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2012-02-02 17:41:15
mental health pharm

Mental Health Phamacology
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    {treats positive sx}
    • High
    • potent- not
    • very sedating, bigger sx:
    • haloperidol, thiothixine(Navane), fluphenazine(prolixin). Come in long acting monthly injections

    Low potent- more sedative; chlorpromazine (thorazine), mezorizidin, thioridazine (off market; mellaril), trifluoperazine (stellazine)

    Medium potent- perphenazine (trilafon) *, Gloxatine, molindone

    OFTEN NEED MEDS TO CONTROL SX. Amantadine (symmetrel), akineton, benztropine (Cogentin), diphenhydramine, trihexyphenadyl (Artane). These work with the psychosis.
    • (med of choice) (works on both
    • positive and negative sx) (fewer EPS and TD and anticholinergic)

    • DONES

    • Respiridone (risperdal), ziprasidone (Geodon), paliperidone (invega), pilopuridone = good for psychosis…but with neuro
    • side effects. Good for voices but watered down. Overall less neuro
    • than traditional. Metabolic side effects . ADD aripiprazole (Abilify). Some come in long acting

    • PINES.
    • Quetiapine( Seroquel), onlanzapine(Zyprexa), {clozapine} – Asinapine – generally sedating…more than dones.
    • More metabolic symptoms… than the dones. Don’t need regular bloodwork.
    • Rob’s story
  3. How do Antipsychotic Drugs
    • Antipsychotic
    • drugs work by blocking receptors of the neurotransmitter dopamine. The typical
    • antipsychotics are good
    • at treating target sx but with many extrapyramidal side effects.. Clozapine has
    • lower incidence of EPSE.
  4. Side
    Effect Profiles
    •Extrapyramidal Side Effects

    •Neuroleptic Malignant Syndrome

    •Tardive Dyskinesia

    •Metabolic Syndrome


    •Anticholinergic Side Effects
  5. Extrapyramidal Side
    •Acute dystonia



    •Treatment: discontinue or anticholinergic
  6. Acute dystonia
    • (1st 3 days)acute muscular rigidity and
    • cramping, a stiff or thick tongue with difficulty swallowing and in severe
    • cases, laryngospasm and resp
    • difficulties. Occurs usually in first week of
    • treatment, < 40, males and those receiving high potency drugs. Torticollis, opisthotonus, oculogyric crisis. Painful
    • frightening. IM or IV ANTICHOLINERGIC {Cogentin
    • or Benadryl}
  7. Pseudoparkinsonism
    • (after weeks to months) – stiff stooped posture, mask-like facies;
    • decrease arm swing; shuffling, festinating gait with small steps; cogwheel
    • rigidity (ratchet-like movements of joints); drooling; tremor; bradycardia; and
    • coarse pill-rolling movements of the thumb and fingers at rest. CHANGE MED OR ANTICHOLINERGIC – amantadine
    • which is dopamine agonist.
  8. Akathisia
    • (1st 10
    • days) intense need to move about. Appears restless or anxious and agitated,
    • often with a rigid posture or gait and lack of spontaneous gestures. Internal
    • restlessness and inability to sit still or rest. BETA BLOCKER, ANTICHOLINERGIC;
    • or BENZO
  9. Neuroleptic
    Malignant Syndrome
    •Potentially fatal reaction


    •High fever (sudden)*

    • •Autonomic instability (unstable BP,
    • diaphoresis, pallor)


    •Elevated CPK levels

    •Confused and mute

    •Agitation to stupor
  10. Neuroleptic
    Malignant Syndrome (CONT)
    • 1st 2 weeks of
    • therapy. TX: immediate DC of meds and supportive medical care
    • Increased CPK, K, leukocytosis, renal failure

    20% mortality rate

    • Can give antipyretics, benzo’s for
    • anxiety, and dantrolene for muscle relaxation
  11. Metabolic
    •Insulin resistance


    •High serum lipids


    •Coagulation abnormalities
  12. Tardive Dyskinesia
    •Permanent involuntary movements


    • –Facial
    • and neck muscles

    • –Upper
    • and lower extremities

    • –Tongue
    • thrusting and protruding lip smacking

    • –Blinking,
    • grimacing
  13. Agranulocytosis
    •Most common with Clozaril

    • •Lab value: d/c drug with WBC
    • <2000

    •Symptoms include:


    • –High
    • fever


    • –Sore
    • throat


    • –Ulceration
    • of mucous membranes

  14. Agranulocytosis (cont)
    • Obtain
    • WBC weekly for 6 months, then every 2 weeks. If baseline WBC is less than 3500
    • don’t’ start on clozaril. If
    • WBC drop less than 200 then take off the
    • med.
  15. Anticholinergic Side
    •Orthostatic hypotension

    •Dry mouth


    •Urinary hesitance or retention

    •Blurred near vision

    •Dry eyes, photophobia

    •Nasal congestion

    •Decreased memory
    • SSRI’s
    • are first choice for depression

    • Used
    • in the tx of
    • major depressive illness, anxiety disorders, the depressed phase of bipolar
    • disorder, and psychotic depression…… Meds can also be used for chronic pain,
    • migraine h/a, neuropathies,
    • sleep apnea, dermatologic disorders, panic disorders, eating disorders.

