This on-demand teaching session is relevant for medical professionals working in psychiatry. Join host and Psychiatry doctor Rebecca to discover the ins and outs of psychiatric medications from SSRIs to SNRIs, Tricyclics, and more. Rebecca will discuss the various classes of psychiatric medications, the guidelines for treatment, how to safely and appropriately provide the right medication option to the patient, common side effects, and more. Get the resources and knowledge you need to succeed in your medical practice today.
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Rebecca is training in psychiatry at SlaM and co-host of the Thinking Mind Podcast.

In this webinar on Psychotropic medications, Rebecca will be taking us through some of the common classes of medications used to treat mental health conditions. This session will be interactive and discuss the common considerations when initiating a medication, monitoring requirements, and important side effects to discuss with your patient. Patients on these medications are encountered not only in psychiatry settings but also in A&E departments, general practice, and on the wards. They can interact with other medications and be affected by intercurrent illness, so it is useful across all specialties to have a general knowledge base of these medications.

Learning objectives

Learning Objectives: 1. Identify the three common classes of psychiatric medications 2. Explain the role of the Cytochrome P450 in psychiatric drug interactions 3. Describe common side effects of SSRI medications 4. Articulate the guidelines of treatment for depression 5. Explain the importance of discussing medication choice with the patient to tailor to their individual needs
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

My name is Rebecca. I am a Psychiatry doctor um CT three. So in my third year of psychiatry specialized training, I'm currently working at South London and the Maudsley NHS Foundation Trust, which is in south of London in the United Kingdom for those who are outside of the UK. Um I'm also a host of the Thinking Mind Podcast. Um If you want to give it a listen, we talk about all things psychiatry psychotherapy. Um If you've enjoyed listening to me talk today, um and that's my Twitter and the podcast, Twitter if you want to check it out. Um I'm just seeing the chat box. Hi, Emma, thanks. Thanks for letting us know where you're from. Um So my first talk was actually who's in the room. Um So we kind of um have started that, but if anyone else wants to pop in the chat where they're from, um I've tried to make this quite informal um by doing an awful Photoshop of my face. Um If at any point in the chat, you want to um, ask me any questions or pop them in the chat. Um I don't mind um, at any point Um, I'm gonna be talking over the next hour about medications in psychiatry. Are there any particular medications that people would like me to cover? Um, I planned the presentation around particular medications but if there's anything in mind that you have that I haven't covered, I will try and discuss it at the end. Um, if we don't have time, it would be really great if you can give feedback. Um, and maybe we could create another session on a particular um type of medications if that's something you particularly want to know about. Um So feel free to post um over the next hour with any questions or medications you want to know about. Um So for full clarity, the majority of the information um I will be giving today has come from the prescribing guidelines in psychiatry, from the water, prescribing guidelines. So that pink book and that's why my slides are all pink because it's in keeping with the prescribing guidelines, other resources and just to say I'm from the UK, so this is based on UK guidelines. And um so hopefully that can be applicable wherever you are. Um So other resources I find really useful are the BNF. Um So on the left hand side of the screen, um I also use nice guidelines when I'm practicing. And also I think it's really helpful to read the patient leaflets that you give your patients when you give them medication so that you understand what they understand in the terms that they've been given to. But patient leaflets are also just really useful in general, um, for myself and then psychiatrists, um, when learning about side effects, in case you've forgotten them, if it's been a while since you've studied about them. And then lastly, um, the rest of the information I'll be talking a few days from my own brain. So that's the, um, picture in the middle, um, and anecdotal, um, anecdotal experience in my, in my practice so far, I think it's really important before we start talking about medications to say, first and foremost, medications are not the only treatment for psychiatric presentations. Um, I think it's really important to treat people with a biopsychosocial model. Um, so yes, medication is, is very helpful depending on the particular medical mental health condition. But it's also really important to consider the psychological aspects of the talking therapies and the social aspects that might be able to help that individual with the mental health presentation, um, that they have. Um, but today I will be talking about medication. So I will only be talking about meds, but please please always bear in mind the biopsychosocial model. So common types of psych medication. So the top three are the ones that I'm going to be talking about today. So that's antidepressants, antipsychotics, and mood stabilizers. Um, these are the common ones that I encounter in my practice. Um, and you're likely to encounter in your practice. Um, there are obviously lots more psychiatric medications that I won't have time to talk about today. Um, but you might commonly come across these so, Adhd medications, stimulants, and non stimulants. Benzos and Ed drugs like zolpidem and ZIC. And then maybe if you're more specialist which tends to be in older age psychiatry, um, you might come across antidementia medications or Parkinson's medications and it's important to bear these in mind if you particularly want to learn about these, like I said, um, give us feedback. Um, if you'd like another, another presentation on those, but today, I will be covering antidepressants, antipsychotics and mood stabilizers before I go on to talk about those individual classes of drugs. Um I'm not going to talk about interactions that much apart from when I specifically talk about cloZAPine and lithium. But to bear in mind across all psychiatric medications or most, not all, but most psychiatric medications um, are involved in the Cytochrome P 4 50 enzyme. So, if you want to learn about drug interactions, I would highly recommend solidly understanding the inducers and inhibitors of the P 4 50 because it is involved in the breakdown of the majority of mental health medications. Um, and it is difficult to remember. Um, but it is useful