PSYCHOTROPIC DRUGS

CHAPTER 3

MOOD STABILIZERS
LITHIUM (ESKALITH, LITHOBID)
Treatment of pt with bipolar disorder May act by affecting electrical conductivity in neurons May reduce excitatory neurotransmitter glutamate causes antimanic effect May inhibit enzyme inositol monophosphate Can induce sinus bradycardia (cardiac contraction) Can lead to convulsions (tremors at therapeutic doses) Can lead to fluid disturbances (polyuria and edema) Long term use can cause hypothyroidism interfering with iodine molecules Lithium has a low therapeutic index (blood level for death not far above the level for treatment) Monitoring lithium levels in patients Side Effects: tremors, ataxia, confusion, convulsions, n/v, diarrhea, arrhythmias, polyuria, polydipsia, edema, goiter, and hypothyroidism

ANTIANXIETY AND HYPNOTIC DRUGS

BENZODIAZEPINES
Promote the activity of GABA inhibits cellular excitation They are efficient as anticonvulsants and help with alcohol withdrawal Rarely inhibit the brain to the degree that respiratory depression, coma or death can result When combined with other CNS depressants (alcohol, opiates, TCAs) can lead to life-threatening CNS depression Patients must be cautioned about engaging in activities that could be dangerous if reflexes and attention are impaired (driving a car) May contribute to falls and broken bones in older adults Ataxia(loss of coordination) side effect secondary to abundance of GABA receptors in the cerebellum

ANTIANXIETY AND HYPNOTIC DRUGS

BENZODIAZEPINES
Calming effect minimizing anxiety
Diazepam (Valium) Clonazepam (Klonopin) Alprazolam (Xanax)

ANTIANXIETY AND HYPNOTIC DRUGS

Treatment of insomnia- hypnotic effect

Flurazepam (Dalmane) Temazepam (Restoril) Triazolam (Halcion) Estazolam (Porsom) Quazepam (Doral)

ANTIANXIETY AND HYPNOTIC DRUGS

Reduce anxiety- without hypnotic effect

Lorazepam (Ativan)
Alprazolam (Xanax

ANTIANXIETY AND HYPNOTIC DRUGS

SHORT-ACTING SEDATIVE-HYPNOTIC SLEEP AGENTS
They have sedative effects w/o the antianxiety, anticonvulsant, or muscle relaxant effects of benzodiazepines Potential for amnesiac and ataxic (unsteadiness) side effects Onset of action is faster than benzodiazepines take when ready for sleep Tolerance and dependence less than benzodiazepines but still addictive These drugs have short half-lives

ANTIANXIETY AND HYPNOTIC DRUGS

SHORT-ACTING SEDATIVE-HYPNOTIC SLEEP AGENTS Z-hypnotics

Zolpidem (Ambien) Zaleplon (Sonata) Eszopiclone (Lunesta)

(7 to 8 hours of sleep unpleasant taste when awakening)

ANTIANXIETY AND HYPNOTIC DRUGS

MELATONIN RECEPTER AGONISTS
Melatonin is a hormone that is only excreted at night as part of the normal circadian rhythm. Acts in same way as naturally occurring melatonin

Hypnotic agent that are melatonin receptor agonist

Only medication approved for the treatment of insomnia that is not classified as a scheduled substance or having abuse potential Side effects: headache and dizziness

Not restricted to short-term use (neither is Lunesta)

Long term use above therapeutic doses can lead to increased prolactin and sexual dysfunction

ANTIANXIETY AND HYPNOTIC DRUGS

MELATONIN RECEPTER AGONISTS
Ramelteon (Rozerem)

ANTIANXIETY AND HYPNOTIC DRUGS

BUSPIRONE
Reduces anxiety w/o having strong sedative-hypnotic properties Doesnt leave patient sleepy or sluggish better tolerated than benzodiazepines Not a CNS depressant no danger of interactions with other CNS depressants (alcohol) Side effects: headache, dizziness, light-headness, nausea, and insomnia

