is a psychiatric medication used to alleviate mood disorders, such as major depression and dysthymia.

Depression

- is a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration.  Three (3) types of depression:

Reactive depression - usually has sudden onset

after a precipitating event › The client knows why she or he is depressed and may call this the “blues.” › Usually last for a month and benzodiazepine agent may be required

Major depression- is characterized by loss
of interest in work and home, inability to complete task, and deep depression (dysphoria)

Bo-polar affective disorder – involves
swings between two moods, the manic (euphoric) and the depressive (dysphoria).

 Electroconvulsive

Therapy

- was used to treat psychosis and depression before the introduction of antipsychotics and antidepressants.

St.John’s wort – can decrease
reuptake of the neurotransmitters serotonin, norepinephrie, and dopamine.

 Gingko

biloba- can be used for

memory enhancement and dementia

St. John’s wort

Gingko biloba

Four groups (4):  tricyclic antidepressants (TCAs)  selective serotonin reuptake inhibitors (SSRIs)  atypical antidpressants that affect various neurotransmitters  monoamine oxidase inhibitors (MAOIs)

are used to treat major depression, because they are effective and less expensive than SSRIs and other drugs.  Imipramine was the first TCA marketed in the 1950s.  The action is to block the uptake of the neurotransmitters norepinephrine and serotonin in the brain.

This group of drugs elevates mood , increased interest in daily living and activity and decreases insomia.  Given at night to minimize problems caused by their sedative action.  When discontinuing TCAs, the drugs should be gradually decreased to avoid withdrawal syndrome such as nausea, vomiting, anxiety, and akathisia.

Examples are:  Amitriptyline (Elavil)  doxepin (Sinequan)  trimipramine (Surmontil)  imipramine  desipramine  nortriptyline
 Polydrug

therapy- the practice of giving several antidepressant or antipsychotic together, should be avoided because of possible serious side effects.

orthostatic hypotension  sedation  anticholigernic effects  cardiac toxicity such as dysrhythmias  seizures  allergic reaction (skin rash , pruritus, and petechiae)  sexual dysfunction (impotence and amennorhea)  blood dyscrasias (leukopenia, thrombocytopenia, and agranulocytosis)

 

Contraindications All antidepressants are contraindicated in patients with a history of hypersensitivity to any component.

Alcohol,hynotics, sedatives and barbiturates potntieate central nervours system (CNS ) depression when taken with TCAs.  Concurrent use of MAOIs with amitrityline may lead to cardiovascular instability and toxic psychosis.  Anti-thyroid medications taken with amitripyline may increase the risk of dysrhymias

was first classified as second generation and anti depressants.  Today they have been reclassified asselective serotonin reuptake inhibitors ( SSRIs ).  blocks the reuptake of serotonin into the nerve terminal of the CNS, thereby enhancing its transmission at the serotonergic synapse.  do not block the uptake of dopamine or norepinephrine, nor they block the cholinergic alpha- adrenergic receptors.

The primary use of SSRIs is for major depressive disorder.  They are also effective fro treating anxiety disorders such as obsessive-compulsiveness, panmic, phobias,post traumatic stress disorders, and other forms of anxiety

EXAMPLE OF SSRIs  Fluoxetine ( Prozac )  Fluvoxamine ( Luvox )  Sertraline ( Zoloft )  Paroxetine ( Paxil )  Citalopram ( Celexa )  Escitalopram ( Lexapro )

Dry mouth  Blurred vision  Insomnia  Headache  Nervousness  Anorexia  Nausea  Diarrhea  Suicidal ideation  Some clients may experience sexual dysfunction

also called second-generation antidepressants  became available in the 1980s and have been used for major depression, reactive depression and anxiety  They affect 1 or 2 of the 3 neurotransmitters: › Serotonin › Norepinephrine › Dopamine  should not be taken with MAOIs and should not be used within 14 days after discontinuing MAOIs.

