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Psychiatry Cheat Sheet, Cheat Sheet of Psychiatry

Psychiatry Cheat Sheet: Check TSH again 4-6 weeks after each thyroid dose change.

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Psychiatry Cheat Sheet Jazzlyn Gallardo, D.O.
Normal TSH: 0.45 5.10 mIU/l
Check TSH again 4-6 weeks after each thyroid dose change.
Levothyroxine: starting dose 25 mcg/d
Take thyroid meds on empty stomach as soon as patient gets up in the morning at least one hour
before eating, which helps with absorption; don’t ever take thyroid meds with vitamins
Therapeutic blood levels
Lithium: 0.5-1.0 mEq/l, run towards the lower end to minimize side effects
Depakote: 50-125 mcg/ml
Lamictal: 3-14 mcg/ml
Anafranil (TCAs): 220-500 ng/ml
Bipolar ‘Ceiling’ Drugs
Lithium: start at 300 mg qhs with food in stomach (“little old lady” dose) or 600-900 mg qhs in
younger, healthier patients, & titrate upwards depending on clinical response, side effects, & blood
levels, better for euphoric, rather than irritable, patients
Depakote (valproic acid) good for rapid cycling (4 or more moodswings per year)/mixed state/irritable
mood in Bipolar with 500 mg qhs starting dose & Depakote titration upwards depending on clinical
response, side effects, & blood levels
oMust start Depakote titration again at low dose if patient stops medication
Tegretol (carbamazepine)/Trileptal(oxcarbazepine) - second-line ceiling drugs
Neuroleptics (preferably second generation)
Bipolar ‘Floor’ Drugs
Lithium
Lamictal (good for concommitant seizures)
Anti-depressants (generally not used as mono-therapy in Bipolar Disorder)
Lithium Management
“Little old lady” dose or for children: starting dose of 300 mg qhs (for healthy patients 600-900 mg
qhs); Emergency: start at 600-900 mg qhs
Titrate upward in 300 mg/d increments
Obtain blood levels 7-10 days after initiating or changing the dosage of lithium (up or down).
oInstruct patient to get blood work done 12 hours after they have taken their last dose (trough).
For lithium-induced hypothyroidism, do not discontinue lithium, instead supplement with
levothyroxine, starting at 25 mcg/d, checking results with repeat TSH in 4-6 weeks
Also get creatinine clearance (CrCl) & TSH every 6-12 months for anyone on lithium plus other
appropriate screening LAB
Lamictal Management
Start at 25 mg qhs (12.5 mg qhs if on concomitant Depakote with corresponding half-strength increased
doses thereafter) for 2 weeks, 50 mg qhs for next 2 weeks, 100 mg qhs for next 2 weeks on Lamictal
Initial target dose at 200 mg qhs (get blood levels after 7-10 days at this dose, 12 hours after dose)
Increase by 100 mg/d thereafter as needed, but not sooner than 2 weeks at each dose (only 50 mg/d
increase if concurrently on Depakote)
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Psychiatry Cheat Sheet Jazzlyn Gallardo, D.O.

