Mental Health Pharm

  1. Key Neurotransmitters for this exam
    • —Serotonin (5-HT)—
    • Norepinephrine (NE)
    • —Dopamine (DA)—
    • Acetylcholine (Ach)
    • —GABA: the chief inhibitory neurotransmitter
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  3. Non-Pharm interventions for anxiety disorders?
    Anxiety frequently disturbs sleep patterns
    • Cognitive behavioral therapy
    • Counseling
    • Biofeedback techniques
    • Meditation
    • Physical activity
  4. Normal sleep pattern
    • NREM and REM 
    • occur every 90 mins
    • NREM-4stages
    • REM-dreaming
  5. Anxiolytic medications
    • Benzodiazepine
    • beta-blockers
    • SSRI
    • others: buspar-non sedating, not very effective.
  6. Benzodiazepine
    • Facilitates GABA-binds to specific receptor- chloride channel molecule (Xanax, ativan, valium, serax, librium)
    • Intensify inhibitory effects of GABA
    • Schedule IV Less addictive, less tolerance than barbiturates
  7. Beta-Blockers
    Antagonize NE(Norepinephrine)-blocking beta receptor site.
  8. SSRI
    PTSD, OCD, SAD Seasonal affective disorder, sometimes GAD.
  9. Sedative
    Calming effects
  10. Hypnotic
    induces sleep
  11. Amnesic
    • short term memory loss
    • generally used for surgery
  12. lorazepam (Ativan)
    • Therapeutic class: Anxiolytic 
    • Preg cat: D
    • MOA: Intensifies inhibitory effects of GABA
    • ALERT: Opiates causes additive effect.
    • Antidote: flumazenil (Romazicon) 
    • Indications: anxiety, insomnia, premed for anesthetic procedures, seizures also has off label used for agitation, alcohol withdrawal.
    • Contraindications: respiratory insufficiency, sleep apnea.
    • Adverse: Respiratory depression, psychological and physical dependence, sedation, dizziness, can develop a tolerance.
    • Interactions: any CNS depressants, digoxin, antiparkinson drugs
  13. Flumazenil (Romazicon)
    • antidote for benzo overdose
    • Rapid IVP
    • reverses sedation from benzo-competes for receptor sites
    • short duration, may need to repeat
  14. zolpidem (Ambien)
    Nonbenzodiazepine, Nonbarbiturate
    • Therapeutic class: Hypnotic
    • Preg cat: B
    • MOA: Binds to GABA, intensifying inhibitory GABA effects.
    • Indications: Insomnia
    • Alert: Short term use only, May have weak reversal with flumazenil
    • Contraindications: severe hepatic impairment.
    • Adverse: Mild nausea, dizziness, diarrhea, daytime drowsiness, amnesia, sleepwalking, ingesting carbohydrates while sleepwalking
    • Interactions: Any CNS depressants, Food delay absorption.
  15. Mood disorders
    • Depression, Bipolar
    • Emotions that impair ability to deal with ADLs
  16. Antidepressants
    MAO Inhibitors (Inhibit Monoamine oxidase which is responsible for terminating Norepinephrine)

    Tricyclics (TCA) (Inhibit reuptake of norepinephrine and serotonin)

    Selective Serotonin Reuptake Inhibitors (inhibit reuptake of serotonin, increases synaptic sensitivity)

    Dual Action Antidepressants

    Selective Norepinephrine Reuptake Inhibitors

  17. Mood stabilizers
    • Lithium Carbonate
    • Valproic Acid
    • Carbamazepine-Tegretol
    • Lamotragine- Lamictal-also anticonvulsant
    • Topirimate-topamax
  18. Depression
    • Most common  mental illness in the USA
    • Neurotransmitter dysfunction (Serotonin, Norepinephrine)
    • Hormonal changes (menses, menopause)
    • Seasonal affective disorder (SAD)
    • Melatonin
  19. SSRI examples
    • ◦Fluoxetine – Prozac
    • Sertraline - Zoloft
    • Paroxetine - Paxil
    • Fluvoxamine - Luvox
    • Citalopram - Celexa
    • Escitalopram - Lexapro
  20. sertraline (Zoloft)
    • therapeutic class: Antidepressant
    • Preg cat: C
    • Alert:Monitor first few weeks of treatment can cause suicidal ideation. Don't abruptly stop taking medication you must taper off(withdrawal SE). Avoid St. Johns wart.
    • MOA: Blocks the reuptake of serotonin allowing more to be available in the brain. leading to enhancement in mood. May take several weeks to work.
    • Indication: depression, anxiety, OCD, Panic disorders.
    • Contraindication: Do not give with MAO or within 14 days of an MAO.
    • Adverse: Agitation, insomnia, headache, dizziness, Increased thought suicidal ideation.
    • Interactions: May cause toxicity when used concurrently with other drugs that are highly protein bound (warfarin or digoxin)
  21. Serotonin syndrome
    Rarely, a cyclic antidepressant can cause dangerously high levels of serotonin. This is known as serotonin syndrome. It most often occurs when two medications that raise serotonin are combined. These include other antidepressants, certain pain or headache medications, and the herbal supplement St. John's wort. Signs and symptoms of serotonin syndrome include anxiety, agitation, sweating, fever, confusion, tremors, restlessness, lack of coordination and rapid heart rate. Seek immediate medical attention if you have any of these symptoms.
  22. Dual action AD
    • —Affinity for both 5-HT and NE.
    • Block re-uptake for both—
    • In this sense, like TCAs

    —Duloxetine - Cymbalta
  23. SNRI
    • —Selectively inhibits NE transporter. 
    • Blocks re-uptake.◦

