Exam 1 Treatments

SSRI Agents

Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline

SSRI Therapeutic Indications

• MDD

• GAD

• OCD

• Panic Disorder

• Social Anxiety Disorder

• PMDD

• PTSD

• Bulimia Nervosa

SSRI Adverse Effects

• GI: Nausea/vomiting (≥25%), Diarrhea, dyspepsia, appetite change

• Sexual: ↓ libido, delayed ejaculation/orgasm, anorgasmia (≈50% in practice; underreported)

• Sweating/night sweats

• Weight change: early loss → possible gain over months

• Sleep issues

• Emotional blunting

• Tremor, mild akathisia

• Hyponatremia

• Cardiac: abnormalities in ECG

• Manic switch

• Serotonin syndrome (emergency)

Discontinuation Syndrome

Withdrawal-type reaction if an SSRI is stopped abruptly or tapered too fast

• Shows up usually 2–4 days after stopping (later with fluoxetine) and often lasts 1–2 weeks (can be longer)

• Symptoms improve quickly (1–3 days) if you reinstate the antidepressant

Which SSRI has a higher risk for Discontinuation Syndrome?

Short half-life agents → paroxetine highest

Fluoxetine lowest

Typical Symptoms of Discontinuation Syndrome

“FINISH”

• Flu-like (fatigue, aches, sweating)

• Insomnia/vivid dreams

• Nausea

• Imbalance (dizzy/vertigo)

• Sensory “brain zaps”/paresthesias (abnormal sensation of the skin)

• Hyperarousal (anxiety/irritability)

Suicidality in SSRIs

Increased suicidal thoughts/behaviors in children, adolescents, and young adults (≤24 y), especially early in treatment or after dose changes → close monitoring is required

What to do in clinic for suicidality?

• Before start: screen for bipolar, ask directly about suicidal ideation, safety plan, involve family when appropriate

• First month + after dose changes: weekly-biweekly check-ins

  • Ask: mood, sleep, activation/akathisia-like restlessness, new/worse suicidal ideation

  • If activation/akathisia or agitation emerges (esp. early, e.g., with fluoxetine): slow the titration, consider dose ↓, switch, or short-term anxiolytic; reassess SI acutely

• If new suicidal ideation w/ plan/intent: urgent safety evaluation; consider ED, document and coordinate care

• Counseling “In the first weeks, a small number of people—especially younger—can feel more restless or have new/worse suicidal thoughts. Tell us right away if this happens.”

SNRI Agents

Desvenlafaxine, venlafaxine, duloxetine, milnacipran, levomilnacipran

SNRI Indications

• Depression

• GAD

• Social Anxiety Disorder

• Panic disorder

SNRI Adverse Effects

HTN in higher doses

Discontinuation Sx

Tricyclics and Tetracyclines Agents (TCA)

Desipramine, Protriptyline, Nortriptyline, Imipramine, Clomipramine, Amitriptyline

Tricyclics and Tetracyclines Indications

• Depression (MDD)

• OCD

Tricyclics and Tetracyclines Adverse Effects

• Seizures

• Fine, rapid tremor

• Dry mouth

• Constipation

• Blurry vision

• Urinary retention

• Cardiovascular : changes in blood pressure & heart rate

• Hepatic

Monoamine Oxidase Inhibitors (MAOI) Agents

Tranylcypromine, Phenelzine, Isocarboxazid , Selegiline

MAOI Indications

• Major and Atypical depression

• Parkinson Disease

• Reserved for treatment-resistant depression or atypical depression because of diet/interaction issues

Warning/Precautions w/ MAOIs

• Nonselective, irreversible MAOIs (phenelzine, tranylcypromine, isocarboxazid) let tyramine trigger massive NE release

• 15–90 min after the meal; sudden occipital headache → pounding, palpitations, nausea/vomiting, diaphoresis, tachycardia; can progress to malignant hypertension, arrhythmia, stroke

  • ***not first line medication d/t adverse effects

Avoid high-tyramine food w/ MAOIs

Aged cheeses

Cured/smoked meats

Fermented soy (soy sauce, miso, natto)

Yeast extracts (marmite)

Sauerkraut/kimchi

Over-ripe/fermented fruits

Tap/“craft” beers

Some red wines

Fava/broad beans

Lower-risk/OK foods w/ MAOIs

Fresh meats/cheeses, pasteurized bottled/canned beer in moderation (verify brand), most spirits

• Educate the pts to check labels and avoid aging/fermentation

Mood Stabilizers

Lamotrigine

Valproate

Lithium

Lamotrigine Indication

Epilepsy

Bipolar Disorders

Lamotrigine Adverse Effects

• Causes life-threatening serious rashes (ex. Stevens-Johnson syndrome, toxic epidermal necrolysis, rash-related death)

  • Rate of serious rash is greater in pediatric patients than in adults

• Additional factors that may increase the risk of rash include:

  • Coadministration with valproate

  • Exceeding recommended initial dose of lamotrigine

  • Exceeding recommended dose escalation for lamotrigine

• Benign rashes are also caused by lamotrigine; however, it is not possible to predict which rashes will prove to be serious or life threatening

• Should be discontinued at the first sign of rash, unless the rash is clearly not drug related

Monitor for __ when using Lamotrigine

Rashes

Valproate Indications

Epilepsy

Bipolar disorder: acute manic or mixed episodes

Migraine: prophylaxis of migraine headaches in adults (not for acute treatment)

