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Chapter 26. Psychopharmacology

Melissa Martinez, M.D.; Lauren B. Marangell, M.D.; James M. Martinez, M.D.
DOI: 10.1176/appi.books.9781585623402.320107

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Excerpt

The pharmacological armamentarium for the treatment of psychiatric illnesses is rapidly expanding with the addition of new medications, innovative formulations of drug delivery, and the identification of potential biological treatment targets. As the psychotropic medication pharmacopoeia grows, clinicians are faced with the daunting task of incorporating an expanded knowledge base of pharmacology and medicine to prescribe these medications safely and effectively.

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TABLE 26–1. Partial list of cytochrome P450 (CYP) substrates and inhibitors
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TABLE 26–2. Antidepressant medications: dosing and half-life information
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TABLE 26–3. Key side effects of major antidepressant drugs
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TABLE 26–4. Monoamine oxidase inhibitor reversibility and selectivity
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TABLE 26–5. Dietary and medication restrictions for patients taking nonselective monoamine oxidase inhibitors (MAOIs)
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TABLE 26–6. Medications for the treatment of major anxiety disorders
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TABLE 26–7. Commonly used anxiolytic and hypnotic agents
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TABLE 26–8. Comparison of benzodiazepines and antidepressants for the treatment of anxiety
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TABLE 26–9. Commonly used atypical and conventional antipsychotic drugs
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TABLE 26–10. Guidelines for the acute use of antipsychotic drugs
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TABLE 26–11. Drugs used to treat extrapyramidal side effects
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TABLE 26–12. Hematological monitoring guidelines for patients taking clozapine
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TABLE 26–13. Key characteristics of mood stabilizers a
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TABLE 26–14. Signs, symptoms, and management of lithium toxicity
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TABLE 26–15. Atypical antipsychotic dosing in the treatment of acute mania
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Accurate diagnosis is the key to a well-informed treatment decision; whenever possible, treat the primary diagnosis and not the symptoms.

Several factors are important when selecting an appropriate medication, including identifying medication-responsive target symptoms, ruling out nonpsychiatric causes of a patient's symptomatology, noting the presence of other medical problems that will influence drug selection, evaluating concomitant medications that may cause drug–drug interactions, and evaluating personal and family histories of medication response.

Whenever possible, the clinician should involve the patient in medication decisions and educate the patient and significant others about the illness and potential benefits, risks, and side effects of any medication being prescribed.

Patients must be educated about the typical time to response for the medication being prescribed and the need for strict adherence to the treatment regimen to ensure an optimal chance for treatment success.

In addition to pharmacotherapy, other interventions such as disease-specific psychotherapies should be considered.

When evaluating a patient with a history of treatment failures, a detailed treatment history should include a review of the dose, duration, tolerability, adherence, and reason for discontinuation for each prior treatment; many prior medication failures may be a result of inadequate dosing, inadequate treatment duration, noncompliance, or poor tolerability.

Ongoing psychiatric and medical monitoring during treatment should be individualized to each patient according to several factors, including the severity of the illness, the current clinical status of the patient (e.g., acutely ill, partially remitted), and the specific medication(s) being prescribed.

The clinician should evaluate response to each prescribed treatment by monitoring symptomatic and functional improvement and strive for complete symptomatic and functional recovery.

Clinicians should be mindful of the response to each medication and consider discontinuing any treatment that has provided no benefit despite an adequate dose and duration of treatment.

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Sample questions:
1.
In the clinical application of psychopharmacology, drug interactions are classified as both pharmacokinetic and pharmacodynamic. Which of the following types of drug interactions is considered to be a pharmacodynamic interaction?
2.
The characterization of specific cytochrome P450 (CYP) enzymes has made it possible to understand and predict many drug–drug interactions. Which of the following CYP enzymes is essential for the metabolism of tricyclic antidepressants (TCAs)?
3.
Tricyclic antidepressants (TCAs) are known for their effects on multiple transmitter systems. Which of the following is not a pharmacological property of TCAs?
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