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Psychopharmacology What you need to know to survive the LMCC and Internship Khalid Bazaid, MD, FRCPC Assistant Professor Child & Adolescent Psychiatrist Children’s Hospital of Eastern Ontario March 23rd, 2017 Based on the 2014 lecture by Dr. Lisa McMurray and 2015/2016 lecture by Dr. Khalid Bazaid Faculty Disclosure I have no financial relationships to disclose relating to the subject matter of this presentation Objectives To review: • indications for • mechanism of action • side effects (remember not everyone gets these) • monitoring parameters for the major classes of psychotropic medications To practice applying this knowledge MCC Objectives for the Qualifying Examination (with updates for DSM-5) • Initiate pharmacologic treatment of – – – – – – – ADHD Agitation in Delirium Dementia/Major Neurocognitive Disorder Major Depressive Disorder Manic Episode Anxiety Disorders Obsessive-Compulsive Disorder (formerly an anxiety disorder) – Substance withdrawal – Substance Use disorders (e.g. nicotine replacement) MCC Objectives for the Qualifying Examination ..Cont’d • Judicious use of pharmacotherapy in personality disorders – Attention to risk of abuse, overdose • Recognize Medication-Induced Movement disorders – e.g. dystonia due to antipsychotics General Pharmacology strategies -1 1. Indication: Establish a diagnosis and identify the target symptoms that will be used to monitor therapy response. 2. Choice of agent and dosage: • • • Select an agent with an acceptable side effect profile Use the lowest effective dose. Delayed response for many psych meds and drug-drug interactions. General Pharmacology strategies -2 1. Establish informed consent: • • • The patient should understand the benefits and risks of the medication. Document this discussion including patient’s understanding and agreement. In fertile women make sure to document teratogenicity discussion. 2. Implement a monitoring program: • Track and document compliance, side effects, target symptom response, blood levels and blood tests as appropriate. General Pharmacology strategies - 3 1. Management: • Adjust dosage for optimum benefit, safety and compliance. • Use adjunctive and combination therapies if needed however always strive for the simplest regimen. • Keep your therapeutic endpoint in mind. General Pharmacology strategies - 4 Bioavailability • Amount of drug that reaches systemic circulation unchanged • Often used to compare one drug to another, usually the higher the bioavailability, the better. General Pharmacology strategies - 5 Cytochrome P450 • Many process carried out by enzyme class Cytochrome P-450 – high affinity for fat-soluble drugs – involved in metabolism of most psychiatric medications – Example: SSRIs inhibitors of the subfamily P4502D6 General Pharmacology strategies - 6 Elimination • Clearance: Total amount of blood, serum, or plasma from which a drug is completely removed per unit time. • Half-life: Time required for plasma concentrations of the drug to be reduced by 50%. • Only a few drugs eliminated by kidneys (lithium) • Most excreted in the liver – excreted in the bile and delivered to the intestine – may be reabsorbed in intestine and “re-circulate” (up to 20%) Pharmacokinetics: Cultural Considerations • 9% of whites - genetically defective P-4502D6 • Asian descent – Metabolize ethanol to produce higher concentrations of acetaldehyde (flushing, palpitations) – Require 1/2 to 1/3 dose antipsychotics and more severe side effects • Cardiovascular effects of propranolol – Asian descent - more sensitive – African descent - less sensitive General Pharmacology strategies Phases of Drug Treatment • • • • Initiation Stabilization Maintenance Discontinuation What is a ‘drug’? • A very vague term • all ingested substances alter bodily function • ‘drug’ is reserved for things that have pronounced effects when ingested in small quantities Basic classification of drug actions • Agonists stimulate or activate • antagonists prevent Ways that drugs can agonize • • • • • Stimulate release receptor binding inhibition of reuptake inhibition of deactivation promote synthesis Ways that drugs can antagonize • Block release • receptor blocker • prevent synthesis Drug Interactions • Synergism (e.g. alcohol + sedative) • Induction of enzymes and increased metabolism • Inhibition of enzymes and delayed metabolism • In vitro versus clinical significance • FDA approval vs. clinical use (“Off-label use”) Selecting a Psychotropic Agent • • • • • • • • • Diagnosis/symptom complex Patient’s prior response Family member’s experience FDA approved indication Pharmacologic actions Documented efficacy Side effect profile Insurance coverage/finances Patient preference Main Psychopharmacological Drugs • • • • • • • Antidepressants Mood stabilizers Antipsychotics Anxiolytics Hypnotics Cognitive enhancers Psychostimulants What is the most common excitatory neurotransmitter in the brain? • • • • • a. b. c. d. e. Serotonin Glutamate Norepinephrine GABA Dopamine Antidepressants • Most antidepressants block the re-uptake of a neurotransmitter of one or more of the bioamines: serotonin, norepinephrine, dopamine. • SSRIs - selective to the serotonin General guidelines for antidepressant use • Antidepressant efficacy is similar so selection is based on past history of a response, side effect profile and coexisting medical conditions. • There is a delay typically of 3-6 weeks after a therapeutic dose is achieved before symptoms improve. • If no improvement is seen after a trial of adequate length (at least 2 months) and adequate dose, either switch to another antidepressant or augment with another agent. Indication of Antidepressants • • • • • • • • • Depressive Disorders Bipolar Disorders Obsessive-Compulsive Disorders Panic Disorders Eating Disorders Somatic Symptom Disorders Posttraumatic Stress Disorder Alcohol and Drugs Withdrawal Symptoms Pain disorders (DSM-5 Somatic Symptom Disorder with predominant pain) • Enuresis • Narcolepsy Neurotransmitter Reuptake Inhibition and Binding Affinity to Receptors Receptors: SE Serotonergic NE Noradrenergic M Muscarinic H Histaminic -N alpha noradrenergic Antidepressants: Monoamine Reuptake Inhibitors 1st Generation of Antidepressants (TCA, TeCA) Generic Name Trade Mark Doses (mg) amitriptyline AMITRIPTYLIN 75-200 nortriptyline NORTRILEN 50-150 imipramine MELIPRAMIN 75-250 clomipramine ANAFRANIL, HYDIPHEN 75-225 dosulepin PROTHIADEN 100-300 dibenzepine NOVERIL 240-720 maprotiline LUDIOMIL, MAPROTILINE 75-150 Mechanism of Efficacy Inhibition of Serotonin and/or Norepinephrine Reuptake Followed by Increase of their Concentrations in Synaptic Cleft Tricyclic antidepressants (TCA): Mechanism of Action 3° amines (eg amitriptyline, imipramine, doxepine) 2° amines (eg nortriptyline, desipramine) • Originally developed as