Rehab Kids

Psychopharmacology:
Essential Updates for Mental
Health Professionals
Kenneth Carter, PhD, ABPP

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Psychopharmacology:
Essential Updates for Mental
Health Professionals
Kenneth Carter, PhD, ABPP

Rehab Kids

ZNM057520
12/20
Copyright © 2020

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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. Prior to this, Dr. Carter
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. In addition
to his teaching and research, Dr. Carter is actively engaged
in translating psychology to everyday language. He has also
appeared in magazines such as Mental Floss and Reader’s Digest,
as well as in news programs such as Connect with Kids and NBC’s
“Today Show.” Dr. Carter recently published Learn Psychology,
an introductory psychology textbook, with Dr. Colleen Seifert of
the University of Michigan.

Speaker Disclosures:
Financial: Dr. Kenneth Carter is a professor at Oxford College of Emory University. He is a clinical
supervisor for Positive Impact Health Centers. He is an author for Cambridge University Pres
and receives royalties. He is an author for Jones and Bartlett Learning and receives royalties. He
receives a speaking honorarium from PESI, Inc.
Non-financial: Dr. Kenneth Carter has no relevant non-financial relationship to disclose.

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.
 Disclaimer
Psychopharmacology:
Essential Updates for Materials that are included in this course may include interventions and
modalities that are beyond the authorized practice of mental health

Mental Health professionals. As a licensed professional, you are responsible for

reviewing the scope of practice, including activities that are defined in law

Professionals
as beyond the boundaries of practice in accordance with and in
compliance with your professions standards.

Kenneth Carter, PhD, ABPP

Charles Howard Candler Professor of Psychology
Oxford College | Emory University

1 2

1 2

Disclosures

I receive no money from

any pharmaceutical
company
Learn Abnormal Buzz!
Psychology Psychology
SAGE Publications Cambridge University Press Cambridge University Press

3 4

3 4

Disclosure Disclaimer & Disclosure

of Off-Label Use
This workshop is intended solely for educational purposes. The 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
information presented herein is to provide practical and useful information
disclosure of labeled uses.
on the subject matter covered. However, the information is provided with
the understanding that we are not engaged in rendering legal services. If 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
legal advice is required, the services of a legal professional should be
suggested should not be used by clinicians without evaluation of their patients'
sought. We will not be liable for any decision or action taken on reliance conditions and possible contraindications or dangers in use.
on the information presented in this activity.
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.
5 6

5 1 6
Psychopharmacology: Limitations Before we
of the Research and Potential
Risks start
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

About me
are sometimes unavoidable for certain understudied treatments and
disorders and medications with a potential for adverse consequences www.drkencarter.com/PIPE
require increased focus on ethical issues including informed consent. [email protected]
Questions
Scope of today’s training

7 8

7 8

Overview

Section 1 Section 2 Section 3 Section 4

Psychopharmacology
Ethics Guidelines Depression Herbals
Neuroscience Anxiety News
Insomnia Resources

Ethics

9 10

9 10

42% of current
Reasons to be clients use
knowledgable psychotropic
medication

11 12

11 2 12
It is important to know
the context in which
clients receive their 75-90%
medication Of antidepressants and benzodiazepines
are written by non-psychiatrists. Mostly by
primary care physicians

(Preston 2017)

13 14

13 14

Complicating such
treatments is the
brief time patients The
are typically seen average
by their primary Primary
care physician Care visit is
8 minutes

15 16

15 16

As clients
•take a history
become more
•make a diagnosis empowered
•prescribe
treatment and “better
•patient education
•answer questions informed”

17 18

17 3 18
We hear
more
questions It becomes important to be
about knowledgeable about the
psychotropic professional, legal, and
medications ethical boundaries regarding
and the discussion of medication-
related issues with clients

19 20

19 20

Because of our role in There are several ways

our clients’ lives, it is that non-prescribers can
important to be proactive partner with prescribers
in speaking with clients to help increase success
and prescribers with medication

21 22

21 22

We can help We observe or

clients have are told about
realistic potential side
expectations of effects that may
their interfere with
medications compliance

