Term
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Definition
Citalopram
SSRI
(Celexa)
Starting dose: 20mg
Max dose: 60mg |
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Term
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Definition
Escitalopram
SSRI
(Lexapro)
enantomer of citalopram. Maybe fewer side effects than other SSRI’s.
starting dose 10mg, final dose 20mg.
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Term
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Definition
Fluoxetine
SSRI
(Prozac)
– very long 1/2 life, many drug interactions (2D6, 3A4) Start at 10-20mg. Can be dosed as high as 80-100(usually for OCD) May be dosed weekly. (90mg)
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Term
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Definition
Fluvoxamine
SSRI
(Luvox)
used primarily in OCD. Dosed 50-300mg daily
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Term
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Definition
Paroxetine
SSRI
(Paxil)
very short 1/2 life
(used often in suspected BPAD pts)
Possibly more prone to side effects (sexual, activation). Discontinuation effect (incr. anxiety, rebound depression). Dosed 20-50mg daily.
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Term
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Definition
Sertraline
SSRI
(Zoloft) – most dopaminergic. Most FDA indications (MDD, PPD, Social, OCD, Panic,
PTSD). Used often in pregnancy (along with Prozac). Dosed 50-200mg. |
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Term
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Definition
Duloxetine
SNRI (Cymbalta) – has neuropathic pain and GAD indication. Dosed 40-60mg for depression. Can go as high as 120mg for GAD. Notorious for discontinuation effect!!! |
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Term
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Definition
Venlafaxine
SNRI (Effexor) – short ½ life (discontinuation effect). Can be very activating. Starting dose 37.5mg and titrate up for efficacy. Max dose 350mg. NE effect begins at doses >150 |
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Term
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Definition
Desvenlafaxine
SNRI
(Pristiq) – start at 50mg per day. Max dose 400mg per day. Activating just like venlafaxine.
Benefit is ease of dosage, and marketed as not having a discontinuation effect. I have not seen this. |
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Term
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Definition
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Term
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Definition
Clomipramine
TCA
FDA approved for OCD |
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Term
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Definition
Desipramine
TCA
Often used for ADHD |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
Older class of antidepressants. Very effective for depression, anxiety, enuresis,
sleep, and neuropathic pain. Reason not used as much is due to narrow therapeutic index and OD can be deadly (even
on just one week supply – 500mg).
Side Effects: Most lethal side effects are cardiac (AV block, QT prolongation, sudden death). Also very anticholinergic
(sedation, tachycardia, urinary retention), and weight gain. |
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Term
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Definition
Inhibit MAO-A and MAO-B thus increasing synaptic concentration of
serotonin, norepinephrine, dopamine, and tyramine. Excellent for depression and anxiety, but known for being good at “atypical depression” (hypersomnia, hyperphagia, leaden limbs, rejection sensitivity). Making a comeback now with Emsam (patch).
Side Effects: Most important is hypertensive crisis caused by excess tyramine intake (cheese, dried meats, beer, wine,
soy). Also causes significant orthostasis, insomnia, sexual dysfunction, Can cause peripheral neuropathy by causing B6
deficiency. |
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Term
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Definition
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Term
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Definition
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Term
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Definition
Selegeline
MAOI
new patch form (Emsam). MAO-B only. Very expensive. Bypassing first pass metabolism
means that diet restrictions can be lessened. Dosing at 6mg (no restrictions), 9mg (some
restrictions), 12mg (all restrictions). |
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Term
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Definition
Buproprion
*Other drug*
(Wellbutrin): One of the most highly prescribed antidepressants. Inhibits NE and
Dopamine reuptake. Very low side effect profile. Can decrease seizure threshold
(especially in anorexia/bulimia). Does not have sexual side effects, and can decrease
smoking craving/pleasure. Also used off label for ADHD. Two forms SR and XL. SR is
150-200mg BID. XL 150-450mg |
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Term
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Definition
Trazodone
*Other drug*
Used mostly as a sleep aid (50mg-100mg). Antidepressant dose is >300mg. Can cause
orthostasis and priapism (1/6000). |
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Term
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Definition
Nefazodone
*Other drug*
Similar to Trazodone, but without SE profile. Black box warning for liver failure |
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Term
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Definition
Mirtazapine
*Other drug*
(Remeron): Enhances the release of Serotonin and NE. Can be used as monotherapy
or as SSRI adjunct. SE include sedation (<30mg), and weight gain. Also may cause
increase in QTc. Dosed 15-45mg qhs |
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Term
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Definition
Standard of care for depression (and almost all anxiety d/o – GAD,
Panic, OCD). First line for ALL depressive disorders (possible exception of Adjustment disorder – remove stressor).Side Effects: Most common side effect is sexual dysfunction (anorgasmia,not ED). Also get GI upset with initial
dosing, activation (insomnia, anxiety, tremor). Black box warning for increasing SI in children (new study may refute
this claim). Can also cause hyponatremia in elderly (esp Paxil). Worst SE is Serotonin Syndrome (especially when
cross titrating with TCA). Presents as altered mental status, hypomania, restlessness, myoclonus, hyperreflexia,
sweating, and tremor. Highly prescribed due to favorable SE profile and low chance of serious complication in OD.
