Psychotropic medications act on the central nervous system to treat symptoms of mental illness such as psychosis, depression, and anxiety. Common types include antipsychotics, antidepressants, mood stabilizers, and sedatives. These medications can cause side effects involving the central nervous system like extrapyramidal symptoms and sleep issues, as well as metabolic side effects like weight gain and insulin resistance. Managing side effects may involve reducing dosage, switching to alternative medications, or adding adjunctive treatments.

1. PSYCHOTROPIC
Medications
AND THEIR
SIDE EFFECTS
Laura Kho Sui San
Pharmacist
Hospital Sentosa

2. OUTLINE
 Introduction
 Types of PSYCHOTROPIC drugs
 Antipsychotics
 Antidepressants
 Mood Stabilizers
 Sedative/Hypnotics
 Medications for Dementia
 Common SIDE EFFECTS
 CNS side effects
 Systemic/Metabolic side
effects
 Demand and supply

3. What are
PSYCHOTROPIC
Medications?

4. PSCYHOTROPIC Medications
Medications that act on the Central
Nervous System (CNS)
Mood
Behavior
Consciousness
Cognition
Perception

5. PSCYHOTROPIC Medications
Treat SYMPTOMS of mental illness
Antipsychotics
Antidepressants
Mood stabilizers
Anxiolytics
Sedatives
Hypnotics
Dementia ……

7. Treat symptoms of PSYCHOSIS
Hallucinations
Delusions
Disorganized behavior, etc

8. PSYCHOSIS usually caused by too much
DOPAMINE in the brain
Antipsychotics
BLOCK dopamine
receptors in the
brain
TYPICAL and
ATYPICAL
antipsychotics

9. CHLORPROMAZINE
PERPHENAZINE TRIFLUOPERAZINE
HALOPERIDOL
SULPIRIDE

10. FLUPHENAZINE
FLUPENTIXOL
ZUCLOPENTIXOL

11. RISPERIDONE
QUETIAPINE
PALIPERIDONE

12. AMISULPRIDE
OLANZAPINE
CLOZAPINE
ARIPRIPAZOLE

13. RISPERIDONE
LONG-ACTING
INJECTION PALIPERIDONE
LONG-ACTING
INJECTION

14. Depo injections : Fluphenzine
(Modecate®), Fluphenthixol
(Fluanxol®), Risperidone (Consta®),
Paliperidone (Sustena®)
 Once every one to four
weeks
 Inject into deltoid or gluteal
muscle.
 Released slowly into the
body
 Ensure adherence

15. Antipsychotics

16. • Used to treat DEPRESSION
• Also used to treat other
conditions, including
Generalised Anxiety
Disorder (GAD), Panic
Disorder, Obsessive-
Compulsive Disorder
(OCD)

17. HOW DO THEY WORK?
• Theory: Increase levels of neurotransmitters
like serotonin and noradrenaline
• Improve mood and emotion
NOT INSTANT FIX!
May take up to 4-6
weeks to start
working

18. Selective Serotonin Reuptake Inhibitors (SSRI)
 1st -line
 Effective and less side effects
ESCITALOPRAM
(LEXAPRO®) 10MG
SETRALINE
(ZOLOFT®) 50MG
FLUOXETINE
(PROZAC®) 20MG
FLUVOXAMINE
(LUVOX®) 50MG,
100MG

19. Which SSRI to choose?
Efficacy is similar
If one SSRI fails, try another SSRI

20. Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs)
 Similar to SSRIs
 Designed to work better than SSRI because they
also affect noradrenaline levels
 Only use if SSRIs do not work
DULOXETINE
(CYMBALTA®)
30MG, 60MG
VENLAFAXINE
(EFEXOR XR®)
75MG, 150MG

21. Tricyclic Antidepressants (TCAs)
 Old
 Effective but NOT 1st choice
 Many side effects such as dry mouth,
constipation, sedation, weight gain
especially in elderly
 TOXIC IN OVERDOSE
 Examples : AMITRIPTYLINE, IMIPRAMINE,
DOTHIEPINE, CLOMIPRAMINE

22. OTHERS
Noradrenegic and Specific Serotonergic
Antidepressant (NaSSA)
Mirtazapine (Remeron®) 15mg, 30mg
(orodispersible tablet)
Monoamine Oxidase Inhibitors
 Moclobemide (Aurorix®) 150mg
 Not popular
 Need for monitoring, many drug-drug,
drug-food interactions.

