psych medications

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Neda317
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236560
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psych medications
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2013-09-24 14:22:25
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psych medications
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  1. The Neurotransmitter story (Amine hypothesis)
    • ⇓ Norepinephrine + Serotonin ->Depression
    • ⇑ Norepinephrine + Serotonin ->Bipolar(mania)
    • ⇑Dopamine -> Psychosis (hallucinations)
    • ⇓ GABA (Gamma Amino Butyric Acid) -> Anxiety
  2. Antipsychotics
    are
    • Buzz word: Antidopaminergics (Block D2A)
    • also called Neuroleptics
  3. A 35 year old homeless man presents with hallucinations, delusions and flat affect for more than 6 months duration He is psychotic (loss of contact with reality)
    what condition and what Rx
    • He is psychotic (loss of contact with reality)
    • Rx: Antidopaminergics
  4. Schizophrenia (splitting of perception from reality)
    Negative symptoms
    • (deficits of normal emotional responses)
    • Flat affect
    • social withdrawal
    • poor speech
  5. Schizophrenia (splitting of perception from reality)
    Positive symptoms
    • (not experienced by normal individuals but are present in schizophrenia)
    • Hallucinations(mostly auditory)
    • Delusions
    • Agitation
  6. Schizophrenia (splitting of perception from reality)
    what is the problem
    The problem is that antidopaminergics ->work only on the positive symptoms
  7. Typical Antipsychotics
    • 1. Phenothiazines (less potent)
    • 2. Butyrophenones (more potent)
  8. 1. Phenothiazines (less potent)
    are
    • Chlorpromazine -> used as antiemetic
    • Fluphenazine -> Long acting available
    • Mesoridazine -> Prolonged QT interval
    • Thioridazine -> Prolonged QT interval, retinal deposits
    • Perphenazine -> Low cardiac risk
  9. 2. Butyrophenones
    are
    Haloperidol : Psychosis, Tourette syndrome, Hyperactivity in children
  10. 3. Other Typical antipsychotics
    • Loxapine -> Low cardiac risk and inc in weight
    • Molindone -> Low cardiac risk
    • Pimozide -> Prolonged QT interval
  11. All Typical Antipsychotics have a big adverse reaction
    what and why?
    • Extra Pyramidal Side effects (EPS)
    • why? decrease of dopamine in the CNS
  12. Extra Pyramidal Side effects (EPS)
    • 1. Pseudoparkinsonism:
    • 2. Akathisia:
    • 3. Acute Muscle dystonia: Muscle spasms
    • 4. Tardive dyskinesia:
    • 5. Neuroleptic malignant syndrome
  13. 1. Pseudoparkinsonism:
    bradykinesia, rigidity, tremor,mask like face, shuffling gait
  14. Akathisia
    Inability to stand still
  15. 3. Acute Muscle dystonia: Muscle spasms
    facial grimacing, torticollis, oculogyric crisis, locked jaw, opisthotonus
  16. 4. Tardive dyskinesia:
    involuntary choreiform movements of the face & limb
  17. 5. Neuroleptic malignant syndrome
    and Rx?
    • Muscle rigidity
    • Hyperpyrexia
    • Tachycardia
    • Rx: diazepam, dantrolene
  18. Other Adverse reactions                  
    1. Anticholinergics:
    2. Orthostatic hypotension
    3. Photosensitivity and rashes -   
    4. Increase appetite and weight gain
    5. Endocrine:
    • 1- Dry mouth and constipation
    • 2-why? alpha blockade, Patients complains of tachycardia?? Reflex, Impaired ejaculation
    • 3-Sunburn

    5-  increase prolactin release, Amenorrhea-galactorrhea, infertility, impotence
  19. Antipsychotics are antidopaminergics
    They block-----
    They block the D2A receptors
  20. The more potent the antipsychotic the more the EPS and the less
    and example
    • anticholinergicside effects
    • Buzz word: Haloperidol and fluphenazine
  21. The less potent the antipsychotic
    w example
    • the less the EPS and the more the nticholinergic side effects
    • Buzz word: Chlorpromazine and thioridazine
  22. Management of patients on Antipsychotics
    • 1. tell the patient that phenothiazines may discolor the urine to pink or red-brown
    • 2. Avoid OTC or herbal medications
    • 3. Monitor QT interval (Risk for cardiotoxicity: Torsades de points) Buzz word: Thioridazine
    • 4. Haloperidol should be withheld 48 Hrs before and 24 hrs after myelography with metrizamide (radio opaque contrast media)
    • 5. Avoid Alcohol and other CNS depressants
    • 6. If EPS occur, swith to a different Antipsychotics and administer Benztropine or diphenhydramine
    • 7. What we do if a schizophrenic on antipsychotic meds comes back to the ER at Bellevue claiming thatthe voices are back and telling him to kill himself????