to get your head around in terms of interactions. But if in doubt, just check the B NF um to see whether the drug you're prescribing interacts with any other medications. So the first class, um, I'm going to talk about is antidepressants. Although I think it's important to know that we don't just use antidepressants for depression. We also use antidepressants for anxiety disorders, such as OCD, body dysmorphia, panic disorders, generalized anxiety disorders, social phobias. Um, and sometimes maybe psychotic depression and things like that. So it, it's not just, um, they're not just medications for antidepressants and I found that a lot of patients don't know that. And when you prescribe antidepressants for their OCD, they might question why you're doing that. So I think it's always important to remind them that it's a bit misleading with the name. So common antidepressants that you might come across in psychiatric medicine are SSRIS and I'll go on to talk about them in more detail and these are a list of the common ssris that we come to, um, that we work with in our practice. Then you've got your tricyclics, which we tend to not to use that much anymore. Although we do use clomiPRAMINE in the treatment of OCD, which is why I'm still going to talk about them and you actually might come into contact with these medications for treatment that aren't mental health related. So, amitriptyline can be used for migraine prophylaxis or neuropathic pain and it's useful to know about their side effects. Um We've got our NASA um or NASA um Mirtazapine, which is commonly used here in the UK uh to treat depression, your SNRI s and I'll explain what these words mean if you're not familiar with them. Um, and the common one used, um, in mental health is Venlafaxine. Um, we do see DULoxetine used, although it's not, not necessarily as commonly used for mental health presentations. Um, but I'll go on to talk about, um, where it might be used and then you've got other, um, antidepressant medications. Um, and there's just a list of those. Now, I'm not going to go over those, but it, it's important to mention. So the top three, are newer antidepressants and sometimes used as a second or third line in the treatment of depression. TraZODone is a slightly older drug, although we do sometimes still see people treated with traZODone and the MAOIs, um, we don't use them that much anymore. Um, because of the cheesy reaction, the hypertensive crisis, um, and they were dangerous in overdose, but you still might come into contact with them and it's important to bear in mind their risks involved in serotonin syndrome, which I'll go on to talk about in a moment. So this is the guidelines of treatment of depression, um, from the more the prescribing guidelines and I don't know if you can see it. Um, you might want to come back and have a look at it at the end of this talk, um, or you'll be able to find it um, in the prescribing guidelines in the book. Um, but I think the most important thing which I've joined the arrow is discuss choice of the antidepressant drug with the patient. That's really important because someone might really prioritize having a sex drive. So you might want to bear that in mind when you're prescribing a certain antidepressant for them and may not necessarily go for SSRI S that have a high risk of sexual, um, drive dysfunction. Uh On the other hand, um, someone might have problems with their sleep and mirtazapine might be best suited to them. Um So it's important to discuss with the patient. Um What, what's important to them and you can have a look through this step wise, um guide on, on when to introduce a different medication. But typically, um once you start a medication, an antidepressant, typically we do use Ssris um as a first line and the evidence suggests that if after two weeks, there's no improvement whatsoever, then you should try a different, a different medication. Um if they are effective. Um then, then the guidelines currently recommend continuing them for at least 6 to 9 months. And that's for a first episode of depression. But if someone is experiencing a second episode or severe depression, then you might want to, to prolong that. Um And again, if they're poorly tolerated, so that the um individuals experiencing bad side effects, uh then you want to change the medication and the guidelines differ depending on the risk of the patient. Um if they're high risk, we recommend that you see them within a week after starting medication. Um And if, if they're not high risk, sometimes two weeks. Um and this is, this is primarily in primary practice. So the GPS, unless it's a complex presentation and you will be doing that in, in kind of secondary mental health services or as an inpatient depending on, on the patient. Once you've tried a second antidepressant, if there's still no effect, then you might consider trying two antidepressants at once or maybe lithium is sometimes used as an adjunct or sometimes antipsychotics can be used as an adjunct. And then further down, you might refer to a specialist service for consideration of BC T or um T MS. But that's the basic guidelines of the treatment of depression. You might want to refer back to this. I'm not gonna talk about it too much, but these are the minimum effective doses of commonly used medications. I'm just gonna go on to the next slide. So, SSRI S um which are selective serotonin reuptake inhibitors and they're, I believe they're the most commonly prescribed antidepressants. Um And you've got the FLUoxetine, citalopram, escitalopram, sertraline and paroxetine. I've put FLUoxetine first, excuse me, because it has the longest half life and I put Peroxetine last cause it has the shortest half life. And this is important when we go on to think about withdrawal symptoms, common side effects of SSRI s, the most common is um G I upset, so, nausea, diarrhea, feeling sick. Um but we also do often see sexual side effects and that includes sex drive, being able to orgasm, being able to maintain erection. It can affect all of those three domains of someone's sex life. People do complain that it can impact their sleep. Um and often people can complain of headaches as well. So these are the important side effects that are common. Um To mention to the individual, I'm gonna go on and talk about SSRI discontinuation syndrome and um Serotonin syndrome in a moment as well. So, SSRI s are good for the first line treatment of common mental health problems. So, not only are they used for depression, they're also used for anxiety disorders and depending on the presentation, you might want to change the change the dose. Um So, in, in presentations such as OCD, uh we tend to see better results with max dose or sometimes even over max dose if it's severe OCD. Um and whereas anxiety and depression, you may see results um at lower doses, but it's always important to work with the person sitting in front of you and