Antipsychotics and their Side Effects is authored by Professor David M. Gardner, Department of Psychiatry and College of Pharmacy, and Associate Professor Michael D. Teehan, Department of Psychiatry, Dalhousie University, Halifax, Canada. The authors are highly experienced clinicians with strong academic interests that include expert knowledge of antipsychotic drugs.
Their book is divided into three sections:
- 20 chapters with references and tables on adverse effects of antipsychotic drugs (including hematological, anticholinergic, metabolic, neurological, ophthalmological, cardiovascular, dermatological, sexual, and urinary effects, and changes in vital signs), emphasizing the adverse effects in relation to specific drugs, with tabulated recommendations about monitoring;
- tabulated specific recommendations and guidelines for monitoring individual drugs (aripiprazole, chlorpromazine, clozapine, flupenthixol, fluphenazine, haloperidol, loxapine, methotrimeprazine, molindone, olanzapine, paliperidone, pericyazine, perphenazine, pimozide, pipotiazine palmitate, quetiapine, risperidone, thioridazine, thiothixene, trifluoperazine, ziprasidone, and zuclopenthixol); and
- guidelines for eliciting information from patients, including the use of novel assessment forms to monitor for adverse effects during treatment with antipsychotic drugs, with the implicit aims of limiting risk of adverse effects and facilitating timely clinical interventions. The material compiled is solidly grounded on findings from the research literature.
A major motivation for writing this book is the authors’ stated impression that the second-generation antipsychotic drugs have brought limited clinical advances in efficacy for the treatment of psychotic, manic, and other disorders over the first-generation neuroleptics that have entered clinical psychiatry since the early 1950s, although with dissimilar patterns of adverse effects. The newer antipsychotics brought variable reductions in risk of some adverse neurological effects but their own set of complexmetabolic and other risks. In turn, Drs. Gardner and Teehan call for dealing with this complexity by particularly active and thoughtful monitoring for a broad spectrum of adverse effects that are addressed systematically in this book. Their approach is particularly timely, as contemporary clinical psychiatry – no doubt encouraged by the substantial, if partial, success of pharmacological treatments for many disorders – appears to be tending increasingly to devalue traditional clinical skills, with the risk of more brief, superficial, and technical approaches to clinical therapeutics. Interactions with patients sometimes seem surprisingly impersonal and far from psychiatry’s tradition of centering the patient–clinician interaction on the views and experiences of individual patients. This book should contribute to limiting such trends.
The modern era of clinical psychopharmacology can be dated from the introduction of lithium carbonate for mania and then for long-term prophylaxis in manicdepressive (bipolar) disorder in the late 1940s, and of chlorpromazine for the treatment of mania and acute psychosis, and later for chronic psychotic disorders including schizophrenia in the early 1950s. These largely serendipitous advances initiated major, even revolutionary, changes in psychiatric diagnostics as well as therapeutics. However, the story of modern antipsychotic drugs only in part is about scientific innovation and rational application of principles arising from basic neuroscience, neuropharmacology, medicinal chemistry, and rational therapeutic experimentation. In addition, it is characterized by powerful sociological trends. These include a degree of wishful overvaluing of the new treatments, and of disinclination to face squarely the limitations and considerable clinical problems associated with this class of palliative drugs. Even such terms as “side effect” and “atypical” with respect to antipsychotic drugs are problematic, and euphemistically suggest occasional minor costs to be balanced against consistent major clinical benefits.
In reality, the benefits of antipsychotic drug treatments often are modest, at least in chronic psychotic disorders including schizophrenia, delusional disorders, schizoaffective conditions, and in the dementias. Even theirmore striking benefits inmania and acute psychotic syndromes typically require weeks or even months for full symptomatic remission, and they often fail to provide substantial benefit for cognitive and functional status at any time. In turn, this is a story of business and marketing in a multibillion dollar per year industry. Importantly, all of these developments have had an important impact on the shaping of modern psychiatric practice, with growing emphasis on standardization and purported “efficiency,” largely driven by a desire to limit clinician time and costs. In amore salutary direction, the book further implies that the range and complexity of adverse clinical effects of antipsychotic and other psychotropic agents encourage renewed interest in general medicine among psychiatric clinicians.
It is to be hoped that choices of drugs, doses, timing, and duration of treatment would arise primarily fromthe clinically interpreted outcomes of randomized, controlled, and well-designed and managed clinical trials. However, for now, such evidence with respect to the antipsychotic drugs is very limited. With the probable and still-unexplained exception of clozapine (an older drug, first patented in 1960),most older and newer antipsychotic drugs are indistinguishable from one another with respect to efficacy in short-termcontrolled trials, or in long-term clinical effectiveness. All antipsychotics currently employed clinically or commercially have passed regulatory requirements of showing evidence of some degree of efficacy or statistical superiority to a placebo or no active treatment. Sometimes, the benefits are only a few percentage points above outcomes associated with a placebo: statistically “significant,” but often of marginal clinical superiority, particularly in the continued or even new treatment of chronic psychotic disorders including schizophrenia. It remains extremely challenging to rank specific drugs by their likelihood or degree of clinical benefits. Although older and newer antipsychotics are remarkably similar in efficacy, the newer and far more expensive agents have been marketed aggressively and very successfully. Most of them do have substantially or even markedly reduced risks of certain adverse neurological effects, particularly acute dystonias, parkinsonism, and perhaps tardive dyskinesia, with continued risk of akathisia, but less or altered presentations of neuroleptic malignant syndrome as delirium and unstable vital signs, but far less muscle rigidity than with most first-generation neuroleptics.
