Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 17 Psychotherapeutic Agents

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antipsychotic Agents  Antipsychotic drugs are divided into two categories: conventional and atypical.  Conventional antipsychotics primarily treat the positive symptoms associated with schizophrenia.  Atypical antipsychotics have a much more tolerable adverse effect profile and target both the positive and negative symptoms of schizophrenia. 2

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antipsychotic Agents  Conventional antipsychotics primarily block all dopamine receptors as well as cholinergic, norepinephrine, and histamine receptors.  Atypical antipsychotics are more specific for dopamine 2 receptors, serotonin, and norepinephrine receptors which results in improved efficacy and lower incidence of adverse effects.  Conventional antipsychotics have antipsychotic effects, antiemetic effects, and sedating effects.  Atypical antipsychotics possess antipsychotic effects. 3

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antipsychotic Agents  Adverse Reactions  Adverse reactions are many and are dependent upon the drug itself. Atypical antipsychotics have a lower incidence of adverse effects.  Several conventional antipsychotics are sedating.  Extrapyramidal Effects These are a result of dopamine blockade in the nigrostriatal pathways of the brain. These are a result of dopamine blockade in the nigrostriatal pathways of the brain. 4

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antipsychotic Agents  Extrapyramidal Effects  Acute dystonic reactions occur within 72 hours of starting the drug or a dose increase.  It is characterized by muscle spasms of the face, tongue, neck and back.  Parkinsonian symptoms consistent with resting tremor, rigidity, and akinesia.  Akathisia which is defined as an inability to sit still.  Tardive dyskinesia which are defined as involuntary, abnormal movements of the tongue, lips, face, and jaw. 5

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antipsychotic Agents  Orthostatic hypotension is a result of peripheral α- receptor blockade. When the patient rises rapidly his or her blood pressure falls.  Other cardiac effects include tachycardia.  Some antipsychotic drugs lower the seizure threshold.  These drugs block cholinergic receptors and can cause dry mouth, blurred vision, constipation, and urinary retention.  Other adverse effects include photosensitivity and blood dyscrasias. 6

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antipsychotic Agents  Drug Interactions  Because these drugs can be sedating they should be used with caution with other drugs that are sedating.  A local anesthetic with epinephrine can be used in patients taking antipsychotic drugs.  Anticholinergic drugs are used in combination with antipsychotic drugs to treat drug-induced extrapyramidal effects. The combination can cause sedation and intense dry mouth. 7

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antipsychotic Agents  Uses  These drugs are used for the treatment of schizophrenia.  Atypical antipsychotics are used to treat bipolar disorder.  Conventional antipsychotics are used as antiemetic drugs. 8

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antipsychotic Agents  Dental Concerns  Sedation Sedation is additive with other sedating drugs such as antianxiety drugs and opioid analgesics. Sedation is additive with other sedating drugs such as antianxiety drugs and opioid analgesics. Patients may require someone to drive them to and from dental appointments. Patients may require someone to drive them to and from dental appointments. They should avoid anything that requires thought or concentration while taking this combination. They should avoid anything that requires thought or concentration while taking this combination.  Orthostatic Hypotension Raise the dental chair slowly and have the patient sit for a few minutes prior to getting out of the chair. Raise the dental chair slowly and have the patient sit for a few minutes prior to getting out of the chair. 9

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antipsychotic Agents  Dental Concerns  Anticholinergic Effects Patients should be encouraged to drink plenty of water or suck on tart, sugarless gum or candy. Patients should be encouraged to drink plenty of water or suck on tart, sugarless gum or candy. They should avoid caffeine-containing fruit juices or alcoholic beverages. They should avoid caffeine-containing fruit juices or alcoholic beverages.  Epinephrine should not be used to treat acute hypotensive crisis. 10

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antipsychotic Agents  Extrapyramidal Effects  These effects can impair the patient’s ability to perform home oral hygiene.  Akathisia may make it difficult for the patient to sit in a dental chair. 11

