Psychotropic Medications Archana Jhawar, PharmD, BCPP Clinical Faculty of UIC Pharmacy Practice Clinical Psychiatric Pharmacist Jesse Brown VA

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1 Psychotropic Medications Archana Jhawar, PharmD, BCPP Clinical Faculty of UIC Pharmacy Practice Clinical Psychiatric Pharmacist Jesse Brown VA Goals of Medications Use least number at lowest dose to get desire response Balance risks vs. benefits Incorporate patient autonomy and goals as possible Ensure appropriate education around medications Depressive Disorder 1

2 Antidepressant Overview Avoid abruptly stopping Take 4 12 weeks for full onset Equally effective Government Warning (aka Black Box Warning) Increased Risk of Suicidal Thoughts and Behaviors Studies show increased risk in those < 18 years of age Labeling specifies individuals less than 24 years of age Can apply to anyone Selective Serotonin Reuptake Inhibitors (SSRI) Names Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) Things to Know Treat depression and anxiety Most common class of antidepressants Little monitoring needed Rare risk: Serotonin Syndrome Side Effects of SSRI Common Sleep Changes Upset stomach Headache Sexual Dysfunction Jitteriness Serotonin Withdrawal: Insomnia, irritable, headache, nausea, brain zaps Specifics Citalopram: Heart complications Sertraline: more stomach upset Paroxetine: Dry mouth, constipation, withdrawal, increased appetite, sedation Fluoxetine: insomnia, decrease appetite, no withdrawal 2

3 Serotonin and Norepinephrine Reuptake Inhibitor (SNRI) Names Venlafaxine (Effexor) Duloxetine (Cymbalta) Desvenlafaxine (Pristiq) Levomilnacipran (Fetzima) Things to Know Can be used for Depression Anxiety Pain (nerve pain) Serotonin withdrawal Rare: Serotonin Syndrome Side Effects of SNRI Common Sleep Changes (decreased sleep) Upset stomach Headache Sexual Dysfunction Jitteriness Can increase blood pressure Sweating Specifics Duloxetine: check liver function, can be used for muscle and nerve pain Venlafaxine: watch for withdrawal and upset stomach Other Common Antidepressants Mirtazapine (Remeron) Well tolerated, few side effects May increase falls Low dose use for: Insomnia To increase appetite Bupropion (Wellbutrin) Used for smoking cessation Can be used for ADHD Very activating increased energy Insomnia Irritable Increased risk of seizures!! 3

4 Tricyclic Antidepressants (TCA) Names Amitriptyline (Elavil) Desipramine (Norpramin) Doxepin (Sinequin, Silenor) Imipramine (Tofranil) Nortriptyline (Pamelor) Protriptyline (Vivactil) Things to Know Can be used for: Depression Anxiety Sleep Pain Poorly tolerated Significant risk of overdose TCA Side Effects Common Sedation Constipation Dry Mouth Dizziness upon standing Increased appetite Sexual dysfunction Rare or Serious Changes in EKG Increased risk of seizure High risk in overdose Monoamine Oxidase Inhibitors (MAOIs) Name Selegiline (Emsam Patch) Tranylcypromine (Parnate) Phenelzine (Nardil) Things to Know Numerous Drug Interactions Cough and cold (pseudoephedrine, chlorpheniramine, phenylephrine, dextromethorphan) Herbals/supplements Selegiline: Watch for application site reactions. 4

5 MAOI Reactions Common Side Effects Sleep Changes (drowsiness) Dry Mouth Upset stomach Constipation Dizziness/lightheaded Sexual dysfunction Cardiac complications Headache Specifics Very rarely used Strict dietary restrictions Difficult to tolerate Can cause: Hypertensive crisis Serotonin syndrome Add on Medications for Depression Antipsychotics Aripiprazole (Abilify) Quetiapine (Seroquel) Brexipiprazole Olanzapine/fluoxetine Lithium Liothyronine Stimulants Anxiety Disorders 5

6 Anxiolytics Antidepressants are very effective and should be used first SSRIs and TCAs especially effective Venlafaxine and Duloxetine are effective Bupropion is generally not effective Benzodiazepines are well known but associated with risks Cognitive behavioral therapy is very effective Benzodiazepines Names Names Alprazolam (Xanax) Diazepam (Valium) Clonazepam (Klonopin) Lorazepam (Ativan) Temazepam (Restoril) Triazolam (Halcion) Oxazepam (Serax) Side Effects Sedation Memory impairment Gait impairment Decreased inhibition Paradoxical: irritability, agitated Benzodiazepines: Things to Know Used for Anxiety/panic Sleep/Sedative Alcohol withdrawal Addictive properties Tolerance Withdrawal Respiratory depression Used with opioids Breathing conditions (COPD, OSA) Effective and fast Use scheduled or as needed Exacerbate/prolong delirium Increased risk of falls (elderly) 6

7 Buspirone (Buspar) Pros Mild side effects (sedation, headache, upset stomach) No addictive potential Cons Only used for treatment of anxiety Must be taken two to three times daily 4 6 weeks before see effect Unclear benefit and effectiveness Other Options Hydroxyzine (Atarax or Vistaril) Can be used in place of benzodiazepines in those with addiction May be used scheduled or as needed In elderly, may increase risk of falls Side Effects: drowsiness, dry mouth Propranolol (Inderal) A blood pressure medication Increased risk of falls May help anxiety/agitation Side effects: dizziness, fatigue Psychotic Disorders 7

