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PSYCH EOR 18%; 14%; 12%; 10%; 8%; 4%

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Depressive Disorders; Bipolar 18% Disorder About Bipolar I/II •Mania: abnormal or persistently elevated, expansive or irritable mood for at least 1 WEEK

Criteria Bipolar I: 1+ full manic or mixed episode and occasional depressive

Treatment •1st line-Lithium •Others: Carbamazepine, Valproic Acid

•Hypomania: mania sx for 4 DAYS; no impairment •Mixed: criteria for one and 3+ sx of other •Rapid: 4+ ep/yr

Bipolar II: 1+ MDD and 1+ hypomania episode

Cyclothymi c

•Similar to bipolar II but less severe •Gender: men=women

2+ YEARS of hypomania and depressive symptoms (no more than 2 free consecutive months)

•Mood stabilizers (Lithium) and neuroepileptics

Major Depressive Disorder (MDD)

Risks: •FHX, female, 20-40yo

2+ WEEKS of 5+ SX must include anhedonia or depressed mood

•Psychotherapy •SSRI x3-6 weeks

Screen: •PhQ2 � PhQ9 •Zung Self-Rated

•Somatic SX: constipation, HA, skin changes, chest or abdominal pain, cough, dyspnea

Pathophys: •Alteration in neurotransmitters serotonin, epi, norepi, dopamine, ach, histamine •Neuroendocrine dysfunction (adrenal, thyroid, GH) Persistent Depressive Disorder (Dysthymia)

•Patients are usually able to function •No SX of hypomania, mania, or psychotic features

Persistently depressed for 2+ YEARS with 2+ symptoms (no more than 2 consecutive free months)

•SSRI and therapy

•MC in women and teens/early adulthood

MDD Subtypes: Seasonal: depressive sx at the same time each year, MC winter - TX: SSRI, light therapy, Bupropion Atypical: mood reactivity with depression (improve in response to positive events) - TX: MAOI Inhibitors (A/B: Nardil, Parnate, Marplan; B only: Selegiline) Melancholia: anhedonia (inability to find pleasure in things), lack of mood reactivity, depression, severe weight loss/loss of appetite, excessive guilt, psychomotor agitation, or retardation & sleep disturbance (increased REM time and reduced sleep). Sleep disturbances may lead to early morning awakening or mood that is worse in the morning Catatonic: motor immobility, stupor, extreme withdrawal

Anxiety; Trauma; Stress 18% Disorder About & Criteria General Excessive anxiety or worry a majority of days for 6+ months with 3+ symptoms Anxiety Disorder (GAD) Panic Attacks/ Disorder

PostTraumatic Stress Disorder (PTSD)

Symptoms •restless/on edge •fatigue •difficulty concentrating

•irritable •sleep disturbance •muscle tension

Physical Symptoms: Panic Attacks: •Episode of intense fear or discomfort that develops •dizzy, trembling, choking, paresthesias, sweating, SOB, CP, abruptly; usually peaks within 10min, last quetiapine, risperidone > aripiprazole, ziprasidone brexpiprazole, cariprazine

Glycemic Abnormalities

Clozapine olanzapine

Dyslipidemia

Low-potency typicals Quetiapine Clozapine & Olanzapine

Overall Metabolic Syndrome

clozapine, olanzapine > quetiapine, low potency> aripiprazole, ziprasidone, brexpiprazole, cariprazine, high

Acne Hirsutism Infertility

Typical (1st Gen; + sx) Low Potency “Thor and Thio” Thioridazine (Mellaril) Chlorpromazine (Thorazine) Prochlorperazine (Compazine)

Blurred vision Cognitive impairment

High Potency “Halo’s Compromize” Haloperidol (Haldol)

Psudoparkinsonism Akathisia Orthostatic hypotension

Dystonia Tardive Dyskinesia *MC elderly, HTN, cardiovascular disease

Neutropenia Agranulocytosis

*CBC weekly x6mo, biweekly x6mo, then mo.

