Psychiatric and Related Drugs © Paradigm Publishing, Inc. Chapter 7 Psychiatric and Related Drugs © Paradigm Publishing, Inc.

Depression and Mood Disorders Clinical depression is the most severe psychiatric disorder Women more likely than men to have depression Depression occurs later in life in men © Paradigm Publishing, Inc.

Neurotransmitters and Depression Therapy Chemicals produced by nerve cells Involved in transmitting information in the body Important in mood disorders and other mental disorders Antidepressants change levels of two neurotransmitters: serotonin, norepinephrine © Paradigm Publishing, Inc.

Four Classes of Antidepressants Selective serotonin reuptake inhibitor (SSRI) Serotonin norepinephrine reuptake inhibitor (SNRI) Tricyclic antidepressants (TCA) Monoamine oxidase inhibitors (MAOIs) © Paradigm Publishing, Inc.

How Antidepressants Work SSRIs block reuptake (reabsorption) of serotonin, little effect on norepinephrine SNRIs increase both serotonin and norepinephrine TCAs prevent reuptake of serotonin and/or norepinephrine MAOIs inhibit enzymes that break down serotonin and norepinephrine © Paradigm Publishing, Inc.

Dispensing Issues of Antidepressants Delay of onset 10 to 21 days Never used on an “as needed” basis Antidepressants are not controlled substances © Paradigm Publishing, Inc.

Dispensing Issues of Antidepressants Warning! Antidepressants as a class must include a Medication Guide Give to all patients with every dispensing Pharmacy technicians make sure every antidepressant has Medication Guide attached © Paradigm Publishing, Inc.

Side Effects of Antidepressants SSRIs and SNRIs safer than TCAs Serotonin syndrome: combining antidepressants that increase serotonin levels with drugs that also stimulate serotonin levels. Can be fatal. Could occur if patient is prescribed triptans (migraines) with antidepressants Many people with migraines also depressed © Paradigm Publishing, Inc.

Dispensing Issues of Antidepressants Warning! Technicians—be aware of serotonin syndrome. Will see warnings on computer Technicians should notify pharmacist and prescriber if patient is prescribed drugs that could cause such interactions © Paradigm Publishing, Inc.

citalopram (Celexa) SSRI Approved for depression and obsessive-compulsive disorder (OCD) OCD: recurrent, persistent urges to perform repetitive acts, e.g. hand washing Structurally different from other drugs in the class Minimal drug interactions © Paradigm Publishing, Inc.

fluoxetine (Prozac) SSRI Indicated for major depression and OCD Anorexia possible adverse effect Take in morning to avoid insomnia Fluoxetine and white light for SAD © Paradigm Publishing, Inc.

escitalopram (Lexapro) SSRI Similar to citalopram (Celexa) More potent with fewer side effects © Paradigm Publishing, Inc.

paroxetine (Paxil) SSRI Indicated for depression, obsessive-compulsive disorder, and panic disorder Side effects: nausea, headache, ejaculatory disturbances, sweating © Paradigm Publishing, Inc.

sertraline (Zoloft) SSRI Indicated for depression and obsessive-compulsive disorder Nausea primary side effect Also can cause drowsiness © Paradigm Publishing, Inc.

Dispensing Issues of Celexa Warning! Often confused Celexa Cerebyx (seizures) Celebrex (arthritis) © Paradigm Publishing, Inc.

Dispensing Issues of Prozac Warning! Look-Alike Prozac Proscar (prostrate enlargement) © Paradigm Publishing, Inc.

Dispensing Issues of Paxil Warning! Can be confused Paxil Pepcid (gastric acid reducer) Same strengths Brand names sound alike © Paradigm Publishing, Inc.

Dispensing Issues of Zoloft Warning! Can be confused Zoloft Zocor (cholesterol reducer) © Paradigm Publishing, Inc.

Dispensing Issues of SSRIs Warning! Do not discontinue abruptly Alcohol consumption should be avoided while taking these medications © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. SNRIs Used when SSRIs are not effective Affect both serotonin and norepinephrine reuptake More effective for pain than drugs affecting one neurotransmitter © Paradigm Publishing, Inc.

duloxetine (Cymbalta) SNRI Approved for major depression and pain associated with diabetic neuropathy Potent serotonin and norepinephrine inhibitor, weak inhibitor of dopamine More interactions than other drugs in class Do not discontinue abruptly © Paradigm Publishing, Inc.

venlafaxine (Effexor) SNRI Blocks reuptake of serotonin and norepinephrine At lower dose affects serotonin At higher dose also affects norepinephrine Prescribed for depression Adverse effects: sustained increase in blood pressure, may produce manic episodes © Paradigm Publishing, Inc.

Cyclic Antidepressants Two varieties 3 fused carbon rings (tricyclic) 4 fused carbon rings (tetracyclic) Tricyclic antidepressants (TCAs) Produce response in 50+% of patients Also used in bed-wetting for children © Paradigm Publishing, Inc.

Dispensing Issues of Cyclic Antidepressants Warning! Improvements usually 10 to 21 days Can be cardiotoxic in high doses May cause postural hypotension Do not discontinue abruptly © Paradigm Publishing, Inc.

Side Effects of Cyclic Antidepressants Sedation is common, but tolerance usually occurs Have many anticholinergic effects © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Discussion Why would cyclic antidepressants be prescribed for bed wetting in children? They may be prescribed because of their anticholinergic side effects. © Paradigm Publishing, Inc.