    • SSRI’s,
    • TCA’s, MAOI’s

    • SSRI,
    • TCA, atypical antidepressants; maoi;
    • other forms
  17. Antidepressant Drugs



    • •NRI
    • – bupropion



  18. What do antidepressants drugs iteract with?
    • Antidepressants interact with norepinephrine and serotonin (reg
    • mood, arousal, attention, sensory processing and appetite.
  19. SSRI
    fluoxetine(prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro)
  20. TCA
    mine, line, and pine…. Imipramine (tofranil); desipramine (norpramin); amitriptyline (Elavil); Nortriptyline (pamelor); Doxepin, trimipramine, protriptyline, maprotiline, Mirtazapine (Remeron); amoxapine, clomipramine (Anafranil)
  21. MAOI
    nardil, parnate, marplan
  22. TCA side effects
    • sedation, orthostatic, anticholinergic side effects. Lethal with OD. TCA’s may
    • take 4-6 weeks to be effective. Block cholinergic receptors causing anitcholinergic effects like dry mouth, constipation,
    • urinary hesitancy or retention, dry nasal passages, blurred near vision. Sex
    • dysfunction and wt gain are common reasons for noncompliance. Anticholinergic effects on the CV system restricts the
    • use in elderly. Terrifying nightmares.
  23. MAOI’s side effects
    • low incidence of sedation and anticholinergic, and in general causes hypotension
    • leading to HF BUT… htn
    • crisis with tyramine… dangerous combined with other drugs….
    • And lethal OD. May need 2-4 weeks. Daytime sedation, ninsomnia, st
    • gain, dry mouth, orhtosypo, sex dysfunction. HTN crisis is biggest
    • thing. (htn,
    • hyperpyrexia, tachy, diaph,
    • tremulousness, cardiac dysrhythmias. Also buspirone, dextromethorphan, opiate derivatives.
  24. SSRI’s side effects
    • SSRI’s now DOC… fewer SE’s. Prozac weekly…. May
    • take 2-3 weeks. Enhanced serotonin transmission can lead to several common side
    • effects such as anxiety, agitation, akathisia (beta blocker), n, insomnia (sedative/
    • hypnotic), sex dysfunction*, wt gain, GI complaints, h/a, dizziness
  25. Tyramine foods
    •Aged cheeses

    •Aged meats

    •Fava beans, tofu, banana peel, overripe fruit, avocado

    •Tap beer and microbrewery beer

    •Sauerkraut, anything soy

    • •Yogurt, sour cream, peanuts,
    • Brewer’s yeast, and MSG

    • •Caffeinated coffee, colas, tea,
    • chocolate

    • CRISIS
    • (explosive occipital headache, nausea, increased HR and BP,
    • head or face flushed and feel “full”,
    • palpitations, chest pain, sweating, fever, nausea, vomiting, dilated pupils,
    • photophobia)

    Do not lie down. IM chlorporamazine 100mg, repeat (blocks norepinephrine); IV phentoloamine 5mg, repeat (binds with norepinephrine receptor sites, blocking norepi.
  27. Serotonin syndrome
    • •Results from taking MAOI and SSRI
    • at the same time

    •Symptoms include







  28. MOOD
    • Two
    • first-line medications most often used for long-term treatment of bipolar
    • disorder are lithium and valproic acid (Depakote)



    • Lithium normalizes the reuptake of certain
    • neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. Also
    • reduces the release of norepinephrine thru competition with calcium and produces its effects intracellulary rather than within neuronal synapses.
    • Acts directly on G proteins and certain enzyme subsystems.

    Valproic acid and topiramate increase GABA. VA and Carbamazepine stablize mood by inhibiting the kindling process
  29. Mood-Stabilizing Drugs

  30. Lithium
    • Lithium
    • was discovered in 1817 by Arfwedson, who named the drug agter the
    • Greek word for stone. It was initially used in the US as a salt substitute for
    • heart patients but quickly removed 2nd toxicity. Then finally back in 1970.

