Psych Pharm

• Most are 24 hours.
• Fluoxetine is 2-4 days (it's metabolite norfluoxetine is 7-10 days. this means it takes over a month to reach steady-state plasma concentrations, the others take 5 days)

Plasma proteins (except fluoxetine). Have much less effect on muscarinic, histaminic, and adrenergic receptors, compared to TCAs so they are better tolerated.

2-4 weeks. Should be continued 6-8 weeks before pt is considered refractory

GI, decreased appetite, insomnia (most common with fluoxetine), headaches, sexual dysfunction, serotonine syndrome (if used with MAOIs)

In general the lesser effects go away after consistent use

Smoking, Carbamazepine, Barbiturates, St. Johns wort

Fuoxetine, Paroxetime, Duloxetime, Sertraline

• longest half life, so no need to taper
• safe in pregnancy
• can elevate levels of neuroleptics

• high risk for GI disturbances
• very few drug interactions

• highly protein bound, so several drug interactions
• anticholinergic effects: sedation, constipation, weight gain
• short half life causes withdrawal if not take consistantly

• treats OCD
• lots of drug interactions
• CYP inhibitor

fewest drug-drug interactions

serotonin syndrome

• fever
• tachycardia
• hypertension
• delerium
• hyperreflexia
• "electric jolt" limb movements

• used for depression and GAD
• low drug interaction potential
• elevates BP (don't use for pts with htn)

• used for pts with depression and neuropathic pain
• side effects include dry mouth and constipation
• liver effects, don't give to alcoholics

• useful for refractory MDD, insomnia
• no sexual side effects, doesn't effect REM sleep
• side effects: nausea, dizziness, orthostatic hypotension, arrhythmias, sedation, and priapism

• used for refractory MDD, especially in pts who need to gain weight
• good for elderly, helps with sleep and appetite

• TCA (sedating)
• Useful in chronic pain, migraines, and insomnia

• TCA
• used in enuresis and panic disorder

• TCA
• most serotonin specific
• used for OCD

• TCA
• used for chronic pain

• TCA
• least likely to cause orthostatic hypotension
• used for chronic pain

• TCA
• least anticholinergic

IV sodium bicarbonate

norepi, serotinin, dopamine, and tyramine

serotonin

also dopamine and tyramine

norepi/epi

also dopamine and tyramine

• Phenelzine
• Tranylcypromine
• Isocarboxazid
• Selegeline

calciam channel blockers (nifedipine). Monitor carefully if use chlorpromazine or phentolamine

• SSRIs (high doses)
• TCAs (clomipramine)

• SSRIs
• TCAs (imipramine)
• MAOIs

• SSRIs (high dose)
• TCAs
• MAOIs

• SSRIs
• TCAs
• MAOIs

• SSRIs
• SNRIs (venlafaxine)
• TCAs

• SSRIs
• TCAs

SSRIs

TCAs (imipramine)

• TCAs (amitriptyline and nortriptyline)
• Duloxetine

• SSRIs
• TCAs

SSRIs

• TCAs (amitriptyline)
• SSRIs

SSRIs

SSRIs

• Mirtazapine
• TCAs (amitriptyline)

• typical block dopamine receptors (D2)
• atypical block D2 and serotonin (2A) receptors

lithium levels, creatinine, and thyroid levels

• higher incidence of anticholinergic and antimuscarinic side effects
• QTc prolongation
• Chlorpromazine - orthostaic hypotension, blue skin discoloration, pohosensitivity, can treat nausea, vomitting, and irretractable hiccups
• Thioridazine - retinitis pigmentosa

• less sedation, orthostatic hypotension, and anticholinergic effects, greater risk for EPS and tardive dyskinesia
• Haloperidol
• Fluphenazine
• Pimozide - cardiac side effects

mesolimbic pathway: nucleus accumbens, fornix, amygdala, hippocampus

mesocortical pathway

• FALTERED:
• Fever
• Autonomic instability
• Leukicytosis
• Tremor
• Elevated CPK
• Rigidity (lead pipe)
• Excessive sweating
• Delerium

• hours to days - acute dystonia
• days to months - EPS/akathisia
• months to years - tardive dyskinesia

• great in refractory schizo, only antipsychotic shown to decrease risk of suicide
• tachycardia, hypersalivation
• more anticholinergic side effects than atypicals or high potency typical
• can develop myocarditis
• agranulocytosis - must stop if absolute neutrophil count drops below 1500

