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Flashcards in Mod 3 Psychotherapeutic Drugs Deck (48):
1

Psychotherapeutic Drugs

Used in the treatment of emotional and
mental disorders
 Ability to cope with emotions can range from occasional depression or anxiety to constant emotional distress
 When emotions significantly affect an individual’s
ability to carry out normal daily functions,
treatment with a psychotherapeutic drug is a possible option

2

Psychotherapeutic Drugs (cont’d

Three main emotional and mental disorders:
 Anxiety
 Affective disorders
 Psychoses
Types of psychotherapeutic drugs
 Antianxiety drugs
 Antimanic drugs
 Antidepressant drugs
 Antipsychotic drugs

3

Biochemical Imbalance

Other biochemicals are necessary for normal
mental function
 GABA
 Acetylcholine (ACh)
 Sodium, potassium, magnesium

4

Anxiety

Unpleasant state of mind, characterized by a
sense of dread and fear
 May be based on actual anticipated
experiences or past experiences May be exaggerated responses to imaginary
negative situations

5

Anxiety Disorders

Six major anxiety disorders (persistent anxiety)
 Obsessive-compulsive disorder (OCD)
 Posttraumatic stress disorder (PTSD)
 Generalized anxiety disorder (GAD)
 Panic disorder
 Social phobia
 Simple phobia

6

Affective Disorders
(Mood Disorders)

Changes in mood that range from mania
(abnormally pronounced emotions) to
depression (abnormally reduced emotions) Some patients may exhibit both mania and
depression: bipolar disorder (BPD)

7

Psychosis

Severe emotional disorder that impairs the
mental function of the affected individual to
the point that the individual cannot participate
in activities of daily living
 Hallmark: loss of contact with reality
 Examples
 Schizophrenia
 Depressive and drug-induced psychoses

8

Psychotherapeutics:
Pathophysiology

Biochemical imbalance theory
 Mental disorders are associated with
abnormal levels of endogenous chemicals,
such as neurotransmitters, in the brain
Biochemical imbalance theory (cont’d)
 Brain levels of certain neurotransmitters play an
important role in maintaining mental health
 Catecholamines
 Dopamine
 Norepinephrine
 Indolamines
 Serotonin
 Histamine

9

Antianxiety Drugs

Reduce anxiety by reducing overactivity in
CNS
Benzodiazepines
• Depress activity in the brainstem and limbic system
Miscellaneous drug: Buspirone (BuSpar)
• Nonsedating and non–habit forming
• May have drug interaction with SSRIs (serotonin
syndrome)
• Do not administer with MAOIs

10

Antianxiety Drugs: Indications

Anxiety
 Insomnia
 Sedation
 Muscle spasms
 Seizure disorders
 Adjuncts in anesthesia
 Adjuvant therapy for depression
 Alcohol (ethanol) withdrawal

11

Common Benzodiazepines

diazepam (Valium)
 lorazepam ( Ativan)
 alprazolam (Xanax)
 clonazepam (Klonopin)
 chlordiazepoxide (Librium)
Midazolam (Versed)*
 Reduces anxiety and patient’s memory of painful
procedures that do not require general anesthesia
(moderate sedation)
 Injection only
*Limited to use as sedative and anesthetic during invasive medical or
surgical procedures

12

Benzodiazepines

Potentially habit-forming and addictive
Should be used at lowest effective dosages
and frequencies needed for symptom control

13

Benzodiazepines:
Adverse Effects

Benzodiazepine adverse effects are an
overexpression of their therapeutic effects
 Decreased CNS activity sedation
activity, Hypotension
 Drowsiness, loss of coordination, dizziness, headaches
 Nausea, vomiting, dry mouth, constipation

14

Benzodiazepines: Overdose

Dangerous when taken with other sedatives
or alcohol
 Treatment is generally symptomatic and
supportive
 Flumazenil may be used to reverse
benzodiazepine effects

15

Affective Disorder Drugs

Mood stabilizers
 Used to treat bipolar disorder
• Involves cycles of mania, hypomania, and depression
 Antidepressants
 Used to treat depression

16

Mood Stabilizers:
Antimanic Drugs

Lithium is the drug of choice for the treatment
of mania
 It is thought to potentiate serotonergic
neurotransmission
 May be used with other medications to stabilize
mood
 Narrow therapeutic range: maintenance serum
levels should range between 0.6 and 1.2 mEq/L
Monitor sodium levels
Low TI

