NURS 663 Exam 1 Questions and
Answers 2022
Bipolar one disorder DSM five criteria – ANSWER-Manic episode: 1+ week of a colon
elevated, expansive or irritable mood and increase energy. 3+ symptoms from B:
distractibility, indiscretion, irresponsible, grandiosity, flight of ideas, activity(Increase
goal-orient), decreased need for sleep, talkativeness or pressured speech.
Bipolar two DSM five criteria – ANSWER-Hypo mania and major depressive disorder:
hypo mania same as mania with decreased severity and duration and no functional
impairment for episode of four or more days and no psychosis
Mixed episodes (bipolar) – ANSWER-Manic and depressive symptoms time by side
usually with comorbid substance abuse increased risk of suicide and psychosis
rapid cycling – ANSWER-Four or more cycles per year no greater than a week well
period
Cyclothymia DSM-V Criteria – ANSWER-Two or more years of mood cycling with
dysthymia and hypo mania decreased intensity than bipolar disorder meets criteria for
hypo mania but does not meet criteria for major depressive disorder
Dysthymia DSM five criteria – ANSWER-HE’S 2 SAD depressive symptoms lasting two
or more years that is subsydromal characterized by hopelessness decreased energy,
decrease self-esteem for two years, abnormal sleep, abnormal appetite impaired
decision-making.
MAOÍ Mechanism of action generally – ANSWER-Catalyzes the deamination of
monoamines intracellularly and MAO transport Reuptake extracellular monoamines
MAO-A Mechanism of action – ANSWER-MAO-A Oxidizes serotonin norepinephrine
and epinephrine
MAO-B Mechanism of action – ANSWER-Oxidizes phenylalanine
MAO-A and MAO-B mechanism of action – ANSWER-Oxidizes dopamine nonpreferentially
MAOs Neumonic -2 – ANSWER-Date with Tyra banks with wine and cheese in Maui—
can cause hypertensive crisis related to tyramine from aged food.
MAWIs= my arms weight increased= effective for atypical depression
MAOs adverse effects-6 – ANSWER-Hypertensive crisis, diet restriction, avoid meds,
five week after Prozac, two week after other antidepressants, no other medications for
two weeks after discontinuing
MAOs diet restriction-4 compounds – ANSWER-Tyrosine, high tyramine, tryptophan,
phenylalanine
Tyrosine foods-10 – ANSWER-Aged cheese, aged wine, fava or broad bean pods,
sauerkraut, soy sauce, tap or draft beer, overripe fruit, cured meat, spoiled food
MAOs drugs to avoid- 6 – ANSWER-Antidepressants, Dextromethorphan, stimulants,
sympathomimetics, meperidine, disulfiram
MAOs side effects 11 – ANSWER-Increased weight, drowsy, dizzy, orthostatic
hypotension, tremor, headache, dry mouth, constipation, change in sexual drive,
peripheral Edema, sweating
Tricyclic mechanism of action – ANSWER-Inhibit 5HT2, norepinephrine, dopamine and
reuptake slows. Amino group interferes with ASP – 98 in HSERT. Causing down
regulation of receptors.
Tricyclic side effects – ANSWER-Anticholinergic effects (dry mouth, blurred vision,
constipation, urine retention, impotence). Histamine effects (sedation, increased
weight). Adrenergic alpha receptor (postural hypotension). Direct membrane effects
(decrease seizure threshold and arrhythmias). 5HT2 receptor (increase weight and
decrease anxiety).
Amitriptyline dosing/Class – ANSWER-Start at 25 to 50 mg per day, titrate 25 to 50 mg
per day per week, Max dose is 300 mg per day/TCA
Names of tricyclics 10 – ANSWER-Amitriptyline, nortriptyline, clomipramine, imipramine,
protriptyline, doxepin, amoxapine, desipramine, mapratiline, tripramine
Tricyclics are useful-2 – ANSWER-Pain, migraine
Tricyclics adverse effects-2 – ANSWER-Overdoses are cardiotoxic, high potency
increases the risk of mania
Nortriptyline mnemonic – ANSWER-No-triptyline equals less sedation and hypotension
Tricyclics mnemonic-2 – ANSWER-Think car goes over tricycle to remember that an
overdose is cardiotoxic. Do you remember mechanism think trans =serotonin and
norepinephrine Chans= Na+ and Ca+ Ans= ACH and histamine
Patient comes in with symptoms of mania followed by periods of depression; what is it?
bipolar 1
patient comes in with hypomania/regular mood (euthymic) followed by periods of depression, what is it?
bipolar 2
how many symptoms of mania must you have to have “full” mania?
seven of thirteen
what is the difference between mania and hypomania?
hypomania has less severe symptoms; 3 symptoms over shorter period of time (hypomania)
Cyclothymia
a disorder that consists of mood swings from moderate depression to hypomania and lasts two years or more
moods are always irregular- not ever to a full extreme
Dysthymia
a form of depression that is not severe enough to be diagnosed as major depression
“eeyore” always kind of down and depressed
SIADH
syndrome of inappropriate antidiuretic hormone
will retain water
hyponatremia will be observed
what is something you should watch out for if a patient is on multiple antidepressants?
