Module 6 – Substance Use Disorders

2. It’s started at 100 mg PO, BID or TID, for 1-2 weeks.
a. If the pt is receiving IV glucose, it’s good to add 100 mg thiamine in
each liter of the glucose solution
ii. Korsakoff’s
1. Impaired mental syndrome, esp recent memory, and anterograde amnesia
in a pt who is alert and response. They may or may not hav
e
confabulation.
2. Also give Thiamine 100 mg PO, BID or TID, but for 3-12 months.
6. Patient education about disulfiram (interaction with alcohol containing product)
a. Should never be taken while intoxicated, and it should not be taken for at least 12 hours
after drinking alcohol. This is because that acetaldehyde will build up, causing the
above-named symptoms. Can occur within 10 minutes of drinking even a small
amount of alcohol, and can last for an hour or more
i. Obtain signed consent
ii. Remember that cough syrup has some alcohol


Module 7 – Pediatric Psychopharm & ADHD

1. Review over ADHD inattentive, hyperactive, and combined type of disorders

⮚ Inattention type: Six or more symptoms of inattention for children up to age 16, or five or
more for older adolescents (17 and older) and adults. Symptoms of inattention have been
present for at least 6 months, and they are inappropriate for developmental level. (DSM –
several symptoms were present before age 12)
▪ Often fails to give close attention to details, or makes careless mistakes in schoolwork, at
work, or with other activities
▪ Often has trouble holding attention on tasks or play activities
▪ Often does not seem to listen when spoken to directly
▪ Often does not follow through on instructions and fails
to finish schoolwork, chores, or duties in the workplace
(ie, loses focuses, becomes sidetracked)
▪ Often has trouble organizing tasks and activities
▪ Often avoids, dislikes, or is reluctant to do tasks that
require mental effort over a long period of time (such
as schoolwork or homework)
▪ Often loses things necessary for tasks and activities,
(ie school materials, pencils, books, tools, wallets,
keys, paperwork, eyeglasses, mobile telephones)
▪ Is often easily distracted. Squirrel!
▪ Is often forgetful in daily activities
▪ Image credit: https://tinyurl.com/6n9hj5cr

⮚ Hyperactivity and Impulsivity Type: Six or more sx of hyperactivity-impulsivity for children up
to age 16, or 5 or more for older adolescents (17 and older) and adults. Symptoms of
hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive
and inappropriate for the person’s developmental level. (DSM – several symptoms were
present before age 12)
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▪ Often fidgets with or taps hands or feet, or squirms in seat
▪ Often leaves seat in situations when remaining seated is expected
▪ Often runs about or climbs in situations where it is not appropriate.
● Adolescents or adults may be limited to feeling restless
● Sometimes adults will internalize their hyperactivity; they will feel internally restless.
They can also be hyper-talkative.
● ADHD can cause anxiety.
▪ Often unable to play or take part in
leisure activities quietly
▪ Is often “on the go” acting as if
“driven by a motor”
▪ Often talks excessively
▪ Often blurts out an answer before a
question has been completed
▪ Often has trouble waiting his or her
turn
▪ Often interrupts or intrudes on others,
ie, butts into conversations or games
▪ Image credit:
https://tinyurl.com/29csvxhe

⮚ Criteria for both inattentive and hyperactive:
▪ Several inattentive or hyperactive-impulsive symptoms were present before age 12 years
▪ Several symptoms are present
● in two or more settings (home, work, school, etc);
♦ get collateral for this
● with friends or relatives;
● in other activities.
▪ There is clear evidence that the symptoms interfere with, or reduce the quality of, social,
school, or work functioning
▪ The symptoms do not happen only during the course of schizophrenia or another psychotic
d/o. The sx are not better explained by another mental d/o (ie, mood d/o, anxiety d/o,
dossociative do, or a personality d/o).
● Anxiety can lead to worry, which can affect concentration and mimic ADHD sx
(distracted, restless).
⮚ Overview of the three types of ADHD
▪ Combined Presentation:
● If enough sx of both criteria inattention and hyperactivity-impulsivity were present for the
past 6 months
▪ Predominantly Inattentive Presentation:
● If enough sx of inattention, but not hyperactivity-impulsivity, were present for the past six
months
▪ Predominantly Hyperactive-Impulsive Presentation:
● If enough sx of hyperactivity-impulsivity, but not inattention, were present for the past six
months.
▪ Notes
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● Because symptoms can change over time, the presentation may change over time as
well
● 80% of kids will grow, their presentation will change. Ie, their activity may shift into inner
restlessness as they get older.
● College kids
♦ Were bright as kids, rarely had to study
♦ Increased rigor in college, brings out historical struggles, ie with sitting still.
Sometimes as adults, they can’t focus on reading, or in lecture.

