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Good, Bad, and the Ugly of Psychiatric Medications
Patrick Klenk, PA-C Psychiatry Physician Assistant Resident Michael E. DeBakey VA Medical Center Houston, TX
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Objectives Good labs and drug interactions to be mindful of
Common side effects of psychiatric medications Black Box Warnings and other major problems
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Caveats Not going to cover every psychiatric medication
Not all inclusive Not going to go over indications
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Topics Antidepressants Mood stabilizers Antipsychotics Anxiolytics
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Antidepressants
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Antidepressants - Suicidality
Black box warning Increased suicidality risk in children, adolescents, and young adults with major depression or other psychiatric disorders
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Antidepressants - TCAs
Side Effects Anticholinergic dry mouth, constipation, blurred vision, urinary retention Antihistamine Sedation, weight gain Antiadrenergic Orthostatic hypotension, reflex tachycardia, arrhythmias Sexual Black Box or Serious “3 Cs”: Cardiotoxicity, Convulsions, Coma 2nd most common cause of OD death (after acetaminophen) Contraindicated Recent MI, ischemic heart disease, conduction defects, urinary retention, narrow angle glaucoma, renal failure Delirium Increased LFTs Can lead to acute hepatitis Labs/Drug interactions Lab: EKG, TCA plasma levels, CMP
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Antidepressants - MAOIs
Side Effects Orthostatic hypotension Sedation Sexual Weight gain Black Box or Serious Hypertensive crisis Liver toxicity Labs/Drug interactions Serotonin syndrome w/ SSRI, SNRI, TCA, buspirone, decongestants
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Antidepressants – Hypertensive Crisis
Cause MAOIs + tyramine-rich food Tyramine-rich food examples Aged cheese, fava beans, red wine, cured meats, chicken liver Symptoms HTN, HA, N/V, chest pain, arrhythmias, death
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Antidepressants – Serotonin Syndrome
Cause Too much serotonin in the brain Symptoms Fever, diaphoresis, tachycardia, HTN, delirium Hyperreflexia Myoclonus Switching Antidepressants Wait at least 2 weeks Except fluoxetine, wait 5-6 weeks
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Antidepressants - SSRIs
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Antidepressants - SSRIs
Side Effects GI Sexual Numbing of emotions Discontinuation syndrome flu-like, give fluoxetine or taper Black Box or Serious Black box QTc: citalopram Caution in high bleeding risk Hyponatremia and seizures Labs/Drug interactions Warfarin: increased levels of free warfarin
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Antidepressants - SNRIs
Side Effects Similar to SSRI GI, sexual Can have more dry mouth and constipation from NE Discontinuation syndrome: venlafaxine Black Box or Serious HTN Caution in liver disease, ESRD, narrow angle glaucoma Labs/Drug interactions BP
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Antidepressants - Bupropion
Side Effects No sexual side effects Stimulating: Anxiety, Insomnia Worsen OCD/tics Worsen psychosis Black Box or Serious Contraindicated History of seizures, anorexia nervosa, bulimia Black Box Neuropsychiatric symptoms Labs/Drug interactions CMP
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Antidepressants - Mirtazapine
Side Effects Sedation Weight gain Increased appetite Dry mouth and constipation Fewer sexual side effects Black Box or Serious Agranulocytosis, neutropenia Labs/Drug interactions CBC
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Antidepressants - Trazodone
Side Effects Drowsiness No sexual side effects Orthostatic hypotension Black Box or Serious Priapism Cardiac arrhythmias Labs/Drug interactions EKG
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Mood Stabilizers
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Mood Stabilizers - Lithium
Side Effects Fine tremor (coarse tremor at toxic levels) Weight gain and sedation Skin (acne to psoriasis) Black Box or Serious Black Box Lithium Toxicity (N/V/D, delirium, ataxia, stupor) Hypothyroidism, hyperparathyroidism, Diabetes insipidus Pregnancy: Ebstein’s anomaly Labs/Drug interactions Serum level Baseline: Renal, thyroid, CMP, CBC, urinalysis, EKG, pregnancy ↑ Li: Thiazide diuretics, furosemide, caffeine, ACEI/ARB, NSAID, reduced Na intake, sweating, impaired renal ↓ Li: Theophylline, osmotic diuretics, increased Na intake, Na Bicarb antacids
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Mood Stabilizers - Valproate
