1. Drugs in Psychiatry
Antipsychotics (Neuroleptics)
Prescribing:
“I wouldreviewthe needforthismedication:”
- Do theyneedanantipsychotic?
- Do theyneeda differentantipsychotic?
- Do theyneedthisdose?
PrescribingBZD:“…butI wouldfollowupfor 2-4 weekstopreventriskof dependence.”
Acute Dystonia- Groups of m. spasms.(e.g.oculogyric–eyesroll over, neckpulledovertoone side.)
Tardive Dyskinaesia – Incurable sloworbelatedonsetinvoluntarymovementdisorder –Orofacial – lipsmacking.Oppositeof Parkinson’sdisease.
Agranulocytosis –Acute neutropeniacausingimmune suppression.MustmonitorWCC
 Before:
o Check FBC
o Register Dr, Pt, Pharmacistwith drug Co.’s monitoringservice
 Subsequently:
o Weekly FBC for 18wks
o Fortnightly FBC for rest of year
o Monthly FBC thereafter.
Procyclidine– Antimuscarinictreatmentof EPSE:usedto balance ACh(excitatory)inresponseto↓dopamine(inhibitory)

2. Typical Antipsychotics (1st
Gen) Advantagesof Atypicals:
 Cheap
 Experience with use and SE
 Emergency – when oral route will taketoo long, can
be injected when pt acutely disturbed.
 Injected as a depot long term Tx. ↑ compliance.
(e.g. Flulpenthixol)
NAME OF MEDICATION Phenothiazines
 Chlorpromazine
 Trifluroperazine
Butropenones
 Haloperidol
 Droperidol
Thioxanthenes
 Flupenthixol
 Zuclopenthioxol
INDICATION Shizophrenia
Mania
Dopamine SE:
HyposthalamicPitutiaryAxis:
 ↑prolactin levels  galactorrhoea,impotence.
EPSE (Nigrostriatal):
 Acute dystonia – anticholinergic
 Parkinsonism–anticholinergic, (NOT L-dopa)
 Akathesia – β-blocker, BZD, anticholinergic
 Tardivedyskinaesia
AnticholinergicSE:
 Constipation
 Blurred vision
 Dry Mouth
 Confusion
Histamine SE:
 Sedation
α1 – SE:
 Postural HoTN
 Impotence
Other SE:
 Neuroleptic malignantsyndrome(rare, high
mortality 30-50%)
 Weight Gain
 Arrhythmia
 ↓seizure threshold
MECHANISMOF ACTION D2 receptorantagonism
(non-selective)
DOSE 0.5-3mg BD
Up to 30mg (resistant
schizophrenia)
Adjustdose forlowest
maintenance.
SIDE-EFFECTS EPSE EPSE EPSE
CAUTIONS
INTERACTIONS Amiodarone– CVS
tachyarrythmias,QTinterval.
ACEi & CCB – Enhanced
hypotensive effect
CONTRAINDICATIONS

3. Atypical Antipsychotics(2nd
Gen.) Advantagesof Atypicals:
 DifferentSEprofile (less
likelytocause EPSE- ↓risk
of tardive dyskinesia.
 As effective astypicals.
Disadvantages
 Expensive (notpreferentially
used1st
line)
 Many onlyavailable asoral
except:
o Olanzapine IM
o RisperidoneIM$$
COMMON SE OF ATYPICALS
 EPSE at highdose
 Sedation
 Weightgain,DM,
Cholesterol.
 ↓seizure threshold
 METABOLIC SYNDROME
GENERAL CAUTIONSATYPICALS
 CVSdisease - ECG
 Parkinson’sDisease–
exacerbatedwith
antipsychotics
 Photosensitisation –Avoid
sunlight.
NAME OF
MEDICATION
Clozapine Olanzapine Amisulpiride Risperidone Quetiapin
e
Aripiprazole
(Abilify)
INDICATION Onlydrug effective in
resistantSchizophrenia
If pt has not improved
after2 trailsof meds
then3rd
optionshould
alwaysbe Clozapine
Schizophrenia Acute
psychosis
Mania
Psychosis
Bipolar
MECHANISMOF
ACTION
D1, D2, 5-HT & α1 D1, D2, 5-HT, H1
antagonist
D2, D3
antagonist
D2, 5-HT, α1
antagonist
DOSE 12.5mg once
25-50mg on 2nd
day
Increase gradually
25mg intervalsif
well toleratedto
300mg
2mg day 1
4mg day 2
Maintenance
dose 4-6mg
SIDE-EFFECTS Sedation
Anticholinergic
Weightgain
↓↓seizure threshold
Hypersalivation
AGRANULOCYTOSIS
Constipation
Dry mouth
N+V
CAUTIONS
INTERACTIONS Diazepam– synergistic
Marrow suppressants -
increasedriskof BM
dysfunction
Citalopram
- ProlongedQTinterval
- Ventriculararrhythmia
CONTRAINDICATIONS CVSdisorders
- Myocarditis
- Prolongedtachycardia
Neutropenia
Coma/CNSdepression
Acute alcohol intoxication
- CNSdepression
- Avoidindrinkers.
Must monitor WCC
Before:
- Check FBC
- Register Dr, Pt, Pharmacistwith
drug Co.’s monitoringservice
Subsequently:
- Weekly FBC for 18wks
- Fortnightly FBC for rest of year
- Monthly FBC thereafter.

