Download Module 3 Indications for Antipsychotic Drugs Flavio Guzmán, MD

Module 3
Indications for Antipsychotic Drugs
Flavio Guzmán, 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
• Potential indication for
quetiapine
• Off label use
• FDA panel
recommended against
its approval for GAD
Advantages
Generalized Anxiety disorder
Benefit comparable
to other approved
drugs
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical
Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.
Disadvantages
More rapid onset of
action than SRIs
Greater risk of
weight gain,
metabolic effects
than approved
medications
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
Did not report risk
• Sink et al. 2005
• Brodaty et al. 2003
• Wooltorton et al. 2004
• 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.
• Huntington’s 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