Kwame Nkrumah University of

Science & Technology, Kumasi, Ghana

PHADT 554 INTEGRATED PATHOPHYSIOLOGY AND PHARMACOTHERAPY OF

NEUROPSYCHIATRY SYSTEM

PSYCHOPHARMACOLOGY OF MOOD
DISORDERS
J. Parkinson

W.K.M. Abotsi, PhD

Associate Professor
Department of Pharmacology, KNUST
Location: C116 Tackie Building, FPPS
Email: wkmabotsi.pharm@knust.edu.gh
 Further Reading
▪Zeind CS, Carvalho MG. (2017). Applied Therapeutics: The
Clinical Use of Drugs (2017). 11th Edition. LWW
▪Boland R., Verdiun, M. & Ruiz, P. (2021). Kaplan & Sadock’s
Synopsis Of Psychiatry. 12th Edition. Philadelphia: Wolters Kluwer
▪Dodds LJ. (2013). Drugs in Use. 5th Edition. Pharmaceutical Press
▪Anderson IM, Mcallister-Williams RH (2016). Fundamentals of
Clinical Psychopharmacology. CRC Press/Taylor & Francis
▪Brunton, L. L., Hilal-Dandan, R. and Knollmann, B.C. (2018).
Goodman & Gilman's: The Pharmacological Basis of
Therapeutics. 13th Edn., New York: McGraw-Hill.
▪UpToDate, Waltham, MA

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 Neurobiology of depression
▪Knowledge about pathophysiology of depression is
rudimentary
▪Depressive disorders may represent an interactive matrix of
reciprocally interactive pathophysiological mechanisms.
oRole of monoamines (monoamine hypothesis)
oRole of neurotrophins & neurogenesis (neurotrophic hypothesis)
oRole of neuroendocrine & neuroimmune interactions
–Hypothalamic-pituitary-adrenal (HPA) axis dysfunction (+role of stress
response)
–Cytokine hypothesis - IF-α, TNF-α , IL-6, IL-1β, etc (role of inflammation)
oRole of glutamate (glutamate theory)
–Rapid actions of ketamine, AMPAkines, etc
oOthers

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 MONOAMINE HYPOTHESIS
▪Proposes that patients with depression have a functional deficit of
monoamine transmitters (NA, 5-HT) at certain sites in the brain.
oSchildkraut (1965) – Proposed catecholamines (NA, DA) to be functionally
deficient in depression and elevated in activity in mania.
oAshcroft – Proposed indolamines (5-HT) to be functionally deficient in
depression.
▪Two primary lines of evidence
oPharmacological effect of antidepressants (TCA, MAOI)
oIn the past, medication of hypertension with reserpine induced depression
▪Several challenges including
oEvidence for primary monoamine disturbance in depressed subjects is limited
and somewhat inconsistent.
oThe effect of ADs on neurotransmitter levels is relatively quick but onset of
antidepressant action is significantly delayed
oDoes not explain satisfactorily the similarity in efficacy of very different agents
acting differentially on monoamine systems.

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Mechanism - neurotransmission

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 MECHANISM OF ACTION of antidepressants

■ Inhibition of SERT, NET

■ Discrepancy between fast
■ Inhibition of MAO onset of neurochemical
■ Monoamine receptor antagonism (e.g. 5HT2) effects and slow onset of the
■ Melatonin receptor agonism (Agomelatine) antidepressant effects 6
Antidepressant drug CLASSIFICATION
▪Monoamine Uptake Inhibitors
oTricyclic antidepressants (TCA)
oSelective Serotonin Re-uptake Inhibitors (SSRI)
oSerotonin-Noradrenaline Reuptake Inhibitors (SNRI)
oNoradrenaline-Reuptake Inhibitors (NRI)
– Atomoxetine, reboxetine
oNoradrenaline-Dopamine Reuptake Inhibitors (NDRI)†
▪Monoamine oxidase inhibitors (MAOI)
▪Atypical antidepressants
oBupropion†, trazodone, nefazodone, mirtazapine, mianserin,
agomelatine, vortioxetine, vilazodone

