16. Psych (Depression, Schizophrenia, Bipolar, ADHD, Anxiety, Sleep), Alzheimer’s, Parkinson’s, Stroke, Epilepsy.pptx

RxPrep Review Session:
Psychiatric and Neurologic Conditions
Audrian Santos, Doctor of Pharmacy Candidate,
Class of 2021
Washington State University College of
Pharmacy and Pharmaceutical Sciences

Table of
Content- 2021
NAPLEX Book
Psychology
• Depression- Chapter 63
• Schizophrenia/Psychosis- Chapter 64
• Bipolar disorder- Chapter 65
• Attention Deficit Hyperactivity Disorder- Chapter 66
• Anxiety- Chapter 67
• Sleep Disorders- Chapter 68
Neurologic Conditions
• Parkinson’s- Chapter 69
• Alzheimer’s- Chapter 70
• Seizures/Epilepsy- Chapter 71

Depression
• Persistent feeling of hopelessness,
dejection, constant worry, poor
concentration, and sometimes,
suicidal tendencies.
• Causes: poorly understood but
involved:
• Neurotransmitters such as
serotonin (5-HT), glutamate,
acetylcholine (Ach), dopamine
(DA), norepinephrine (NE) and
epinephrine (Epi).

Select Drugs
that Cause
or Worsen
Depression
Key Drugs
ADHD Medications
- Atomoxetine (Strattera)
CV medications
- Beta blockers (especially
propranolol)
Analgesics
- Indomethacin
Hormones
- Hormonal contraceptives
- Anabolic steroids
Antiretrovirals (NNRTIs)
- Efavirenz (in Atripla)
- Rilpivirine (in Complera,
Odefsey)
Other
- Antidepressants
- Benzodiazepines
- Systemic steroids
- Interferons
- Varenicline
- Ethanol

Depression Diagnosis
• Relies on symptom assessment according to Diagnostic and
Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
• The HDRS (aka Ham-D) is the most widely known depression
assessment scale.
DSM-5 Criteria (At least 5 of the following symptoms during the same
two week period- must include depressed mood or diminished interest
Mood- depressed Concentration- decreased
Sleep- increased/decreased Appetite- increased/decreased
Interest/pleasure- diminished Psychomotor agitation or retardation
Guilt or feelings of worthlessness Suicidal Ideation
Energy- decreased
Remember:
M SIG E CAPS

Drug Treatment
• RULE OUT bipolar disorder!
• When depression and anxiety occur together, BZDs should
not be used alone
• Natural products- less evidence of efficacy
• St. John’s Wort
• SAMe
• Valerian

Drug Treatment- SSRI
Drug Dosing Safety/Side effects/Monitoring
Citalopram (Celexa) 20-40 mg/day
Max dose: 40 mg/day
Max dose (>60 y/o): 20 mg/day
CI: do not use with MAOI,
linezolid, IV methylene or pimozide
Fluoxetine: do not use with
thioridazine
Fluvoxamine: do not use with
aldosterone or tizanidine
Sertraline soln: do not use with
disulfram
Warnings: QT prolongation, liver
disease, CYP2C19 poor
metabolizers or on 2C19 inhibitor
SIADH/hyponatremia, fall risk
Bleeding
Escitalopram (Lexapro) 10 mg/day
Max dose: 20 mg/day
Max dose (>60 y/o): 10 mg/day
Fluoxetine (Prozac)
Sarafem- for PMDD only
+ olanzapine (Symbyax)-
treatment resistant depression
10-60 mg/day
Max dose: 80 mg/day;90 mg/week
Sarafem: 20 mg daily or 20 mg daily
starting 14 days prior to menstruation
through 1st full day of bleeding
Symbyax: initial 6 mg/25 mg QHS

Drug Treatment- SSRI
Paroxetine (Paxil) IR: 10-60 mg/day
CR: 12.5-62.5 mg/day
10 mg IR = 12.5 mg CR
Side effects: sexual side effects,
somnolence, insomnia, nausea,
dry mouth, diaphoresis, weakness,
tremor, dizziness, headache
Most activating: fluoxetine
Most sedating: paroxetine
Notes: all approved for depression
and a variety of anxiety disorders
except fluvoxamine (OCD)
All available in solution except
fluvoxamine
Sertraline is preferred in pt with
cardiac risk
Sertraline (Zoloft) 50-200 mg/day
Premenstrual dysphoric disorder: 50-
150 mg daily starting 14 days prior to
menstruation through 1st full day or
bleeding.
Fluvoxamine IR/ER 50-300 mg/day (daily dose >100
mg/day should be divided BID)

Drug Treatment- SNRI
Venlafaxine (Effexor XR)
Depression, generalized,
anxiety disorder (GAD), panic
disorder, social anxiety
disorder
37.5-375 mg/day
Max dose: 375 mg/day (IR), 225
mg/day (ER)
Different generics: check orange book
CI: SNRIs and MAOI: hypertensive
crisis
Do not initiate in a patient
receiving linezolid or IV methylene
blue
Warnings: SIADH/hyponatremia,
fall risk
SE: similar to SSRIs
SE due to NE: increase HR,
dilated pupils, dry mouth,
excessive sweating and
constipation
Duloxetine (Cymbalta)
Depression, peripheral
neuropathy, fibromyalgia, GAD,
chronic musculoskeletal pain
40-60 mg/day (or 20-30 BID)
Max dose: 120 mg/day: dose >60
mg/day not more effective
Increase 5-HT and inhibit reuptake of norepinephrine (NE)

Drug Treatment- SNRI
Desvenlafaxine (Pristiq)
Depression
50 mg/day (can increase to 400
mg/day, but no benefit >50 mg
Increase BP
Osteopenia/osteoporosis
Notes
Do not use levomilnacipran with
CrCl <15 ml/min or duloxetine with
CrCl <30 ml/min.
Levomilnacipran (Fetzima)
Depression
Start 20 mg/day x 2 days then
increase to 40 mg/day; can titrate by
40 mg/day no sooner than every 2
days
Max dose: 120 mg/day
Do not open, chew or crush capsules;
do not take with alcohol
Increase 5-HT and inhibit reuptake of norepinephrine (NE)

SNRI Drug Interaction
• Additive QT prolongation risk with venlafaxine
• Duloxetine is a moderate CYP2D6 inhibitor.
• Increase bleeding risk with concurrent use of anticoagulants,
antiplatelets, NSAIDS and select natural products.