In addition, the substantial but limited efficacy of most psychotropic drugs, coupled with powerful but often exaggerated iatrogenic expectations supporting their use, has encouraged increasingly complex and largely non-rational, or at least untested and unproved, applications of combinations and higher doses of drugs, including the antipsychotics. In turn, these trends can increase risks of sometimes unpredicted drug interactions and of adverse effects, even when individual drugs are prescribed at moderate doses.
An important theme of this book is that the important but partial benefits of the antipsychotic drugs as a class need to be balanced against their considerable risk of adverse metabolic, neurological, and other unwanted general medical effects [5,6]. It is particularly ironic that some of the most effective antipsychotic agents, such as clozapine and olanzapine, are complicated by a range of potentially severe or even life-threatening adverse medical effects. In the absence of clear, evidencebased differences in efficacy of most antipsychotics, such adverse-effect risks can usefully guide selection of drugs and doses for individual patients, with the aim of limiting risks. These risks range from the clinically incidental to severely uncomfortable, sometimes disabling, and occasionally lethal effects. The search continues for a scientific basis of rational psychiatric therapeutics based on research evidence of differences in efficacy among specific drugs, as a component of “evidence-based medicine.” Progress to that aim would be greatly facilitated by head-to-head, direct, randomized comparisons of different agents or doses to test comparative efficacy directly. However, for now, individualized assessments of the impact of adverse effects, and the large variance in acquisition costs of individual drugs, arguably, are more significant factors in drug selection than differences in efficacy.
In short, the often minor or subtle differences in clinical benefits among specific antipsychotics make adequate understanding of the nature, recognition, and avoidance or amelioration of their adverse effects all the more important. Selection of drugs and doses that are well tolerated by individual patients is highly dependent on an informed clinician, alert to emerging signs and symptoms and, perhaps most important, of subjective distress that requires some effort and attention to elicit from each patient. These downsides of the clinical use of this important class of psychotropic drug are addressed comprehensively, thoughtfully, and critically by this book. In short, it is a valuable and timely teaching and reference work.
- Ross J. Baldessarini, MD -
Contents
- Foreword page
- Preface
- Acknowledgements
- Purpose, development, and limitations of Antipsychotics and their Side Effects
- Guide to using Antipsychotics and their Side Effects
- Lists of appendices, figures, tables, and monitoring schedules
- About the authors
- About the cover art
Section 1: Antipsychotic side effects and monitoring implications
- 1.1 Introduction
- 1.2 Agranulocytosis and other blood dyscrasias
- 1.3 Anticholinergic effects
- 1.4 Diabetes mellitus
- 1.5 Dyslipidemia
- 1.6 Extrapyramidal symptoms
- 1.7 Hepatic effects
- 1.8 Neuroleptic malignant syndrome
- 1.9 Obesity and weight gain
- 1.10 Ocular effects
- 1.11 Prolactin effects
- 1.12 QTc prolongation, arrhythmias, and sudden cardiac death
- 1.13 Sedation and sleep disturbances
- 1.14 Seizures
- 1.15 Sexual dysfunction
- 1.16 Sialorrhea
- 1.17 Skin and hypersensitivity reactions
- 1.18 Tardive dyskinesia and other late-onset movement disorders
- 1.19 Urinary incontinence
- 1.20 Venous thromboembolism
- 1.21 Vital signs
Section 2: Summary of monitoring recommendations for individual antipsychotics
- 2.1 Aripiprazole
- 2.2 Chlorpromazine
- 2.3 Clozapine
- 2.4 Flupenthixol
- 2.5 Fluphenazine
- 2.6 Haloperidol
- 2.7 Loxapine
- 2.8 Methotrimeprazine
- 2.9 Molindone
- 2.10 Olanzapine
- 2.11 Paliperidone
- 2.12 Pericyazine
- 2.13 Perphenazine
- 2.14 Pimozide
- 2.15 Pipotiazine palmitate
- 2.16 Quetiapine
- 2.17 Risperidone
- 2.18 Thioridazine
- 2.19 Thiothixene
- 2.20 Trifluoperazine
- 2.21 Ziprasidone
- 2.22 Zuclopenthixol
Section 3: General monitoring form for patients taking antipsychotics
- 3.1 Overview of the General Antipsychotic Monitoring Form
- 3.2 Frequently asked questions
- 3.3 Guide for using the General Antipsychotic Monitoring Form
Index
Book Details
- Paperback: 228 pages
- Publisher: Cambridge University Press; 1 edition (December 13, 2010)
- Language: English
- ISBN-10: 0521132088
- ISBN-13: 978-0521132084
- Product Dimensions: 9.6 x 7.4 x 0.6 inches
List Price: $59.00