A Brief Overview of Psychotropic Medications

1. A Brief Overview of Psychotropic Medications Coni Kalinowski, M.D. 8 February 2013

3. Some general principles regarding medications: • Psychotropic medications are one tool among many that may lessen mental distress. • All medications have “side effects.” No medication is “safe.” • The effects of psychotropic medications on individuals are unique. • Anything can be a side effect of medication. • Side effects of psychotropic medications can mimic psychiatric symptoms. • Psychotropic medications do not cure psychiatric difficulties. • Psychotropic medications do not “treat” behaviors. • The mechanisms of action of psychotropic agents are essentially unknown.

4. Some general principles regarding medications: • “Medical” medications, over-the-counter medications, and herbal remedies can have significant psychotropic side effects. • Medication combinations can be unpredictable. • Recreational substances and “social” substances often interact with psychotropic medications. • Older people, people who have health problems, people who have had brain injuries, and people having intellectual disabilities may be more sensitive to psychotropic medications and their side effects. • Psychiatric treatment must be differentiated from chemical restraint and social control. • No medication is “safe” during pregnancy. • More is not always better.

5. Antipsychotic Medications (Neuroleptics) • Conventional medications (older): • haloperidol (Haldol) • fluphenazine (Prolixin) • pimozide (Orap) • trifluoperazine (Stelazine) • thiothixene (Navane) • perphenazine (Trilafon) • mesoridazine (Serentil) • loxapine (Loxitane) • molindone (Moban) • thioridazine (Mellaril) • chlorpromazine (Thorazine)

6. Antipsychotic Medications (Neuroleptics) Atypical medications (newer): • clozapine (Clozaril) • risperidone (Resperidal) • olanzapine (Zyprexa) • quetiapine (Seroquel) • ziprasodone (Geodon) • aripiprazole (Abilify) • paliperidone (Invega) • iloperidone (Fanapt) • asenapine (Saphris) • lurasidone (Latuda)

7. Antipsychotic Medications (Neuroleptics) Uses: • -reduce hallucinations • -improve organization of thought processes • -reduce preoccupations with improbable beliefs • -tranquilization • -anti-emesis • -treatment of Tourette's disorder

8. Common Side effects of antipsychotics: • sedation • drowsiness • anergy • decreased motivation • slowing of thought processes • depression • dry mouth or drooling • constipation • blurred vision • weight gain, diabetes, hyperlipidemia • orthostatic hypotension • amenorrhea • galactorrhea • gynecomastia

9. Common Side effects of antipsychotics: • rashes • sun sensitivity • sexual dysfunction • restlessness • restless leg syndrome • discontinuation syndrome • headache (especially aripiprazole and ziprasidone) • nausea and vomiting (especially risperidone and ziprasidone)

10. Neurological side effects of antipsychotics • Parkinsonian Side Effects • Onset generally about 7 days after beginning antipsychotic medications • Key features: • "pill-rolling" tremor • increased muscle tone and "cogwheeling" • stooped, shuffling gait • bradykinesia • mask facies • impaired balance

11. Neurological side effects of antipsychotics • Akathisia • Characterized by extreme motor restlessness or "nervousness" • People may be observed to pace, jog their legs, repeatedly sit then stand • When severe, people may not be able to sleep • May be a cause of increased SIB or aggression in people having developmental disabilities • Onset: immediate to a few days

12. Neurological side effects of antipsychotics • Dystonia • Characterized by a sustained, painful contraction of one or more muscle groups. • Common presentations: • rigid tongue protrusion • throat "closing up" or tongue drawn back • upward deviation of the eyes • torticollis • oculogyric crisis • Onset: frequently within an hour of dosage, may be recurrent • Can be lethal if airway obstruction occurs

13. Neurological side effects of antipsychotics • Tardive Dyskinesia • Characterized by involuntary muscle movements • Onset generally after many years of taking antipsychotic medications, but can occur within weeks • Can be progressive and permanent • Typical movements: • chewing, lip-smacking, lip-licking, puffing • frequent blinking and blepharospasm • tongue flickering or protrusion • flexion-extension movements of fingers, writhing or arms • foot tapping, ankle movements • shrugging, twisting of torso or hips • eructation, reflux, vomiting • Progresses to cause dysphagia, respiratory difficulties, aspiration pneumonia

14. Serious side effects of antipsychotics • neutropenia • seizures • neuroleptic malignant syndrome • cardiac arrhythmias • hyperthermia • cataracts • precipitation of glaucoma • priapism • diabetes • hyperlipidemia

