bh midterm meds

medications for bh midterm disorders

short acting BZDs

triazolam (halcion) and midazolam (versed)

intermediate acting BZDs

alprazolam (xanax), lorazepam (ativan), temazepam (restoril), clonazepam (konopin), oxazepam

long acting BZDs

diazepam (valium), chlordiazepoxide (librium), flurazepam (dalmane), and chlorazepate (tranxene)

first gen antipsychotics

haloperidol (haldol), fluphenazine (prolixin), and chlorpromazine (thorazine)

SGA D2 antag/5-HT2A antag

quetiapine (seroquel), risperidone (risperdal), paliperidone (invega), asenapine (saphris), lumateperone (caplyta), olanzapine (zyprexa), lurasidone (latuda), ziprasidone (geodon), clozapine (clozaril)

SGA D2 partial ag/5-HT2A antag

aripiprazole (abilify), brexpiprazole (rexulti), and cariprazine (vraylar)

haloperidol (haldol) info

very aggressive

oxidative stress,

rebound symptoms

quetiapine (seroquel) info

weakest antipsychotic

orthostatic hypotension common

often prescribed for sleep

risperidone (risperdal)

gynecomastia common (prolactin increase)

fertility affected (FSH)

NOT for pregnant/trying

paliperidone (invega) info

active metabolite of risperidone

usually taken in the morning

asenapine (saphris) info

sublingual

olanzapine (zyprexa) info

#2 most effective

SEVERE weight gain and diabetes possible

monitor A1c, consider metformin

lurasidone (latuda) info

MUST be taken w/350+ calories

can cause weight loss

ziprasidone (geodon) info

most likely to cause QT prolongation

better with food

clozapine (clozaril) info

most effective but ONLY for treatment resistant (never first line)

arpiprazole (abilify) info

akathisia common

cariprazine (vraylar) info

longest half life

possible benefits for cognitive function

labs that must be run for FEP or starting SGA

fluid/electrolytes: CMP

infection: CBC, UA, cultures

liver abnormalities: CMP, ammonia, PIT, PT/INR

thyroid: TSH

HIV: HIV immunoassay

B12 deficiency: B12

substance use: UDS, serum ETOH

UTI: UA

syphilis: serum treponemal

bipolar disorder medications mood stabilizers

lithium, valproate (depakote), lamotrigine (lamictal)

bipolar disorder medications SGAs

aripiprazole (abilify), asenapine (saphris), cariprazine (vraylar), olanzapine (zyprexa), quetiapine (seroquel), risperidone (risperdal), ziprasidone (geodon), lurasidone ( latuda), lumateperone (caplyta)

bipolar disorder medications combo

olanzipine + fluoxetine (symbyax)

lithium or valproate + SGA

SSRIs

fluoxetine (prozac), sertraline (zoloft), paroxetine (paxil), citalopram (celexa), excitalopram (lexapro), vilazodone (viibryd)

SNRIs

venlafaxine (effexor), desvenlafaxine (pristiq), duloxetine (cymbalta), levomilnacipran (fetzima)

atypical antidepressants

bupropion (wellbutrin), mirtazapine (remeron), vortioxetine (trintellix)

MAOIs

trancylpromine (parnate), phenelzine (nardil), selegiline (emsam)

TCAs

AMITRYPTYLINE, nortriptyline (pamelor), imipramine (tofranil), clomipramine (anafranil)

sleep medications for PTSD

prazosin, trazodone/desyrel, quetiapine (seroquel), benadryl, ambien/sunata/lunesta, benzos, rozarem, melatonin

fluoxetine (prozac) info

longest half life

least likely to cause weight gains

sertraline (zoloft) info

VERY effective

paroxetine (paxil) info

shortest half life

weight gain and withdrawal

citalopram (celexa)

dose limit: <60 - 40mg

>60 - 20mg

escitalopram (lexapro) info

drowsiness effects (scrip qhs)

EXPENSIVE MDD treatments

vilazodone (viibryd), desvenlafaxine (pristiq), vortioxetine (trintellix)

duloxetine (cymbalta)

similar to gabapentin

risk of hypertension

bupropion (wellbutrin)

often with kids released from the hospital (no time to r/o BD and won’t flip them into mania)

works for DA and NE

get energy back before mood

mirtazapine (remeron)

risk of weight gain

benzodiazepine chronic use pathophysiology

GABA-A receptors

anxiolytic, sedative, anticonvulsant, muscle relaxant effects

downregulation of GABA-A receptors and desensitization of remaining receptors

benzodiazepine withdrawal pathophysiology

DANGER

deficiency in inhibitory signaling leads to anxiety, agitation, insomnia, seizures

compensatory increase in Glu = CNS hyperexcitability

benzo rapid taper

3-7 days

medically observed

20-30% reduction daily

benzo prolonged taper

weeks to months

10% reduction weekly

convert to short acting benzo to taper

ALWAYS ASK THESE QUESTIONS WITH H&P

appetite, sleep, mood, hallucinations, suicidality, aggression, substances

mental status exam contents

appearance, behavior/attitude, speech and language, mood, affect, thought process, thought content, suicidal/homicidal, cognition, insight/judgement

when to hospitalize

suicidal, homicidal, acutely psychotic, overdose, extreme anorexia, BZD/alcohol withdrawal, medication toxicity, panic, serotonin syndrome, agranulocytosis, SJS, catatonia, extreme aggression, tardive dyskinesia