SIADH
what medical problems mimic mood disorders?
hypothyroid- depression
hyperthyroid- mania
involuntary admission
hurt yourself
hurt someone else
inability to care for self
Carbamazepine (Tegretol)
mood stabilizer
indication: bipolar disorder
major side effects:
CYP 450: (inducer- speeds up metabolism of other drugs)
patient education:
what 3 medications must have blood draws associated with them?
carbamazepine, lithium, valproic acid
Mood Disorder Questionnaire
Screens for Bipolar Disorder
7+ is a positive screening
4-5 might be hypomania
how is the PHQ-9 scored
1-4 minimal depression
5-9 mild depression
10-14 moderate depression
15-19 moderately severe
20 + severe
PHQ-9
assessment that evaluates the degree of depression
What is the DSM criteria for Major Depressive Disorder?
**no history of mania, hypo, or mixed symptoms
symptoms >2 weeks
must have: sadness, anhedonia (loss pleasure/interest)
4 of following: – appetite/sleep changes, psychomotor retardation, lack of energy, guilt/worthlessness, issues w/ concentration, thoughts suicide/death
What are the “frequency” modifiers for MDD?
episodic: symptoms dissipate over time
recurrent: likely to reappear in future
subclinical: sadness + 3 symptoms > 10 days (full criteria not met)
how is the severity of depression rated?
- Mild: no suicidal thoughts/death wishes
- Moderate: some thoughts of death/self-harm
- Severe: plan/attempted
what other modifiers might be present with diagnosis of MDD?
- With psychotic features: hallucinations, paranoia
- In partial remission: some symptoms still present, but full criteria not met; period without any significant
symptoms lasting less than 2 months - In full remission: no signs/symptoms >2 months
- Unspecified: symptoms vague, hard to tell
DSM 5 for bipolar I disorder
depression + mania
DSM 5 for bipolar 2 disorder
depression + hypomania
what is the #1 predictor of suicide?
Hopelessness and loneliness
what are risk factors for suicide?
- Gender: men are more likely to complete suicide
- Age: men 45 years +; women 55 years +
o Suicide is the 3rd leading cause of death in 15-24-year-olds - Race: Caucasian, Native American, Alaskan native, and immigrants
- Divorce
- Widows
- High-ranking jobs and unemployment
- Physicians
- MDD most common mental illness associated, schizophrenia, and alcohol use disorder
- Past suicide attempt (might be the best indicator)
what is the criteria for involuntary commitment?
Danger to self (suicide)
Danger to others (homicide)
Gravely disabled d/t mental illness (unable to provide food, clothing, shelter)
- Courts must have probable case hearing within 96 hours of admission
What is vagus nerve stimulation?
–For Tx of treatment-resistant MDD
implantation of a device that causes intermittent electrical stimulation of vagus nerve
What is TMS (transcranial magnetic stimulation)?
noninvasive procedure for treatment resistant depression, uses magnetic pulses
what is ECT used for?
severe depression
mania
catatonia
severe agitation in dementia
How is ECT performed?
premedication with atropine, followed by general anesthesia and administration of a muscle relaxant. a generalized seizure is then induced by passing a current of electricity across the brain.
seizure lasts <1min
- 8 treatments over 2-3 weeks
Side effects of ECT
temporary memory loss and confusion, headache
can increase HR and BP
what are distinguishing characteristics of serotonin syndrome?
Hyperreflexia
Clonus
Dilated pupils (mydriasis)
MAOIs
Block enzyme monoamine oxidase
MAO break down monoamines into inactive metabolites
** directly increase the neurotransmission of all 3 NT (DA, 5ht, NE)
A lot of dietary restrictions (tyramine)
A lot of drug- drug interactions
“Not Popular Meds”
Phenelzine (nardil)
Tranylcypromine (parnate)
Isocarboxazide (marplan)
TCAs
- “dirty” because affect many receptor sites
- H1: sedation/weight gain
- M1: anticholinergic
- A1: orthostatic hypotension
- TCA overdose: WIDE QRS, respiratory depression, hypotension * no anecdote; treat with supportive care
Imipramine
Nortriptyline
Amitriptyline
Lithium
Therapeutic window: 0.6 – 1.2
Steady state generally achieved in 5 days
Check lithium dosing 8-12 hours after previous dose
Signs of toxicity:
T wave flattening, renal toxicity, hyperreflexia, coarse tremor, nystagmus, delirium
Treat toxicity:
HEMODIALYSIS
Valproic Acid (Depakote)
Antiseizure med. Precautions/interactions: contraindicated in liver disease, pregnancy. Side effects: hepatotoxicity, teratogenic effects, pancreatitis.
Therapeutic window: 50-100
Peak plasma concentration: 1-4hours
Collect trough level just before the next dose
(24 hours)
Collecting at the 12-hour mark can lead to false high trough level
Signs of Depakote toxicity:
Cerebral edema, hyperammonemia, hepatotoxicity, electrolyte abnormalities
· Supportive therapy for toxicity
What is rapid cycling bipolar disorder?
-four or more distinct mood episodes within a 12 month period
-can occur in any order
-up to 20% of all bipolar pts
-risk factors: longer length of illness, female, ANTIDEPRESSANT USE, thyroid disease, older age
what birth defects might be seen with valproic acid?
cleft palate
what medications are safe in postpartum depression?
why is lithium XR a good option for some patients?
