Transcript Document 7279770

Drugs for Treating Psychiatric
Disorders
Chapter 13
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).
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.
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
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
• Serotonin–norepinephrine reuptake inhibitors (SNRIs)
– Effexor, Pristiq, Cymbalta, Dalcipran, Meridia
• Monoamine oxidase inhibitors MAOIs (used rarely)
– Apresoline, Harmalol, Selegiline, Moclobemide
TCAs
Pharmacokinetics
Absorption
• Orally (once a day at bedtime to
minimize unwanted side effects
like persistent sedation)
Distribution
• 4 days of clinical effect and readily
crosses the placental barrier
Metabolism
• Rapidly and almost completely
metabolized by enzymes located in
the liver.
Elimination
• Urine
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
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
SSRIs
Related Neurotransmitters
Blocks the re-uptake of serotonin
*Each drug has a different half life
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 > 60%
Anxiety
Agitation
Insomnia
Rarely suicide
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
SNRIs
Related Neurotransmitters
Blocks the reuptake of serotonin
Blocks the reuptake of norepinephrine
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*
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
MAOIs
Related Neurotransmitters
Breaks down norepinephrine and
serotonin permanently –which means it
could be weeks before new
neurotransmitters are manufactured.
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
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.
Wellbutrin (Bupropion)
works on the
neurotransmitter
dopamine, is unique in that
it does not fit into any
specific drug type.
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
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
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
Bipolar Disorder
4% LPR Laryngopha
-ryngealreflux
> 55% have a
history of
substance abuse
1 in 4 or 5
commits suicide
Must rule out
mania caused by
antidepressants,
caffeine, herbals,
stimulants,
corticosteroids,
cough and cold
preparation, diet
aids, and
hyperthyroid
Bipolar Disorder
Most common drugs used:
• Lithium
• 28% of patients discontinue the drug
• 38% experience recurrences on the drug
• Only 23% don’t have reoccurring episodes
• Valproic Acid
• Antipsychotics
Lithium –a salt
Pharmacokinetics
Absorption
• Orally (once daily due to long
half life)
Distribution
Metabolism
• Peak blood levels reach within 3
hours; crosses blood-brain
barrier incompletely
• Excreted unchanged by kidneys
Elimination
• Urine and skin
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
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
Valproic Acid –antiepileptic drug
Pharmacokinetics
Absorption
• Orally and intravenously for
acute mania
Distribution
• 90% bound to proteins in blood,
10% may make it to the brain (this
Metabolism
Elimination
% 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
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
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
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
Atypical Antipsychotics
Related Neurotransmitters
Serotonin antagonism
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)
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)
Schizophrenia
1% LPR
10-15% commit
suicide
Schizophrenia and the Brain Animation
Schizophrenia
Most common drugs used:
• Typical Antipsychotics (also called
neuroleptics)
- Clozapine, Thorazine, Haldol,
• Atypical antipsychotics
– Risperdal, Abilify, Seroquel
Typical Antipsychotics
Related Neurotransmitters
Dopamine receptor blockage
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)
Atypical Antipsychotics
Related Neurotransmitters
Serotonin antagonism
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)
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.
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
Generalized Anxiety Disorder
Most common drugs used:
• Buspirone (Buspar)
• Benzodiazepines ►
• SSRIs
– Celexa, Prozac, Lexapro, Paxil, Zoloft
• SNRIs
– Effexor, Pristiq, Cymbalta, Dalcipran, Meridia
Buspar (buspirone)
Related neurotransmitters
unknown (possible serotonin receptor agonist; possible
dopamine antagonist)
Buspar (buspirone)
Effects
Anxiety remission with
less withdrawal
symptoms than benzos
dizziness
Headache
Lightheadedness
nausea
Excitement
Sweating/clamminess
Attention Deficient Hyperactivity
Disorder
Inattention Symptoms
6 or more, in more than one situation +
•
•
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•
•
•
•
•
•
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.
Attention Deficient Hyperactivity
Disorder
Hyperactivity Symptoms
Maladaptive in more than one
situation
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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
Attention Deficient Hyperactivity
Disorder
ADHD animation
http://www.healthcentral.com/adhd/video-39189-47.html
Attention Deficient Hyperactivity
Disorder
Most common drugs used:
• Ritalin►
• Adderal ►
Less common drugs used
• Methamphetamine ►
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.
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
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
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).
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.