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Psychopharm 6002
ETSU 2018 PMHNP
| Question | Answer |
|---|---|
| What IS Psychopharmacology? | Study of the Mediation & Modulation of Behavior through both direct means (exogenous drugs) and indirect means (endogenous signaling substances) |
| Direct Means - Exogenous | Drugs can directly mediate & modulate behavior through direct impact on CNS functioning |
| Indirect Means-Endogenous Signaling Substances | Small Molecular Weight Molecules in the brain Hormones: Neurotransmitters, Neuromodulators Cellular Secondary Messengers: Specific enzymes needed to produce a specific substance |
| What is Goal of Psychopharmacology? | Mediation & Modulation of behavior |
| What is Target Symptom | Specific, precise, and individualized symptom (behavior) that can reasonably be expected to be improved or eliminated through medication use |
| Essential #1: History | -Use open ended questions -Clarify (ie. when a client c/o poor sleep, ask specifics) -Obtain chronological symptom history -Identify Target Symptoms |
| Essential #2: Thorough Assessment | -Physical Exam -Mental Status Exam -Standardized Rating Scales |
| Testing | Mental Status Examination Write–a-Sentence Test Draw-a-Clock Test Copy-a-Three-Dimensional-Figure-Test Standardized Instruments (Zung Depression Scale, Beck Anxiety Scale, PANSS) |
| Mental Status Examination (MSE) | It gives the clinician a better understanding of the client’s current status/ lvl of fx. Should be used at the initial eval & ea follow-up visit in order to assess response to treatment. |
| Essential #3: Laboratory Testing | Complete Blood Counts, Thyroid function tests, Electrolytes, Glucose, Renal function, Hepatic function, Urinalysis, Urine drug screen, STD screen and hepatitis panel in high-risk populations, ****Pregnancy test |
| Complete Blood Count (CBC) | Red blood cell count (RBC), Hematocrit (Hct), Hemoglobin (Hgb), Platelets, Mean Corpuscular volume (MCV), Mean corpuscular hemoglobin (MCH), Mean corpuscular hemoglobin concentration (MCHC), Red cell distribution width (RDW), WBC, Differential: neutrophils, eosinophils, basophils, lymphocyte, monocytes |
| CBC cont. | RBC: Males: 4.4 – 6.1 mil/mm3, Females: 4.2 – 5.5 Hct: Male: 40.7-50.5%, Female: 36.1-44.3% Hgb: Male: 13.8-17.2 gm/dl, Female: 12.1-15.1 gm/dl Platelets: 150-400 K/mm3 |
| WBC | Normal: 4,000-11,000 Variability: Increased WBC = Leukocytosis Shift to the left = increase in immature neutrophils called bands Shift to the right=increase in very mature neutrophils |
| WBC (Remember 500) | Less than 500 WBC = panic Less than 500 neutrophils = bacterial infection Less than 500 lymphocytes = viral infection Less than 5.0 Hgb = heart failure and death |
| Why order a CBC? | Used to detect: Polycythemia, Anemias, Infections, Monitor fluid status, blood loss, Inflammation, Need to conduct further tests such as bone marrow biopsy |
| Liver Function Tests | Total bilirubin & direct bilirubin values are elevated in hepatocellular injury, variety of meds and substance use/abuse. Liver damage: abnormal LFT’s & may impair clearance of a drug, Increased LFTs may be seen with any drug that utilizes hepatolic metabolism |
| Liver Function Tests cont. | Serum Enzyme: Alkaline Phosphate: 13-39 U/ml Aspartate aminotransferase (AST, was SGOT): 5-40 U/ml Alanine aminotransferase (ALT was SGPT): 5-35 U/ml Lactate dehydrogenase (LDH): 200-500 U/ml 5’-nucleotidase: 2-11 U/ml Gamma glumatic transpeptidase (GGT) |
| Liver Function Tests cont. | ALT: increased when hepatic cells have been inflamed or died AST: Also reflects hepatic cell damage though less specific for liver disease (increased in MI) GGT: Meds/ETOH will cause increases in GGT |
| Thyroid Panel | Thyroid hormone: thyroxine T4 or triodothyronine T3 Thyroid-releasing hormone (TRH) stimulates the release of TSH, TRH increases with exposure to cold, stress, decreased levels of T4 *Thyroid tests : TSH, T4 (free or total), T3 (free or Total) |
| TSH | Thyroid-stimulating hormones (TSH) Increases release of stored thyroid hormones |
| Subclinical Hypothyroidism | Subclinical Hypothyroidism: Normal free T3 &T4 Suppressed TSH |
| Essential #4: Explore client’s concerns about using medications | -What are the client’s thoughts about medication use? -Clarify misconceptions &/or myths of med use -Discuss realistic expectations -Compliance issues |
| Essential #5: Medication Education | -EDUCATE, EDUCATE, EDUCATE! -DOCUMENT, DOCUMENT, DOCUMENT! |
| Essential #6: Follow-up | -Schedule appropriate follow-up care -Give contact information |
| Essential #7: Make medication adjustments appropriately | Know correct dosing of meds and when a dose change might be warranted |
| Essential 8 Polypharmacy | Polypharmacy and off label use. Remember off label means using a medication that does not have FDA approval for it’s use in the disorder you want to treat. |