Atypical (2nd Gen; +/-sx) “ABCC ROQZ” Clozapine (Clozaril) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Risperidone (Risperidal) Aripiprazole (Abilify) Brexipiprazole (Rexulti) Cariprazine (Vraylar) “-pine, done, zole + Cariprazine”

Lower seizure threshold

Prolonged ventricular repolarization (long QT)

*dose dependent

Positive s/s respond well to antipsychotics Negative s/s respond better to atypical Before treatment, screen for: ● BMI, waist circumference, HR, BP, EKG, movement disorder, CBC, CMP, lipids, TFTs

Insulin resistance DKA Increased glucose Especially elevated triglycerides

Therapeutic lag of about 4-6 weeks -> minimum of 6 weeks trial per drug as long as no adverse SE -No high-dose therapy until 6wk

potency typicals Side Effects: - Neuroleptic Malignant Syndrome (NMS): life threatening disorder due to D2 inhibition in basal ganglia � mental status changes, extreme muscle rigidity, tremor, autonomic instability (tachycardia, tachypnea, fever), diaphoresis, incontinence � Treatment: stop offending agent (MC with typical antipsychotics) Typicals: Hyperprolactinemia

Olanzapine “all except SHEAA” *all except arrhythmia, extrapyramidal, hypotension, agranulocytosis, and seizure ● Hyperprolactinemia ● Anticholinergic ● Sedation ● Weight gain ● Glycemic abnormalities ● Dyslipidemia ● Overall metabolic syndrome

High-Potency Typicals (Haloperidol) “DASSH” *intermediate for metabolic syndrome ● Anticholinergic ● Sedation ● Hypotension ● Seizure ● Dyslipidemia Low potency Typical (Thorazine, Thioridazine, Compazine) “EXTRA HIGH” ● Extrapyramidal Symptoms Risperidone (Atypical) ● Hyperprolactinemia & Hypotension Cardiac arrhythmia “TZ” ● thioridazine, ziprasidone ANXIETY PHARM Drug MOA Enhance GABA Benzodiazepines at receptor Short: -Midazolam -Triazolam Long: -Diazepam -Flurazepam -Chlordiazepoxide

Indication •Anxiety, panic •insomnia, •ETOH withdrawal •agitation •seizure •procedural sedation

Clozapine “all except HEAr” *only one to cause agranulocytosis *all except arrhythmia, hyperprolactinemia, and extrapyramidal Quetiapine “DHS” *intermediate for weight gain and metabolic syndrome ● Sedation ● Hypotension ● Dyslipidemia

Side effects •Drowsiness •dizziness •decreased motor coordination •decreased libido •disinhibition •rebound anxiety, SI

DDI •ETOH •Opioids •CNS depressants •Anticonvulsants •antidepressants •antifungal

CI •Pregnancy •Allergy •Myasthenia gravis •Glaucoma

Rare: respiratory depression

Buspirone

•5HT-1a receptor agonist •dopamine receptors

Anxiety

•Dizziness •Drowsiness, nausea, HA •Serotonin Syndrome

•Other Psych meds •CNS depressants

Allergy

Hydroxyzine (Vistaril, Atarax)

Histamine receptor antagonist

•Anxiety •muscle relax •antihistamine •antiemetic •insomnia

•Drowsiness •dizziness •dry mouth •rash •respiratory depression

•Potassium •MAOIs •CNS depressants

Allergy 1st trimester prego *only use po route

DEPRESSION PHARM Depression MOA SSRIs Selectively decreased FIRST LINE action of 5-HT reuptake

CI •Allergy •MOAI w/n 2 weeks *Fluoxetine 5wks

Side effects •N/D, anorexia •Sleep changes, HA, anxiety, dizziness •Decreased libido, anorgasmia, ED •Prolonged QT, WT gain, bleeding •Serotonin syndrome, increased SI

Differences •Sertraline: diarrhea, less QT, drowsy •Citalopram/Escitalopram: more QT, least liver •Fluvoxamine: shorted t ½ and CYP •Fluoxetine: long t ½ and don’t use with Tamoxifen •Paroxetine: anticholingeric SE, CYP, don’t use with Tamoxifen *panic disorders 1st line

•Venlafaxine: high SE, elevated BP •Desvenlafaxine: less HTN •Cymbalata: least associated with BP •Milnacipran/Levomilnacipran: anticholinergic SE

SNRIs 2nd line if cant tolerate SSRIs

Block reuptake of 5-HT and NE (Milnacipran and Levomilnacipran greater)

•Allergy •MOAI w/n 2 weeks •Angle closure glaucoma

•N/D/V, constipation, dry mouth •Sleep changes, HA, anxiety, dizziness •Decreased libido, anorgasmia, ED •Diaphoresis, HTN, SS syndrome •LESS SEX and NO WEIGHT GAIN!

