Module 6 Psych Med Review

Psychiatric Med Review

• Psychiatric Med sections in the ATI textbook provide in-depth information.

• Presented by Dr. Elisha Tribble from Middle Georgia State University.

Selective Serotonin Reuptake Inhibitors (SSRIs)

• First-line therapy for depression; not recommended for Tricyclics (TCAs).

  • Common SSRIs:

    • Prozac (Fluoxetine)

    • Zoloft (Sertraline)

    • Paxil (Paroxetine)

    • Celexa (Citalopram)

    • Lexapro (Escitalopram)

    • Luvox (Fluvoxamine)

• Side Effects:

  • Nausea, headache, agitation, insomnia, anxiety (CNS stimulation) - typically resolves within 3 weeks.

  • Weight changes (loss or gain) with chronic use.

• Serotonin Syndrome:

  • Toxic effects possible if SSRIs/SNRIs are combined with MAOIs, TCAs, St. John’s Wort.

  • Consult a pharmacist for new prescriptions or OTC medications.

  • Avoid OTC medications, like dextromethorphan, Migraine Triptans, and others without consultation.

Symptoms of Serotonin Syndrome

• Mnemonic: FEVER + MAN

  • Fever: Hyperpyrexia

  • M: Mental status changes (hostility, agitation, confusion)

  • A: Autonomic instability (diaphoresis, nausea, vomiting, diarrhea, tremors)

  • N: Neuromuscular hyperactivity (hyperreflexia, incoordination, myoclonus)

• Patient Education: Important to educate patients and families on recognizing symptoms.

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

• Function: Block norepinephrine and serotonin reuptake; second-line treatment after SSRIs fail.

• Examples:

  • Effexor (Venlafaxine) - may cause night sweats.

  • Cymbalta (Duloxetine) - helps with muscle/bone/nerve pain.

  • Pristiq (Desvenlafaxine) - effective for PMDD, fewer side effects than Venlafaxine.

• Caution: Do not use concurrently with SSRIs, SNRIs, or TCA to avoid Serotonin Syndrome.

Discontinuation Syndrome - SSRIs/SNRIs

• Common Symptoms:

  • Dizziness, nausea, lethargy, anxiety, electric shock sensations, flu-like symptoms, headache.

• Usually mild; symptoms start within 1 week after abrupt cessation and resolve in 3-4 weeks.

• Importance: Proper documentation is crucial to prevent future noncompliance with antidepressants. Medications should be tapered off gradually.

Tricyclic Antidepressants (TCAs)

• Overview: Oldest class of antidepressants.

• Risks: Cardiac toxicity (QT prolongation) with overdoses; considered more lethal than SSRIs in suicide attempts.

• Neurotransmitter Coverage: Effective on serotonin and norepinephrine.

• Effects can take 10-14 days to manifest.

• Common Side Effects: Anticholinergic effects.

• Examples:

  • Elavil (Amitriptyline) - prototype, used for sleep.

  • Tofranil (Imipramine)

  • Pamelor (Nortriptyline)

  • Anafranil (Clomipramine) - still used for OCD.

  • Doxepin (Sinequan)

Anticholinergic Side Effects of TCAs

• Similar to effects of Benadryl; include:

  • Dry mouth

  • Constipation

  • Urinary retention

  • Blurred vision

  • Sedation

  • Orthostatic hypotension

  • Tachycardia

• Most effects are transient, particularly risky for the elderly.

Patient Education for TCAs

• Minimize Anticholinergic Effects:

  • Chew sugarless gum for dry mouth.

  • Increase dietary fiber to avoid constipation.

  • Stay hydrated.

  • Stand slowly to prevent orthostatic hypotension.

Alcohol Consumption

• Advice: Alcohol can block the effects of antidepressants; patients should abstain from drinking.

Choosing Antidepressants

• Considerations for Prescription:

  • Ease of administration

  • Likelihood of compliance

  • Patient’s history of past responses

  • Safety and medical considerations

  • Genotyping (enzyme profile) when available

Monoamine Oxidase Inhibitors (MAOIs)

• Use: Last line of medications for profound depression when others have failed.

• Examples:

  • Marplan (Isocarboxazid)

  • Nardil (Phenelzine)

  • Parnate (Tranylcypromine) - dietary restrictions due to tyramine.

• Diet Restrictions: Avoid wine, avocados, figs, bananas (overripe), aged cheeses, smoked/fermented meats, chocolate, ginseng.

• Consultation Needed: No OTC medications without physician’s approval.

Serotonin Antagonists and Reuptake Inhibitors (SARIs)

• Usage: Reuptake of serotonin and norepinephrine and/or dopamine; often used as adjunctive therapies.