24.  Control emotion and behaviour
 Mania (“high”) and to prevent both episodes
of mania and depression in bipolar disorder
 Mood symptoms like depression and
aggression in schizophrenia
 Behavioral problems in mental retardation

25. Mr Hamid comes to the pharmacy with a
prescription for T. Sodium Valproate
400mg BD and T. Olanzapine 5mg ON. Is
Mr Hamid suffering from epilepsy?
+

26.  Sodium Valproate (Epilim®) 200mg
 Carbamazepine 200mg, 400mg
 Lamotrigine 50mg, 100mg
 Lithium 300mg
 Not common
 Selected patients need to be quite well
educated.
 Narrow therapeutic index – risk of toxicity

27. Sedatives / Hypnotics

28. INSOMNIA
(SLEEP)
WORRY
ANXIETY
AGGRESSION /
AGITATION

29.  Benzodiazepines (BDZ)
 Clonazepam (Rivotril®, Klonopin®)
 Lorazepam (Ativan®)
 Alprazolam (Xanax®)
 Diazepam (Valium®)
 Z compound (Non-benzodiazepine)
– Zolpidem (Stilnox®)
SEDATIVE/ HYPNOTIC

30. For sleep :
– INDUCE sleep : Zolpidem
– MAINTAIN sleep : benzodiazepines
– Choice of BDZ depends on onset of action and
length of action
For anxiety :
– Usually but not always alprazolam (short-acting)
For aggression/agitation :
– BDZ : intermediate- to long-acting like
clonazepam, diazepam, lorazepam
SEDATIVE/ HYPNOTIC
USE SHORT TERM!

31. • TOLERANCE : need MORE and MORE BDZ to achieve the
required effect
• How fast does tolerance develop?
• Hypnotic effects (more rapidly)
• Anxiolytic effects (more slowly)
• Depends on dose, potency and duration of therapy
• After 4-6 months of REGULAR use, become less effective
• If you suddenly stop or reduce dose → WITHDRAWAL
SYMPTOMS
PROBLEMS with BDZ : TOLERANCE
and DEPENDENCE
Short-term use of BDZ: Less than 4 weeks OR
intermittent courses (e.g. EOD)

33. • Most types of dementia are
PROGRESSIVE, cannot be cured
e.g. Alzheimer’s disease
• BUT, medicines may prevent
symptoms from getting worse
for a period of time.
• Early to middle stages of the
disease.
• Not everyone will benefit from
medication.

34.  Cholinesterase inhibitors
 Donepezil (Aricept®) tablets 10mg
 Rivastigmine (Exelon®)
 Capsules 1.5mg, 3mg
 Patch 4.6mg/24hr and 9.5mg/24hr
 NMDA-antagonist
– Memantine (Ebixa®) tablets 10mg, 20mg

35. Are the side
effects from
my medicines
making me
sicker?
Or am I feeling
ill because of
my disease?

36. WHAT ARE THE COMMON
SIDE EFFECTS
OF PSYCHOTROPIC MEDICINES?

37. COMMON SIDE EFFECTS
CNS
• ExtraPyramidal
Symptoms(EPS)
• SLEEP
disturbances
• SEIZURES
Systemic /
Metabolic
• Metabolic syndrome
• Hypersalivation
• AntiCHOLINERGIC
side effects
• Cardiovascular
• Agranulocytosis

38. EXTRAPYRAMIDAL SYMPTOMS (EPS)

39. EXTRAPYRAMIDAL SYMPTOMS (EPS)
Higher risk in typical
antipsychotics e.g.
haloperidol and
trifluoperazine.

40. PSYCHOSIS usually caused by too much
DOPAMINE in the brain
Antipsychotics
BLOCK dopamine
receptors in the
brain
TYPICAL and
ATYPICAL
antipsychotics

41. EXTRAPYRAMIDAL SYMPTOMS (EPS)
• Acute dystonia
• Pseudoparkinsonism
• Tardive dyskinesia (TD)
• Akathisia

42. EXTRAPYRAMIDAL SYMPTOMS (EPS)
3 situations
Start new antipsychotic
(Rapidly)Increase dose of
antipsychotic
Reduce dose of anticholinergic
DOSE-RELATED

43. Acute DYSTONIA
“Sudden, involuntary muscle
contractions or spasms.”
Acute dystonia
Uprolling eyeballsHead and neck
twisted to one side.

44. Start oral
new
antipsychotic
IM / IV e.g.
IM Haloperidol
Within
days/hours
Within
minutes
More common in :
 Young males
 New patients
 Those treated with older
drugs
Acute DYSTONIA

45. Management of DYSTONIA
ACUTE :
 Give anticholinergic drugs
IM or orally.
 Usually IM Procyclidine
(Kemadrin®) 5mg stat
 Usually effective within 20
minutes.
Occasionally, 2nd or 3rd injections are
necessary; they should be
administered at half hour intervals.CONTINUE with Tab. BENZHEXOL
for prophylaxis

46. Pseudoparkinsonism
“Adverse effect of drug
that causes symptoms
resembling parkinsonism.”
Reversible
Can be mistaken for
negative symptoms
of schizophrenia.

