The Practitioner's Guide to Psychoactive Drugs

1. Introduction: The Practice of Pharmacotherapy.- I. Historical Perspective.- II. Current Trends in Psychopharmacology.- A. Definition of Clinical Syndromes.- B. Development of Brain Chemistry Models and New Pharmacological Agents.- C. Pharmacokinetics.- D. Design of Drug Studies.- III. Perspectives on Clinical Practice.- A. Matching Medications with Drug-Responsive Syndromes.- B. Properties of Medication.- C. Attributes of the Clinician.- D. Attributes of the Patient.- E. Pharmacotherapy and Psychotherapy.- IV. General Clinical Guidelines.- A. Patient Evaluation.- B. Principles of Drug Use.- 1. Use Nonbiological Treatments When They Are as Effective as Pharmacotherapy.- 2. Do Not Deny a Patient Appropriate Medication.- 3. Choose the Drug with the Best Risk/Benefit Ratio.- 4. Understand the Pharmacokinetics of Psychotropic Agents.- 5. Learn the Differences between Preparations.- 6. Minimize Drug Use.- 7. Prescribe the Simplest Drug Regimen to Increase Compliance.- 8. Avoid Polypharmacy.- 9. Provide the Most Cost-Effective Treatment.- 10. Exercise Special Care with Medically Ill Patients.- 11. Establish an Ongoing Therapeutic Relationship.- 12. Complete Each Drug Trial.- V. Conclusion.- References.- 2. Depression.- I. Introduction.- A. Psychological Models.- B. Biological Models.- C. Integrative Model.- II. Diagnostic Considerations.- A. Clinical Presentations.- B. Classifications.- C. Biological Diagnosis.- 1. Amine Metabolites.- 2. Cortisol Metabolism.- D. Symptom Profiles and Drug Responsiveness.- III. General Therapeutic Measures.- A. Milieu and Crisis Techniques.- B. Psychotherapy.- C. Electroconvulsive Therapy.- 1. Introduction.- 2. Mechanism of Action.- 3. Indications.- 4. Contraindications and Adverse Reactions.- 5. Technique.- IV. Pharmacotherapy.- A. Heterocyclic Antidepressants.- 1. Chemistry.- 2. Mechanism of Action.- 3. Adverse Reactions.- a. Gastric.- b. Hematological.- i. Leukocytic Effects and Purpura.- ii. Agranulocytosis.- c. Hepatic.- d. Endocrine.- e. Ocular.- f. Cardiovascular.- g. Neurological.- h. Cutaneous.- i. Autonomic.- j. Drug Interactions.- k. Miscellaneous Adverse Reactions.- 4. Precautions for Administration during Pregnancy.- 5. Acute Toxicity.- a. Intoxication Syndromes.- b. Anticholinergic Syndromes.- i. Description.- ii. Anticholinesterase Therapy.- 6. Pharmacokinetics.- 7. Therapeutic Plasma Levels.- 8. Preparations and Dosage.- B. Monoamine Oxidase Inhibitors.- 1. Chemistry.- 2. Mechanism of Action.- 3. Adverse Reactions.- a. Cardiovascular.- b. Autonomic.- c. Gastrointestinal.- d. Neurological.- e. Hepatic.- f. Drug Interactions.- g. Miscellaneous Adverse Reactions.- 4. Contraindications.- 5. Use during Pregnancy.- 6. Toxicity.- 7. Pharmacokinetics.- 8. Preparations and Dosage.- C. Evaluation of the Depressed Patient.- D. Drug Therapy for the Depressed Patient.- 1. Initiating Treatment.- 2. Completing a Medication Trial.- 3. Discontinuing Medication.- 4. Maintenance Therapy for Chronic or Recurrent Depressions.