17

Depression

Etiology (cont’d)
 Permissive hypothesis
 Affective disorders are caused by decreased
concentrations of serotonin
• Depression results from decreases in both serotonin and
catecholamine levels
• Mania results from increased catecholamine but decreased serotonin levels

18

Antidepressants

Tricyclic antidepressants
 Monoamine oxidase inhibitors (MAOIs)
 Newer-generation antidepressants
 Selective serotonin reuptake inhibitors (SSRIs) Second- and third-generation antidepressants

19

Tricyclic Antidepressants:
First-Generation Antidepressants

Have largely been replaced by SSRIs as
first-line antidepressant drugs
 Considered second-line
 For patients who fail with SSRIs or other newer-generation antidepressants
 As adjunct therapy with newer-generation
antidepressants

20

Common Tricyclics

amitriptyline (Elavil, Endep)
 doxepin (Sinequan)
 imipramine (Tofranil)
 desipramine (Norpramin)
nortriptyline (Aventyl, Pamelor)

21

Mechanism of Action

Block reuptake of neurotransmitters, causing
accumulation at the nerve endings
 It is thought that increasing concentrations of
neurotransmitters will correct the abnormally low levels that lead to depression

22

Drug Effects

Blockade of norepinephrine reuptake
 Antidepressant,* tremors, tachycardia
 Blockade of serotonin reuptake
 Antidepressant,* nausea, headache, anxiety, sexual dysfunction
*Desired therapeutic effects

23

Indications

Depression
 Childhood enuresis (imipramine)
 Obsessive-compulsive disorders
(clomipramine)
 Adjunctive analgesics for chronic pain
conditions, such as trigeminal neuralgia

24

Adverse Effects

Sedation
 Impotence
 Orthostatic hypotension
 Dysrhythmias
 Seizures
 Older patients
 Dizziness, postural hypotension, constipation,
delayed micturation, edema, muscle tremors

25

Overdose

Lethal—70% to 80% die before reaching the
hospital
 CNS and cardiovascular systems are
mainly affected
 Death results from seizures or dysrhythmias
No specific antidote
 Decrease drug absorption with activated charcoal
 Speed elimination by alkalinizing urine
 Manage seizures and dysrhythmias
 Basic life support

26

MAOIs

Highly effective
 Considered second-line treatment for
depression, not responsive to cyclics
Disadvantage: potential to cause
hypertensive crisis when taken with tyramine
Examples
phenelzine (Nardil)
tranylcypromine (Parnate

27

MAOIs: Mechanism of Action

Inhibit MAO enzyme system in the CNS
Amines (dopamine, serotonin,
norepinephrine) are not broken down,
resulting in higher levels in the brain
Result: alleviation of symptoms of depression

28

MAOIs: Indications

Depression, especially types characterized by increased sleep and appetite
Depression that does not respond to other antidepressants

29

Hypertensive Crisis
and Tyramine

Ingestion of foods or drinks with tyramine
leads to hypertensive crisis, which may lead
to cerebral hemorrhage, stroke, coma, or
death
Avoid foods that contain tyramine!
Aged, mature cheeses (cheddar, blue, Swiss)
Smoked/pickled or aged meats, fish, poultry (herring,
sausage, corned beef, salami, pepperoni, paté)
Yeast extracts
Red wines (Chianti, burgundy, sherry, vermouth)
Italian broad beans (fava beans)

30

MAOIs

Concurrent use of MAOIs and SSRIs may
lead to serotonin syndrome
If the decision is made to switch to an SSRI,
there must be a 2- to 5-week “wash-out”
period between MAOI therapy and SSRI
therapy

31

Newer-Generation
Antidepressants

Fewer adverse effects than tricyclics and
MAOIs
Very few drug-drug or drug-food interactions
Still take about 4 to 6 weeks to reach
maximum clinical effectiveness
 Now considered first-line drugs for
depression

32

Newer-Generation
Antidepressants (cont’d)

trazodone (Desyrel)
 bupropion (Wellbutrin)
 SSRIs
 fluoxetine (Prozac)
 paroxetine (Paxil)
 sertraline (Zoloft)
 fluvoxamine (Luvox)
 citalopram (Celexa)
 escitalopram (Lexapro

33

Newer-Generation
Antidepressants (cont’d)

venlafaxine (Effexor)
 nefazodone (Serzone)
 mirtazapine (Remeron)
 duloxetine (Cymbalta)
 desvenlafaxine (Pristiq)

