• Part 1 Psychotherapy

• Part 2 Electroconvulsive Therapy and Transcranial Magnetic Stimulation

• Part 3 Psychopharmacotherapy

Part 1. Psychotherapy

Although there are literally hundreds of types of psychotherapy, psychological or “talking therapy” treatments fall into four broad categories: (1) individual psychotherapy, (2) behavior modification, (3) cognitive therapies, and (4) social therapies.

1. Individual psychotherapy: Varies according to the time frame used (psychotherapy can be either brief or protracted). It can be supportive, directive, and reality-oriented versus expressive, exploratory, and oriented toward a discussion of unconscious material.

   1. Supportive psychotherapy

      1. Goals: Form a close alliance with the patient, help the patient define current problems, consider and implement possible problem solutions, and “shore up” the patient’s current ego defenses.

      2. Indicated in the treatment of adjustment disorders, acute emotional crises, and when a long-lasting “cure” is not expected but improved functioning is hoped for (as in the case of chronic schizophrenia).

   2. Insight-oriented psychotherapy

      1. Goals: Form an alliance with the patient, recognize transference/countertransference feelings as they occur, and uncover unconscious wishes and defenses that have caused the patient to behave in a maladaptive manner.

      2. Indicated in the treatment of anxiety, depression in all of its forms, somatoform and dissociative disorders, personality disorders, neuroses, and trauma. It should be noted that although psychotherapy can be indicated for all these disorders, the degrees of patient insight and motivation for undergoing treatment are critical to its success.

2. Behavior modification/therapy: Includes a group of loosely related therapies that work according to the principles of learning. A short list of examples of these therapies follows:

   1. Systematic desensitization: Exposing the patient to increasingly anxiety-provoking stimuli and at the same time teaching him or her to relax. This therapy is used in the treatment of phobias and in preventing compulsions.

   2. Substitution: Replacing an undesirable behavior (smoking) with a desirable one (chewing gum).

   3. Hypnosis: Induction of an advanced state of relaxation or a “trance” during which suggestions can be made. Hypnosis works in selected patients in the management of pain, the resolution of conversion disorders, and relaxation training.

3. Cognitive therapy

   1. Focuses on the cognitive responses that are the primary targets for intervention.

   2. Used in changing maladaptive behavior occurring as a result of cognitive responses.

   3. The most common use for this form of therapy is in the treatment of major depression, where the self-defeating attitudes (called automatic thoughts) that are so common are identified, challenged, and replaced with more realistic thoughts.

4. Social therapies: These therapies use the principles of supportive and individual or marital therapy but occur in groups of similar patients, a family, or a couple.

Part 2. Electroconvulsive Therapy and Transcranial Magnetic Stimulation

Electroconvulsive therapy (ECT) is most often used in one of several scenarios. First, when medications for depression have been ineffective, ECT is often prescribed. Second, when a patient has a severe and life-threatening depression (unrelenting serious suicidal ideation, patient will not eat or drink), ECT can cause a much more rapid improvement in the severe depressive symptoms than can medication, and thus it is often used in these situations. ECT is the most effective treatment for severe major depressive disorder. ECT is also very effective for patients suffering from mania, though it is more rarely used in that circumstance. ECT is safe and effective. Electrodes are placed on the patient’s scalp and a current is applied while the patient is under a short general anesthetic and a muscle relaxant. The current causes a brief seizure in the brain. The patient awakens minutes after the seizure is completed, does not remember the treatment, and is often confused, though this confusion lasts for only a very short period of time. Side effects include retrograde memory loss, headache, nausea, and muscle stiffness. The risk of long-term cognitive impairment is small to nonexistent. Contraindications to ECT include elevated intracranial pressure and space-occupying lesions in the brain, recent myocardial infarction (3 months or less), and severe arterial hypertension. Pregnancy is not a contraindication to ECT.

Transcranial magnetic stimulation (TMS), a noninvasive modality using an electromagnetic coil on the patient’s scalp, is reserved for situations when other treatments for major depressive disorder have been ineffective. An electrical pulse generator exerts a changing magnetic field to the coils, which is thought to induce a changing electrical current in the brain, stimulating the nerve cells in the brain under area of the coil. The overall goal is to stimulate the nerve cells involved in mood control and depression. TMS must be given repetitively (generally daily, five times per week for 4-6 weeks), so it is called repetitive TMS (rTMS). Common side effects include syncope, twitching or tingling of facial muscles, scalp discomfort at the site of treatment, or headache. All of these are generally mild to moderate and decrease over time. Serious side effects are rare but may include hearing loss (the machine delivers a loud sound, and ear protection should be used during treatment), seizures, or mania (in people with bipolar disorder).

