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Handbook of Psychiatry 2021 v2 Sample 1
Handbook of Psychiatry 2021 v2 Sample 1
HANDBOOI'f OF PSYCHIATRY
2021
SAMPLE
SAMPLE
HANDBOOK OF
PSYCHIATRY
2021
Break-through anxiety....................56
Pain.................................................56
Pruritus...........................................56
Akathisia.........................................56
Dystonic reactions..........................56
Parkinsonism..................................57
Tardive Dyskinesia..........................57
Psychopharmacology.................................58
Drug Schedules......................................58
Terms & Definitions...............................58
Drug Levels, Labs, & Monitoring............60
Antipsychotics........................................61
SIDE EFFECTS (LEAST TO MOST)........61
Benzodiazepines....................................61
Benzodiazepine Equivalency Table: ..
64 Treating Extrapyramidal Symptoms. 64
Drug Interactions Table.........................65
High Yield Psychopharmacology concepts
.................................................................. 67
General Concepts...................................67
Lithium...................................................71
Antidepressants.....................................73
Antipsychotics........................................76
Mood Stabilizers....................................79
Important Drug-Drug Interactions.............81
Valproic acid (VPA) + Lamotrigine.........81
Carbamazepine (CBZ) is an inducer of
CYP3A4...................................................81
Lithium + NSAIDs (not aspirin), ACE
Inhibitors, Thiazide diuretics, low sodium
diet.........................................................82
Lithium + caffeine, theophylline, high
sodium diet............................................82
Grapefruit Juice......................................82
Smoking Tobacco cigarettes..................83
Tyramine................................................83
Fluoxetine, Paroxetine, and Bupropion
are potent inhibitors of CYP2D6............83
Antimicrobial-Psychotropic Drug
Interactions............................................84
Other Interactions/Adverse Reactions: 84
Medication Quick Reference.....................86
Fluoxetine (Prozac)................................86
Sertraline (Zoloft)...................................88
SiMPlY PSYCH EDU © HANDBOOK Of PSYCHiATRY
10
Paroxetine (Paxil)...................................90
Fluvoxamine (Luvox)..............................92
Citalopram (Celexa)...............................94
Escitalopram (Lexapro)..........................96
Duloxetine (Cymbalta)...........................98
Venlafaxine (Effexor)...........................100
Desvenlafaxine (Pristiq).......................103
Levomilnacipran (Fetzima)..................105
Bupropion (Wellbutrin).....................106
Mirtazapine (Remeron).....................108
Trazodone (Desyrel)..........................110
Vortioxetine (Trintellix).....................112
Tricyclic Antidepressants (TCAs)..........114
Buspirone (Buspar)..............................117
Gabapentin (Neurontin)......................119
SAM
Chief Complaint Reason for visit/admission
PE L
History of Present
Illness
Symptom (s)
SA
Employment History
Legal History (arrests, DUIs, prison time)
M PEL
Medical Constitu tional
Skin
R eview of
Systems HEENT
Neck
Cardiovascular
SAM
ALERTNESS/ORIENTATION
PE L
Is the patien t awake,
SA P L
Does the patient have a normal gait?
M E
SPEECH
How is the p atient’s
TREATING EXTRAPYRAMIDAL
SYMPTOMS
Side Effect Treatment Options
Acute Akathisia Propranolol (30mg-90mg/day)
Benzodiazepines
Diphenhydramine
Parkinsonism Reduce dose
Benztropine 1-2mg/day
Tardive Dyskinesia Reduce dose
Discontinue
Ingrezza
Hyperprolactinemia Reduce dose
(symptomatic) Discontinue
Acute Dystonia Benztropine 1mg-2mg IM
DRUG INTERACTIONS TABLE
Substrates Inhibitor Inducer
1 Caffeine Fluvoxamine Cimetidine Phenobarbital Modafinil
A Theophyline Fluoxetine Omeprazole Secobarbital Tobacco
2 TCAs Paroxetine Fluoroquinol. Carbamazepine Charcoal-
Ropinirole Sertraline Ticlopidine Phenytoin grilled meat
Duloxetine Rifampin
Mirtazapine
Clozapine
Haloperidol
Olanzapine
Asenapine
Tacrine
Zolmitriptan
GENERAL CONCEPTS
1) Elderly patients in general require lower doses of
medications due to normal changes in total body water
(TBW), muscle mass, fat %, and kidney/liver function
associated with aging.
