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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