Side Effects Tremor Weight gain and sedation Alopecia Black Box or Serious Black box: Hepatoxicity, Increased hepatotoxicity risk in mitochondrial disease, Pancreatitis, Fetal risk (neural tube) Stephens-Johnson Thrombocytopenia: check hx of agranulocytosis Polycystic ovaries Labs/Drug interactions Serum level CBC-diff, platelets, LFTs, PT, PTT, amylase Pregnancy Protein bound (ASA, warfarin, digoxin)
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Mood Stabilizers - Lamotrigine
Side Effects HA, dizziness, sedation Peripheral edema Rash Black Box or Serious Black Box Stephens-Johnson syndrome Labs/Drug interactions ↑ Lamotrigine: Valproate LFTs and CBC
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Mood Stabilizers – Gabapentin
Side Effects Sleepiness Dizziness Black Box or Serious Renal adjustment Labs/Drug interactions Not protein bound, not metabolized Few drug interactions
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Antipsychotics
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Antipsychotics – Black box
Dementia related psychosis Increased mortality risk in elderly dementia patients on antipsychotics Most deaths due to cardiovascular or infectious events
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Antipsychotics – Typical – Low Potency
Side Effects Anticholinergic dry mouth, constipation, blurred vision, urinary retention Antihistamine Sedation, weight gain Antiadrenergic Orthostatic hypotension, reflex tachycardia, arrhythmias Lower EPS Hyperprolactinemia Chlorpromazine: blue-gray skin Black Box or Serious Overdose: QTc prolongation Chlorpromazine: depositis in lens and cornea Thioridazine: retinitis pigmentosa, proarrhythmic effects Labs/Drug interactions EKG Tobacco
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Antipsychotics – Typical – High Potency
Side Effects Anticholinergic, Antihistamine, Antiadrenergic Higher extrapyramidal symptoms (EPS) Black Box or Serious Overdose: QTc prolongation Neuroleptic malignant syndrome Labs/Drug interactions EKG
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Antipsychotics – EPS Rule of 4’s 4 hours = acute dystonia
Muscle spasms 4 days = Parkinsonism Bradykinesia, rigidity, tremor 4 days to 4 weeks = akathisia Restlessness 4 months = tardive dyskinesia involuntary, repetitive movements of facial, tongue, neck muscles
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Antipsychotics – Neuroleptic malignant syndrome
Cause Idiopathic, life-threatening reaction to antipsychotics Symptoms Fever Autonomic instability Leukocytosis Tremor Elevated CPK Rigidity (“lead pipe”) Excessive sweating Delirium Most likely Young muscular male on high potency
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Antipsychotics – Atypical
Side Effects Some antihistaminic, antiadrenergic, antimuscarinic Hyperprolactinemia, EPS: risperidone Akathisia: abilify Black Box or Serious Metabolic syndrome: weight gain, hyperlipidemia, hyperglycemia QTc prolongation Clozapine: Agranulocytosis, neutropenia, orthostatic hypotension, seizure, myocarditis, cardiomyopathy Labs/Drug interactions EKG Weight, waist?, BP, fasting glucose/lipids LFTs
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Anxiolytics
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Anxiolytics - Benzo Side Effects Black Box or Serious
Dependence, addiction, abuse Drowsiness Reduced motor coordination Black Box or Serious Respiratory depression Delirium Labs/Drug interactions Vitals Additive cognitive impairment with anticholinergics
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Anxiolytics - Hydroxyzine
Side Effects Antihistamine Sedation, dry mouth, constipation, urinary retention, blurry vision Black Box or Serious QT prolongation Labs/Drug interactions EKG Pimozide: contraindicated
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Anxiolytics - Buspirone
Side Effects Takes several weeks to take effect HA, nausea, dizziness No weight gain, sedation, sexual No cognitive impairment No respiratory depression No addiction or tolerance No withdrawal Labs/Drug interactions Grapefruit can increase concentration
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Anxiolytics - Prazosin
Side Effects HA Dizziness Black Box or Serious No black box warnings Hypotension – 1st dose orthostasis or syncope Labs/Drug interactions BP
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Questions?
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References Ganti L, Kaufman MS, Blitzstein SM. Psychopharmacology. In: First Aid for the Psychiatry clerkship. 4th ed. New York, NY: McGraw-Hill Education; 2016: Papadakis MA, McPhee SJ. Psychiatric Disorders. In: Current Medical Diagnosis & Treatment. 53rd ed. New York, NY: McGraw-Hill Education; 2014: Toy, Klamen. Case Files Psychiatry. 5th ed. New York, NY: McGraw-Hill Education; 2016.
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