Anxiety, Depression, Bipolar Disorder, Schiz

Celexa → generic

Lexapro → generic

MOA →

ADE →

DDI →

Unique

• Highest rates of…(ADE)

• Max doses…(if >60 yo…)

Celexa → Citalopram

Lexapro → Escitalopram

MOA → SSRIs increase 5-HT

ADE → sexual dysfunction, bleeding

DDI →

• MAOIs and other serotonergic agents

• Bleeding agents (anticoag, antiplatelets, NSAIDs, ginkgo, garlic, ginger, ginseng, glucosamine, fish oil)

Unique

• Highest rates of QTc prolongation

• Good in pregnancy (just like Sertraline)

• Max doses

  • Citalopram: 40 mg/day (if >60 yo → 20 mg/day)

  • Escitalopram: 20 mg/day (if >60 yo → 10 mg/day)

Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox)

Prozac → generic

Paxil → generic

MOA →

ADE → (2)

DDI →

• (2)

Unique →

• CYP…

• Most…, t1/2

Prozac → Fluoxetine

Paxil → Paroxetine

MOA → SSRIs increase 5-HT

ADE → sexual dysfunction, bleeding

DDI →

• MAOIs and other serotonergic agents

• Bleeding agents (anticoag, antiplatelets, NSAIDs, ginkgo, garlic, ginger, ginseng, glucosamine, fish oil)

Unique →

• Both CYP2D6 inhibitor (decrease tamoxifen efficacy)

• Fluoxetine → Most activating, longest t1/2

• Paroxetine → Most sedating, shortest t1/2

Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox)

Zoloft

Generic

MOA →

ADE →

DDI →

• (2)

Unique →

• Good for…(population)

Sertraline

MOA → SSRIs increase 5-HT

ADE → sexual dysfunction, bleeding

DDI →

• MAOIs and other serotonergic agents

• Bleeding agents (anticoag, antiplatelets, NSAIDs, ginkgo, garlic, ginger, ginseng, glucosamine, fish oil)

Unique →

• Good in pregnancy (just like Citalopram)

Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox)

Luvox

Generic

MOA →

Indication →

Fluvoxamine

MOA → SSRI

Indication → only OCD (not the usual depression)

Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox)

Viibryd → generic, Regards to food

Trintellix → generic, CYP

Nefazodone → ADE

Trazodone → ADE, off label indication

MOA →

Less…(ADE)

Viibryd → Vilazodone, Take with food

Trintellix → Vortioxetine, CYP2D6 substrate (avoid with CYP2D6 inhibitors like fluoxetine and paroxetine)

Nefazodone → hepatotoxicity

Trazodone → priapism, off label indication sleep (50-100 mg QHS)

-

MOA → serotonin modulator

Less sexual dysfunction

Effexor XR → generic

Cymbalta → generic

Pristiq → generic

MOA →

ADE →

DDI →

Effexor XR → Venlafaxine

Cymbalta → Duloxetine

Pristiq → Desvenlafaxine

MOA → SNRI (both serotonin and NEP)

ADE → increase HR, dilated pupils, constipation, excessive sweating esp in Venlafaxine

• think NEP = stimulating

DDI → MAOI and other serotonergic agents

Amitriptyline

Doxepin

Pamelor → generic

Which are tertiary vs secondary amines

Indication →

• Amitriptyline →

• Silenor →

MOA →

ADE →

• MOA → ADE (2)

DDI → (1)

Silenor → generic, indication

Tertiary amines

• Amitriptyline

• Doxepin

Secondary amines

• Pamelor → Nortriptyline

Indication → depression (not as much anymore)

• Amitriptyline → migraine ppx

• Silenor → Doexpin used for insomnia

MOA → block serotonin and NE reuptake (just like SNRI)

