9/17/20151 psychopharmacology khalid bazaid, mb bs, frcpc assistant professor child & adolescent...
TRANSCRIPT
04/19/2304/19/23 11
PsychopharmacologyPsychopharmacology
Khalid Bazaid, MB BS, FRCPCKhalid Bazaid, MB BS, FRCPCAssistant ProfessorAssistant Professor
Child & Adolescent PsychiatristChild & Adolescent PsychiatristDepartment of PsychiatryDepartment of Psychiatry
College of MedicineCollege of MedicineKing Saud UniversityKing Saud University
04/19/2304/19/23 22
OutlinesOutlines
The role of psychotropic in the mental health and its The role of psychotropic in the mental health and its therapeutic indicationstherapeutic indications
Identify specific cautions to be aware of the various Identify specific cautions to be aware of the various psychotropic medicationspsychotropic medications
Discuss the adherence to medication treatmentDiscuss the adherence to medication treatment
Psychotropic Medications ClassificationsPsychotropic Medications Classifications
04/19/2304/19/23 33
The aim is learn how to choose a psychotropic drug that is more:
• Effective• Less toxic• Better-tolerated• The most targeted therapeutic agents
PsychopharmacologyPsychopharmacology
04/19/2304/19/23 44
Psychotropic DrugsPsychotropic Drugs Focus of all mental activity is the CNS (brain)Focus of all mental activity is the CNS (brain)
Origin of psychiatric illness caused by many factors:Origin of psychiatric illness caused by many factors:– GeneticsGenetics– Neurodevelopment factorsNeurodevelopment factors– Endocrinologic e.g. HypothyroidismEndocrinologic e.g. Hypothyroidism– Autoimmune system (infections)Autoimmune system (infections)– DrugsDrugs– Psychosocial experiences, stressors … etc.Psychosocial experiences, stressors … etc.
To date …Theories behind use of psychotropic drugs To date …Theories behind use of psychotropic drugs focuses on neurotransmitters and their receptorsfocuses on neurotransmitters and their receptors
Psychotropic drugs act by modulating neurotransmittersPsychotropic drugs act by modulating neurotransmitters
04/19/2304/19/23 55
Use of psychotropic medicationsUse of psychotropic medications
Relieve or reduce symptoms/signs of dysfunctional Relieve or reduce symptoms/signs of dysfunctional thoughts, moods, or actions of mental illnessthoughts, moods, or actions of mental illness
Improve client’s functioningImprove client’s functioning
Increase compliance to other therapiesIncrease compliance to other therapies
04/19/2304/19/23 66
Therapeutic Effects of Therapeutic Effects of Psychotropic MedicationsPsychotropic Medications
Do not “cure”Do not “cure” Relieve or decrease Relieve or decrease
symptomssymptoms Prevent or delay return Prevent or delay return
of S/Sof S/S Cannot be used as the Cannot be used as the
sole treatment for sole treatment for disordersdisorders
Need informed consent Need informed consent before startingbefore starting
Are broad spectrum and Are broad spectrum and have effects on a large have effects on a large number of S/Snumber of S/S
Initial effects are Initial effects are sedative in naturesedative in nature
May take weeks for May take weeks for effects to be seeneffects to be seen
04/19/2304/19/23 77
Reasons for Non- adherence:Reasons for Non- adherence:
Medications are Medications are expensiveexpensive
Unpleasant side effectsUnpleasant side effects
Feel better and decide Feel better and decide no longer needno longer need
Stigma associated with Stigma associated with having a mental illness having a mental illness and taking medicationsand taking medications
Paranoia or fears about Paranoia or fears about medication usage medication usage particularly additionparticularly addition
04/19/2304/19/23 88
Encouraging Compliance to Encouraging Compliance to Medication RegimenMedication Regimen
Follow-up appointments With client to verify that client Follow-up appointments With client to verify that client understands:understands:
the purpose, proper administration, intended effects, side and the purpose, proper administration, intended effects, side and toxic effects of, and how to treat problems associated with toxic effects of, and how to treat problems associated with medicationsmedications
Appropriate lab tests must be conducted to prevent Appropriate lab tests must be conducted to prevent complications and assure correct levels of drugscomplications and assure correct levels of drugs
Encourage clients to participate in medication groupsEncourage clients to participate in medication groups
Can use injections of antipsychotics which will last Can use injections of antipsychotics which will last from 2-4 weeks if clients are non-compliantfrom 2-4 weeks if clients are non-compliant
04/19/2304/19/23 99
Efficacy of Psychotropics with Efficacy of Psychotropics with Children & ElderlyChildren & Elderly
Use with great caution Use with great caution
Start Start low and go slowlow and go slow for both elders and for both elders and childrenchildren
Children are faster metabolizer whereas elders Children are faster metabolizer whereas elders have decrease liver & renal functionhave decrease liver & renal function
Risk of injuries and falls with elderlyRisk of injuries and falls with elderly
04/19/2304/19/23 1010
Client & Family TeachingClient & Family Teaching
Purpose of the meds Purpose of the meds and benefits, side and benefits, side effects and how to effects and how to treat SEtreat SE
What S/S indicate a What S/S indicate a toxic effect, and how toxic effect, and how to treat, and whom to to treat, and whom to call.call.