2) In patients with hepatic impairment, adjust dose by
calculating the Child-Pugh Score (see above).
3) AST, ALT, and Alkaline Phosphatase are not
reliable indicators of hepatic function.
4) Young men with increased muscle mass who abuse
stimulants (methamphetamine) might be at higher risk for
extrapyramidal symptoms after administering high
potency antipsychotics (Minimal empirical evidence
supporting this, but mainly anecdotal support)
5) Seasonal Affective Disorder (SAD) can be treated with
light therapy. Bupropion is also effective.
6) Avoid beta blockers, if possible, in patients with COPD or
asthma
7) Oxazepam, Temazepam, and Lorazepam are typically used
in patients with hepatic impairment as they do not
undergo Phase 1 metabolism and primarily undergo
glucuronidation. (“Outside The Liver”)
8) Zolpidem (Ambien) and Zaleplon can case dissociative-like
state (sleep walking, binge eating, aggressive outbursts,
night driving) and the patient will not remember doing
any of those things
9) Restless Leg Syndrome: Replete iron if deficient. 1st line
treatment are dopamine agonists (levodopa, ropinirole,
pramipexole, rotigotine); Alternatives
are benzodiazepines (clonazepam), gabapentin,
anticonvulsants, opioids.
10) In patients who are overweight, obese, or who have a
large neck circumference: Think Obstructive Sleep Apnea
(OSA) if presents with excessive daytime sleepiness,
fatigue, irritability, or memory problems. Order a sleep
study.
11) Stimulants (Amphetamines, Methylphenidate), non-
stimulants (atomoxetine, a norepinephrine reuptake
inhibitor), and modafinil are used to treat ADHD and
narcolepsy
12) Stimulants can be used in terminally ill elderly patients
with depression and/or demoralization syndrome.
13) Stimulants in children/adolescents: side effects include
insomnia, anorexia, and tics
14) Remelteon is a good for initial insomnia due to short
half life.
15) Benzodiazepine overdose treated with flumazenil (may
precipitate seizures in those with pre-existing seizure
disorders)
16) Naloxone (Narcan) is used for opioid overdose. Has a
short half life so must give in intervals or patient may
revert back to opioid/opiate induced coma/respiratory
depression.
17) Anticholinergic agents (benztropine, atropine,
diphenhydramine, doxepin, low-potency antipsychotics)
can cause cognitive impairment, worsen dementia, and
precipitate delirium in the elderly.
18) Electroconvulsive therapy (ECT) is has shown efficacy for
severe refractory depression, depression during
pregnancy, psychosis, mania, catatonia, malignant
catatonia, and treatment refractory NMS
19) There are no absolute contraindications to ECT. Avoid ECT
in patients with intracranial masses (due to increased
intracranial pressure and risk of herniation). ECT alters
cerebral hemodynamics.
20) Ethanol is broken down to acetaldehyde by alcohol
dehydrogenase. Acetaldehyde is broke down to Acetyl
CoA by acetaldehyde dehydrogenase. Disulfiram inhibits
acetaldehyde dehydrogenase causing accumulation of
acetaldehyde (facial flushing, nausea, vomiting, etc.).
These reactions can occur with over the counter cough
syrups or anything with alcohol in it. It is most effective
for motivated patients with a good support system.
21) Narcolepsy (sudden REM sleep with loss of muscle
tone/cataplexy) is diagnosed by Multiple Sleep Latency
Test and treated with stimulants or modafinil.
22) Steady state of oral drugs is usually reached after 4-5 half-
lives (Example: Li takes ~5 days to reach steady state after
initiation or dose change)
23) Chronic alcoholic patients should always receive
parenteral thiamine before administering
glucose/dextrose
24) Treatment of Catatonia: Benzodiazepines (IV lorazepam
first line) or ECT
25) ECT side effects: musculoskeletal pain, amnesia, headache
26) Seizures: Potential culprits are clozapine, chlorpromazine,
clomipramine, bupropion, lithium (toxicity), abrupt
withdrawal from benzodiazepines or anticonvulsants.
Flumazenil also reduces seizure threshold.
