Mental Health

Schizophrenia: Positive symptoms

hallucinations, delusions, paranoia, disordered thinking

Schizophrenia: Negative symptoms

social withdrawal, poor judgment, poor self-care

Schizophrenia: Cognitive symptoms

inability to focus attention, learning and memory difficulty

What is the duration of symptoms required for Schizophrenia diagnosis (Criteria A)?

Symptoms must be present for at least 1 month

What are the key symptoms under Criteria A for Schizophrenia?

Delusions, Hallucinations, Disorganized Speech

What additional symptom is required for a Schizophrenia diagnosis, aside from delusions, hallucinations, and disorganized speech?

Presence of negative symptoms (e.g., social withdrawal)

What type of abnormal behavior is included in the diagnosis of Schizophrenia?

Grossly abnormal psychomotor behavior (e.g., catatonia)

What is the minimum duration for negative symptoms in Schizophrenia diagnosis?

Negative symptoms must be present for at least 6 months

What must be ruled out in the diagnosis of Schizophrenia?

Symptoms should not be related to drug abuse or a medical disorder

What functional impairments are associated with Schizophrenia?

Social/Occupational Dysfunction must be present

What are the three major objectives of Schizophrenia drug therapy?

suppression of acute episodes, prevention of acute exacerbations, maintenance of the highest possible level of functioning

How is the dosing for Schizophrenia drug therapy determined?

Dosing is highly individualized based on the patient’s needs

What is important about dosing for older adult patients with Schizophrenia?

Older adult patients require relatively small doses

How does dosing change over the course of Schizophrenia therapy?

The size and timing of the doses are likely to be changed over the course of therapy.

What is key to improving treatment adherence in Schizophrenia?

establish a good therapeutic relationship with the patient, ensure medication is taken by developing a plan

What instructions should be provided to the patient regarding antipsychotic medication?

inform patient and family that antipsychotics must be taken on a regular schedule, explain potential side effects, reassure that antipsychotic medication use does not lead to addiction

What are some non-medication therapies for Schizophrenia?

Counseling for the patient and family, behavioral therapy, vocational training

How are first-generation antipsychotic agents classified? Low potency

chlorpromazine HCl (Thorazine)

How are first-generation antipsychotic agents classified? medium potency

loxapine (loxitane)

How are first-generation antipsychotic agents classified? high potency

haloperidol (Haldol)

How do first-generation antipsychotic agents work in the brain?

They block dopamine receptors in the mesolimbic area of the brain

What serious movement disorders can first-generation antipsychotic agents cause?

Extrapyramidal symptoms (EPS): Acute dystonia, Parkinsonism, Tardive dyskinesia

What is acute dystonia and when does it develop?

develops within hours or days of the first dose, it involves severe muscle spasms of the tongue, face, neck, or back (can impair respiration), includes involuntary upward deviation of the eyes

What are the symptoms of Parkinsonism caused by first-generation antipsychotics?

Mask-like face, Drooling, Tremor, Shuffling gait

What is tardive dyskinesia?

involves twisting movements of the tongue and face, including:

• Fly-catcher tongue

• Lip-smacking

What are some anticholinergic effects of first-generation antipsychotics?

Dry mouth, Blurred vision, Photophobia, Constipation, Urinary hesitancy

What are other common adverse effects of first-generation antipsychotics?

Orthostatic hypotension, Daytime sedation, Gynecomastia, Seizures, Sexual dysfunction, Fatal cardiac dysrhythmias (Prolonged Q-T interval)

What is Neuroleptic Malignant Syndrome (NMS)?

A life-threatening reaction to antipsychotic medication caused by the blockade of dopamine receptors

When does Neuroleptic Malignant Syndrome (NMS) most commonly occur?

It most commonly occurs within the first two weeks of therapy.

What are the first symptoms of Neuroleptic Malignant Syndrome (NMS)?

Muscle cramps, Tremors, Fever

What are the most severe symptoms of Neuroleptic Malignant Syndrome (NMS)?

Rhabdomyolysis, Hypertensive crisis, Metabolic acidosis

How is Neuroleptic Malignant Syndrome (NMS) treated?

discontinue antipsychotic, muscle relaxants, dopamine agonists (pramipexole)

What is the key characteristic of second-generation (atypical) antipsychotics?

They produce a moderate blockade of dopamine receptors and a stronger blockade for serotonin receptors

What is a major advantage of second-generation (atypical) antipsychotics over first-generation antipsychotics?

