Rehab Kids

Psychopharmacology
Essential Information for Mental
Health Professionals
Kenneth Carter, PhD, ABPP

WELCOME!
Connecting Knowledge With Need is our mission. Thank you for joining us today!
We’d love to hear where you are and what you’re learning. Share your photos by tagging us
and using #PESISeminar and/or #LearningWithPESI. You’ll receive a special offer each time!
And be sure to follow us for FREE tips, tools, and techniques.

@PESIinc linkedin.com/company/pesi www.youtube.com/c/PESIInc

@PESIinc www.pinterest.com/pesiinc

www.pesi.com/blog | www.pesirehab.com/blog | www.pesihealthcare.com/blog | https://kids.pesi.com/blog

 Psychopharmacology
Essential Information for Mental
Health Professionals
Kenneth Carter, PhD, ABPP

Rehab Kids

ZNM054845
2/22
Copyright © 2022

PESI, INC.
PO Box 1000
3839 White Ave.
Eau Claire, Wisconsin 54702

Printed in the United States

PESI, Inc. strives to obtain knowledgeable authors and faculty for its publications and
seminars. The clinical recommendations contained herein are the result of extensive
author research and review. Obviously, any recommendations for client care must be
held up against individual circumstances at hand. To the best of our knowledge any
recommendations included by the author reflect currently accepted practice. However,
these recommendations cannot be considered universal and complete. The authors
and publisher repudiate any responsibility for unfavorable effects that result from
information, recommendations, undetected omissions or errors. Professionals using
this publication should research other original sources of authority as well.

All members of the PESI, Inc. planning committee have provided disclosures of financial
relationships (including relevant financial relationships with ineligible organizations)
and any relevant non-financial relationships prior to planning content for this activity.
None of the committee members had relevant financial relationships with ineligible
companies or other potentially biasing relationships to disclose to learners. For speaker
disclosures, please see the faculty biography in activity advertising.

PESI, Inc. offers continuing education programs and products under the
brand names PESI HealthCare, PESI Rehab, PESI Kids, PESI Publishing and
Psychotherapy Networker. For questions or to place an order, please visit:
www.pesi.com or call our customer service department at: (800) 844-8260.

133pp

2/22

Rehab Kids
 MATERIALS PROVIDED BY

Kenneth Carter, PhD, ABPP, is a board-certified clinical

psychologist and professor of psychology at Oxford College of
Emory University in Atlanta, Georgia. Dr. Carter received his M.A.
and PhD in clinical psychology from the University of Michigan in
Ann Arbor and a postdoctoral master’s degree in clinical psycho-
pharmacology from Fairleigh Dickerson University. Dr Carter has
taught clinical psychopharmacology classes at Emory University
since 2005 and has presented highly rated psychopharma-
cology workshops to clinicians throughout the United States
since 2010. Dr. Carter has served as a senior assistant research
scientist in the Epidemic Intelligence Service of the Centers for
Disease Control and Prevention. He has been a psychotherapist
and researcher for more than 20 years, during which time he
has garnered awards from the National Institutes of Health, the
National Heart, Lung and Blood Institute, and the University of
Michigan. Dr. Carter has presented at numerous conferences and
written several books and articles on introductory psychology,
neuropsychology and psychopharmacology.

For speaker disclosures, please see the faculty biography in activity advertising.

Materials that are included in this course may include interventions and modalities that are beyond the
authorized practice of mental health professionals. As a licensed professional, you are responsible for
reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of
practice in accordance with and in compliance with your professions standards.
Psychopharmacology:
Essential Information
for Mental Health
Professionals
Kenneth Carter, PhD, ABPP
Charles Howard Candler Professor of Psychology
Oxford College | Emory University
drkencarter.com/pesi

Disclaimer

Materials that are included in this course may include interventions and
modalities that are beyond the authorized practice of mental health
professionals. As a licensed professional, you are responsible for
reviewing the scope of practice, including activities that are defined in law
as beyond the boundaries of practice in accordance with and in
compliance with your professions standards.

1
Disclosures

Learn Abnormal Buzz!

Psychology Psychology
SAGE Publications Cambridge University Press Cambridge University Press

I receive no money from

any pharmaceutical
company

2
Disclosure

As required by several accrediting boards, speaker and activity planning

committee conflicts of interest (including financial relationships with
ineligible organizations) were disclosed prior to the start of this activity.
To view disclosure information, please see activity advertising.

Disclosure

This workshop is intended solely for educational purposes. The

information presented herein is to provide practical and useful information
on the subject matter covered. However, the information is provided with
the understanding that we are not engaged in rendering legal services. If
legal advice is required, the services of a legal professional should be
sought. We will not be liable for any decision or action taken on reliance
on the information presented in this activity.

3
Disclaimer & Disclosure
of Off-Label Use
I may include discussion of unlabeled uses of agents that are not currently labeled for
such use by the FDA. Please consult the product prescribing information for full
disclosure of labeled uses.

The information in this workshop is presented for educational discussion and is not
meant to serve as a guideline for patient management. Any medications discussed or
suggested should not be used by clinicians without evaluation of their patients'
conditions and possible contraindications or dangers in use.

Every effort has been made in to provide accurate and up-to-date information that is in
accord with accepted standards and practice at the time of release. However, I make
no warranties that the information contained herein is totally free from error. Clinical
standards are constantly changing because of research and regulation. I disclaim all
liability for direct or consequential damages resulting from the use of this material.

