PSYCHOPHARMACOL

OGY

Shantavia Reid
 Objectives

• Classification of psychotropic medications.

• Mechanism of action of psychotropic medications.

• Choose a psychotropic medication rationally.

• Know common & dangerous adverse effects.

• Manage failure of response to a therapeutic trial.

 Psychopharmacology
Psychopharmacology is the study of the effects
of drugs on affect, cognition, and behavior
The term drug has many meanings:
• Medication to treat a disease
• A chemical that is likely to be abused
• An “exogenous” chemical that significantly alters the
function of certain bodily cells when taken in relatively
low doses (chemical is not required for normal cellular
functioning)
 Pharmacokinetics
Drug molecules interact with target sites to effect the
nervous system
The drug must be absorbed into the bloodstream and then
carried to the target site(s)
Pharmacokinetics is the study of drug absorption,
distribution within body, and drug elimination
– Absorption depends on the route of administration
– Drug distribution depends on how soluble the drug
molecule is in fat (to pass through membranes) and on the
extent to which the drug binds to blood proteins (albumin)
– Drug elimination is accomplished by excretion into urine
and/or by inactivation by enzymes in the liver
 Drug Effectiveness
Dose-response (DR) curve: Depicts the relation
between drug dose and magnitude of drug effect
Drugs can have more than one effect
Drugs vary in effectiveness
Different sites of action
Different affinities for receptors
The effectiveness of a drug is considered relative to its
safety (therapeutic index)
 Routes of Drug Administration
Routes of drug administration into the body
– Intravenous (IV): into a vein (rapid absorption)
– Intraperitoneal (IP): into the gut (used in lab
animals)
– Subcutaneous (SC): under the skin
– Intramuscular (IM): into a muscle
– Inhalation of the drug into the lungs
– Topical: absorbed through the skin
– Oral (PO): via the mouth
 Tolerance and Sensitization
Repeated administration of a drug can alter its
subsequent effectiveness
Tolerance: Repeated drug administration results in
diminished drug effect (or requires increased
dosage to maintain constant effect)
• Withdrawal effects are often the opposite of the drug
effect and often accompanies tolerance
• Tolerance can reflect decreased drug-receptor binding
or reduced postsynaptic action of the drug
Sensitization: Repeated drug administration results
in heightened drug effectiveness
 Synaptic Transmission
Transmitter substances are
Synthesized, stored, released, and terminated
Susceptible to drug manipulation
Definitions:
Direct agonist: a drug that binds to and activates a
receptor
Antagonist: a drug that binds to but does not
activate a receptor
Indirect antagonists are drugs that interfere with the
normal action of a neurotransmitter without binding to
its receptor site
 Presynaptic Drug Actions
Presynaptic autoreceptors regulate the amount of
NT released from the axon terminal
– Drugs that activate presynaptic autoreceptors reduce
the amount of NT released, an antagonistic action
– Drugs that inactivate presynaptic autoreceptors
increase the amount of NT released, an agonistic
action
Presynaptic heteroreceptors are sensitive to NT
released by another neuron, can be inhibitory or
facilitatory
 Why Medications ?

Dopaminergic theory of Schizophrenia

Monoaminergic theory of Mood Disorders

 Neurotransmitters Go
through 7 steps
1. Synthesis
2. Storage
3. Enzymatic destruction if not stored
4. Exocytosis
5. Termination of release via binding with autorecptors
6. Binding to receptors
7. Inactivated

Drugs are developed that address these actions as an

AGONIST (mimic the NT ) or ANTAGONIST (block the NT)
 Psychopharmacologic Drugs
Work over A Spectrum

Antipsychotics

Antidepressants Mood stabilizing agents

Anxiolytics/sedatives Others
 General principles about adverse effects

• Psychopharmacological agents affect the whole body.

• Remember the common and dangerous side effects.

• They indicate the drug is working.

Antipsychotics
 Antipsychotics
Average Daily Doses in mg

Typicals Atypicals

Risperidone (4-8)
Haloperidol (5-15) Olanzapine (10-20)
Thioridazine(100-300) Quetiapine (600-1200)
Chlorpormazine (50-400) Clozapine (100-600)

Lower numbers indicate higher potency

 Antidepressants
• Used in many psychiatric disorders other than Depression.