Part 3. Psychopharmacotherapy

Medications can be subdivided into antidepressants, including miscellaneous and mood-stabilizing agents, antipsychotic medications, and anxiolytic/hypnotic medications. Tables II–1, II–2, II–3, II–4, II–5, II–6, II–7, II–8, II–9 summarize the characteristics of these agents. Many of these medications affect neurotransmitters (Figure II–1). The main neurotransmitters are monoamines (norepinephrine, dopamine, serotonin, acetylcholine, histamine), amino acids (gamma-aminobutyric acid [GABA]), and glutamic acid.

1. Antidepressants: Antidepressants can be placed in four main categories:

   1. Tricyclics and heterocyclics once represented the first line of treatment. These drugs work by increasing the level of monoamines in the synapse by reducing the reuptake of norepinephrine and serotonin. Although they are quite effective, they are dangerous in overdose because they have a rather narrow therapeutic to toxic range, causing fatal cardiac arrhythmias (Table II–1).

   2. Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) are the most commonly used antidepressants today. Major side effects include gastrointestinal disturbances and sexual dysfunction (Table II–2).

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      Table II–2SELECTIVE SEROTONIN REUPTAKE INHIBITORS

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      Table II–2 SELECTIVE SEROTONIN REUPTAKE INHIBITORS

      Name	Half-Life	Side Effects	Comments
      Nearly all selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SSNRIs)		Agitation, akathisia, anxiety, panic, insomnia, diarrhea, gastrointestinal distress, headache, sexual dysfunction: delayed ejaculation or impotence (male); anorgasmia (female); may increase risk of suicidal thoughts and behaviors in children, adolescents, and young adults	To avoid fatal serotonin syndrome,b no SSRI or SSNRI should be combined with a monoamine oxidase inhibitor (MAOI), and an SSRI should be discontinued at least 5 wk before starting an MAOI
      Fluoxetine (Prozac)	1-3 d		SSRI; used in the treatment of obsessive-compulsive disorder (OCD)
      Sertraline (Zoloft)	25 h		SSRI; causes diarrhea more commonly than others; used in the treatment of OCD
      Paroxetine (Paxil)	24 h		SSRI; mildly anticholinergic; used in the treatment of OCD
      Fluvoxamine (Luvox)	15 h		SSRI; nausea and vomiting more common; used in the treatment of OCD
      Citalopram (Celexa)	35 h		SSRI; possibly fewer sexual side effects
      Escitalopram (Lexapro)	27-30 h		SSRI
      Venlafaxine (Effexor)	3.5 h (active metabolite 9 h)	Anxiety, may increase blood pressure at higher doses, headache, insomnia, sweating	Serotonin-norepinephrine reuptake inhibitor (SNRI); used to treat generalized anxiety disorder (GAD) and social anxiety
      Levomilnacipran (Fetzima)	12 h	Blood pressure increases, nausea/vomiting, sweating, constipation, erectile dysfunction	SNRI
      Desvenlafaxine (Pristiq)	24 h		SNRI
      Duloxetine (Cymbalta)	12 h		SNRI; used for the treatment of GAD and painful diabetic neuropathy

      ^aProprietary names are given in parentheses.

      ^bSerotonin syndrome is characterized by (in order of appearance) diarrhea, restlessness, extreme agitation, hyperreflexia, autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, and death.

   3. Monoamine oxidase inhibitors (MAOIs) are not commonly used because a tyramine-free diet (no red wine or aged cheese) must be followed or a hypertensive crisis can result. These agents can be more helpful in depression with atypical features (overeating, oversleeping, irritability) (Table II–3).