it might help decrease stomach upset
Paroxetine (Paxil)
SSRI antidepressant
-short half life (good in case mania pops up)
- can be sedating, so consider dosing at night to help sleep
SE: most anticholinergic SSRI, ↑↑sexual dysfunction
Inhibits antipsychotics
***SIGNIFICANT 2D6 inhibition
can cause discontinuation syndrome (nausea, vertigo)
Sertraline (Zoloft)
SSRI
antidepressant
treats major depressive disorder, panic disorder, OCD, PTSD, social phobia, PMDD
contraindicated with MAOI
Adverse reactions: neuroleptic malignant syndrome, suicidal thoughts, seratonin syndrome
common side effects: dizziness, drowsiness, fatigue, headache, insomnia diarrhea, dry mouth, nausea, sexual dysfunction,sweating, tremors
Pros:
** short half-life
** less sedating than paroxetine
** very weak CYP 450 interactions (very slight 2d6)
Cons:
** requires full stomach for max absorption
** lots of GI affects
Fluoxetine (Prozac)
Antidepressant, SSRI’s
- long half life (must have 5 weeks between this and MAOI)
can be activating, which can help with energy
can use when tapering off other SSRI to help minimize discontinuation syndrome
not a good option for hepatic patients (d/t long half life)
*** a lot of cyp 450 interactions, so not a good option with other meds
watch for mania since activating
Escitalopram (Lexapro)
Antidepressant, SSRI: 10-20 mg qd
can cause QT prolongation (especially in doses >20mg)
minimal drug-drug interactions
what medications can cause SIADH?
carbamazepine
SSRIs
amitriptyline
morphine
how is SIADH reflected in lab values?
decreased serum osmolality (increased serum volume)
increased urine osmolality (decreased urine volume)
what two medications are most likely to cause discontinuation syndrome?
paroxetine (paxil) and venlafaxine (effexor)
— short half lives
which SSRIs have no sexual side effects
mirtazapine, nefazadone, buproprion
which antidepressants are more activating?
bupropion, venlafaxine, fluoxetine
which antidepressants are more sedating?
trazodone, TCAs, paroxetine, mirtazapine
which antidepressants are more associated with weight gain?
Mirtazapine
Paroxetine
TCA’s
which antidepressants might be associated with weight loss?
bupropion
what antidepressant is useful for nicotine cessation?
bupropion
what antidepressant might help with methamphetamine withdrawal?
mirtazapine
what antidepressants might be useful with ADHD?
bupropion, venlafaxine
which antidepressants might be useful with pain disorders?
•Duloxetine
•Venlafaxine
Amitriptyline
which antidepressant might be useful with headaches?
amitriptyline
which preexisting condition should be avoided in the prescription of bupropion?
seizure disorder
how does paroxetine interact at the 2d6 site?
it is a potent inhibitor and substrate (tons of medication interactions)
how could the long half life of fluoxetine been of benefit and risk?
benefit: decrease withdrawal/discontinuation symptoms
negative: if patient has side effects, long time to get out of system
what are the biggest risks in TCAs?
cardiotoxic
very dangerous in overdose (NO SUICIDAL PATIENTS!)
what are MAOIs minimally prescribed?
lots of food interactions (tyramine)
require 2-6 weeks to build up in system d/t long period between RX and other medications
dangerous in overdose
Case: 26 year old woman without a psychiatric history who presents for treatment of depression after her mother died. It has been over a year but she is still struggling with frequent bouts of sadness, has lost 15 lbs in the last four months, is unable to sleep past 4am, and is getting poor performance reviews at work due to impaired concentration and memory. She feels like nothing in life is enjoyable anymore.
diagnosis and medications to consider?
MDD
-Sertraline
-Escitalopram
-Fluoxetine
-Mirtazapine
case: 35 year old woman with a history of major depressive disorder who presents complaining of persistent depression despite treatment with maximum dose sertraline and escitalopram in the past. She has been depressed for over eight months, and spends up to 16 hours per day lying in bed. She reports that she doesn’t have the energy to get up in the morning, and that there is nothing that she enjoys doing, anyway. She has gained 35 lbs in the last eight months, reports feeling like she has failed everyone in her life, and states that she only leaves the house about once a week to shop for groceries. Recently, she has begun hearing vague voices when she feels especially badly, although she cannot make out specific words.
diagnosis and medications?
MDD
-Bupropion
-Venlafaxine
-Duloxetine
-Maybe fluoxetine
case: 39 year old man with a history of PTSD and depression who presents after returning from a recent deployment to Afghanistan. He is having trouble sleeping because of nightmares about combat, is unable to tolerate being in crowded places, and visibly jumps at small noises during your interview. His unwillingness to leave the house is exacerbated by a lower spinal injury that has left him with chronic leg pain and a limp that he thinks makes him look “like an easy target.” He also reports that he has difficulty sleeping through the night, is having trouble enjoying doing anything with his family, feels extremely guilty for the time that he was away from them while deployed, has low energy and concentration, but adamantly denies suicidal thoughts. He has tried maximum dose sertraline and venlafaxine, but neither were helpful. He also tried mirtazapine, but it was far too sedating and didn’t work either.
diagnosis and medications?
PTSD, MDD, Chronic Pain
-Nortriptyline or another TCA
-Duloxetine
-Escitalopram
-Prazosin
all antidepressants carry what 5 warnings?
- increased risk of suicide (especially in children and young adults)
- mania activation
- serotonin syndrome
-discontinuation syndrome
- bleeding risk
What antidepressants are more activating?
Wellbutrin, Prozac, Effexor, Pristiq, Viibryd
what antidepressants are more sedating?
Paxil, Remeron, TCAs
which antidepressants increase appetite?
Paxil, Remeron, TCAs, Nardil
which antidepressants decrease appetite?
Wellbutrin, Prozac, Effexor, Pristiq, Fetzima, Parnate
what strategies should be considered for augmentation?