Please pay careful attention to information provided by the manufacturer of any

medication that you plan to use.
7

Psychopharmacology: Limitations
of the Research and Potential
Risks
The evidence base for psychopharmacological interventions can vary
and ethical considerations pertain to medication trials for certain
populations

Potentially controversial treatment practices and off-label prescribing

are sometimes unavoidable for certain understudied treatments and
disorders and medications with a potential for adverse consequences
require increased focus on ethical issues including informed consent.

4
 Before we
start

About me
www.drkencarter.com/pesi
ken@drkencarter.com
Questions
Scope of today’s training

Overview

Section 1 Section 2 Section 3 Section 4

Ethics Ethics II Depression Bipolar
Guidelines Anxiety ADHD
Neuroscience Psychosis
Insomnia
Herbals
News
Resources

10

5
Objectives

Discuss the proper role of mental health professionals who treat clients receiving
both psychotherapeutic medications and psychotherapy.

Explore specific ethical issues and resolutions related to communicating with clients
and prescribing professionals about psychotropic medications.

Explain the neurotransmitter systems and neuroanatomy underlying the biological

basis for mental disorders and pharmacotherapy.

Identify the major classes of drugs used to treat mental disorders and which mental
disorders are appropriately treated with each class of drugs.

Describe adverse effects and drug reactions of the commonly prescribed

psychotropic medications and when to alert the prescriber about them.

Analyze the role that half-life plays in the efficacy of insomnia medications
prescribed for clients and how it may affect behavioral interventions.
11

Psychopharmacology
Ethics

12

6
Sleepy
Susan

13

Sleepy

crying

anhedonia

problems with concentration

no appetite

initial insomnia

guilt

Diagnosis?
14

7
 Susan is
depressed

15

went to her primary with a chief complain of insomnia

care physician

16

8
 What do you
do?

17

As a non prescriber is
telling her not to take it
unethical?

18

9
Is it unethical to withhold
the information you
have?

19

Reasons to be
knowledgable

20

10
42% of current
clients use
psychotropic
medication

21

It is important to know
the context in which
clients receive their
medication

22

11
75-90%
Of antidepressants and benzodiazepines
are written by non-psychiatrists. Mostly by
primary care physicians

(Preston 2021)

23

Complicating such
treatments is the
brief time patients
are typically seen
by their primary
care physician

24

12
The
average
Primary
Care visit is
8 minutes

25

•take a history
•make a diagnosis
•prescribe
treatment
•patient education
•answer questions

26

13
As clients
become more
empowered
and “better
informed”

27

We hear
more
questions
about
psychotropic
medications
and

28

14
It becomes important to be
knowledgeable about the
professional, legal, and
ethical boundaries regarding
the discussion of medication-
related issues with clients

29

Because of our role in

our clients’ lives, it is
important to be proactive
in speaking with clients
and prescribers

30

15
There are several ways
that non-prescribers can
partner with prescribers
to help increase success
with medication

31

We can help
clients have
realistic
expectations of
their
medications

32

16
We observe or
are told about
potential side
effects that may
interfere with
compliance

33

We know
information
clients may be
too embarrassed
to tell their
prescribers

34

17
Survey from
USA Today
Reasons people
have kept health
information from
their doctors

35

36

18
We are aware
when clients
aren’t taking
their medications
as prescribed or
have stopped

37

We are on the
front line at
witnessing the
emergence of
late-onset side
effects

38

19
We can
recognize
break-
through
symptoms

39

We can
encourage
clients to
discuss
substance use
with prescribers

40

20
We can recognize
inadequate
medication
response which
may warrant dosage
adjustments or
augmentation

41

What are the limits

of non-prescribers
discussion of
medications?
42

21
Lessons from
other fields

43

There have been cases

brought against
pharmacists for failing to
warn patients about the
effects of medication.

44

22
Ingram v.
Hooks
Drugs, Inc

45

Ingram argued that

pharmacists have a
legal obligation to
warn patients
about the harmful
effects of
medications

46

23
Most court decisions have resolved that
pharmacists do not have legal obligation to
warn about the harmful effects of medicines for
2 reasons:
Scope of practice

Protecting the physician-patient relationship

47

Courts ruled that

a duty to warn
clients about
medications was
the responsibility
of the prescriber

48

24
Requiring
pharmacists to
warn could
undercut the
effectiveness of
ongoing medical
treatment

49

It did not, however,

suggest that warnings
were prohibited

50

25
“
We do not conclude by
this decision that
warnings beyond those
given by the physician are
harmful or to be
discouraged
Leeley v West

51

It is okay for non

prescribers to
discuss prescribers’
treatments

52

26
The Field of
Nursing
Tuma v. Board of Nursing

53

“
The legal system has
elected against the
creation of a system in
which only a physician
may discuss physician-
prescribed treatments
Littrell & Ashford

54

27
Ethics
American Psychological Association
American Association of Marriage and Family Therapists
American Counseling Association
National Association of Social Workers

55

APA Ethics Code 10.04

In deciding whether to offer or provide services to those already

receiving mental health services elsewhere, psychologists carefully
consider the treatment issues and the potential client's/patient's
welfare. Psychologists discuss these issues with the client/patient or
another legally authorized person on behalf of the client/patient in
order to minimize the risk of confusion and conflict, consult with the
other service providers when appropriate, and proceed with caution
and sensitivity to the therapeutic issues.

56

28
National Association of
Social Workers
Ethical Principle: Social workers practice within their areas of
competence and develop and enhance their professional expertise.

Social workers continually strive to increase their professional

knowledge and skills and to apply them in practice. Social workers
should aspire to contribute to the knowledge base of the profession.