- 5. Depressive Episodes in Bipolar Affective Disorders.- 6. Agitated, Anxious, or Hostile Depressions of Moderate Severity.- 7. Mild Depressions.- 8. Psychotic Depressions.- 9. Depression in Schizophrenic Patients.- 10. “Atypical” Depressions.- 11. Resistant Depressions.- 12. Use of Stimulants for Depression.- V. Conclusion.- References.- 3. Bipolar Affective Disorder and Recurrent Unipolar Depression.- I. Introduction.- II. Manic—Depressive Disorder (Bipolar Affective Disorder).- A. Clinical Presentation.- B. Course of the Illness.- III. General Measures for Treating Manic—Depressive Illness and Recurrent Depressions.- A. Electroconvulsive Therapy.- B. Milieu Therapy.- C. Group Therapy.- D. Psychotherapy and the Therapeutic Relationship.- IV. Pharmacotherapy.- A. General Clinical Considerations.- B. Pharmacokinetics.- C. Adverse Reactions.- 1. Endocrine.- a. Thyroid.- b. Diabetes Mellitus.- 2. Renal.- a. Polydipsia and Polyuria.- b. Diabetes Insipidus.- c. Structural Kidney Damage.- d. Other Kidney Effects.- 3. Hematological.- 4. Cardiovascular.- 5. Cutaneous.- 6. Gastrointestinal.- 7. Central Nervous System and Neuromuscular.- 8. Ocular.- 9. Weight Gain.- 10. Other Adverse Reactions.- 11. Pregnancy.- D. Drug Interactions.- E. Toxicity.- F. Preparations and Dosage.- V. Clinical Applications.- A. Diagnostic Evaluation.- B. Medical Evaluation.- C. Initiating Treatment.- D. Bipolar Affective Disorder.- 1. Acute Manic Episode.- 2. Hypomania.- 3. Maintenance Therapy.- E. Acute Depressive Episode.- F. Recurrent Depression.- G. Schizoaffective Disorder.- H. Other Possible Applications.- 1. Emotionally Unstable Character Disorders.- 2. Premenstrual Tension.- VI. Conclusion.- References.- 4. Psychoses.- I. Introduction.- II. Other Treatments.- A. Nonbiological.- B. Nondrug, Biological.- 1. Electroconvulsive Therapy.- 2. Psychosurgery.- 3. Megavitamin Therapy.- III. Antipsychotic Drugs.- A. Introduction and Terms.- B. Effects on Behavior and the Nervous System.- C. Mechanism of Action.- D. Classes and Chemistry.- E. General Principles of Use.- F. Pharmacokinetics.- G. Adverse Effects and Toxicity.- 1. Neurological.- a. Extrapyramidal Syndromes.- i. Acute Dystonic Reactions.- ii. Akathisia.- iii. Parkinson’s Syndrome.- iv. Tardive Dyskinesia.- b. Sedation.- c. Seizures.- d. Neuroleptic Malignant Syndrome.- 2. Anticholinergic.- a. Peripheral.- b. Central.- c. Serious Toxicity.- 3. Cardiovascular and Respiratory.- a. Hypotension.- b. Cardiac.- 4. Ocular.- 5. Cutaneous.- 6. Hormonal, Sexual, and Hypothalamic Reactions.- 7. Hepatic.- 8. Hematological.- 9. Pregnancy and Lactation.- 10. Withdrawal Reactions.- 11. Overdose.- H. Drug Interactions and Combinations.- I. Laboratory Tests and Monitoring.- J. Clinical Uses of the Antipsychotic Drugs.- 1. Acute Treatment.- 2. Transition and Continuation Therapy.- 3. Maintenance Therapy.- a. Definition.- b. Chronic Schizophrenia.- c. Other Diagnostic Groups.- K. New Drugs.- IV. Conclusion.- References.- 5. Anxiety.- I. Introduction.- A. Anxiety: A Symptom.- B. Symptoms.