More Related Content
Similar to psychotropic medications (1).pptx
Similar to psychotropic medications (1).pptx (20)
Recently uploaded
Recently uploaded (20)
psychotropic medications (1).pptx
- 1. Overview of Psychotropic Medications By: Jean-Pierre Arditi
- 2. OBJECTIVES Identify Identify anxiolytic classes and indications for use State Describe mood stabilizers including indications for use and side effects Give Give examples of psychotropic medications used to treat depression, bipolar disorder, and anxiety disorder as well as general psychiatric disorders including addiction Describe Describe the concept of depression, bipolar disorder, and anxiety disorder and addiction Define Define the term "psychotropic”
- 3. General Pharmacology strategies • Indication • Choice of agent and dosage
- 4. General Pharmacology strategies • Establish informed consent • Make sure to document this discussion including pt understanding and agreement. • Implement a monitoring program
- 5. General Pharmacology strategies • Management: • Use adjunctive and combination therapies if needed. .
- 6. What are Psychotropic Medications? Psychotropic drugs are used to treat various types of mental disorders.
- 7. Types of Mental Disorders that can be Treated with Medication • Depresion • BipolarDisorder • Anxiety Disorders • Schizophrenia • ADHD (Attention Deficit Hyperactivity Disorder)
- 8. What is Depression? Depression is a mood disorder and is likely caused bya combination of • genetic, biologic, and environmental factors. In terms of the biologic basis, there is an abnormality in neurotransmitters in the brain. • Depression is derived from the Latin word depressare and the classical Latin word deprimere. Deprimere literally means “press down” (Kanter et al., 2008)
- 9. Types of Medications Used to Treat Depression Antidepressant medications are grouped based on which neurotransmitter in the brain is being affected. Groups include: serotonergic, dopanergic, and GABAergic receptors • SSRI’s Selective Serotonin Reuptake Inhibitor • SNRI’s Serotonin and Norepinephrine Reuptake Inhibitors • NDRI’s Norepinephrine and Dopamine Reuptake Inhibitors • Tricyclic Antidepressants (Decreased reuptake of Serotonin and Norepinephrine) • MAOIs Monoamine Oxidase Inhibitors (Increases concentration of neurotransmitters in the brain) • Combined reuptake inhibitors and receptorblockers
- 10. SSRIs, MAOIs
- 11. Serotonin/Norepinephrine reuptake inhibitors (SNRIs) • Inhibit both serotonin and norepinephrine. • Like Tricyclics, they do not have antihistamine, antiadrenergic or anticholinergic side effects • Used for depression, anxiety and possibly neuropathic pain
- 12. AntidepressantMedication Chart SSRIs SNRIs NDRIs Tricyclic MAOIs Combined Fluoxetine (Prozac) Venlafaxine (Effexor) Buproprion (Wellbutrin) Amitriptyline (Elavil) Isocarboxazid (Marplan) Trazodone (Desyrel) Paroxetine (Paxil) Duloxetine (Cymbalta) Desipramine (Norpramin) Phenelzine (Nardil) Nefazodone (Serzone) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Imipramine (Tofranil) Nortriptyline (Aventyl, Pamelor) Clomipramine (Anafranil) Maprotiline Mirtazpine (Remeron)
- 13. Novel antidepressants Mirtazapine (Remeron) Pros • Is a 5HT2 and 5HT3 receptor antagonist • Can be utilized as a hypnotic at lower doses secondary to antihistaminic effects Cons • Increases serum cholesterol by 20% in 15% of patients and triglycerides in 6% of patients • Very sedating at lower doses. At doses 30mg and above it can become activating and require change of administration time to the morning. • Associated with weight gain
- 14. What is BipolarDisorder? • It is characterized by drastic mood swing • Consists of periods of mania and depression • Characterized by a chemical imbalance in the CNS
- 15. BipolarDisorderMedicationChart Mood Stabilizers Atypical Antipsychotics Antidepresants (Always used with other medications) • Lithium •Clozapine(Clozaril) •Fluoxetine(Prozac) • Valproate (Valproic Acid)/ Divalproex Sodium (Depakote) •Olanzapine(Zyprexa) •Risperidone(Risperdal) •Quetiapine(Seroquel) •Sertraline(Zoloft) •Paroxetine(Paxil) • Carbamazepine (Tegretol) •Ziprasidone(Geodon) •Ariprazole(Abilify) • Lamotrigine (Lamictal) • Oxcarbazepine (Trileptal)