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PHARMACOTHERAPY – general points

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 PHARMACOTHERAPY – general points
▪“Therapeutic lag" lasting 2-4 weeks before a measurable
therapeutic response becomes evident
oECT for severe depression when delay is hazardous or intolerable
▪ADs are not recommended as monotherapy for bipolar illness
o“Switch" from a depressed episode to a manic or hypomanic episode
▪Increased potential for agitation, anxiety & suicidal ideation
during 1st few weeks of treatment
▪ADs are not addictive but discontinuation syndrome may occur
after (abrupt) stopping treatment
ousually mild & self-limiting, but may be severe

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 HISTORY of antidepressants

1st
gen

---*TeCA

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 History

2nd Gen.

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History

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 SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (SSRI)

▪Most common first-line antidepressants used for

depression and anxiety disorders
oImproved tolerability, safety in overdose
▪All share the property of relatively selective
5-HT reuptake blockade but are structurally
distinct.
oMost have some minor degree of other actions on
different neurotransmitter systems

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 SSRIs
▪Fluoxetine (prototype) – 20-60mg/day
▪Fluvoxamine – 50-300mg/day
▪Paroxetine – 20-60mg/day
▪Sertraline† - 50-200mg/day
▪Citalopram – 20-40mg/day
▪Escitalopram (S-enantiomer of Citalopram) – 10-20mg/day

†
Sertraline has been shown to be safe in patients with unstable angina or who have had a recent myocardial infarction.

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 Pharmacokinetics
▪Good absorption after oral administration
▪Important biotransformation in the liver
oCYP450 – 2D6 and 2C19 isoforms (polymorphism →
interindividual variability in the clinical effect) and active
metabolites (e.g. fluoxetine)
oFluoxetine and paroxetine are potent inhibitors of the
CYP2D6; fluvoxamine is an inhibitor of CYP3A4
▪Elimination t½ consistent with once-daily dosing
oFluoxetine has the longest half-life
– has to be discontinued 4 weeks or longer before an MAOI

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 Adverse effects
▪GI symptoms – nausea, vomiting, diarrhoea, dry mouth
▪Headache, insomnia/somnolence, fatigue
▪Anxiety or agitation during early treatment (BDZs might be of benefit)
▪Sexual dysfunction (erectile dysfunction, anorgasmia, and ejaculatory
delay) - more prominent with paroxetine
▪Increased risk of (GI) bleeding (esp. + NSAIDs)
▪Serotonin syndrome upon intoxication or drug interactions (allow washout
between 2-5 weeks)
▪Discontinuation syndrome possible with short half-life drugs (e.g
paroxetine)
▪Paroxetine – teratogenic risk (cardiac) in 1st trimester of pregnancy

RARE: Bruxism, EPS, SIADH, QTc elongation (citalopram), etc

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 SSRI-induced sexual dysfunction
▪Patience. Wait for tolerance to develop (may
improve after 2-4 wks)??
▪Reduce the current dose (if possible)??
▪Drug holidays (sert., parox., cital., & escital. only)
▪Antidotes
oBupropion, sildenafil, mirtazapine, cyproheptadine,
methylphenidate, yohimbine, amantadine, buspirone, gingko
▪Switching to antidepressants with little risk of
inducing sexual dysfunction e.g. bupropion and
mirtazapine

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 Interaction with other drugs
▪Based on plasma protein binding and CYP blockade
oincreased effect of co-administered TCA
o Start low, go slow to evaluate the potential importance of the interaction

▪Serotonin syndrome (+MAOIs, TCA, linezolid, some

opioids e.g. pethidine, dextromethorphan, tramadol)
oA rare but potentially fatal interaction from the combination
Triptans? of two or more drugs that enhance serotonergic
transmission
ohyperthermia, changes in mental status (confusion, agitation),
neuromuscular abnormalities (hyperreflexia, tremor, clonus, myoclonus,
and rigidity), autonomic instability (diaphoresis, ↑/↓BP, tachycardia,
and tachypnoea)

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Serotonin syndrome

▪Tx: discontinue serotonergic agent, treat symptoms?, give serotonergic

antagonists e.g. cyproheptadine, methysergide. Dantrolene?