provide individualized care. They're generally safe in pregnancy and breastfeeding. However, always check the B NF depending on the specific medication you're prescribing and always assess it um as a risk benefit. Um depending on the the presentation of the mental health condition. And what's one of the main reasons why SSRIS are commonly prescribed is because they're safer in overdose than other medications, particularly the tricyclics. Um, and that's something really important given the, the type of clients that we're prescribing to, um, if they're having suicidal thoughts, it's important, um, to have certain cautions when I'm prescribing some of these medications. Citalopram and escitalopram, you need to be cautious, um, if they have preexisting heart conditions, so do check the guidelines and they can prolong the GTC. So you need to do your ECG and, and continue to do it when you're changing the dose. Um SSRI S and other antidepressants can cause low sodium and this is particularly important in the elderly population. Um So you need to take your baseline sodium levels and repeat the sodium levels and look out for signs and symptoms of low sodium and lastly bleeding disorders. So, SSR medications have been linked to G I bleeds. Um and you need to be conscious if the individual is on other medication um that um can contribute or affect their bleeding um or if they have other health conditions. So it's always really important when prescribing these medications to take a full medical history. SSRI discontinuation syndrome, um typically uh occurs with abrupt withdrawal of ssris. Although I I do understand that there's emerging evidence to suggest that it can happen on low doses when you're tapering off the most um likely met SSRI to cause SSRI discontinuation syndrome is paroxetine because it has the shortest half life and like paroxetine, venlafaxine, which I'll go on to talk about in a moment also has a short half life. So you're also, um we also can see a um discontinuation syndrome in Venlafaxine. The symptoms tend to be quite similar to the side effects when taking the medications. Um, but SS r discontinuation syndrome, if you're in an exam, they commonly like to mention shock like sensations as well. So if you see that, um think about SS R discontinuation syndrome, I have a new helpful mnemonic um for SSRI discontinuation syndrome which is finish. Um So you finish taking the medication. Um so you can use that, you want to try remember the the the symptoms. So flu like symptoms, problems with your sleep, insomnia, nausea, problems with your balance, imbalance, sensory disturbance, like the shock, like sensations and hyperarousal. I think it's really important to mention that sometimes when people come off their antidepressant medications, they might be experiencing withdrawal symptoms. And as a clinician, you might confuse this with relapse of depression or anxiety or whatever you were prescribing for because of the symptoms that, that we get in discontinuation. So be cautious to think is this relapse or is this discontinuation? And I tend to consider the timeline. So typically, discontinuation happens pretty quickly after um stopping medication. Um whereas uh relapse might tend to occur a bit more in the future. Um But be cautious that different antidepressants have different half lives. So, paroxetine, discontinuation syndromes will, symptoms will be seen quicker than with FLUoxetine that has a, a longer half life. Um So just bear that in mind as well. Um I'm going to quickly mention tricyclics because as I said, they're not too commonly prescribed now because the main reason is they're dangerous and overdose. So we don't tend to prescribe them as much as we used to. But clomiPRAMINE is a tricyclic that is used in second line for the treatment of OCD. Um And I worked in O CD and we did use it quite often because it, it did provide good results for people struggling with severe or moderate OCD. The side effects of tricyclics are similar to SSRIS, but because they act on the other monoamine, you also get antimuscarinic side effects, antihistaminic side effects and anti aic side effects. So bear those in mind and depending on the particular tricyclic, you'll have a different side effect profile depending on how that affects the different systems in the brain. Amitriptyline is also a commonly used tricyclic and in lower doses, it can be used for neuropathic pain and migraine prophylaxis, which is why I've got it there. And there are other tricyclics that you might see in your practice. I think something important to bear in mind is um tricyclics can cause confusion or delirium, especially in the elderly. So if you see someone that's delirious, do ask yourself or consider, are they taking tricyclic medication. Um tricyclics can also um have cause problems with the heart rhythm and QTC prolongation, especially Mira. Um So bear that in mind. Um And they also can have problems causing hypertension and tachycardia. Um Now, depending on where you're at in your training, um you might be quite up to date and remember your anticholinergic side effects or you might need a little bit of a reminder like I do cause I always struggle to remember which anti and which are. Um so I just got a reminder slide here. So, anticholinergic side effects, urinary retention, dry throat, dry mouth, constipation, feeling hot, raised heart rate, tachycardia and blurred vision and dry eyes. Another class of antidepressants. So the NASA so the nor adrenergic and specific serener antidepressants um of which is commonly known by the most common one we use is Mirtazapine. Um And it is commonly used here in the UK. Mirtazapine is good for weight gain because it increases people's appetite. Um So that's good if you, your client is struggling with their appetite, which is, is is a problem for people suffering with anxiety and depression and it's good if someone's suffering with sleep problems, it can improve people's sleep. Um Mirtazapine typically doesn't um have the sexual side effect profile, side effect profile. Um like other antidepressants and um the prescribing guidelines do recommend it if people are struggling with sexual side effects on other antidepressants and it is safer in overdose than tricyclics. Although it's not as safe as Ssri's, which is something to bear in mind. It's bad if your patient doesn't have a problem with their appetite and actually they want to lose weight. Um, because you're at risk of making them gain further weight and people do tend to complain of tummy upset and also sedative effects because, although it's good for sleep, some people complain that they're oversedated. I'm talking a lot, please feel free to ask me any questions. Um If you like, I can slow down. Um So next up, we've got the SNRI, so the serotonin and no adrenaline reuptake inhibitor. Um and most commonly you'll come across Venlafaxine, which I would say is quite commonly