Chapter 7Antidepressants, Antipsychotics,

Antianxiety Agents, and Alcoholism

Chapter 7 Topics

• Antidepressants

• Antipsychotics

• Antianxiety Agents– Panic Disorders– Sleep Disorders

• Alcoholism

Learning Objectives

• Differentiate the antidepressant, antipsychotic, and antianxiety agents.

• Be prepared to discuss the antidepressant classes, their uses, and their side effects.

• Know why and how lithium and other drugs are used in treating bipolar disorders.

Learning Objectives

• Be familiar with antipsychotics and the drugs that prevent their side effects.

• Define anxiety, learn its symptoms, and know the drugs used in its treatment.

• Recognize the course and treatment of panic disorders, insomnia and alcoholism.

Antidepressants

• Used to treat depression• Depression, common feelings

– Pessimism– Worry– Intense sadness– Loss of concentration– Slowing of mental processes – Problems with eating and sleeping

Antidepressants Common Symptoms of Depression

– Loss of interest in usual activities

– Low self-esteem

– Self-pity

– Significant weight loss or gain

– Insomnia or hypersomnia

– Extreme restlessness

– Loss of energy

– Feelings of worthlessness

– Diminished ability to think

– Feelings of guilt

– Recurrent thoughts of death

– Suicide attempts

Antidepressants

Depression

• Women are affected more often than men

• When men are affected, it is usually later in life

• Levels of neurotransmitters in the brain may be a causative factor

Mood Disorders

• Mania

• Bipolar Disorder

• Unipolar Disorder

Mood Disorders

• ManiaMood of extreme excitement, excessive elation, hyperactivity, agitation, and increased psychomotor activity

• Bipolar Disorder

• Unipolar Disorder

Mood Disorders

• Mania

• Bipolar DisorderMood swings alternate between major depression and mania

• Unipolar Disorder

Mood Disorders

• Mania

• Bipolar Disorder

• Unipolar DisorderMajor depression with no previous occurrence of mania

Discussion

Describe the differences that may be seen in patients with unipolar and bipolar disorders.

Discussion

Describe the differences that may be seen in patients with unipolar and bipolar disorders.

Answer

Unipolar – Depression Symptoms Bipolar – Depression and Mania Symptoms

Treatment for Depression

Electroconvulsive Therapy• Introduction of brief, but convulsive

electrical stimulation through the brain

• Can induce seizures

• Effective for major and delusional depression

Antidepressants

• Selective Serotonin Reuptake Inhibitors (SSRIs)

• Cyclic Antidepressants

• Monoamine Oxidase Inhibitors (MAOIs)

Antidepressants

Selective Serotonin Reuptake Inhibitors (SSRIs)

– Block the reuptake of serotonin, with little effect on norepinephrine

– Fewer side effects than older meds

Treatments

Cyclic Antidepressants – Two Types

• Tricyclic antidepressants (TCAs)• Tetracyclic antidepressants

– Prevent reuptake of norepinephrine and/or serotonin

– Agents in this class differ in adverse effects, cost, and response

Treatments

Monoamine Oxidase Inhibitors (MAOIs)Allows for buildup of norepinephrine at the synapse

SSRIs for Depression

• citalopram (Celexa)

• escitalopram (Lexapro)

• fluoxetine (Prozac,)

• paroxetine (Paxil)

• sertraline (Zoloft)

• venlafaxine (Effexor)

Drug List

Dispensing Issues

Look-Alike Drugs

– Prozac and Proscar (urinary drug)

– Zoloft and Zocor (high cholesterol)

– Celexa and Cerebyx (seizures) and Celebrex (arthritis)

Warning!

SSRIDispensing Issues

• Do not discontinue abruptly

• Alcohol consumption should be avoided while taking these medications

Warning!

fluoxetine (Prozac)

• Indicated for major depression and obsessive-compulsive disorder (OCD)

• Anorexia is a possible adverse effect

• Take in the morning to avoid insomnia

paroxetine (Paxil)

• Indicated for depression, obsessive-compulsive disorder, and panic disorder

venlafaxine (Effexor)

• Blocks reuptake of serotonin and norepinephrine

• Indicated for depression

• May cause increase in blood pressure and blurred vision

sertraline (Zoloft)

• Indicated for depression and obsessive-compulsive disorder

• Primary side effect is nausea

• May also cause drowsiness

citalopram (Celexa)

• Indicated for depression and obsessive-compulsive disorder

• Minimal drug interactions

escitalopram (Lexapro)

• Similar to Celexa

• More potent with fewer side effects

Cyclic Antidepressants

Tricyclic• amitriptyline (Elavil)• nortriptyline (Pamelor)

Drug List

Tricyclic Antidepressants Dispensing Issues

• Improvements are usually seen in 10 to 21 days

• Can be cardiotoxic in high doses

• May cause postural hypotension

Warning!

