CLINICAL QUESTIONS

Rapid, high-yield Q→A for rounds, the OR, and specialty clinics.

Depression
PHARM
MANIA
SUBSTANCE USE
PSYCHOSIS
CHILD PSYCH

  • Mirtazapine

  • Increases appetite and helps with sleep, can cause increased weight gain.

Depression

  • Citalopram

  • Sertraline is the SSRI of choice in post-MI patients.

  • No absolute contraindications. Relative contraindications: Recent MI (past 3 months), intracranial mass, severe hypertension, cerebral aneurysm.

  • ECT is SAFE in pregnancy.

  • Refractory cases of depression or catatonia, suicidality, psychotic depression, malnutrition due to food refusal.

  • Works in days, not weeks  best for life threatening depression.

  • VMAT-2 inhibitors: Valbenazine, Deuterobenzene.

  • 1st line is to switch to a Clozapine or Olanzapine (medication with less EPS symptoms).

Psychosis

  • Propranolol, Benztropine, or a Benzodiazepine.

  • 1st would be to lower the dose or switch to another drug with lower risk of EPS.

  • Schizoaffective disorder is 2 or more weeks of psychosis without mood symptoms + mood symptoms present for most of the illness. Schizophreniform disorder is the precursor to schizophrenia where symptoms are present for 1-6 months.

  • Schizophreniform: “forming” Schizophrenia.

  • Derealisation: patient’s environment feels unreal. Depersonalisation: Patient feels detached from their own body.

  • Reality testing remains intact  differentiates from psychosis.

  • Risperidone and Aripiprazole

  • Risperidone is the most effective for aggression but has high risk of weight gain. Aripiprazole is less sedation and less weight gain

Child Psych

  • Fluoxetine

  • If no response  Escitalopram is 2nd choice.

  • DMDD: severe irritability + frequent outbursts, usually seen before age 10. Conduct disorder, the child violates the rights of others, theft, aggression.

  • Conduct disorder is termed antisocial personality disorder past the age of 18.

  • Buprenorphine (partial mu opioid agonist) + Naloxone (mu opioid antagonist).

  • If drug is injected or inhaled, naloxone negates the partial agonist effect of Buprenorphine.

Substance use

  • Suboxone, Methadone, Naltrexone.

  • Naltrexone can be given only after withdrawal. Methadone is safe to be used in pregnancy.

  • General agitation: IM Haloperidol. Alcohol withdrawal agitation: Benzodiazepine.

  • Antipsychotic use in alcohol withdrawal can precipitate seizures.

  • PCP

  • Think superhuman strength, aggression, anaesthesia like analgesia.

  • Buproprion

  • Lowers seizure threshold and increases seizure risk.

  • TSH, BMP, BUN, Cr, Pregnancy Test.

  • Lithium can cause hypothyroidism or goiter.

Pharm

  • Olanzapine

  • Can cause weight gain + hyperlipidemia. Also causes asymptomatic rise in liver enzymes.

  • Renal absorption increases  toxicity.

  • Other causes: NSAIDs, thiazides, ACE inhibitors.

  • Risperidone

  • Strong D2 blockage: Galactorrhoea, Gynecomastia, Amenorrhea.

  • Extreme neuroleptic sensitivity  rigidity, worsening confusion, NMS like reaction.

  • If antipsychotic is needed: use Quetiapine or Pimavanserin.

  • Lamotrigine

  • Slow titration is necessary to reduce risk.

  • Agranulocytosis

  • ANC needs to be monitored periodically, and if signs or infection or drop in ANC, then stop the medication.

  • A subtype of bipolar disorder with 4 or more episodes of mania/hypomania or depression in a year.

  • Strongly associated with hypothyroidism and antidepressant use in bipolar patients. Worse prognosis.

Mania