They cause fewer extrapyramidal symptoms (EPS)

What are some risks associated with second-generation (atypical) antipsychotics?

Higher risk of metabolic effects like diabetes and dyslipidemia, Sedation and orthostatic hypotension

What are some common drug interactions with atypical antipsychotics?

Anticholinergic drugs (intensify the anticholinergic effects), CNS depressants (can intensify the depressant effect), Levodopa and dopamine agonists (may counteract the antipsychotic effects)

What are examples of atypical (second-generation) antipsychotics?

Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel)

What is the use of risperidone (Risperdal) aside from treating schizophrenia?

Treats bipolar disorder, Suppresses agitation in severe mania, Suppresses nausea in chemotherapy patients

What are the benefits of olanzapine (Zyprexa)?

Improves positive symptoms, negative symptoms, and cognitive function in schizophrenia

What are the benefits of quetiapine (Seroquel)?

Improves positive symptoms, negative symptoms, and cognitive function in schizophrenia

What are the side/adverse effects of atypical antipsychotic agents (second-generation)?

Weight gain, elevated blood sugars, diabetes mellitus

What is an example of a dopamine system stabilizer?

Aripiprazole (Abilify)

What conditions does aripiprazole (Abilify) treat?

Mania, Depression, Irritability

What makes aripiprazole (Abilify) different from other atypical antipsychotics regarding receptor blocking?

It does not block cholinergic receptors

What are the cardiovascular benefits of aripiprazole (Abilify)?

less risk of cardiac arrhythmias, low risk of orthostatic hypotension

What are the most common side effects of aripiprazole (Abilify)?

Headache, Anxiety, Insomnia

What was Bipolar Disorder (BPD) formerly known as?

Manic-depressive illness

What type of condition is Bipolar Disorder (BPD)?

A chronic condition requiring lifelong treatment.

How is Bipolar Disorder (BPD) defined?

A cyclic disorder with recurrent fluctuations in mood, alternating between mania and depression.

How long do mania and depression episodes last without treatment?

They can persist for months.

What are the main treatments for Bipolar Disorder (BPD)?

Medications (mood stabilizers, antipsychotics), Psychotherapy

What are the symptoms of a Major Depressive Episode in BPD?

Loss of pleasure or interest in almost all activities, persistent sadness or hopelessness

What is a Mixed Episode in BPD?

Combination of agitation and irritability, feelings of worthlessness and depression

What are the characteristics of a Pure Manic Episode (Euphoric Mania)?

Persistently heightened, expansive and irritable mood, excessive enthusiasm (flight of ideas)

What is a Hypomanic Episode (Hypomania)?

Milder form of mania, Symptoms do not alter social or occupational functioning

What are the three main purposes of Mood Stabilizers (e.g., Lithium) in BPD treatment?

Relieve symptoms during manic and depressive episodes, Prevent recurrence of mood episodes, Do not worsen symptoms or accelerate cycling

When are Antipsychotics used in BPD treatment?

They are given during severe manic episodes.

How is Lithium eliminated from the body?

Short half-life, Excreted by the kidneys, Excretion is reduced when serum sodium levels are low

How often should Lithium levels be monitored?

Every 2–3 days at the start of therapy, Every 3–6 months once stabilized

What are common side effects of Lithium?

Gastrointestinal upset, Fine hand tremors, Polyuria (excessive urination), Muscle weakness, Renal toxicity, Goiter & hypothyroidism, Teratogenic effects (harmful in pregnancy)

Why are diuretics dangerous with Lithium?

Diuretics cause sodium loss, which can increase the risk of Lithium toxicity.

How do NSAIDs (nonsteroidal anti-inflammatory drugs) affect Lithium levels?

NSAIDs can increase Lithium levels by 60%.

When are antipsychotic drugs used in Bipolar Disorder (BPD)?

Used to acutely control symptoms during manic episodes, Used long-term to help stabilize mood

What are the antipsychotics approved for Bipolar Disorder?

Olanzapine, Quetiapine, Risperidone, Aripiprazole, Ziprasidone

Which approved antipsychotic for BPD is a dopamine stabilizer?

Aripiprazole (Abilify)

What is Depression?