57

“
Given the precedent established by
other professions it is unlikely that a
non prescriber’s discussion of
medication could be thought of as
practicing medicine without a
license.

Littrell and Ashford

58

29
Practice
Guidelines
Regarding
Involvement in
Pharmacological
Issues
American Psychologist 2011

59

2
Evaluate your own feelings and attitudes
about the role of medication in treatment.

60

30
4
Identify and obtain a level of
knowledge of medications that is
appropriate to the populations you
serve.
61

9
Explore issues surrounding patient
adherence and feelings about medication.

62

31
10
Develop a relationship that will
allow clients to feel comfortable
exploring issues surrounding
medication use.
63

17
Maintain appropriate relationships
with prescribers.

64

32
Expanded Informed
Consent Process
describe agent explanation of any examinations
or labs
problems it will address
references for patient education
estimate of the duration
describing ongoing non-
time to therapeutic effect prescriber partnerships
cost of treatment inviting questions and concerns
possible drug interactions

risks associated with sudden

discontinuation

65

Ask Questions

66

33
importance of
asking questions
67

What are some

common questions
that you are asked
about medicines?

68

34
A prescriber
asks you
“What do you
recommend?”

69

Survey
Asked the Psychology
Boards in the US
“Are psychologists
permitted to make
medication suggestions
to referring physicians”

70

35
19 States said yes

71

States said yes

72

36
California

73

New Hampshire

74

37
Particular issues
that necessitate
consultation
with a
prescriber
...or to empower the client to discuss
the issue with the prescriber

75

Prescriber
recommends
stopping a
medication
when the client
is benefiting

76

38
Client is being
under-treated

77

Treatment
recommended is not
successful and not
standard

78

39
 A medication that
is cautioned for a
suicidal client

79

SNRI are more lethal in

overdose than SSRIs

80

40
but how?

81

Complementary
colleague vs one down
approach

82

41
Advise
against any
of the
following

83

Not okay to
administer
or dispense
drugs
samples
OTC

84

42
Not okay to tell clients Unless they are having an
to stop taking adverse effect that requires
immediate discontinuation
medication

85

Not okay to advise clients

to change medication
dose or switch to another
medication

86

43
Questions?

87

Psychopharmacology
101

88

44
General
Overview of
the Neuron

89

Neurons
90

45
Parts of the neuron
91

Dendrites
92

46
Soma
93

Axon Hillock
94

47
Axon
95

Axon terminal
96

48
Synapses
97

The Synapse

An area that is comprised of 3

structures

The axon terminal

Synaptic Gap

Dendrite of next neuron

98

49
Synapse
99

Neurotransmitter
100

50
Synaptic Vesicle
101

102

51
Synaptic Vesicles
103

Receptor Site
104

52
Transporter
105

Monoamine oxidase
106

53
 Monoamine oxidase
107

drkencarter.com/pesi 108

54
mouse party!
find link at
www.drkencarter.com/pesi

109

110

55
Brand vs
Generics

111

Brand vs Generics

80%-120% range of potency for generics

Some brand-name medications also contain

special binders

112

56
Theraputic Window

113

113

Focus Concepts

Selective Serotonin Reuptake Inhibitors (SSRI)

Keep serotonin in the synapse

Serotonin Norepinephrine Reuptake Inhibitors

(SNRI)
Keep serotonin and norepinephrine in the synapse

Benzodiazepines (BZD)
“Hits the breaks” of the nervous system

and we will touch on medicines for ADHD/Bipolar/

Psychosis/Insomnia as well

114

57
SSRI SNRI Benzodiazepines

escitalopram venlafaxine alprazolam

citalopram desvenlafaxine diazepam
sertraline duloxetine
fluoxetine

115

Depressive
Disorders

116

58
Monoamine
hypothesis of
depression

117

Neurobiology of
depression

118

59
Monoamine hypothesis
of depression
Suggests that symptoms of depression are caused
by malfunctions in a family of neurotransmitters
called monoamines

Serotonin (5-HT)

Norepinephrine

Dopamine

119

Malfunction
can occur in
many ways
•Decreased release in the
synapse
•Excessive reuptake
•Overactive MAO
• Receptor abnormality

120

60
 Many
antidepressants
attempt to keep
one or more
monoamines in
the synaptic gap

121

SSRI

122

61
 SSRI

block the areas

that recycle
serotonin

123

This results in a
build up of
serotonin in the
synaptic cleft
which results in
increased
binding with
serotonin
receptor sites

124

62
The next video demonstrates you can also see it in my website
the mechanism of action of drkencarter.com/pesi
SSRIs
125

126

63
Treatment Effects of
SSRIs
Well tolerated

Once daily dosing

Safer in overdose

Generically available

127

Adverse Effects of SSRIs

Include
High rates of sexual dysfunction

Decreased appetite (initially)

GI upset (nausea, diarrhea)

Insomnia

Headaches

128

64
Serotonin Syndrome

Mild: increased heart rate, shivering, sweating,

dilated pupils, intermittent tremor or twitching

Moderate: high blood pressure and high

temperature

Severe: Potentially life threatening

129

Serotonin Withdrawal
Syndrome
Some may experience dizziness, lethargy, nausea,
irritability, and headaches on discontinuation

These symptoms can be prevented by reducing

the medication slowly over several weeks

Not a relapse

130

65
Medications in this
category
Citalopram

Escitalopram

Fluoxetine

Fluvoxamine

Paroxetine

Sertraline

131

Fluoxetine Sertraline Escitalopram Citalopram Paroxetine

Sedation 1 1 3 3 5

Activation 5 4 3 3 1

Weight Gain 2 2 3 3 5

Sexual
Dysfunction
3 2 3 3 5

Stephen M. Stahl (2017) Stahl’s Essential Psychoparmacology (4th ed). New York: Cambridge 132
University Press

