Antipsychotic& antidepressant Drugs

Antidepressants r classified as the following:

Selective serotonin reuptake inhibitors (SSRis)

Citalopram ( Celexa)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)

Serotonin norepinephrine reuptake inhibitors (SNRis)

Duloxetine (Cymba Ita)
Venlafaxine (Effexor. Effexor XR)
Desvenlafaxine (Pristiq)

Tricyclic and heterocyclic antidepressants (TCAs)

Amitriptyline (Eiavil)
Clomipramine (Anafranil)
Doxepin (Sinequan)
Nortriptyline (Pamelor)

Monoamine oxidase inhibitors (MAOis)

Phenelzine (Nardil)
Tranylcypromine (Parnate)

Other or atypical antidepressants

Bupropion (Wellbutrin)
Mirtazapine (Remeron)
Trazodone (Desyrel)

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Antipsychotics are classified as typical and atypical.

Typical :
haloperidol
chlorpromazine
fluphenazine

Atypical :
oral aripiprazole
asenapine
iloperidone
olanzapine
paliperidone

quetiapine
risperidone
ziprasidone.
Antipsychotic medications (e.g. risperidone) cause dopamine blockade
and since dopamine is a prolactin-inhibiting factor, the blockade of dopamine
can lead to hyperprolactinemia and symptoms such as gynecomastia
,galactorrhea, menstrual dysfunction, and decreased libido.
Prolactinomas tend to produce very high levels of prolactin (>200
ng/mL).

Extrapyramidal symptoms (EPS) frequently occur as side effects of typical

antipsychotics but can occasionally occur with atypical antipsychotics.
Risperidone the most likely atypical antipsychotic to cause EPS.
Clozapine is the least likely atypical antipsychotic to cause EPS
but is considered to be a medication of last resort because it can cause
agranulocytosis.
(TD)is best managed by:
replacing risperidone with clozapine.
A complete blood count should be done before starting clozapine and throughout
treatment to monitor for possible agranulocytosis.
Depot antipsychotics (e.g., fluphenazine, risperidone, paliperidone, and
haloperidol) are the treatment of choice for :
schizophrenic patients who suffer relapses due to treatment noncompliance
with oral medications
Atypical antipsychotics ( eg, quetiapine) other than clozapine are
considered first-line treatment for: psychosis secondary to schizophrenia
or bipolar disorder due to the lower risk of extrapyramidal side effects
in comparison to typical antipsychotics.
Side effects
Chlorpromazine: jaundice. although this is not due to hemolysis.
thioridazine: Pigmentary retinopathy
quetiapine : Cataracts


1.
2.
3.

Treatment of acute dystonia:

antihistamines (e.g. diphenhydramine)
anticholinergics (e.g. benztropine or trihexyphenidyl).
Beta-blockers such as propranolol can be used to treat akathisia.

Levodopa is a treatment for Parkinson's disease

haloperidol should be given immediately in case of agitation because of its
acute onset of action

Olanzapine
Olanzapine is an atypical antipsychotic medication often used to treat
schizophrenia, bipolar disorder, or agitation.
Although all atypical antipsychotics have a lower risk of extrapyramidal side
effects, they are all associated with :
an increased risk of weight gain
hyperglycemia
dyslipidemia
hypertension.
Clozapine and olanzapine appear to pose the greatest risk of weight gain.
Due to these potential side effects, the American Psychiatric Association
recommends :
baseline assessment of weight
fasting plasma glucose
blood pressure
fasting lipid profile before starting atypical antipsychotics.
In addition, these parameters should be reassessed after 12 weeks of
treatment in all patients taking these medications.
Diabetes mellitus is a concerning side effect of olanzapine, as is
dyslipidemia.
It is not observed as often as weight gain or obesity.
Extrapyramidal side effects are unusual in patients taking atypical
antipsychotics. Therefore, dystonia is not a common side effect of olanzapine.

Postural hypotension does occur as an occasional side effect of olanzapine, but

it is not as common as weight gain.

Although there have been rare reports of olanzapine causing agranulocytosis,

complete blood counts (CBC) are not routinely checked.
Patients taking clozapine, however, require weekly blood counts for the first
six months of treatment.
An electrocardiogram (ECG) does not need to be obtained when starting a
patient on olanzapine.
However, it may be appropriate to obtain an ECG in patients taking the atypical
antipsychotic ziprasidone due to its potential for causing QT prolongation.
Olanzapine can lead to an increase in liver transaminase levels, but routine
monitoring of liver function tests is not necessary.
Hyperprolactinemia can occur when using typical antipsychotics as well as the
atypical antipsychotic risperidone.
Olanzapine, however, is not well known to increase prolactin levels.
Lithium, not olanzapine, may cause hypothyroidism, and requires routine
monitoring of thyroid function.
Contraindications to clozapine:
Myeloproliferative disorders
Uncontrolled epilepsy
History of clozapine-induced agranulocytosis or severe granulocytopenia
Severe central nervous system depression

Methylphenidate
mild CNS stimulant commonly used to treat attention deficit hyperactivity
disorder (ADHD),
Common side effects:
Nervousness
loss of appetite
nausea
abdominal pain
insomnia
tachycardia.

