Psychiatry

Prescriber’s guide to Stahl’s essential psychopharmacology by Stephen M. Stahl

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By Stephen M. Stahl

This advisor is meant to counterpoint Stahl’s crucial Psychopharmacology. Stahl’s
Essential Psychopharmacology emphasizes mechanisms of motion and the way psychotropic
drugs paintings upon receptors and enzymes within the mind. This advisor offers practical
information on tips to use those medications in medical practice.
It will be very unlikely to incorporate all to be had information regarding any drug in a
single paintings, and no test is made the following to be finished. the aim of
this consultant is in its place to combine the artwork of scientific perform with the technological know-how of
psychopharmacology. that implies together with in simple terms crucial evidence as a way to keep
things brief. regrettably that still capacity aside from much less serious proof to boot as
extraneous details, that could however be valuable to the reader yet would
make the ebook too lengthy and dilute an important details. In deciding
what to incorporate and what to fail to remember, the writer has drawn upon logic and
30 years of medical event with sufferers. He has additionally consulted with many
experienced clinicians and analyzed the proof from managed medical trials
and regulatory filings with executive corporations.

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Psychopharmacol Bull 1998; 34:191–95. Jonas JM, Cohon MS. A comparison of the safety and efficacy of alprazolam versus other agents in the treatment of anxiety, panic, and depression: a review of the literature. J Clin Psychiatry 1993;54(Suppl):S25–45. van Marwijk H, Allick G, Wegman F, Bax A, Riphagen II. Alprazolam for depression. Cochrane Database Syst Rev 2012; 7:CD007139. 15 Amisulpride THERAPEUTICS Brands • Solian see index for additional brand names Generic? , antipsychotic action without a high incidence of extrapyramidal symptoms), especially at low doses, but not a serotonin dopamine antagonist • Mediates its atypical antipsychotic properties via novel actions on dopamine receptors, perhaps dopamine stabilizing partial agonist actions on dopamine 2 receptors • May be more of a dopamine 2 antagonist than aripiprazole, but less of a dopamine 2 antagonist than other atypical or conventional antipsychotics • Low dose activating actions may be beneficial for negative symptoms in schizophrenia • Very low doses may be useful in dysthymia • Compared to sulpiride, amisulpride has better oral bioavailability and more potency, thus allowing lower dosing, less weight gain, and fewer extrapyramidal symptoms • Compared to other atypical antipsychotics with potent serotonin 2A antagonism, amisulpride may have more extrapyramidal symptoms and prolactin elevation, but may still be classified as an atypical antipsychotic, particularly at low doses • Patients have very similar antipsychotic responses to any conventional antipsychotic, which is different from atypical antipsychotics where antipsychotic responses of individual patients can occasionally vary greatly from one atypical antipsychotic to another • Patients with inadequate responses to atypical antipsychotics may benefit from determination of plasma drug levels and, if low, a dosage increase even beyond the usual prescribing limits • Patients with inadequate responses to atypical antipsychotics may also benefit from a trial of augmentation with a 21 Amisulpride (continued) conventional antipsychotic or switching to a conventional antipsychotic • However, long-term polypharmacy with a combination of a conventional antipsychotic with an atypical antipsychotic may combine their side effects without clearly augmenting the efficacy of either • For treatment-resistant patients, especially those with impulsivity, aggression, violence, and selfharm, long-term polypharmacy with 2 atypical antipsychotics or with 1 atypical antipsychotic and 1 conventional antipsychotic may be useful or even necessary while closely monitoring • In such cases, it may be beneficial to combine 1 depot antipsychotic with 1 oral antipsychotic • Although a frequent practice by some prescribers, adding two conventional antipsychotics together has little rationale and may reduce tolerability without clearly enhancing efficacy The Art of Switching Switching from Oral Antipsychotics to Amisulpride • It is advisable to begin amisulpride at an intermediate dose and build the dose rapidly over 3–7 days • Clinical experience has shown that asenapine, quetiapine, and olanzapine should be tapered off slowly over a period of 3–4 weeks, to allow patients to readapt to the withdrawal of blocking cholinergic, histaminergic, and alpha-1 receptors • Clozapine should always be tapered off slowly, over a period of 4 weeks or more * Benzodiazepine or anticholinergic medication can be administered during cross-titration to help alleviate side effects such as insomnia, agitation, and/or psychosis dose Target dose amisulpride aripiprazole 1 week dose Target dose iloperidone lurasidone paliperidone ER risperidone ziprasidone * amisulpride 1 week dose Target dose * asenapine quetiapine olanzapine amisulpride 1 week dose Target dose 1 week 1 week * clozapine amisulpride 1 week 22 1 week 1 week 1 week 1 week 1 week (continued) Amisulpride Suggested Reading Burns T, Bale R.