GABA substance use

alcohol

bzd

glutamate substance use

alcohol

hallucinogens

serotonin substance use

hallucinogens

norepinephrine substance use

stimulants

nicotine

endogenous opioids

opioids

acetylcholine

nicotine

endocannabinoids

THC

binge/intoxication dopamine structure

nucleus accumbens

withdrawal/negative affect dopamine structure

extended amygdala

preoccupation/anticipation dopamine structure

prefrontal cortex

normal/pre-substance use pathophysiology

dopamine released from ventral tegmental area and stores memory in hippocampus

general substance abuse pathophysiology

substance produces MUCH higher dopamine release from VTA and memory overrides previous pleasurable behaviors

dopamine thermostat changes baseline - tolerance

bzd MOA

enhances activity at GABA-A receptor to increase GABA binding

bzd uses

anxiety

seizures

alcohol withdrawal

sedation

alcohol use disorder chronic use pathophysiology GABA

alcohol enhances GABA-A which are then downregulated

alcohol use disorder chronic use pathophysiology glutamatergic

alcohol inhibits NMDA glu receptors which are then upregulated

alcohol use disorder withdrawal pathophysiology GABA

downregulated GABA-A leads to decreased inhibitory control

alcohol use disorder withdrawal pathophysiology NMDA/glu

upregulated NMDA leads to increased excitatory signaling

labs for alcohol use disorder

gamma-glutamyl transferase

carbohydrate-deficient transferrin

wernicke’s encephalopathy traid

endephalopathy

oculomotor dysfunction

gait ataxia

wernicke’s encephalopathy treatment

thiamine

korsakoff syndrom

late stage WE

alcohol intoxication treatment

dextrose

correct electrolytes

IV thiamine and folate

monitor ABCs

alcohol use withdrawal treatment

chlordiazepoxide or diazepam (bzd) to control autonomic hyperactivity

opioid chronic use pathophysiology

tolerance to respiratory effects

decreased respiratory drive

opioid intoxication pathophysiology

DANGER

hypoxia

respiratory arrest

opioid intoxication treatment

naloxone

AIRWAY

opioid withdrawal treatments

methadone, bupenorphine, naltrexone

methadone MOA

full agonist of mu receptors

methadone concerns

must taper eventually

access

drug screens and counseling required

bupenorphine/naloxone (suboxone) MOA

partial agonist of mu receptors

suboxone concerns

DO NOT give to someone actively in withdrawal

naltrexone MOA

antagonist for mu receptors

naltrexone concerns

MUST BE ABSTINENT FOR 7-10 DAYS BEFORE STARTING

pt will have lower opioid tolerance - warn of OD/death risk

bupenorphine LAI MOA

partial agonist for mu receptors

opioid chronic use pathophysiology

binds mu receptors and inhibits NE so the receptors are upregulated

opioid withdrawal pathophysiology

DANGER

absence of opioid leads to DECREASED inhibition of NE and exaggerated release

stimulant use pathophysiology dopamine

stimulants block reuptake or promote release of DA which leads to excessive levels and euphoria, energy, etc

stimulant use pathophysiology norepinephrine

increased release and blocked reuptake leads to increased cardiac symptoms and downregulation of NE

stimulant use pathophysiology serotonin

elevated serotonin leads to mood elevation, reduced appetite

stimulant withdrawal pathophysiology dopamine

anhedonia

fatigue

severe depression

stimulant withdrawal pathophysiology norepinephrine

fatigue

hypotension

lethargy

increased craving

stimulant withdrawal pathophysiology serotonin

mood instability

anxiety

stimulant intoxication treatment

manage ABCs

control agitation with benzo

monitor hyperthermia and metabolic acidosis (bicarb)

stimulant withdrawal treatment

no proven medications

therapy

PCP MOA

NMDA receptor antagonist leads to dissociation

hallucinogen MOA

5-HT2A agonist leads to changes in sensory processing and cognition

PCP intoxication

manage ABCs

seizures gets lorazepam/diazepam

AVOID HALOPERIDOL/OLANZIPINE

hallucinogen intoxication treatment

manage ABCs

calm quiet environment

seizures get lorazepam/diazepam

PCP concerns/considerations

severe agitation

seizures

rhabdo

MDMA/ecstasy concerns/considerations

serotonin syndrome

hyponatremia (treat with bzd, cooling)

tobacco withdrawal treatment

chantix:alpha-4 agonist/beta-2 antagonist for nicotinic acetylcholine receptors and increase DA

SUICIDAL IDEATION COMMON

also NRT

mania symptoms

distractability

indiscretion

gradiosity

flight of ideas

activity increase

sleep deficit

talking increase

depression symptoms

sleep disturbance

interest loss

guilt

energy loss

concentration issues

appetite changes

psychomotor agitation

suicidal