PSYCHOTROPIC MEDICATIONS OVERVIEW

1. PSYCHOTROPIC MEDICATIONSOVERVIEW M. Catalina Melo, M.D.

2. Classes of Psychiatric Medications • Antipsychotics: -first generation -atypical or second generation • Antidepressants: -tricyclics -SSRI’s & SNRI’s -Others (wellbutrin, remeron, nefazodone, trazodone, viibryd) -MAO Inhibitors • Mood Stabilizers: -Lithium -Anticonvulsants

3. Classes of Psychiatric Medications • Anxiolytics and Hypnotics: -Benzodiazepines -Buspar -Antihistamines (benadryl, vistaril) -Sleep agents (ambien, lunesta, sonata, melatonin) • Stimulants and Cognitive enhancers: -Amphetamines, methylphenidate, strattera, provigil -Aricept, Namenda, Reminyl, Exelon

4. First Generation Antipsychotics -> D2 Receptors Antagonists * Chlorpromazine=Thorazine * Thioridazine=Mellaril * Fluphenazine=Prolixin (injection) * Perphenazine=Trilafon * Trifluoperazine=Stelazine * Thiothixene=Navane * Haloperidol=Haldol (inj) * Pimozide=Orap

5. Antipsychotic Side Effects * EPS, TD (haldol) * Sedation * Orthostatic hypotension * NMS *leukopenia(low white blood cell count) * Constipation * Urinary retention, dry mouth, blurry vision * Galactorrhea, breast enlargement * Skin pigmentation (mellaril) * Seizures (increases risk)

7. ABNORMAL MOVEMENTS • EPS (Extrapyramidal Symptoms): inability to move, akathisia (restlessness), acute dystonia, tremor, difficulty with gait, mouth/tongue tremor. • TardiveDyskinesia: rapid repetitive movements. * Neuroleptic Malignant Syndrome: confusion, fever, muscle rigidity.

8. Atypical or Second Generation Antipsychotics ->5HT2A and 5HT2C Serotonin Blockeade • Clozapine= Clozaril • Risperidone= Risperdal (constainj) • Olanzapine= Zyprexa • Quetiapine= Seroquel • Ziprasidone= Geodon • Aripiprazole= Abilify • Paliperidone= Invega (sustennainj) • Asenapine= Saphris • Iloperidone= Fanapt • Lurasidone= Latuda

9. SIDE EFFECTS • Sedation (seroquel +++) • Weight gain (zyprexa, clozaril+++) • Metabolic changes (zyprexa, seroquel, clozaril) • EPS, TD • Risks if pregnancy • Constipation, dry mouth • Irritability • Changes in blood cells (clozaril needs blood counts regularly)

10. Indications • Psychotic Disorders: Schizophrenia, Schizoaffective Disorder, Schizophreniform Disorder, depression with psychosis, drug induced and other organic psychosis. • Acute mania • Maintenance of Bipolar Illness • Tourette’s Syndrome and other tic disorders • Treatment-Resistant Depression: Abilify and Seroquel • Other uses (not FDA): personality disorders, chronic aggression, OCD. • Psychosis and Bipolar illness in Children and adolescents.

12. Mood Stabilizers • Lithium= Eskalith, Lithobid • Valproic acid = Depakote, Depakene, ER • Carbamazepine= Tegretol, Equetro, Carbatrol, XR • Lamotrigine = Lamictal • Oxcarbamazepine= Trileptal • Gabapentin= Neurontin • Topiramate= Topamax

13. LITHIUM • Thirst/ Increased Urination • Tremor • Weight gain • Nausea, diarrhea • Acne • Fatigue • Thyroid abnormalities • Toxicity: severe tremor, confusion, seizures • Interactions with Diuretics, NSAID’s, lisinopril

14. Valproic Acid -> Increases GABA transmission • Gastrointestinal • Low platelet count • Tremor • Sedation • Weight gain • Alopecia

15. Carbamazepine -> Blocks sodium channels • Dizziness, uncoordination • Double vision • G.I. upset • Tremor • Decreased white blood cells • Rash * Interactions with other drugs

16. Other Mood Stabilizers • Lamotrigine : no weight gain. RASH. • Neurontin: used for pain. Somnolence. • Topiramate : migraine prophylaxis. Weight loss, memory deficits, sedation, osteoporosis. *ALL: Neonatal complications and fetal malformations. Neurological side effects.

