Psych Meds

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TCAs - list of meds:

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Imipramine (Tofranil)
Trimipramine (Surmontil)
Desipramine (Norpramin) - least sedating, least anticholinergic SE
Clomipramine (Anafranil) - most serotonin specific, useful in treating OCD
Amitriptyline (Elavil)
Nortriptyline (Pamelor) - least likely to cause orthostatic HTN
Doxepin (Sinequan)

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TCAs - mech of action + use:

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inhibit reuptake of NE and Serotonin (increase availability in synapse); rarely used as 1st-line agents bc have higher incidence of SE, require greater monitoring of dosing, and can be lethal in overdose.

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TCA - side effects

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1. antihistaminic - sedation
2. antiadrenergic - orthostatic hypotension, tachycardia, arrhythmias
3. antimuscarnic - dry mouth, constpiation, urinary retention, blurred vision, tachycardia
4. weight gain
5. lethal in oversoe
6. major complications: convulsions, coma, cardiotoxicity

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MAOIs: mech of action + use:

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prevent inactivation of biogenic amines (NE, serotonin, DA). Not used as 1st line agents bc of increased safety/tolerability of newer agents. Effective for refractory depression and refractory panic disorder.

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MAOIs - list of meds:

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Phenelzine (Nardil)
tranylcypromine (Parnate)
isocarboxazid (Marplan)

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MAOIs - side effects:

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common: orthostatic hypotension, drowsiness, weight gain, sexual dysfunction, dry mouth, sleep dysfunction

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Serotonin syndrome

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Occurs when SSRIs and MAOIs are taken together. Initially characterized by lehtargy, restlessness, confusion, flushing, diaphoresis, tremor, and myclonic jerks. May progress to hyperthermia, hypertonicity, rhabdomyolysis, renal failure, convulsions, coma, death. Wait at least 2 weeks bf switching from SSRI to MAOI.

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Hypertensive risk with MAOIs

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Risk when taken with tyramine-rich foods (red wine, cheese, cured meats) or sympathomimetics.

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SSRIs - mech of action + use:

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inhibit presynaptic serotonin pump, leading to increased availability of serotonin in synapse. Most commonly presecribed antidepressants due to several distinct advantages (low incidence of side effects, no food restrictions, safer in overdose). Also used for treatment of some anxiety disorders, OCD, and premenstrual dysphoric disorder.

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SSRIs - list of drugs:

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Fluoxetine (Prozac) - longest halflife with active metabolites (do not need to taper)
Sertraline (Zoloft) - highest risk for GI disturbances
Paroxetine (Paxil) - most serotonin specific, stimulant
fluvoxamine (Luvox) - use in OCD
Citalopram (Celexa)
Escitalopram (Lexapro)

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SSRIs - side effects:

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1. sexual dysfunction (25-30%)
2. GI
3. insomnia
4. headache
5.anorexia, weightloss

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SNRIs

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Effexor (venlafaxine): useful in treating refractory depression and CAP. very low drug interaction potential. can increase BP (not to be used in patients with untreated or labile BP). potential withdrawal symptoms can be seen with 1-3 missed doses.

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NDRIs

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Bupropion (wellbutrin) - commonly used to aid in smoking cesssation, and also useful in treatment of seasonal affective d/o and adult ADHD. LACK of sexual side effects. can exagerate psychosis in high doses. SE include increased sweating, increased risk of seizures and psychosis at high doses. Not optimal for patients w signficant anxiety and are contraindicated in pts w seizure or active eating d/o and in those currently on MAOI.

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SARIs

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Nefazodone (Serzone)
Trazodone (Desyrel)
treatment of refractory MDD, MDD w anxiety, and insomnia. SEs include nausea, dizziness, orthostatic hypotension, cardiac arrhythmias, sedation, and priapism.

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NASAs

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Mirtazapine (Remeron) - useful in tx of refractory MDD, especially in pats who need to gain weight. side effects include sedation, weight gain, dizziness, somnolence, tremor, and agranulocytosis.

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traditional antipsychotics: low potency

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-block DA receptors
Chloropromazine (Thorazine)
Thioridazine (Mellaril)
-high incidence of anticholinergic and antihistaminic side effects

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traditional antipsychotics: high potency

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-block DA receptors
Haloperidol (Haldol)
Fluphenazine (Prolixin)
Trifluoperazine (Stelazine)
Perphenazine (Trilafon)
Pimozide (Orap)
-higher incidence of extrapyramidal SEs and neuroleptic malignant syndrome

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extrapyramidal SEs

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-anti DA side effects as seen with high potency traditional antipsychotics:
1. parkinsonism: masklike face, cogwheel rigidity, pill-rolling tremor
2. akathisia - subjective anxiety and restlessness, objective fidgetiness
3. dystonia - sustained contraction of muscles of neck, tongue, eyes (painful)
-treat by reducing dose of antipsychotic and administering amantadine (symmetrel), benadryl, or benztropine (cogentin).

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anti-HAM effects

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-anti histaminic, adrenergic, and muscarinic SEs