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Psychopharmacology in Psychiatry

Drugs
STUDY
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Paroxetine (Paxil)...SSRI
Pros: short 1/2 life with no active metabolites (build up), very sedating (may help with insomnia and anxiety)

Cons: sedating, weight gain, anticholinergic agent, most likely to cause discontinuation syndrome, significant CyP2D6 inhibition (if 2 drugs go through the same liver pathway, levels of both will increase in the blood)
Sertraline (Zoloft)...SSRI
Pros: very weak P450 interactions/slight CYP2D6 (can use with other meds), short 1/2 life with no build up of metabolites, less sedating than PAXIL

Cons: max absorption requires full stomach, increased GI side effects (nausea and vomiting)
Fluoxetine (Prozac)...SSRI
Pros: long 1/2 life-less indcidence of discontinuation syndrome (good for pts with noncompliance), increased energy initially

Cons: long 1/2 life (active metabolites may build up and this could be a problem for patients with liver disease), significant P450 interactions, initial activation may cause insomnia and anxiety, more likely to induce mania than other SSRIs (DO NOT GIVE TO MANIC PATIENTS)
Citalopram (Celexa)...SSRI
Pros: lower inhibition of P450 (fewer drug interactions), intermediate 1/2 life (low risk for discontinuation syndrome)

Cons: sedating, GI side effects
Tertiary Tricyclics
TOFRANIL, ELAVIL, SILENOR, ANAFRANIL
- Have tertiary amine side chains that are prone to cross react with other types of receptors which leads to more side effects:

antihistamine-sedation, weight gain
anticholinergic- dry mouth/eyes, constipation, memory deficits, delirium
Secondary Tricyclics
NORPRAMIN, PAMELOR
- often metabolites of tertiary amines
- same side effects as tertiary TCAs but generally less severe
Venlafaxine (Effexor)...SNRI
Pros: minimal drug interactions and almost no P450 activity, short1/2 life and fast renal clearance (good for elderly)

Cons: can cause increased diastolic BP, may cause significant nausea, can cause bad discontinuation syndrome, may caused prolonged QT in some people, sexual side effect > 30%
Duloxetine (Cymbalta)...SNRI
Pros: may help some physical symptoms of depression, less increase in BP than EFFEXOR

Cons: CYP2D6 and CY1A2 inhibitor, cannot break capsules (patients have to swallow pills)
Mirtzapine (Remeron)...Novel antidepressant
Pros: may be good for use with SSRIs, can be used as a hypotonic at lower doses secondary to antihistamine effects

Cons: increases serum cholesterol by 20% in 15% of patients (triglycerides in 6%), very sedating at lower doses (doses >30 mg cna be activating instead), may cause weight gain (increases appetite)
Bupropion (Wellbutrin)...Novel antidepressant
Pros: good as an augmenting agent, increases levels of dopamine and norepinephrine, no weight gain, no sexual side effects, no sedation, no cardiac interactions, low induction of mania, good for patients with ADHD and depression

Cons:may increase seizure risk (avoid in patiens with TBI, anorexia, or bulemia), does not treat anxiety (may CAUSE it), can induce psychotic symptoms at high doses (potential for abuse)
Lithium...Mood stabilizer
ONLY medication to reduce suicide rate, very effective (70%) in long term prophylaxis of mania and depressive episodes in patients with Bipolar 1

Factors affecting positive response of lithium: prior long term response, family member with good response, classic pure mania, mania is followed by depression
Valproic Acid (Depakote)...Mood stabilizer
as effective as lithium in mania prophylaxis, not as effective in depression prophylaxis, better tolerated than litium.

Factors affecting a good response: rapid cyclers, comorbid substance issues, comorbid anxiety disorders
Carbamazepine (Tegretol)...Mood stabilizer
FIRST LINE agent for acute mania and mania prophylaxis, indicated for rapid cyclers and patients with mixed presentations, usually started inpatient and not long term
Lamotrigine (Lamictal)...Mood stabilizer
indications similar to other anticonvulsants, specific efficacy for bipolar depression, used for neuropathic/chronic pain, initiation/titration
High Potency Typical Antipsychotics
PROLAXIN, HALDOL, ORAP
Low Potency Typical Antisychotics
THORAZINE, MELLARIL
Risperidone (Risperdal) Atypical antipsychotic
Regular tabs, IM, and rapidly dissolving tabs are available...Functions like a typical antipsychotic at doses > 6mg...increased extrapyramidal side effects (dose dependent)...most likely to induce hyperprolactinemia...weight gain and sedation (dose dependent)
Olanzapine (Zyprexa) Atypical antipsychotic
regular tabs, immediate release, IM, rapidly dissolving tabs...wight gain very common (can be 30-50 lbs)...may cause hypertriglyceridemia, hyperglycemia, hypercholesteremia
Quetiapine (Seroquel) Atypical antipsychotic
regular tabs only...weight gain, triglyceride, cholesterol, and glucose elevation (less than Zyprexa)...most likely to cause orthostatic hypotension
Ziprasidone (Geodon) Atypical antipyschotic
regular tabs, IM, immediate release...clinically significant QT prolongation...may cause hyperprolactinemia (but <Risperidone)...no weight gain...absorption increased up to 100% with food
Ariprazole (Abilify) Atypical antipsychotic
Unique MOA as a D2 partial antagonist...regular tabs, IM...low extrapyramidal symptoms...no QT prolongation, low sedation...CYP2D6 interactions...no weight gain...fairly new drug
Clozapine (Clozaril) Atypical Antipsychotic
regular tabs...reserved for treatment resistent patients because of side effects...associated with agranulocytosis (requires blood draw every 6 months)...increased seizure risk...increased risk of increased triglycerides, cholesterol, glucose and weight gain...can cause coma and death...
Buspirone (Buspar)...Anxiolytic
Pros: good augmentation strategy (works independent of endogenous release of serotinin)...no sedation

Cons: takes ~2 weeks for results...won't reduce anxiety in patients who are used to taking BZDs b/c there is no sedation effect to "take the edge off"
Benzodiazepines (BZDs)...Anxiolytic
used to treat insomnia and anxiety disorders, used for CNS depressant withdrawal protocols (like alcohol withdrawal)...

SFX: somnolence, cognitive effects, amnesia, disinhibition, tolerance, DEPENDENCE

Ex...XANAX, KLONOPIN, VALIUM, ATIVAN, RESTORIL
Psychotherapy
Psychodynamic psychotherapy is modern systematic therapy...usually <40 sessions with a focus on the PRESENT...conflicts and themes are the focus of treatment with attention to wishes, dreams, and fantasies
Interpersonal psychotherapy
theory is that intrapsychic conflicts are less important than one's relationships to ones sense of self and to others...GOOD FOR DEPRESSSION
Cognitive behavioral therapy (CBT)
examination of cognitive distortions and the use of behavioral techniques to treat common disorders...effective in depression, phobias, OCD, PTSD, and panic disorders...CBT and pharmacotherapy are thought to be synergistic...better long term effects than meds alone!
Dialectical-behavioral therapy (DBT)
desgined specifically for borderline personality disorders...focuses on the therapist and patient acceptance of the patiet as the foundation for developing skills for behavioral/emotional change...take ownership of issues and deal with them
Electroconvulsive therapy (ECT)
one of the oldest and most effective treatments for depression...helpful in mania and in psychosis with prominent mood components and catatonia...works via induction of generalized seizure in the brain...peripheral manifestations and memory or event is blocked...produces short term memory loss and confusion...bilateral is better than unilater but produces more cognitive side effetcs