A Brief Overview of
Psychotropic Medications
Coni Kalinowski, M.D.
8 February 2013
Some general principles regarding
medications:
• Psychotropic medications are one tool among many that
may lessen mental distress.
• All medications have “side effects.” No medication is
“safe.”
• The effects of psychotropic medications on individuals
are unique.
• Anything can be a side effect of medication.
• Side effects of psychotropic medications can mimic
psychiatric symptoms.
• Psychotropic medications do not cure psychiatric
difficulties.
• Psychotropic medications do not “treat” behaviors.
• The mechanisms of action of psychotropic agents are
essentially unknown.
Some general principles regarding
medications:
• “Medical” medications, over-the-counter medications,
and herbal remedies can have significant psychotropic
side effects.
• Medication combinations can be unpredictable.
• Recreational substances and “social” substances often
interact with psychotropic medications.
• Older people, people who have health problems, people
who have had brain injuries, and people having
intellectual disabilities may be more sensitive to
psychotropic medications and their side effects.
• Psychiatric treatment must be differentiated from
chemical restraint and social control.
• No medication is “safe” during pregnancy.
• More is not always better.
Antipsychotic Medications
(Neuroleptics)
• Conventional medications (older):
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haloperidol (Haldol)
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fluphenazine (Prolixin)
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pimozide (Orap)
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trifluoperazine (Stelazine)
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thiothixene (Navane)
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perphenazine (Trilafon)
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mesoridazine (Serentil)
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loxapine (Loxitane)
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molindone (Moban)
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thioridazine (Mellaril)
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chlorpromazine (Thorazine)
Antipsychotic Medications
(Neuroleptics)
Atypical medications (newer):
• clozapine (Clozaril)
• risperidone (Resperidal)
• olanzapine (Zyprexa)
• quetiapine (Seroquel)
• ziprasodone (Geodon)
• aripiprazole (Abilify)
• paliperidone (Invega)
• iloperidone (Fanapt)
• asenapine (Saphris)
• lurasidone (Latuda)
Antipsychotic Medications
(Neuroleptics)
Uses:
• -reduce hallucinations
• -improve organization of thought processes
• -reduce preoccupations with improbable beliefs
• -tranquilization
• -anti-emesis
• -treatment of Tourette's disorder
Common Side effects of
antipsychotics:
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sedation
drowsiness
anergy
decreased motivation
slowing of thought processes
depression
dry mouth or drooling
constipation
blurred vision
weight gain, diabetes, hyperlipidemia
orthostatic hypotension
amenorrhea
galactorrhea
gynecomastia
Common Side effects of
antipsychotics:
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rashes
sun sensitivity
sexual dysfunction
restlessness
restless leg syndrome
discontinuation syndrome
headache (especially aripiprazole and ziprasidone)
nausea and vomiting (especially risperidone and
ziprasidone)
Neurological side effects of
antipsychotics
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Parkinsonian Side Effects
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Onset generally about 7 days after beginning
antipsychotic medications
Key features:
"pill-rolling" tremor
increased muscle tone and "cogwheeling"
stooped, shuffling gait
bradykinesia
mask facies
impaired balance
Neurological side effects of
antipsychotics
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Akathisia
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Characterized by extreme motor restlessness or
"nervousness"
People may be observed to pace, jog their legs,
repeatedly sit then stand
When severe, people may not be able to sleep
May be a cause of increased SIB or aggression
in people having developmental disabilities
Onset: immediate to a few days
Neurological side effects of
antipsychotics
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Dystonia
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Characterized by a sustained, painful
contraction of one or more muscle groups.