•Lithium
•Atypical Antipsychotics
•Thyroid Hormone
•Buspirone
•Pindolol
•Omega-3 Fatty Acids (Lovaza)
•SAMe (S-adenosyl-l-methionine)
•L-methylfolate (Deplin)
•Modafinil
•Stimulants
•Light Therapy
behavioral therapy
focuses on changing behavior by identifying problem behaviors, replacing them with appropriate behaviors, and using rewards or other consequences to make the changes
•Behavioural therapy is based on the concept that a deficit of ‘reinforcers’, such as pleasant activities and positive interpersonal contacts, leaves patients vulnerable to depression
•Sample interventions: increase activity level, structured goal setting, interpersonal skills training
interpersonal therapy
treatment that strengthens social skills and targets interpersonal problems, conflicts, and life transitions
•Interpersonal psychotherapy is based on the concept that depression arises from problematic patterns in relationships
•Sample interventions: develop awareness of patterns in primary relationships and the therapeutic relationship, interpersonal skills training, communication analysis
•In general, interpersonal psychotherapy has shown efficacy equivalent to pharmacological therapy in randomised, controlled trials
cognitive-behavioral therapy (CBT)
a popular integrative therapy that combines cognitive therapy (changing self-defeating thinking) with behavior therapy (changing behavior)
•Cognitive therapy is based on the concept that habitual negative thinking patterns leave patients vulnerable to depression in response to specific situations. Therefore, the patient is taught to challenge the beliefs and assumptions that contribute to depression
•Over time, cognitive therapy has evolved to include behavioural elements; it is now known as ‘cognitive-behavioural therapy’
•Sample interventions: identify and challenge automatic thoughts, engage in activities that provide evidence to disprove dysfunctional beliefs, modify core beliefs by reviewing evidence
•In general, CBT has shown efficacy equivalent to pharmacological therapy in randomised, controlled trials.Furthermore, the combination of CBT and pharmacotherapy is superior to pharmacotherapy alone
what are the recommendations for ECT?
•severe major depression with psychotic features
•severe major depression with psychomotor retardation
•’true’ treatment-resistant major depression
•refusal of food intake or in other special situations when rapid relief from depression is required (e.g., in severe suicidality) or when medication is contraindicated (e.g., in pregnancy)
•patients who have experienced a previous positive response to ECT, and patients who prefer ECT for a specific reason.
what are the recommendations for VNS?
•VNS may be an option in patients with depression with insufficient response to trials of pharmacotherapy.
what is the recommendation for TMS?
there is currently insufficient evidence to recommend the clinical efficacy of TMS in the standard clinical setting. Further research is needed
What is Carbamazepine used for?
-Especially useful in Txing mixed episodes and rapid-cycling bipolar DO, less effective for depressed phase
what blood tests should be done when taking carbamazepine?
kidney, liver, TSH, and CBC
what major side effects can be associated with carbamazepine?
SIADH
aplastic anemia
leukocytosis
what is the dosage range of carbamazepine?
400-1200mg/day
what is the starting dose of carbamazepine?
200mg BID (titrate up by 200mg each week)
what is the CYP 450 of carbamazepine?
3a4: substrate and inducer (induces self- requiring higher dosing)
renally excreted
what birth defects might be associated with carbamazepine?
neural tube defects
What is escitalopram used for?
GAD , depression
what are the most common side effects of escitalopram?
GI upset, sexual dysfunction
what is the standard dosing range of escitalopram?
10-20mg/day
what is the starting dose of escitalopram?
10mg/day
what is the CYP 450 of escitalopram?
minimal; minimal drug interactions
What is fluoxetine used for?
depression, PMDD, OCD
GAD/panic disorder (possibly)
is fluoxetine activating or sedating?
activating; good for patient who has a hard time getting out of bed
what is the dosage range of fluoxetine?
20-80mg/day
what is the starting dose of fluoxetine?
20mg in the AM
how long is the half life of fluoxetine?
long- approx 10-14 days
what is the CYP 450 of fluoxetine?
inhibits 2d6 and 3a4
when can an MAOI be started after fluoxetine use?
5 weeks
who would you consider for fluoxetine use?
atypical depression (hypersomnia, hyperphagia, low energy, mood reactivity)
What is Paroxetine used for?
SSRI
depression, ocd, panic, GAD
what are the most common side effects of paroxetine?
constipation, dry mouth, sedation
weight gain, sedation
what is the dosage range of paroxetine?
20-50mg/day
what is the starting dose of paroxetine?
20mg x few weeks
titrate by 10mg if needed
what patients should have a lower dose of paroxetine?
renal and hepatic
how does paroxetine affect CYP 450?
inhibits 2d6 (potent)
who is best canidate for paroxetine?
anxious depression patients
what can happen when paroxetine is stopped?
withdrawal effect/discontinuation syndrome
What is sertraline used for?
SSRI, depression
Panic disorder
OCD
Social anxiety disorder
PTSD
what is the dosage range for sertraline?
50-200mg/day
what is the starting dose of sertraline?
50mg/day
how does sertraline affect CYP 450?
minimally (2d6, 3A4)
who might sertraline be good for?
atypical depression
What is lamotrigine used for?
MOOD STABILIZER
-Efficacy in bipolar , little efficacy for acute mania or prevention of mania (better for bipolar depression)
-MOA: sodium channels that modulate glutamate and aspartate
-SE: MC are dizziness, sedation, HA, and ataxia, most serious is Stevens-Johnson Syndrome in 10% (most likely in first 4-6 weeks, go low and slow to avoid)
-Valproate increases lamotrigine levels and lamotrigene decreases valproate levels
what is the dosage range for lamotrigine?
100-200mg/day
what is the starting dose of lamotrigine?
