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USMLE Step 2 Psychiatry Antipsychotic Medication Chp. 18


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Antipsychotic medications
What do old drugs attach to?
Newer drugs bind to what?
What do old drugs S/E?
block muscarinic receptors: dry mouth, blurry vision, urinary retention, confusion, hallucination
What other Symp. Do you expect with histamine block?
sedation and weight gain
What symp. Do you get with alpha block?
orthostatic hypotension
What are the older antipsychotics?
What antipsychotic gives your retinitis pigmentosa?
thioridizine eye
What happens when you block the mesolimbic tract?
reduce psychotic symptoms
What happens when you block nigrostriatal block?
increase tremors, parkinsons EPS symptoms!
What tract does clozapine block?
Mesolimbic Tract
What does a block in the tuberoinfundibilar block?
no galactorrhea, gynecomastia, amenorrhea
Pat. w/ psychotic, what tx?
olanzapine (atypical any)
If all other drugs fail what is next tx?
clozapine (agranulocytosis be careful)
If pat. Is noncompliant?
1st choice haloperidol or fluphenazine depot decanoid form
Pat. Is agitated?
use IM forms (typicals)
How do antipsychotic medication work?
block dopamine receptors

old D2
new D4
What do new antipsychotics work as well as D4?
they work on serotonin as well

What are some other effects of antipsychotics?
1) block central and peripheral cholinergic receptors
2) histaminic block
3) alpha-block
What are the symptoms of muscarinic block?
urinary retention
dry mouth
blurry vision
If you are going to prescribe to the elderly what do you avoid?
avoid drugs w/ muscarinic block
Where do new antipsychotics work on?
D4 more and also serotonin 5HT3
What do antipsychotics block?
muscarinic block, alpha block, histamine block
What is an important S/E of antipsychotics?
sedation and weight gain (histamine blockade)
hypotension (alpha block)
dry mouth, urinary retention, constipation, confused, blurry vision (muscarinic block)
Where do antipsychotics work on?
D2 and D4 receptors

Old work on D2
new on D4
What are the side-effects of histamine blockade?
weight gain and sedation
What do you find with alpha blockade?

so be careful on the elderly
they might fall and break a hip
Main groups for antipsychotics?
typicals D2 antagonists only low-potency: Clopromazine

High-potency: Haloperidol

old drugs D2: Haloperidol, Thioridazine, Olanzapine, fluphenazine

new drugs Risperidone
Of the newer drugs, which one of these cause movement side effects of antipsychotics? EPS symptoms?
Risperidone is the answer
WHat are the multiple receptor antagonist work on?
D2, D4 and Serotonin 5HT
What are the new antipsychotics multiple receptors?
What does the D2 blockade cause?
EPS symptoms
What decreases EPS symtpoms?
D4 receptors
What are the indications of antipsychotics?
patients get agitated
Which one in the E.R. antipsychotics?
since it comes in I.V.

easier to give them a shot
DOC for schizophrenia?
Tx for agitation for schizophrenia, mood disorders, psychoses, delusional disorders, brief psychotic disorders, schizophreniform disorder?
Why do you avoid giving elderly diazepine?
makes them more confused
problems with their memory
What is another name for Dopamine?
Prolactin Inhibitory Factor

What happens when you inhibit dopamine with antipsychotics?
PIF is not there
so prolactin goes up
What happens when prolactin goes up?
galactorrhea, gynecomastia, amenorrhea
What does dopamine block?
tuberoinfundibular tract
mesolymbic/mesocortical tract
nigrostriatal tract

all involved
What happens when you block tuberoinfundibular block?
prolactin increases
What are other S/E of the older antipsychotics?

Retinitis pigmentosa
What antipsychotics produces retinitis pigmentosa?
What are other problems with thioridazine?
cardiac conduction problems
WHat are S/E of clozapine?
What happens when dopa blocks mesolymbic tract?
reduce psychotic symptoms

decrease psychosis
What happens when you block nigrostriatal tract?
increase in movement disorders

tremors, parkinsonian disease
WHat does clozapine block?

no EPS (nigrostriatal)
no amenorrhea, no galatorrhea, no gynecomastia (tuberinfundibular)
Does clozapine cause amenorrhea, galactorrhea, gynecomastia, EPS symptoms?

only blocks mesolimbic tract
reducing psychosis
What are the types of movement disorders?
acute dystonia
tardive dyskinesia
Which movement disorder is the first one to appear?
acute dystonia
When does acute dystonia appear?
occurs within hours or days of treatment

patients get really scared
Why do patients get scared with acute dystonias?
its a muscle spasms
cant' move
What happens to Ach when Dopamine is high?
Ach decreases