4. Antidepressants TCA SSRI SNRI NARI
NAME OF MEDICATION Amitryptilline
Imipramine
Dosulepin
Lofepramine
Fluoxetine(Prozac)
Citalopram
Paroxetine(Seroxat)
Sertraline (Lustral)
Venlafaxine Raboxetine
INDICATION Depressive illness
Migraine prophylaxis
Helpful inresistant
disease where SSRIfail.
Rarelyused
MECHANISM OF ACTION Inhibitreuptake of 5-HT& NA Selectiveserotoninreuptake
inhibition.
Serotonin+
Noradrenalinereuptake
inhibitor.
NA reuptake
inhibitor.
DOSE
SIDE-EFFECTS Anticholinergic
- Dry mouth
- Constipation
- Blurredvision
Histamine
- Sedation
α1
- Postural HoTN
- Impotence
Quinidinelike
- ECG changes
- Arrhythmia
5-HT
- GI upset,sweating
NA
- TREMOR
GI – Nausea, Diarrhoea
Sweating
Insomnia/agitation/akathesia
Sexual dysfunction
↓seizure threshold(inep.)
Discontinuationsyndrome
Generallywelltolerated.
SimilartoSSRI,
Can getdiscontinuation
syndrome:“Brainzaps”
Interferencewithnormal
social function
Nausea
Insomnia
Tremor
CAUTIONS DANGEROUS IN OD
DANGEROUS IN CVSDISEASE
INTERACTIONS
CONTRAINDICATIONS
TCA withdrawal symptoms:
 ↑anxiety
 Sleepdisturbance
 Psychoticfeatures
Cautionabruptwithdrawal 
seizures,coma&death.

5. α2 ReceptorAntagonist MAOI ECT Psychosurgery
NAME OF
MEDICATION
Mirtazipine
Mianserin
Isocarboxazid
RIMA moclobemide
Phenelzine
Tranylcypromine
Depression (if severe orresistant)
Mania(infrequently)
Schizophrenia (rarely)
Indications:
Intractable depression
OCD
Techniques:
Cingulotomy
Subcaudate
tractotomy
Section57 MHA (2nd
opinion+consent)
INDICATION α2 receptorantagonist
(some postsynaptic5HT
action)
Rarelyused unlesspartof
combinationtherapy - not
veryeffective
Anaesthetic+ muscle relaxant
Brief pulse of electricity
Modifiedgrandmal fit(15-60s)
Bilateral
 Electrode oneachtemple
 More effectivethan unilateral andeasierto
administer
 ↑memoryimpairment
Unilateral
 One electrode onRtemple one onback of
head.
 Technicallydifficult&lesseffective
↓memoryimpairment
LEGALITY :
Informal Pt. – Informedconsent
DetainedPt.
Either informedconsent
Or 2nd
opinionfromMHA commissionedDr.(SOAD)
Emergency – can give 1-2 Tx while waitigforSOAD
SIDE EFFECTS:
Mortality1/22,000
Headache
MemoryImpairment.
 STM esp.autobiographical
 No evidenceforpermanentdmg.
MECHANISMOF
ACTION
Preventbreakdown of:
 Serotonin
 Melationin
 Adrenaline
 Noradrenaline
 Dopamine
 Tyramine
DOSE
SIDE-EFFECTS Sedation&weightgain
MianserinCan cause
blooddyscrasias
Cheese rxn  HTN crisis
stroke death.
CAUTIONS
INTERACTIONS TCA (2wksposst)
Cheese rxn  HTN crisis
stroke death.
CONTRAINDICATIONS CVSdisease
Pheochromocytoma
Elderly

