In the name of GOD

Rasool Soltani, PharmD, BCPS Patients counseling Rasool Soltani, PharmD, BCPS

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Educating Patients When educating patients with psychiatric disorders, pharmacists should: inform the patients when they should expect the meds to begin working. inform the patients it may take weeks before the meds cause noticeable improvements in mood. inform patients that long-term therapy may be required to prevent the return of symptoms.

Educating Patients When educating patients with psychiatric disorders, pharmacists should: inform the patients never to stop taking their meds abruptly, as withdrawal symptoms may occur. educate the patients not to change the dose without 1st talking to the physician. review the importance of avoiding interacting agents such as alcohol or other CNS depressants.

Antidepressants All antidepressants almost the same efficacy. For reasons not yet understood, some people respond better to some antidepressants. Thus, some patients may need to try other antidepressants to find the one that works for them. It is important to take med at an adequate dose and over an extended period of time (often 4 to 6 weeks) to work.

Antidepressants Once a patient start taking antidepressants, it is important not to stop them. Sometimes patients feel better and stop taking the meds & symptoms return. When it is time to stop the med, it should be slowly and safely decreased. When the patient stop taking the dose abruptly, withdrawal symptoms may be seen.

Antidepressants Some antidepressants may cause more side effects than others. The most common observed side effects listed by the FDA include: Nausea and vomiting Weight gain Diarrhea Sleepiness Sexual dysfunction

Serotonin Syndrome Usually MAOIs Combining SSRIs or SNRIs with one of Triptans Life-threatening condition Symptoms: Agitation hallucinations high temperature unusual blood pressure changes

Adverse effects (TCAs) Sedation Memory deficits Agitation Anticholinergic effects (transient or persistent) Orthostasis (Imipramine; less with Nortriptyline) Cardiac arrhythmias Sexual dysfunction Weight gain (Amitriptyline)

Adverse effects (SSRIs) GI complaints Nausea (transient or persistent) Diarrhea Constipation (Paroxetine) CNS disturbances Insomnia (Fluoxetine, Sertraline) Sedation (Paroxetine) EPS: akatisia, dystonias, pakinsonism

Adverse effects Sexual dysfunction Headache Dry mouth Sweating Not transient Fluoxetine, Paroxetine Headache Dry mouth Sweating Weight gain Teeth grinding

Antipsychotics Certain symptoms (e.g. feeling agitated and having hallucinations) usually go away within days of starting an antipsychotic meds. Symptoms like delusions usually go away within a few weeks. Full effects of the meds may not be seen for up to six weeks.

Antipsychotics Some people may develop a relapse. Usually relapses happen when people stop taking their meds, or when they only take it occasionally. Some patients stop taking the meds because they feel better & think they don't need them anymore, but anti-psychotics should not be discontinued without consulting a physician.

Antipsychotics Many patients stay on antipsychotics continuously for months or years in order to control the symptoms, however treatment should be personalized for each individual.

Antipsychotics Typical antipsychotic medications can cause additional side effects related to physical movement, such as: Rigidity Persistent muscle spasms Tremors Restlessness

Antipsychotics Long-term use of typical antipsychotics may lead to tardive dyskinesia (TD). TD causes muscle movements, commonly around the mouth, that a person can't control. TD can range from mild to severe, and in some patients it cannot be cured. Sometimes people with TD have partial or full recovery after stopping to take typical antipsychotics. TD rarely occurs while taking atypical antipsychotics.

Adverse Effects Autonomic nervous system: Central nervous system: Loss of accommodation, dry mouth, difficulty urinating, constipation, orthostatic hypotension, impotence, failure to ejaculate Central nervous system: Parkinson's syndrome, akathisia, dystonias, Tardive dyskinesia

Torticollis

Retrocollis

Trismus

Tongue protrusion

Oculogyric crisis

Blepharospasm

Adverse Effects Endocrine system: Other: Hyperprolactinemia (Amenorrhea, galactorrhea, infertility, impotence) Weight gain (Possibly combined H1 and 5-HT2c blockade)   Other: Seizures: chlorpromazine, clozapine Cardiac arrhythmia

Adverse Effects Toxic or Allergic Reactions: Ocular Complications: cholestatic jaundice and skin eruptions Agranulocytosis: clozapine Ocular Complications: Deposits in the cornea and lens: chlorpromazine retinal deposits: thioridazine (browning of vision)

Tardive dyskinesia a late-occurring syndrome of abnormal choreoathetoid movements relative cholinergic deficiency secondary to supersensitivity of dopamine receptors 20–40% of chronically treated patients Early recognition is important sometimes self-limited

Tardive dyskinesia movements of the tongue Lateral jaw movements frequent blinking, grimacing Restless choreiform (irregular spasmodic) or distal athetosis (slow, writhing movement) of limbs: twisting, spreading, flexion (bending) and extension of fingers, toe tapping, and toe dorsiflexion

Tardive dyskinesia to discontinue or reduce the dose of the current antipsychotic agent switching to quetiapine or clozapine to eliminate all anticholinergics action If they fail, the addition of diazepam (30–40 mg/day) Valproate Clonidine Vit E

Neuroleptic Malignant Syndrome (NMS) life-threatening disorder in patients who are extremely sensitive to the extrapyramidal effects of antipsychotic agents muscle rigidity fever autonomic instability (altered blood pressure and pulse rate) stress leukocytosis

Neuroleptic Malignant Syndrome (NMS) Management: Muscle relaxants: diazepam, dantrolene, or dopamine agonists, such as bromocriptine Switching to an atypical drug after recovery

Mood Stabilizers If a patient with bipolar disorder is on lithium (Li), blood levels of Li and kidneys and thyroid function should be checked regularly. Li is eliminated through the kidneys, so the dose should be lower in older people. Water loss (e.g. through sweating or diarrhea): Li level, necessitating a temporary lowering of the daily dose.

Pregnancy While no med is considered perfectly safe for all women at all stages of pregnancy, this must be balanced for each woman against the fact that untreated serious mental disorders can pose a risk to both pregnant woman and fetus. Meds should be selected based on available scientific research & be taken at the lowest possible dose.

Pregnancy The following should be avoided during pregnancy: Mood stabilizers are known to cause birth defects. Benzodiazepines and Li have been shown to cause "floppy baby” syndrome (i.e. baby is drowsy, limp, and cannot breathe or feed well). BZPs birth defects or other infant problems, esp if taken during the 1st trimester.

Pregnancy SSRIs are considered to be safe during pregnancy. Antidepressants do cross the placental barrier and may reach the fetus. Birth defects or other problems are possible, but are very rare. Effects of antidepressants on childhood development remain under study.

Pregnancy Studies have found that fetuses exposed to SSRIs during 3rd trimester may be born with withdrawal symptoms. These symptoms in babies are generally mild and short-lived & no deaths have been reported. Risks from the use of antidepressants need to be balanced with the risks of stopping meds; in many cases: it mean you must continue the medications.

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