23 24

23 4 24
We know Survey from
information USA Today
clients may be Reasons people
too embarrassed have kept health
to tell their information from
prescribers their doctors

25 26

25 26

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

27 28

27 28

We can
encourage
clients to Practice
Guidelines
discuss Regarding
substance use Involvement in
Pharmacological
with prescribers Issues
American Psychologist 2011

29 30

29 5 30
2 4
Evaluate your own feelings and attitudes Identify and obtain a level of
about the role of medication in treatment. knowledge of medications that is
appropriate to the populations you
serve.
31 32

31 32

9 10
Explore issues surrounding patient Develop a relationship that will
adherence and feelings about medication. allow clients to feel comfortable
exploring issues surrounding
medication use.
33 34

33 34

17 Ask Questions
Maintain appropriate relationships
with prescribers.

35 36

35 6 36
 Psychopharmacology
101

importance of
asking questions
37 38

37 38

General
Overview of
the Neuron

Neurons
39 40

39 40

Parts of the neuron Dendrites

41 42

41 7 42
Soma Axon Hillock
43 44

43 44

Axon Axon terminal

45 46

45 46

The Synapse

An area that is comprised of 3

structures

The axon terminal

Synaptic Gap

Dendrite of next neuron

Synapses
47 48

47 8 48
Synapse Neurotransmitter
49 50

49 50

Synaptic Vesicle
51 52

51 52

Synaptic Vesicles Receptor Site

53 54

53 9 54
Transporter Monoamine oxidase
55 56

55 56

Monoamine oxidase
57
drkencarter.com/pipe 58

57 58

mouse party!
find link at
www.drkencarter.com/pipe

59 60

59 10 60
 Most prescribed
psychotropics
Zoloft Xanax Lexapro Desyrel Wellbutrin
(sertaline) (alprazolam) (escitalopram) (trazodone) (bupropion)
Adderall
(dextroamphetamine
Prozac Celexa Cymbalta Ativan Brand vs
Generics
(fluoxetine) (citalopram) (duloxetine) (lorazepam)
and amphetamine)

Effexor Seroquel Lamictal Concerta Kapvay

(venlafaxine) (quetiapine) (lamotrigine) (methylphenidate) (clonidine)
pops
Remeron Elavil Vyvanse Depakote
Paxil (paroxetine)
(mirtazapine) (amitriptyline) (lisdexamfetamine) (divalproex)

Abilify Risperdal Zyprexa Intuiv Trileptal

(aripiprazole) (risperidone) (olanzapine) (guanfacine) (oxcarbazepine)
2018 61 62

61 62

Brand vs Generics Therapeutic Window

80%-120% range of potency for generics

Some brand-name medications also contain

special binders

64

63 64

63 64

Focus Concepts

Selective Serotonin Reuptake Inhibitors (SSRI)

Keep serotonin in the synapse
SSRI SNRI Benzodiazepines
Serotonin Norepinephrine Reuptake Inhibitors
(SNRI) Lexapro Effexor Xanax
Keep serotonin and norepinephrine in the synapse Zoloft Pristiq Valium
Benzodiazepines (BZD) Prozac Cymbalta
“Hits the breaks” of the nervous system
Celexa
and we will touch on medicines for ADHD/Bipolar/ Paxil
Psychosis/Insomnia as well

65 66

65 11 66
 Administration
through the skin
Transdermal patches provide
Drug continuous, controlled release

Delivery Allows for slow, continuous

absorption over hours or days,
Systems minimizing side effects

Examples

Selegiline (depression)

Methyphenidate (AD/HD in
children)

67 68

67 68

Immediate
Release Beads
All goes in Slow release system

69 70

69 70

OROS Osmotic controlled-release oral

delivery system (OROS)

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

71 72

71 12 72
Prodrug Intramuscular
A prodrug is a compound that
is not pharmacologically
active. It needs to be
metabolized by the body to
be active.