Most common psychiatric disorder, affects 30% of the U.S. population in their lifetime, 5% of adults are currently depressed, twice as common in women as in men, high risk of suicide, often goes untreated

Principle Symptoms of Depression

Depressed mood, loss of interest or pleasure in activities once enjoyed

Associated Symptoms (Physical Changes)

Insomnia or hypersomnia, anorexia (loss of appetite) or hyperphagia (overeating)

Associated Symptoms (Mental & Emotional Effects)

Slowed thinking, difficulty concentrating, feeling hopeless or helpless, thinking about or attempting suicide

Causes of Depression (Pathophysiology)

genetic heritage, difficult childhood, chronic low self-esteem, situational

Monoamine-Deficiency Hypothesis

Depression is linked to low levels of key brain chemicals: Norepinephrine, Serotonin

Treatment Options for depression

Meds, Cognitive Behavioral Therapy (CBT), Combination therapy

Time Course of Antidepressant Response

Symptoms resolve slowly, Initial effects: 1–3 weeks, Maximum effects: Up to 12 weeks, Failure if no response after 1 month

Drug Selection for Depression

All antidepressants have similar efficacy, Selection is based on side effects & adverse reactions

Suicide Risk with Antidepressants

May increase suicidal tendencies early in treatment; Precaution: Inpatients should be directly observed when taking doses

Classes of Antidepressants

SSRIs, SNRIs, TCAs, atypical antidepressants, genesight testing

SSRIs – Common Medications

fluoxetine, sertraline, citalopram, escitalopram

Mechanism of Action of SSRIs

Selective inhibition of serotonin reuptake, increases serotonin transmission in the brain and spinal cord

Other Uses of SSRIs (also used to treat)

Obsessive-Compulsive Disorder (OCD), Bulimia Nervosa, Premenstrual Dysphoric Disorder (PMDD)

Common SNRIs

Venlafaxine, Duloxetin

Indications for SNRIs

Major Depression, Generalized Anxiety Disorder (GAD), Social Anxiety Disorder (Social Phobia), Panic Disorder

Mechanism of Action of SNRIs

Blocks norepinephrine & serotonin reuptake

Side Effects of SNRIs/SSRIs

Nervousness / Sweating, Sexual dysfunction, Weight gain

Adverse effects for SNRIs/SSRIs; Serotonin Syndrome (Rare but Serious) and symptoms

Onset: 2–72 hours after treatment starts, Agitation, confusion, anxiety, hallucinations, Incoordination, excessive sweating, tremor, fever (resolve after drug discontinuation of drug)

Withdrawal Syndrome (SNRIs/SSRIs)

Occurs with abrupt discontinuation; Onset: within days of last dose

Mechanism of Action of TCAs (Amitriptyline (Elavil))

Blocks reuptake of norepinephrine & serotonin, therapeutic effect develops over several weeks

Common Adverse Effects of TCAs

Sedation, Orthostatic hypotension, Anticholinergic effects (dry mouth, blurred vision)

Most Dangerous Adverse Effect of TCAs

cardiac toxicity

Suicide Risk with TCAs

May increase suicide risk early in treatment

Mechanism of Action of Bupropion (Wellbutrin) (atypical antidepressants)

Acts as a stimulant & suppresses appetite

Adverse Effects of Bupropion (Wellbutrin)

Seizures, Agitation, Tremor, Tachycardia, Blurred vision, Dizziness, Headache, Insomnia

What is Anxiety?

Uncomfortable state with psychological & physical symptoms, Characterized by: Fear, Apprehension, Dread, Uneasiness

What is Generalized Anxiety Disorder (GAD)?

Excessive, uncontrollable worrying lasting 6+ months, not linked to a specific situation

Non-Medication Treatments for GAD

Supportive therapy, Cognitive Behavioral Therapy (CBT), Biofeedback, Relaxation training

Physical Symptoms of Anxiety

Palpitations / Racing heart, Chest pain / Shortness of breath

First-Line Medications for GAD

SSRIs / SNRIs (See depression treatment), Buspirone (BuSpar)

Buspirone (BuSpar) “non” and “no”

Non-CNS depressant (Unlike benzodiazepines) and No sedation/ dependency risk

Buspirone Drug & Food Interactions

Erythromycin & grapefruit juice increase drug levels

Common Benzodiazepines for Anxiety

Alprazolam (Xanax) – Short-acting, Diazepam (Valium) – Long-acting

Mechanism of Action of Benzodiazepines

Enhance GABA effects (Exact mechanism not well understood)