66
Genetic Testing

Slow Typical Ultra Rapid

Metabolizer Metabolizer Metabolizer

133

Significance of Genetic Testing

in the Determination of Drug
Dosage for an Antidepressant

134

67
Fluoxetine

Activating antidepressant

Very long half-life

Side effects: gastrointestinal

symptoms, sexual dysfunction,
insomnia, headache, dizziness

Advantages: comes in weekly

format, helpful for patients with low
energy

135

Sertraline

Activating

More prone to gastrointestinal side

effects than other SSRIs

May be a first-line choice for atypical

depression (low energy, mood
reactivity)

136

68
Paroxetine

May be contraindicated in pregnancy

More prone to discontinuation

symptoms

137

Citalopram

Minimal sedation and weight gain

If withdrawal symptoms emerge during

discontinuation raise dose to stop
symptoms then discontinue more slowly

Is a helpful medication for clients who might

be excessively activated by other SSRIs

Can be sedating in some clients

May have less sexual dysfunction than

other SSRIs

Can cause affective “flattening” in some

clients
138

69
Escitalopram

Minimal sedation and weight gain

Similar to citalopram but with fewer

side effects

May have a faster onset of action

than other SSRIs

139

Vilazodone

140

70
Vilazodone

The most commonly observed adverse reactions in

patients treated with vilazodone in placebo-controlled
studies were: diarrhea (28% vs. 9%), nausea (23% vs.
5%), insomnia (6% vs. 2%), and vomiting (5% vs. 1%)

141

Vortioxetine

May also affect dopamine

Possible benefit of improved cognition

May have less sexual dysfunction than SSRIs

142

71
SNRI
Work by keeping both serotonin AND
norepinephrine in the synapse

143

Treatment
effects of SNRIs

Benefits of SSRIs

Plus they treat depression in an

additional way (targeting
norepinephrine)

144

72
Adverse Effects
of SNRIs include

GI upset

Dry mouth

Hypertension

Nervousness

Insomnia

Sexual Dysfunction

145

Venlafaxine

MOA: Increases release of several different

neurotransmitters (serotonin, norepinephrine, dopamine,
glutamate, acetylcholine, and histamine)

Side effects: May cause hypertension, GI upset

Advantages: Less sexual dysfunction than SSRIs, helps

cognitive symptoms

Disadvantages: can cause cardiac problems in overdose

146

73
Desvenlafaxine

Metabolite of venlafaxine

May have fewer GI side effects than

venlafaxine

Contraindicated in pregnancy

147

Duloxetine

Can also treat neuropathic pain

More balanced for effects on

serotonin and norepinephrine

148

74
Levomilnacipran
(Fetzima)
MOA: SNRI; much more
balanced reuptake
inhibitors of serotonin and norepineph
rine

Side effects: GI, sweating, sexual

dysfunction

Advantages: may be more helpful for

somatic symptoms, fatigue, and pain

Disadvantages:cost; may increase

hypertension in people with high
blood pressure
149

Other

150

75
Bupropion

Energizing

Few sexual side effects

Less weight gain

May increase anxiety and insomnia

151

Esketamine Nasal Spray for

Treatment Resistant Depression
Increases the amount of glutamate in the synapse

Helps neurons communicate with each other along

new pathways

Can cause high blood pressure, nausea,

perceptual disturbances during use

152

76
Anxiety

153

DSM-5 Disorders with

Anxiety Components
Anxiety Disorders Trauma and Stress OCD and Related
Related Disorders Disorders
Specific Phobia Posttraumatic Stress Obsessive
Disorder Compulsive Disorder
Social Phobia
Acute Stress Body Dysmorphic
Agoraphobia
Disorder disorder
Panic Disorder
Hoarding Disorder
Panic Attack
Excoriation Disorder
Specifier
Hair Pulling Disorder
Generalized Anxiety
Disorder

154

77
Deconstructionist
Approach
Rather than looking at anxiety disorders in their
respective categories, some psychopharmacologists use
a deconstructionist approach

Examine the biological links to the symptoms and use

that information to choose medicines to treat symptoms

Anxiety disorders may be deconstructed into just two

different kinds of symptoms

155

Neurobiology of Anxiety

Fear Worry
Panic Anxious misery
Phobia Apprehensive expectation
Obsessions

156

78
Medications for Anxiety
Disorders

SSRI Benzodiazepines Other

Fluoxetine Alprazolam
Sertraline Clonazepam
Paroxetine Lorazepam

National Library of Medicine 157

158

79
Treatment Effects: Fear

There are GABA neurons in the cortex and

amygdala

GABA is an inhibitory neurotransmitter

Anything that will “turn on” GABA should calm

things down

Inputs from serotonin will also smooth out activity

in the fear loop as well

159

Anything that increases

GABA or increases
serotonin should smooth
out activity in the fear loop

160

80
 Not that much GABA in the worry loop

161

Serotonin will help

with worry
GABA is LESS
successful in
shutting down worry

162

81
SSRIs for Anxiety

Should work for fear and for worry

With the same adverse effects as when they are used as

an antidepressant

But remember, they take a few weeks to start working

Often need to be given at higher doses to be effective

Some clients have an increase in anxiety for the first week

or so on an SSRI

163

Benzodiazepines

164

82
 Benzodiazepines

Action is on GABA

Increase in GABA will increase inhibition, which

quiets down abnormally activated circuits

Works quickly

Will not work as effectively for worry as it might

for fear

165

Short Intermediate Long

Midazolam Lorazepam Chlordiazepoxide

Triazolam Estazolam Clorazepate
Alprazolam Clonazepam Diazepam
Oxazepam Flurazepam
Temazepam Halazepam

