Drugs for Treating Psychiatric Disorders

1
Drugs for Treating Psychiatric Disorders

• Chapter 13

2
What are Psychotropic Medications?

• Medications are used to treat the symptoms of
  mental disorders such as schizophrenia,
  depression, bipolar disorder (sometimes called
  manic-depressive illness), anxiety disorders, and
  attention deficit-hyperactivity disorder (ADHD).

3
Side Effects to Psychotropic Drugs?

• Some people get side effects from medications and
  other people don't
• Factors that can affect how medications work in
  people include
• Type of mental disorder, such as depression,
  anxiety, bipolar disorder, and schizophrenia
• Age, sex, and body size
• Physical illnesses
• Habits like smoking and drinking
• Liver and kidney function
• Genetics
• Other medications and herbal/vitamin supplements
• Diet
• Whether medications are taken as prescribed.

4
Depression

• Symptoms
• Most symptoms, felt most days over 2 weeks
• Depressed mood most of the day,
• Markedly diminished interest or pleasure
• Significant weight loss when not dieting or
  weight gain
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Diminished ability to think or concentrate, or
  indecisiveness
• Recurrent thoughts of death

5
Depression

• Most common drugs used
• Tricyclic antidepressants (TCAs) used mostly in
  the past though no other group of antidepressants
  was been demonstrated as more effective or fast
  working)
• Elavil, Tofranil, Pamelor
• Selective serotonin reuptake inhibitors (SSRIs)
• Celexa, Prozac, Lexapro, Paxil, Zoloft
• Serotoninnorepinephrine reuptake inhibitors
  (SNRIs)
• Effexor, Pristiq, Cymbalta, Dalcipran, Meridia
• Monoamine oxidase inhibitors MAOIs (used rarely)
• Apresoline, Harmalol, Selegiline, Moclobemide

6
TCAs
Pharmacokinetics

• Orally (once a day at bedtime to minimize
  unwanted side effects like persistent sedation)
• 4 days of clinical effect and readily crosses the
  placental barrier
• Rapidly and almost completely metabolized by
  enzymes located in the liver.
• Urine

• Absorption
• Distribution
• Metabolism
• Elimination

7
TCAs
Related Neurotransmitters

• Therapeutic effects comes from blocking reuptake
  of dopamine, serotonin, and norepinephrine
• Blockade of ACH receptors results in dry mouth,
  confusion, memory impairments, and blurred vision
• Blockage of histamine receptors results in
  drowsiness and sedation

8
TCAs
Effects

• Elevated mood
• Increased physical activity
• Improved appetite
• Improved sleep patterns
• Reduced morbid preoccupation
• Clinically effective in the long-term therapy of
  dysthymia

• Dry mouth
• Confusion
• Memory impairments
• Blurred vision
• Sedation
• Cardiac depression
• Cardiac arrhythmias

9
SSRIs
Related Neurotransmitters

• Blocks the re-uptake of serotonin
• Each drug has a different half life

10
SSRIs
Effects

• Elevated mood
• Increased physical activity
• Improved appetite
• Improved sleep patterns
• Reduced morbid preoccupation
• Clinically effective in the long-term therapy of
  dysthymia

• Sexual dysfunction gt 60
• Anxiety
• Agitation
• Insomnia
• Rarely suicide

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SSRIs
Caution!

• Suicide
• Serotonin syndrome (most likely to occur when
  SSRIs are combined with each other, other
  antidepressants, or valerian root)
• - Alterations in cognition, autonomic nervous
  system, and neuromuscular activity which could be
  life threatening.
• Serotonin Withdrawal Syndrome (occurs in perhaps
  60 of SSRI-treated patients following drug
  removal)
• - Disequilibrium, gastrointestinal symptoms,
  sensory disturbances (sensation of electric
  shocks), sleep disturbances

12
SNRIs
Related Neurotransmitters

• Blocks the reuptake of serotonin
• Blocks the reuptake of norepinephrine

13
SNRIs
Effects

• Elevated mood
• Increased physical activity
• Improved appetite
• Improved sleep patterns
• Reduced morbid preoccupation
• Clinically effective in the long-term therapy of
  dysthymia

• Dry mouth
• Dizziness
• nausea
• Blurred vision
• Sedation

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SNRIs
Caution!

