting, palpitations, suicidal thoughts, serotonin syndrome, mania (can induce mania or hypomania), seizures, elevated BP

MOA and SE of trintellix

-Mechanism of action is not fully understood. It is an inhibitor of serotonin (5-HT) reuptake. It is also an agonist at 5-HT1A receptors, a partial agonist at 5-HT1B receptors and an antagonist at 5-HT3, 5-HT1D and 5-HT7 receptors -Side effects: Nausea, vomiting, constipation

use of lithium and maintenance

-Mood Stabilizer Drugs -Short term and prophylactic treatment of bipolar I disorder -Gold standard for Bipolar disorder in textbooks -Maintenance: --Decreases frequency, severity, and duration of manic and depressive episodes in Bipolar I disorder --Maintenance is needed after a second episode of bipolar I disorder depression or mania --Maintenance after a first episode for adolescents, family hx of bipolar I disorder, poor support system, no precipitating factor for the episode, first episode of mania

Precautions and adverse reactions of valproate

-N/V/D, most common in the first month. Sedation, ataxia, dysarthria, tremor, dizziness, hair loss -WEIGHT GAIN is very common -Can have tachycardia or bradycardia -Pancreatitis and hepatotoxicity (lethargy, malaise, anorexia, N/V, edema, abdominal pain) → not common --Black box warnings -PREG CAT D

examples of MAOIs

-Nardil -Parnate -Eldepryl -Marplan

risks with DRAs

-Neuroleptic Malignant Syndrome and Tardive Dyskinesias. Anticholinergic side effects: dry mouth, blurred vision, constipation, somnolence and weight gain

drug interactions of MOAIs

-Never with SSRI's. Wash out of 14 days with most. --Causes a HTN crisis (tyramine crisis) -People have to watch their diet (aged cheese, alcohol...etc- certain foods interact)

What is an NDRI and what is a common one

-Norepinephrine and dopamine reuptake blockers -Bupropion (Wellbutrin): --Treatment of depression and Smoking cessation (Zyban)

pretreatment evaluation for SDAs

-Obtain informed consent -History of blood disorders, epilepsy, Cardiovascular Disease, hepatic/renal disease -Screen for orthostatic hypotension -ECG (SDA's can lengthen the QT interval), CBC, Glucose, LFT's, BUN/Creatinine -Increased risk of metabolic syndrome (hyperglycemia, insulin resistance, dyslipidemia), and weight gain. (esp. Zyprexa and Clozaril) --Check weight before starting any med

features of fluoxetine (prozac)

-Oldest SSRI -Starting with a lower dose can decrease the initial anxiety or agitation that is commonly seen upon starting the medication. -Side effects: Rash, fever, leukocytosis -Treatment of Major depression/OCD in adult/pediatric, bulimia, panic disorder -Less likely to have withdrawal- long half-life

important things to monitor with Clozapine (Clozaril)

-Only use for refractory cases. Weight gain (significant) and Diabetes Mellitus is common. -*Most effective SDA.* -Can cause severe agranulocytosis --Need to do weekly blood work (problem with noncompliance)

use of Alprazolam (Xanax)

-Panic Disorder --Works rapidly and very well

use of Clonazepam (Klonopin)

-Panic disorder, Adjunct for mania/psychosis --Better choice over xanax if people need to be on it for longer periods

SE of Nortriptyline: Pamelor

-Photosensitivity -Weight gain

what three aspects of schizophrenia do SDAs work on

-Positive symptoms - hallucinations, delusions, disordered thoughts, agitation -Negative symptoms - anhedonia, flat affect, withdrawal, catatonic, can't care for themselves -Cognitive impairment - does not necessarily improve cognition intellectually --Decreases distortions or helps focus Additional Indications: -Effective for the treatment of mood disorders with psychotic or manic features --Ie abilify for manic episodes -Effective for adults and adolescents. -Acute treatment of manic or mixed episodes in bipolar disorder and psychoses. -Acute illness, treatment-refractory persons, and treatment with medication can help prevent relapses

important things to monitor with risperidone (Risperdal)

-Possible metabolic syndrome. + weight gain. One of the most frequently prescribed antipsychotics. -Elevated Prolactin levels - causing galactorrhea (need to educate patients of the risk, very rare for it to occur) --Occurs in males and females -Paliperidone (Invega): metabolite of Risperdal. --Inj or oral pill

special considerations of pregnant and nursing and medically ill persons

-Pregnant and Nursing: Avoid medications to pregnant or nursing women. -- Only one antipsychotic med approved in pregnancy- Latuda --Avoid most antidepressant meds- especially in first trimester --When you're first starting out as a provider, make sure the psychiatrist is seeing them instead of you -Medically Ill Persons: Small doses, treat conservatively

adverse effects of all SDAs

-Rare: Neuroleptic Malignant Syndrome is still a risk, but much less -Rare: Tardive dyskinesia. Less common. -Rare: Anticholinergic side effects -Metabolic syndrome: abdominal obesity, dyslipidemia, hypertension, insulin resistance. (Geodon does not increase Weight) -Hyperglycemia -Most common complaint is sedation (sleeping 15 hours, not able to function)

