a brief overview of psychotropic medications coni kalinowski, m.d. 8 february 2013

A Brief Overview of A Brief Overview of Psychotropic MedicationsPsychotropic Medications

Coni Kalinowski, M.D.Coni Kalinowski, M.D.

8 February 20138 February 2013

Some general principles regarding Some general principles regarding medications: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 Some general principles regarding medications: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 Antipsychotic Medications (Neuroleptics)(Neuroleptics)

• Conventional medications (older):• haloperidol (Haldol)• fluphenazine (Prolixin)• pimozide (Orap)• trifluoperazine (Stelazine)• thiothixene (Navane)• perphenazine (Trilafon)• mesoridazine (Serentil)• loxapine (Loxitane)• molindone (Moban)• thioridazine (Mellaril)• chlorpromazine (Thorazine)


Atypical medications (newer):• clozapine (Clozaril)• risperidone (Resperidal)• olanzapine (Zyprexa)• quetiapine (Seroquel)• ziprasodone (Geodon)• aripiprazole (Abilify)• paliperidone (Invega)• iloperidone (Fanapt)• asenapine (Saphris)• lurasidone (Latuda)


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 Common Side effects of antipsychotics:antipsychotics:

• 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 Common Side effects of antipsychotics:antipsychotics:

• 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 Neurological side effects of antipsychoticsantipsychotics

• Parkinsonian Side Effects– 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


• Akathisia– 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


• Dystonia– 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


• Tardive Dyskinesia– 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:

• 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 Serious side effects of antipsychoticsantipsychotics

• neutropenia• seizures• neuroleptic malignant syndrome• cardiac arrhythmias• hyperthermia• cataracts• precipitation of glaucoma• priapism• diabetes• hyperlipidemia

AntidepressantsAntidepressants

• SSRI's – fluoxetine (Prozac)– sertraline (Zoloft)– paroxetine (Paxil)– fluvoxamine (Luvox)– citalopram (Celexa)– escitalopram (Lexapro)


• SNRI's and Novel agents– trazodone (Deseryl)– nefazodone (Serzone)– venlafaxine(Effexor)– bupropion (Wellbutrin)– mirtazepine (Remeron)– duloxetine (Cymbalta)– desvenlafaxine (Pristiq)– vilazodone (Viibrid)


• Uses:– 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 Common side effect of antidepressants: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 Common side effect of antidepressants:antidepressants:

• 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 Serious side effects of antidepressantsantidepressants

• 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 MedicationsAnticonvulsant Medications

• Divalproex sodium (Depakote)

• Carbamazepine (Tegretol)

• Oxcarbazapine(Trileptal)

• Topiramate (Topamax)

• Lamotrigine (Lamictal)

• Gabapentin (Neurontin)

Anticonvulsant MedicationsAnticonvulsant Medications

• Uses:– treatment of seizure disorders – treatment of mood swings – treatment of explosive aggression– treatment of complex post-traumatic

stress disorder

Common side effects of Common side effects of anticonvulsants:anticonvulsants:

• 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 Serious side effects of anticonvulsantsanticonvulsants

• Tegretol -

• agranulocytosis

• aplastic anemia

• hyponatremia

• hypothyroidism

• toxic epidermal necrolysis

• Stevens-Johnson syndrome


• Depakote –

• hepatic failure

• thrombocytopenia

• polycystic ovary

• anemia

• pancreatitis

• hyperammonemia


• Neurontin –

• elevated liver enzymes

• hypertension

• increased lability

• sudden death elevated liver functions

• pure red cell apalasia (risk in hemoglobinopathies)


• Trileptal- hyponatremia

• severe cognitive SE

• Topamax – severe cognitve SE

• kidney stones

• hyperthermia, oligohidrosis

Common Medication ErrorsCommon 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


• Polypharmacy (more than one drug in the same class)– Common causes:– adding a new medication without

removing ineffective medications.

– stalled cross titration


• 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.


• 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.


• 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.

a brief overview of psychotropic medications coni kalinowski, m.d. 8 february 2013

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