Anti depressants and mood stabilizers
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  • 1. ANTIDEPRESSANTS & Mood Stabilizers
  • 2. AntidepressantsActions:Block the reuptake of serotonin and norepinephrine(neurotransmitters) so that more are available in thebrain to transmit messages.
  • 3. AntidepressantsIndications:  Recurrent depressive disorders  Psychomotor retardation  Depression with no clear precipitating event  Family history of depression  Chronic pain  Eneuresis
  • 4. Antidepressants Have a long half life and can often be given once a day. Therapeutic effects of some may not be seen until 3-4 weeks.
  • 5. Three classifications SSRIs/ SNRIs Tricylcics Mono-amine Oxidase Inhibitors
  • 6. A. Selective Serotonin reuptake Inhibitors (SSRIs)Fluoxetine HCL (Prozac)  Non-tricyclic, less sedation, fewer side effectsSertraline HCI (Zoloft)  Lower risk of toxicity in overdose, fewer side effects, shorter half-life than prozac
  • 7. SSRI Antidepressants (cont’d.)Paroxetine HCI (Paxil): Effectiveness comparable to Imipramine (Tofranil), shortest half-life, safer for elderly.Fluvoxamine (Luvox)Citalopram (Celexa)Escitalopram oxalate (Lexapro)
  • 8. SSRIs Block transport mechanism that returns unbound serotonin left in synaptic cleft into the presynaptic neuron Terminates transmission of the message carried by that receptor When blocked, more serotonin is available to the postsynaptic receptor
  • 9. A. Serotonin & norepinephrinereuptake inhibitor SNRIs Effexor (Venlafaxine)  Inhibits serotonin & norepinephrine re-uptake  Side effects include:  dizziness, migraine, weight gain Pristiq (Desvenlafaxine) Serzone (Nefazadone) Trazodone HCL (Desyrel)
  • 10. Norepinephrine-Dopamine AntagonistBupropion Hycrochloride (Wellbutrin) Increases norepinephrine and dopamine Provides mild dopamine reuptake Blocks reuptake of norepinephrine Does not affect serotonin reuptake Does not inhibit monoamine oxidase
  • 11. Side Effects SSRIs and SNRIs Weight gain Impotence and ejaculatory problems Arousal problems
  • 12. B. Trycyclic Antidepressants TCAsImipramine…….TofranilDesipramine……Norpramine, PertofraneAmitriptyline……Elavil, EndepNortriptyline……Pamelor, AventylProtriptyline……VivactilDoxepin…………Sinequan
  • 13. Trycyclic Antidepressants Affect norepinephrine, serotonin acetylcholine and histamine receptors Increase availability of norepinephrine, serotonin Inhibit transport back into the presynaptic neuron
  • 14. Side Effects: TCAsAnticholinergic effects: Common and troublesomein tricyclics: interfere with patient compliance.  dry mouth  sweating  constipation  drowsiness  urinary hesitancy/retention  blurred vision Cardiovascular: Postural hypotension, tachycardia, heart conduction defects.
  • 15. – TCAs Side EffectsAnticholinergic effects:  Closed angle glaucoma worsened  Toxic: confusion, psychosisOther: Weight gain, lowered seizure threshold, EPSOverdose: 1000 – 4000 mg is fatal
  • 16. TCAs Side effects Managing Side Effects of Tricyclic Antidepressants(Cont’d.)If these dangerous side effects occur, advise the patienteither to call provider stop the medication, or reduce thedosage.  Orthostatic hypotension  Marked, persistent sedation  Atropine-like psychosis  Cardiovascular conduction defect  Seizures  Severe anticholinergic effect: urinary retention, etc.
  • 17. C. Mono-amine OxidaseInhibitors MAOIsphenelzine….…………Nardilisocarboxazide ……….Marplantranylcypromine………Parnate
  • 18. MAO InhibitorsActions: Monamine oxidase is an enzyme responsiblefor destroying epinephrine, norepinephrine andserotonin. MAO inhibitors block this enzyme. Theeffect is CNS stimulation and increased psychomotoractivity.  symptoms relieved in 2-4 weeks  Potential hypertensive crisis it certain foods or medicines ingested
  • 19. MAOIs  Dietary restrictions necessary: foods high in tyramine must be avoided: aged cheese, chicken liver, beer, Chianti wine, cold or sinus medicines, diet pills, blood pressure regulating meds. Severe atypical headache is usually the first signSide effects: autonomic: orthostatic hypotention,dizziness, increased appetite anticholinergic effects arerare.
