4.4.5 Prescribing in special circumstances

Prescribing in Special Circumstances

Special circumstance:	Noteworthy prescribing:
Children and adolescents	Psychiatric medications for children and adolescents must be prescribed carefully after thorough evaluation and close monitoring, taking into consideration potential benefits and risks, and involving the child, their parents, and relevant professionals in the decision-making process.
The elderly	In the elderly population, the use of psychiatric medications requires caution, considering their physiological and psychological changes, potential drug interactions, and the risk for side effects, and weighing the benefits and risks of treatment against individual needs and goals.
Eating disorders	Prescribing psychiatric medications for eating disorders must be done carefully and individually, considering the person’s symptoms, overall health, and involvement of support and healthcare professionals.
Physical co-morbidities: hepatic failure/renal failure/cardiovascular disease	Prescribing psychiatric medications in individuals with physical co-morbidities such as hepatic failure, renal failure, and cardiovascular disease requires a cautious and individualized approach, taking into consideration the potential impact of the medication on the person’s underlying physical health and potential drug interactions.
Pregnancy	When it comes to psychiatric medications and pregnancy, it is important to weigh the potential risks and benefits and make informed decisions with the guidance of a mental health professional, as some medications may have harmful effects on the developing fetus while others may be necessary for maternal well-being.

(Semple, 2019)

Children and adolescents:

In children and adolescents, the use of psychiatric medications can be challenging and requires careful consideration. The decision to prescribe psychiatric medication to a child or adolescent should be based on a thorough evaluation of their symptoms and underlying conditions, a consideration of the potential benefits and risks, and the use of non-pharmacological interventions when appropriate.

It’s important to note that children and adolescents may respond differently to psychiatric medications compared to adults, and the side effects of the medication may also be different. For this reason, it’s crucial to closely monitor the child or adolescent’s response to the medication and adjust the treatment plan as necessary.

It’s also essential to involve the child or adolescent, their parents or caregivers, and any other relevant professionals in the decision-making process and to provide ongoing support and education about the medication and its effects.

The elderly:

In the elderly population, there are several factors to consider when prescribing psychiatric medications. The ageing process can lead to changes in the way the body metabolizes medications, making them more potent and increasing the risk of adverse effects. This population may also be taking multiple medications, so it’s important to evaluate potential drug interactions and make appropriate adjustments to treatment.

Additionally, the elderly may be more susceptible to cognitive decline and other age-related changes that could affect their ability to tolerate and respond to psychiatric medications. For example, some antipsychotics can cause confusion, dizziness, and an increased risk of falls in older adults.

Finally, it’s important to assess the benefits and risks of psychiatric medication in this population, taking into account their individual needs and goals of treatment. In some cases, non-pharmacological interventions, such as psychotherapy or behavioural therapy, maybe a more appropriate treatment option for older adults. The use of psychiatric medications in the elderly population must be approached with caution, taking into account their unique needs and considering the potential benefits and risks of treatment.

Eating disorders:

Eating disorders, such as anorexia nervosa and bulimia nervosa, are complex conditions that affect a person’s physical, emotional, and mental well-being. The decision to use psychiatric medications in the treatment of eating disorders should be based on a comprehensive assessment of the person’s symptoms and overall health status.

In some cases, medication may be used to address specific symptoms associated with the eating disorder, such as depression or anxiety. Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), can be effective in treating these symptoms, but they may also have an impact on the person’s weight and eating patterns. It’s important to closely monitor the person’s response to the medication and adjust the treatment plan as necessary.

In severe cases of anorexia nervosa, weight restoration may be necessary for the person’s overall health and well-being, and medication may be used to help address associated symptoms and support weight restoration.

Physical co-morbidities: hepatic failure/renal failure/cardiovascular disease:

In individuals with hepatic failure, the metabolism and elimination of many psychiatric medications can be impaired, increasing the risk of toxicity and adverse effects. Additionally, some psychiatric medications can be liver toxic and cause additional damage to the liver. Therefore, it’s important to evaluate each medication carefully and adjust the dose or switch to a different medication if necessary.