27) Therapeutic Index (TI) = TD50/ED50
28) Propranolol (Inderal) is effective for social phobia (public
speaking), akathisia, and essential tremor
LITHIUM
1) Lithium is toxic to the thyroid gland
2) 5-10% of patients on lithium develop hypothyroidism, >30%
of lifetime lithium patients have elevated TSH
3) Check TSH levels prior to starting lithium, at 6 months, then
annually
4) Lithium Toxicity: Emergency dialysis indicated with
symptoms of toxicity (tremors, ataxia, slurred speech, AMS)
and Lithium levels > 2.5
5) Lithium is not protein bound and therefore is easily
dialyzed.
6) Dialysis is not a contraindication for using lithium. Dose
lithium immediately after dialysis only.
7) Lithium worsens skins conditions such as Acne and Psoriasis
8) Lithium’s mechanism of action is incompletely understood
but thought to interact with signal transduction pathways
(e.g., IP3 pathway)
9) Lithium and ECT: Lithium dose should be reduced or
discontinued in patients undergoing ECT (may cause
prolonged seizures)
10) Lithium use during pregnancy (especially 1st trimester)
increases risk of Epstein’s anomaly (congenital downward
displacement of tricuspid valve into the right ventricle)
11) Lithium level normal range is 0.6-1.2 (for acute mania target
should be 1.0-1.5)
12) Decreased lithium levels with: Theophylline, caffeine,
osmotic diuretics, acetazolamide, increased sodium intake
13) Increased lithium levels with: Na depletion, Diuretics,
NSAIDs (not aspirin), COX-2 inhibitors, Tetracycline, ACE
inhibitors
14) Lithium is also known to be a potential precipitant of
serotonin syndrome in people concurrently on
serotonergic medications such as antidepressants,
buspirone, and certain opioids such as pethidine
(meperidine), tramadol, oxycodone, fentanyl and others.
15) Lithium co-treatment is also a risk factor for neuroleptic
malignant syndrome in people on antipsychotics and other
anti-dopaminergic medications.
16) Lithium causes acquire nephrogenic diabetes insipidus in
about 50% of patients on long term Lithium treatment
17) Lithium treatment and EKG changes: T-wave flattening or
inversion
18) Lithium interferes with AV conduction and the pace making
activity of the sinus node (avoid in sick sinus syndrome).
Also avoid in Brugada syndrome (genetic defect of cardiac
sodium channels)
ANTIDEPRESSANTS
1) In Elderly patients with depression or anxiety: Use
SSRIs due to minimal side effects.
2) In Elderly patients with depression or anxiety: Avoid
tricyclic antidepressants (TCAs), if possible, due to
anticholinergic side effects (constipation, urinary retention,
cognitive impairment, delirium risk), cardiovascular side
effects, cognitive impairment, and orthostatic hypotension)
3) Selective Serotonin Reuptake Inhibitors (SSRIs) are first
line treatments for Obsessive Compulsive Disorder but
usually require higher doses than would be prescribed for
depression.
4) Clomipramine is most serotonergic of the Tricyclic
Antidepressants (TCAs) and therefore is a good choice for
SSRI-refractory Obsessive Compulsive Disorder.
5) All SSRIs, except maybe paroxetine, are very safe to use
during pregnancy. Sertraline and Fluoxetine are the best
first choices for pregnant patients as these have the most
data for safety.
6) Paroxetine and Sertraline are minimally secreted in
breastmilk and are the best choices for individuals who are
breastfeeding
7) SSRIs and the reported risk of persistent pulmonary
hypertension of the newborn during 2nd and 3rd
trimesters is controversial.
8) Safest SSRIs during pregnancy: Sertraline, Fluoxetine,
Citalopram
9) Safest SSRIs during breast feeding: Paroxetine, Sertraline,
Fluoxetine, Citalopram
10) Paroxetine is not a the best first choice as an
antidepressant and anxiolytic during pregnancy due to a
small risk of congenital defects
11) Paroxetine should be dosed once daily at bedtime due
to anticholinergic and antihistamine properties (usually
sedating)
12) Fluoxetine and Sertraline are generally considered more
“activating” SSRI antidepressants (but not always).
13) Paroxetine does not have an active metabolite and has a
relatively short half-life and therefore often causes
withdrawal syndrome when abruptly stopped.
14) Paroxetine has anticholinergic properties and a potent
inhibitor of CYP2D6
15) Sertraline (Zoloft) is a weight neutral SSRI
16) SSRIs have shown effectiveness in premenstrual dysphoria
and irritability. Also for “hot flashes” in perimenopause.