25 mg/day for 1 and 2 weeks, then 50 mg/day for 3 and 4 weeks, then 100 mg/day for 5 week, then 200 mg/day for 6 week, and beyond
if a patient was taking lamotrigine and valproate together, but valproate stopped- what might need to occur with the lamotrigine dose?
increased
What is lithium used for?
MOOD STABILIZER
bipolar disorder
good for mania
what tests should be used in lithium?
TSH and kidney function
what should the plasma level of lithium be?
0.6-1.2 mEq/L
what are the most common side effects of lithium?
weight gain, sedation
- Hand tremor, ataxia, and muscle weakness
- Cognitive impairments and mood numbing
- Polyuria, weight gain and acne
if a patient has GI upset from lithium, what can you consider?
extended release lithium
what is the starting dose of litium?
300mg BID-TID (dose for plasma blood level)
initially, check 1-2 weeks into therapy, then 2-3 months until stabilized
what medications can increase lithium levels?
NSAIDs, diuretics
what are signs of lithium toxicity?
Signs and symptoms include vomiting, diarrhea, drowsiness, decreased coordination, and muscle weakness. – ataxia
what birth defect might be associated with lithium?
ebstein anomoly
What is valproic acid used for?
Bipolar disorder (mixed, rapid cycling)
what labs should be monitored with valproic acid?
CBC, LFT
what major side effects are associated with valproic acid?
++++ weight gain, sedation
issues with pancreas and liver
- watch for yellowing of skin, bruising (liver)
- watch for abdominal pain/nausea (pancreas)
what is the dosage range of valproic acid?
1200-1500mg/day
what is the starting dose of valproic acid?
acute mania: 1000mg/day
less acute mania: 250-500mg/day
what might be observed when taking valproic acid during pregnancy?
AVOID USE
neural tube defects
how is lithium toxicity graded by blood trough level, and what symptoms would you see?
mild (1.5-2) – vomiting, diarrhea, ataxia, dizziness, slurred speech, nystagmus
moderate (2.0-2.4) nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope
severe (>2.5) oliguria, renal failure, generalized convulsions
what medication decreases suicide rates?
lithium
why does lithium cause weight gain?
water retention
what side effects might rapidly occur with lithium?
•Sedation
•Weight gain
•Cognitive blunting
•Nausea/vomiting
•Polyuria/urinary frequency
•Benign atrioventricular block
•Leukocytosis (Li is used in cases of neutropenia)
•Tremor
what are late side effects associated with lithium?
rare- renal failure
thyroid failure
nephrogenic diabetes insipidus
Bipolar one disorder DSM five criteria
Manic episode: 1+ week of a colon elevated, expansive or irritable mood and increase energy. 3+ symptoms from B: distractibility, indiscretion, irresponsible, grandiosity, flight of ideas, activity(Increase goal-orient), decreased need for sleep, talkativeness or pressured speech.
Bipolar two DSM five criteria
Hypo mania and major depressive disorder: hypo mania same as mania with decreased severity and duration and no functional impairment for episode of four or more days and no psychosis
Mixed episodes (bipolar)
Manic and depressive symptoms time by side usually with comorbid substance abuse increased risk of suicide and psychosis
rapid cycling
Four or more cycles per year no greater than a week well period
Cyclothymia DSM-V Criteria
Two or more years of mood cycling with dysthymia and hypo mania decreased intensity than bipolar disorder meets criteria for hypo mania but does not meet criteria for major depressive disorder
Dysthymia DSM five criteria
HE’S 2 SAD depressive symptoms lasting two or more years that is subsydromal characterized by hopelessness decreased energy, decrease self-esteem for two years, abnormal sleep, abnormal appetite impaired decision-making.
MAOÍ Mechanism of action generally
Catalyzes the deamination of monoamines intracellularly and MAO transport Reuptake extracellular monoamines
MAO-A Mechanism of action
MAO-A Oxidizes serotonin norepinephrine and epinephrine
MAO-B Mechanism of action
Oxidizes phenylalanine
MAO-A and MAO-B mechanism of action
Oxidizes dopamine non-preferentially
MAOs Neumonic -2
Date with Tyra banks with wine and cheese in Maui— can cause hypertensive crisis related to tyramine from aged food.
MAWIs= my arms weight increased= effective for atypical depression
MAOs adverse effects-6
Hypertensive crisis, diet restriction, avoid meds, five week after Prozac, two week after other antidepressants, no other medications for two weeks after discontinuing
MAOs diet restriction-4 compounds
Tyrosine, high tyramine, tryptophan, phenylalanine
Tyrosine foods-10
Aged cheese, aged wine, fava or broad bean pods, sauerkraut, soy sauce, tap or draft beer, overripe fruit, cured meat, spoiled food
MAOs drugs to avoid- 6
Antidepressants, Dextromethorphan, stimulants, sympathomimetics, meperidine, disulfiram
MAOs side effects 11
Increased weight, drowsy, dizzy, orthostatic hypotension, tremor, headache, dry mouth, constipation, change in sexual drive, peripheral Edema, sweating
Tricyclic mechanism of action
Inhibit 5HT2, norepinephrine, dopamine and reuptake slows. Amino group interferes with ASP – 98 in HSERT. Causing down regulation of receptors.
Tricyclic side effects
Anticholinergic effects (dry mouth, blurred vision, constipation, urine retention, impotence). Histamine effects (sedation, increased weight). Adrenergic alpha receptor (postural hypotension). Direct membrane effects (decrease seizure threshold and arrhythmias). 5HT2 receptor (increase weight and decrease anxiety).