Normal TSH: 0.45 – 5.10 mIU/l Check TSH again 4-6 weeks after each thyroid dose change. Levothyroxine : starting dose 25 mcg/d  Take thyroid meds on empty stomach as soon as patient gets up in the morning at least one hour before eating, which helps with absorption; don’t ever take thyroid meds with vitamins Therapeutic blood levels  Lithium : 0.5-1.0 mEq/l, run towards the lower end to minimize side effects  Depakote : 50-125 mcg/ml  Lamictal : 3-14 mcg/ml  Anafranil (TCAs): 220-500 ng/ml Bipolar ‘Ceiling’ Drugs  Lithium: start at 300 mg qhs with food in stomach (“little old lady” dose) or 600-900 mg qhs in younger, healthier patients, & titrate upwards depending on clinical response, side effects, & blood levels, better for euphoric, rather than irritable, patients  Depakote (valproic acid) – good for rapid cycling (4 or more moodswings per year) / mixed state/irritable mood in Bipolar with 500 mg qhs starting dose & Depakote titration upwards depending on clinical response, side effects, & blood levels o Must start Depakote titration again at low dose if patient stops medication  Tegretol (carbamazepine)/Trileptal(oxcarbazepine) - second-line ceiling drugs  Neuroleptics (preferably second generation) Bipolar ‘Floor’ Drugs  Lithium  Lamictal (good for concommitant seizures)  Anti-depressants (generally not used as mono-therapy in Bipolar Disorder) Lithium Management  “Little old lady” dose or for children: starting dose of 300 mg qhs (for healthy patients 600-900 mg qhs); Emergency: start at 600 - 900 mg qhs  Titrate upward in 300 mg/d increments  Obtain blood levels 7 - 10 days after initiating or changing the dosage of lithium (up or down). o Instruct patient to get blood work done 12 hours after they have taken their last dose (trough).  For lithium-induced hypothyroidism, do not discontinue lithium, instead supplement with levothyroxine, starting at 25 mcg/d, checking results with repeat TSH in 4-6 weeks  Also get creatinine clearance (CrCl) & TSH every 6-12 months for anyone on lithium plus other appropriate screening LAB Lamictal Management  Start at 25 mg qhs (12.5 mg qhs if on concomitant Depakote with corresponding half-strength increased doses thereafter) for 2 weeks, 50 mg qhs for next 2 weeks, 100 mg qhs for next 2 weeks on Lamictal  Initial target dose at 200 mg qhs (get blood levels after 7- 10 days at this dose, 12 hours after dose)  Increase by 100 mg/d thereafter as needed, but not sooner than 2 weeks at each dose (only 50 mg/d increase if concurrently on Depakote)

o To allow the body to get used to the drug and to avoid Stevens-Johnson Syndrome (life- threatening rash) o Must restart original titration protocol at 25 mg qhs if they miss Lamictal more than 3 days in a row  Side effects: tremor, dizziness, word-finding problems, rash Medications that need Tapering (basically everything except LiCO3)

Medication Groups

Atypical Antipsychotics/Second-generation neurolepticsAbilify (aripiprazole)  Geodon (ziprasidone)  Seroquel (quetiapine) – start 25 mg po qhs then increase by 25 - 100 mg/day  Zyprexa (olanzapine) – start 5 mg po qhs, may adjust by 5 mg/day prn o if still cannot sleep within 3 hours of first dose, add another 5 mg o *Seroquel and Zyprexa have the most anti-histaminic properties, and are therefore weight gainers OTHERS:  Risperdal (risperidone)  Latuda (lurasidone)  Clozaril (clozapine)   Serotonin-Norepinephrine Re-Uptake Inhibitors (SNRIs) for depression, OCD, panic disorder, anxiety, chronic pain  Effexor (venlafaxine) - cheaper than Pristiq; start at 25 mg bid (take after breakfast & after lunch, may cause upset stomach)  Cymbalta (duloxetine) - still more expensive than Effexor; starting dose 30-60 mg; may cause upset stomach  Pristiq (desvenlafaxine) - first active metabolite of venlafaxine, just more expensive  Fetzima (levomilnacipran) – as expensive as Pristiq  _ Selective Serotonin Re-Uptake Inhibitor (SSRIs) : for depression, OCD, panic disorder, anxiety  Prozac (fluoxetine) – preferred; long half-life (if patient misses dose, won’t go into discontinuation syndrome); relatively weight neutral; associated with decreased libido (or other sexual dysfunction, like delayed orgasm) o start at 10 - 20 mg po qam, take with food in stomach; can go up in 10-20 mg/d increments not more than every 2 weeks  Zoloft (sertraline)  Luvox (fluvoxamine)  Lexapro (escitalopram) – not used as much due to potential QTc prolongation  Celexa (citalopram) – not used as much due to potential QTc prolongation  Paxil (paroxetine) – may cause severe discontinuation syndrome, weight gain   ____________________________________________________________________________________Remeron (Mirtazapine) – helpful for anxious depression with insomnia, starting dose: 30 mg qhs  α 2 Antagonist (increases release of NE and serotonin) and potent 5-HT 2 and 5-HT 3 receptor antagonist  sedation, weight gain