Examples of psychiatric medications that can be affected by hepatic failure and may need to be adjusted or avoided include:

• Benzodiazepines: These medications are metabolized in the liver and can accumulate in the body, increasing the risk of toxicity, especially in individuals with liver impairment.
• Antipsychotics: Some antipsychotics, such as chlorpromazine, are metabolized in the liver and can cause liver toxicity in individuals with liver impairment.
• Antidepressants: Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) can cause additional liver damage and should be used with caution in individuals with liver impairment.
• Mood stabilizers: Some mood stabilizers, such as valproic acid, can cause liver damage and should be used with caution in individuals with liver impairment.

In individuals with renal failure, the elimination of many psychiatric medications can be impaired, increasing the risk of toxicity and adverse effects. Additionally, some psychiatric medications can be eliminated by the kidneys and can accumulate in the body, leading to toxicity.

Examples of psychiatric medications that can be affected by renal failure and may need to be adjusted or avoided include:

• Antipsychotics: Some antipsychotics, such as risperidone and olanzapine, can cause additional renal damage and should be used with caution in individuals with renal impairment.
• Antidepressants: Tricyclic antidepressants (TCAs) can cause additional renal damage and should be used with caution in individuals with renal impairment.
• Mood stabilizers: Lithium is eliminated by the kidneys and can accumulate in the body, leading to toxicity in individuals with renal impairment.

In individuals with cardiovascular disease, some psychiatric medications can have potential impacts on cardiovascular function, such as affecting heart rate, and blood pressure, or causing an increased risk of heart attack or stroke.

Examples of psychiatric medications that can affect cardiovascular function and may need to be adjusted or avoided in individuals with cardiovascular disease include:

• Antidepressants: Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) can cause changes in heart rate and blood pressure and should be used with caution in individuals with cardiovascular disease.
• Stimulants: Some stimulants, such as methylphenidate and dextroamphetamine, can cause changes in heart rate and blood pressure and should be used with caution in individuals with cardiovascular disease.
• Antipsychotics: Some antipsychotics, such as haloperidol and pimozide, can cause changes in heart rate and blood pressure and should be used with caution in individuals with cardiovascular disease.

Pregnancy:

The use of psychiatric medications during pregnancy can have potential impacts on both the mother and the developing fetus, so it’s important to carefully consider the risks and benefits before making decisions about treatment.

In general, most psychiatric medications have the potential to cross the placenta and affect the developing fetus. Additionally, some medications can have impacts on the mother’s health, such as affecting blood pressure or causing changes in hormones.

Examples of psychiatric medications that may need to be adjusted or avoided during pregnancy include:

• Antidepressants: The use of certain antidepressants, such as paroxetine and fluoxetine, has been associated with an increased risk of birth defects and should be used with caution during pregnancy.
  • SSRIs, such as fluoxetine and sertraline, are commonly used to treat depression during pregnancy. While they are generally considered safe, they may be associated with a small increased risk of birth defects and complications during delivery.
  • TCAs, such as amitriptyline, may be associated with a higher risk of birth defects and should be used with caution during pregnancy.
• Mood stabilizers: The use of certain mood stabilizers, such as valproic acid, has been associated with an increased risk of birth defects and should be used with caution during pregnancy.
  • Lithium is associated with a risk of birth defects and may cause complications during delivery, so it’s important to carefully consider the risks and benefits before using it during pregnancy.
  • Valproic acid is associated with a risk of birth defects and should be avoided during pregnancy, if possible.
• Antipsychotics:
  • Second-generation antipsychotics, such as risperidone and quetiapine, are generally considered safe during pregnancy. However, they may be associated with an increased risk of complications during delivery and should be used with caution.
  • First-generation antipsychotics, such as haloperidol, may be associated with a higher risk of birth defects and should be avoided during pregnancy, if possible.
• Benzodiazepines: The use of benzodiazepines during pregnancy has been associated with an increased risk of birth defects, complications during delivery, and behavioural problems in newborns. It’s generally recommended to avoid the use of benzodiazepines during pregnancy, if possible.

References:

(1) Semple, D. and Smyth, R. (2019). Oxford handbook of psychiatry. Oxford ; New York, Ny: Oxford University Press.