treatment for schizophrenia (similar 3-ringed chemical structure); found ineffective for psychosis but helpful for depression. • Therapeutic effects and side effects from blocking Serotonin, Norepinephrine & Dopamine Reuptake • Some also have 5HT2 blocking ability (blocks sex & sleep side effects) • Side effects from blocking H1 histamine receptors, muscarinic receptors, alpha one adrenergic receptors TCAs • Very effective but potentially unacceptable side effect profile i.e. antihistaminic, anticholinergic, antiadrenergic • Lethal in overdose: can lead to seizures and arrhythmias due to blockade of ion channels • Can cause QT lengthening even at a therapeutic serum level • Desipramine and Notrtriptyline: Secondary TCAs Primarily block norepinephrine Side effects are the same as tertiary TCAs (Imipramine, Amitriptyline, Doxepin, Clomipramine), but generally are less severe TCA: Side Effect Profile • Antihistamine – weight gain & sedation • Anticholinergic – dry mouth, constipation, ocular side effects and urinary hesitancy • Anti-alpha adrenergic – dizziness, orthostatic hypotension TCA: Rare but Dangerous Side Effects • • • Torsades de Pointes (due to blockade of fast sodium channels) • EKG – rule out bradycardia and prolonged QTc • Lytes – rule out electrolyte imbalance • Make sure not on type 1 or 3 antiarrythmic drugs SIADH Serotonin Syndrome Antidepressants Monoamine Oxidase Inhibitors (MAOIs) • Action: Inhibit enzyme responsible for the metabolism of serotonin, dopamine, norepinephrine, and tyramine. • Increases levels of norepinephrine and serontonin in the CNS • Interacts with food -- low tyramine diet (Table 18.3) MAO Inhibitors Non Selective and Irreversible: (IMAO A, IMAO B) phenelzine NARDIL isocarboxazid MARPLAN nialamide NIAMID, NUREDAL tranylcypromine PARNATE Selective and Reversible MAO A moclobemide AURORIX brofaromine CONSONAR toloxatone MAO B selegiline (L-deprenyl) HUMORYL SEPATREM, JUMEX MAOI: Mechanism of Action Monoamine oxidase inhibitors: “the classics” (phenylzine/nardil, tranylcypromine/parnate) Reversible inhibitor: (moclobemide/mannerix) HISTORY: • The first clinically effective antidepressants • Originally, an anti-tuberculosis drug, found to decrease comorbid depression • Irreversibly bind MAO (2 wks) & destroy its function, therefore decrease monoamine breakdown, increasing 5HT, NE & DA MAOI: Side Effect Profile • Side effects related to increase in serotonin norepinephrine & dopamine (see SSRI’s & NDRI’s) • Orthostatic hypotension MAOI: Rare but Dangerous Side Effects • Hyperthermia i.e.Serotonin Syndrome • even more susceptible than with other serotonergic antidepressants; need to avoid anything that has serotonergic effects such as antidepressants and opioids) • When you see an MAOI, get a pharmacy consult, the patient should consult their pharmacist about any over - the – counter medications • Hypertensive crisis • Consult the dietician Re: MAOI diet • Patients need to avoid all foods with tyramine (aged foods such as aged cheeses and wines or tap beer) and any medications with noradrenergic effects (cold remedies, stimulants etc) • Hepatotoxicity • Blood dyscrasias Hypertensive Crisis • Norepinephrine (NE) is the amine most closely linked with control of blood pressure • MAO normally inactivates norepinephrine (NE) • Tyramine, an amine present in aged foods, causes release of norepinephrine (NE) • In the presence of MAOI, this increased NE cannot be broken down, resulting in a hypertensive crisis Serotonin Selective Reuptake Inhibitors (SSRI) 3rd Generation of Antidepressants Generic Name Trade Mark Mean Doses (mg) Mechanism SSRI fluvoxamine FEVARIN 100-300 fluoxetine DEPREX, DEPRENON, PROZAC, PORTAL, FLOXET, FLUXONIL, MAGRILAN 20-60 citalopram SEROPRAM, CITALEC, CEROTER, PRAM 20-60 escitalopram CIPRALEX 10-20 paroxetine SEROXAT, PAROLEX, APO-PAROX, REMOD 20-60 sertraline ZOLOFT, SERLIFT, ASENTRA, STIMULOTON 50-200 Selective Serotonin Reuptake Inhibition SSRIs • The exact mechanism of SSRIs is unknown. • SSRIs are believed to increase the extracellular level of the neurotransmitter serotonin by limiting its reabsorption into the presynaptic cell, increasing the level of serotonin in the synaptic cleft available to bind to the postsynaptic receptor. • They have varying degrees of selectivity for the other monoamine transporters, with pure SSRIs having only weak affinity for the norepinephrine and dopamine transporters. Which of the following is NOT a common side effect of SSRI’s? • • • • • a. b. c. d. e. Nausea Headache Rigidity Anxiety Sleep disruption Side Effects -- SSRIs • • • • • • • Headache Anxiety Transient nausea Vomiting Diarrhea Weight gain Sexual dysfunction SSRI: Rare but Dangerous Side Effects • UGI bleeding (platelet dysfunction), esp. in combo with NSAID’s or other bloodthinning agents • SIADH • Osteoporosis and fractures in the elderly • Serotonin syndrome • Increase suicide in children and adolescents SSRI discontinuation syndrome • Incidence: 20% after 6 weeks of use • • • • • • Flu-like symptoms Insomnia Nausea Imbalance Sensory disturbances Hyperarousal (agitation/anxiety) Prevent with slow taper Serotonin Syndrome: HARMED • • • • • • Hyperthermia Agitation/Autonomic instability Rigidity/Reflexes increased Myoclonus/tremors Encephalopathy Diaphoresis 4th Generation of Antidepressants Dual acting antidepressants Mixed reuptake inhibitors Generic Name Trade Mark Mean Doses (mg) Mechanism SNRI venlafaxine EFECTIN 75-375 venlafaxine ER EFECTIN ER (extended relesase) 75-225 milnaciprane 50-100 IXEL, DALCIPRAN Serotonin and Norepinephrine Reuptake Inhibition DNRI bupropione WELLBUTRIN ZYBAN 150-300 Dopamine and Norepinephrine Reuptake Inhibition Norepinephrine & Dopamine Reuptake Inhibitor:Mechanism of Action (Bupropion/Wellbutrin) • Blockade of norepinephrine and dopamine reuptake pumps, leads to similar cascade as with SSRI’s NDRI: Side Effect Profile • Seizures (not with extended release formulations & following correct dosing; contraindicated with Bulimia or electrolyte disturbances) • Headache, Hypertension (SNS activation) • Agitation (mood and psychomotor circuits) and • Anticholinergic (relative decrease in parasympathetic tone) • Rash • Emesis, decreased appetite and weight loss (SNS activation) • Sleep disruption, Shaking and Sweating (sleep and psychomotor circuits and SNS activation) Serotonin & Noradrenergic reuptake Inhibitors: Mechanism of Action (Venlafaxine/Effexor, Desvenlafaxine/Pristiq, Duloxetine/Cymbalta) • Blockade of serotonin reuptake at lower dose range • Blockade of serotonin and norepinephrine reuptake in mid dose range • Blockade of serotonin, norepinephrine and dopamine reuptake at very high dosages SNRI: Side Effect Profile • As with SSRI’s in lower to mid dose range • As with NDRI in mid to high dose range SNRI: Rare but Dangerous Side Effects • As with SSRI’s 