What is the drug class of choice for treating anorexia and bulimia?
Selective serotonin reuptake inhibitors
What are the three first-line drug classes for the treatment of anxiety?
Selective serotonin reuptake inhibitors, benzodiazepines, and buspirone
What are the three first-line drugs (all mood stabilizers) for the treatment of bipolar disorder?
Lithium, valproic acid, and carbamazepine; atypical antipsychotics can also be used
What are the three first-line drug classes for the treatment of depression?
Serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, and tricyclic antidepressants
A patient presents with depressed mood, decreased interest, decreased appetite, and poor sleep. He reports sleeping only approximately 3 hours a night. What are two treatment options for this patient?
Trazodone and mirtazapine; both are sedating antidepressants
What two drug classes are used in the treatment of atypical depression?
Monoamine oxidase inhibitors and selective serotonin reuptake inhibitors
What drug classes are used in the treatment of panic disorder?
Selective serotonin reuptake inhibitors, tricyclic antidepressants, and benzodiazepines
What two drugs or drug types are used in the treatment of obsessive-compulsive disorder?
Selective serotonin reuptake inhibitors and clomipramine
What is the drug class of choice for the treatment of schizophrenia?
Antipsychotics; typical or atypical
What is the treatment for Tourette’s syndrome?
Antipsychotics; often haloperidol
What are the two drugs (one is a drug class) used to treat attention-deficit hyperactivity disorder?
Methylphenidate and amphetamines
A Vietnam War veteran presents with flashbacks, nightmares, and avoidance of his closet where his wife keeps his uniform. What is a treatment option for this patient?
Selective serotonin reuptake inhibitors could be used to treat his posttraumatic stress disorder
Explain the mechanism of action of methylphenidate.
It increases presynaptic norepinephrine vesicular release (like amphetamines) and is used to treat attention-deficit hyperactivity disorder
Name the typical antipsychotics
Thioridazine, haloperidol, fluphenazine, trifluoperazine, and chlorpromazine
How do antipsychotics cause galactorrhea?
Dopamine receptor antagonism releases inhibition on the prolactin-secreting cells of the pituitary
Approximately 4 weeks ago, a patient started taking a neuroleptic medication. She now states that she is unable to sit still and that she has a desire to be constantly fidgeting and moving. What adverse effect is she experiencing?
Akathisia
What adverse effect of neuroleptic medications is characterized by the inability to initiate purposeful movement?
Akinesia
What are the symptoms of acute dystonia? When does dystonia develop after use of neuroleptics?
Abnormal muscle contractions and involuntary twisting movements; it usually develops 4 hours after drug administration
Typical antipsychotics block which receptors?
D2-dopamine receptors
What extrapyramidal adverse effect of neuroleptics is irreversible?
Tardive dyskinesia
A patient presents with rigidity, myoglobinuria, autonomic instability, and hyperpyrexia after recently starting a medication for schizophrenia. What adverse effect is this patient experiencing?
Neuroleptic malignant syndrome; he should be treated with dantrolene and bromocriptine
The antimuscarinic effects of neuroleptics cause what adverse effects?
Dry mouth and constipation
The antihistamine effects of neuroleptics cause what adverse effect?
Sedation
Blockade of the α-receptors by neuroleptics cause what adverse effect?
Hypotension
What is the treatment for neuroleptic malignant syndrome?
Dopamine agonists and dantrolene
Which neuroleptics are low-potency drugs with a low incidence of neurologic adverse effects?
Thioridazine and chlorpromazine
Which neuroleptics are high-potency drugs with neurologic adverse effects?
Haloperidol, fluphenazine, and trifluoperazine
Place the following extrapyramidal adverse effects of neuroleptics in the order in which they occur: akathisia, akinesia, dystonia, tardive dyskinesia.
Dystonia (within 4 hours), akinesia (within 4 days), akathisia (within 4 weeks), and tardive dyskinesia (after 4 months)
In reference to neuroleptic malignant syndrome, what is the FEVER mnemonic?
FEVER: Fever, Encephalopathy, Vitals unstable, Elevated enzymes, Rigidity of muscles
Which two neuroleptics cause ocular adverse effects?
