Psych meds — SSRIs, mood stabilizers, antipsychotics

Pick by indication; know the deadly side effects (serotonin syndrome, NMS, lithium tox).

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◆SSRIs (fluoxetine, sertraline, escitalopram, citalopram, paroxetine)

•First-line: depression, anxiety (GAD, OCD, panic, PTSD, social), PMDD
•Side effects: sexual dysfunction, GI upset, weight neutral or modest gain (paroxetine = most weight gain)
•QT prolongation: citalopram (dose-dependent), escitalopram
•Withdrawal: especially paroxetine (short half-life) — taper
•Pregnancy: sertraline preferred; paroxetine TERATOGENIC (cardiac defects) — avoid
•Serotonin syndrome with MAOI/tramadol/linezolid/triptans: clonus, hyperthermia, autonomic instability, AMS

•SNRIs (venlafaxine, duloxetine): depression + neuropathic pain; HTN, sweating
•Bupropion: no sexual side effects, smoking cessation, ADHD adjunct; LOWERS SEIZURE THRESHOLD (avoid in seizure disorder, eating disorders)
•Mirtazapine: weight gain + sedation (good for elderly with depression + insomnia + low appetite)
•Trazodone: sleep (low-dose) > antidepressant; priapism
•TCAs (amitriptyline, nortriptyline): neuropathic pain, migraine prophylaxis; anticholinergic, orthostatic, CARDIAC TOXICITY in overdose (wide QRS — give bicarb)
•MAOIs (phenelzine, tranylcypromine): rarely used; hypertensive crisis with tyramine; serotonin syndrome with serotonergic drugs

•Lithium: bipolar mania prophylaxis; narrow therapeutic index (0.6–1.2); tremor, polyuria (nephrogenic DI), hypothyroidism, weight gain, EBSTEIN anomaly in pregnancy; toxicity at >1.5 → confusion, seizures, arrhythmia
•Valproate: bipolar, seizures; hepatotoxicity, pancreatitis, weight gain, thrombocytopenia, NEURAL TUBE DEFECTS, alopecia
•Lamotrigine: bipolar depression, seizures; STEVENS-JOHNSON syndrome (titrate slowly)
•Carbamazepine: seizures, trigeminal neuralgia; SJS, agranulocytosis, SIADH, neural tube defects

•Typical (haloperidol, fluphenazine, chlorpromazine): D2 blockade; high EPS, tardive dyskinesia, hyperprolactinemia
•Atypical (risperidone, quetiapine, olanzapine, aripiprazole, ziprasidone, clozapine): lower EPS; METABOLIC syndrome (weight, DM, lipids — esp olanzapine)
•Clozapine: refractory schizophrenia ONLY; AGRANULOCYTOSIS (weekly ANC × 6 mo), myocarditis, seizures, sialorrhea, ileus; lowest EPS, best for negative symptoms
•Quetiapine: sleep-friendly, low EPS; orthostasis
•Aripiprazole: partial agonist; activating
•Neuroleptic Malignant Syndrome (NMS): rigidity, hyperthermia, AMS, autonomic instability; days to weeks after start; stop drug, supportive, dantrolene/bromocriptine

•Benzos (lorazepam, clonazepam): rapid anxiety relief, alcohol withdrawal, seizures; ADDICTIVE, fall risk in elderly; reverse with flumazenil (rarely used — seizure risk)
•Buspirone: GAD; non-addictive; takes 2–4 weeks
•Z-drugs (zolpidem): sleep; sleep-driving/eating; tolerance

Syndrome	Features / antidote
Serotonin syndrome	Clonus, hyperthermia, hyperreflexia; stop drug, cyproheptadine
Neuroleptic Malignant Syndrome	Rigidity, hyperthermia, AMS; stop drug, dantrolene/bromocriptine
Lithium toxicity	Tremor, AMS, seizures; hydration, dialysis if severe
TCA overdose	Wide QRS, hypotension, seizures; IV bicarb
Tyramine + MAOI	Hypertensive crisis; phentolamine

◆Pregnancy + bipolar → lamotrigine or low-dose lithium (avoid valproate, carbamazepine; avoid lithium 1st trimester if possible)
◆SSRI in pregnancy → sertraline preferred; AVOID paroxetine
◆Wellbutrin (bupropion) → AVOID in eating disorders + seizure disorders
◆Clozapine starts → weekly CBC × 6 mo, then biweekly × 6, then monthly
◆Lithium + NSAID/ACE-I/thiazide → ↑ lithium level (toxicity)

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