ADE →

• Anticholinergic → dry mouth, blurred vision, urinary retention, constipation

• Antihistamine → sedation, weight gain

DDI → MAOIs

Generic

• Wellbutrin XL → indication

• Zyban → indication

Auelity → generic, formulation, indication

Contrave → generic, indication

-

MOA →

CI in…(2 conditions)

DDI →

Bupropion

• Wellbutrin XL → depression, seasonal affective disorder

• Zyban → smoking cessation

Auelity → Dextromethorphan + Bupropion, ER tabs, depression

Contrave → Bupropion + Naltrexone, weight management

-

MOA → DNRI (dopamine and NEP reuptake inhibitor, just like mini stimulants)

• No sexual dysfunction (Doesnt touch serotonin)

CI in seizure disorder, anorexia/bulimia (seizure risk)

DDI → MAOIs

Marplan → generic

Nardil → generic

Parnate → generic

Emsam → generic (formulation, frequency)

MOA, ADE

Marplan → Isocarboxazid

Nardil → Phenelzine

Parnate → Tranylcypromine

Emsam → Selegiline (patch QD, MAO-B inhibitor at low doses)

MAOIs that can cause serotonin syndrome

Remeron

ADE→ (2)

Indication → (2)

Mirtazapine

ADE → sedation and weight gain
Indication → often used for sleep and increase appetite

Antipsychotics approved for MDD

Antipsychotics approved for Bipolar disorder

Antipsychotics approved for MDD

• Aripiprazole (Abilify)

• Brexpiprazole (Rexulti)

• Quetiapine (Seroquel)

• Olanzapine/Fluoxetine (Symbyax)

Antipsychotics approved for Bipolar disorder

• Aripiprazole

• Quetiapine

• Olanzapine

• Asenapine

• Risperidone

• Ziprasidone

• Lurasidone

Symbyax

Generic

Indication →

Taken at…(time of day)

Olanzapine/Fluoxetine

MOA → adjunctive therapy for treatment resistant depression

Taken at night (fluoxetine activating but olanzapine sedating)

Spravato

MOA →

Formulation →

Schedule…controlled substance, only given by…

Must check…

Esketamine

MOA → NMDA receptor antagonist

Formulation → nasal spray

Schedule 3 controlled substance, only given by healthcare provider

Must check BP

Depression Diagnosis

OTC meds for depression

OTC meds for depression:

• St John’s Worts

• SAMe also for osteoarthritis

DSM-5 Diagnostic Criteria for Schiz

Negative vs Pos s/s

EPS Side Effects

More common in…

Test →

Akathisia (presentation) → DOC

Dystonia (presentation) → DOC

Pseudoparkinsonism → DOC

More common in first gen antipsychotics

Test → AIMS (abnormal involuntary movement scale)

Akathisia (inner restlessness) → propranolol (alt → BZD)

Dystonia (involuntary muscle contractions) → Bentropine

Pseudoparkinsonism → anticholinergics (Trihexyphenidyl, Diphenhydramine, Benztropine, Amantadine)

TD (lip smacking, involuntary tongue movementsm, side jaw movements) →

Antipsychotics (both typical and atypical)

MOA:

• First gen (typical) antipsychotic →

• Second gen (atypical) antipsychotic →

ADE

• (6)

MOA:

• First gen (typical) antipsychotic → block D2 receptors (affect pos symptoms)

• Second gen (atypical) antipsychotic → block D2 AND 5-HT2 receptors (affect pos AND neg symptoms)

ADE

• Sedation

• EPS

• TD (use lowest dose or switch to clozapine)

• Hyperprolactinemia → release milk (only fluid high secretion bc anticholinergic)

• Anticholinergic ADE (mainly clozapine)

• Neuro malignant syndrome (central autonomic instability → muscle rigidity, hyperthermia, CK >1000) tx →

  • Stop antipsychotic. Control patient temp.