prescribed for depression in the UK. Um Another SN R is DULoxetine doesn't tend to be commonly used for depression um in the UK, although it can be used for stress, um urinary um incontinence in elderly people. So that's just something to bear in mind. Um Venlafaxine is generally pretty effective. Um So it's good for being effective. And um there is some evidence to say, especially in combination with mirtazapine, it is very effective. Although I do think it's important to mention that there isn't actually any consistent evidence to say that one antidepressant is more effective than the other at the moment, reviewing all the evidence of antidepressants. Um and it's generally bad because it's got a short half life, like I said. So people do tend to complain of side effects, especially sweating and sexual side effects. And that's because of the short half life. And as I mentioned before, people do tend to complain of withdrawal symptoms when you discontinue the medication. I'm going to quickly mention serotonin syndrome. Um I haven't actually ever seen serotonin syndrome. Um, so I don't, I don't know how common it is but it is something that common commonly comes up in medical school examinations or at least it did where I studied. Um, so drugs that have a high risk of serotonin syndrome. And this is typically when they're combined. Um, Ssris and MAOIs, like I mentioned, um tricyclics and also other drugs like LSD and MDMA that can affect the serotonin levels in the brain. TraMADol also can affect serotonin and increase it pethidine. So just bear these in mind if someone's coming in and they've had a night where they've taken um illicit drugs and they're also on SSRI S and they might also be on pain medication like traMADol. Just keep in the back of your mind. Serotonin Syndrome. It's definitely a question that's come up a lot in my exams before even in my psych exams. Um, the treatment for Serotonin Syndrome is to stop the drugs that are causing it. Um And you can give supportive medication as well. Um This table is from the mor prescribing guidelines. Um and that just um denotes the severity of the serotonin syndrome um you can have a look maybe when you come back and look at these slides later, but I'm gonna continue in the interested of time. So next up, we've got antipsychotics and like antidepressants, they're not just used for psychosis. Um So just wanted to quickly mention that although we use antipsychotics primarily for psychosis, we can also use them, like I said, as an adjunct in severe or treatment resistant, depression, severe and treatment resistant OCD or BDD. Sorry, I just had some words from outside um in OT D or BDD. And you can also use them um for behavioral symptoms in individuals struggling with dementia. So kind of end stage dementia when people are having very difficult behavioral um presentations, I have to say these are medications are typically last line treatment for that and we try and do the via psychosocial model. So try and um help people that are struggling without, without medication and practice, but we can use those. Um and there are certain antipsychotics that are licensed um in treating people with learning difficulties in their behavior as well. But like I said, it's not first line but just to bear that in mind. And you can refer to the more the prescribing guidelines um for more information specifically. So I'm going to break these down into class because we do get quizzed on, on the, on the class, whether they're first generation or typical antipsychotics or second generation or atypical antipsychotics um it was thought back in the nineties that the primary difference between these um were the extra pyramidal side effects. And if you don't know what those are, don't worry, I'll go and explain them in the next slide. Although the evidence, um it was thought people were thought to believe that first generations caused more extra pyramidal side effects than the second generations. But currently, the evidence in that isn't actually consistent and there appears to be not a real distinction between the two. But nonetheless, we still define these in these two separate, um, first generation, second generation categories. Um, so you've got your list of your first and your list of your seconds there. Uh, the second generation, um, antipsychotics do tend to have worse metabolic side effects and that's something important to bear in mind. Although that being said, quite a few of the first generations also can have significant effects on, on the metabolic syndrome. Um, does anyone know why I have starred the, um, medications in the, in the table? Can anyone think of why those particular medications might have a star next to their name? Uh, if you pop it in the chat, um, it's ok. If no one knows, I'll give you maybe a few more seconds. Ok. Anyone, no. Um, so the, the medications with the stars next to them are the medications that come in depo form. So where you give someone an injection typically intramuscularly and the medication can last for a few weeks, a month, sometimes multiple months, depending on the depo medication that you're giving. And that's actually really important because if we move on to the all thanks specific side effects, close, close, they probably do have specific side effects though. You're right. Um But if we go on to the next slide, it's important to bear in mind depa medications because actually there's evidence to suggest that depots provide the best protection against relapse of psychosis. Um, so that's the last box in the slide here, which I think is really, really important. Um, other general rules for antipsychotics use lower dose as possible and I don't mean just use low dose and, and it not work. Um, you want, you want it to be therapeutic, so you want it to be a high enough dose to, um, help the patient, um, with what they're presenting typically psychosis, um, or bipolar affective disorder. But you want it to be a low enough dose that it's not causing side effects. Um, now, sometimes you might not be able to not cause any side effects. These medications do tend to have um, a side effect profile, but it's important to use as low dose as you can to get a therapeutic effect, um, but not have too significant side effects because Hi. Hi Oliver. I'm just seeing your chats because we know that adherence to antipsychotic medication is pretty poor and that's probably because of the side effects. And it's also probably because of the nature of psychosis is that people may tend to not have good insight into their mental health condition and therefore not think they need to take the medication. Um But like I said, it's important as with antidepressants and psychotics, it's really important to choose the antipsychotic in combination with what the patient would want and what's important to the patient. Um If they don't want to come to the collect their prescription all the time, then the depot