Pharmacology - Psychiatric Medications (Vocabulary Flashcards)

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General Principles of Antidepressants (All Antidepressants)

  • Mechanism of Action / Patient Education (RN Top Focus):
    • Takes weeks to achieve effect; many weeks required for therapeutic affect.
    • Do not cure depression; they manage symptoms to facilitate therapy and address underlying sources.
    • Must take regularly (daily) as prescribed to reach therapeutic effect.
    • Cannot just stop meds abruptly; withdrawal symptoms occur if discontinued improperly; must taper gradually.
  • Practical takeaway: After weeks of regular dosing, therapy can be effective; plan a gradual taper if stopping.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Mnemonic: How to Remember SSRIs

  • Sertraline, Paroxetine, Citalopram
  • Memory aid: "Suicidal No Sex Sarah Sertraline, Met Peter Paradox Paroxetine, and Moved to the Happy City of Citalopram"

ALL SSRIs (and SNRI’s) in General: Side Effects (RN Top Focus: Side/Adverse Effect x 8)

  • Serotonin-related adverse effects due to excessive serotonin:
    • Drowsiness
    • Weight gain
    • Diarrhea
    • Decreased libido
  • Suicide risk associated with SSRI use (theories exist; monitor closely)
  • Anti-cholinergic related effects (ACh): "Anti-Chol No Spit"; mild anticholinergic effects include:
    • Dry mouth
    • (Associated) weight gain
  • Serotonin Syndrome: restlessness, confusion, mental status changes, poor concentration, fever; STOP SSRI if suspected
  • Hyponatremia: SSRI-induced ADH increase → water retention → diluted sodium; monitor sodium levels
  • Mnemonic phrases for sexual function and weight change: “Interested in Sex… Nope”; helps recall sexual dysfunction and weight gain risk with SSRIs

Tricyclic Antidepressants (TCAs)

“Meet Triple AAA, on a Good” - Triptyline (amitriptyline) family

  • Contraindications (RN Top Focus):
    • All due to anticholinergic effects; caution with glaucoma due to anticholinergic effects
    • Mild hypertension may be acceptable; significant urinary retention risk due to anticholinergic effects
    • Alcohol: combined use worsens sedation and CNS depression; avoid
  • Generic: amitriptyline; Brand: Elavil
  • Indications/Off-Label: Major depressive disorder; off-label for neuropathic pain, migraines, insomnia, anxiety, bedwetting
  • Mechanism of Action: Tricyclic antidepressant; FDA approval in 1961

“Meet Triple AAA, on a Good” - Triptyline #2 (continued)

  • RN Top Focus: Side/Adverse Effects
    • Orthostatic hypotension
    • Weight gain
    • Anti-cholinergic effects: constipation, urinary retention, dry mouth; not associated with severe hypertension
  • Overdose: potential lethal due to anticholinergic toxicity and cardiovascular effects

Monoamine Oxidase Inhibitors (MAOIs)

How to Remember Them (Mnemonic and Imagery)

  • Phenelzine, Isocarboxazid, Selegiline
  • Memory aids:
    • Imagery of a Happy funnel scene with aged foods (phenelzine and isocarboxazid) to illustrate tyramine interactions; "Sell in Jeans" (selegiline) mnemonic
    • Phrases linking names and endings: -azid, -nelzine rhymes with -giline
    • Wizard Chairman Mao rhyme: “Azid Nelzine Giline!”

MAOI Generics/Brands and Uses

  • Generic/Brand: phenelzine (Nardil); isocarboxazid (Marplan); selegiline (Emsam)
  • Purposes: Depression, Panic Disorder, Parkinson’s disease
  • Off-label: Bulimia nervosa, PTSD
  • Key history: isocarboxazid (1959); phenelzine (1961); selegiline (1969)

Patient Education: Tyramine interactions

  • Tyramine-rich foods to avoid (aged/fermented):
    • Red wine, beer; aged cheeses (e.g., cheddar); processed meats (sausage, Bologna); chocolate
  • Tyramine exposure with MAOI can trigger headaches and hypertensive crisis
  • Quick rule: Fresh fruit OK; old/aged fruit, beer, aged foods not OK on MAOIs
  • If aged foods or tyramine-containing foods are consumed, risk of hypertensive crisis

Atypical Antidepressants

Bupropion (Wellbutrin / Zyban)

