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This pragmatic, full-color guide for prescribers gives essential information for over 100 psychotropic drugs in five categories: general therapeutics, dosing and use, side effects, special populations, and pearls. Key elements have target icons for easy location. Indices give generic and proprietary drug names, and generic drugs by use and class.
32 Avenue of the Americas, New York, NY 10013-2473, USA
Cambridge University Press is part of the University of Cambridge.
It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning, and research at the highest international levels of excellence.
Stephen M. Stahl 2005, 2006, 2009, 2011, 2014
This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.
First published 2005
Revised and updated edition published 2006
Third edition published 2009
Fourth edition published 2011
Fifth edition published 2014
Printed in the United States of America
A catalog record for this publication is available from the British Library.
Library of Congress Cataloging in Publication Data
Stahl, Stephen M., 1951– author.
Stahl’s essential psychopharmacology : the prescriber’s guide / Stephen M. Stahl ; editorial assistant, Meghan M. Grady ; with illustrations by Nancy Muntner. – Fifth edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-107-67502-5 (pbk. : alk paper)
I. Title. II. Title: Essential psychopharmacology. III. Title: Prescriber’s guide.
[DNLM: 1. Psychotropic Drugs – pharmacology – Handbooks. 2. Drug Prescriptions – Handbooks. QV 39]
ISBN 978-1-107-67502-5 Paperback
Additional resources for this publication at www.stahlonline.org
Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.
The figures and illustrations in Stahl's Essential Psychopharmacology online are the copyright of the author. They may be downloaded for the sole purpose of research and study, including classroom instruction, on the condition that they are not used for any commercial purpose and the author is appropriately acknowledged. Separate permission and licensing fees may be required for commercial reuse. For more information please visit http://www.cambridge.org/about-us/rights-permissions/permissions/permissions-requests
Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party Internet Web sites referred to in this publication and does not guarantee that any content on such Web sites is, or will remain, accurate or appropriate.
(trade names and generic names)
Commonly Prescribed For (bold for FDA approved)
This Guide is intended to complement Stahl’s Essential Psychopharmacology. Stahl’s Essential Psychopharmacology emphasizes mechanisms of action and how psychotropic drugs work upon receptors and enzymes in the brain. This guide gives practical information on how to use these drugs in clinical practice.
It would be impossible to include all available information about any drug in a single work, and no attempt is made here to be comprehensive. The purpose of this guide is instead to integrate the art of clinical practice with the science of psychopharmacology. That means including only essential facts in order to keep things short. Unfortunately that also means excluding less critical facts as well as extraneous information, which may nevertheless be useful to the reader but would make the book too long and dilute the most important information. In deciding what to include and what to omit, the author has drawn upon common sense and 30 years of clinical experience with patients. He has also consulted with many experienced clinicians and analyzed the evidence from controlled clinical trials and regulatory filings with government agencies.
In order to meet the needs of the clinician and to facilitate future updates of this Guide, the opinions of readers are sincerely solicited. Feedback can be emailed to firstname.lastname@example.org. Specifically, are the best and most essential psychotropic drugs included here? Do you find any factual errors? Are there agreements or disagreements with any of the opinions expressed here? Are there suggestions for any additional tips or pearls for future editions? Any and all suggestions and comments are welcomed.
All of the selected drugs are presented in the same design format in order to facilitate rapid access to information. Specifically, each drug is broken down into five sections, each designated by a unique color background: therapeutics, side effects, dosing and use, special populations, and the art of psychopharmacology, followed by key references.
Therapeutics covers the brand names in major countries; the class of drug; what it is commonly prescribed and approved for by the United States Food and Drug Administration (FDA); how the drug works; how long it takes to work; what to do if it works or if it doesn’t work; the best augmenting combinations for partial response or treatment resistance; and the tests (if any) that are required.
Side effects explains how the drug causes side effects; gives a list of notable, life-threatening, or dangerous side effects; gives a specific rating for weight gain or sedation; and gives advice about how to handle side effects, including best augmenting agents for side effects.
Dosing and use gives the usual dosing range; dosage forms; how to dose and dosing tips; symptoms of overdose; long-term use; if habit forming, how to stop; pharmacokinetics; drug interactions; when not to use; and other warnings or precautions.