2. Review over psychostimulant and non-stimulant options for pediatrics

⮚ Psychostimulants
▪ Increase mood, energy, and wakefulness
▪ Called sympathomimetics b/c they increase physiological effects of NE epinephrine.
● Use caution with cardiac risk factors
▪ Most commonly used to treat ADHD
▪ Classified as controlled d/t rapid onset, immediate behavioral effects, and propensity to
develop tolerance
● Schedule II. Write for 30 days at a time, write WHEN the next rx can be refilled, etc.
You might do three 30 day scripts, with a date on each.
● Abuse potential, monitor for abuse/selling
▪ Also used in narcolepsy (this is a medical dx, we may come across it in practice but we
don’t prescribe to treat narcolepsy)
▪ Have been used in cognitive d/o’s that result in secondary depression or profound apathy,
multiple sclerosis, post-stroke depression & dementia, and augmentation of
antidepressants in tx-resistant depression.

⮚ Non-Stimulant Drugs:
⮚ Atomoxetine (Strattera)
▪ Elective NE reuptake inhibitor (NRI)
● Great with anxiety d/o also
▪ First non-stimulant approved by the FDA for treatment of ADHD. Not a controlled
substance.
▪ Long-acting so only requires once-daily dosing. Inhibits presynaptic NE transport, which
increases NE availability.
● Random fact, Japan does BID dosing, which is interesting.
▪ Dosing:
● Starting dose: 20 mg
● Usual daily dose: 40-80 mg
♦ Nausea is common, take at night; peaks in the morning
● Max dose:
♦ Children: 80mg/day
♦ Adults: 100 mg/day

⮚ Bupropion (Wellbutrin)
▪ Norepinephrine Dopamine Reuptake Inhibitor (NDRI)
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▪ Usual dosage:
● IR or SR 150-300 mg daily in BID dosing
● XL can be dosed up to 450 mg, taken QD
▪ Similar to the stimulants
▪ Can be used for adults
▪ Use cautiously with patients that have bipolar/psychosis history (decrease risk of
mania/psychosis compared to stimulants)

⮚ Alpha-adrenergic agonists
▪ Mechanism unknown – reduces hyperactivity and/or impulsivity – goal reduction of
inattentiveness
▪ Help with irritability
▪ Also used for tic disorder / tourette’s (throat clearing / verbalizations)
▪ Monitor BP, can cause sedation (prescribe HS to start)
▪ Clonidine (Catapres)
● Clondiine XR (Kapvay)
● Initial: start 0.1mg at bedtime
♦ Very sedating, important to give at night
♦ Can increase by 0.1mg each week by divided doses
⮚ How do you divide the dose if you give it once a day?
● Usual dose (short acting): up to 0.1 mg TID
♦ Kapvay up to 0.2 mg BID
▪ Guanfacine (Tenex)
● Guanfacine XR (Intuniv)
♦ Initial: start 1mg at bedtime, can increase by 1mg each week. Check bp; can
tolerate better in the AM.
♦ Usual dose (short acting): 0.5-1.5 mg/day, or intuniv up to 4mg/day


