Psychopharmacology 101

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Psychopharmacology 101

• Its all in the neurotransmitters

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• Neurotransmitters are the chemicals that
• communicate between neurons.
• The most common are norepinephrine, dopamine,
  serotonin,
• GABA, and acetylcholine.
• Each neuron has its
• own neurotransmitter, which is received by a
• special receptor on an adjacent nerve cell, then
• released and taken up again by the original
• sending nerve.
• When enough neurotransmitters are
• received, the nerve fires.

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• The relationship between neurotransmitters,
• nerve connections, special areas of the
• brain, and behavior/symptoms of mental
• illness is very complicated and not yet
• understood.
• Beware of oversimplified explanations.

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• Psychotropic drugs apparently effect
  neurotransmission in several ways
• Synthesis
• Storage
• Release
• Degradation
• Access/Reuptake

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How most psychoactive medicines work

• Blocks receptor sites
• Counteracts effects of neurotransmitter
• Attaches to receptor sites
• Increases effects of nerves action
• Blocks the enzyme that breaks down the
  neurotransmitter
• Increases neurotransmitter-increases activity of
  nerve
• Blocks the reuptake of the neurotransmitter
• Increases neurotransmitter-increases activity of
  nerve

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MECHANISMS OF ACTION

• The etiopathology of psychiatric illnesses is
  still unknown
• Most psychotropics have been developed
  serendipitiously, and their mechanism of action
  is unknown We know these drugs work, but we have
  very little idea how
• However, there are reliable hypotheses on what
  the first step may be of the cascade of events
  that leads to symptoms improvement after a
  medication is administered.

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• Current research indicates that the primary
• mechanism of psychotropic drugs may not
• be a direct effect on neurotransmitters, but
• effects on the internal mechanisms of the
• cell, including the DNA transcription of
• proteins that promote cell death. These
• pathways will be the targets of the next
• generation of psychiatric medications.

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NEUROTRANSMITTERS

• ACH
• MUSCARINIC RECEPTORS
• NICOTINIC RECEPTORS
• MONOAMINES
• Cathecolamines (Dopamine, Norepinephrine,
  Epinephrine)
• Serotonin
• Histamine
• NEUROPEPTIDES
• e.g., Opioids (endorphins)
• AMINOACIDS
• GABA, Glycine Inhibitory
• Glutammate, Aspartame Excitatory

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Basic Neurotransmission

• RECEPTORS
• CELL MEMBRANE PROTEINS THAT
• ARE STIMULATED BY SPECIFIC
• NEUROTRANSMITTERS
• PROTEIN KINASE
• ION CHANNELS
• G PROTEIN COMPLEXES
• NEUROTRANSMITTERS
• CHOLINERGIC
• MONOAMINES
• NEUROPEPTIDES
• AMINOACIDS

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Neurotransmitter Activity
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Neurotransmitter roles

• Dopamine
• Acts on the nervous system to increase heart rate
  and blood pressure. Controls movements. In
  frontal lobe helps with memory, attention and
  problem solving. A disruption has been linked to
  psychosis and schizophrenia.

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Neurotransmitter roles

• Serotonin
• Involved with depression, bipolar disorder and
  anxiety

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Neurotransmitter roles

• Norepinephrine
• Involved in control of alertness and wakefulness.
  Disturbances implicated in affective disorders

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Neurotransmitter roles

• GABA
• Works to inhibit the re-firing of a neuron. May
  interfere with memory formationmay regulate
  activity underlying sleep and arousal

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Cytochrome P450 Monooxidase System

• More than 200 enzymes
• At least 40 in humans
• 6 Enzymes are responsible for about 90 of all
  the metabolic activity of P450 enzymes 1A2,
  3A4, 2C9, 2C19, 2D6, and 2E1
• Induction and Inhibition is relatively common

