Brand
Generic
Navane
Thiothixene
Thorazine,
Anafranil
Chlorpromazine
Haldol
Haloperidol
Mellaril, Rideril
Thioridazine
Prolixin
Fluphenazine
Seroquel
Quetiapine
Invega
Paliperidone
Zyprexa
Risperdal
Clozaril
Latuda
Olanzapine
MOA/Class
1st Gen.
Antipsychotic
1st Gen.
Antipsychotic
1st Gen.
Antipsychotic
1st Gen.
Antipsychotic
1st Gen.
Antipsychotic
2nd Gen.
Antipsychotic,
Depression,
Bipolar Disorder
2nd Gen.
Antipsychotic
2nd Gen.
Antipsychotic
Side Effects
Notes
Increased risk of
developing
jaundice
Low potency
High risk of EPS
High potency, Depot
available
Pigmentary
retinopathy
High potency, Depot
available
Cataracts
Elevation in
prolactin
Weight gain
Sedation
Hyperglycemia
Dyslipidemia
New onset
diabetes mellitis
Asymptomatic
inc. LFTs
Orthostatic
hypotension
(due to A1
antagonism)
Extended release
Much less likely to
cause EPS.
Not associated with
increased prolactin
levels.
2nd Gen.
Antipsychotic
Mild Sedation,
Hypotension,
Elevation in
prolactin,
Weight gain
Also available in long
acting injectable form
(Consta), Most likely
atypical antipsychotic
to cause Parkinsonian
EPS
Clozapine
2nd Gen.
Antipsychotic
Agranulocytosis
(+ leukopenia)
Seizures (lowers
threshold)
Myocarditis
Metabolic
syndrome
Most effective
Very good for
treatment resistant
Schizophrenia or high
risk of suicidality
Lurasidone
2nd Gen.
Antipsychotic
Risperidone
Used to treat
depressive episodes
associated with
Abilify
Aripiprazole
Geodon
Ziprasidone
Artane
Trihexyphenidyl
Cogentin
Inderal
Tegretol
Benztropine
Propranolol
Carbamazepine
Lamictal
Lamotrigine
Depakote
Valproic Acid
2nd Gen.
Antipsychotic
2nd Gen.
Antipsychotic
Bipolar I. Approved as
a mono-agent or in
combination with
Valproate or lithium
Low risk of adverse
metabolic effects
Low risk of adverse
metabolic effects
Anticholinergic,
Parkinson dz,
dystonia
Anticholinergic,
Parkinsonism,
Drug induced
EPS
Used to treat Acute
Dystonic Reactions.
Treats and prevents
EPS
Beta-blocker
Anticonvulsant
and Mood
Stabilizer
Antimanic
agent, Bipolar
agent
Anticonvulsant
and Mood
Stabilizer
Antimanic
agent, Bipolar
agent
Anticonvulsant
and Mood
Stabilizer
Antimanic
agent, Bipolar
agent
Bipolar Agent
Eskalith, Lithobid
Lithium
Sometimes used to
treat antipsychotic
induced akathisia, but
is not useful with
Parkinsonian
symptoms
MOA:
Therapeutic
Adverse reaction
possible: StevenJohnson Syndrome
(Life-threatening
mucocutaneous rxn)
Indicated for
treatment of
depression in pts with
bipolar disorder.
Pregnancy Cat
D: Ebstein’s
anomaly
In young women prior
to prescribing check:
- Thyroid function
- Renal Function
Gastrointestinal
distress
Nephrotoxicity
Hypothyroidism
Leukocytosis
Tremors
Acne
Psoriasis Flairs
Hair Loss
Edema
- hCG levels
Pts must avoid
food high in
tyramine can
cause HTN crisis
Pts must avoid
food high in
tyramine can
cause HTN crisis
Dietary restriction,
serious reactions
possible with abrupt
discontinuation
Dietary restriction,
serious reactions
possible with abrupt
discontinuation
Citalopram
SSRI, first line
for moderate to
severe
depression
Sexual
dysfunction,
anorexia
If no effect (4-6
weeks) increase dose
or try another SSRI
before switching
classes
Fluoxetine
SSRI, first line
for moderate to
severe
depression
*only SSRI
