Lithium
USE: for mania in bipolar

MECHANISM: modulates Na+ of nerve & muscle cells => reduces manic episodes. It's highly attracted to thyroid gland and thus causes hypothyroidism.

SIDE EFFECTS:

• Vulnerable population:
•  Women: effective birth controls => D category for pregnancy & lactating
• Elderly: lower dosage
• Adolescents: FDA approved for >12 y/o
• Organs:
• Heart - arrhythmias & hypotension
• Neuro - impaired thought process & drowsiness
• Skin - hives, acne, alopecia, eruption of psoriasis

MONITORING:

1. Renal (BUN, Cr, GFR q3 mo.)-----Need to drink lots of water due to risk of nephrogenic diabetes insipidus
2. Thyroid (TSH) ----Similar to Iodine, Lithium as a chemical element is also attracted to thyroid
3. Monitor blood level ---- Narrow therapeutic index, Toxicity is closely related to serum lithium concentrations and may occur at dosages close to therapeutic levels; monitor therapy by measuring serum lithium

Lithium:
Metabolism: Not metabolized (Therefore, not worried about Liver function).----it cannot be further broken down, kinda similar to Sodium
Elimination: Renal (Check renal function)

Generic	Brand	Dosage
Duloxetine	Cymbalta	30-60mg 20mgBID 30mgBID
Venlafaxine* (Incr BP)	Effexor	37.5mgBID 25mgTID
Desvenlafaxine* (Incr BP)	Pristiq	50mgqd same time
Levomilnacipran	Fetzima	40-120mgQD Start 20mgqd x2-3d Then 40mg

*Check Liver & Renal functions
*Do not combine with MAOI (causes erotonin syndrome)

Generic	Brand	Dosage	Elderly***
Citalopram	Celexa	20-40mg qd*	20mg max (QTc)**
Escitalopram***	Lexapro	10mg qd
Fluoxetine	Prozac	20-60mg 90mgqweek Extended Release AM 20mg PM20mg	10mg initial
Paroxetine	Paxil	20-50mg	10mg initial
Sertraline	Zoloft	25-50mg
Vilazodone	Viibryd	20-40mg Start @ 10mg initial

Mnemonics:
Parrot               savors the       ecstatic               citrus            fruit in the       village
Paroxetine        Sertraline       Escitalopram      Citalopram   Fluoxetine      Vilazodone




Citalopram

* The SSRIs are not thought to be as worrisome in patients with cardiac disease, as they do not appear to exert any effect on blood pressure, heart rate, cardiac conduction, or cardiac rhythm; however, dose-dependent QT prolongation has been reported with citalopram. Because of the risk for QT prolongation, citalopram is contraindicated in individuals with congenital long QT syndrome.
**The FDA advises that the dose of citalopram not exceed 40 mg/day because of the risk of potentially fatal QT prolongation. Furthermore, higher doses have not been shown to be more effective in treating depression.


***Escitalopram is an SSRI and S-enantiomer of citalopram

**** Elderly is always half the dosage

3 brain chemicals:

1. serotonin
2. dopamine
3. norepinephrine

A - Reuptake inhibitors: SSRIs, SNRIs, NDRIs
Premise: Serotonin, Dopamine, Norepinephrine are feel-good chemical in the brain. Therefore, blocking the reuptake (brain cells take those neurotransmitting chemicals back in the brain) will help more of them available for you to feel good.

1. SSRI - Selective Serotonin Reuptake Inhibitor
2. SNRI - Serotonin Norepinephrine Reuptake Inhibitor  
3. NDRI - Norepinephrine Dopamine Reuptake Inhibitor - Wellbutrin (Zyban) 
4. SARIs - Serotonin antagonist reuptake inhibitors -Nefazodone & Trazodone

B - Older:  MAOIs & TCAs

1.  TCAs
2. MAOIs - Monoamine oxidase is a natural enzyme that breaks down serotonin, epinephrine, and dopamine. MAOIs block the effects of this enzyme. As a result, the levels of those neurotransmitters might get a boost.The downside is that MAOIs also prevent the body's ability to break down other medicines metabolized by this enzyme (such as Sudafed, or stimulants) -- raising the risk for high blood pressure -- as well as an amino acid called tyrosine, which is found in certain foods like aged meats and cheeses. MAOIs also shouldn't be combined with other medicines that can raise serotonin (such as certain migraine medicines, or other antidepressants), because that can cause a buildup of excessive serotonin (called "serotonin syndrome"), which could be life threatening.

