Psychopharmacology Tips

Evidence on the efficacy and safety of with schizophrenia is limited. Toren et al. (2004) reviewed the literature on use of atypical antipsychotics in children and adolescents with schizophrenia. The major findings were:

• Risperidone, and possibly also olanzapine, may be the drugs of choice in children with comorbid tic disorders.
• Ziprasidone may be administered as an augmenting agent in children and adolescents with schizophrenia and comorbid anxiety and mood disorders.
• Risperidone, olanzapine and clozapine are effective in the treatment of aggression and mania.
• In children and adolescents receiving clozapine, olanzapine and quetiapine, particularly those with obesity or a family history of diabetes mellitus, fasting blood glucose and lipid levels must be monitored frequently. Weight gain might be better controlled when the children and their parents are properly informed about this adverse effect and diet is regulated.
• Hyperprolactinaemia is another major disadvantage of the atypical antipsychotics, especially risperidone. Hyperprolactinaemia can lead to hypogonadism-induced osteoporosis, galactorrhoea, gynaecomastia, irregular menstruation and sexual dysfunction. Other atypical antipsychotics, namely olanzapine and ziprasidone, have been reported to be prolactin sparing in adults, but may not be completely devoid of hyperprolactinaemic effects in children and adolescents. Thus, prolactin levels should be assessed routinely in young patients treated with atypical antipsychotics. Further, children and adolescents with hyperprolactinaemia-related effects should be switched to a prolactin-sparing agent, such as quetiapine.
• The use of typical antipsychotics has been limited to patients who are resistant to atypical antipsychotics, intolerant to their adverse effects, or require injections or depot preparations.

Ref: - Toren, P., Ratner, S., Laor, N. & Weizman, A. (2004) Benefit-risk assessment of atypical antipsychotics in the treatment of schizophrenia and comorbid disorders in children and adolescents. Drug Safety, 27, 14, 1135-1156.

• Constipation: encourage high-fiber diet, adequate fluid intake, use of aperients if persistent
• Fever: Symptomatic relief, check full blood count and look for sources of infection
• Hypersalivation: Consider use of hyoscine hydrobromide (upto 300 mcg tds), pirenzepine (upto 50 mg tds)
• Hypertension: Monitor closely, slow rate or halt dose increase, if persistent consider use of hypotensive agent (e.g., atenolol)
• Hypotension: advise caution when getting up quickly, monitor closely, slow or halt dose increase.
• Nausea: Consider use of antiemetic (avoid metoclopramide and prochlorperazine if previous problems with extrapyramidal side effects).
• Neutropenia/agranulocytosis: Stop Clozapine, if outpatient admit to hospital
• Nocturnal enuresis: avoid fluids in the evening, alter dose scheduling, if severe consider use of desmopressin
• Sedation: reschedule dosing to give smaller morning or total dose
• Seizures: Withhold clozapine for 24 hours, recommence at lower dose, consider prophylactic anticonvulsant
• Weight gain: Dietary and exercise counseling

Ref: - Semple, D., Smyth, R., Burns, J., Darjee, R. & McIntosh, A. (2005) Oxford Handbook of Psychiatry, New York: Oxford University Press.

Preictal and ictal depression do not usually require treatment with antidepressants, as an improvement in seizure frequency should reduce the occurrence of these forms of depression (Labert & Robertson, 1999). Antidepressant therapy will be usually necessary in patients suffering from interictal depression or comorbid depressive disorders. SSRIs are recommended as first-line treatment (Labert & Robertson, 1999, Kanner and Nieto, 1999; Kanner and Palac, 2000). Citalopram and sertraline can be considered first-line SSRIs because of their minimal pharmacokinetic interactions with antiepileptic drugs (Kanner and Nieto, 1999; Barry et al., 2001).

If depression develops, it should be determined whether the patient takes an antiepileptic drug with a known depression-inducing effect, or if treatment with an antiepileptic drug with mood-stabilizing effects was discontinued. In first case, replacement with an antiepileptic drug with mood-stabilizing effects, such as carbamazepine, valproate, lamotrigine, gabapentin or topiramate can be considered. In the latter case, the discontinued agent should be readministered (Labert & Robertson, 1999, Kanner and Nieto, 1999; Kanner and Palac, 2000). In agitated patients who require treatment with sedative preparations, mirtazapine can be considered a treatment option. In general, dosages should be increased carefully and in small increments. Regular EEG recordings are recommended (Prueter and Norra, 2005).

Ref: -

Barry, J.J., Lembke, A. & Hyunh, N. (2001) Affective disorder sin epilepsy. In: Ettinger, A.B. & Kanner, A.M. (Eds.), Psychiatric issues in epilepsy: a practical guide to diagnosis and treatment, Lippincott Williams and Wilkins: Philadelphia. pp 45 - 71.

Kanner, A.M. & Nieto, J.C. (1999) Depressive disorders in epilepsy. Neurology, 53, 5 (suppl 2), s 26 - s32.

Kanner, A.M. & Palac, S. (2000) Depression in epilepsy: a common but often unrecognised comorbid malady. Epilepsy and Behavior, 1, 37-51.

Labert, M.V. & Robertson, M.M. (1999) Depression in epilepsy: etiology, phenomenology, and treatment. Epilepsia, 40 (suppl 10), s21 - 47.

Prueter, C. & Norra, C. (2005) Mood disorders and their treamtnet in patients with epilepsy. Journal of Neuropsychiatry and Clinical Neurosciences, 17, 1, 20-28.

Goodwin and Goldstein (2003) advocate the following measures to prevent weight gain in patients on lithium carbonate:

Dietary/lifestyle measures

• Encourage daily physical exercise
• Restrict fluid intake to non-sugary liquids (e.g., water, diet soft drinks)
• Avoid intake of simple carbohydrates, particularly early in the day (lithium may induce mild hypoglycemia, causing patients to increase caloric intake as they “chase” their blood sugar through the day)

Medical/pharmacological measures

• Measure free T4 and supplement thyroid hormone if necessary (T4 at or below the lower quartile of normal may indicate hypothyroidism, another cause of weight gain
• If possible, avoid concurrent medications with additive weight gain effect
• Consult with primary care physician about other options if weight gain exceeds 5 lbs despite preventive measures

Ref: - Goodwin, F.K. & Goldstein, M.A. (2003) Optimizing lithium treatment in bipolar disorder: a review of the literature and clinical recommendations. Journal of Psychiatric Practice, 9, 5, 333-343.

After a detailed review of the literature, Allen and Hollander (2000) concludes that SSRIs are the first-line therapy for body dysmorphic disorder, with the dosage and length of trial similar to those used for OCD. In refractory cases, especially if delusional conviction is present, augmentation with low doses of atypical antipsychotics might be effective. Other augmentation strategies that are clinically used include adding bupropion, gabapentin, or stimulants such as dexamphetamine to the SSRI therapy.

Ref: - Allen, A. & Hollander, E. (2000) Body dysmorphic disorder. The Psychiatric Clinics of North America, 23 (3), 617 – 628.