Literature and clinical lore suggests SSRI may “flip” BPAD pts into mania. |
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Term
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Definition
Long considered second line agent, now often being used as a
first line agent due to positive STAR-D reports on Effexor (highest rated med by patients). Also being utilized for
chronic pain pts (Cymbalta FDA approved for neuropathic pain).Side Effects: Side effect profile similar to SSRI. Major SE is . May be more activating than SSRI due to NE. Concern
over possible increase in BP with Effexor. |
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Term
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Definition
Alprazolam
Benzodiazepines:(Xanax) – very short ½ life so affect is almost immediate and can have a withdrawal
phenomena so increased abuse potential. (Dose equivalence 0.5mg) |
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Term
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Definition
Chlordiazepoxide
Benzodiazepines:(Librium) – very long ½ life with numerous active metabolites. (Equivalent
dose 25mg) |
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Term
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Definition
Clonazepam
Benzodiazepines:(Klonipin) – very long ½ life and no active metabolites (Dose equivalence 0.5mg) |
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Term
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Definition
Diazepam
Benzodiazepines:(Valium) – long half life with many active metabolites that can stay in body for
“weeks” (prolonging withdrawal). Associated with cleft palate in pregnancy. (Dose
equivalence 10mg) |
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Term
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Definition
Lorazepam
Benzodiazepines:(Ativan) – short ½ life. Only metabolized by phase II, so can be used in liver disease. |
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Term
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Definition
Oxazepam
Benzodiazepines:(Serax) – short ½ life. Also phase II metabolized. (Equivalent dose 20mg) |
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Term
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Definition
Temazapam
Benzodiazepines:(Restoril) – highly hypnotic. Used mostly for sleep. (Equivalent dose 20mg) |
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Term
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Definition
Anxiolytic and hypnotic. Used very often in psychiatry for acute anxiety reactions, anxiety
disorders, alcohol detoxification, mania, catatonia, and insomnia. Increases GABA activity by increasing frequency of
Cl channel opening. Dose equivalence below based on dose of Lorazepam 1mg.Side Effects: Somnolence, amnesia, disinhibition, respiratory depression. Effects additive with ETOH and barbiturates.
Can treat acute OD (respiratory depression with Flumazenil. Withdrawal can also be lethal and results in anxiety,
insomnia, seizures, autonomic instability, tremor, and sweating (like ETOH). Use of Flumazenil can send someone into
acute withdrawal, so use with extreme caution. |
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Term
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Definition
All end in –barbital. Very narrow therapeutic index so very rarely used in psychiatry. Enhance
GABA, and no mare effective in anxiety than benzos. Used primarily for seizure d/o. |
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Term
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Definition
Used commonly for anxiety and insomnia in substance abuse populations. Do not use in the
elderly (may cause delirium). Study has shown that Hydroxizine may be just as effective for anxiety as low dose benzo
for maintenance therapy. |
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Term
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Definition
Diphenhydramine
Anti-histamines (Benadryl) |
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Term
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Definition
Hydroxyzine
Anti-histamines (Vistaril, Atarax) |
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Term
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Definition
Buspirone
*Other drug*
(Buspar) – Partial serotonin agonist, but no indication for depression. FDA approved
for GAD (at doses >30mg). May be used as adjunct with SSRI for anxiety/depression or
to alleviate sexual side effects (5HT1A). |
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Term
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Definition
Chlorpromazine
Typical Antipsychotic
Low potency:
(Thorazine)
Very sedating. Also used for hiccups. |
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Term
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Definition
Thioridizine
Typical Antipsychotic
Low potency:
(Mellaril)
Notorious QTc prolongation. Used often for sleep |
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Term
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Definition
Molindone
Typical Antipsychotic
Medium potency
(Moban)
only antipsychotic the shows weight loss |
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Term
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Definition
Perfenazine
Typical Antipsychotic
Medium potency
(Trilafon) – medium potency used in the mentioned study |
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Term
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Definition
Haloperidol
Typical Antipsychotic
High potency
(Haldol): - Most widely used typical. Can get bad EPS (“Haldol
Shuffle”). Dosed BID for psychosis in 5mg increments |
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Term
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Definition
Fluphenizine
Typical Antipsychotic
High potency
(Prolixin) - Very high potency |
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Term
| Typical Antipyschotic info |
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Definition
D2 receptor antagonists. The are often divided by potency. Low potency agents have increased sedation,
orthostasis, weight gain, anticholinergic symptoms and EKG changes. High potency agents produce more EPS and
akasthesia. Both can cause hyperprolactinemia, TD, and NMS.