might be a good option for them. Um Or if they particularly don't want to gain weight, then probably don't try OLANZapine or cloZAPine. I'll talk about the more specific side effects on the next few slides, but they're most common to cause weight gain. Um And if previously movement disorders have been a big problem, then you might want to go for a medication that's less likely to cause movement disorders such as ARIPiprazole. So that's, it's really important to talk um to the person sitting in front of you and, and find what's important to them. Avoid combining antipsychotics. This is a general rule. Um In the MOLY guidelines, we don't tend to unless they're in severe and complex presentations. Um And that will be in tertiary services if they've had treatment resistant psychosis or treatment resistant schizophrenia, um commence baseline, physical health monitoring and regular monitoring. So when you, before you start, you want to get the baseline, um BP, heart rate, et cetera. You need to take a baseline ecg especially looking at the QTC um which can be prolonged with certain antipsychotics and certain antidepressants. Like I said, escitalopram and citalopram, you want to take weights. Um and they also say um waist circumference um for antipsychotics as well. And then you want to take bloods. So full blood count eery LFTs, you want to do a lipid profile, you want to do plasma glucose or an HBA one C really important to do prolactin as well. And with antipsychotics, you also want to do a CK level as recommended by the CY guidelines. I think that's all of them off the top of my head. Apology if I've missed one. Um I've mentioned already, adherence is generally poor. Um And that's important because relapse rates are high upon discontinuation with antipsychotics. Um So it's really important to give good psychoeducation about psychosis and antipsychotic medication. Um You might want to come back to this slide. I'm not going to go through it all, but I think it's important to just make a note that different antipsychotics have significantly different half lifes. And why, why that is important is the time that you expect to see an improvement. If you have a long half life such as ARIPiprazole, which is 75 hours and it takes two weeks to reach a steady state, then it's going to take a longer time to start to see the benefits of that medication. So, if after a week you haven't seen an improvement, I wouldn't be too concerned because it takes a long time to reach a steady dose. On the other hand, if after two weeks you haven't seen an an improvement in cloZAPine, um you might want to reconsider that. Um, but it's important to bear this table in mind when waiting to see and it's important to educate the family and the patient on this as well because they might be very worried why they don't feel better side effects of antipsychotics depend on the systems they affect in the brain. Um So, depending on um different antipsychotics, they'll affect different systems differently. And this isn't a Pharmacology lecture. So I'm not going to go too in depth in terms of the systems. They affect. The antipsychotics do tend to affect the dopamine primarily primarily dopamine. And that's how we think they work. Um dopamine system, the cholinergic system, the adrenergic system and the histaminergic system. So, antipsychotics tend to um reduce dopamine in the brain. Um And that can lead to galactorrhea because it increases prolactin gynecomastia. It might affect menstruation, low sperm count, reduced libido, it can lead to parkinsonism or, or symptoms of Parkinson's because you're reducing the dopamine. Um or some people call it pseudoparkinsonism or extra pyramidal side effects. And I, I've got a slide that I'll go and talk about that on the next one. Um You can see dystonia as an effect of affecting the dopamine levels, akathisia, so, restlessness, um and also tardive dyskinesia. And I, I'll mention a few of these in the next slide in terms of the cholinergic system or the anticholinergic effects. And we've already discussed those previously with the tricyclic so similar dry mouth, blurred vision, urinary retention. Um The adrenergic or anti adrenergic effects tend to be postural hypotension. Although also in some medications, they tend to have a long term effect of increasing BP. Um But when people stand up, so, postural hypotension can be a problem with certain antipsychotics. Um And people also have ej ejaculatory failure, which is specifically related to the adrenergic system as well as the other sexual side effects related to the dopaminergic system due to the hyper Latin. I hope this isn't too confusing. Um And then people might feel drowsy due to the effects on the histamine or the histaminergic system. Now, I've got another slide on some of the more important side effects to be aware of with antipsychotics like I just mentioned. So if you see someone or hear someone say eps s in relation to antipsychotic side effects, they're referring to extra pyramidal side effects and this is due to the anti dopamine, dopaminergic effects of the antipsychotics. Um And I've just got a picture there. Um Some people call it parkinsonism or pseudo. Um So you might get a masks like face that you get in people with Parkinson's slowed movement or bradykinesia reduced arm swing because they might be rigid, freezing. So, when people can't move, um they might have a resting tremor like a pill, rolling tremor and postural instability and also shuffling steps. Um Sometimes people call it a haloperidol shuffle, which is a type of antipsychotic. Um So those are the extrapyramidal side effects um which was thought to be more common with the um typical or first generation antipsychotics. Although we do tend to see them as well in the atypical or second generation antipsychotics. I'm not going to talk about neural syndrome because we haven't got time, but it is something to be aware of and briefly, just to mention it's a problem with the um thermoregulation. Um And um people become very hot and rigid and it's a medical emergency that some people typically more common in young men. When they take antipsychotics, we don't fully understand um the mechanism of what happens in some people and not in others. Um But it is a medical emergency. Um And, and if you want to read more about it, um then you then please feel free to at the end of this tardive dyskinesia. Um So that tends to be movements that you see in individuals that are out of their control, tend to revolve around the mouth. Um And we tend to see tard dyskinesia um in people after they've taken antipsychotics for a long period of time. Akathisia. So, restlessness, which can be really debilitating for some people. And there are medications you can give to treat that. Although, um, the to, is pretty difficult, um, to treat. Um, so you can, people can also suffer with dystonia. And of note, this is also a common exam, ocular gyra crisis