ABCs of Psychiatric Medicines
ABCs of Psychiatric Medicines
ABCs of Psychiatric Medicines
Dr Rathi Mahendran
ABC
s
Psychiatric
of
Medication
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Contents
Chapters
Page
1. Introduction......................................................................... 3
2. Antipsychotics..................................................................... 5
3. Antidepressants................................................................... 10
4. Anxiolytics / Hypnotics.......................................................... 16
5. Drugs Used for Dementia...................................................... 20
6. Drugs Used to Stabilise Moods.............................................. 23
7. Drugs Used for Substance Dependence................................... 27
8. Drugs Used for Attention-Deficit Hyperactivity Disorder............. 29
9. Anticholinergics Medicines.................................................... 32
10. Contributors........................................................................ 35
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Contents
Chapters
Page
1. Introduction......................................................................... 3
2. Antipsychotics..................................................................... 5
3. Antidepressants................................................................... 10
4. Anxiolytics / Hypnotics.......................................................... 16
5. Drugs Used for Dementia...................................................... 20
6. Drugs Used to Stabilise Moods.............................................. 23
7. Drugs Used for Substance Dependence................................... 27
8. Drugs Used for Attention-Deficit Hyperactivity Disorder............. 29
9. Anticholinergics Medicines.................................................... 32
10. Contributors........................................................................ 35
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1. Introduction
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2. Antipsychotics
Introduction
Antipsychotics are used to treat and prevent the recurrence of symptoms of
psychosis in schizophrenia. These include hearing or seeing things which
are actually not present, disorganised or unreal thoughts, suspiciousness,
uncontrollable anger or social isolation.
They can be divided into two groups, namely the typical and atypical
antipsychotics.
TYPICAL (or First Generation)
Chlorpromazine
Clozapine
Haloperidol
Amisulpiride
Sulpiride
Olanzapine
Trifluoperazine
Risperidone
Quetiapine
Paliperidone
Aripiprazole
Ziprasidone
treating
used in
children
be used
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Precautions
Most of the antipsychotics can interfere with your bodys ability to cool
down and make you sweat less. This might cause your body temperature to
rise. Take extra care not to overheat your body, especially during strenuous
exercise. Atypical antipsychotics may sometimes worsen your blood glucose
control and cholesterol levels. You may need to have periodic blood tests
while on medication. Typical antipsychotics may make your skin become
more sensitive to sunlight. Avoid prolonged exposure by wearing protective
clothing or using sunscreen. If you are a smoker, the amount of Olanzapine
or Clozapine that stays in your body may be decreased due to your smoking
habit. Clozapine may cause seizures (fits).
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Side Effects
Common
The following side effects may lessen or go away with time.
Let your doctor know if any of these persists or affects you significantly.
Typical antipsychotics
Atypical antipsychotics
Dry mouth
Dry mouth
Constipation
Constipation
Tremor or shaking
Increase in appetite and weight gain
Increased salivation or drooling
Headache
Nausea or vomiting
Stomach discomfort or indigestion
Difficulty in sleeping
Anxiety
Stuffy or runny nose
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Stopping Medication
Do not stop taking your medicines without telling your doctor, especially if
you have taken large doses for a long time. Otherwise, your condition may
worsen very quickly.
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3. Antidepressants
Introduction
There are many different types of antidepressants which are available in the
market today. The following antidepressants are currently available at IMH,
grouped under their respective classes:
Antidepressant drugs
Selective
Serotonin
Reuptake
Inhibitors
(SSRIs)
Tricyclic
Antidepressants
(TCAs)
Fluoxetine
Amitriptyline
Fluvoxamine
Clomipramine
Escitalopram
Imipramine
Sertraline
Dothiepin
Paroxetine
Nortriptyline
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Serotonin and
Norepinephrine
Reuptake
Inhibitors
(SNRIs)
Others
Mirtazapine
Venlafaxine
Duloxetine
Trazodone
Bupropion
Tianeptine
Moclobemide
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Stopping Medication
Continue to take your medicines regularly even if you feel well. Do not stop
taking it without first discussing with your doctor. Doing so especially after
taking it for a long time may lead to unwanted effects. It may also cause
your condition to worsen quickly.