Specific instructions Specific instructions about how to take the about how to take the medicationsmedications
04/19/2304/19/23 1111
Psychotropic Medications Psychotropic Medications ClassificationsClassifications
Antipsychotics Antipsychotics (Neuroleptics)(Neuroleptics)
Mood StabilizersMood Stabilizers
AntidepressantsAntidepressants
Anxiolytics Anxiolytics (antianxiety)(antianxiety)
SedativesSedatives
HypnoticsHypnotics
PsychostimulantsPsychostimulants
Antihistamines, Antihistamines, antimuscarinics, antimuscarinics, dopamine agonistsdopamine agonists
Psychotropic Medications Psychotropic Medications Classifications … Classifications … continuedcontinued
In many instances, drugs have multiple indications:
• SSRIs (selective serotonin reuptake inhibitors) are both antidepressants and anxiolytics.
• SDAs (serotonin-dopamine antagonists) are both antipsychotics and mood stabilizers.
• Psychotropic drugs have also been organized according to structure (e.g. Tricyclic).
• mechanism (e.g. monoamine oxidase inhibitor [MAOI])
04/19/2304/19/23 1313
AntipsychoticsAntipsychotics
Schizophrenia Schizophrenia DisordersDisorders
Bipolar disorderBipolar disorder
Major Depression with Major Depression with psychotic featurespsychotic features
Tourette’s SyndromeTourette’s Syndrome
Delirium, Dementia, Delirium, Dementia, and Delusions and Delusions
Control of intractable Control of intractable hiccupshiccups
Aggressive behaviorAggressive behavior
Antipsychotic - NeurolepticsAntipsychotic - Neuroleptics First generationFirst generation Post synaptic D2 receptor.Post synaptic D2 receptor. Dopamine receptor antagonists Dopamine receptor antagonists
(DRAs)(DRAs)
Low potency: Low potency: hypotension, sedation, weight gainhypotension, sedation, weight gain more anticholinergicmore anticholinergic less antidopamenergic less antidopamenergic less EPS.less EPS.
e.g.e.g. Mellaril, chlorpromazineMellaril, chlorpromazine
High potency:High potency: More antidopamenergicMore antidopamenergic more EPSmore EPS less anticholinergic less anticholinergic
e.g. e.g. HaldolHaldol
Atypical AntipsychoticsAtypical Antipsychotics ((22ndnd and 3 and 3rd rd generation)generation)
D2, D4, 5HT2 D2, D4, 5HT2 Serotonin dopamine antagonists Serotonin dopamine antagonists
(SDAs)(SDAs) Alpha adrenergic, muscarinic Alpha adrenergic, muscarinic
receptorsreceptors
e.g.e.g. ClozarilClozaril RisperdalRisperdal ZyprexaZyprexa
SeroquelSeroquel Abilify Abilify GeodonGeodon InvegaInvega ZeldoxZeldox
04/19/2304/19/23 1515
First Generation Antipsychotic First Generation Antipsychotic Block predominantly Block predominantly
dopamine activitydopamine activity– High incidence of abnormal High incidence of abnormal
movementsmovements
– little effect on serotoninlittle effect on serotonin
(Also blocks acetylcholine, (Also blocks acetylcholine, norepinephrine to some norepinephrine to some degree)degree)
Blocks the H receptor Blocks the H receptor for histaminefor histamine– results in sedation and results in sedation and
weight gainweight gain
04/19/2304/19/23 1616
Side Effects of 1Side Effects of 1stst Gen Drugs-1 Gen Drugs-1 DystoniaDystonia (EPS) (EPS)
spasms of the eye, neck-spasms of the eye, neck-torticollis, back, tongue-torticollis, back, tongue-happens within 72 hrs happens within 72 hrs ( ( reversible)reversible)
Akathisia Akathisia (EPS)(EPS)
restlessness restlessness
Pseudoparkinson Pseudoparkinson - S/S - S/S similar to Parkinson's-see similar to Parkinson's-see in 1-2 weeks. May in 1-2 weeks. May disappear. TX. With disappear. TX. With CogentinCogentin
Tardive DyskinesiaTardive Dyskinesia--bizarre facial and tongue bizarre facial and tongue movements (movements (irreversible)irreversible)
04/19/2304/19/23 1717
Side Effects of 1Side Effects of 1stst Gen Drugs-2 Gen Drugs-2
Blurred vision, dry mouth, Blurred vision, dry mouth, constipation and urinary constipation and urinary retention, tachycardia-retention, tachycardia-anticholinergic S/Eanticholinergic S/E
Sexual dysfunctionSexual dysfunction
Severe dysrhythmiasSevere dysrhythmias
Orthostatic hypotensionOrthostatic hypotension
AgranulocytosisAgranulocytosis
In men can lead to In men can lead to gynecomastiagynecomastia
AmenorrheaAmenorrhea
GalactorrheaGalactorrhea
photosensitivity & skin rashes photosensitivity & skin rashes
Reduction is seizure threshold Reduction is seizure threshold – Low potency – Low potency
04/19/2304/19/23 1818
Precautions and/or contraindicated Precautions and/or contraindicated When using 1When using 1stst Gen Antipsychotics Gen Antipsychotics
Blood dyscrasiasBlood dyscrasias
Liver, renal, or cardiac insufficiencyLiver, renal, or cardiac insufficiency
CNS depressants, including ETOHCNS depressants, including ETOH
Tegretol in conjunction with Tegretol in conjunction with antipsychotics causes up to 50% antipsychotics causes up to 50% reduction in antipsychotic reduction in antipsychotic concentrationsconcentrations
SSRI’s in conjunction with SSRI’s in conjunction with antipsychotics may cause sudden antipsychotics may cause sudden onset of EPSonset of EPS
Don’t give if have: Parkinson's Don’t give if have: Parkinson's disease, prolactin dependent cancer disease, prolactin dependent cancer of the breastof the breast
Cigarette smoking causes reduced Cigarette smoking causes reduced plasma concentrations of plasma concentrations of antipsychoticsantipsychotics
Antacids, activated charcoal can Antacids, activated charcoal can reduce the absorption of DRAsreduce the absorption of DRAs
Faverin in conjunction with Faverin in conjunction with antipsychotics causes increased antipsychotics causes increased concentrations of Haldol and Clozarilconcentrations of Haldol and Clozaril
Beta Blockers in conjunction with Beta Blockers in conjunction with antipsychotics cause severe antipsychotics cause severe hypotensionhypotension
Antidepressants in conjunction with Antidepressants in conjunction with antipsychotics may cause increased antipsychotics may cause increased plasma level of bothplasma level of both
04/19/2304/19/23 1919
First Generation Antipsychotic First Generation Antipsychotic MedicationsMedications
Are useful in getting out of control behavior under Are useful in getting out of control behavior under control quickly. control quickly.