• can increase prolactin
• orthostatic hypotension and reflex tachycardia

sedation and orthostatic hypotension

weight gain

• Unique mechanism of partial D2 agonism
• less potential for weight gain
• more activating and less sedating

• metabolic syndrome
• weight gain
• hyperlipidemia
• hyperglycemia
• liver function
• QTc prolongation

• metabolized by kidney
• Prior to initiating, do ECG, basic chemistry, thyroid function tests, CBC, pregnancy test
• onset of action 5-7 days

• NSAIDS (decrease)
• Aspirin
• Dehydration (increase)
• Salt deprivation (increase)
• Sweating - salt loss (increase)
• Impaired renal function (increase)
• Diuretics, esp thiazides

• anticonvulsant
• tx mixed episodes and rapid-cycline bipolar disorder (less for depressed phase)
• tx trigeminal neuralgia
• acts by blocking Na channels and inhibiting action potentials
• Onset of action 5-7 days
• Must do CBC and LFTs before treatment, monitor regularly - leukocytosis esp dangerous if given with other meds that lower WBC (clozapine)
• Side effects - GI, sedation, ataxia, Steven-Johnson syndrome, leukopenia, hyponatremia, aplastic anemia, agranulocytosis, elevation of liver enzymes causing hepatitis, TERATOGENIC (neural tube defects)
• Autoinduction of CYP450

• tx mixed and rapid-cycling bipolar
• Must montor LFTs and CBC
• Levels checked after 3-5 days (normal 50-150)
• Side effects: GI, weight gain, sedation, alopecia, pancreatitis, hepatotoxicity, increased ammonia, thrombocytopenia, teratogenic (neural tube)

• tx bipolar depression (not mania)
• works on Na channels that modulate glutamate and aspartate
• May cause Stevens-Johnson syndrome by 4-6 weeks

Note: Valproate will increase lamotrigine levels, and lamotrigine with decrease valproate levels

mood stabalizer like carbamasepine, but less risk of rash and hepatotoxicity

often used adjunctively to help with anxiety and sleep

• tx impulse control disorder and anxiety
• weight loss, hypochloremic non-anion gap metabolic acidosis, kidney stones, cognitive slowing

• LOT:
• Lorazepam
• Oxazepam
• Temazepam

• Valium
• Rapid onset, long acting
• used for detox

• tx anxiety, panic attacks
• long acting
• avoid with renal dysfunction

• Xanax
• tx anxiety, panic attacks
• shot onset of action causes euphoria, high abuse potential

• Ativan
• tx panic attacks, detox, agitation

• Restoril
• tx insomnia

• short acting
• tx insomnia, medical and surgical settings

flumazenil (must be done slowly so withdrawal isn't too quick)

• Versed
• used in medical and surgical settings

• non-benzo hypnotics
• selective receptor binding to bendo receptor 1, which is responsible for sedation

• non-benzzo hypnotic
• selective melatonin MT1 and MT2 agonist

• partial agonist of 5HT-1A receptor
• takes 1-2 weeks for effect
• tx anxiety when combined with SSRI, useful in alcoholics bc doesn't potentiate CNS depression of alcohol

tx autonomic effects of panic attacks or performanch anxiety, or to tx akathisia from typical antipsychotics

• sympathomimetics
• analgesics
• antibiotics (isoniazid)
• anticholinergis
• anticonvulsants
• antihistamines
• corticosteroids
• anti-parkinsonian meds
• esp: isoniazid, cimetidine, steroids

• antipsychotics
• antidepressants
• antiarrhythmics
• antineoplastics
• corticosteroids
• cardiac glycosides
• esp: procainamide, quinidine, albuterol
• NSAIDs
• antiasthmatics
• antibiotics
• antihypertensives
• antiparkinsonian mends
• thyroid hormones
• esp: albuterol, quinidine, procainamide, steroids

• antihypertensives
• antiparkinsonian agents
• corticosteroids
• Ca channel blockers
• NSAIDs
• antibiotics
• peptic ulcer drugs
• esp: tetracycline, nifedipine, verapamil, cimetidine

• sympathomimetics
• antiasthmatics
• antiparkosonian meds
• hypoglycemic
• NSAIDs
• thyroid hormones
• esp: albuterol, steroids

• Parkonsonian - masklike face, cog-wheel rigidity, pill-rolling tremor
• akathisia - restlessness and agitation
• dystonia - sustained contraction of muscles of neck, tongue, eyes, diaphragm
• Occur with high potency typical antipsychotics
• tx: benztropine

• Cardiotoxicity
• Convulsions
• Coma