73 74

73 74

Depressive Monoamine
Disorders hypothesis of
depression

75 76

75 76

Neurobiology of Monoamine hypothesis

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

Serotonin (5-HT)

Norepinephrine

Dopamine

77 78

77 13 78
 Many
antidepressants
Malfunction attempt to keep
one or more
can occur in monoamines in
many ways the synaptic gap
• Decreased release in the
synapse
• Excessive reuptake
• Overactive MAO
• Receptor abnormality

79 80

79 80

SSRI SSRI

block the areas

that recycle
serotonin

81 82

81 82

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

The next video demonstrates you can also see it in my website

www.drkencarter.com/PIPE
the mechanism of action of
SSRIs
83 84

83 14 84
 Treatment Effects of
SSRIs
Well tolerated

Once daily dosing

Safer in overdose

Generically available

85 86

85 86

Adverse Effects of SSRIs Serotonin Syndrome

Include
High rates of sexual dysfunction Mild: increased heart rate, shivering, sweating,
dilated pupils, intermittent tremor or twitching
Decreased appetite (initially)
Moderate: high blood pressure and high
GI upset (nausea, diarrhea) temperature
Insomnia Severe: Potentially life threatening
Headaches

87 88

87 88

Serotonin Withdrawal Medications in this

Syndrome category
Some may experience dizziness, letheragy, Citalopram (Celexa)
nausea, irritability, and headaches on
discontinuation Escitalopram (Lexapro)

These symptoms can be prevented by reducing Fluoxetine (Prozac)

the medication slowly over several weeks
Fluvoxamine (Luvox)
Not a relapse
Paroxetine (Paxil)

Sertraline (Zoloft)

89 90

89 15 90
 Commonly Prozac Zoloft Lexapro Celexa Paxil
Prescribed
SSRIs
Zoloft Sedation 1 1 3 3 5

Lexapro

Celexa Activation 5 4 3 3 1

Prozac

Weight Gain 2 2 3 3 5

Sexual
Dysfunction
3 2 3 3 5

91 Stephen M. Stahl (2017) Stahl’s Essential Psychoparmacology (4th ed). New York: Cambridge 92
University Press

91 92

Genetic Testing Significance of Genetic Testing

in the Determination of Drug
Dosage for an Antidepressant

Slow Typical Ultra Rapid

Metabolizer Metabolizer Metabolizer

93 94

93 94

Fluoxetine Sertraline
(Prozac) (Zoloft)
Activating antidepressant

Very long half-life Activating

Side effects: gastrointestinal More prone to gastrointestinal side

symptoms, sexual dysfunction, effects than other SSRIs
insomnia, headache, dizziness May be a first-line choice for atypical
Advantages: comes in weekly depression (low energy, mood
format, helpful for patients with low reactivity)
energy

Tom Varco

95 96

95 16 96
Paroxetine Citalopram
(Paxil) (Celexa)
Minimal sedation and weight gain

If withdrawal symptoms emerge during

discontinuation raise dose to stop
symptoms then discontinue more slowly
May be contraindicated in pregnancy Is a helpful medication for clients who might
be excessively activated by other SSRIs
More prone to discontinuation
symptoms Can be sedating in some clients

May have less sexual dysfunction than

other SSRIs

Can cause affective “flattening” in some

clients
97 98

97 98

Escitalopram Vilazodone
(Lexapro)

Minimal sedation and weight gain

Similar to citalopram but with fewer

side effects

May have a faster onset of action

than other SSRIs

Image: Tom Varco

99 100

99 100

Vilazodone Vortioxetine
(Viibryd) (Trintellix)

The most commonly observed May also affect dopamine

adverse reactions in patients treated
Possible benefit of improved
with Viibryd in placebo-controlled
cognition
studies were: diarrhea (28% vs. 9%),
nausea (23% vs. 5%), insomnia (6% May have less sexual dysfunction
vs. 2%), and vomiting (5% vs. 1%) than SSRIs

101 102
National Library of Medicine National Library of Medicine

101 17 102
 Treatment
effects of SNRIs

SNRI Benefits of SSRIs

Plus they treat depression in an

additional way (targeting
Work by keeping both serotonin AND
norepinephrine in the synapse norepinephrine)

103 104

103 104

Adverse Effects Commonly Prescribed

of SNRIs include SNRIs

GI upset

Dry mouth

Hypertension

Nervousness

Insomnia
Venlafaxine Desvenlafaxine Duloxetine
Sexual Dysfunction Effexor Prestiq Cymbalta