• Suicide
• Serotonin syndrome (most likely to occur when
  SSRIs are combined with each other, other
  antidepressants, or valerian root)
• - Alterations in cognition, autonomic nervous
  system, and neuromuscular activity which could be
  life threatening.
• Serotonin Withdrawal Syndrome (occurs in perhaps
  60 of SSRI-treated patients following drug
  removal)
• - Disequilibrium, gastrointestinal symptoms,
  sensory disturbances (sensation of electric
  shocks), sleep disturbances

15
MAOIs
Related Neurotransmitters

• Breaks down norepinephrine and serotonin
  permanently which means it could be weeks before
  new neurotransmitters are manufactured.

16
MAOIs
Effects

• Elevated mood
• Increased physical activity
• Improved appetite
• Improved sleep patterns
• Reduced morbid preoccupation
• Clinically effective in the long-term therapy of
  dysthymia

• Potential fatal blood pressure increases when
  mixed with common foods

17
MAOIs
Caution!

• Death when mixed with common foods like cheese,
  wine, beer, soy, coffee, chocolate
• Serotonin syndrome (most likely to occur when
  MAOIs are combined with each other, other
  antidepressants, or valerian root)
• - Alterations in cognition, autonomic nervous
  system, and neuromuscular activity which could be
  life threatening.

18
Wellbutrin (Bupropion)
works on the neurotransmitter dopamine, is unique
in that it does not fit into any specific drug
type.
19
Herbal Remedies for Depression?

• NIH conducted a clinical trial to determine the
  effectiveness of treating adults who have major
  depression with St. Johns wort.
• The single-blind study included 340 people
  diagnosed with major depression.
• 1/3 took the herbal medicine, 1/3 took an SSRI,
  and 1/3 took placebo.

The study found that St. John's wort was no more
effective than the placebo in treating major
depression
20
Bipolar Disorder

• Depressive Symptoms
• 5 or more, in same 2 week period
• Depressed mood most of the day,
• Markedly diminished interest of pleasure
• Significant weight loss when not dieting or
  weight gain
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Diminished ability to think or concentrate, or
  indecisiveness
• Recurrent thoughts of death

21
Bipolar Disorder

• Mania Symptoms
• 3 or more, lasting at least 1 week
• inflated self-esteem or grandiosity
• decreased need for sleep
• more talkative than usual or pressure to keep
  talking
• flight of ideas or subjective experience that
  thoughts are racing
• distractibility increase in goal-directed
  activity or psychomotor agitation
• excessive involvement in pleasurable activities
  that have a high potential for painful
  consequences

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Bipolar Disorder
4 LPR - Laryngopha-ryngeal- reflux
1 in 4 or 5 commits suicide
gt 55 have a history of substance abuse
Must rule out mania caused by antidepressants,
caffeine, herbals, stimulants, corticosteroids,
cough and cold preparation, diet aids, and
hyperthyroid
23
Bipolar Disorder

• Most common drugs used
• Lithium
• 28 of patients discontinue the drug
• 38 experience recurrences on the drug
• Only 23 dont have reoccurring episodes
• Valproic Acid
• Antipsychotics

24
Lithium a salt
Pharmacokinetics

• Orally (once daily due to long half life)
• Peak blood levels reach within 3 hours crosses
  blood-brain barrier incompletely
• Excreted unchanged by kidneys
• Urine and skin

• Absorption
• Distribution
• Metabolism
• Elimination

25
Lithium
Effects

• Less mania (though not less time to recurrence
  compared to placebo)
• Reduction in suicidal behaviors

• Nausea, vomiting, diarrhea, abdominal pain
• tremor, lethargy, impaired concentration, slurred
  speech, ataxia, muscle weakness
• Memory loss
• Weight gain (depressed thyroid)
• Hallucinations
• Muscle rigidity, coma, renal failure, cardiac
  arrhythmias, and death

