03/03/2023

Psychopharmacology in medically ill patients

Gizachew Asnake
MD, Psychiatrist

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PRINCIPLES OF PSYCHOPHARMACOLOGY
IN CL SETTING

03/03/2023
 Review patients medical problem
 Review all medications

 Avoid polypharmacy

 Use the minimum effective dose

 Add or discontinue one drug at a time

 Avoid PRN medications

 Check for medications that could cause altered mental

state

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 Impaired hepatic, renal, cardiac, and gastrointestinal
functioning can alter the absorption, metabolism,
distribution, and excretion of the psychotropic
medications.
 Elderly patients have slower absorption, metabolism and
elimination of drugs.
 It is very important to start psychotropic medications at a
lower dose and titrate the dose slowly monitoring for
side effects

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PSYCHOPHARMACOLOGY IN ORGAN DISEASES

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Liver disease
 Highly prevalent psychiatric illness and comorbid substance
use disorder
 It can affect medication pharmacokinetics from absorption to
metabolism, to distribution and elimination.
 Valproate, carbamazepine, duloxetine

 Causes hepatotoxicity
 TCA and low potency antipsychotics

 Exacerbate hepatic encephalopathy

 Haloperidol

 In low dose the most chosen 4

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Rule of thumb

 Reduce the initial dose of medication and titrate the dose

slowly for drugs primarily metabolized by the liver.

 Choose drugs with wide therapeutic index and monitor

for side effects.

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RENAL DISEASE

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ESRD
 Subsyndromal depression -25%

 Major depression -5-22%

 Most psychotropic medications are well tolerated and efficacious

in the treatment of patients with ESRD and renal insufficiency

 Two-thirds the usual or maximum dose of most psychotropic

drugs

 The greater the protein binding of a medication, the lower the 6

dose required in renal failure.
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Antidepressants
 SSRIs are beneficial in renal disease.

 Excretion of fluoxetine and sertraline is unchanged in

ESRD
Antipsychotics
 Less than 1 % of haloperidol is excreted in the urine and
it appears to be a safe medication to use in ESRD.
 Clearance of the sum of risperidone and its metabolite is
reduced to 60% in renal failure.
 Thioridazine and ziprasidone best avoidedin ESRD
 QTc prolongation and life threating arrhythemia 7
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 Benzodiazepines –dose reduction not necessary

 Half life of lorazepam may be prolonged in ESRD

 Lithium -CI in Acute renal failure

 It is completely dialyzed and can be given as a single dose post

hemodialysis

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GI disease
 Psychotropic drugs with anticholinergic properties
should be avoided
 TCAs have been found to be effective in controlling
symptoms in irritable bowel syndrome
 Gastrointestinal side effects are common with initiation
of SSRIs and may be undesirable inpatients with
increased gastric motility or diarrhea.
 SSRI prolong bleeding time

 Decreased serotonin in platelets may increase the risk of

abnormal bleeding 9
Cardiovascular disease

03/03/2023
 Depression is highly prevalent and associated with poor
prognosis
 Sertraline is considered safe and effective in patients with
recurrent depression post MI.
 TCAs and low potency antipsychotics
 cause postural hypotension resulting in syncope and fall.
 TCA are contraindicated after MI because of their cardiotoxic
side effects including
 QTc prolongation,
 postural hypotension
 anticholinergic effects 10
 and conduction delays
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 Lithium should be used with caution in patients with
CHF
 Lithium associated with
 sinus node dysfunction or sinoatrial block,
atrioventricular conduction disturbances and the
appearance or aggravation of ventricular irritability
and premature ventricular contractions
Psychotropic and QTc prolongation
 Thioridazine and ziprasidone have the highest risk of
QTc prolongation.
 Clinically significant risk is associated with
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haloperidol given intravenously in high doses.
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 QTc prolongation has been reported with
 quetiapine, risperidone, olanzapine, clozapine
 Most of the tricyclic and tetracyclic antidepressants, selective
monoamine reuptake inhibitors—citalopram, fluoxetine, paroxetine,
venlafaxine, and lithium.
 Thioridazine, pimozide, sertindole, droperidol, and IV haloperidol
have been documented to cause torsade de pointes and sudden
death.
 Discontinue psychotropic medication if the QTc is longer than 500
ms
 Use alternate medication for agitation like benzodiazepines or
anticonvulsants until QTc returns to normal. 12
NEUROLOGICAL CONDITIONS

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Cerebrovascular Disease
 Psychotropic drugs causing postural hypotension like
TCAs and low potency typical antipsychotics should be
avoided in patients with syncopal episodes

 SSRIs are preferred in post-stroke depression

 All antipsychotics—typical and atypical—are associated

with an increased risk of stroke when used in elderly
demented patients
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Epilepsy

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 Lower seizure threshold

 All antidepressants and antipsychotics

 Medication risk factors for seizure include

 Higher dose
 Rate of upward titration of medication and sudden drug
withdrawal.
 Drugs with highest seizure risk

 Bupropion, maprotiline, and clomipramine, chlorpromazine and

clozapine
 Drugs with lowest seizure risk

 Fluoxetine, paroxetine, sertraline, trazadone, and venlafaxine,

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Fluphenazine,haloperidol, pimozide, and risperidone

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Parkinson’s disease
 Neuropsychiatric symptoms are common in PD including
depression, anxiety, apathy, fatigue, and cognitive
impairment.

 Medications used for the treatment of PD can cause

psychiatric symptoms including delusions, hallucinations,
manic symptoms, impulsive behaviors, and agitation.

 Most antidepressants are effective and well tolerated when

used to treat depression and anxiety symptoms in PD
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 Benzodiazepines should be used with caution
 Increase the risk for falls and worsen cognitive, autonomic, and
sleep related problems
 Conventional antipsychotics are not recommended
 Significantly worsen the motor symptoms of PD
 Clozapine is effective treatment psychosis in PD

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Diabetes mellitus
 SNRI provide benefit both for depression and diabetic
neuropathic pain
 TCAs can treat neuropathic pain but

 Anticholinergic side effects, postural hypotension, and

sexual dysfunction
 Atypical antipsychotics

 Risk of metabolic syndrome

 weight gain, glucose intolerance, new onset type 2

diabetes mellitus, diabetic ketoacidosis, and

hyperlipidemia.
 Clozapine and olanzapine have the highest risk and should
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be avoided in diabetics
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Respiratory illness
 Anxiety ranges from 10 to 55 % among patients with COPD

 Depressive symptoms is 2.5 times greater for patients with

severe COPD than controls

 Antidepressants (SSRIs and SNRIs) are indicated as first line

agents for treating depression and anxiety in COPD patients

 Benzodiazepines can significantly reduce the ventilatory

response to hypoxia
 May precipitate respiratory failure 18
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 Antipsychotics in small doses are safer alternatives to
benzodiazepines for treating acute anxiety in COPD
 ? Their potential neurological and cardiovascular side
effects should be considered before use in medically
ill patients

 Non pharmacological therapy

 CBT, Relaxation therapy, pulmonary rehabilitation

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REFERENCES

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 Handbook of consultation-liaison psychiatry,2nd
edition

 Kaplanand sadock’s comprehensive text book f

psychiatry,10th edition

 Psychosomatic medicine ,first edition

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Thank you

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