These can be given with lithium to get treat acute These can be given with lithium to get treat acute mania.mania.
Seroquel is effective in the maintenance treatment of Seroquel is effective in the maintenance treatment of Bipolar-Depressive phaseBipolar-Depressive phase
04/19/2304/19/23 2020
Atypical AntipsychoticsAtypical Antipsychotics Action: Blocks dopamine receptors and to a lesser degree Action: Blocks dopamine receptors and to a lesser degree
serotonin receptors, serotonin receptors, Also block receptors for norepinephrine , histamine, Also block receptors for norepinephrine , histamine,
acetylcholineacetylcholine
Nicer drugs and are used more Nicer drugs and are used more
Decrease positive and negative S/S of SchizophreniaDecrease positive and negative S/S of Schizophrenia
Lower Incidence of abnormal movementsLower Incidence of abnormal movements
Biggest S/E is weight gain e.g. ZyprexaBiggest S/E is weight gain e.g. Zyprexa
04/19/2304/19/23 2121
Positive & Negative S/S of Positive & Negative S/S of SchizophreniaSchizophrenia
Positive:Positive:– HallucinationsHallucinations– DelusionsDelusions– Abnormal thoughtsAbnormal thoughts– Bizarre behaviorBizarre behavior– Confused thoughtsConfused thoughts
Negative:Negative:– Blunted affectBlunted affect– Poverty of speechPoverty of speech– Social withdrawalSocial withdrawal– Poor motivationPoor motivation
04/19/2304/19/23 2222
Atypical Antipsychotics-2Atypical Antipsychotics-2ndnd & 3 & 3rdrd generation: Clozaril (clozapine)generation: Clozaril (clozapine)
low incidence of abnormal movementslow incidence of abnormal movements
Most common S/E: Most common S/E: – Nausea, constipation, sedation, drowsiness, weight gainNausea, constipation, sedation, drowsiness, weight gain
Other S/E are:Other S/E are:– hypersalivation, tachycardia, dizziness, seizure riskhypersalivation, tachycardia, dizziness, seizure risk
possible fatal side effect:possible fatal side effect:– bone marrow suppression & Agranulocytosis (rare)bone marrow suppression & Agranulocytosis (rare)
04/19/2304/19/23 2323
Atypical Antipsychotics-2Atypical Antipsychotics-2ndnd & 3 & 3rdrd generation - 2generation - 2
RisperidoneRisperidone– Does not cause bone Does not cause bone
marrow suppressionmarrow suppression– Can cause at higher Can cause at higher
doses movement doses movement disordersdisorders
– Available as a long Available as a long acting injectionacting injection
– Can be used to treat Can be used to treat maniamania
SeroquelSeroquel (Quetiapine) (Quetiapine)– S/E sedation, weight S/E sedation, weight
gain and headache gain and headache – Not associated with Not associated with
abnormal movementsabnormal movements– May cause AV blockMay cause AV block
04/19/2304/19/23 2424
Atypical Antipsychotics-2Atypical Antipsychotics-2ndnd & 3 & 3rdrd generation - 3generation - 3
Zyprexa Zyprexa (Olanzapine)(Olanzapine)– does not cause bone marrow suppressiondoes not cause bone marrow suppression– Can cause weight gain & hyperglycemiaCan cause weight gain & hyperglycemia– Drowsiness, dry mouth, constipation, and restlessnessDrowsiness, dry mouth, constipation, and restlessness
Geodon Geodon (Ziprasidone)(Ziprasidone)– Binds to multiple receptor sitesBinds to multiple receptor sites– Drowsiness, headache, GI upsetDrowsiness, headache, GI upset– Can prolong the QT interval-can be fatal if history of cardiac arrhythmiasCan prolong the QT interval-can be fatal if history of cardiac arrhythmias
AbilifyAbilify (Aripiprazole) (Aripiprazole)– Dopamine stabilizerDopamine stabilizer– Partial agonist at the D2 receptorPartial agonist at the D2 receptor– In areas of the brain with excess dopamine, it lowers dopamineIn areas of the brain with excess dopamine, it lowers dopamine– In areas of low dopamine, it stimulates receptors to raise the dopamine levelIn areas of low dopamine, it stimulates receptors to raise the dopamine level– Main S/E are headache, somnolence, agitation, anxiety, insomnia, and GI Main S/E are headache, somnolence, agitation, anxiety, insomnia, and GI
upsetupset
04/19/2304/19/23 2525
Antipsychotics-Long acting Antipsychotics-Long acting preparationpreparation
Can be given be given as an IM injection Can be given be given as an IM injection (depot preparations) if have difficulty (depot preparations) if have difficulty taking oral meds.taking oral meds.