Drug Treatment- Tricyclics
Tertiary Amines
Amitriptyline (Elavil)
Doxepin- for depression,
Silenor (depression) Zonalon
(pruritus)
Clominaprine (Anafranil)
Imipramine (Tofranil)
Trimipramine
Amitriptyline
Depression: 100-300 mg/day QHS or
in divided doses
Neuropathic pain/migraine
prophylaxis: 10-50 mg QHS
Doxepin: depression 100-300 mg/day
CI: do not use with MAOI,
linezolid, IV methylene blue
SE: cardiotoxicity (QT prolongation
with OD)
Orthostasis, tachycardia
Anticholinergic
Vivid dreams, weight gain,
sedation, sweating, myoclonus
TCAs primarily inhibit NE and 5-HT reuptake. They also block Ach and histamine receptors.
Secondary amines vs Tertiary Amines

Drug Treatment- Tricyclics
Secondary Amines
Nortriptyline
Amoxapine
Desipramine (Norpramin)
Maprotiline
Protriptyline
Nortriptyline:
Depression: 25 mg TID-QID
Notes
Tetrtiary amines have increase
anticholinergic properties, and
more likely to cause sedation and
weight gain
TCAs primarily inhibit NE and 5-HT reuptake. They also block Ach and histamine receptors.
Secondary amines vs Tertiary Amines

Drug Treatment- Dopamine and NE Reuptake Inhibitor
Bupropion (Wellbutrin SR,
Wellbutrin XL, Aplenzin, Forfivo
XL)
Zyban- for smoking cessation
Wellbutrin XL and Aplenzin are
approved for SAD
+ Naltrexone (Contrave)- for
weight management
300-450 mg daily
Bupropion IR is TID
Wellbutrin SR is BID (<200 mg/dose)
Wellbutrin XL is daily
Do not exceed 450 mg/day (up to 522
mg/day with Aplenzin) due to seizure
risk
CI: seizure disorders, history of
anorexia/bulimia, do not use with
MAO inhibitors, linezolid,
methylene blue or other forms of
bupropion
Warnings: neuropsychiatric ADE
possible when used for smoking
cessation
SE: dry mouth, CNS stimulation,
weight loss
Sexual dysfunction is rare

Drug Treatment- MAO Inhibitors
Isocarboxazid (Marplan) 20 mg/day in divided doses
Max dose: 60 mg/day
CI: history of CV disease, HA, hepatic
disease, pheochromocytoma
Do not use with other sympathomimetic and
related compounds; severe renal issue
Warnings: watch for DDI an DFI- if missed
could be fatal
Hypertensive crisis or serotonin syndrome
SE: anticholinergic effects; orthostasis,
sedation, sexual dysfunction
Selegiline
CI: use with serotonergic drugs
SE: constipation, gas, dry mouth, loss of
Phenelzine (Nardil) 5 mg TID
Max dose: 60-90 mg/day
Tranylcypromine (Parnate) 30 mg/day in divided doses
Max dose: 60 mg/day
Selegiline transdermal patch
(Emsam)
MAO-B selective inhibitor
Zelapar (ODT) is for
parkinsons’s
Start at 6 mg patch/day, can
increase by increments of 3
mg to 12 mg/day

Drug Treatment- Miscellaneous
Tetracycline antidepressant
Mirtazapine
Used commonly in SNF to help
with sleep and increase
appetite
15-45 mg QHS Warnings: anticholinergic effects, QT
prolongation, CNS depression
SE: sedation, increase appetite, weight gain
Trazodone
Rarely used as an
antidepressant
IR: 150-300 mg/day in
divided doses
ER: 150-375 mg QHS
Sleep: dosed 50-100 mg
QHS
CI: do not use with MAOI, linezolid or IV
methylene blue
SE: sedation, sexual dysfunction and
priapism
Boxed warning: hepatotoxicity
CI: hepatic disease, concurrent of MAOI
SE: similar to trazodone, but less sedating
Nefazodone
Rarely used due to
hepatotoxicity
200-600 mg/day divided BID

Selecting the Best Antidepressant
• Cardiac/QT risk
• Sertraline preferred
• Do not choose a QT prolongation drug/dose
• Smoker
• Bupropion SR
• Peripheral neuropathy or pain
• Consider duloxetine
• Taking serotonergic antidepressants
• Avoid multiple serotonergic medications
• Increase bleeding risk
• Seizure disorder
• Do NOT use bupropion

Selecting the Best Antidepressant
• Pregnant
• Do not use paroxetine
• Mild to moderate depression: psychotherapy
• Severe depression: SSRIs
• Daytime sedation
• Do not take a sedating drug early in the day
• Activating medications taken in the morning preferred
• Insomnia
• Sexual dysfunction
• High risk with SSRIs and SNRIs
• Lower risk with bupropion and mirtazapine