Commonly used SDA's:

-Risperidone (Risperdal)- oldest -Olanzapine (Zyprexa) -Quetiapine (Seroquel) -Ziprasidone (Geodon) *wgt --Can be an inj -Aripiprazole (Abilify) -Clozapine (Clozaril)* less common -Need to start with these above (with the exception of clozapine), and fail this tx before starting the medications below

features and precations with Venlafaxine (Effexor)

-SNRI -Treatment: Depression and Severe depression with melancholic features -Possibility for death in overdose. -Precautions and Adverse Reactions --*Most common reaction is nausea*, somnolence, dry mouth, dizziness, nervousness. Sexual dysfunction. Can feel anxiety, nervousness. -Discontinuation syndrome of nausea, somnolence and insomnia -Increase BP can occur especially if >300mg/day. Low dose in HTN patients. --Tell pts to monitor their BP

other examples of ADHD/Stimulants (not sympathomimetics)

-SNRI: Atomoxetine (Strattera) - taken daily -Modafinil (Provigil) -Centrally acting alpha 2A-adrenergic receptor agonists --Guanfacine extended-release (long-acting) tablets (Intuniv)

use and precautions with Desvenlafaxine (Pristiq)

-SSNRI -Treatment of depression -Increases the amounts of serotonin and norepinephrine -Precautions and adverse reactions --Constipation, dry mouth, somnolence, sexual dysfunction, sweating, difficulty urinating

use and precautions of Duloxetine (Cymbalta)

-SSNRI -Treatment of major depression, diabetic peripheral neuropathy, fibromyalgia -Precautions and adverse reactions --Nausea, dizziness, somnolence, dry mouth, insomnia. Sexual dysfunction

unlabeled uses for antidepressants

-SSRI's: Prozac/diabetic neuropathy, hot flashes; Paxil/premenstrual disorder, stuttering; -TCA's: Chronic pain, myofascial pain, IBS -Bupropion: enhance weight loss (and smoking cessation) -Trazodone: Cocaine withdrawal, insomnia

indications of DRAs

-Second-line agent for schizophrenia and psychotic disorders. -Immediate calming effects, often used for acute psychotic episodes

sertraline (Zoloft) vs paroxetine (Paxil)

-Sertraline (Zoloft): Less concern about weight gain -Paroxetine: (Paxil): Weight gain -- Shortest half life

precaution and adverse reactions of SSRIs

-Sexual dysfunction in 80%: Decreased libido, inhibited orgasm. Usually continues as long as the drug is taken. Treatment: decrease dose, change to bupropion, add Viagra --Can add bupropion because it has the opposite effect -GI: N/V/D (usually goes away over time- if they can wait it out), anorexia, weight loss. -Weight gain: 1/3 gain weight. >20 lbs. -Anxiety: agitation, restlessness in the first few weeks. -Extrapyramidal Symptoms (low risk, not high like SDAs)

indications for antipsychotic drugs

-Short and long term management of -Psychotic Disorders. Schizophrenia --Schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, manic episodes, major depressive disorder with psychotic features

features of anti-insomnia agents- duration of use and class

-Short term should be 7-10 days. -Class: GADA-BZ receptor agonists: --rapid onset of action -LOOK UP sleep hygiene - better answer for people to get good sleep --Go to bed and wake up at same time, no naps, no lights at night- electronics, caffeine, etc

what are MAOIs indicated for and what are the warnings

-Should only be prescribed by Psychiatrists -MDD, Dysthymia, Panic disorder, bulimia -Bad interaction with Tyramine --Risk of HTN crisis -When changing from or to an MAOI, there must be a wash out period (at least 14 days)

SSRIs- indication, commonly used ones

-Six are first line for treatment of depression --Fluoxetine (Prozac) --Sertraline (Zoloft) --Paroxetine (Paxil) --Citalopram (Celexa) --- Paroxetine CR (Paxil CR) --Escitalopram (Lexapro) -SSRI's are approved for a broad range of anxiety disorders (GAD, OCD, PTSD,)

monitoring during SDA treatment

-Some risk of tardive dyskinesia still remains. --Risk is still there with SDA meds, but not as prevalent -Monitor glucose levels early in treatment and with weight gain -Can lengthen the QT interval and lead to fatal arrhythmias. --Make a note, if the pt is up to the EKG because those with schizophrenia can be combative -Taper by no more than 50% every two weeks when you need to switch them to another medication