17. Indications • Bipolar Illness type I and II (prophylaxis) • Acute mania • Cyclothymia • Schizoaffective Disorder • Aggression • Personality Disorders with unstable affect • Alcohol Abuse (+/-) • Anxiety • Chronic pain syndromes

19. SSRI’s & SNRI’s • Fluoxetine= “Prozac” • Paroxetine= “Paxil, Paxil CR, Pexeva” • Citalopram= “Celexa” • Sertraline= “Zoloft” • Fluvoxamine= “Luvox” * • Duloxetine= “Cymbalta” • Venlafaxine= “Effexor, Effexor ER, XR” • Desvenlafaxine= “Pristiq” • Vilazodone= “Viibryd”

20. SSRI’s and SNRI’s • Nausea and decreased appetite • Increased sweating • Tremor • Headaches • Sleep changes (quantity, quality, dreams) • Sexual dysfunction* • Diarrhea/constipation • Bruxism • HTN (SNRI’s)

21. Other Antidepressants • Tricyclics: sedation, hypotension, dry mouth, blurry vision, constipation, cardiac toxicity. • Bupropion “Wellbutrin”: low appetite, headaches, seizures. • Mirtazapine “Remeron”: increased appetite, somnolence. • Nefazodone: Liver damage. • Trazodone: somnolence, priapism. • MAO (-): rarely used due to dietary limitations. • Viibryd: newest antidepressant. No sexual side effects?

22. Indications (SSRIS’s) • Major Depressive Disorder • Dysthymic Disorder • Panic Disorder • Social Anxiety Disorder • Generalized anxiety Disorder • PTSD (zoloft) • OCD (fluvoxamine), Impulse Control Disorders • Bulimia Nervosa • Personality Disorders (BPD)

23. Other Indications • Neuropathic Pain, Fibromyalgia • Insomnia • Enuresis (imipramine) • ADHD (Wellbutrin) • Smoking cessation (Wellbutrin)

25. Anxiolytics and Hypnotics • Alprazolam= “xanax” • Clonazepam= “Klonopin” • Diazepam= “Valium” • Lorazepam= “ativan” • Temazepam= “restoril” • Zolpidem= “Ambien” • Eszopiclone= “Lunesta” • Buspirone= “Buspar” • Hydroxyzine= “Vistaril” Side Effects: sedation, memory deficits, incoordination, dependence, coma in OD (BZD).

26. CNS Stimulants • Atomoxetine= Strattera • Methylphenidate = ritalin, focalin, concerta, daytrana. • Amphetamines = dexedrine, adderall, vyvanse. • Modafinil = Provigil. (Narcolepsy). *Uses: ADHD, narcolepsy, treatment resistant depression. *Side Effects: Cardiac, insomnia, irritability, G.I.

27. Cognitive Enhancers -> Acethylcholinesterase inhibitors • Donepezil= “Aricept” • Galantamine= “Reminyl” • Memantine= “Namenda” • Rivastigmine= “Exelon” Side Effects: G.I., insomnia, mood changes.

28. Always remember…. • “All things are poison, and nothing is without poison” • Patients with a psychiatric diagnosis have a higher incidence of co-existent medical problems, therefore are at higher risk of pharmacological interactions • Most patients do not take medications as prescribed • Providers forget to ask about the use of CAM • Birth Control • Substance Abuse • Epocrates.com • Erowid.org

29. Hispanic Population • High risk of depression, anxiety and substance abuse: women • Attempted suicide: high rate in US Latino high school students • Higher rate of mental illness: US born and long-term residents

30. Challenges of Providing Care to Hispanic Populations • Less than 10% with a Dx seek services • Largest uninsured group in the US • Research on Evidence based treatments tested mainly on white populations • Over-reliance on family and religion • Low socio-economic status: 2-3 times more likely to have a mental illness • Poor Health overall

31. Factors Interfering with Access to Mental Health Care • Stigma of mental illness and Psychiatry care • Being an “Illegal alien” • Lost in Translation: 1% of APA members are Hispanic • Gender roles • Different Hispanic cultures/ countries • Over-representation in the criminal and Juvenile justice systems