Mental Health Book

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Anti-psychoticAka: Antipsychotic, Neuroleptic

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  1. Indications
    1. Psychosis (e.g. Schizophrenia)
  2. Efficacy: Newer low potency agents
    1. Atypicals only slightly better than high potency agents
      1. Similar efficacy in control of Psychosis
      2. Slightly less Extrapyramidal Side Effects (EPSE)
        1. Clozapine has much less EPSE, but has diabetes risk
      3. Higher weight, lipid and diabetes related conditions
      4. Compliance is similar for both types of agents
      5. Atypical Antipsychotics are much more expensive
    2. References
      1. Barry (2003) Am Fam Physician 68(5):943
      2. Leucht (2003) Lancet 361:1581
  3. D2 Antipsychotic Agents: High Potency
    1. Extrapyramidal Side Effects (EPSE) with all
    2. Haloperidol (Haldol) or Haloperidol decanoate
    3. Perphenazine (Trilafon)
      1. Well tolerated with similar efficacy to other agents
        1. Lieberman (2005) N Engl J Med 353:1209
    4. Thiothixene HCl (Navane)
      1. Typical Dose: 10 mg tid
      2. Maximum Dose: 60 mg per day
    5. Fluphenazine HCl (Prolixin)
      1. Typical Dose: 2.5 mg PO bid
      2. Maximum Dose: 40 mg PO or 100 mg IM per day
    6. Trifluoperazine (Stelazine)
  4. D2 Antipsychotic Agents: Medium Potency
    1. Loxapine (Loxitane)
    2. Molindone (Moban)
  5. D2 Antipsychotic Agents: Low Potency
    1. Chlorpromazine HCl (Thorazine) - not available in U.S.
      1. Anticholinergic Symptoms
      2. Alpha adrenergic blockade (Hypotension)
      3. Sedation
      4. Maximum dose: 1000 mg per day
    2. Thioridazine HCl (Mellaril) - not available in U.S.
      1. Anticholinergic Symptoms
      2. Alpha adrenergic blockade (Hypotension)
      3. Sedation
      4. Maximum Dose: 800 mg per day
  6. Atypical Antipsychotics: Serotonin-Dopamine Antagonists
    1. DiBenzodiazepine (Clozapine, Clozaril)
    2. Olanzapine (Zyprexa)
    3. Quetiapine (Seroquel)
    4. Risperidone (Risperdal)
    5. Ziprasidone (Geodon)
    6. Aripiprazole (Abilify)
  7. Adverse effects
    1. See Extrapyramidal Side Effects (EPSE)
    2. Ventricular arrhythmia (including Cardiac arrest)
      1. Antipsychotic agent relative risk: 3.2
      2. Drugs studied
        1. Risperidone (Highest risk)
        2. Haloperidol (Second highest risk)
        3. Thioridazine
        4. Clozapine
      3. References
        1. Hennessy (2002) BMJ 325:1070
  8. Monitoring
    1. Extrapyramidal Side Effects (EPSE) - all agents
      1. Screen for Tardive Dyskinesia at each visit
      2. Screen for other EPSE symptoms
      3. Educate about Neuroleptic malignant syndrome
    2. Obesity Monitoring (all Antipsychotics)
      1. Calculate BMI every 6 months
    3. Diabetes Mellitus Screening (Newer, atypical agents)
      1. Baseline fasting Serum Glucose
      2. Hemoglobin A1C at four months after starting agent
      3. Screen for polyuria and polydipsia at each visit
    4. Hyperlipidemia (Newer, atypical agents)
      1. Baseline lipid profile
      2. Repeat lipids every 6 months if abnormal
        1. May decrease frequency to every 2 years if normal
    5. References
      1. Marder (2004) Am J Psychiatry 161:1334
  9. References
    1. Geddes (2000) BMJ 321:1371
    2. Glick (2001) Ann Intern Med 134:47
    3. Lieberman (2005) N Engl J Med 353:1209

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