Treatment Resistant Depression
Antipsychotics
Aripiprazole (Abilify, Abilify
Maintena)
Tablet, ODT, solution, injection
Oral formulation= only
treatment resistant depression
Start 2-5 mg/day (QAM); can increase
to 15 mg/day
Boxed warnings
Elderly patients with dementia-
related psychosis treated with
antipsychotics= increase risk of
death
CI: Olanzapine/fluoxetine: do not
use with pimozide, thioridazine &
caution with other drugs/conditions
(QT prolongation)
Warnings: neuroleptic malignant
syndrome
Multiorgan hypersensitivity
Pathological gambling, compulsure
behavior
Olanzapine/fluoxetine
(Symbyax)
Usually started at 6 mg/25 mg QHS
Quetiapine (Seroquel,
Seroquel XR)
Start 50 mg QHS, increase nightly to
150-300 mg QHS
Brexipiprazole (Rexulti) Start 0.5-1 mg/day, can increase 3
mg/day (titrate weekly)
Depression that does not fully respond to two full treatment trials

Treatment Resistant Depression
Esketamine (Spravato)
Nasal spray
Start 56 mg intranasally twice weekly,
can increase to 84 mg twice weekly if
tolerated
Must be administered under the
supervision of a health care prodiver
Boxed warning: sedation and
dissociative changes, potential for
abuse and misuse
Notes
Due to risks, only available
through a restricted distribution
system under the REMS program
Depression that does not fully respond to two full treatment trials

Schizophrenia/Psychosis
• Chronic, severe and disabling disorder
• Primarily involving dopamine, serotonin, and glutamine.
• Genetics and environmental factors (e.g stress) contribute to
disease risk
• Common symptoms: hallucinations, delusions, disorganized
thinking/behavior

DSM-5 Diagnostic Criteria for Schizophrenia
Negative Signs and Symptoms Positive Signs and Symptoms
Loss of interest in everyday activities Hallucinations
Lack of emotion (apathy) Delusions
Inability to plan or carry out activities Disorganized thinking/behavior
Poor hygiene Difficulty to pay attention
Social withdrawal
Loss of motivation (avolition)
Lack of speech (alogia)

Medications/Illicit Drugs that Can Cause
Psychotic Symptoms
Medications Illicit Drugs
Anticholinergic (centrally-acting, high doses) Bath salts
Dextromethorphan Cannabis
Dopamine or dopamine agonists Cocaine, especially “crack” cocaine
Interferons Lysergic acid diethylamide
Stimulants, especially if already at risk Methamphetamine, ice, crystal
Systemic steroids (typically with lack of sleep) Phencyclidine (PCP)

Drug Treatment
• Antipsychotics primarily block dopamine receptors. Newer
antipsychotics also block serotonin
• First line: second generation antipsychotics (due to lower
incidence of EPS.
• Formulations: long-acting injections, ODTs, oral
solutions/suspensions, acute IM injections
• Olanzapine and benzodiazepine should not be given together

First Generation Antipsychotics
Drug Dosing Safety/Side Effects/Monitoring
Low potency Boxed warnings: elderly patients
with dementia-related psychosis=
increase risk death
Thioridazine: QT prolongation
Warnings: CV effects: QT
prolongation, orthostasis/falls
Anticholinergic effects, CNS
depression, EPS,
Hyperprolactinemia, NMS, blood
dyscrasias
Chlorpromazine 300-1000 mg/day, divided
Thioridazine 300-800 mg/day, divided
Mid potency
Loxapine (Loxitane, Adasuve-
inhalation powder for acute
agitation)
30-100 mg/day, divided
High potency
Haloperidol (Haldol, Haldol
decanoate)
Class butyrophenone (also used
for Tourette syndrome)
Oral: start 0.5-2 mg BID-TID, up to
30 mg/day
Deconoate (monthly): IM only; for
conversion from PO, use 10-20x
PO dose

First Generation Antipsychotics
Fluphenazine 6-12 mg/day, divided
Deconoate (every 2 weeks): IM
only
SE: sedation, dizziness,
anticholinergic effects, increase
prolactin
EPS: can give anticholinergics
Adasuve: dysgeusia
Notes
Sedation and EPS: lower potency
have increase sedation and
decrease EPS; higher potency
have decrease sedation and
increase EPS.
Thiothixene 15-60 mg/day, divided
Trifluoperazine 15-50 mg/day, divided

Second Generation Antipsychotics
Aripriprazole (Abilify, Abilify
Maintena, Aristada injection)
Also approved for irritability with
autism and Tourette syndrome
10-30 mg PO QAM
Abilify maintena: IM suspension:
give monthly
Aristada: IM suspension, give
every 4-8 weeks.
Akathisia, HA, anxiety, sedating or
activating constipation
Lower of weight gain, some QT
prolongation, EPS
Notes: aristada frequency
dependent on dose
Clozapine (Clozaril, FazaClo ODT,
Versacloz suspension)
300-900 mg/day, divided (start at
12.5 mg and titrate, also titrate off
since abrupt d/c can cause
seizures
Clozapine is very effective and
has increase risk of EPS/TD, but
severe SE potential
Boxed warnings, clozapine-
specific
Significant risk of
neutropenia/agranulocytosis
(REMS program)
Myocarditis and cardiomyopathy,
d/c if suspected
Seizure, dose related
SE: agranulocytosis, seizures,