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antidepressant Agents  Many different classes of antidepressants are available.  They are similar in therapeutic effects.  They differ in their adverse effect profile.  Choice of antidepressant is usually based upon adverse effect profile, history of use, and patient response. 12

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antidepressant Agents  Pharmacologic Effects  These drugs block the reuptake of serotonin and/or epinephrine to a varying extent.  Monoamine oxidase inhibitors block the enzyme monoamine oxidase.  Pharmacologic effects include elevation of mood, increased ability to concentrate, improvement in sleep, and sedation. 13

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antidepressant Agents  Adverse Effects – Tricyclic Antidepressants  The adverse effects of antidepressant drugs are many and are dependent upon the chemical class of the drug.  Almost all of the tricyclic antidepressants cause sedation. Patients should develop tolerance to it.  These drugs also block cholinergic receptors and cause dry mouth, blurred vision, constipation, and urinary retention.  These drugs can also be cardiotoxic.  Acute poisoning or overdose can occur.  These drugs interact with other sedating and drying drugs, monoamine oxidase inhibitors, and epinephrine. 14

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antidepressant Agents 15

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antidepressant Agents  Selective Serotonin Reuptake Inhibitors  These drugs are stimulating and can cause insomnia. Headache, dizziness, tremor, agitation, and sweating also occur.  These drugs also cause weight loss.  A small percentage of patients complain of xerostomia. 16

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antidepressant Agents  Bupropion  This drug has a higher propensity to cause seizures than other antidepressants.  Because of its seizure potential it is only used in patients who don’t respond to other drugs and in those who are not at risk for seizures. 17

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antidepressant Agents  Monoamine Oxidase Inhibitors (MAOIs)  MAOIs interact with sympathomimetic or adrenergic drugs.  This includes many over-the-counter cough and cold products.  They also interact with foods that contain tyramine and include aged cheeses, red wine, yeast extracts, and smoked or aged meats. 18

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antidepressant Agents  Monoamine Oxidase Inhibitors (MAOIs)  The interaction of MAOIs with sympathomimetics or tyramine-containing foods can precipitate a hypertensive crisis.  A hypertensive crisis is characterized by a headache, stiff neck, sweating, nausea, vomiting, and hypertension.  It is treated with antihypertensive drugs. 19

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Drugs for Treatment of Bipolar Disorder  Lithium  Lithium is used to treat bipolar disorder, which is characterized by cyclic recurrence of mania alternating with depression.  Lithium is a narrow therapeutic index drug that requires 2-4 weeks before a positive therapeutic effect is achieved.  Its adverse effects are many and the drug must be carefully monitored. 20

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Drugs for Treatment of Bipolar Disorder  Lithium  Adverse Effects Adverse effects include polyuria, fine hand tremor, thirst. Adverse effects include polyuria, fine hand tremor, thirst. More severe adverse effects include slurred speech, coarse hand tremor, ataxia, nausea, vomiting, and diarrhea. More severe adverse effects include slurred speech, coarse hand tremor, ataxia, nausea, vomiting, and diarrhea. Sodium levels can alter lithium levels. Sodium levels can alter lithium levels. Some nonsteroidal antiinflammatory drugs can decrease lithium clearance leading to increased lithium levels. Some nonsteroidal antiinflammatory drugs can decrease lithium clearance leading to increased lithium levels. 21

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Drugs for Treatment of Bipolar Disorder  Lithium  Dental Concerns Polydipsia Polydipsia  Increased sugar and caffeine consumption  Lithium interacts with ibuprofen – end up with lower lithium levels because of fluid retention  Elevated heart rate may indicate lithium toxicity  Be concerned about administering epinephrine  Use of aspirin and other NSAIDs with GI upset 22

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Drugs for Treatment of Bipolar Disorder  Other Treatments for Bipolar Disorder  Carbamazepine and valproate are approved for treating bipolar disorder. They have a much more tolerable adverse effect profile.  The atypical antipsychotics have been approved for the treatment of bipolar disorder. 23