tardive dyskinesia

-TD are abnormal involuntary movements. Rhythmic involuntary movement of the tongue, face, mouth or jaw. Can be disabling. -- Starts in the face --If it starts and you stop the medication, may remain life-long --Haldol is known to have this SE -Benzotropine (Cogentin) is an anticholinergic medication that can be used for the Parkinsonism or Acute Dystonic Reaction. Cognitive Deficits can be seen if used long term

common anti-anxiety and anti-insomnia medications

-Temazepam (Restoril) -Lorazepam (Ativan) -Alprazolam (Xanax) -Clonazepam (Klonopin) -Chlordiazepoxide (Librium) -Diazepam (Valium) -Buspirone (BuSpar)

indications for anxiolytics and hypnotics

-Treatment of *Anxiety Disorders, Panic disorder*. Often these are present with other psychiatric illness -GAD, Panic disorder, SAD, PTSD -Common for *insomnia* -Mainstay of treatment for alcohol withdrawal and detox -Used for acute agitation in psychotic disorder and Bipolar disorder -Commonly used for acute anxiety management until SSRI/SNRI takes effect -Work quickly and has an immediate gratification- issue with overuse/ abuse/ addiction

use of Bupropion (Wellbutrin)

-Treatment of depression and Smoking cessation (Zyban). Increase effect when added to an SSRI -Less adverse reactions: Less sedation, and less sexual dysfunction (added to SSRI when experiencing these, ENHANCES libido) -*Should not be the first choice in patient with anxiety*. -Can cause weight loss -For younger patient, this one is picked initially → gives them more energy and works pretty fast

example of Serotonergic Antidepressant and what is it used for

-Trintellix (previously Brintellix) (vortioxetine) -Newer medication. Similar to SSRI -Major Depressive Disorder

example of SSRI and partial agonist at 5HT receptor

-Vilazodone Hcl (Viibryd) -Indicated for the treatment of major depressive disorder

Bupropion vs Buspirone

Sounds similar to Buspirone (busbar) - used for anxiety and has opposite effect as bupropion (can make you more anxious)

black box warnings for SDAs

-Warnings: All have a boxed warning for increased mortality in elderly patients with dementia-related psychosis -DON'T want to give to demeted elderly pts with psychosis → INCREASED mortality

important things to monitor with aripiprazole (Abilify)

-Weight gain (marketed as not, pts cant stop eating). May have agitation and akathisia when starting the medication. Metabolic syndrome -Need to start slow and titrate up -Akathisia is bad when they first start -Approved for adjunctive depression tx --Rx with an SSRI (boosts mood) -If borderline, or not sure if they have bipolar or depression → use this since it works for both

important things to monitor with quetiapine (Seroquel)

-Weight gain (significant). Metabolic syndrome --Does help people sleep but a lot of pts abuse it --In prescriber's guide- called baby heroin

Cariprazine (Vraylar)

-Weight neutral SDA -One of the only ones approved for bipolar depression

Lurasidone (Latuda)

-Weight neutral SDAs -Cat B for pregnancy

commonly used anti-insomnia agents

-Zolpidem (Ambien) -Zaleplon (Sonata) -Eszopiclone (Lunesta) -Ramelteon (Rozerem)

use of Lorazepam (Ativan)

-acute anxiety, alcohol withdrawal, agitation

features and tx of acute dystonic reaction

-after rapid increase in dose or after starting medication. Torticollis, lockjaw, laryngeal dystonia --May be extremely stiff and rigid when testing muscle tone -IM Cogentin and continue treatment for a month (half-life)

duration of therapeutic trials

-are usually 4-6 weeks for antidepressants, antipsychotics, and mood stabilizing drugs. Anxiolytic and stimulant drugs often see benefits within hours -Let the patients know it will be about 4 weeks before anything happens -Then another 4-6 weeks to see if it really is working - can bump up dose after this time

Most psychotherapeutic drugs are oxidized by... and why is this important

-hepatic cytochrome P450 -CYP enzymes are responsible for the inactivation of most psychotherapeutic drugs. -There are many possible interactions that effect the bioavailability: -- Alcohol, certain drugs, smoking can induce the CYP genes and increase metabolism -- Certain inhibitors (medications) can decrease the metabolism

indications for antidepressants

-indications: -Major Depression -OCD -Smoking Cessation -Anxiety Disorder (takes longer to work, but the preferred tx) -Diabetic peripheral neuropathy (i.e. symbalta)

akathisia

-inner restlessness and restless movements. --An inner uncontrollable restlessness- such a severe agitation → crawling out of themselves --As bad it causes people to not take medications (esp abilify)