Lurasidone (Latuda) 40-160 mg/day, divided
Take with food > 350 kcal
CI: use with strong CYP450 3A4
inducers and inhibitors
SE: somnolence, EPS, nausea,
metabolic syndrome
Olanzapine (Zyprexa, Zyprexa
Zydis ODT, Zyprexa Relprevv inj
+ fluoxetine for treatment resistant
depression
10-20 mg QHS
IM injection (acute agitation)
Relprevv inj suspension lasts 2-4
weeks, restricted use
Boxed warnings: Zyprexa relprevv:
sedation; must be monitored for 3
hours post-inj
SE: somnolence, metabolic
syndrome
Paliperidone (Invega, Invega
sustena, Invega Trinza)
PO: 3-12 mg daily
CrCl < 50 ml/min: 3 mg daily
CrCl <10 ml/min not
recommended
Invega sustena: IM inj given
monthly
Invega trinza: IM inj given every 3
Increase prolactin
EPS, especially in higher doses
Metabolic syndrome
Notes: Invega can leave a ghost
tablet in the stool

Quetiapine (Seroquel), Seroquel
XR)
400-800 mg/day, divided BID or
XR QHS
Somnolence, metabolic syndrome
Low EPS risk
Notes: take XR at night without
food or with a light meal
Risperidone (Risperdal, Risperdal
Consta, Perseris)
Also approved for irritability
associated with autism
4-16 mg/day; divided
Risperdal consta: IM inj given
every 2 weeks, 25-50 mg
Perseris: SC inj, give monthly
Increase prolactin, EPS especially
in higher doses
Tachycardia, QT prolongation
Metabolic syndrome
Ziprasidone (Geodon) 40-160 mg/day, divided BID taken
with food
Acute inj: Geodone IM 10 mg Q2H
or 20 mg Q4H
Max: 40 mg/day IM
CI: QT prolongation, do not use
with QT risk
SE: somnolence, EPS, dizziness,
nausea

Asenapine (Saphris, Secuado)
Saphris: sublingual tab
Secuado: patch
10-20 mg/day, divided BID
No food or drink for 10 mins after
Secuado: applied daily
CI: severe hepatic impairment
SE: somnolence, tongue
numbness (SL tab), EPS
Brexipiprazole (Rexulti) 2-4 mg daily SE: Weight gain, dyspepsia,
diarrhea, akathisia
Cariprazine (Vraylar) 1.5-6 mg daily SE: EPS, dystonia, HA, insomnia
Iloperidone 12-24 mg/day, divided
Titrate slowly due to
orthostasis/dizziness
SE: dizziness, somnolence,
orthostasis, tachycardia
Lumateperone (Caplyta) 42 mg daily SE somnolence, EPS

Selecting an Antipsychotic
• STAT! (Acute psychosis and refusing PO meds)
• Chronic treatment (Not adherent to daily PO treatment or
swallowing difficulties)
• Chronic treatment (adherent to daily PO treatment)

Psychosis in Parkinson Disease
Drug Dosing Safety/SE/Monitoring
Pimavanserin 34 mg PO daily (two 17 mg tabs) Warnings: not approved for
dementia-related psychosis; QT
prolongation
SE: peripheral edema, confusion

Tardive Dyskinesia
Valbenazine (Ingrezza) Start 40 mg daily, increase in 1
week to 80 mg PO daily
Moderate-severe hepatic
impairment: adjustment required
CYP2D6 poor metabolizer:
consider dose reduction
Warnings: somnolence, QT
prolongation
Deutetrabenazine (Austeda)
Also approved for chorea
associated with Huntington’s
disease
Start 6 mg PO BID, increase
weekly based on response (max
48 mg/day)
Concurrent strong CYP2D6
inhibitors or CYP2D6 poor
metabolizer: max dose 36 mg/day
CI: hepatic impairment;
administration with tetrabenazine
or valbenazine; administration with
MAOI
Warnings: somnolence, QT
prolongation

Neuroleptic Malignant Syndrome
• Rare but Highly fatal! Occurs mostly with FGA due to D2 blockade.
• Signs: hyperthermia, extreme muscle rigidity, mental status
change, other signs such as tachycardia, blood pressure changes
• Laboratory results: increase creatine phosphokinase and increase
white blood cells
• Treatment: taper off antipsychotics quickly and consider another
choice; supportive care; muscle relaxation with BZD or dantrolene

Bipolar Disorder
• Characterized by fluctuations in mood (extremely sad to overexcited)
• Bipolar I
• At least one episode of mania, and usually, bouts of intense depression
• Bipolar II
• At least one episode of hypomania (lasting > 4 consecutive days) and at least
one depressive episode (lasting > 2 weeks)
• Bipolar Depression
• Psychosis

Diagnostic Criteria (DSM-5)
• Symptoms: inflated self-esteem, need less sleep, more talkative
than normal, jumping from topics, easily distracted, increase in
goal-directed activity, high risk pleasurable activities
• Definition: abnormally elevated or irritable mood for at least a week
(or any duration if hospitalizations is needed)
• Diagnosis: exhibits >3 symptoms (if mood is only irritable, exhibits
>4 symptoms.

Drug Treatment
• Acute treatment
• Manic episode: first line treatment is valproate, lithium, or an antipsychotic.
• Depressive episode: first line treatment lithium but lamotrigine can be used
as an alternative.
• Maintenance
• Lithium and valproate are preferred

Pregnancy
• Valproate exposure can increase risk of fetal abnormalities, including
neural tube defects, fetal valproate syndrome and long-term cognitive
defects.
• Carbamazepine exposure in pregnancy can cause fetal carbamazepine
syndrome
• Lithium exposure in pregnancy can cause increase congenital cardiac
malformations and abnormalities.
• During pregnancy, lamotrigine is safer option relative to other mood
stabilizers.
• Lurasidone most favorable safety profile in pregnancy (approved for
bipolar depression)