Examples:  amoxapine (Asendin)  bupropion (Wellbrutin)  maprotiline (Ludiomel)  nefazodone (Serzone)  trazodone (Desyrel)  mirtazipine (Remeron)  venlafaxine (Effexor)

Manic episodes in persons with bipolar disorder (If not combined with a mood-stabilizing drug, atypical antidepressants may induce manic episodes in individuals with bipolar disorder.)  Seizures (Atypical antidepressants may lower the threshold for seizures; that is, seizures may occur more easily. Caution is advised for individuals prone to seizures or those who have a history of seizures.)  Drowsiness (Caution is advised when operating machinery, driving, or performing other tasks that require alertness.)

 relieve

depression by preventing the enzyme monoamine oxidase from metabolizing the neurotransmitters norepinephrine, serotoninand dopamine in the brain  are currently not the antidepressants of choice and are usually prescribed when the client does not repond to TCAs or secondgeneration antidepressants.  Should not be taken together with TCA when treating depression

MAO- A
the brain

– inactivates dopamine in

MAO-

– inactivates norepinephrine and serotonin

B

1. tranyclypromine sulfate (Panate) 2. isocarboxazid (Marplan) 3. phenelzine sulfate (Nardil)

Orthostatic

hypotension CNS stimulation (agitation, restlessness, insomnia) Anticholinergic effects

MAO inhibitors may cause serious and possibly life-threatening reactions, such as sudden high blood pressure, when taken with certain foods, beverages, or medicines.  The dangerous reactions may not begin until several hours after consuming these items.  Aged cheeses, red wines, smoked or pickled meats, chocolate, caffeinated beverages, and foods containing monosodium glutamate (MSG) are among the foods and drinks to be avoided

Anyone who is taking MAO inhibitors should not use any other medicine unless it has been approved or prescribed by a physician who knows that they are taking MAO inhibitors, this includes: › nonprescription (over-the-counter) medicines such as  sleep aids; medicines for colds, cough,hay fever, or asthma (including nose drops or sprays); medicines to increase alertness or keep from falling asleep; and appetite control products.

also known as neuroleptics or psychotropics  have been available since the mid1950s.  refers to any drug that modifies psychotic behavior and exerts an antipsychotic effect

Psychosis
  

  

or losing contact with reality is manifested in a variety of mental or psychiatric disorders is usually characterized by more than one symptom, but these may include difficulty in processing information and coming to a conclusion, delusions, hallucinations, incoherence, catatonia, and aggressive or violent behavior sometimes called dopamine antagonist block D2 dopamine receptors in the brain, reducing psychotic symptoms many antipsychotics block the chemoreceptor trigger zone and vomiting center in the brain, producing an antiemetic effect

Schizophrenia
a chronic psychotic disorder  is the major category of psychosis in which many of these symptoms are manifested  symptoms usually develop in adolescence or early adulthood

“Positive” symptoms - may be characterized exaggeration of normal function, incoherent speech, hallucination, delusion, and paranoia  “Negative” symptoms – are characterized by a decrease or loss in function and motivation - there is poverty of speech content, poor self-care, and social withdrawal - tend to be more chronic and persistent

 Are

divided into 2:

› Typical Antipsychotics  Division of typical antipsychotics
 Phenotiazines Nonphenotiazine

> Atypical Anti Psychotics -

Antipsychotics block the action of dopamine and thus may be classified as dopaminergic antagonists. There are five subtypes of dopaminergic antagonists. There are five subtypes of dopamine receptors. D1 through D2. All antipsychjotics block the D1 (dopaminergic) receptor, which in turn promotes the presence of EPS, resulting in pseudoparkinsonism. Atypical antipsychotics have a weak affinity to D2 receptors, a stronger affinity to D4 receptors and they block the serotonin receptor.

Extrapyramidal Syndrome
Pseudoparkinsonism, which resembles symptoms of Parkinson’s disease is a major side effect of typical antipsychotic drugs.
      

Symptoms: stooped posture masklike facies rigidity tremors at rest, shuffling gait, pill-rolling motion of the hand, a and bradykinesia.

Contraindications to Antipsychotic Treatment Narrow angle glaucoma is an absolute contraindication to the use of antipsychotics. Antipsychotic treatment while a patient is suffering from glaucoma is inadvisable. Glaucoma must be treated before a patient can continue with an antipsychotic treatment. Prostatic hypertrophy is a relative contraindication to the use of antipsychotics. Bethanechol at 25 to 50 mg/day can be used throughout treatment to offset the obstruction, but patients must be carefully monitored.

