Wednesday, February 29, 2012

Psychiatric Disorders and Pharmacology

Mood Disorders 
Major Depression (MD)
  • Theories of Cause 
      1. o Genetic: Genes play role but must interact w/environment to develop MD 
      2. o Biochemical: Initially thought path dysfunction of serotonin (regs sleep, appetite, libido) and norepi (energy, pleasure, concentration) cause; But prob also i/c dopamine, Ach, Gaba; Also probably not sole cause 
      3. o Hormonal regulation: Hypo-Pit-Adrenal path malfunction →↑ cortisol which is often high in depressed pts 
      4. o Circadian rhythm: Most pts w/MD have loss of deep and REM sleep 
      5. o Psychodynamic: Stressors and events trigger episode if vulnerable 
      6. o Cognitive: Experience teaches negative thoughts which depression; Three learned thoughts responsible: 1) Negative self view, 2) Pessimistic view of world, 3) No hope for future 
      7. o Learned Helplessness: Normal anxiety is replaced by depression as person learns they have no control over situations; Popular modern theory that believes remedy is teaching coping skills and self confidence (i.e. groups) 
  • Facts: *Pt presents w/history of one or more major depressive events and NO manic/hypomanic episodes; *s/s represent a change in usual behavior (slight difference from dysthymia); *Usually have more than one episode in life; *Not verbally mediated; *One episode means meds for life 
  • DX: 5 or more of following occur daily for 2 wks: 1) Depressed mood most of day, 2) Anhedonia, 3) Wt loss (5% in month), 4) Insomnia/hypersomnia, 5) or motor activity, 6) Anergia, 7) Feel worthless or guilty, 8) indecisive or concentration, 9) Death/suicide thoughts 
  • Subtypes: MD may include following features: Psychotic (halluc/delusions), Catatonic (echo, strange movement), Melancholic (wt, early morn wake), Postpartum onset (4 wks PP), Seasonal (winter), Atypical (wt, oversleep) 
  • NX: Severe vegetative (∆ in activity necessary to support life) s/s include: severe wt, psychomotor retard, early morn waking, libido; Main NX DX suicide risk after few days on meds during cycle out, coping, self carev Monitor sleep, wt/eating, bowel movements; Expect withdrawn behavior; Usual TX for MD is Cognitive behavior therapy and ECT (NPO 6hr prior; remove contacts, dentures; Give premeds 30 min prior)
Dysthymia
  • Facts: S/S represent usual behavior for 2 yrs; Less severe low, verbal mediate 
  • DX: 2 or more of: 1) or appetite (often ), 2) or sleep, 3) Anergia, 4)self-esteem, 5) Poor concentration/decision making, 6) hopelessness 
Bipolar Disorders
  • Facts: Chronic, recurrent shifts in mood, energy, and functioning; Severe mortality w/highest suicide rate of all Psych illnesses; Often starts at 20 yrs; Probable genetic influence as bipolar pts often have bipolar relatives 
  • Type 1: At least one Manic episode alternating with MD 
  • Type 2: At least one Hypomanic episode alternating with MD (often OCD) 
  • Cyclothymia: Hypomanic episode alternates with minor depression (2 yrs) 
  • Psychotic: Severely impaired mental state w/hallucination, delusion, and/or personality ∆, w/disorganized thought and loss of touch w/reality; Emergency! 
  • Mania: impairment in activity/relationships; TX needed to avoid harm to self/others; Psychotic features; S/S not due to drugs/disease 
  • Hypomania: ∆ in functioning/mood that is not ordinary for pt and can be observed by others, no impairment socially, S/S not due to drugs/disease, TX not an emergency 
  • Bipolar DX: Distinct abnormal/persistent in mood for 4 d (hypo) or 1 wk (mania), AND 3 or more of: 1) Grandiosity, 2) need for sleep (rested w/3 hrs), 3) need to be talkative, 4) Flight of ideas, 5) Distractible, 6) goal-directed activity, 7) need for unhealthy living ( spending, sex) 
  • Bipolar episodes: Mixed ( and daily for 1 wk); Rapid Cycling (4 or more episodes in 1 yr); Regular (at least 1 manic episode w/depression) 
  • Mental Status Exam: Depending upon manic () vs depressed () will show: Appearance ( bizarre dress, frequent ∆; poor hygiene); Speech ( flight of ideas, rapid; retarded); Thought ( grandiose, distracted; hope/helpless); Affect ( labile; flat/dull); Psychomotor ( hyper; retarded); Delusions ( grandeur, bizarre; negative triad); Hallucinations (any in both states) 
  • NX: Don’t let make big decision when or ; Extreme risk of self harm; Electroconvulsive therapy possible (for psychotic depression); Sleep therapy; Distractibility can be used positively during interventions; environmental stimulus (such as neutral colored rooms, coordinated accessories) 
Mood Disorder Pharmacology 
Antidepressants (MD pts)
