COMMON PSYCHOTROPIC MEDICATIONS


MOOD DISORDERS

Use: Depressive and anxious disorders including Dysthymia (loss of pleasure), Major Depression, Panic Disorder, Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Posttraumatic Stress Disorder. Note the use of these medications for anxiety or depression require a “lag period” of at least three weeks until effective symptom relief.

SSRI Antidepressants:

Side effects (typically minimal) may include nausea, decreased appetite, weight loss, excessive sweating, insomnia, jitteriness, sedation, dizziness, sexual dysfunction.
  • Prozac (fluoxetine): Typically “activating”.
  • Paxil (paroxetine): Typically “sedating”. Has an associated “withdrawal” syndrome with abrupt discontinuation.
  • Zoloft (sertraline): Usually neither activating or sedating. Has milder “withdrawal” syndrome with abrupt discontinuation.
  • Celexa (citalopram): Usually neither activating or sedating. Few drug interactions.
  • Luvox (fluvoxamine): Typically “sedating”.
  • Remeron (mirtazapine): Can be used as sleep aid at lower doses. Most frequent complaint is weight gain.

Miscellaneous Antidepressants:

  • Wellbutrin/Zyban (Buproprion): Also used for mood difficulties particularly in Bipolar patients, smoking cessation and ADHD. May also be used to “augment” the action of other antidepressants. Mechanism of action involves increasing dopamine and norepinephrine turnover in the brain. More problematic in the increased risk for seizures in those with a seizure disorder, less risk with the slow-release form.
  • Effexor (Venlafaxine): Considered activating. Some believe may be helpful in ADHD and depression. Often used after other antidepressants fail. Mechanism of action also involves increased norepinephrine reuptake blockade as well as serotonin reuptake blockade.
  • Tricyclic antidepressants (TCA): Including Tofranil (imipramine), Pamelor (nortriptyline), Anafranil (clomipramine), Elavil (amytriptyline). These medications have largely been replaced by the SSRI’s for treatment of depressive and anxiety disorders including Obsessive-Compulsive Disorder and PTSD. Side-effects for these medications are numerous and include anticholinergic effects (dry mouth, blurred vision, constipation, difficulties with urination, fast heart rate, delirium and seizures), antihistamine effects (sleepiness, weight gain), positional dizziness/BP changes and cardiac effects (slowed conduction through heart’s electrical system).
  • Desyrel (trazadone): Older antidepressant with sedation as a prominent side effect now used to treat insomnia. Dosage is variable and generally adjusted to effect.
  • Monoamine Oxidase Inhibitors (MAOI): Includes Nardil (phenylzine), Marplan (isocarboxazid) and Parnate (tranylcypromine). Rarely used medications due to dietary restriction. Never used with SSRI since may precipitate a serotonergic crisis.

ANXIETY DISORDERS

Use: Long-term management (but not treatment) of Generalized Anxiety Disorder, Panic Disorder, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, anxiety associated with Eating Disorders.

Tricyclic antidepressants (TCA)

Same general comments as above. May be used as a first line medications by clinicians that wish to take advantage of the sedative and anticholinergic side-effects or to treat co-morbid conditions such as headache or irritable bowel syndrome.

Anxiolytics

Medications that for the most part alleviate anxious symptoms soon after ingestion. Benzodiazapines are controlled substances with the potential for physical dependence, withdrawal and escalated dosing over time to maintain effectiveness.
Use: Judicious and cautious application in the early stages of an “anxious depression”, Bipolar Affective Disorder, Panic Disorder, Social Phobia and possibly Posttraumatic Stress Disorder, as well as management of anxiety associated with psychosis or delirium. SSRI’s and exposure/cognitive behavioral therapy is currently the preferred treatment for most anxiety disorders. Because benzodiazepines interact with nerves similar to those affected by alcohol they are frequently used for detoxification of alcohol dependent individuals and to prevent potentially fatal withdrawal seizures. In general, benzodiazepines should not be used for the treatment of anxiety in individuals with substance related issues due to their abuse potential possibility for triggering cravings for other substances. Similar to alcohol, benzodiazepines can “disinhibit” patients resulting in increased aggression.
  • Valium (diazepam): Muscle spasm, convulsive disorders
  • Klonapin (clonazapam): convulsive disorders
  • Versed (midalzom): induction of anesthesia
  • OTHERS

Miscellaneous

  • Buspirone: Used most frequently to treat mild-moderate Generalized Anxiety Disorder. May also be used as an “augmentation” strategy with an SSRI.
  • Propranolol: Called a beta-blocker of blood pressure, this medication is used primarily for performance anxiety.
  • Neurontin (gabapentin): Some belief that this medication may be effective in social phobia.

MOOD STABILIZERS

Use: Bipolar Affective Disorder (“manic-depression”), Aggression and Impulsivity. Not typically used for primary psychotic disorders unless there is suspicion of a mood component, ie. Schizoaffective Disorder. Some of these medications are also used by neurologists for seizure disorders.

Depakote (Valproic Acid)

Currently thought to be the best choice for Bipolar patients with “mixed states” and rapid-cycling. Doses are frequently divided into two or three times daily dosing. Blood chemistries and levels are obtained on a regular basis when using this medication due to the potentially serious life-threatening side-effects of liver and pancreatic damage as well as blood disorders. Side-effects are numerous and include sedation, dizziness, weight gain and hair loss.

Tegretol (Carbamazepine)

Similar indications as above except may be more frequently used for pain conditions and less for headache. Doses may be divided by two to four intervals/day. Has a very popular use for aggression and rage in children and some adults. Blood monitoring is necessary for levels as well as potentially fatal blood condition and liver failure.