4th Generation of Antidepressants Generic Name Trade Mark Mean Doses (mg) Mechanism Blockade of 2-adrenoceptors mianserin LERIVON, MIABENE 60-90 mirtazapine REMERON, ESPRITAL, REMERON sol. tab. 15-45 Increasing Synthesis and Releasing of Norepinephrine, Blockade Alpha-2 Adrenoceptors on Serotonergic Neurons and Increasing Production and Releasing of Serotonin Other Monoamine Reuptake Inhibitors hypericum perforatum JARSIN 900 Weak Inhibitor of NA, 5HT, DA NaSSA: Mechanism of Action • Blocks Alpha 2 autoreceptors on norepinephrine neurons & heteroreceptors on Serotonin neurons, causing more NE & 5HT to be released • NE neurons from the locus coeruleus innervate midbrain raphe 5HT neurons. Therefore, increased NE causes a further increase in 5HT release • Blocks 5HT2 receptors, having an anxiolytic effect & blocking sleep & sexual side effects • Blocks 5HT3, blocking GI side effects from peripheral receptors & from brainstem chemoreceptor trigger zone • Blocks H1 histamine receptors, causing sedation & weight gain NaSSA: Side Effect Profile • Weight gain (H1 blockade) • Anticholinergic (relative decrease in parasympathetic tone) – very weak effect • Drowsiness (H1 blockade) • Equilibrium NaSSA: Rare but Dangerous Side Effects • Neutropenia • Serotonin syndrome • Hepatotoxicity • SIADH • QT prolongation (Health Canada, 28 March 2014, post-marketing) SARI: Mechanism of Action Serotonin 2A antagonists/reuptake inhibitors (Trazodone/Desyrel) • Primarily blocks 5HT2A, reducing sexual dysfunction & sleep disruption & increasing effect of 5HT1A stimulation (5HT2A & 5HT1A oppose one another’s actions in several ways) • Weak 5HT reuptake inhibitor, increasing 5HT stimulation of 5HT1A (therapeutic effects) • H1 blockade causes sedation • Alpha One blockade leads to orthostatic hypotension SARI: Side Effect Profile • Orthostatic hypotension • Sedation • Rare but Dangerous Side Effects: – Serotonin syndrome – Priapism Starting Antidepressants: General Guidelines • Start with a reuptake inhibitor or mirtazapine (not a TCA or MAOI) • Start at lowest possible dose (half of this with anxiety and in the elderly and medically frail) • Increase by this increment about every five half lives (or about once a week) until one of the following endpoints: • Intolerable side effects • Full response • Maximum dose • Continue to monitor for therapeutic effects, side effects and safety • How you use them is more important than which one you choose Course of Recovery From Depression Response 2-3 weeks: 3-4 weeks: 6-8 weeks: Improved sleep, appetite, vegetative shifts objective improvement energy suicidal ideation may subjective improvement Choice of Initial Antidepressant in Adults • There is comparable efficacy between and within classes of medication, therefore, initial selection is based on: • Symptom profile • Side effect profile in relation to the individual patient • Patient preference • Cost • History of previous response of the patient or family members • Comorbid psychiatric or medical illnesses • Potential drug-drug interaction • The BEST antidepressant is the one that a patient will actually take acutely and for the long haul…and one that you know well Treatment choices in children • Concerns were raised about the safety of antidepressants (Paroxetine and Venlafaxine) in children and youth in 2004 • Further metaanalyses and epidemiologic studies now confirm that antidepressants in children and youth are safe with close (weekly) monitoring. • Problems with Venlafaxine and Paroxetine may have been related to poor adherence and discontinuation symptoms Choice of Initial Treatment in children/youth • Mild to moderate depression: – Start with psychotherapy or non-medication interventions as first line – Second line is to add medication; best evidence is for Fluoxetine; other SSRI’s could be considered next • Moderate to severe depression: – First line is to consider medication but depending on patient/family preference, may also start with psychotherapy or monitoring • Note that the clinical presentation in children and youth can change quickly; they may appear severely depressed one week then by the next week be in a new relationship and everything is better… FDA Suicide Warning • Black Box Warning • All antidepressants • Increased risk of suicidal thinking and behaviors • Affects 18-24 y/o Antidepressant-Induced Sexual Dysfunction Desire Decreased libido Arousal Difficulties w/ erection/lubrication Orgasm Delayed orgasm/anorgasmia Management – – – – Spontaneous resolution Decrease dose Change agent Adjunctive medication Selective PDE5 Inhibitor Cyproheptadine (Periactin) Bupropion (Wellbutrin) Goals of antidepressant therapy • REMISSION of symptoms and maintaining that level of improvement in order to prevent relapse and recurrence • Rate of relapse is significantly less for patients who achieve full remission of symptoms • Patients who have been ill longer tend to be more treatment resistant; there is also evidence of hippocampal atrophy with prolonged illness, leading to the concept of disease progression and the hope that this can be modified by treating all mood episodes to the point of remission Treatment Resistant Depression 1. Is the patient medication compliant? 2. Is the diagnosis correct? 3. Change agents-Within/between classes 4. Antidepressant combinations -Complementary mechanisms of action 5. Add psychotherapy 6. Augmentation strategies – Lithium – Antipsychotic Thyroid hormone Estrogen 7. ECT/Focal Brain Stimulation Recommended Site http://psychopharmac ologyinstitute.com/a ntidepressants/ At which dose level does Venlafaxine/Effexor XR typically begin to have a noradrenergic effect? • • • • a. b. c. d. 75mg 150mg 225mg 300mg Which of the following receptors does Mirtazepine/Remeron NOT block? • • • • • a. b. c. d. e. Histamine 5HT1 5HT2 5HT3 Alpha 2 Fluoxetine (Prozac) • Pros – Long half-life so decreased incidence of discontinuation syndromes. Good for pts with medication noncompliance issues – Initially activating so may provide increased energy – Secondary to long half life, can give one 20mg tab to taper someone off SSRI when trying to prevent SSRI Discontinuation Syndrome • Cons – Long half life and active metabolite may build up (e.g. not a good choice in patients with hepatic illness) – Significant P450 interactions so this may not be a good choice in pts already on a number of meds – Initial activation may increase anxiety and insomnia – More likely to induce mania than some of the other SSRIs Citalopram (Celexa) • Pros – Low inhibition of P450 enzymes so fewer drug-drug interactions – Intermediate ½ life – Cons • Cons – Dose-dependent QT interval prolongation with doses of 10-30mg daily- due to this risk doses of >40mg/day not recommended! – Can be sedating (has mild antagonism at H1 histamine receptor) – GI side effects (less than sertraline) Escitalopram (Cipralex) • Pros – Low overall inhibition of P450s enzymes so fewer drugdrug interactions – Intermediate 1/2 life – More effective than Citalopram in acute response and remission • Cons – Dose-dependent QT interval prolongation with doses of 10-30mg daily – Nausea, headache Sertraline (Zoloft) • Pros – Very weak P450 interactions (only slight CYP2D6) – Short half life with lower build-up of metabolites – Less sedating when compared to paroxetine • Cons – Max absorption requires a full stomach – Increased number of GI adverse drug reactions Fluvoxamine (Luvox) • Pros – Shortest ½ life – Found to possess some analgesic properties – Cons • Cons – Shortest ½ life – GI distress, headaches, sedation, weakness – Strong inhibitor of CYP1A2 and CYP2C19 Paroxetine (Paxil) • Pros – Short half life with no active metabolite means no buildup (which is good if hypomania develops) – Sedating properties (dose at night) offers good initial relief from anxiety and insomnia • Cons – Significant CYP2D6 inhibition – Sedating, weight gain, more anticholinergic effects – Likely to cause a discontinuation syndrome • Pros Venlafaxine (Effexor) – Minimal drug interactions and almost no P450 activity – Short half life and fast renal clearance avoids build-up (good for geriatric populations) • Cons – Can cause a 10-15 mmHG dose dependent increase in diastolic BP. – May cause significant nausea, primarily with immediaterelease (IR) tabs – Can cause a bad discontinuation syndrome, and taper recommended after 2 weeks of administration – Noted to cause QT prolongation – Sexual side effects in >30% Desvenlafaxine (Pristiq) • Pros – Minimal drug interactions – Short half life and fast renal clearance avoids build-up (good for geriatric populations) • Cons – GI distress in 20%+ – Dose related increase in total cholesterol, LDL and triglycerides – Dose related increase in BP Duloxetine (Cymbalta) • Pros – Some data to suggest efficacy for the physical symptoms of depression – Thus far less BP increase as compared to venlafaxine, however this may change in time • Cons – CYP2D6 and CYP1A2 inhibitor – Cannot break capsule, as active ingredient not stable within the stomach – In pooled analysis had higher drop out rate • Pros Novel antidepressants Mirtazapine (Remeron) – Different mechanism of action may provide a good augmentation strategy to SSRIs. Is a 5HT2 and 5HT3 receptor antagonist – Can be utilized as a hypnotic at lower doses secondary to antihistaminic effects • Cons – Increases serum cholesterol by 20% in 15% of patients and triglycerides in 6% of patients – Very sedating at lower doses. At doses 30mg and above it can become activating and require change of administration time to the morning. – Associated with weight gain (particularly at doses below 45mg Which mood stabilizer can reduce the risk of suicide in Bipolar Disorder? • • • • a. b. c. d. Valproic Acid/Epival Lamotrigine/Lamictal Lithium Carbamazepine/Tegretol The Heterogeneity of Bipolar Disorder Taken from: http://www.psychosisbipolar.com/information-aboutpsychoses-57.htmlTaken Mood Stabilizers: Indications • A heterogeneous group of medications • Used to treat diverse conditions, including • • • • • • Bipolar Disorder Migraine or cluster headaches Chronic aggression or impulsivity Seizure disorders Pain conditions (TGN, migraine) Lithium reduces suicidal risk in Bipolars and augments antidepressants in MDD Goals of treatment in BD • Treat to complete remission • It has been theorized that under-treated discrete depressive and manic episodes may progress to mixed and dysphoric episodes, rapid cycling and treatment resistance • The hope is that recognition and full treatment of mood episodes may prevent progression to more difficult mood states Choice of Treatment in BD (Bipolar Disorder) • First line for acute mania: • Lithium, • Valproic Acid • atypical antipsychotics (olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole lurasidone) – taper and discontinue antidepressants • First line for acute bipolar depression: • Lithium • lamotrigine • quetiapine • Lurasidone (July 2013) – do not use antidepressant monotherapy • First line for maintenance therapy: – Lithium – Valproic acid – Lamotrigine – Atypical antipsychotics quetiapine, risperidone LAI and Olanzapine Lithium: Mechanism of Action • MOA is unclear • Thought to be involved in: • Modulating second messenger systems (ie G protein-coupled receptors, through which most hormones and neurotransmitters mediate their effects) which leads to: • • • • Increasing GABA activity Reducing glutamate activity Stabilizing catecholamine receptors Blocking the effects of some hormones (eg. ADH and TSH) on end organs • Works in acute bipolar mania, depression and maintenance phases • Decreases suicide, deliberate self harm and death from all causes in patients with mood disorders Lithium: Side Effect Profile • Lethargy • Insipidis (diabetes insipidis) • Tremor/Teratogen (increased risk Ebstein’s anomaly (0.1% vs 0.005%) in first trimester) • Hypothyroid • Increased weight • Vomiting, nausea, GI • Miscellaneous: EKG changes (T wave flattening or inversion, sick sinus syndrome), acne, hair loss, hypercalcemia Lithium: Toxicity • Narrow therapeutic index!!! • Anything that affects water and electrolyte imbalance can contribute to Lithium toxicity (CAUTION with flu, dehydration, meds) • Levels are increased by NSAIDS, diuretics, ACE inhibitors, tetracycline, anticonvulsants • Levels are decreased by caffeine and salt Lithium: Toxicity • There is delayed distribution and elimination in the brain relative to serum therefore early signs are peripheral and later signs are central unless high level is chronic, in which case peripheral and central symptoms will occur simultaneously • Peripheral symptoms: nausea, vomiting, cramping, diarrhea • Central symptoms: tremulousness, hyperreflexia, ataxia, mental status changes, coma, seizures • Can lead to irreversible neurotoxicity including cognitive impairment, peripheral neuropathy and cerebellar dysfunction • Hospitalize for levels >2.0 or based on clinical symptoms Lithium: Initial Work-up • • • • Lytes, BUN, Cr (renally excreted) Calcium TSH (5% hypothyroidism) EKG with rhythm strip (contraindicated with sick sinus syndrome) • B-hcg • Metabolic baseline including baseline weight and BMI; consider checking for diabetes/pre-diabetes and hypercholesterolemia in those who are overweight (BMI 25-30) or obese (BMI>30) Lithium: Ongoing Monitoring • Lithium level every five days until steady state is reached then at 3-6 months, with signs of dehydration or toxicity or with change in medications or salt intake • Repeat kidney functions, TSH and EKG every 6-12 months, Calcium • Monitor weight and BMI during treatment and re-check for diabetes/pre-diabetes and hypercholesterolemia if >5% weight gain • Avoid during pregnancy. Lithium : Rx • Adult • Acute mania about 1800mg/day (bid-tid dosing) • Acute mania level 1.0 – 1.5 • Maintenance usually about 900-1200 mg/d; give at hs for renal protection • Maintenance level 0.6-1.0 • Geriatric • Dosing 150 – 600 mg/d (bid dosing) • Level 0.4 – 0.8 • For maintenance, give at hs for renal protection Valproic Acid: treatment effects • Treats bipolar mania • First line for bipolar depression in combination with lithium or SSRI/bupropion • Second line monotherapy for bipolar depression • Indicated for maintenance phase Valproic Acid: Acute Side Effect Profile STUN • • • • Sedation (31%) Tremor (10-29%) Unsteadiness (dizziness) Nausea (20%) /GI Valproic Acid: longer term side effects • On the surface: – Acne , hair loss • Under the surface: – weight gain, edema • Systemic: – thrombocytopenia – liver dysfunction +/- elevated ammonia levels – reproductive changes including menstrual irregularities (up to 45%), PCOS, teratogenicity (5-15%) • Avoid use in women of childbearing age Valproic Acid: Initial Work-up & Ongoing Monitoring Initial • CBC + LFT’s • Epival level every 3-4 days until steady state reached • Metabolic baseline including baseline weight and BMI; consider checking for diabetes/pre-diabetes and hypercholesterolemia in those who are overweight (BMI 25-30) or obese (BMI>30) Ongoing • Repeat tests monthly x 6 months then Q6mos or if symptoms develop • Monitor weight and BMI during treatment and re-check for diabetes/pre-diabetes and hypercholesterolemia if >5% weight gain Valproic Acid: Rx Reference only • Starting dose: • 250 qhs (geriatrics) • 250 bid-tid (adults) • 15-30 mg/kg/day in bid dosing for acute mania in adults • Levels: 350 – 800 umol/l Lamotrigine: Treatment effects • Treats bipolar depression (modest effect) • First line maintenance treatment Lamotrigine: Side Effect Profile • Rash – 0.3% adults / 1% in children. With slow titration risk was reduced to 0.01% comparable to other anticonvulsants. Can develop into Stevens-Johnson Syndrome (increased risk with Valproate) • Activation (3-8%), Ataxia • Spaced out (cognitive slowing), Sedation, Sleep disturbances • H/A, Hypersensitivity reactions Lamotrigene: Rx • Start with 25 mg/d • Double the dose every 2 weeks • Usual maintenance dose is 200 mg in 2 divided doses (reached by week six) Atypical Antipsychotics: Olanzapine and Quetiapine • All atypical antipsychotics are indicated to treat bipolar mania • Quetiapine is first line monotherapy for bipolar depression; so is Lurasidone • Olanzapine, Quetiapine, Aripiprazole, and Risperidone LAI are first line maintenance treatments Schizophrenia • Affects about 1/100 people • Begins in 20’s • Often triggered by stress, illness, etc. but there’s also a genetic predisposition The Disease Process Positive Symptoms • Hallucinations • Delusions • Disorganization • Agitation Negative symptoms • Blunted affect • Emotional withdrawal • Social withdrawal • Anhedonia Beyond dopamine New generation antipsychotics affect serotonin as well Glutamate antagonists can help with negative symptoms Schizophrenia likely affects a host of systems perhaps by disturbing a fundamental balance among neurotransmitters Overview of Antipsychotics Conventional Antipsychotics Chem. Group Generic Name Trade Mark chlorpromazine CHLORPROMAZIN, LARGACTIL, PLEGOMAZIN, MEGAPHEN, THORAZIN levomepromazine TISERCIN, NOZINAN thioridazine THIORIDAZIN, MELLERIL periciazine NEULEPTIL chlorprothixene CHLORPROTHIXEN, TRUXAL clopenthixol CISORDINOL, CLOPIXOL Dose (mg) 200-800 50-400 Phenothiazines Thioxanthes 100-600 10-40 100-600 20-100 Overview of Antipsychotics Conventional Antipsychotics Chem. Group Generic Name Trade Mark Dose (mg) 16-24 flufenazine PERFENAZIN, TRILAFON, PERATSIN PROCHLORPERAZIN, STEMETIL MODITEN trifluoperazine STELAZIN 10-50 flupenthixol FLUANXOL 6-18 haloperidol melperone HALOPERIDOL, HALDOL, APO-HALOPERIDOL BURONIL pimozide ORAP 2-10 Diphenylbutyl piperidines fluspirilen IMAP 2-10 penfluridol SEMAP 2-60 Perathiepines oxyprothepin MECLOPIN 5-20 perfenazine Phenothiazines Thioxanthenes Butyrophenones prochlorperazine 20-80 2-16 2,5-10 50-300 Antipsychotics of the 2nd Generation Generic Name Trade Mark Dose (mg) D2, D3 selective antagonists sulpiride DOGMATIL, PROSULPIN 50-1200 amisulpride SOLIAN, DENIBAN 50-1200 SDA risperidone RISPERDAL, RISPEN, RISPERDAL QUICKLET 4-8 ziprasidone ZELDOX 40-160 sertindole SERDOLECT 12-20 MARTA clozapine LEPONEX 200-600 olanzapine ZYPREXA i.m. inj. 10 mg 5-20 quetiapine SEROQUEL 300-600 zotepine ZOLEPTIL 75-300 Antipsychotics of the 2nd Generation Efficacy 1. Positive symptoms are influenced significantly better than placebo, and equally or more then by the classical antidopaminergic neuroleptics. 2. Negative symptoms are reduced significantly better than by placebo or classical antidopaminergic neuroleptics. 3. Affective symptoms are influenced better than by placebo or classical antidopaminergic neuroleptics. 4. They significantly reduce or prevent the cognitive impairment. The reduction is higher in comparison to classical antidopaminergic neuroleptics. 5. The treatment resistant patients with schizophrenia are improved significantly better than by placebo and at least equally as by clozapine. 6. Maintenance treatment is more effective than maintenance on placebo and at least as effective as maintenance on classical neuroleptics. Antipsychotics of the generation Generic Name název Trade Mark Dose (mg) rd 3 Mechanism of Efficacy Dopamine-serotonin stabiliser aripiprazol ABILIFY 15-30 Parcial agonist of D2 and 5-HT1A receptors Antagonist of 5-HT2A receptors Depot Antipsychotics Generic Name Trade Mark Mean Dose (mg) flufenazin MODITEN DEPOT 25 oxyprothepin MECLOPIN 25 haloperidol HALDOL DEPOT flupenthixol FLUANXOL DEPOT zuclopenthixol CISORDINOL DEPOT fluspirilen IMAP risperidone RISPERDAL CONSTA 100 Interval 14-28 days 40 200 6 7 days !! 