Prolonged therapy has been shown to cause mild growth retardation or weight
loss.
Methylphenidate should not be used in children younger than 6 years old
because safety and efficacy in this age group have not been evaluated.

SSRIs
SSRis such as fluoxetine are the first-line treatment for depression and
may take 4-6 weeks before a beneficial effect is noticed.
If his symptoms have not improved within 4-6 weeks, the antidepressant
dosage should be increased.
Abrupt cessation of antidepressant therapy before six months have
passed would put the patient at high risk for relapsing
a dose reduction in SSRI is not warranted unless the nausea is very
severe or incapacitating.
SSRI medications are generally considered the first-line treatment for patients
with moderate-to-severe depression.
If there is no improvement and/or side effects:
Treatment guidelines recommend switching to a different medication in
same class
If there is no improvement and/or side effects after 2 trials. switching
to a different class of antidepressants is indicated.
When treating a single episode of major depression, the antidepressant
should be continued for a period of six months following the patient's
response.
SSRis are the best option in patients with a longer life expectancy.
For patients with a shorter life expectancy:Psychostimulants
(eg. methylphenidate. modafinil) may be the more appropriate
treatment as SSRis usually take longer to reach full therapeutic
effect.
Important side effects of SSRis :
anorexia
sexual dysfunction ( eg. decreased libido. delayed/retrograde ejaculation.
Erectile dysfunction).
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Buspirone is not considered an antidepressant. It is used to treat generalized

anxiety disorder. not depression
Phenelzine. an MAOI. is rarely used for the treatment of depression due
primarily to dietary restrictions associated with MAOI use and the development
of newer alternate medications.
Risperidone is an atypical antipsychotic and is not used for the treatment of
depression.
Trazodone has antidepressant properties and sedation as a side effect.,It is
used primarily for the treatment of insomnia related to depression.,Priapism is
another potential side effect.
Tricyclic antidepressants (TCAs) such as amitriptyline are less appealing for the
treatment of depression because they frequently cause unwanted side effects.
TCAs are most often used when SSRis are deemed inappropriate or ineffective.

Bupropion
Bupropion is an antidepressant that produces its effects primarily through the
inhibition of the re-uptake of norepinephrine. dopamine. and serotonin.
used for the treatment of generalized anxiety disorder.
It does not cause the sexual dysfunction.
making it a good choice for young patients or those who are particularly
concerned about sexual side effects.

imp
side effect of bupropion is:
(decreased seizure threshold)which is usually seen at higher doses.
This medication should therefore be avoided in patients with seizure disorders
or conditions that predispose to seizures
( eg. concurrent alcohol or benzodiazepine use. eating disorders).
Individuals with anorexia nervosa or bulimia nervosa frequently develop
electrolyte abnormalities that can precipitate seizures.
Therefore. a history of anorexia nervosa/bulimia is a contraindication to
bupropion usage.
Although heart failure can result from an overdose with bupropion. the
presence of ischemic heart disease is not an absolute contraindication to its
use. However, dose adjustment would be advisable

TCA
TCAs are not recommended as first-line treatment for depression
Mirtazapine is a tetracyclic antidepressant that also has anxiolytic and appetite
stimulating Properties
Imipramine is an effective tricyclic antidepressant, although medications in this
class are not considered first-line agents.
Amitriptyline is a TCA that can be lethal in overdose.
The tricyclic antidepressant, amitriptyline. has been used for conditions other
than depression. such as diabetic neuropathy and prevention of migraine
headaches.

Seizures
alprazolam (Xanax). a short-acting benzodiazepine. is the most likely to result
in seizures following abrupt discontinuation.
.Lamotrigine is an anticonvulsant used in the treatment of bipolar disorder.
Missing doses could result in seizures in a patient with an underlying seizure
disorder.
Quetiapine is an atypical antipsychotic with abuse potential but is not readily
associated with risk of seizure following abrupt discontinuation.
Anticonvulsive medications such as carbamazepine and valproate are mood
stabilizers known to cause craniofacial defects, neural tube defects, and genital
anomalies in the unborn child.

TTT
Neuroleptic malignant syndrome (NMS).
dantrolene sodium (which is a direct muscle relaxant):
amantadine. and/or the dopamine agonist bromocriptine.

Tourette syndrome :
Individuals with severe, uncontrolled symptoms are best treated with the
traditional antipsychotics such as haloperidol or pimozide.