Acute dystonia
 

 

Symptoms usually occur in 5% of clients within days of taking typical antipdsychotics This condition is treated with anticholinergic/antiparkinsonism drugs such as benztropine (Cogentin). The benzodiazepine lorazepam (Atrivan) may also be prescribe. Characteristics of the reaction include:

muscle spasms of face, tongue, neack, and back; › facial grimacing; › abnormal or involuntary upward eye-movement; › and laryngeal spasms that can impair respiration

Akathisia
Incidence occurs in approximately 20% of clients who take a typical psychotic drug.  is best treated with a benzodiazepine 9e.g lorazepam) or beta-blocker (e.g propranolol)

Characteristics:
› trouble standing still, › is restless, › paces the floor, › and is in constant motion

Tardive dyskinesia
  

is a later phase of extrapyramidal reaction to antipsychotics is a serious adverse rection occulting in clients who have taken a antipsychotic drug for more than a year The likelihood of developing tardive dyskinesia depends on the dose and duration of the antipsychotic factor Characteristics: › protrusion and rolling of the tongue, › sucking and smacking movements of the lips in chewing motion, › and involuntary movement of the body and extremities.

Neuroleptic Malignant Syndrome
is a rare but potentially fatal condition associated with antipsychotic drugs.  Treatment of NMS involves immediate withdrawal of antipsychotics, adequate hydration, benzodiazepines, and muscle relaxants such as dantolene (Dantrium). Symptoms:  involve muscle rigidity,  sudden high fever,  altered mental status,  blood pressure fluctuations,  tachycardia,  dysrhythmias,  seizures,  rhabdomyolysis,  acute renal failure,  respiratory failure,  and coma

 In

1952 chlorpromazine hydrochloride (Thorazine) was the first phenothiazine introduced for treating psychotic behavior in clients in psychiatric hospitals  are subdivided into three groups:
› aliphatic, › piperazine, › and piperidine

 produce

a strong sedative effect, decreased blood pressure, and may cause moderate effect of EPS (pseudoparkinsonism).  Chlorpromazine (Thorazine) is in the aliphatic group and may produce pronounced orthostatic hypotension ( low blood pressure that occurs when an individual assumes an upright position from a supine position).

 produce

a low sedative and strong antiemetic effect but have little effect on blood pressure.  They cause more EPS than other phenothiazines. examples of piperazine phenothiazines are fluphenazine (Prolixin) and perphenazine (Trilafon).

 have

a strong sedative effect, cause few EPS, have a low to moderate effect on blood pressure , and have no antiemetic effect  Thioridazine ( MEllril ) is an example of piperidine phenothiazines.

Includes › Butyrophenone › Dibenzoxazepines › Dihydroindolone › Thioxanthene

 Drowsiness  Dry

mouth  Increased heart rate  Urinary retention  Constipation  Decrease blood pressure

 

Dosage adjustment of an anticonvulsant may be necessary If either aliphatic phenotiazine or the thioxanthene group is administered, a higher dose of anticonvulsant may be necessary Antipsychotics interact with alcohol, hypnotics, sedatives, narcotics and benzodiazepines to potentiate the sedative effects of antipsychotics Antipsychotics should not be given with other antipsychotic or antidepressant drugs except to control psychotic behavior for selected individuals who are refractory to drug therapy. When discontinuing antipsychotics, the drug dosage should be reduced gradually

Older adults usually require smaller doses of antipsychotics – from 25% to 50% less than young middle-aged adults  Dosage amount need to be individualized according to the client’s age and physical status

A new category of antipsychotics that was marketed in the US in the early 1990s  Differs from the typical/ traditional antipsychotics   2 advantages of the atypical agents  They are effective in treating negative symptoms  They are not likely to cause EPS or tardive dyskinesia

Atypical drugs available  clozapine (Clozaril)  risperidone (Risperdal)  olanzapine (Zyprexa)  quetiapine (Seroquel)  paliperidone (Invega)