Psych and Geriatric Medication Clin Med

Antidepressants

• Selective Serotonin Reuptake Inhibitors (SSRIs)

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

• Atypical Antidepressants

• Tricyclic Antidepressants (TCAs)

Antipsychotics (neuroleptics)

Used for schizophrenia, bipolar disorder, and as augmenting agents for depression

• Atypical (Second-Generation)

• Typical (First-Generation)

Mood stabilizers

Primarily used for the treatment of bipolar disorder and certain seizure disorders

• Lithium Carbonate (Lithobid, Eskalith)

• Divalproex Sodium (Depakote)

• Lamotrigine (Lamictal)

• Carbamazepine (Tegretol, Equetro)

• Oxcarbazepine (Trileptal)

Anxiolytics and Sedatives

Used for acute anxiety, panic attacks, and insomnia

• Benzodiazepines

• Non-benzodiazepine sedatives

• Other Anxiolytics

Selective Serotonin Reuptake Inhibitors (SSRIs)- Antidepressants

• Fluoxetine (Prozac)

• Paroxetine (Paxil)

• Sertraline (Zoloft)

• Fluvoxamine (Luvox)

• Escitalopram (Lexapro)

• Citalopram (Celexa)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)- Antidepressants

• Venlafaxine (Effexor)

• Desvenlafaxine (Pristiq)

• Duloxetine (Cymbalta)

• Levomilnacipran (Fetzima)

Atypical antidepressants- Antidepressants

• Bupropion (Wellbutrin)

• Mirtazapine (Remeron)

• Trazodone (Desyrel)

• Vortioxetine (Trintellix)

• Vilazodone (Viibryd)

Tricyclic Antidepressants (TCAs)- Antidepressants

• Amitriptyline (Elavil)

• Nortriptyline (Pamelor)

• Imipramine (Tofranil)

• Clomipramine (Anafranil)- OCD

• Desipramine (Norpramin)

Atypical (Second-generation)- antipsychotics

• Quetiapine (Seroquel)

• Olanzapine (Zyprexa)- Anorexia

• Clozapine (Clozaril)

• Cariprazine (Vraylar)

• Aripiprazole (Abilify)

• Brexpiprazole (Rexulti)

• Risperidone (Risperdal)

• Lurasidone (Latuda)

• Ziprasidone (Geodon)

• Paliperidone (Invega)

Typical (first generation)- antipsychotics

• Haloperidol (Haldol)

• Chlorpromazine (Thorazine)

• Fluphenazine (Prolixin)

• Perphenazine (Trilafon)

• Loxapine (Loxitane)

Benzodiazepines- anxiolytics and sedatives

• Alprazolam (Xanax)

• Lorazepam (Ativan)

• Clonazepam (Klonopin)

• Diazepam (Valium)

• Temazepam (Restoril)

• Chlordiazepoxide (Librium)

Non-benzodiazepine sedatives- anxiolytics and sedatives

• Zolpidem (Ambien)

• Eszopiclone (Lunesta)

• Zaleplon (Sonata)

Other anxiolytics- anxiolytics and sedatives

• Buspirone (Buspar)

• Hydroxyzine (Vistaril, Atarax)

Ciproheptadine

Appetite stimulant

• often used in ARFID

Alpha 1 adrenergic agonists

Prazosin

• used to treat nightmares

• often used in PTSD

MOA of a neuroleptic (antipsychotics)

Block D2 (dopamine) receptors

• more effective at treating the positive s/s of psychosis (versus the negatives)

SE of neuroleptics (antipsychotics)

• Extrapyramidal symptoms (EPS)- first gen

• Anticholinergic symptoms

• Metabolic syndrome- second gen

• Tardive Dyskinesias- first gen

• Neuroleptic malignant syndrome- first gen

• Other: prolonged QTc interval, hyperprolactinemia, fatigue, sexual dysfunction, rashes and photosensitivity

Extrapyramidal SE of neuroleptics

More common in high-potency first generation antipsychotics, can be permanent

• Dystonia: spasms of the face, neck, and tongue

• Parkinsonism: tremor, rigidity, bradykinesia

• Akathisia: feeling of restlessness, need to keep moving

Anticholinergic SE in neuroleptics

Dry mouth, constipation, blurred vision, hyperthermia

Metabolic syndrome SE in neuroleptics

More common in second generation antipsychotics

• Increased BP, increase blood sugar, weight gain especially in the abdomen, dyslipidemia

Tardive dyskinesia SE in neuroleptics

More common in first generation antipsychotics (related to extrapyramidal)

• Choreathetoid movements in face, tongue, head

• Can become permanent even with discontinuation

Neuroleptic Malignant Syndrome

More common in first generation meds, MEDICAL EMERGENCY MUST STOP PSYCH MEDICATIONS

• Change in mental status, autonomic instability (high fever, labile BP, tachycardia, diaphoresis), lead-pipe rigidity, elevated CPK levels (muscle break down), leukocytosis, metabolic acidosis