ANTIANXIETY AND HYPNOTIC DRUGS

BUSPIRONE

BuSpar

ANTIDEPRESSANT DRUGS
TRICYCLIC ANTIDRESSANTS (TCA)
Were widely used before development of SSRIs No longer considered 1st line treatment for depression (3rd) More side effects, take longer to reach optimal dose, far more lethal in overdose (cardiac conduction disturbances) Blocks muscarinic receptors that normally bind acetylcholine Causes anticholinergic effects: blurred vision, dry mouth, tachycardia, urinary retention, and constipation

Can limit patient adherence with this regimen

Side effects: causes sedation and drowsiness

ANTIDEPRESSANT DRUGS

Block reuptake of norepinephrine- secondary amines

Nortriptyline (Pamelor)

ANTIDEPRESSANT DRUGS

Block reuptake of norepinephrine and serotonintertiary amines Amitriptyline (Elavil) Imipramine (Tofranil)

ANTIDEPRESSANT DRUGS
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) Block the reuptake and destruction of serotonin 1st line Does not elicit anticholinergic and sedating sided effects Side effect: Inhibit reflexes of orgasm, low libido, n/v

ANTIDEPRESSANT DRUGS
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) Fluoxetine (Prozac) Sertraline (Zoloft) Paraoxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) Fluvoxamine (Luvox)

ANTIDEPRESSANT DRUGS
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS(SNRI) Increase serotonin and norepinephrine 2nd line Hypertension is a dose dependent effect Therapeutic effects on neuropathic pain (nerve injury or pain) Inhibits pathways to the spinal cord limiting pain signals to the brain

ANTIDEPRESSANT DRUGS
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS(SNRI) Venlafaxine (Effexor) Duloxetine (Cymbalta) -(depression & diabetic peripheral neuro)

ANTIDEPRESSANT DRUGS
SEROTONIN NOREPINEPHRINE DISINHIBITORS (SNDIs) Increases norepinephrine and serotonin transmission by blocking noradrenergic receptors Offers both antianxiety and antidepressant effects with minimal sexual dysfunction Suited for patient with nausea (antiemtic) Side effects: sedation and weight gain

ANTIDEPRESSANT DRUGS
SEROTONIN NOREPINEPHRINE DISINHIBITORS (SNDIs)

Mirtazapine (Remeron)

ANTIDEPRESSANT DRUGS
MONOAMINE OXIDASE INHIBITORS (MAOIs)
Antidepressant that has desirable effects on brain but dangerous effects on the other parts of body Drugs that prevent the destruction of monoamines by inhibiting the action of MAO MAO is an enzyme located in neurons of the liver Act by inhibiting the enzyme and interfering with destruction of neurotransmitters increasing antidepressant effects

Tyramine poses a threat of hypertensive crisis produces significant vasoconstriction (avoid aged cheeses, pickled or smoke fish, wine)
Contraindicated with use of any other antidepressants and sympathomimetic drugs Concurrent use with some over the counter products w/ sympathomimetic properties (oral decongestants) should be avoided. Patients must be given a list of foods high in tyramine and drugs to avoid

ANTIDEPRESSANT DRUGS
MONOAMINE OXIDASE INHIBITORS (MAOIs) Phenelzine (Nardil) Tranylcypromine (Parnate) Selegilline (EMSAM)

ANTIDEPRESSANT DRUGS
OTHER ANTIDEPRESSANTS
Bupropion (Wellbutrin) effective antidepressant Zyban used for smoking cessation Trazodone is not 1st choice but it is given with other agent because of sedation helps with insomnia (need high doses) can lead to priapism Contraindicated in patients with seizure disorders, anorexia, or bulimia, and abrupt discontinuation of alcohol or sedatives No sexual side effects Side effects: insomnia, tremor, anorexia, and weight loss

MOOD STABILIZERS
Lithium (Eskalith, Lithobid)
May reduce glutamate and exert antimanic effect May inhibit inositol monophosphatase Can induce sinus bradycardia, convulsions, tremor Can cause polyuria, edema, hypothyroidism Low therapeutic index Monitoring blood levels on regular basis S/E: tremor, ataxia, confusion, n/v, diarrhea, arrhythimias, polyuria, polydipsia, edema, goiter

ANTICONVULSANT DRUGS
VALPROATE
Used in treatment of bipolar disorder 1st choice drug- drugs reduce mood swings in pt with bipolar disorder

Recommended for mixed episodes used for rapid cycling (3-4x/yr)