• Full clinical response in 6-8 weeks in major depression, up to

6/12 in obsessive compulsive disorder.

Examples:
Fluoxetine & Paroxetine (20-60 mg/d)
Fluovoxamine & Sertraline (50-200 mg/d)
Imipramine(200-300 mg/d)
 THREE PHASES OF TREATMENT
Remission Recovery
Normal

Relapse Recurrence
Symptom Severity

Response
Relapse
> 50%
STOP 65 to 70%
Rx STOP
Rx
Acute Continuation Maintenance
Phase (3 months+) Phase (6-12 months) Phase (years)
Time
 Potential Adverse Effects of
Antidepressant Therapy
Central Nervous System
Cardiac
Dizziness, cognitive impairment,
Orthostasis
sedation, light-headedness,
hypertension
somnolence, nervousness,
heart block,
insomnia, headache, tremor,
tachycardia
changes in satiety and appetite
Gastrointestinal
Nausea, constipation,
Urogenital
vomiting, dyspepsia,
Erectile dysfunction, diarrhea
ejaculation disorder,
anorgasmia, Autonomic Nervous System
priapism Dry mouth, urinary retention,
blurred vision, sweating
Antidepressants and the Cytochrome P450
System

• Antidepressants and mood stabilizers may be

inhibitors, inducers or substrates of one or more
cytochrome P450 isoenzymes
• Knowledge of their P450 profile is useful in predicting
drug-drug interactions
• When some isoenzymes are absent of inhibited,
others may offer a secondary metabolic pathway
• P450 1A2, 2C (subfamily), 2D6 and 3A4 are especially
important to antidepressant metabolism and drug-
drug interactions
 Mood Stabilizers

• Lithium, Valproic acid, Carbamazepine, Lamotrigine,

Gabapentine, Topiramate.

• Used in the treatment of Bipolar affective disorder and similar

conditions associated with impulsivity.

• Drug level measurements are available for many of them.

• Mechanism of action is not clearly understod.

 Common Mood Stabilizers

Carbamazepine Valproic Acid Lithium

4-12 mg/ml
Therapeutic Level 40-100 mg/ml 0.5-1.2 mEq/L

nausea,
Dizziness, sedation, nausea, diarrhea,
hypothyroidism,
ataxia, leukopenia, ataxia, dysarthria,
tremors, dysarthria,
Common S/E weight gain, slight
rash, ataxia
elevation of hepatic
transaminases

sinus node
Agranulocytosis, dysfunction, T-wave
teratogenicity (neural changes,
teratogenic (neural teratogenic (cardiac
Dangerous S/E tube defect), induction tube defects) anomalies)
of hepatic metabolism
 Anxiolytics/sedatives

• Benzodiazepines, Trazodone, Zolpidem and others

• Alprazolam, clonazepam, lorazepam, diazepam.

• Risk of dependence & withdrawal.

 Other pharmacological agents

Cholinesterase inhibitors:
Donepezil, Rivastigmine, Galantamine, (Tacrine has been
withdrawn)

Sympathomimetics:
Methylphenidate, Dextroamphetamine.

Anticholinergic agents:
Procyclidine, Benztropine
 Dangerous Side Effects
Hypertensive crisis
Associated with MAOIs.

Neuroleptic malignant syndrome

Autonomic instability, severe EPS, delirium, ↑CK, ARF, myoglobulinuria

Serotonin syndrome
Restlessness, myoclonus, ↑reflexes, tremors, confusion.
Due to combination of serotenergic agents

Agranulocytosis
( Clozapine, carbamazepine).
 Prescribing a Psychotropic Agent
After Diagnostic Assessment

• Choose a medication based on FDA approval

• Family or personal hx of response
• Adverse effects vs. key symptoms
• Starting dose
• Monitor side effects & clinical response
• Adjust dose if needed
 Failure of Response
What to do?
• Check Compliance & availability

• Review the diagnosis

• Is the dose appropriate?

• Is the duration of treatment long enough?

• Any ongoing substance abuse?

• Other drugs/preparation causing drug-drug Interaction?

• Individual Variation?
Thank you