PSYCHOSIS

DRUGS USED FOR PSYCHOSES

Batch 15 B – Term III
April 4, 2011
Team Members: Mary Rea; Michelle McKay; Blanca Diaz; Chris Esguerra; Larissa Sabsay
 P S Y C H O S I S
Loss of contact with reality, usually including false beliefs about
what is taking place or who one is (delusions) and seeing or hearing
things that aren’t there (hallucination), deterioration in social
functioning
Symptoms associated with many illnesses:
Dementia
Delirium
Depression
Schizophrenia – The most common
Bipolar disorders

Psychotic disorders influenced by different circumstances:

Biologic
 P S Y C H O S I S
Psychotic Desorder: Delusion
Delusions are a symptom of either medical, neurological, or mental
disorder.
Is a falls or irrational belief that is firmly held despite obvious
evidence to the contrary

Types of Delusion:

Persecutory - involve the theme of being followed, harassed,

cheated, poisoned or drugged, conspired against, spied on..

Grandiose - An individual exaggerates his or her sense of self-

importance and is convinced that he or she has special powers,
 P S Y C H O S I S
Psychotic Disorders: Delusion contd.
Types of delusion contd.

Hypochondriac - A fixed belief that person is physically ill or,

more extreme, that his organs are rotting or are destroyed

Delusion of reference – a person has the delusional idea that

random external events, objects, the behavior of others, etc., refer
to the self.

“Bizarre” delusion- clearly irrational and do not derive from

ordinary life experiences e.g., aliens have removed the affected
person's brain
 P S Y C H O S I S
Psychotic Disorder: Hallucinations
Perceptions in a conscious and awake state in the absence of
external stimuli which have qualities of real perception.
They can appear in the form of visions, voices or sounds, tactile
feelings, smells, or tastes.

Pts suffering from dementia and psychotic disorders such as

schizophrenia frequently experience hallucinations

Hallucinations can also occur in patients who are not mentally ill
as a result of stress overload, hypertension or exhaustion
 P S Y C H O S I S
Psychotic Disorder: Disorganized Thinking
Describe incomprehensible language, either speech or writing, that
is presumed to reflect thinking. Consist of a loosening of
associations, or flight of ideas, so that the speaker jumps from one
idea or topic to another unrelated one (derailment) in an illogical,
disorganized, or inappropriate way

Answers to questions completely unrelated

Speakers wards become garbled or unrecognizable
Speech may be repetitive and little or no information
Examples:
Derailment - "The next day when I'd be going out you know,
I took control, like uh, I put bleach on my hair in California
Distractible speech - "Then I left San Francisco and moved to... where
 P S Y C H O S I S
Psychotic Disorder: Disorganized Thinking Contd.
 P S Y C H O S I S
Psychotic Disorder: Disorganized Behavior
Involves the inability or motivation to initiate a goal-oriented task,
or to complete the task once it is started, leading to difficulties in
performing ADLs. Behavior appears bizarre to other people, and
can vary in degree from childlike and silly to aggressive and violent.

Person may dress inappropriately, engage in public sex, exhibit sudden

anger or laughter, or confront people for no apparent reason.

It is not unusual for someone with this type of schizophrenia to neglect

personal hygiene and have a very unkempt appearance.

Occasional confusion and disorganization is normal for most people. In

this type of schizophrenia, the degree of confusion and disorganization
 P S Y C H O S I S
Psychotic Disorder: Changes in Affect

Emotional expressiveness is diminished: there is a poor eye

contact, and reduced spontaneous movement. Also known as
“Blunted/Flat Affect”