approved for
kids
Sexual
dysfunction,
anorexia
If no effect (4-6
weeks) increase dose
or try another SSRI
before switching
classes
Paroxetine
SSRI, first line
for moderate to
severe
depression
Sexual
dysfunction,
anorexia
Sertraline
SSRI, first line
for moderate to
severe
depression
Sexual
dysfunction,
anorexia
Duloxetine
Serotonin
Norepinephrine
Reuptake
effects are
attributed to its
ability to inhibit
inositol-1phosphatase in
neurons
Vistaril, Atarax
Nardil
Hydroxyzine
Prozac
Paxil
Zoloft
Cymbalta
Dose adjustment needed in
pts with renal insufficiency
Antihistamine
1st gen.
Phenelzine
MAOI
Tranylcypromine
MAOI
Parnate
Celexa
Therapeutic window:
[0.8-1.2 mEq/L]
If no effect (4-6
weeks) increase dose
or try another SSRI
before switching
classes
If no effect (4-6
weeks) increase dose
or try another SSRI
before switching
classes
Effexor
Pristiq
Venlafaxine
Desvenlafaxine
Inhibitor (SNRI)
SNRI
SNRI
Elavil
Amitriptyline
Tricyclic and
Heterocyclic
Antidepressants
(TCAs)
Anafranil
Clomipramine
TCA
Sinequan
Doxepin
TCA
Pamelor
Nortriptyline
TCA
Imipramine
TCA
Atypical
Antidepressant,
Smoking
cessation
Wellbutrin
Bupropion
MOA: inhibition of
the reuptake of
norepinephrine,
dopamine, and
serotonin
Atypical
Antidepressant,
Used to
stimulate
appetite in
depressed
patients who
may be anorexic
Used for
Insomnia
related to
depression
Cardiac
complications
Also used in:
-Diabetic Neuropathy
- Prevention of
migraine HAs
Cardiac
complications
Cardiac
complications
Cardiac
complications
Cardiac
complications
Lowers seizure
threshold (dose
dependent, at
higher doses).
Lowest risk of
sexual sideeffects
OD can cause
Heart failure.
Do not use in pts with risk of
seizures or electrolyte
imbalances including bulimics
or anorexics. Avoid concurrent
alcohol consumption or
benzodiazepine use
The presence of ischemic heart
disease is not an absolute
contraindication, but dose
adjustment would be advisable
Remeron
Mirtazapine
Weight gain
Desyrel
Trazodone
BuSpar
Buspirone
Used to treat
generalized
anxiety disorder
Not an antidepressant,
does not treat panic
disorders
ProVigil
Modafinil
Chemically
novel stimulant,
Chemically novel
stimulant – have
Priapism
Highly sedating
NuVigil
Ritalin, Concerta
Dexedrine
Desoxyn [Crystal
Meth]
Adderall
Armodafinil
Treats
narcolepsy,
Shift work sleep
disorder
replaced amphetamine
stimulants as first line
agents in treatment of
narcolepsy
Chemically
novel stimulant,
Treats
narcolepsy
Chemically novel
stimulant – have
replaced amphetamine
stimulants as first line
agents in treatment of
narcolepsy
Amphetamine
stimulants,
Methylphenidate
Schedule II:
controlled
substance
Amphetamine
stimulants,
Dextroamphetamine Schedule II:
controlled
substance
Reduces thetawaves, promotes
wakefulness.
Has been used to increase
motivation and energy in some
patients with psychiatric illness
RISK OF ABUSE
RISK OF ABUSE,
potential for
tolerance,
significant SEs
Methamphetamine
Amphetamine
stimulants,
Schedule II:
controlled
substance
RISK OF ABUSE,
ILLICT USE,
potential for
tolerance,
significant SEs
Both a medical drug and a
recreational drug.
FDA approved for ADHD
and exogenous obesity.
Very unlikely to be
prescribed.
Levo – formula found in
some nasal decongestants
Amphetamine Salts
