Comprehensive Study Guide: Neuroleptics, Antidepressants, and Mood Stabilizers

Indications for Use: Neuroleptics are utilized to manage a range of psychiatric conditions characterized by psychosis, including: * Psychosis * Schizophrenia * Bipolar disorder * Mania * Psychotic Depression
Mechanism of Action: Neuroleptics function by blocking dopamine, which results in the reduction of psychotic symptoms.
Classifications: * Typical (Older Generation): * Characterized by a higher incidence of side effects. * Associated with potential side effects such as bone seizures and a high risk of Extrapyramidal Symptoms (EPS). * Example: Haldol. * Atypical (Newer Generation): * Most commonly used in modern practice. * Offer fewer adverse effects compared to typical neuroleptics. * Effective in treating both positive and some negative symptoms of schizophrenia. * Examples: Risperidone, Olanzapine, and butipine.

General Characteristics: EPS specifically affects voluntary movements. Symptoms usually manifest early in treatment but can also occur following medication changes, such as an increase in dosage.
Reversibility: Most EPS are reversible, but they require close monitoring.
Specific Symptoms and Definitions: * Dystonia: Defined as muscle rigidity or intense muscle spasms. This is considered a medical emergency because it can lead to difficulties with breathing and swallowing. * Pseudo-parkinsonism: Symptoms that mimic Parkinson's disease, including: * Shuffled gait. * Masked face (a decrease in facial expression). * Tremors and drooling. * Pill rolling (a specific type of hand tremor). * Weakness and muscle rigidity. * Waxy skin. * Akathisia: Defined by profound restlessness and agitation. Patients exhibit an inability to sit still, frequent pacing, and a constant feeling of needing to be on the move.
Treatment for EPS Symptoms: Common pharmacological interventions include: * Peytonhydramine (Antihistamine). * Cogentin (Anticholinergic). * Propranolol.

Tardive Dyskinesia (TD): * Status: Permanent and non-reversible. * Presentation: Involuntary muscle movements involving the face, neck, or extremities. * Specific Signs: Lip snapping, excessive blinking, grimacing, and tongue thrust. * Monitoring: The AIMS (Abnormal Involuntary Movement Scale) is used for monitoring. It should be conducted every $3-6 \text{ months}$ . An increased score on the AIMS should be reported immediately.
Neuroleptic Malignant Syndrome (NMS): * Primary Symptom: A high fever is the hallmark sign. * Associated Symptoms: Muscle rigidity, autonomic nervous system instability (uncontrolled blood pressure), diaphoresis (excessive sweating), and delirium. * Status: This is a medical emergency that can occur early in treatment or with medication changes. * Clinical Intervention: Immediately stop the medication, stabilize the patient, and determine a new course of medical action.

Endocrine Effects: Elevated prolactin levels, which may cause "bursting margin" and tingling signals.
Metabolic and Physical Effects: * Sedation. * Significant weight gain. * Development of Diabetes. * Orthostatic hypotension. * Sexual dysfunction.
Anticholinergic Effects: Frequently described by the mnemonic: * "Can't see, can't pee, can't spit, can't poop" (indicating dry eyes/blurred vision, urinary retention, dry mouth, and constipation).

Mechanism of Action: Antidepressants induce changes in neurotransmitters, specifically targeting and altering the levels of norepinephrine and serotonin.
Common Uses: * Depression. * Bipolar depression.
Selective Serotonin Reuptake Inhibitors (SSRIs): * Considered the first-line treatment option. * Examples: Prozac (introduced in $1987$ ) and Sertraline. * Function: They increase the amount of available serotonin. * Therapeutic Lag: It takes $2-4 \text{ weeks}$ for these medications to work. It is essential to educate patients to continue taking the medication despite the lack of immediate effects. * Side Effects: Nausea, weight gain, sexual dysfunction, and insomnia. * Patient Education: To manage insomnia, patients should take SSRIs in the morning and avoid late-day doses. * Critical Warning: There is an increased risk of suicide during early treatment. As patients start feeling better, they gain the energy required to act on a suicidal plan.

Tricyclic Antidepressants (TCAs): * Generally avoided due to serious side effects and the fact that they are extremely dangerous in overdose situations. * Examples: Amitriptyline, Topranolol, and Nortriptyline.
Monoamine Oxidase Inhibitors (MAOIs): * Rarely used because of significant risks and numerous drug interactions. * Risk: Hypertensive crisis. * Examples: Nardil, Carnate, Marplan, and the skin patch Cellagoline. * Dietary Restrictions (Low Tyramine Diet): Patients must avoid foods containing tyramine, including: * Mature or aged cheese. * Aged meats. * Tap beer and wine. * Sauerkraut, soy sauce, and soybean products. * Yogurt and sour cream. * Peanuts. * Brewer's yeast and MSG.
Atypical Antidepressants: Examples include Wellbutrin and Effexor.

Serotonin Syndrome: Occurs when mixing SSRIs and MAOIs. * Symptoms: Fever, agitation, and tremors.
MAOIs and Tyramine: Mixing these results in a hypertensive crisis.
Avoidance List for MAOIs: MSG, aged cheese, aged meats, beer, wine, sauerkraut, sour cream, and yogurt.

Clinical Use: Primarily used for the treatment of Bipolar Disorder.
Lithium (Panacid): * Considered a "tried and true" treatment but carries a high risk of toxicity due to a narrow therapeutic range. * Monitoring: Regular monitoring of blood levels is required. * Toxicity Signs: Diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination. * Patient Education: Patients should be advised to maintain adequate water intake, maintain normal salt intake, and never skip doses.
Other Mood Stabilizers (Anticonvulsants): * Valproic Acid (Depakote): Carries a risk of liver damage. * Tegretol: Can cause serious blood disorders, including leukopenia, thrombocytopenia, neutropenia, and aplastic anemia. * Lamictal (Lamotrigine): Associated with the risk of a serious, life-threatening skin rash.

Dialogue on EPS Symptoms: * Query: "What does EPS affect?" * Answer: Movement, specifically voluntary movements.
Dialogue on Pseudo-parkinsonism: * Query: "What is their gait?" * Answer: Shuffled. * Query: "What about their face?" * Answer: Masked face.
Dialogue on Akathisia: * Query: "What's that?" * Answer: Agitation and restlessness. Inability to sit still. Pacing.
Dialogue on Anticholinergic Effects: * Interaction: The speaker and audience repeated the mnemonic "Can't see, can't pee, can't spit, can't poop" approximately $20 \text{ times}$ throughout the session to ensure recall.
Dialogue on Antidepressants: * Query: "What is my first line?" * Answer: SSRIs. * Query: "Why is there an increased suicide risk?" * Answer: Because they have the energy to act on their plan as they start feeling better.