ADHD: Methylphenidate
extrapyramidal side effects of antipsychotics ( eg, dystonia, tardive
dyskinesia).: Benztropine
specific phobia:
The first-line treatment for specific phobia is cognitive behavioral therapy
( CBT).
Medication is considered second-line treatment for specific phobias.
If medication isneeded.: BB,SSRI

Narcolepsy:
Psychostimulants such as modafinil or methylphenidate are effective in reducing
the episodes of daytime somnolence.
while a combination of antidepressants and psychostimulants helps to decrease
cataplexy.
circadian rhythm sleep disorder. nightmare disorder. sleep terror disorder.
and sleepwalking disorder:Benzodiazepines
Bereaved patients who have at least 2 weeks of symptoms of depression 6-8
weeks after a major loss should be considered for treatment with:
both psychotherapy and a trial of antidepressants.

bipolar disorder
First-line pharmacologic treatment for bipolar disorder includes the following:
1 . Atypical antipsychotics ( eg, risperidone, aripiprazole, olanzapine)
2. Lithium
3. Valproic acid
4. Lamotrigine
Monotherapy with atypical antipsychotics is preferred for mild to moderately ill
patients. Monotherapy with lithium or valproic acid can be used as alternate
therapy.
For more severe episodes, combination therapy with lithium or valproate plus
atypical antipsychotics is usually preferred over monotherapy.
Combination therapy (compared to lithium or valproate monotherapy) has a more
rapid onset of action.

 For a bipolar patient on lithium, maintenance therapy should be continued

for at least one year following an acute episode.
If there are no relapses and the patient has attained good symptomatic
control, then the lithium can be gradually tapered off and ultimately
discontinued.
Because abrupt cessation of lithium increases the risk of suicide and relapse,
tapering the medication is always recommended.
The following guidelines apply to lithium therapy in patients with bipolar
1) single manic episodes require long-term maintenance for a period of at least
one year;
2) three or more relapses require treatment with lifelong maintenance therapy.
The therapeutic effects of lithium carbonate are attributed to its ability to
inhibit inositol-1-phosphatase in neurons.
Because the margin of safety for lithium is very low, frequent monitoring is
required to avoid toxicity.
The potential adverse effects associated with lithium usage include:
gastrointestinal distress (e.g. nausea. vomiting, diarrhea, or abdominal
pain).
nephrotoxicity (resulting in polyuria and polydipsia, ultimately leading to
nephrogenic diabetes insipidus).
hypothyroidism.
leukocytosis.
tremors.
acne.
psoriasis flares.
hair loss.
edema.
teratogen that is associated with Ebstein's anomaly (a cardiac defect).
This condition is characterized by a malformed and inferiorly attached tricuspid
valve that causes atrialization of the right ventricle and a decrease in the size
of the functional right ventricle.
In a young woman.
it is therefore important to evaluate thyroid function. renal function. and
human chorionic gonadotropin levels before prescribing lithium.
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 A selective serotonin re-uptake inhibitor antidepressant such as

fluoxetine or bupropion
could aggravate manic symptoms in this patient and is therefore inappropriate

Prophylactic propranolol is effective in the treatment of performance-related

anxiety but is not used in the treatment of GAD.

(ECT)
Indications:
severe depression
depression in pregnancy
refractory mania
neuroleptic malignant syndrome
catatonic schizophrenia.
One of the most common side effects of ECT:
Amnesia, which can either be anterograde or retrograde.
Anterograde amnesia tends to resolve rapidly, while retrograde amnesia may
persist for a longer period.
Other adverse effects : include prolonged seizures, delirium, headache, nausea,
or skin burns.

Alzheimer's dementia:
The cholinesterase inhibitors:
donepezil (Aricept)
galantamine (Razadyne)
galantamine ER (Razadyne ER)
rivastigmine (Exelon) (mild-to-moderate dementia. )
Donepezil is approved for all stages of Alzheimer's dementia.
Memantine, an N-methyl-0-aspartate receptor antagonist,(moderate-tosevere dementia.)
Amantadine is a dopamine agonist used in the treatment of Parkinson's disease.
It has been shown to delay the onset and minimize the severity of dementia in
patients with Parkinson's disease.
However, the utility of amantadine in Alzheimer's patients is quite limited

Enuresis
1. When behaviour modification is unsuccessful.
2. desmopressin. the antidiuretic hormone analogue. can be tried.

The exact mechanism of action of desmopressin in nocturnal enuresis is

unclear.
3. Tricyclic antidepressants such as imipramine are second-line agents.

OCD
Cognitive behavioral therapy can be beneficial for these patients.
Medications that are FDA-approved first-line treatments for OCD include the
following:
Clomipramine (Anafranil)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft).