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Module 3 Indications for Antipsychotic Drugs

Flavio Guzmn, MD

Outline
Use in psychotic disorders Use in non-psychotic disorders

Indications for antipsychotic drugs

Psychosis
Schizophrenia Schizophreniform disorder Schizoaffective disorder Delusional disorder Brief psychotic disorder Medical conditions Mood disorders with psychotic symptoms
Janicak, P G., Marder S R., and. Pavuluri M N. Principles and Practice of Psychopharmacotherapy. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2010.

Use for non-psychotic disorders


Off-label use
Generalized anxiety disorder

Post-traumatic stress disorder


Obsessive-compulsive disorder

Borderline personality disorder


Dementia

Other uses

Generalized Anxiety disorder


Potential indication for quetiapine Off label use FDA panel recommended against its approval for GAD
Advantages Benefit comparable to other approved drugs More rapid onset of action than SRIs Greater risk of weight gain, metabolic effects than approved medications Disadvantages

Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

Post-Traumatic Stress Disorder


Strength of evidence:
Moderate : risperidone Low: Olanzapine Quetiapine: very low

There is no evidence that antipsychotics improve the core symptoms of PTSD. They can be useful adjunctive agents for the management of agitation, irritable aggression, anxiety and sleep difficulties.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

Obsessive-compulsive disorder
Resistant OCD: augmentation with antipsychotics. There is evidence that the addition of olanzapine or risperidone to a selective reuptake inhibitor helps some patients.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

Borderline personality disorder


Psychotherapy is the mainstay of treatment. Antipsychotics may be useful as adjunctive therapy in some cases. Should not be routinely used.

Tasman, A; Lieberman, J; Key, J; Maj, M. Psychiatry. 3rd ed. John Wiley & Sons, 2008

Borderline personality disorder


Olanzapine has shown superiority over placebo for symptoms such as:
Anxiety Depression Anger and hostility Impulsive aggression Interpersonal sensitivity

There is not convincing information suggesting that any antipsychotic agent changes the underlying character structure of patients with BPD
Tasman, A; Lieberman, J; Key, J; Maj, M. Psychiatry. 3rd ed. John Wiley & Sons, 2008

Antipsychotics in Dementia
Used for behavioral disturbances. Aripiprazole, olanzapine and risperidone have modest but defined efficacy. Off-label use The FDA reported in a public health advisory that the use of SGAs is associated with increased mortality.

Antipsychotics and stroke risk


Reported risk
Sink et al. 2005 Brodaty et al. 2003 Wooltorton et al. 2004

Did not report risk


Herrmann et al., 2004 Barnett et al. 2007

Antipsychotics for Dementia


For each patient, an individual assessment and documentation of risks and benefits of therapy is necessary. The use should be assessed in a case-by-case basis.

Tourette Syndrome
Pathophysiology: thought to involve dysfunction of basal ganglia. Antipsychotics can be effective in reducing motor and vocal tics Haloperidol and pimozide have been the most commonly used drugs for moderate to severe tics. The SGAs risperidone and ziprasidone were superior to placebo in small RCTs.
Tasman, A; Lieberman, J; Key, J; Maj, M. Psychiatry. 3rd ed. John Wiley & Sons, 2008

Substance-abuse disorders
Case reports, open label studies, and a few RCTs suggest SGAs may have a role in reducing substance abuse when it is comorbid with a psychotic disorder (dual diagnosis). When a psychotic disorder is not present , antipsychotics are not generally efficacious.
Tasman, A; Lieberman, J; Key, J; Maj, M. Psychiatry. 3rd ed. John Wiley & Sons, 2008

Other uses
Delirium:
APs used as symptomatic treatment.
Psychotic symptoms and agitation.

Huntingtons disease:
Patients might progress to delusional state or manic episodes.
Sadock, B J., V A. Sadock, and P Ruiz. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2009.

Other uses
Pervasive Developmental Disorders
Few controlled studies SGAs have shown some efficacy

Impulse Control Disorders


Appropriate only when other measures failed

Sadock, B J., V A. Sadock, and P Ruiz. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2009.

References and further reading


Janicak, P G., Marder S R., and. Pavuluri M N. Principles and Practice of Psychopharmacotherapy. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2010. Sadock, B J., V A. Sadock, and P Ruiz. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2009. Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010 Tasman, A; Lieberman, J; Key, J; Maj, M. Psychiatry. 3rd ed. John Wiley & Sons, 2008