side effects of TCAs

-many side effects (*cardiac Arrhythmias, seizures, anticholinergic effects*) - cardiac arrhythmias, heart block, constipation, drowsiness, can induce mania, sedation, weight gain, orthostatic hypotension. Sudden death after MI -Priapism can occur -LETHAL in overdose (2 week supply) -Try to avoid due to overdose potential and suicide ideation (esp if taken off) -VERY sedating - helps people sleep

use of valproate (Valproic acid; Depakene and Depakote) and maintenance

-mood stabilizer -1st line treatment for *acute manic episodes* in Bipolar I Disorder. -Equal efficacy to Lithium (and better tolerated) --Depakote Manic episodes: Decreases psychiatric symptoms and the need for supplemental doses of benzo' s or dopamine receptor agonists -Depressive Episodes: less effective for the short-term treatment of depressive episodes in bipolar I disorder than for manic episodes. *More effective for agitation than dysphoria* Maintenance: -*Not FDA approved for maintenance* treatment of bipolar I disorder -Long term is associated with fewer, less severe, and shorter manic episodes

parkinsonian symptoms

-more common in elderly and higher potency antipsychotic -Bradykinesia, stooped posture, shuffling gait, trouble initiating movement

rapid onset vs slow onset Benzos

-rapid onset: diazepam (Valium) -Slower onset: chlordiazepoxide (Librium) and oxazepam (Serax)- Alcohol withdrawal. -- Lorazepam (Ativan)- usually order half ativan prior to MRI and pt has claustrophobia

specific monitoring during clozapine tx

-requires ANC (absolute neutrophil count) testing weekly for the first 6 months then q2weeks. (very difficult for compliance) -Check for agranulocytosis. -Immediate eval for fever or signs of infection. If ↓ WBC or granulocytes -Hematology consult and possible bone marrow biopsy --Signs of infection are problematic for these patients -Interrupt treatment if neutropenia is suspected to be clozapine-induced for ANC<1000/uL --If it drops too low they have to be taken on the rx and that can be devastating for the pt

monitoring of benzos

-short half life: more withdrawal symptoms (tachycardia, increased Blood Pressure, tremor, confusion, seizures, delirium, death) --If it has a short half life and they abruptly stop the med, will go back to the sx they had before (tachycardia if they were anxious) -long half-life: monitor for excessive sedation, concentration and memory difficulties -Avoid with COPD, respiratory depression

black box warning of antidepressants

-warning in adolescence, increase in suicidal thinking -Better to treat them for depression rather than doing nothing and letting it continue (will most likely lead to their death anyways) --Choose to use an SSRI over TCAs --2 wks worth of TCA → they can overdose

symptoms of serotonin syndrome

1. diarrhea 2. restlessness 3. extreme agitation, hyperreflexia and autonomic instability with possible rapid fluctuation of V.S. 4. myoclonus, tremor, seizure, hyperthermia, uncontrolled shivering, diaphoresis, rigidity 5. Confusion, delirium, coma, status epilepticus, cardiovascular collapse, death

baseline levels needed for SDAs

1. personal and family history of obesity, diabetes, dyslipidemia, HTN, Cardiovascular disease 2. weight and height (BMI) 3. waist circumference (at umbilicus) 4. blood pressure 5. fasting plasma glucose 6. fasting lipid profile

Examples of sympathomimetics

ADHD- may not need to be taken daily -Methylphenidate (Ritalin, Concerta) -Dextroamphetamine (Dexedrine) -Dextroamphetamine and amphetamine (Adderall) -Lisdexamfetamine (Vyvanse)

higher potency benzos for panic attacks

Alprazolam (Xanax) and clonazepam (Klonopin) --Klonopin still high potency, but chosen over xanax for addictive properties

types of psychotropic medications

Antidepressants Anxiolytics and Hypnotic Antipsychotics Antimanic and Mood Stabilizers Stimulants Cholinesterase Inhibitors

classes of antidepressants (1st, second, and third line)

Class: 1st line treatment: -SSRI- usually first choice -SNRI -NDRI (Norepinephrine and dopamine reuptake inhibitor) -Alpha 2 noradrenergic antagonists -Class: 2nd line: TCA's have many side effects; Cheaper, good for pain -Class: 3rd line: MAOI's (monoamine oxidase inhibitors) have many interactions. Prescribed by Psychiatrists.

oxcarbazepine

Trileptal- antimania drug - usually used for migraines, seizures -NOT approved for bipolar, usually only used if failed others -Can DECREASE weight -Sedation, rash, nausea

Fluvoxamine: Luvox

Used for OCD- causes a lot of nausea and secual dysfunction in higher doses

example of an Alpha 2 noradrenergic antagonist

mirtazapine (Remeron)

tx of chronic anxiety for pt with hx of addition

put them on a faster acting SSRI and skip the benzodiazepines