20-30 14 days Rapid Tranquilizers pro dosi (mg) pro die (mg) chlorpromazin 100-200 800-1200 levopromazin (TISERCIN) 50-100 500-600 haloperidol 5-10 40-100 chlorprothixen 100-150 500-600 zuclopenthixol 50-150 (CISORDINOL ACUTARD) (24-72 hours) tiapride (TIAPRIDAL) 600-1200 Typical Antipsychotics: Side effects High potency EPS Haldol Loxapine Perphenazine Low potency Chlorpromazine QT prolongation with pimozide, CPZ Antihistamine AntiAlphaAdrenergic Anticholinergic Antipsychotics: Indications • • • • Psychotic illness Delirium Mood disorder with psychosis Severe agitation or aggression Typical Antipsychotics: Mechanism of action • D2 blockade • Produces antipsychotic effect in the mesolimbic pathway • Causes worsening of negative and cognitive symptoms in the mesocortical pathway, where a dopamine deficit is thought to cause these symptoms • Causes EPS (dystonia, dyskinesia, akathesia, parkinsonism) in the nigrostriatal pathway • Causes increased prolactin in the tuberoinfundibular pathway (gynecomastia, galactorrhea and sexual dysfunction) FDA Approved Indications for Atypical Antipsychotics Indication OLA RIS ILO QUE Schizophrenia Schizoaffective Disorder X X X X Bipolar Mania/Mixed X X Bipolar Depression X X Adjunct in MDD X X ZIP ARI ASEN X X X X X X X X X OLA = Olanzapine, RIS = Risperidone, ILO = Iloperidone, QUE = Quetiapine, ZIP = Ziprasidone, ARI = Aripiprazole, ASEN = Asenapine Features of Atypical Antipsychotics • Block both D2 and 5HT2A • Cause less EPS than typical antipsychotics • Improve positive symptoms as well as typical antipsychotics Atypical Antipsychotics: Mechanism of action • 5HT2A, when stimulated, normally stops dopamine release; when this is blocked, it causes dopamine release • The different dopamine pathways have varying amounts of D2 and 5HT2A receptors Atypical Antipsychotics: Side Effects Less effects on: • EPS, negative symptoms and cognition A different set of concerns: • Weight gain (get baseline weight) • Akathisia • Sedation • Hyperglycemia/Hyperlipidemia(baseline fasting lipids and glucose) • Dizziness (orthostatic hypotension; check BP) • In dementia increase mortality and risk of cardiovascular events • Risk of agranulocytosis and seizure (dose dependent) with Clozapine Atypical (2nd Generation) Antipsychotics Side Effect HL CPZ CLZ RIS OLZ QTP ZIP - +++ ++++ - +++ - - +++++ +++ + ++ + + ++ Sedation + ++++ +++++ + +++ +++ ++ Orthostasis + +++ ++++ + + + + Weight gain + +++ ++++ ++ +++ + - Lipid increase - ?? +++ ?? ++ ?? - +++ ++ - +++ + - + Anticholinergic EPS Prolactin elevation HL=haloperidol (Haldol), CPZ=chlorpromazine (Thorazine), CLZ=clozapine (Clozaril), RIS=risperidone (Risperdal), OLZ=olanzapine (Zyprexa), QTP=quetiapine (Seroquel), ZIP=ziprasidone (Geodon) (Taken from: Jam, MW. Advances in the treatment of psychosis: a multidisciplinary continuing education program. Power-Pak CE, New York, NY 2001, p. 8.) Metabolic Syndrome & Atypical Antipsychotics Medication Clozapine Olanzapine Quetiapine Risperidone Aripiprazole Ziprasidone Weight Gain +++ +++ ++ ++ 0 0 ↑FBS +++ +++ ++ ++ 0 0 Risk of adverse effects at therapeutic doses: 0 = None, ++ = Sometimes, +++ = Frequently J. Clin. Psych 2004: 66; 267-272 ↑ Lipids +++ +++ ++ ++ 0 0 Atypical Antipsychotics: Monitoring • Baseline personal and family history of vascular risk factors • Obtain baseline weight and calculate BMI; BMI monthly for three months and then 3x per year • Baseline waist circumference at the umbilicus, BP, fasting glucose and lipid profile; repeat at 3 months and then annually Neuroleptic Malignant Syndrome • Antipsychotic use (+) fever (+) rigidity (+) 2 others of: • • • • • Fever Encephalopathy (neuro s/s or change in mental status) Vital signs unstable Elevated CPK/ WBC Rigidity Which of these is the most prominent side effect of atypical antipsychotics? • • • • a. b. c. d. Rigidity Dystonia Dyskinesia Akathisia Which of the following is an example of a low potency typical antipsychotic? • • • • • a. b. c. e. f. Haloperidol (Haldol) Pimozide (Orap) Olanzapine (Zyprexa) Clomipramine (Anafranil) Chlorpromazine (Thorazine) Which is NOT an indication for the use of Benzodiazepines? • • • • • a. b. c. d. e. Catatonia Long term hypnotic Mania Alcohol withdrawal Anxiety Benzodiazepine Anxiolytics Indication: • States of Anxiety • Sleeplessness • Withdrawal Symptoms • Depressive States • Epilepsy • Convulsions • Tetanus Neonatorum • Extrapyramidal Undesirable Side Effects of Antipsychotics • Premedication in Anaestesiology • Panic States (Alprazolam, Bromazepam, Clonazepam in High Doses) • Algidic Syndromes (Stomatodynie, Neuralgie Trigemini, Cephalgia) Anxiolytics Generic Name Trade Mark Form Mean Doses (mg) Propandiol Derivates guaiphenesine GUAJACURAN drg. 200,400mg inj. 1 g 400 - 3000 Mephenoxalone DORSIFLEX, DIMEXOL tbl. 200 mg 400 - 1200 meprobamate MEPROBAMAT LÉČIVA tbl. 400 mg 800 - 2400 Piperazin Derivates hydroxyzine ATARAX tbl. 10, 25 mg inj. 100 mg sir. 20 – 100 300 - 400 Azapiron Derivates buspirone ANXIRON, BUSPIRON-EGIS tbl. 5, 10 mg 15-30 Anxiolytics (Benzodiazepine Derivates) Generic Name diazepam Trade Mark Form Mean Doses (mg) 10 - 60 DIAZEPAM SLOVAKOFARMA APO-DIAZEPAM APAURIN, SEDUXEN DIAZEPAM DESITIN DIAZEPAM DESITIN SUPP. DEFOBIN, ELENIUM RAPEDUR OXAZEPAM LÉČIVA tbl. 2.5; 10 mg inj. 10 mg tbl. 0.25 mg ; 1 mg tbl. 0.25; 0.5; 1; 2 mg 1 - 10 bromazepam NEUROL XANAX FRONTIN, HELEX LEXAURIN tbl. 1; 5; 3 mg 3 - 36 medazepam ANSILAN, RUDOTEL tbl. 10 mg 20 - 40 tofisopam GRANDAXIN tbl. 50 mg 100 - 400 K+ clorazepate TRANXENE lorazepam TAVOR tbl. 5; 10; 50 mg inj. 20; 50; 100 mg tbl. 1; 2,5 mg clobazam FRISIUM tbl. 10 mg 20 - 60 prazepam DEMETRIN tbl. 10 mg 20 - 40 clonazepam RIVOTRIL tbl. 0.5 ; 2 mg gttae 10-25 mg/ml inj. 1 mg tbl. 0.25; 1 mg chlordiazepoxide oxazepam alprazolam ANTELEPSIN supp. 5 mg tbl. a drg. 10 mg tbl. 10 mg 20 - 60 10 - 60 15 – 30 50 - 300 2 1-4 Action Profiles of Benzodiazepines Relief of anxiety Anticonvulsant action Sedation Induction of sleep Muscle relaxation Ansseau, M., Doumont, A., Diricq, S.: Methodology required to show clinical differences between benzodiazepines. Curr Med Res Opin 8, Suppl. 4, 108114 (1984). (Except <Dormicum> and <Dalmadorm>) Anxiolytics: Indications e.g. Benzodiazepines (lorazepam) • Short term hypnotic (But decrease REM, Stages 3 & 4 sleep) • Anxiolytic • Acute mania • Alcohol withdrawal • Catatonia Anxiolytics: Mechanism of action • ↑ Affinity of GABA-A receptor for GABA (a positive allosteric modulator) • GABA-A receptors with alpha one subunits most important for sleep • GABA-A receptors with alpha two or three subunits are most important for anxiety (but all available at this time are non-selective and therefore also sedating) Benzodiazepines Benzodiazepine Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Lorazepam (Ativan) Oxazepam (Serax) Half-life (hr) 12 100 34 100 100 15 8 Active metabolites Yes Yes No Yes Yes No No Anxiolytic dose range (mg/day) 0.5-4 15-100 0.5-10 7.5-60 2-40 2-4 30-120 Approximate dose equivalency (mg) 0.25 10 0.5 7.5 5 1 15 Taken from: Kaplan SI, Sadock BJ. Kaplan & Sadock’s Synopsis of Psychiatry, 8 th ed., Lippincott, Williams & Wilkins, Philadelphia, 1998, p. 996. Advantages -Rapid onset of action -Highly effective Disadvantages -Physiologic dependence -Addicting -Impaired cognition Anterograde amnesia Anxiolytics: Side effects • • • • Memory decline Addiction(dependency &withdrawal) Ataxia/Falls Drowsiness/dizziness/disinhibition Anxiolytics: Contraindications • With COPD or sleep apnea • Avoid in the elderly; with long term use taper by 25 % q-monthly after treating the underlying anxiety disorder with an SSRI as indicated How are the novel hypnotics (e.g. Zopiclone, Zolpidem) different from Benzodiazepines? • • • • a. Do not cause falls b. Do not lead to tolerance c. Used as long term hypnotics d. More