Tricyclic AntidepressantsDispensing Issues

Do not discontinue abruptly.

Warning!

Cyclic Antidepressants Side Effects

• Sedation is common, but tolerance usually occurs

• Have many anticholinergic effects

Discussion

Why would cyclic antidepressants be prescribed for bed wetting in children?

Discussion

Why would TCAs be prescribed for bed wetting in children?

Answer They may be prescribed because of their anticholinergic side effects.

MAOIs

• phenelzine (Nardil)

• selegiline (Eldepryl)

• tranylcypromine (Parnate)

Drug List

MAOI Dispensing Issues

Be cautious of many interactions with foods such as aged cheeses, concentrated yeast extracts, pickled fish, sauerkraut, broad bean pods, chocolate, and alcohol.

Warning!

MAOI Dispensing Issues

If changing to another class of antidepressant, patient must have a two-week “wash out” period before starting the new medication.

Warning!

Other Antidepressants

• bupropion (Wellbutrin, Zyban)

• mirtazapine (Remeron)

• trazodone (Desyrel)

Drug List

trazodone (Desyrel)

• Prevents reuptake of serotonin and norepinephrine

• Has a better side effect profile than TCAs

• Caution: possible interaction with Ginkgo

bupropion (Wellbutrin, Zyban)

• Dopamine-uptake inhibitor

• Does not cause sedation, blood pressure changes, or ECG changes

• Do not discontinue abruptly

• Approved in the aid of smoking cessation

Other Antidepressant Dispensing Issues

• Wellbutrin SR = BID dosing

• Wellbutrin XL = QD dosing

Warning!

Bipolar Disorders

Signs or Symptoms– Decreased need for sleep– Elevated or irritable mood– Excessive involvement in pleasurable activities

with a big potential for painful consequences– Grandiose ideas– Pressure to keep talking– Racing thoughts

Discussion

What is the drug of choice for treating bipolar disorders?

Discussion

What is the drug of choice for treating bipolar disorders?

Answer

Lithium

Discussion

What is the two-fold objective of drug therapy for bipolar disorder?

Discussion

What is the two-fold objective of drug therapy for bipolar disorder?

Answer

Treat acute episodes

Prevent subsequent attacks

Drugs to Treat Bipolar Disorders

• carbamazepine (Tegretol)

• divalproex (Depakote)

• lithium (Lithobid)

• olanzapine-fluoxetine (Symbyax)

• valproic acid (Depakene)

Drug List

Lithium Side Effects

• Gastrointestinal

• Dermatologic

• Hematologic

• Neuromuscular

• Weight

• Renal

• Teratogenic

Lithium Dispensing Issues

Lithobid tablets are only effective for 6 months. Be sure to highlight expiration dates on containers.

Warning!

divalproex (Depakote)

• Beneficial for patients with rapid mood changes

• Take with food or milk, but not carbonated drinks

• Beware of symptoms of thrombocytopenia

Antipsychotics

• Also called neuroleptics• Schizophrenia is the primary indication

– Retreat from reality– Delusions– Hallucinations– Ambivalence– Withdrawal– Bizarre or regressive behavior

Antipsychotics

• Helps with thought disorders, hallucinations, and delusions

• Does not help with emotional and social withdrawal, ambivalence, or poor self-care

Antipsychotics

• aripiprazole (Abilify)

• clozapine (Clozaril)

• fluphenazine (Prolixin)

• haloperidol (Haldol)

• loxapine (Loxitane)

Drug List

Antipsychotics

• molindone (Moban)

• olanzapine (Zyprexa)

• prochlorperazine (Compazine)

• quetiapine (Seroquel)

Drug List

Antipsychotics

• risperidone (Risperdal)

• thioridazine

Drug List

Antipsychotic Side Effects

• Anticholinergic

• Cardiovascular

• Dermatologic

• Endocrine

• Hematologic

• Ophthalmologic

Antipsychotic Side Effects

• Withdrawal

• Neurologic– Dystonia– Akathisia– Pseudoparkinsonism

• Tardive dyskinesia

Atypical Antipsychotics

• Have improved efficacy and reduced side effects

• Better tolerated, but associated with metabolic side effects

risperidone (Risperdal)

• Indicated for management of psychotic disorders and dementia in the elderly

• It is a serotonin-dopamine antagonist

Dispensing Issues

Clozaril (antipsychotic) and Clinoril (antibiotic) are look-alike/sound-alike drugs.