Thioridazine causes retinal deposits whereas chlorpromazine causes corneal deposits
What is the reason for the long half-life of neuroleptics?
They are highly lipid soluble, so there is a large volume of distribution; therefore, it takes a long time for them to be removed from the body
Name the atypical antipsychotics.
Clozapine, olanzapine, and risperidone
A patient on haloperidol experiences torticollis and tremor. What is an alternative treatment option?
Atypical antipsychotics, because these drugs have a lower risk of extrapyramidal symptoms
What blood tests do patients need if they are taking clozapine?
They need periodic complete blood cell tests since clozapine can cause agranulocytosis
What are the indications for atypical antidepressant use?
Schizophrenia, mania, Tourette’s syndrome, and obsessive-compulsive disorder
Atypical antidepressants useful in treating _____ (positive/negative/both) types of schizophrenia symptoms.
Both
typical antipsychotics are useful only in treating positive symptoms
What is the most common adverse effect of long-term atypical antipsychotic use?
Severe weight gain, which can lead to type II diabetes
True or False? Olanzapine is contraindicated in the treatment of mania.
FALSE
olanzapine can be used to treat mania
Atypical antipsychotic medications block what type of receptors in addition to dopamine receptors?
5-hydroxytryptamine2, α, H1
Lithium is primarily used to treat patients with what psychiatric diagnosis?
Bipolar disorder
A patient with a history of bipolar disorder, controlled with lithium, presents with massively increased urination and thirst. Can this patient be treated with exogenous antidiuretic hormone?
No, this patient is suffering from nephrogenic diabetes insipidus secondary to lithium use, which will not respond to antidiuretic hormone
In what population is lithium absolutely contraindicated?
Pregnant women
What lab test should be ordered on a patient taking lithium who complains of lethargy, constipation, and feeling cold?
Thyroid-stimulating hormone test; lithium can cause hypothyroidism
What might be seen on an electrocardiogram of a patient taking lithium?
Electrocardiogram consistent with heart block
What are the toxicities of lithium use?
Tremor, nephrogenic diabetes insipidus, hypothyroidism, teratogenicity (remember: LMNOP to recall Lithium adverse effects, Movement [tremor], Nephrogenic diabetes insipidus, HypOthyroidism, Pregnancy problems)
What is the mechanism of action of buspirone (a psychiatric medication)?
It stimulates serotonin receptors (class 1A receptors)
What is buspirone used for clinically?
Anxiolysis; it is commonly used to treat generalized anxiety disorder
What adverse effects are avoided with use of buspirone?
Sedation, addiction, and tolerance, which are seen with benzodiazepines and barbiturates
True or False? Patients treated with buspirone must avoid alcohol.
FALSE
buspirone does not interact with alcohol, but most other treatments for anxiety (eg, barbiturates, benzodiazepines) do
Do monoamine oxidase inhibitors work on noradrenergic neurons, serotonergic neurons or both?
Both
Both tricyclics and maprotiline act on which type of neuron?
Noradrenergic
Selective serotonin reuptake inhibitors and trazodone act on which type of neuron?
Serotonergic
Mirtazapine acts on what type of neuron and specifically, which receptor on that neuron?
Noradrenergic neuron; α2 receptor
Name the tricyclic antidepressants.
Imipramine, amitriptyline, desipramine, nortriptyline, clomipramine, doxepin, and amoxapine
A 17-year-old male presents with nocturnal bedwetting. What antidepressant is a treatment option for this patient?
Imipramine
Which tricyclic antidepressant is specifically indicated for obsessive-compulsive disorder?
Clomipramine
What are the major toxicities of tricyclic antidepressant overdose?
Convulsions, coma, and cadiotoxicity (remember: Tri-C’s: Convulsions, Coma, Cardiotoxicity [arrhythmias])
An elderly patient presents to the emergency room with delirium associated with hallucinations of her deceased husband. She recently started a new drug for depression. What could cause her presentation?