26
Lithium
Caution!

• Illness course is believed to be worse after
  stopping lithium than having never received the
  drug (including super high suicidal behaviors and
  completions).
• Low compliance due to side effects, high
  likelihood of relapse, and missing the high
• High rate of interactions with other drugs
• About 40 are either resistant to lithium or
  develop side effects that limit its effectiveness

27
Valproic Acid antiepileptic drug
Pharmacokinetics

• Orally and intravenously for acute mania
• 90 bound to proteins in blood, 10 may make it
  to the brain (this rises shockingly if too much
  is administered)
• 95 broken down by liver with metabolites that
  contribute to side effects. Differences between
  peak and trough levels can be extreme
• Urine

• Absorption
• Distribution
• Metabolism
• Elimination

28
Valproic Acid
Effects

• Less mania (though not less time to recurrence
  compared to placebo)
• Reduction in suicidal behaviors

• GI upset
• Sedation
• Lethargy
• Hand tremor
• Alopecia (loss of hair)
• Metabolic changes in liver
• Decreased cognitive function
• Obesity (rarer side effects)
• Fertility problems in women and masculinization

29
Valproic Acid
Caution!

• Causes excess ammonia in the blood
  (hyperammonemia) which can lead to brain damage
• Overdose tremor, stupor, respiratory
  depression, coma, metabolic acidosis and death

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Antidepressants used in treatment of bipolar
disorder

• Fluoxetine (Prozac), paroxetine (Paxil), or
  sertraline (Zoloft) are sometimes given to people
  with bipolar disorder
• CAUTION should not take an antidepressant on its
  own. Doing so can cause the person to rapidly
  switch from depression to mania

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Atypical Antipsychotics
Related Neurotransmitters

• Serotonin antagonism

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Atypical Antipsychotics
Effects

• Less mania (depending on drug used)
• More mania (depending on drug used)

• Sedation (in some drugs)
• Increased motor activity
• Agitation
• Weight gain
• Extrapyramidal effects
• Akathesia (sensation of inner restlessness)
• Tardive dyskinesia (purposeless movements)

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Schizophrenia

• Symptoms
• 2 or more for a sig. portion of time during 1-mo.
  period
• delusions
• hallucinations
• disorganized speech (e.g., frequent derailment or
  incoherence, echolalia)
• grossly disorganized or catatonic behavior
• negative symptoms (i.e. affective flattening,
  mental confusion, or lack of initiation/motivation
  )

34
Schizophrenia
1 LPR
10-15 commit suicide
Schizophrenia and the Brain Animation
35
Schizophrenia

• Most common drugs used
• Typical Antipsychotics (also called neuroleptics)
• - Clozapine, Thorazine, Haldol,
• Atypical antipsychotics
• Risperdal, Abilify, Seroquel

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Typical Antipsychotics
Related Neurotransmitters

• Dopamine receptor blockage

37
Typical Antipsychotics
Effects

• Less positive symptoms of schizophrenia

• Worse negative symptomatology of schizophrenia
• Sedation
• Extrapyramidal effects
• Akathesia (sensation of inner restlessness)
• Tardive dyskinesia (purposeless movements)

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Atypical Antipsychotics
Related Neurotransmitters

• Serotonin antagonism

39
Atypical Antipsychotics
Effects

• Less positive symptoms of schizophrenia

• Sedation (in some drugs)
• Increased motor activity
• Agitation
• Weight gain
• Extrapyramidal effects
• Akathesia (sensation of inner restlessness)
• Tardive dyskinesia (purposeless movements)

40
Medications for Anxiety Disorders

• Anxiety disorders include
• Obsessive compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Generalized anxiety disorder (GAD)
• Panic disorder
• Social phobia
• Fear of open and closed spaces
• (agoraphobia)
• Antidepressants, anti-anxiety medications, and
  beta-blockers are the most common medications
  used for anxiety disorders.

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Generalized Anxiety Disorder

• Symptoms
• 3 or more, felt most days over 6mos
• Feeling wound-up, tense, or restless
• Easily becoming fatigued or worn-out
• Concentration problems
• Irritability
• Significant tension in muscles
• Difficulty with sleep

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Generalized Anxiety Disorder

• Most common drugs used
• Buspirone (Buspar)
• Benzodiazepines ?
• SSRIs
• Celexa, Prozac, Lexapro, Paxil, Zoloft
• SNRIs
• Effexor, Pristiq, Cymbalta, Dalcipran, Meridia

43
Buspar (buspirone)
Related neurotransmitters

• unknown (possible serotonin receptor agonist
  possible dopamine antagonist)

44
Buspar (buspirone)
Effects

• Anxiety remission with less withdrawal symptoms
  than benzos

• dizziness
• Headache
• Lightheadedness
• nausea
• Excitement
• Sweating/clamminess

45
Attention Deficient Hyperactivity Disorder

• Inattention Symptoms
• 6 or more, in more than one situation
• Often does not give close attention to details or
  makes careless mistakes in schoolwork, work, or
  other activities.
• Often has trouble keeping attention on tasks or
  play activities.
• Often does not seem to listen when spoken to
  directly.
• Often does not follow instructions and fails to
  finish schoolwork, chores, or duties in the
  workplace (not due to oppositional behavior or
  failure to understand instructions).
• Often has trouble organizing activities.
• Often avoids, dislikes, or doesn't want to do
  things that take a lot of mental effort for a
  long period of time (such as schoolwork or
  homework).
• Often loses things needed for tasks and
  activities (e.g. toys, school assignments,
  pencils, books, or tools).
• Is often easily distracted.
• Is often forgetful in daily activities.

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Attention Deficient Hyperactivity Disorder

• Hyperactivity Symptoms
• Maladaptive in more than one situation
• Often fidgets with hands or feet or squirms in
  seat.
• Often gets up from seat when remaining in seat is
  expected.
• Often runs about or climbs when and where it is
  not appropriate (adolescents or adults may feel
  very restless).
• Often has trouble playing or enjoying leisure
  activities quietly.
• Is often "on the go" or often acts as if "driven
  by a motor".
• Often talks excessively.

• Impulsivity Symptoms
• Maladaptive in more than one situation
• Often blurts out answers before questions have
  been finished.
• Often has trouble waiting one's turn.
• Often interrupts or intrudes on others

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Attention Deficient Hyperactivity Disorder
ADHD animation
http//www.healthcentral.com/adhd/video-39189-47.h
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Attention Deficient Hyperactivity Disorder

• Most common drugs used
• Ritalin?
• Adderal ?
• Less common drugs used
• Methamphetamine ?

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Special Needs Groups

• Psychiatric medications are taken by all types of
  people, but some groups have special needs,
  including
• Children and adolescents
• Older adults
• Women who are pregnant or may become pregnant.

50
Children

• Great care needs to be taken in prescribing
  psychotropic drugs to children
• FDA indicated that Prozac should never be used in
  children because of brain damage issues
• Brain is still developing and impacted more
  negatively than in adults

51
Older Adults

• Often have more medical problems
• than other groups and tend to take
• more medications than younger
• people, including prescribed, over-the-counter,
  and herbal medications.
• Higher risk for experiencing bad drug
  interactions, missing doses, or overdosing.
• More sensitive to medications.
• More likely to experience paradoxical effects

52
Women pregnant or planning

• Research is inconsistent in determining whether
  antidepressants are safe during pregnancy
• Some research suggests the use of SSRIs during
  pregnancy is associated with miscarriage or birth
  defects, but other studies do not support this
• Fetuses exposed to SSRIs during the third
  trimester may be born with "withdrawal" symptoms
  such as breathing problems, jitteriness,
  irritability, trouble feeding, or hypoglycemia
  (low blood sugar).

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Some medications should not be taken during
pregnancy.

• Benzodiazepines may cause birth defects or other
  infant problems, especially if taken during the
  first trimester.
• Mood stabilizers are known to cause birth
  defects.
• Benzodiazepines and lithium have been shown to
  cause "floppy baby syndrome," which is when a
  baby is drowsy and limp, and cannot breathe or
  feed well.