Transcript 14-Psychopharmacology_Course 426_Student

Psychopharmacology
Khalid Bazaid, MB BS, FRCPC
Assistant Professor
Child & Adolescent Psychiatrist
Department of Psychiatry
College of Medicine
King Saud University
3/21/2017
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Outlines
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The role of psychotropic medications in the mental
health and its therapeutic indications
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Identify specific cautions to be aware of the various
psychotropic medications
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Discuss the adherence to medication treatment
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Overview Psychotropic Medications Classifications
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Psychopharmacology
The aim is learn how to choose
a psychotropic drug that is more:
• Less toxic
• Effective
• Better-tolerated
• The most targeted therapeutic agents
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Use of psychotropic medications
 Relieve or reduce symptoms/signs of dysfunctional
thoughts, moods, or actions of mental illness
 Improve client’s functioning
 Increase compliance to other therapies
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Psychotropic Drugs
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Focus of all mental activity is the CNS (brain)
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Origin of psychiatric illness caused by many factors:
– Genetics
– Neurodevelopment factors
– Endocrinologic e.g. Hypothyroidism
– Autoimmune system (infections)
– Drugs
– Psychosocial experiences, stressors … etc.
 To date …Theories behind use of psychotropic drugs
focuses on neurotransmitters and their receptors
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Psychotropic drugs act by modulating neurotransmitters
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Therapeutic Effects of
Psychotropic Medications
 Do not “cure”
 Relieve or decrease
symptoms
 Prevent or delay return
of S/S
 Cannot be used as the
sole treatment for
disorders
 Need informed consent
before starting
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 Are broad spectrum and
have effects on a large
number of S/S
 Initial effects are
sedative in nature
 May take weeks for
effects to be seen
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Reasons for Non- adherence:
 Medications are
expensive
 Unpleasant side effects
 Feel better and decide
no longer need
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 Stigma associated with
having a mental illness
and taking medications
 Paranoia or fears about
medication usage
particularly addition
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Encouraging Compliance to
Medication Regimen
 Follow-up appointments With client to verify that client
understands:
the purpose, proper administration, intended effects, side and
toxic effects of, and how to treat problems associated with
medications
 Appropriate lab tests must be conducted to prevent
complications and assure correct levels of drugs
 Encourage clients to participate in medication groups
 Can use injections of antipsychotics which will last
from 2-4 weeks if clients are non-compliant
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Efficacy of Psychotropics with
Children & Elderly
 Use with great caution
 Start low and go slow for both elders and
children
 Children are faster metabolizer whereas elders
have decrease liver & renal function
 Risk of injuries and falls with elderly
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Client & Family Teaching
 Purpose of the meds
and benefits, side
effects and how to
treat SE
 What S/S indicate a
toxic effect, and how
to treat, and whom to
call.
 Specific instructions
about how to take the
medications
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Psychotropic Medications
Classifications
 Antipsychotics
(Neuroleptics)
 Mood Stabilizers
 Antidepressants
 Anxiolytics
(antianxiety)
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 Sedatives
 Hypnotics
 Psychostimulants
 Antihistamines,
antimuscarinics,
dopamine agonists
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Antipsychotics
NEUROLEPTICS / MAJOR TRANQUILIZERS
 Block D2 receptors in the mesolimbic
system
 Not addictive
 Treat all psychoses & psychotic symptoms
Schizophrenia Disorders
Tourette’s Syndrome
Bipolar disorder
Delirium, Dementia, and
Delusions
Major Depression with
psychotic features
Control of intractable
hiccups
Aggressive behavior
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ANTIPSYCHOTIC DRUGS
NEUROLEPTICS / MAJOR TRANQUILIZERS
Mechanism of action
 In typical antipsychotics
– Blockage of D2 – receptors in:
 Nigro-strial (psychiatric tract)
 Substantia Nigra (Neurological tract)
 Tubero-infundibular tract (Endocrine tract)
 In atypical antipsychotics:
– Blockage of 5HT2A/D2 receptors
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ANTIPSYCHOTIC DRUGS
Side effects (hint)
 High Potency typical antipsychotics:
Neurological side effects
e.g. Haloperidol
 Low Potency typical antipsychotics: other
side effects
e.g. Chlorpromazine
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ANTIPSYCHOTIC DRUGS
Neurologic Side effects
 Due to D2 blockade
Parkinsonian syndrome
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Position & gait
Apathy
Drooling
Fine tremor
Staring eyes
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ANTIPSYCHOTIC DRUGS
Neurologic Side effects
 Due to D2 blockade
– Parkinsonian
syndrome
– Akathesia (Motor
restlessness)
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Subjective feelings of restlessness
Objective signs of restlessness
Feelings of anxiety, inability to relax,
jitteriness, pacing, rocking motions
while sitting, rapid alterations of
position.