Can use lower doses when given IM, so Can use lower doses when given IM, so less risk of tardive dyskinesialess risk of tardive dyskinesia
04/19/2304/19/23 2626
Neuroleptic Malignant SyndromeNeuroleptic Malignant Syndrome
Rare, but fatal complication from all antipsychotic drugsRare, but fatal complication from all antipsychotic drugs
See more with 1See more with 1stst generation drugs generation drugs
Severe muscle rigiditySevere muscle rigidity
High temperatureHigh temperature
Associated S/S:Associated S/S:
TachycardiaTachycardia
HypertensionHypertension
StuporStupor
ComaComa
Abnormal labs including leukocytosis , Elevated Creatinine phosphokinase (CPK) & Abnormal labs including leukocytosis , Elevated Creatinine phosphokinase (CPK) & LFTLFT
04/19/2304/19/23 2727
Mood StabilizersMood Stabilizers
Used in the treatment of Manic (Bipolar) Used in the treatment of Manic (Bipolar) disorder, and in some forms of depressiondisorder, and in some forms of depression
Drugs used: Lithium and Antiepileptic DrugsDrugs used: Lithium and Antiepileptic Drugs
04/19/2304/19/23 2828
LithiumLithium
Mechanism of action Mechanism of action unknownunknown
Alters electrical Alters electrical conductivityconductivity – potential threat to all potential threat to all
body functions that body functions that are regulated by are regulated by electrical currentselectrical currents
Can cause polyuria and Can cause polyuria and polydipsa due to Na and polydipsa due to Na and K alterationsK alterations
Has the lowest Has the lowest therapeutic index of all therapeutic index of all psych drugspsych drugs
Have to monitor blood Have to monitor blood levels levels
04/19/2304/19/23 2929
LithiumLithium Maintenance blood levels of Maintenance blood levels of
lithium are usually 0.4-1.3 mEq lithium are usually 0.4-1.3 mEq (toxicity occurs with levels > (toxicity occurs with levels > 1.5 mEq/L)1.5 mEq/L)
Sign of toxicity is a fine Sign of toxicity is a fine intention tremor that becomes intention tremor that becomes more pronounced and coarsemore pronounced and coarse
Risk of thyroid & kidney Risk of thyroid & kidney diseasedisease
If toxic S/S occur discontinue If toxic S/S occur discontinue the drug and notify health care the drug and notify health care providerprovider
Lithium should be taken with Lithium should be taken with foodfood
Client must eat a balanced diet Client must eat a balanced diet with normal sodium intake and with normal sodium intake and take in adequate fluid (about 2-3 take in adequate fluid (about 2-3 liters/day). liters/day).
Excretion is via renal system Excretion is via renal system
Dehydration and salt restriction Dehydration and salt restriction can increase lithium levels & can increase lithium levels & cause toxicity.cause toxicity.
Takes 2-3 weeks for lithium to Takes 2-3 weeks for lithium to become effective (may use become effective (may use antipsychotic until therapeutic antipsychotic until therapeutic levels are reached)levels are reached)
04/19/2304/19/23 3030
Signs & Symptoms of Lithium Signs & Symptoms of Lithium ToxicityToxicity
Fine hand tremors that Fine hand tremors that progress into coarse progress into coarse tremorstremors
Mild GI upset Mild GI upset progressing to progressing to persistent upsetpersistent upset
Slurred speech and Slurred speech and muscle weakness muscle weakness progressing to mental progressing to mental confusionconfusion
Severe ToxicitySevere Toxicity: : – decrease level of decrease level of
consciousness to consciousness to stupor and finally stupor and finally comacoma
– Seizures, severe Seizures, severe hypotension, severe hypotension, severe polyuria with dilute polyuria with dilute urineurine
04/19/2304/19/23 3131
LithiumLithium
Lithium serum concentrations are increased by Lithium serum concentrations are increased by Flouxetine (Prozac), ACE inhibitors, Thiazide diuretics, Flouxetine (Prozac), ACE inhibitors, Thiazide diuretics, and NSAIDsand NSAIDs
Lithium serum concentrations are decreased by Lithium serum concentrations are decreased by theophylline, osmotic diuretics, and urine alkalinizerstheophylline, osmotic diuretics, and urine alkalinizers
04/19/2304/19/23 3232
Contraindications for LithiumContraindications for Lithium Renal diseaseRenal disease
Cardiac diseaseCardiac disease
Severe dehydrationSevere dehydration
Sodium depletionSodium depletion
Brain damageBrain damage
Pregnancy or lactationPregnancy or lactation
Use with caution in the elderly or clients with diabetics, thyroid Use with caution in the elderly or clients with diabetics, thyroid disorders, urinary retention, and seizuresdisorders, urinary retention, and seizures
04/19/2304/19/23 3333
Anticonvulsants/Antiepileptic Anticonvulsants/Antiepileptic DrugsDrugs
Causes an increase in GABA in the CNS-which causes Causes an increase in GABA in the CNS-which causes a decrease in anxiety.a decrease in anxiety.