Common presentations:
rigid tongue protrusion
throat "closing up" or tongue drawn back
upward deviation of the eyes
torticollis
oculogyric crisis
Onset: frequently within an hour of dosage, may
be recurrent
Can be lethal if airway obstruction occurs
Neurological side effects of
antipsychotics
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Tardive Dyskinesia
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Characterized by involuntary muscle movements
Onset generally after many years of taking antipsychotic
medications, but can occur within weeks
Can be progressive and permanent
Typical movements:
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chewing, lip-smacking, lip-licking, puffing
frequent blinking and blepharospasm
tongue flickering or protrusion
flexion-extension movements of fingers, writhing or arms
foot tapping, ankle movements
shrugging, twisting of torso or hips
eructation, reflux, vomiting
Progresses to cause dysphagia, respiratory difficulties,
aspiration pneumonia
Serious side effects of
antipsychotics
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neutropenia
seizures
neuroleptic malignant syndrome
cardiac arrhythmias
hyperthermia
cataracts
precipitation of glaucoma
priapism
diabetes
hyperlipidemia
Antidepressants
• SSRI's
– fluoxetine (Prozac)
– sertraline
(Zoloft)
– paroxetine (Paxil)
– fluvoxamine (Luvox)
– citalopram (Celexa)
– escitalopram (Lexapro)
Antidepressants
• SNRI's and Novel agents
– trazodone (Deseryl)
– nefazodone (Serzone)
– venlafaxine (Effexor)
– bupropion (Wellbutrin)
– mirtazepine (Remeron)
– duloxetine (Cymbalta)
– desvenlafaxine (Pristiq)
– vilazodone (Viibrid)
Antidepressants
• Uses:
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treatment of depression
treatment of anxiety
treatment of social phobia
treatment of panic attacks
treatment of eating disorders
treatment of attention deficit disorder in adults
treatment of migraine
treatment in autism (especially SSRI's)
treatment of obsessive-compulsive disorder (especially
SSRI's)
– treatment of irritability in posttraumatic stress disorder
Common side effect of
antidepressants:
• G.I. side effects: nausea, constipation or diarrhea
• Sexual and reproductive dysfunction: anorgasmia,
erectile dysfunction, decreased libido,
dysmenorrhea, menstrual irregularity
• Sleep disturbance: insomnia, nightmares,
somnolence
• Weight gain
• headache
• tremor
• agitation or "jitters"
• excessive sweating
• palpitations
• dry mouth
Common side effect of
antidepressants:
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weight loss
asthenia
muscle pain
“poop out”
dizziness
paresthesias
visual disturbances, blurred vision
akathisia
rash
sun sensitivity
yawning
changes in taste
discontinuation syndrome
worsening of depression
Serious side effects of
antidepressants
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seizures
intense suicidality or impulsivity
kindling of mania or psychosis
dyskinesias
extrapyramidal side effects
electrolyte disturbances
elevation of cholesterol
decreased platelet aggregation and bleeding
birth defects
Anticonvulsant Medications
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Divalproex sodium (Depakote)
Carbamazepine (Tegretol)
Oxcarbazapine (Trileptal)
Topiramate
(Topamax)
Lamotrigine
(Lamictal)
Gabapentin
(Neurontin)
Anticonvulsant Medications
• Uses:
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treatment of seizure disorders
treatment of mood swings
treatment of explosive aggression
treatment of complex post-traumatic
stress disorder
Common side effects of
anticonvulsants:
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drowsiness
fatigue
mental slowing
nausea and vomiting
tremor
rash
motor slowing
weight gain
hair loss (Depakote)
changes in blood pressure
birth defects
suicidal impulses
Serious side effects of
anticonvulsants
• Tegretol •
agranulocytosis
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aplastic anemia
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hyponatremia
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hypothyroidism
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toxic epidermal necrolysis
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Stevens-Johnson syndrome
Serious side effects of
anticonvulsants
• Depakote –
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hepatic failure
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thrombocytopenia
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polycystic ovary
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anemia
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pancreatitis
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hyperammonemia
Serious side effects of
anticonvulsants
• Neurontin –
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elevated liver enzymes
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hypertension
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increased lability
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sudden death
elevated liver functions
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pure red cell apalasia (risk in
hemoglobinopathies)
Serious side effects of
anticonvulsants
• Trileptal- hyponatremia
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severe cognitive SE
• Topamax – severe cognitve SE
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kidney stones
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hyperthermia, oligohidrosis
Common Medication Errors
• Over-medication (excessive dosage)
– Common causes:
– not waiting for therapeutic effect, overshooting the
therapeutic dose.
– increasing dose in a crisis, but forgetting to return to
maintenance dose.
– using medication for sedative side effect
– “more is better”
– failure to compensate for advanced age, medical
problems, brain injury
Common Medication Errors
• Polypharmacy (more than one drug in the
same class)
– Common causes:
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adding a new medication without removing
ineffective medications.
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stalled cross titration
Common Medication Errors
• Failure to recognize medication
interactions.
• Confusion of medication side effect with
symptoms of the psychiatric disability.
• Failure to assess a change in “medical”
health.
• Inadequate evaluation of situational and
environmental contributors to psychiatric
symptoms.
Common Medication Errors
• Failure to fully assess “medical”
medications and non-prescription
substances.
• Inadequate monitoring of side effects.
• Failure to take the person’s report of
medication side effects seriously.
Common Medication Errors
• Over-reliance on medications; inadequate
use of alternative or adjunct treatment.
• Inadequate attention to informed consent.
• Failure to warn about possible prenatal
effects of medications.