 Sedating antidepressants: Remeron  Tertiary tricyclics (potentially dangerous/toxic)   Weight gain: Seroquel, Depakote, mirtazapine, Paxil  Weight neutral: Prozac, Lamictal, Tegretol    Cogentin (benztropine) – anticholinergic remedy for extrapyramidal side effects from neuroleptics; H antagonist  start at 1 mg bid, titrating upwards to 2 mg bid   TerminologyMixed state : feeling depressed yet manic “high” symptoms at the same time Reduced by Depakote/ Atypical Antipsychotics (Second-generation neuroleptics) o  Pharmacokinetic drug-drug interaction : one drug affects the blood level of the second drug o Example: Depakote and Lamictal  Pharmacodynamic drug-drug interaction : two drugs accomplish the same action or side effect o Cross-tolerance : one can be used to withdraw another  Recurrence : new episode of symptoms after having been taken off the medicine for more than 6 months  Relapse : old/original episode coming back less than 6 months after being taken off the medication  Response : 50% improvement in symptoms  Remission : PHQ-9 score of 4 or less (minimal to no depression or anxiety)  Serotonin syndrome : occurs with any drug that increases serotonin (e.g., MAO inhibitors, SSRI’s, SNRI’s)

  • hyperthermia, myoclonus, cardiovascular collapse, flushing, diarrhea (serotonin receptors activated in GI tract), seizures.   Pearls  Anxiety and panic disorders generally respond to serotonergic drugs not norepinephrine ones.  Anti-convulsants/SNRI’s have anti-pain properties (especially chronic pain).  Generic drugs may be "porcelain clangers" (go through patient unabsorbed)  “The dose that got them well, keeps them well.” You typically don’t reduce the dose if they’re doing well.   Zyprexa and Seroquel: more sedation  Abilify, Geodon: less weight gain, more likely to cause EPS, less sedation   Clozaril/clozapine must get CBCs each week; terrible weight gain; seizures; gold standard for refractory psychosis with potentially less Tardive Dyskinesia (TD).   Anticholinergic effects in tertiary TCAs  Blind as a bat ( blurred vision )  Dry as a bone ( dry mouth ) o Remedy: tart substances; sugarless candy/gum or water with unsweetened lemon juice  Red as a beet ( flushing )  Mad as a hatter ( confusion )  Hot as a hare ( hyperthermia )

 Can’t see ( vision changes )  Can’t pee ( urinary retention )  Can’t sh*t ( constipation )   ToxicitiesTypical Antipsychotics/Neuroleptics o Highly lipid soluble and stored in body fat; thus, very slow to be removed from body o Extrapyramidal system (EPS) side effects  4 hours : acute dystonia – muscle spasm, stiffness, oculogyric crisis  4 days : akinesia – parkinsonian symptoms  4 weeks : akathisia (restlessness)  4 months : tardive dyskinesia – stereotypic oral-facial movements and twisting/tapping of the lower extremities due to long-term antipsychotic use; often irreversible o Endocrine side effects (e.g., dopamine receptor antagonism  hyperprolactinemia  galactorrhea) o Side effects arising from blocking receptors  Muscarinic – dry mouth, constipation  Alpha adrenergic – hypotension  Histamine – sedation  Atypical antipsychotics o Fewer extrapyramidal/TD side effects than traditional antipsychotics o olanzapine/clozapine/quetiapine - significant weight gain (insulin resistance and hyperlipidemia) o Clozaril/clozapine – agranulocytosis (requires weekly WBC monitoring) o Geodon/ziprasidone – QTc prolongation o Seroquel/quetiapine – cataracts o Risperidal/risperidone – highest risk of all atypicals for developing EPS and hyperprolactinemia