Psychopharmacology – Antipsychotics and Antidepressants

Question 1

Psychopharmacology – Antipsychotics and Antidepressants
Usage statistics

Answer 1

In the United States, approximately 1 in 6 adults filled prescriptions for psychiatric drugs in 2013, with antidepressants being the most commonly prescribed type (12%), followed by anxiolytics, sedatives, and hypnotics (8.3%), and antipsychotics (1.6%).

Question 2

Antipsychotics:

First-Generation Antipsychotics (FGAs):

Answer 2

Also known as traditional or conventional antipsychotics.
Used to treat schizophrenia and other psychotic disorders.
More effective for positive symptoms of schizophrenia.
Mechanism: Primarily block dopamine (especially D2) receptors.

Question 3

First-Generation Antipsychotics (FGAs) Examples

Answer 3

Examples: Chlorpromazine (Thorazine), haloperidol (Haldol), thioridazine (Mellaril), fluphenazine (Prolixin).

Question 4

First-Generation Antipsychotics (FGAs) - Side effects

Answer 4

Anticholinergic Side Effects: Dry mouth, blurred vision, urinary retention, constipation, tachycardia.
Extrapyramidal Side Effects: Parkinsonism, dystonia, akathisia, tardive dyskinesia.
Neuroleptic Malignant Syndrome (NMS): Rare and life-threatening; symptoms include muscle rigidity, fever, autonomic dysfunction, altered mental state.

Question 5

Management of tardive dyskinesia

Answer 5

Management of tardive dyskinesia involves gradually withdrawing the drug, administering benzodiazepines, or switching to second-generation antipsychotics. Neuroleptic malignant syndrome requires immediate discontinuation of the drug and supportive therapy.

Question 6

Second-Generation Antipsychotics (SGAs)

Answer 6

Also known as atypical antipsychotics, SGAs include clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and aripiprazole (Abilify).

Question 7

Second-Generation Antipsychotics (SGAs)
Uses

Answer 7

Treatment of schizophrenia and other psychotic disorders.
Some are FDA-approved as adjunctive treatments for major depressive disorder.

Question 8

Second-Generation Antipsychotics (SGAs)
Efficacy

Answer 8

SGAs are as effective as or more effective than FGAs for treating positive symptoms of schizophrenia.
They are more effective than FGAs for treating negative symptoms, particularly clozapine.
SGAs may be effective when FGAs have been ineffective.

Question 9

Second-Generation Antipsychotics (SGAs)
Mechanism

Answer 9

Primarily block dopamine receptors, especially D3 and D4, to alleviate positive symptoms.
Block serotonin receptors to alleviate negative and cognitive symptoms.

Question 10

Second-Generation Antipsychotics (SGAs)
Side Effects

Answer 10

Less likely to cause extrapyramidal side effects compared to FGAs.
Can cause anticholinergic effects, neuroleptic malignant syndrome, and metabolic syndrome.
Metabolic syndrome includes weight gain, high blood pressure, insulin resistance, hyperglycemia, and increased risk for diabetes mellitus and heart disease.
Clozapine and other SGAs can cause agranulocytosis, a potentially life-threatening condition characterized by a dangerously low white blood cell count. Regular white blood cell monitoring is necessary

Question 11

Antidepressants

Answer 11

The major antidepressants include the selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), norepinephrine dopamine reuptake inhibitors (NDRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs).

Question 12

Selective Serotonin Reuptake Inhibitors (SSRIs)

Answer 12

SSRIs include fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), and citalopram (Celexa).

SSRIs offer an effective and generally well-tolerated treatment option for various psychiatric disorders, but precautions should be taken to avoid potential side effects and drug interactions.

Question 13

Selective Serotonin Reuptake Inhibitors (SSRIs)
Uses

Answer 13

First-line pharmacological treatment for major depressive disorder and persistent depressive disorder.
Also used to treat premenstrual dysphoric disorder, obsessive-compulsive disorder (OCD), panic disorder, generalized anxiety disorder, post-traumatic stress disorder (PTSD), bulimia nervosa, and premature ejaculation.

Question 14

Selective Serotonin Reuptake Inhibitors (SSRIs)
Mechanism

Answer 14

Therapeutic effects primarily achieved by blocking the reuptake of serotonin at nerve synapses.
Fluoxetine may also increase levels of norepinephrine and dopamine.

Question 15

Selective Serotonin Reuptake Inhibitors (SSRIs)
Efficacy

Answer 15

Comparable efficacy to tricyclic antidepressants (TCAs) but with fewer side effects.

Question 16

Selective Serotonin Reuptake Inhibitors (SSRIs)
Advantages

Answer 16

Fewer side effects compared to TCAs.
Safer in overdose and for older adults.
Delayed onset of therapeutic effects (about two to four weeks).

Question 17

Selective Serotonin Reuptake Inhibitors (SSRIs)
Side Effects

Answer 17

Mild anticholinergic effects.
Gastrointestinal disturbances.
Insomnia.
Anxiety.
Sexual dysfunction.
Discontinuation syndrome upon abrupt cessation.
Potential for serotonin syndrome when combined with MAOIs, lithium, or other serotonergic drugs.

Question 18

Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin Syndrome

Answer 18

Potentially fatal condition characterized by extreme agitation, confusion, autonomic instability, hyperthermia, tremor, seizures, and delirium.
Requires immediate withdrawal of serotonergic drugs and appropriate medical interventions.

Question 19

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Answer 19

SNRIs include venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq).