  • Relax muscles → Dantrolene and sometimes Bromocriptine (increase DA)

  • Try new antipsychotic once better

Chlorpromazine → …potency → ADE

Generic → …potency → ADE

• Haldol → formulation

• Haloperidol Decanoate → formulation, frequency

Fluphenazine decanoate → …potency, formulation, frequency

Chlorpromazine → low potency → high sedation, low EPS

Haloperidol → high potency → low sedation, high EPS

• Haldol → PO, IV/IM

• Decanoate → IM only, monthly

Fluphenazine decanoate → high potency, IM, Q 2 weeks

Antipsychotics formulations

Oral solution → acronym

• Names

ODT → acronym

• Names

Rapid acting IM → acronym

• Names

Use if patient has QTc prolongation → acronym

• Names

Oral solution → H-CAR

• Haloperidol

• Clozapine

• Aripiprazole

• Risperidone

ODT → O-CAR

• Olanzapine

• Clozapine

• Aripiprazole

• Risperidone

Rapid acting IM → HZZ

• Haloperidol

• Ziprasidone

• Zyprexa

Use if patient has QTc prolongation → C LAB

• Cariprazine

• Lurasidone

• Aripiprazole

• Brexpiprazole

Antipsychotics formulations

Long acting injectables → acronym

• Names

Long acting injectables → OPAR-HF

• Olanzapine

  • Zyprexa Relprevv → Q2-4 weeks

• Paliperidone

  • Invega Sustenna → Q monthly, no overlap

  • Invega Trinza, Invega Hafyera → Q3 months, Q6 months respectively, both overlap with Sustenna for at least 4 weeks

• Aripiprazole

  • Abilify Maintena or Abilify Asimtufii → Q monthly, Q2 months respectively, both 2 weeks overlap

  • Aristada → Q1-2 months, 3 weeks overlap

• Risperidone (SQ)

  • Risperidone Consta, Rykindo → Q2 weeks, Consta overlap for 3 weeks

  • Perseris → Q monthly

  • Uzedy → Q1-2 months

• Haloperidol

  • Haloperidol decanoate → Q monthly

• Fluphenazine

  • Fluphenazine decanoate → Q 2 weeks

Generic, class

• Abilify Maintena → LAI frequency

• Aristada → LAI frequency

• Abilify Asimtufil → LAI frequency

Rexulti → generic

ADE → (1)

-

Formulation

QTc

Aripiprazole, 2nd gen antipsychotic (D2 partial agonist, not the usual antagonism)

• Abilify Maintena → Q monthly

• Aristada → Q 1-2 months

• Abilify Asimtufil → Q 2 months

Rexulti → Brexpiprazole

ADE → Akathsia (-piprazole)

-

Oral solution → H-CAR

• Haloperidol

• Clozapine

• Aripiprazole

• Risperidone

ODT → O-CAR

• Olanzapine

• Clozapine

• Aripiprazole

• Risperidone

Use if patient has QTc prolongation → C LAB

• Cariprazine

• Lurasidone

• Aripiprazole

• Brexpiprazole

-

Paliperidone

• Invega Trinza, Invega Hafyera → Q3 months, Q6 months respectively, both overlap with Sustenna for at least 4 weeks

Aripiprazole

• Abilify Maintena or Abilify Asimtufii → Q monthly, Q2 months respectively, both 2 weeks overlap

Risperidone

• Risperidone Consta, Rykindo → Q2 weeks, Consta ONLY overlap for 3 weeks

Clozaril

Indication →

ADE →

Unique

• Does NOT cause…

• ADE (discontinued REMS)

  • Before starting, ANC…

  • Stop when ANC…

-

Formulation

Clozaril

Clozapine, 2nd gen antipsychotic

Indication → treatment resistant schiz

ADE → metabolic syndrome, weight gain (-apine)

Unique

• Does NOT cause EPS or TD (good to switch if have TD from other meds)

• Agranulocytosis (discontinued REMS)