Haloperidol (Haldol)

Typical (first generation) antipsychotic

• High EPS symptoms

• Low anticholinergic, orthostasis, and sedation

• Good to use for short term use and in the elderly

  • Ex. Short term use in elderly with UTI related psychosis

Drugs used to treat (or prophylaxis) of EPS SE in antipsychotics

• Benztropine (Cogentin): acute EPS, dystonia (spasms), prophylaxis

• Diphenhydramine (Benadryl)

• Amantadine (Symmetrel): dopamine facilitator, cannot tolerate anticholinergic s/s

• Propranolol (Inderal): akathisia (restlessness)

Clozapine (Clozaril)

Atypical neuroleptics (2nd generation) used for refractory schizophrenia

• RISK OF AGRANULOCYTOSIS: Monitor WBC and CBC with diff before, during, and after treatment

• Monitor for hyperglycemia

Risperidone (Risperidol)

Atypical (2nd generation) antipsychotic used in psychosis

• Orthostatic HoTN, slight sedation

• Rare EPS risk

Quetiapine (Seroquel)

Atypical (2nd generation) antipsychotics used for schizophrenia

• Do eye exam initially and every 6 months

• Low incidence of EPS, sedation, orthostatic HoTN

  • good in elderly

Olanapine (Zyprexa)

Atypical (2nd generation) antipsychotic used for psychosis and anorexia

• Low EPS risk

• High risk sedation, orthostatic HoTN

• Potentate with fluvoxamine (Luvox) (SSRI)

Adjunct tx in psychotic disorders

If pt responds to antipsychotics but remains agitated

• Lorazepam (Ativan)

• Propranolol (Inderal): restlessness (akathisia) or marked tremor

SE of SSRIs

• Nausea, sedation, weight gain, sexual dysfunction, hyponatremia in elderly

• Can cause withdrawal symptoms, so patients must taper off if needed

• Safter than most other antidepressants in the case of overdose (hard to OD on)

MOA of SSRIs

Leaves more serotonin in between synapses for the brain to use on the respective receptor

MOA of SNRIs

Leaves more norepinephrine in between synapses for the brain to use on the respective receptor

SE of SNRIs

Generally the same as SSRIs (Nausea, sedation, weight gain, hyponatremia in elderly) but less risk of sexual dysfunction than SSRIs

• Can cause HTN, constipation, dry mouth (norepinephrine uptake)

Secondary uses of SNRIs

Migraines, chronic pain, nerve pain

MOA of TCAs

Mostly work by inhibiting norepinephrine and serotonin uptake

SE of TCAs

Not often used first line or mono therapy because of the SE (adjunct to SSRI/SNRI)

• Anticholinergic effects and orthostatic HoTN (bad in the elderly)

• Sedation

• CV effect

Alternative uses for TCAs

insomnia, migraine, chronic pain, IBS

MAOis

Inhibit monoamine oxidase, an enzyme that breaks down serotonin, norepinephrine, and dopamine

• Very rarely used d/t potential drug interactions and dietary restrictions

  • Cannot be used with SSRIs due to serotonin syndrome (requires a wash out)

  • Cannot eat tyramine containing food (red wine, aged cheese, cured meat)

• SE: HoTN, dizzy, insomnia, peripheral edema

Wellbutrin XL (buproprion)

Atypical antidepressant; NE/DE retake inhibitor

• Can help with smoking cessation at higher doses

• Contraindications: CANNOT USE IN SEIZURE DISORDER OR EATING DISORDERS D/T ELECTROLYTE IMBALANCE

Desyrel (trazodone)

Atypical anti-depressant, serotonin receptor antagonist

• useful in insomnia without being a controlled substance

Remeron (mirtazapine)

Useful in elderly patients who struggle with sleep and low appetite

• can be an appetite stimulant in small doses

Serotonin syndrome

Taking more than one SSRI or combining with an MAOi can cause

• S/S: lethargy, confusion, diaphoresis, tremor, myoclonus that can sometimes progress to hyperthermia, rigidity, seizures and death

• Tx: STOP all serotonin medications, can give cyproheptadine (serotonin antagonist)

• RARE

Lithium

Most effective mood stabilizer for mania and suicide prevention but largely underutilized

• Lithium serum blood levels periodically to monitor toxicity every 3-12 months

• Regular thyroid and CMP studies for thyroid and kidney function (hypothyroid and decreased GFR)

• DO NOT USE IN NSAIDS or DIURETICS

Depakote (Valproate)

Anti-convulsant used in the treatment of mild/mod/mixed bipolar disorder (Mood stabilizer)

• SE: thrombocytopenia, leukopenia, hepatotoxicity

  • Check LFTs and CBC

• Serum drug levels checked if worried about compliance

Lamotrigine

Anti-convulsant used in the treatment of depressive bipolar disorder (Mood stabilizer)

• No lab work needed

• SE: STEVEN JOHNSON SYNDROME, “start low go slow dosing”

• OCPs can decrease efficacy by almost 50%