Mental Health Psychopharmacology

What the drug does to the body

How the drug works in terms of symptoms, cure of disease and the symptoms the drug does.

Acetylcholine
Dopamine
Serotonin
Glutamate

2 Subdivisions:
nicotinic and muscarinic cholinergic receptors
Important:
M1 postsynaptic receptor for mediating effect in memory function

Controls movement
Involved in pleasurable sensation, euphoria, delusions and hallucinations
Intervenes positive and negative psychotic symptoms
Release of prolactin, promotes breastmilk

Reciprocal relationship

Inhibitory catecholamine
Receptors start with “5-HT”
Intervenes with cognitive effects, emotions, pains, memory, anxiety, sleep-wake cycles and inhibits dopamine release.

Major excitatory neurotransmitter

Focuses on the return of baseline functions and no symptoms.

Prevents recurrence of illness

Increases pt functioning while decreasing symptoms

Emphasizes individual growth and achievement despite having a mental illness.

Positive

Negative

Cognitive Function Impairment

Aggressive and Hostile

Depressive and Anxious

1st generation: block D2 receptors

2nd generation: lower potential for EPS (extrapyramidal effects), does not affect negative and cognitive symptoms.

Schizophrenia & schizoaffective disorders
Delusional disorders
Adjunct therapy for Bipolar disorder

Pt needs to follow through with long term care

Cigarette smoking increases drug metabolization and pts would require higher doses.

Use the lowest dose for shortest time.
Positive symptoms are relieved within hours while affective symptoms takes 2-4 weeks to be relieved.
Cognitive and Perceptual symptoms take 2-8 weeks for response.
Negative symptoms take longer to respond.
Always start with 3-4 divided dose/day and wean down to 1-2 dose/day.

No response after 6 weeks
Severe or unusual adverse reaction
Physically ill, older adults and young children

Dystonia
Pseudoparkinsonism
Akathisia
Tardive Dyskinesia

Occur in the initial treatment regimen
Reversed with IM diphenhydramine ( Benadryl) or benztropine (Cogentin)
Spasms of eye, neck, back, tongue or other muscles.

Tx: reduce antipsychotic dose or change med, or oral antiparkinsonian agent
Decreased movements. muscle rigidity, resting hand tremor, drooling and masklike face and shuffling gait.

Restlessness. pacing, rocking and inability to sit still.

Tx: Propranolol and benzodiazepam.

Monitor BP

Severe abnormal movements of any voluntary muscle group that occurs after a long dopamine blockade
No effective Tx.

When tardive dyskinesia occurs, decreasing the med dose worsens tardive dyskinesia but improves EMS.
Increasing dose improves tardive dyskinesia but worsens EPS.

MEDICAL EMERGENCY

Decreased LOC,

increased muscle tone and autonomic dysfunction (hyperreflexia, labile HTN, tachycardia, tachypnea, diaphoresis, and drooling) ,

Fever

myoglobinuria,

leukocytosis

elevated creatine phosphokinase levels.

Discontinue antipsychotic meds
Hydrate with IV fluids
Give Tylenol and cooling blankets for Hyperthermia
IV Heparin for PE if PRN
Manage arrythmias
Monitor Renal Function
Give IV dantrolene (Dantrium), muscle relaxant
Possible dopaminergic drugs (Bromocriptine, amantadine)
Wait 1-2 weeks before restarting antipsych meds

Postural hypotension, esp. older adults
Arrhythmias and Palpitations
Changes in QT intervals - monitor with EKG.

Sedation / Drowsiness

Weight gain

Photosensitivity

Poikilothermic

Galactorrhea and Gynecomastia

Used for short term symptoms of agitation.
Given IV and IM
Caution with elderly pts

Long-Acting Injectible Typical Antipsychotics
Given IM or subQ
Feel effects within 48-96 hours

Long-Acting Injectible Typical Antipsychotics
Deep IM
Given every 4 weeks

Atypical Antipsychotics
Not a first-line therapy due to agranulocytosis
High receptor affinity for D4 and 5-HT2
Used for refractory illness

Risk for Agranulocytosis- decrease or lack of agranulocytic WBCs.

Side Effects:

Sedation,

Anticholinergic effects,

orthostatic hypotension,

weight gain,

hypersalivation and

risk for seizures.

Dry mouth

Blurry vision

Constipation

Urinary retention

Ejaculatory inhibition

Atypical Antipsychotics
Blocks dopamine (D2) receptors
Treats both positive and negative symptoms
Used for older pts and has few anticholinergic effects
Side Effects: insomnia, hypotension, agitation, headache and hyperthermia

Atypical Antipsychotics
Greater D2 blocker and weaker D4 and a-adrenergic blockade
Treats both positive and negative symptoms of schizophrenia, monotherapy for bipolar
Side Effects: Sedation, anticholinergic effects, weight gain, adult onset DM, risk for seizures and hyperprolactinemia

Atypical Antipsychotics
Multiple receptors
Treatment of schizophrenia
Monitor cholesterol and triglycerides for elevation

Atypical Antipsychotics
5HT and D2 antagonist, protects against EPS and inhibits norepinephrine reuptake
Treatment of acute agitation of schizophrenia

Contraindicated pts with heart problems
Increased risk of death with dementia-related psychosis
Take with food
Side Effects: GI discomfort, drowsiness, EPS, akathisia, dizziness, dystonia, hypertonia, tachycardia and postural hypotension, rash, fungal dermatitis, and abnormal vision and upper respiratory function.