Reduce the mood swings with bipolar Reduce the mood swings with bipolar
04/19/2304/19/23 3434
Anticonvulsants/Antiepileptic Anticonvulsants/Antiepileptic DrugsDrugs
Tegretol Tegretol (carbamazepine)-also used to treat (carbamazepine)-also used to treat severe pain (i.e. trigeminal neuralgia), cause severe pain (i.e. trigeminal neuralgia), cause agranulocytosis and aplastic anemiaagranulocytosis and aplastic anemia
DepakoteDepakote (Valproic acid)-can cause hepatic (Valproic acid)-can cause hepatic failure, pancreatitis, & thrombocytopenia. failure, pancreatitis, & thrombocytopenia. Watch Watch for liver failurfor liver failuree
KlonopinKlonopin (Clonazepam)(Clonazepam)
LamictalLamictal (Lamotrigine)-can have a rare but fatal (Lamotrigine)-can have a rare but fatal dermatological conditiondermatological condition
04/19/2304/19/23 3535
Toxic Effects of AnticonvulsantsToxic Effects of Anticonvulsants
Tegretol can cause agranulocytosis and Tegretol can cause agranulocytosis and aplastic anemiaaplastic anemia
Depakote can cause liver dysfunction, hepatic Depakote can cause liver dysfunction, hepatic failure, and blood dyscrasias including failure, and blood dyscrasias including thrombocytopenia thrombocytopenia
Depakote interacts with drugs that are Depakote interacts with drugs that are metabolized by the livermetabolized by the liver
04/19/2304/19/23 3636
Contraindications for Contraindications for AnticonvulsantsAnticonvulsants
Hepatic or renal diseaseHepatic or renal disease
PregnancyPregnancy
LactationLactation
Presence of blood dyscrasiasPresence of blood dyscrasias
04/19/2304/19/23 3737
Psychoeducation when using Psychoeducation when using anticonvulsantsanticonvulsants
Monitor blood levels of mood stabilizers to prevent Monitor blood levels of mood stabilizers to prevent toxicitytoxicity
Monitor liver, renal function tests and CBCsMonitor liver, renal function tests and CBCs
Depakote must be swallowed whole, not cut, Depakote must be swallowed whole, not cut, chewed, or crushed to prevent irritationchewed, or crushed to prevent irritation
Evolution of Antidepressant DrugsEvolution of Antidepressant Drugs
Phenelzine
Isocarboxazid
Tranylcypromine
Imipramine
Clomipramine
Nortriptyline
Amitriptyline
Desipramine
Fluoxetine
Sertraline
Paroxetine
Fluvoxamine
CitalopramBupropion
Nefazodone
MirtazapineReboxetine
Maprotiline
Amoxapine
1950 1960 1970 1980 1990
Phenelzine
Isocarboxazide
Tranylcypromine
Imipramine
Clomipramine
Nortriptyline
Amitriptyline
Desipramine
Fluoxetine
Sertraline
Venlafaxine
Maprotiline
AmoxapineEscitalopramDuloxetine
2000
MianserineTrazodone
Moclobemide
TianeptineMilnacipran
2009
Valdoxan
04/19/2304/19/23 3939
AntidepressantsAntidepressants
Treatment of depressive moods, including Treatment of depressive moods, including bipolar disease bipolar disease
4 categories:4 categories:– Tricyclics (TCA)Tricyclics (TCA)– MAOI’sMAOI’s– SSRI’SSSRI’S– Atypical AntidepressantsAtypical Antidepressants
04/19/2304/19/23 4040
Antidepressant DrugsAntidepressant Drugs
TricyclicsTricyclics- Elavil, Tofranil- Elavil, Tofranil
SSRI’sSSRI’s- Lustral, Seroxat - Lustral, Seroxat
MAOI’sMAOI’s- Nardil, Parnate- Nardil, Parnate
04/19/2304/19/23 4141
Atypical AntidepressantsAtypical Antidepressants
Inhibits reuptake of Inhibits reuptake of serotoninserotonin::
Trazodone (desyrel)Trazodone (desyrel)
Norepinephrine Dopamine Norepinephrine Dopamine Reuptake Inhibitor (NDRI)Reuptake Inhibitor (NDRI): : Wellbutrin (Bupropion)Wellbutrin (Bupropion)
Sertonin Norepinephrine Sertonin Norepinephrine Reuptake InhibitorReuptake Inhibitor-(SNRI): -(SNRI): Effexor (venlafaxine)Effexor (venlafaxine)
Cymbalta (duloxetine)Cymbalta (duloxetine)
Increases release of Increases release of serotonin & norepinephrine: serotonin & norepinephrine: Remeron (mirtazapine)Remeron (mirtazapine)
04/19/2304/19/23 4242
Atypical AntidepressantsAtypical Antidepressants
Trazodone:Trazodone:alternative to TCA’s, may cause orthostatic hypotension, alternative to TCA’s, may cause orthostatic hypotension, sedation, and priapism in malessedation, and priapism in males
Remeron:Remeron: causes sedation, weight gain, dry mouth, constipationcauses sedation, weight gain, dry mouth, constipation
Wellbutrin Wellbutrin (zyban): rarely causes sedation, weight Gain, (zyban): rarely causes sedation, weight Gain, or sexual dysfunctionor sexual dysfunction– Used for smoking cessation. Most common S/E are headaches, Used for smoking cessation. Most common S/E are headaches,
