Psychotropic Medications Overview

Depression

  • Antidepressants Overview
    • Work slowly, effects may take time to manifest.

Fluoxetine (Prozac/Sarafem)

  • Most widely prescribed SSRI globally.
  • Patient Education:
    • Medication regimen must last at least 4 weeks before any changes.
    • Indicated for treating:
      • Bipolar disorder
      • Obsessive-Compulsive Disorder (OCD)
      • Panic disorder
      • Bulimia
    • Mnemonic: Fluoxetine sounds like you have the flu for 4 weeks!

Citalopram

  • SSRI, indicated for major depression.
  • Adverse Drug Events (ADEs):
    • Nausea
    • Somnolence
    • Dry mouth
    • Sexual dysfunction
  • Risks:
    • Causes neonatal abstinence syndrome (withdrawal symptoms in newborns).
    • Interacts with monoamine oxidase inhibitors (MAOIs); should be avoided.

Post-Partum Depression

  • Screening:
    • Utilize the Edinburgh scale for postnatal depression assessment, typically at 6-8 weeks postpartum.
  • Preferred treatment: Zoloft (Sertraline)
    • Chosen for breastfeeding mothers as it does not cross into breast milk readily.

SSRI Side Effects and Drug Holiday

  • Serotonin Syndrome:
    • Onset: 2-72 hours after treatment initiation.
    • Symptoms:
      • Altered mental status
      • Incoordination
      • Hyperreflexia
      • Sweating, tremor, fever
    • Risk factors increase with concurrent MAOI use or other serotonergic agents.
  • Withdrawal Syndrome:
    • Potential for teratogenic effects and neonatal impacts when used during pregnancy.
  • Bruxism:
    • Symptoms include headache and jaw pain during sleep due to teeth grinding.
    • Management: Stress/relaxation techniques, and dental evaluation for potential mouth guard need.
  • Sexual Dysfunction:
    • Concerns about decreased libido can warrant a drug holiday to mitigate side effects.
  • Drug Holiday:
    • A planned temporary break (typically weekends) to manage specific side effects and evaluate treatment efficacy.

Venlafaxine

  • SNRI (Serotonin-Norepinephrine Reuptake Inhibitor).
  • ADE:
    • Neonatal withdrawal syndrome characterized by irritability, abnormal crying, tremor, respiratory distress, seizures.
    • Sustained mydriasis (pupil dilation).

Duloxetine

  • SNRI.
  • Contraindications:
    • Causes elevation of liver transaminases; contraindicated in patients with liver disease history or alcohol abuse.

Tricyclic Antidepressants (TCAs)

  • Contraindications:
    • Avoid in combination with muscarinic receptor blockers and in patients with cardiac disease.
  • Amitriptyline:
    • Administer at bedtime to minimize daytime sedation.
    • Mnemonic: Run a-MI-ter (meter) at night.
  • General Side Effects of TCAs:
    • Sedation
    • Orthostatic hypotension: advise sitting or lying down when feeling lightheaded.
    • Anticholinergic effects (dry mouth, constipation, etc.).
    • Cardiac toxicity; dosing for older patients should be adjusted to q12.

TCA Overdose Treatment

  • Reduce Absorption:
    • Gastric lavage and activated charcoal.
  • Cardiotoxicity Management:
    • IV sodium bicarbonate for dysrhythmias, cardiac monitoring essential.
  • Avoid Sedatives:
    • Not to combine with benzodiazepines due to compounding effects.

Monoamine Oxidase Inhibitors (MAOIs)

  • Contraindications:
    • Hypotensive patients.
    • Tyramine-rich foods (e.g., cheese, wine) may lead to hypertensive crises.
    • Risks of hypertensive crisis manifest as headache, tachycardia, and sweating.

Bupropion

  • Benefits:
    • Does not cause weight gain, sexual dysfunction, or sedation.
    • Mnemonic: Still have your BUP (BUTT) because there’s no weight gain/sexual/sedation problems.

Anxiety

  • No agent definitively “cures” anxiety; treatments focus on symptom reduction.

Lorazepam

  • Preferred for acute anxiety; rapid onset and short duration.
  • Patient Education:
    • PRN for social and panic anxiety.
    • Avoid abrupt withdrawal.
    • Avoid grapefruit juice (GFJ).
    • Titrate dose slowly to achieve therapeutic effect.

Clonazepam

  • Similar to Lorazepam; indicated for severe anxiety.
  • Patient Education:
    • PRN for social and panic anxiety.
    • Same precautions as Lorazepam regarding withdrawal and GFJ.

