1. Drugs Used in Mental Health Antianxiety Drugs

2. Anxiety – a feeling of apprehension, worry, or uneasiness that may or may not e based on reality Anxiolytics – another name for antianxiety medications

3. Antianxiety Drugs Block neurotransmitter receptor sites preventing anxious feelings from reaching brain Also prevents body’s physical reaction to anxiety

4. Antianxiety Drugs Common Uses Anxiety disorders and panic attacks Preanesthetic sedation and muscle relaxants Convulsions or seizures - diazepam (Valium) Alcohol withdrawal

5. Antianxiety Drugs Benzodiazepines –diazepam (Valium) half life : 36-200 hr –clonazepam (Klonopin) half life : 18-50 hr –chlordiazepoxide (Librium) half life : 5-25 hr –alprazolam (Xanax) half life : 6-12 hr –lorazepam (Ativan) half life : 10-20 hr

6. Antianxiety Drugs Nonbenzodiazepines –doxepin (Sinequan) half life : 28-52 hr –buspirone HCl (BuSpar) half life : 2-3 hr * buspirone (BuSpar) drug of choice with elderly because it does not cause excessive drowsiness and poses less fall risk

7. Antianxiety Drugs Side Effects / Adverse Reactions Drowsiness / sedation Lightheadedness / dizziness Headache, visual disturbances Lethargy, apathy, fatigue Confusion, restlessness, agitation GI disturbances, dry mouth

8. Antianxiety Drugs Benzodiazepine Toxicity –Results from overdose –Sedation, respiratory depression, coma, death –Antidote: flumazenil (Romazicon) Parenteral Alert –IM, IV route may lead to apnea and cardiac arrest –Use care with elderly, debilitated, respiratory compromised

9. Antianxiety Drugs High Risk for Physical Dependence Long term use Tolerance Physical dependence Withdrawal symptoms After 3 months of use, do NOT discontinue abruptly

10. Antianxiety Drugs Withdrawal Symptoms Increased symptoms of anxiety Fatigue, hypersomnia Metallic taste, nausea, sweating Headache, difficulty concentrating Cramps, tremors Hallucinations, convulsions

11. Contraindications Psychoses Acute narrow angle glaucoma Pregnancy –Floppy infant syndrome Lactation –Infant becomes lethargic and loses weight Significant hypotension / bradycardia

12. Precautions Use cautiously with elderly –Initial Low Dose: excreted more slowly, high risk for toxic levels –Exception: lorazepam (Ativan), safe for elderly at usual ranges Use cautiously in patients with –Impaired liver function –Impaired kidney function –Overall debilitation Avoid alcohol

13. Interactions Other CNS depressants: Increased risk of sedation, confusion, convulsions –Alcohol –Narcotic Analgesics –Other Psychotropics Digoxin –Increased risk for Digitalis Toxicity

14. Antidepressants Depression – feelings of hopelessness that interfere with daily functioning

15. Antidepressants Neurotransmisson –Important Neurotransmittors Dopamine Epinephrine Norepinephrine Serotonin

16. Antidepressants Types of Antidepressants Tricyclic Antidepressants (TCA’s) Monoamine Oxidase Inhibitors (MAOI’s) Selective Serotonine Reuptake Inhibitors (SSRI’s) Miscellaneous

17. Antidepressants Tricyclic Antidepressants (TCA’s) –Earliest antidepressants –Enhances movement of serotonin from one neuron to the next –Examples Doxepin (Sinequan) Imipramine (Tofranil)

18. Antidepressants Tricyclic Antidepressants (TCA’s) –Uses Depressive episodes Bipolar disorder Obsessive – compulsion disorder Chronic neuropathic pain Depression accompanied by anxiety Enuresis

19. Antidepressants Tricyclic Antidepressants (TCA’s) –Side Effects Anticholinergic-like side effects (insomnia, dry mouth, lethargy, confusion, blurred vision, urinary retention) Constipation Photosensitivity

20. Antidepressants Tricyclic Antidepressants (TCA’s) –Contraindications and Precautions Use with caution in patients with cardiac history Do not give during pregnancy or lactation Use with caution with hyperthyroid disease Use with caution with seizure disorder Use with caution with hepatic / renal impairment

21. Antidepressants Tricyclic Antidepressants (TCA’s) –Interactions Avoid other CNS depressants, including alcohol Dicumarol (similar to warfarin): increased bleeding times Cimetidine (Tagamet): increased anticholinergic-like effects MAOI’s: hypertension, convulsions, fever Adrenergics: arrhythmias, hypertension