166

83
Diazepam

Binds to benzodiazepine receptors at the

GABA-A ligand-gated chloride channel complex
to enhance the inhibitory effects of GABA

Rapid onset of action

Long-acting (half-life 30-60 hours)

May lead to abuse

One of the most commonly prescribed

benzodiazepine

Useful to treat alcohol withdrawal

One of the few available in an oral liquid

formulation

167

Chlordiazepoxide

Rapid onset of action

Can also treat alcohol withdrawal

168

84
Clonazepam

One of the most popular

benzodiazepines for anxiety

Easier to taper than some other

benzodiazepines because of its long
half-life

May have less abuse potential than

some benzodiazepines

169
National Library of Medicine

Lorazepam

Short and inactive metabolites

MOA: Binds to benzodiazepine

receptors at GABA-A

Advantages: available in liquid and

injectable formulation, rapid onset

Disadvantages: may lead to abuse,

possibly more sedation than other
benzodiazepines

170

85
Alprazolam

Binds to GABA receptors to enhance

the effects of GABA

Less sedating than other

benzodiazepines

Half-life about 12 hours

171

Flumazenil

Reduces the sedative effects of

benzodiazepines

Blocks benzodiazepine receptors

preventing benzodiazepines from
binding there

Onset in 1-2 minutes

Can sometimes wear off before the

action wears off

James Heilman, MD
172

86
 FDA requires
stronger warning
labels for
benzodiazepines

The US Food and Drug Administration

(FDA) has ordered changes to the
labeling for benzodiazepines, requiring
them to include information on the risks
of abuse, misuse, addiction, physical
dependence, and withdrawal reactions.

173

Other anti-
anxiety agents

174

87
Buspirone

Works on serotonin

Takes about 2-4 weeks to work (can

take up to 8 weeks)

Gradual onset

Dizziness, headache, nervous,

sedation, nausea, and restlessness
are the most common side effects

Lack of dependence or withdrawal

symptoms

175

Hydroxyzine

MOA: Blocks histamine receptors

Side effects: Dry mouth, sedation,

tremor

Advantages: No abuse,
dependency, or withdrawal

Disadvantages: Can be sedating;

not as effective as benzodiazepines

176

88
Bipolar

177

178

89
 Pharmacotherapy
for Bipolar Disorder

Lithium Anticonvulsants

Atypical
Antidepressants
antipsychotics

179

Lithium

True bipolar medication

Helps with manic/hypomanic phase and

depressive phase

Helps with suicidal thoughts

Narrow therapeutic window

180

90
Lithium

Demonstrated efficacy for acute mania, acute

depressive episodes, and maintenance treatment
for relapse prevention

Effective in 60–80% of acute episodes.

About 1/3 relapse

181

Lithium

Compliance with therapy is very poor

Side effects become intolerable

Miss the “highs” and the mood swings

182

91
Lithium Toxicity

Early Signs Ataxia, lack of coordination

Listlessness, nausea,
Mild (1.5–2.0 mEq/L) slurring, diarrhea, coarse
tremor
Coarse tremor, confusion,
Moderate (2.0–2.5 mEq/L) delirium, pronounced
ataxia
Alteration in consciousness,
Severe (2.5–3.0 mEq/L) hyperextension of extremities,
seizures, coma, death
183

Anticonvulsant Drugs

Originally developed as anticonvulsants

Used in bipolar disorder; to treat relapse to substance abuse; as

detoxification agent for alcohol withdrawal

Stephens Johnson Syndrome

184

92
Carbamazepine

Anticonvulsant effects may occur

because it reduces neuronal excitation
by blocking sodium channels and thus.
ability of sodium to initiate action
potentials

Side effects: GI upset, sedation, ataxia,

visual disturbances, skin reactions,
cognitive impairments

Reduces frequency of episodes; may be

better for mixed mania and rapid cycling
episodes

Drug interactions
185

Oxcarbazepine

Analogue of carbamazepine

Does not induce hepatic enzymes

Fewer drug-drug interactions

compared to carbamazepine

Side effects: tiredness, headache,

dizziness and ataxia, some allergic
reactions, teratogenic effects likely

Has been shown to be superior to

placebo in the treatment of acute
mania
186

93
Valproic Acid

Stabilizes GABA-B receptors in

hippocampus

Used to treat acute mania, mixed states,

and rapid cycling bipolar disorder

70% response rate in lithium-resistant

patients

Side effects: GI, sedation, lethargy, tremor,

hair loss, liver enzyme changes, some
weight gain

Reduced cognitive function

Can inhibit metabolism of other drugs (e.g.,

can “double” the blood level of lamotrigine)
187

Lamotrigine

Effective in acute bipolar depression and rapid

cycling bipolar II disorder, and in prevention of
recurrent depressive disorders

Poorly effective in treating acute mania

Side effects: dizziness, tremor, somnolence,

headache, nausea, and rash. Most serious
side effect is rash, which may be severe
enough to require hospitalization and prove
fatal

