Psychotropic medication

Psychotropic medication includes some of the most commonly prescribed medication in the the world. This article will cover the types of medication you will tend to encounter, important side effects, monitoring and emergencies.

Mood disorders

When initiating patients on anti-depressant medication it is important to follow them up within 2 weeks. This is because one of the earliest benefits is an increased motivation, which can paradoxically increase the risk of suicide.

Antidepressants
  • SSRIs (selective serotonin reuptake inhibitors) e.g. sertraline, citalopram, fluoxetine (1st line in <18), paroxetine
  • SNRIs (serotonin noradrenaline reuptake inhibitors) e.g. venlafaxine, duloxetine
  • NaSSA (noradrenergic and specific serotonergic antidepressant) e.g. mirtazapine
  • TCAs (tricyclic antidepressants) e.g. amitriptyline, gabapentin – these are not recommended to be used due to risk in overdose.
Screenshot 2022 01 24 at 19.47.29

NB: antidepressants are also indicated in anxiety and eating disorders.

Lithium
  • Indication: bipolar affective disorder (BPAD), severe depression
  • Forms: lithium carbonate or citrate
  • MOA: not fully understood – permeates voltage-gated Na+ ATPase channels
  • Has a very narrow therapeutic index (0.4-1.0mmol/L) so must prescribe by same brand and form, and advise on regulating hydration status
  • ADRs:
    • Common: metallic taste, GI upset, fine tremor, polydipsia, polyuria
    • Notable: weight gain, acne, hypothyroidism, nephrogenic diabetes insidious, hypercalcaemia (due to increased PTH)
    • Serious: arrhythmia (T wave flattening), risk of toxicity
  • Monitoring:
    • Baseline: ECG, blood tests (FBC, U&Es, LFTs, TFTs, bone profile)
    • Serum lithium: take level 12 hours after dose – 1 week after initiation/dose change then weekly till stable
    • 6 monthly: U&Es, TFTs, bone profile
Other mood stabilisers
  • Semisodium valproate:
    • Used for manic episodes of BPAD
    • ADRs: GI upset, weight gain, hepatotoxicity, acute pancreatitis
    • Teratogenic – neural tube defects
  • Carbamazepine:
    • Used for rapid cycling BPAD
    • ADRs: GI upset, agranulocytosis, SIADH, Stevens-Johnson syndrome
  • Lamotrigine:
    • Used for depressive episodes associated with BPAD
    • ADRs: GI upset, fatigue, blurred vision, Stevens-Johnson syndrome
    • Teratogenic – oral cleft defects

Antipsychotics

  • 1st gen ‘typical‘: haloperidol, zuclopenthixol, chlorpromazine
  • 2nd gen ‘atypical‘: olanzapine, risperidone, quetiapine, clozapine
  • 3rd gen ‘atypical‘: aripiprazole
ADRs
  • Common: GI upset, sedation, postural hypotension
  • Notable: metabolic disturbance (weight gain, dyslipidemia), sexual dysfunction (hyperprolactinemia), extrapyramidal side effects
  • Serious: QT prolongation, decreased seizure threshold, neuroleptic malignant syndrome

‘Atypical’ antipsychotics have a higher affinity for 5-HT2A receptors and a lower affinity for D2-like (dopamine) receptors making extrapyramidal side effects milder and therefore being the preferred agent. Aripiprazole is considered a 3rd-gen atypical antipsychotic as it is a newer drug and a partial D2 agonist, so tends to have the least side effects.

What are the extrapyramidal side effects (EPSEs)?
Parkinsonism: treated with procyclidine. Akathisia (inner restlessness): treated with propranolol. Acute dystonia (painful muscular spasms): treated with procyclidine. Tardive dyskinesia (involuntary repetitive movements of lips, tongue and jaw): difficult to treat, can treat with tetrabenazine
Monitoring
  • Before starting: assess cardiovascular risk
  • Baseline: BMI, BP, ECG, bloods (FBC, HbA1c, U&Es, LFTs, TFTs, CK, prolactin)
  • Blood tests should be monitored every 6 months
Clozapine
  • ‘Atypical’ antipsychotic used in treatment resistant schizophrenia
  • Unique ADRs: agranulocytosis, constipation, myocarditis, hypersalivation, nocturnal enuresis
  • Requires re-titration if missed 2 days of dosing
  • Has unique FBC monitoring due to risk of agranulocytosis – must monitor FBC weekly for 18 weeks then fortnightly till a year
images
‘Traffic light’ monitoring for clozapine

Emergencies

Lithium toxicity
  • ABCDE – involve ITU and notify liaison psychiatry
  • History + neurological examination
  • ECG
  • Bloods: U&Es, TFTs, serum lithium:
    • Serum lithium >1.5mmol/L: coarse tremor, weakness, drowsiness
    • Serum lithium >2.0mmol/L: hyperreflexia, seizures, renal failure
  • IV volume replacement if mild/moderate, haemodialysis if severe
Serotonin syndrome VS Neuroleptic malignant syndrome
Screenshot 2022 01 24 at 21.09.39

Written by: Dr Muhammad Zain Haq, Psychiatry Lead (F2)
Reviewed by Dr Patrick Ezeani (Consultant Psychiatrist)

How useful was this post?

Click on a star to rate it!

Average rating 5 / 5. Vote count: 1

No votes so far! Be the first to rate this post.

As you found this post useful...

Follow us on social media!

We are sorry that this post was not useful for you!

Let us improve this post!

Tell us how we can improve this post?

Leave a Comment

Your email address will not be published.

Follow us

Our Newsletter

Trending Now

Junior Doctor Pay Calculator
We’ve created a junior doctor pay calculator to help you better understand your salary, tax, student...
Fluid Balance
Almost every patient admitted to hospital receives IV fluids at some point in their journey. However,...
Preparing for FY1
It is common for FY1s to feel anxious & feel like they’re not ready to start. We expect you...
Referral Cheat Sheet
Our referral cheat sheet is our most popular resource having been downloaded thousands of times! It has...
Audits & Quality Improvement Projects (QIPs)
Audits & QIPs are a way to identify issues, drive changes and assess the effects they have. It is...
ePortfolio
Your eportfolio is a tool to store and record evidence that demonstrates your progress, clinical competencies...
Urinary Retention
Urinary retention can be acute or chronic. When acute it occurs within a number of hours causing significant...
Scroll to Top

Sign up for our awesome resources

Free webinars every week, referral cheat sheet & other amazing content!