  • Generic: bupropion
  • Brand: Wellbutrin, Zyban; FDA approval 1985
  • Indications: Depression, seasonal affective disorder, smoking cessation
  • Off-label: ADHD, weight loss, antidepressant-induced sexual dysfunction
  • Mechanism of Action: Norepinephrine-Dopamine Reuptake Inhibitor (NDRI)
  • RN Top Focus: Purpose
    • Primary use: Smoking cessation
  • Side/Adverse Effects (x1): Hypertension (from increased norepinephrine)
  • Contraindications (x1):
    • History of seizures or epilepsy
    • Congestive heart failure
    • Anorexia nervosa
  • Practical note: Consider potential weight changes and seizure risk when selecting therapy

Lithium

“lith me out of bipolar”

  • FDA approval: 1970
  • RN Top Focus: Drug Administration and LABS
  • Effects on thyroid hormone: can affect thyroxine (thyroid function monitoring recommended)
  • Therapeutic range and monitoring:
    • Normal range: 0.6extmEq/L≤L≤1.2extmEq/L0.6 ext{ mEq/L} \leq L \leq 1.2 ext{ mEq/L}
    • Low level: drug may not work
    • High level: toxicity risk
  • Renal monitoring: periodic renal function tests required
  • Lithium level timing: trough level drawn about 12 hours after last dose; monthly monitoring recommended
  • Brand/Generic: Lithium (Lithobid)
  • Mechanism of action: not fully clear
  • Indications: Bipolar disorder
  • Off-label: Schizophrenia, impulse control disorders

Lithium Side/Adverse Effects and Toxicity (RN Top Focus: Side/Adverse Effects x 8)

  • Lithium toxicity signs (STOP medication and check levels):
    • Ataxia (impaired coordination)
    • Vomiting, nausea
    • Diarrhea
    • Slurred speech
    • Tremors (fine tremors may be acceptable; high levels cause significant symptoms)
  • Advanced toxicity: cannot walk or talk; severe symptoms include vomiting and confusion
  • Management: immediate assessment of lithium level and appropriate intervention

Valproic Acid (Depakote)

History and Indication Timeline

  • 1882: originally developed as a solvent
  • 1962: observed antiseizure effects in animals; seizures reduced in models
  • 1972: approved for treatment of seizures
  • 1995: approved for bipolar disorder
  • Generic: divalproex / valproic acid
  • Brand: Depakote
  • Indications: Epilepsy, Bipolar disorder
  • Off-label: Neuropathic pain, agitation
  • Mechanism of Action: Increases GABA activity
  • RN Top Focus: Purpose
    • Primary: Control manic phase of bipolar disorder; reduce seizure activity (absence seizures)
  • Side/Adverse Effects: Liver damage; routine liver function tests recommended; dizziness, nausea, vomiting; yellow sclera can indicate liver damage
  • Mnemonic emphasis: Regular liver labs essential due to hepatotoxic risk

Carbamazepine

Overview and Indications

  • Generic: carbamazepine; Brand: Tegretol
  • Timeline: 1953 – initially for depression/psychosis; 1962 – trigeminal neuralgia; 1963 – seizures; 2004 – bipolar
  • RN Top Focus: Side/Adverse Effects
    • Blood disorders requiring CBC monitoring (easy bruising/bleeding)
    • Anticholinergic effects: dry mouth
    • No requirement for diuretic use with this medication
  • Mnemonic: "Car BAM! all my CBC’s, I bruise now GET a CBC!!"
  • Primary/Purpose (one of many):
    • Trigeminal neuralgia (pain relief in facial pain)
  • Additional context: Used for pain relief in trigeminal neuralgia; seizures management as well

Antipsychotic Medications (Psychotics)

How to Remember the Psychotic Meds

  • Method #1: Wordplay: endings -idone, -peridol, -azine, and -apine
  • Method #2: Imagery showing evolution from first-generation (old) to second-generation (newer)
    • Example imagery: Old magazines (Thorazine), old perimeter (Haloperidol), gentle pines (Clozapine) and I done (Risperidone)

ALL Antipsychotics: Side/Adverse Effects (RN Top Focus)

  • Neuroleptic Malignant Syndrome (NMS):
    • Hyperthermia and hypertension, sweating, markedly increased muscle tone/rigidity, respiratory depression
    • Action: Stop medication immediately
  • Extrapyramidal Symptoms (EPS) – broad category including:
    • Pseudoparkinsonism
    • Acute dystonia
    • Akathisia
    • Tardive dyskinesia (late-onset, potentially irreversible)
  • Pseudo-Parkinsonism signs:
    • Shuffling gait
    • Head tilt to one side
    • Tremors
  • Tardive dyskinesia signs:
    • Involuntary oral-facial movements (lip smacking, puckering, chewing, grimacing)
    • Tongue thrusting, rapid blinking, neck twisting (torticollis), limb movements
  • Note: EPS and other severe motor side effects are major safety considerations with antipsychotics