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• The cytochrome p450 family of genes, expressed
  primarily in the liver, affect psychotropic and
  other medications.
• There are three main ones
• CYP3A4 -lots of drug effects, few polymorphism
• CYP2D6 -lots of drug effects, lots of
  polymorphism
• CYP2C19 -few effects, lots of polymorphism

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CYP 2D6

• Antidepressants
• desipramine, fluoxetine, nortriptyline,
  paroxetine, venlafaxine
• Antipsychotics
• fluphenazine, perphenazine, risperidone
• Stimulants
• atomoxetine
• Other
• codeine, dextromethorphan, oxycodone
• beta blockers

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2C19

• Antidepressants
• amitriptyline, clomipramine, imipramine,
  citalopram, escitalopram, sertraline
• Benzodiazepines
• diazepam
• Other
• phenytoin
• propanolol

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Examples

• SSRIs Increase serotonin at brain neurons by
  blocking serotonin reuptake, long-term probably
  affect receptor numbers and distribution.
• MAOIs Inhibit the action of MAO-A and B enzymes
  that metabolize 5-HT, DA, NE
• Benzodiazepines Bind to the BDZ-GABA-Cl receptor
  complex, facilitating the action of GABA
  (inhibitory neurotransmitter) on CNS excitability
• Antipsychotics Antagonism or partial agonism of
  dopamine receptors

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Classes of Psychotropic Medications

• Antidepressants
• SSRIs
• SNRIs
• Tricyclics
• MAOIs
• Other
• Psychostimulants
• Antipsychotics
• Typical
• Atypical

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Classes of Psychotropic Medications

• Mood Stabilizers
• Lithium
• Divalproex
• Carbamazepine
• Lamotrigine?
• Anti-anxiety
• Benzodiazepine
• Non Benzodiazepine

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Classes of Psychotropic Medications

• Dementia Drugs
• Antiparkinsonians
• Medications for Substance Dependence

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Diagnostic and Therapeutic Dilemmas with
Behavioral Disorders

• How to quantify disorder
• No blood culture
• How to decide behavior that is target
• Often one behavior may respond better than other
  to various psychotropic medication
• How to manage divergent reporting

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Psychopharmacology in Preschoolers

• Less published data regarding outcome
• Less straight forward
• Less clear guidelines for use

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Choosing a Medication

• Diagnosis
• Symptoms
• Risk/Benefits
• Alternative Treatments
• Comorbid Medical Diagnoses
• Concurrent Treatments

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Factors that affect dosing

• The following can effect the appropriate dosage
  of
• medication by a factor of 10
• Age, concurrent disease, other medications
• Height, weight
• Lean/fat ratio
• Diet
• Exercise
• Smoking
• Alcohol use

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Treatment Adherence

• 80 adherence is anticipated by studies.
• Good adherence increases the likelihood of
• a good outcome by a factor of 2.88.
• Doctors estimate compliance at 95.
• Electronic monitoring indicates 47 and
• declines over time.

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Treatment Adherence

• Adherence seems to be worse in younger clients
  and African-Americans.
• SGAs do not have better adherence, although
  clients like them better.
• Non-adherence to health behavior recommendations
  is twice the rate of medication non-adherence.

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• Interventions must be complex with a focus on
  enhancing client convenience, providing
  information, reinforcement and enlisting social
  support.
• Written materials are less effective than
  telephone, individual, or group formats.
• Even the most effective interventions have only a
  modest effect.

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Non adherence

• inadvertent or intentional
• Different responses needed
• Cognitive adaptation training may be useful for
  inadvertent non-adherence
• This training includes signs, alarms on
  medication containers, single-dose packs,
  notebooks for recording side-effects, etc.
• CBT can be adapted for intentional non-adherence.