More in middle aged women
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ANTIPSYCHOTIC DRUGS
Neurologic Side effects
 Due to D2
blockade
Acute dystonia
– Parkinsonian
syndrome
– Akathesia (Motor
restlessness)
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Brief or prolonged muscle
contraction leading to abnormal
movements or postures e.g.
Occulogyric crises, tongue
protrusion, torticollis, laryngeal
pharyngeal dystonias and dystonic
Postures
Early onset, more in young men and
high doses of typical neurosleptics
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ANTIPSYCHOTIC DRUGS
Neurologic Side effects
 Due to D2 blockade
– Parkinsonian
syndrome
– Akathesia (Motor
restlessness)
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Involuntary choreiform, athetoid or
rhythmic movements of the tongue,
jaw, trunk or extremities
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More with long term typical neuroleptic
treatment, old age, female sex, mood
disorder, cognitive disorders.
– Acute dystonia
– Tardive Dykinesia
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ANTIPSYCHOTIC DRUGS
Neurologic Side effects
 Due to D2 blockade
– Parkinsonian syndrome
– Akathesia (Motor
restlessness)
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Muscular rigidity, , Hyper-thermia , Akinesia,
mutism, obtundation & agitation, sweating,
tachycardia, Hypertension.
Increased WBC, increased CPK, liver enzymes,
and plasma myoglobulin. Myoglobulinuria,
may occur and may lead to renal failure.
Symptoms evolve in 1-3 days & may last 10-14
days.
May occur at any time
More common in young men
Mortality: 20% - 30%( higher with depot)
– Acute dystonia
– Tardive Dyskinesia
– Neuroleptic malignant
syndrome
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ANTIPSYCHOTIC DRUGS
Other Side effects
 Muscarenic (anti-cholenergic):
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dry mouth
Constipation
Blurred vision, urinary retention
Precipitation of narow angle glucoma
 Alpha–1–adrenergic blockade:
– Orthostatic hypotension
– Impotence
– Impaired ejaculation
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ANTIPSYCHOTIC DRUGS
Other Side effects
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CNS Side effects:
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Sedation
Metabolic / Endocrine Side
effects:
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weight gain
Increased BS & lipids
Galactorrhea
Amenorrhea
Allergic Side effects
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Cholestatic jaundice
Agranulostasis
 Cardiac side effects:
– EKG changes
– Arrythmias
 Occular Side effects:
– Corneal Opacities
– Retinitis pigmentoza
 Dermatological Side effects:
– Photosensitivities
– Metallic discoloration
– Contact dermatitis
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Antipsychotics-Long acting
preparation
 Can be given be given as an IM injection
(depot preparations) if have difficulty
taking oral meds.
