Update on Antipsychotics and Mood Stabilizers

David S. Rad, M.D.Medical Director, Crisis Resolution Unit

Harbor-UCLA Medical CenterAssistant Clinical Professor, UCLA

Overview

• Antipsychotics– Typicals

– Atypicals

– New Atypicals

– Long Acting Injectable

• Mood Stabilizers– Antipsychotics

– Lithium

– Anticonvulsants (seizure medications)

Medication Decision

• Prior treatment response

• Family treatment response history

• Side effects and current physical health

• Target symptomatology

Antipsychotics

• Also known as:

– Neuroleptic

– Major Tranquilizers

• Used in treatment of other conditions

– Mood disorders

• All current antipsychotic medications share dopamine blocking property

• Have other effects, however

Side effects of Antipsychotics

• Weight gain

• Metabolic changes

• Menstrual abnormalities

• Galactorhea- milk production

• Sexual Side effects:

– Anorgasmia, Lack of libido, impotence

Side Effects Continued

• Extrapyramidal Side Effects (EPS):

– Neuroleptic-Induced Parkinsonism

– Neuroleptic-Induced Acute Dystonia

– Neuroleptic-Induced Acute Akathisia

• Neuroleptic-Induced Tardive Dyskinesia

• Neuroleptic Malignant Syndrome

First Generation Antipsychotics

• Also known as:

– typical and conventional antipsychotics

• More frequent movement disorders

• Some have cardiac side effects

• Less frequent wt gain and metabolic changes

First Generation Continued

DRUG Dose (mg)

• Haldol 2• Prolixin 2• Navane 5• Trilifon 8• Stelazine 15• Moban 25• Loxipine 25• Serentil 50• Mellaril 95• Thorizine 100

Decanoate Formulation

• Lipid (fat) soluble

• More consistent concentration

• Prolixin (Fluphenazine) Decanoate

– Every 2-3 weeks

• Haldol (Haloperidol) Decanoate

– Every 3-4 Weeks

• Oral medications are still needed for the first 3-4 injections

Atypcial Antipsychotics

• Also known as:

– Second generation

• Less movement disorder side effects

• Some cause significant weight gain and metabolic changes

Clozapine (Clozaril)

• First atypical antipsychotic

• Reserved for treatment resistant Schizophrenia– May help with negative symptoms

• Significant side effects:– Agranulocytosis (bone marrow suppression)

• Weekly blood monitoring for first 6 months

• Every other week 6mo-1yr

• Every four weeks following 1yr

– Seizures

– Cardiac

Old Atypicals

• Risperidone (Risperdal) 1-6mg

• Olanzapine (Zyprexa) 5-20mg

• Qeutiapine (Seroquel) 50-600mg

• Ziprasidone (Geodon) 40-160mg

• Aripiprazole (Abilify) 5-30mg

• Paliparidone (Invega) 6-12mg

New Atypicals

• Iloperidone (Fanapt):

– 12-24mg twice a day

– Low incidence of EPS and sedation

– Intermediate risk of wt gain and diabetes

– Significant hypotension

• 1mg titration required

New Atypicals

• Asenapine (Saphris)– Sublingual formulation

• No food 20mins before and after

– 10-20mg twice a day

– Side effects:• Numbing of tongue

• Hypotension

• Sedation

• Wt gain

• Lower risk of diabetes

New Atypicals

• Lurasidone (Latuda):

– 40-80mg a day with food

– Low incidence of hypotension and sedation

– Intermediate EPS

– Good diabetes and wt gain profile

Long-Acting Injectable (LAI)

• Risperidone Microspheres (Risperdal Consta)

– IM every 2 weeks

– 25, 37.5 and 50mg injections

• Paliperidone (Invega Sustenna)

– Two loading doses separated by a week, then monthly

– 39, 78, 117, 156 and 234 mg injections

Long Acting Injectable

• Olanzapine pamoate (Zyprexa Relprevv)– 150, 210, 300 and 405 mg injections

– No requirement for overlap with oral

– Biweekly injections recommended

– Higher incidence of post injection syndrome requires extended observation following injection

• Aripiprazole (Abilify Sustenna)– 300 and 400 mg injections

– Monthly dosing

Mood Stabilizers

• Atypical antipsychotics

• Lithium

• Anticonvulsants (Seizure medications)

Atypical Antipsychotic

• RPD, OLP, QTP, ARP, ZPD, and asenapine(ASEN) are indicated in mania

• OLP + FOT, QTP work in bipolar depression

• OLP, APR, QTP, ZPR prevent relapse rates, and appear separate from the antipsychotic effects

• No antipsychotic has been proven to not be useful in bipolar disorder

Lithium

• Lithobid, Eskalith CR (450mg)• First mood stabilizer used• Dosed 600 – 2,700 mg

– Therapeutic level = 0.5 – 1.2

• Excreted by the kidneys• Side effects:

– Can affect thyroid and kidney function• Lab monitoring

– GI, urinary, skin and hair– Contraindicated in pregnancy

Valproic Acid

• Valproate, Depakote, Depakene

• 750 – 2,500mg– Blood level 50-125

• Side effects:– Can affect liver functioning

• Requires monitoring

– Sedation, wt gain, hair loss

– Polycystic ovarian syndrome

– Contraindicated with liver or pancreatic disease, and pregnancy

Carbamazepine

• Tegretol, Carbatrol,Equetro

• 400-1,200 mg/day

• Side effects:– Sedation, dizziness and GI symptoms are common

– Rare lethal rash

– Bone marrow suppression

– Long term use can affect liver, kidney and thyroid

– Contraindicated in pregnancy and can lower serum level of oral contraceptive

Lamotrigine

• Lamictal

• Works better for depression phase of Bipolar Disorder

• Most rashes are benign

• Low incidence of potentially lethal rash– Steven-Johnson syndrome

– Facial, eyes and mouth involvement

– Fever, sore throat, body pain

– Requires slow titration

Oxcarbazeine

• Trileptal

• 1,200 – 2,400 mg/day

• Side effects:

– Sedation, dizziness and GI

– Rash

– Sodium depletion