Amitriptyline dosing/Class
Start at 25 to 50 mg per day, titrate 25 to 50 mg per day per week, Max dose is 300 mg per day/TCA
Names of tricyclics 10
Amitriptyline, nortriptyline, clomipramine, imipramine, protriptyline, doxepin, amoxapine, desipramine, mapratiline, tripramine
Tricyclics are useful-2
Pain, migraine
Tricyclics adverse effects-2
Overdoses are cardiotoxic, high potency increases the risk of mania
Nortriptyline mnemonic
No-triptyline equals less sedation and hypotension
Tricyclics mnemonic-2
Think car goes over tricycle to remember that an overdose is cardiotoxic. Do you remember mechanism think trans =serotonin and norepinephrine Chans= Na+ and Ca+ Ans= ACH and histamine
Clomipramine mnemonic/class
TCA- think comipramine for obsessive compulsive disorder
Imipramine- pneumonic and class
I’m peeingamine- nocturnal enuresis
Unilateral electrode in ECT indications
Typically first line because it has less cognitive side effects but has less efficacy
What is ECT?
The use of electrical shock current delivered to the brain to induce a seizure that treats depression. Goal is to reverse atrophy.
ECT is FDA approved for what
Bipolar disorder, schizophrenia, schizoaffective disorder, catatonia, neuroleptic malignant syndrome, treatment resistant refractory major depressive disorder
What is ECT schedule
Typically Monday Wednesday Friday for 6 to 12 sessions
Bilateral electrode placement in ECT indications
Classic placement increases cognitive side effects but has better efficacy. Reserved for urgency such as life-threatening depression profound distress and catatonia
ECT side effects and Risks 8
Cognitive side effects such as memory loss, head, neck, jaw pain, nausea, myalgia’s procedure is low risk
What is vagus nerve stimulation
It’s an implant in the chest that stimulates the left Vegas nerve by Paul stations and it’s controlled by an on off switch that is activated by a magnet
How does vagus nerve stimulation work
Stimulates the brain stem nuclei which changes serotonin in the limbic and cortical systems
Vagal nerve stimulation side effects-4
Voice altered, breathlessness, neck pain, no cognitive side effects
Vagus nerve stimulation is FDA approved for what in under investigation for what
FDA approved for epilepsy and under investigation for major depressive disorder and bipolar disorder
What is trans cranial magnetic stimulation
Placement of rapid alternating magnets on scalp cause impulse to structures and is focused
Goal of trans cranial magnetic stimulation
Firing of neurons will alter pathology
Trans cranial magnetic stimulation is FDA approved for and not approved for
Approved for refractory treatment resistant depression It is not approved for bipolar disorder or schizophrenia
What is cognitive therapy based on
Negative thinking increase his depression vulnerability, this therapy challenges beliefs and assumptions related to depression
Cognitive therapy indications 11
Depression, anxiety, PTSD, schizophrenia, phobia, OCD, bipolar disorder, sexual disorder, eating disorders, sleep disorders, substance abuse disorders
Cognitive therapy interventions
Automatic thought restructuring, provide evidence just prove beliefs, antidepressants plus cognitive behavioral therapy is greater than just antidepressants and anti-depressants are greater than just cognitive behavioral therapy in efficacy
What is interpersonal therapy based on
Based on the theory that depression Arises from problematic patterns and relationships
Interpersonal therapy indications 5
Indicated for depression, grief, interpersonal dispute, role transitions, interpersonal skill deficits
Interpersonal therapy interventions 3
Increase relationship awareness, increase interpersonal skills, communication analysis
What is behavioral therapy based on
Deficits in reinforcers like present activities and positive interpersonal contacts increased depression vulnerability
Behavioral therapy interventions 3
Increase activity level, structure goalsetting, interpersonal skills training
Dialectical behavioral therapy is based on
Increasing emotional regulation
Dialectical behavioral therapy Indications
Borderline, bulimia, binge eating, PTSD, substance abuse
Dialectical behavioral therapy interventions 4
Increase skills, mindful practice, monitoring/responding to crisis
Involuntary commitment reasons
Danger to self, danger to others, and self Neglect
Are there main points of involuntary commitment
- Mental illness/developmental disability or drug/alcohol dependence. 2. It is treatable. 3. It is related to the danger to self or others
Broad categories of suicide risk factors
Psychological disorder, Nuro biological factors, social factors, psychological factors
Psychological disorders related to suicide
Bipolar is greater than depression however 50% are depressed at time of suicide
Neurobiological factors of suicide
Decrease serotonin, hereditary, increase reaction of H PA system
Social factors of suicide
Economic recession, media reports of suicide, social isolation, decrease social belonging
Psychological factors of suicide
Decrease problem-solving and life satisfaction, increase hopelessness and impulsivity
Suicidal ideation safety mnemonic
DIOSMIO Detained, impatient, observe, sharp, medical clearance, injuries, or occult overdose
Likelihood of attempt pneumonic
Guns & ROSES recent attempt, ongoing thoughts, self harm, ethanol, substance abuse
Capacity eval mnemonic
CURBSID communicate, understand, risk, benefit, situation, impact, decision
Likelihood of violence mnemonic
PV’d MALES previous violence, male, adult, low intelligence, estranged, substance-abuse
Causes of delirium mnemonic
DIMTOP drugs, infection, metabolic derangement, trauma, oxygen deprivation, psychological
Substances that increase the risk of violence with intoxication Pneumonic
PISSE PCP, inhalants, stimulants, steroids, ethanol
Visual hallucinations medical cause mnemonic
Visual hallucinations from disease of the viscera
Signs and symptoms that suggest abuse mnemonic
TEN4 Over & OUT torso, ears, neck, less than four months of age, all over the body, observable pattern, unexposed Body part, timing
Suspected child abuse mnemonic
Fuzzy DETAIL details are fuzzy or vague, denied, evolving, tardy, absent, inconsistent, lacking
Catatonia mnemonic
Turns a man into a manikin referring to the state of purposeless stupor
What is SIADH?