  23. 4. Haloperidol should be withheld
    why?
    • 48 Hrs before and 24 hrs after myelography with metrizamide (radio opaque contrast media)
    • why? risk of seizures
  24. 7. What we do if a schizophrenic on antipsychotic meds comes back to the ER at Bellevue claiming thatthe voices are back and telling him to kill himself????
    • Atypical Antipsychotics that has No or less EPS, Blocks D2  , 5HT2A  
    • work on both positive and negative symptoms
  25. Atypical Antipsychotics
    drugs
    • ★Clozapine -> Agranulocytosis, weight gain
    • Olanzapine ->Weight gain and DM
    • Quetiapine -> Rx of Autism in children
    • Risperidone -> EPS with high doses
    • Ziprasidone ->blocks dopamine and serotonin
    • Aripiprazole -> dopamine agonist/antagonist activity
  26. Antidepressants
    Rx of Affective disorders
    • ⇑ Norepinephrine and Serotonin
    • Rx of Affective disorders = Mood disorders
  27. Depression
    • feeling of hopeless and helpless, loss of interest in life and social activities, loss of energy, loss of appetite and inability to sleep
    • for more than 2 weeks
  28. Depression
    Endogenous depression
    • No external cause
    • Genetic
    • Chemical imbalance
    • Antidepressants
  29. Depression
    Exogenous depression
    • Reactive to external cause
    • Loss of a loved one
    • Psychotherapy and Antidepressants
  30. Major Affective disorders
    Unipolar
    • Major depression
    • ⇓Norepinephrine + Serotonin
    • Antidepressants
  31. Major Affective disorders
    Bipolar
    • Mania + depression
    • ⇑Norepinephrine + Serotonin
    • Mood stabilizer
    • Lithium
  32. Antidepressants
    • 1. Tricyclic [TCAs] 
    • 2. Tetracyclics
    • 3. Second generation
  33. Tricyclic [TCAs] 
    MOA
    (Inhibit reuptake of NE)
  34. 1. Tricyclic [TCAs]  (Inhibit reuptake of NE)
    drugs and the use
    drugs and buzz words
    • Clomipramine ->OCD
    • Imipramine -> Used for enuresis(children bed wetting)
    • Trimipramine -> No GI upset
    • Doxepin -> Used for anxiety
    • Desipramine -> Sudden cardiac death in children
    • Nortriptyline -> used for chronic pain
    • Amitriptyline ->used for chronic pain
  35. Tetracyclics
    drugs and buzz words
    • Amoxapine -> Dopamine blockers
    • Maprotiline -> can cause seizures
    • Mirtazapine -> cause seizures and agranulocytosis
  36. 3. Second generation
    drugs and the cause
    • Nefazodone -> hepatotoxicity
    • Trazodone -> Priapism(unwanted penile erection)
    • Bupropion(wellbutrin) -> cause Seizures, use as Smoking Cessation,
    • Venlafaxine -> Dose dependent
  37. Adverse effects of  TCAs:
    • 1.Anticholinergic
    • 2. CNS
    • 3. CVS
    • 4. MAO (MonoAmine Oxidase) Inhibitors
  38. 1.Anticholinergic:
    dry mouth, epigastric distress, constipation, tachycardia, palpitation, blurred vision, and urinary retention(spe. in elderly male)
  39. Adverse effects of  TCAs: on CNS:
    sedation, confusion, Seizure threshold is lowered
  40. Adverse effects of  TCAs on CVS:
    orthostatic hypotension, sinus tachycardia, cardiac arrhythmias, conduction defects prolonged QRS interval)
  41. 4. MAO (MonoAmine Oxidase) Inhibitors
    • Phenelzine (Non selective MAO inhibitor) -> Hypertensive crisis, with food containing tyramine, Cheese and wine ( cheese reaction)
    • Tranylcypromine -> Hypertensive crisis, with food containing tyramine, Cheese and wine
  42. RIMA (Reversible Inhibitors of MAO-A):
    • Moclobemide
    • Broforamine
    • - inhibit MAO-A
    • advantage less like to make cheese reaction