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      Table II–3MONOAMINE OXIDASE INHIBITORS

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      Table II–3 MONOAMINE OXIDASE INHIBITORS

      Namea	Half-Life (h)	Side Effects	Comments
      Phenelzine (Nardil)	4-5	Orthostatic hypotension, somnolence, weight gain	All cheese, fermented or aged foods, wine, and liver should be avoided. Should not be coadministered with SSRIs; should never be coadministered with drugs that increase intrasynaptic levels of amine neurotransmitters.
      Isocarboxazid (Marplan)	2.5	Orthostatic hypotension, somnolence, weight gain	All cheese, fermented or aged foods, wine, and liver should be avoided. Should not be coadministered with SSRIs; should never be coadministered with drugs that increase intrasynaptic levels of amine neurotransmitters.
      Selegiline (Eldepryl, Emsam)	2	Orthostatic hypotension, somnolence, weight gain, irritation at site of patch	All cheese, fermented or aged foods, wine, and liver should be avoided. Should not be coadministered with SSRIs; should never be coadministered with drugs that increase intrasynaptic levels of amine neurotransmitters. A transdermal delivery system is available for use in depression; also used to treat parkinsonism.
      Tranylcypromine (Parnate)	2-3	Orthostatic hypotension, somnolence, weight gain	All cheese, fermented or aged foods, wine, and liver should be avoided. Should never be coadministered with SSRIs; should never be coadministered with drugs that increase intrasynaptic levels of amine neurotransmitters.

      ^aProprietary names are given in parentheses.

   4. Miscellaneous medications (Table II–4).

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      Table II–4MISCELLANEOUS ANTIDEPRESSANT MEDICATIONS

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      Table II–4 MISCELLANEOUS ANTIDEPRESSANT MEDICATIONS

      Namea	Mechanism of Action	Half-Life (h)	Side Effects	Comments
      Nefazodone (Serzone)	Serotonin-2 antagonist and serotonin reuptake inhibitor	2-4	Sedation, hepatotoxicity	Less sexual dysfunction than other similar agents
      Trazodone (Desyrel)	Serotonin-2 antagonist and serotonin reuptake inhibitor	10-15	Priapism: prolonged erection may lead to impotence, orthostatic hypotension, sedation	Can be used in lower doses to manage sleep problems; should be avoided with monoamine oxidase inhibitors
      Mirtazapine (Remeron)	Noradrenergic and specific serotonin antagonist	20-40	Weight gain, sedation	No interference with sexual function, no nausea or diarrhea
      Bupropion (Wellbutrin)	Norepinephrine and dopamine reuptake inhibitor	14	Gastrointestinal: nausea, anorexia; risk of seizures at higher doses	Used for smoking cessation; contraindicated in patients with an eating disorder or a seizure disorder; less sexual dysfunction than other similar agents
      Vortioxetine (Brintellix)	Serotonin modulator and stimulator	66	Constipation, nausea/vomiting, diarrhea, sexual dysfunction
      Vilazodone (Viibryd)	5-HT1A receptor partial agonist, serotonergic reuptake inhibitor	25	Diarrhea, nausea, headache	Also used for generalized anxiety disorder and obsessive-compulsive disorder

      ^aProprietary names are given in parentheses.

2. Mood stabilizers: These medications are used to treat mania and include agents such as lithium, valproic acid, and carbamazepine. Lithium has many adverse effects including tremor, polyuria/diabetes insipidus, acne, hypothyroidism, cardiac dysrhythmias, weight gain, edema, and leukocytosis. Lithium is cleared through the kidneys and must be used carefully in older patients and in those with renal insufficiency. Valproic acid is teratogenic and must be used with caution in women of childbearing age (Table II–5).

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   Table II–5MOOD STABILIZERS

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   Table II–5 MOOD STABILIZERS