  • Before starting, ANC >1,500/mm3

  • Stop when ANC <1000/mm3

-

Oral solution → H-CAR

• Haloperidol

• Clozapine

• Aripiprazole

• Risperidone

ODT → O-CAR

• Olanzapine

• Clozapine

• Aripiprazole

• Risperidone

Lutada → formulation, regards to food

Geodon → formulation, regards to food, ADE

Seroquel → formulation, regards to food

2nd gen antipyschotic

Lutada → Lurasidone, with food

Geodon → Ziprasidone, with food, QTc prolongation

Seroquel → Quetiapine, empty stomach

-

ADE →

• -done → EPS

• -apine → weight gain, metabolic syndrome

-

Use if patient has QTc prolongation → C LAB

• Cariprazine

• Lurasidone

• Aripiprazole

• Brexpiprazole

Generic

• Zyprexa

• Zydis → formulation

• Zyprexa Relprevv → formulation, frequency,…program

ADE →

Formulation

Symbyx → generic

Lybalvi → generic

Olanzapine

• Zyprexa

• Zydis → ODT

• Zyprexa Relprevv → LAI IM, Q 2-4 weeks, REMS program (monitored for 3 hrs post injection)

ADE → metabolic syndrome, weight gain (-apine)

Symbyx → Olanzapine + Fluoxetine

Lybalvi → Olanzapine + Samidorphan (decrease Olanzapine-induced weight gain

-

ODT → O-CAR

• Olanzapine

• Clozapine

• Aripiprazole

• Risperidone

Generic

• Invega Sustenna →

• Invega Trinza, Invega Hafyera →

ADE →

Paliperidone

• Invega Sustenna → IM Q monthly, no overlap

• Invega Trinza, Invega Hafyera → IM Q3 months, Q6 months respectively, both overlap with Sustenna for at least 4 weeks)

ADE → EPS (-done)

-

Paliperidone

• Invega Trinza, Invega Hafyera → Q3 months, Q6 months respectively, both overlap with Sustenna for at least 4 weeks

Aripiprazole

• Abilify Maintena or Abilify Asimtufii → Q monthly, Q2 months respectively, both 2 weeks overlap

Risperidone

• Risperidone Consta, Rykindo → Q2 weeks, Consta ONLY overlap for 3 weeks

Generic, class

• Risperidone Consta, Rykindo → formulation, frequency

• Perseris → formulation, frequency

• Uzedy → formulation, frequency

ADE →

Risperidone, 2nd gen antipsychotics

• Risperidone Consta, Rykindo → IM, Q2 weeks (Consta overlap for 3 weeks)

• Perseris → SQ, Q monthly

• Uzedy → SQ, Q1-2 months

All other 2nd gens are IM

ADE → EPS (-done)

-

Oral solution → H-CAR

• Haloperidol

• Clozapine

• Aripiprazole

• Risperidone

ODT → O-CAR

• Olanzapine

• Clozapine

• Aripiprazole

• Risperidone

-

Paliperidone

• Invega Trinza, Invega Hafyera → Q3 months, Q6 months respectively, both overlap with Sustenna for at least 4 weeks

Aripiprazole

• Abilify Maintena or Abilify Asimtufii → Q monthly, Q2 months respectively, both 2 weeks overlap

Risperidone

• Risperidone Consta, Rykindo → Q2 weeks, Consta ONLY overlap for 3 weeks

Generic

• Saphris → formulation

• Secuado → formulation

ADE →

Asenapine, 2nd gen antipsychotic for bipolar

• Saphris → SL, dont eat/drink for 10 min

• Secuado → patch

ADE→ tongue numbness (for SL)

Mania Diagnosis

Bipolar 1 vs 2

Bipolar 1 (mania + depression) vs Bipolar 2 (HYPOmania + depression)

Lithobid

Generic

Levels →

Clearance rule →

DDI

• Increase Lithium levels

• Decrease Lithium

• Increase risk of…

Manageable ADE

• (5)