 Can use lower doses when given IM, so
less risk of tardive dyskinesia
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Antidepressants
 Treatment of depressive moods, including
bipolar disease
 4 categories:
– Tricyclics (TCA)
– MAOI’s
– SSRI’S
– Atypical Antidepressants
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Major Indications for
Antidepressants
 Major Depressive
disorder
 Bipolar depression
 Anxiety disorders:
 Panic disorder
 Obsessive-Compulsive
 Phobic disorders
 PTSD
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Substance Abuse
Chronic Pain
Tourette’s Disorder
ADHD
Eating disorders
Sleep disorders
Migraines
Enuresis
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Antidepressant Drugs
 Tricyclics- Amitriptyline, Imipramine
 SSRI’s- Fluoxetine, Sertraline
 MAOI’s- Phenelzine , Tranycypramine
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Atypical Antidepressants
 Inhibits reuptake of
serotonin:
desyrel (Trazodone)
 Norepinephrine Dopamine
Reuptake Inhibitor (NDRI):
Wellbutrin (Bupropion)
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 Serotonin Norepinephrine
Reuptake Inhibitor-(SNRI):
Effexor (venlafaxine)
Cymbalta (duloxetine)
 Increases release of
serotonin & norepinephrine:
Remeron (Mirtazapine)
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Atypical Antidepressants
 Trazodone:
alternative to TCA’s, may cause orthostatic hypotension,
sedation, and priapism in males
 Remeron:
causes sedation, weight gain, dry mouth, constipation
 Wellbutrin (zyban): rarely causes sedation, weight Gain,
or sexual dysfunction
– Used for smoking cessation. Most common S/E are headaches,
insomnia & nausea
– May lower seizure threshold
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Atypical Antidepressants:
Serotonin Norepinephrine Reuptake
Inhibitor (SNRI)
 SNRI-blocks uptake of
serotonin and norepinephrine
 Skipping 1 dose can
cause withdrawal S/S
 Drugs include Effexor
& Cymbalta
 Very effective in
treating severe
depression
 Good for clients with anxiety
 S/E:GI, sexual dysfunction,
insomnia, agitation
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 Cymbalta is effective in
treating somatic
symptoms e.g. pain
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ANTIDEPRESSANT DRUGS
Side effects
 HETEROCYCLICS:
– Muscarenic (anti-cholenergic):
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Dry mouth
Constipation
Blurred vision, urinary retention
Precipitation of narow angle glucoma
 Alpha–1–adrenergic blockade:
– Orthostatic hypotension
– Impotence
– Impaired ejaculation
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ANTIDEPRESSANT DRUGS
Side effects
Central anti-cholenergic syndrome:
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Delirium
Coma seizures
Agitation
Hallucinations
Severe hypotension
Supra-ventricular
tachycardia
Flushing
Mydriasis
Dry skin
Hyperthermia
Decreased bowel sounds.
Management
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Stop HCA immediately
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Physostigmine
(anticholinesterase inhibitor) 12 mg IV or IM every 20 – 60
minutes, until improvement
occurs
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Cardiac monitoring and life
support (physostigmine may
lead to severe BP drop and
bronchial constriction)
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Benzodiazepines may be
used.
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ANTIDEPRESSANTS
Side effects
 HETEROCYCLICS:
 SSRI:
– have a much better side effect profile:
 Agitation
 Sexual problems
 Stomach upset
 Hypersomnia/insomnia
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ANTIDEPRESSANTS
Side effects
 HETEROCYCLICS:
 SSRI:
 MAOI:
– Cardiovascular (orthostatic hypotension, tyramine
hypertensive crisis)
– Sexual (Impotence & delayed ejaculation)
– Neurologic (insomnia, seizure& euphoria)
– Hepatic: (Cholestatic reaction).
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ANTIDEPRESSANTS
Side effects
 HETEROCYCLICS:
 SSRI:
 MAOI:
– Interaction:
– Diet:
Aged cheese
Pickled herriag
Raisin
Alcohol
Chicken liver
Beans
Figs
Yeast products
Chocolate
Amphetamines
Decongestants & nasal sprays (Ephedrine….)