where the eyes roll back, sometimes the tongue can protrude. Um, just to say, um, I haven't, I haven't, I've only ever seen neurotic syndrome once and I've never seen an ocular gyre crisis, but they do tend to come up in medical school exams. Um So just bear that in mind. Sexual dysfunction is common with antipsychotic use. Um but it's also seen in people with schizophrenia. Um, so important to bear that in mind, is it the schizophrenia or is it the antipsychotic causing sexual dysfunction? Antipsychotics tend to reduce the seizure threshold. So be wary of doses if someone has a history of seizures or epilepsy and antipsychotics do have an effect on the cardiac. So they can prolong the QTC or cause other heart problems. And they have um they have been um strongly related to metabolic syndrome. So weight gain type two diabetes, raised cholesterol. Um and also they have been linked to an increased risk of causing blood clots. So, in the legs or in the heart, leading to myocardial infarction strokes, pulmonary embolisms. There is a there is an established risk, uh increased risk in people that take antipsychotics. So it's important to bear that in mind, if you've got someone presenting with shortness of breath, low oxygen levels, think is this a pe or pulmonary embolism I've taken this is a, this is a short snapshot from the moly prescribing guidelines. Um And so it's not an exhaustive list of the antipsychotics, but it's a good table to see that compares the likelihood of that particular an psychotic causing the common side effects. You can see here, the ARIPiprazole tends to have a pretty low side effect if you compare it to something like cloZAPine. So people on ARIPiprazole don't tend to gain weight and I can confirm that. I definitely see that in practice. Whereas people on cloZAPine, um cloZAPine um is along with OLANZapine is the highest risk of weight gain among the antipsychotics. Um You can see the effect of prolactin elevation which is important. Um Akathisia. Um So if historically, a patient has stopped taking their antipsychotics and they say it's because they got really bad weight gain, then you might want to consider prescribing ARIPiprazole. Um because it's less likely to get weight gain, they're more likely then to adhere to their medication and get better. Um I'm not going to talk to you much about antipsychotic withdrawal symptoms, but I thought I put this in the slide just to be aware of if you want to come back and look at it later. Um So lots of people are interested in cloZAPine. It comes up commonly in exams and it's also a really effective drug. So it's really good to learn and know about cloZAPine in psychiatric practice. I'm quite passionate about cloZAPine because I've seen it absolutely change lives. Um cloZAPine is an atypical or a second generation antipsychotic. And in the UK, we only use it after two other antipsychotics have not been successful or have not been tolerated and they have to be for a long time at a good dose that we expect to be successful. But if that hasn't worked, then um the guidelines suggest next line using cloZAPine. CloZAPine is effective. And and of course, there are people that don't sadly respond to cloZAPine, but lots and lots of people do respond to cloZAPine and do get better. So don't be scared of cloZAPine because it's a very effective drug. It has a slightly bad uh reputation because it has some serious side effects. Um Common side effects. I'll talk about first and then we'll talk about the more serious ones that you need to be aware of. Um cloZAPine is, is rather sedating and people do complain of feeling drowsy. Um constipation is a common side effect, but also I've drawn an arrow because it can become a serious side effect and people can actually die because of cloZAPine um related constipation leading to bowel obstruction or bowel ischemia. So it's really important that you um have a bowel chart if someone's newly started on cloZAPine and if someone's on cloZAPine, complaining of constipation to you take it seriously and prescribe laxatives. It's really important because it can become fatal hypersalivation. So about a third or 31% of people that take cloZAPine experience increased elevation. Um and, and it, and it can be really bad and actually some people can choke on their spit and cause aspiration pneumonia. Um There are medications that can help with hypersalivation or so you can kind of get pillows because at night time people tend to um hyper salivate and you can get pillows that absorb it so that it's more comfortable for that individual. Like I said, weight gain um is seen in cloZAPine um as well as OLANZapine, the most likely antipsychotics to cause weight gain. Um people can get postural hypertension and dizziness, but people also on the long term can develop hypertension. So it's important to monitor, it can affect people's sleep and people also complain of nausea and vomiting and those are the more common side effects. But it's important to mention serious side effects because cloZAPine does have a few. Um hopefully or uh you, you probably will come aware that cloZAPine can cause a granulocytosis or neutropenia. And that's important because if you don't have your um immune fighting cells and you get an infection, you're at significant risk of that infection becoming severe and potentially fatal. So here in the UK, we monitor people's FBC S when we're starting people on cloZAPine once a week for the 1st 18 weeks, which sounds like a long time. So people have to have a blood test when they start Pozen for 18 weeks, then if everything's fine, it's every two weeks and gradually you can reduce the frequency. Um And what we're looking for is the neutrophils or if they go on to develop a granulocytosis. Um And we have a system here in the UK, a traffic light system depending on what um number the cells are. Um depends on whether they can continue to take their cloZAPine or reduce the dose or stop completely. Um And then you might consider reintroducing cloZAPine. Um but back in back go, cloZAPine was first introduced, lots of people were dying because of this and it was only until the nineties that it was gradually reintroduced with this kind of safety plan to ensure that we monitor it closely. So people don't die. Um cloZAPine can cause myocarditis and cardiomyopathy and, and it actually can be fatal myocarditis. So it's important to look out for the signs and symptoms of myocarditis. And if you suspect someone has it, if they're tachycardia, um or they've got chest pain, do an ECG take some blood including troponin and A CK refer to them or to prescribing guidelines because they've got very clear, prescribing guidelines of what to do if you suspect myocarditis. Um in terms of referral or monitoring, but it's really important to look out for cloZAPine reduces seizure threshold. So, um seizures um are more common in people taking cloZAPine and it's something to be