What are first choice drugs of psychosis?
Olanzapine, Quetiapine, Ziprasidone
What are the S/E of Olanzapine, quetiapine, ziprasidone?
Weight gain and sedation
What is the S/E of clozapine?
What are the S/E of ziprasidone?
prolongation of QT interval
What patients have a contraindication of ziprasidone?
What are the S/E of Olanzapine and Clozapine?
Cause Diabetes
What patients have a contraindication of Olanzapine/Clozapine?
What antipsychotics are used to tx non-compliant patients?
haloperidol and fluphenazil
Why do haloperidol and fluphenazil are prolonged in their action?
they have the decanoid form
I.M. deposit
Is Tardive Diskinesia reversible or irreversible for Step 2 USMLE?
Antidepressants are used to Tx what?
Mood disorders, adjustment disorders, psychotic disorders
What are other uses for antidepressants?
anxiety disorders
Why is anxiety treated with antidepressants?
use same neurotransmitter
What percentage of pat. w/ depression have anxiety?
90% of the patients have anxiety w/ depression
Why are antidepressants used to tx bulemia?
act on same neurotransmitter

Why do antidepressants work on impulse control disorders?
What are amytriptiline of TCA (triciclics) commonly used for?
If the patient has depression he will surely have?
What is used for chronic pain?
Why is amytriptiline used for chronic pain?
amytriptiline increases endorphins

increase endogenous opiates

patients complain less of pain
Which ones are dangerous in OD?
specially TCA
Pat. comes after OD of TCA, what do they need to be attached to?
cardiac monitor

causes conduction problems
What is the effect/toxicity of TCAs Overdose?
heart conduction problems
How do TCAs work?
block the reuptake of neurotransmitter (serotonin and NE, and dopamine)

work by down regulation of beta adrenagic receptors
How do the MAO inhibitors work?
work on the enzyme that metabolizes Sertonin, NE, Dopa

doesn't break down the neurotransmitters
so more NE, Ser, DOPA
Where do the SSRIs work?
they only block the reuptake of serotonin
Why do you choose an SSRI instead of TCA or MAO?
because of less S/E
What is the first line of antidepressants?

cleaner, pat. like it, less S/E
What other receptors are blocked w/ TCAs?
muscarinic receptors are blocked
What do you expect w/ the TCA muscarinic block?
dry mouth
blurry vision
urinary retention
What are other two receptors that TCA block?
Histamine and alpha receptors
What happens when you give TCAs and block alpha receptors?
What happens when you give TCAs and block histamine?
sedation and weight gain
Which TCA is the worst cause it gives you the most S/E?

takes you on a bad trip!
What patient would be a relative contraindication for giving him amytriptiline?
90 yo, demented, w/ glaucoma, and prostathic hyperthrophy...

why? hypotension, urinary retention, blurry vision (might fall)
TCA stands for?
T for upTake blocker
T is for hisTamine blocker
C is for musCarinic blocker
A is for alpha blocker
Which drugs are the fasest of the TCAs?
nortryptiline and disipramine

less S/E
What are antidepressants used for?
Tx: depression,

- depression in Bipolar Dis.
- ALL anxiety dis.
What is the efficacy of antidepressants?
Which drugs are used first?
Newer ones
Which antidepressants are more dangerous?
usually older ones

more S/E
How long do we keep patients before we know the antidepressants are working?
they start working until 4-6 weeks
What is the MCC of drug failure?
the time doctors try the drugs less than 4-6 weeks.

Need to maximize doze and maximize dose switching
When do you stop antidepressants?
if S/E are not tolerated by patient
If you have a patient not responding you need to give another medication in order to boost 1st antidepressants?
Lithium or Thyroxine

or even Amphetamine like drugs
HOw long do we keep patients on antidepressants?
Tx should continue for 6 months to 1 year

since they relapse
What antidepressant drugs cause the most sedation?
Doxapine, amytriptiline, trazodone
What is the use of doxapine and trazodone?
give it to patients at night so they can sleep

causes sedation
Which antidepressants cause less sedation?
Cleaner ones, newer less S/E