Epinephrine (local anesthesia)
Aldomet
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MOOD STABLIZERS
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Lithium Carbonate
Sodium Valproate
Carbamazepine
Lamotrigine
Topiramate
Clozapine
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MOOD STABLIZERS
 Used in the treatment of Manic (Bipolar)
disorder, and in some forms of depression
 Drugs used: Lithium and Antiepileptic Drugs
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Lithium
 Mechanism of action
unknown
 Alters electrical
conductivity
– potential threat to all
body functions that
are regulated by
electrical currents
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 Can cause polyuria and
polydipsa due to Na and
K alterations
 Has the lowest
therapeutic index of all
psych drugs
 Have to monitor blood
levels
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LITHIUM CARBONATE
Side effects
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Neurological: Tremor (50%), weakness, cog-wheeling
Renal: Occur in 10-50 % e.g. polyuria, polydipsia, nephrogenic
D.I., nephrotic syndrome, (tubular changes with chronic use
and high levels)
Cardiac: Similar to those of hypokalimia e.g. U-wave and Twave depression
Endocrine: Goiter, hypothyroidism, abnormal thyroid functions
(30-40%)
Dermatological: Acne, exacerbation of psoriasis ), hair loss.
Pregnancy and lactation: Teratogenicity (level in milk=30-100%
of maternal blood level)
Toxicity: (seizures, delirium, cerebellar signs, coma) occurs in
blood level= 1.2 – 2 mEq/l. Lethal levels above that.
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Signs & Symptoms of Lithium
Toxicity
 Fine hand tremors that
progress into coarse
tremors
 Mild GI upset
progressing to
persistent upset
 Slurred speech and
muscle weakness
progressing to mental
confusion
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 Severe Toxicity:
– decrease level of
consciousness to
stupor and finally
coma
– Seizures, severe
hypotension, severe
polyuria with dilute
urine
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Contraindications for Lithium
 Renal disease
 Cardiac disease
 Severe dehydration
 Sodium depletion
 Brain damage
 Pregnancy or lactation
 Use with caution in the elderly or clients with diabetics, thyroid
disorders, urinary retention, and seizures
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Sedative/Hypnotic Drugs
 Anxiolytic and hypnotic
 Can lead to tolerance and dependency
 Use for short term
 Drugs used
benzodiazepines: Dalmane, Restoril, Halcion
Non-benzodiazepines: Ambien, Sonata, Lunestra
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Benzodiazepines
 Valium, Xanax, Ativan ,
Librium, Lexotanil
 Risk of dependency
 Avoid ETOH
 Dalmane, Halcion (used as
sleep aides-short term)
 Causes sedationdon’t drive!!
 Used for anxiety disorders,
ETOH withdrawal, muscle
spasm, sedation, insomnia,
and epileptics/seizures
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Benzodiazepines
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Side Effects
– Drowsiness, confusion, sedation, and lethargy
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Toxic Effects
– Respiratory depression esp. with ETOH use!
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Contraindications
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Combination with other CNS depressants
Renal or hepatic dysfunction (may use Ativan)
History of drug abuse or addiction
Depression and suicidal tendencies
Teaching
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Use short term due to risk of drug dependency
Avoid ETOH and other CNS depressants
Can impair ability to drive
Sudden D/C of benzodiazepines might cause withdrawal s/s
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Non-benzodiazepine Anxiolytic
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BuSpar (Buspirone)
Reduces anxiety without strong sedative-hypnotic properties
Not a CNS depressant
Takes 2 weeks to feel effects
No potential for addiction
 Side Effects
– Dizziness, dry mouth, nervousness, diarrhea, headache, excitement
 Toxic Effects
– Lethal dose is 160-550 times the daily recommended dose
 Contraindications
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Use with caution in PG women
Nursing mothers
Clients with renal or hepatic disease
Anyone taking MAOs
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Questions after lecture?
 Please e-mail ([email protected]) or call
(01 467 1717)
 Interested in learning more about child and
adolescent psychiatry?
– Arrange to attend OPD
– Consider an elective rotation during internship or
otherwise
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