47. Mask-like face

48. Management of
Pseudoparkinsonism
 REDUCE dose
 SWITCH to another
antipsychotic
 Tab. BENZHEXOL
for treatment and
prophylaxis. (Review
use after 3 months)

49. Tardive Dyskinesia (TD)
“Repetitive,
involuntary,
purposeless
movements.”
“Worsen under stress.”

50.  Grimacing
 Tongue
protrusion
 Lip smacking
 Excessive eye
blinking
 Choreiform hand
movements (e.g.
pill rolling)
Tardive dyskinesia
Can lead to difficulty
breathing, eating or speaking!

51. More common in :
 Elderly females
Prior history of
acute EPS earlier in
treatment
Tardive Dyskinesia (TD)
The result of
PROLONGED use or HIGH-
DOSE antipsychotics

52. Management of Tardive
Dyskinesia (TD)
 REDUCE to lowest
possible dose
 SWITCH to another
antipsychotic (e.g.
clozapine)
Tab. BENZHEXOL
can WORSEN TD!

53. AKATHISIA
“A feeling of
INNER RESTLESSNESS”
Akathisia
 Foot stamping
when seated
 Constantly pacing
up and down
 Rocking from foot
to foot

54. Management of AKATHISIA
 REDUCE dose
 SWITCH to another
antipsychotic
 Low-dose beta-
blocker. eg
propranolol 20-80
mg/day
 Benzodiazepines

55. ANTICHOLINERGICS– How to handle
side effects from ANTIPSYCHOTICS?
Oral: Benzhexol 2mg (Artane®)
Only if patients are on antipsychotics
ALWAYS QUERY if there is
BENZHEXOL but NO injection or oral
ANTIPSYCHOTIC
IM : Kemadrin® (Procyclidine)
Acute / emergency situation
KPK item

56. SLEEP

57. SLEEP
PSYCHIATRIC
DRUGS
Sedating
Activating
Insomnia
Restlessness
Somnolence
Daytime
sedation

58. Examples of sedating and
activating drugs
↓↓Sedating
 Clozapine
 Chlorpromazine
 Olanzapine
 Quetiapine
 Fluvoxamine
 Benzodiazepines
↑↑Activating
 Fluoxetine
 Sertraline
 Benzhexol
 Aripriprazole

59. How to Manage …?
Somnolence
Reduce dosage.
 Change to single
bedtime dose.
Switch to less
sedating alternative
Insomnia
 Take in the
daytime
Switch to less
activating
alternative if
cannot tolerate.

60. SEIZURES

61. All antipsychotics have the risk of ing
seizure threshold
o Psychotic disorders, depression and OCD
may also seizure threshold
Highest risk : CHLOPROMAZINE and
CLOZAPINE (high dose)
MONITOR, MONITOR, MONITOR ……
Prophylaxis : Anticonvulsant
(SODIUM VALPROATE)

62. COMMON SIDE EFFECTS
CNS
• ExtraPyramidal
Symptoms(EPS)
• SLEEP
disturbances
• SEIZURES
Systemic /
Metabolic
• Metabolic syndrome
• Hypersalivation
• AntiCHOLINERGIC
side effects
• Cardiovascular
• Agranulocytosis

63. METABOLIC

64. METABOLIC
Insulin
RESISTANCE
↑ blood sugar
Weight GAIN ˃5%
Of initial weight
DYSLIPIDEMIA
↑ cholesterol, LDL
and mostly TGs

65. METABOLIC
Common in ATYPICAL ANTIPSYCHOTICS
CLOZAPINE
OLANZAPINE
QUETIAPINE

66. Ref: American Diabetes Association. Consensus development conference on antipsychotic drugs and
obesity and diabetes. Diabetes Care 2004;27:596-601
MANAGEMENT
Monitor, monitor, monitor…….