Desipramine, protrityline and SSRIs
Which antidepressant causes most Hypotension?
Which TCA causes the most hypotension?
Which is Best TCA for antidepressants?
Nortriptyline and Desipramine
Which antidepressant drug has the worst anticholingergic?
Which antidepressant has less anticholinergic effects?
nortriptyline and desipramine

also SSRIs since they only work on serotonin
What do you have to remember about the TCAs and the heart?
prolong the QRS interval

need to do a EKG
What is the effects of antidepressant and seizures?
lower the seizure threshold
Which TCA causes the most seizures?
Does bupoprion cause seizures?
Do women with bulemia have a high incidence of seizures?
Do antidepressants cause sexual dysfunction?
yes all of them cause
What are the sexual dysfunction S/Es caused by antidepressants?
decrease libido
delayed ejaculation
What antidepressant causes anorgasmia and decrease libido? also delayed ejaculation
What antidepressant causes priapisms?
Which one of the SSRIs causes less sexual dysfunction?

What is priapism?
prolonged and painful erections
What are the SSRIs?
SSRI with least sexual S/E?
Why are SSRIs used to Tx OCD?
serotonin involved

panic as well as bulemia
What are the S/E of SSRIs?
patient agitation
What do you tell a patient that gets agitated when takin SSRI?
tell them to take it at night
What if a pat. feels sedation of SSRIs?
take the SSRI at night to take advantage of the S/E
What are all the S/E of SSRI?
sexual dysfunction
What is trazodone called?
heterocyclic antidepressant

off shoot of TCA family
used for its sedation effect
used in insomnia
Where does fenazodome works?
NE and serotonin

more like an SSRIs
What is bupoprion used for tx what age patients?
older patients less S/E
What neurotransmitter is involved when using Bupoprion?
What is bupoprion similar to?

used as Wellbutrin

dose is different
Why is dopamine associated with smoking sessation?
Dopamine is linked to reward centers

decrease the pleasure
What is bupoprion use to Tx?
smoking sessation
What drug blocks the pleasure of alcohol?
What is venlafaxine similar to?
What is mirtazapine similar to and S/E?

lots of Sedation
What are TCAs divided into?
tertiary and secondary
What are the teriary TCAs?
What are the secondary TCAs?
What happens when imipramine is broken down from its tertiary form?
it converts into its active form desipramine secondary form
When amitriptyline breaks down, what does it form?

the secondary active form
Which ones are cleaner talking about S/E between tertiary and secondary?
secondary don't have that many S/E since they are the active form of the drug

no intermediates
less S/E
What is a problem for all TCAs?
they have a therapeutic window

the drug has to fall within range to be effective
What is the efficacy of TCA drugs?
mood disorders
Which drug can be used to tx panic?
What is clomipramine used for?

works most on serotonin
What is amytriptyline used for?
Chronic Pain
Why are MAOIs are not used in a regular basis?
Can't eat foods rich in Tyramine

will cause a reaction of increase blood pressure
What foods should you avoid if taking MAOIs?
- red wine
- aged cheeses
- chocolate
- sausages
- nuts
- pickled products
- herring

white wine ok, processed cheeses ok
What is the best tx for depression?
Is ECT the MC tx for depression?
Why is ECT not used as first line for depression?
nobody wants ECT
When is ECT prescribed?
severely depressed/suicidal tendencies

1)patient still tries to kill himself

2) patient has not responded on TCA,MAIO, Lithium, Amphetamine like drugs
Is ECT used only for depression?
no, also:
In synthesis when do you use ECT?
typically when all other conventional therapies have failed
Are there any absolute contraindications of ECT use?
What is the only situation you have to be careful with the use of ECT?
only in a case of increase intracraneal pressure

since ECT increase pressure
What is another case in a pat. w/ depression which you might be inclined to use ECT?
when the pat. has received ECT previously w/ success
What is the only problem w/ ECT?
some memory loss
What is the characteristic of the memory loss w/ ECT?
What does transient memory loss mean?
when the Tx is over, your memory comes back
What are some of the complications of ECT?
induced paralysis
Do you need a seizure in order for ECT to work?
What is the typical course of ECT?
10-15 treatments
What tests are done before ECT administration?
rule out tumors that increase intracraneal pressure

x-rays of bodies (fractures that haven't healed)
WHat are the mood stabilizer medications?
lithium (bipolar)
What are some of the symptoms treated w/ mood stabilizers?
impulse control disorder
What are the indications of lithium?
bipolar disorder
schizoaffective disorders

also mood disorders
(augment response to medication)
What is lithium not perfect?
Has a narrow margin or safety
What does narrow margin of safety mean?
constantly have to monitor lithium in blood

check blood levels since it could become toxic/lethal
What is the most common S/E of lithium?
tremor, shaking
worsen acne

gain weight
conduction problems
What test is essential to perform before administering lithium?
TSH before starting lithium
What are other major S/E of Lithium?