Atypicals Buproprion Remeron

Buproprion: dopamine and NE reuptake inhibitor

•Buproprion:, seizure, anoremia, MAOI 2 weeks

Buproprion: *NO WT GAIN OR SEX •dry mouth, insomnia, nausea •seizures, tobacco cessation

•Remeron: MAOI 2 wks Remeron: antagonizes alpha-2 and 5-HT2/3

Serotonin Modulators

Nefazadone/Trazadone: Antagonize 5-HT

Remeron: •dry mouth, drowsiness, sex dysfunction •wt gain, increased appetite

•Allergy •MOAI w/n 2 weeks

HA, N/D, SI risk, serotonin syndrome *with initiation and increase in dose

Vilazadone/ Vortioxetine: Partial agonist 5-HT

MAOIs Parnate Nardil Marplan Selegiline

TCAs

TeCAs Ludiomil Asendin

MAOa: Break down serotonin and NE MAOb: Break down dopamine

Inhibits reuptake of 5-HT and NE

•Ludiomil: block NE & 5-HT •Asendin: blocks NE, dopamine

•Nefazadone: BBW-hepatotoxicity ● Drowsiness, xerostomia, hypotension •Trazadone: SEDATION, dry mouth, WT NEUTRAL ● Rare: priapism, cardiac arrhythmia •Vialazdone/Vortioxetine: N/V/C/D, sex dysfunction ● Faster onset and less sexual dysfunction

•Allergy •Serotonin w/n 2 weeks •Cardiovascular •Pehochromocytoma •Hepatic/renal

*MANY DDI INTERACTIONS •hypotension •GI, urinary hesitancy •HA, myoclonic jerks •edema •Hypertensive crisis-foods with tyramine

Selegiline (Eldepryl): low doses for Parkinsons ● Less CI than other MAOIs ● Less hypertensive crisis with transdermal

•Allergy •MOAI w/n 2 weeks •Acute recovery of MI

•Anticholinergic, drowsiness, sweating •sexual dysfunction, wt gain & appetite •tremor, OD fatality •Cardiotoxicity (QT)

Nortiptyline and Desipramine: highest tolerability

•Less anticholinergic and more antihistaminic than TCAs •SI risk

*have extra cyclic ring *last resort, don’t ever really prescribe

Tertiary(5-HT): Amitriptyline, Doxepin, Imipramine Secondary (NE): Nortrip, Despiramine, Protriptyline

SUBSTANCE ABUSE PHARM Alcohol Chronic Use Drug

MOA

Side Effects

Dosing

•Low BP •Effect glucose metabolism

Thiamine (B1)

CI/DDI

Acute: 50-100mg IV/po Wernicke: 100mg IV 500 BID x2d, qd x5d, then 100mg Chronic: 50mg po daily

Naltrexone 1st LINE

Blocks dopamine release, antagonizes mu receptor � decreases craving and reward

BBW: hepatocellular •N/V/D/C, abd pain •dizzy, HA, anxiety, fatigue

50mg daily

CI: opioid dependency

Vivitrol: 380mg IM monthly

DDI: opioids

Acamprosate (Campral) 1st LINE

Restores glutamate � Stops withdrawal S/S

•Diarrhea, nausea, abd pain •fatigue, HA, amnesia, mood

66mg TID (333 for renal)

CI: renal (Cr 12/min

DI: “WAM” warfarin, amitriptyline, metronidazole

Side Effects

Opioid Use Treatment Dose 25-50mg daily

Side Effects BBW: hepatocellular N/V/D/C, abd pain, dizzy, HA, anxiety, fatigue

Vivitrol (IV): 380mg IM/4wks

Methadone

Long-acting opioid agonist

20-30mg po, titrate up (80-120mg)

•Constipation, drowsiness, sweating •peripheral edema, hyperalgesia •reduced libido, ED •QT prolongation, OVERDOSE

Buprenorphine

Partial agonist *take home therapy

*often in combo with Naloxone 4mg B/1mg N daily most stabile on 16-20mg/d B

•HA, nausea, pain •insomnia •withdrawal syndrome

Taper by reducing 2mg/1-2wk

Rare: liver, necrosis, anaphylaxis

Tobacco Use Treatment (Tobacco Replacement) Drug Transdermal Patch

Use Apply to skin once daily, avoid hair, change places each day

Dose >10 cig: 21 x6wk, 14 x2wk, 7 x2wk

Side Effects •Skin irritation •Insomnia, vivid dreams

10 or less cig: 14 x6wk, 7 x2wk Oral Nicotine Lozenge

DON’T CHEW

Smoke w/n 30 min: 4mg All others: 2mg

•Mouth irritation •N/V/D •palpitations •HA, insomnia

Max: 5 every 6hrs or 20/day Oral Nicotine Gum

Diminishes withdrawal “chew and park” method

Nicotine Inhaler

Absorbs through mucosa Satisfies behavioral & sensory cravings

25+ cigs: 4mg all others: 2mg

6-16 cartridges/d for 6-12 wk

•N/V/D, HA •excess salivation •mouth irritation *avoid TMJ, poor dentition, dental appliances Oropharynx irritation, bronchospasm *avoid RAD (asthma)

Nicotine Nasal Spray

Absorbed through nasal mucosa

1-2 sprays/3mo Max: 10 sprays/hr or 80/day

•Nasal and throat irritation •sneezing, tearing

Tobacco Use Treatment (Pharmacological) Drug Buproprion (Wellbutrin)

MOA Blocks dopamine and NE reuptake Antagonizes nicotinic rec.