105 106

105 106

Venlafaxine Desvenlafaxine
(Effexor) (Pristiq)
MOA: Increases release of several
different neurotransmitters (serotonin,
norepinephrine, dopamine, glutamate,
acetylcholine, and histamine)
Metabolite of venlafaxine
Side effects: May cause
hypertension, GI upset May have fewer GI side effects than
venlafaxine
Advantages: Less sexual
dysfunction than SSRIs, helps Contraindicated in pregnancy
cognitive symptoms

Disadvantages: can cause cardiac

problems in overdose Image: Tom Varco

107 108

107 18 108
Duloxetine Levomilnacipran
(Cymbalta) (Fetzima)
MOA: SNRI; much more
balanced reuptake
inhibitors of serotonin and norepineph
rine

Can also treat neuropathic pain Side effects: GI, sweating, sexual
dysfunction
More balanced for effects on
serotonin and norepinephrine Advantages: may be more helpful for
somatic symptoms, fatigue, and pain

Disadvantages:cost; may increase

hypertension in people with high
blood pressure
109 110

109 110

Bupropion
(Wellbutrin)

Energizing

Other Few sexual side effects

Less weight gain

Bupropion (Wellbutrin)
May increase anxiety and insomnia

111 112
National Library of Medicine

111 112

Esketamine Nasal
Spray for Treatment
Resistant
Depression

Anxiety

113 114

113 19 114
Medications for Anxiety DSM-5 Disorders with
Disorders 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
SSRI Benzodiazepines Not Hair Pulling Disorder
Fluoxetine Alprazolam Benzodiazepines Generalized Anxiety
Sertraline Clonazepam Disorder
Paroxetine Lorazepam

National Library of Medicine 115 116

115 116

Deconstructionist Neurobiology of Anxiety

Approach

Fear Worry
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

Panic Anxious misery
that information to choose medicines to treat symptoms
Phobia Apprehensive expectation
Anxiety disorders may be deconstructed into just two Obsessions
different kinds of symptoms

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117 118

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

119 120

119 20 120
 Not that much GABA in the worry loop

Anything that increases

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

121 122

121 122

Serotonin will help

with worry
GABA is LESS
successful in
shutting down worry SSRIs for Anxiety

123 124

123 124

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

Benzodiazepines
Some clients have an increase in anxiety for the first week
or so on an SSRI

125 126

125 21 126
 Benzodiazepines

Short Intermediate Long

Midazolam (Versed) Lorazepam (Ativan) Chlordiazepoxide

Action is on GABA
(Librium)
Increase in GABA will increase inhibition, which
Triazolam (Halcion) Estazolam (ProSom)
quiets down abnormally activated circuits Clorazepate (Tranxene)
Alprazolam (Xanax) Clonazepam (Klonopin)
Works quickly Diazepam (Valium)
Oxazepam (Serax)
Will not work as effectively for worry as it might
for fear Flurazepam (Dalmane)
Temazepam (Restoril)
Halazepam (Paxipam)

127 128

127 128

Diazepam (Valium) Chlordiazepoxide

(Librium)
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)

Rapid onset of action
May lead to abuse
Can also treat alcohol withdrawal
One of the most commonly prescribed
benzodiazepine

Useful to treat alcohol withdrawal

One of the few available in an oral liquid

formulation

129 130

129 130

Clonazepam Lorazepam (Ativan)

(Klonopin)
Short and inactive metabolites
One of the most popular
benzodiazepines for anxiety MOA: Binds to benzodiazepine
receptors at GABA-A
Easier to taper than some other
benzodiazepines because of its long Advantages: available in liquid and
half-life injectable formulation, rapid onset

May have less abuse potential than Disadvantages: may lead to abuse,
some benzodiazepines possibly more sedation than other
benzodiazepines

131 132
National Library of Medicine

131 22 132
Alprazolam (Xanax) Flumazenil
(Anexate)
Reduces the sedative effects of
Binds to GABA receptors to enhance benzodiazepines
the effects of GABA Blocks benzodiazepine receptors
Less sedating than other preventing benzodiazepines from
benzodiazepines binding there