syndrome of inappropriate antidiuretic hormone- increase ADH production equals more water retention in kidneys equals less serum sodium
Medications thought to cause SIADH
Carbamazepine, SSRI, amitriptyline, morphine
Mood Disorder Questionnaire (MDQ)
Screens for Bipolar Disorder- 13 questions based on bipolar DSM five criteria, screen every patient with depression
MDQ Positive score
Includes 7+ symptoms in question one, question two, moderate severe problem in question three
Patient health questionnaire nine
Screen all patients with depressive symptoms, nine question based on DSM five criteria for major depressive disorder
Other causes of SIADH
Medications, Traumatic brain injury, infections, cancer, hypothyroid
SIADH dysfunction
Decreased serum osmolality equals increased urine osmolality related to vasopressin in kidney malfunction
Patient health questionnaire nine scores
0-4 equals minimal, 5-9 equals mild, 10-14 equals moderate, 15 or more is moderate or severe
DSM five criteria for major depressive disorder
Sad mood or anhedonia for two weeks or more, Plus for the following: sleep changes, cycle motor changes, appetite or weight change, decreased energy, guilt/worthless, difficulty concentrating/thinking/decisions, recurrent thought of suicide/death
Major depressive disorder mnemonic
SIGECAPs, Sleep, decrease interest, guilt, decreased energy, decreased concentration, how to say change, psycho motor agitation or retardation, suicide
SIGECAPs, sleep, decrease interest, guilt, decreased energy, decreased concentration, how to say change, psycho motor agitation or retardation, suicide
Medical conditions that look like mania or depression 4
Substance abuse, metabolic, infection, neurological, cerebrovascular
Bipolar disorder brain structure mnemonic
Let’s live outrageously forget consequences equals left lateral orbital frontal cortex
Differentiating bipolar II disorder mnemonic
BP II Equals lower lows
Mania often seen symptoms mnemonic
MANIA more activity not inherently affective. Increase goal directed activity is seen more than elevated mood
Depression assessment across the lifespan mnemonic
Reactive PLANETS reactivity, polarity, lability, attributability, normalcy, episodic, treatment response, severity
Anti-depressants adverse effects 4
Serotonin syndrome, mania shift, suicidal ideation, bleeding
Don’t use anti-depression’s with what disorders
Bipolar and borderline personality disorder
Negative affective biased pneumonic
NAB To nab the correct diagnosis and treatment. These patients don’t see happiness like happy faces and if the treatment is working they will start to see that
Atypical depression Mnemonic
ATE typical increase eating, heaviness/Leaden paralysis/hypersomnia, rejection sensitivity
Depression with psychotic features requires treatment with
And anti-depressant and an antipsychotic
Trazodone mnemonic
TraZoBONE Z sleep aid, bone for priapism
Venlafaxine mnemonic 2
Think fax because it is fast like a fax because it has rapid metabolism and discontinuation affects
vENlafaxine Think hypertENsion like norepinephrine
Duloxetine Mnemonic
DUALoxetine for its door mechanism, and DULL oxetine because it can dull pain
Mirtazapine mnemonic
MEALtazipine- related to increased appetite/weight and sedation
Bupropion mnemonic 4
Bu DA NE to remember neurotransmitters. Think butane lighter because it is hot like sex related to no sexual side effects and also think to decrease smoking for smoking cessation. Think BUproprion to remember not to give to those with BUlimia or others at risk for seizures related to decreasing the seizure threshold.
You don’t use bupropion on with other disorders
Traumatic brain injury, seizure disorder, neurological disorder, those who have had brain surgery, disorders with electrolyte. Abnormalities (eating disorders, severe renal or gastrointestinal issues)
Used cautiously in substance abusers related to abuse potential because of psychotic symptoms at high doses.
Can increase anxiety irritability and agitation
Bupropion dosing
The 12 hour give 100 mg daily to start then increase 100 mg daily every three weeks to a max dose of 200 mg twice a day. The 24 hour start at 150 mg then increase 150 mg each day every week to a maximum of 450 mg per day
Bupropion mechanism of action
Like SSRI/SNRI, inhibits dopamine reuptake, an alpha three beta 4 nicotinic antagonist
Bupropion side effects advantages and other uses 7
No sexual dysfunction, substance abuse especially nicotine, ADHD, increased energy, decreased appetite, good augmentation, low induction of mania
Escitalopram adverse effects 2
QTc prolongation/SI
escitalopram dosing
Initial dose is 10 mg per day increase at 10 mg a day per week and the max dose is 30 mg a day
Fluoxetine mnemonic
FLUoxetine remember that the flu lasts 1 to 2 weeks which is related to the longer half-life of fluoxetine
Fluoxetine interactions
-Warfarin (flux can displace it)
-St. John’s wort (may cause Serotonin Syndrome) burn up and can overdose
-Dabigatran
P450 interactions are significant
Sertraline mnemonic
SQUIRTraline related to its adverse effects of increased diarrhea and the benefit of a safe while pregnancy and breast-feeding
sertraline indication/benefits
MDD, OCD, PMDD middle of the road antidepressant with no buildup
Paroxetine adverse effects
Withdrawal symptoms, more sedating, increase appetite
Paroxetine mnemonic
Think pair of oxen related to it works fast and has a short half-life
Paroxetine Interactions
Potent CYP 2D6 Inhibitor and substrate equals many interactions
Paroxetine dosing
Immediate release start at 20 mg per day and titrate 10 to 20 mg per day per week max dose is 50 mg per day, Extended release start at 25 mg per day increase by 12.5 mg per day each week to a max dose of 62.5 mg
Anti-depressants side effects 10
Anhedonia, apathy, n/v, drowsy/dizzy, somnolence, headache, bruxism, vivid dreams, fatigue, change in sexual behavior.
