Dr Aseni Gammampila

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1. Antidepressants 2. Anxiolytics 3. Mood stabilizers 4. Antipsychotics

 Mainly to treat severe depression  Other treatable diseases ◦ Obsessive-compulsive disorder ◦ Generalised anxiety disorder ◦ Post-traumatic stress disorder ◦ Panic attacks ◦ Chronic pain ◦ Eating disorders

 Changes the levels of neurotransmitters  Neurotransmitters, such as serotonin and norepinephrine can improve mood and emotion (physiology is not well understood)  Used for symptomatic relief of depression  In complicated conditions used adjunct with other methods of treatment

 Mode of action is slow  Improvement of symptom may only be seen after 2-4 weeks of continuous treatment  Change treatment if symptom relief is not seen after 6 weeks of continuous use  Increased levels of neurotransmitters can also disrupt pain signals sent by nerves (use some antidepressants as a reliever of chronic pain)

 feeling sick  dry mouth  insomnia  erectile dysfunction  excessive sweating ◦ Side effects wear off with time ◦ A course of treatment usually lasts for six months

1. Tricyclic 2. MAOI (Monoamine oxidase inhibitors) 3. SSRI (Selective Serotonin Reuptake Inhibitors) 4. SNRI (Serotonin and Noradrenaline Reuptake Inhibitors) 5. NASSA (Noradrenaline and Specific Serotoninergic Antidepressants)

Antidepressant drugs’ mechanisms of action

 The chemicals most involved in depression are thought to be Serotonin and Noradrenaline  50% and 65% get well after a minimum of 3 months treatment with antidepressant

 Older type of antidepressants  No longer recommended as first-line treatment for depression  Fatal in an overdose  More unpleasant side effects than SSRIs and SNRIs  May be tried when SSRI and SNR fail (in severe depression)  Can be used in OCD and bipolar disorder

 amitriptyline (Tryptizol)(used also for chronic pain relief)  clomipramine (Anafranil)  imipramine (Tofranil)  lofepramine (Gamanil)  nortriptyline (Allegron)

 Dry mouth  A slight tremor  Fast heartbeat  Constipation  Sleepiness  Weight gain  In older people,  confusion  Dribbling urine  faintness through low blood pressure  falls  Not advisable in heart patients  Dangerous in overdose

 Most widely prescribed antidepressants  Fewer side effects – less fatal  Fluoxetine is probably the best known SSRI (Prozac)  Other SSRIs include: ◦ citalopram (Cipramil) ◦ paroxetine (Seroxat) ◦ sertraline (Lustral)

 feel sick and more anxious within the first 2 weeks  indigestion  interfere with sexual function.  rare episodes of aggression  in younger or middle-aged people  problems with urinating  difficulty in remembering  falls  confusion  hyponatraemia – in elderly

 Similar to SSRIs  SNRIs include: ◦ duloxetine (Cymbalta and Yentreve) ◦ venlafaxine (Efexor)  The side-effects are very similar to the SSRIs  Venlafaxine should not be used during heart diseases ( increase blood pressure)

 1/3 of people who stop SSRIs and SNRIs have withdrawal symptoms which can last between 2 weeks and 2 months. ◦ stomach upsets ◦ flue like symptoms ◦ anxiety ◦ dizziness ◦ vivid dreams or nightmares ◦ sensations in the body that feel like electric shocks

 Serotonin syndrome is uncommon but potentially serious  levels of serotonin in your brain is too high  triggered by combined treatment of SSRI or SNRI or with another medication such as another antidepressant or St John’s Wort containing serotinin

◦ confusion ◦ agitation ◦ muscle twitching ◦ sweating ◦ shivering ◦ diarrhoea ◦ Fever of 39.4°C (103°F) or above ◦ seizures (fits) ◦ irregular heartbeat (arrhythmia) ◦ unconsciousness

 Early antidepressant -First developed in the 1950s  Rarely prescribed now  Wide range of side effects  Only used when other types of antidepressants are ineffective ◦ Moclobemide (manerix) ◦ phenelzine (nardil)  With MAOI treatment certain foods and drinks with protein called tyramine should be avoided  Red wine and pickled fish  Can cause a dangerous rise in blood pressure

 Antidepressants may cause sleepiness and slow reactions  Taper off the dose than sudden stop  If you have had two or more attacks of depression then treatment should be continued for at least two years  Counselling is useful in mild depression  Herbal remedies ◦ Hypericum ( st johns wort)  Light ◦ Seasonal affective disorder (SAD) - a source of bright light which you have on for a certain time each day and which can make up for the lack of light in the winter.

