Chapter 17: Psychotherapeutic Agents DH206: Pharmacology Lisa Mayo, RDH, BSDH Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights

Chapter 17: Psychotherapeutic Agents

DH206: PharmacologyLisa Mayo, RDH, BSDH

Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.


Chapter 17 Outline

Psychiatric meds classified:1. Antipsychotic agents: tx of psychosis

(schizophrenia)2. Antidepressant agents: mood elevators

(unipolar, bipolar)3. Anxiolytic agents – CH11 (anxiety disorders)4. Sedative/hypnotic agents – CH11 (for sleep)

Most psychiatric drugs are weak bases (like dental LA) – absorbed from intestines into the blood (best to

take on empty stomach)


Antipsychotic Agents


Antipsychotic AgentsO Conditions can cause:

1. Positive symptoms: hallucinations, delusions, paranoia

2. Negative symptoms: emotional withdrawalO Agents very diverse in actionO 2 major groups of drugs (see table 17-1,

p.225) 1. Conventional/Typical antipsychotics2. Atypical antipsychotics

O More patients are now being treated with newer “atypical” antipsychotics

OFewer anticholinergic & sedative effects


Antipsychotic AgentsO Main action is on the neural pathways

involving the cerebral cortex & limbic systemO These are the areas of the body thought

to have excessive activity of NTs in people with psychosis


LIMBIC SYSTEMPortion of the brain that deals with emotions,

memories, and arousal


Antipsychotic AgentsDopamine

O Important role in etiology of psychotic disorderO Controlling dopamine is essential for tx!O Drugs are DOPAMINE ANTAGONISTS

Drugs bind to dopamine (D2) receptors ↓

Prevent dopamine from attaching ↓

↓ dopamine in synapseO Excessive blockage of dopamine receptors is

the main cause of EXTRAPYRIMIDAL SYNDROMEO Conventional drugs block dopamine receptors &

are more likely to cause extrapyramidal effects


Antipsychotic AgentsO Serotonin (5HT) is another NT that also plays a key role in

psychotic disordersO Atypical drug can block the serotonin receptors as well

as dopamine receptorsO Conventional drugs are only active blockers of

dopamineO Atypical drugs have less extrapyramidal effects than

conventional due to this (important to know!)O Drugs also bind non-specifically to these receptors & will

produce side effects:1. Muscarinic (Anticholinergic effects = dry mouth,

blurred vision, tachycardia, sexual dysfunction, constipation & urinary retention))

2. α1 (SANS effects = hypotension, reflex tachycardia, dizzy, syncope)

3. H1 (Anti-histamine effects = sedation, drowsy, weight gain)


Dopamine & Serotonin produce the antipsychotic

effects

Side Effects

ConventionalAtypical

Atypical

Don’t need to know which drugs cause which side effects TABLE17-1

Xerostomia


Extrapyramidal EffectsO All drugs can cause – conventional higher

incidenceO Binding to D2 receptors can causeO 50-75% patients on these drugs will

developO Can be permanent even after stop the drugO Dystonia: muscle spasms (face, tongue,

neck)O Parkinsonism: tremors, rigidityO Akathisia: Most common, swaying from

foot-to-foot, sense that pt must keep moving

O Tardive dyskinesia: involuntary movements involving tongue, lips, face, jaw, extremitiesCan lead to broken teeth, bruxism, tongue

trauma, ulcerations




PHARMACOLOGICAL EFFECTS1. Conventional antipsychotics2. Atypical antipsychotics

Drugs are listed p.204, Table 17-1 & p.206 Table 17-2Only need to know drugs on drug list



1st atypical in USABlack Box *Seizures *Agranulocytosis ATYPICAL

CONVENTIONAL

Phenothiazides *Change in BP common *Limit EPI


PHARMACOLOGICAL EFFECTS1. Conventional antipsychotics

O Primarily dopamine antagonistsO Active against positive symptoms only (not

negative)O Antiemetic: a result of depression of the

chemoreceptor trigger zone in the medulla of the brain prochlorperazine(Compazine) used most

often



PHARMACOLOGICAL EFFECTS2. Atypical antipsychotic agents

O Active against positive & negative symptoms of the psychosis Conventional antipsychotics: only positive

