SSRI

Examples
• Fluoxetine
• Paroxetine
• Citalopram
• Sertraline

Indications
• Depression
• Anxiety
• OCD
• Bulimia nervosa (fluoxetine)

Contraindication
Mania

Prescription Notes
• Opposed to TCAs, SSRIs are alerting not sedating, so prescribe them for the morning
• The only SSRI recommended in under 18s is fluoxetine

Common Side Effects

• Early side effects — increased anxiety (suicide risk in young people), GI disturbances
• Loss of appetite and weight loss (sometimes weight gain)
• Insomnia
• Sweating
• Sexual dysfunction (anorgasmia, delayed ejaculation)


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Antipsychotics
First Generation Drugs
Chlorpromazine
Haloperidol
Sulpiride
Flupentixol
Zuclopenthixol

Second Generation Drugs

Clozapine
Olanzipine
Quetiapine
Risperidone
Amisulpride

Clinical and Side Effects

1st gen is more associated with EPS. 2nd gen is more associated with metabolic syndrome.

Dopamine D2 receptor antagonism:

• Mesolimbic: treatment of psychotic symptoms
• Mesocortical: worsen negative and cognitive symptoms of schizophrenia
• Nigrostriatal pathway: EPS
• Parkinsnian symptoms (rigidity, bradykinesia, tremors)
• Acute dystonia
• Akathisia
• Tardive dyskinesia
• NMS
• Tuberoinfundicular pathway: hyperprolactinaemia — galactorrhea, amenorrhea, sexual
dysfunction
• Chemoreceptor trigger zone: anti-emetic effect

Other side effects:

• Anticholinergic (muscarinic): dry mouth, constipation, urinary retention, blurred vision
• anti a-adrenergic: postural hypotension
• anti histaminergic: sedation, weight gain
• Cardiac: prolong QT, arrhythmias, myocarditis, sudden death
• Metabolic: increased risk of metabolic syndrome
• Dermatological: photosensitivity, skin rashes (especially chlorpromazine with blue-grey
discoloration in sun)
• Neurological: lowering of seizure threshold
• Hepatic: hepatotoxicity, cholestatic jaundice
• Hematological: pancytopenia, agranulocytosis

*Clozapine is particularly associated with agranulocytosis, myocarditis, and cardiomyopathy. It is

reserved for treatment resistant cases

Indications
• Schizophrenia, schizoaffective disorder, delusional disorder
• Depression or mania with psychotic features
• Psychotic episodes secondary to medical condition or substance use
• Delirium (caution in alcohol withdrawal as it lowers seizure threshold)
• Behavioural disturbance in dementia (caution as increased risk of CVA)

• Motor tics
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• Nausea and vomiting (prochlorperazine)
• Intractable hiccups and pruritis (chlorpromazine, haloperidol)

Contraindications/cautions
• Severely reduced consciousness level (sedating)
• Phaeochromocytoma
• Parkinson’s disease
• Epilepsy
• Cardiac disease (can induce arrhythmias, consider baseline ECG)
• Metabolic syndrome
• Clozapine should not be re-prescribed to someone with history of agranulocytosis

Clozapine Monitoring
Clozapine is particularly associated with agranulocytosis, myocarditis, and cardiomyopathy. It is
reserved for treatment resistant cases.

Blood taking (CBC, LRFT + CaPO4, metabolic — BP, BMI, FPG, lipids) weekly until week 18, then
biweekly CBC for one year, and monthly indefinitely.


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Neuroleptic Malignant Syndrome
Clinical Features
Occurs within 4-11 days of initiation or dose increase of dopamine antagonist (e.g. antipsychotic,
metoclopramide). Insidious onset over 1-3 days.

Characterised by triad of altered consciousness level, autonomic dysfunction (hyperthermia,

sweating, tachycardia, unstable BP), and severe rigidity (dysphagia, dyspnea from pharyngeal and
thoracic muscles, bradyreflexia).