ABCs of Psychiatric Medication
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Difficulty
sleeping
Drowsiness
Common Side Effects
Sexual
dysfunction
Diarrhoea
Increased
nervousness
TCAs
Drowsiness
Tiredness
Sexual
dysfunction
Constipation
Dryness of
mouth
Weight gain
SNRIs
Difficulty
sleeping
Decreased
appetite
Constipation
Dryness of
mouth
Increased
nervousness
Sexual
dysfunction
Fever, severe
weakness,
muscle
twitching
Rare but Serious Side Effects
Intense
agitation or
anxiety
Manic
symptoms2
1
2
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Is
Mirtazapine
Trazodone
Bupropion
Tianeptine
Moclobemide
Nausea
Headache
Dizziness
y
g
ed
ation
Drowsiness
Drowsiness
Increased
appetite
may lead to
weight gain
Tiredness
of
Dryness of
mouth
Diarrhoea or
constipation
Difficulty
sleeping
Difficulty
sleeping
Dryness of
mouth
Drowsiness
Dryness of
mouth
Stomach
discomfort
Stomach
discomfort
Loss of
appetite
Increased
nervousness
Weight loss
Sexual
dysfunction
d
ness
Drowsiness
Constipation
Dryness of
mouth
tion
r
at
Allergic reactions1
Seizures (fits)
Confusion
Swelling in
Priapism
Fast or
hands, ankles
irregular
Blurred vision
or feet
heartbeat
Water
Severe
Intense
retention (in
vomiting or
agitation or
the limbs)
diarrhoea
anxiety
Flu-like
symptoms
Muscle
twitching
Fast
heartbeat
Muscle or
joint pain
Fast or
irregular
heartbeat
Severe
throbbing
Yellow skin or
headache
eyes
which starts
Dark-coloured
at the back
urine
of the head
and radiates
Pain in
forward
the upper
abdomen
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SSRIs
Pregnancy
Usage in Breastfeeding
TCAs
SNRIs
To be used
with caution in
most cases. Not
recommended
for Paroxetine.
To be used
with caution
discuss with
your physician
To be used
with caution
discuss with
your physician
To
wi
d
yo
Excreted in
breast milk
to use with
caution
Excreted in
breast milk
to use with
caution. Not
recommended
for Dothiepin.
Excreted in
breast milk
to use with
caution
Ex
bre
t
ca
Note: Common side effects of the respective drugs may lessen or go away with
time. Let your doctor know if any of these persist or affect you significantly.
Talk to your pharmacist about how to manage these side effects.
All serious side effects should be reported immediately.
The side effects listed above are not exhaustive. Talk to your doctor if you
experience any other side effects that you think may be medication-related.
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Is
Mirtazapine
Trazodone
Bupropion
d
on
with
cian
To be used
with caution
discuss with
your physician
To be used
with caution
discuss with
your physician
To be used
with caution
discuss with
your physician
n
k
ith
Excreted in
breast milk
to use with
caution
Enters breast
milk to use
with caution
Enters breast
milk not
recommended
Seek medical
attention
immediately if
you experience
priapism:
Painful,
persistent
and abnormal
penile erection,
unaccompanied
by sexual desire
or excitation.
Tianeptine
Moclobemide
Not to be used
Use in
pregnancy
is not
recommended
Not to be used
Enters breast
milk to be
used with
caution
Moclobemide
may cause
dangerous reactions such as
a sudden rise in
blood pressure
when taken
with certain
substances.
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4. Anxiolytics / Hypnotics
Introduction
Benzodiazepines, Z-hypnotics and Antihistamines are some classes of drugs
that are used in the acute treatment of anxiety and insomnia.
The following diagram shows some of the anxiolytic and hypnotic drugs
available at IMH:
Anxiolytics / Hypnotics
Benzodiazepines
Alprazolam
Clonazepam
Diazepam
Lorazepam
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Z-hypnotics
Antihistamines
Zolpidem CR
(controlledrelease)
Hydroxyzine
Zopiclone
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Some of the medicines listed in the diagram may have other uses. For example,
Hydroxyzine may be used to relieve skin itch. Some Benzodiazepines can
also be used to prevent or control seizures. Be very clear what you are
taking the medication for.
There are other drugs that can be used in the long-term treatment of anxiety
disorders (e.g. certain antidepressants). This chapter elaborates on drugs
that can only be used in the short-term.
Stopping Medication
Anxiolytic and hypnotic medicines should ideally be used on a short-term
basis. However, if you have been taking the specific drug on a long-term
basis or at high doses, do not stop the medicine abruptly. Discuss with your
doctor to come up with a discontinuation plan to cut down the dose slowly
over a few weeks.