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Improved Medication Adherence

• Treatment obviously helps
• Transportation and medical care available
• Monotherapy, single dosing, blister paks, depot,
  liquid, sublingual
• Good physician communication and rapport
• Serious, painful, acute treatment problem

• Nice treatment setting
• Subjective sense of well being
• Social support
• Skill training, modeling, memory enhancement,
  motivational interviewing techniques

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Behavioral Treatment Adherence

• 40 terminate therapy prematurely.
• Modal number of sessions is 1.

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Improved Adherence

• First impression of therapist is confident and
  competent
• Belief in therapy and prediction of how many
  appointments are needed
• Strong therapeutic alliance
• Education about therapy before beginning
• Contracting for homework
• Motivational interviewing techniques

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The Placebo Effect

• The placebo effect is improvement in health,
  often
• measurable and observable, that is not
  attributable
• to treatment.
• Placebos have successfully treated
• depression, pain, asthma, arthritis,
  hypertension,
• warts, colitis, insomnia, and other conditions.
• Placebos can also cause negative effects
  including
• vomiting, dizziness, fatigue, numbness, hives,
• rashes, tremor, and death (voodoo.)
• The placebo effect probably accounts for most of
  
• the benefit due to acupuncture, aromatherapy,
• homeopathy, and most other alternative
  treatments.
• and 33 of the response to antidepressants.

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Placebos in Psychiatric Disorders

• Panic disorder is highly responsive to placebos
  -
• 50 improvement in symptoms.
• PTSD, GAD placebo improvement is 30-40.
• 73 of improvement with antidepressants is
  placebo.
• OCD and psychosis do not show much placebo
  response.
• The overwhelming majority of studies that
  compared CBT to pill placebo show no difference.

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The Placebo Effect

• Conditions which cause significant psychological
  
• distress are most likely to respond to placebo.
• Possible mechanisms
• Psychological theory our beliefs effect our
  biochemistry and behavior, supported by fMRI
  studies
• Nature taking its course we often get better
  if we do nothing at all
• Process of treatment administering the placebo,
  touching, caring, attention, communication -may
  cause a response

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PositiveElements of the Treatment Situation

• Recognized healer
• Healing symbols
• Evaluation
• Healing rituals
• Diagnosis
• Prognosis
• Plausible treatment

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Using the placebo effect

• Convey honest, appropriate, positive
  expectations
• Find out what your patients believe about their
  illness
• Suggest placebo type treatments (a lot of people
  get better drinking this tea, following this
  diet, etc)

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Using the Placebo Effect

• Inspire confidence
• Look professional
• Display symbols of healing
• Make notes
• Take time, ask questions
• Provide a diagnosis
• Perform simple diagnostic tests
• Enhance response to treatment
• Elicit patients beliefs and select consistent
  treatment
• Offer optimistic prognosis
• Use a prescription pad

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Best messages to improve adherence

• Take pills daily
• The antidepressant may not work right away
• Continue taking it even if you feel better
• Dont stop without talking to your doctor
• Feel free to call

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AD/HD Primary v. Secondary

• Much of information on response to medication
  based on plain AD/HD
• Long term outcome worrisome
• Co-morbid conditions increase with age including
  LD, CD
• Short term response to stimulant medication high
• Many children have AD/HD as a result of another
  condition ESPECIALLY young children
• Anxiety, Specific Learning disability, Mood
  disorders, Poor environmental conditions in home

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Stimulants

• More information available than for other
  medication types
• Several long term studies
• Affects primarily both dopamine and
  norepinephrine neuro-transmitter systems
• Various preparations available

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Stimulant Drugs to Treat ADHD

• The side effects are the same among the
  medications
• decreased appetite, initial sleep difficulty,
  headaches, tics, and irritability.
• Growth suppression, if at all, appears dose
  related, and childrens height and weight should
  be monitored.
• There is no evidence of tolerance or later
  substance abuse.
• Sudden cardiac death has been a concern with
  stimulants

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Drugs to Treat ADHD

• Attention deficit hyperactivity disorder is the
  most common psychiatric disorder in childhood.
• Stimulant medication has become the mainstay
  treatment, methylphenidates being first choice.
• All of these medications seem to be equally
  effective with about a 70 response rate.
• Some children do not respond to medication and do
  not experience total remission of symptoms.