Lithium
Lithium (Lithobid) Start: 300-900 mg/day, divided
BID-TID; usual range is 900-1,800
mg/day, divided BID-TID
Extended release: Take BID
Titrate slowly, as tolerated
Take with or after meals to reduce
nausea
Therapeutic range: 0.6-1.2 mEq/L
(trough level)
Acute mania may require up to 1.5
mEq/L initially
Boxed warning: serum lithium levels should be
monitored to avoid toxicity
Warnings: increase lithium toxicity, serotonin
syndrome
SE:
Within therapeutic range: GI upset, cognitive
effects, cogwheel rigidity, tremor, thirst, weight
gain, hypothyroidism
Toxicity:
> 1.5 mEq/L: ataxia, coarse hand tremor,
vomiting
> 2.5 mEq/L: CNS depression, arrhythmia,
seizure, coma
Monitoring: serum lithium levels, renal function,
thyroid function

Attention Deficit Hyperactivity Disorder (ADHD)
• Characterized by symptoms of inattention, hyperactivity, and
impulsivity.
• Primary treatment is stimulant medications (because they raise
dopamine and NE levels.
• ADHD medications are considered first line in patients > 6 years
old.

Diagnostic Criteria (DSM-5)
Inattention Hyperactivity & Impulsivity
> 6 symptoms of inattention for children up to age
16 or > 5 symptoms for ages 17 and older;
symptoms must have been present for at least 6
months
Symptoms: fails to pay attention, does not pay
attention when someone is talking, does not follow
through on instructions,
> 6 symptoms of hyperactivity-impulsivity for
children to age 16 or > 5 symptoms for ages 17 and
older; symptoms must have been presented for at
least 6 months.
Symptoms: often fidgets or squirms, leaves seat
unexpectedly, runs about when not appropriate
The following conditions must be met:
Several inattentive or hyperactive
Symptoms must have been present in 2 or more settings
Symptoms interfere with functioning, and are not caused by another disorder

Drug Treatment- Stimulant
Methylphenidate
IR tab: Ritalin
IR oral solution: Methylin
IR chewable tablet
ER tablets: Concerta (OROS
delivery), Metadate ER, Refexxil
ER capsules: Ritalin LA, Adhansia
XR, Aptensio XR, Jornay PM
ER oral suspension: Quillivant XR
ER chewable tablet: QuilliChew ER
ER orally-disintegrating tablet:
Costempla XR-ODT
Transdermal patch: Daytrana
IR: start 5 mg BID, 30 min before
breakfast and lunch
Max: 60 mg/day
Concerta: start 18-36 mg QAM
Max: 72 mg/day
Ritalin LA: start 20 mg QAM
Aptensia XR: start 10 mg QAM
Max (both): 60 mg/day
Start 20 mg QAM
Start 20 mg QAM
Start 17.3 mg QAM for ages 6-
17 years
Max: 51.8 mg/day
Start 10 mg/9 hr patch QAM
Max: 30 mg/9 hr
Warnings: Daytrana: loss of
pigmentation at application site
and areas distant from the
application site
SE: insomnia, decrease
appetite/weight loss, HA, irritability
Monitoring: consider ECG prior to
treatment: monitor BP and HR,
abuse potential and height and
weight

Drug Treatment
Dexmethylphenidate
Dexmethylphenidate (Focalin,
Focalin XR)
IR tablet, ER capsule
IR: start 2.5 mg BID, given at least
4 hrs apart
Max: 20 mg/day
ER: start 5 mg (children) or 10 mg
(adults) QAM
Max: 30 mg/day (children) or 40
mg/day (adults)
See methylphenidate
Notes
Active isomer of methylphenidate
Amphetamine, Dexamphetamine and Combinations
Dextroamphetamine/Amphetamine
IR tablet: Adderall
ER capsules: Adderall XR, Mydayis
Start 5 mg QAM or BID, with 2nd
dose 4-6 hrs after 1st dose
Max: 40 mg/day
Start: 5-10 mg (6-12 y.o), 10 mg
(13-17 y.o) or 20 mg (adults) QAM
Max: 30 mg/day

Drug Treatment
Amphetamine
ER orally-disintegrating tablet:
Adzenys XR-ODT
ER oral suspensions: Dyanavel XR,
Adzenys ER
IR tablet: Evekeo
IR orally-disintegrating tablet; Evekeo
ODT
Adzenys XR-ODT and ER: start
6.3 mg (children) or 12.5 mg
(adults) QAM
Max: varies based on age
Dyanavel XR: start 2.5-5 mg QAM
Max: 30 mg/day
See methylphenidate SE and
warnings
Boxed warning: misuse can cause
sudden death and serious CV
events
Warnings: Adzenys ER: risk of
intestinal necrosis when used with
sodium polystyrene sulfonate or
sorbital
Notes
Dextroamphetamine
ER capsule: Dexedrine Spansule
IR oral solution: ProCentra
IR tablet: Zenzedi
All formualtions: start 5 mg QAM
or BID, with 2nd dose 4-6 hrs after
1st dose
Max: 40 mg/day

Drug Treatment
Lisdexamfetamine (Vyvanse)
Capsule, chewable tablet
Start 30 mg QAM
Max: 70 mg/day
warnings
Notes
Low abuse potential
Methampetamine (Desoxyn)
Tablet
Start 5 mg QAM or BID
Max: 20-25 mg daily
warnings
Boxed warnings: missuse can
cause sudden death and serious
CV events

Drug Treatment- Non-Stimulant
Selective NE Reuptake Inhibitor
Atomoxetine (Strattera)
Capsule
For adults and children >6 y.o
>70 kg: 40 mg daily
< 70 kg: start 0.5 mg/kg/day
Strong CYP450 2D6 inhibitors max
is 80 mg daily
Boxed warnings: risk of suicidal
ideation
CI: MAOI use within the past 14
days
Warnings: aggressive behavior,
treatment-emergent psychotic
SE: decrease appetite, insomnia,
somnolence, dry mouth,
hypertension, tachycardia
Monitoring: BP, HR, ECG, mood,
height and weight (children)