3. Mechanism of action of amphetamines and methylphenidate and effect on
neurotransmitters

⮚ Pharmacological Action
▪ The primary pharmacologic effect of both amphetamine and methylphenidate is to increase
central dopamine and norepinephrine activity, which impacts executive and attentional
function (Farone, 2018).
● It especially increases DA and NE in the PFC.
▪ Methylphenidate inhibits the reuptake of DA and NE; increased dopaminergic and
noraderenergic activity in the PFC may explain its efficacy in ADHD (Guzman, 2018).
▪ Amphetamine increases dopamine release across multiple brain regions, including the
dorsal and ventral striatum, substantia nigra, and regions of the cortex (Farone, 2018).
● Has a stronger effect
● Increased dopamine release means the body is making more dopamine.
▪ These meds are well absorbed in the GI tract
▪ Amphetamine (Adderall) & Dextroamphetamine (Dexedrine) reach peak plasma
concentrations in 2-3 hours and have a half-life of about 6 hours.
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● Given in once or twice daily dosing. If given BID, don’t give past 4pm d/t risk for
insomnia
▪ Methylphenidate (Ritalin) peaks in 1-2 hours, and has a short half-life of 2-3 hours
▪ Extended Release Methylphenidate (Concerta, Quallivant XR) peaks in 4-5 hours, and is
designed to last 12 hours.
▪ Dexmethylphenidate (Focalin) peaks in 3 hours and is prescribed BID
▪ Lisdexamfetamine (Vyvanse) is a prodrug that is activated in the GI tract (specifically, it is
activated by the lysine portion of molecule by enzymes in RBC’s. The end result is a
couple of things:
● One, the drug is gradually released, which can give more stable control over time, as
mentioned earlier.
● Two, because it’s a prodrug, its abuse potential is greatly reduced. If you give it via
injection or IV, it simply won’t be activated because those routes bypass the GI tract.
● Also, it’s not a schedule II drug, so it’s a good alternative to a stimulant.

⮚ Therapeutic Indications
▪ First line drugs for tx of ADHD, work about 75% of the time
▪ Methylphenidate and dextroamphetamine are equally effective; they work wthin 15-30
minutes.
● So there is no need to wait weeks. Huh.
▪ They improve both inattention and hyperactivity sx.
▪ Methylphenidate is the most commonly used.
● Immediate Release dosing is 5-10mg every 3-4 hours; may be increased to max of 20
mg QID, or 1mg/kg/day.
▪ Sustained release methylphenidate is designed to provide 6 hours of benefit and prevent
dosing at school.
● However, it can wear off after school; you might see a crash.
▪ Dextroamphetamine is about twice as potent as methylphenidate on a per mg basis, and
provides 6-8 hours of benefit (in sustained release form).
● Immediate Release form has 3-4 hours of benefit.

4. Review side effects of psychostimulants

⮚ Adverse Effects
▪ Anorexia/weight loss / nausea
● Administer at meals
● Use caloric supplements
● Patient may have a reduced appetite at lunchtime; give a good breakfast
▪ Insomnia
● Administer early in the day
● Consider adjunctive treatment with antihistamines, clonidine
● Avoid caffeine. That means no afternoon starbucks runs for the teenagers on this
medication.
● Don’t give after 3pm
▪ Dizziness
● Monitor BP
● Encourage fluid intake, change to long-acting
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● Vyvanse is a good option here. Because it releases slowly during the day, it carries a
much lower risk of dizziness as a SE.
▪ Rebound phenomena
● Change to long-acting
● Adjunctive tx with clonidine, tenex
▪ Irritability
● Assess timing during peak or withdraw
● Evaluate comorbid dx
● Reduce dose
● Check the time of day this occurs (it could be withdraw, from the medication having
cleared the body, like an after school low amount)
● Add a short-acting dose at 2pm to prevent ‘coming home’ in withdrawal (similar to
previous point, this is a low serum level after school d/t medication having exited the
body due to the timing of its half-life).
▪ Dysphoria, moodiness, agitation
● Consider a mood disorder
● Reduce dosage or change to long acting
● Consider adjunctive tx:
♦ Antidepressants, lithium, anticonvulsants
● Or is this medication related / dopamine related dysphoria (from excessive dopamine)
♦ Interesting!
▪ HR/BP/Cardiac hx
● Monitor for increase in HR/BP, or chest pain
● Rule out cardiac hx, may need a baseline EKG prior to starting tx
● Check for family history of cardiac risk; definitely do EKG if a family hx is present
● Can be dose dependent. Check EKG if symptoms develop.

5. Options for medication treatment for pediatric patients for treatment of ADHD if a
patient develops side effects from the psychostimulants.
a. See above, interventions listed with side effects.

6. Which medication class is used to treat anxiety disorders?
a. Presumably SSRI, because sertraline was listed as first line in the reading “appropriate
use of psychotropic drugs in children and adolescents” (p 18) (along with CBT).
b. Straterra is also great with anxiety d/o, per the lecture
7. which medication class is used to treat depressive disorders?
a. Answer taken from the reading – “Guidelines for Adolescent Depression in Primary
Care”
b. SSRIs are the tx of choice
c. Fluoxetine (Prozac) and escitalopram (Lexapro) are the only SSRIs approved for use in
adolescents with depression. Fluoxetine also has the indication for children with
depression.
d. Positive randomized clinical trials (RCTs) in anxiety disorders of children and
adolescents using fluvoxamine (Luvox) and sertraline (Zoloft) have been published, and
both are FDA approved for adolescent obsessive-compulsive disorder.
e. Recent positive studies of citalopram (Celexa) and sertraline (Zoloft) in adolescent
depression have also been published. Other SSRIs are possibly effective.
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f. The FDA reviewed treatment trials of SSRIs used with children and adolescents for
safety and efficacy because of concerns that, in some children and adolescents, these
agents may provoke extreme irritability, suicidal thinking and behavior, and/or other
unusual symptoms.

Module 8 Neurocognitive & Geriatric Psychopharm

1. Review difference between delirium and dementia types of disorders

❖ Delirium
⮚ Acute decline in both the level of consciousness and cognition, with impairment in attention
⮚ Key: here and now. Acute. Sudden onset.
⮚ Other neurological sx:
▪ Abnormalities of mood, perception, and behavior
▪ Tremor
▪ Nystagmus
▪ Incoordination
▪ Urinary incontinence
⮚ Delirium Precipitating Factors
▪ Drugs (sedative hypnotics, narcotics, anticholinergics, alcohol withdrawal)
▪ Neurologic diseases (Stroke, meningitis, intracranial bleeding)
▪ Infections, hypoxia, shock, anemia, fever, poor nutrition, dehydration
▪ Surgery (cardiac or orthopedic)
● People get confused by the anesthesia
▪ Environmental (use of physical restraints, pain, emotional stress, prolonged sleep
deprivation
⮚ Delirium vs Dementia:
Delirium Dementia
▪ Rapid Onset ▪ Slow Onset
▪ Hours to weeks duration ▪ Months to years Duration
▪ Fluctuating Attention ▪ Preserved Attention
▪ Impaired recent & immediate
memory
▪ Impaired remote memory
▪ Incoherent speech (slow or rapid) ▪ Difficulty in word finding
▪ Disorganized thoughts ▪ Impoverished thoughts
▪ Frequent disruption in sleep/wake
cycle
▪ Fragmented sleep
▪ Reduced awareness of
surroundings
▪ Unchanged awareness of
surroundings.
▪ They know what is going on around
them.
▪ Hypervigilant or reduced vigilance ▪ Usually normal alertness.
▪ They can be confused but alert.

⮚ Delirium Treatment
▪ Goal is to treat the underlying cause.
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● Ie, if the cause is a steroid medication, you would adjust the dose (lower it).
● If the pt is dehydrated, give fluids. You get the idear.
▪ Provide physical sensory, and environmental support.
▪ Treat if psychosis and insomnia
● Haldol (can be given PO or IM)
● Risperidone
● Olanzapine
● Quetiapine
● Lorazepam
● Ziprasidone / Geodon
♦ Has an injectiable form
♦ Often used for acute psychosis

❖ Dementia
⮚ Evidence of significant cognitive decline from a previous level of performance in one or
more cognitive domains.
▪ Learning and memory
▪ Executive function
▪ Complex attention
▪ Perceptual-motor
▪ Social cognition
▪ Overall:
● Decreased performance, happens slowly, gradually.
● Treat symptoms only.
● Imaging studies
● Can’t diagnose tangles until autopsy; you won’t know while they are alive if they have
this.
⮚ The cognitive deficits interfere with independence in everyday activities
⮚ The cognitive deficits do not occur exclusively in the context of a delirium
⮚ The cognitive deficits are not better explained by another mental disorder (MDD,
Schizophrenia)
▪ MDD can have poverty of thought/speech, something to consider as those symptoms can
mimic dementia.
▪ Schizophrenia – these patients will still be AAOX3; dementia patients will not.
⮚ Lecture Notes
▪ For the dx, specify whether WITH or WITHOUT behavior disturbances
▪ Without:
● No change in functioning or cognition
● No psychosis, agitation, anxiety, irritability or anger
▪ With:
● Would include any of the above sx.
▪ Assessment:
● MMSE
♦ <23 = cognitive deficit
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♦ True psychosis can score low, as low as 16-18; be cautious, as they don’t have
dementia.
⮚ Etiology
▪ Degenerative Type
● Alzheimer’s
● Parkinsons’s dz / Huntington’s
● Lewy Body
● Frontotemporal dementia (Pick’s Disease)
♦ Interesting condition, can strike when you’re young
♦ https://www.youtube.com/watch?v=EHSdNjhkvE8
▪ Psychiatric (pseudodementia depression, cognitive decline, late life schizophrenia)
▪ Tumor
▪ Trauma
▪ Cardiac, vascular anoxia (can be s/p MVA, or anoxia s/p hanging SA)
▪ Drugs/toxins
▪ Demyelinating (MS)