Valproate doubles and carbamazepine halves

the half-life of lamotrigine

FDA-approved for long-term maintenance

treatment of bipolar I in adults
188

94
Atypical Antipsychotics for
Bipolar Disorders
Second generation antipsychotics

ziprazidone

risperdone

Reduce agitation in mania

189

Attention Deficit
Hyperactivity
Disorder

190

95
Weak norepinephrine (NE) and
dopamine (DA) signals in
prefrontal cortex are
associated with ADHD

191

ADHD: Impaired
activation in attentional
networks

192

96
Methylphenidate
Dose-dependently blocks
DAT (dopamine
transporter) in striatum

193

Amphetamines
Blocks vesicular
monoamine transporters
(VMATs) in cortex,
releasing dopamine

194

97
Methylphenidate and
Amphetamines
Both: increase spontaneously released dopamine
responsive to environmental stimuli

Increases signal-to-noise ratio

Increases saliency of stimuli

Delivery systems are important

195

Drug
Delivery
Systems

196

98
Administration
through the skin
Transdermal patches provide
continuous, controlled release

Allows for slow, continuous

absorption over hours or days,
minimizing side effects

Examples

Selegiline (depression)

Methyphenidate (AD/HD in
children)

197

Immediate
Release
All goes in

198

99
Beads
Slow release system

199

OROS
Osmotic controlled-released
oral deliver system (OROS)
Concerta

200

100
OROS Osmotic controlled-release oral
delivery system (OROS)

201

Prodrug
A prodrug is a compound that
is not pharmacologically
active. It needs to be
metabolized by the body to
be active.

202

101
Intramuscular

203

Psychosis

204

102
Psychosis

Positive Negative
Delusions Anhedonia
Hallucinations Affective Blunting
Thought disorder Alogia
Catatonia Avolition

205

Key Dopamine Pathways

involved in Psychosis

mesocortical mesocortical tubero-

mesolimbic nigrostriatal
pathway to pathway to infundibular
pathway pathway
DLPFC VMPFC pathway

High Low Low Normal Normal

cognitive and affective and

Positive
negative negative
symptoms
symptoms symptoms

206

103
 Receptor Treatment Effects Adverse Effects
Sedation, Postural hypotension, Sexual dysfunction,
Alpha 1 Weight gain
Decreased depression, anxiety, EPS
5-HT 1a Increased cognition

5-HT 2a Relief of negative symptoms

Causes dopamine to decrease with leads to

5-HT 2a / DA2 reduced EPS
Increase in cognition
5-HT 2c Decrease in depression
Weight gain

Increased cognition
5-HT 2c Decreased depression
Weight gain

Decreased depression
5-HT 2d Decreased anxiety

D2 Relief of negative simptoms Increases EPS

Decreased depression
D3 Increase in cognition
Sedation
H1 Sedation
Weight gain
Memory impairment
M1 GI symptoms

SRI Decreased depression and anxiety

Decreased depression
NRI Increased cogntion
207

208

104
Antipsychotics

First Generation Second Generation

Helps with positive symptoms but less Helps with positive and negative
effective on negative symptoms. symptoms, lower rates of EPS, higher
rates of metabolic symptoms.

209

Insomnia

210

105
Insomnia

Having a hard time falling asleep

Having a hard time staying asleep during the

night

Walking up too early in the morning

Each results in feeling tired and

unrefreshed in the morning

211

Insomnia

According to the National Sleep Foundation, up

to 72% experience some symptoms of a sleep
disorder at least a few nights a week

212

106
Diagnosing Insomnia

DSM IVtr

Primary Insomnia

Insomnia secondary to another condition

DSM 5

Insomnia Disorder

213

Sleep
System
&
Wake
System

214

107
Treatments

Behavioral Diphenhydramine Trazodone

Sedating antihistamine Sedating antidepressant

215

Behavioral
Interventions
216

108
Half Life
A half life is the amount of time it
takes for 1/2 of the medicine to
be broken down by the body

217

218

109
219

220

110
221

222

111
Half Life
Most medicines will be used up
in about 5 half-lives

The therapeutic effect might be

much shorter than 5 half-lives

223

Eszopiclone

Binds to a site near the benzodiazepine area

of the GABA receptor

Half life: 6 hours

224

112
Eszopiclone

day-time drowsiness, dizziness, "hangover"

feeling

problems with concentration

anxiety, depression, nervous feeling

headache

nausea, stomach pain, loss of appetite,

constipation

dry mouth

unusual or unpleasant taste in your mouth

mild skin rash

225

Zaleplon

Binds to a site near the

benzodiazepine area of the GABA
receptor

Half life 1 hour

226

113
Zaleplon

day-time drowsiness

problems with concentration

numbness or tingling

anxiety, depression, nervous feeling

problems with vision

headache

nausea, stomach pain, loss of appetite, constipation

dry mouth

increased menstrual pain (cramps)

back pain, joint or muscle pain

mild skin rash

227

Zolpidem

Binds to a site near the

benzodiazepine area of the GABA
receptor

Half-life 2-3 hours

228

114
Zolpidem

Dizziness

GI upset

Nausea

Vomiting

Anterograde amnesia

Morning hangover

229

Ramelteon

selective melatonin receptor agonist

Melatonin is regulated by pineal

gland on a 24-hour cycle, with levels
increasing towards bedtime.

