Pharmacology of Psychotherapeutic Drugs By : Dr Seddigh HUMS

Pharmacology of Psychotherapeutic Drugs By : Dr SeddighHUMS

Psychiatric Diagnoses

Diagnoses of ConcernMood Disorders Substance abuse relatedSomatoform DisordersAnxiety DisordersPsychotic DisordersPersonality DisordersImpulse Control DisordersFactitious Disorders (Munchausens)Malingering

Critical SituationsSuicide risk v. accidental overdosePotential for violence toward othersMulti-substance abuseUndiagnosed depressionOpioids and benzodiazepinesPoor impulse control

What is Multi-Axial Diagnosis?Axis I: Clinical Disorders & other conditions that may be focus of attentionAxis II: Personality Disorders, Mental RetardationAxis III: General Medical ConditionsAxis IV: Psychosocial and Environmental ProblemsAxis V: Global Assessment of FunctioningAm Psychiatric Association, 2000. Quick Reference to the Diagnostic Criteria from DSM-IV-TR. Washington, DC: APA Press.

Mood DisordersMajor Depressive DisorderDysthymic DisorderDepressive Disorder (NOS)Bipolar

Psychotic Disorders

Psychotic DisordersSchizophreniaSchizophreniformSchizoaffective DisorderDelusional DisorderBrief Psychotic Disorder

Pharmacology Basics

Classes of Psychiatric DrugsTricyclics & TetracyclicsSelective Serotonin Reuptake InhibitorsMonoamine Oxidase InhibitorsAtypical antidepressantsBenzodiazepinesNonbenzodiazepine anxiolyticsAntipsychoticsAtypical antipsychoticsLithiumAntiepileptic drugsStimulantsAnti-EPS agents

Cyclic AntidepresantsImipramine (Tofranil)Desipramine (Norpramin)Amitriptyline (Elavil)Nortriptyline (Pamelor)Clomipramine (Anafranil)Trimipramine (Surmontil)Doxepin (Sinequan)Protriptyline (Vivactil)Amoxapine (Asendin)Maprotiline (Ludiomil)

Cyclic Antidepressant IndicationsGeneralized Anxiety DisorderObsessive-Compulsive DisorderPanic Disorder with AgoraphobiaAnorexia Nervosa &BulimiaCataplexy & narcolepsyDepressionChildhood enuresisMigraine & painUrticaria & itching

Cyclic Adverse EffectsWeight gainInducing maniaAnticholinergic dry mouth, constipation, blurred vision, urinary retention SedationAutonomicorthostatic hypotension, profuse sweating, palpitations, hypertension Cardiac tachycardia, flattened T waves, prolonged QT intervals, depressed ST segmentsNeurologicaldelirium, psychomotor stimulation, myoclonic twitches, tremors, paresthesias, peroneal palsies, ataxia

Selective Serotonin Reuptake InhibitorsCitalopram (Celexa)Escitalopram (Lexapro)Fluoxetine (Prozac)Fluvoxamine (Luvox)Paroxetine (Paxil)Sertraline (Zoloft)

SSRI IndicationsDepression & suicidalityObsessive-Compulsive DisorderPanic DisorderEating DisordersAlcoholismObesity

Features of Serotonin SyndromeDiarrheaDiaphoresisTremorAtaxiaMyoclonusHyperactive reflexesDisorientationRigidityUncontrollable shiveringHyperthermiaDeliriumComaStatus epilepticusCardiovascular collapseDeath

MAO Inhibitors

MAOI IndicationsAtypical depressionMajor depressionDysthymiaMelancholiaPanic disorderBulimiaAtypical facial painParkinsons DiseaseObsessive-compulsiveNarcolepsyHeadacheChronic pain disorderGeneralized anxiety

MAO Inhibitor DrugsMAO ANonselective inhibitorsPhenelzine (Nardil)Tranylcypromine (Parnate)Avoid tyramine-containing foodsMAO BSelective inhibitorSelegiline [deprenyl] (Eldepryl)Avoid tyramine and SSRIsLose selectivity at high doses

MAO Inhibitor drug interactionsAntidepressantsSSRIsTricyclic antidepressants SympathomimeticsEphedrineSome opioidsMeperidinePentazocineDextromethorphan

MAOI Dietary Interactions Contain TyramineCheeseOverripe aged fruitFava beansSausage, salamiSherry, liquorsSauerkrautMSG (glutamate)Pickled fishBrewers yeastBeef & chicken liverFermented productsRed wineCaffeinated beveragesChocolate

Medications to Avoid with MAOIsAntiasthmaticsAntihypertives (methyldopa, guanethidine)BuspironeLevodopaOpioidsCold, allergy or sinus medications with dextromethorphan or sympathomimeticsSSRIs, clomipramine, venlafaxine, sibutramineSympathomimeticsL-Tryptophan

Medications to Use Carefully with MAOIsAnticholinergicsAntihistaminesDisulfiramBromocriptineHydralazineSedative-hypnoticsTerpin hydrate with codeineTricyclics & tetracyclics

Atypical Antidepressants

Atypical AntidepressantsBuproprion (Wellbutrin, Zyban)Duloxetine (Cymbalta)Mirtazapine (Remeron)Nefazodone (Serzone)Trazodone (Desyrel)Venlafaxine (Effexor)

Atypical Antidepressant IndicationsDepressionGeneralized Anxiety DisorderObsessive-Compulsive DisorderSmoking CessationPanic DisorderAgoraphobiaChronic pain

Atypical Antidepressant Adverse Effects and ProblemsBuproprion: headache, insomnia, upper respiratory complaints, nausea, restlessness, agitation & irritability Duloxetine: nausea, dry mouth, fatigue, dizziness, constipation, somnolence & sweatingMirtazapine: somnolence, dizziness, increased appetite, increased cholesterol and triglycerides, orthostatic hypotensionNefazodone: postural hypotension, activation of mania, liver dysfunctionTrazodone: sedation, orthostatic hypotension, dizziness, headache, nausea, priapismVenlafaxine: nausea, somnolence, dry mouth, hypertension, dizziness, nervousness, constipation, etc.

