Psych Drugs Info Sheet

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Table 1. Selective SerotoninReuptake Inhibitors (SSRIs):Overview

Efficacy First-line treatment in

MDD (FDA approved for all exceptfluvoxamine), dysthymia

PD (FDA approved for fluoxetine, paroxetine,and sertraline)

OCD (FDA approved for all except citalopramand escitalopram)

Social anxiety disorder (FDA approved forsertraline and paroxetine)

PTSD (FDA approved for sertraline and

paroxetine)Bulimia (FDA approved for fluoxetine)

GAD (FDA approved for paroxetine andescitalopram)

PMDD (FDA approved for fluoxetine [Sarafemonly], paroxetine [controlled release only],and sertraline)

Side effects GI side effects (nausea, diarrhea, heartburn)

Sexual dysfunction (2 libido, delayedorgasm)

Headache

Insomnia/somnolence

Safety inoverdose

Generally safe in overdose to 30–90 days’supply; manage with vital sign support,lavage

Seizures/status epilepticus (rare)

Dosage andadministration

Citalopram, paroxetine, fluoxetine: qd dosing,starting at 10–20 mg, increasing to amaximum of 40 mg (citalopram), 50 mg(paroxetine), and 80 mg (fluoxetine).

Escitalopram: qd dosing, starting at 10 mg,increasing to 20 mg after minimum of 1week.

Sertraline: starts at 25–50 mg and isincreased, as needed, to 200 mgmaximum.

Full benefits in 4–8 weeks

Discontinuation Paroxetine, fluvoxamine, sertraline:discontinuation associated withparasthesias, nausea, headaches, flulikesymptoms 1–7 days after suddendiscontinuation

Drug interactions MAOI (contraindicated): serotonin syndrome

1 TCA levels (paroxetine, fluoxetine)

1 Carbamazepine, phenobarbital, phenytoinlevels

1 Haloperidol, clozapine levels (fluvoxamine)

1 Theophylline levels (fluvoxamine)

1 Encainide, flecainide levels (avoid)

Note. FDA U.S. Food and Drug Administration; GAD gener-alized anxiety disorder; GI gastrointestinal; MDD majordepressive disorder; MAOI monoamine oxidase inhibitor; OCD obsessive-compulsive disorder; PMDD premenstrual dys-phoric disorder; PD panic disorder; PTSD posttraumaticstress disorder; TCA tricyclic antidepressant.

Table 2. Tricyclic Antidepressants (TCAs):OverviewEfficacy Second- or third-line agents for MDD (FDA

approved for all)

Panic disorder

OCD (FDA approved for clomipramine)

Pain syndromes

Migraine prophylaxis

Enuresis (FDA approved for imipramine)

Side effects Dry mouth, constipation, urinary retention, blurredvision, confusion

Weight gain

Sedation

Sexual dysfunction

Orthostasis

Tachycardia

Cardiac conduction abnormalities


Individualize with low hs dosing (25–50 mg) forimipramine and amitriptyline. Increase by 25–50 mg every 3–7 days to target dosage of150–300 mg/day. (Nortriptyline should bestarted at 10–25 mg and increased, as needed,to a maximum dosage of 150 mg/day.) Monitorlevels and ECGs after dose stabilized.

Safety inoverdose

Lethal in overdose (induces arrhythmias).

Lavage and monitor on a cardiac bed for QRSwidening.

Discontinuation Flulike and gastrointestinal symptoms fromcholinergic rebound. Reduce by 25–50 mgevery 3 days.

Druginteractions

CNS depressants: 1 sedation, ataxia

Anticoagulants: 1 warfarin levels

Antipsychotics: 1 TCA and antipsychotic levels

Cimetidine: 1 TCA levels

Clonidine: hypertensive crisis (avoid)

L-Dopa: TCAs 2 absorption

MAOIs: serotonin syndrome (avoid clomipramine;imipramine and amitriptyline may be used withclose monitoring)

Stimulants: 1 TCA levels

Oral contraceptives: 1 TCA levels

Quinidine: 1 arrhythmias (avoid)

SSRIs: 1 TCA levels

Sympathomimetics:1 arrhythmias, hypertension,tachycardia

Note. CNS central nervous system; ECG electrocardiogram;FDA U.S. Food and Drug Administration; GI gastrointesti-nal; MDD major depressive disorder; MAOI monoamineoxidase inhibitor; OCD obsessive-compulsive disorder; SSRI selective serotonin reuptake inhibitor.

The tables in this section are from Schatzberg AF, Cole JO, DeBattista C. Manual of Clinical Psychopharma-cology Fifth edition. 2005 American Psychiatric Pub-lishing Inc., Arlington, VA

Reprinted with permission.

QuickReferenceF O R P S Y C H O P H A R M A C O L O G Y

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Table 3. Monoamine OxidaseInhibitors (MAOIs): Overview

Efficacy Third-line agents for

MDD (FDA approved for resistant depression)

Social anxiety

Panic disorder

Second-line agents for Parkinson’s disease (selegiline

has FDA approval)Side effects Weight gain

Orthostasis

Sexual dysfunction

Dry mouth

Insomnia/somnolence

Headache

Safety inoverdose

Lethal in overdose. Hypertensive crisis, stroke, andmyocardial infarction have been reported. Managewith lavage, emesis induction, and close managementof blood pressure and airway.