22. Antidepressants Monoamine Oxidase Inhibitors (MAOI’s) –No longer in common use –Inhibit the enzyme responsible for inactivating (destroying) certain neurotransmittors –Example Phenelzine (Nardil)

23. Antidepressants Monoamine Oxidase Inhibitors (MAOI’s) –Uses Depressive episodes Unlabelled used: bulemia, night terrors, migraines, seasonal affective disorder (SAD), multiple sclerosis

24. Antidepressants Monoamine Oxidase Inhibitors (MAOI’s) –Side Effects Orthostatic hypotension Anticholinergic-like side effects (insomnia, dry mouth, lethargy, confusion, blurred vision, urinary retention) Constipation Hypertensive Crisis

25. Antidepressants Monoamine Oxidase Inhibitors (MAOI’s) –Hypertensive Crisis with Foods Containing the amino acid Tyramine Cheese Wines (especially red) Caffeine Soy

26. Antidepressants Monoamine Oxidase Inhibitors (MAOI’s) –Symptoms of Hypertensive Crisis Headache (usually occipital) Stiff, sore neck Nausea, vomiting Sweating, fever, chest pains, mydriasis Severe hypertension

27. Antidepressants Monoamine Oxidase Inhibitors (MAOI’s) –Contraindications and Precautions Use with caution in patients with cerebrovascular disease Use with caution in patients with history of hypertension and/or congestive heart failure Do not give to pregnant women or children Use with caution with hepatic / renal impairment

28. Antidepressants Monoamine Oxidase Inhibitors (MAOI’s) –Interactions Avoid other CNS depressants, including alcohol Hydrochlorothiazide: increased hypotension Tyramine, tryptophan: increased risk of hypertensive crisis TCA’s: hypertension, convulsions, fever Adrenergics: arrhythmias, hypertension

29. Antidepressants Inhibiting Serotonin Reuptake

30. Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI’s) –Widespread use –Inhibits reuptake of serotonin, thus allowing more serotonin to travel across neurons –Examples Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft)

31. Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI’s) –Uses Depressive episodes Obsessive – compulsion disorder Bulemia nervosa Unlabelled uses: menstrual disorders, post traumatic stress disorder (PTSD), phobias –Therapeutic Effect: 2-4 weeks

32. Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI’s) –Side Effects Somnolence, insomnia, dizziness Headache, tremors, weakness Constipation, dry mouth, nausea Pharyngitis, rhinitis Loss of libido, erectile dysfunction Serotonin syndrome

33. Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI’s) –Serotonin Syndrome (increased levels of serotonin) Increased metabolism (diarrhea, vomiting, fever) Increased cardiovascular (tachycardia, hypertension) Increased neuromuscular (agitation, ataxia, muscle spasms)

34. Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI’s) –Contraindications and Precautions Use with caution in patients with cardiac history Use with caution in patients with diabetes Do not give until two weeks after stopping MAOI Use with caution with hepatic / renal impairment Monitor closely for serotonin syndrome during first two weeks of therapy or dosage increase

35. Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI’s) –Interactions Avoid other CNS depressants, including alcohol Other antidepressants: increased toxic effects Cimetidine (Tagamet): increased anticholinergic effects Aspirin, NSAID’s: increased risk of GI bleeding Lithium: increased risk of lithium toxicity

36. Antidepressants Miscellaneous –Brupropion HCl (Wellbutrin): often used for smoking cessation as well as depression –Duloxetine HCl (Cymbalta): often used for diabetic neuropathy discomfort as well as depression

37. Drugs Used in Mental Health Antipsychotic Drugs

38. Psychosis – affects mood and behavior Characterized by hallucinations and / or delusions

39. Antipsychotic Drugs Common Uses Acute and chronic psychoses Bipolar illness Agitated behaviors associated with dementia

40. Antipsychotic Drugs Common Medications Aripiprazole (Abilify) Haloperidol (Haldol) Risperidone (Risperdal) Lithium

41. Antipsychotic Drugs Side Effects / Adverse Reactions Drowsiness / headache Dry mouth / constipation Photophobia / photosensitivity Extrapyramidal symptoms Tardive dyskinesia Neuroleptic malignant syndrome

42. Antipsychotic Drugs Lithium Toxicity High levels of lithium toxic to body Antacids: decreased effectiveness of lithium Loop diuretics: increased risk for lithium toxicity

43. Psychotropics: Patient Teaching Take as directed Do not discontinue abruptly Avoid hazardous activity Advise physician of all OTC medications and supplements Do not drink alcohol Mouth care, hard candies, sugarless gum for dry mouth Fluids and fiber to prevent constipation