Benzodiazepines

BenzodiazepinesTriazolam (Halcion)Alprazolam (Xanax)Lorazepam (Ativan)Oxazepam (Serax)Temazepam (Restoril)Chlordiazepoxide (Librium)Clonazepam (Klonopin)Diazepam (Valium)Clorazepate (Tranxene)Halazepam (Paxipam)Prazepam (Centrax)Flurazepam (Dalmane)Estzolam (ProSom)Midazolam (Versed)

Benzodiazepine IndicationsSedative-hypnoticsMuscle relaxantsAnticonvulsantsAlcohol withdrawalAnxiety disordersAgitation controlNocturnal myoclonusTic douloureuxTetanusCerebral malariaChloroquine toxicityMaternal eclampsia

Nonbenzodiazepine AnxiolyticsMeprobamate (Miltown)Buspirone (Buspar)Gepirone (Ariza)IpsapironeTandospirone

Antipsychotics

AntipsychoticsPhenothiazines: Chlorpromazine (Thorazine), Fluphenazine (Prolixin), Mesoridazine (Serentil), Trifluoperazine (Stelazine), Perphenazine (Trilafon), Thioridazine (Mellaril)Butyrophenones: Haloperidol (Haldol)Thioxanthenes: Thiothixene (Navane)Dihydroindolones: Molindone (Moban, Lidone)Dibenzoxazepines: Loxapine (Loxitane)Diphenylbutylpiperidines: Pimozide (Orap)

Antipsychotic MechanismsD2 receptor antagonists5HT2 receptor antagonistsOlder agents generally have higher 5HT/DA binding ratiosThe atypical antipsychotics have less potential for extrapyramidal side effects (EPS)

Antipsychotic IndicationsAcute SchizophreniaChronic SchizophreniaSchizoaffective DisordersDepression with Psychotic FeaturesAgitationManiaChorea

Antipsychotic Adverse EffectsCardiac toxicity & sudden deathOrthostatic hypotensionHematological toxicityIncreased secretion of prolactinSexual dysfunctionsWeight gain JaundiceDermatitis and photosensitivitySadock BJ & Sadock VA, 2003. Kaplan & Sadocks Synopsis of Psychiatry 9th Ed. Philadelphia, PA: Lippincott Williams & Wilkins.Neuroleptic-induced ParkinsonismNeuroleptic-induced Acute DystoniaNeuroleptic-induced Tardive DyskinesiaNeuroleptic Malignant SyndromeLowered seizure thresholdSedationAnticholinergic effects

Atypical Antipsychotics

Atypical AntipsychoticsAripiprazole (Abilify)Clozapine (Clozaril)Olanzapine (Zyprexa)Quentiapine (Seroquel)Risperidone (Risperdal)Ziprazadone (Geodon)

Advantages of Atypical Antipsychotic Agents These are serotonin-dopamine antagonists (except aripiprazole which is partial agonist for D2 receptors, but behaves as functional antagonist in hyper DA states & agonist in hypo DA states)Lower risk for Extrapyramidal Side Effects (EPS) than DA antagonistsEffective for positive & negative symptomsEffective for treatment of mood disorders with psychotic or manic features & for behavioral disturbances with dementia

Toxicities of Atypical Antipsychotic AgentsAripiprazole: Too new to be fully known (mild nausea & vomiting, wt. loss, lowered prolactin levels, low levels of EPS)Clozapine: sedation, dizziness, syncope, tachycardia, hypotension, ECG changes, leukopenia (aplastic anemia), wt. gainOlanzapine: Somnolence, dry mouth, dizziness, constipation, dsypepsia, increased appetite & wt. gain, tremorQuetiapine: somnolence, postural hypotension, dizziness, modest wt. gainRisperidone: dose-dependent EPS, wt. gain, anxiety, nausea, erectile and orgasmic dysfunction Ziprasidone: somnolence, headache, dizziness, nausea, QT prolongation (fatal in pts with Hx of cardiac arrhythmia)Many cause abnormalities with glucose & lipid metabolism leading to DM & hyperlipidemias

Risk Factors Leading to Acute Dystonic ReactionsMale genderYounger agePrevious dystonic reactionUsing higher doses of medicationGiving higher potency antipsychoticsIntramuscular route of administration

Drugs to Treat ExtrapyramidalSide EffectsBenztropine (Cogentin)Trihexyphenidyl (Artane)Procyclidine (Kemadrin)Diphenhydramine (Benadryl)Biperiden (Akineton)Amantadine (Symmetrel)

Strategies for Extrapyramidal Side Effects (EPS)Reduce antipsychotic medication doseSubstitute lower-potency antipsychoticAdd an anticholinergic agent, titrate upAdd amantadine to anticholinergic agentAdd a benzodiazepine or beta-blockerStop antipsychotic medicationSubstitute an atypical agent

Antimania MedicationsLithiumBenzodiazepinesAnticonvulsantsCarbamazepine (Tegretol)Gabapentin (Neurontin)Lamotrigine (Lamictal)Topiramate (Topamax)Valproate (Depakote); valproic acid (Depakene)Calcium Channel AntagonistsAmlodipineIsradipineNicardipineNifedipineNimodipineNisoldipineVer