 Dopamine is the main neurotransmitter affected by these medications.  Dopamine controls ◦ Important, significant and interesting activities ◦ Satisfaction ◦ Motivation ◦ Muscle control

 Hallucinations  Delusions  Thought disorder  Extreme mood swings of manic depression/bipolar disorder

1. ‘Typical’ - the older drugs 2. ‘Atypical’ - the newer drugs

 first appeared in the mid-1950s  ‘typical’ or 'first-generation' antipsychotics  block the action of dopamine

 usually high doses  stiffness and shakiness, like Parkinson’s disease  slow thought process  uncomfortable restlessness (akathisia)  Sexual dysfunction  if high therapeutic doses cause side effects ancholinergics (Orphenadrine and Procyclidine) can be used to reduce the effects  long-term effect- tardive dyskinesia (TD) – continual movements of the mouth, tongue and jaw.

 Over the last 10 years  ‘Atypical’ or ‘second-generation’ antipsychotics  Block dopamine  Also work on serotonin

 Sleepiness and slowness  Weight gain  Sexual dysfunction  Increased chance of developing diabetes.  In high doses, some have the same Parkinsonian side-effects as the older medications  Long-term use can produce movements of the face (tardive dyskinesia) and, rarely, of the arms or legs.

 Newer ◦ less likely to cause Parkinsonian side-effects ◦ less likely to produce tardive dyskinesia. ◦ more likely to produce weight gain ◦ more likely to produce diabetes ◦ more likely to give you sexual problems ◦ may help with “negative symptoms” in schizophrenic patients

 Best antipsychotic medication  Reduce suicidal feelings in people with schizophrenia  Minimal effect on the dopamine systems which control movement  Hardly causes any stiffness, shakiness or slowness seen in other antipsychotics.  May make increase drowsiness than older antipsychotics

 can affect your bone marrow, leading to a shortage of white cells – immediate discontinuation of medication ( followed with weekly blood tests for the first 6 months and 2 weekly blood tests)  Other side effects ◦ weight gain ◦ excessive salivation ◦ epileptic fits  usually only suggested after at least two other antipsychotics have been tried

 Injection every 2-4 weeks  Difficult to change dose  Effects are known later  Difficult to monitor and control dose according to side effects

 Other ways of helping will usually be added to antipsychotic treatment rather than replacing it.   Cognitive behaviour therapy (CBT)   Psychoeducation   Family therapy

 Benzodiazepines  Azapirones  Beta-Blockers

High-potency benzodiazepines combat anxiety  Benzodiazepines are potentially dangerous when used in combination with alcohol.  Effective for most anxiety disorders  Overdoses can be serious, very rarely fatal

Clonazepam (Klonopin®) - social phobia and GAD Lorazepam (Ativan®) - panic disorder Alprazolam (Xanax®) - panic disorder and GAD. May experience withdrawal symptoms if benzodiazepines are stopped abruptly ◦ Tapering off gradually is the best approach to stop taking these drugs  Benzodiazepines taken during pregnancy are associated with birth defects (such as cleft palate)

Buspirone (Buspar®) Newer anti-anxiety medication used to treat GAD  Act on serotonin receptors called 5-HT(1A).  Works as well as a benzodiazepine for treating generalized anxiety disorder.  Takes several days to weeks for the drug to be fully effective  No withdrawal effects

Less pronounced side effects than benzodiazepines Side effects ◦dizziness ◦headaches ◦drowsiness ◦nausea. ◦must be taken consistently for at least 2 weeks to achieve an anti- anxiety effect.  Buspirone should not be used with monoamine oxidase inhibitors (MAOIs)  Not addictive, despite long-term use  May be helpful for the patient whose anxiety disorder coexists with alcoholism or drug abuse

◦ propranolol (Inderal) ◦ atenolol (Tenormin)  block the nerves that stimulate a rapid heart rate  affect only the physiologic symptoms of anxiety- for social phobias and performance anxiety

 Lithium  Anticonvulsants  Atypical antipsychotics

 Transcranial magnetic stimulation  Deep brain stimulation

Deep brain stimulation

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