Antidepressant Mechanism on action
Ser-438 residue determines potency (hSERT) SSRI (unk exact mech).
sertraline dose
Init 20mg/day, titrate 25-50mg/day every 1-2wk, max dose 200mg
Fluoxetine indications
Depression, d/c syndrome (give 20mg tab), for activation, noncompliance, and to decrease appetite
Citalopram (Celexa) and Escitalopram (Lexapro) Pneumonic
Think car seat for SEATalopram to remember to obtain an Electrocardiogram forQTC prolongation
Carbamazepine treats
First line and acute mania, acute/prophylaxis mania, anti-aggressive, rapid cycling, mix patience
Carbamazepine labs
Level range is 4-12, LFTs, CBC, EKG, multiple drug to drug interactions
Carbamazepine dosing
100 milligrams a day initially then increase 200 mg per day everyone to four days to a max dose of 1.6 g per day
Carbamazepine mnemonic
CBZ Cranial nerve pain, bipolar disorder, seiZures. CarbamASIApine Do you remember that Asian dissent patients have an increased risk of Steven Johnson syndrome and are recommended to be screened
Carbamazepine side effects
Water retention, ataxia, n/v/d, rash, dizzy, sedation, confusion, transaminitis
Carbamazepine adverse effects
CNS, rash. Rarely SJS/toxic epidermal necrolysis. Black box warning for aplastic anemia, thrombocytopenia, leukopenia.
Carbamazepine mechanism
Block voltage-dependent sodium channels, anticholinergic, antidiuretic, antimania, anticonvulsant, antineuralgic, antiarrythmic
Valproic Acid (Depakote) mnemonic
ValproATE a folate PLaTe, folate linked to neural tube defects. Pancreatitis, Liver problems (hepatotoxic), Thrombocytopenia
Valproate (Depakote) indications
Mania (equal to Li), comorbid sub. Abuse/anxious, mixed patient, rapid cycling
Valproate labs
LFT, HCG, CBC, steady state 4-5 days-12hr after last dose check level/CBC/LFT again, target level 50-125
Valproate side effects
Depakote. liver toxicity, bone marrow depression, nausea, vomiting, amenorrhea (cessation of menstruation), alopecia (excessive hair loss), sedation, tremor and increased weight
Valproate Dosing
Initially 500-750mg/day Titrate 250-500mg every 1-3days, Max 1500-2500mg/day
Valproate adverse effects
Steven-Johnson syndrome, toxic epidermal necrolysis, NTD, PLT dysfunction, transaminitis, thrombocytopenia
Lithium indications
manic episodes in bipolar disorder and maintenance for prevention of such episodes, decreased efficacy in depression symptoms
Lithium mnemonic for SEs?
LI: Leukocytosis (increased WBCs)
T: Tremors/Thirst
H: Hypothyroidism
IU: Increased urine output
M: Muscle weakness, mental disorders, memory loss
Pregnancy: LIT for Low Implanted Tricuspid (Epstein’s anomaly).
Side Effects: LMNOP Lithium, Movement, Nephrotoxic, hypOthyroid, Pregnancy
Lithium labs to monitor
Li level- 0.6-1.2 after steady state of 5 days, 12 hr after dose, then at dose change or every 3 months, creatinine, HCG, TSH, CBC
Lithium dosing
Init 300-600mg/day titrate 300mg/day every 1-5 days to max 1800 mg/day (based on labs)
Lithium side effects
Hand tremor, polyuria/dypsia r/t ADH, thirst, muscle weakness, nausea, incoordination, acne, thyroid abnormal, dec. SZ threshold, non-sig leukocytosis, kidney fibrosis
Init treatment acute mania and mnemonic
Antipsychotic are quicker, Quietly Lifting Out Quitiepine, Lurazidone and Olanzapine
Lamotrigine mnemonic
LamotrITCHgine r/t rash (Steven-Johnson) LAMOtrigine lamb greater than lion (BP depression)
Lamotrigine (Lamictal) indications
epilepsy, seizures, BP depression
Lamotrigine (Lamictal) dosing
Init dose 25mg/day, increase 25mg/day every 2wks (faster equals increased risk of rash), max 400mg/day. (If stopped for 5 or more days start again at 25 mg/day
Lamotrigine (Lamictal) labs
LFT
Lamotrigine (Lamictal) adverse effects
Steven-Johnson, toxic epidermal necrolysis, blood dyscrasias
Lamotrigine (Lamictal) interactions
VPA increases dose by double slower titration required and Sertraline increases dose
Lamotrigine (Lamictal) side effects
Nausea, diplopia, dizziness, unsteadiness, HA
Rash, SJS, Hematologic, liver failure, ataxia, sedation
LAMOtrigine mechanism of action
Na channel effect, possibly inhibits glutamate, weak affect on serotonin