Side effects: tremor, weight gain, sedation, thromobyctopenia, pancreatitis, hepatic failure, and birth defects Liver function indicators and CBC before starting and measured periodically after starting this medication Therapeutic blood levels of this drug are monitored

ANTICONVULSANT DRUGS
VALPROATE Divalproex sodium (Depakote) Valproic acid (Depakene

ANTICONVULSANT DRUGS
CARBAMAZEPINE (Tegretol)
Used in preventing mania during episodes of acute mania-2nd choice Reduces firing of neurons by reducing sodium channel activity Side effects: anticholinergic side effects (dry mouth, constipation, urinary retention, blurred vision), orthostasis, sedation, ataxia, rash Baseline laboratory work: liver function test, CBC, electrocardiogram, and electrolyte levels, blood levels monitor toxicity (>12mcg/mL) No established levels for treatment of bipolar disorder

ANTICONVULSANT DRUGS
CARBAMAZEPINE (Tegretol)

ANTICONVULSANT DRUGS
LAMOTRIGINE (Lamictal)
Maintenance therapy of bipolar disorder not effective in acute mania 3rd choice Works well in treating the depression of bipolar disorder less incidence of mania Modulates the release of glutamate and aspartate Pt should promptly report any rashes- Stevens Johnson syndrome Slow titration to therapeutic doses needed

ANTICONVULSANT DRUGS
LAMOTRIGINE (Lamictal)

ANTICONVULSANT DRUGS
OTHER ANTICONVULSANTS None have FDA approval as mood stabilizers

Typically use Klonopin during mania episodes

ANTICONVULSANT DRUGS
OTHER ANTICONVULSANTS Gabapentin (Neurontin) Topiramate (Topamax) Oxcarbazepine (Trileptal)

ANTIPSYCHOTIC DRUGS

Clozapine (Clozaril)
First of atypical antipsychotic drug Blocks dopamine receptors in mesolimbic system No EPS (EXTRAPYRAMIDAL SIDE EFFECTS) Potential to suppress bone marrow and induce agranulocytosis- infection possible Potential for inducing convulsions/ myocarditis S/E: drowsiness, sedation, hypersalivation, weight gain, reflex tachycardia, constipation, dizziness

ANTIPSYCHOTIC DRUGS
Risperidone (Risperdal)
Atypical Antipsychotic drug Low potential for inducing agranulocytosis or convulsions May lead to motor difficulties at high dosage (>6) Can cause orthostatic hypotension that can lead to falls in older adults S/E: weight gain, sedation, sex dysfunction, CVA Available in long acting injection (every 2 wks)

ANTIPSYCHOTIC DRUGS
Quetiapine (Seroquel)
Atypical Antipsychotic drug High sedation Weight gain and metabolic syndrome Orthostasis Low risk for EPS or prolactin elevation

ANTIPSYCHOTIC DRUGS
Other Atypical Antipsychotics
Olanzapine (Zyprexa) Ziprasidone (Geodon)- no cardiac issues
S/E: sedation, weight gain, hyperglycemia (type 2), metabolic syndrome S/E: dizziness and moderate sedation Contraindicated in pts w/ QT interval prolongation (MI) Dopamine system stabilizer Little sedation & weight gain S/E: insomnia and akathisia Newest antipsychotic S/E: EPS , prolactin elevation, orthostasis, sedation Available as 24hr release

Aripiprazole (Abilify)

Paliperidone (Invega)

HERBAL TREATMENTS
ST. JOHNS WORT WITH OTHER SERTONERGIC AGENTS (SSRI AND TRIPTANS) CAN CAUSE SEROTONIN SYNDROME HYPERTENSIVE CRISIS

BENZODIAZEPINES
GENERIC NAME BRAND NAME

DIAZEPAM CLONAZEPAM ALPRAZOLAM FLURAZEPAM TEMAZEPAM TRIAZOLAM ESTAZOLAM QUAZEPAM LORAZEPAM

VALIUM KLONOPIN XANAX DALMANE RESTORIL HALCION PROSOM DORAL ATIVAN

SHORT ACTING SEDATIVE HYPNOTIC

GENERIC NAME BRAND NAME

ZOLPIDEM ZALEPLON ESZOPICLONE

AMBIEN SONATA LUNESTA

MELATONIN RECEPTOR AGONIST

GENERIC NAME BRAND NAME

RAMELTEON

ROZEREM

BUSPIRONE
GENERIC NAME BRAND NAME

BUSPIRONE

BUSPAR

TRYCYCLIC ANTIDEPRESSANT
GENERIC NAME BRAND NAME

NORTRIPTYLINE AMITRIPTYLINE IMIPRAMINE

PAMELOR ELAVIL TOFRANIL

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)