  43. 5. SSRI (Selective Serotonin Reuptake Inhibitors)
    •  All SSRI are safe in less side effects Pregnancy
    • Fluoxetine (Prozac)
    • Paroxetine (Paxil) 
    • Sertraline (Zoloft)
    • Fluvoxamine
    • Escitalopram ( Lexapro)
  44. Adverse effects of SSRIs:
    • •Gastrointestinal symptoms
    • Sexual dysfunction(delayed ejaculations)
    • •Agitation and restlessness – fluoxetine
    • •Insomnia (how u can differentiate it bw tryc and ssri)
  45. Management of patients on Antidepressants
    • 1. Tricyclics takes 30 days or more to work
    • 2. SSRI may take 1 to 4 weeks
    • 3. Fluoxetine should be taken early in the day
    • 4. Tricyclic cause sedation and dry mouth
    • 5. Don't mix SSRI and MAO inhibitors (St.John’s wort / SSRI & MAOI
    • 6. 2-week washout period after stopping SSRI
    • and starting MAO inhibitor
  46. 3. Fluoxetine should be taken early in the day
    why?
    interfere with sleep
  47. 5. Don't mix SSRI and MAO inhibitors (St.John’s wort / SSRI & MAOI
    why?
    • Risk of Serotonin Syndrome
    • Fever, hypertension, hyperthermia, seizures
  48. Antimanics
    Bipolar disorder
    Lithium (mood stabilizer)
  49. Mania:
    • Hyperactivity, reduce sleep, excessive spending poor judgment and aggressiveness
    • Bipolar disorder: Mania + Depression
    • Effects on second messengers
  50. Mania:
    Mechanism of action of Lithium:
    • -Effects on second messengers
    • inhibits inositol formation  
    • Inhibits the conversion of IP2 to IP1
    •   - Decreased action of transmitters
  51. Lithium
    • Narrow therapeutic index (0.8 to 1.2 mEq/L)
    • NDI(Nephrogenic Diabetes Insipidus )causing Hyponatremia poly uria, polydipsia, loss of ADH
    • due to vomiting and diarrhea
    • Tremore-most common adverse effect
  52. Carbamazepine
    Agranulocytosis
  53. drugs
    faster actin than lithium
    • Carbamazepine
    • Valproic acid
    • Olanzapine
    • Lamotrigine
  54. Management of patients on Lithium
    • 1. Therapeutic range for lithium from 0.6 to 1.2 mEq/L
    • 2.Tolerance for lithium is high in acute mania, slow onset of action
    • 3. Assess suicidal tendencies
    • 4. Assess for lithium toxicity: tremors
    • 5. Teach the patient to drink 2 L of fluid daily maintain adequate salt intake(bc of NDI)
    • 6. May cause hypothyroidism (measure TSH every 6 months)
  55. Antianxiety Drugs
    Anxiolytic
    Panic Disorder
  56. Panic Disorder:
    • Brief episode of intense fear
    • Shortness of breath, trembling and palpitations
    • You have concern about getting another one
  57. Panic Disorder
    • Alprazolam -> tx of attach
    • TCAs, SSRIs -> prevention
    • Beta blockers -> prevention
    • Benzodiazepines -> tx of acute attach
    • SSRI --> tx
  58. Phobia
    Fearof an objector situation and the need to avoid it.
  59. OCD (Obsessive Compulsive Disorder)
    • Recurrent thoughts and recurrent acts to relief the thoughts
    • Clomipramine
    • Paroxetine
    • Fluvoxamine newly FDA approved
  60. PTSD (Post traumatic Stress disorder)
    • - Flashbacks of a traumatic stressor
    • ("persistent reexperiencing of the traumatic event“)
    • SSRI
    • Atypical Antipsychotics
  61. GAD (Generalized Anxiety disorder)
    • Fear and worrying about many things for at least 6 months
    • Buspirone --> serotonin agonist (5-HT1A)
  62. Other Antianxiety
    Zolpiden
    Nonbenzodiazepine but works like bex=nzo
  63. Other Antianxiety
    Hydroxyzine
    Antihistamines

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