Major Depression

Anxiety

OCD

Panic

Bulimia

Anorexia

PTSD

Bipolar

Social Phobia

IBS

Enuresis

Neuropathic pain

Migraine headache

ADHD

Smoking cessation

Autism

Increased neurotransmitter in synapse but less neurotransmitter in synapse

Selective Serotonin Reuptake Inhibitor (SSRIs)
Tricyclic Antidepressants (TCAs)
Monoamine Oxidase Inhibitors (MAOIs)

First-line treatment of antidepressants
Inhibiting reuptake of 5HT
Efficacy depends on pt's tolerance to adverse effects and cost

Life threatening due to interactions with other drugs

Confusion

Hypomania

Restlessness

Myoclonus

Hyperreflexia

Diaphoresis

Shivering

Tremor

Diarrhea

Discontinue med that increases serotonin | Suppoertive measures

Side effects are most severe beginning of tx

GI upset

Insomnia

restlessness

irritability

headache

Sexual dysfunction

EPS

Not lethal with overdose

Second-line therapy
Blocks reuptake of 5-HT and norepinephrine
Anticholinergic side effects, Orthostatic hypotension

Take at bedtime because of sedative effect
Use EKG before therapy - possible cardiotoxicity
Risk of fatality with overdose
Avoid with elderly pts

Block enzyme for degrades norepinephrine, serotonin and dopamine.
Increases postsynaptic downregulation
Used as last resort, resistant to TCAs
Rapidly absorbed and half-life is 24 hours

Cerebrovascular defects

Cardiovascular disease

Pheochromocytoma - tumor in adrenal medulla

Pregnancy

Older than 65yrs old

MAOIs inhibit monoamine oxidase, they decrease the breakdown of tyramine from ingested food, thus increasing the level of tyramine in the body. Excessive tyramine can elevate blood pressure and cause a hypertensive crisis
Symptoms include: Headache, Stiff neck, Sweating, Nausea and vomiting,
Treatment: Nifedipine, and Monitor vital signsq10-15 min

Aged cheese, ripe avocados

• Ripe figs, anchovies, bean curd

• Broad beans, yeast, liver

• Deli meats, pickled herring

• Meat extracts, fermented foods

• Chianti and sherry

Cottage cheese, cream cheese

• Yogurt, sour cream

• Coffee, chocolate

• Spinach, raisins, tomatoes, eggplant

Anti-asthmatics

Antihypertensives

Epinephrine

Allergy, hay fever decongestants

Cough and cold products

Buspirone

Meperidine

SSRIs

Yohimbine

Orthostatic hypotension

Edema

Sexual dysfunction

Weight gain

Insomnia

Confusion and feeling drunk is excessive dose

Teach pt and family about foods to avoid, - give handouts
Teach pts not to take any additional medication without consulting HCP, Dentist and Pharmacist
Teach pt about hypertensive crisis and toxicity
Wait 5 weeks before starting MAOI after discontinuing fluoxetine.
Must be tapered, do not stop abruptly

Venlafaxine (Effexor) – Serotonin-norepinephrine reupdate inhibitor (SNRI)
Nefazodone -
Trazodone – Serotonin modulator
Bupropion – Aminoketone (related to tricyclic, tetracyclic and SSNRI)
Mirtazapine - Noradrenergic and specific serotonergic antidepressant
Saint John's Wort

1st wk: decreased anxiety, improved sleep, pt unaware of changes
1-3 wk: increased activity, sex drive, and self-care abilities, improved concentration and memory and psychomotor retardation resolves
2-4wks: relief of depressed mood, less hopeless, and suicidal ideation subsides

Can increase suicidal thinking and behavior | Can happen in adults as well but monitor the kids

Lithium

Valproate

Carbamazepine

Oxcarbazepine

Lamotrigine

Topiramate

Gabapentin

Tiagabine

Zonisamide

Levetiracetam

Treatment for bipolar mania and depressed episodes
Narrow therapeutic range
Risk for toxicity in older pts
Combine with valproate as first line tx

Monitor blood serum level to avoid adverse effects
Monitor renal function, thyroid function, urinalysis, CBC with differentials, serum electrolytes, ECG and weight.
Pregnancy test to women on child bearing age
Teach pt the side effects of lithium and potential drug interactions
Monitor fluid intake
Avoid salt-restricting diet