symptomsO Receptor action: effective at more receptors

Dopamine, Norepi, Serotonin Conventional: only dopamine



O Preferred agents now are the atypicals because they have less extrapyrimidal effects All but Clonazepine do not cause significant

anticholinergic, α-blocking or antihistaminic actions compared to conventional



DRUG INTERCATIONS Metabolized by P450 enzymes (many drug

interactions) Epinephrine

O Many drugs are α–receptor blockersO Epi could cause hypotension & reflex tachycardiaO Administer cautiously & prevent intravascular

injectionsO Avoid levonordephrinO Cardiac dose of epiO Book correction: epi CANNOT be used safely in the

dental office (p.206) EITHER AVOID OR CARDIAC DOSE



Antidepressant Agents


Antidepressant AgentsO Research has shown that the levels of

SEROTONIN & NOREPI in the brain influence mental behaviors

O Action drugs is to ↑ serotonin and/or norepi but blocking the re-uptakeO TricyclicO SSRI

O MAOI action different: inhibit monoamine oxidase enzyme which breaks down epi & norepi

Antidepressant Drug Classes

Tricyclic antidepressants (TCAs)

Selective serotonin reuptake inhibitors (SSRIs)

Monoamine oxidase inhibitors (MAOI)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Atypical Antidepressants




TRICYCLIC ANTIDEPRESSANTSAmitripyyline(Elavil)Desipramine(Norpramin)Doxepin(Adapin, Sinequan)Imipramine(Tofranil)


Antidepressant AgentsTricyclic Antidepressants

O 1st antidepressants on marketO Many severe adverse side effects – not used as

much with the development of newer drugsO Full effect of the drug can take weeks to occurO Uses

DepressionNocturnal bruxismChronic orofacial pain

P.208


Antidepressant AgentsTricyclic Antidepressants

ADVERSE EFFECTSO Non-selective blocking of other receptors (like

antipsychotics)1. Muscarinic (Anticholinergic effects)2. α1 (SANS effects = hypotension, reflex

tachycardia, dizzy, syncope)3. H1 (Anti-histamine effects = sedation, drowsy,

weight gain) O Do not use in cardiac patientsDENTAL CONSIDERATIONSLA with cardiac doseNo levonordefrin


All of the following drugs are tricyclic antidepressants EXCEPT which one?a. Amitriptyline(Elavil)b. Clomipramine(Anafranil)c. Imipramine(Tofranil)d. Sertraline(Zoloft)

NBQ


All of the following drugs are tricyclic antidepressants EXCEPT which one?a. Amitriptyline(Elavil)b. Clomipramine(Anafranil)c. Imipramine(Tofranil)d. Sertraline(Zoloft)

NBQ





SSRICitalopram(Celexa)Escitalopram(Lexapro)Fluoxetine(Prozac) PROTYPEFluvoxamine(Luvox)Paroxetine(Paxil)Sertraline(Zoloft)



SSRIO More selective drug than TCAs: LESS SIDE

EFFECTSO Protype: fluoxentine(Prozac)O NO contraindication for EPI in LA (only one

in this ppt!)O Increase serotonin levels

Inhibit reuptake of serotoninDo NOT interact with Norepi



SSRI USESDepressionAnxiety disordersEating disordersOCDPMSFibromalagia





Antidepressant AgentsSSRI ADVERSE EFFECTS

O ↑ Bleeding (esp if take aspirin, ibuprofen)O Reduced apatite: weight loss (gain with

TCAs)O Sexual dysfunctionO Oral side effects

Can induce bruxismBook correction: remove otheroral side

effects p.207


Antidepressant AgentsSSRI DRUG INTERCATIONS

O EPI can be used with no precautionsO Jan 2006 warning

venlafaxine(Effexor) can cause hypertension = monitor BP

O “Serotonin Syndrome”Elevated serotonin levels = fatalResults when combo SSRI + MAOI



Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Duloxetine(Cymbalta)

Venlafaxine(Effexor)

Desvenlafaxine(Pristiq)

Similar action to TCAs



MAOI

Isocarboxazid(Marplan)

Phenelzine(Nardil)

Tranylcypromine(Parnate)