  • Trazodone: Causes sedation, used for anxiety.

Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs)

• Examples:

  • Wellbutrin (Bupropion) - stimulating, appetite reduction.

  • Buspar (Buspirone) - anxiety improvement at small doses.

  • Zyban - smoking cessation aid.

• Usage: As sole antidepressants, adjuncts for anxiety management, or to counteract SSRI side effects.

Noradrenergic and Specific Serotonergic Antidepressants (NaSSAs)

• Example: Remeron (Mirtazepine) - similar antidepressant effect to SSRIs but with faster onset; significant weight gain and sedation potential.

Antipsychotics Overview

• Function: Stabilizers of the dopamine system, used for psychosis (hallucinations, delusions).

• Primary conditions treated: Schizophrenia and mania due to excess dopamine.

• Administration Strategy: High doses in acute phases, then taper as stabilization occurs.

• Neuroprotective Effects: Particularly beneficial for children and adolescents with severe psychosis.

First Generation Antipsychotics

• Characteristics: Target positive symptoms of schizophrenia but carry higher risks of side effects.

  • Advantages: Less expensive and longstanding efficacy.

  • Disadvantages: Higher incidence of extrapyramidal symptoms (EPS), tardive dyskinesia, and sedation.

• Examples:

  • Thorazine (Chlorpromazine)

  • Haldol (Haloperidol)

Second Generation Antipsychotics

• Benefits: Treat both positive and negative symptoms with minimal EPS or tardive dyskinesia.

• Risks: Significant weight gain and metabolic syndrome potential.

• Examples:

  • Risperdal (Risperidone)

  • Zyprexa (Olanzapine)

  • Clozaril (Clozapine) - fewer EPS but potential for agranulocytosis.

Agranulocytosis (Clozaril)

• Definition: Severe leukopenia leading to increased infection risk.

• Symptoms: Sudden fever, chills, sore throat, weakness, ulcers.

• Monitoring Required: Need baseline CBC with differential and regular follow-up for leukopenia.

Newer Antipsychotics

• Mechanism: Block D-2 and 5HT-2A receptors; treat broader spectrum of symptoms.

• Examples:

  • Abilify (Aripiprazole)

  • Latuda (Lurasidone) - effective in bipolar depression.

  • Vraylar (Cariprazine)

  • Improve symptoms with minimal risk of EPS and anticholinergic effects.

Neuroleptic Malignant Syndrome

• Overview: Rare, potentially deadly adverse reaction to antipsychotics.

• Symptoms: High fever, sweating, rigidity, blood pressure fluctuations, confusion, and can lead to coma/death.

Lithium Carbonate

• Indication: Primarily used for treating mania and stabilizing bipolar disorder cycling.

• Dosage Range: 0.4-1.4 or 0.5-1.5 Eq/L; effective in stopping manic episodes within 10-21 days.

• Indications for Combination Therapy: May require mood stabilizers like Depakote for initial stability until Lithium reaches therapeutic levels.

• Effects of Lithium: Reduces symptoms like elation, irritability, and grandiosity.

Lithium Toxicity

• Problematic: High efficacy but not a cure; mild toxicity above 1.5 mEq/L leads to nausea and metallic taste.

• Monitoring: Weekly serum levels to maintain between 0.5-1.5 mEq/L.

  • Early toxicity may present as polyuria or muscle weakness; severe toxicity can lead to seizures or renal shutdown.

• Preventive Measures: Avoid dehydration and diuretics that can elevate lithium serum concentration.

Lithium Discontinuation Protocol

• Signs of Toxicity: Discontinue and contact a prescriber if symptoms such as diarrhea, vomiting, tremor, or ataxia occur.

  • Severe intoxication can result in life-threatening cardiac issues or death.

Anticonvulsant Drugs (Mood Stabilizers) for Bipolar Disorder

• Uses: Also prescribed for migraine prevention, seizure disorders, and neuropathy.

• Examples:

  • Valproic Acid (Depakote)

  • Carbamazepine (Tegretol)

  • Lamotrigine (Lamictal) - caution for Stevens-Johnson syndrome; discontinue at first sign of rash.

• Mechanism: Inhibit glutamate to suppress CNS excitation.

Mood Stabilizers Administration

• Considerations: Administer lowest effective doses, avoid grapefruit juice with Tegretol, and be aware of decreased efficacy of contraceptive methods caused by Lamictal.

• Stevens-Johnson Syndrome Risk: Highlight importance in patient education around symptoms.

Knowledge Check Question

• Question: Why is blood drawn for lithium level assessment?

  • B: Lithium levels demonstrate whether you are within a therapeutic dose of the drug.