insomnia & nauseainsomnia & nausea– May lower seizure thresholdMay lower seizure threshold
04/19/2304/19/23 4343
Atypical Antidepressants:Atypical Antidepressants: serotonin norepinephrine reuptake serotonin norepinephrine reuptake
inhibitor (SNRI)inhibitor (SNRI)
SNRI-blocks uptake of SNRI-blocks uptake of serotonin and norepinephrineserotonin and norepinephrine
Drugs include Drugs include EffexorEffexor & & CymbaltaCymbalta
Good for clients with anxiety Good for clients with anxiety
S/E:GI, sexual dysfunction, S/E:GI, sexual dysfunction, insomnia, agitationinsomnia, agitation
Skipping 1 dose can Skipping 1 dose can cause withdrawal S/Scause withdrawal S/S
Very effective in Very effective in treating severe treating severe depressiondepression
Cymbalta is effective in Cymbalta is effective in treating somatic treating somatic symptoms e.g. painsymptoms e.g. pain
04/19/2304/19/23 4444
Major Indications for Major Indications for AntidepressantsAntidepressants
Major Depressive Major Depressive disorderdisorder
Bipolar depressionBipolar depression Anxiety disorders:Anxiety disorders:
Panic disorderPanic disorder Obsessive-CompulsiveObsessive-Compulsive Phobic disordersPhobic disorders
PTSDPTSD
Substance AbuseSubstance Abuse Chronic PainChronic Pain Tourette’s DisorderTourette’s Disorder ADHDADHD Eating disordersEating disorders Sleep disordersSleep disorders MigrainesMigraines EnuresisEnuresis
04/19/2304/19/23 4545
TriCyclicAntidepressant (TCA): TriCyclicAntidepressant (TCA): Tryptizol, Pamelor, Tofranil, Anafranil, Tryptizol, Pamelor, Tofranil, Anafranil,
Aventyl, Asendin, SinequanAventyl, Asendin, Sinequan
Blocks the reuptake of Blocks the reuptake of norepinephrine and norepinephrine and serotoninserotonin
Tricyclic drugs block the Tricyclic drugs block the muscarine receptors muscarine receptors causing anticholinergic causing anticholinergic side effectsside effects
Other side effects:Other side effects:– Orthostatic Orthostatic
hypotensionhypotension– SedationSedation– Weight gainWeight gain– Confusion-esp. elderlyConfusion-esp. elderly– ArrhythmiasArrhythmias
04/19/2304/19/23 4646
TCA’s ContraindicationsTCA’s Contraindications Do not mix with ETOH Do not mix with ETOH
(none of the psych drugs (none of the psych drugs should be mixed with should be mixed with ETOH)ETOH)
DementiaDementia Suicidal clientsSuicidal clients Cardiac diseaseCardiac disease PregnancyPregnancy Seizure disordersSeizure disorders Urinary retentionUrinary retention
Dose for elderly should Dose for elderly should be ½ of adult dosebe ½ of adult dose
TCA’s and MAOIs are TCA’s and MAOIs are effective in treatment of effective in treatment of depressiondepression– are not as safe nor are not as safe nor
well tolerated as the well tolerated as the newer antidepressantsnewer antidepressants
Toxic Effects:Toxic Effects:possibility of cardiac possibility of cardiac toxicity in toxicity in overdoseoverdose
04/19/2304/19/23 4747
SSRI’sSSRI’s Prozac, Lustral, Seroxat, Faverin, Cipralex, SerzoneProzac, Lustral, Seroxat, Faverin, Cipralex, Serzone
Blocks the reuptake of serotonin into the neuronBlocks the reuptake of serotonin into the neuron
Are very safe and are not lethal in overdoseAre very safe and are not lethal in overdose
Good choice with the elderly-very few side effectsGood choice with the elderly-very few side effects
If used with MAOI’s may cause Serotonin Syndrome: seizure, deathIf used with MAOI’s may cause Serotonin Syndrome: seizure, death
If used with TCA’s may cause TCA toxicityIf used with TCA’s may cause TCA toxicity
Takes 2 weeks to feel effectsTakes 2 weeks to feel effects
Side-effect:Side-effect: GI, CNS however the biggest is sexual dysfunction & weight GI, CNS however the biggest is sexual dysfunction & weight gain gain
Contraindication: Cardiac dysrhythmiasContraindication: Cardiac dysrhythmias
04/19/2304/19/23 4848
MAOI’sMAOI’s Nardil, ParnateNardil, Parnate
Inhibits MAO, thus interfering with breakdown of Inhibits MAO, thus interfering with breakdown of norepinephrine, dopamine, and serotoninnorepinephrine, dopamine, and serotonin
Avoid foods with tyramine (aged cheese, red wine, Avoid foods with tyramine (aged cheese, red wine, beer, chocolate, etc.) beer, chocolate, etc.)
