Psychopharmacology Manuel D. Reich, DO

Psychopharmacology The study and practice of the effects that drugs have on mood and behavior A wide range of substances from plant sources to metals Neuropsychopharmacology: the relationship between drugs and the cells in the nervous system that casue change in mood and behavior Psychoactive drugs cause chemical interactions between target receptors in the CNS

History India: Fly Agaric 10,000 BCE Hunter/Gather/Tribes: Hallucinogenic Drugs Farming: cannabis, opium herbs, farming societies fermentation  alcohol Scientific Revolution: rejection of herbs and natural preparations 20th Century: psychiatric drugs as a by-product of organic compounds and reassessment of traditional remedies

Psychoactive Categories Antidepressants: TCA, MAOI, SSRI, SNRI, Other Alcohol; a depressant Anxiolytic: Benzodiazepines Antipsychotic: 1* , 2*, 3* Stimulants : Amphetamines Mood Stabilizer: Anti-seizure Hypnotic Cannabis Opiates: Narcotic analgesic Hallucinogens Hormones Neurotransmitters

Research & Development Chemical Models: In relation to CNS anatomy and physiology Designed based on organic properties Physical properties Mechanical properties Neurotransmitters Re-evaluation of existing medications

Specific Testing FDA Guidelines Lab chemical analysis Animal models Human testing Benefit over placebo Distinct number of studies

Mental Illness and Medications Significant percentage Americans suffers a diagnosable mental illness in any six month period Significant percentage of these people will improve or recover if they get treatment All medicines have effects based on their positive and negative effects Chemical properties: Therapeutic effect Side effect

Mental Illnesses and Medications People suffering from many mental illnesses have imbalances in brain physiology The neurotransmitters ↓ Transmission ↑ Re-up take ∆ Production ? Anatomy ? Receptor – Neuroreceptor function

Nomenclature Diagnosis Physiological Action/ Administration SSRI Anti-depressant Anti-anxiety Anti-psychotic Anti-epileptic Physiological Action/ Administration SSRI Stimulant Transdermal NSRI Oral Depot Typical Atypical ODT

Chemical Formula Receptor Clinical Effect Mood Stabilizer Pain Anxiolytic Hypnotic Anesthesia Recreation Ritual/Spiritual Military

Generic Name Trade Name ® Clinical Utilization “Off Label” Use FDA Indication Age Diagnosis “Off Label” Use Pharma Medical

Anti-Depressants Depression afflicts millions Americans in any six-month period Profound and unremitting sadness, hopelessness, helplessness, guilt and fatigue, no happiness or joy in activities once enjoyed or being irritable for greater than 2 weeks Depression can be lethal, patients are at high risk for suicide 80% of patients suffering from major illness respond well to treatment Psychiatrists usually recommend treatment with anti-depressant medications for a minimum of six months after a 3 month stabilization period ( 9-12-18 months) Longer for multiple episodes especially after age 40

Anti-Depressant Medication The classes of medication are used as anti-depressants Tricyclics MAOIs SSRI (Specific Serotonin Re-Uptake Inhibitors) SNRI (Norepinephine Serotonin Re-uptake Inhibitors) Tetracyclic Other

Tricyclic Anti-Depressants Elavil (Amitryptiline) Norpramin (Despiramine) Tofranil (Imipramine) Pamelor (Nortryptiline)

Tricyclic Antidepressants Side Effects Blurred vision Constipation Light-headedness Dry mouth Retention of urine Side effects generally disappear after a few weeks More serious side effects: narrow-angle glaucoma seizures Confusion Sweating Racing heartbeat Low blood pressure Allergic skin reactions Sensitivity to sun

MAOI’s Nardil Marplan Emsam Diet Considerations

Serotonin-Specific Agents Prozac Zoloft Less effect on the cardiovascular system (safer if overdose) Generally have fewer effects than other classes of anti-depressants Side Effects Anxious or nervous, sleep disturbances, stomach cramps, nausea, skin rash and, rarely, sleepiness Extremely rare cases may develop a seizure Discontinuation syndrome Serotonin syndrome Celexa Paxil Luvox Lexapro

Serotonin – Norepinephrine Reuptake Inhibition (dual action) Fetzima Effexor Pristiq Cymbalta

Tetracyclics and Others Remeron Ludiomil Viibryd Brintellix

Mood Stabilizers Bipolar Disorder patients have symptoms of severe depression that alternate with periods of feeling normal and/or periods of excessive excitement and activity known as mania Manic Phases may include: Extremely high energy Grandiose and unrealistic ideas Spending sprees Go for days without sleeping Thoughts become chaotic, speak rapidly

Mood Stabilizer – Anti-Epileptic Depakote Tegretol Lithium Trileptal Lamictal Neurontin Topomax Atypical Anti-psychotics

Effective in controlling wild thoughts and behaviors of mania Treats manic symptoms in seven to ten days and reduces depressive symptoms Effective in controlling wild thoughts and behaviors of mania Side Effects Tremor Weight gain Nausea Diarrhea Confusion Slurred speech Fatigue Weakness Difficulty walking Blood count changes Liver changes Steven Johnson Syndrome

Atypical Anti-Psychotic Abilify Zyprexa Geodon Seroquel Risperdal Rexulti Metabolic Syndrome

Anti-Anxiety Medications Generalized anxiety Phobias – a strong persistent fear of objects, activities, persons and situations, which is excessive, and unreasonable and interferes with life function and is beyond self control Panic disorders: Panic disorder has both physical and mental symptoms Obsessive-compulsive disorder Repeated, unwanted and often very disturbing thoughts and/or ritualistic behaviors and actions Post-traumatic stress disorder

Anxiolytics SSRI NSRI Anti-psychotic TCA Azaspirodecanediones (Buspar) Benzodiazepines Barbiturates Sedative hypnotics

Variable drugs in all classes Chronic and acute indications Side Effects Depends on class and type Sedation Dependence

Antipsychotic Drugs Psychosis is a symptom, not a disease Part of several mental illnesses such as schizophrenia, bipolar disorder, major depression Psychosis alters person’s ability to test reality as shown by alteration of: Any/all of the five senses (hallucination) Thinking and communication (formal thought disorder) Ideation (paranoia, delusions)

Example: Schizophrenia Bipolar Disorder Brief Reactive Psychosis Delusional Disorder Schizoaffective Disorder

Medications Abilify, Clozaril, Geodon, Haldol, Prolixin, Risperdal, Seroquel, Stelazine, Trilafon, Zyprexa, Navane, Loxitane, Moban, Mellaril Side Effects: dry mouth, blurred vision, constipation and drowsiness Other Side Effects: photo sensitivity, blood cell count, low blood pressure, parkinsonism, tardive dyskinesia, movement disorder Metabolic syndrome, weight gain

Insomnia Sedative hypnotics Barbiturates Narcotics Lunesta Sonata Ambien Barbiturates Narcotics

Stimluants Amphetamine products Methylphenidate products These are named for the believed pharmacological action of stimulating the neurotransmission in the CNS Long and short acting preparations Coverage is from 2 – 10 hours depending on the preparation; each dose is discreet

Stimlulants II Methylphenidate products are for 5 and older Amphetamine products: Dexedrine, Adderall, Vyvanse Methylphenidate products: Ritalin, Focalin, Concerta Listed short to long acting

Non-Stimulants Strattera Alpha agonists (short and long acting) Clonidine Tenex

Q & A