Half-life about 12 hours Onset in 1-2 minutes

Can sometimes wear off before the

action wears off

James Heilman, MD
133 134

133 134

FDA rehires
stronger warning
labels for
benzodiazepines

The US Food and Drug Administration Other anti-

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

135 136

135 136

Buspirone Hydroxyzine
(Buspar) (Vistaril)
Works on serotonin

Takes about 2-4 weeks to work (can MOA: Blocks histamine receptors
take up to 8 weeks) Side effects: Dry mouth, sedation,
Gradual onset tremor

Dizziness, headache, nervous, Advantages: No abuse,

sedation, nausea, and restlessness dependency, or withdrawal
are the most common side effects Disadvantages: Can be sedating;
Lack of dependence or withdrawal not as effective as benzodiazepines
symptoms

137 138
National Library of Medicine

137 23 138
 Insomnia

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

139 140

139 140

Insomnia Diagnosing Insomnia

DSM IVtr

Primary Insomnia

Insomnia secondary to another condition

DSM 5
According to the National Sleep Foundation, up
to 72% experience some symptoms of a sleep Insomnia Disorder
disorder at least a few nights a week

141 142

141 142

Sleep Treatments
System
&
Wake
System

Behavioral Diphenhydramine Trazodone

Sedating antihistamine Sedating antidepressant

143 144

143 24 144
 Lunesta Sonata Ambien Belsomra
eszopiclone zaleplon zolpidem suvorexant

Behavioral Sleep Medicines

Interventions
145 146

145 146

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

147 148

147 148

149 150

149 25 150
 151 152

151 152

Eszopiclone
(Lunesta)

Half Life Binds to a site near the benzodiazepine area

of the GABA receptor

Half life: 6 hours

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

The therapeutic effect might be

much shorter than 5 half-lives

153 154

153 154

Eszopiclone Zaleplon
(Lunesta) (Sonata)
day-time drowsiness, dizziness, "hangover"
feeling

problems with concentration

anxiety, depression, nervous feeling

Binds to a site near the
headache benzodiazepine area of the GABA
receptor
nausea, stomach pain, loss of appetite,
constipation Half life 1 hour
dry mouth

unusual or unpleasant taste in your mouth

mild skin rash

155 156
National Library of Medicine National Library of Medicine

155 26 156
Zaleplon Zolpidem
(Sonata) (Ambien)
day-time drowsiness

problems with concentration

numbness or tingling

anxiety, depression, nervous feeling

Binds to a site near the
problems with vision
benzodiazepine area of the GABA
headache receptor
nausea, stomach pain, loss of appetite, constipation
Half-life 2-3 hours
dry mouth

increased menstrual pain (cramps)

back pain, joint or muscle pain

mild skin rash

157 158
National Library of Medicine National Library of Medicine

157 158

Zolpidem Ramelteon
(Ambien) (Roserem)
selective melatonin receptor agonist
Dizziness Melatonin is regulated by pineal
gland on a 24-hour cycle, with levels
GI upset
increasing towards bedtime.
Nausea
Nonaddictive
Vomiting
Very modest effect in controlled trials
Anterograde amnesia
Sleep onset only 10–15 minutes
Morning hangover earlier than placebo

Little affect on total sleep time

159 160
National Library of Medicine National Library of Medicine

159 160

Suvorexant Lemborexant
(Belsomra) (Dayvigo)

MOA: Works on the wakefulness

system
Also works on the wakefulness system
Side effects: headache, dizziness,
abnormal dreams, dry mouth

Advantages: might work when

other medicines haven’t

Disadvantages: Cost

161 162
National Library of Medicine

161 27 162
 Over the Counter
and Herbal Products

OTC &
Herbals By some estimates about 20 percent
of the US population reported use of
herbal products

163 164

163 164

Over the Counter Over the Counter

and Herbal Products and Herbal Products

Herbal and over the counter (OCT)

The most rapidly growing segment of products are not regulated by the
the market was for products used to FDA
treat or prevent psychological Only limitation is that they cannot
concerns advertise they prevent or treat certain
diseases

165 166

165 166

OTC and Herbal OCT and Herbal

Concerns Concerns

No assurances of strength or
potency

Some products contain impurities or

contaminants

167 168

167 28 168
 OTC and Herbal
Concerns

Serious adverse reactions can occur

Some herbals have significant effects

on liver metabolism

Can be expensive
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.