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Stimulants

• Dexmethylphenidate
• Short acting
• Focalin
• Long acting
• Focalin XR
• Methylphenidate
• Short acting
• Ritalin, Methylin
• Intermediate
• Metadate ER,
• Ritalin SR, Methylin ER
• Extended release
• Concerta,
• Daytranatransdermal patch,
• MetadateCD,
• Ritalin LA

• Dextroamphetamine
• Short acting
• Dexedrine, Dextrostat
• Intermediate
• Dexedrine CR (spansules)
• Amphetamine Mixed Salt
• Intermediate
• Adderall
• Long acting
• Adderall XR

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Non stimulant medications

• Atomoxetine (Strattera)
• Affects noradrenergic transport and has similar
  improvement to the stimulants.
• Adverse effects include decreased appetite, GI
  problems, dizziness, and sedation. The most
  serious is the potential for severe liver injury
  and the possibility of suicidal thinking.
• Tenex/Clonidine
• Beta blocker (antihypertensive)
• Used for aggressive kids

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Side effects

• Methylphenidate, dexedrine
• Appetite and weight
• Height
• Insomnia
• Cognitive blunting
• Atomoxetine
• Nausea
• Sedation
• Tenex
• Sedation

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Antidepressants?

• Wrong name for category
• Often used for anxiety
• Also used in AD/HD
• Rarely used alone

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Choosing an Antidepressant

• Previous Response/Tolerability
• Family History
• Comorbid Psychiatric Symptoms
• Comorbid Psychiatric Diagnoses
• Comorbid Medical Diagnoses
• Concurrent treatments

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Antidepressant Adherence

• 10 never fill prescription, 16 stop first
  week,
• 41 in 2 weeks, 68 by 1 month
• Risks of non-adherence
• Side effects
• Cost
• Improvement
• Lack of education about illness and treatment
• Delayed onset of benefit
• Fear of dependence
• Stigma

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Treating Depression

• Clients seen weekly for six weeks show more
• improvement than those seen less often.
• Clients are more likely to tolerate side effects
  if
• they know they are going to see the doctor in a
• few days.
• Using scales to assess outcome improves care,
• client satisfaction, and overall treatment
  outcome.

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Antidepressants and Suicide

• On October 15, 2004, the FDA issued its
• strongest possible warning (black box) for
• all antidepressants stating that these
• medications may increase the risk of
• suicidal thinking and behavior in children
• and adolescents with major depressive or
• other psychiatric disorders.

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Archives of General Psychiatry(March 2006)

• All PC studies submitted to FDA (4,582
• patients, 24 trials)
• 16 studies looked at MDD, 8 at anxiety
• disorders
• 4 trials had no events in drug or placebo
• group

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• Results
• No completed suicides
• The overall relative risk was 1.95
• Risk was lower in the MDD group (1.66)
• Risk varied greatly among different trials
• Annualized rate of suicide attempts from data
• General population0.6
• Adult antidepressant trials2.6
• Child/adolescent trials3.9

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Hypotheses

• Subjects are recruited early in the illness when
  suicide risk is high
• Adverse selection of treatment resistant
  subjects into the trial
• Intense monitoring for events
• Delay of antidepressant effects
• Antidepressants do not reduce short-term suicide
  risk
• Antidepressant induction of mixed or psychotic
  states
• Rate inflation due to identifying suicidal
  events in brief time samples early in acute
  illness

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Antidepressants and Suicide

• We are left with a great deal of uncertainty
  regarding
• the use of antidepressants, especially in young
  people
• under 18. There seems to be evidence that
  suicidal
• ideation may emerge during early treatment with
• antidepressants. There is no evidence that this
• increases the risk of completed suicide. (No
  suicides in
• 4,000 children in any of these studies.)
  Completed
• suicides have also fallen during the last ten
  years, a
• time of increased usage of antidepressants in
  this age
• group.
• The best approach is to monitor everyone
• who is started on an antidepressant closely
• for the appearance of suicidal ideation,
• agitation, and irritability, especially during
• the initial months of therapy, and be sure
• that the risk is discussed during the
• informed consent process.