Patient appear to be withdrawn fro others

The face appears immobile and unresponsive

Speech is often minimal with only brief slow motion replies to questions

Withdrawal from areas of functioning in interpersonal relationship, work

education, self care
 P S Y C H O S I S
Treatment of Psychosis
Important to assess pt. for accurate diagnosis:
• Complete physical
• Neurologic
• Mental status
• Complete family and social history
• Lab tests to exclude other causes of psychosis e.g., drug abuse
Pharmacologic and Nonpharmacologic therapies are critical to the
treatment.
Nonpharmacologic therapies are very beneficial:
Individual psychotherapy ( assist with coping with stress)
Group therapy (to enhance socialization skills)
Behavioral or cognitive therapy
 P S Y C H O S I S
Treatment of Psychosis Contd.
Before initiation of therapy the treatment goals and baseline
level of functioning must be established. The ultimate goal is:
Restore behavioral, cognitive and psychosocial processes and skills to as
close baseline as possible
Realistically most patients will have recurring symptoms of the
mental disorder for the rest of their lives unless psychosis is part
of another medical diagnosis such as substance abuse
Treatment therefore
Frequency focused
and type on decreased
of agitation severity
Grooming of and
habits the hygiene
target
Degree that
symptoms of suspiciousness Sleep pattern
most interfere with functioning:
Delusions Speech pattern
Hallucinations Social skills
Loose association Judgment
 P S Y C H O S I S
Drug Therapy for Psychosis
Pharmacologic therapy
The first and the second generation antipsychotic agents
Benzodiazepines used often to control acute psychotic symptoms
The beta-adrenergic-blocking agents (propranolol), Lithium,
anticonvulsants (valproic acid, arbamazepine), antiparkinsonian
agents, and anticholinergic agents occasionally play a role in
controlling adverse effect of antipsychotic therapy

Antipsychotic agents aca as neuroleptic are:

Ø Divided into phenothiazines and nonphenothiazines
Classified as low patency and high potency drugs
Ø
 P S Y C H O S I S
Drug Therapy for Psychosis Contd.
Pharmacologic therapy contd.

Low Potency Agents High Potency Agents

Chlopromazine Trifluoperazine
Thioridazine Fluphenazine
Thiothixene
Haloperidol
Loxapine
Molindone
Since 1990 antipsychotic agents also calcified as and based on
mechanism of action:

• Typical - First Generation •Atypical - Second Generation

 P S Y C H O S I S
Drug Therapy for Psychosis Contd.
Pharmacologic therapy contd.
Atypical Agents (2nd generation) Typical Agents (1st generation)
aripiprazole ( Abilify) Phenothiazine
clozapine (Clozaril) Chlorpromazine
quetiapine (Seroquel) Fluphenazine
risperidone (Risperdal) Perphenazine
ziprasidone(Geodon) Proclorperazine (Compazine)
Thioridazine
Trifluoperazine

Thioxanthenes
thiothixene (Navane)

Nonphenothiazines
haloperidol (Haldol)
loxapine (Loxitane)
molindone ( Moban)
 P S Y C H O S I S
Drug Therapy for Psychosis Contd.
Actions
The typical antipsychotic agents block the neurotransmitter dopamine in CNS
The atypical antipsychotic agents block dopamine and serotonin receptors in
CNS by varying degree
Exact mechanism is unknown

The word antipsychotics /neuroleptic drugs was derived from the

Greek: "νεῦρον“ (neuron, originally meaning "sinew" but today referring
to the nerves) and "λαμβάνω" (lambanō, meaning "take hold of"). Thus,
the word means taking hold of one's nerves.
This may refer to common side effects such as reduced activity, lethargy, and impaired
motor control. Although these effects are unpleasant and in some cases harmful, they
were at one time considered a reliable sign that the drug was working
 P S Y C H O S I S
Drug Therapy for Psychosis Contd.
Uses
The initial goal – calming the agitated patient who may be a physical threat to self or others and
beginning treatment of the psychosis and thought disorder
All antipsychotic agents are equal in efficacy when used in equipotent doses
Selection of medication should be based on the need to avoid certain adverse effects in
concurrent medical or psychiatric disorder
Medication history should be major factor in drug selection
Individual response is the best determinant which drug is to be used
Combined therapy with benzodiazepines (e.g., Lorazepam) allows lower doses of antipsychotics
thus reducing serious adverse effect that have seen more commonly with higher doses
 P S Y C H O S I S
Drug Therapy for Psychosis Contd.

Uses Contd.