Antidepressant AgentsMAOI

O Monoamine oxidase enzyme (MAO)O Function: break down norepi & serotoninO MAO-Inhibitors prevent MAO from

removing norepi & serotonin thus increases levels of both in the brain



O Last line drugs due to adverse rxns & food restrictionsO Dietary Restrictions

O One of main disadvantages of these drugsO Many foods contain tyramine (causes release norepi

inside nerve endings) ↓

When MAO is inhibited by these drugs, tyramine can cause a dramatic increase in norepi

↓

Cause stroke or hypertensive crisisO Foods that contain tyramine: cheese, bananas,

raisins, avocados, soy sauce, yogurt, sour cream, bologna, salami, hot dogs, sauerkraut, wine, beer, herring(fish)



O Dental Epi with cardiac dose No levonordefrin

O Drug Interactions Sympathetic drugs used to tx cold symptoms

(decongestants & bronchodilators) O Adverse Rxns: MANY! P.209

Xerostomia, urinary retention, constipation, blurred vision, hypotension, weight gain, sexual dysfunction

Fatal liver damage


NBQ

All of the following are MAOI EXCEPT which one?a. Paroxetine(Paxil)b. Isocarboxazid(Marplan)c. Tranylcypromine(Parnate)d. Phenelzine(Nardil)


NBQ

All of the following are MAOI EXCEPT which one?a. Paroxetine(Paxil)b. Isocarboxazid(Marplan)c. Tranylcypromine(Parnate)d. Phenelzine(Nardil)



Atypical Antidepressantsnefazodone(Serozone)

Black-box: liver failure

bupropion(Wellbutrin)

Smoking cessation

trazadone(Desyrel)Similar action to TCAs

Book has this category listed as “Other Antidepressants,” but they are atypical antidepressants


NBQ

All of the following are used to treat psychosis EXCEPT which one?a. Chlorpromazine(Thorazine)b. Risperidone(Risperdal)c. Nitrous oxided. Quetiapine(Seraquel)e. Haloperidol(Haldol)


NBQ

All of the following are used to treat psychosis EXCEPT which one?a. Chlorpromazine(Thorazine)b. Risperidone(Risperdal)c. Nitrous oxided. Quetiapine(Seraquel)e. Haloperidol(Haldol)


Drug Used To Tx HIGH Levels of NTs

O All other drugs up to this point addressed LOW levels of NTs in psychosis, these are the drugs for HIGH levels (usually assoc with bipolar disorder)

1. Lithium 2. Anticonvulsants3. Atypical Antipsychotics


Drug Used To Tx Bipolar

Drug Name Classification Dental Considerations

Lithium carbonate(Eskalith)

Unknown: alters Na channels & catecholamines

Orthostatic hypotensionXerostomiaTongue movementsMetallic taste

Carbamazepine(Equetro, Tegretol)

Anticonvulsant Monitor WBC counts & vitals

Lamotrigine(Lamictal) Anticonvulsant Orthostatic hypotension

Valproic acid(Depakene) Anticonvulsant Monitor clotting

Gabapentin(Neurotin) Anticonvulsant Xerostomia

Olanzapine(Zyrexia) Atypical antipsychotic (1st approved atypical for bipolar)

Orthostatic hypotension

Quetiapine(Seroquel) Atypical antipsychotic Orthostatic hypotension



1. lithium(Eskalith, Lithobid)O Used to be the only drug on the market for

tx bipolarO Treat manic & depressive statesO Black box: narrow therapeutic indexO MANY systemic side effectsO Drug Interactions

No metronidazole, NSAIDsP450 enzymes NOT involved



2. AnticonvulsantsO Used for mixed episode states (mania &

depression)


NBQ

Which 2 groups of antidepressant drugs has the highest incidence of dry mouth?a. Tricyclic antidepressantsb. SSRIc. Serotonin and norepinephrine reuptake

inhibitorsd. MAOI


NBQWhich 2 groups of antidepressant drugs has the highest incidence of dry mouth?a. Tricyclic antidepressantsb. SSRIc. Serotonin and norepinephrine reuptake

inhibitorsd. MAOI

Remember: SNRI similar to TCAs

Documents

Chapter 17: Psychotherapeutic Agents DH206: Pharmacology Lisa Mayo, RDH, BSDH Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights