Psych Drugs

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Examples of TCAs

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Imipramine
Desipramine
Amitriptyline
Nortriptyline

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Tranylcypromine

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MAO-I that thereby blocks NE/serotonin degradation in neurons, increasing NE/serotonin release. This eventually leads to amine receptor down-regulation--> Depression relief. Adverse: Sexual dysfxn, Tyramine foods (cheese, red chianti, fava beans, soy, aged meats) can lead to hypertensive crisis. Use w/ SSRIs can cause serotonin syndrome. Used for bipolar & atypical depression, dysthymia, phobic anxiety, migraines.

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Alpha-2 Adrenergics for ADHD & examples

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Increase CNS NE (& dopamine?) at synapses. Used to tx hyperactive sxs of ADHD & tics of ADHD pts. Do little for inattention sxs, tho. Adverse: Sedating (b/c they incr NE tone in central inhibiting synapses).
Ex: Clonadine

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Phencyclidine

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aka PCP, angel dust. Hallucinogen structurally related to ketamine. Causes tachycardia, hypertension, diaphoresis, ataxia, agitation, szs, hallucinations, & coma. Cyclical nystagmus is pathognomonic. Tx w/ support as needed.

Front 5

Lithium

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Mood stabilizer. Anti-manic via incr in glutamate reuptake. Anti-depression via enhancing NE & serotonin effect. 1st line for acute mania, bipolar disorder prophylaxis. May have a specific anti-suicide effect. Adverse: Competes w/ Na+ in the heart, kidney, thyroid--> Bradycardia (rare), imparied renal concentrating, & hypothyroid. Lithium toxicity at hi dose (tremor, confusion, ataxia, coma, death). Has teratogenic effects (Heart defects). NSAIDs, ACE-Is, HCTZ, spironolactone incr blood conc of this.

Front 6

Valproic Acid

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Depakote.
Anticonvulsant that interferes w/ Ca+2 & Na+, enhancing GABA & inhibiting glutamate. Used in mania, rapid cycling bipolar, & mixed episodes. More effective than lithium for mixed states, rapid cycling bipolar. Adverse: Weight gain, hair loss, sedation, tremor, osteoporosis. Can induce hepatic failure, pancreatitis, thrombocytopenia, neural tube defects in fetus. But generally, has low side effects profile. Watch for drug interactions (warfarin, aspirin, carbamazepine, phenytoin).

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Valerian

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Mild hypnotic derived from plant. Active component is unknown. Has anxiolytic & muscle relaxing activity. The effects on slepp aren't fully characterized. Nor are side effects. Sometimes used for insomnia.

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Haloperidol

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Haldol.
1st gen antipsychotic w/ high potentcy & almost solely D2 receptor blockade. Lots of extrapyramidal side effects but few other adverse rxns (except rarely neuroleptic malignant syndrome). Used for schizophrenia, acute psychosis, & delirium.

Front 9

Thioridazine

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1st gen antipsychotic. Blocks D2 receptors. Adverse: Retinitis pigmentosa (progressive visual loss caused by defects in photoreceptors) rarely occurs. Extrapyramidal effects.

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Clozapine

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2nd gen/atypical antipsychotic that blocks D1 & D4 as well as serotonin receptors. Most effective drug for schizophrenia, but relegated to 3rd line b/c of side effects: Agranulocytosis, Szs, Weight gain, Drooling. Must check WBC count to use this. Less effect at D2 receptors than other antipsychotics, so less EPS.

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Sertraline

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Zoloft.
SSRI w/ shorter half-life than for fluoxetine. Therefore has faster time to steady state & faster drug wash-out if needs to be DC'ed. Increases appetite, so used for eating d/o. Serotonin syndrome is more likely to occur if used w/ MAOI, TCA, lithium, or carbamazepine.

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Carbamazepine

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Anticonvulsant that acts on Na+ & K+ channels to incr GABA availability. Used off label as mood stabilizer for non-responders to lithium or valproate. Adverse: Fatal agranulocytosis, hepatitis, Stevens-Johnson rxn. Many drug interactions. Auto-induces own metabolism, so start low & titrate up.

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Venlafaxine

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Effexor.
NE & serotonin reuptake inhibitor. Higher levels of those neurotransmitters--> Receptor downregulation--> Depression relief. An activating antidepressant. Adverse: Dose-dependent hypertension, withdrawal w/ abrupt discontinuation, lowers sz threshold.

Front 14

Ziprasidone

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Geodon.
2nd gen/atypical antipsychotic, blocking dopaminergic neurons. improves neg & pos schizophrenic symptoms & reduces EPS effects. Adverse: QT prolongation, but weight neutral unlike other 2nd gen drugs.

Front 15

Chlorpromazine

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Thorazine.
1st gen antipsychotic w/ low potency. Effects other receptors besides D2, so lower EPS, but multiple other side effects (constipation, sedation, hypotension).

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Dantrolene

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Tx for neuroleptic malignant syndrome (caused by antipsychotics) or malignant hyperthermia.

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Phenelzine

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MAO-I that blocks NE/serotonin degradation--> Amine receptor down-regulation & depression relief. Adverse: Weight gain, orthostatic hypotension, sexual dysfxn. This is more anxiolytic but has slower onset than tranylcypromine. Tyramine foods (cheeses, chianti, fava, soy) can lead to hypertensive crisis. Use w/ SSRIs can cause serotonin syndrome.

Front 18

Tx for cocaine or ecstacy toxicity

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Hyperthermia--> Ice water over body, Consider sedation via benzos.
Hypertension--> Sodium nitroprusside, Phentolamine.
Szs--> Benzos, Phenobarbital.

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Risperidone

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Risperdal.
2nd gen/atypical antipsychotic. Adverse: Hyperprolactinemia & some EPS (both dose dependent). Not for women trying to get pregnant.

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Olanzapine

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Zyprexa.
2nd gen/atypical antipsychotic. This & Clozapine are the only antipsychotics that improve both neg & pos symptoms of schizophrenia & EPS effects. Adverse: Bad metabolic syndrome!

Front 21

Buproprion

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Wellbutrin.
Blocks reuptake of NE & dopamine, leading to higher levels of these molecules in synapses. This eventually leads to downregulation of their receptors at the synapse, which corresponds to depression relief. Adverse: Agitation, insomnia, dose-dependent szs, false positive amphetamine tests. Not for sz patients or people w/ h.o. eating d/o. Used for depression (w/ fewer sexual side effects than SSRIs), smoking cessation, ADHD. Also good for bipolar depression b/c causes less switch into mania.

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Amphetamine Stimulants & Examples

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Increase CNS dopamine & NE at synapses. Used for ADHD as 1st line tx & for excessive daytime sleepiness. Examples: Methylphenidate (Ritalin), Dexmethylphenidate, Mixed amphetamine salts. These work best on the attention deficit symptoms. They can be abused, but untreated ADHD pts are more likely to abuse drugs.

Front 23

Diphenhydramine

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Benadryl.
Antihistmine also used for insomnia & EPS counteraction. Adverse: Paradoxical excitation at high doses, anti-cholinergic effects, confusion, next day sedation.

Front 24

LSD

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Hallucinogen that interacts w/ serotonin receptors in brain, causing euphoria, panic attacks, paranoia, & hallucinations. Tx w/ support as needed.

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Volatile hydrocarbons

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Inhalants like tolulene, trichloroethane that have rapidly intoxicating effects, causing euphoria, dysrhythmias. Chronic use can cause metabolic acidosis, hypokalemia, hypochloremia, & severe weakness. Tx w/ support & consider beta blockers for arrhythmias.

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Flumazenil

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Reversing agent for acute benzo toxicity. Can induce sedative withdrawal (insominia, nausea, diaphoresis, confusion, tachycardia, hypertension, szs).