(combination)
Amphetamine
stimulants,
Schedule II:
controlled
substance
RISK OF ABUSE,
potential for
tolerance,
significant SEs
Used to treat ADHD
RISK OF ABUSE
and illicit use
Reduces cataplexy
Approved for treatment of
excessive daytime
sleepiness associated with
narcolepsy
MOA: not entirely
Xyrem [GHB]
Exelon
Concerta is extended
release formula
Sodium oxybate
Rivastigmine
known, Antagonizes
GABA receptors
Schedule III:
controlled
substance
Cholinesterase
inhibitors,
Dementia Tx
(slows cognitive
decline)
Shown to be effective in patients
with mild-to-moderate dementia
May improve quality of life and
cognitive functions including:
- memory
- language
- thought
- reasoning
Razadyne
Aricept
Galantamine
Doneprazil
Shown to be effective in patients
with mild-to-moderate dementia
May improve quality of life and
cognitive functions including:
- memory
- language
- thought
- reasoning
Cholinesterase
inhibitors,
Dementia Tx
(slows cognitive
decline)
*Approved for all
stages of dementia.
Cholinesterase
inhibitors,
Dementia Tx
(slows cognitive
decline)
Shown to be effective in patients
with mild-to-moderate dementia
May improve quality of life and
cognitive functions including:
- memory
- language
- thought
- reasoning
MOA: N-methyl-DNamenda
Memantine
Approved for
moderate-to-severe
dementia
Aspartate (NMDA)
receptor antagonist
Dementia Tx
Symmetrel
(generic
discontinued)
Mirapex
MOA: a dopamine
Amantadine
Pramipexole
agonist
Dementia Tx,
influenzae
Benzodiazepine:
Alcohol
Withdrawal
[Given IV]
Lorazepam
Benzodiazepine:
short acting,
Anxiety
Alprazolam
Limited utility in
patients w/
Alzheimer’s dz
Used to treat
symptoms of
Parkinson’s Dz and
Restless Leg syndrome
MOA: a
dopamine
agonist
Ativan
Xanax
Used in the treatment
of Parkinson’s dx. It
has been shown to
delay the onset and
minimize the severity
of dementia in these
patients.
MOA: increases
effect of GABA by
increasing frequency
of chloride channel
opening
RISK OF ABUSE
Abrupt
discontinuation
(in cases of
consistent long
term use) can
cause seizures
RISK OF ABUSE
Abrupt
discontinuation
(in cases of
consistent long
term use) can
cause seizures
Used in alcohol
withdrawal, especially
in the setting of liver
disease.
There are no active
metabolites.
DO NOT prescribe to
patients with history
of substance abuse.
Schedule IV:
controlled
substance
By Side Effect
Side Effect
Amenorrhea (can also cause
lacation)
Weight Gain
Most Common Drug
Paliperidone, Risperidone
Most gain with Olanzapine and
Clozapine
Agranulocytosis (and leukopenia) Clozapine
Explanation
Dopamine inhibition -> Elevated
Prolactin levels
Note: Prolactinoma (usually
>200ng/mL) levels are not this
high.
Thought to be from antagonism
of H1 and 5-HT2C receptors
*requires weekly blood tests for
first 6 months
Never give Bupropion and Clozapine together -> Greatly increases risk of seizures
Midazolam (Versed) – is a benzodiazepine used most often to induce conscious sedation during medical
procedures. It has no role in treating panic disorder or other psychiatry ailments
Risperidone
Most likely atypical antipsychotic to cause Parkinsonian EPS [Bradykinesia, masked facies, micrographia]
Due to: Excessive dopamine blockade
EPS: [Treated with anticholinergic]