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 Indications
▪Major depressive disorder
oFirst-line agents
oDoubtful efficacy and increased risk of harmful outcomes in
individuals<18; only fluoxetine has been shown in trials to have a
favourable risk/benefit ratio
▪Anxiety disorders
oGAD, PD, SAD
▪OCD, PTSD, PMDD, bulimia nervosa
▪PE
▪Ischaemic stroke motor recovery (fluoxetine)

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 SEROTONIN-NORADRENALINE REUPTAKE INHIBITORS (SNRI)
▪Venlafaxine (75-225 mg/day) ■ Sibutramine
Obesity
▪Desvenlafaxine
■

■ Tramadol
▪Duloxetine ■ weak SNRI with weak

▪Milnacipran
μ-opioid receptor agonist
effects
▪Levomilnacipran

■ Venlafaxine inhibits 5-HT reuptake at low doses, with

additional NE reuptake at higher doses (>112.5
mg/day).
■ All active orally. Venlafaxine and duloxetine are
metabolised by CYP2D6
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 SEROTONIN-NORADRENALINE REUPTAKE INHIBITORS (SNRI)

▪Indications
oMajor depressive disorder, anxiety disorders (GAD, PD, SAD), PTSD
oDiabetic neuropathy, fibromyalgia, stress urinary incontinence (duloxetine);
perimenopausal symptoms e.g. hot flushes & insomnia (desvenlafaxine)
▪Adverse effects
oHeadache, insomnia, sexual dysfunction, hypertension, dry mouth, dizziness,
sweating and decreased appetite.
oDuloxetine--hepatotoxicity and is contraindicated for patients with hepatic
impairment
oVenlafaxine has been associated with an increased risk of manic switch in
bipolar depression.
▪Overdose
oCNS depression, serotonin toxicity, seizure, cardiac conduction abnormalities.

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 TRICYCLIC ANTIDEPRESSANTS (TCAS)
▪Chemical structure with characteristic three-ring nucleus – lipophilic nature
▪Prototype: Imipramine (Tofranil); originally developed as an antipsychotic
(1949), but was found to have no effect in this indication.

▪Neurochemistry
oBlockade of re-uptake of monoamine neurotransmitters (NA &
5-HT) by competition for binding site of the carrier protein.
o5-HT and NA neurotransmission is similarly affected but the effect
on the dopamine system is much less important (compare with
cocaine)
oWith most TCAs, other receptors (incl. those outside the CNS) are
also affected: blockade of H1-receptor, α-receptors, M-receptors
oMost are Na+ and L-type Ca2+ channel blockers.

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 Examples imipramine

▪Imipramine (prototype) – 100-300 mg/day

▪Desipramine (demethylated form, the active metabolite of imipramine) –
100-300 mg/day
Ini.
Dose: 25 ▪Amitriptyline – 100-300 mg/day
mg/d
▪Nortriptyline (demethylated form, the active metabolite of amitriptyline)
– 50-200 mg/day
▪Clomipramine – 100-250 mg/day
▪Others: dosulepin, doxepin, lofepramine, trimipramine, amoxapine*

▪Clinical use and efficacy is relatively close within the group; the more significant
difference is in their adverse effects

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Indications
▪Major depressive disorder
oNot first line agents
oAppears to be especially effective in severe depression
(hospitalized patients)
oNot effective in children
▪Obsessive compulsive disorder – clomipramine
▪Enuresis – imipramine
▪Neuropathic pain
▪Migraine prophylaxis
▪PE – clomipramine