GENERIC NAME BRAND NAME

FLUOXETINE SERTRALINE PAROXETINE CITALOPRAM LEXAPRO FLUVOXAMINE

PROZAC ZOLOFT PAXIL CELEXA LEXAPRO LUVOX

SEROTONIN- NOREPINEPHRINE REUPAKE INHIBITORS (SNRI)

GENERIC NAME BRAND NAME

VANLAFEXINE DULOXETINE

EFFEXOR CYMBALTA

SEROTONIN- NOREPINEPHRINE DISINHIBITORS

GENERIC NAME BRAND NAME

MIRTAZAPINE

REMERON

MONOAMINE OXIDASE INHIBITORS (MAOI)

GENERIC NAME BRAND NAME

PHENELZINE TRANYLCYPROMINE

NARDIL PARNATE

OTHER ANTIDEPRESSANTS
GENERIC NAME BRAND NAME

BUPROPION

WELLBUTRIN ZYBAN DESYREL OLEPTRO

TRAZODONE

MOOD STABILIZERS
GENERIC NAME BRAND NAME

LITHIUM

ESKALITH LITHOBID

ANTICONVULSANT
GENERIC NAME BRAND NAME

VALPROATE

DEPAKOTE DEPAKENE DIVALPROEX

ANTICONVULSANT DRUGS
GENERIC NAME BRAND NAME

CARBAMAZEPINE

TEGRETOL

ANTICONVULSANT DRUGS
GENERIC NAME BRAND NAME

LAMOTRIGINE

LAMICTAL

TYPICAL ANTIPSYCHOTIC DRUGS

GENERIC NAME
HALOPERIDOL MOLINDONE LOXAPINE THIORIDAZINE THIOTHIXENE FLUPHENAZINE MESORIDAZINE TRIFLUOPERAZINE CHLORPROMAZINE PERPHENAZINE

BRAND NAME
HALDOL MOBAN LOXITANE MELLARIL NAVANE PROLIXIN SERENTIL STALAZINE THORAZINE TRILAFON

ATYPICAL ANTIPSYCHOTIC DRUGS

GENERIC NAME BRAND NAME

CLOZAPINE RISPERIDONE QUETIAPINE OLANZAPINE ZIPRASIDONE ARIPIPRAZOLE PALIPERIDONE

CLOZARIL RISPERDAL SEROQUEL ZYPREXA GEODON ABILIFY INVEGA

ANTIANXIETY & HYPNOTIC DRUGS

BENZODIAZEPINES SHORT ACTING SEDATIVE HYPNOTIC SLEEP AGENTS MELATONIN RECEPTOR AGONISTS BUSPIRONE

ANTIDEPRESSANT DRUGS
TRICYCLIC ANTIDEPRESSANTS (TCA) SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI) SEROTONIN-NOREPINEPHRINE DISINHIBITORS (SNDI) MONOAMINE OXIDASE INHIBITORS (MAOI)

MOOD STABILIZERS
LITHIUM

ANTICONVULSANT DRUGS
VALPROATE CARBAMAZEPINE LAMOTRIGINE

TYPICAL ANTIPSYCHOTIC DRUGS

HALOPERIDOL MOLINDONE LOXAPINE THIORIDAZINE THIOTHIXENE FLUPHENAZINE MESORIDAZINE TRIFLUOPERAZINE CHLORPROMAZINE PERPHENAZINE

ATYPICAL ANTIPSYCHOTIC DRUGS

CLOZAPINE (CLORZARIL) RISPERIDONE (RISPERDAL) QUETIAPINE (SEROQUEL) OLANZAPINE (ZYPREXA) ZIPRASIDONE (GEODON) ARIPIPRAZOLE (ABILIFY) PALIPERIDONE (INVEGA) \