17) Bupropion is a good choice for patients who smoke or
have low libido.
18) Bupropion is a good choice for SSRI induced sexual side
effects.
19) Bupropion is a good choice for seasonal affective disorder.
20) Bupropion should be used with caution in patient’s with a
history of seizure disorders and/or eating disorders
(appears to lower the seizure threshold)
21) Bupropion is the least likely of the studied antidepressants
to induce mania or cause rapid cycling in depressed
patients with bipolar disorder
22) TCAs cause slowing of cardiac conduction leading to a
widening of the QRS complex and fatal heart blocks.
SAMPLE
23) Antidepressants with noradrenergic properties may be the
best choice for patients with depression and neuropathic
pain.
24) SNRIs be dosed in the morning as they can cause insomnia
if dosed too late in the day (but not always).
25) For patients with TCA overdose, the treatment of choice is
NaHCO3 (sodium bicarbonate)
26) Monoamine Oxidase Inhibitors (MAOIs) carry a risk for
hypertensive crises when used in combination with
tyramine rich foods (aged cheese, red wine, deli meats,
sausage, sauerkraut) as well as other catecholaminergic
drugs (ephedrine, pseudoephedrine, amphetamines, and
other monoamine antidepressants).
27) A discontinuation syndrome occurs most frequently with
Paroxetine, Sertraline, duloxetine, and venlafaxine when
abruptly stopped.
28) Fluoxetine is rarely associated with a discontinuation
syndrome due to its very long half-life (fluoxetine is often
used for SSRI discontinuation syndrome).
29) Trazodone: Risk of priapism “traza-BONE”
30) Trazodone has minimal anticholinergic activity and is a good
choice for elderly patients (but there is a risk for falls due to
alpha 1 antagonism and associated orthostatic
hypotension)
31) In patients with Bipolar Depression: Best choices are
Lithium, Quetipaine, Olanzapine-Fluoxetine combination,
Lurasidone, Lamotrigine, or Aripiprazole.
32) Before increasing the dose of antidepressants, ensure that
the antidepressant treatment has been administered for a
sufficient duration and at a sufficient dose. At least four (4)
weeks are needed before it can be concluded that a patient
is partially responsive or unresponsive to a specific
intervention. No treatment should continue unmodified if
there has been no symptomatic improvement after four (4)
weeks.
33) Serotonin Syndrome: Seen with TCAs, MAOIs, SSRIs, SNRIs,
Triptans, Linezolid, Methylene blue, meperidine, tramadol,
dextromethorphan, fentanyl, St johns wort, MDMA
ANTIPSYCHOTICS
1) Clozapine ANC Monitoring: Weekly for 6 months, then
biweekly for 6 months then monthly after 12 months
2) Neuroleptic Malignant Syndrome (NMS): Patient starts
typical or atypical antipsychotic then develops delirium,
fever, muscle rigidity, and extremely elevated CPK.
3) NMS can be caused by antipsychotics, phenothiazine
antiemetics (promethazine, prochlorperazine),
metoclopramide, or abrupt discontinuation of L-dopa.
4) NMS Treatment: Stop antipsychotic and administer
intravenous fluids (IVF). Also, use cooling blankets,
dantrolene, and/or bromocriptine if needed
5) Antipsychotics increase risk of extrapyramidal symptoms
(EPS). Typical antipsychotics are associated with higher
risk compared to atypical antipsychotics.
6) EPS includes Acute Dystonia, Pseudoparkinsonism,
Akathisia, and Tardive Dyskinesia.
7) Acute dystonia (painful muscle spasms and contractions)
can be lethal if laryngeal muscles involved.
8) Treatment of acute dystonia: Intramuscular benztropine
(Cogentin) or diphenhydramine (benadryl)
9) Tardive dyskinesia: Repetitive, involuntary movements
of the limbs, torso, and fingers. Grimacing, tongue
movements, lip smacking, lip puckering, pursing of lips,
excessive eye blinking
10) Treatment of Tardive Dyskinesia: Decrease dose or stop
the offending agent. Try one of the new treatments
available. If this is not possible, try clozapine.
11) Akathisia: Restlessness, can’t sit still, feel like they
always need to be moving, rocking back and forth in
chair.
12) Treatment of Akathisia: Propranolol.