Drug Treatment- Non-Stimulant
Central Alpha-2A Adrenergic Receptor Agonists
Clonidine ER (Kapvay)
Tablet
Clonidine IR (Catapres)
-for HTN
Start 0.1 mg QHS, increase by
<0.1 mg weekly
Max: 0.4 mg/day
Take BID: if uneven dosing take
the higher dose QHS
Warnings: dose dependent CV
effects, sedation and drowsiness
Do not d/c abruptly
Guanfacine: skin rash, dose
adjustment required for CYP3A4
inducer and inhibitors
SE: somnolence, fatigue, dizziness,
nausea, constipation, abdominal
pain
Monitoring: BP, HR
Notes: must be tapered off to
decrease risk of rebound HTN
Guanfacine ER (Intuniv)
Tablet
IR tablet (Tenex)- for HTN
Start 1 mg daily and increase by <
1 mg weekly
Max: 4 mg/day if 6-12 y.o or when
used with stimulants
Do not take with high-fat meals

Anxiety
• Symptoms: occasional anxiety, and any physical symptoms.
• Non-drug treatment: lifestyle changes, cognitive behavioral therapy
(CBT)
• Natural Products: Valerian (anxiety and sleep) but some products
may be contaminated with liver toxins

Drug Treatment
Drug/Drug Class Comments
First line: SSRIs and SNRIs
Escitalopram
Fluoxetine
Paroxetine
Sertraline
Duloxetine
Venlafaxine
Start at half the initial dose used for depression and
slowly titrate
Will not provide immediate relief
Second line
Buspirone Can be used in combination with antidepressants
Considered a more favorable add on medication
than BZD in elderly patients.
Does not provide immediate relief
Tricyclic antidepressants (Amitriptyline, Imipramine,
Nortriptyline)
Not FDA approved
Hydroxyzine (Vistaril) Sedating antihistamine
Should not be used long term
Pregabalin (Lyrica) Not FDA- approved

Drug Treatment
Drugs Monitoring
Propranolol (Inderal LA) Not FDA-approved but can reduce symptoms of
stage fright
Dose 10-40 mg one hour prior to an event
Buspirone Start 7.5 mg PO BID
Can increase by 5 mg/day every 2-3
days, to a max dose of 30 mg PO
BID
Take with or without food but most be
consistent
CI: use with MAOI
Warnings: risk of serotonin syndrome
SE: dizziness, HA, lightheadedness, nausea,
excitement
Note: no potential for abuse, tolerance or
physiological dependence

Benzodiazepine
• Enhance gamma aminobutyric acid (GABA)
• Provide fast relief of symptoms
• Can be useful for short term treatment of acute anxiety
• Potentially inappropriate in patients > 65 years old

Drug Treatment
Drugs Monitoring
Alprazolam (Xanax) 0.25-0.5 mg PO TID Boxed warnings: use with opioids can result in
sedation, respiratory depression and death
CI: acute narrow-angle glaucoma, severe liver
disease
Warnings: physiological dependence and tolerance,
CNS depression, anterograde amnesia, pregnancy
SE: somnolence, dizziness, ataxia, weakness
Notes:
C-IV
Diazepam: lipophilic, fast onset, long half life.
Alprazolam: fast onset, often abused
Commonly used for alcohol withdrawal syndrome:
lorazepam, diazepam and chlordiazepoxide
Antidote: flumazenil
Chlordiazepoxide 5-25 mg TID-QID
Clonazepam (Klonopin) 0.25-0.5 mg PO BID
Clorazepate (Tranxene) 30 mg PO daily in divided
doses
Diazepam (Valium) 2-10 mg PO BID-QID
Lorazepam (Ativan) 2-3 mg PO daily in
divided doses
Oxazepam 10-30 mg PO TID-QID

Sleep Disorders
• Diagnosis of chronic insomnia: symptoms at least three times per
week for at least three months.
• Nondrug treatment: CBT, treat underlying medical conditions, d/c
medications that can worsen insomnia.
• Insomnia Guidelines
• Start with non-drug treatment
• Sleep problems?

Sleep Disorders
• Need help falling asleep?
• Eszopiclone, Zolpidem, Ramelteon, Zaleplon
• Need help staying asleep?
• Eszopiclone, Zolpidem, Doxepin, Suvorexant
• Need help falling and staying asleep?
• Eszopiclone, Zolpidem

Restless Legs Syndrome
• Primary treatment includes dopamine agonists and
gabapentin.
• Pramiprexole (Mirapex) and Ropinorole (Requip)
• Immediate release formulation is taken 1-3 hours before
bedtime.
• Rotigotine (Neupro) dopamine agonist in patch form.