selective for the alpha one subtype of GABA-A receptor Novel hypnotics (e.g. Zopiclone/Imovane) Indications: short term hypnotic agents Mechanism of action: Some are selective for the alpha 1 subtype of GABA-A receptor (sedating effects) and not the alpha 2 (anxiolytic, muscle relaxant and alcohol potentiating) or alpha 5 (linked to memory) Side Effects: Similar to benzodiazepines FDA Approved Indications MDD PD OCD SP PTSD GAD PMDD BN ND FM SSRI Citalopram (Celexa) X Escitalopram (Lexapro) X X Fluoxetine (Prozac) X X X X X Paroxetine (Paxil/CR) X X X X X X X Sertraline (Zoloft) X X X X X X SNRI Duloxetine (Cymbalta) X X X Venlafaxine (Effexor/XL) X X X X Tricyclic Antidepressant Fluvoxamine (Luvox) X Other Bupropion (Wellbutrin) X X Buspirone (BuSpar) X Mirtazapine (Remeron) X MDD=major depressive disorder, PMDD=peri-menstrual dysphoric disorder, PD = panic disorder, PTSD=post-traumatic stress disorder, GAD=generalized anxiety disorder, OCD=obsessive-compulsive disorder, SP=social phobia, BN = bulimia nervosa, ND = nicotine dependence, FM = fibromyalgia SSRI/SNRIs in Anxiety Disorders Advantages • High efficacy • Non-addicting • Effective for a number of conditions Disadvantages • Can take 2-8 weeks or longer to be effective • Side effects • Drug interactions • Discontinuation syndrome Other Options for Anxiety Disorders • Buspirone (BuSpar) • Beta blockers • Combinations – SSRI/SNRI + Benzodiazepine • Antipsychotics – Trifluoperazine (Stelazine) – Quetiapine (?) • Pregabalin (?) Psychotropic Choices for Specific Conditions Condition Pharmacotherapy Option Obsessive compulsive disorder SSRI Clomipramine Social anxiety disorder SSRI/SNRI Panic disorder SSRI/SNRI TCA Benzodiazepine PTSD SSRI Generalized anxiety disorder SSRI/SNRI Benzodiazepine Buspirone Alzheimer’s Disease First described by Alois Alzheimer in 1907 Course of disease: - initially, some memory loss (new memories and disorientation - persistently progressive until one loses identity Neuropathology in Alzheimer’s disease Cognitive Enhancers Cholinergic Agents - Donepezil/Aricept - Rivastigmine/Exelon - Galantamine/Reminyl NMDA Antagonist - Memantine/Ebixa Cognitive Enhancers: Indications AChEI: early to moderate Alzheimer’s severe Alzheimer’s Some evidence for: Lewy Body Dementia Galantamine in Mixed Dementia Donepezil in Vascular Dementia Memantine: Moderate to severe AD Cholinesterase Inhibitors: Effects • Abilities • Behaviour • Cognition • Decrease in caregiver time • Entry into Nursing Home Cholinesterase Inhibitors Mechanism of Action • Inhibits centrally-acting acetylcholinesterase, making more acetylcholine available • This compensates in part for degenerating cholinergic neurons that regulate memory AChEI: Common Side Effects Muscle Cramps Insomnia/incontinence Nausea Diarrhea • • • • • • • • Diarrhea Urination Miosis/muscle weakness Bronchorrhea Bradycardia Emesis Lacrimation Salivation/sweating Cholinesterase Inhibitors: use caution or consultation with: • History of seizures • History of bradycardia, sinus node dysfunction or other serious conduction abnormality • History of PUD or other risk factors for GI bleeding • History of COPD or asthma Memantine: Mechanism of action • A dysfunction of glutamatergic neurotransmission, manifested as neuronal excitotoxicity, is hypothesized to be involved in the etiology of Alzheimer’s disease • Memantine binds the NMDA receptor with a higher affinity than Mg2+ (which are normally there), inhibiting a prolonged influx of Ca2+ (thereby preventing excitotoxicity) • The receptor can still be activated by the relatively high concentrations of glutamate released following depolarization of the presynaptic neuron Memantine: Common Side Effects Confusion Headache Equilibrium (dizziness) Constipation Kidney function (But in large studies had a similar rate of treatment emergent side effects as placebo) Cognitives ACETYLCHOLINESTERASE INBITORS rivastigmine EXELON 8 -12 mg donepezil ARICEPT 5 - 10 mg galantamine REMINYL 8 - 24 mg NMDA (N-methyl-D-aspartate) RECEPTOR ANTAGONISTS memantine EBIXA 10 - 30 mg Which class of cognitive enhancers is indicated in mild to moderate Alzheimer’s Disease? • a. Cholinesterase inhibitor • b. NMDA receptor antagonist Attention Deficit Hyperactivity Disorder 1. Stimulants – – – – Amphetamine salts (Adderall) Methylphenidate (Ritalin, Concerta, Focalin) Dextroamphetamine (Dexedrine) Pemoline (Cylert) 2. Non-stimulants – Atomoxetine (Strattera) – Guanfacine extended release (Intuniv) – Others • Bupropion(Wellbutrin) • Tricyclic antidepressants • Venlafaxine (Effexor) 3. New Delivery Systems – Methylphenidate patch (Daytrana) – Pro-drug: lisdexamfetamine (Vyvanse) Psychostimulants Generic Name Trade Mark Doses (mg) amphetamine PSYCHOTON, ADDERAL 5 – 50 dexamphetamine DEXEDRON 5 – 30 ephedrine EPHEDRIN 12,5 – 50 mezocarb SYDNOCARB 5 – 50 methylphenidate RITALIN, CENTEDRIN 10 – 40 modafinil VIGIL, PROVIGIL 200 – 400 Stimulants: Indications • • • • ADHD Narcolepsy (treatment resistant depression) (apathy in elderly) Stimulants: Mechanism of action (1) • Increases dopamine and NE actions by blocking their reuptake and facilitating their release • Improves the efficiency of information processing in the frontal subcortical circuits, relieving frontally mediated symptoms of inattention, hyperactivity and impulsivity. Stimulants: Mechanism of action (2) • Action in DL prefrontal cortex improves attention, concentration, executive function and wakefulness • Action in cortical and subcortical motor areas may improve hyperactivity • Action in the orbital frontal cortex may improve impulsivity • Action in medial prefrontal cortex may improve depression, fatigue and sleepiness Stimulants: Common Side Effects • Headaches and Heart concerns (palpitations, tachycardia and hypertension) • Insomnia, Irritibility and Increased stimulation • Dizziness • Exacerbation of tics, tremor • Stomach: anorexia, nausea, abdo pain, weight loss, possibly slowing of normal growth in children Stimulants: Rare Side Effects • • • • Psychosis Leukopenia Anemia Seizures Stimulants: Ongoing Monitoring • Blood pressure at baseline and with dose increases • In children, ongoing monitoring of height and weight PRACTICE CASES CDMQ 1 A 25 year old man (who was previously a PhD candidate at McGill but has been unemployed and not seeking work for the last two years) is brought in to the emergency by police. Police were called as he had been breaking into the homes of strangers saying that he was looking for “Amour”. They were concerned by his disorganized speech and brought him into hospital for assessment. When seen in the emergency, he is not concerned about being in hospital. He says that he has been possessed by the goddess of love, “Amour”, and is looking for others like himself. When introduced to the assessing psychiatrist, he tells her that he heard