Common practical questions - and answers - at the British Association for Psychopharmacology child and adolescent psychopharmacology course.

The British Association for Psychopharmacology course on child and adolescent psychopharmacology has been run for more than 20 years and is currently a very popular course, attracting around 140 delegates/year from across the United Kingdom and abroad. As Faculty of recent sessions of the course, we have selected the most common questions we have been asked in recent years and provided evidence-based and/or expert-informed answers. We have included 27 questions and answers related to attention-deficit/hyperactivity disorder, anxiety and depressive disorders, autism spectrum disorder, bipolar disorder, eating disorders, epilepsy (in differential diagnosis or comorbid with mental health conditions), obsessive-compulsive disorder, personality disorders, psychotic spectrum disorders, and tics/Tourette syndrome in children and young people. We hope that this article will be helpful for prescribers in their daily clinical practice and we look forward to further, high-level evidence informing the answers to these and other questions in child and adolescent psychopharmacology.

Practical Psychopharmacology: Using a Knowledge of Pharmacokinetics to More Rapidly Stabilize Patients at Lower Drug Doses.

Three drug dosing strategies can be employed to address dose-dependent drug adverse effects. The usual strategy is to continue the drug but at a lower dose; it would then take 5 half-lives of the drug for the new steady state to be attained and for a dose-dependent adverse effect to correspondingly attenuate. Such slow offset of the adverse effect could be disadvantageous for drugs such as fluoxetine, penfluridol, and cariprazine that have long half-lives. A second strategy is to stop the drug and to resume it at a lower dose when the adverse effect attenuates as the drug blood level falls. This strategy introduces subjectivity in timing the reintroduction of the drug, requires closer patient monitoring, and risks nonadherence and relapse. The third strategy is to stop the drug for a prespecified number of days and to then reintroduce it at a lower dose. From a knowledge of pharmacokinetics, it can be shown that stopping a drug for just 1 half-life and then resuming it at half the dose results in the immediate achievement of steady state; that is, there is no need to wait for 4 additional half-lives as with the usual strategy of dose reduction without dosing interruption. A limitation of this pharmacokinetically driven dosing strategy, however, is that it would work well in the average patient but not in those with outlying pharmacokinetic parameters.

Treating PTSD and Alcohol Use Disorder: Concurrent Cognitive Processing Therapy and Psychopharmacology.

Comorbidity is common with posttraumatic stress disorder, and alcohol use disorder (AUD) is among the most common co-occurring disorders. When viewed through the lens of avoidance behaviors, AUD can shape an individual's response to distressing trauma reminders by dulling the emotional response and promoting disengagement from the traumatic memory. Over time, this response strengthens posttraumatic distress by reinforcing the belief that traumatic memories and their emotional responses are themselves dangerous and intolerable. In turn, this belief may impede treatment progress. Concurrent trauma-focused therapy and AUD treatment can serve to establish more adaptive coping strategies. Reducing reliance on alcohol for coping while engaging safely and effectively with trauma memories allows the individual to process the memories, build tolerance to emotional distress, and ultimately reframe maladaptive trauma-related beliefs and decrease the intensity of reactions. This case presents concurrent psychopharmacology and cognitive processing therapy for co-occurring posttraumatic stress disorder and AUD. We explore how alcohol use, and emotional avoidance more broadly, become targets for change.

Psychopharmacology in the Elderly: Why Does Age Matter?

A growing percentage of the population is aging, with a large subset of this group meeting criteria for one or more neuropsychiatric disorders. Generally, physiological changes due to aging affect most of the pharmacokinetic processes in the body, with age-related physiologic changes in cardiovascular, gastric, hepatic, and renal function leading to changes in the pharmacokinetics of medications that can affect the absorption, distribution, accumulation, and clearance and elimination of various medications. This article aims to discuss the common pharmacodynamic and pharmacokinetic changes associated with physiologic aging and their impacts on the use of psychotropic medications in the elderly.

