1. Drugs for Mental Health chapter-31 “the Mentally Healthy person” – one who can perceive reality accurately and has control over expression of emotions Mental Health: not a concrete achievable goal …but a lifelong process resulting in a sense of harmony and balance in a person’s life -difficult to define, highly individualized -varies from person-to-person

2. Medication in Psychotherapy Among the most prescribed drugs Used to reduce/alleviate symptoms of STRESS …to allow the patient’s participation in other psychotherapies DRUGS – temporarily change behavior, addiction/dependence are major concerns PSYCHOTHERAPY – more long-term, but … the results are more permanent

3. Neurosis vs Psychosis Neurosis: patient is still in contact with reality Psychosis: patient is out of contact with reality, unable to communicate DRUGs for Anxiety (see Table 31-1) known generally as ‘anxiolytics’ which literally means ‘to break apart, or dissolve anxiety’ Benzodiazepines – long and/or short-acting Misc Anxiolytics – Buspar, Paxil, Effexor, Desyrel

4. Anxiolytics (cont) Benzodiazepines - introduced in the 1960’s Generic names end in ‘-pam’ - diazepam, lorazepam, clonazepam (exception: alprazolam, whose brand name is Xanax) ‘drugs-of-choice’ – safer, lower abuse potential, less tolerance and dependence (again, except for Xanax!) Effect: a calming-effect without extreme sedation (2)general types: Short-acting and Long-acting

5. Benzodiazepines Patient-education Take with food if GI symptoms occur Take exactly as directed (don’t modify dose) DO NOT mix with alcohol! Drowsiness occurs … careful in hazardous situations, driving, machinery, etc Physical dependence is rare, except Xanax ! Benzo’s should NOT be used in pregnancy!

6. Misc Anxiolytics Buspar (buspirone) Vistaril/Atarax (hydroxyzine pamoate/hcl) Paxil (paroxetine) Effexor (venlafaxine) Desyrel (trazodone) See “Facts about Anxiolytics” on p.662

7. Major tranquilizers/ Neuroleptics Drugs used to treat Psychosis (see Table 31-2) are also known as “Antipsychotics” Antipsychotics are effective in 3 main areas: 1)hallucinations,delusions,combativeness (psychosis) 2)relief of nausea/vomiting (chemo, narcotic s/e) 3)to increase potency of analgesics (ex: promethazine) The two major forms of Psychosis are … Schizophrenia and Depression

8. Anti-Mania & Bi-polar drugs Bi-polar Disorder (formerly referred to as Manic-Depression) common meds used in the bi-polar patient: Lithium (Lithobid, Eskalith) – mainstay carbamazepine (Tegretol) – developed as an anti-seizure drug valproic acid (Depakote, Depakene) –also originally for seizure disorders

9. Depression !(study Box 31-3 on p. 668) aka ‘mood-disorders’ or ‘affective-disorders’ Among the most common psychiatric disorders, and is of (2) major types … Exogenous – “the blues”, a response to ‘external’ factors, normally self-limiting Endogenous (unipolar) – no apparent ‘external’ cause, basis is typically genetic or biochemical …

10. Exogenous/Endogenous Depression (cont) Exogenous Depression: Caused by external factors such as - divorce, loss of loved one, job loss, serious illness, etc Drug therapy often successful w/ Exogenous Endogenous: seems to come from ‘within’ the person, biochemical imbalance, hereditary Endogenous type DOES NOT respond well to medication therapy

11. Anti-depressant Drugs (study Box 31-4 on p.669) All major classes have a similar response rate … So the choice-of-drug is based on things like: *side-effects *patient-history *if sedation is needed MAOI’s (monoamine oxidase inhibitors) TCA’s (tricyclic antidepressants) SSRI’s (selective serotonin reuptake inhibitors) SNRI’s (selective norepinephrine reuptake inhib) NRI’s (natural reuptake inhibitors) –herbal, St.John’s wort for example

12. MAOI – patient ed Very high number of potentially dangerous DRUG and FOOD interactions! Avoid TYRAMINE containing foods, such as *cheese *wine *beans *chocolate (31-4, p.672) See DDI (Dangerous-Drug-Interactions) (31-5,p.672) MAOI must be ‘cleared’ from body before starting any new antidepressant (taper)

13. ‘Atypical’ Antidepressants (2 nd generation) Introduced in the 1980’s These will treat --- major depressions, reactive depressions, and anxiety disorders Wellbutrin (bupropion) Remeron (mirtazapine) Desyrel (trazodone)

14. Alzheimer’s disease ~ 250,ooo new cases per year! Progressive (worsening) illness Degradation of nerve pathways (cholinergic) Impaired thinking, confusion, disorientation, ‘sundowning’ = symptoms worse in evening No specific ‘test’ for this, can only be diagnosed with certainty by autopsy Drugs are used to slow the deterioration and/or improve patient’s nerve function

