Psychopharmacology
Part 1
عمار يوسف. د:اعداد
Introduction – general points before
prescribing the medication
. Always exclude other medical causes that may mimic the underlying
disorder.
. Always consider other therapies before prescribing.
. Consider the side effects to ensure the benefits outweigh the risks.
. Choose the appropriate drug based on side-effect profile, e.g. sedating
versus non-sedating.
. Consider possibility of discontinuation syndrome or toxicity and risk of
overdose.
. When a patient complains of any symptom, look at the drug chart; is it
iatrogenic?
. Monitor outcome of the therapy (relapse/improvement).
. Always consider drug interactions when combinations of drugs are
prescribed.
. Ensure that the medication you are prescribing does not interact with
other medication they may be taking for physical health problems
(particularly important for lithium).
. Good communication skills are essential to ensure medication
compliance.
. Every patient needs to know:
-the name of the drug you are prescribing
- the objective of the treatment – to treat the disease/relieve
symptoms
- how to take and when to take the medicine
-what to do if they miss a dose
-how long the drug is likely to be needed
-how to recognize side effects and any action that should be taken
-whether there is a need for special monitoring of blood levels of the
drug.
. For children, the elderly and those with a learning disability you should
(start low and go slow), i.e. use a small dose and increase it very
gradually
. Keep in your mind before you prescribe the psychotropic drugs:
availability and cost of these drugs
CLASSIFICATION OF PSYCHOTROPIC DRUGS
The drugs which have a significant effect on higher mental functions
are called as psychoactive or psychotropic drugs. These psychotropic
drugs can be broadly classified as follows:
1. Antipsychotics
2. Antidepressants
3. Mood stabilizing drugs (or drugs for maintenance treatment of
bipolar disorder)
4. Anti-anxiety and hypno-sedatives
5. Anticonvulsants (or anti-epileptics)
6. Alcohol and drugs of dependence.
7. Antiparkinsonian drugs
Antidepressants
– Selective serotonin reuptake inhibitors SSRI.
Examples.
1_Citalopram. (Long half-life)
2_Fluoxetine. (Longest half-life)
3_Paroxetine. (Shortest half-life)
4_Sertraline. (Short half-life)
Indications
. Depressive illness (treatment and prophylaxis in recurrent episodes)
. Anxiety disorders (e.g. GAD Generalized anxiety disorder, panic
disorder)
. Bulimia (fluoxetine)
. OCD (Obsessive compulsive disorder)
. PTSD (Post-traumatic stress disorder)
Side effects
. Gastrointestinal disturbance (dose related and usually transient)
_Nausea
_Vomiting
_Anorexia
_Weight loss
_ Diarrhea.
.Sexual (temporary side effect)
_ Lower libido
_ Delayed orgasm
. Hypersensitivity reactions
. Other
_Headache
_ Anxiety
_Sleep disturbance
_ Restlessness
Contraindications
. Mania, use with caution in bipolar disorder
Prescribing notes
. Usually given once a day.
. Used as first line for treatment of depressive illness.
. May take 2 weeks before any effect and 6 weeks for full effect.
. Discontinuation symptoms have been reported (especially with
paroxetine).
. Relatively safe in overdose, although some patients have reported
increased suicidal ideation initially.
– Antidepressants – tricyclic antidepressants
Examples
. Amitriptyline
. Imipramine
. Lofepramine (shortest half-life)
. Clomipramine
Indications
. Depression
. Anxiety disorders (phobic disorders, GAD Generalized anxiety
disorder)
. OCD (clomipramine)
. Neuropathic pain (amitriptyline) (e.g. trigeminal neuralgia)
. Nocturnal enuresis in children (imipramine)
Side effects
. Antimuscarinic
_ Dry mouth
_Blurred vision
_Constipation
_Urinary retention
_Drowsiness
. Cardiovascular
_ Postural hypotension
_ Arrhythmias
. Toxicity in overdose
_Cardiotoxic
_Respiratory failure
_Seizures
_Convulsions
_ Coma
Contraindications
. Recent MI
. Arrhythmias
. Severe liver disease
. Mania – use with caution in bipolar disorder
Prescribing notes
. Given in divided doses or a single dose at bedtime.
. May take 2 weeks before any effect and 6 weeks for full effect.
. May cause drowsiness – advise patients to avoid driving.
. Avoid if high suicide risk in outpatient as can be lethal in overdose
(lofepramine is the safest TCA in overdose)
– Antidepressants – monoamine oxidase inhibitors
EXAMPLES MAOI
– Irreversible: Phenelzine Isocarboxide.
– reversible: Moclobemide
INDICATIONS
Refractory/atypical depression
Chronic dysthymia
SIDE-EFFECTS
Cardiovascular: postural hypotension arrhythmias
Neuropsychiatric: drowsiness/insomnia headache
GI: increased appetite weight gain
Sexual: anorgasmia
Hepatic: hepatotoxic – raised LFT
SERIOUS SIDE-EFFECTS
Hypertensive crisis
– due to interactions between MAOIs and tyramine-containing
compounds.
5-HT syndrome (serotonin syndrome)
– due to interactions between MAOIs and 5-HT (5-Hydroxytryptamine
receptors)-enhancing drugs (TCA, SRIs).
Side-effects and interactions are less common with RIMAs.
CONTRAINDICATIONS
Mania – use with caution in bipolar disorder
Hepatic impairment
Cerebrovascular disease
Phaeochromocytoma
PRESCRIBING NOTES
. Given orally (tablets) o.d.
. Patients must carry a card indicating that they are taking MAOIs and
must be educated and given written information about MAOIs,
especially about dietary requirements.
. Foods to be avoided include cheese, pickled fish, meats, broad beans,
yeast extracts.
. Patients are advised only to eat food that is fresh and to avoid
undercooked food.
. Patients are advised to avoid alcohol.
. Other antidepressants should not be prescribed until 2 weeks after
cessation of MAOIs.
– Antidepressants – others
Examples.
.Venlafaxine and Duloxetine (serotonin and noradrenaline reuptake
inhibitor)
. Mirtazapine It is a noradrenergic and specific serotonergic
antidepressant (NaSSA) also in some textbook named as (tetracyclic
antidepressant) and most likely still unknown mechanism of action
Indications
. Depression
. Generalized anxiety disorder (venlafaxine)
. Chronic pain especially (Duloxetine)
Side effects
. Venlafaxine
_Constipation
_Nausea
_Dizziness
_Sleep disturbance
_Hypertension
. Mirtazapine
_Increased appetite and weight gain
_Oedema
_Sedation
Contraindications
. Venlafaxine
_High risk of cardiac arrhythmia
_Uncontrolled hypertension
_Pregnancy
Prescribing notes
. Mirtazapine is given at bedtime as it aids sleep.
. Mirtazapine has few antimuscarinic side effects and so can be useful in
elderly patients.
. Venlafaxine can be given once daily in a modified-release preparation.
. Venlafaxine should be used as a second-line treatment under
specialist supervision.
. Venlafaxine requires monitoring of blood pressure