Fine tremor

Nausea, vomiting, diarrhea

Mild polydipsia, polyuria

Lethargy, muscle weakness

Weight gain

Increased WBC

Acne, alopecia

Hypothyroidism

Lithium level >1.5 mEq/L

• Coarsening of tremor

• Worsening GI symptoms

• Confusion, slurred speech

• Sedation, lethargy

Lithium level >2.5 mEq/L

RISK FOR PERMANENT NEUROLOGIC IMPAIRMENT

- Arrhythmias

- Bradycardia

- Myocarditis

- Seizures

- Coma

- Death

4 or more mood disorder episodes within 12 months

Anticonvulsant med
First line tx of rapid cycling bipolar
Minor side effects and wider therapeutic range than lithium

Sedation

GI distress

Benign transaminase elevation

Osteoporosis

Tremor

Hair loss

Increased appetite

Weight gain

Monitor baseline liver functions and signs of hepatoxicity
Severe vomit, monitor serum amylase level and evaluate for pancreatitits
Take at bedtime
Anticoagulation therapy, monitor for clotting function
Monitor hepatic function and CBC every 6 months
Teach pt side effects, risks and what to look for

Anticonvulsants
Tx of acute bipolar mania
second-line treatment for bipolar disorder
Does not reach steady state until 4 weeks after initial therapy

Dizziness

Ataxia

Sedation

Diplopia

Stupor

Coma

Tx: gastric lavage and symptom management

Effects does not show until 4 weeks after initial dose
Monitor CBC and liver function test every 2 weeks
Teach pts to monitor for signs and symptoms of hematologic and hepatic abnormalities
Teach pt to call HCP when rash occurs

Treatment for bipolar disorder
Alternate tx to carbamazepine
Risks for hyponatremia esp with older adults
Decreases T4 hormone in thyroid

Treatment for rapid cycling bipolar disorder
Reduce the dose of lamotrigine by half if taken with valproate
risks for steven johnson syndrome

Adjunctive therapy for seizures
Treatment for binge eating, bulimia, cluster headache, Tourette's syndrome and trigeminal neuralgia
Risk for acute myopia and glaucoma
Caution with renal impairment pts and avoid pts with glaucoma
Risk for anemia

Use of mood stabilizer | For agitation, benzodiazepine can be added to initial tx

Avoid TCAs | Monitor pt because antidepressant can cause pt to have mania

Antidepressant
Benzodiazepine - rapid onset
Buspirone - longer onset

Rapid onset

Cognitive impairment
Decreased coordination
Potential Drug Abuse
Withdrawal symptoms

Clonazepam
Lorazepam
Alprazolam

Persistent and recurrent thoughts, images, impulses and behaviors that are distressing to the individual and impair daily function

Antidepressants: SSRIs and clomipramine

Cognitive Behavioral Therapy

Dopamine-blocking agents: Haloperidol

Busipirone

Lithium

Clonazepam

Recurrent life symtoms in response to very serious life events

Antidepressants: SSRIs
Benzodiazepines: Clonazepam
Mood stabilizers

Most common anxiety disorder
Strong persistent anxiety that results from fear of scrutiny by others, embarrassment or humiliation
High incidence with alcohol abuse and depression

Antidepressant: SSRIs

Benzodiazepine: Clonazepam and alprazolam

Gabapentin

Kava Kava

Valerian

Educate pt that anxiety is a treatable illness
Educate about different types of medications, side effects, precautions and contraindications
Encourage pt to be part of decision making
Meds take several weeks to achieve maximum effects
Advise pt regarding drug-drug and drug-herb interactions
Encourage nonpharmacologic interventions
Caution pts with mixing alcohol with drinks, avoid driving or operating machinery

Hypnotics: benzodiazepine

Nonbenzodiazepine hypnotics

Trazadone - avoid alcohol

Chloral Hydrate - avoid alcohol

Diphenhydramine - tolerance in 2 weeks and avoid in older adults

Melatonin - Avoid with other CNS drugs

Barbituates

Kava Kava

Valerian

Triazolam - Difficulty falling asleep
Temazepam - awakens early who cannot stay asleep
Flurazepam - difficulty falling asleep and staying asleep. Possible rebound insomnia

Zolpidem - limit to 7-10 days and reevaluate pt
Zaleplon - For middle night to early morning, dizziness and headache
Eszopiclone -
Rozarem

SSRI
For pts undergoing drug and alcohol detox
Side effects: sedation, orthostatic hypotension and priapism.

Sedate and calm pts and prevent self-harm or harm to others | Treat chronic aggressive behaviors

Antipsychotics: Haloperidol Ziprasidone Quetiapine Risperidone Olanzapine
Benzodiazepines
Traozodone

Schizophrenia: Antipsychotics
Mania: Lithium & Valproate
Seizure disorder: Carbamazepine & Valproate
Older adults: Trazodone