- 16. What is an Anxiety Disorder? • Generalized anxiety disorder (GAD), is a disorder that consists of chronic free-floating anxiety with an association of anxiousness or worry about daily life • Anxiety disorders are the most prevalent psychiatric disorders • Specific phobias are the most common • Includes and umbrella of with disorders associated with it
- 17. Antianxiety Medication Chart Antidepressants Benzodiazepines Beta Blockers Atypical Anticonvulsants Fluoxetine (Prozac) Paroxetine (Paxil) Clonazepam (Klonopin) Lorazepam (Ativan) Alprazolam (Xanax) Propranolol (Inderal) Olanzapine (Zyprexa) •Pregabalin (Lyrica) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Atenolol (Tenormin) •Gabapentin (Neurontin) Valproic acid (Depakote) Venlafaxine (Effexor) Duloxetine (Cymbalta) Bupropion (Wellbutrin) Imipramine (Tofranil) Clomipramine (Anafranil) Nortriptyline (Pamelor) Desipramine (Norpramine) **Azapirone** Buspirone (Buspar)
- 18. Antipsychotics as mood stabilizers
- 19. Key pathways affected by dopamine in the Brain
- 20. Antipsychotics: Typicals • Dopamine receptor antagonists • High risk for extrapyramidal symptoms (EPS) • Tardive Dyskinesia (TD)-involuntary muscle movements that may not resolve with drug.
- 21. Antipsychotics: Atypicals The Atypical Antipsychotics - Serotonin- dopamine 2 antagonists (SDAs) • Produce the least amount of EPS and include drugs such as, Olanzapine and Clozapine .
- 22. Agents for EPS • Anticholinergics • Dopamine facilitators • Beta-blockers
- 23. Anxiolytics Used to treat many diagnoses including panic disorder, generalized Anxiety disorder, substance-related disorders and their withdrawal, insomnias and parasomnias. In anxiety disorders often use anxiolytics in combination with SSRIS or SNRIs for treatment.
- 24. What is Addiction • Addiction- is a complex psychological disorder that is characterized my compulsive substance use despite consequences • Normally associated with drugs, sex and gambling
- 25. Addiction Medication Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014)
- 26. Mental Health Therapy • Mental health therapies in conjunction with psychotropic medication, have shown to be more effective than any one single target therapy alone. • This has shown to be the case in depression, and anxiety. • These therapies include psychodynamic therapy and interpersonal therapy (IPT)
- 27. Criticism of Psychotropic Drugs • No conclusive evidence that links a physiochemical basis for mental illness • Judgments of drug action are most often reported in experiments that were poorly designed and executed.
- 28. Questions?
Editor's Notes
- Establish and identify proper treatment protocols for target symptoms that will be used to monitor therapy response. Be able to select an appropriate agent with the least side effects Use the lowest effective dose. Remember the delayed response for many psych meds and drug-drug interactions.
- It is important that the patient understands the benefits and risks of taking psychotropic medication, including the side effects and how long they might on them for. Documenting is Key. It establishes a log of a patient treatment plan, protects you from HIPAA violations, Track and document compliance, side effects, target symptom response, blood levels and blood tests as appropriate.
- Adjust dosage for optimum benefit, safety and compliance. Remember to always strive for the simplest treatment. It is important to note that when picking a treatment plan, to monitor your patients closely for adverse reactions or dependency. Keep your therapeutic endpoint in mind. The point of these treatment plans to help and mitigate. These plans are not meant for long term use.
- Other mental health disorders include mood disorders, schizoaffective disorder, other anxiety disorders including OCD, panic, social phobia, PTSD, premenstrual dysphoric disorder and impulsivity associated with personality disorders. It is important to listen to your patient about other medications or health issues that may arise as they may be contraindicated or contribute to mental health issues. If a patient suffers from one or more of these disorders it is important to choose a treatment plan that can treat multiple symptoms with the fewest medications possible. Some combinations may result in increase mental stress or have adverse reactions.