13) Clozapine and Olanzapine are the most likely to cause
metabolic syndrome (insulin resistance, glucose
abnormalities, dyslipidemia), worsen diabetes, or even
precipitate diabetic ketoacidosis.
SiMPlY PSYCH EDU © HANDBOOK Of PSYCHiATRY
122
SIDE EFFECTS: Peripheral Edema, Dizziness, Fatigue, Ataxia,
Weight Gain
FDA INDICATIONS:
1) Diabetic Peripheral Neuropathy
2) Neuropathic Pain
3) Post-herpetic neuralgia
4) Partial Seizures
5) Fibromyalgia
Off label: Generalized Anxiety Disorder, Alcohol withdrawal,
Benzodiazepine withdrawal, cannabis use disorder, and
restless leg syndrome
ADDITIONAL INFORMATION:
Pregabalin is structurally similar to Gabapentin but
more potent with greater bioavailability.
Pregabalin is a schedule V controlled substance due to
potential for abuse/dependence (abrupt withdrawal can
cause insomnia, nausea, diarrhea, headache)
LITHIUM
ADDITIONAL INFORMATION:
Lithium is a cation metal first used in the 19 th century to
treat gout and discovered by John Cade in 1949 to exert
anti-manic effects
Lithium does not undergo metabolism and is not
protein bound. It is cleared via the kidneys.
Benign leukocytosis is common due to demarginalization of
WBCs
Despite being highly effective, lithium is not widely used
due to its narrow therapeutic index. Optimal plasma
concentrations for treatment of bipolar mood disorder are
0.8 to 1.2 meq/L, however, toxic signs and symptoms may
begin at concentrations as low as 1.5 meq/L and serious
toxicity with risk of permanent neurological injury may
occur at concentrations as low as 2.0 meq/L.
Lithium may worsen skin conditions such as acne and
psoriasis
Lithium use during the first trimester of pregnancy may be
associated with an increased risk of Epstein’s anomaly
(downward displacement of tricuspid valve into a
malfunctioning right ventricle) although this is
controversial. Note that lithium has been safely used in
pregnancy in select patients.
Lithium is easily dialyzed and can be administered
to patients on hemodialysis (Give dose after dialysis
treatment)
Caffeine may decrease lithium levels
Lithium + Haloperidol may increase the risk of NMS and
delirium
Lithium may cause abnormal involuntary movements
Lithium may increase the risk of serotonin syndrome if
administered with serotonergic agents
An increase or decrease of 300mg/day changes serum Li
levels approximately 0.25 mEq/L (rough estimate)
Effective for chronic suicidal thoughts in bipolar and
unipolar depression
Effective for aggressive and violent behaviors
Increased risk of nephrogenic diabetes insipidus (usually
reversible) – may be reduced with once daily dosing
Propranolol is an effective treatment for tremors associated
with lithium
Bradycardia, cardiac arrhythmia, sinus node dysfunction
may be seen with lithium therapy
VALPROIC ACID (DEPAKOTE)
SAMPLE
shown to be harmful so not a bad idea to use)
BREASTFEEDING: Avoid
FDA INDICATIONS:
1) Seizures
2) Acute Mania associated with Bipolar Disorder
3) Migraine prophylaxis
MECHANISM(S) OF ACTION:
Blocks voltage sensitive sodium channels
Increases brain concentrations of GABA
Unlike many other medications, lithium and the
antiepileptics alter brain signal transduction by dampening
axonal signal transmission and by inhibiting cellular
response to excitatory signals. Part of this is mediated by
partial blockade of voltage-dependent sodium
channels. This property alone is not sufficient as anti-
epileptics which DO NOT show benefit in bipolar illness
also exhibit inhibitory effects at voltage-dependent sodium
channels.
To date, the property best correlated with prophylaxis of
mood cycling has been depletion of the second-messenger,
triphosphoinositol (IP3).
Another candidate mechanism is increased guanine
synthase kinase, type 3, activity. This enzyme plays a role in
modulating both voltage and ligand-gated sodium channels.
SAMPLE
ADDITIONAL INFORMATION:
Valproic acid (Valproate) is considered an anticonvulsant
with mood stabilizing properties
se oUf anticonvulsants in mood disorders developed out of
research looking at the effects of anticonvulsants on seizure
activity and the process of “kindling” in mice (i.e.,
repeatedly inducing seizures via electrical stimulation
results in seizure activity even in the absence of any
stimulation).