  • Facts: All but MAOI block reuptake of serotonin and sometimes norepi making more available in synapse ( mood, alert, concentration); Can be given once a day, but often has 3-4 wk time to therapeutic effectiveness 
  • Indications for use: Recurrent depression, Psychomotor retardation, Depression w/no clear cause, Family Hx, Chronic pain, Eneuresis 
  • Types 
    • Benzodiazepines
      • Alprazolan (Zanax): Short term only as dose needed over time
    • SSRI (selective serotonin reuptake inhibitor) 
      • SSRI S/E: Sexual depression/dysfunction, N/V/D, insomnia, anxiety, dry mouth, tremor, fatigue, H/A, toxic s/e rare 
      • NX: Never take w/MAOIs, Liver/renal/CBC test, d/c meds slow 
      • Fluoxetine (Prozac): sedation, S/E
      • Sertraline (Zoloft): toxicity in OD, S/E, halflife than Prozac 
      • Paroxetine (Paxil): Safest for elderly, Lowest halflife 
      • Fluvoxamine (Luvox) ƒ Citalopram (Celexa
      • Escitalopram oxalate (Lexapro)
    • SNRIs (Serotonin/Norepinephrine reuptake inhibitor) 
      • Pros: sex probs, insomnia, response quicker, anxiolytic like 
      • Cons: BP, Sedating, Anticholinergic s/e (constipation, sweat) 
      • Effexor (Venlafaxine): S/E: dizziness, migraine, wt gain 
      • Serzone 
      • Trazodone (Desyrel
      • Remeron: S/E: somnolence, dizzi, wt gain; Adverse: agranulocytosis, neutropenis; NX: some respond well only to this
    • Norepi/dopamine agonist 
      • Facts: Stimulant inhibits reuptake and release of Norepi/dopa 
      • Cons: seizure risk ƒ Bupropion HCl (Wellbutrin): No effect on serotonin/ MAO 
    • Tricyclics (Norepi/serotonin reuptake inhibitor + minor Ach/Hista effect 
      • Examples: Imapramine (Tofranil), Desipramine (Norpramine, Pertofrane), Amitriptyline (Elavil, Endep), Nortriptyline (Pamelor, Aventyl), Protriptyline (Vivactil), Doxepin (Sinequan)
      • S/E: Anticholinergic effects (dry mouth, constipation, urinary hesitant/retention, sweating, drowsiness, blurred vision); EPS Cardiovascular (postural BP, HR, heart conduction probs); Glaucoma worsened, Toxic confusion/psychosis; Wt gain, SZ,
      • Overdose: 1000-4000 mg can be Fatal
    • MAOIs 
      • Facts: Monoamine (epi, norepi, sero, dopa) oxidase responsible for destroying excess/used MAs; Inhibiting enzyme level of all 
      • Types: Phenelzine (Nardil), Isocarboxazide (Marplan), Tranylcypromine (Parnate)
      • CX!: Some foods contain MAs (tyramine) which if not metabolized in liver causes ↑↑ HT and CVA; Foods include aged cheese, chicken liver, beer, red wine, chocolate, cold/sinus meds, diet pills; Avoid certain restaurants (Chinese); 1o s/s is severe h/a
      • S/E: BP most critical; Orthostatic BP, dizziness, appetite 
      • Key: BP is toxic effect (wrong food); BP is med caused S/E
    • Psychostimulants 
      • Facts: Meds such as Ritalin, Dexedrine, Adderall, and Cylert can be used sparingly in depression; Block reuptake and production 


Mood Stabilizers (Bipolar 1 pts)
    • Lithium 
      1. Facts: Used in psychiatric disorders non-responsive to other meds; Blood level of 0.1-1.5 key as toxic death possible. Higher only w/psychosis; Must maintain adequate salt in diet (consistent level, not too or
      2. Indications: Acute Mania, Bipolar prophylaxis 
      3. Possible use: Bulimia, Alcohol abuse, Schizoaffective (mania or depression with schizo like delusions/hallucinations/etc) 
      4. Method of action: Replaces Na+ in many neurons but creates different resting potential, limiting speed of nerve impulse = mania/hyperactive 
      5. S/E: Major risk of hypothyroidism and urine concentration probs; Parkinson like, cog wheeling, sluggish, forgetful; Chronic N/V/D so take w/food; Wt gain, Polydypsia, Polyuria, Allergic rash w/capsules 
      6. C/I: Never take with diuretics or Anticholinergic meds 
      7. Causes of toxic levels: Na intake (more room for Li); Sweating, Illness 
    • Anticonvulsants 
      • Carbamazepine (Tegratol): Used when no response to Lithium; Better for rapid cycle Bipolar; Blood levels at 6-8 mg/l
        • S/E: Sedation, Mal coordinated, agranulocytosis, aplastic anemia so NX: monitor CBC and alert for fever/sore throat; birth defects
      • Valproate (Depakene, Depakote): Used w/manic or schizoaffective; Blood levels at 50 mg/l
        • S/E: Severe/Fatal Hepatotoxicity, platelets, neural tube defects
      • Clonazepam (Klonopin): Benzo for acute mania, acute help while waiting for Lithium effects to occur ƒ S/E: Sedation, Anoxia, Disinhibition effect
Schizophrenia 
Facts: Psychotic Disorder (other PDs are schizoaffective, delusional, induced psychosis); Drug abuse (50%), nicotine addiction (90%) common; cause of death is suicide