aware of and like with other antipsychotics, thromboembolism. So blood clots are more common in people taking cloZAPine. And these risks need to be, the patient needs to be made aware of or at least you need to monitor them, especially the agranulocytosis or the neutropenia. If they feel like fever or they start to feel unwell, then they need to let their mental health professional know. Ok. Um it's important to mention the um cloZAPine interactions. Um You might want to come back to this, but I've just star caffeine and tobacco um because lots of medications um can affect the level of cloZAPine. Um and caffeine can increase the level of cloZAPine in the blood and smoking and tobacco can decrease and other medications can also interact with cloZAPine. And that's important to bear in mind because um I think I believe there is an increased prevalence of smoking in people that take cloZAPine. So they really need to be made aware and if they suddenly stop um smoking, then their, their cloZAPine levels might be affected. So you need to make sure they're aware of that and to let their mental health professional know on the back of that, I know I've spoken about severe side effects of antipsychotics and, and cloZAPine, but they are really good drugs and they absolutely change and save lives. Um and don't be afraid to prescribe them. Um Just make sure you're, you're monitoring um effectively. So, last time I'm going to talk about mood stabilizers. Um Now I think it's important to mention that actually. Um although we've got four commonly used mood stabilizers here, we do. Actually, in bipolar affective disorder use antipsychotics and sometimes antidepressants. Um depending on the, the presentation because um someone with bipolar affective disorder might present with acute mania or you might need to treat them to prevent another episode of mania. They might present with depression or they might want a medication that prevents depression. So, depending on the presentation, um depends on the medication. Um That's best to give at that moment in time. And actually, in acute mania, we tend to give antipsychotics to work um quickly. Um and then um I think the recommended guidelines is to start lithium if they, if they are likely to comply with medication because lithium has very good um evidence at preventing um manic relapses. And it's also got evidence to suggest that it reduces suicidality in people with bipolar affective disorder. Um but I'm not going to be able to go through all the prescribing guidelines of the different presentations. Um but you can refer to them mostly prescribing guidelines for the specifics. Um So commonly prescribed mood stabilizers here in the UK. Um probably see lithium, mostly prescribed, I would say in my practice, at least I have although I work in South London. So that might be different depending on where in the country you are. Um carBAMazepine, lamoTRIgine and sodium valproate um are also prescribed and you might have been made aware of them as antiepileptic medication, but they also have mood stabilizing properties. Um and just to recap carBAMazepine and lamoTRIgine affect the sodium channels in the brain and also evidence to suggest that they affect the um calcium channels as well. And sodium val again. Um I think it affects uh the sodium channels. Um but it also affects Gaba in the brain as well. And lithium, we don't exactly know how it works. It's it, it's one of those um wonder drugs where we're not completely entirely sure of how it works, but it is um it does work. Um and it's important, um it's a very important drug in mental health because it, it's got significant, as I said, reduced suicidality in people with bipolar affective disorder. It prevents relapses in people with bipolar affective disorder. And as I said, it can be used as an adjunct um as third line um in severe depression as well. I'm going to specifically talk about lithium um because I think it's probably the more common one and definitely comes up lots in exams. Um So lithium is a mood stabilizer. We're not entirely sure exactly how it works. Common side effects of lithium include stomach upset. Um it can cause hypothyroidism but also hyperthyroidism is less common but has been reported um it can exacerbate or worsen psoriasis and acne and other skin problems. Um It can cause weight gain in some people, sometimes weight loss, but most commonly weight gain. Um it's teratogenic. Um so it can affect um baby and pregnancy. Actually, I'll just go back. That reminds me the reason why I started sodium valpo rate in the last slide is because sodium valpo rate is the most teratogenic um mood stabilizing medication so much. So that here in the UK, if you're a child bearing woman or no, if you're a woman of childbearing potential, so you're, you're a fertile woman. Um So you're, you're not premenopausal or postmenopausal. Um It's, we, we very strongly recommend that you are not prescribed sodium varo and if you are, you have to have yearly checks to prove that you are on contraception or there is no likelihood of you getting pregnant. Um because I, one in 10 um women, um one in 10 babies, um born, two mothers that have taken sodium fibrate in the pregnancy have um birth defects and 30 to 40% have learning difficulties. So the, the risks are significantly high. Um So it's important to bear that in mind and, and we, we strongly encourage unless it's absolutely um required. Um We don't recommend prescribing sodium for irate and here in the UK to women of childbearing potential. And if you do, you have to ensure that they are, aren't able to get pregnant Um So just going back to um lithium lithium also is dangerous um in pregnancy to the unborn baby. Um I don't know if you've heard about Ebstein anomaly. There is evidence suggests it increases the risk of ebstein anomaly from one in 20,000, which is the general population to one in 1000, which is still small, but it is a significant increase in risk. Um And there are other effects that can have to the unborn baby. Um ECG changes um can be seen in people that take lithium. So make sure you do an ECG before and while you're titrating the dose. Um and uh regular reviews, um people tend to complain of a fine tremor in lithium use. Although in lithium toxicity that um tends to turn into a course tremor which is one of the signs and symptoms of lithium toxicity. Um And long um long term lithium use has been associated with a red reduce in the EGFR. So your renal function, lithium is ex um excreted by the kidneys. Um So you need to be and I've got another slide, um cautious of medications that affect kidney function. Um When giving lithium, you need to talk to your um patient about salt intake cause that can affect um the excretion of lithium because lithium has a very narrow therapeutic index which means that there's only a certain amount of dose that's safe to give. Um And if you're too low, it's not likely to be