Nonaddictive

Very modest effect in controlled trials

Sleep onset only 10–15 minutes

earlier than placebo

Little affect on total sleep time

230

115
Suvorexant

MOA: Works on the wakefulness

system

Side effects: headache, dizziness,

abnormal dreams, dry mouth

Advantages: might work when

other medicines haven’t

Disadvantages: Cost

231

Lemborexant

MOA: Works on the wakefulness

system

Side effects: headache, dizziness,

abnormal dreams, dry mouth

Advantages: might work when

other medicines haven’t

Disadvantages: Cost

232

116
OTC &
Herbals

233

Over the Counter

and Herbal Products

By some estimates about 20 percent

of the US population reported use of
herbal products

234

117
Over the Counter
and Herbal Products

The most rapidly growing segment of

the market was for products used to
treat or prevent psychological
concerns

235

Over the Counter

and Herbal Products

Herbal and over the counter (OCT)

products are not regulated by the
FDA

Only limitation is that they cannot

advertise they prevent or treat certain
diseases

236

118
OTC and Herbal
Concerns

No assurances of strength or
potency

Some products contain impurities or

contaminants

237

OCT and Herbal

Concerns

238

119
OCT and Herbal
Study of 44 products

Newmaster, S. G., Grguric, M., Shanmughanandhan, D.,

Concerns
Ramalingam, S., & Ragupathy, S. (2013). DNA barcoding
detects contamination and substitution in North American
herbal products. BMC medicine, 11(1), 222.

239

OTC and Herbal

Concerns

Serious adverse reactions can occur

Some herbals have significant effects

on liver metabolism

Can be expensive

240

120
OTC and Herbal
Concerns

Seventy percent of people who use

herbals never inform their doctors

241

Over the Counter

and Herbal Products

In the US, research on herbals has

been impeded by two factors

Little incentive for pharmaceutical

industry

Misleading claims by some

companies

242

121
OCT Products with
Research Efficacy

Saint-John’s Wort

SAM-E

Omega 3

Folic Acid

243

OCT Products that may

increase symptoms

Yohimbine

can cause anxiety

Kava Kava

may increase effects of alcohol,

and antipsychotics, can be toxic
in high doses

244

122
Resources

245

QUICK REFERENCE TO PSYCHOTROPIC MEDICATIONS® DEVELOPED BY JOHN PRESTON, PSY.D., ABPP

To the best of our knowledge recommended doses and side effects listed below are accurate. However, this is meant as a general reference only, and should not serve as a guideline for prescribing
of medications. Please check the manufacturer’s product information sheet or the P.D.R. for any changes in dosage schedule or contraindications. (Brand names are registered trademarks.)

ANTIDEPRESSANTS Usual Selective Action On

NAMES Daily Dosage Neurotransmitters2
Generic Brand Range Sedation ACH1 NE 5-HT DA
imipramine Tofranil 150-300 mg mid mid ++ +++ 0
desipramine Norpramin 150-300 mg low low +++++ 0 0
amitriptyline Elavil 150-300 mg high high ++ ++++ 0
nortriptyline Aventyl, Pamelor 75-125 mg mid mid +++ ++ 0
protriptyline Vivactil 15-40 mg mid mid ++++ + 0
trimipramine Surmontil3 100-300 mg high mid ++ ++ 0
doxepin Sinequan, Adapin3 150-300 mg high mid ++ +++ 0
clomipramine Anafranil 150-250 mg high high 0 +++++ 0
maprotiline Ludiomil 150-225 mg high mid +++++ 0 0
amoxapine Asendin 150-400 mg mid low +++ ++ 0
trazodone Desyrel 150-400 mg mid none 0 ++++ 0
nefazodone Generic Only 100-300 mg mid none 0 +++ 0
4
, Sarafem 20-80 mg low none 0 +++++ 0
bupropion-X.L. Wellbutrin-X.L.4 150-400 mg low none ++ 0 ++
sertraline Zoloft 50-200 mg low none 0 +++++ +
paroxetine Paxil 20-50 mg low low + +++++ 0
venlafaxine-X.R. Effexor-X.R.4 75-350 mg low none ++ +++ +
desvenlafaxine Pristiq 50-400 mg low none ++ +++ +

mirtazapine Remeron 15-45 mg mid mid +++ +++ 0

citalopram Celexa 10-60 mg low none 0 +++++ 0

Reading your quick

escitalopram
duloxetine
atomoxetine
Lexapro
Cymbalta
Strattera
5-20 mg
20-80 mg
60-120 mg
low
low
low
none
none
low
0
++++
+++++
+++++
++++
0
0
0
0

reference guide
MAO INHIBITORS
phenelzine
tranylcypromine
Nardil
Parnate
30-90 mg
20-60 mg
low
low
none
none
+++
+++
+++
+++
+++
+++
selegiline Emsam (patch) 6-12 mg low none +++ +++ +++
1
ACH: Anticholinergic Side Effects 246
2
NE: Norepinephrine, 5-HT: Serotonin, DA: Dopamine (0 = no effect, + = minimal effect, +++ = moderate effect, +++++ = high effect)
3
Uncertain, but likely effects
4
Available in standard formulation and time release (XR, XL or CR). Prozac available in 90mg time released/weekly formulation
123
BIPOLAR DISORDER MEDICATIONS 1
Anticholinergic Effects

Anticholinergic means blocking the effects of the

neurotransmitter acetylcholine. Since acetylcholine
is involved in learning and memory, glands, and
involuntary muscles, an anticholinergic drug

247

Anticholinergic Effects

Dry mouth Blurred vision

Decrease in Memory problems

perspiration
Loss of coordination
Increased heart rate (ataxia)

Constipation Sensitivity to heat

Increase in blood
pressure

248

124
QUICK REFERENCE TO PSYCHOTROPIC MEDICATIONS® DEVELOPED BY JOHN PRESTON, PSY.D., ABPP
To the best of our knowledge recommended doses and side effects listed below are accurate. However, this is meant as a general reference only, and should not serve as a guideline for prescribing
of medications. Please check the manufacturer’s product information sheet or the P.D.R. for any changes in dosage schedule or contraindications. (Brand names are registered trademarks.)