Buspirone

  • Non-sedating; primarily targets anxiety without causing somnolence.
  • Patient Education:
    • Effects realized over weeks; do not expect immediate control.
    • Interacts with erythromycin and ketoconazole; avoid GFJ.

Insomnia

Lifestyle Modifications

  • Recommendations:
    • Get out of bed if unable to sleep within 20 minutes; perform relaxation activities instead.
    • Avoid large meals before bedtime and alcohol, and daytime napping.

Benzodiazepines vs. Phenobarbital

  • Benzodiazepines (e.g., Lorazepam/Diazepam):

    • Safer; act via GABA receptor modulation.
    • ADEs include sedation and dependence risk, necessitating tapering to avoid withdrawal.
    • Antidote: Flumazenil.

  • Phenobarbital (Barbiturate):

    • Not safe due to CNS depression.
    • Does not require GABA action.
    • Severe respiratory depression risk; no antidote.
    • Never mix with alcohol or stop abruptly.

Flurazepam

  • Benzodiazepine; patient education:
    • Causes “hangover” effects; patients may feel drowsy next morning.

Zolpidem

  • Sedative hypnotic for short-term insomnia management.
  • ADEs: daytime drowsiness, dizziness.

Zaleplon

  • Effective for sleep initiation; very short duration makes it ideal for jet lag.
  • ADEs: myalgia and abdominal pain.

Eszopiclone

  • Effective for both onset and maintenance of sleep.
  • ADE: common bitter aftertaste.

Ramelteon

  • Non-controlled; melatonin receptor agonist, rapid onset.
  • Caution: Avoid high-fat meals which impede absorption.

Trazodone

  • Atypical antidepressant used for sleep issues caused by antidepressant side effects.

Schizophrenia

Antipsychotic Medications: First vs. Second Generation

  • First-Generation Antipsychotics (FGAs):

    • Mechanism: Strong block of D2 dopamine receptors in CNS.
    • Risks: Higher risk for Extrapyramidal Symptoms (EPS); lower metabolic risk.
    • Cost-effective compared to SGAs.

  • Second-Generation Antipsychotics (SGAs):

    • Mechanism: Moderate dopamine blockade with stronger serotonin blockade.
    • Risks: Higher chance for metabolic side effects, lower EPS risk.

Movement Disorders from FGAs

  1. Dystonia
    • Facial spasms, head thrust; treat with anticholinergic (e.g., Diphenhydramine).
  2. Parkinsonism
    • Symptoms: Shuffling gait, mask-like face; treatment varies with severity.
  3. Akathisia
    • Uncontrollable urge for motion; confusion with psychosis can complicate treatment.
    • Treatment options: Anticholinergics, Beta-blockers, or adjust FGA dose.
  4. Tardive Dyskinesia
    • Uncontrolled, jerky movements; associated with long-term treatment.

Haloperidol

  • Indications include schizophrenia and acute psychosis; proactive monitoring for side effects is essential.
  • ADEs include EPS, neuroendocrine issues, and cardiac prolongation leading to dysrhythmia risk.
  • Serious conditions include Neuroleptic Malignant Syndrome (NMS); monitoring and immediate action are vital.

Fluphenazine

  • Educate patients on EPS signs and managing orthostatic hypotension and anticholinergic side effects.

Bipolar Disorder

Lithium

  • Primary Mood Stabilizer:
    • Benefits: Drug of choice for euphoric mania and stabilizes mood without rapid cycling.
    • Baseline Testing Required:
    • Renal function for lithium excretion risk.
    • Thyroid function tests due to potential goiter/hypothyroidism.
    • Monitor serum lithium levels and electrolytes (particularly sodium).
  • Side Effects:
    • Therapeutic: GI upset; Toxic levels: neurological impairment.
    • Patient Education: Maintain salt intake, hydrate sufficiently, and be cautious with certain medication interactions.

Divalproex Sodium (Valproate/VPA)

  • Effective for mania but monitor closely for thrombocytopenia, weight gain, and liver function.

Lamotrigine

  • Long-term maintenance risk for Stevens-Johnson Syndrome; monitor for skin changes.

Alcohol Withdrawal

Chlordiazepoxide

  • Gold standard for managing alcohol withdrawal; effects include CNS depression and respiratory distress.

Diazepam Overdose Treatment

  • Flumazenil as a benzodiazepine antagonist for overdose management but with caution due to seizure potential.

ADHD

Methylphenidate

  • Daytrana patch application instructions; Concerta is long-acting and must be swallowed whole.

Amphetamines

  • Considerations include abuse potential, cardiovascular risks, and growth suppression in children. Monitor attentively for side effects and assess baseline cardiovascular function.

Atomoxetine

  • Non-stimulant with delayed effects; caution with liver health and side effect management.