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Classifications of Antidepressants

• Tricyclic antidepressants (TCAs)
• Monoamine Oxidase Inhibitors (MAOI)
• Strong serotonin reuptake Inhibitors (SSRIs)
• Serotonin and Norepinephrine Reuptake Inhibitors
  (SNRIs)

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TCA

• Introduced for depression in 1950s
• Hundreds of studies demonstrating efficacy in
  adult depression studies
• Introduced in children in 1960s as alternative to
  stimulants
• Concern of reports of sudden deaths has limited
  use

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TCA

• Imipramine, desipramine, amitryltiline
• Uses
• Depression
• AD/HD
• Enuresis
• OCD
• Effective EXCEPT for depression in children in
  studies

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TCA

• Sudden death and cardiac effects
• Related to prolonged conduction
• First reported in 1990
• All cases associated with desipramine

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Tricyclic Antidepressants

• amitriptyline(Elavil)
• amoxapine(Asendin)
• clomipramine(Anafranil)
• desipramine(Norpramin)
• doxepin(Adapin, Sinequan)
• imipramine(Tofranil)
• maprotiline(Ludiomil)
• nortriptyline(Pamelor)
• protriptyline-(Vivactil)
• trimipramine-(Surmontil)

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Tricyclic Antidepressants

• Advantages
• Inexpensive
• Sedating
• Provides weight gain and pain relief in
  medically ill, useful in Parkinsons, treatment
  resistance
• Clomipramine works in OCD.

• Disadvantages
• Fatal in overdose
• Anticholinergic side effects, orthostatic
  hypotension
• Cardiac effects
• Hard to dose
• No antidepressant efficacy in children and
  adolescence

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MAO Inhibitors

• React with other medications
• FDA endorsed for depression in ages gt16

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Monoamine Oxidase Inhibitors

• isocarboxazid(Marplan)
• phenelzine (Nardil)
• tranylcypromine(Parnate)
• transdermalselegiline(EmSam)
• Advantages
• May help in atypical depression
• Disadvantages
• Requires special diet
• Cause dizziness
• Fatal with other drugs and in overdose

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SSRIs

• Fluvoxetine (Prozac)
• Fluvoxamine (Luvox)
• Sertraline (Zoloft)
• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Paroxetine (Paxil)

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SSRIs

• Seven different families of re-uptake
  inhibitionall a little different
• Also are 5HT receptor agonists included in
  category
• Nefazodone (Serzone)
• Mirtazapine (Remeron)

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SSRIs

• Side effects
• CNS headache, insomnia, anxiety, tremor
• GI nausea, constipation, anorexia, dyspepsia,
  weight gain
• Sexual dysfunction decreased libido, impotence
• Pediatric specific Aggressiveness, epistaxis,
  sinusitis, urinary incontinence, hyperkinesia

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SSRIs

• Serotonin syndrome
• Fever, confusion, muscle rigidity, diaphoresis,
  agitation, hyper-reflexia, caridac, renal and
  liver problems
• Discontinuation syndrome
• Flu-like symptoms

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Stopping the Medication

• All antidepressants, particularly SSRIs can
  cause a withdrawal syndrome. The reactions may be
  more common and severe with short-acting drugs
  like paroxetine and venlafaxine.
• Common symptoms (usually resolve in 2-3 weeks)
• Neurosensory(vertigo, parathesia, shock-like,
  myalgia)
• Neuromotor(tremor, myoclonus, ataxia, visual,
  piloerection)
• Gastrointestinal (nausea, vomiting, diarrhea)
• Psychiatric (anxiety, depression, suicidality,
  irritabililty)