References:
http://www.webmd.com/depression/how-different-antidepressants-work#1

Types:

• Psychotic depression
• Persistent depression: 2 years (mnemonics: think nursing school!)
• PMDD: dysthymia, erratic mood swings before menstruation

Etiology: genetics + biological + environmental + psychological
Epidemiology:

• Women: attempt more suicides (keep trying again and again, unable to complete the suicide like men)
• Men: choose ETOH & Drugs
• Elderly: usually mistaken grief for depression

Timing:

• Postpartum blues: 1 fortnight 

S/s:

Test: PHQ9
Tx:

  Psychotherapy:

	Goal	Population	Caution
Cognitive Behavioral Therapy (CBT)	Change behavior
InterPersonal Therapy (IPT)	relationship issues
Problem Solving Therapy (PST)	realistic solutions	Good for elderly
Internet-Computer based therapy	CBT + IBT	Homebounds, teens, LGBTQ, rural	Viz-a-viz still preferable

Meds:

• Adolescents: suicidal thoughts
• Onset: 1-2 fortnights (2-4 weeks) or up to 1/2 year (6 mo.) to work
• SSRIs, SNRIs, TCAs should NOT be used with MAOI
• Common antidepressant side effects: 
• Monitor Liver/Renal function (cleared thru hepatic and renal chanels)
• Decreased libido
• St John Wort: bleeding side effects (due to being an anticoagulant)
• Need to wean before stopping antidepressant

•  SSRI - Serotonin:
• 
  

• Generic	Brand	Dosage	Elderly***
  Citalopram	Celexa	20-40mg qd*	20mg max (QTc)**
  Escitalopram***	Lexapro	10mg qd
  Fluoxetine	Prozac	20-60mg 90mgqweek Extended Release AM 20mg PM20mg	10mg initial
  Paroxetine	Paxil	20-50mg	10mg initial
  Sertraline	Zoloft	25-50mg
  Vilazodone	Viibryd	20-40mg Start @ 10mg initial

   

Others: ECT, rTMS, VNS

Beta blockers

•  Propanolol (Inderal); Atenolol (Tenormin); Nadelol (Corgard) 
• Pre-treatment EKG for baseline
• Side effects:
• Fatigue, dizziness, weakness, decreased BP or HR (think: beta blocker is like a damping break on the machine of the heart = the heart can't increase BP or HR => leading to fatigue & weakness. Of course, the heart can't work as fast leading to weakness
• Tx: 
• always start with lowest dose
• elder caution!

Types - Generalized, social, panic

	Timing
Generalized	Months/years (trait temperament)
Social	Stressor precedent
Panic	Minutes

Epidemiology - females mostly
Etiology - genetics

Tx - Social (CBT); Meds(most common)-BZD (withdrawal/sz - needs taper!), Antidepressants (Adolescent caution!), BB (elderly caution!); Meds (most helpful for long term)-BuSpar


Meds:
Common side effects:

• Blurred vision, nausea (rest & digest)
• Fatigue (Beta blocker)
• HA (Buspirone)
• Confusion (cloudy thinking - rest &digest)
• Nightmares (Buspirone)

Severe side effects:

• It's like Rest & Digest (relaxation mechanism) going too much (severe/adverse Side effects): drowsy (rest!), dizzy (rest!), increased saliva (digest!), blurred vision (dim light sleepiness!), difficult with cognition (!!!), decreased libido (rest!), unsteady gait
• Anaphylaxis: swelling of face, sob, rash
• Psych (antidepressants in youth): suicidal thoughts
• Metabolic issue: jaundice

1.     BB

•  Propanolol (Inderal); Atenolol (Tenormin); Nadelol (Corgard) 
• Pre-treatment EKG for baseline
• Side effects:
• Fatigue, dizziness, weakness, decreased BP or HR (think: beta blocker is like a damping break on the machine of the heart = the heart can't increase BP or HR => leading to fatigue & weakness. Of course, the heart can't work as fast leading to weakness
• Tx: 
• always start with lowest dose
• elder caution!

