C H A P T E R 2 2
Psychotherapeutic agents
347
■■
Lithium, a membrane stabiliser, is the standard
antimanic drug. Because it is a very toxic salt, serum
levels must be carefully monitored to prevent severe
toxicity.
■■
Many other CNS drugs, including many of the
atypical antipsychotics, are now approved for use
in bipolar disorder. Many people respond to a
combination of these drugs to control their bipolar
signs and symptoms.
CENTRAL NERVOUS SYSTEM STIMULANTS
CNS stimulants are used clinically to treat both atten-
tion deficit disorders and narcolepsy. Paradoxically,
these drugs calm hyperkinetic children and help them
to focus on one activity for a longer period. They also
redirect and excite the arousal stimuli from the RAS
(Figure 22.2; see also Figure 22.1). The CNS stimulants
KEY POINTS
that are used to treat attention-deficit disorder and nar-
colepsy include methylphenidate (
Ritalin
,
Concerta
and
others); dexamphetamine (generic); modafinil (
Modav-
igil
), which is not associated with many of the systemic
stimulatory effects of some of the other CNS stimulants;
as well as the newer drug—atomoxetine (
Strattera
)
which is a selective noradrenaline reuptake inhibitor
with anticholinergic effects but without the CV and
stimulatory effects, making it preferable in people who
cannot tolerate the systemic stimulatory effects (see
Table 22.3).
■
■
Monitor for adverse effects (CV toxicity, renal
toxicity, GI upset, respiratory complications).
■
■
Evaluate effectiveness of the teaching plan (person
can give the drug name and dosage and describe
the possible adverse effects to watch for, specific
measures to help avoid adverse effects, warning
signs to report and the need to avoid pregnancy).
■
■
Monitor effectiveness of comfort measures and
compliance with the regimen.
Cortex
Diffuse
thalamo-
cortical
projections
Thalamus
Brainstem
reticular
formation
(RAS)
Ascending
projectional
system
CNS
stimulants
work here
FIGURE 22.2
Site of action of the central nervous system (CNS)
stimulants in the reticular activating system (RAS).
TABLE 22.3
DRUGS IN FOCUS Central nervous systems stimulants
Drug name
Dosage/route
Usual indications
atomoxetine (Strattera)
Adults and children >70 kg: 40 mg/day PO,
slowly increase to a target daily dose of
80 mg
Children ≤70 kg: 0.5 mg/kg per day, increase to
a target daily dose of 1.2 mg/kg per day
Hepatic impairment: decrease dose by 50%
Treatment of attention-deficit/hyperactivity
disorders as part of a total treatment
program
dexamphetamine (generic)
Narcolepsy: 5–60 mg/day PO in divided doses
Attention-deficit disorders: 2.5–5 mg/day PO
taken in the morning
Treatment of narcolepsy, attention-deficit
disorders, behavioural syndromes
methylphenidate
(Ritalin, Concerta
and others)
Adult: 10–60 mg/day PO in divided doses,
depending on preparation
Paediatric: 5 mg PO b.d.; increase gradually,
do not exceed 60 mg/day
Treatment of attention-deficit disorders
and other behavioural syndromes
associated with hyperactivity, as well as
narcolepsy; currently available in various
forms allowing for dosing one, two or
three times a day
modafinil (Modavigil)
200 mg/day PO as a single dose; reduce dose
with hepatic impairment and in the elderly
Treatment of narcolepsy in adults, for
improving wakefulness in various sleep
disorders and for improving wakefulness
in people with obstructive sleep apnoea/
hypopnoea syndrome