Warning!

olanzapine (Zyprexa)

• Used for schizophrenia

• Blocks dopamine and serotonin receptors

• Causes fewer movement disorders and is more effective

• Alcohol must be avoided

Dispensing Issues

Zyprexa (antipsychotic) and Zyrtec (antihistamine) are look-alike/sound-alike drugs.

Warning!

quetiapine (Seroquel)

• Related to Clozaril

• Lower incidence of hematologic toxicities

Minimizes Side Effects of Antipsychotics

• benztropine (Cogentin)

• diphenhydramine (Benadryl)

• meclizine (Antivert)

Drug List

Antianxiety Agents

Anxiety

State of uneasiness characterized by apprehension and worry about possible events

Antianxiety Agents

Two Types of Anxiety

• ExogenousResponse to external stresses

• EndogenousNot related to external stresses, result of abnormality in cellular function in the CNS

Discussion

What is the most common self-prescribed treatment for anxiety?

Discussion

What is the most commonly self-prescribed treatment for anxiety?

Answer

Alcohol

Antianxiety Agents

• Benzodiazepines

• Other Controlled Medications

• Some Non-Controlled Medications

Antianxiety Agents

• amoxapine

• buspirone (BuSpar)

• hydroxyzine (Vistaril), antihistamine

• paroxetine (Paxil), SSRI

Drug List

Antianxiety Agents

• propranolol (Inderal), beta blocker

• venlafaxine (Effexor)

Drug List

Antianxiety Agents

Benzodiazepines, C-IV• alprazolam (Xanax)• chlordiazepoxide (Librium) • clorazepate (Tranxene)• diazepam (Valium)• lorazepam (Ativan)• oxazepam (Serax)

Drug List

Antianxiety Agnets

Benzodiazpines

• May cause physical dependence, C-IV

• Should not be stopped abruptly

• Side Effects– Muscle relaxation– Paradoxical excitement– Sedation

Dispensing Issues

Xanax (antianxiety) and Zantac (H2 Antagonist for the stomach) are look-alike/sound-alike drugs.

Warning!

propranolol (Inderal)

• Beta blocker used to treat physical symptoms of anxiety

• Not officially indicated for this use

• Lowers heart rate which decreases nervousness due to stage fright or test anxiety

buspirone (Buspar)

• Selectively antagonizes serotonin receptors

• Take with food

• Report changes in the senses

Dispensing Issues

Buspirone (antidepressant/antianxiety) and bupropion (antidepressant) are look-alike/sound-alike drugs.

Warning!

Panic Disorders

Panic• Intense, overwhelming, and uncontrollable

anxiety

• Neither a controllable voluntary emotion nor a condition that can be avoided by ignoring it or wishing it away

Panic Disorders

• Can occur anywhere at anytime

• Criteria for Diagnosis– Three attacks in a three-week period– At least four qualifying symptoms

Panic Disorders

Pathophysiology

• Result from a neurochemical defect

• The brain stem is a pathway for sensory information

• If there is a defect in the brain stem, stimuli can be excessively amplified and cause an overreaction

Panic Disorders

Treatment• Combination of antipanic medication and

behavioral therapy• Psychotherapy is preferred treatment when

symptoms cause significant discomfort or impairment

• Antianxiety medications are indicated for short-term treatment

Discussion

What fraction of Americans 18 and older have a sleep disorder?

Discussion

What fraction of Americans 18 and older have a sleep disorder?

Answer

1/3

Sleep Disorders

Insomnia

• Difficulty falling or staying asleep or not feeling refreshed on awakening

• Treated with hypnotics (to induce sleep)