Complications
Rhadomyolysis
Acute respiratory failure
Acute renal failure (from myoglobinuria)
Hyperthermia -> DIC
Acquired infections

Investigations and Lab Features

CBC, PT/PTT -> hyperthermia triggers DIC
LFT -> mild enzyme derangement
RFT, CaPO4 -> electrolyte disturbances

Urine toxicology -> look for offending drug

Urine myoglobin and serum CK -> look for rhadomyolysis

Treatment
Supportive:
Monitor vitals (BP, HR, RR, PaO2) & MSE
IV hydration
Oxygen
Cooling (e.g. cooling blankets, ice packets, ice water enema)
Antipyretics

Therapeutic:
Dopamine agonists: bromocriptine, amantidine
Muscle relaxant: dantrolene

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Lithium
Indications
Acute mania (particularly if optimistic about long term compliance)
Prophylaxis of BAD
Lithium augmentation in TRD
Adjuncts to antipsychotics in psychotic disorders
Aggression and impulsivity in personality disorders

Contraindications/Caution
Pregnancy/breastfeeding
Renal impairment
Thyroid disease
Cardiac disease
Neurological disease (e.g. parkinson’s, huntington’s)

Therapeutic Range and Toxic Levels

Acute range: 0.8-1.2 mmol/L
Long term prophylaxis: 0.4-0.8

Toxic above 1.5, dangerously toxic above 2

Side effects
Water — thirst, polydipsia, polyuria, impaired renal function, edema, weight gain
Fire — fine tremor, concentration/memory issue,
Heart blood — T wave flattening or inversion, leucocytosis, hypothyroidism
Other — teratogenecity (ebstein’s anomaly in 1st trimester, and other issues)

Toxic > 1.5 — n/v, coarse tremors, ataxia, muscle weakness, apathy
Toxic > 2.0 — impaired consciousness, nystagmus, dysarthria, hyperreflexia, oliguria, hypotension,
coma

Lithium withdrawal may precipitate mania

Interactions
Diuretics (thiazide, lithium clears almost 100% through kidney coupled with sodium, dehydration
and hypoNa reduces clearance), NSAID, ACEi increases lithium levels

Antipsychotics may increase neurotoxicity

Investigations and Monitoring

Prior to initiating therapy — FBC, RFT + CaPO4, TFT, pregnancy test, ECG

Blood levels monitored every week until therapeutic level stable for 4 weeks. Then levels
monitored every 3 months, RFT every 6 months, TFT every 12 months.

Treatment of Lithium Toxicity

Supportive. Stop the drug. Ensure hydration and electrolytes, anticonvulsants if needed,
hemodialysis if renal failure.


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Anticonvulsants
Indications
Epilepsy

Valproate — acute mania, 2nd line prophylactic drug in mania

Carbamazapine — 3rd line prophylactic drug in mania
Lamotrigene — bipolar depression mood stabiliser, 3rd line prophylactic drug in mania

Contraindications
Pregnancy/breastfeeding

Side effects
Valproate:
• Sedation and dizziness, N/V
• Haematological abnormalities (prolonged bleeding time, thrombocytopenia, leucopenia; serious
blood issues rare)
• Raised liver enzymes (liver damage rare)
• Tremors

Carbamazapine
• Sedation and dizziness, N/V
• Haematological abnormalities (eosinophilia, thrombocytopenia, leucopenia; serious blood issues
rare)
• Raised liver enzymes (hepatic or cholestatic jaundice rare)
• Blurred or double vision
• Ataxia
• HypoNa and fluid retention

Lamotrigene
• Sedation and dizziness, N/V
• Irritability and aggression
• Skin rashes (consider withdrawal)
• Headache
• Tremors
• Steven Johnson Syndrome (0.3%, usually within 2-8 weeks of therapy)
• Teratogenicity (cleft palate)

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