8 Antipsychotics Black Box Warning in Dementia: Increased risk of all cause mortality Increased risk of pneumonia, blood clots, and cerebrovascular events Atypical Antipsychotics used more commonly Can be used for a variety of indications: As needed for agitation Psychotic disorders Bipolar Disorder (specific ones) Add on for Depression (specific ones) First Generation aka Typical Antipsychotics Names Haloperidol (Haldol) Fluphenazine (Prolixin) Chlorpromazine (Thorazine) Trifluoperazine (Stelazine) Perphenazine (Trilafon) Thiothixene (Navane) Things to Know Long Acting Injectable Form: Haloperidol Fluphenazine Short Acting Injectable: Haloperidol Fluphenazine Chlorpromazine Second Generation aka Atypical Antipsychotic Names Aripiprazole (Abilify) 1,3 Asenapine (Saphris) 1 Brexipiprazole (Rexulti) 3 Cariprazine (Vraylar) 1 Clozapine (Clozaril) Iloperidone (Fanapt) Lurasidone (Latuda) 2 Olanzapine (Zyprexa) 1,2,3 Paliperidone (Invega) Quetiapine (Seroquel) 1,2,3 Risperidone (Risperdal) 1 Ziprasidone (Geodon) 1 Key for additional indications 1: bipolar mania 2: bipolar depression 3: add on for depression 8

9 Second Generation aka Atypical Antipsychotic Things to Know Long Acting Injectable Risperidone Aripiprazole Paliperidone Olanzapine* Orally Disintegrating Aripiprazole Clozapine Olanzapine Risperidone Short Acting Injectable Olanzapine Ziprasidone Dissolve Under Tongue Asenapine Antipsychotic Side Effects First and Second Generation Drowsiness Dizziness Dry mouth/constipation Movement Disorders Pacing Shuffling steps Rigid muscles Specifics First Generation Lack of motivation Lack of emotion Second Generation Increased appetite Increased triglycerides Increased blood sugars Clozapine For treatment resistant psychosis Extensive government requirements, monitoring, and exclusions Requires very strict monitoring of blood levels Must be willing to get weekly labs x 6 months, biweekly x 6 months, monthly Difficult to tolerate Severe constipation Dry mouth Increased appetite May not use if: certain blood disorders or heart conditions, seizures, prone to fainting Drug Interactions (smoking, benzodiazepines) 9

10 Mood Stabilizer Medications Mood Stabilizers Used for bipolar disorder Bipolar Depression Lithium Lamotrigine Quetiapine, lurasidone, olanzapine/fluoxetine ***Avoid antidepressants Bipolar Mania Lithium Valproic acid/divalproex Carbamazepine Risperidone, aripiprazole, ziprasidone, quetiapine, olanzapine, asenapine, cariprazine Lithium Used for bipolar mania and bipolar depression Can be toxic if not monitored closely Elderly patients likely need lower doses Interactions with Sodium (table salt) NSAIDs (ibuprofen, naproxen, advil, aleve, motrin) Blood pressure medications Monitoring: Lithium level ( ), kidney, thyroid, pregnancy, heart (EKG), white blood cells 10

11 Lithium, continued Side Effects Sedation Increased appetite Tremor Upset stomach Worsening acne/eczema Low thyroid levels Increased thirst/urination Toxicity Worsening of all side effects Confusion Muscle spasms Slurred speech Delirium, seizures, coma, death Valproic Acid, Divalproex (Depakote) Helpful for Bipolar mania Aggression, impulsivity, irritability Can try in dementia with aggression or inappropriate behaviors Labs Liver Function Level (50 125) Platelets Pregnancy Rare: ammonia Valproic Acid, Divalproex (Depakote), continued Side Effects Sedation Dizziness Increased appetite Upset stomach Tremor Balding Black Box Warning Hepatitis Pancreatitis Pregnancy 11

12 Lamotrigine (Lamictal) Used for bipolar depression Lots of drug interactions Strict titration schedule Compliance is a MUST 3 5 days without meds, restart titration Side Effects: Drowsy/dizzy Headache Upset stomach Blurred or double vision Black Box Warning: Rash Can be benign/harmless or life threatening If patient develops, go to ER immediately to evaluate Carbamazepine (Tegretol) Not used as commonly because harder to tolerate Side Effects Dry mouth, constipation Dizziness Sedation Increased appetite Dangerous decreases in sodium Life threatening rashes Alter blood levels (white blood cells, red blood cells) Lots of drug interactions Sleep Medications 12

13 Sleep Medications, continued Antidepressants Trazodone Low dose mirtazapine Doxepin Over the Counter Diphenhydramine (Benadryl) Doxylamine (Unisom) Herbals Melatonin (safe) Valerian (not safe) Benzodiazepines Triazolam (Halcion) Temazepam (Restoril) Z hypnotics Zolpidem (Ambien) Eszopiclone (Lunesta) Zaleplon (Sonata) *Caution with unusual nighttime behaviors Sleep Hygiene Questions? 13