Sleep Disorders

Causes– Situational

Sleep Disorders

Causes– Situational– Medical

Sleep Disorders

Causes– Situational– Medical– Psychiatric

Sleep Disorders

Causes– Situational– Medical– Psychiatric– Drug induced

Sleep Disorders

Stages of Sleep

Stage 1 Somewhat aware of surroundings, but relaxed

Sleep Disorders

Stages of Sleep

Stage 1 Somewhat aware of surroundings, but relaxed

Stage 2Unaware of surroundings, but can easily be awakened

Sleep Disorders

Stages of SleepStage 1

Somewhat aware of surroundings, but relaxed

Stage 2Unaware of surroundings, but can easily be awakened

Stage 3Deep sleep (REM sleep); dreams occur

Sleep Disorders

Narcolepsy

• Involves recurring, inappropriate episodes of sleep during the daytime hours

• No known cause

• Occurs four times more in men than women

Sleep Disorders

Characteristic Symptoms

1. Patient feels sleepy during the daytime and then enters into REM sleep

Sleep Disorders

Characteristic Symptoms

1. Patient feels sleepy during the daytime and then enters into REM sleep

2. Patient experiences cataplexy with sudden emotions

Sleep Disorders

Characteristic Symptoms

1. Patient feels sleepy during the daytime and then enters into REM sleep

2. Patient experiences cataplexy with sudden emotions

3. Sleep paralysis

Sleep Disorders

Characteristic Symptoms1. Patient feels sleepy during the daytime

and then enters into REM sleep2. Patient experiences cataplexy with sudden

emotions3. Sleep paralysis4. Very vivid hallucinations at the onset of

sleep

Sleep Disorders

Treatment of Narcolepsy

• Nondrug TherapyLifestyle changes

• Drug Therapy– Stimulants – Tricyclic antidepressants– SSRIs

Sleep Disorders

• Pharmacological TreatmentHypnotics

• Nonpharmacological Treatment– Normalizing sleep schedule– Increases physical exercise– Discontinuing alcohol use as a sedative– Sleep only 7-8 hours/24 hr– Reducing caffeine and nicotine intake

Sleep Disorders

Treatment

• Hypnotics should be used in conjunction with other medical therapeutics

• Benzodiazepines are the preferred agents

• Hypnotics should not be taken every night, only as needed

Dispensing Issues

Diazepam, lorazepam, and alprazolam can be misread and misheard.

Warning!

Sleep Agents

Benzodiazepines, C-IV• alprazolam (Xanax)• chlordiazepoxide (Librium)• clorazepate (Tranxene)• diazepam (Valium)• estazolam (ProSom)• flurazepam (Dalmane)

Drug List

Sleep Agents

Benzodiazepines, C-IV

• lorazepam (Ativan)

• oxazepam (Serax)

• temazepam (Restoril)

• triazolam (Halcion)

Drug List

Sleep Agents

Barbiturates• amobarbital (Amytal), C-II• butabarbital (Butisol), C-III• secobarbital (Seconal), C-II

Antihistamines• diphenhydramine (Benadryl)• hydroxyzine (Vistaril)

Drug List

Sleep Agents

Hypnotic

• chloral hydrate

Others

• zaleplon (Sonata)

• zolpidem (Ambien)

Drug List

zolpidem (Ambien)

• Targets benzodiazepine receptors with less effects on skeletal muscles and seizure threshold

• Short-term treatment only– Should not be used for more than 10 days – Alert the pharmacist, but realize there are

exceptions

Alcoholism

• Denial is one of the major roadblocks for a patient to overcome before getting help

• Linked to genetics

• No cure, but can be arrested

Alcoholism

Effects on Metabolism and Excretion

• Alcohol is an anesthetic and can cause loss of consciousness

• Emetic action prevents death by preventing absorption of lethal concentrations

• Habitual drinkers metabolize ETOH quicker, which increases tolerance

Alcoholism Side Effects

• Vitamin deficiency

• Gastritis

• Organic brain damage

• Alcoholic psychosis and dementia

• Cirrhosis of the liver (irreversible damage)

Alcoholism

Symptoms of Dependence on Alcohol• Blackouts or lapses of memory• Concerns of family, friends, and employers

about the substance use• Doing things that cause regret afterwards• Financial or legal problems from substance

use• Loss of pleasure with the substance

Alcoholism

Symptoms of Dependence on Alcohol• Neglecting responsibilities• Trying to cut down or quit using a

substance, but failing• Using alone; hiding evidence• Using to forget about problems• Willingness to do almost anything to get the

substance

Alcoholism

Steps Towards Recovery

1. Acknowledge the problem

2. Limit the time spent with substance abusers

3. Seek professional help

4. Seek support from recovering alcoholics

Alcoholism

Withdrawal Symptoms• Agitation• Circulatory disturbances• Convulsions• Delirium treatments• Digestive disorders• Disorientation• Extreme fear

Alcoholism

Withdrawal Symptoms• Hallucinations• Mental disturbances• Nausea and vomiting• Restlessness• Sweating• Temporary suppression of REM sleep• Tremor and weakness

Alcohol Antagonists

• disulfiram (Antabuse)

• naltrexone (Revia)

• topiramate (Topamax) – not approved yet

Drug List

disulfiram (Antabuse)

• Stops the metabolism of alcohol• Upon consumption of alcohol, side effects

are immediate:– Blurred vision – Confusion– Difficulty breathing – Chest

pain– Severe headache – Nausea– Severe vomiting – Uneasiness– Face becomes hot & scarlet – Thirst

disulfiram (Antabuse)

• Patients must read labels to avoid ETOH:– Cough medicines– Mouthwashes– Flavorings– Salad dressings

topiramate (Topamax)

• Anticonvulsant that can reduce cravings for alcohol

• Takes six weeks to be effective

• Topamax mixed with behavioral therapy looks promising in the treatment of alcoholism