SNRIs offer an effective alternative to SSRIs for the treatment of various psychiatric disorders, but caution is needed regarding potential side effects and contraindications, particularly in patients with cardiovascular issues.

Question 20

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Uses

Answer 20

Treatment of major depressive disorder.
Management of social anxiety disorder.
Relief of neuropathic pain and other pain disorders.

Question 21

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Mechanism

Answer 21

Inhibition of the reuptake of both serotonin and norepinephrine at synapses.

Question 22

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Efficacy

Answer 22

Similar efficacy to SSRIs, with some evidence suggesting they may be more effective for severe depression.

Question 23

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Side Effects

Answer 23

Similar to SSRIs, including mild anticholinergic effects, gastrointestinal disturbances, insomnia, anxiety, sexual dysfunction.
Discontinuation syndrome upon abrupt cessation.
Potential for serotonin syndrome when combined with other serotonergic drugs.
May elevate blood pressure due to effects on norepinephrine, potentially contraindicated in patients with hypertension or heart problems.

Question 24

Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs)

Answer 24

NDRIs include bupropion (Wellbutrin, Zyban).

Bupropion offers unique advantages compared to other antidepressants, making it a valuable option for patients who may not tolerate or respond well to other medications. However, caution is needed regarding the risk of seizures and other potential side effects.

Question 25

Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs)
Uses

Answer 25

Treatment of major depressive disorder.
Smoking cessation aid.

Question 26

Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs)
Mechanism

Answer 26

Inhibits the reuptake of both norepinephrine and dopamine at synapses.

Question 27

Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs)
Efficacy

Answer 27

Effective for treating depression and assisting with smoking cessation.

Question 28

Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs)
Side Effects

Answer 28

Skin rash.
Decreased appetite and weight loss.
Agitation.
Insomnia.
Dizziness.
Seizures (particularly at higher doses).

Question 29

Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs)
Advantages:

Answer 29

Few anticholinergic effects.
Does not cause sexual dysfunction.
Not cardiotoxic.

Question 30

Tricyclic Antidepressants (TCAs)

Answer 30

TCAs include amitriptyline (Elavil), imipramine (Tofranil), clomipramine (Anafranil), nortriptyline (Pamelor), desipramine (Norpramin), and doxepin (Sinequan).

Tricyclic antidepressants are effective medications for various psychiatric and neurological conditions but require careful consideration of potential side effects and risks, especially in vulnerable patient populations.

Question 31

Tricyclic Antidepressants (TCAs)
Uses

Answer 31

Major depressive disorder.
Panic disorder.
Obsessive-compulsive disorder (especially clomipramine).
Neuropathic pain (especially nortriptyline and amitriptyline).

Question 32

Tricyclic Antidepressants (TCAs)
Mechanism

Answer 32

Inhibit the reuptake of norepinephrine, serotonin, and dopamine at synapses.

Question 33

Tricyclic Antidepressants (TCAs)
Efficacy

Answer 33

Effective for treating depression, anxiety disorders, and neuropathic pain

Question 34

Tricyclic Antidepressants (TCAs)
Side Effects

Answer 34

Cardiovascular effects (e.g., hypertension, tachycardia, orthostatic hypotension).
Anticholinergic effects (e.g., dry mouth, blurred vision, constipation, urinary retention).
Sedation.
Weight gain.
Sexual dysfunction.
Risk of overdose, which can be lethal due to cardiotoxic effects.

Question 35

Tricyclic Antidepressants (TCAs)
Precautions

Answer 35

Caution required in patients with heart disease or suicidal tendencies due to the cardiotoxic and lethal potential in overdose.

Question 36

Monoamine Oxidase Inhibitors (MAOIs):

Answer 36

MAOIs include phenelzine (Nardil), isocarboxazid (Marplan), and tranylcypromine (Parnate).

MAOIs can be effective antidepressants but require careful management due to their potential for serious interactions and side effects. They are typically reserved for use in patients who have not responded to other treatment options.

Question 37

Monoamine Oxidase Inhibitors (MAOIs):
Uses

Answer 37

Treatment-resistant depression.
Atypical depression (characterized by reversed vegetative symptoms such as hypersomnia, increased appetite, and reactive dysphoria).

Question 38

Monoamine Oxidase Inhibitors (MAOIs):
Mechanism

Answer 38

Inhibit the activity of monoamine oxidase enzyme, which deactivates norepinephrine, serotonin, and dopamine.
Increase levels of these neurotransmitters in the brain.

Question 39

Monoamine Oxidase Inhibitors (MAOIs):
Efficacy

Answer 39

Effective for depression, particularly in patients who have not responded to other antidepressant medications.

Question 40

Monoamine Oxidase Inhibitors (MAOIs):
Side Effects

Answer 40

Anticholinergic effects (e.g., dry mouth, blurred vision, constipation, urinary retention).
Orthostatic hypotension.
Sedation.
Sexual dysfunction.
Risk of hypertensive crisis when taken with certain foods or medications.

Question 41

Monoamine Oxidase Inhibitors (MAOIs):
Precautions

Answer 41

Avoid foods high in tyramine (e.g., aged cheese and meat, soy products, beer, red wine, sauerkraut, fava beans, ripe bananas) and medications that can interact with MAOIs to prevent hypertensive crisis.
Monitor for signs of hypertensive crisis, including severe headache, neck stiffness, rapid heart rate, nausea, vomiting, sweating, sensitivity to light, confusion, and delirium.