- Depression is characterized By a change in negative emotional states such as sadness. It has co-occurring behavioral responses like “elicited unconditioned reflexes, conditioned reflexes, operant predispositions that appear to be integrated because the behaviors are occasioned by common discriminant and are controlled by common consequences (Kanter et al., 2008, p. 2).” Antidepressants are commonly use in the treatment of depression. Neurotransmitters are chemicals released in the brain in respond to electrical signals that can affect an organism's mood and emotional responses. Antidepressant medications act to help balance out specific neurochemicals such as, serotonin or dopamine in the treatment of depression. Serotonin, Norepinephrine, and Dopamine are the 3 types neurotransmitters that are involved in depression.
- It is important to note that Some SSRI’s and MAOI’s are contraindicated with those who have heart issues or suffer from suicidal thought as they can increase thoughts of suicide. Tricyclic Antidepressants Can cause QT lengthening even at a therapeutic serum level Lethal in overdose (even a one-week supply can be lethal!) With using TCAs make sure to monitor the patient's hearts with regular EKG monitoring. Long QT waves… Tertiary TCAs Have tertiary amine side chains Act predominantly on serotonin receptors Examples: Imipramine, amitriptyline, doxepin, clomipramine Have active metabolites including desipramine and nortriptyline Secondary TCAs Are often metabolites of tertiary amines Primarily inhibits norepinephrine Side effects are the same as tertiary TCAs but generally are less severe Monoamine Oxidase Inhibitors (MAOIs) Bind irreversibly to monoamine oxidase which is an enzyme involved in the “degradation process for various monoamines released by neurons and glia cells, including DA, serotonin, and norepinephrine which is responsible for flight or fight (Monoamine Oxidase - an Overview | ScienceDirect Topics, n.d.).” Hypertensive crisis can develop when MAOI’s are taken with tyramine-rich foods or sympathomimetics (Monoamine Oxidase - an Overview | ScienceDirect Topics, n.d.).” . Serotonin Syndrome can develop if taking MAOI with meds that increase serotonin or have sympathomimetic actions. Medications: Desipramine, nortriptyline
- If you look at the figure, we can see how the various treatment options affect the neuron during pre- and post-synaptic transmission. MAOIs target Monoamine Oxidase that is produced in the mitochondria. Substrates for MAO include “monoaminergic neurotransmitters such as catecholamines (i.e., dopamine, norepinephrine, and epinephrine) and 5-hydroxy-tryptamine (serotonin) (Monoamine Oxidase - an Overview | ScienceDirect Topics, n.d., Chapter 12). Selective Serotonin Reuptake Inhibitors (SSRIs) Block the presynaptic serotonin reuptake Treat both anxiety and depression Serotonin (5-hydroxytryptamine, 5-HT) is a “neurotransmitter that influences multiple processes including autonomic function, motor activity, hormone secretion, cognition, and complex processes associated with affection, emotion, and reward (Sangkuhl et al., 2009, p. 1).” Synthesis of serotonin is catalyzed in two-steps. It is first catalyzed by tryptophan hydroxylase and then by aromatic decarboxylase. SSRIs play a role in inhibiting the reuptake of serotonin by blocking their transporter at the receptor site on an axon.
- Serotonin and Norepinephrine reuptake inhibitors Inhibition is cased by blocking binding sites on both 5-HT and Norepinephrine transporters. Venlafaxine, milnacipran, and duloxetine are the three main drugs given. SNRIs block the reuptake of both serotonin (5-HT) and norepinephrine with differing selectivity and affinities. Milnacipran blocks both neurotransmitters with equal affinity, Duloxetine has a “10-fold selectivity for 5-HT and venlafaxine a 30-fold selectivity for 5-HT (Stahl et al., 2005).” All three SNRIs are efficient in treating anxiety disorders. Currently there is no evidence to support any major differences between SNRIs and SSRIs in their efficacy in treating anxiety disorders. However SNRIs are more efficient in treating and managing chronic pain associated with and independent of depression to their counterpart. SNRIs are also used in the treatment of chronic pain for pain management.