| Selective Toxicity | using the best medication with the least side effects |
| Drugs fit into two large categories | Agonists-produce effect (or turn on) Antagonists-block effect (or turn off) Partial Agonists |
| Pharmokinetics | What happens between taking & leaving. Variable in how long trip through body it takes, how long till effect occurs, how long will effect last. |
| Drug Absorption | As a drug is distributed in the body, it comes in contact with numerous membranes. Drugs pass some membranes but not others. |
| Drug Distribution | Several factors influence drug distribution: Membrane permeability, Plasma protein binding, Depot storage |
| Membrane Permeability | To enter an organ, a drug must permeate all membranes that separate the organ from the site of drug action. Ex. drugs that are lipophilic (fat loving) such as benzodiazepines, readily cross the blood-brain barrier |
| Plasma protein binding | Binding of drugs to plasma protein such as albumin. Reduces the amount of free drug in the blood. |
| Depot Storage | Lipophilic drugs accumulate in fat and released slowly from fat stores. Antipsychotics are highly lipophilic so they tend to hang around in your system for 1-3 months after they are discontinued. |
| Metabolism Elimination | P450 system Some drugs are excreted after they have been metabolized while others are excreted unchanged. |
| Half Life | Time required for the serum concentration of drug to decrease by one-half (how rapidly half the drug is excreted). Generally, 4-5 half lives = steady state Blood levels will be reliable generally after 5 half lives |
| Steady State | Point at which a specific dose of drug given over a several-day period produces consistent blood level Predicts likely point therapeutic response |
| Half lives | Medications with longer ½ lives take longer to reach steady state. The shorter the ½ life of antidepressants, the more likely patients will experience discontinuation symptoms. |
| Half lives cont. | (ie. Effexor has a very short ½ life so it does cause discontinuation symptoms while the ½ life of Prozac is very long, therefore there are no discontinuation symptoms assoc. with Prozac. |
| Cmax: | patient ingests a drug, it gets absorbed then reaches a peak concentration which is Cmax. |
| Tmax: | the time required for a particular drug to reach Cmax is called Tmax. |
| Cmin | after Cmax, the concentration of the drug graduallly comes down, eventually reaching a Cmin or trough concentration, just before the next dose is taken. |
| AUC (area under the curve): | entire amount of drug that is present in the blood over a given period of time so AUC is a measure of the total amount of drug absorbed by the body |
| Area under the curve (AUC) cont. | ER (extended release) formulation leads to an auc comparable to BID or TID dosing of IR (immediate release formulation). |
| Pharmacodynamics | How do drug and receptors in body interact: Affinity: How much receptors like each other Dose-Response Curvature (3 curves, see next slide) Side-Effect, Interactions |
| Dose-Response Curvature Linear | the more you take, the better you feel up to the point it can harm you. Meds with linear response can be increased if not seeing a therapeutic response. |
| Curving linear: | Patients will improve and then max out; then the more they take, the worse they feel. For example, tricylic antidepressants have a curving linear response. If a patient is not responding to a tricylic, don’t increase the dose because it could make them feel worse. |
| Plateau: | Patients will improve up until a certain point and then they will plateau, they will not get any better. Example: SSRI antidepressants |
| Hormetic Effect (Arndt-Shultz Law) | Describes the relationship between dose and response Hormetic effect: there is not always a simple linear relationship between the dose of a drug and the clinical response |
| Hormetic Effect (Arndt-Shultz Law) cont | It is not always the case that the higher the dose, the more effective the drug will be. |
| Hormetic Effect (Arndt-Shultz Law) cont | Because of the hormetic effect, the higher doses beyond a certain point may actually be less effective. 50% of drugs demonstrate the hormetic effect |
| FDA Trials | Phase I: test drug for safety in animals then in human volunteers. Phase II: test drug in groups of patients. Phase III: test drug in very large groups of patients |
| Bioequivalence | (determined by administering drug to volunteers and obtaining average Cmax, half lives, and AUC. |
| Generic bioequialence | 80%-125%: the bioequivalence of generic must be between 80-125% of original brand. |
| ***please note many psychiatrists and patients complain about problems when switching from name brands to generic. | Ie. Clozaril and Depakote |
Created by:
palmerag
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