Dose 150mg/d x3d, 150mg BID x12wk

Side Effects •Insomnia, agitation •dry mouth, HA

*start 1wk before quite date •CI: Epilepsy, seizure, h/o anorexia/bulimia Varenicline (Chantix)

Partial agonist of nicotinic rec. -Decreases withdrawal -Interferes with reward

0.5mg x3d, 0.5mg BID x4d, 1mg BID x12wk *start 1wk before quite date

•Vivid dreams •nausea, insomnia •syncope Serious: neuropsych (SI, mood, behavior)

ADHD PHARM Stimulants

MOA

Route

SE

CI

Methylphenidate (Ritalin, Focalin, Concerta, Quillichew, Methylin) Amphetamines (Vyvanse, Adderall)

Blocks catecholamine reuptake *NE, dopamine � increases intrasynpatic levels

IR and ER Daytrana is a transdermal patch *USE IN PRESCHOOLERS

•less weight loss •priapism

Blocks catecholamine reuptake *NE, dopamine; increases dopamine release � increases intrasynpatic levels

IR and ER Vyvanse is a prodrug of dextroamphetamine *activated from oral ingestion

•may be slightly more effective •more weight loss

*don’t use within 14 days of MAOI

Non-Stimulants Atomoxetine (Strattera)

MOA Selective NE reuptake inhibitor *not controlled

Route PO, QD, BD Delay of 1-2wks for efficacy

Uses •If stimulants can’t be used *not first line •Intolerable to stimulates, desire to avoid stimulants, h/o tic disorder, risk of abuse

Side Effects •GI: decreased appetite, N/V, abdominal pain, dyspepsia, wt loss •CV: rare, increased BP and HR •Priapism •Liver injury •Neuro/Psych: psychosis, SI thoughts, tics

CI •Allergy •2wk of MAOI •Glaucoma •Pheochromocytoma •CV Disease

XR Clonidine (Kapvay) a-Adrenergic 3rd line

Stimulates alpha-2 adrenergic receptors

PO, BID *taper if DC

Fail to respond to or cannot tolerate stimulates or atomoxetine

•Sedating *helpful if agitate, aggressive, active •offset of stimulant SE •depression, HA •bradycardia, low BP

Hypersensitivity

PO, QD *taper if DC

Improve ADHD symptoms Fewer SE than Clonidine

•Sedation, fatigue •HA •Abdominal pain

Hypersensitivity

XR Guanfacine (Intuniv) a-Adrenergic

NON-PHARM ● Behavioral : preferred in preschool ADHD; adjunct for older children and teens; helps improve parent-child relationship o Daily schedule, chart/checklists, minimal distractions, limiting choices for them, specific/logical storage places, reward, calm disciplines ● Cognitive Therapy: NOT recommended as monotherapy, may be an adjunct for pts with comorbid psych disorders ● Dietary Modifications (limited evidence): elimination diets, fatty acid sup; megavitamins, chelation, detox, herbal or mineral supplement PHARMACOTHERAPY-STIMULANTS *FIRST LINE children 6yo+ with functional impairment; can use for all ages **SCHEDULE II-potential for abuse ● Dosing: start at low dose, gradually tirate up; adjust dosing schedule based on symptom and activing; dosing holidays for weekends/vacations ● Common SE: reduced appetite, insomnia/nightmares, on-edge or jittery, emotional, wt loss/decreased ht, tics; *mild and correctable ● Less common SE: increased HR and BP, palpitations, raynauds, priapism (RARE), HA, dizziness, N/V/D, psychotic, manic, diversion or misuse (BIGGEST!) ● CI: allergy, h/o substance abuse, hyperthyroidism, glaucoma, cardio disease, tics/Tourette, agitated, anxiety ANTIDEPRESSANTS: *4th line therapy TCAs: ● SE: cardiotoxicity (consult!) ● Helpful in children with comorbid mood disorders Bupropion (Wellbutrin) *4th line therapy; not extensively studied ● MOA: Blocks reuptake of NE and dopamine ● Reduces aggressive, hyperactivity ● SE: insomnia, anorexia, tics, seizures...