6. Bipolar
Management
Mood Stabilisers Anti-Epileptics Atypical
Antipsychotics:
 Quetiapine
 Olanzapine
 Aripiprazole
 Asenapine
Mania:
 Valproate
 Olanzapine
Depression
 Lamotrigine
 Quetiapine
NAME OF MEDICATION Lithium SodiumValproate Carbamazepine Lamotrigene
INDICATION Mania Epilepsy –TC, absence
Mania
Epilepsy –TC
Mania
Epilepsy - TC,Absence
Depressive symptoms
MECHANISMOF ACTION Unknown ↑GABA
Na channel inhibitor
Na channel inhibition Na channel inhibition
DOSE
SIDE-EFFECTS Thyroid– Hypothyroid,
goitre
Renal – Polyuria,renal
damage
CNS– Tremor
Weightgain
Teratogenicity 
Ebstein’sCNS
abnormality.
VALPROATE
Appetite increase
Liverfailure
Pancreatitis
Reversible hairloss
Oedema
Ataxia
Teratogenicity,Tremor,
Thrombocytopenia
Encephalopathy(due to
↑ammonia)
Blurredvision,impaired
balance,mild
erythematousrash,
drowsiness,headaches,
coordination
impairment,decreased
alcohol tolerance.
CAUTIONS Dehydration
Li Toxicity:
 Diarrhoea
 Coarse Tremor
 Confusion
 Ataxia
 Slurredspeech
 UNM signs
 Seizures
Death
Agranulocytosis
(↓WCC)
INTERACTIONS Anythingaffecting
kidneys:
 NSAIDS
 ACEi
Diuretics
CONTRAINDICATIONS

7. Alzheimer’s MemoryEnhancingDrugs - Anticholinesterases
NAME OF MEDICATION Donepezil
INDICATION Alzheimer’sDisease Only
- Onlyinearlydisease
- Givenas trail
- Monitorcarefully
MECHANISMOF ACTION Final pathwayof
Alzheimer’sislossof
cholinergicfunction.
Improve Chfunc.Improve
symptoms?
- Cognitive
improvement
- May slow
decline/temporarily
stop/improve
- Nota cure.
DOSE
SIDE-EFFECTS
CAUTIONS Rapiddecline if donepezil
stopped.
INTERACTIONS
CONTRAINDICATIONS

8. Alcohol
Dependence
1. Detoxification 2. Maintaining Abstinence If alcohol abruptly
stoppedptmay die
of eitherfitsorDT.
WKS – Alcohol
entersKrebb’scycle
to produce energy
afterthe step
requiringthiamine.
If glucose given
bodywill suddenly
switchenergy
source and krebbs
will require
thiamine.Therefore
body’sdepleted
thiamine supply
will↓↓ punches
holesinthe brain
 Acute
confusional state.
Sedatives - BZD B-vitamins
NAME OF
MEDICATION
Diazepam Chlordiazepoxide Thiamine PO/IV Disulfiram
(Antabuse)
Acamprostate Naltrexone
INDICATION Preventsimplewithdrawal,DT,
fits.
Prevention
Wernick-Korsakoff
syndrome
MECHANISMOF
ACTION
Fool brainto replace alcohol
withBZD.
Inhibitaldehyde
dehydrogenase
causingunpleasant
reactionondrinking.
GABA
analogue –
reduces
craving
Parial
opiate
agonist–
reduces
craving
(NOT
LISCENCED
IN UK)
DOSE
SIDE-EFFECTS
CAUTIONS Cross Tolerant
(Will have developed tolerance
to BZD as a result of alcohol.)
INTERACTIONS
CONTRAINDICATIONS

9. NAME OF MEDICATION
INDICATION
MECHANISMOF ACTION
DOSE
SIDE-EFFECTS
CAUTIONS
INTERACTIONS
CONTRAINDICATIONS