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INTRODUCTION: OVERALL PRINCIPLES

The focus of this chapter is the review of the pharmacological treatment of neuropsychiatric syndromes including depression, anxiety, psychosis, agitation, apathy, and pathological laughing and crying. The chapter also includes a discussion of cognitive disorders from a syndrome or domain-based perspective, and their pharmacological treatment. The details of the pharmacological treatment of each specific neuropsychiatric disorder are presented in the chapters devoted to each disorder, in Section IV of this textbook.

Pharmacotherapy is one of many available interventions to help alleviate suffering in neuropsychiatric disorders. Medications can be an effective and important tool when used in a thoughtful, stepwise approach, addressing syndromes as varied as cognitive impairment, psychosis, aggression, sleep, depression, and aberrant behavior, among others. It is usually the combination of pharmacotherapy and other interventions, such as environmental modification, cognitive rehabilitation, neurostimulation, and forms of behavioral therapy, that is more effective than any singular approach.1–4 Because of the complex overlap between many neuropsychiatric syndromes, a prudent strategy is to conduct a careful clinical evaluation before treatment, to identify the presenting symptoms and syndromes to be targeted with drug regimens, and to consistently monitor their effect once treatment is initiated. The pharmacological intervention may target aberrations in a neurotransmitter system that is involved in the pathogenesis of several presenting disturbances. For example, a patient with anxiety, sleep disruption, and attention deficits, may respond to just one medication targeting anxiety, rather than necessarily one medication for each problem. This makes sense from a clinical and empirical standpoint in other disorders as well: A medication initiated for depression can have significant benefits for attention difficulties tied to the depression.

With neuropsychiatric pharmacotherapy, one is often navigating through clinical scenarios without the guidance of a robust evidence basis for any unique case. It is thus essential to prescribe medications in a stepwise manner, adding or discontinuing medications one at a time, titrating slowly, and carefully monitoring for efficacy and side effects. It is also helpful to use patient or caregiver feedback, including rating scales, as benchmark for treatment responses and to consistently track, challenge, or corroborate one’s clinical impression. In neuropsychiatry, establishing a strong, therapeutic alliance and durable trust with neuropsychiatric patients and families leads to better outcomes, and is critical given that the wide variability of treatment responses necessitates frequent follow-ups and interactions.5,6

PSYCHOPHARMACOLOGY OF COGNITIVE DISORDERS: A DOMAIN-BASED APPROACH

An effective way to plan cognitive pharmacotherapy is to first determine what specific functional “domains” (e.g., arousal, attention, executive function, memory) are affected or seem most affected. This domain-based approach allows providers to most effectively and parsimoniously target overlapping symptoms. Many pharmacotherapy solutions are “off label” of typical neurologic or psychiatric indications. Combining a detailed clinical interview with a thorough review of neurocognitive or neuropsychological test results is very valuable, as affected domains can be challenging to identify or dissociate from each other.

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