- 1. Psychological.- 2. Physical.- C. What Anxiety Is Not.- II. Models.- A. Psychoanalytic.- B. Behavioral.- C. Separation Anxiety.- D. Biological.- III. Differential Diagnosis.- A. Medical.- B. Psychiatric.- IV. Primary Anxiety Disorders and Their Treatment.- A. Phobic Disorders.- 1. Agoraphobia.- 2. Social Phobia.- 3. Simple Phobia.- B. Anxiety States.- 1. Panic Disorder.- 2. Generalized Anxiety Disorder.- 3. Obsessive—Compulsive Disorder.- C. Posttraumatic Stress Disorders.- V. Antianxiety Agents.- A. Benzodiazepines.- 1. Chemistry.- 2. Pharmacological Effects and Mechanism of Action.- 3. Kinetics.- 4. Adverse Effects.- 5. Toxicity.- 6. Tolerance, Dependence, and Withdrawal Reactions.- 7: Drug Interactions.- 8. Nonpsychiatric Uses.- B. Other Antianxiety Agents.- 1. Antihistamines.- 2. Barbiturates.- 3. Propanediols.- 4. Propranolol.- 5. Antipsychotic Drugs.- VI. Clinical Use of Antianxiety Agents.- A. Introduction.- B. Evaluating the Patient.- C. Treating Anxiety with the Benzodiazepines.- D. Indications for Using Other Antianxiety Drugs.- E. Discussing Treatment with the Patient.- F. Choosing a Specific Benzodiazepine.- VII. Summary.- References.- Selected Reading.- 6. Insomnia.- I. Introduction.- II. Sleep.- A. Normal.- B. Insomnia.- III. Hypnotic Drugs.- A. Benzodiazepines.- B. Barbiturates.- C. Chloral Derivatives.- D. Piperidinedione Derivatives.- 1. Glutethimide.- 2. Methyprylon.- E. Methaqualone.- F. Ethchlorvynol.- G. Ethinamate.- H. Diphenhydramine.- I. Paraldehyde.- J. Bromides.- K. Tryptophan.- L. Over-the-Counter Drugs.- M. Other Psychotropic Drugs for Insomnia.- IV. Clinical Use of Hypnotics.- V. Summary.- References.- Selected Reading.- 7. Substance Abuse.- I. Introduction and Definitions.- II. Abuse of Opiate Drugs.- A. Classlification.- B. Pharmacology.- C. Acute Effects.- 1. Central.- 2. Peripheral.- D. Tolerance and Physical Dependence.- E. Acute Intoxication and Overdose.- 1. Etiology.- 2. Clinical Manifestations.- 3. Management.- a. General Life-Support Measures.- b. The Use of Naloxone.- c. Other Considerations.- F. Opiate Withdrawal.- 1. Clinical Manifestations.- 2. Management.- a. Detoxification with Methadone.- i. Pharmacology.- ii. Principles of Use.- iii. Clinical Application.- b. The Use of Clonidine in Opiate Detoxification.- c. Neonatal Addiction and Withdrawal.- G. Treatment of Chronic Opiate Abuse.- 1. Medical Complications.- 2. Treatment Approaches.- a. General Considerations.- b. Methadone Maintenance.- i. Background and Theory.- ii. Clinical Application.- iii. Detoxification from Methadone.- iv. l-?-Acetylmethadol (LAAM).- v. Current Issues in Methadone Treatment.- c. The Use of Narcotic Antagonists.- i. Rationale.- ii. Clinical Use.- d. Outpatient Drug-Free Treatment.- e. Therapeutic Communities.- III. Abuse of Central Nervous System Depressants.- A. Introduction.- B. Tolerance and Physical Dependence.- C. Classification.- 1. Barbiturates.- 2. Benzodiazepines.- 3. Other Sedative—Hypnotics.- D. Abuse of CNS Depressants.- E. Acute Intoxication and Overdose.