2.     BuSpar = Boost Spa = relaxing for Anxiety

BuSpar = Boost Spa
Side effects:

• Dizziness, HA (if tapered too quickly); Nausea -----Mnemonics: if get up to leave from boost spa (BuSpar) too quickly, it will cause you to have orthostatic low blood pressure & middle ear vertigo (dizziness, HA, nausea)
• Nervousness/Excitement/Insomnia ----Mnemonics: if you leave Boost Spa (BuSpar), you may get nervous rebound, thus insomnia - can't sleep, at times get paradoxical excitement

~By Qt

Benzodiazepines for anxiety mnemonics:
LA-AX-Clo =LAX Clorox eases ur zepam anxiety = Lorazepam (Ativan); Alprazolam (Xanax); Clonazepam (Klonopin)

Note: withdrawal/sz - needs taper! = Mnemonics: just think of BZD like alcohol = can cause seizure and w/drawal - needs taper Viz: pt on ETOH cold turkey = needs to be given BZD bc they will be having sz and w/drawal)


~by Qt

•  Antidepressants [DOC]
• BuSpar (antianxiety 
•  not related to BZD or barbituates = minimal side effect; 
• a novel antianxiety agent with no other members in its class;  
• Unlike the immediate relief of symptoms that occurs with benzodiazepine therapy, buspirone's onset of action takes two to three weeks = 2-3 wk for full efficacy)

• BZD (Oral, IV - early onset but high abuse potential)
• Immediate onset & short half life: IV Lorazepam (Ativan)
• Drugs: Lorazepam (Ativan); Alprazolam (Xanax); Clonazepam (Klonopin)
• Mnemonics: LA-AX-Clo =LAX Clorox eases ur zepam anxiety = Lorazepam (Ativan); Alprazolam (Xanax); Clonazepam (Klonopin)
• lead to dependence; that is, withdrawal symptoms occur once the medications are discontinued. Withdrawal symptoms include anxiety, irritability and insomnia, and it can be difficult to differentiate between withdrawal symptoms and the recurrence of anxiety. Seizures occur rarely during withdrawal.28 Withdrawal symptoms tend to be more severe with higher dosages, with agents that have short half-lives, with rapidly tapered dosages, and in patients with current tobacco use or with a history of illegal drug use.15 The risk of dependence increases as the dosage and the duration of treatment increases, but it can occur even when appropriate dosages are used continuously for three months.4,27 Withdrawal symptoms begin six to 12 hours after the last dose of an agent with a short half-life and 24 to 48 hours after the last dose of an agent with a longer half-life.27 In patients who have taken a benzodiazepine for more than six weeks, the dosage should be decreased by 25 percent or less per week to prevent withdrawal symptoms.4 Patients may experience rebound anxiety (akin to the rebound hypertension that occurs when some antihypertensives are discontinued) once the tapering process is completed, but this is transient and ends within 48 to 72 hours.28 Once the rebound anxiety ends, a patient may re-experience the original symptoms of anxiety, referred to as recurrent anxiety.

• Beta blockers - Propanolol (Inderal); Atenolol (Tenormin); Nadelol (Corgard) (Pre-treatment EKG for baseline, Tx: always start with lowest dose, elder caution!)

BuSpar = Best Spa = relaxing for Anxiety
BuSpar = Boost Spa
Side effects:

• Dizziness, HA (if tapered too quickly); Nausea -----Mnemonics: if get up to leave from boost spa (BuSpar) too quickly, it will cause you to have orthostatic low blood pressure & middle ear vertigo (dizziness, HA, nausea)
• Nervousness/Excitement/Insomnia ----Mnemonics: if you leave Boost Spa (BuSpar), you may get nervous rebound, thus insomnia - can't sleep, at times get paradoxical excitement

Buspar = Push bar = Push the bar = trying to exercise to get the edge off. (by Qt).

Buspar is used for long-term management of anxiety. (Viz: long term exercise = long-term feel good)

 

 

What do most people go to when they need to quell some anxiety? They need Booze(pirone).

