P.I.E.C.E.S. Psychotropic Template Three-Question Framework for Selection and the Detection, Monitoring the Use, Risk, and Benefits of Psychotropics
1. When should a psychotropic be used or considered? 2. How do I select the right medication?
Important Note:
3. How do I monitor the response and side effects (with person, family, providers)?
Withdrawal symptoms are associated with many
Are the benefits outweighing the risks and side effects (to this treatment vs. other treatments)??
psychoactives, including SSRIs (flu-like symptoms).
; How long is the medication to be used, and when is it to be reviewed?
The dose must be reduced slowly and the status
; What are the indicators for increasing or decreasing the medication?
If no response, consider non-adherence, wrong diagnosis, wrong dose, or not enough time.
Preferred choices, starting doses Side Effects Notes & max. recomm. doses Headache, Agitation, Nausea, Diarrhea Sweating, Somnolence HANDS
Paroxetine, fluoxetine, fluvoxamine: Anticholinergic effects: paroxetine
more common or severe drug interactions; prolonged side effects with fluoxetine
Headache, nausea, elevated BP in higher doses.
Watch for suicidal risk when “energy” increased
but still despondent. Max. recommended dose: 300 mg daily
Dry mouth, Appetite loss, Nausea, Constipation
Not for use with persons with liver disease and/
Equilibrium (dizziness), Somnolence or DANCES
glaucoma. Watch for drug-drug interaction (i.e.
not with fluvoxamine, MAOI some antibiotics i.e. Cipro etc)
Dry mouth, drowsiness, weight gain, dizziness: mild
Seizures, Headache, Agitation, Rash, SHARES Emesis, Sleep disturbance
Used more for sedation than for antidepressant
Monitor for hypotension. When combined with MAO-B
In doses up to 600 mg per day, no dietary
(Eldepryl), MAOI diet/full precautions needed
precautions required. Given BID from 300 mg to 600 mg daily
STIMULANT Methylphenidate (5 mg in morning)
Cardiovascular risks: high BP, agitation, sleeplessness Usually not a first line treatment
(C)ardiovascular: Orthostatic hypotension
Anti(C)holinergic: Urinary retention 3 C’s
constipation, dry mouth, blurred vision (C)onfusion: Monitor with the C.A.M. Atypical Antipsychotics Newer Antipsychotics – Side Effects to Monitor Clinical Response Dizziness, Agitation (early), Somnolence, Hypotension
The clinical factors to monitor include the
May cause tachycardia, with higher doses – EPS
DASH Dangerous, threatening Distressing to self Advantages of New Antipsychotics Cautions: Disturbing to others Direct Action, if acting on them
Less risk of developing tardive dyskinesia
5. JeoparDizing independence Distant or present Definite (fixed) vs insight
Tranquilizing effect usually occurs early; however, resolution of psychosis may take 1-2 months
Traditional antipsychotics or neuroloeptics Traditional Antipsychotics - Side Effects to Monitor Mainly used if delirium Constriction: EPS: rigidity, tremors, showed movements, drooling, leaning
to one side, parkinsonian gait and falls
4C’s
Less EPS but more anti-cholinergic than haloperidol
• Anti-Cholinergic side effects, Confusion, Cardiovascular side effects If it is an anxiolytic, what class is it? Side Effects to Monitor Response
Confusion and memory problems, ataxia (poor balance) and falls, disinhibition
leading to inappropriate or aggressive behaviour
Best in panic attacks or catastrophic reactions
Mood stabilizers Side Effects to Monitor Response Lithium Carbonate
stabilization of mood and behaviour within 2-4
Ataxia and falls, confusion, weakness, diarrhea usually when serum level is
Mostly used when previous recurrent mood
some GI upset in early treatment. Polyuria, tremor may occur at therapeutic
doses. Maintain serum levels between 0.4 to 0.7 mMol/L
Valproate, Sedation, ataxia, nausea; if there is bruising or bleeding of any type,
May be considered in lability of mood and
call physician. Check if drug levels and blood work done regularly (liver,
hematology). Watch for rashes particularly with Lamotrigine.
Drugs to treat Dementia Side Effects to Monitor Response
Improve or prevent decline in ADLs, Behaviour,
Muscle cramp, Insomnia, Nausea, Diarrhea and weight loss MIND Cognitive Enhancers (Potential Problems) P.I.E.C.E.S.TM Consultation Team & Associates January 2009
Pam Hamilton BA Curriculum and Clinical and Education Consultant.
Joanne Collins. RSW. Curriculum and Education Consultant> Nova Socita Coordinator.
Diane Harris R.N. MSc CHRD, CPT. Performance & Learning Consultant, Project Coordinator
Nausea and peptic ulcer Low pulse (bradycardia)
J. Kenneth LeClair MD, FRCP(C). Clinical Advisor, Curriculum & Education Consultant Marie France Rivard MD, FRCPC(C). Chair, Steering Committee for P.I.E.C.E.S. for Family Physicians
Glutaminergic agent Side Effects to Monitor Response Memantine
Confusion, Headache, Equilibrium, Constipation,
CHECK C-SHAPES
Indicated for moderate to severe dementia
Excessive activity/irritability decreased
Tokiko Fukuda, MD, PhD, Ashley Roberts, BS, Paul H. Plotz, MD, and Nina Raben, MD, PhD Corresponding author enlarged lysosomes. Recent efforts have brought about the Nina Raben, MD, PhDArthritis and Rheumatism Branch, National Institute of Arthritis development and production of the recombinant human and Musculoskeletal and Skin Diseases, National Institutes of GAA (rhGAA) for enzyme r