Special populations gives specific information about any possible renal, hepatic, and cardiac impairments, and any precautions to be taken for treating the elderly, children, adolescents, and pregnant and breast-feeding women.
The art of psychopharmacology gives the author’s opinions on issues such as the potential advantages and disadvantages of any one drug, the primary target symptoms, and clinical pearls to get the best out of a drug.
In addition, drugs for which switching between medications can be complicated have a special section called The Art of Switching, which includes clinical pearls and graphical representations to help guide the switching process.
At the back of the guide are several indices. The first is an index by drug name, giving both generic names (uncapitalized) and trade names (capitalized and followed by the generic name in parentheses). The second is an index of common uses for the generic drugs included in the guide and is organized by disorder/symptom. Agents that are approved by the FDA for a particular use are shown in bold. The third index is organized by drug class and lists all the agents that fall within each particular class. In addition to these indices there is a list of abbreviations; FDA definitions for the Pregnancy Categories A, B, C, D, and X; and, finally, an index of the icons used in the guide.
Readers are encouraged to consult standard references1 and comprehensive psychiatry and pharmacology textbooks for more in-depth information. They are also reminded that the art of psychopharmacology section is the author’s opinion.
It is strongly advised that readers familiarize themselves with the standard use of these drugs before attempting any of the more exotic uses discussed, such as unusual drug combinations and doses. Reading about both drugs before augmenting one with the other is also strongly recommended. Today’s psychopharmacologist should also regularly track blood pressure, weight, and body mass index for most of his or her patients. The dutiful clinician will also check out the drug interactions of non–central-nervous-system (CNS) drugs with those that act in the CNS, including any prescribed by other clinicians.
Certain drugs may be for experts only and might include clozapine, thioridazine, pimozide, nefazodone, mesoridazine, and MAO inhibitors, among others. Off-label uses not approved by the FDA and inadequately studied doses or combinations of drugs may also be for the expert only, who can weigh risks and benefits in the presence of sometimes vague and conflicting evidence. Pregnant or nursing women, or people with two or more psychiatric illnesses, substance abuse, and/or a concomitant medical illness may be suitable patients for the expert only. Controlled substances also require expertise. Use your best judgment as to your level of expertise and realize that we are all learning in this rapidly advancing field. The practice of medicine is often not so much a science as it is an art. It is important to stay within the standards of medical care for the field, and also within your personal comfort zone, while trying to help extremely ill and often difficult patients with medicines that can sometimes transform their lives and relieve their suffering.
Finally, this book is intended to be genuinely helpful for practitioners of psychopharmacology by providing them with the mixture of facts and opinions selected by the author. Ultimately, prescribing choices are the reader’s responsibility. Every effort has been made in preparing this book to provide accurate and up-to-date information in accord with accepted standards and practice at the time of publication. Nevertheless, the psychopharmacology field is evolving rapidly and the author and publisher make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. Furthermore, the author and publisher disclaim any responsibility for the continued currency of this information and disclaim all liability for any and all damages, including direct or consequential damages, resulting from the use of information contained in this book. Doctors recommending and patients using these drugs are strongly advised to pay careful attention to, and consult information provided by, the manufacturer.