- It is important to note that some of these medications can be used for other neurological conditions such as: seizures, migraines and anti-convulsion It is also important to note that using SSRIs or SSNIs in combination with triptan medications which is used to treat migraines could cause a life-threatening illness called serotonin syndrome. Serotonin syndrome is a life-threatening condition that is triggered by the use of serotonergic drugs and overactivation of both the peripheral and central postsynaptic 5HT-1A and 5HT-2A receptors (Sangkuhl et al., 2009; Volpi-Abadie et al., 2013). Serotonin syndrome is comprised of a mixture of altered mental status, neuromuscular hyperactivity, and autonomic hyperactivity. Occurrence can be caused by the use of serotonergic drugs alone, overdose, or by a “complex drug interaction between two serotonergic drugs that work by different mechanisms (Volpi-Abadie et al., 2013).”
- Mirtazapine is an atypical antidepressant used for the treatment of a major depression. Mirtazapine acts as a sedative, antiemetic, anxiolytic, and appetite stimulant. It is also used for the treatment of insomnia, panic disorder, post-traumatic stress disorder, obsessive-compulsive disorder, generalized anxiety disorder, social anxiety disorder, headaches, and migraines (Jilani et al., 2020). Mirtazapine is prescribed as a last resort for individuals that have been unable to achieved success with other pharmacological therapies for major depressive disorder (Jilani et al., 2020).
- Bipolar disorder is a mental disorder that causes unusual mood swings. It affects the ability to carry out day-to-day tasks and is characterized by a shift in a person’s energy, activity levels, and concentration. There are three types of bipolar disorder. These changes in moods range from periods of extremely “up and down,” irritability, or erected behavior (mania). Less severe manic periods are known as hypomanic episodes (NIMH » Bipolar Disorder, n.d.). Bipolar I Disorder— defined by manic episodes and can last up to 7 days. depression can occur as well, lasting at least 2 weeks. Bipolar II Disorder— is a combination of both depressive and hypomanic episodes, but not the full-blown manic episodes that are typical of Bipolar I Disorder (NIMH » Bipolar Disorder, n.d.). Cyclothymic Disorder (Cyclothymia)— Has a mixture of hypomanic, depressive symptoms lasting for at least 2 years However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode (NIMH » Bipolar Disorder, n.d.).
- Lithium is used in the treat of not only depression but in the treatment of mania as well. It has both acute and prophylactic antimanic effects and recent studies have demonstrated, to have prophylactic antidepressant effects as well (Post, 2018). Lithium has shown to have anti-suicide effects, may reduce risk of dementia and studies have shown that lithium can cause cognitive deterioration to slow down in elderly women with mild cognitive impairment (Post, 2018). Some side effect of lithium includes deterioration in renal function, can lower thyroid hormone levels, increase TRH, induce hypothyroidism and can cause nephrogenic diabetes (Post, 2018).
- Categories include: (GAD) Panic Disorder Phobic Disorder OCD PTSD Separation Anxiety Anxiety disorders are the most prevalent psychiatric disorders. Benzodiazepines as a first line treatment is not recommended due to their potential side effects. SSRIs and SNRIs are recommended as first-line treatments (Thibaut, 2017). Psychotherapy, along with pharmacotherapy, is also recommended as it yields a higher efficacy rate (Thibaut, 2017).
- Most antianxiety medications are used to treat various other neurologic and psychological conditions. For example, the use of Depakote and Neurontin are used as anti-convulsant medication and for the treatment of migraines as a preventive. Beta blockers like Atenolol and Propranolol not only help treat antianxiety but are the primary treatment for high-blood pressure. These work by selectively binding to the beta-1 adrenergic receptors found in vascular smooth muscle and the heart. Some side-effects can include reduce sex drive, headaches and dizzeness.
