Medications in Psychiatry

1. Antidepressants

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Examples:
  • Fluoxetine (Prozac)
  • Sertraline (Zoloft)
  • Citalopram (Celexa)
• Side Effects:
  • Common: Nausea, headache, sexual dysfunction, insomnia, dry mouth
  • Less Common: Diarrhea, increased sweating, nervousness, dizziness
• Toxicity:
  • Symptoms: Serotonin syndrome (agitation, confusion, rapid heart rate, high blood pressure, dilated pupils, muscle rigidity)
  • Management: Discontinue SSRI, supportive care, serotonin antagonists (e.g., cyproheptadine)
• Contraindications:
  • Concurrent use with MAOIs (risk of serotonin syndrome)
  • Hypersensitivity to the drug
• Monitoring:
  • Not typically necessary for organ function, but periodic checks of liver function tests (LFTs) can be considered due to potential hepatotoxicity.

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Examples:
  • Venlafaxine (Effexor)
  • Duloxetine (Cymbalta)
• Side Effects:
  • Common: Nausea, dry mouth, dizziness, insomnia, increased blood pressure
  • Less Common: Sweating, fatigue, constipation, sexual dysfunction
• Toxicity:
  • Symptoms: Similar to SSRIs with the addition of hypertension risk
  • Management: Monitor blood pressure, supportive care
• Contraindications:
  • Uncontrolled hypertension
  • Concurrent use with MAOIs
• Monitoring:
  • Blood pressure, especially at higher doses
  • LFTs for Duloxetine due to potential hepatotoxicity

Tricyclic Antidepressants (TCAs)

• Examples:
  • Amitriptyline (Elavil)
  • Nortriptyline (Pamelor)
• Side Effects:
  • Common: Sedation, weight gain, dry mouth, blurred vision, constipation, urinary retention
  • Less Common: Orthostatic hypotension, tachycardia, cognitive disturbances
• Toxicity:
  • Symptoms: Cardiotoxicity in overdose (arrhythmias, hypotension, seizures)
  • Management: ECG monitoring, activated charcoal, intravenous sodium bicarbonate for arrhythmias
• Contraindications:
  • Recent myocardial infarction
  • Arrhythmias
  • Narrow-angle glaucoma
• Monitoring:
  • ECG, particularly in older adults or those with cardiovascular disease
  • LFTs for potential hepatotoxicity

2. Antipsychotics

Typical Antipsychotics

• Examples:
  • Haloperidol (Haldol)
  • Chlorpromazine (Thorazine)
• Side Effects:
  • Common: Extrapyramidal symptoms (EPS), tardive dyskinesia, sedation, weight gain
  • Less Common: Anticholinergic effects (dry mouth, constipation), orthostatic hypotension
• Toxicity:
  • Symptoms: Neuroleptic malignant syndrome (NMS) – fever, muscle rigidity, altered mental status
  • Management: Discontinue antipsychotic, supportive care, dantrolene or bromocriptine for NMS
• Contraindications:
  • Severe CNS depression
  • Parkinson’s disease
• Monitoring:
  • Liver function tests (LFTs)
  • Glucose levels and lipid profile due to metabolic side effects

Atypical Antipsychotics

• Examples:
  • Risperidone (Risperdal)
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)
• Side Effects:
  • Common: Weight gain, diabetes risk, sedation, EPS (less than typical antipsychotics)
  • Less Common: Hyperprolactinemia, orthostatic hypotension
• Toxicity:
  • Symptoms: Neuroleptic malignant syndrome (NMS), metabolic syndrome
  • Management: Discontinue antipsychotic, supportive care, treatment for NMS as above
• Contraindications:
  • Severe liver disease
  • Uncontrolled diabetes
• Monitoring:
  • Glucose levels
  • Lipid profile
  • Weight
  • Complete blood count (CBC) for clozapine (Clozaril) due to risk of agranulocytosis

3. Mood Stabilizers

Lithium

• Side Effects:
  • Common: Tremor, increased thirst, weight gain, hypothyroidism, polyuria, nausea
  • Less Common: Cognitive impairment, dermatologic effects (acne, psoriasis exacerbation)
• Toxicity:
  • Symptoms: Narrow therapeutic window – early signs (nausea, vomiting, diarrhea, tremor), severe toxicity (confusion, seizures, coma)
  • Management: Discontinue lithium, IV fluids, hemodialysis in severe cases
• Contraindications:
  • Severe renal or cardiovascular disease
  • Dehydration, sodium depletion
  • Concurrent use with diuretics, NSAIDs, ACE inhibitors (due to increased lithium levels)
• Monitoring:
  • Thyroid function tests (TFTs) due to risk of hypothyroidism
  • Renal function tests (BUN, creatinine)
  • Serum lithium levels (target: 0.6-1.2 mEq/L)
  • Electrolytes (especially sodium)

Valproate (Valproic Acid)

• Side Effects:
  • Common: Nausea, tremor, weight gain, hair loss, liver dysfunction, thrombocytopenia
  • Less Common: Pancreatitis, polycystic ovarian syndrome (PCOS), encephalopathy (due to hyperammonemia)
• Toxicity:
  • Symptoms: Hepatotoxicity, pancreatitis, teratogenic effects (neural tube defects)
  • Management: Discontinue valproate, supportive care, L-carnitine for valproate-induced hyperammonemia
• Contraindications:
  • Liver disease
  • Urea cycle disorders
  • Pregnancy (due to teratogenicity)
• Monitoring:
  • Liver function tests (LFTs)
  • CBC (for thrombocytopenia)
  • Valproate levels (target: 50-100 mcg/mL)
  • Pregnancy test (for women of childbearing age)

4. Anxiolytics

Benzodiazepines

• Examples:
  • Lorazepam (Ativan)
  • Diazepam (Valium)
  • Alprazolam (Xanax)
• Side Effects:
  • Common: Sedation, dizziness, dependence, respiratory depression (at high doses)
  • Less Common: Cognitive impairment, paradoxical agitation (especially in the elderly)
• Toxicity:
  • Symptoms: Overdose can lead to severe CNS depression, respiratory failure
  • Management: Supportive care, flumazenil as a benzodiazepine antagonist (use with caution due to seizure risk)
• Contraindications:
  • Severe respiratory insufficiency
  • Myasthenia gravis
  • Acute narrow-angle glaucoma
• Monitoring:
  • Not typically necessary for organ function but monitor for signs of dependence and misuse

5. Stimulants

Used primarily for ADHD

• Examples:
  • Methylphenidate (Ritalin, Concerta)
  • Amphetamine salts (Adderall)
• Side Effects:
  • Common: Insomnia, appetite suppression, weight loss, increased heart rate, hypertension
  • Less Common: Tics, mood swings, growth suppression in children
• Toxicity:
  • Symptoms: Cardiovascular events, potential for abuse and dependence
  • Management: Discontinue stimulant, supportive care, benzodiazepines for severe agitation
• Contraindications:
  • Cardiovascular disease
  • Hyperthyroidism
  • Glaucoma
• Monitoring:
  • Blood pressure
  • Heart rate
  • Weight
  • Potential for misuse and dependence