34

SSRIs

Mechanism of action
 Selectively inhibit serotonin reuptake
 Little or no effect on norepinephrine or dopamine reuptake
Result in increased serotonin concentrations atnerve endings
Advantage over tricyclics and MAOIs: little or no effect on cardiovascular system

35

Newer-Generation
Antidepressants: Indications

Depression
Bipolar disorder
  Obesity
 Eating disorders
 Obsessive-compulsive disorder
Panic attacks or disorders
 Social anxiety disorders Posttraumatic stress disorders (PTSDs)
 Treatment of various substance abuse
problems (bupropion [Zyban] is used for
smoking cessation treatment

36

Newer-Generation
Antidepressants: Adverse Effects

Body System Effects
CNS Headache, dizziness,tremor,nervousness,insomnia,* fatigue
GI Nausea diarrhea
Nausea, diarrhea,constipation, dry mouth
Other Sexual dysfunction,weight gain*,
weight
loss*, sweating

37

Serotonin Syndrome

Signs/symptoms
 Delirium, tachycardia, hyperreflexia, shivering,agitation, sweating, muscle spasms, coarse
tremors
Signs/symptoms of severe cases
Hyperthermia, seizures, renal failure,
rhabdomyolysis, dysrhythmias, disseminated
intravascular coagulation (DIC)

38

Newer-Generation
Antidepressants: Drug
Interactions

Highly bound to plasma proteins
 Compete with other protein-binding drugs, resulting in more free, unbound drug to cause a more pronounced drug effect
Inhibition of cytochrome P-450 system
MAOIs

39

Antipsychotics

Drugs used to treat serious mental illness
 Behavioral problems or psychotic disorders
 Have been known as tranquilizers or
neuroleptics
Thioxanthenes: thiothixene (Navane)
 Butyrophenones: haloperidol (Haldol)
 Dihydroindolones: molindone (Moban)
 Dibenzoxazepine: loxapine (Loxitane)
 Phenothiazines: three structural groups
 Atypical antipsychotics: new class

40

Mechanism of Action

Block dopamine receptors in the brain (limbic
system, basal ganglia)—areas associated
with emotion, cognitive function, motor
function
Result: tranquilizing effect in psychotic
patients

41

Atypical Antipsychotics:
Second-Generation
Antipsychotics

clozapine (Clozaril)
 risperidone (Risperdal)
 olanzapine (Zyprexa)
 quetiapine (Seroquel)
 ziprasidone (Geodon)
 aripiprazole (Abilify)
 paliperidone (Invega)

42

Atypical Antipsychotics:
Mechanism of Action

Block specific dopamine receptors: DA-2 (D2)
receptors
Also block specific serotonin receptors: 5HT 2
5HT-(5HT2) receptors
This is responsible for their improved efficacy and safety profiles

43

Antipsychotics: Indications

Treatment of serious mental illnesses
 Bipolar affective disorder
 Depressive and drug-induced psychoses
 Schizophrenia
Autism
 Movement disorders (such as Tourette’s
syndrome) Some medical conditions
 Nausea, intractable hiccups

44

Adverse Effects

Body System Adverse Effects
CNS Sedation, delirium
Cardiovascular Orthostatic hypotension,
syncope, dizziness, ECG changes
Dermatologic Photosensitivity, skin
rash, hyperpigmentation, pruritus

45

Adverse Effects (cont’d)

Body System Adverse Effects
GI Dry mouth, constipation
GU Urinary hesitancy or
retention, impaired erection
Hematologic Leukopenia and
agranulocytosis
Body System Adverse Effects
Metabolic/endocrine Galactorrhea,
irregular menses, increased appetite, polydipsia

46

Adverse Effects (cont’d)

Neuroleptic malignant syndrome (NMS)
 Potentially life threatening
 High fever, unstable BP, myoglobinemia
 Extrapyramidal symptoms (EPS)
 Involuntary muscle symptoms similar to those of Parkinson’s disease
Akathisia (distressing muscle restlessness)
Acute dystonia (painful muscle spasms)
 Treated with benztropine (Cogentin) and
trihexyphenidyl (Artane)

47

Adverse Effects (cont’d

Tardive dyskinesia (TD)
Involuntary contractions of oral and facial muscles
Choreoathetosis (wavelike movements of
extremities)
Occurs with continuous long-term antipsychotic therapy

48

Herbal Products: St. John’s Wort

Used for depression, anxiety, sleep disorders,
nervousness
May cause GI upset, fatigue, dizziness,
confusion, dry mouth, photosensitivity
Severe interactions if taken with MAOIs and SSRIs
Food-drug interaction with tyramine containing foods