The atypical antipsychotic agents tend to be more effective in

symptoms associated with :
Ø schizophrenia
Ø Refractory schizophrenia
Ø Have much lower incidence of extrapyramidal symptoms
Ø Hyperprolactinemia

Therapeutic effect such as reduced psychomotor agitation,

 P S Y C H O S I S
Adverse Effect of Antipsychotic Drug Therapy

Extrapiramidal Effects
Extrapyramidal effects are the most troublesome adverse effects
and the most common cause of nonadherence associated with
antipsychotic therapy
 P S Y C H O S I S
Adverse Effect of Antipsychotic Drug Therapy Contd.
Extrapyramidal Effects Contd.

Dystonias
Acute are spasmodic
Dystonia Symptoms movement of the onset
- The earliest muscleofgroups
all thesuch
EPS as
the tongue protrusion, rolling back the eyes, jaw spasm, or neck
torsion.

These symptoms are often frightening and painful for the patient..
They may be controlled by intramuscular injections of :
Ø Diphenhydramine
 P S Y C H O S I S
Adverse Effect of Antipsychotic Drug Therapy Contd.
Pseudoparkinsonian Symptoms of Tremor:

Typically begin after 2 to 3 weeks of antipsychotic drug therapy

The cause of these symptoms is a relative deficiency of dopamine
with cholinergic excess caused by antipsychotic agents.

They are controlled by anticholinergic antiparkinsonia agents

Ø muscular rigidity
Ø masklike expression
Ø
 P S Y C H O S I S
Adverse Effect of Antipsychotic Drug Therapy Contd.
Akathisia:

Akathisia is a syndrome consisting of subjective feelings of

anxiety and restlessness, the objective signs of pacing, rocking, and
inability to sit or stand.

It occurs more commonly when high potency antipsychotics agents used

The mechanism of action is not known
It can increase aggression and is a frequent cause of noncompliance
Reducing the dose of the antipsychotic agent or switching to low potency
should be considered
It can be treated with anticholineric agents
Benzodiazepines (e.g., diazepam, lorazepam)
Beta adrenergic blocking agents (e.g., propranolol)
 P S Y C H O S I S
Adverse Effect of Antipsychotic Drug Therapy Contd.
Tardive Dyskinesia:

Syndrome of persistent and involuntary hyperkinetic abnormal

movements. The cause of tardive dyskinesia is unknown.

It develops in about 20%to 25% of patients that are receiving typical

antipsychotic agents such as:
Ø Buccolingual masticatory (BLM) or orofacial movements
These drugs induce late-appearing neurologic disorders
Patients with this syndrome may interfere with their ability to:
Ø chew,
Ø Speak
 P S Y C H O S I S
Adverse Effect of Antipsychotic Drug Therapy Contd.
The abnormal involuntary movement scale (AIMS)
Rates diskinetic movements
Not exclusevly diagnostic for tardive dyskinesia

The dyskinesia identification system - Condensed user scale (DISCUS)

Rates the presence and severity of abnormal movements
Considers other variable when formulating a conclusion
The DISCUS evaluation specifically describes the type of tardive dyskinesia
Allows diagnoses to change over time

Treatment of tardive dyskinesia is not particuarly successful The best

treatments are:
 P S Y C H O S I S
Adverse Effect of Antipsychotic Drug Therapy Contd.
Newroleptic Malignant Syndrome(NMS)

Potentially fatal adverse effect of antipsychotic therapy, with that the

patients will display extra- pyramidal manifestation that are part of
the symptoms of the disorder.