169 170

169 170

OTC and Herbal Over the Counter

Concerns and Herbal Products

In the US, research on herbals has

been impeded by two factors

Seventy percent of people who use Little incentive for pharmaceutical

herbals never inform their doctors industry

Misleading claims by some

companies

171 172

171 172

OCT Products with OCT Products that may

increase symptoms
Research Efficacy

Yohimbine
Saint-John’s Wort
can cause anxiety
SAM-E
Kava Kava
Omega 3
may increase effects of alcohol,
Folic Acid and antipsychotics, can be toxic
in high doses

173 174

173 29 174
Resources
medscape.com
175 176

175 176

cochrane.org scholar.google.com
177 178

177 178

epocrates

The
Prescriber’s
Guide
Stephen M. Stahl

179 180

179 30 180
 The The
Prescriber’s Prescriber’s
Guide Guide

How the drug works Drug interactions

How long until it works When NOT to use

If it doesn’t work Information on special populations

Notable side effects Advantages

Dangerous side effects Disadvantages

Stephen Stahl Stephen Stahl

181 182

181 182

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

The
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

Prescriber’s
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

Guide
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
fluoxetine Prozac4, 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 ++ +++ +
Stephen M. Stahl desvenlafaxine Pristiq 50-400 mg low none ++ +++ +
fluvoxamine Luvox 50-300 mg low low 0 +++++ 0
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 http://psyd-fx.com/quick-reference-chart/quick-
low
low
none
none
low
0
++++
reference-direct/
+++++
+++++
++++
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 +++ +++ +++
183 1
ACH: Anticholinergic Side Effects 184
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

183 BIPOLAR DISORDER MEDICATIONS 184

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)
fluoxetine 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

Anticholinergic Effects Anticholinergic Effects

NAMES NAMES
Generic Brand Daily Dosage1
Generic Brand Dose Range1
methylphenidate Ritalin 5-50 mg
clomipramine Anafranil 150-300 mg methylphenidate Concerta2 18-54 mg
fluoxetine Prozac1 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
fluvoxamine Luvox1 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 modafinil Provigil, Sparlon 100-400 mg

Anticholinergic means blocking the effects of the Dry mouth

symptoms than the doses generally used to treat depression.

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

Blurred vision 1
Note: Adult Doses. 2Sustained release

neurotransmitter acetylcholine. Since acetylcholine

is involved in learning and memory, glands, and Decrease in Memory problems
involuntary muscles, an anticholinergic drug perspiration
Loss of coordination
Increased heart rate (ataxia)

Constipation Sensitivity to heat

Increase in blood
pressure

185 186

185 31 186
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

questions
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
fluoxetine Prozac4, 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 ++ +++ +
fluvoxamine Luvox 50-300 mg low low 0 +++++ 0
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 +++ +++ +++ 187 188

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

selegiline Emsam (patch) 6-12 mg low none +++ +++ +++
1
2
3
ACH: Anticholinergic Side Effects
187
NE: Norepinephrine, 5-HT: Serotonin, DA: Dopamine (0 = no effect, + = minimal effect, +++ = moderate effect, +++++ = high effect)
Uncertain, but likely effects
188
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)
fluoxetine 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
clomipramine Anafranil 150-300 mg

Web links,videos, and

methylphenidate Concerta2 18-54 mg
fluoxetine Prozac1 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
fluvoxamine Luvox1 50-300 mg dextroamphetamine Dexedrine 5-40 mg

references may be
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 modafinil Provigil, Sparlon 100-400 mg
symptoms than the doses generally used to treat depression. 1
Note: Adult Doses. 2Sustained release
© Copyright 2010, John Preston, Psy.D and P.A. Distributors

found at
drkencarter.com/pipe
189

189

32
NOTES
NOTES