Valproate Adverse Effects

Boxed/serious

• Hepatotoxicity

• Pancreatitis

• Teratogenicity (can’t use in pregnant women)

• Hematologic: thrombocytopenia, platelet dysfunction

Common / dose-related

• GI: nausea, vomiting, dyspepsia, diarrhea

• Neuro: tremor

• Weight gain, edema

• Alopecia (hair loss; sometimes regrows curlier)

• Menstrual irregularities

• Rash, pruritus

• Elevated LFTs (asymptomatic transaminase rise)

Lab Monitoring before starting Valproate

LFTs, CBC

Lithium Indication

Bipolar disorder

Acute mania & Maintenance

Lithium Adverse Effects

• Hypothyroidism

• Hypercalcemia / hyperparathyroidism (uncommon): check calcium yearly; refer if persistent elevation

• Nephrogenic diabetes insipidus (NDI) → polyuria/polydipsia, nocturia

• Fine tremor (very common): reassure;

• Nausea/diarrhea, abdominal discomfort

• Weight gain, edema

• Acne

• Reproductive / Pregnancy: Teratogenic risk (esp. 1st trimester)

Lithium Toxicity

Red flags:

• Coarse tremor

• Worsening GI (vomiting/diarrhea)

• Ataxia (clumsy movements)

• Slurred speech

• Confusion

Immediate actions: hold lithium, check level & BMP, IV fluids

• Dialysis if severe neuro symptoms

  • Removes waste products and excess fluid from the blood when the kidneys are unable to do so

Lab Monitoring before starting Lithium

TSH, BMP (creatinine/eGFR), Ca2+, pregnancy test when applicable, consider ECG if cardiac risk

Benzodiazepine Agents

Diazepam, lorazepam, triazolam, temazepam, oxazepam, midazolam, chlordiazepoxide, alprazolam

• End in “-pam” or “lam”

Benzodiazepine Indication

Anxiety

Panic disorder

Spasticity

Status epilepticus (lorazepam, diazepam, midazolam)

Eclampsia

Medical supervised withdrawal

Night terrors

Sleepwalking

General anesthetic (amnesia, muscle relaxation)

Hypnotic (insomnia)

Those w/ liver disease who drink a LOT d/t minimal first-pass metabolism (Lorazepam, Oxazepam, and Temazepam)

Benzodiazepine Adverse Effects

Dependence

Addictive CNS depression

Cognitive impairment

Sedation

Respiratory depression

Can precipitate seizures by causing acute benzodiazepine withdrawal

Benzodiazepine Clinical Approach

Consider short-term only in severe cases; PRN for specific situations (e.g., rare unavoidable events like flights); taper slowly to avoid withdrawal

Cognitive Behavioral Therapy (CBT) Steps for Depression

(1) Catch the thought Notice the automatic, harsh thought that shows up when your mood drops (e.g., “I’m useless,” “They hate me”)

(2) Test the thought Ask, “What’s the evidence for/against it? What’s a more balanced take?” (write it down)

(3) Do a small, doable action Schedule one meaningful activity (walk 10 min, text a friend, shower, eat) and track how you feel after

How does CBT help?

Depression creates loop: negative thoughts → avoidance → fewer rewards → lower mood

• CBT breaks loop by changing story (thoughts) & adding small actions (behavioral activation)

Targets negative thoughts/behaviors → fast symptom relief

What is CBT best for?

• Anxiety, depression, related conditions

• Great for mild–moderate MDD

Psychodynamic Therapy

once-weekly, insight-oriented talk therapy that helps patients notice repeating patterns in feelings, thoughts, and relationships—often rooted in past experiences—so they can respond differently and feel better

How does Psychodynamic Therapy work?

(1) Make the unconscious conscious: bring hidden motives/conflicts into awareness

• Talk about random topics to analyze subconscious thought

(2) Spot defenses: notice avoidance (ex. joking, intellectualizing) that blocks feelings

(3) Work with relationships: use transference (how the patient relates to the therapist) to understand real-life patterns

(4) Link past → present → new choices: understanding drives behavior change

What do Psychodynamic Therapy sessions look like?

• 45–50 minutes, usually weekly (months to years), open-ended conversation

• Therapist listens for themes, reflects, and offers interpretations; light homework (reflection/journaling) rather than worksheet

Behavioral Activation (BA)

Systematically schedule rewarding/valued activities to break avoidance/anhedonia; simple tools (activity monitoring, graded tasks)

Behavioral Activation (BA) Best Fits

Systematically schedule rewarding/valued activities to break avoidance/anhedonia; simple tools (activity monitoring, graded tasks)

Problem-Solving Therapy (PST)

Brief, structured steps (define problem → brainstorm → choose → plan → review) to reduce depressive distress from practical stressors

• Systematic reviews in primary care show moderate effects; workable even when delivered by medical clinicians with training

Problem-Solving Therapy (PST) Best Fits

Depression driven by concrete hassles (finances, caregiving, work disputes); limited visit time

Exposure-Based Therapy

Gradual, repeated exposure to feared stimulus without avoidance → habituation & reduced anxiety over time

Exposure-Based Therapy Examples

In vivo (real-life)

Imaginal, interoceptive (for panic)

Virtual reality (for flying, heights)

Applied tension for BII phobia (repeated 10–15-sec muscle tensing to prevent syncope)

Exposure-Based Therapy is best for…

Specific phobias, panic disorder, agoraphobia, social anxiety, OCD (exposure & response prevention)