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 Pharmacokinetics
▪Well absorbed orally but may undergo first-pass
metabolism
▪Strong binding to plasma proteins (90-95% bound).
Have high volumes of distribution and are not readily
dialyzable.
▪Extensive hepatic metabolism is required before their
elimination; some metabolites are active. CYP450
polymorphisms!
▪Long plasma half-lives usually permit once-daily dosing
▪Relationship between plasma levels & efficacy in depression ---TDM

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 Adverse effects
▪TCA are effective antidepressants but their use is complicated by
numerous troublesome adverse effects
▪Anticholinergic: Dry mouth, blurred vision, constipation, urinary retention (more in
amitriptyline, less in imipramine), palpitations, tachycardia, etc
▪α1-adrenoceptor blockade: Postural hypotension+reflex tachycardia (frequent in
elderly), dizziness
▪H1-blockade: sedation, drowsiness, difficulty in concentration (esp. amitriptyline),
weight gain
▪Sexual dysfunction: erectile dysfunction, anorgasmia, ejaculatory delay --
Possible problems with compliance ?!!!
▪Cardiotoxicity (Na+ and Ca2+ channel blockade): QTc prolongation, arrhythmias and
possibly ST elevation.
▪Neurotoxic: Delirium, movement disorders, seizures, coma.
▪Discontinuation syndrome

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 Acute toxicity
▪TCAs have low TI and hence very dangerous in overdose
▪Frequently used for suicide attempts – patients with depression
often have suicidal tendencies
▪Precautions
otaking care about patient education (remind him/her that
2-4 week delay in the effect is anticipated and that it is
NOT a failure of medication)
oprescription of limited quantities of TCA
ohigh risk patient should be treated under supervision of
specialists or treated as inpatients

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 Acute toxicity
▪Toxic effects mainly affect CNS and heart
oExcitement and delirium → convulsions →coma and respiratory
depression lasting for some days. Pronounced atropine-like effects.
oCardiac dysrhythmias, sudden death (rare) may occur from ventricular
fibrillation.
oHypotension
▪Treatment
oCardiac monitoring, airway support, and gastric lavage.
oDiazepam (seizures)
oSodium bicarbonate is often administered to uncouple the TCA from
cardiac sodium channels.
oNo effect of haemodialysis and haemoperfusion is practically
ineffective

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 Interaction with other drugs
▪Elevated plasma levels
–Phenytoin, aspirin, phenothiazines, etc
• competition for binding sites on pl. proteins
–antipsychotics, methylphenidate, oral contraceptives, some
SSRIs
• inhibition of hepatic TCA metabolism (CYP2D6)
▪Serotonin syndrome (+MAOIs)
▪Interferes with the action of antihypertensives (e.g.
methyldopa)
▪Prolongs and profounds the effect of: alcohol and
anaesthetic agents; sympathomimetic amines

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 NORADRENALINE REUPTAKE INHIBITORS (NRI)

▪Reboxetine – also rather activating

oAdverse effects: Dizziness, Insomnia, anticholinergic effects
▪Maprotiline
oActions similar to TCAs but fewer sedative and
antimuscarinic actions
▪Atomoxetine

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 MONOAMINE OXIDASE INHIBITORS (MAOI)
▪The risk of adverse reactions with older MAOIs has relegated
them to specialist use after failure to respond to other drugs.
▪Neurochemistry
oInhibition of MAO-A in CNS neurons → increased
cytoplasmic pool of monoamines (5-HT, NE, DA)
▪In contrast to other antidepressants, when given to normal
non-depressed subjects they increase motor activity and
cause euphoria + excitements (while TCA would cause only
sedation and/or confusion). ⇒ risk of abuse!