Occurs in patients younger than 40 y/o, twice as often in males

This occurs in 0.5% to 1.4% of patients that receiving antipsychotic therapy
Once NMS begins, symptoms usually progress over 24 to 72 hrs
Last 5 to 10 days after meds are discounted
With depot antipsychotic therapy they last 13 to 30 days
Symptoms:
Fever
Severe EPS –rigidity, trismus, choreiform, movement, opisthotonos
 P S Y C H O S I S
Adverse Effect of Antipsychotic Drug Therapy Contd.
Seizures:
Antipsychotic agents may lower the seizures threshold in patients with
seizures disorder and those with no previous history of seizures
The agents higher incidence of inducing seizures
Ø The low-potency typical agents
Ø Clozapine
Ø An atypical agent
Weight Gain:
There is higher prevalence of obesity associated with schizophrenia
Weight gain often contributes to nonadherence of therapy
Moderate weight gain is reported with:
Ø Risperidone
 P S Y C H O S I S
Adverse Effect of Antipsychotic Drug Therapy Contd.
Hyperglycemia:
It occurs more frequently with:
Ø Clozapine
Ø Olanzapine
Ø Quetiapine
Development of hyperglycemia by the other atypical agents cannot yet be ruled
out because these agents are so new.
Dyslipidemia
Agents that appear to in crease serum triglyceride levels
Ø Clozapine
Ø Olanzapine
Ø Quietiapine
 P S Y C H O S I S
Adverse Effect of Antipsychotic Drug Therapy Contd.
Dysrhythmias:
These agents have rarely been associated with torsades pointe –
ventricular dysrithmias associated with prolongation of the QTc
interval on ECG, syncope and sudden death:
Ø Thioridazine
Ø Ziparasidone
Ø Halopaeridol
Ø Quetiapine
Ø Olanzapine
Ø Risperidone
These findings can increase the risk of torsades de pointes
and sudden death in patients receiving antipsychotic age
Ø Bradycardia
Ø Electrolyte imbalance
Ø The presence of congenital prolongation of the QTc interval concomitant use of other meds that
significantly prolong the QTc interval
 P S Y C H O S I S
Other Adverse Effects
Other adverse effects of antipsychotic therapy can also be predicted based on
the receptor-blocking activity of the agents:
Blocking the cholinergic (acetylcholine) receptors explains the anticholinergic
effects associated with antipsychotic agents:
Ø Constipation
Ø Sinus tachycardia
Ø Urinary retention

Blocking Histamine-1 receptors cause:

Ø Sedation
Ø Drowsiness
Ø Appetite stimulant
 P S Y C H O S I S
Other Adverse Effects Contd.
Antipsychotic agents also block alpha-1 and alpha-2 adrenergic receptors,
causing
Ø postural hypotension
Ø sexual dysfunction.
Ø Hepatotoxicity
Ø blood dyscrasias
Ø allergic reactions
Ø endocrine disorders
Ø and reversible effects in the eyes.
The most potent alpha-1 blockers are:
Ø Chlopromazine
Ø Thioridazine
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy
Assessment
History of behavior:
Gather information from the patient:
The onset, duration and progression of symptoms
Previous treatments for this or other disorders
Coexisting health conditions
List of all medications taken in the past 3 months
Inquire about the substance abuse
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.
Mood and Affect:
Careful evaluation of verbal and nonverbal actions.
Facial expression (e.g., worried, angry, sad, blank)
Consistency of expression of feelings verbally and nonverbally
Overreaction to situation at times

Clarity of Thoughts and Perception:

Presence of delusions,
disorganized speech pattern
Flight of ideas
Ask about presence of hallucinations
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.
Psychomotor function:
Assess activity level
Pt ability to sit still
Pacing continually

Sleep pattern:
Person’s normal sleep pattern
Assess if insomnia present
Amount and quality of sleep nightly

Dietary history:
Ask questions about appetite
Note weight gain or losses not associated with intentional dieting.
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.

Nursing Diagnoses:
Risk for Injury
Impaired Environmental Interpretation Syndrome
Disturbed Sensory Perception
Impaired Verbal Communication
Ineffective Role Performance
Ineffective Coping
Risk for Other-Directed Violence
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.
Planning
History of Psychotic Behavior

Review data collected to identify individual’s strengths and weaknesses.

Review medications being taken to identify any that are known to cause any
of the symptoms exhibited.