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SSRIs

• Adverse effect suicides and suicide ideation
• NO suicide in pediatric trials
• Increased risk for all patients with major
  depressive disorder
• Current concerns over Paxil and Prozac with major
  depressive disorder patients

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SSRI differences

• Paroxetine higher somnolence (23) higher
  constipation (13), and slightly lower diarrhea
  (11) rate. Inhibits CYP-450 2D6
• Paroxetine is only SSRI with significant
  anticholinergic effects.

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SSRI differences

• Fluoxetine higher agitation and lower somnolence
  rate, longer half life. Inhibits CYP-450 2D6
• Fluvoxamine has higher rate for nausea (40) and
  insomnia (21). Inhibits CYP-450 1 A2

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SSRI differences

• Sertraline Generally low in side effects, weaker
  inhibitor of 2 D6 enzyme system, maximum
  absorption requires full stomach.

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Preexisting Conditions

• Obsessive-compulsive disorder SSRI,
  clomipramine, SNRI usually first choice.
• Panic disorder avoid trazodone and bupropion
  because they are relatively ineffective for
  panic.
• Bipolar disorder avoid TCAs

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Comorbid Conditions-ADs are used for

• Agoraphobia
• Borderline personality disorder
• Depression (unipolar / bipolar)
• Dysthymic disorder
• Generalized Anxiety Disorder (GAD)
• Hypochondriasis

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Comorbid Conditions-ADs are used for

• Obsessive-Compulsive Disorder
• Panic Disorder
• Premenstrual Syndrome (PMS)
• Post-Traumatic Stress Disorder (PTSD)
• Schizoaffective disorder
• Social Phobia

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Side Effects

• General side effects may abate after a few
  weeks of Tx
• For sustained SEs, the pt will not necessarily
  experience the same SEs if switched to another
  drug within the same class.
• Beware of drug interactions

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The SNRIs

• Venlafaxine (Effexor)
• Duloxetine (Cymbalta)

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Venlafaxine

• Potent reuptake inhibitor of 5-HT, with less
  potent effect on NE and dopamine. 30 fold higher
  affinity for 5-HT transporters than NE
  transporters. In healthy humans, whereas 75 mg/d
  was sufficient to block platelet 5-HT uptake,
  only at 375 mg/d was NE function affected.
• May Increase diastolic blood pressure

Effexor XR. Prescribing Information. PDR 2006,
Thompson Eds, 2006 Wellington et al. CNS Drugs
2001 15643-69
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Bupropion

• Does not increase serotonin
• Approved also for quitting smoking
• Very low sexual side effects
• May have therapeutic window
• Caution in patients with seizure risk

Wellbutrin XL Prescribing Information. PDR 2006,
Thompson Eds, 2006 Stahl. Essential
Psychopharmacology. Cambridge University Press,
2005 Masand et al. Ann Clin Psych 2002 14175-182
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Mirtazapine

• Acts as a central antagonist at presynaptic
  alpha-2 receptors, thought to result in an
  increase in central noradrenergic and
  serotonergic activity
• Potent antagonist of 5-HT2 and 5-HT3 receptors
• Potent antagonist of H1 receptors, accounting for
  sedative effects
• Moderate antagonist of peripheral alpha-1
  receptors and muscarinic receptors, accounting
  for occasional orthostatic hypotension and
  anticholinergic effects, respectively.