Rigidity
Bradykinesia
Tremor
Akathisia
Risperidone
Antagonizes
D2 Receptors
 Antipsychotic effect
Psychosis is associated
with increased
dopaminergic activity
Alpha-1
adrenergic
receptors
Associated with
orthostatic
hypotension in 2nd
gen. antipsychotics
Serotonin Receptors
 Improves negative
symptoms of
schizophrenia
 Reduces incidence of EPS
 Concomitant treatment
of depression
Take Away:
D2 Receptors are the main target for antagonism in antipsychotic drugs
Metabolic effects of second generation antipsychotics:



Weight gain
Dyslipidemia
Hyperglycemia (including new-onset diabetes)
Highest risk:
 Olanzapine
 Clozapine
Lowest risk:


Aripiprazole (Abilify)
Ziprasidone (Geodon)
Monitoring Guidelines:





BMI: Baseline and monthly
Fasting glucose: Baseline, 3 months, then annually
Fasting lipid panel: Baseline, 3 months, then annually
Blood pressure: Baseline, 3 months, then annually
Waist circumference: Baseline, 3 months, then annually
Early and more frequent monitoring recommended in patients with diabetes or
who have gained >5% initially
Second generation (atypical) antipsychotics

Treat:
 Schizophrenia
 Bipolar disorder
 Other psychotic disorders



Lower risk of extrapyramidal side effects
All carry risk of metabolic adverse effects
Commonly cause asymptomatic increase in liver enzymes.
Significant increased levels uncommon
Extrapyramidal Symptoms (EPS)
Risk:




Related to degree of D2 blockade
High potency typical antipsychotics (eg Haloperidol) > Low potency antipsychotics (eg
Chlorpromazine)
Typical antipsychotics > Atypical antipsychotics
Greater Risk with High or Rapid Dose Escalation
Acute Dystonia

a type of EPS that develops within hours to days of initiation or dose escalation of
antipsychotics.
It is characterized by:
 Muscle spasms
Or
 Stiffness in the head or neck
Including:
 Tongue protrusion or twisting
 Facial grimacing
 Torticollis
 Opithotonus (back)
 Oculogyric crisis
 Forced, sustained, elevation of the eyes in an upward position
Treatment:
Anticholinergic -> Benzptropine
Antihistamine -> Diphenhydramine
Risk of Acute Dystonia is greater with high-potency typical antipsychotics (eg Haloperidol)
compared to low-potency typical antipsychotics and atypical antipsychotics
Risperidone is the most likely atypical antipsychotic to cause EPS
Clozapine is the least likely antipsychotic to cause EPS
Akathisia

a type of EPS
It is characterized by:

Inner restlessness
 Subjective restlessness, inability to sit still, constant need to move
 Examples include:
 Repeated leg crossing
 Weight shifting
 Stepping in place
Treatment:
Beta-Blocker (propranolol)
Drug-Induced Parkinsonism
= a type of EPS, with gradual onset
It is characterized by:







Tremor
Rigidity
Bradykinesia
Masked Facies
Shuffling gait
“Pill-rolling” finger tremor
Cog-wheel rigidity
Treatment:
Anticholinergic or Amantadine (dopamine agonist)
Tardive Dyskinesia (TD)

Defined as a hyperkinetic movement disorder that is a side effect of medications (usually
dopamine receptor blocking drugs) [eg antipsychotics and metoclopramide]
Typically patient presents within 1-6 months of starting the medication
It is characterized by:


Oral Facial: (involuntary perioral movements)
 Tongue protrusion + twisting
 Lip smacking, pouting, and puckering
 Retraction of corners of mouth
 Chewing movements
 Grimacing
 Biting
Limb:
 Limb twisting + spreading
 “Piano-playing” finger movements
 Foot tapping
 Dystonic extension of toes
Note: Tremor is rarely seen in these patients

Neck & Trunk:
 Torticollis
 Shoulder shrugging
 Rocking or swaying

 Rotary hip movements
Respiratory:
 Grunting noises
Treatment:
Change antipsychotic -> Clozapine
Lithium (Eskalith, Lithobid)
Therapeutic window: [0.8-1.2 mEq/L]
Therapeutic effects are attributed to its ability to inhibit inositol-1-phosphatase in neurons

Pregnancy Category D:
 Ebstein’s anomaly
 Septal defect where there is a malformed and inferiorly attached
tricuspid valve causing a portion of the right ventricle to becoming
functionally part of the right atrium
 Exposure during the 2nd and 3rd trimester can also cause goiter and transient
neonatal neuromuscular dysfunction.