Phenelzine: start at 15 mg bid or tid and increase by 15mg per week to target dosage of 60–90 mg/day.

Tranylcypromine: start at 10 mg bid or tid and increaseby 10 mg per week to target dosage of 40–60 mg/

day.

Isocarboxazid: Start at 10 mg bid and increase dosage,if the drug is tolerated, by 10 mg every 2–4 days to40 mg/day by end of first week. Maximumrecommended dosage is 60 mg/day, administered individed doses.

Selegiline transdermal system (Emsam)

Discontinuation Flulike symptoms, hallucinations, hypomania, anddysphoria reported with sudden dis-continuation.Taper dose by 25% per week.

Druginteractions

Foods containing high levels of tyramine(contraindicated) (see Table 3–14): hypertensive crisis

-Blockers: 1 hypotension, bradycardia

Oral hypoglycemics: 1 hypoglycemic effects

Bupropion (contraindicated): hypertensive crisis, seizure

Carbamazepine (contraindicated): hypertensive crisisMeperidine (contraindicated): serotonin syndrome

Nefazodone: possible serotonin syndrome

Sympathomimetics: hypertensive crisis

SSRIs (contraindicated): serotonin syndrome

TCAs: clomipramine contraindicated

Note. FDA U.S. Food and Drug Administration; MDD majordepressive disorder; SSRI selective serotonin reuptake inhibi-tor; TCA tricyclic antidepressant.

Table 4. Atypical (Dopamine-Serotonin Antagonist)

Antipsychotics: OverviewEfficacy Schizophrenia (FDA approved for all)

Treatment-resistant schizophrenia (clozapine)

Mania (FDA approved for olanzapine)

Depression/anxiety/agitation (efficacy established but

not FDA approved for these purposes)Side effects Weight gain

Insulin resistance

Sedation

Akathisia

Orthostatic hypertension

Dizziness

1 Triglycerides

EPS, NMS (rare)

Agranulocytosis (clozapine) (rare)

Seizures (clozapine)

Safety inoverdose

Seizures with clozapine in overdose. Respiratorydepression in combination with other CNSdepressants. QT interval changes. Lavage and vitalsign support.


Clozapine: 12.5–25 mg; then increase dosage 25–50mg per week, as needed and tolerated, to 300–600mg/day

Risperidone: 0.5–1 mg bid to 3 mg bid by end of firstweek, as tolerated

Olanzapine: 2.5–5 mg hs; increase by 5 mg everyweek to 20 mg hs

Quetiapine: 25 mg bid; increase total daily dose by 50mg, as needed and tolerated, to 300–600 mg/day

Ziprasidone: 20 mg qd or bid; increase by 20–40 mgper week, to a maximum dosage of 80 mg bid

Aripiprazole: 15 mg qd; increase up to 30 mg/day after1 week

Full benefits in 4 weeks to 6 months

Discontinuation Mild cholinergic rebound, faster relapse.

Taper as slowly as titrated up.

Druginteractions

Fluvoxamine (1A2 inhibitor): 1 atypical antipsychoticlevels

EtOH: 1 sedation and orthostasis

Antihypertensives: may1 orthostasis

Carbamazepine:2 serum levels of olanzapine;contraindicated with clozapine

CNS depressants: 1 sedation

Ciprofloxacin (Cipro) (potent 1A2 inhibitor): 1 atypicalantipsychotic levels

Note. CNS central nervous system; EPS extrapyramidalsymptoms; EtOH ethanol; FDA U.S. Food and Drug Admin-istration; NMS neuroleptic malignant syndrome.

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Table 5. Typical (D2 Antagonist) Antipsychotics: OverviewEfficacy Schizophrenia (positive symptoms) (FDA-approved

indication)

Tourette’s disorder (pimozide; FDA-approvedindication)

Mania (FDA-approved indication for chlorpromazineonly)

Psychotic depression (with antidepressant)

Drug-induced psychosis

Agitation,a nausea, hiccups (non–FDA approved forthese purposes; off-label)

Side effects EPS (more common in high-potency drugs)

NMS (rare)

Dry mouth, constipation, urinary retention, sedation,weight gain (more common in low-potencydrugs)

QT interval prolongation (thioridazine)


Individualize dosing.

50–150 mg chlorpromazine equivalents (see Table4–2) to start, with maximum total daily dose of300–600 mg chlorpromazine equivalents (e.g.,

6–12 mg haloperidol).Safety in

overdoseCNS depression, hypotension, ECG changes, EPS.

Manage with vital sign support, gastric lavage.Do not induce emesis secondary to aspirationrisk.