Valproic acid (Depakote) was found to be superior to
lithium in type II bipolar illness and in rapid cycling illness
(but anticonvulsants and lithium together showed additive
benefits)
In manic patients, plasma levels greater than 45 ug/mL may
be required for antimanic effects (levels up to 100-125
ug/mL are often tolerated in manic patients)
There is no consensus on the therapeutic plasma level
range for valproic acid but likely between 50-100 ug/mL
Valproate inhibits Lamotrigine metabolism
Combination of valproate and lamotrigine increases
lamotrigine levels and increases risk of rash and SJS/TEN
The dose of lamotrigine must be decreased by half the
normal dose when given in combination with valproic acid
(valproic acid inhibits lamotrigine metabolism).
Valproic acid associated with dose-related
thrombocytopenia in ~24% of patients
Commonly associated with elevated liver enzymes
Valproic acid has been associated with encephalopathy,
specifically from elevated ammonia levels
Valproic acid + Topiramate increases risk of encephalopathy
Valproic acid metabolized primarily by liver but by
NonCYP450 enzymes
Valproic acid associated with Polycystic Ovarian Syndrome
(10% of women)
Valproic acid has been shown to be effective in neuropathic
pain
CARBAMAZEPINE (TEGRETOL)
PREGNANCY: AVOID
BREASTFEEDING: AVOID
FDA INDICATIONS:
1) Seizures
2) Trigeminal Neuralgia
3) Acute mania associated with Bipolar Disorder (Equetro)
ADDITIONAL INFORMATION:
Reports of CNS toxicity (dizziness, diplopia) associated
with combination of carbamazepine and lamotrigine
Metabolized primarily by CYP3A4 and also induces its own
metabolism by inducing CYP3A4
Induces multiple other CYP450 isozymes as well as P-
Glycoprotein
May test positive (false positive) for tricyclics (TCAs)
LAMOTRIGINE (LAMICTAL)
HOW TO DOSE:
If dosing without valproic acid:
>Initial 25mg PO Daily for two weeks
>Increase to 25mg PO BID for two weeks
>Increase to 50mg PO BID for two weeks
>If tolerated, can consolidate to once daily dosing
>Max dose without valproate typically 200mg per day
ADDITIONAL INFORMATION:
Lamotrigine shows prophylactic and antidepressant
properties, but is no better than placebo in treating mania
SAMPLE
amoL trigine has been shown to reduce glutamate release
and modulate reuptake of monoamines including serotonin
and dopamine
Lamotrigine has been shown to increase the time
between both depressive and manic episodes
May be a good add-on medication with lithium for bipolar
depression
Mostly case reports and open labeled trials support
lamotrigine in rapid cycling bipolar disorder, bipolar
depression, and mixed episodes but RCTs have not
consistently demonstrated efficacy for these conditions
Lamotrigine carries a risk of both benign rash and Steven
Johnson’s Syndrome/TEN
Rash associated with rapid dose escalation
Reduce dose and slow titration if benign rash develops
Interaction between valproic acid and lamotrigine: Valproic
acid inhibits lamotrigine metabolism; dose of lamotrigine
must be decreased by half the normal dose when given in
combination with valproic acid
Many hormonal contraceptives decrease lamotrigine levels
– Caution during contraceptive-free “pill-free” periods as
lamotrigine levels may rise substantially. Conversely,
lamotrigine may decrease levels of hormonal
contraceptives
Carbamazepine decreases lamotrigine levels
If lamotrigine stopped/missed for >5 half-lives then
strongly consider restarting titration
TOPIRAMATE (TOPAMAX)
SAMPLE
HALF-LIFE: 19-25 hours
FDA INDICATIONS:
1) Epilepsy
2) Prophylaxis of Migraine headaches
MECHANISM(S) OF ACTION:
Blocks voltage sensitive sodium channels
Inhibits glutamate release
Potentiates activity of GABA
Blocks calcium channels
Topiramate inhibits carbonic anhydrase (increased risk
of metabolic acidosis and kidney stones)
Topiramate may have prophylactic properties, but
appears to exert little benefit during acute bipolar
depression or mania.