   Namea	Mechanism of Action	Half-Life (h)	Side Effects	Testing	Comments
   Lithium	Inhibits adenylate cyclase enzyme	24	Nausea, tremor, hypothyroidism, cardiac dysrhythmias, diarrhea. Diabetes insipidus: thirst, urination, weight gain, acne. At toxic levels, significant alterations in consciousness, seizures, coma, and death may occur.	A white blood cell (WBC), serum electrolyte determination, thyroid and renal function tests (specific gravity, blood urea nitrogen [BUN], and creatinine), fasting blood glucose determination, pregnancy test, and an electrocardiogram (ECG) are recommended before treatment and yearly thereafter (every 6 mo for a thyroid-stimulating hormone [TSH] and creatinine). Lithium levels should also be monitored at least every 3 mo once the patient has been stabilized on the medication.	Propranolol may help with tremor; benign increase in WBC count seen
   Valproic acid, valproate (Depakene)	Opens chloride channels, unknown	8	Thrombocytopenia, pancreatitis, weight gain, hair loss, gastrointestinal distress, cognitive dulling, neural tube defects in pregnancy.	Complete blood count (CBC), liver function tests, pancreatic enzyme levels, serum human chorionic gonadotropin (hCG) level in childbearing women.
   Divalproex sodium (Depakote)	Opens chloride channels, unknown	6-16	Thrombocytopenia, pancreatitis, weight gain, hair loss, gastrointestinal distress, cognitive dulling, neural tube defects in pregnancy.	CBC, liver function tests, pancreatic enzyme levels, serum hCG level in childbearing women.
   Carbamazepine (Tegretol)	Inhibits kindling, inhibits repetitive firing of action potentials by inactivating sodium channels	18-55	Nausea, vomiting, slurred speech, dizziness, drowsiness, low WBC count, high liver function tests, cognitive slowing, may cause craniofacial defects in newborn.	A pretreatment CBC should be obtained to assess for agranulocytosis. A CBC should be drawn every 2 wk for the first 2 mo of treatment, and thereafter, once every 3 mo. Platelet, reticulocyte, and serum iron levels should also be determined and all these tests performed yearly thereafter. Liver function tests should be performed initially, every month for the first 2 mo of treatment, and every 3 mo thereafter. Carbamazepine levels should also be monitored this often. Serum electrolytes and an ECG should be done before treatment and yearly thereafter as well.	Potent inducer of P450 system
   Lamotrigine (Lamictal)	Stabilizes presynaptic neural membranes and inhibits the release of glutamate by selectively inactivating sodium channels	15	Leukopenia, rash, hepatic failure nausea, vomiting, diarrhea, somnolence, dizziness.	CBC with platelet count every 6-12 mo.	Alternative choice, may have acute antidepressant effect; dose must be increased slowly to avoid rash
   Gabapentin (Neurontin)	Selectively inhibits voltage-gated calcium channels by targeting the α2δ-1 subunit	5-9	Somnolence, dizziness, ataxia, fatigue, leukopenia, weight gain.		No drug interactions, rash can be fatal
   Topiramate (Topamax)	Exact mechanism is unknown	19-23	Psychomotor slowing, memory problems, fatigue.		Many drug-drug interactions

3. Antipsychotic agents

   1. First-generation antipsychotics (typical antipsychotics)

      1. These medications work by blocking central dopamine receptors. They are most effective in reducing the positive symptoms of schizophrenia, including hallucinations and delusions.

      2. Side effects (Table II–6) include the following:

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         Table II–6FIRST-GENERATION ANTIPSYCHOTIC AGENTS

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         Table II–6 FIRST-GENERATION ANTIPSYCHOTIC AGENTS

         Namea	Half-Life (h)	Potency	Comments
         Chlorpromazine (Thorazine)	24	Low	Sedation and orthostatic hypotension are very common
         Haloperidol (Haldol)	24	High	Extrapyramidal syndrome very common; available in a long-acting intramuscular depot
         Thioridazine (Mellaril)	24	Low	Higher incidence of cardiac disturbances, retinitis pigmentosa
         Mesoridazine (Serentil)	30	Low	Cardiac arrhythmias (torsade de pointes)
         Molindone (Lidone, Moban)	12	Medium
         Fluphenazine (Prolixin)	18	High	Available in a long-acting intramuscular depot
         Trifluoperazine (Stelazine)	18	High
         Thiothixene (Navane)	34	High
         Perphenazine (Etrafon, Trilafon)	12	High
         Loxapine (Loxitane)	8	Medium
         Pimozide (Orap)	55	High

         ^aProprietary names are given in parentheses.

         1. Central nervous system effects:

            1. Extrapyramidal symptoms (EPS): Parkinsonian syndrome, acute dystonias, and akathisia.

            2. Tardive dyskinesias: Late onset of choreiform and athetoid movements of the trunk, extremities, or mouth.

            3. Sedation.

            4. Neuroleptic malignant syndrome (NMS): Can occur at any time with an antipsychotic agent, typically movement disorder (muscle rigidity, dystonia, agitation) and autonomic symptoms (high fever, sweating, tachycardia, hypertension). Treatment is mostly supportive (hydration and cooling) but can include medication with dantrolene and/or bromocriptine.