Both booze and boozpirone will take the edge off. We can even get fancy and use its trade name, Buspar. No better place to get that booze than down at the BoozeBar….
Go get smart! (Source: https://www.medschooltutors.com/blog/mastering-mnemonics-for-the-usmle-neuro-psych-drugs)

ranolazine is kinda a new med that is used to treat angina. it's adjunct. however, if you're worried about orthostatic hypotension, you can use this. it's a newer drug with lesser side effects. There was one question on the exam that talks about this.  I wasn't so sure about it because there was another choice in which you can just not give Metoprolol that the pt has been taking for his HTN and use diltiazem instead - this is a wrong answer. However, since metoprolol is working for the pt, you don't want to d/c it (I questioned my instructor for this). Diltiazem tho has little if any vasodilation effects. Diltiazem works similarly to the beta blockers. so you don't want to use it because despite its little-if-any vasodilator effects, it could cause slowing heart rate. So, when you have orthostatic hypotension, what happens when you stand up? You feel dizzy and your heart beats faster to compensate for the drop in blood pressure. So, if you're on diltiazem, you're gonna put your pt at risk for too slow a heart beat. This could cause worsening of orthostatic hypotension. So, you wanna use Ranolazine to combat this.

-Tardive: the involuntary movements are tardive, meaning they have a slow or belated onset. This neurological disorder, by definition, most frequently occurs as the result of long-term (usually at least 3 months duration) or high-dose use of antipsychotic drugs. (1)

- Mech.: DA receptors become hypersensitive
Mnemonics: when the typical neuroleptics guys work so hard to get rid of the dean DA out. They can create a tardy university schedule (tardive). This causes many students and the affected people to cau co' mat may aka scowl aka they can't help but have those bizarre involuntary movements of the tongue, face, lip, and puffing cheeks. 



ref.:
https://en.wikipedia.org/wiki/Tardive_dyskinesia

Dystonia---- DYS-tO-nia (DYSCO)---abnormal tonicity (head & neck)  such as torcolitis  
Akathisia ----Aka-THIS-ia (At THIS)----- feeling of inner restlessness ---restless compulsive movements such as pacing, shifting, tapping feet .... Viz.: THIS, this this this, the dean DA keeps tapping her hands on the desk trying to think how to get the univ. which is in the trouble back to work.
Pseudo-Parkinsonism---pseudo-PARKinsonism (PARK)--- reversible

Mnemonics:

If too much of the high potency drugs (such as HaloPeridol which tries to get rid of the dean DA from the pyramid). This hits the dean DA hard. The dean falling from the pyramid down the ground causing the dean to have torcollitis (DYStonia).

This horrible incident can cause the dean DA to really leave the university causing the university to be not working or functining or moving forward with life (motion movement disorder). Thus, it causes the entire univ. to play disco like it is at a park

Increased Ach fish => increase cognitive function
Increase DA @ the univ. => helps parkinsonism
Decrease DA @ the library => decrease psychosis (schizophrenia)
Increase NorEpi & Increase 5-HT => improve moods
Increase GABA receptors => calm down => less seizures & less anxiety

Source: http://www.who.int/medicines/services/inn/StemBook_2011_Final.pdf

from WHO

Place in therapy: non-CNS stimulant for ADHD, not as effective as a monotherapy compared with CNS stimulant

Mnemonics for bupropion:  butt-prop to get your attention

Avoid: in pts w/ seizures
Use: Good for pts/ with depression & ADHD (depressed pts go party where there's lots of butt-prop which make them less depressed and the butt-prop got their attention)

butt-prop-ion => Bu-prop to get your attention

-oxetine root word BUT NOT a SSRIs
Place in therapy: Non-CNS stimulant (NOT as effective as monotherapy compared w/ CNS stimulants)
Mnemonics: strattera straightens up these kids' improper behaviors. (1)

==> Wonder Me's mnemonics: oxygen tubing needs to be straighten => cannot be kinked to be used effectively on these kids.

Atom Oxygen = Atom-Oxytine

Oxygen tank = Oxetine

                                           

(1): https://books.google.com/books?id=uhSjCwAAQBAJ&pg=PA91&lpg=PA91&dq=oxetine+mnemonics&source=bl&ots=ZDbPjeAI7Z&sig=p60bSG8Xq0L2gUnJiJKRxhTZeMU&hl=en&sa=X&ved=0ahUKEwiutsiS7pTMAhVL6mMKHe8TBMQQ6AEIMjAD#v=onepage&q=oxetine%20mnemonics&f=false

Mnemonics for -oxetine: oxy-tank

ex: fluoxetine, paroxetine

oxy-tank = -oxetine (with oxygen = u're happy and less hyperventilating <=> less anxiety, less depressant)

serotonin mnemonics:

Sarong tony = Serotonin = the party girl (more of her, more fun = full of self-esteem)