Nephrogenic DI
What is the most important S/E for Lithium?

cardiac malformations
What are the teratogenic effects of lithium on the fetus?
cardiac malformations
epsteins anomaly
(tricuspid valve affected)
What test do you give a woman that is young and needs to start lithium Tx?
Test pack
pregnancy test
What advice do you give the female patient if they are on lithium?
make sure not to get pregnant while on lithium

- if she does get pregnant she should stop lithium immediately
What is the therapeutic index of lithium?
0.6-1.3 or 1.5

you should keep it at 1

the higher the dose, the higher the S/Es
What is a recommendation to ALL patients on Lithium?
drinks lots of fluids
- if pat. becomes dehydrated, then toxic levels may accumulate in plasma

hyponatremia increases toxicity
lithium follows sodium
What is the Tx of Choice for Lithium at toxic levels above 2.0?
What are some S/E of lithium at hight doses?

What is one of the first indications that lithium levels are high?
gait disturbances (Ataxia)
What is valproex used for?

rapid cyclers (within days)
When do you use valproex?
- when lithium is not working
- when lithium is contraindicated (ie. thyroid disease)
How many days does valproex take to reach desired effect?
10-14 days
What are the S/E of divalproex?
cognitive impairment
tremors (like lithium)
GI disturbances
What is the difference in toxicity of valproex?

lithium (nephrotoxic)
What test do you request before administering divalproex?
liver function tests
hepatic function panel
What is the teratogenicity of valproex?
Spina Bifida

shape of the letter V
What is second line of bipolar?

also valproate (divalproex)
Tx of Choice for bipolar disorder?

(if lithium not there divalproex)

last resort carbamazepine
What toxicity does carbamazepine produce?
hepatic toxicity
What are S/E of carbamazepine?
What are two drugs that cause agranulocytosis?
carbamazepine and clozapine

escarba colcha y cloza
What are the other mood stabilizers?

not as effective
What is different about topiramate?
helps patients reduce weight
Pat. comes in w/ mania... tx?
mood stabilizer

if not divalproic acid
If a pat. has acute mania (emergency) can't wait two weeks to calm him down?
What are the anxiolytics?
MOA of axiolytics/benzodiazepines?
work on GABA receptors
open Cl- channels increaseing the frecuency
What are other uses of benzodiazepines other than anxiety?
insomnia specially in the elderly
Where does buspirone work?
buspirone maybe works on serotonin
What is buspirone used for?
Generalized Anxiety Disorder (GAD)
Social Phobias
What is the Tx. for adjustment disorder? anxious
benzos w/ psychotherapy
What is the Tx. for Panic Disorder? anxiety
Benzos, SSRIs
What is the Tx. of OCD?
What is MC used for social phobias?
What do you adjust with the elderly on Tx. w/ benzos?
lower the dosage

sedation, memory problems, confusion
What DDI (drug drug interaction) is lethal w/ benzos?

potentiates benzos
respiratory arrest (diaphragm paralisis)
What is the problem with taking benzos?
Very Addictive
What are the S/Es of benzos?
sedation, memory problems, confusion

impairment of cognitive and motor performance
possible teratogenicity
Is buspirone addictive?
What is buspirone the DOC for?
GAD (generalized anxiety disorder)
Pat. alcoholic that needs to be placed on anti-anxiety medication?
then better to place him on buspirone since not addictive/no withdrawal symptoms

pat. is going to drink and might have DDI w/ benzo+alcohol
What is the only S/E of buspirone?

complain some patients headache
Tx for Depression? A) fluoxetine or b) nortriptiline?

Tx for Depression?
Nortryptiline or Amytriptiline?

less S/E
Pat. w/ bipolar disorder who has kidney problems?
not lithium
but valproic acid (metabolized in liver)
What 3 test do you ask for if patient needs to start lithium?
Pregnancy Test
Thyroid (TSH)
Kidney function

regular blood work
Tx for panic disorder? general and specific...
any benzos but specifically alprazolam

What drug is used for the prevention of alcohol withdrawal?
chlordiazepoxide (taper dose)
What other drug besides chlordiazepoxide is used on alcohol withdrawal?
safe detox with oxazepam

(out the liver)
Which benzo doesn't go through CP450?
OTL out the liver
Pat. comes in w/ alcohol abuse, while in E.R. he becomes agitated? What benzo do you use?
Oxazepam, temazepam, or lorazepam

lorazepam is I.V. or I.M.

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