The anticholinergic effects of her depression treatment (tricyclic antidepressant)
Tricyclic antidepressants block the reuptake of what two neurotransmitters?
Serotonin and norepinephrine
What is the least sedating tricyclic antidepressant?
Desipramine
What adverse effects of tricyclic antidepressants are the result of anticholinergic action?
Tachycardia and urinary retention
What tricyclic antidepressant should be used in the elderly to treat depression, to lessen the chances of anticholinergic adverse effects?
Nortriptyline
How is tricyclic antidepressant toxicity treated?
Intravenous NaHCO3 to prevent cardiac arrhythmias
Name the selective serotonin reuptake inhibitors.
Fluoxetine, sertraline, paroxetine, and citalopram
Selective serotonin reuptake inhibitors are indicated in the treatment of which conditions?
Obsessive-compulsive disorder, bulimia, social phobias, and depression
It normally takes how many weeks for an antidepressant to show some clinical benefit?
2-3 weeks
What are the common adverse effects of selective serotonin reuptake inhibitors?
Gastrointestinal upset, sexual adverse effects
A patient on treatment for depression presents with a temperature of 105° F and rigidity. What is the treatment for this condition?
Cyproheptadine, a serotonin receptor antagonist
Which sexual side-effect is seen with selective serotonin reuptake inhibitors?
Anorgasmia, the inability to have an orgasm
If a person is taking both a selective serotonin reuptake inhibitor and a monoamine oxidase inhibitor, what is the potential serious adverse effect?
Serotonin syndrome (muscle rigidity, hyperthermia, and cardiovascular collapse)
Name two serotonin-norepinephrine reuptake inhibitors.
Venlafaxine, duloxetine
What effects do serotonin-norepinephrine reuptake inhibitors have on neurons?
Inhibition of serotonin and norepinephrine reuptake
What are the indications for venlafaxine?
Depression and generalized anxiety disorder
What are the indications for duloxetine?
Depression and diabetic peripheral neuropathy
What are the adverse effects of serotonin-norepinephrine reuptake inhibitors?
Increased blood pressure, sedation, nausea
Name the monoamine oxidase inhibitors.
Phenelzine and tranylcypromine
Which drugs must be avoided while taking monoamine oxidase inhibitors to prevent a hypertensive crisis?
α-Adrenergic agonists
What is the mechanism of action of monoamine oxidase inhibitors?
Inhibition of monoamine oxidase prevents breakdown of neurotransmitters
To prevent serotonin syndrome, patients should avoid which drugs while taking monoamine oxidase inhibitors?
Selective serotonin reuptake inhibitors and meperidine
What psychiatric disorders are monoamine oxidase inhibitors used to treat?
Atypical depression, anxiety, hypochondriasis
What foods must be avoided while on monoamine oxidase inhibitors? Why?
Wine and cheese
wine and cheese are high in tyramine that can lead to hypertensive crisis if ingested while taking monoamine oxidase inhibitors
Which heterocyclic antidepressant is also used in smoking cessation programs?
Bupropion
True or False? Sexual adverse effects are major adverse effects of bupropion.
FALSE
bupropion is the one heterocyclic antidepressant that does not cause sexual adverse effects
Maprotiline, a heterocyclic antidepressant, blocks the reuptake of what substance?
Norepinephrine
A patient presents with priapism after starting an antidepressant medication for insomnia and depression. What medication is this patient taking?
Trazodone, which is a heterocyclic antidepressant
Bupropion is contraindicated in what patients?
Patients with bulimia or history of seizure disorders
Why might a patient complaining of sedation with a prior antidepressant be prescribed bupropion?
Bupropion may cause insomnia
What neurotransmitter receptors are blocked by mirtazapine?
An a2 - and serotonin antagonist
What are the adverse effects of mirtazapine?
Sedation, increased appetite, weight gain, dry mouth
What effect does trazodone have on neurons?
Inhibits serotonin reuptake
What are the adverse effects of maprotiline?
Sedation, orthostatic hypotension
Which antidepressant is commonly used for insomnia?
Trazodone
What are the adverse effects of trazodone?
Sedation, nausea, priapism, postural hypotension