         2. Anticholinergic effects.

         3. Cardiovascular effects.

            1. Alpha-adrenergic blockade, which causes orthostatic hypotension.

            2. Cardiac rhythm disturbances, especially prolongation of the QT interval.

         4. Endocrine effects: Decreasing the amount of dopamine in the pituitary gland leads to increased prolactin levels, which can cause gynecomastia and galactorrhea as well as sexual dysfunction.

         5. Weight gain.

   2. Second-generation antipsychotics (atypical antipsychotics): These medications are more commonly used than first-generation antipsychotics because they are less likely to produce EPS, tardive dyskinesia, and NMS. However, many have significant side effects (Table II–7) of their own that limit their use (eg, clozapine can cause fatal agranulocytosis). Atypical antipsychotics can increase the risk of type 2 diabetes. The two of most concern are olanzapine (Zyprexa) and clozapine (Clozaril).

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      Table II–7SECOND-GENERATION ANTIPSYCHOTIC AGENTS

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      Table II–7 SECOND-GENERATION ANTIPSYCHOTIC AGENTS

      Namea	Site of Action	Half-Life (h)	Side Effects	Comments
      Clozapine (Clozaril)	Serotonin-dopamine antagonist	5-15	Agranulocytosis, anticholinergic side effects, weight gain, sedation, neuroleptic malignant syndrome	Complete blood count and differential counts required weekly or for the first 6 mo and biweekly thereafter
      Risperidone (Risperdal)	Serotonin-dopamine antagonist	3 in fast metabolizers, 120 in poor metabolizers	Extrapyramidal withdrawal syndrome in high doses, postural hypotension, increased prolactin; weight gain, sedation, decreased concentration	Present in breast milk
      Olanzapine (Zyprexa)	Serotonin-dopamine antagonist	31	Increased prolactin, orthostatic hypotension, anticholinergic side effects, weight gain, somnolence	Alanine amino-transferase levels, as drug affects the liver
      Quetiapine (Seroquel)	Serotonin-dopamine antagonist	7	Orthostatic hypotension, somnolence, transient increase in weight	Slit-lamp eye examination at baseline and every 6 mo for those at risk for developing cataracts
      Ziprasidone (Geodon, Zeldox)	Serotonin-dopamine antagonist	7	Dose-related QT interval prolongation, postural hypotension, sedation	Present in breast milk; baseline potassium and magnesium measurements
      Aripiprazole (Abilify)	Partial agonist at dopamine and serotonin-1A receptors and antagonist at postsynaptic serotonin-2A receptors	75	Headache, nausea, anxiety, insomnia, somnolence	Nonsedating; no increased risk of weight gain or diabetes
      Aripiprazole lauroxil (Aristada)	Partial agonist at dopamine and serotonin-1A receptors and antagonist at postsynaptic serotonin-2A receptors	29.2-34.9 d	Headache, nausea, anxiety, insomnia, somnolence	Extended-release injectable
      Lurasidone (Latuda)	Mechanism of action unknown; speculation: central dopamine type 2 (D) and serotonin type 2 (5HT2A) receptor antagonism	18	Nausea/vomiting, dyspepsia, somnolence	Increased mortality in elderly patients with dementia-related psychosis
      Paliperidone (Invega)	Dopamine antagonist	23	Headache, tachycardia, somnolence	Increased mortality in elderly with dementia-related psychosis; comes in 1 mo injectable form
      Brexpiprazole (Rexulti)	Dopamine D2 receptor partial agonist	91	Upper respiratory infection, weight gain, akathisia, nasopharyngitis	For the treatment of schizophrenia and treatment-resistant major depression; slightly altered version of aripiprazole
      Cariprazine (Vraylar)	D3 receptor and D2 partial agonist	2-5 d	Akathisia, insomnia, weight gain	For the treatment of schizophrenia and bipolar disorder

      ^aProprietary names are given in parentheses.

4. Anxiolytics and sedative/hypnotics

   1. Benzodiazepines: These drugs work by binding to sites on GABA receptors. They are effective in anxiety and sleep disorders and in reducing anxiety and agitation in other disorders such as acute psychosis. They are generally safe in overdose if used alone. They are metabolized mainly in the liver. Their side effects include sedation, behavioral disinhibition (especially in the young or the elderly), psychomotor impairment, cognitive impairment, confusion, and ataxia. They are addictive, and after prolonged use, withdrawal can cause seizures and death. Shorter-acting benzodiazepines carry a higher risk for dependency, although they carry less risk of a “hangover” after use. Table II–8 lists commonly used benzodiazepines. Table II–9 lists other anxiolytics.