Narcolepsy
• Excessive daytime sleepiness and cataplexy
• Treated with stimulants:
• Modafinil (Provigil)
• Armodafinil (Nuvigil)
• Narcolepsy with cataplexy:
• Sodium oxybate
• Other oral medications for narcolepsy
• Pitolisant (Wakix)
• Solriamfetol (Sunosi)

Parkinson’s Disease
• Neurological disorder
• Occurs when neurons in the substantia nigra die or impaired
• When 80% of the dopamine producing cells are damaged, the
motor symptoms of the disease appears
• Symptoms: tremor, rigidity, akinesia, postural instability
• Additional symptoms: micrographia, shuffling walking, muffled
speech, depression, incontinence

Drug Treatment
Drugs Dosing Safety/SE/Monitoring
Carbidopa/Levodopa
(Sinemet)
IR (starting dose): 25/100 mg PO
TID
CR (starting dose): 50/200 mg PO
BID
Rytary: start at 23.75/95 mg PO
TID if levodopa-naïve
Inbrija: 84 mg inhaled up to 5
times daily as needed.
Max dose 420 mg/day
CI: nonselective MAOI within 14
days
SE: nausea, dizziness,
orthostasis, dyskinesia,
hallucinations, psychosis;
discoloring of urine
Notes:
70-100 mg/day of carbidopa
required to inhibit dopa
decarboxylase

Drug Treatment
Entacapone (Comtan)
+ levodopa/carbidopa
200 mg PO with each dose of
carbidopa/levodopa
Max=1600 mg/day
SE: similar to levodopa
Notes: decrease in levodopa of
10-30% when adding COMT
inhibitor
Pramiprexole (Mirapex) IR: start with 0.125 mg PO TID,
titrate weekly to max of 1.5 mg TID
ER: start with 0.375 mg PO daily,
titrate weekly to max 4.5 mg daily
Warnings: somnolence,
dyskinesias,
SE: dizziness, nausea, vomiting,
dry mouth, peripheral edema
Notes: slow titration
Patch: apply once daily
Ropinirole (Requip XL) IR: start with 0.25 mg PO TID;
titrate weekly to max of 8 mg TID
XL: start with 2 mg PO daily, titrate
weekly to max of 24 mg daily
Rotigotine (Neupro)
Patch
Approved for RLS
Patch: start with 2mg/24 hrs
Max dose: 8 mg/24hrs

Drug Treatment
Apomorphine (Apokyn) injection Start with 0.2 ml (2 mg) SC PRN
(up to 5x day), titrate by 1 mg
every few days
Max: 0.6 ml (6 mg)
CI: do not use with 5-HT-3
antagonists
SE: severe NV, hypotension
Notes
Amantadine
Amantadine ER (Gocovri,
Osmolex ER)
IR: 100 mg PO BID
Osmolex ER: 137 mg PO daily,
increase after 1 week to 274 mg
daily
Gocovri: 129 mg daily, increase
weekly to max dose of 322 mg
daily
CI: ER: eGFR < 15 ml/min/1.73
m2
Warnings: somnolence, psychosis
SE: dizziness, orthostatic
hypotension, livedo reticularis
Notes

Drug Treatment
Selegiline (Zelapar) Capsule, tablet: 5 mg PO BID, with
breakfast or lunch
ODT: 1.25-2.5 mg daily
Can be activating (do not take at
bedtime)
CI: in combination with MAOI,
opioids, SNRIs, TCAs
Xadago: severe hepatic
impairment
Warnings: serotonin syndrome,
hypertension, CNS depression,
dyskinesia, impulse control
Monitoring: BP, signs of serotonin
syndrome, visual changes
Notes
Rasagiline (Azilect) 0.5-1 mg PO daily
Safinamide (Xadago) Start with 50 mg daily; after 2
weeks may increase to 100 mg
once daily

Drug Treatment
Benztropine (Cogentin) 0.5-2 mg TID SE: high incidence of peripheral
and central anticholinergic effects
Notes: avoid in elderly
Trihexyphenidyl 1-5 mg TID (start with 1 mg QHS)
Isatradefylline (Nourianz) 20 mg PO daily, can titrate to a
max of 40 mg daily
Warnings: hallucinations,
dyskinesia, impulse control
disorders
Droxidopa (Northera) Start at 100 mg PO TID, can titrate
every 24-48 hour to a max of 1800
mg/day
Boxed warnings: supine HTN
SE: syncope, falls, HA

Alzheimer’s Disease
• Symptoms: memory loss, difficulty communicating, inability to learn,
difficulty planning, poor coordination, personality changes, inappropriate
behavior, paranoia
• Screening tools: Mini-Mental State Exam (MMSE)
• Score <24 indicated memory disorder
• Natural products: vitamin E (2,000 IU daily) and Ginkgo biloba
• Non-drug treatment
• Keep blood glucose, blood pressure and cholesterol well controlled
• Engage in thinking activities and physical activity
• Eat a healthy diet

Drug Treatment
Donepezil (Aricept) Start: 5 mg QHS, can increase to
10 mg QHS after 4-6 weeks
Moderate to severe: can increase
to 23 mg QHS after >3 months of
10 mg QHS
Warnings: cardiac effects,
anorexia, neuroleptic malignancy
syndrome
SE: nausea, diarrhea, insomnia,
weight loss
Notes:
Donepezil is dosed QHS to reduce
nausea
Exelon patch and donepezil ODT
have less GI side effects
Rivastigmine (Exelon) Capsule: start 1.5 mg BID, can
increase every 2 weeks to 6 mg
BID
Patch: start with 4.6 mg/24 hr, can
increase every 4 weeks 13.3
mg/24 hrs (patch changed daily)
Hepatic impairment: max patch is
4.6 mg/24 hrs

Drug Treatment
Memantine (Namenda)
+ donepezil
IR: start with 5 mg PO daily, titrate
weekly to 10 mg PO BID
ER: start with 7 mg PO daily, titrate
weekly to 28 mg PO daily
Warnings: caution with
drugs/conditions that increase
urine pH
SE: can cause dizziness,
confusion, HA, constipation,
syncope
Notes

Seizure/Epilepsy
• Classification
• Focal seizure
• Focal aware
• Complex partial
• All seizure types can be described based on the patient’s symptoms
• Clonic
• Atonic
• Myoclonus
• Tonic
• Absence