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 MAOI drugs
▪Irreversible non-selective inhibitors (Traditional MAOIs)
Long lasting inhibition (up to 1-2 weeks) despite of the elimination rate of a
drug
– Hydrazines: Phenelzine, Isocarboxazid
– Non-hydrazines: Tranylcypromine

▪Reversible Inhibitors of MAO-A (RIMA)

– Moclobemide

▪Great difference in adverse reactions between these groups

Selegiline transdermal patch (inhibition of both MAO-A & MAO-B)

oTransdermal administration reduces GI effects and first-pass metabolism, so
the need for food restrictions and the risk of hypertensive crises are much less.

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 Indications
▪Major depressive disorder
oCommonly third-line
oSevere depression, especially with lethargy and poor
motivation.
oDepression resistant to treatment (with lithium and/or
L-tryptophan).
oAtypical depression
▪Anxiety disorders resistant to other treatments
oSAD
oPD – phenelzine
oPTSD* - phenelzine

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 Adverse reactions and toxicity
▪Postural hypotension
▪CNS stimulation
otremor, excitement, insomnia, convulsions (in overdose)
▪Weight gain (increased appetite)
▪Atropine-like adverse effects – like in TCA but less
common
▪Rare severe hepatotoxicity (hydrazine MAOI)
▪Sexual dysfunction

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 Interaction with foods
▪The most serious problem of this class of drugs
▪Tyramine “cheese and wine” reaction
oHypertensive crisis, severe headache and potentially fatal
intracranial haemorrhage or other organ damage.
ocan occur up to 2 weeks after treatment is discontinued
▪Dietary precautions: restriction in the consumption of
foods high in tyramine (e.g. ripe cheeses, wine,
beer, yogurts, soy products, etc)
▪This risk is minimal with modern RIMA drugs (e.g.
moclobemide) or transdermal selegiline (EMSAM)
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 Interaction with drugs
▪MAOIs do not appear to cause clinically meaningful PK
drug-drug interactions. Most of the DDI are PD.
▪Hypertension & hypertensive crisis
oTCA wash-out period (2 weeks) when switching these
antidepressants! Lower risk in RIMA (short t1/2+reversibility).
oLevodopa, sympathomimetics (e.g. ephedrine)
▪Prolongs and profounds the CNS depressant effect of
benzodiazepines, antihistamines, alcohol and barbiturates
▪Serotonin syndrome (+SSRI, TCA, some opioids e.g.
pethidine) – Allow 2 weeks washout

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 ATYPICAL ANTIDEPRESSANTS
▪Comprise a disparate group of drugs that are
unrelated to each other and to the other
antidepressant drug classes – multiple mechanisms of
action
oBupropion
oMirtazapine
Serotonin modulators
oVortioxetine • Vortioxetine
oVilazodone† • Vilazodone
oAgomelatine • Nefazodone
oNefazodone • Trazodone
oTrazodone

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 Bupropion
▪Enhances both noradrenergic and dopaminergic
neurotransmission via inhibition of NE and DA reuptake
▪Has anticraving properties; tx for smoking cessation
▪Side effects
oHeadache, nausea, dry mouth, agitation, weight loss, hypertension.
Seizures (at higher doses) – avoid in those with history of epilepsy, bulimia or
heavy drinking
▪Low apparent risk of causing manic switch
▪Used in combination with SSRIs for treatment-resistant
depression and sexual dysfunction
▪Usual dosage range is 150-300 mg/day

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 Mirtazapine
▪Net effect is to enhance NE & 5-HT (via various
mechanisms) – blocks α2, 5-HT2A , 5-HT2C , 5-HT3 and
H1receptors
▪Adverse effects: Dry mouth, sedation & weight gain
▪Safe in overdose, interactions with other drugs are rare
and discontinuation symptoms have not been reported.
▪Less nausea and sexual dysfunction than SSRIs
▪Usual dosage range is 15-45 mg/day.