First-Generation (Typical) Antipsychotics

  • Example: Thorazine (chlorpromazine)
    • 1954 FDA approval
    • Uses: Schizophrenia, bipolar disorder, nausea/vomiting; off-label: ADHD, behavior problems in children, hiccups
    • Mechanism: Dopamine receptor blockade (dopamine excess linked to symptoms)
  • Common Side/Adverse Effects (RN Top Focus):
    • Photosensitivity
    • Worsened blood dyscrasias
    • Agranulocytosis (neutrophil depletion in bone marrow)
    • Mnemonic: “Nukes your WBCs, especially neutrophils”

Second-Generation (Atypical) Antipsychotics

  • Example: Clozapine (Clozaril), Quetiapine (Seroquel)
  • Generic: clozapine; quetiapine; Brand: Clozaril, Seroquel
  • FDA approval: 1989
  • Uses: Schizophrenia; reduce suicide risk
  • Off-label: Aggressive dementia, autism, PTSD, borderline personality disorder, anxiety, insomnia
  • Mechanism: Dopamine receptor blocker (D2 blockade) with additional serotonin effects (atypical profile)
  • RN Top Focus: Side/Adverse Effects
    • Agranulocytosis (major risk; requires WBC monitoring)
    • Myocarditis (rare but serious)
    • Bone marrow suppression risk
    • WBC monitoring: Normal range ~ 5,000–10,000 cells/mm³; if WBC falls below safe level, discontinue
    • Orthostatic hypotension
    • Other safety considerations: higher adherence due to lower EPS risk, but other systemic risks exist

Risperidone (Risperdal) – 2nd Gen Antipsychotic

  • Generic: risperidone; Brand: Risperdal
  • Uses: Schizophrenia, bipolar disorder, irritability related to autism; off-label: ADHD, depression, OCD
  • FDA approval: 1993
  • Mechanism: Dopamine receptor blocker
  • RN Top Focus: Side/Adverse Effects
    • Metabolic syndrome risk (weight gain, high glucose, dyslipidemia)
    • Sedation, especially with alcohol use
    • Hand tremors
    • Orthostatic hypotension
    • Photosensitivity
  • Notable catchphrase: “I done with schizo symptoms” (but watch for weight gain)
  • Gen 2 status: part of second-generation antipsychotics

Notes on Memory Aids and Practical Implications

  • Memory aids can help recall drug families and key side effects, but should be used in addition to clinical guidelines and pharmacology texts.
  • Patient education is critical for all antidepressants and antipsychotics: adherence, tapering, recognizing adverse effects, and when to seek medical attention.
  • Safety monitoring is integral for several agents: CBCs with clozapine, liver enzymes with valproate, thyroid function with lithium, renal function with lithium, and metabolic parameters with second-generation antipsychotics.
  • Ethical and practical considerations: balancing efficacy with potential severe adverse effects (e.g., agranulocytosis with clozapine, hypertensive crisis with MAOIs, serotonin syndrome with SSRIs), ensuring informed consent, and coordinating with psychotherapy.

Quick Reference: Key Lab Values and Timeframes

  • Lithium:
    • Normal range: 0.6extmEq/L≤L≤1.2extmEq/L0.6 ext{ mEq/L} \leq L \leq 1.2 ext{ mEq/L}
    • Trough level timing: about 12 hours after last dose
    • Monitor renal function and thyroid function due to systemic effects
  • Valproic acid / Divalproex (Depakote): liver function tests required due to hepatotoxic risk; monitor for signs of liver injury (yellow sclera, jaundice)
  • Clozapine: WBC monitoring due to agranulocytosis risk; baseline and ongoing CBCs are required; risk of myocarditis

Final Practical Takeaways

  • Always assess indication, patient history (including seizure disease, cardiac status, hepatic/renal function, glaucoma risk, age, pregnancy status), and comorbidities before selecting an antidepressant or antipsychotic.
  • Monitor for specific adverse effects depending on drug class, and plan for long-term safety surveillance (labs, vital signs, metabolic panels).
  • Education and follow-up are essential for optimizing outcomes with antidepressants and antipsychotics, as highlighted in the slides.