MAOI’s don’t play well with other drugs!!MAOI’s don’t play well with other drugs!! Toxic effects:Toxic effects: hypertensive criseshypertensive crises
Adverse effets linked with Adverse effets linked with neurotransmitter neurotransmitter
activity and receptor bindingactivity and receptor binding
Adapted from Richelson 1993
Activating sideeffects
5-HT5-HT2 2
agonismagonism
Weight gain
Ach Ach antagonismantagonism
Blurred visionNausea5-HT5-HT3 3
agonismagonism
Activating effects
NE reuptakeNE reuptakeinhibitioninhibition
Postural hypotensionDizziness
Reflex tachycardia
αα2 2 antagonismantagonism
Priapism
DA reuptakeDA reuptakeinhibitioninhibition
Psychomotor activation
TraditionalAntidepressants
5-HT5-HTreuptakereuptakeinhibitioninhibition
H1H1
antagonismantagonism
αα1 1 antagonismantagonism
Dry mouth
Urinary retention
Activating effectsTremor-CV troubles
Sexual dysfunction
GI disturbances
Sedation/drowsiness
Dry mouth
Constipation
Sinus tachyardia
Urinary retention
Memory dysfunction
Psychosis - Abuse
04/19/2304/19/23 5050
Antianxiety/Anxiolytic DrugsAntianxiety/Anxiolytic Drugs
GABA exerts an inhibitory effect on neuronsGABA exerts an inhibitory effect on neurons
These drugs enhance its effect and produce a These drugs enhance its effect and produce a sedative effectsedative effect
Therefore reduce anxietyTherefore reduce anxiety
The most common used drugs here are the The most common used drugs here are the BenzodiazepinesBenzodiazepines
04/19/2304/19/23 5151
BenzodiazepinesBenzodiazepines Valium, Xanax, Ativan , Valium, Xanax, Ativan ,
Librium, LexotanilLibrium, Lexotanil
Dalmane, Halcion (used as Dalmane, Halcion (used as sleep aides-short term) sleep aides-short term)
Used for anxiety disorders, Used for anxiety disorders, ETOH withdrawal, muscle ETOH withdrawal, muscle spasm, sedation, insomnia, spasm, sedation, insomnia, and epileptics/seizuresand epileptics/seizures
Risk of dependency Risk of dependency
Avoid ETOHAvoid ETOH
Causes sedation-Causes sedation-don’t drive!!don’t drive!!
04/19/2304/19/23 5252
BenzodiazepinesBenzodiazepines Side EffectsSide Effects
– Drowsiness, confusion, sedation, and lethargyDrowsiness, confusion, sedation, and lethargy
Toxic EffectsToxic Effects– Respiratory depression esp. with ETOH use!Respiratory depression esp. with ETOH use!
ContraindicationsContraindications– Combination with other CNS depressantsCombination with other CNS depressants– Renal or hepatic dysfunction (may use Ativan)Renal or hepatic dysfunction (may use Ativan)– History of drug abuse or addictionHistory of drug abuse or addiction– Depression and suicidal tendenciesDepression and suicidal tendencies
TeachingTeaching– Use short term due to risk of drug dependencyUse short term due to risk of drug dependency– Avoid ETOH and other CNS depressantsAvoid ETOH and other CNS depressants– Can impair ability to driveCan impair ability to drive– Sudden D/C of benzodiazepines might cause withdrawal s/sSudden D/C of benzodiazepines might cause withdrawal s/s
04/19/2304/19/23 5353
Non-benzodiazepine AnxiolyticNon-benzodiazepine Anxiolytic BuSpar (Buspirone)BuSpar (Buspirone) Reduces anxiety without strong sedative-hypnotic propertiesReduces anxiety without strong sedative-hypnotic properties Not a CNS depressantNot a CNS depressant Takes 2 weeks to feel effects Takes 2 weeks to feel effects No potential for addictionNo potential for addiction Side EffectsSide Effects
– Dizziness, dry mouth, nervousness, diarrhea, headache, excitementDizziness, dry mouth, nervousness, diarrhea, headache, excitement
Toxic EffectsToxic Effects– Lethal dose is 160-550 times the daily recommended doseLethal dose is 160-550 times the daily recommended dose
ContraindicationsContraindications– Use with caution in PG womenUse with caution in PG women– Nursing mothersNursing mothers– Clients with renal or hepatic diseaseClients with renal or hepatic disease– Anyone taking MAOsAnyone taking MAOs
04/19/2304/19/23 5454
Sedative/Hypnotic DrugsSedative/Hypnotic Drugs Anxiolytic and hypnoticAnxiolytic and hypnotic
Can lead to tolerance and dependencyCan lead to tolerance and dependency
Use for short termUse for short term
Drugs usedDrugs used
benzodiazepines:benzodiazepines: Dalmane, Restoril, Halcion Dalmane, Restoril, Halcion
Non-benzodiazepines:Non-benzodiazepines: Ambien, Sonata, Lunestra Ambien, Sonata, Lunestra
04/19/2304/19/23 5555
Psychoeducation when using Psychoeducation when using Benzodiazepine TeachingBenzodiazepine Teaching
Use short term(1-2 weeks)Use short term(1-2 weeks)
Carefully need to taper these off-never stop cold turkeyCarefully need to taper these off-never stop cold turkey
Do not take with other meds without talking to provider Do not take with other meds without talking to provider firstfirst
Do not drive if sedated on these!!Do not drive if sedated on these!!