- 1. Etiology.- 2. Clinical Manifestations.- 3. Management.- F. Withdrawal from CNS Depressants.- 1. Clinical Manifestations.- 2. Management.- 3. Mixed Opiate—Sedative Dependence.- G. Treatment of Chronic Sedative Abuse.- IV. Alcohol Abuse.- A. Introduction.- B. Risk Factors in Alcoholism.- C. Pharmacology.- D. Tolerance and Physical Dependence.- E. Acute Intoxication.- 1. Simple Type.- 2. Idiosyncratic “Pathological” Intoxication.- F. Chronic Intoxication.- 1. Peripheral and Central Nervous System Effects.- 2. Effects on Other Organ Systems.- 3. Fetal Alcohol Syndrome.- G. Alcohol Withdrawal.- 1. Minor Abstinence Syndrome.- a. Clinical Manifestations.- b. Management.- 2. Major Abstinence Syndrome (Delirium Tremens).- a. Clinical Manifestations.- b. Management.- 3. Alcoholic Hallucinosis.- H. Treatment of Chronic Alcohol Abuse.- 1. Introduction.- 2. Biological Treatment.- a. Disulfiram.- b. Psychotropic Drugs.- 3. Behavioral Approaches to Treatment.- a. Aversion Therapy.- b. Other Behavioral Techniques.- 4. The Psychotherapies.- 5. Alcoholics Anonymous.- 6. Adjunctive Services.- 7. Summary.- V. Abuse of Central Nervous System Stimulants.- A. Amphetamines and Methamphetamine.- 1. Introduction.- 2. Pharmacology.- 3. Acute Effects.- 4. Tolerance and Physical Dependence.- 5. Patterns of Abuse.- 6. Acute Intoxication.- a. Clinical Manifestations.- b. Management.- 7. Amphetamine Withdrawal.- 8. Amphetamine-Induced Psychosis.- B. Cocaine.- 1. Introduction.- 2. Pharmacology.- 3. Tolerance and Physical Dependence.- 4. Patterns of Abuse.- 5. Acute Intoxication.- 6. Sequelae of Chronic Cocaine Abuse.- C. Treatment of Chronic Stimulant Abuse.- VI. Abuse of Hallucinogenic Substances.- A. Introduction.- B. Classification.- C. d-Lysergic Acid Diethylamide.- 1. Pharmacology.- 2. Tolerance and Physical Dependence.- 3. Acute Intoxication.- D. Adverse Reactions following Use of LSD or Other Hallucinogens.- 1. Panic Reactions.- 2. Toxic Delirium.- 3. Drug-Precipitated Functional Psychosis.- 4. Recurrent Drug Experiences (“Flashbacks”).- E. Sequelae of Chronic Hallucinogen Use.- VII. Phencyclidine Abuse.- A. Introduction.- B. Pharmacology.- C. Acute Intoxication.- D. Phencyclidine Overdose.- E. Phencyclidine Psychosis.- F. Sequelae of Chronic Phencyclidine Use.- VIII. Inhalant Abuse.- A. Introduction.- B. Patterns of Abuse.- C. Acute Intoxication.- D. Sequelae of Chronic Inhalant Use.- E. Treatment Approaches.- IX. Marijuana Use and Abuse.- A. Introduction.- B. Pharmacology.- C. Tolerance.- D. Patterns of Use and Abuse.- E. Acute Intoxication.- 1. Subjective Effects.- 2. Physiological Changes.- 3. Cognitive and Psychomotor Effects.- F. Adverse Reactions following Marijuana Use.- 1. Acute Panic.- 2. Toxic Delirium.- 3. Recurrent Reactions (“Flashbacks”).- G. Sequelae of Chronic Use.- 1. Cannabis Psychosis.- 2. Amotivational Syndrome.- 3. Medical Problems.- H. Potential Medical Uses of Marijuana.- I. Treatment of Chronic Marijuana Abuse.- X. Substance Abuse in Perspective.- Selected Reading.- Opiates.- CNS Depressants.