    • Lithium
    • levels should be about 1.0. greater than 1.5 is toxic. Level every 2-3 days
    • then weekly, then monthly. Tight therapeutic
    • index (0.6 – 1.5) Stuart and Laraia say renal and thyroid test also. Every 3
    • months lithium level for 1st 6 months then every 6 months. Keltner .6 - 1.2.

    • Regular
    • se – n,d,anorexia,
    • fine hand tremor, polydipsia, polyuria, metallic taste, fatigue, lethargy, wt
    • gain, acne

    • Toxic effects of lithium are severe diarrhea,
    • vomiting, drowsiness, muscle weakness, and lack of coordination….renal failure,
    • coma, and death.

    • Anticonvulsants – drowsiness,
    • sedation, dry mouth, blurred vision. Rashes, ortho hypo, WA wt gain, alopecia, hand tremor,
    • liver failure
  31. Lithium Toxicity
    • •Fine hand tremors progressing to
    • coarse tremors

    • •Mild GI upset progressing to
    • persistent upset

    • •Slurred speech, muscle weakness to
    • mental confusion, muscle hyperirritability, poor coordination, and EEG changes

    • •SEVERE: decreasing LOC to stupor to coma, seizures, severe hypotension,
    • severe polyuria
  32. Kindling Effect
    • •Process by which seizure activity
    • in an specific area of the brain is initially stimulated by reaching a
    • threshold of the cumulative effects of stress, low amounts of electric
    • impulses, or chemicals such as cocaine that sensitize nerve cells and pathways.
    • Also
    • called anxiolyticsBenzo’s vs.
    • non benzo’s

    • Hypnotics,
    • benzo and
    • hypnotics, nonbenzo and hypnotic; antihistamines; betablocker;
    • SSRI and Atypical antidepressants

    • Used to treat anxiety, anxiety
    • disorders, insomnia, OCD, depression, PTSD, alcohol withdrawal. Most widely
    • prescribed med today.

    • Mediate the actions of the amino
    • acid GABA, the major inhibitory neurotransmitter in the brain. Powerful potentiators of the inhibitory neurotransmitter GABA.

    • What sociocultural factors may help to explain why
    • benzodiazepines are the most commonly prescribed medications in the US?
  34. Antianxiety Drugs



    • All
    • stimulant medications release norepinephrine and
    • dopamine into the CNS and inhibit the reuptake of norepinephrine and
    • dopamine

    • Amphetamines:
    • potential for abuse is high. Weight loss,
    • attention. Now used mostly for ADHD.

    • Methylphenidate (ritalin);
    • amphetamine (adderall) and dextroamphetamine (dexedrine). Atomoxetine (strattera) a selective norepinephrine reuptake inhibitor was first nonstimulant med for ADHD

    • Act
    • by causing release of the neurotransmitters (norepi, dop, and
    • serotonin) from presynaptic nerve terminals as opposed to having
    • direct agonist effects on the postsynaptic receptors. Block reuptake of these
    • NT’s.

    • Mood
    • elevators

    • Drug
    • Holidays….growth suppression
    • Addicting…abstinence syndrome. Mild overdose – restlessness,
    • insomnia, nervousness. Severe overdose – panic, hallucinations, circulatory
    • collapse, and seizures.
  36. Cognitive
    • Pharmacotherapeutics is based on the theory that Alzheimer’s
    • disease is a result of depleted levels of the enzyme acetyltransferase, which is necessary to produce the
    • neurotransmitter acetylcholine
  37. Cholinesterase inhibitors




  38. What do Cholinesterase inhibitors
    Temporarily slow the progress of dementia.

    • Levels of numerous
    • neurotransmitters (acetylcholine, dopamine, norepinephrine, and serotonin) are decreased.

    • Cognex –
    • liver problems…not med of choice

    • Namenda – an
    • NMDA receptor antagonist. NMDA is a substance that contributes to degeneration
    • of brain cells. Blocks the entry of calcium into nerve cells and thus slows
    • down brain cell death.
  39. Disulfiram (Antabuse)
    • •Sensitizing agent that causes an
    • adverse reaction when mixed with alcohol in the body.

    Useful for those motivated to stop drinking.

    • 5-10 minutes after alcohol: facial
    • and body flushing from vasodilation, throbbing headache, tachycardia,
    • decreased bp,
    • sweating, dry mouth, n,v,d,
    • weakness. Last for 30 min to 2 hours.

    • Inhibits the enzyme aldehyde hehydrognase which is involved in the metabolism of
    • ethanol. Acetaldehyde levels are then increased from 5-10 times higher than
    • normal…

    • Other items with alcohol…. shaving
    • cream, aftershave lotion, cologne, deodorant and otc meds like cough syrup….
  40. Methadone
    •Maintains abstinence from heroin


    •Outpatient clinics