Monoamine Oxidase Inhibitors (MAOIs) Second-line treatment because of many interactions with food and other drugs Most beneficial in atypical depression Currently used to treat conditions other than depression © Paradigm Publishing, Inc.

Dispensing Issues of MAOIs Warning! 2 weeks washout period before starting new class of antidepressant Severe hypertensive reactions with food containing high level of tyramine Aged cheeses, concentrated yeast extracts, pickled fish, sauerkraut, broad bean pods © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. trazodone (Desyrel) Prevents reuptake of serotonin and norepinephrine Better side effect profile than TCAs Ginkgo—possible interaction Priapism © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Psychosis Antipsychotics or neuroleptics Schizophrenia is primary indication Retreat from reality Delusions Hallucinations Ambivalence Withdrawal Bizarre or regressive behavior © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Antipsychotics Help with thought disorders, hallucinations, and delusions Do not help with emotional and social withdrawal, ambivalence, or poor self-care © Paradigm Publishing, Inc.

Atypical Antipsychotics Improved efficacy and reduced side effects Better tolerated, but associated with metabolic side effects Weight gain Hyperglycemia New-onset diabetes Dyslipidemia © Paradigm Publishing, Inc.

quetiapine (Seroquel) Related to Clozaril Lower incidence of hematologic toxicities © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Anxiety State of uneasiness characterized by apprehension and worry about possible events Two types of anxiety Exogenous: response to external stresses Endogenous: not related to external stresses, result of abnormality in cellular function in CNS © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Discussion What is the most common self-prescribed treatment for anxiety? Alcohol © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Antianxiety Agents Also called sedatives Include both noncontrolled and controlled substances Benzodiazepines, buspirone, and to a lesser extent, beta blockers are most used for panic attacks © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Benzodiazepines May cause physical or psychological dependence or both, C-IV Should not be stopped abruptly Side effects Muscle relaxation Paradoxical excitement Sedation © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Panic Disorders Panic: form of intense, overwhelming, and uncontrollable anxiety Neither a controllable voluntary emotion nor a condition that can be avoided by ignoring it or wishing it away © Paradigm Publishing, Inc.

Treatment of Panic Disorders Combination of antipanic medication and behavioral therapy Psychotherapy preferred treatment when symptoms cause significant discomfort or impairment Antianxiety medications indicated for short-term treatment © Paradigm Publishing, Inc.

Sleep and Sleep Disorders Sleep is fundamental to human health Four stages of sleep © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Four Stages of Sleep Stage I. Somewhat aware of surroundings, relaxed, NREM Stage II. Unaware of surroundings. Easily awakened, NREM Stages III and IV. Increased autonomic activity, REM with dreams, 4 to 5 times a night © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Insomnia Difficulty falling or staying asleep, or not feeling refreshed on awakening Treated with hypnotics (drugs that induces sleep) Chronic, occasional, or short-term insomnia Transient insomnia not sleep disorder © Paradigm Publishing, Inc.

Causes of Some Sleep Disorders Situational: job stress, hospitalization, travel Medical: pain, respiratory or GI problems Psychiatric: schizophrenia, depression, mania Drug induced: alcohol, caffeine, sympathomimetic agents © Paradigm Publishing, Inc.

Treatment for Sleep Disorders Diagnosis and effective treatment can often eliminate need for hypnotic drugs For clearly defined insomnia, hypnotics used as an adjunct © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Narcolepsy Recurring, inappropriate episodes of sleep during the daytime hours No known cause Occurs four times more in men than women © Paradigm Publishing, Inc.

Four Characteristics of Narcolepsy Patient feels sleepy during daytime and immediately enters REM sleep Patient experiences cataplexy with sudden emotions Sleep paralysis Very vivid hallucinations at the onset of sleep © Paradigm Publishing, Inc.

Treatment of Narcolepsy Nondrug Therapy Lifestyle changes Drug Therapy Stimulants Tricyclic antidepressants SSRIs © Paradigm Publishing, Inc.

Treatment of Sleep Disorders Pharmacological: hypnotics Nonpharmacological Normalizing sleep schedule Increase physical exercise Discontinue alcohol as a sedative Sleep only 7 to 8 hours in 24-hour period Reduce caffeine and nicotine intake Eliminate any drug that could lead to insomnia © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Sleep Agents Should be used in conjunction with other medical therapeutics Take 1 hour before bedtime Take only a limited number of times each week Duration of use: 4 to 6 week period © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Antihistamines Do not reduce REM sleep Safest drugs to use in treating insomnia © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. ramelteon (Rozerem) Approved for sleep onset insomnia Not a controlled substance because works in a different way than other hypnotics Rapid onset, no next-day hangover © Paradigm Publishing, Inc.

Dispensing Issues of Rozerem Warning! Look-alike Rozerem Razadyne (galantamine), Alzheimer disease © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. Z Hypnotics Preferred treatment of sleep disorders No seizures if drug abruptly discontinued Relatively short half-life Do not significantly impact REM sleep © Paradigm Publishing, Inc.

Side Effects of Z Hypnotics Sleepwalking, eating, or driving (sleepdriving) with no recall of events FDA looking at side effects and encouraging manufacturers to include in labeling © Paradigm Publishing, Inc.

© Paradigm Publishing, Inc. zolpidem (Ambien) Schedule IV drug Many of the same properties as benzodiazepines, but structurally different Approved for long-term use Prevents early awakening © Paradigm Publishing, Inc.

Dispensing Issues of zolpidem (Ambien) Warning! Watch prescriptions—should not be used more than 10 days Alert pharmacist, but may be exceptions © Paradigm Publishing, Inc.