Treatment - Pharmacotherapy Overview

Pharmacotherapy consists of the decision to start an agent or to refrain for the time being. While important to consider adding a medication, it is equally as important to consider reducing medication that is either ineffective or potentially causing adverse effects.

Antidepressants

a. SSRIs – generally equivalent in efficacy

• paroxetine is avoided due to anticholinergic burden and medication interactions

• fluoxetine is helpful to avoid withdrawal in patients with nonadherence due to its long half-life

• fluvoxamine has been studied to be effective in patients with OCD

b. SNRIs – if SSRI trials are failed, may consider SNRI. If there is an element of chronic pain, consider duloxetine

c. DNRI (bupropion) – good to consider if there is an element of inattention / fatigue, or if the patient is interested in the treatment of nicotine use disorder, due to the dopaminergic quality of bupropion, avoid in patients with seizure disorders, and eating disorder

d. TCAs – this category has greater anticholinergic burden, though nortriptyline and amitriptyline may be helpful in patients with chronic headaches; clomipramine has been studied to be effective in patients with OCD

e. MAOIs – generally avoided due to diet restrictions and medication interactions

Anxiolytics

a. SSRIs and SNRIs – as above

b. Buspirone – low side-effect profile, can be taken three times a day

c. Benzodiazepines – helpful in short-term treatment of anxiety, but generally should be tapered off due to dyscognitive side-effects, increased fall risk, and generally ineffective for long-term use

d. Antiadrenergics – may be a good option for anxiety and agitation in TBI patients, caution in patients with lower blood pressure or bradycardia

• Beta-blockers – propranolol can be used TID and eventually consolidated into once a day long-acting medication

• Clonidine

• Prazosin – helpful to treat PTSD associated nightmares

Mood stabilizers

a. Lamotrigine – slow titration to avoid Stevens-Johnson Syndrome, though beneficial for bipolar depression

b. Lithium – beneficial for both control of mania and depression in bipolar disorder, though many side effects (weight gain, polydipsia/polyuria, thyroid dysfunction, neuropathy, tremors, extrapyramidal side effects, acne, alopecia), requires blood serum monitoring

c. Valproic acid – beneficial for control of mania or in agitation; not helpful for depression, should be avoided in women of childbearing age

d. Carbamazepine – beneficial for control of mania; not helpful for depression, many medication interactions, should not be given to women of childbearing age

e. Antipsychotics – have mood stabilizing properties

Antipsychotics

a. First generation – acts on dopamine

b. Second generation – acts on dopamine and serotonin

• Quetiapine favored by neurologists due to low dopaminergic component, however, to reach dopaminergic effects and benefit antipsychotic properties, typically doses of 400mg+ is required. It has not been shown to be effective in controlling psychosis in Parkinson disease or agitation in dementia. Also beneficial for bipolar depression

• Clozapine is more effective in controlling psychotic symptoms though it requires weekly blood draws to monitor for possible blood dyscrasia; it also has the worst side-effect profile regarding weight gain and metabolic effects.

• Pimavanserin – no dopaminergic qualities, has been approved for treatment of Parkinson's disease psychosis

• Lurasidone - shown to be beneficial for bipolar depression

• Aripiprazole – partial agonist; shown to be beneficial as a potential augmenting agent for depressive disorder, long half-life