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Mood Stabilizers

• Controversy more over what is childhood Bipolar
  Affective Disorder
• What constitutes Bipolar in prepubertal children?
• Irritibility
• Few periods of normal functioning
• Different at different times of day
• Often overlaps with children already diagnosed as
  AD/HD

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Mood Stabilizers

• Lithium
• Antiepileptics
• Tegretol
• Depakote
• Possibly
• Klonopin
• Trileptil
• Lamictal
• Antipsychotics, esp. atypicals

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Mood Stabilizers

• Lithium
• Divalproex
• Carbamazepine
• Lamotrigine
• Lithium daily dose (mg) 100.5 752.7 x
  expected lithium concentration -3.6 x age (years)
  7.2 x weight - 13.7 x BUN (Terao, 1999)

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Antipsychotics

• Indications
• Typical (Classic) antipsychotics
• Haloperidol
• Chlorpromazine
• Perphenazine
• Other

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Second Generation Antipsychotics

• All of these medications work on dopamine
• receptors, like the typical antipsychotics,
• but they are more selective at certain sites,
• and also effect serotonin receptors.
• Because of this, their effects -both positive and
  
• negative -are quite different. They are also very
  different from each other
• Another ongoing area of interest is whether or
  not
• SGAs are also mood stabilizers. They probably
• are, but it is not clear how they are distinct
  from
• each other, or what advantages they have over
• lithium and the anticonvulsants.

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Newer (Atypical) Antipsychotics

• Lower side effects
• Lower risk of TD
• Lower EPS
• Better in negative symptoms (deficits in
  emotional responsiveness, flattening of affect,
  poverty of speech, lack of volition and drive,
  loss of feeling, social withdrawal and decreased
  spontaneous movement)
• Lower cognitive impairment
• Mood stabilizing properties

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Atypical antipsychotics

• Clozapine (Clozaril)
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Zisprasidone (Geodone)
• Aripiprazole (Abilify)

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Side Effects

• PROLACTIN
• Increased with all antipsychotics except
  clozapine, ziprasidone, aripiprazole and maybe
  quetiapine.
• SSRIs, particularly paroxetine, may increase
  prolactin and exacerbate neuroleptic-induced
  prolactinemia.

Metabolic Risks

• Increased with all atypical antipsychotics but
  Aripiprazole and Ziprasidone have a lower risk

Agranulocytosis

• Clozapine. Common presentation Acute sore throat,
  high fever, mouth sores and ulcers.

TD - EPS

• More common for classic/typical Neuroleptics

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Chronic Side Effects

• Weight gain/Metabolic Syndrome
• Certain SGAs increase the risk for metabolic
  syndrome
• -increased weight, high blood pressure, diabetes,
  
• increased serum cholesterol and triglycerides
• Clients need to be monitored for these findings
  
• because of the risk of cardiovascular
  complications.
• The medications most likely to increase weight
  are
• clozapine, olanzapine, divalproex, and lithium

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Antianxiety

• Benzodiazepines
• Buspirone
• SSRIs
• Antihistamine

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Benzodiazepines for Anxiety

• Advantages
• Well-tolerated
• Quick onset
• Effective
• Safe in overdose
• Low Cost

• Disadvantages
• Withdrawal reactions
• Sedation
• Risk of abuse
• Poor antidepressant effect

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SSRIs for Anxiety

• Advantages
• Effective
• Safe
• No risk of abuse
• Effective on depression

• Disadvantages
• Possible increase in anxiety during initial
  period of use
• Sexual side-effects

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Dementia Medications

• Donepezil (Aricept)
• Rivastigmine (Exelon)
• Galantamine (Reminyl)

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Anticholinergics

• Benztropine (Cogentin)
• Diphenhydramine (Benadryl)

Used for EPS and acute dystonia
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Substance Abuse Meds

• Disulfiram (Antabuse)
• Aldehyde dehydrogenase inhibitor
• When ETOH consumed, results in flushing, anxiety,
  nausea, sweating, dyspnea, tremor, confusion,
  headache, nausea/vomiting
• Naltrexone (ReVia)
• Opioid receptor antagonist
• Decreases craving for ETOH

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Latest information on Web

• www.nimh.nih.gov
• Patient/provider handouts
• www.aacap.org
• Facts for families