Toxicity signs

Lithium carbonate vs citrate (formulation, %)

Equivalence

Avoid in…(population)

Lithium

Levels → 0.6-1.2 mEq/L (trough)

Clearance rule → Low sodium = high lithium (and vice versa)

DDI

• Increase Lithium levels

  • NSAIDs (except Aspirin, Sulindac), ACEi/ARBs → high K → low Na

  • thaizide/loops → low Na

  • Renal insufficiency, dehydration, Na restrictions

• Decrease Lithium

  • Caffeine, Theophylline

  • High salt intake, sodium bicarb

  • Acetazolamide

  • Pregnancy

• Increase risk of serotonin syndrome with SSRI/triptans

Manageable ADE

• Hand tremor (treat with propranolol)

• Hyper/Hypothyroidism

• Hypercalcemia / Hyperparathyroidism

• Weight gain and GI upset (take with food)

• Polyuria, polydipsia

Toxicity signs

• Mild-Moderate: Coarse hand tremor, persistent diarrhea, vomiting, hyperreflexia, slurred speech.

• Severe (> 2.0 mEq/L): CNS depression, arrhythmias, seizures, coma, death.

Lithium carbonate caps/ tabs (40%)

Lithium citrate syrup (20%)

300 mg of Lithium Carbonate = 8 mEq = 5 mL of Lithium Citrate syrup

Avoid in pregnancy

Meds also indicated for bipolar disorder

Antiseizure meds (3)

2nd gen antipsychotics (6)

Antiseizure meds

• Lamotrigine

• Valproate (and deriv)

• Carbamazepine

2nd gen antipsychotics → LOZ-QAR

• Lurasidone

• Olanzapine

• Ziprasidone

• Quetiapine

• Aripiprazole

• Risperidone

Anti-anxiety meds

• First line →

• Beta blocker →

• Alt →

• First line → SSRI, SNRI

• Beta blocker → Propranolol (stage fright)

• Alt → BZD

Buspar

Generic

MOA → ADE

Indication →

Buspirone

MOA → unknown, effect on serotonin receptors → serotonin syndrome (avoid MAOIs, 14 days)

Indication → anxiety without tolerance/dependence issues (vs BZD)

Takes 4 weeks to work

Class

• Xanax → generic

• Klonopin → generic

• Valium → generic

• Ativan → generic

MOA →

Indication

• (3)

Schedule…controlled substance (abuse, dependence, tolerance w chronic use)

ADE

Avoid in…(2 populations, 1 condition)

If used in elderly and hepatic impairment →

t1/2

• Short → (1)

• Intermediate → (1)

• Long → (2)

BZD

• Xanax → Alprazolam

• Klonopin → Clonazepam

• Valium → Diazepam

• Ativan → Lorazepam

MOA → enhance GABA (just like Phenobarbital, Primidone, Propofol, Ethanol) → think CNS/resp depression

Indication

• Anxiety after SSRI/SNRIs

• Sleep after non-BZD hypnotics (ie Zolpidem)

• Seizures

  • IV/IM → Lorazepam, Diazepam (Valium), Midazolam

  • Rectal → Diazepam (Diastat)

Schedule 5 controlled substance (abuse, dependence, tolerance w chronic use)

ADE: Confusion, amnesia, abuse

Avoid in pregnancy and age >65 yo, liver disease

If used in elderly and hepatic impairment → LOT drugs (metabolized via conjugation and cleared by kidneys)

• Lorazepam

• Oxazepam

• Temazepam

t1/2

• Short → Lorazepam

• Intermediate → Alprazolam

• Long → Diazepam, Clonazepam

2nd gen antipsychotics

Highest rates of weight gain → 2

Highest rates of EPS → 2

Lowest rates of EPS → 2

Highest rates of weight gain → Clozapine, Olanzapine

Highest rates of EPS → Risperidone, Paliperidone

Lowest rates of EPS → Clozapine, Quetiapine