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Neuroleptic Malignant Syndrome

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Life threatening condition caused by DA receptor blockers (antipsychotics/neuroleptics)--> Muscle rigidity, altered mental state, & autonomic dysfxn (hyperthermia, hypertension, tachycardia). Mortality 20-30%. Affects minority of pts, & it's unpredictable when it will occur. Occurrence does not predict reoccurrence w/ resumed neuroleptic use. Risk factors: Dehydration, male, rapid titration, & young age. Benzos can reverse catatonia. Dantrolene used for muscle rigidity. DA agonists may help reverse condition.

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Paroxetine

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Paxil.
SSRI w/ some anticholinergic action. Therefore more sedating w/ early relief of anxiety & insomnia in pts w/ combined depression & anxiety. Adverse: Constipation, severe discontinuation syndrome if stopped abruptly (restlessness, akathesia, dizziness, dysesthesia). Used for depression, OCD, panic disorder, PTSD, eating disorder, generalized anxiety disorder, premenstrual syndrome. Serotonin syndrome is more likely if used w/ MAOI, TCA, lithium, or carbamazepine.

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Selective Serotonin Reuptake Inhibitors (SSRIs)

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Block reuptake of serotonin at the synapse--> down reg of post-synapse serotonin receptors--> Depression relief. These have more benign side effects than TCAs (Less anticholinergic, sedation, orthostatic hypotension. No weight gain. No need to follow blood levels.) Adverse: Transient insomnia, sexual dysfxn, serotonin syndrome.

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Fluoxetine

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Prozac.
Prodrug related to SSRIs. Increases appetite, so used for eating d/o. An activating antidepressant. Serotonin syndrome is more likely to occur if used w/ MAOI, TCA, lithium, or carbamazepine.

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Quetiapine

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Seroquel.
2nd gen/atypical antipsychotic. Low EPS, but causes metabolic syndrome. Has best proven results in treating bipolar depression.

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Tricyclic Antidepressants

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Block reuptake of NE & serotonin--> Downreg of receptors--> Depression relief. Used for SSRI-resistant depression. Adverse: Sedation, anticholinergic, orthostatic hypotension, ECG change, weight gain, impotence, mania. Tx overdose w/ cardiac monitoring, gastric lavage, NaHCO3 + KCl, lidocaine or phenytoin. Also used for enuresis (bedwetting), chronic pain, neuropathy. Blocks the effect of anti-hypertensives.

Front 33

Aripiprazole

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Abilify.
Dopamine partial agonist. Acts as antagonist in areas w/ excessive DA (neurolymbic path) & as an agonist in DA deficient areas (frontal lobes, nigrastriatal path). Not very effective, though, until unsafe dose reached. More effective used for psychotic bipolar d/o.

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Extra-Pyramidal Symptoms

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Movement disorders caused by DA blockade in substantia nigra. 1) Dystonia (In minutes). 2) Akathesia (In hrs). 3) Parkinsonisn (In days-wks). 4) Tardive dyskinesia (In mos-yrs).

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Zolpidem

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Ambien.
A non-benzo hypnotic that potentiates GABA receptors via the same site as benzos. Used as sleeping agent.

Front 36

Unexpected use for benzos (like Ativan/Lorazepam)

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Causes rapid improvement of symptoms in depressive catatonia (but not schizophrenic catatonia).

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Doxepin

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A TCA-like anti-depressant w/ sedating properties. Used for insomnia as well as for depression. Blocks reuptake of NE & serotonin--> Receptor downregulation & depression relief.

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Duloxetine

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Cymbalta.
Serotonin/NE reuptake inhibitor used for depression, chronic pain, generalized anxiety disorder.

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Mirtazapine

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Remeron.
Tetra-cyclic antidepressant. Has sedating properties at low dose, but at high dose it becomes activating. Used for depression, all of the anxiety disorders, pruritis, loss of apetite, cluster headache, or migraines.

Front 40

Biperiden

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Anticholinergic used to combat EPS. Like other anticholinergics, this is effective for acute dystonia, Parkinsonism, but not for akathesia. Should be tapered after 1-6 mos.

Front 41

Amantadine

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Anti-influenza drug also used to treat Parkinson's. Increases dopamine release in the brain via unknown mechanism. Also used to counter EPS. Does not cause anti-cholinergic effects (dry mouth, constipation, blurred vision, urinary hesitancy, incr heart rate), but it can cause nausea, insomnia, decr concentration, irritability, ataxia. Contraind in renal failure.