04/19/2304/19/23 5656
Client Teaching forClient Teaching for Non-benzodiazepines Non-benzodiazepines
Long term use not recommendedLong term use not recommended
Do not drive when takingDo not drive when taking
Can repeat Sonata up to 4 hours before arisingCan repeat Sonata up to 4 hours before arising
04/19/2304/19/23 5757
ADD/ADHD-PsychostimulantsADD/ADHD-Psychostimulants
Ritalin, Adderall, Ritalin, Adderall, Dexedrine, Concerta,Dexedrine, Concerta,
DaytranaDaytrana
Action=Action=
increasing the release increasing the release and blocking the and blocking the reuptake of reuptake of monoamines monoamines (dopamine, (dopamine, norepinephrine)norepinephrine)
S/E:S/E: wt. loss, anorexia, wt. loss, anorexia, insomnia, headache, long-insomnia, headache, long-term growth suppressionterm growth suppression
Potential for abusePotential for abuse
Also used to treat Also used to treat narcolepsynarcolepsy
04/19/2304/19/23 5858
ADD/ADHD-PsychostimulantsADD/ADHD-Psychostimulants
Intended effects:Intended effects:– Increased attention span & concentrationIncreased attention span & concentration– Decreased distractibility, hyperactivity, and impulsivityDecreased distractibility, hyperactivity, and impulsivity– Treatment of ADHD, ADD, & narcolepsyTreatment of ADHD, ADD, & narcolepsy
S/E:S/E:– AnorexiaAnorexia– Wt. lossWt. loss– Growth retardation in childrenGrowth retardation in children– InsomniaInsomnia– HeadacheHeadache– Cardiovascular effects-high blood pressure, dysrhythmiasCardiovascular effects-high blood pressure, dysrhythmias
Contraindications:Contraindications:– Hx of drug abuse & dependency, severe anxiety, anorexia, Hx of drug abuse & dependency, severe anxiety, anorexia,
MAIOIsMAIOIs
04/19/2304/19/23 5959
ADD/ADHD- Non-StimulantsADD/ADHD- Non-Stimulants StratteraStrattera (atomoxetine)(atomoxetine)
– Controls symptoms thru selective inhibition of Controls symptoms thru selective inhibition of norepinephrinenorepinephrine
– Takes 1-3 weeks to feel effectsTakes 1-3 weeks to feel effects
– No abuse potential and is not considered a No abuse potential and is not considered a controlled substancecontrolled substance
04/19/2304/19/23 6060
Meds used to Treat Meds used to Treat Extrapyramidal SEExtrapyramidal SE
CogentinCogentin BenadrylBenadryl ArtaneArtane SymmetrelSymmetrel RequipRequip AkinetonAkineton KemadrinKemadrin
These meds should be These meds should be taken simultaneously taken simultaneously with antipsychotic with antipsychotic meds to prevent EPSmeds to prevent EPS
04/19/2304/19/23 6161
Herbal MedicinesHerbal Medicines Ginkgo biloba-helps with memoryGinkgo biloba-helps with memory Kava-KavaKava-Kava St. John’s WartSt. John’s Wart
04/19/2304/19/23 626204/19/23 62
Questions after lecture?Questions after lecture?
Please e-mail ([email protected]) or call Please e-mail ([email protected]) or call (01 467 1717)(01 467 1717)
Interested in learning more about child and Interested in learning more about child and adolescent psychiatry?adolescent psychiatry?– Arrange to attend OPD Arrange to attend OPD – Consider an elective rotation during internship Consider an elective rotation during internship
or otherwiseor otherwise
04/19/2304/19/23 6363
Meds for Alzheimer’sMeds for Alzheimer’s
Drugs here are used to Drugs here are used to slow the progression slow the progression of the diseaseof the disease
MemantineMemantine (Namenda, Ebixa)(Namenda, Ebixa)
Cognex Cognex (tacrine)(tacrine) Aricept Aricept (donepezil)(donepezil) Exelon Exelon (Rivastigmine) (Rivastigmine) RazadyneRazadyne
(galantamine)(galantamine)
04/19/2304/19/23 6464
PET ScanPET Scan=positron-emission =positron-emission tomography (PET) scanstomography (PET) scans
Useful in identifying physiological and biochemical Useful in identifying physiological and biochemical changes as they occur in living tissue changes as they occur in living tissue – i.e. clients with i.e. clients with schizophreniaschizophrenia PET scans show a PET scans show a
decrease of glucose in the frontal lobes of unmedicated decrease of glucose in the frontal lobes of unmedicated clients, also can indicate clients, also can indicate mood disordersmood disorders, , ADHD ADHD
Radioactive substance is injected, travels to the Radioactive substance is injected, travels to the brain, and illuminates the brain. Have 3D brain, and illuminates the brain. Have 3D visualizations of the CNSvisualizations of the CNS