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Miscellaneous
▪Ketamine
oInfusion of subanaesthetic doses of ketamine exerts
immediate antidepressant effect in pts with
treatment-resistant unipolar or bipolar depression and
can immediately reduce suicidal thoughts.
oan effect that lasts for a few days.
oEsketamine nasal spray - approved (USA) for
treatment-resistant depression (TRD) & MDD with
accompanying suicidal ideation

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Miscellaneous
▪Brexanolone
oIV formulation of allopregnanolone (neuroactive steroid, an allosteric
modulator of GABAA)
oApproved (US FDA, 2019) for the treatment of postpartum
depression.
oApparent rapid effect, reducing depressive symptoms as early as 24
hours after administration.

▪St John´s wort (Hypericum perforatum)

oa herb containing number of active compounds (including hyperforin, a
RI; other constituents--MAOI).
oIt was proved to be clinically effective and well tolerated but it induces
CYP450 (risk of drug interactions!)

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 AD discontinuation syndrome
▪Symptoms usually begin within 3–5 days of abruptly stopping established
treatment with ADs, particularly those with short half-lives.
▪Symptoms are variable & differ between AD classes but include:
o Dizziness, nausea, paraesthesias, anxiety/insomnia, flu-like symptoms.
▪Worse with paroxetine and venlafaxine (short half-lives)
▪MAOIs may cause more severe symptoms including confusion and
psychotic symptoms.
▪MANAGEMENT
oUsually mild and self-limiting over 1–2 weeks; Education and reassurance
usually sufficient.
oIf more severe, restart AD and taper more slowly; for SSRIs/SNRIs, consider
switch to/start fluoxetine (because of long half-life), and then withdraw the
drug.

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 Suicidality
▪Antidepressants (not just SSRIs), compared with placebo,
slightly increase the risk of suicidal ideation or suicidal behaviour
in adolescents and younger adults up to age of 25 years but
have a neutral or protective effect in older adults which
increases with age.
▪Only fluoxetine had a favourable risk-benefit ratio in
adolescents – UK Committee on Safety of Medicines (2003)
▪Recommendations
oClose monitoring of patients at increased risk, esp. those < 30 years;
oSupplying limited quantities of medication for those at increased risk;
oStopping therapy if marked agitation or akathisia (restlessness) is seen
in the first few weeks.

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 Depression in pediatric & young adults
▪Expert guidelines recommend
oSupportive care and formal talking therapy be the first
option for mild-to-moderate depression.
oMedications can be used if symptoms are moderate to
severe.
▪Pharmacotherapy options are limited compared to
adults.
oFluoxetine from age 8
oEscitalopram from age 12
▪Close monitoring for suicidality

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 Switching Strategies
▪Switching to an alternative AD is generally recommended for
patients who have shown minimal or no response to a
first-choice antidepressant, or for those who experience
intolerable side effects.
oPatients not responding to one SSRI drug may be appropriately
switched to a second, alternative SSRI.
oPatients who are not responding after 2 adequate SSRI medication
trials, however, generally should be switched to an alternative
antidepressant from another class.
oThe older TCA and MAOI medications can be effective for TRD -
adverse side effect/safety issues
oThe EMSAM, which is safer and better tolerated than older MAOI
drugs, may be a more popular alternative MAOI treatment option for
depression

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 Combining Antidepressant
Drugs
▪Combinations of ADs may be useful to enhance efficacy or to
counter side effects
oEfficacy of AD combinations for TRD has not been well studied??
▪The first consideration regarding combining ADs should be
the safety of the combination.
oWith the exception of MAOIs, combining ≥ 2 antidepressant drugs can
usually be done safely
▪Examples
oSSRIs + bupropion or mirtazapine or venlafaxine or TCAs (e.g.
Fluoxetine + desipramine)
oSSRIs + trazodone (combat insomnia)
oBupropion + SSRIs or SNRIs (combat sexual dysfunction)