Eskalith (Lithium carbonate)

Similar indications as above except thought to be the drug of choice for the treatment of acute mania especially in “classic” bipolar patients. Also needs frequent blood monitoring for levels and indicators of toxicity. Toxicity also includes thyroid/kidney concern, primarily long term. Also increased drinking and urination.

Miscellaneous

Lamictal (lamotrigine) and Topamax (toprimate). There is some emerging evidence that Lamictal might be helpful in Bipolar depressions.

PSYCHOTIC DISORDERS

Use: To treat psychotic symptoms in mood disorders, schizophenic spectrum illnesses, impulse control difficulties and perseveration in Pervasive Developmental Disorders and mental retardation, Tourette’s disorder and delirium. Sometimes used in other disorders where a “quasi-psychotic” process is suspected. Antipscyhotics are grouped as Atypical (“second” and “third” generation, or “novel”), or Typical (“first generation” or traditional). Atypical antipsychotics are preferred because of a decreased tendency to produce temporary and permanent neurological conditions (extrapyramidal symptoms; EPS) such as muscle stiffness, agitation, tardive dyskinesia (muscle twitching and spasm) and dystonia (inability to move). They are also more effective in treating the negative symptoms of schizophrenia such as depression and withdrawal. Antipsychotics generally produce clinically significant side effects, and should be used with caution and only when required.

Atypical Antipsychotics

  • Risperdal (risperdone): Most likely to cause EPS. Side-effects include agitation, anxiety, heart conduction abnormalites and headache. Increased prolactin may result in nipple enlargement and discharge regardless of sex. Has been shown to reduce agitation in patients with Alzheimer’s dementia.
  • Zyprexa (olanzapine): Most likely to cause significant weight gain that is not dependent on dosage. Similar indications as Risperdal, frequently used as an adjunctive
  • medicine with psychotic mood disorders. Side effects include dry mouth, constipation and possible aggravation of diabetes mellitus.
  • Seroquel (quetiapine): Very sedating, but fewer anticholinergic side-effects. Typically take at bedtime.
  • Geodon: Newest on the market since about August, 2000. Looks promising for schizoaffective disorder, company now suggesting greater efficacy at higher dosages than originally suggested.
  • Clozaril (Clozapine): Very sedating, but thought to have nil risk for causing or contributing to tardive dyskinesia. Typically reserved to treat psychosis after others have failed. Most significant side-effect is potential for agranulocytosis (decreased white blood cells). Initially requires weekly monitoring for blood cell count, then followup every two weeks. Also carries a risk for lowering seizure threshold and increasing heart rate. Patients may complain of drooling.

Typical antipsychotics

These medications are still used especially in acute hospital settings although becoming less preferred for the long-term treatment of psychosis due to increased cumulative risk for the development of tardive dyskinesia. They are believed to be more effective for treating positive symptoms of schizophrenia (e.g. hallucinations, agitation, etc.) May be used as an adjunct during initial treatment of mood disorders (e.g. Major Depression with Psychotic Features) and bipolar disorder when mood symptoms are accompanied by psychosis. Other indications include Tourette’s disorder, impulsivity/aggression, and agitation in delirium. These medications have cardiac, dermatological, endocrinological, blood, sexual and neurological side-effects.
Typical antipsychotics have historically been classified according to potency and anticholinergic side-effects. High potency refers a lower dose to effectively treat positive symptoms compared to lower potency drugs. Anticholingic side effects are related to blood pressure changes or dizziness, constipation and decreased secretions. In general the relationship between these two effects is inverse.
  • High Potency: Haldol, Navane (thiothixene), Prolixin (fluphenazine), Stelazine (trifluorperazine)
  • Mid Potency: Loxitane (loxipine), Moban (molindone)
  • Low Potency- examples: Thorazine (chlorpromazine), Serentil (mesoridazine), Mellaril (thioridazine)

IMPULSE CONTROL DISORDERS

Use: Attention Deficit Hyperactivity Disorder, narcolepsy, augmentation of narcotics for pain relief. Side-effects (most common to all) include appetite suppression, suspension in growth, dizziness, anxiety, dysphoria, irritability and occasionally headache. “Rebound” syndrome includes fatigue, excessive sleepiness, increased appetite, dysphoria and depression. These medications are DEA schedule II drugs indicating a high likelihood for abuse.

Psychostimulants

  • Ritalin, Ritalin SR, Concerta (methylphenidate)
  • Adderall, Dexedrine (dextroamphetamines)
  • Cylert (pemoline): Not usually a first choice due to documented liver toxicity.

Miscellaneous

Use: Attention Deficit Hyperactivity Disorder, agitation, Posttraumatic Stress Disorder, Sleep disturbance.
  • Catapress (clonidine): Also used to treat hypertension and Tourette’s syndrome. Patients need to be carefully tapered off due to rebound effect on blood pressure. Side effects include, sedation, dry mouth/eyes, BPchange/dizziness, nausea, depression, vivid dreams, cardiac effects. Recent evidence suggest concerns when used with Ritalin.
  • Tenex (guanifesin): In addition to ADHD, Also used to treat tic disorders and sleep disorders. Produces less sedation and difficulties with mood than Catapress, but also less likely to be effective in treating aggression.
  • Trazadone (Desyrel): Sometimes used for aiding sleep onset, but may produce residual morning drowsiness.

Adapted from: http://www.ssw.umich.edu/icwtp/mentalHealth/Brief_Overview_of_Common_Psychotropic_Medications.pdf.