15. Antidepressants • SSRI's • fluoxetine (Prozac) • sertraline (Zoloft) • paroxetine (Paxil) • fluvoxamine (Luvox) • citalopram (Celexa) • escitalopram (Lexapro)

16. Antidepressants • SNRI'sand Novel agents • trazodone (Deseryl) • nefazodone (Serzone) • venlafaxine (Effexor) • bupropion (Wellbutrin) • mirtazepine (Remeron) • duloxetine (Cymbalta) • desvenlafaxine (Pristiq) • vilazodone (Viibrid)

17. Antidepressants • Uses: • treatment of depression • treatment of anxiety • treatment of social phobia • treatment of panic attacks • treatment of eating disorders • treatment of attention deficit disorder in adults • treatment of migraine • treatment in autism (especially SSRI's) • treatment of obsessive-compulsive disorder (especially SSRI's) • treatment of irritability in posttraumatic stress disorder

18. Common side effect of antidepressants: • G.I. side effects: nausea, constipation or diarrhea • Sexual and reproductive dysfunction: anorgasmia, erectile dysfunction, decreased libido, dysmenorrhea, menstrual irregularity • Sleep disturbance: insomnia, nightmares, somnolence • Weight gain • headache • tremor • agitation or "jitters" • excessive sweating • palpitations • dry mouth

19. Common side effect of antidepressants: • weight loss • asthenia • muscle pain • “poop out” • dizziness • paresthesias • visual disturbances, blurred vision • akathisia • rash • sun sensitivity • yawning • changes in taste • discontinuation syndrome • worsening of depression

20. Serious side effects of antidepressants • seizures • intense suicidality or impulsivity • kindling of mania or psychosis • dyskinesias • extrapyramidal side effects • electrolyte disturbances • elevation of cholesterol • decreased platelet aggregation and bleeding • birth defects

21. Anticonvulsant Medications • Divalproex sodium (Depakote) • Carbamazepine (Tegretol) • Oxcarbazapine (Trileptal) • Topiramate (Topamax) • Lamotrigine (Lamictal) • Gabapentin (Neurontin)

22. Anticonvulsant Medications • Uses: • treatment of seizure disorders • treatment of mood swings • treatment of explosive aggression • treatment of complex post-traumatic stress disorder

23. Common side effects of anticonvulsants: • drowsiness • fatigue • mental slowing • nausea and vomiting • tremor • rash • motor slowing • weight gain • hair loss (Depakote) • changes in blood pressure • birth defects • suicidal impulses

24. Serious side effects of anticonvulsants • Tegretol - • agranulocytosis • aplastic anemia • hyponatremia • hypothyroidism • toxic epidermal necrolysis • Stevens-Johnson syndrome

25. Serious side effects of anticonvulsants • Depakote – • hepatic failure • thrombocytopenia • polycystic ovary • anemia • pancreatitis • hyperammonemia

26. Serious side effects of anticonvulsants • Neurontin – • elevated liver enzymes • hypertension • increased lability • sudden death elevated liver functions • pure red cell apalasia (risk in hemoglobinopathies)

27. Serious side effects of anticonvulsants • Trileptal- hyponatremia • severe cognitive SE • Topamax – severe cognitve SE • kidney stones • hyperthermia, oligohidrosis

28. Common Medication Errors • Over-medication (excessive dosage) • Common causes: • not waiting for therapeutic effect, overshooting the therapeutic dose. • increasing dose in a crisis, but forgetting to return to maintenance dose. • using medication for sedative side effect • “more is better” • failure to compensate for advanced age, medical problems, brain injury

29. Common Medication Errors • Polypharmacy (more than one drug in the same class) • Common causes: • adding a new medication without removing ineffective medications. • stalled cross titration

30. Common Medication Errors • Failure to recognize medication interactions. • Confusion of medication side effect with symptoms of the psychiatric disability. • Failure to assess a change in “medical” health. • Inadequate evaluation of situational and environmental contributors to psychiatric symptoms.

31. Common Medication Errors • Failure to fully assess “medical” medications and non-prescription substances. • Inadequate monitoring of side effects. • Failure to take the person’s report of medication side effects seriously.

32. Common Medication Errors • Over-reliance on medications; inadequate use of alternative or adjunct treatment. • Inadequate attention to informed consent. • Failure to warn about possible prenatal effects of medications.