Learning the "Science of the Art of Prescribing": From Evidence-based Algorithms to Individualized Medicine in Psychiatric Care.

The purpose of this review is to highlight the limitations of the traditional diagnosis/evidence-based symptom reduction paradigm and advocate for an individualized medicine approach that incorporates psychological and relational aspects of prescribing in addition to the objective patient presentation. Potential barriers, challenges, and proposed future directions for improving education in psychological and relational aspects of prescribing are discussed. Psychological aspects of prescribing, as recently spelled out in the field of psychodynamic psychopharmacology, are generally acknowledged as important, but they do not have a well-defined position in contemporary residency training throughout North America. While residents receive in-depth exposure to diverse aspects of what to prescribe in their psychopharmacological training, and they work with patients' subjective and relational meaning and the quality of the therapeutic alliance in their psychotherapy rotations, an integrated approach to how to prescribe is generally lacking. Despite many legitimate challenges, the authors suggest that teaching an integrated approach that incorporates objective, subjective, and relational factors in the provision of psychopharmacology and utilizing evidence-based principles of individualized care should be prioritized in both residency training and the provision of psychiatric treatment as a whole.

An evidence-based approach to psychopharmacology for posttraumatic stress disorder (PTSD) - 2022 update.

Algorithms for posttraumatic stress disorder were published by this team in 1999 and 2011. Developments since then warrant revision. New studies and review articles from January 2011 to November 2021 were identified via PubMed and analyzed for evidence supporting changes. Following consideration of variations required by special patient populations, treatment of sleep impairments remains as the first recommended step. Nightmares and non-nightmare disturbed awakenings are best addressed with the anti-adrenergic agent prazosin, with doxazosin and clonidine as alternatives. First choices for difficulty initiating sleep include hydroxyzine and trazodone. If significant non-sleep PTSD symptoms remain, an SSRI should be tried, followed by a second SSRI or venlafaxine as a third step. Second generation antipsychotics can be considered, particularly for SSRI augmentation when PTSD-associated psychotic symptoms are present, with the caveat that positive evidence is limited and side effects are considerable. Anti-adrenergic agents can also be considered for general PTSD symptoms if not already tried, though evidence for daytime use lags that available for sleep. Regarding other pharmacological and procedural options, e.g., transcranial magnetic stimulation, cannabinoids, ketamine, psychedelics, and stellate ganglion block, evidence does not yet support firm inclusion in the algorithm. An interactive version of this work can be found at www.psychopharm.mobi.

The Practical Importance of Half-Life in Psychopharmacology.

The half-life of a drug is most commonly defined as the time taken for the plasma or blood level of the drug to fall by half. Elimination half-life, pharmacologic half-life, and biologic half-life are interchangeably used most commonly to describe the half-life of drugs that follow first-order or linear pharmacokinetics; that is, in single-compartment models, where the fall in blood level is proportionate to the concentration of the drug in blood. In 2 compartment models, where the drug equilibrates between blood and (for example) adipose tissue, during elimination there is a sharp initial fall in blood levels followed by a gradual subsequent fall; when drugs display this biphasic elimination pattern, the half-life corresponding to the second phase is what is clinically relevant, and this half-life is known as the terminal half-life. Half-life is influenced by drug distribution, drug metabolism, and drug excretion, each of which can be influenced by many factors such as age, use of concurrent medications, and presence of liver or renal disease. In order to maintain uniform blood levels and reduce the adverse effect risk, drugs with short half-lives need to be dosed more frequently. Drugs with short half-lives are more likely to be associated with withdrawal or discontinuation syndromes. The duration of action of a drug, time to steady state levels, and time to washout are each influenced by the value of the drug half-life. All these terms and concepts are defined and explained with the help of clinically relevant examples. Mental health care professionals who prescribe to patients need to know the half-lives of the drugs that they prescribe, the half-lives of active metabolites, if any, how these half-lives may differ with individual patient characteristics, and how to use this knowledge to prescribe to best advantage.