High potency agents Haldol and Prolixin have decanoate forms which aids in compliance. Haldol – one shot every 4
weeks. Prolixin – one shot every two weeks.Side Effects (*rule of 4’s): 1. Dystonia: involuntary contraction on the muscles. Seen often in muscles of the face,
eyes, neck (torticollis), or back. Common with high potency typicals. Seen often in young AA males. Tx with cogentin
(benztropine) or diphenhydramine (benedryl). *Occurs 4hrs to 4days after initiation.
2. EPS: also known as parkinsonism. Observed to be rigidity, tremor, bradykinesia, masked. facies.
Check for “cogwheeling” on exam. Tx with benztropine or amantadine. *occurs 4days to 4mo
3. Akasthesia: feeling of internal restlessness especially in the lower extremities. Can tx with bblocker,
benztropine, or benzo. *occurs 4days to 4mo
4. Tardive Dyskinesia (TD): involuntary choreiform movements, seem mosst prominent in the
tongue. Also can be seen in the upper extremities and trunk. 5% incidence per year of exposure. Quantify by using
Abnormal Involuntary Movement Scale (AIMS). *occurs 4mo to 4yrs
5. Neuroleptic Malignant Syndrome (NMS): Rare side effect, but lethal. Hyperthermia, autonomic instability,
delirium, elevated CPK, diaphoresis, and rigidity. Tx with d/c of neuroleptic, aggressive IV hydration, temperature
control, and can use dantrolene or bromocriptine. |
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Term
| Atypicals Antipsychotic info |
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Definition
Antipsychotics with both D2 and serotonin receptor antagonism. Have become first line agents for
psychotic illnesses due to better SE profile than typicals (less incidence of EPS and prolactinemia). Also, seem to have
more efficacy in treating the negative symtpms of schizophrenia. It is assumed that these will produce less TD and
NMS (not proven – some increased incidence of NMS recently). Biggest issue with atypicals now is their metabolic
effects: weight gain, insulin resistance, and hypertriglyceridemia (need to check levels every 6mo).Atypicals are now being used for much more than SCZ. They also are being used for Bipolar d/o as tx for acute mania
(Seroquel, Risperdal, Zyprexa, Geodon, Abilify, Saphris, Invega), bipolar depression (Seroquel, Symbiax – Zyprexa
plus Prozac), and for maintenance (Zyprexa, Abilify). Also being studied in PTSD (Seroquel, Risperdal, Saphris).
Abilify and Seroquel now have indications for MDD adjunct therapy (with SSRI). Abilify and Risperdal also being
used with efficacy in Autism spectrum disorders for aggression and social withdrawal. Seroquel has some apparent
anxiolytic properties and is being looked at currently for GAD (study in progress). Some studies of atypicals in OCD as
well (Ability, Seroquel). |
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Term
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Definition
Aripiprizole
Atypicals Antipsychotic
(Abilify) – Dopamine antagonist/partial agonist. Neutral with regard to metabolic
effects. Dosed 10-30mg/day. |
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Term
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Definition
Olanzapine
Atypicals Antipsychotic
(Zyprexa) – Similar in structure to Clozaril. Most pronounced metabolic changes.