Remember to check for pregnancy before prescribing lithium to a female of child
bearing age
Other possible adverse effects:
 Gastrointestinal distress:
 Nausea
 Vomiting
 Diarrhea
 Abdominal pain
 Nephrotoxicity:
 Polyuria & Polydipsia ->> nephrogenic diabetes insipidus
 Chronic interstitial nephritis
 Hypothyroidism
 Leukocytosis
 Tremors
 Acne
 Psoriasis Flairs
 Hair Loss
 Edema



Kidney and thyroid function should be monitored
Lithium also accumulates in patients with renal insufficiency (excreted through the kidneys)
-> Dose adjustment is needed.
If you get a question with lithium and they have provided you with lab results, double check
creatinine levels. This is not the best drug for patients with pre-existing kidney dysfunction.
Drugs of Abuse
Alcohol Withdrawal Syndrome
Manifestation
Symptom/Sign






Mild Withdrawal
Onset since last drank
(hours)
Anxiety
Insomnia
Tremors
Diaphoresis
Palpitations
Gastrointestinal upset
Intact orientation
6-24

Single or multiple generalized
tonic-clonic
Seizures





Alcoholic Hallucinosis
Visual
Auditory
Tactile
Intact orientation
Stable (normal) vital signs
12-48
12-48
Onset: 12-24
Resolves within: 24-48
* Major Distinguishing features from DT








Delirium Tremens
(DTs)
Confusion
Agitation
Hallucinations
Disorientation
Fever
Tachycardia
Hypertension
Diaphoresis
=
Autonomic
Instability
48-96
[2-4 days]
Fatal in up to 5% of cases
Treatment:




Should treat with Benzodiazepine (eg Lorazepam, Diazepam, chlordiazepoxide)
Goal is to control symptoms and prevent progression to DT
PRN (rather than fixed dose).
Lorazepam is preferred in patients with liver disease (No active metabolites). [IV
administered]

In addition to IV lorazepam,
Adjunct management includes:


IV Fluids
Frequent monitoring of Vital Signs




Thiamine
Folate
Nutritional support
Phenobarbital has been used as an adjunct to benzodiazepines in treatment of
refractory alcohol withdrawal syndrome. Not recommended as a monotherapy.
Disulfiram (Antabuse)


Used as a behavioral
deterrent in high-functioning alcoholics who desire long-term abstinence.
It is not beneficial
during acute withdrawal
MOA: Inhibits aldehyde dehydrogenase, causing the patient to feel ill if alcohol is ingested
due to the accumulation of acetaldehyde.
Heroin Withdrawal (not life-threatening)
Signs:
- Pupillary dilation (mydriasis)
- Diaphoresis
- Rhinorrhea
- Lacrimation
- Muscle and joint aches
- Muscle spasms
- Abdominal cramping
- Nausea + vomiting
- Diarrhea
- Irritability
[Autonomic instability: Hypertension and/or Goosebumps may be evident]
Symptoms are severe and out of proportion to physical findings.
Treatment: Naloxone
Cocaine or Amphetamine Withdrawal
Signs:
- Irritability
- Fatigue
- Increased appetite
- Psychomotor disturbance
- Depression may also occur
Cocaine Abuse
Should be suspected in an individual presenting with:



Weight loss (secondary to decreased appetite)
Behavioral changes
Erythema of the turbinates and nasal septum
Nicotine Withdrawal
Signs:









Irritability
Anxiety
Depression
Insomnia
Restlessness
Poor concentration
Increased appetite
Weight gain
Bradycardia
Marijuana Use
Should be suspected in an individual presenting with:



Injected conjunctivae
Lack of motivation
Increased appetite
Alcohol Intoxication
Signs:




Ataxia
Nystagmus
Aggression
Impaired judgment
Heroin Intoxication
Signs:




Pinpoint pupils (miosis)
Drowsiness [May seem to “nodded off”]
CNS depression [eg shallow breathing, slow HR]
Constipation
Cocaine (or amphetamine) Intoxication
May present with:










Anxiety
Aggression
Agitation
Psychosis
Delirium
Paranoia
Nose bleeds
Septal perforations
Chest pain
Palpitations
Physical findings may include:






High or Low BP
Tachycardia or Bradycardia
Diaphoresis
Pupillary dilation (mydriasis)
Nausea or vomiting
Insomnia
Rarely can cause Formication = “Cocaine bugs”
Cocaine Overdose
[Amount needed varies person to person. If any cocaine is found on toxicology in an otherwise
unexplained death, it is ruled COD]
Can cause:





Cardiac Arrhythmias
Myocardial Infarctions
Seizures
Strokes
Intracerebral hemorrhages
Phencyclidine [PCP] Intoxication
Symptoms develop shortly after ingesting the drug
Usually presents with distinct behavioral changes
Such as:







Physical aggression
Severe agitation
Impulsivity
Impaired judgment
Psychosis
Paranoia
Hallucination
Physical signs:








Nystagmus
Hypertension
Tachycardia
Ataxia
Dysarthria
Muscle Rigidity
Seizures
Coma
Lysergic Acid Diethylamide [LSD] Intoxication
A hallucinogen
MOA of hallucinogenic effect: Agonizes 5-HT2A receptors and D2 receptors, Derived from ergots
Symptoms develop shortly after ingesting the drug
Users experience:





Mood impairment
Hallucinations
Subjective perceptual intensification
(ie Colors are richer, tastes are heightened, sensations are enhanced)
Depersonalization
Illusions
Physical signs:





Diaphoresis
Tachycardia
Pupillary dilation (mydriasis)
Palpitations
Tremors

Poor coordination
To treat intoxication:
Reassurance is a calm, safe environment is beneficial
Patient is more likely to be scared than aggressive
Note: Uterine contractions are stimulated by LSD and therefore can have adverse effects on
pregnancy
Note: V. high therapeutic index and low addiction potential
Check out: CIA experimentation on American citizens
http://en.wikipedia.org/wiki/Project_MKUltra
Anticholinergic Poisoning
Signs:










Mydriasis
Delirium
Hyperthermia
Tachycardia
Hypertension
Dry Skin
Dry Mucous Membranes
Motor Symptoms
 (eg myoclonic jerks, tremors)
Ileus
Urinary retention
Treatment:

Physostigmine
Serotonin Syndrome
Signs:


Fever (high)
Rigidity



Diarrhea
Restlessness
Autonomic instability
Neuroleptic Malignant Syndrome (NMS)




Unusual by potentially lethal side effect of antipsychotics (neuroleptics)
Can occur at any point in time during treatment with dopamine
antagonists
Mortality from NMS is high (approaching 10-20%)
More commonly associated with use of high potency typical
antipsychotics (eg Haloperidol)
Cardinal features:




Hyperthermia (fever)
Autonomic instability
Muscular rigidity
Altered Sensorium (mental status changes)
Lab Results:

Elevated CPK levels
Known possible complication:

Rhabdomyolysis
o Followed by myoglobinuria and leading to acute kidney failure
Treatment:



Prompt discontinuation of responsible neuroleptic agent
ICU monitor
Followed by:
Supportive care:
 Control Hyperthermia
 Aggressive cooling
 Antipyretics
 Maintenance of electrolyte balance
 Fluid and electrolyte repletion
 Alkaline diuresis (in cases w/ rhabdomyolysis)
 Beta blockers can be used to treat hypertension + tachycardia (but these are
not to be used alone)
 Dantrolene Sodium (direct muscle relaxant)
 Amantadine and/or the dopamine agonist Bromocriptine