ANTIDEPRESSANTS Usual Selective Action On

NAMES Daily Dosage Neurotransmitters2
Generic Brand Range Sedation ACH1 NE 5-HT DA
imipramine Tofranil 150-300 mg mid mid ++ +++ 0
desipramine Norpramin 150-300 mg low low +++++ 0 0
amitriptyline Elavil 150-300 mg high high ++ ++++ 0
nortriptyline Aventyl, Pamelor 75-125 mg mid mid +++ ++ 0
protriptyline Vivactil 15-40 mg mid mid ++++ + 0
trimipramine Surmontil3 100-300 mg high mid ++ ++ 0
doxepin Sinequan, Adapin3 150-300 mg high mid ++ +++ 0
clomipramine Anafranil 150-250 mg high high 0 +++++ 0
maprotiline Ludiomil 150-225 mg high mid +++++ 0 0
amoxapine Asendin 150-400 mg mid low +++ ++ 0
trazodone Desyrel 150-400 mg mid none 0 ++++ 0
nefazodone Generic Only 100-300 mg mid none 0 +++ 0
4
, Sarafem 20-80 mg low none 0 +++++ 0
bupropion-X.L. Wellbutrin-X.L.4 150-400 mg low none ++ 0 ++
sertraline Zoloft 50-200 mg low none 0 +++++ +
paroxetine Paxil 20-50 mg low low + +++++ 0
venlafaxine-X.R. Effexor-X.R.4 75-350 mg low none ++ +++ +
desvenlafaxine Pristiq 50-400 mg low none ++ +++ +

mirtazapine Remeron 15-45 mg mid mid +++ +++ 0

citalopram Celexa 10-60 mg low none 0 +++++ 0
escitalopram Lexapro 5-20 mg low none 0 +++++ 0
duloxetine Cymbalta 20-80 mg low none ++++ ++++ 0
atomoxetine Strattera 60-120 mg low low +++++ 0 0
MAO INHIBITORS
phenelzine Nardil 30-90 mg low none +++ +++ +++ 249

tranylcypromine Parnate 20-60 mg low none +++ +++ +++

selegiline Emsam (patch) 6-12 mg low none +++ +++ +++
1
ACH: Anticholinergic Side Effects
2
NE: Norepinephrine, 5-HT: Serotonin, DA: Dopamine (0 = no effect, + = minimal effect, +++ = moderate effect, +++++ = high effect)
3
Uncertain, but likely effects
4
Available in standard formulation and time release (XR, XL or CR). Prozac available in 90mg time released/weekly formulation

BIPOLAR DISORDER MEDICATIONS

NAMES Daily Serum1 NAMES Daily Serum1
Generic Brand Dosage Range Level Generic Brand Dosage Range Level

lithium carbonate Eskalith, Lithonate 600-2400 0.6-1.5 divalproex Depakote 750-1500 50-100
olanzapine/ lamotrigine Lamictal 50-500 (2)
Symbyax 6/25-12/50mg4 2 topiramate Topamax 50-300 (3)
carbamazepine Tegretol,Equetro 600-1600 4-10+ tiagabine Gabitril 4-12 (3)
oxcarbazepine Trileptal 1200-2400 (2)
1
Lithium levels are expressed in mEq/l, carbamazepine and valproic acid levels express in mcg/ml.
2
Serum monitoring may not necessary 3Not yet established 4Available in: 6/25, 6/50, 12/25, and 12/50mg formulations

ANTI-OBSESSIONAL PSYCHO-STIMULANTS
NAMES NAMES
Generic Brand Daily Dosage1
Generic Brand Dose Range1
methylphenidate Ritalin 5-50 mg

questions
clomipramine Anafranil 150-300 mg methylphenidate Concerta2 18-54 mg
1
20-80 mg methylphenidate Metadate 5-40 mg
sertraline Zoloft1 50-200 mg methylphenidate Methylin 10-60 mg
methylphenidate Daytrana (patch) 15-30 mg
paroxetine Paxil1 20-60 mg dexmethylphenidate Focalin 5-40 mg
1
50-300 mg dextroamphetamine Dexedrine 5-40 mg
citalopram Celexa1 10-60 mg lisdexamphetamine Vyvanse 30-70 mg
escitalopram Lexapro1 5-30 mg pemoline Cylert 37.5-112.5 mg
d- and l-amphetamine Adderall 5-40 mg
1
often higher doses are required to control obsessive-compulsive Provigil, Sparlon 100-400 mg
symptoms than the doses generally used to treat depression. 1
Note: Adult Doses. Sustained release
2

© Copyright 2010, John Preston, Psy.D and P.A. Distributors

250

125
What you should know
about
psychopharmacology
during COVID-19
251

1
Addressing medication adherence

252

126
2
Sleep patterns
253

3
COVID-19 can exacerbate existing
conditions

254

127
4
COVID-19 is associated with
symptoms of anxiety and depression

255

5
COVID-19 and drug/drug interaction

256

128
6
COVID-19 and medications

257

7
COVID treatments and drug/drug
interactions

258

129
8
Mental health medications might
interact with COVID-19 treatments

259

9
Review current treatments and dose

260

130
10
We are always learning more

261

Web links and videos

may be found at
drkencarter.com/pesi

262

131
132
133
NOTES
NOTES