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      Table II–8BENZODIAZEPINES

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      Table II–8 BENZODIAZEPINES

      Name	Proprietary Name	Half-Life (Including Metabolites) (h)
      Diazepam	Valium	20-70
      Lorazepam	Ativan	10-70
      Clonazepam	Klonopin	19-50
      Alprazolam	Xanax	8-15
      Chlordiazepoxide	Librium	24-48
      Oxazepam	Serax	5-15
      Temazepam	Restoril	8-12
      Midazolam	Versed	1.5-3.5
      Triazolam	Halcion	1.5-5

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      Table II–9OTHER ANXIOLYTICS/SEDATIVE-HYPNOTICS

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      Table II–9 OTHER ANXIOLYTICS/SEDATIVE-HYPNOTICS

      Namea	Indication	Half-Life (h)	Side Effects	Comments
      Buspirone (BuSpar)	Generalized anxiety	5-11	Headache, gastrointestinal distress, dizziness	Less useful in patients who have used benzodiazepines; should not be used with monoamine oxidase inhibitors
      Zolpidem (Ambien)	Insomnia	2-4	Headache, drowsiness, dizziness, nausea, diarrhea	Increased effect with alcohol or selective serotonin reuptake inhibitors
      Zaleplon (Sonata)	Insomnia	1	Headache, peripheral edema, amnesia, dizziness, rash, nausea, tremor
      Ramelteon (Rozerem)	Insomnia	1-2.6	Headache, galactorrhea	Melatonin receptor agonist, no affinity for GABA receptor complex
      Eszopiclone (Lunesta)	Insomnia	6	Anxiety, decrease in sexual desire, dry mouth, unpleasant taste	Stopping the drug suddenly may cause anxiety, unusual dreams, stomach and muscle cramps, nausea, vomiting, sweating, and shakiness

      ^aProprietary names are given in parentheses.

5. Drugs used to treat the side effects of other psychotropic medications

   1. Anticholinergic agents used to treat dystonias (caused by the use of antipsychotic medication) include benztropine, biperiden, diphenhydramine, and trihexyphenidyl.

   2. Medications used to treat akathisias (restlessness caused by the use of antipsychotic medication) include propranolol and benzodiazepines.

   3. Medications used to treat parkinsonian side effects (caused by the use of antipsychotic medication) include amantadine and levodopa.

6. Stimulants: These drugs exert their effects through a number of different pharmacologic mechanisms, the most prominent of which include facilitation of norepinephrine (noradrenaline) and/or dopamine activity. They are used to increase attention and alertness in a variety of conditions, including attention-deficit/hyperactivity disorder (ADHD). Table II–10 lists commonly prescribed stimulants.

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   Table II–10STIMULANTS

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   Table II–10 STIMULANTS

   Namea	Indication	Half-Life (h)	Side Effects	Comments
   Dextroamphetamine and amphetamine (Adderall)	Attention-deficit hyperactivity disorder (ADHD)	10	Nervousness, restlessness, and difficulty falling asleep or staying asleep	May slow children’s growth or weight gain; may be addictive
   Modafinil (Provigil, Alertec, Modavigil)	Narcolepsy, excessive daytime sleepiness	15	Dizziness, insomnia, diarrhea	Increases the release of monoamines and elevates hypothalamic histamine levels
   Dextroamphetamine (Dexedrine)	ADHD, narcolepsy	2-3	Nervousness, restlessness, and difficulty falling asleep or staying asleep	May be addictive
   Methylphenidate (Ritalin, Concerta)	ADHD, narcolepsy	2-3	Nervousness, restlessness, and difficulty falling asleep or staying asleep	May be addictive
   Methylphenidate (liquid) (Quillivant XR)	ADHD	5.6	Decreased appetite, weight loss, trouble falling asleep, nervousness	May be addictive
   Dexmethylphenidate (Focalin)	ADHD	4 (7 for XR)	Decreased appetite, weight loss, trouble falling asleep, nervousness	May be addictive
   Lisdexamfetamine (Vyvanse)	ADHD	10-13	Decreased appetite, weight loss, trouble falling asleep, nervousness	May be addictive
   Atomoxetine (Strattera)	ADHD	5.2	Nausea, dry mouth, appetite loss, insomnia, fatigue, headache, cough	A selective-norepinephrine reuptake inhibitor (SNRI); no abuse potential

   ^aProprietary names are given in parentheses.

