Psych Meds

1st Gen Antipsychotics Indication

Positive Sx of schizophrenia

1st Gen Antipsychotics

D2 (dopamine receptor) blockers or antagonists

• also block ACh, histamine & NE

• ACh block causes EPS

1st Gen Antipsychotics Generic Names

• haloperidol

• chlorpromazine

• fluphenazine

• perphenazine,

• loxapine

• thiothixene

1st Gen Antipsychotics EPS Sx

• Acute Dystonia

  • Severe spasms of tongue, neck, face or back

• Parkinsonism

  • Bradykinesia, rigidity, shuffling gait, tremors, drooling

• Akathisia

  • Unable to stand still or sit; continually pacing & agitated

• Tardive Dyskinesia (TD)

  • Involuntary movements of tongue/face (ex: lip smacking), or limbs

1st Gen Antipsychotics Adverse Effects

• Anticholinergic effects

  • Can’t see, can’t pee, can’t spit, can’t [poop]

  • Dangerous in the elderly

• Orthostatic hypotension

• Sedation

• QT prolongation → Cardiac Arrhythmias

• ↑ Prolactin → gynecomastia, amenorrhea, sexual dysfunction

• Rash & Photosensitivity

• NMS

Neuroleptic Malignant Syndrome (antipsychotics)

Dopamine blockade

• in hypothalamus → Temp dysregulation

• In nigrostriatal pathway → severe rigidity

  • Muscle breakdown → ↑↑ Creatine Kinase (CK) → risk of acute renal failure (↑ Cr)

NMS Sx

• Hyperthermia (often > 104 F)

• “Lead-Pipe” Rigidity

  • (no movement due to ↓ dopamine)

• Altered mental status

• Autonomic instability (↑ HR, ↑ ↓ BP, sweating)

• Leukocytosis

NMS Interventions

• Stop the antipsychotic

• Rapid Response → Transfer to ICU

• Apply cooling blankets & administer antipyretics (acetaminophen)

• Monitor V/S

• ↑ IV fluids

• Benzodiazepines for anxiety/agitation

Acute Dystonia Tx

• benztropine

• trihexyphenidyl

  • both anticholinergics

• diphenhydramine

• clonazepam and lorazepam

Parkinsonism Tx

• benztropine

• trihexyphenidyl

  • both anticholinergics

• diphenhydramine

• amantadine

  • dopamine agonist

Akathisia Tx

• benztropine

• trihexyphenidyl

• propranolol

  • beta blocker

• clonidine

  • alpha-2 agonist

• clonazepam and lorazepam

TD Tx

No medication to treat TD

• Must start off on low dose of antipsychotic to avoid this sx

2nd Gen Antipsychotics

1st Gen Antipsychotics Contradictions

• Parkinson’s Disease

  • Dopamine blockade → worsens motor symptoms

• Severe hypotension

• History of Neuroleptic Malignant Syndrome

1st Gen Antipsychotics Interactions

• Anticholinergics

• CNS Depressants

• Levodopa (counteracts effects of antipsychotic agents)

2nd Gen Antipsychotics Generic

• clozapine - gold standard

• quetiapine

• olanzapine

• risperidone

• ziprasidone

• iloperidone

• asenapine

• lurasidone

3rd Gen Antipsychotics Generic

• aripiprazole

• brexipiprazole

• cariprazine

Atypical Antipsychotics Indication

1^st line treatment of schizophrenia

• ↑ effect and ↓ adverse events than 1^st gen

• Relieve positive & negative symptoms

Atypical Antipsychotic Mechanism

• Block 5HT

• Less dopamine blockade

  • Fewer / no extrapyramidal symptoms (including TD) due to ↓ dopamine blockade

  • 3^rd gen: agonist-antagonist of dopamine

• Also ↓ NE, ↓ histamine

  • Fewer anticholinergic side effects (little/no ACh blockade except clozapine)

Atypical Antipsychotics Adverse Effects

• New onset diabetes (or loss of glucose control in patients with DM)

• ↑ cholesterol

• Sexual Dysfunction

• Weight gain

• EPS with 3rd Gen

Atypical Antipsychotics Contradictions

• New onset diabetes (or loss of glucose control in patients with DM)

• ↑ cholesterol

• Sexual Dysfunction

• Weight gain

Lithium Indications

Bipolar Disorder 

• Controls & prevents acute manic episodes

Lithium Mechanism

salt ion that works intracellularly on G proteins and enzymes, stabilizing serotonin (antagonist), dopamine, and acetylcholine and decreasing norepinephrine

Lithium Therapeutic Range

• 1.0 to 1.5 mEq/L to address acute mania​

• 0.6 to 1.2 mEq/L for maintenance dosing​

Blood levels checked 14 days after beginning treatment, 14 days after every dose change, and routinely every 3-6 months after stability is achieved.

Lithium Caution

• Pregnancy and lactation

• Toxicity

• Hyponatremia or dehydration

• Schizophrenia

• Hypothyroidism

• Seizure Disorder

Mild Lithium Toxicity

• Metallic taste in mouth

• Fine hand tremor

• N/V/D

• Polyuria

• Muscle weakness

• Wt gain

• Edema

• Memory impairments

Moderate Lithium Toxicity

• N/V/D

• Dry mouth

• Dizziness

• Incoordination

• Tinnitus

• Blurred Vision

• Increasing tremor

Severe Lithium Toxicity

• Cardiac arrhythmias

• Blackouts

• Nystagmus

• Coarse tremors

• Visual or tactile hallucinations

• Renal failure

• Seizures

• Coma'

• Death

Lithium Toxicity Interventions

1. Withhold additional doses of lithium​

2. Immediately obtain a blood sample to analyze the lithium level​

3. Push fluids if the patient can take fluids​

4. Contact the treating provider for further direction about relieving the symptoms​

Antiepileptics Generic

• valproic acid

• carbamazepine

• oxcarbazepine

• lamotrigine

• gabapentin,

• topiramate

• levetracetam

• zonisamide

Antiepileptics Indications

Mood stabilizer for bipolar disorder

Lamotrigine

monitored for leukopenia and life-threatening Stevens-Johnsons rash.