67. MANAGEMENT
Monitor, monitor, monitor……. (as per
protocol)
 Lifestyle modifications
 If weight gain >5% of initial
weight, suggest switching to another
weight-neutral AP. e.g. Aripriprazole
OPTION: (up to
2g/day has been studied)
 Decrease body weight
 Improve metabolic abnormalities
METFORMIN

68. Hypersalivation
Antipsychotics
esp CLOZAPINE

69. HYPERSALIVATION
• Drooling, especially at night
• Usually at initiation
• May reduce in severity over time but
may also persist
How to Manage?
 BENZHEXOL (Take before 7pm for
nighttime relief)
 DAYTIME : CHEW sugarless gum to
aid swallowing

70. Hyperprolactinaemia
Serum prolactin ˃ 25mcg/L
(10-25 mcg/L)
Not always symptomatic
 Gynecomastia
 Galactorrhea
 Menstrual abnormalities
 Sexual dysfunction

71. Hyperprolactinaemia
 REDUCE dose
 SWITCH drug
 AUGMENT with aripriprazole
Potent D2 blockers:
 Haloperidol
 Risperidone
 Paliperidone
 Amisulpiride

72. ANTICHOLINERGIC SIDE EFFECTS

73. • Common culprits :
ANTICHOLINERGIC SIDE EFFECTS
ANTIPSYCHOTICS
Clozapine
Chlopromazine
ANTICHOLINERGIC
AGENTS
Benzhexol
Benztropine
TRICYCLIC
ANTIDEPRESSANTS
Amitriptyline
Clomipramine
Dothiepine
Imipramine
Constipation
Urinary Retention
Other peripheral side effects (eg dry mouth,
blurred vision)
Confusion, memory impairment and delirium

74. CONSTIPATION
Usually persists after chronic usage of AP
↓ed gastric motility
CLOZAPINE
Clozapine-induced GI hypomotility syndrome,
bowel ischemia, intestinal obstruction.

75. Prevention and Treatment
of CONSTIPATION
 Lifestylemodifications: HIGH-FIBRE diet,
adequate fluid intake and exercise.
 Stool softeners, bulk-forming
laxatives and stimulants (can use in
combination)
 Lactulose, bisacodyl tablets, Ravin
enema.
AVOID combining constipating drugs
(BENZHEXOL)

76. Urinary Retention
Urinary hesitation or retention
Peripheral anticholinergic side effect
Can result in secondary overflow incontinence,
enuresis, an increased risk of urinary tract
infection or sepsis.

77. Management of Urinary Retention
 Urinary hesitancy / retention:
 Rule out UTI and structural defects
 Minimize dose of culprit drug(s)
 AVOID combining drugs with
anticholinergic activity
 Incontinence / euresis :
 Monitor fluid intake
 Void bladder before bed
 Limit diuretic use (caffeine, alcohol)

78. Confusion
Ranges from impaired concentration,
memory impairment, attention deficits
and confusion.
May worsen delirium.
AVOID use in the
ELDERLY.

79. Cardiovascular Side Effects
 Postural Hypotension
 Tachycardia
 Cardiac Arrhythmia

80. Postural Hypotension
“A systolic blood pressure decrease
of at least 20 mmHg or a diastolic
blood pressure decrease of at least
10 mmHg within three minutes of
standing.” *
Common : (α1-adrenergic
antagonism )
Chlorpromazine, clozapine, quetiapine
* American Academy of Neurology

81. Management of Postural Hypotension
 Tell the patient to RISE SLOWLY from a lying or
sitting position.
 Maintain adequate fluid intake
 Tilt the head of the bed at night.
 Divide or decrease the dose of the culprit
drug
 Use support stockings.

82. Tachycardia
Heart rate is over 100 bpm.
Dose-dependent
More common in MALE and younger
patients.

83. How to manage tachycardia ?
 Start LOW and go SLOW
 ß-blockers (propranolol 10-
80mg/day) may help

84. Cardia Arrythmia
 All antipsychotics can contribute to
prolongation of QT interval
 Dose-dependent
 Incidence of sudden cardiac death ~ 2x
HIGHER among patients taking AP
 Do baseline ECG and monitor regularly

85. OTHER SERIOUS BUT
RARE SIDE EFFECTS

86. CLOZAPINE and AGRANULOCYTOSIS

87. CLOZAPINE
• Age
• Female
• Asian
Agranulocytosis
~ 1%
Within 3 months of
starting treatment
Upon initiation, weekly WBC for the 1st
six months, 2-weekly for the next six
month and thereafter, monthly.
WBC < 3.50 ×
109per L
ANC < 1,500 cells per
mm3

88. CLOZAPINE and AGRANULOCYTOSIS
If ↓ing trend in TWBC, REFER
If TWBC <3.5 × 109per L, REFER
If heart rate ˃100 bpm, REFER

89. ALL MEDICINES HAVE
SIDE EFFECTS.
BUT NOT EVERYONE WILL SUFFER
FROM SIDE EFFECTS.
Thank You…