Psychopharmacology

Incorrect assumptions

• Patient is triaged as psychiatric , therefore patient is psychiatric .

• Patient has a history of psychiatric presentations , therefore this presentation is psychiatric .

• Patient is young , therefore this must be a functional disorder .

• Abnormal vital signs are due to mental/emotional state .

= ?

Traditional Antidepressants

• TCA– amitriptylline – clomipramine – doxepin -desipiramine– imipramine – nortriptylline – trimipramine

• MAOIs

– Tranylcypromine

Newer antidepressants• SSRIs

– citalopram

– fluoxetine – fluvoxamine – paroxetine – sertraline

• RIMA – moclobemide

Newest antidepressants

SNRI :VenlafaxineDuloxetine

DNRI:Bupropion

Choice of Initial Antidepressant in Adults

• Symptom profile • Side effect profile in relation to the individual patient• Patient preference• Cost• History of previous response of the patient or family members• Comorbid psychiatric or medical illnesses• Potential drug-drug interaction

SSRI: Side Effect Profile

• Headache• Anxiety and Agitation • Nausea • Diarrhea • Sexual dysfunction and Sleep disruption or Somnolence

SSRI: Rare but Dangerous Side Effects

• UGI bleeding (platelet dysfunction), esp. in combo with NSAID’s or other blood-thinning agents

• SIADH• Osteoporosis and fractures in the elderly• Serotonin syndrome• SSRI discontinuation syndrome (slow taper)

• Flu-like symptoms• Insomnia• Nausea• Imbalance• Sensory disturbances• Hyperarousal (agitation/anxiety)

SNRI: Side Effect Profile

• As with SSRI’

TCA: Side Effect Profile

• Antihistamine – weight gain & sedation

• Anticholinergic

• Anti-alpha adrenergic – dizziness, orthostatic hypotension

MAOI: Side Effect Profile

• Hypertention crisis

• Orthostatic hypotension

Benzodiazepinesalprazolam short-mid

chlordiazepoxide long

clonazepam mid-long

diazepam long

flurazepam long

lorazepam short-mid

oxazepam short-mid

Anxiolytics: Side effects

• Memory decline• Addiction(dependency &withdrawal)• Ataxia/Falls• Drowsiness/dizziness/disinhibition

Anxiolytics:Contraindications

• With COPD or sleep apnea 

• Avoid in the elderly

Traditional Antipsychotics

• Phenothiazines– chlorpromazine – fluphenazine – flupenthixol – -perphenazine– pimozide – thioridazine – trifluoperazine

• Butyrophenon– haloperidol

Newer Antipsychotics

• Atypical agents– aripiprazole– clozapine – risperidone – quetiapine – olanzapine

Neuroleptic Malignant Syndrome

• Fever• Encephalopathy • Vital signs unstable• Elevated CPK/ WBC• Rigidity

Lithium: Side Effect Profile

• Lethargy• Insipidis• Tremor/Teratogen (increased risk Ebstein’s

anomaly in first trimester)• Hypothyroid• Increased weight• Vomitting, nausea, GI• Miscellaneous: EKG changes (T wave flattening

or inversion), acne, hair loss

Valproic Acid: Acute Side Effect Profile

• Sedation • Tremor • Unsteadiness (dizziness)• Nausea /GI

Valproic Acid:longer term side effect

monitoring• On the surface:

– Acne , hair loss

• Under the surface: – weight gain, edema

• Systemic: – blood dyscrasias (esp plt dysfn) – liver dysfunction +/- elevated ammonia levels– reproductive changes incl menstrual irregularities ,

PCOS, teratogenicity

Lamotrigene: Side Effect Profile

• Rash – • Activation , Ataxi• , Sedation, Sleep disturbances• , Hypersensitivity reactions