- Alcohol.- CNS Stimulants.- Hallucinogens.- Phencyclidine.- Inhalants.- Marijuana.- 8. Geriatric Psychopharmacology.- I. Introduction.- II. Pharmacokinetic Changes.- A. Absorption and Distribution.- B. Protein Binding.- C. Hepatic Metabolism.- D. Excretion.- III. Adverse Reactions.- A. Central Nervous System.- 1. Sedation.- 2. Confusion.- 3. Extrapyramidal.- 4. Other Central Nervous System Symptoms.- B. Cardiac.- 1. Effects on Blood Pressure.- 2. Effects on Rate, Rhythm, and Contractility.- C. Other Organ Systems.- IV. Clinical Application.- A. Principles of Medication Use.- B. Clinical Use.- 1. Agitated Behavior and Psychotic Thinking.- a. Acute Psychosis or Behavior Problems.- b. Treatment of Extrapyramidal Symptoms.- 2. Dementia.- 3. Anxiety.- 4. Insomnia.- 5. Depression.- 6. Bipolar Affective Disorder.- V. Conclusion.- Selected Reading.- 9. Pediatric Psychopharmacology.- I. Introduction.- II. Psychoses and Severe Behavior Disorders.- A. Introduction.- B. Antipsychotic Drugs.- 1. Principles of Use.- 2. Adverse Effects.- 3. Clinical Application.- III. Tic Disorders.- IV. Depression.- A. Introduction.- B. Heterocyclic Antidepressants.- 1. Principles of Use.- 2. Adverse Effects.- 3. Overdose in Children.- C. Monoamine Oxidase Inhibitors.- V. Bipolar Affective Disorders.- A. Introduction.- B. Lithium.- VI. Enuresis.- A. Introduction.- B. Therapeutic Methods.- VII. School Refusal.- VIII. Anxiety Disorders.- A. Antihistamines.- B. Benzodiazepines.- C. Other Sedative—Hypnotics.- IX. Sleep Disorders.- A. Insomnia.- B. Nightmares.- C. Night Terrors (Sleep Terror Disorder).- D. Sleepwalking (Sleepwalking Disorder).- E. Narcolepsy.- X. Attention Deficit Disorder with Hyperactivity (Minimal Brain Dysfunction).- A. Introduction.- B. CNS Stimulants.- 1. Mechanism of Action.- 2. Types of CNS Stimulants.- a. Methylphenidate.- i. Principles of Use.- ii. Chemistry.- iii. Adverse Effects.- iv. Clinical Application.- b. d-Amphetamine.- i. Principles of Use.- ii. Adverse Effects.- iii. Clinical Application: Children 3 to 5 Years Old.- iv. Clinical Application: Children 6 Years Old or Older.- c. Magnesium Pemoline.- C. Other Drugs Used in the Treatment of Attention Deficit Disorder with Hyperactivity.- D. Diet.- XI. Conduct Disorders.- XII. Anorexia Nervosa.- XIII. “Borderline” Children.- XIV. Conclusion.- Selected Reading.- General.- Psychosis and Severe Behavior Disorders.- Tic Disorders.- Depression.- Bipolar Affective Disorders.- Enuresis.- School Refusal.- Anxiety Disorders.- Sleep Disorders.- Attention Deficit Disorder with Hyperactivity.- Conduct Disorders.- Anorexia Nervosa.- “Borderline” Children.- 10. The Use of Psychotropic Drugs during Pregnancy and Nursing.- I. Introduction.- II. General Therapeutic Approaches: Nonbiological.- III. General Issues Related to Pharmacotherapy.- A. Gross Teratogenesis.- B. Behavioral Teratogenesis.- C. Adverse Effects on the Neonate.- 1. Direct Effects.- 2. Intoxication and Withdrawal Syndromes.- D. Psychoactive Drugs and Lactation.- IV. Emotional Illness during and after Pregnancy.