Psychiatric Medications: Lithium, Fluoxetine, Haloperidol, Clozapine, and Sertraline

Lithium

  • Lithium is an anti-mania medication, not an antidepressant or tranquilizer.
  • It is an electrolyte that decreases mania but does not treat depression.

Side Effects (The 3 P's):

  • Lithium is unique among psych drugs, as its side effects are not the typical A, B, C, D.
  • Polyuria: Frequent urination.
  • Persistent Diarrhea: Ongoing diarrhea.
  • Paresthesia: Numbness and tingling. This is related to its nature as an electrolyte. Earliest sign of electrolyte imbalance is numbness and tingling.
  • These side effects do not warrant holding the drug or calling the doctor; continue administering the drug.

Toxic Effects (Lithium Toxicity)

  • Lithium toxicity occurs at levels ≥2\geq 2. Normal Range is 0.6 - 1.2 mEq/L

  • Metallic Taste: A distinct metallic taste in the mouth.

  • Severe Diarrhea: Significant and excessive diarrhea.

  • Neurological Signs (excluding paresthesia): Any neurological symptoms other than numbness and tingling (which is a side effect).

    • If toxic effects are observed, stop the lithium and notify the healthcare provider immediately.

Number One Intervention

  • Forced Fluids: Due to polyuria and diarrhea, patients are prone to dehydration.

    • Encourage intake of 10-12 glasses of water per day, which is more than the usual 8-10 glasses.

  • Electrolyte Fluids: If the patient is sweating or overexerting, provide electrolyte-containing fluids like Gatorade, Pedialyte, or other electrolyte solutions (not just water or soda).

Relationship with Sodium

  • Lithium is closely linked to sodium levels in the body; sodium levels must be monitored.

    • High Sodium: Lithium is less effective; it won't treat mania effectively.
    • Low Sodium: Risk of lithium toxicity increases.

  • Maintain normal sodium levels to ensure proper lithium action.

Fluoxetine (Prozac)

  • Fluoxetine (Prozac) is an SSRI (Selective Serotonin Reuptake Inhibitor) antidepressant.
    • Drugs with "XET" or "XEP" typically indicate an SSRI.

Side Effects (A, B, C, D, E)

  • Anticholinergic: Dry mouth, blurred vision, bladder retention, constipation.
  • Drowsiness
  • Euphoria
  • Insomnia: Can cause insomnia, administer before 12 noon.

Special Considerations

  • Adolescents/Young Adults: When changing the dose, monitor for suicidal ideation.

Haloperidol (Haldol)

  • Haloperidol (Haldol) is a major tranquilizer, similar to the "zines" but does not end in "zine."

Side Effects (A, B, C, D, E, F, G)

  • Anticholinergic: Dry mouth, blurred vision, bladder retention, constipation.
  • Drowsiness
  • EPS
  • Photosensitivity
  • Agranulocytosis

Neuroleptic Malignant Syndrome (NMS)

  • Elderly patients are at risk for NMS.
  • Hyperpyrexia: High fever with temperatures exceeding 104∘F104^{\circ}F. Temperatures often range from 106∘F106^{\circ}F to 108∘F108^{\circ}F.
  • NMS is potentially fatal; monitor elderly patients closely.
  • Administer one-half the normal adult dose to elderly patients.

Safety Concerns

  • Safety concerns related to tranquilization, similar to other tranquilizers.

Clozapine

  • Clozapine is a major tranquilizer/antipsychotic, like the "zines," developed to reduce side effects.
    • Drugs with "zap" are in this class.

Advantage

  • Does not have side effects A, B, C, D, E, or F (anticholinergic, drowsiness, EPS, etc.).

Disadvantage

  • Causes agranulocytosis (severely low white blood cell count).

Administration and Monitoring

  • Initially, patients receive only 7 days' worth of pills.
  • Weekly white blood cell counts are required for the first four weeks.
  • If the white blood cell count is acceptable, another 7 days' supply is given.
  • After four weeks, if stable, patients receive a month's supply with monthly white blood cell count monitoring.

Caution

  • Do not confuse clozapine with clonazepam (a benzodiazepine tranquilizer).

Sertraline (Zoloft)

  • Sertraline (Zoloft) is an antidepressant with side effects A, B, C, D, and E.

Advantage over other antidepressants

  • Does not cause insomnia, so it can be administered at bedtime (HS).

Drug Interactions

  • Sertraline has many drug interactions. Be cautious with concurrent medications.
Serotonin Syndrome
  • Avoid taking Saint John's Wort with sertraline to prevent serotonin syndrome.
  • Serotonin syndrome is a potentially fatal hypertensive crisis.
Signs and Symptoms (SAD HEAD)

  • Sweating

  • Apprehension: Impending sense of doom.

  • Dizziness

  • Headache

  • If a patient on sertraline exhibits these symptoms, ask if they are taking Saint John's Wort and advise them to stop immediately if they are.

Warfarin Interaction
  • Sertraline is notorious for interacting with warfarin (anticoagulant), increasing bleeding risk.
  • Monitor for increased bleeding.
  • Consider reducing the warfarin dosage.