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The following table describes characteristics which are specific to each type
of anxiolytic or hypnotic medicines:
Benzodiazepines
Indication
Us
Not to be used
To
dis
Not recommended
To
dis
Pregnancy
Usage in Breastfeeding
Note: Common side effects of the respective drugs may lessen or go away with
time. Let your doctor know if any of these persist or affect you significantly.
The side effects listed above are not exhaustive. Talk to your doctor if you
experience any other side effects that you think may be medication-related.
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erm
Zolpidem (CR)
Used for insomnia only
Zopiclone
Used for insomnia only
Hydroxyzine
Can be used for short-term
anxiety and insomnia
Stomach discomfort
Drowsiness or daytime sleepiness
Dizziness
Headache
Dry mouth and taste
alteration
Dry mouth
Allergic reactions
Memory impairment
Unusual behaviour or activities while partially asleep
Abnormal thinking or changes in behaviour such as unusual excitement,
nervousness, irritability or agitation
Confusion
To be used with caution
discuss with your physician
Not recommended
Excretion in breast
milk unknown not
recommended
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Introduction
Dementia medicines are used to treat the symptoms of dementia in
Alzheimers disease. These include difficulty remembering recent events,
activities, or the names of familiar people or things, problems with thinking,
speaking, understanding, reading or writing, poor concentration or judgment.
It will not cure or stop the disease from getting worse but can help improve
the patients ability to think and perform daily activities.
The drugs that are available in IMH include Donepezil, Rivastigmine,
Galantamine and Memantine.
The initial medicine prescribed is usually continued throughout the course
of the patients illness, unless there is a decline in cognitive function after
one year. In such cases, an alternative drug will be considered.
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Side Effects
Common
The following side effects may lessen or go away with time.
Let your doctor know if any of these persists or affects you significantly.
Donepezil
Rivastigmine
Memantine
Galatamine
Drowsiness
Drowsiness
Drowsiness
Drowsiness
Dizziness
Dizziness
Dizziness
Dizziness
Loss of appetite or
weight
Loss of appetite or
weight
Loss of appetite or
weight
Diarrhoea
Diarrhoea
Diarrhoea
Muscle cramps
Stomach pain or
indigestion
Stomach pain or
indigestion
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Galantamine
Confusion
Tremors or
shaking
Sudden severe
headache
Rivastigmine
Hallucinations
(seeing or hearing
things that are not
present)
Donepezil
Severe stomach
discomfort
Tremors or
shaking
Confusion
As with all other medicines, the side effects listed in the above categories
are not exhaustive.
Talk to your doctor if you experience any other side effects that you think
may be related to the medicine.
Stopping Medication
If you have missed your medication for several days in a row, do not restart
it on the same dose. Consult your doctor on what dose you should take.
Do not stop your medicines suddenly without first checking with your doctor
as this can worsen cognition and behaviour, especially if you have been
taking the medicine in high doses and/or for a long period of time.
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Introduction
Mood stabilisers are used primarily to reduce the severity of mood swings
in bipolar disorders, depression and other mood disorders. Besides Lithium,
the other mood stabilisers can be used to control some types of seizures (fits)
in the treatment of epilepsy. Sodium Valproate can also be used to prevent
migraine headaches, while Carbamazepine is used to relieve symptoms of
facial nerve pain.
Side Effects
Common
The following side effects may lessen or go away with time.
Let your doctor know if any of these persists or affects you significantly.
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Carbamazapine
Lamotrigine
Lithium
Sodium valproate
Dizziness
Dizziness
Drowsiness
Drowsiness
Headach
Headache
Headache
Nausea or vomiting
Nausea or vomiting
Nausea or vomiting
Nausea or vomiting
Stomach discomfort
Stomach discomfort
Stomach discomfort
Stomach discomfort
Diarrhoea or
constipation
Diarrhoea or
constipation
Diarrhoea
Diarrhoea
Dry mouth
Dry mouth
Clumsiness or
unsteadiness
Fine tremor
Trembling of hands
and arms
Increase in appetite
or weight gain
Slight initial and
temporary hair loss
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Lamotrigine
Sodium valproate
Yellowing of eyes
or skin
Yellowing of eyes
or skin
Thoughts about
harming or killing
yourself
Thoughts about
harming or killing
yourself
Lithium
Blistering, peeling,
red skin rash
Change in how
much or how often
you urinate
Dark coloured urine
or pale stools
Severe loss of
appetite, stomach
pain and vomiting
that does not go
away
Severe vomiting,
nausea or diarrhoea
that does not go
away
Severe shaking /
tremor
Lamotrigine
Check with your doctor immediately if you develop a skin rash.