Druginteractions

CNS depressants: 1 sedation

Antacids: 2 antipsychotic absorption

Carbamazepine: 2 antipsychotic levels

SSRIs: 1 antipsychotic levels

Nicotine: 2 antipsychotic levels

Meperidine: 1 sedation, hypotension

-Blockers: 1 hypotension; may 1 antipsychoticand -blocker levels

TCAs: may 1 antipsychotic and TCA levels

Valproic acid: chlorpromazine may1 valproic acidlevels

Note. CNS central nervous system; ECG electrocardiogram;EPS extrapyramidal symptoms; FDA U.S. Food and Drug

Administration; NMS neuroleptic malignant syndrome; SSRI selective serotonin reuptake inhibitor; TCA tricyclic antide-pressant.a Agitation associated with psychosis: FDA-approved indication forolanzapine im only.

Table 6. Lithium Therapy:Overview

Efficacy Bipolar mania and prophylaxis (FDA indicated)

Depression augmentation

Side effects Tremor

Polyuria

Polydipsia

Weight gain

Cognitive slowing

Hypothyroidism

2 Renal function

Safety inoverdose

Frequently lethal in blood levels above 3.0 mEq/L andtoxic above 1.5 mEq/L. Maintain fluid/electrolytebalance. Gastric lavage; mannitol diuresis vs.hemodialysis for higher blood levels.


Start at 300 mg bid or tid and increase total dailydose by up to 300 mg, as needed and tolerated, toblood level of 0.6–1.2 mEq/L for bipolar mania and0.4–0.8 mEq/L for augmentation.

Discontinuation Sudden discontinuation associated with1 risk ofrelapse. Taper over 3 months for bipolar mania iffeasible.

Druginteractions

Antipsychotics: may1 lithium toxicity

Bupropion: may 1 seizure risk

Carbamazepine: neurotoxicity (rare)

Diuretics: 1 lithium levels

Iodide salts: 1 hypothyroidism

Neuromuscular blockers: respiratory depression

NSAIDs: 1 lithium levels

SSRIs: serotonin syndrome (rare)

Theophylline: 2 lithium levels

Urinary alkalinizers: 2 lithium levels

Verapamil:1 or 2 lithium levels

Note. FDA U.S. Food and Drug Administration; NSAID non-steroidal anti-inflammatory drug; SSRI selective serotoninreuptake inhibitor.

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Editors note: since initial publication of tables reprinted from the Manual of Clinical Psychopharmacology,additional medications have FDA approval. Some of these recent indications include: clonazepam approvedfor panic disorder; risperidone, quetiapine, ziprasidone, and aripiprazole approved for acute mania. Olan-zepine-fluoxetine combination and quetiapine approved for bipolar depression. Lamotrigine approved forthe prevention of depression.

N O T E S

Table 7. Valproate Therapy:OverviewEfficacy Acute mania (FDA approved)

Bipolar prophylaxis (may be effective)

Mixed, rapid-cycling bipolar

Seizure disorders (FDA approved)

Side effects Weight gain

Sedation

GI upset

Safety inoverdose

Serious effects notable mostly at 20 times normalserum level. Symptoms include nausea,vomiting, CNS depression, and seizures.Manage with gastric lavage, forced emesis,and assisted ventilation.


Start at 15 mg/kg in divided doses, up to amaximum of 60 mg/kg. Achieve serum levelsof 50–100 g/mL.

Discontinuation Rapid discontinuation increases the risk of rapidrelapse in bipolar disorder. Otherwise,discontinuation symptoms are uncommon.

Druginteractions

Drugs that 1 valproate serum levels include:

cimetidine

erythromycin

phenothiazines

fluoxetine

aspirin

ibuprofen

Drugs that 2 valproate serum levels include:

rifampin

carbamazepine

phenobarbital

ethosuximide

Note. FDA U.S. Food and Drug Administration; GI gastrointestinal.

Table 8. Benzodiazepines (e.g.,Diazepam, Clonazepam,

Alprazolam): OverviewEfficacy Generalized anxiety (FDA approved)

Panic disorder (FDA approved for alprazolam)

Insomnia (FDA approved)

Seizure disorder (FDA approved for

clonazepam)Muscle relaxation

Anesthesia

Side effects Sedation

Lethargy

Dependence/Withdrawal

Safety inoverdose

Safe in overdose up to 30 times the normaldaily dose. Usual symptoms of overdoseinclude sedation, drowsiness, ataxia, andslurred speech. May result in respiratorydepression in combination with other CNSdepressants. Management includes gastriclavage, forced emesis, and assistedventilation.


Varies by benzodiazepine and indication; seeTable 6–1.

Discontinuation Taper by no more than 25% of total dose perweek after long-term administration.Withdrawal includes insomnia, agitation,anxiety, and, rarely, seizures.

Druginteractions

Additive CNS depression with ethanol,barbiturates, and other CNS depressants

Drugs that 1 triazolo-benzodiazepine levelsinclude: P450 3A4 inhibitors, ketoconazole,fluconazole, nefazodone

Drugs that 2 triazolo-benzodiazepine levelsinclude: carbamazepine

Note. FDA U.S. Food and Drug Administration.

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