2. Medication treatment for agitation in an elderly individual (IM or PO)= Risperidone
3. Medication choices to assist with insomnia in dementia patient with behavior
disturbances= Mirtazapine
4. Patient education regarding cholinesterase inhibitors= GI upsets
5. Identify cholinesterase inhibitors goal of treatment= Boost the availability of ACh
6. Review Tacrine, Rivastigmine, Donepezil, Memantine and which are used for moderate
to severe dementia. Which are used for mild dementia?
a. Memantine (NMDA receptor antagonist) for moderate to severe dementia (kahoot)
b. Tacrine (was discontinued), Rivastigmine, Donepezil for mild to moderate.

Module 9 – Pregnancy and Lactation

1. Review the difference between postpartum blues, postpartum depression, postpartum
psychosis

2. Which antidepressants, mood stabilizers, or antipsychotic medications are safe in
pregnancy? (Are there any meds in each of these classes of meds that are safe in
Pregnancy?) Antidepressants=SSRI=Prozac, TCA=Desipramine and Nortriptyline; Bupropion
can be used if the first ones fail; SNRI= Venlafaxine and Duloxetine. Do not use an MAOI in
pregnancy as this may produce a hypertensive crisis when combined with tocolytic
medications, such as terbutaline. Mood stabilizers= Lamotrigine (Lamictal). Antipsychotics=
Quetiapine (Seroquel) is a reasonable first choice when a new atypical antipsychotic is
indicated for a pregnant patient. In clinical practice, higher potency neuroleptic agents such as
haloperidol (Haldol), perphenazine (Trilafon), and trifluoperazine (Stelazine) are
recommended over the lower potency agents in managing pregnant women with psychiatric
illness.

Module 10 – CAM

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1. What is St. Johns wort? Is an herb, Hypericum. Ingredients= hypericin, flavonoids,
xanthones. Is used to treat mild to moderate depression, anxiety, and sleep problems.
2. What patient education would you provide about St. John’s wort to your patient?
Can cause headaches, photosensitivity (maybe severe), constipation.
3. Gingko Biloba-What is this type of herb used to treat?
Symptomatic relief of delirium, dementia; improves concentration and memory deficits;
possible antidote to SSRI-induced sexual dysfunction.
4. What education would you provide to a patient about this med?
Anticoagulant: use with caution because of its inhibitory effect on PAF; increased bleeding
possible. Allergic skin reactions, GI upset, muscle spasms, headache.
5. Ginseng-what is this herb for?
Stimulate, for fatigue elevation of mood, immune system.
6. What education would you provide on this medication?
Not to be used with sedatives, hypnotic agent, MAOIs, antidiabetic agents, or steroids. Cause
insomnia do not take at night.
7. What is Melatonin?
Is a hormone produced mainly at night in the pineal gland. Exogenous Melatonin is available
as a dietary supplement and is not a medication. Used to treat conditions as insomnia, jet lag,
and sleep disturbances related to shift work, cancer, seizures, depression, anxiety, and
seasonal affective disorder.
8. Patient education that would be important regarding Melatonin?
May reduce fertility in both men and women. Caution is suggested in co-administering
melatonin with blood thinners (e.g., warfarin [Coumadin], aspirin, and heparin), antiseizure
medications, and medications that lower blood pressure.
9. What is N-acetylcysteine used for?
Used as an antidote for acetaminophen overdose, augmentation of SSRIs in the treatment of
trichotillomania
10. Patient education that would be important regarding this medication?
Rash, cramps, and angioedema may occur. Interacts with activated charcoal, ampicillin,
carbamazepine, cloxacillin, oxacillin, nitroglycerin, and penicillin G.
11. What is SAMe used for?
Mood elevation, osteoarthritis
12. What patient education would be important regarding this medication?
Hypomania, hyperactive muscle movement, caution in patients with cancer.

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