Medications for Alcohol Dependence

Three medications are now FDA approved for treatment of alcohol dependence disulfiram, naltrexone, and acamprosate. Disulfiram binds irreversibly to aldehyde dehydrogenase, the enzyme that catalyzes the oxidation of acetaldehyde (a metabolite of alcohol) to acetic acid. It therefore changes the body's response to alcohol. Ingestion of alcohol results in the accumulation of acetaldehyde, causing an extremely dysphoric experience of palpitations, hypotension, nausea and vomiting, and diaphoresis....

Special Considerations in the Selection of an Antidepressant

The following factors should be considered when selecting an antidepressant agent. Gender Women may have slower gastrointestinal absorption than men due to less gastric acid and slower gastric emptying. A woman's volume of distribution differs as well, given her increased ratio of adipose tissue to lean body mass. Water retention associated with the menstrual cycle may also affect the volume of distribution. Oral contraceptives can alter the hepatic metabolism of TCAs. Ethnic and Racial Factors...

Third Generation Antidepressants

Venlafaxine does not substantially inhibit the CYP enzyme, and is not highly protein-bound, thus it tends to have few clinically significant drug-drug interactions. Duloxetine is metabolized by 1A2 and 2D6 P450 isoenzymes, and may increase plasma levels of other antidepressants, antipsychotics, and Type 1C antiarrhythmics, such as flecainide (Tambocor). Nefa-zodone is highly protein-bound, and has several active metabolites. It is also a strong inhibitor of CYP3A4, and affects other drugs also...

Drug Treatments for Nicotine Dependence

Nicotine resembles other addictive drugs in that it induces similar addictive behavior patterns (such as inability to control consumption) and similar neuroadaptive changes (e.g., tolerance). Nicotine intoxication and withdrawal are not associated with the acutely harmful behavior that other drugs of abuse cause but the health consequences of nicotine make it the most important drug of abuse. Withdrawal symptoms associated with nicotine addiction include anxiety, restlessness, difficulty...

Anticholinergic Effects

Common side effects include dry mouth, constipation, urinary retention, blurred vision, and less commonly narrow-angle glaucoma. These effects are usually dose-related and worse in patients with pre-existing defects. Dry mouth can be alleviated by saliva substitutes or sugar-free hard candy, over-the-counter bulk-forming laxatives can treat the constipation caused by some agents, and the cholin-ergic agonist bethanechol has been used to treat anticholin-ergic side effects, particularly urinary...

Medications for Opiate Dependence

Agonist maintenance treatment for opiate dependence is a powerful treatment with a large effect size. When properly prescribed, methadone will rapidly induce a dramatic remission in 50 or more of patients. It prevents or reduces illicit opiate use, craving for illicit opiates, criminal behavior associated with acquisition of illicit opiates, and diseases associated with illicit opiate use (such as illness related to infection with human immunodeficiency virus), and improves employment and other...

Treatment Initiation And Dose Titration

Once the questions above are answered, the clinician should select an antipsychotic medication and initiate the treatment trial. The algorithm from the practice guidelines for schizophrenia developed by the American Psychiatric Association may be useful for drug selection (Figure 1-1). Selection of an agent in emergency settings for the management of the gross agitation, excitement, and violent behavior associated with psychosis might be based on clinical symptoms, differences in efficacy or...

Acute Extrapyramidal Side Effects Dystonia Parkinsonism Akathisia

Antipsychotic-induced EPS occur both acutely and after chronic treatment. All antipsychotic medications are capable of producing EPS. In general, first-generation antipsychotics are more likely to cause EPS than second-generation antipsychotics when the drugs are used at usual therapeutic doses. Among second-generation drugs, clozapine and quetiapine have been shown to carry minimal to no risk for EPS within the therapeutic dosage range. Risperidone can produce dose-related EPS (> 6mg day)....

Pharmacotherapy for Specific Psychiatric Disorders

It is difficult to be definitive about when a substance-induced mood disorder becomes a major depressive episode. According to most experts, there should be a period of sobriety lasting two weeks before a second diagnosis can be made in a patient presenting with a depressive syndrome. However, clinical trials have shown the benefit of antidepressant medication in patients who are not abstinent to begin with. Thus, there is room for clinical judgment, and, if significant depression persists and...

Therapeutic Drug Monitoring

Although blood levels are available for many antidepressants, those for imipramine, desipramine, and nortriptyline have been best established. Imipramine and desipramine appear to have a curvilinear dose-response curve with an optimal range of 150 to 300 ng mL. Nortriptyline appears to have a therapeutic window in the range of 50 to 150 ng mL, usually reached by doses ranging from 50-100 mg day. These blood levels are TABLE 2-3. Starting Dose, Titration Steps, and Target Doses for Common...

Premenstrual Dysphoria PMDD

PMDD is a chronic cyclical disorder in which serotoninergic function is reduced during the luteal phase. The treatment of choice is a SSRI either sertraline or modified-release parox-etine, taken daily or only during the luteal phase. Treatment with sertraline should be initiated at a dose of 50mg day and if necessary increased in increments of 50mg day at each menstrual cycle to a maximum of 150 mg day if taken every day or 100 mg day if taken during the luteal phase only. The initial dose of...

Withdrawal from Opiates

Opiate withdrawal, by contrast with withdrawal from sedative-hypnotics, may be intensely uncomfortable but for most adults (with the important exceptions of adults with little reserve, such as those with advanced AIDS, and newborn infants) it is not usually life-threatening. Nevertheless, easing symptoms can be an important part of the process of engaging an individual in treatment for their opiate addiction and to facilitate other medical treatment. The time to onset of withdrawal symptoms...