Front 42

Benzatropine

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Cogentin.
Anti-cholinergic used to combat EPS. Works well vs dystonia, Parkinsonism, akathesia, but not tardive dyskinesia. Taper after 1-6 mos. Anticholinergic side effects.

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Neuroleptic malignant syndrome mneumonic

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Fever
Autonomic instability
Leukocytosis
Tremor
EPS
Rigidity

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Dopamine Pathways Affected by Schizophrenia

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Excess DA in the:
Prefrontal cortical- Assoc w/ negative symptoms
Mesolimbic- Assoc w/ positive symptoms
Tuboinfundibular- Assoc w/ hyperprolactinemia
Nigrostriatal- Assoc w/ EPS

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Topiramate

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Topamax.
Anti-cocaine drug. Controls cocaine cravings as well as helping other impulse control issues (e.g. bulemia). Adverse: Renal metabolism, so not for renal impairment or hx of kidney stones. Also reduces sz threshold & inactivates birth control, so not for sz pts or women on OCPs.

Front 46

Flumazenil

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Very short-acting benzo receptor antagonist. Used to tx benzo overdose. Use w/ care b/c can precipitate seizures.

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Cholinesterase inhibitors used to tx Alzheimer's. (They only work transiently on 25% of pts.)

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Tacrine
Donepezil
Rivastigmine

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Carbidopa

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Prevents conversion of Levadopa to dopamine in the periphery so that the Levadopa can make it to the CNS. This doesn't cross the BBB, though. Used for Parkinson's.

Front 49

Bromocriptine

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Dopamine agonist used to tx Parkinson's.

Front 50

Selegiline

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MAO-B inhibitor that prevents breakdown of dopamine. Used to tx Parkinson's.

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Hydroxyzine

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Antihistamine & anxiolytic with sedating effects. Used to help sleep b/c it's not addictive, unlike other hypnotics. Esp useful for elderly pts.

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Treatment for akathesia

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Propanolol

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Cyproheptadine

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Drug that reverses the sexual side effects of anti-depressive meds. Bupropion also does this.

Front 54

What drugs do you not want to give elderly pts?

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Anticholinergics such as:
- Low potency 1st gen antipsychotics
- Most sleep agents
- MAO-Is, TCAs

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Serotonin Syndrome

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Abd pain, diarrhea, fever, tachycardia, HTN, delerium, & myoclonus. Can even cause shock & death. Stems from use of 2 SSRIs or an MAO-I + another SSRI or TCA.

Front 56

Lithium Toxicity

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Sxs: tremor, confusion, ataxia, coma, death.
More likely to occur w/ dehydration or decreased Na+ intake.

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Lamotrigine

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Anti-seizure med also used as mood stabilizer.

Front 58

Sedating antidepressants

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TCAs
Trazadone
Mirtazapine

Front 59

Delusional Disorder Tx

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Antipsychotics are generally ineffective.
Psychotherapy may help.

Front 60

Catatonic Depression Tx

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Benzos in acute state
Antidepressants + Antipsychotics for prophylaxis

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Panic D/O Tx

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Benzos for acute episode.
Paroxetine or Sertraline for maintenance. Start slow & build up b/c these pts can have activation sxs on SSRI's.
Beta Blockers don't work well.

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Agoraphobia Tx

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SSRI's

Front 63

Social Phobia Tx

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Paroxetine for prophylaxis.
Beta Blockers for acute episodes.

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PTSD or Acute Stress D/O tx

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Antidepressants +/- Anticonvulsants for flashbacks & nightmares

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General Anxiety D/O tx

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Buspirone,
SSRI's,
Venlafixine,
Benzos(?)

Front 66

Personality d/o most effectively treated w/ pharm

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Borderline Personality D/O. Use SSRI's. Still, psychotherapy is first line tx.

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Avoidant Personality D/O

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Psychotherapy, including Assertiveness Training