1. Psychiatric and Related Drugs © Paradigm Publishing, Inc.
Chapter 7
Psychiatric and Related Drugs
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2. 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
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3. 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
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4. Four Classes of Antidepressants
Selective serotonin reuptake inhibitor (SSRI)
Serotonin norepinephrine reuptake inhibitor (SNRI)
Tricyclic antidepressants (TCA)
Monoamine oxidase inhibitors (MAOIs)
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5. 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
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6. Dispensing Issues of Antidepressants
Delay of onset 10 to 21 days
Never used on an “as needed” basis
Antidepressants are not controlled substances
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7. 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
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8. 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
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9. 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
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10. 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
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11. 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
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12. escitalopram (Lexapro) SSRI
Similar to citalopram (Celexa)
More potent with fewer side effects
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13. paroxetine (Paxil) SSRI
Indicated for depression, obsessive-compulsive disorder, and panic disorder
Side effects: nausea, headache, ejaculatory disturbances, sweating
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14. sertraline (Zoloft) SSRI
Indicated for depression and obsessive-compulsive disorder
Nausea primary side effect
Also can cause drowsiness
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15. Dispensing Issues of Celexa
Warning!
Often confused
Celexa
Cerebyx (seizures)
Celebrex (arthritis)
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16. Dispensing Issues of Prozac
Warning!
Look-Alike
Prozac
Proscar (prostrate enlargement)
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17. Dispensing Issues of Paxil
Warning!
Can be confused
Paxil
Pepcid (gastric acid reducer)
Same strengths
Brand names sound alike
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18. Dispensing Issues of Zoloft
Warning!
Can be confused
Zoloft
Zocor (cholesterol reducer)
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19. Dispensing Issues of SSRIs
Warning!
Do not discontinue abruptly
Alcohol consumption should be avoided while taking these medications
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20. © 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
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21. 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
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22. 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
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23. 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
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24. 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
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25. Side Effects of Cyclic Antidepressants
Sedation is common, but tolerance usually occurs
Have many anticholinergic effects
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26. © 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.
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27. 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
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28. 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
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29. © Paradigm Publishing, Inc.
trazodone (Desyrel)
Prevents reuptake of serotonin and norepinephrine
Better side effect profile than TCAs
Ginkgo—possible interaction
Priapism
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30. © Paradigm Publishing, Inc.
Psychosis
Antipsychotics or neuroleptics
Schizophrenia is primary indication
Retreat from reality
Delusions
Hallucinations
Ambivalence
Withdrawal
Bizarre or regressive behavior
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31. © Paradigm Publishing, Inc.
Antipsychotics
Help with thought disorders, hallucinations, and delusions
Do not help with emotional and social withdrawal, ambivalence, or poor self-care
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32. Atypical Antipsychotics
Improved efficacy and reduced side effects
Better tolerated, but associated with metabolic side effects
Weight gain
Hyperglycemia
New-onset diabetes
Dyslipidemia
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33. quetiapine (Seroquel)
Related to Clozaril
Lower incidence of hematologic toxicities
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34. © 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
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35. © Paradigm Publishing, Inc.
Discussion
What is the most common self-prescribed treatment for anxiety?
Alcohol
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36. © 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
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37. © 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
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38. © 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
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39. 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
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40. Sleep and Sleep Disorders
Sleep is fundamental to human health
Four stages of sleep
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41. © 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
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42. © 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
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43. 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
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44. Treatment for Sleep Disorders
Diagnosis and effective treatment can often eliminate need for hypnotic drugs
For clearly defined insomnia, hypnotics used as an adjunct
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45. © Paradigm Publishing, Inc.
Narcolepsy
Recurring, inappropriate episodes of sleep during the daytime hours
No known cause
Occurs four times more in men than women
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46. 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
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47. Treatment of Narcolepsy
Nondrug Therapy
Lifestyle changes
Drug Therapy
Stimulants
Tricyclic antidepressants
SSRIs
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48. 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
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49. © 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
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50. © Paradigm Publishing, Inc.
Antihistamines
Do not reduce REM sleep
Safest drugs to use in treating insomnia
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51. © 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
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52. Dispensing Issues of Rozerem
Warning!
Look-alike
Rozerem
Razadyne (galantamine), Alzheimer disease
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53. © 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
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54. 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
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55. © 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
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56. Dispensing Issues of zolpidem (Ambien)
Warning!
Watch prescriptions—should not be used more than 10 days
Alert pharmacist, but may be exceptions
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