- Used to treat schizophrenia schizoaffective disorder, bipolar disorder- for mood stabilization and/or when psychotic features are present, delirium, psychotic depression dementia, and other anxiety disorders
- MESOCORTICAL- Runs from the brain stem to the cerebral cortex. This pathway is thought to be where negative symptoms and cognitive disorders arise. Patients suffering from psychosis is due too little dopamine. MESOLIMBIC-runs from the dopaminergic cell bodies in the ventral tegmentum to the limbic system. This pathway is where the positive symptoms come from (hallucinations, delusions, and thought disorders). Patients suffering from psychosis is due too much dopamine. NIGROSTRIATAL- runs from the dopaminergic cell bodies in the substantia nigra to the basal ganglia. This pathway is involved in movement regulation. Dopamine suppresses Ach activity. Hyperpolarization of dopamine can cause Parkinsonian movements i.e. rigidity, bradykinesia, tremors), akathisia and dystonia. TUBEROINFUNDIBULAR- runs from the hypothalamus to the anterior pituitary. dopamine oversees release inhibits/regulates prolactin release. Blocking dopamine in this pathway will predispose your patient to hyperprolactinemia (gynecomastia/galactorrhea/decreased libido/menstrual dysfunction).
- Low potency typical antipsychotics have less affinity for the D2 receptors but tend to interact with nondopaminergic receptors resulting in more cardiotoxicity and anticholinergic adverse reactions including sedation, hypotension. Examples include chlorpromazine and Thioridazine. High potency typical antipsychotics bind to the D2 receptor with high affinity. The side effects of typicals are associated with effects stemming from CNS transmission and receptor sites. There side-effect profile can affect everybody system with side-effects ranging from jaundice to blindness. Typicals antipsychotics are characterized based on their ability to cause extrapyramidal effects. EPS are drug-induced movement disorders thought to be due to the antagonistic binding of dopaminergic D2 receptors within the mesolimbic and mesocortical pathways of the brain (D’Souza & Hooten, 2020). *However, the antidopaminergic action in the caudate nucleus and other basal ganglia may also contribute significantly to the occurrence of EPS. * first-generation antipsychotics haloperidol and phenothiazine neuroleptics, are the most common medications associated with EPS. While EPS occurs less frequently with atypical antipsychotics, the risk of EPS increases with dose escalation.*
- Atypical antipsychotics with a “high selectivity for serotonin 5-HT2A receptors and dopamine D2 profile and α1-adrenoceptors (Horacek et al., 2006, p. 391). They inhibit mainly D2 And D3 subtypes. They also have a more favorable effect profile, “they are associated with a lower risk of EPS, tardive dyskinesias, hyperprolactinemia, morphological changes in the CNS and noncompliance, as well as better overall tolerability (Horacek et al., 2006, p. 391).”
- Need to watch for anticholinergic particularly if taken with other meds with anticholinergics like TCAs
- Addicts are said to have distorted thinking, behavior and body functions. Addiction is said to be gene regulated and phenotypically passed down through progeny. Brain scans show changes in the brain related to prefrontal cortex and cellebrum (What Is Addiction?, n.d.). People with addictive disorders are sometimes aware of their problems but are unable to stop it. The addiction can cause health related issues as well as issues between them and society.
- This table represents the Three main class used for the treatment of opioid addiction: Methadone, Buprenorphine and Naltrexone. Treatment for opioid dependency should be kept closely due to the patient's behavior. Methadone has the potential to use and abused and is addictive by nature, it acts as an agonist for opioid receptor.
- Patients with more severe depression should receive combined treatment as they typically respond to combined treatment over single-modality treatment. Patients how have not responded well to antidepressants show an increased rate of response when that treatment is paired with psychotherapy (Combining Drug Therapy and Psychotherapy for Depression, n.d.). Combined treatment have been shown to produce faster and greater short-term benefits, but greater long-term benefits as well (Combining Drug Therapy and Psychotherapy for Depression, n.d.). Patients receiving combined treatment with CBT have a lower relapse rate than do patients receiving medications alone (Combining Drug Therapy and Psychotherapy for Depression, n.d.).
- Some criticisms for the use of psychotropic drugs argue that the risk associated with these drugs can bring more harm then good to the patient and can cause revocable damage. These drugs have the potential to be abuse or misused thus, creating or adding to the patient's problems. The use of psychotropic drugs alone is not considered to be enough to ensure the recovery of individuals, many of whom have lost years of their lives to dysfunctional lifestyles (Correctional_mental_health_from_theory_to_best_practice_1e | WebViewer, n.d.).