Basic mental status

Plan to perform a baseline assessment of the individual mental status at

specific intervals throughout the course of treatment.
Schedule specific times to discuss the patient’s behavior with the family
members or significant other(s) to foster understanding of this behavior.
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.
Planning Contd.
Mood and Affect
Review assessment data to develop strategies to assist the individual to
cope more effectively.
Reward positive accomplishments for progress made

Clarity of Thought and Perception

Plan to monitor the patient carefully for altered thoughts and perceptions
Develop approaches that could be tried when the individual is having
delusions or hallucinations
Identify areas in which the patient is capable of input to set goals and make
decisions
Set goals to involve the patient as abilities change with treatment
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.
Planning Contd.
Thought of Death
Provide for a safe environment for the individual. Search for objects that
could be armful to self.
Psychomotor Function
Review activities offered with in the clinical setting and plan for the patient
to participate.
Sleep Pattern
Provide specific parameters in which the patient can function and meet the
need for sleep.
Dietary Needs
Provide an opportunity for the individual to be involved in selecting foods
appropriate needs
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.
Implementations
Nursing interventions must be must be individualized and based
on patients assessment data.

Provide the individual with the a structured environment that is

safe and decreases stimuli.

Provide opportunity for the person to express feelings. Allow

persons to express feelings in non-verbal ways.

Involve the patient in self-care activities.

 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.
Implementations Contd.
If patient is suicidal, ask for details of the plan being formulated. Follow
up with family members or significant others.

For example: having guns removed from home.

Provide patient safety and supervision and record observations at

specified intervals consistent with severity of the suicidal threat.

Use physical restraints within the guidelines of the clinical setting as

appropriate to the behaviors being exhibited. Have enough staff to
handle violent staff.
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.
Patient Education and Health Promotion
Orient the individual to the unit, explaining rules and the process of
privileges, as well as how they re obtained or lost.

Explain unit rules and therapeutic rules. Keep explanations clear and
precise.

Patient education must be based on assessment and be individualized.

Explain the activity groups available and how and when the individual
will participate.
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.
Patient Education and Health Promotion Contd.
Fostering Health Maintenance

Discuss the medication information and how it will benefit the patient’s
symptoms and circumstances

Although symptoms may improve, they may not be totally eliminated

Tracking medications being taken needs careful scrutiny because no

adherence is a major problem

No adherence is a major problem in this group of patients; therefore

medications must be tracked
 P S Y C H O S I S
Nursing Process For Antipsychotic Therapy Contd.
Patient Education and Health Promotion Contd.
Written Record

Enlist the patient’s aid in developing and maintaining a written record of

monitoring parameters.

There are a number of debilitating adverse effects and others that are life-
threatening if not acted on correctly, it is important that open
communication with the health care provider, nurses, therapist, and
pharmacist be encourages throughout course of therapy.
 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents
Actions

phenothiazines molindone aripiprazole

loxapine ouetiapine
clozapine risperidone
thioxanthenes olanzapine ziprasidone
haloperidol
molindone

All Antipsychotics agents similar in act by blocking the action of dopamine in

the brain

The atypical antipsychotic agents block serotonin and dopamine receptors

 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents
Actions
• Used to treat psychoses associated with mental illness (schizophrenia,
mania, psychotic depression, and psychotic organic brain syndrome)

Typical antipsychotics (first generation)

Blocks the action of dopamine in the brain
• Phenothiazines, nonphenothiazines-thioxanthenes, haloperidol, molidone,
loxapine

Atypical antipsychotics (second-generation)

Blocks serotonin receptors in addition to dopamine receptors
• Tend to be more effective with fewer adverse effects than typical agents
• Aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone are
 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents Contd.
Actions Contd.

Aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone –

considered the first line of significant relief of active psychotic
symptoms
Aripiprazole - approved for treatment of schizophrenia in 13-17 y/o,
and as an adjunctive Tx to antidepressant therapy in adults with
depression
Quetiapine - approved to treat depressive episodes with bipolar
disorders
Clozapine – for more resistant cases that do not respond to other
atypical agents
 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents Contd.
NURSING PROCESS
Premedication Assessment

• Obtain blood pressures in supine, sitting, and standing positions

Ø Record and report significant lowering to the health provider before
administering medication
Ø Monitor on yearly bases thereafter

• Check electrolytes, body weight, waist circumference, height, blood

glucose, lipid profile, hepatic function, cardiac function, and thyroid
function before initiation and periodically throughout the course of
administration
Ø Weight should be monitored every 4 weeks until 12 weeks after
 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents Contd.
NURSING PROCESS CONTD.

