Most psychiatric disorders remain without well-established biological substrates; however, standardized diagnostic nosology has gained acceptance, primarily in the form of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-4). As with other areas of medicine, there is no substitute for a careful diagnostic evaluation using externally validated diagnostic criteria. Whenever possible, the diagnostic evaluation should draw on a comprehensive database that includes family members, previous or concurrent providers, and other sources of information, and the evaluation should focus more on longitudinal data than just acute presentation.
PHARMACOKINETICS & PHARMACODYNAMICS
An understanding of the basic pharmacokinetics and pharmacodynamics of psychotropic drugs is required for their safe and effective utilization. With the exception of lithium (which is an element), most psychotropic drugs are lipophilic polycyclic amines. These drugs interact with neurotransmitter-binding sites, which confer their psychotropic effects. For example, most antidepressants act by allosteric binding to catecholamine- or indolamine-uptake binding sites (or with the monoaminergic catalytic enzyme monoamine oxidase), which enhances the synaptic availability of monoamines such as norepinephrine and serotonin. These effects can produce direct antidepressant actions but also may produce side effects such as nausea or nervousness. These drugs also interact with muscarinic cholinergic-binding sites, producing significant side effects such as dry mouth, blurred vision, and constipation, and with histamine-binding sites, producing drowsiness and weight gain. The relative profile of receptor binding affinities will allow the clinician to predict both the beneficial effects and side effects of specific drugs.
Most psychotropic drugs are fairly rapidly and completely absorbed from oral and intramuscular sites and, because of their relatively high lipid solubility, readily cross the blood–brain barrier. Intramuscular administration yields rapid absorption and distribution and bypasses first-pass hepatic metabolism. Therefore, plasma levels are achieved much more rapidly. Intramuscular delivery of antipsychotic drugs (e.g., haloperidol, olanzapine, ziprasidone) or antianxiety agents (e.g., lorazepam) is reserved primarily for the acute management of agitated and psychotic patients. An exception to this is the use of haloperidol or fluphenazine decanoate; both drugs are provided in oil suspension for long-term treatment of psychotic conditions. They require injection every 2–4 weeks and are given to patients who have problems with treatment compliance.
Most psychotropic drugs have high levels of protein (e.g., α1 glycoproteins) binding. Notable exceptions include lithium and venlafaxine. Therefore, drug interactions could occur at the level of protein binding, in which case these drugs will displace (and be displaced by) other drugs with significant binding. This can result in unexpected toxicities; therefore, clinicians should take a careful drug history whenever they plan to prescribe a new drug to a patient.
With the exception of lithium, all psychotropic drugs are metabolized, at least in part, via cytochrome enzymes. After one or more metabolic steps, water-soluble products (e.g., glucuronides) are formed and eliminated via the kidney. Certain psychopharmacologic agents may induce or inhibit metabolism by cytochrome P-450 (CYP) enzymes. For example, ...