Theories: Dopamine, Serotonin, and Norepi elevation is suspected but no concrete proof exists; Genetics plays role (45% chance with schizo twin or schizo parents) and with environmental factors is possible cause; MRI shows enlarged ventricles
4 steps to DX: (must meet all 4 for schizo dx)
  • Characteristic S/S, active phase: 2 or more of following in 1 month period: 1) Delusions, 2) Hallucinations, 3) Unorganized speech, 4) Catatonic behavior 5) Negative symptoms 
  • IF: (bizarre delusions or auditory hallucinations) AND (continuous voices or multiple voices) is enough to satisfy first step 
  • Social Dysfunction: Marked decline in social abilities (work, relations, self-care, etc) or failure to achieve expected level in adolescence 
  • Duration: Continuous s/s for 6 months w/at least 1 month of active phase s/s 
  • Rule Outs: Other mental diseases and medical conditions have been r/o; If pt has developmental disorder then must present w/ prominent hallucinations or delusions for 1 month for schizo dx 
Symptom Groups (which ones are present varies between individuals)
    • Positive
      1. Acute onset, Normal CT/neuro tests, Good response to antipsychotic meds 
      2. Types: Hallucinations, Delusions, Unorganized speech, bizarre behavior, Ideas of reference delusions (others are plotting against me) 
    • Negative
      1. Insidious onset, CT shows atrophy, abnormal neuropsychological tests, Poor response to antipsych meds, More destructive than positive s/s 
      2. Types: Blunt affect, Poverty of thought (alogia), motivation (avolition), Inability to experience pleasure (anhedonia) 
    • Cognitive: Inattentive, Distractible, Poor memory/problem solving/decisions, Illogical thinking, Impaired judgement, Can’t name familiar objects 
    • Mood: Dysphoria, Suicidal, Hopelessness 
Subtypes: Paranoid, Catatonic, Disorganized, Undifferentiated, Residual
Course of Disease: Prodromal s/s may appear up to 1 yr prior to first psychotic break
and include withdrawal, lonely, depressed, unrealistic future plans; Early phase s/s include anxiety, phobias, obsessions, compulsions, concentration/schoolwork probs 
NX: For auditory hallucinations, pt should tell voices to go away; for poisoning suspicion the nurse can taste food in pts presence,
Schizophrenia Pharmacology 
Facts
  • Inhibit neurotransmitters dopa, serotonin, norepi, histamine to psychosis 
  • S/E: Dop antagonist (parkinsonism, akinesia, akathisia, dyskinesia; (↑prolactin/amen/galactorhea) ACH antag (Blurred Vision, dry mouth, constipation, urinary hesitancy) Norepi antag (orthostatic hypotension, ejaculation probs) Hist antag (wt gain, sedate); Atropine Psychosis (Dry, Fever, Confused, Diplopia)
Atypical Antipsychotics:
  • Facts: Target (+) and (-) schizo signs w/few S/E b/c Dop antag only in limbic 
  • Olanzapine: S/E wt gain, CHO, DM 2 (best at improving cognition) 
  • Clozapine (Clozaril) S/E can be WBC so NX CBC weekly for 6mos; S/E: sedation, salivate, tachycard, dizzi; b/c of effects NOT 1st CHOICE 
  • Risperidone (Risperdol) Does not WBC but at dose just above normal causes motor probs; S/E: Sedates, orthohypo, wt gain, sex probs, CVAs; Only Atypical available in Depot Form (oil based time released SQ) 
  • Quetiapine (Seroquel) Broad antagonist especially Norepi/Hist (see S/E in 1st gen); Very few extrapyramidal symptoms (movement probs) 
  • Ziprasidone/Geodon (sero/norepi reuptake inhibitor; s/e BP, QT interval so fatal with arrhythmias, EKG and K/Mg test prior to Rx) 
  • Aripiprazole/Abilify ( dopa levels where high and dopa levels where low, s/e sedate, BP, anticholinergic) 
Traditional Antipsychotics
  • Facts: Pros: Cheap, Depot form (oil based time released SQ) Cons:Dopa receptor block in limbic/motor areas which can cause severe EPS s/e! 
    • EPS: extrapyramidal s/s: Akisthesia (restless feet), Dystonia (muscle spasm), Akinesia (heavy limbs), Parkinson like, Tardive dyskinesia (face muscle spasms) 
    • o Anti-EPS: Common meds for EPS tx are Benadryl, Cogentin, Artane
    • Common Types (Phenothiazines except Haldol, a Butyrophene) 
      • Haloperidol (Haldol): sedation, doses used to aggressive behavior,  risk of EPS, hallucinations, hypotension risk, used w/elderly
      • Chlorpromazine (Thorazine): sedation, hypotension risk, EPS risk 
      • Thiorizidine (Mellaril): Severe ECG ∆s, sudden death, Last resort med 
      • Trifluoperazine (Stelazine): low sedation, used with withdrawal/paranoia 
      • Fluphenazine (Prolixin): Very little sedation 

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