Transcript Drugs for Mental Health chapter-31

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
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
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
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
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!
Misc Anxiolytics
• Buspar (buspirone)
• Vistaril/Atarax (hydroxyzine pamoate/hcl)
• Paxil (paroxetine)
• Effexor (venlafaxine)
• Desyrel (trazodone)
• See “Facts about Anxiolytics” on p.662
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
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
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 …
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
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
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)
‘Atypical’ Antidepressants
(2nd generation)
• Introduced in the 1980’s
• These will treat --- major depressions, reactive
depressions, and anxiety disorders
• Wellbutrin (bupropion)
• Remeron (mirtazapine)
• Desyrel (trazodone)
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
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
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
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
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
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
Dosing calculations
review (chapter-9)
•LET’S REVIEW !!!
•ANY QUESTIONS are
fine …
Calculating Doses (oral,
nonparenteral,
parenteral)
• 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 !
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 !
Basic Rules for confident calculating
• 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
“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 unknownamount of the on-hand drug that we are
calculating
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
b) we know that
( … see next slide … )
x minutes/2.5 hours
60min/hr (60min = 1hr, written as fraction)
ratio-and-proportion
• Let’s try one!: how many minutes in 2.5 hours ?
1st: we are looking for
x minutes/2.5 hours
2nd: we know that 60min/hr …(60min = 1hr, written as fraction) so
set-up the problem as xmin/2.5hr = 60min/hr
3rd: now we cross-multiply x-min x 1-hr = 2.5hr x 60min
4th: ‘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.
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 drugordered (DO) and the drug-available (DA) are in
the same-unit-of-measure!