1 For example, Physician's Desk Reference and Martindale: The Complete Drug Reference.
|alcohol dependence treatment||alpha adrenergic blocker|
|alpha 2 agonist||anticonvulsant|
|cholinesterase inhibitor||conventional antipsychotic|
|monoamine oxidase inhibitor||nefazodone (serotonin antagonist/reuptake inhibitor)|
|nicotinic partial agonist||N-methyl-D-aspartate antagonist|
|noradrenergic and specific serotonergic antidepressant||norepinephrine and dopamine reuptake inhibitor|
|sedative-hypnotic||selective norepinephrine reuptake inhibitor|
|selective serotonin reuptake inhibitor||serotonin-dopamine antagonist|
|serotonin and norepinephrine reuptake inhibitor||serotonin 1A partial agonist|
|serotonin partial agonist reuptake inhibitor||sodium oxybate|
|topiramate/phentermine||trazodone (serotonin antagonist/reuptake inhibitor)|
|How the drug works, mechanism of action||Best augmenting agents to add for partial response or treatment-resistance|
|Life-threatening or dangerous side effects||Weight Gain: Degrees of weight gain associated with the drug, with unusual signifying that weight gain has been reported but is not expected; not unusual signifying that weight gain occurs in a significant minority; common signifying that many experience weight gain and/or it can be significant in amount; and problematic signifying that weight gain occurs frequently, can be significant in amount, and may be a health problem in some patients|
|Drug interactions that may occur|
|Warnings and precautions regarding use of the drug|
|Dosing and other information specific to children and adolescents|
|Tips for dosing based on the clinical expertise of the author||Sedation: Degrees of sedation associated with the drug, with unusual signifying that sedation has been reported but is not expected; not unusual signifying that sedation occurs in a significant minority; common signifying that many experience sedation and/or it can be significant in amount; and problematic signifying that sedation occurs frequently, can be significant in amount, and may be a health problem in some patients|
|Information regarding use of the drug during pregnancy|
|Clinical pearls of information based on the clinical expertise of the author|
|The art of switching|
|AChE||acetylcholinesterase||ADHD||attention deficit hyperactivity disorder|
|ALPT||total serum alkaline phosphatase||ALT||alanine aminotransferase|
|AMPA||alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid||AST||aspartate aminotransferase|
|bid||twice a day||BMI||body mass index|
|BuChE||butyrylcholinesterase||BUN||blood urea nitrogen|
|CBC||complete blood count||CSF||cerebrospinal fluid|
|CMI||clomipramine||CNS||central nervous system|
|COPD||chronic obstructive pulmonary disease||CPAP||continuous positive airway pressure|
|DLB||dementia with Lewy bodies||ECG||electrocardiogram|
|EPS||extrapyramidal side effects||ERT||estrogen replacement therapy|
|FDA||Food and Drug Administration||FSH||follicle-stimulating hormone|
|GABA||gamma aminobutyric acid||GAD||generalized anxiety disorder|
|HMG CoA||beta-hydroxy-beta-methylglutaryl coenzyme A||HRT||hormone replacement therapy|
|LDL||low-density lipoprotein||LFT||liver function tests|
|LH||luteinizing hormone||MAO||monoamine oxidase|
|MAOI||monoamine oxidase inhibitor||mCPP||meta-chloro-phenyl-piperazine|
|MDD||major depressive disorder||MDMA||3,4-methylenedioxymethamphetamine (ecstasy)|
|mm Hg||millimeters of mercury||NE||norepinephrine|
|OSAHS||obstructive sleep apnea/hypopnea syndrome||PBA||pseudobulbar affect|
|PCP||phencyclidine||PET||positron emission tomography|
|PK||pharmacokinetic||PMDD||premenstrual dysphoric disorder|
|PMS||premenstrual syndrome||prn||as needed|
|PTSD||posttraumatic stress disorder||qd||once a day|
|qhs||once a day at bedtime||qid||4 times a day|
|RBC||red blood cell||RIMA||reversible inhibitor of monoamine oxidase A|
|SDA||serotonin-dopamine antagonist||SGPT||serum glutamic pyruvic transaminase (ALT)|
|SGRI||selective GABA reuptake inhibitor||SNRI||dual serotonin and norepinephrine reuptake inhibitor|
|SSRI||selective serotonin reuptake inhibitor||TCA||tricyclic antidepressant|
|tid||3 times a day||TSH||thyroid-stimulating hormone|
|VM A||vanillylmandelic acid|
|Category A:||Controlled studies show no risk: adequate, well-controlled studies in pregnant women have failed to demonstrate risk to the fetus|
|Category B:||No evidence of risk in humans: either animal findings show risk, but human findings do not; or, if no adequate human studies have been performed, animal findings are negative|
|Category C:||Risk cannot be ruled out: human studies are lacking, and animal studies are either positive for fetal risk or lacking as well. However, potential benefits may outweigh risks|
|Category D:||Positive evidence of risk: investigational or postmarketing data show risk to the fetus. Nevertheless, potential benefits may outweigh risks|
|Category X:||Contraindicated in pregnancy: studies in animals or humans, or investigational or postmarketing reports, have shown fetal risk that clearly outweighs any possible benefit to the patient|
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