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 Adjuncts (for augmentation)
▪Atypical antipsychotics (+SSRIs)
oQuetiapine (also effective as monotherapy), aripiprazole, risperidone,
olanzapine?
▪Lithium – Effective as an adjunctive treatment to antidepressants
(most evidence with TCAs)
▪L-Tryptophan - Precursor of 5-HT; Weak antidepressant
oPrimarily used as an adjunct with MAOIs and TCAs.
▪S-Adenosylmethionine
oEvidence for antidepressant efficacy given orally and intravenously.
▪Triiodothyronine (T3)
▪L-Methylfolate

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DRUGS FOR BIPOLAR DISORDER

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Antimanic/Mood stabilizing drugs

▪Lithium
▪Some anticonvulsants (valproate,
carbamazepine, lamotrigine)
▪Some atypical antipsychotics (olanzapine,
risperidone, quetiapine, aripiprazole)
▪Adjunctive agents (antidepressants and
benzodiazepines)

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 Drugs for bipolar disorder
Acute bipolar
Acute Mania Maintenance
depression
▪ Lithium ▪ Lithium ▪ Lithium
▪ Divalproex/VPA ▪ Divalproex/VPA ▪ Lamotrigine
▪ Aripiprazole ▪ Lamotrigine ▪ Quetiapine
▪ Olanzapine ▪ Aripiprazole ▪ Lurasidone
▪ Quetiapine ▪ Olanzapine ▪ Olanzapine
▪ Risperidone ▪ Quetiapine (+fluoxetine)
▪ Ziprasidone ▪ Risperidone ▪ Carbamazepine
*Tamoxifen ▪ Asenapine ▪ Carbamazepine ▪ Divalproex/VPA
(Palacios et al
(2019). J
Psychopharm ▪ Haloperidol
acol, 33 (2),
177-184 ▪ Carbamazepine
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 Lithium
▪Since 1949 - indication as a prophylactic treatment in bipolar disorder
o 1st modern evidence-based trial on the efficacy of lithium in mania was done in Australia (Cade,
1949)

▪The onset of the therapeutic effect takes 2–3 weeks

▪Only known anti-suicidal treatment with randomised evidence of a
reduction in the risk of suicide of more than 50%
▪Mechanism of action
oremains elusive though interference with inositol trisphosphate formation (IP3)
and the inhibition of kinases (GSK3) is supposed.
▪Pharmacokinetics
oLithium is rapidly absorbed, is widely distributed with no protein binding, is
not metabolized, and is excreted unchanged in the urine and in other body
fluids

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Lithium – adverse effects &
Interactions
▪Adverse effects
▪ GIT disturbances (nausea/vomiting, diarrhoea)
▪ Polyuria, polydipsia, nephrogenic diabetes insipidus
▪ some evidence suggests that once-a-day dosing could be safer for the kidneys than divided doses.
▪ Fine tremor
▪ Thyroid disorders - benign, reversible thyroid enlargement; rarely
hypothyroidism
▪ Mild cognitive impairment
▪ Hair loss
▪ Weight gain
▪Drug interactions
▪ Sodium-depleting diuretics (thiazides and loop diuretics such as furosemide),
ACEI (e.g. lisinopril) and NSAIDs (e.g. indomethacin) impair elimination and
increase lithium levels.
▪Li is contraindicated during 1st trimester of pregnancy - possible risk of fetal
congenital abnormalities. Avoid also breast feeding
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 Lithium – toxicity
▪Lithium has a narrow therapeutic window
▪Critical importance of TDM to reach desirable effects without
risk of toxicity!
▪The effects as well as toxicity correlates much better with
plasma concentrations than with dose.
▪ Therapeutic range of serum concentrations is narrow: 0.6-1.2 mmol/L (above
1.5 mmol/L toxic effects appear)
▪ Above 2 mmol/L: confusion (important first sign of toxicity), drowsiness, vomiting,
ataxia, dizziness, and severe tremors develop.
▪ Above 2.5 mmol/L: clonic movements of the limbs, seizures, circulatory collapse, and
coma occur.

▪Treatment includes discontinuing lithium administration,

haemodialysis, and the use of anticonvulsants.
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