Premedication Assessment Contd.

• Use baseline evaluation rating scale at specified intervals:

Ø Brief Psychiatric Rating Scale (BPRS)
Ø Positive and Negative Syndrome Scale (PANSS)
Ø Clinical Global Impression (CGI)

Adverse effect scales:

Ø Toronto Western Torticollis Rating Scale(TWSTRS)
Ø Global Dystonia Scale (GDS) for dystonia
 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents Contd.
NURSING PROCESS
Implementations

It often takes several weeks for a patient to show improvement and become stabilized on
an adequate maintenance
As result of cumulative effects of these agents, patients must be reevaluated periodically to
determine the lowest effective dosage necessary to control psychiatric symptoms

Evaluations
Common Adverse Effects:
Central Nervous System (CNS):
Chronic fatigue, Drowsiness.
If these symptoms occur, give the dose of medication at bedtime
 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents Contd.
NURSING PROCESS – Evaluation Contd.
Common Adverse Effects Contd:
Cardiovascular
Orthostatic Hypotension
All antipsychotic agents may cause orthostatic hypotension
Monitor BP dayly in the supine, sitting, standing position
Teach patient to rise slowly

Sensory
Blurred Vision
Provide safety
 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents Contd.
NURSING PROCESS – Evaluation Contd.
Common Adverse Effects Contd:
Gastrointestinal
Constipation, Dryness of mucosa of the mouth, throat, nose
Dryness can be relieved by sucking hard candy or ice chips, or chewing gum
High fiber diet, stool softeners (docusate, or basacodyl)

Serious Adverse Effects:

Neurologic
Seizure Activity
Provide patient safety during episodes of seizures
Adjustments of anticonvulsant therapy may be required

Parkinsonian Symptoms
Report drooling, cogwheel rigidity, shuffling gait, tremors, flat face
 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents Contd.
NURSING PROCESS – Evaluation Contd.
Serious Adverse Effects Contd
Neurologic
Tardive Dyskinesia
Occurs more commonly with first generation antipsychotics
Report tremors of the tongue, lip smacking

Gastrointestinal
Hepatotoxicity (e.g., anorexia, N/V, jaundice, hepatomegaly, splenomegaly
abnormal liver function tests:
ØElevated bilirubin
 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents Contd.
NURSING PROCESS – Evaluation Contd.
Serious Adverse Effects Contd
Hematologic
Blood Discriasias
Routine Blood Studies: WBC, RBC
Monitor for sore throat, fever, purpura, jaundice

Hypersensitivity
Hives, pruritus, rash

Photosensitivity
Patient should avoid prolonged exposure to sunlight and ultraviolet light
 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents Contd.
NURSING PROCESS – Evaluation Contd.

Antihistamines, alcohol, analgesics, anesthetics, tranquilizers,

barbiturates, opiates, St. John’s wart, and sedative-hypnotics
increase the toxic effects of antipsychotic drugs
Ø Monitor for excessive sedation and reduce the dosage that increase the
toxic effects

Dopamine agonist (levadopa, bromocriptine, pergolide, amantadine,

ropinirole, pramipexole) decreases the therapeutic effects of
antipsychotic drugs

Carbamazepine stimulates the metabolism of haloperidol, clozapine,

 P S Y C H O S I S
DRUG CLASS: Antipsychotic Agents
Contd.
NURSING PROCESS – Evaluation
Contd.
Drug Interactions Contd.

Erythromycin, clarithromycin, fluoxetine,

grapefruit juice, ketoconazole, nefazodone
inhibits the metabolism of aripiprazole,
clozapine, quetiapine, and ziprasidone.
Cimetidine inhibits the metabolism of