Psych 1

Serotonin

sleep, appetite, pain, mood

linked to obsessions and compulsions

low levels linked in increased suicide risk

Norepinephrine

alertness/attention, concentration, cognitive ability, energy

can trigger anxiety

Dopamine

motivation, pleasure and reward, perception of reality

dysfunction seen with psychosis and addiction

ECT

electroconvulsive therapy

triggers a seizure in the brain to improve symptoms

high relapse rate following cessation of treatment

TMS

transcranial magnetic stimulation

magnetic stimulation to the brain, stimulates nerve cells

side effects are uncommon

VNS

vagus nerve stimulation

pulses of electrical energy to the brain via the vagus nerve to change the way brain cells work and/or alters neurotransmitters

Depression Treatment Guidelines (acute phase)

induce remission, retrieve baseline functioning

4-8 weeks at max tolerated dose

Depression Treatment Guidelines (continuation phase)

prevent relapse

6-12 months after resolution of symptoms

Depression Treatment Guidelines (maintenance phase)

2 or more serious episodes or risk factors for recurrence

2 years vs chronic treatment

Mild Depression Treatment

watchful waiting, psychotherapy (CBT, family counseling), exercise

antidepressants not recommended

Moderate-Severe Depression Treatment

suicide assessment, antidepressants (SSRIs, SNRIs, NDRI, atypicals), psychotherapy

ketamine, ECT, TMS, VNS for treatment resistant depression

ECT: depression with psychotic features or catatonia

TCA or MAO-i

SSRIs

citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, vilazodone, vortioxetine

SNRIs

desvenlafaxine, duloxetine (use for pain), levomilnacipram, milnacipram, venlafaxine

Atypicals for Depression

mirtazapine: tricyclic antidepressant, for insomnia, anorexia

trazodone: serotonin modulator, insomnia

bupropion: NDRI, also for smoking cessation, seasonal affect

antipsychotics: quetiapine, aripiprazole, brexpiprazole, caripraszine (vraylar)

TCA Side Effects

anticholinergic and sedation

orthostatic hypotension

cardiac dysrhythmias

AVOID WITH SUICIDAL PATIENTS

MAO-i Side Effects

anticholinergic and tyramine foods

orthostatic hypotension

tyramine rich foods can cause malignant hypertension

PDD Treatment

first line: psychotherapy alone

increase in severity: add SSRI, SNRI, NDRI

PMDD Treatment

first line: SSRI (fluoxetine, paroxetine, sertraline) and OCP

CBT, acupuncture, OTC supplements, dietary changes, cycle tracking

Depression Standard Work Up

TSH, CBC, CMP, B12, UA/UDS, RPR, HIV, hepatitis panel

Bipolar Treatment of Choice

gold standard: lithium

also divalproex, carbamazepine, lamotrigine

Bipolar Treatment (manic episode)

lithium, divalproex, carbamazepine

Bipolar Treatment (MDE)

lithium, lamotrigine

can add atypicals (olanzapine/fluoxetine, quetiapine, lurasidone, caripraszine, lumateperone)

Bipolar Treatment (mixed episode)

lithium, divalproex, carbamazepine

can use atypicals (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone, caripraszine)

Lithium Side Effects

ebstein anomaly formation in pregnancy

hypothyroidism

lithium toxicity: tremor, nausea, diarrhea, vertigo, confusion, increased DTRs, can lead to coma/death

always monitor lithium levels every 3-6 months

Divalproex Side Effects

asymptomatic thrombocytopenia

BBW for hepatoxicity (elevation in LFTs)

Carbamazepine Side Effects

thrombocytopenia, agranulocytosis, aplastic anemia

hyponatremia

SJS

spina bifida in pregnancy

Lamotrigine Side Effects

lacy rash

SJS

GAD Acute Treatment

benzos or hydroxyzine

GAD Maintenance Treatment

gold standard: CBT

add SSRI first (paroxetine, escitalopram)

switch to SNRI (duloxetine, venlafaxine)

consider adding buspirone

quetiapine, gabapentin, pregabalin not FDA approved

Specific Phobia Treatment

gold standard: CBT (exposure and response prevention)

benzos are minimally effective

educate patient to avoid stimuli or substances

Social Anxiety Treatment

SSRIs (paroxetine, sertraline, fluvoxamine) and SNRI (venlafaxine)

CBT (exposure and response prevention)

performance only: propranolol

Panic Disorder Treatment

SSRIs (paroxetine, sertraline, fluvoxamine) and SNRI (venlafaxine)

benzos can be added

CBT (exposure and response prevention) - highly effective

OCD Treatment (pharmacologic)

first line: SSRIs (sertraline, fluoxetine, fluvoxamine, paroxetine)

doses may be higher

OCD Treatment (psychotherapy)

first line: CBT (exposure and response prevention)

OCD Treatment Resistance

max tolerable SSRI dose

switch between SSRIs

can switch to clomipramine, venlafaxine, mirtazapine

can augment with buspirone, benzos, atypicals, mood stabilizers

can try TMS

PTSD (4 Clusters of Symptoms)

1. re-experiencing the trauma

2. avoiding reminders of the trauma

3. negative alteration in mood

4. increased physiological arousal and/or startle

PTSD DSM Criteria

1. exposure to highly traumatic event

2. presence of 1 or more intrusive symptoms

3. avoidance of stimuli associated with the traumatic event

4. 2 or more negative alterations in cognition and mood

5. marked alterations in arousal and reactivity

6. disturbances last at least 1 month

PTSD Treatment (psychotherapy)

CBT: prolonged exposure therapy

EMDR: eye movement desensitization and reprocessing

PTSD Treatment (pharmacological)

SSRIs (sertraline, paroxetine)

PNS symptoms: propranolol

Impulsivity/anger management: carbamazepine

Nightmares: prazosin

Adjustment Disorder Treatment

behavioral: stress reduction techniques

psychological: supportive psychotherapy, coping mechanisms

pharmacotherapy: benzos or other anxiolytics short term

SSRI/SNRI if chronic depression