Acute Seizure Management
• Stabilization Phase (0-5 minutes)
• Time the seizure
• Start EEG, oxygen may be needed, check AED levels, electrolytes
• Initial Treatment Phase (5-20 minutes)
• If seizure continues:
• Give IV lorazepam, alternatives if IV unavailable
• IV midazolam or rectal diazepam
• Second Treatment Phase (20-40 minutes)
• If seizure continues:
• Give regular AED: IV fosphenytoin, valproic acid, and levetiracetam
• If seizure last longer, there is no clear treatment

Chronic Seizure Management
• AEDs first line treatment for epilepsy
• AEDs should not be stopped abruptly as this can lead to seizures
• Alternative Treatments
• Medical marijuana
• Ketogenic diet

Drug Treatment
Lamotrigine (Lamictal) Initial: week 1 and 2: 25 mg daily
Week 3 and 4: 50 mg daily
Week 5 and on: can increase by
50 mg daily every 1-2 weeks
Maintenance dose: 300-400 mg
daily, divide BID, unless using XR
Boxed warnings: serious skin
reactions
Warnings: risk of aseptic
meningitis, blood dyscrasias,
DRESS
SE: n/v, somnolence, tremor,
ataxia, alopecia
Monitoring: Rash
Notes

Drug Treatment
Levetiracetam (Keppra) Initial: 500 mg BID or 1000 mg
daily (XR)
Max: 3000 mg/day
Warnings: psychiatric reactions,
suicidal behavior, anaphylaxis,
angioedema
SE: irritability, dizziness,
weakness, asthenia, vomiting
Topiramate (Topamax) Initial:
Week 1: 25 mg BID (IR) or 50 mg
daily (XR)
Weeks 2-4: increase by 25 mg
BID (IR) or 50 mg daily (XR) each
week
Week 5 and on: increase by 100
mg weekly until max dose or
therapeutic effect
CI: Trokendi XR only: alcohol use
6 hours before or after doses.
Warnings: nonanion gap metabolic
acidosis, oligohidrosis,
nephrolithiasis, angle-closure
glaucoma, hyperammonemia, fetal
harm
SE: somnolence,
memory/concentration/attention,
weight loss, anorexia

Drug Treatment
Valproic acid (Depakene)
Divalproex (Depakote)
Also used for bipolar and migraine
prophylaxis
Initial: 10-15 mg/kg/day
Max: 60 mg/kg/day
Therapeutic range: 50-100 mcg/ml
(total level)
Boxed warnings: hepatic failure,
fetal harm
CI: hepatic disease, urea cycle
disorders
Warnings: hyperammonemia,
dose related thrombocytopenia
SE: alopecia, n/v, HA, anorexia,
abdominal pain
Monitoring: LFTs, CBC with
differential, platelets

Drug Treatment
Carbamazepine (Tegretol) Initial:
200 mg BID (or divided QID for
suspension)
Max: 1600 mg/day
Boxed warnings: serious skin
reactions, patient of Asian descent
to be tested for HLA-B*1502,
aplatic anemia, agranulocytosis
CI: myelosuppression, use of
MAOI within past 14 days
Warnings: DRESS, hyponatremia
(SIADH), fetal harm
SE: dizziness, drowsiness, ataxia,
n/v
Monitoring: CBC with differential
and platelets prior to and during
therapy

Drug Treatment
Lacosamide Initial: 50-100 mg BID
Max: 400 mg/day
CrCl< 30 ml/min: max dose is 300
mg/day
Warnings: prolong PR interval and
increase risk of arrhythmias
SE: dizziness, HA, diplopia,
blurred vision
Monitoring: ECG in at risk patients
Oxcarbazepine (Trileptal) Initial: 300 mg BID; 600 mg daily
Max: 2400 mg/day
CrCl <30 ml/min: start 300 mg
daily
CI: hypersensitivity to
eslicarbazepine
Warnings: increase risk of serious
skin reactions, consider screening
patients of Asian American
descent for HLA-B*1502,
hyponatremia
SE: somnolence, dizziness, n/v,
abdominal pain, visual issues

Drug Treatment
Phenobarbital Initial 50-100 mg BID or TID
(adults)
15-40 mcg/ml (children)
CI: severe hepatic impairment,
dyspnea
Warnings: habit forming,
paradoxical reactions, respiratory
depression, fetal harm
SE: somnolence, cognitive
impairment, dizziness, ataxia,
physiological dependence,
tolerance, hangover effect

Drug Treatment
Phenytoin (Dilantin) Loading dose: 15-20 mg/kg
Max dose: up to 300-600 mg/day
(total level)
1-2.5 mcg/ml (free level)
Boxed warnings: phenytoin IV
administration rate should not
exceed 50 mg/min and
fosphenytoin should not exceed
150 mg PE/minute or 2 mg
PE/kg/min
CI: prev hepatotoxicity due to
phenytoin
Warnings: extravasation, avoid in
patients with a positive HLA-
B*1502, fetal harm
SE: dose related: nystagmus,
ataxia, diplopia
Chronic: gingival hyperplasia, hair
growth, hepatotoxicity
Fosphenytoin (Cerebryx)

Concerns with AEDs
• Monitoring- have therapeutic ranges
• Drug Interactions
Enzyme inducers Enzyme inhibitor
Carbamazepine Valproic acid
Oxcarbamazepine
Phenytoin
Fosphenytoin
Phenobarbital
Primidone

Concerns with AEDs
• CNS depression
• Bone loss
• Suicidal Risk and Rash
• Use in Pregnancy
• Use in children

16. Psych (Depression, Schizophrenia, Bipolar, ADHD, Anxiety, Sleep), Alzheimer’s, Parkinson’s, Stroke, Epilepsy.pptx

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