Pharmacology of Psychotherapeutic Drugs By : Dr Seddigh HUMS

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  • 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