Psychotropic Medications – Side-Effect Quick Notes

Systematic Assessment of Side-Effects

• Clarify symptom nature (onset, pattern, associated findings)
• Gauge severity (distress, functional / medical risk)
• Examine causality (recent drug starts, dose changes, interactions)
• Management ladder: lower dose → timing/formulation change → switch drug → add symptomatic agent

Antidepressants

• SSRIs

• Early: GI upset, CNS activation or sedation (agent-specific)
• Long-term: sexual dysfunction (≈ one-third), possible weight gain & $\text{SIADH}$
• Cardiac: modest $\text{QTc}$ risk; citalopram not above $40\,\text{mg}$ daily without ECG
• Withdrawal (short half-life drugs): flu-like, sensory "zaps", anxiety

• SNRIs

• Similar to SSRIs plus noradrenergic issues
• Venlafaxine: dose-related $\uparrow$ BP; duloxetine: monitor liver; levomilnacipran: urinary hesitancy, weight neutral

• TCAs

• Triad: anticholinergic, sedation, orthostasis (worse in tertiary amines)
• Cardiac conduction block, $\text{QT/QRS}$ widening; lethal in overdose
• Withdrawal: flu-like, anxiety

• MAOIs

• Orthostasis, weight gain, insomnia/sedation pattern differs by agent
• Risks: tyramine hypertensive crisis; serotonin syndrome; dangerous overdose
• Selegiline patch (low dose) spares diet limits

• Miscellaneous

• Bupropion: seizure threshold $\downarrow$; avoid in eating-disorders / epilepsy
• Mirtazapine: sedation & weight gain; less sexual dysfunction
• Trazodone: priapism warning; used mainly for sleep
• Vilazodone / Vortioxetine: transient GI; no clear sexual advantage

Mood Stabilisers

• Lithium

• Early: GI, tremor, polyuria/polydipsia
• Chronic: hypothyroidism, nephrogenic diabetes insipidus, weight gain
• Narrow index → monitor levels; toxicity needs IV fluids / dialysis

• Lamotrigine

• Dizziness, ataxia; key risk: $\text{SJS/TEN}$ (slow titration)
• Rare cardiac conduction issue; evaluate any rash urgently

• Valproic Acid

• GI, tremor, weight gain, alopecia; serious: hepatitis, pancreatitis, thrombocytopenia, hyperammonemia

• Carbamazepine / Oxcarbazepine

• GI, neuro side-effects; hyponatremia, rash $\to$ SJS; carbamazepine: blood dyscrasias, conduction block

Antipsychotics

• Typical (FGAs)

• Low-potency: anticholinergic, sedation, orthostasis; High-potency: EPS (dystonia, parkinsonism, akathisia)
• Long-term: tardive dyskinesia (≈ $5\%$ per year), hyperprolactinemia
• Rare: neuroleptic malignant syndrome, $\text{TdP}$

• Atypical (SGAs) – shared themes

• Lower EPS/TD (except high-dose risperidone)

• Variable metabolic load: highest with clozapine/olanzapine; lowest with ziprasidone, aripiprazole, lurasidone, cariprazine

• All can prolong $\text{QTc}$; ziprasidone & iloperidone among highest

• Dementia patients: increased mortality → black-box

  Specific pearls

• Clozapine: agranulocytosis monitoring (weekly $\to$ monthly), seizures, myocarditis, sialorrhea

• Risperidone / Paliperidone: highest prolactin, moderate EPS

• Olanzapine: marked weight gain, diabetes risk

• Aripiprazole / Brexpiprazole: akathisia common, prolactin neutral (aripiprazole lowers)

Anxiolytics & Hypnotics

• Benzodiazepines

• Sedation, ataxia, falls (elderly); dependence & withdrawal (anxiety, seizures, delirium)

• Z-drugs (zolpidem, zaleplon, eszopiclone)

• Similar to BZD but less next-day sedation; rare sleep-drive/eat behaviors

• Ramelteon & Buspirone

• Minimal abuse; buspirone GI / dizziness; no withdrawal

Other Psychotropics

• Stimulants (methylphenidate, amphetamines)

• Insomnia, ↓ appetite, BP/HR rise; rare psychosis; caution in cardiac disease

• Atomoxetine

• GI upset, mild BP/HR rise; rare hepatitis; early growth slowing

• Modafinil

• Headache, insomnia; rare SJS; mild BP/HR rise

• Beta-blockers (for akathisia, anxiety)

• Bradycardia, fatigue; taper to prevent rebound HTN/angina

• Alpha-2 agonists (clonidine, guanfacine)

• Sedation, dry mouth; rebound hypertension with abrupt stop

• Topiramate

• Cognitive slowing, paresthesias, weight loss, kidney stones; rare glaucoma

• Agents for substance use

• Naltrexone: nausea, $\uparrow$ LFTs; precipitates opioid withdrawal
• Acamprosate: diarrhea; adjust in renal disease
• Buprenorphine: typical opioid effects but lower respiratory risk

• Ketamine (antidepressant use)

• Acute: dissociation, BP rise; caution in hypertension, intracranial pathology; long term: urinary / cognitive issues

Key Monitoring Tips

• ECG for drugs with $\text{QTc}$ liability or cardiac history
• Metabolic panel & weight per ADA schedule for SGAs
• CBC for clozapine (ANC thresholds)
• Serum drug levels: lithium, valproate, carbamazepine

Red-Flag Side-Effects (Require Immediate Action)

• New rash on lamotrigine or carbamazepine (possible $\text{SJS/TEN}$)
• Agranulocytosis signs on clozapine (infection, sore throat)
• Serotonin syndrome (hyperthermia, clonus) on serotonergic combos
• Hypertensive crisis on MAOI + tyramine/sympathomimetic
• Neuroleptic malignant syndrome (fever, rigidity) on antipsychotics
• Severe lithium toxicity (ataxia, diarrhea, tremor with level elevation)