Psychoses Pharmacotherapy

Psychoses Pharmacotherapy

1. Management

   • Many patients don't see behavior as strange
     • May not understand need for meds.
       • May become agitated, distrustful, and extremely frustrated b/c they may not comprehend why others can't think like them.
   • Noncomplience may result when side effects are severe
     • Especially high in schizophrenics.
   • Primary goal is reducing symptoms to allow social relationships and ADLs
   • Can be controlled, but adverse effects are common and sometimes severe/
   • Little difference in efficacy among drugs.
     • Newer ones have lower incidence of adverse effects.
   • Drug selection is based on clinician experience, occurrence of adverse effects, and pt. needs.
   • 3 generations of antipsychotics.

2. Conventional Antipsychotics (first gen)

   • Also called neuroleptics b/c of neurologic side effects.
   • Phenothiazines
     • Positive signs of schizophrenia.
       • Block excitement associated w/symptoms.
       • Difference in potency & side effect profiles.
         • Hallucination & delusions diminish within days, but other symptoms can require 7-8 wks.
           • Life-long treatment.
             • Prevent dopamine & serotonin from occupying critical neurologic receptor sites.
               • Anticholinergic effects are common.
                 • Dry mouth, postural hypotension, & urinary retention.
                 • Ejaculation disorders & delay in orgasm are common causes for noncompliance
                   • Menstrual disorders also common
                     • High fever, tachycardia, incontinence, confusion, and other signs of NMS may occur.
                       • Each drug has slightly different side effect spectrum
                         • Many of these have a broader spectrum of action than just psychoses.
                           • Many have calming effects & ease restlesness.
                           • Perminant extrapyramidal effects can result
                             • Dystonia, akathisia, secondary parkinsonism, and tardive dyskinesia
                               • Acute dystonias occur early on.
                                 • Severe muscle spasms,
                                 • Akathisia is most common; pt. cannot rest or relax.
                                   • Symptoms of secondary parkinsonism include tremor, muscle rigidity, stooped posture, and shuffling gait.
                                     • Tardive dyskinesia occurs w/long term therapy.
                                       • Unusual tongue & face movement, such as lip smacking & wormlike tongue motions.
                               • Concurrent use of an anticholinergic may be indicated when EPS cannot be prevented.
                                 • Benzotropine (Cogentin) may be used for acute dystonia.
                                   • Meds w/levodopa are usually avoided,
                                     • Beta-blockers and benzos are sometimes given for akathisia
   • Non-phenothiazines
     • Therapeutic effects & efficacy equal to phenothiazines
       • Same spectrum of adverse effects as phenothiazines.
         • Less sedation & fewer anticholinergic effects.
           • CNS depressants may have an additive effect.
             • They also block postsynaptic D2 dopamine receptors.
               • No significant advantage over phenothiazines in treating schizophrenia.

3. Atypical antipsychotics (second gen)

   • Treats both positive and negative symptoms.
     • Exhibit therapeutic action w/o EPS effects.
       • Action likely unknown, but thought to block dopamine D2, serotonin, and alpha-adrenergic receptors.
         • Loosely bound to D2 receptors, so fewer EPS symptoms are caused.
         • Adverse effects are fewer, but still significant. Pt. must be monitored.
           • Increased risk of weight gain, diabetes, hypertriglyceridemia, and stroke.
             • Increased risk for death if used to treat dementia-related psychoses.
               • Some of these increase prolactin, which can lead to menstrual disorders, decreased libido, and osteoporosis in women.
                 • Decreased iibido, impotence, and man boobs in men.

4. Dopamine-Serotonin System Stabilizers (third gen).

   • Also controls both positive and negative symptoms.
     • Well tolerated in schizophrenics.
       • Associated w/lower incidence of EPS than haloperidol, and fewer weight-gain issues than other atypicals.
         • Anticholinergic effects are virtually non-existent.
           • Ariprprazole (Abilify) is also used for bipolar and mixed episodes of mania and depression.
             • Aripiprazole is used with brexpiprazole for major depressive disorder
               • Side effects include headache, nausea, vomiting, fever, constipation, and anxiety.