The role of extended-release benzodiazepines in the treatment of anxiety: a risk-benefit evaluation with a focus on extended-release alprazolam. J Clin Psychiatry 2002;63(Suppl 14):S27–33. Greenblatt DJ, Wright CE. Clinical pharmacokinetics of alprazolam. Therapeutic implications. Clin Pharmacokinet 1993; 24:453–71. Speigel DA. Efficacy studies of alprazolam in panic disorder. Psychopharmacol Bull 1998; 34:191–95. Jonas JM, Cohon MS. A comparison of the safety and efficacy of alprazolam versus other agents in the treatment of anxiety, panic, and depression: a review of the literature.

J Clin Psychiatry 1993;54(Suppl):S25–45. van Marwijk H, Allick G, Wegman F, Bax A, Riphagen II. Alprazolam for depression. Cochrane Database Syst Rev 2012; 7:CD007139. 15 Amisulpride THERAPEUTICS Brands • Solian see index for additional brand names Generic? , antipsychotic action without a high incidence of extrapyramidal symptoms), especially at low doses, but not a serotonin dopamine antagonist • Mediates its atypical antipsychotic properties via novel actions on dopamine receptors, perhaps dopamine stabilizing partial agonist actions on dopamine 2 receptors • May be more of a dopamine 2 antagonist than aripiprazole, but less of a dopamine 2 antagonist than other atypical or conventional antipsychotics • Low dose activating actions may be beneficial for negative symptoms in schizophrenia • Very low doses may be useful in dysthymia • Compared to sulpiride, amisulpride has better oral bioavailability and more potency, thus allowing lower dosing, less weight gain, and fewer extrapyramidal symptoms • Compared to other atypical antipsychotics with potent serotonin 2A antagonism, amisulpride may have more extrapyramidal symptoms and prolactin elevation, but may still be classified as an atypical antipsychotic, particularly at low doses • Patients have very similar antipsychotic responses to any conventional antipsychotic, which is different from atypical antipsychotics where antipsychotic responses of individual patients can occasionally vary greatly from one atypical antipsychotic to another • Patients with inadequate responses to atypical antipsychotics may benefit from determination of plasma drug levels and, if low, a dosage increase even beyond the usual prescribing limits • Patients with inadequate responses to atypical antipsychotics may also benefit from a trial of augmentation with a 21 Amisulpride (continued) conventional antipsychotic or switching to a conventional antipsychotic • However, long-term polypharmacy with a combination of a conventional antipsychotic with an atypical antipsychotic may combine their side effects without clearly augmenting the efficacy of either • For treatment-resistant patients, especially those with impulsivity, aggression, violence, and selfharm, long-term polypharmacy with 2 atypical antipsychotics or with 1 atypical antipsychotic and 1 conventional antipsychotic may be useful or even necessary while closely monitoring • In such cases, it may be beneficial to combine 1 depot antipsychotic with 1 oral antipsychotic • Although a frequent practice by some prescribers, adding two conventional antipsychotics together has little rationale and may reduce tolerability without clearly enhancing efficacy The Art of Switching Switching from Oral Antipsychotics to Amisulpride • It is advisable to begin amisulpride at an intermediate dose and build the dose rapidly over 3–7 days • Clinical experience has shown that asenapine, quetiapine, and olanzapine should be tapered off slowly over a period of 3–4 weeks, to allow patients to readapt to the withdrawal of blocking cholinergic, histaminergic, and alpha-1 receptors • Clozapine should always be tapered off slowly, over a period of 4 weeks or more * Benzodiazepine or anticholinergic medication can be administered during cross-titration to help alleviate side effects such as insomnia, agitation, and/or psychosis dose Target dose amisulpride aripiprazole 1 week dose Target dose iloperidone lurasidone paliperidone ER risperidone ziprasidone * amisulpride 1 week dose Target dose * asenapine quetiapine olanzapine amisulpride 1 week dose Target dose 1 week 1 week * clozapine amisulpride 1 week 22 1 week 1 week 1 week 1 week 1 week (continued) Amisulpride Suggested Reading Burns T, Bale R.

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