- A. Schizophrenic Disorders.- 1. Phenothiazines.- 2. Antiparkinson Agents.- B. Depressive and Bipolar Affective Disorders.- 1. Heterocyclic Antidepressants.- 2. Lithium.- 3. Electroconvulsive Therapy.- C. Anxiety States.- 1. Benzodiazepines.- 2. Antihistamines—Diphenylmethane Derivatives.- 3. Other Sedative-Hypnotics.- D. Insomnia.- E. Hyperemesis Gravidarum.- F. Ptyalism.- G. Substance Abuse.- 1. Opiates.- 2. CNS Depressants: Barbiturates, Minor Tranquilizers.- 3. Stimulants: Caffeine, Amphetamines, Cocaine.- 4. Marijuana, d-Lysergic Acid Diethylamide, and Phencyclidine.- 5. Alcohol Use and Abuse.- V. Conclusion.- References.- 11. Temporal Lobe Epilepsy.- I. Introduction.- II. Temporal Lobe Epilepsy.- A. Characteristics of Complex Partial Seizures.- 1. Aura.- 2. Complex Partial Seizures.- 3. Postictal States.- 4. Pseudoseizures.- B. Interictal Behavior Syndrome.- 1. Definition.- a. Characteristics of the IBS.- b. Dissociative Episodes.- c. Phobias.- 2. Aggression and Violence.- 3. Psychoses and the IBS.- 4. Laterality of the Lesion.- C. Acute Psychotic Episodes.- 1. Medication Toxicity.- 2. Overcontrol of Seizures.- 3. Medication Withdrawal.- 4. Delirium.- 5. Other.- III. Diagnosis of Temporal Lobe Epilepsy.- A. History.- B. Electroencephalogram.- C. Neurological Examination.- D. Physical Examination and Laboratory Tests.- IV. General Therapeutic Measures.- A. Psychotherapy.- B. Surgery.- C. Pharmacotherapy.- V. Medications.- A. Carbamazepine.- 1. Chemistry.- 2. Adverse Reactions.- a. Neurological.- b. Gastrointestinal.- c. Ocular.- d. Hematological.- e. Cutaneous.- f. Cardiovascular.- g. Renal.- h. Cross Sensitivity.- i. Pregnancy.- 3. Drug Interactions.- 4. Kinetics.- 5. Toxicity.- 6. Preparation and Dosage/Monitoring.- B. Phenytoin.- 1. Chemistry.- 2. Adverse Reactions.- a. Neurological.- b. Cardiovascular.- c. Cutaneous.- d. Gastrointestinal.- e. Endocrine.- f. Hematological.- g. Pregnancy.- 3. Drug Interactions.- 4. Toxicity.- 5. Kinetics.- 6. Preparation and Dosage/Monitoring.- C. Phenobarbital.- 1. Chemistry.- 2. Adverse Reactions.- a. Neurological.- b. Hematological.- c. Endocrine.- 3. Drug Interactions.- 4. Toxicity and Withdrawal.- 5. Kinetics.- 6. Preparation and Dosage/Monitoring.- D. Primidone.- 1. Chemistry.- 2. Adverse Reactions.- a. Neurological.- b. Hematological.- c. Endocrine.- d. Cutaneous.- 3. Drug Interactions.- 4. Toxicity.- 5. Kinetics.- 6. Preparation and Dosage/Monitoring.- VI. Clinical Applications.- A. Control of Seizures.- B. Control of Interictal Problems.- C. Treatment of Psychosis in the Patient with a Seizure Disorder.- 1. Antipsychotic Drugs.- 2. Lithium.- 3. Antidepressants.- VII. Conclusion.- Selected Reading.- 12. Legal Issues in Prescribing Psychoactive Medications.- I. Introduction.- II. Basis for Litigation.- A. Tort Action.- B. Civil Rights Complaint.- III. Informed Consent.- IV. Patient’s Right to Withhold Consent.- V. Specific Areas of Liability.- VI. Suggestions for Avoiding Litigation.- Selected Reading.- Articles.- Books.- Cases.