effective. And if you're too high, um individuals can develop lithium toxicity which can be dangerous. Um And, and can be fatal if not treated appropriately. Um If you want to take a blood level of lithium, this is a classic exam question. Take it 12 hours after you've given the dose. Um And treatment for lithium toxicity involves stopping lithium and when, when it's um severe. So the lithium level is greater than four. people you can consider hemodialysis. Um So it can be extremely severe and I have seen it before and it is very dangerous. Um So be aware to look out for the signs and symptoms of lithium toxicity. Um I'm just going to talk about interactions with lithium because these can, can precipitate toxicity. Um So ace inhibitors and diuretics um and nsaids as well that affect the kidney function. There are other medications you need to be aware of. Um and you can refer to the BN F or the more the prescribing guidelines for the other meds but um or refer back to this, this table. Um So I've actually come to the end of my talk. Um There's one last question um just to reinforce um one of my last points. Um If anyone is able to tell me, don't worry if you can't, I wouldn't have been able to probably, um just by gazing at it. I know the um it's probably not easy to see. Um but is anyone able to tell me what might be wrong with the CC G? Um, I'll give you a little tip in that. Um. Oh, amazing. Yes. Erin smashed it. So it's got a prolonged QTQTC. Um, the QTC in this ECG. I got it from Life in the Fast Lane website, which is a great website if you need to recap your ECG knowledge. And the QTC in, in this is 5 50. Um And I've just put that to reinforce the fact that lots of mental health medications can affect and prolong the QTC. Thank Yeah, am R as well? Well done. Um So also be aware, check the guidelines of how often or frequent you need to perform an ECG on an individual. Um This person according to life in the first line had congenital, prolonged QT C. Um And that is also just to emphasize if your um patient that you're treating has congenital heart defects or has heart problems, um Just make sure you ask for them before prescribing any mental health medication. Um because because lots of medications can affect um heart rhythms and prolonged QTC. So whe five minutes left for questions, if anyone has any, that was a whistle stop tour of antidepressants, an psychotics and mood stabilizers. I hope it wasn't too boring. I know it's probably a lot of information. Unfortunately. Um, medications um are medications and there's a lot of facts. Um But I hope that was useful um with whatever stage you're at in your training or whatever type of training you're at. Um And yeah, feel free to provide me any feedback and also ask me any questions. I'll be here for the next few minutes. Um Thanks for coming guys and um have a great evening or maybe have a great day if, if you're, if you're international and it's not, it's not 7 30. Uh Thank you very much, Rebecca. That was really, really useful. It was good to um definitely recap a lot of stuff um And have some time posting to useful resources because it's definitely you find when you're on call that something comes up with one of these medications and yeah, you need to kind of come around for a resource. Absolutely. II I always do it when I'm on call now. Um In psychiatry just control f on my PDF of my prescribing guidelines, scribed guidelines and find out what exactly to do. It's so helpful. Um We've got one question from R actually, can clomiPRAMINE be combined with bisoprolol for a different issue? Is it ok. Um Off the top of my head. Um I would say yes, but I would, I would check the B NF. I'm not 100% sure. Um clomiPRAMINE is more likely to increase your heart rate and bisoprolol is more likely to decrease your heart rate. So you wouldn't get a double decreasing or increasing effects. Um And I think actually I would be surprised if that was a common um medication prescribed together because if you're using it in anxiety disorders such as OTD, people can also use Bisoprolol. Um uh But I, I don't know off the top of my head. Um I would check the BNF. Um And if the BNF doesn't say it's an interaction then it should be fine. Um So, yeah, not 100% sure. Sorry, I think also because I noticed we've had the, um, quite a few med students from various areas of the world, but I'd say when you start as a doctor, a lot of your role is actually picking up when these patients come in and it might be in the general medical settings, even on your surgery job, you on these meds, especially in terms of the English system. I don't know if it's the same abroad, but it can be that the Psychiatry trust is separate and there's not, you know, easy records to find in terms of what they're on. So it just important about making sure you continue those medications safely, um, while they are in for physical reasons so that they don't have a relapse. Um, and to kind of contact your psychiatry colleagues, if you're thinking that they should actually be having their depot while they're as an inpatient or anything like that. I think that's a kind of a very common thing as a junior to be doing because you might not be starting these medications, let alone, you won't be doing it alone. But more commonly you're kind of making ensuring that they, they're on their kind of maintenance doses. Yeah. Absolutely. Especially with cloZAPine because if you miss two doses of cloZAPine or two days, you have to restart titration all over again. And if that cloZAPine is really keeping that patient mentally well, pain, they can become very unwell and that can lead to really significant problems with treating them for medical things as well. And it happens, it really does happen, a patient with a mental health problem will go to hospital and their mental health medications will get stopped and it gets you in real, real difficulty. Um depending on the the mental health condition. Um So absolutely, please don't stop them, just give your psychiatric colleagues a call and ask for their advice, but please just don't, don't just stop them. Yeah, unless like they have like Serotonergic syndrome or something. And that's the treatment obviously. Yeah. Um I think that's, I don't think there's any other questions that have been added. So, um yeah, yeah, thank you very much again. Um, and just for everyone, this is the last and the first p last session and the first Psychiatry series and they're all available um on demand if you want to watch any of the previous ones. Um, and there'll be some more series in the future. I'm sure and please feel free to bring the feedback, if there are any webinars that you would like to come up in the future or articles that would be useful because we're continuously writing them planning. So, um we are always open to suggestions. So thank you all. Cool and uh have a good evening. Thank you. Thanks so much. Take care. Bye bye.