Psychopharmacology

Incorrect assumptions Patient is triaged as psychiatric, therefore patient is psychiatric. Patient has a history of psychiatric presentations, therefore this presentation is psychiatric. Patient is young, therefore this must be a functional disorder. Abnormal vital signs are due to mental/emotional state.

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Traditional Antidepressants TCA –amitriptylline –clomipramine –doxepin -desipiramine –imipramine –nortriptylline –trimipramine MAOIs –Tranylcypromine

Newer antidepressants SSRIs –citalopram –fluoxetine –fluvoxamine –paroxetine –sertraline RIMA –moclobemide

Newest antidepressants SNRI : Venlafaxine Duloxetine DNRI: Bupropion

Choice of Initial Antidepressant in Adults Symptom profile Side effect profile in relation to the individual patient Patient preference Cost History of previous response of the patient or family members Comorbid psychiatric or medical illnesses Potential drug-drug interaction

SSRI: Side Effect Profile Headache Anxiety and Agitation Nausea Diarrhea Sexual dysfunction and Sleep disruption or Somnolence

SSRI: Rare but Dangerous Side Effects UGI bleeding (platelet dysfunction), esp. in combo with NSAID’s or other blood-thinning agents SIADH Osteoporosis and fractures in the elderly Serotonin syndrome SSRI discontinuation syndrome (slow taper) Flu-like symptoms Insomnia Nausea Imbalance Sensory disturbances Hyperarousal (agitation/anxiety)

SNRI: Side Effect Profile As with SSRI’

TCA: Side Effect Profile Antihistamine – weight gain & sedation Anticholinergic Anti-alpha adrenergic – dizziness, orthostatic hypotension

MAOI: Side Effect Profile Hypertention crisis Orthostatic hypotension

Benzodiazepines alprazolam short-mid chlordiazepoxide long clonazepam mid-long diazepam long flurazepam long lorazepam short-mid oxazepam short-mid

Anxiolytics: Side effects Memory decline Addiction(dependency &withdrawal) Ataxia/Falls Drowsiness/dizziness/disinhibition

Anxiolytics:Contraindications With COPD or sleep apnea Avoid in the elderly

Traditional Antipsychotics Phenothiazines –chlorpromazine –fluphenazine –flupenthixol –-perphenazine –pimozide –thioridazine –trifluoperazine Butyrophenon –haloperidol

Newer Antipsychotics Atypical agents –aripiprazole –clozapine –risperidone –quetiapine –olanzapine

18 EPS + TD Weight Gain Insulin Resistance Insulin Resistance Hyper- glycemia Hyper- glycemia CVD Hyper- lipidemia Hyper- lipidemia Weight Gain Diabetes Hyper Glycemia Hyper Glycemia Insulin Resistance Insulin Resistance QTc CVD Dyslipidemia Prior Safety Concerns Current Safety Concerns Side Effects of Atypical Antipsychotics: Shift in Risk Perception QTc EPS Neurologic Side Effects

Neuroleptic Malignant Syndrome Fever Encephalopathy Vital signs unstable Elevated CPK/ WBC Rigidity

Lithium: Side Effect Profile Lethargy Insipidis Tremor/Teratogen (increased risk Ebstein’s anomaly in first trimester) Hypothyroid Increased weight Vomitting, nausea, GI Miscellaneous: EKG changes (T wave flattening or inversion), acne, hair loss

Valproic Acid: Acute Side Effect Profile Sedation Tremor Unsteadiness (dizziness) Nausea /GI

Valproic Acid: longer term side effect monitoring On the surface: –Acne, hair loss Under the surface: –weight gain, edema Systemic: –blood dyscrasias (esp plt dysfn) –liver dysfunction +/- elevated ammonia levels –reproductive changes incl menstrual irregularities, PCOS, teratogenicity

Lamotrigene: Side Effect Profile Rash – Activation, Ataxi, Sedation, Sleep disturbances, Hypersensitivity reactions