Dosed 10-20mg/day. |
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Term
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Definition
Queitiapine
Atypicals Antipsychotic
(Seroquel) – Very sedating, severe orthostasis. Wide dosing range 25mg-1200mg. Appears to
have clinical benefits in wide range of pathology (mania, depression, anxiety, OCD, PTSD). XR
formulation with no true benefits (maybe less sedation). |
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Term
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Definition
Risperidone
Atypicals Antipsychotic
(Risperdal) – Very effective for positive symptoms. Most like a typical and begins to act like one past 6mg/day (EPS, dystonia, akasthesia). Also increased prolactin more thanothers. Dosed 1-8mg/day. Newer version (Paliperidone-Invega) on the market, claims decreased SE profile. |
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Term
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Definition
Paliperidone
Atypicals Antipsychotic
(Invega) – Active metabolite of Rsperidone. Theory is that it has fewer side effect. Doesn’t
seem to be holding up, though.4wk depot available (Sustena). Dosed in 3mg steps |
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Term
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Definition
Iloperidone
Atypicals Antipsychotic
(Fanapt) - 6-24mg/day dosed BID |
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Term
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Definition
Ziprasidone
Atypicals Antipsychotic
(Geodon) – Fewer metabolic changes than others, but black box for increased QTc.
Dosed 20-80mg BID. At lower doses appears to have antidepressant effect. Give with food. |
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Term
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Definition
Lurasidone
Atypicals Antipsychotic
(Latuda) – No anticholinergic affinity. Marketed as a antipsychotic with less cognition changes,
low EPS and weight changes. 40-80mg/day. Give with food. Severe akasthesia side effect. |
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Term
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Definition
Asenapine
Atypicals Antipsychotic
(Saphris) – High 5HT affinity, low Ach affinity. Also some alpha-2 affinity (decrease fight or
flight). Dose 5-10mg BID. |
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Term
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Definition
Clozapine
Atypicals Antipsychotic
(Clozaril) – Gold standard for antipsychotic treatment. Considered an atypical, but truly
is its own medication. Must be titrated slowly to final dose due to its ability to decrease
seizure threshold. Other SE include agranulocytosis (rare), hepatitis (rare),
cardiomyopathy, orthostasis (frequent), metabolic SE, siallorhea (most common). Dosed
150-300mg BID |
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Term
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Definition
The majority of Mood Stabilizers are anticonvulsants (except Lithium). While it is not known exactly how they work,
the theory is that these agents work on postsynaptic second messengers to qwell a “kindling” phenomena, as seen in
seizure patients, that prevents manic episodes. Monitoring is very important as the chief SE of these medications are
dose dependant. Remember: Very (3) True (4) Levels (5). V-VPA, T-Tegretol, L-Lithium.Others: Other anti-epileptics have been used for Bipolar disorder as well. Oxcarbezapine (Trileptal) is a metabolite of
Tegretol and has fewer side effects on the liver. Topamax and Neurontin have also been used to some degree with
minimal evidence. |
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Term
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Definition
Valproate
Mood Stabilizer
(Depakote) – FDA for acute mania and maintenance therapy. Works better than
Lithium for mixed states. Level of 75-125 is therapeutic. Side Effects include
thrombocytopenia (rare), Stevens-Johnson (rare), acute liver failure (NON DOSE
DEPENDANT – very rare), and PCOD. More common SE are: incr LFT’s, nausea,
weight gain, alopecia. Do not use in pregnancy – neural tube defects. Dose 500-
3000mg/day. Available in ER form, if not dose should be split BID. |
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Term
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Definition
Carbamazepine
Mood Stabilizer
(Tegretol) – FDA approved for acute mania and maintenance. Level of 8-12 is
therapeutic. Notorious enzyme inducer (even induces itself and may have to incr dose in
4-8wks.) SE include agranulocytosis (rare), aplastic anemia (rare), severe hyponatremia,
SIADH. Common SE: dizziness, ataxia, blurred vision, hyponatremia, and elevated LFT.
Dosed 800-1200mg/day div BID-TID. |
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Term
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Definition
Lamotrigine
Mood Stabilizer
(Lamictal) – FDA approved for maintenance therapy. Used frequently in BP
depression (decreased depressive episodes in studies). Well tolerated with few side
effects, but most feared is Stevens-Johnson. You must titrate to therapeutic dose slowly.
Dosed 200mg/day. |
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Term
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Definition
Lithium
Mood Stabilizer
Gold standard for mood stabilization. FDA approved for bipolar mania, depression, and
maintenance. Unlike other agents Lithium is a natural elemental cation that is excreted by
the kidney (not metabolized in the liver). Narrow therapeutic index with therapeutic
levels btwn 0.8- 1.2. At levels above 2.5 emergent dialysis is needed to reverse SE.
Remember SE by LITHIUM: Leukocytes Increased (leukocytosis), Tremor,
Hypothyroidism, Increased Urine (DI), Moms beware (Ebstein’s Anomaly). Also has
FDA indication for acute suicidality. |
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