Lithium
Its effectiveness is affected by its concentration in your blood. Therefore, it
is important to comply with all appointments with your doctor. Your doctor
may order blood tests to monitor your response to lithium. The amount of
salt in the diet can also affect the level of lithium in the blood. Do not change
your diet from a high to low salt diet or vice versa. Drink plenty of fluids (at
ABCs of Psychiatric Medication
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least 8 12 glasses of water or other beverage per day) when you exercise
or during hot weather as you may lose large amounts of water and salt from
your body under such conditions. Excessive loss of water can cause serious
side effects. Avoid drinking too much caffeinated beverages, such as tea,
coffee, cola or chocolate milk. If you have an infection or illness that causes
heavy sweating, vomiting or diarrhoea, consult the doctor immediately.
Stopping Medication
Do not stop taking your medicines suddenly without talking to your doctor,
especially if you have been taking them in high doses and/or for a long
period of time. Otherwise, your condition may worsen.
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Side Effects
Common
Naltrexone
Bupropion
Diarrhoea or constipation
Diarrhoea or constipation
Headache
Headache
Stomach cramp
Difficulty sleeping
Difficulty sleeping
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Bupropion
Allergic reaction: skin rash or itch, difficulty Allergic reaction: skin rash or itch, difficulty
in breathing, swelling in the face, lips or
in breathing, swelling in the face, lips or
other parts of the body
other parts of the body
Visual disturbances
Suicidal ideation
Confusion, clumsiness and unsteadiness
Loss of seizure (fits) control
Uncontrolled restlessness
Stopping Medication
Do not stop taking either medicine without first checking with your doctor,
especially if you have been taking the medicine in high doses and/or for a
long period of time.
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Side Effects
Common
The following side effects may lessen or go away with time.
Let your doctor know if any of these persists or affects you significantly.
Methylphenidate
Atomoxetine
Decreased appetite
Decreased appetite
Stomach discomfort
Stomach discomfort
Insomnia
Insomnia
Headache
Headache
Nervousness
Dizziness
Tiredness
Nausea and Vomiting
Dry mouth
Loss of interest in sex, or sexual side
effects
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Methylphenidate
Atomoxetine
Joint pain
Tremors
Seizures (fits)
Confusion
Confusion
As with all other medicines, the side effects listed in the above categories
are not exhaustive.
Talk to your doctor if you experience any other side effects that you think
may be related to the medicine.
Stopping Medication
Do not stop taking either medicine without first checking with your doctor,
especially if you have been taking the medicine in high doses and/or for a
long period of time. Doing so may result in unwanted effects.
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9. Anticholinergic Medicines
Introduction
Anticholinergic drugs are often used to help control some of the side effects
that can occur from taking antipsychotic medicines. These side effects
include tremors, stiffness and movement difficulties. They may also be
used to control the symptoms of Parkinsons disease.
Benzhexol and Benztropine are two types of anticholinergic drugs used to
control side effects a patient may experience. Benzhexol acts by slowing
down the parasympathetic nervous system of the body and relaxing
its muscles. Benztropine prolongs the action of the neurotransmitter,
Dopamine, in some parts of the brain.
Side Effects
Common
The following side effects may lessen or go away with time.
Let your doctor know if any of these persists or affects you significantly.
Dryness of mouth
Nausea
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Constipation
Blurred vision
Rare but Serious
Let your doctor know immediately if you experience any of the following
side effects after starting these medicines.
Allergic reaction: Skin rash or itch, difficulty breathing, swelling on
the ankles or other parts of the body.
Confusion or agitation
Hearing or seeing things that are not actually present
Difficulty or pain when passing urine, or a decrease in the amount of
urine
Fast or irregular heartbeat
Benzhexol may also cause a euphoric effect in some people and a sense
of well-being. Therefore, there is an increased possibility of dependence on
the drug for some patients. Please be aware of the effect Benzhexol may
have on you and take necessary precautions not to take more than what
you need.
Stopping Medication
If you have been taking Benzhexol or Benztropine regularly, do not stop
taking it abruptly. It is best to gradually reduce the dosage with advice from
your doctor or pharmacist. However, if you have been taking either drug
only when necessary, the above would not apply.
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10. Contributors
Dr Rathi Mahendran
MBBS, MMed (Psych), DPM, FAMS, Dip Mgt
Lee Chen graduated from the National University of Malaysia in 2006. She
worked in a psychiatric hospital in Malaysia prior to joining the Institute of
Mental Health, Singapore. She is an inpatient pharmacist.
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