  • 20. Other Antidepressant MedicationsPsychostimulants Methylphenidate Hydrochloride (Ritalin) Dextroamphetamine Sulfate (Dexedrine) Pemoline (Cylert)Source: Gomez (1993)
  • 21. Serotonin Syndrome Occurs when serotonin excitement occurs  A second antidepressant is given before the first has cleared-need 3 weeks  Overdose of any classification
  • 22. Serotonin syndrome Altered mental state Fever Tachycardia Tremors High or low blood pressure Clonus
  • 23. Mood Stablilizers Lithium Antic-convulsants
  • 24. Lithium Effective in manic excitement and preventative for manic and depressive recurrences in bipolar 1 patients. Also used in other psychiatric disorders that do not respond to other drug therapies. Can lead to toxic reactions which may be fatal. Blood level monitoring is necessary to maintain in therapeutic range. Therapeutic levels range from .7 to 1.5. Higher levels are used to treat manic or psychotic excitement.
  • 25. LithiumCommon Indications: Acute Mania Bipolar ProphylaxisPossibly Effective: Bulimia Alcohol Abuse Aggressive Behavior Schizoaffective disorder
  • 26. LithiumMechanism of Action Adverse Effects Unclear  Excessive drug levelsDosing Narrow therapeutic  Therapeutic drug levels index Drug Interactions Monitor blood levels  q 2-3 days initially  Diuretics then  q 1-3 months  Anticholinergic drugs  levels must be below 1.5mEq/L
  • 27. Lithium Side effects: Neuromuscular and CNS: tremor (fingers) cog wheeling and mild parkinsonism possible. sluggishness and forgetfulness treated by decreased dose. GI: Chronic nausea, diarrhea, take with food. Weight gain and endocrine effects: Increased appetite andexcessive thirst may cause weight gain - transitoryDecreased thyroid levels: Thyroid medication may be necessary. Renal: polyuria and polydypsia may occur. Dose of drug should be lowered.
  • 28. LithiumAllergic rashes – may be due to some ingredient in the capsule. Drug form can be changed to liquid citrate. Cause birth defects
  • 29. LithiumCommon Causes for Increased Lithium Level: Decreased sodium intake Diuretic therapy Decreased renal functioning Fluid-electrolyte loss (sweating, diarrhea, dehydration) Medical illness Overdose
  • 30. Anti-convulsants– used to promote mood stabilization Carbamazepine (Tegratol): Used in patients who do not respond to lithium. More effective for rapid-cycling bipolar patients (4 or more affective episodes per year). Blood levels should be monitored weekly for the first eight weeks. Dose should be adjusted to maintain a serum levels of 6-8 mg/L.
  • 31. Anti convulsantsSide effects: sedation, mal coordination (common)agranulocytosis, aplastic anemia (rare) regularblood counts unnecessary . Watch for fever andsore throat.Can cause increased liver enzymes but serioushepatic problems rare.Associated with birth defects.
  • 32. Anti convulsantsValproate (Valproic acid) – Depakene, Depakote used inmanic and schizoaffective patients (treatment resistant)Improvement occurs in 1-2 weeks. Blood levels should beobtained every few days until 50 mg/l is reached.Side effects – Major concern – severe hepatotoxicity (maybe fatal).Liver function tests should be done every month.Decreased platelet levels can occur.Associated with neural tube birth defects.Very toxic when taken in suicide attempt.
  • 33. Anti-convulsants Lamitrogine- Lamictal  Anit-convulsant used for type 2 BPD  Side effect- rash, nausea, vomitting and diarrhea.
  • 34. Other Mood Stabilizers(cont’d.)Clonazepam (Klonopin) – Benzodiazepine which isuseful in treating acute maniaSide effects: sedation, atoxia, disinhibition effect.