15. Drug therapy for Alzheimer’s See Table 31-6 on p.675 Cognex, Aricept: increases nerve-function only Reminyl: slows disease progression AND improves nerve function (increased Ach) Namenda: newest agent – ‘anti-Alzheimer’ agent, reduces deterioration of cholinergic nerve pathways in moderate-severe cases

16. ADHD Common behavioral disorder (average of one ADHD child per classroom) – cause unknown! Diagnosis usually based on symptoms that occur before age 7, and last > 6 months Symptoms (begin from 3 – 7 yo, thru teenage) Inattention Hyperactivity Impulsivity

17. Drugs for ADHD (study Table 31-7 on p.677) CentralNervousSystem (CNS) Stimulants Not to be given >1 year without a ‘break’ from the drug! …may suppress child’s growth Break is known as ‘Drug-Holiday’ Suggested Drug-Holiday opportunities … Weekends, summer-breaks, vacations, etc

18. ADHD drug names Methylphenidate (Ritalin) – CII (schedule-2) Dextroamphetamine (Dexedrine) -CII Amphetamine (Adderall) -CII Lisdexamfetamine (Vyvanse) -CII Atomoxetine (Strattera) only one that’s not a ‘scheduled’ drug, also used as antidepressant

19. ADHD drug side-effects CII’s (methylphenidate, etc) – insomnia, growth suppression, headache, abdominal pain, lethargy, weight loss, dry mouth, irritability Strattera (lisdexamfetamine) – headache, dyspepsia, nausea/vomiting, fatigue, decreased appetite, dizziness, altered mood Clonidine (HTN agent) – hypotension, sedation

20. Dosing calculations review (chapter-9) LET’S REVIEW !!! ANY QUESTIONS are fine …

21. Calculating Doses (oral, nonparenteral) 3 calculation methods --- Ratio-and-Proportion method --- Formula-Method --- Dimensional-analysis Choose the ONE method that you’re most comfortable with … and stick with it !

22. Why just ONE method ? …you will become very familiar with your ‘chosen’ method … this will reduce the chance of medication errors that may occur from switching between calculation methods !

23. Basic Rules for confident calculating (see Box 9-1 on p.166 … dosage-forms) Always check UNIT’s (numerator/denominator) Always work the problem ON PAPER, even the math seems EASY Check and RE-CHECK all Decimals, Fractions LOOK at the RESULT! …does it look reasonable? Take ONE LAST LOOK to make sure you calculated dose in the correct units

24. Box 9-1 (p.166) Dosage-forms What type of dosage-forms can be divided ? Scored tablets Oral – syrups, liquids Time-release (sustained, delayed)

25. “labeling” the math “DA” = dose-available, what is ‘on-hand’ “DO” = dose-ordered, what you ‘want’ “DF” = dosage-form, of the ‘on-hand’ “DG” = dose-given, this is the unknown- amount of the on-hand drug that we are calculating

26. Ratio-and-Proportion Units must match … numerator/denominator Ratio examples: 60-minutes/1-hour Proportion examples: 60min/1hr = 120min/2hr Let’s try one!: how many minutes in 2.5 hours ? a) we are looking for x minutes/2.5 hours b) we know that 60min/hr (60min = 1hr, written as fraction) ( … see next slide … )

27. ratio-and-proportion Let’s try one!: how many minutes in 2.5 hours ? 1 st : we are looking for x minutes/2.5 hours 2 nd : we know that 60min/hr …(60min = 1hr, written as fraction) so set-up the problem as xmin/2.5hr = 60min/hr 3 rd : now we cross-multiply x -min x 1-hr = 2.5hr x 60min 4 th : ‘hr’s cancel, leaving: x = (2.5)(60min) = 180 minutes … our final answer, which makes sense! 2-1/2 hours is 60min + 60min + 30min = 180 minutes.

28. Formula - method “DA” = dose-available, what is ‘on-hand’ “DO” = dose-ordered, what you ‘want’ “DF” = dosage-form, of the ‘on-hand’ “DG” = dose-given, this is the unknown-amount of the on-hand drug that we are calculating Always check that the strengths of the drug- ordered (DO) and the drug-available (DA) are in the same-unit-of-measure!

29. Formula-method cont. Look at page-171 Example #3, then Example #4 Ask yourself … (also, page-171) --what the Dr. ordered (DO)? --what strength is available (DA)? --what is the unit of measure (DF)? --how much do we need to give (DG)? REMEMBER … 1-grain = 60-mg (gr i = 60 mg)

30. Dimensional - analysis Look at page-173 of Textbook Once learned, this is a very good system Try a few examples in your Textbook May be the ‘one for you’ !