her say the number 17 which alerted him to the fact that there is a special connection between his circumstance and the television show “House”. Which of the following is the most likely diagnosis? A. Major depressive disorder B. Schizophrenia C. Delirium D. ADHD E. Dissociative identity disorder Which of the following medications would be most appropriate to discuss starting with the patient? A. Olanzapine/Zyprexa 5 mg at bedtime B. Haldoperidol/Haldol 10 mg twice daily C. Chlorpromazine/Thorazine 100 mg at bedtime D. Risperidone/Risperdal Consta 50 mg IM q2wks E. Quetiapine/Seroquel XR 900 mg at bedtime Which of the following side effects would you counsel the patient about? A. Headaches, agitation, nausea, diarrhea B. Tremor, increased blood pressure, increased sweating C. Insomnia, decreased appetite, elevated blood pressure, tics D. Weight gain, akathisia, sedation, increased lipids and sugars E. Sedation, increased thirst, tremor, hypothyroidism, nausea, hair loss CDMQ 2 • A 30 year old woman presents to your family medicine clinic after several visits to the local emergency department for episodes of racing heart, shortness of breath, nausea and a sense that she was dying. Cardiograms and bloodwork (CBC, TSH) were normal. As a result of these episodes, she has become reluctant to leave the house as she is afraid this will happen when she is driving or when in a situation where she will not be able to access help. Which of the following is the most accurate diagnosis? A. Hyperthyroidism B. Generalized anxiety disorder C. Panic disorder D. Agoraphobia E. Major depressive disorder In the emergency, this lady received some lorazepam/ativan which she found quite helpful. She would like a prescription for this medication. How would you respond to this request? A. Describe to her that although benzodiazepines can help reduce anxiety symptoms acutely that they are not in fact first line treatment. They can best be used as an adjunct to the first line SSRI while waiting for these to become effective B. Give her a prescription for ativan 0.5 mg bid for one month and follow up at that time to reassess C. Reinforce with her that benzodiazepines are the best way of dealing with panic attacks and give her a prescription of ativan 1 mg bid prn to be used as soon as she experiences symptoms so that she never needs to experience the trauma of a full blown panic attack again. You give her a prescription for escitalopram 10 mg daily and lorazepam 0.5 mg bid for one week at which point you will follow up with her. Which of the following side effects should you discuss with her in regards to the lorazepam? A. This medication can cause drowsiness and incoordination. Longer term use will lead to dependence. B. The most common side effects are weight gain and sedation C. The most common side effects are drowsiness and orthostatic hypotension D. The most common side effects are restlessness, nausea, diarrhea and sexual dysfunction E. This medication can rarely cause a serious rash and must be adjusted upwards slowly CDMQ 3 • A forty five year old woman with a history of multiple previous psychiatric hospitalizations is brought in to hospital by police • They were called by her mother who says she has been calling at all hours of the day and night, very upset and talking really quickly. She has been borrowing large sums of money which her mother later found out she used to gamble, which is out of character for her. Tonight she showed up at her mother’s home and was yelling in the street that her father was a menace to society and she would save everyone by killing him. • In the emergency room, she is irritable, crying and cannot sit still. She is speaking so quickly that it is difficult to follow what she is saying. She describes her mood as depressed. She admits she has not been eating well in a few weeks and feels so worthless that she has been thinking about killing herself. Which of the following is the most accurate description of her current episode? A. Major depressive episode B. Bipolar affective disorder, current episode depressed C. Bipolar affective disorder, current episode manic D. Bipolar affective disorder, current episode mixed E. Borderline personality disorder You decide to start a mood stabilizer; she tells you that she has had a bad reaction with one of these medications in the past where she had to pee a lot and her sodium level was really high. Which of the following most likely caused this? A. Lamotrigine/Lamictal B. Valproic acid/Epival C. Quetiapine/Seroquel D. Risperidone/Risperdal E. Lithium You decide to start Quetiapine as well as standard admission prn medication, given her significant agitation and recent threats of violence. You are called by nursing staff in the middle of the night to inform you that the patient is acutely distressed, with her head arched back and her tongue protruding. What is the best treatment for this condition? A. Haloperidol/Haldol 10 mg IM STAT B. Lorazepam/Ativan 2 mg IM STAT C. Propranolol 20 mg PO tid D. Benztropine/Cogentin 2 mg PO bid E. Benztropine/Cogentin 2 mg IM STAT CDMQ 4 • A 70 y.o. man reluctantly attends your family medicine clinic with his daughter. She is concerned as he has not been getting out for the last few months and has lost a lot of weight, about 20 lbs. She continues to invite him to spend time with her and her family but he has recently been declining, preferring to stay home and do nothing. He seems tired and sad all of the time. • When you see him, you note that he moves and speaks more slowly than he did in the past . • When you ask him if he feels that he may be ill, he responds that he knows that he is being punished for having shoplifted once when he was a teenager and that he deserves to feel this way. Which of the following would be the best treatment for this condition? A. Start Citalopram/Celexa 20 mg daily B. Start Seroquel XR/Quetiapine 100 mg qhs C. Start both A&B simultaneously D. ECT/electroconvulsive therapy E. Start Donepezil/Aricept 5 mg qhs You continue to follow up with this patient after he is in complete remission from his depression. Which of the following conditions will he be at increased risk for in follow up given his late presentation with depression? A. Delirium B. Schizophrenia C. Dementia D. Panic disorder E. Borderline personality disorder Over the next few years, he gradually begins to complain of memory deficits, shows evidence of word finding problems and now requires assistance with grocery shopping and paying his bills. His MMSE score has dropped from 30 to 23 during this time period. Which of the following treatments would be most appropriate? A. Start Citalopram/Celexa 20 mg daily B. Start Seroquel XR/Quetiapine 100 mg qhs C. Start both A&B simultaneously D. ECT/electroconvulsive therapy E. Start Donepezil/Aricept 5 mg qhs THANK YOU! GOOD LUCK