Psychoses Pharmacotherapy

Management
1. Many patients don't see behavior as strange
  1. May not understand need for meds.
    1. May become agitated, distrustful, and extremely frustrated b/c they may not comprehend why others can't think like them.
2. Noncomplience may result when side effects are severe
  1. Especially high in schizophrenics.
3. Primary goal is reducing symptoms to allow social relationships and ADLs
4. Can be controlled, but adverse effects are common and sometimes severe/
5. Little difference in efficacy among drugs.
  1. Newer ones have lower incidence of adverse effects.
6. Drug selection is based on clinician experience, occurrence of adverse effects, and pt. needs.
7. 3 generations of antipsychotics.
Conventional Antipsychotics (first gen)
1. Also called neuroleptics b/c of neurologic side effects.
2. Phenothiazines
  1. Positive signs of schizophrenia.
    1. Block excitement associated w/symptoms.
    2. Difference in potency & side effect profiles.
      1. 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
3. Non-phenothiazines
  1. Therapeutic effects & efficacy equal to phenothiazines
    1. Same spectrum of adverse effects as phenothiazines.
      1. 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.
Atypical antipsychotics (second gen)
1. Treats both positive and negative symptoms.
  1. Exhibit therapeutic action w/o EPS effects.
    1. Action likely unknown, but thought to block dopamine D2, serotonin, and alpha-adrenergic receptors.
      1. Loosely bound to D2 receptors, so fewer EPS symptoms are caused.
      2. 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.
Dopamine-Serotonin System Stabilizers (third gen).
1. Also controls both positive and negative symptoms.
  1. Well tolerated in schizophrenics.
    1. Associated w/lower incidence of EPS than haloperidol, and fewer weight-gain issues than other atypicals.
      1. 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.

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Psychoses Pharmacotherapy

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