ADDITIONAL INFORMATION:
Used in children with Lennox-Gastaut Syndrome
Carbamazepine increases elimination of topiramate
Topiramate may increase plasma levels of phenytoin
Topiramate is a weak inhibitor of CYP219
Topiramate is weak inducer of CYP3A4
Alcohol enhances sedation and may increase risk of seizures
METHYLPHENIDATE (RITALIN,
CONCERTA)
*IR (INSTANT RELEASE) | XR (EXTENDED RELEASE)
SAMPLE
Generic Name Brand Name Usual Typical
Starting Daily Dose
Dose Range
MPH, Methylphenidate;
SAMPLE
XR, Extended Release;
SR, Sustained Release;
LA, Long-Acting
FDA INDICATIONS:
1) Attention deficit hyperactivity disorder in children and
adults
2) Narcolepsy (R139italin, Concerta, 139Ritalin-sr,
R139italin-la)
ADDITIONAL INFORMATION:
HOW TO DOSE:
FDA INDICATIONS:
1) ATTENTION DEFICIT HYPERACTIVITY DISORDER IN
CHILDREN AND ADULTS
2) NARCOLEPSY
3) EXOGENOUS OBESITY
NOTABLE INTERACTIONS:
GI/Urinary Acidifying agents decrease plasma levels of
amphetamine
GI/Urinary Alkalinizing agents increase plasma levels
of amphetamine
Desipramine should be used with extreme caution if used
with amphetamine
Dopamine antagonists such as haloperidol and
chlorpromazine as well as lithium may inhibit the stimulant
effects of amphetamines
Amphetamines increase the pain relieving effects of
meperidine
Avoid using with monoamine oxidase inhibitors
(MAOIs) due to risk of hypertensive crises (extremely
high blood pressures) and malignant hyperthermia
(extremely high body temperatures)
ADDITIONAL INFORMATION:
Adderall is a mixture of the two isomeric forms of
amphetamine (D and L Amphetamine) in a ratio of 3 to 1 (D
to L)
HOW TO DOSE:
FDA INDICATIONS:
1) Attention deficit hyperactivity disorder in children and
adults
2) Narcolepsy
ADDITIONAL INFORMATION:
Dexedrine contains ONLY the dextro isomer of
amphetamine
LISDEXAMFETAMINE (VYVANSE)
SAMPLE
TARGET DOSING RANGE: 20mg-70mg per day
FDA INDICATIONS:
1) Attention deficit hyperactivity disorder in children and
adults
2) Binge eating disorder
ADDITIONAL INFORMATION:
Lisdexamfetamine is an inactive prodrug, which means it
needs to be metabolized in order for it to be active
Lisdexamfetamine is metabolized primarily by
gastrointestinal (gut) enzymes to the active metabolite
dextroamphetamine.
Snorting or injecting lisdexamfetamine will not result in
“highs” and therefore there is less abuse potential
overall
Anecdotally, patients experience less peripheral
sympathetic side effects and anxiety with lisdexamfetamine
(likely related to slower onset/offset of action but may also
be due to stereospecificity of dextroamphetamine (active
metabolite).
Lisdexamfetamine 70mg is approximately equivalent
to 30mg of D,L-Amphetamine (Adderall)
Some evidence suggests lisdexamfetamine may be
beneficial for residual depressive symptoms (but
controversial as RCTs failed to show separation from
placebo in treatment resistant depression)
TYPICAL ANTIPSYCHOTICS
SAMPLE
Fluphenazine Prolixin
Haloperidol Haldol
Loxapine Loxatane
Perphenazine Trilafon
Pimozide Orap
Thiothixene Navane
Trifluoperazine Stellazine
SAMPLE
Increased Appetite
Blood Pressure Changes and Lightheadedness
Dry Mouth
Urinary Retention/Difficulty Urinating
Constipation
Blurry Vision
Cognitive Impairment
Slowed Movements (Parkinsonism)
Emotional “Blunting” or “Flattening”
Seizures (rare)
Cardiac Arrhythmias (rare)
Tardive Dyskinesia
NEURODEVELOPMENTAL DISORDERS
Intellectual Disability
mild F70
moderate F71
severe F72
profound F73
Global dev’al delay F88
Unsp’d intel’al disabil. F79
Communication Disorders
Language disorders F80.9
Speech Sound do F80.0
Childh onset flu’cy do F80.81
Social (Pragmatic)
communication do F80.89
Unspec’d commun. Do F80.9
Autism spectrum do F84.0
SiMPlY PSYCH EDU © HANDBOOK Of PSYCHiATRY
237
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