A 63-year-old woman with a long history of schizophrenia complains of blurriness and a clouding of vision. The clinician believes that it is medication side effect. Which of the following agents is most likely responsible?

A. Haloperidol

B. Quetiapine

C. Risperidone

D. Chlorpromazine

E. Clozapine

Quetiapine is a second-generation antipsychotic that may cause the development of cataracts. Slit-lamp eye examination at baseline and every 6 months is suggested for those at risk for developing cataracts who are started on this drug.

A 28-year-old man with a history of a psychiatric admission 6 months previously is seen in the emergency department with a painful erection, which he says has persisted for 18 hours. Which of the following is the best next step?

A. Epinephrine injection into the penis

B. Follow-up in 12 hours

C. Oral benzodiazepines and careful observation

D. Magnetic resonance imaging of the lumbosacral spine

E. Intramuscular (IM) injection of benztropine

Priapism is defined as persistent penile erection that continues hours beyond or is unrelated to sexual stimulation. This condition can cause ischemia to the penis and when there is absent or very little cavernous blood flow associated with pain and swelling. This is considered a medical emergency. This priapism is most likely caused by trazodone. One treatment is epinephrine injected into the corpus of the penis.

A 53-year-old woman is admitted to the inpatient psychiatry unit after a serious (and almost fatal) suicide attempt. She remains nearly catatonic on the unit and will not eat or drink. She requires one-to-one observation constantly, as she remains suicidal with intent. Which of the following is the most appropriate treatment of the patient at this time?

A. Transcranial magnetic stimulation

B. SSRI + an antipsychotic

C. Tricyclic + an SSRI in combination

D. ECT

E. MAOI

ECT is the treatment of choice in this case, as it is more rapidly effective than medication.

A 34-year-old man is seen in the emergency department with a headache, dizziness, and blood pressure of 210/150 mm Hg. He has no medical problems, states that he feels fine, and says that last night he even had a nice meal with wine. Which of the following medications is he most likely taking?

A. Bupropion

B. Lithium

C. Amitriptyline

D. Phenelzine

E. Fluoxetine

This patient probably experienced a hypertensive crisis induced by an interaction between the wine and phenelzine, an MAOI.

A 22-year-old college student with a history of depression is being treated with sertraline. He enjoys drinking beer on the weekends. Which of the following side effects is most likely to occur?

A. Alcohol potentiation

B. Alcohol withdrawal

C. Sexual dysfunction

D. Diabetes insipidus

E. Serotonin syndrome

Sexual dysfunction is a very common side effect of SSRI medications.

Because of the side effects of his original antidepressant, the college student in Question II.5 is switched to another agent. He comes to the emergency department several days later with muscle spasms, confusion, fever, tachycardia, and hypertension. Which of the following is the most likely cause?

A. Serotonin syndrome

B. Cocaine intoxication

C. Meningitis

D. Alcohol withdrawal (delirium tremens)

E. Neuroleptic malignant syndrome (NMS)

This patient was likely switched from an SSRI, sertraline, to an MAOI, such as phenelzine. Because both agents increase serotonin levels, 5 weeks should elapse between discontinuation of one medication and initiation of the other. This is to avoid the danger of very serious serotonin syndrome, which has features similar to those of NMS.

A 17-year-old adolescent suffers from bulimia nervosa and is very depressed. She is also suffering from insomnia and apathy. Which of the following medications should be avoided?

A. Fluoxetine

B. Trazodone

C. Imipramine

D. Bupropion

E. Amitriptyline

Seizure disorders and eating disorders are contraindications for bupropion because of its possible lowering of the seizure threshold and its anorectic effects.

A 32-year-old woman has been taking medication (the name of which she does not remember) for her psychiatric condition. She complains of excessive thirst and urinating “all the time.” Which of the following is the woman’s most likely diagnosis?

A. Bipolar disorder

B. Major depression

C. Panic disorder

D. Schizophrenia

E. Social phobia

This patient has symptoms of diabetes insipidus, a side effect of lithium used in the treatment of bipolar disorder.

A 29-year-old man who “hears voices” at times complains of fever and chills. His temperature is 102 °F (38.9 °C) with no findings of infection. His white blood cell (WBC) count is 800 cells/mm³. Which of the following medications is most likely responsible?

A. Haloperidol

B. Risperidone

C. Clozapine

D. Thioridazine

E. Fluphenazine

This individual has neutropenic fever as a result of agranulocytosis, a side effect of the atypical antipsychotic agent clozapine.

A 38-year-old woman is admitted to the hospital for an elective hysterectomy. On hospital day 3, she experiences auditory and visual hallucinations, has tremors, and is agitated. Which of the following would be the best therapy?

A. SSRI

B. Propranolol

C. Imipramine

D. Benzodiazepine

E. Atypical antipsychotic

This woman is probably experiencing either alcohol or benzodiazepine withdrawal; in either case, benzodiazepines would be the treatment.

A 35-year-old woman with bipolar disorder delivers a male newborn who has spina bifida. Which of the following is the most likely etiology?

A. Advanced maternal age

B. Mood-stabilizing medication

C. Folate excess

D. Random mutation

E. Maternal malnutrition

This woman was likely taking valproic acid, a mood stabilizer used in treating bipolar disorder, which increases the risk for teratogenicity (eg, a neural tube defect).

A 39-year-old man attempts suicide by taking an overdose of amitriptyline tablets. He is rushed to the emergency department, where resuscitation is attempted but fails. Which of the following is most likely to be noted at autopsy?

A. Massive coronary artery occlusion

B. Aortic valve stenosis

C. Electrocardiographic conduction abnormalities

D. Cardiac tamponade

E. Massive pulmonary embolism

A tricyclic antidepressant overdose can lead to increased QT intervals and ultimately to cardiac dysrhythmias.

A 25-year-old man with bipolar disorder took too many pills, had two seizures, and is now in a coma.

A. Benztropine

B. Propranolol

C. Amantadine

D. Dantrolene

E. Dialysis

F. Flumazenil

G. Methylphenidate

H. Modafinil

Dialysis is used to treat lithium toxicity when it is severe and life threatening, such as causing seizures or coma.

A 38-year-old schizophrenic woman feels restless and cannot sit still; her provider states that this behavior is caused by her medication.

A. Benztropine

B. Propranolol

C. Amantadine

D. Dantrolene

E. Dialysis

F. Flumazenil

G. Methylphenidate

H. Modafinil

Akathisia (restlessness) can be treated with propranolol.

A 32-year-old woman with panic disorder and anxiety took an overdose of diazepam and is taken to the emergency department with somnolence and hypoventilation.

A. Benztropine

B. Propranolol

C. Amantadine

D. Dantrolene

E. Dialysis

F. Flumazenil

G. Methylphenidate

H. Modafinil

A benzodiazepine overdose can be treated with flumazenil, which is a benzodiazepine antagonist.

A 30-year-old man being treated for schizophrenia complains of tremor and a slow gait.

A. Benztropine

B. Propranolol

C. Amantadine

D. Dantrolene

E. Dialysis

F. Flumazenil

G. Methylphenidate

H. Modafinil

The parkinsonian-like symptoms of neuroleptic agents are treated with amantadine or levodopa.

A 14-year-old adolescent boy frequently gets in trouble at school for interrupting, not turning in homework despite understanding material and doing well on tests, and constantly asking for hall passes so he can get up and walk around.

A. Benztropine

B. Propranolol

C. Amantadine

D. Dantrolene

E. Dialysis

F. Flumazenil

G. Methylphenidate

H. Modafinil

Methylphenidate is a common treatment for ADHD. This drug has a common side effect—insomnia. For this reason, it is rarely prescribed for patients to take in the late afternoon or early evening.

A 56-year-old man on the night shift complains of excessive daytime sleepiness.

A. Benztropine

B. Propranolol

C. Amantadine

D. Dantrolene

E. Dialysis

F. Flumazenil

G. Methylphenidate

H. Modafinil

Modafinil may be used for the treatment of excessive daytime sleepiness in shift workers. It is a nonamphetamine psychostimulant with an unknown mechanism of action.

References