    Atomoxetine (Strattera)
  24. Other antidepressant
    • Bupropion (Wellbutrin)
    • No effect on either 5-HT or NE
    • Effective at blocking DA (dopamine)reuptake
    • May be similar action to cocaine
    • Lowers seizure threshold
    • Venlafaxine (Effexor)
    • 5-HT, DA and NE reuptake blocker
  25. Tricyclic antidepressants
    • Side effects are the major problem
    • Cardiotoxic
    • Sedative action –take at bedtime
    • High incidence of sexual dysfunction
    • Weight gain
    • Block acetylcholine system, especially muscarinic receptors
    • ex: blurred vision, dry mouth, urinary retention, constipation, mental confusion
  26. imipramine (Tofranil)
    Tricyclic anti-depressant
    • Therapeutic class: Antidepressant
    • Preg Cat: C
    • Alert: sedating-take at bedtime, monitor for SI. Can be fatal in small amounts overdose warnings/children safety.
    • MOA: Inhibit reuptake of norepinephrine and serotonin, can block histamine as well-acetylocholine system. causing sedation 
    • Indications: Depression, pain control, anxiety disorders, prevention of bedwetting in children
    • Contraindications: Cardiac disease, Thyroid medications,
    • Adverse effects: Anticholinergic side effects: dry mouth, drowsiness, constipation, urinary retention, insomnia, orthostatic hypotension, sedation
    • Interactions: CNS depressants, St Johns wort may cause serotonin syndrome, other meds: cimetidine , antithyroid medications,
  27. Antidepressant education
    • —The full therapeutic effects of Antidepressants often take 2-6 weeks or more to appear.
    • —Encourage patient to take the drug even if no benefits are felt immediately
  28. MAOI
    • last resort medications
    • MAO degrades 5-HT, NE & DA-allowing more free floating neurotransmitters 
    • Tyramine found in cheese, wine, smoked fish
    • MAO breaks down Tyramine-leading to hypertensive crisis "Cheese Syndrome"-causing strokes, heart attacks, DEATH
  29. phenelzine (Nardil)
    • Therapeutic class: Antidepressants
    • Preg cat: C
    • Alert: Lasts for 2-3 weeks after last dose
    • MOA: irreversibly inhibits monoamine oxidase, which causes intensification of norepinephrine
    • Indications: Severe and unrelenting depression
    • Contraindications: concomitant use within 14 days of another MAOI, SSRI.
    • Adverse effects: Orthostatic hypotension, headache, insomnia, and diarrhea, abrupt discontinuation will cause severe hypertension
    • Interactions: extensive interactions with other medications, foods with tyramine, and herbals
  30. Mixing meds
    • —Although classified as a certain type of drug most psych meds used for many different disorders.
    • Antipsychotics in Bipolar Disorder–
    • Abilify
    • –Zyprexa
    • Mood stabilizers in alcoholism–
    • Topiramate
  31. Drugs for bipolar
    • Lithium
    • Valproic Acid
    • Carbamazepine/Oxcarbazepine
    • Lamotragine
    • Topirimate
    • Symbyax – Combo of olanzepine and fluoxetine (Zyprexa & Prozac)
  32. Lithium carbonate (Eskalith)
    Mood stabilizer
    • Therapeutic class: Anti-manic
    • Preg cat: D
    • Alerts: Narrow therapeutic index, monitor for hyponatremia and toxicity(Increase in SE)
    • MOA: exact mechanism is not understood, but influences dopamine, norepinephrine and serotonin. Therapeutic level: 0.5-1.5 mEq/L. Monitor first 2-3 days and once every 2-3 months after. Stay hydrated 1-2L a day.
    • Indications: Bipolar disorder
    • Contraindications: Diuretics, NSAIDS
    • Adverse: nausea, loss of appetite, slight tremors, fatigue, excessive loss of sodium, can cause hypothyroidism, arrhythmias, Kidney impairment, WBC problems.
    • Interactions: Numerous
  33. Categories of Anti-psychotics
    • —Typical (conventional) antipsychotic
    • Control positive signs of schizophrenia–
    • Phenothiazines
    • Phenothiazine-like drugs– Chemical structure similar to phenothiazines.
    • —Atypical antipsychotic
    • Control positive and negative signs of schizophrenia–
    • Nonphenothiazines: less sedation and antiholinergic SE, but increase chance of EPS
  34. Typical antipsychotic examples
    • Chlorpromazine - Thorazine
    • Haloperidol – Haldol
    • Fluphenazine (piperazine phenothiazine)
  35. chlorpormazine (Thorazine)
    • Therapeutic class: Phenothiazine
    • Preg cat: C
    • Alert: Lowers seizure threshold
    • MOA: Blocks dopamine and serotonin receptors
    • Indications: Positive symptoms of schizophrenia, severe mood disorders, unrelenting N/V, uncontrolled hiccups, porphyria (disorder that accumulates chemicals related to red blood cell proteins, leading to neuro or organ issues.)
    • Contraindications: active seizures..
    • Adverse: EPS, NMS, numerous others.
    • Interactions: Many, CNS depressants
  36. haloperidol (Haldol)
    • Therapeutic class: Nonphenothiazine; antipsychotic: Dopamine antagonist. 
    • Preg cat: C
    • Alert: Increased risk of geriatric death with use.
    • MOA: blocking the dopamine type 2 receptor
    • Indications: positive symptoms of schizophrenia, 
    • Contraindications: comatose state from any cause, parkinson's disease
    • Adverse: EPS, NMS, Numerous others
    • Interactions: Many, CNS depressants
  37. risperidone (Risperdal)
    Atypical antipsychotic
    • Therapeutic class: Serotonin-dopamine antagonist. 20 times higher affinity for serotonin than dopamine
    • Preg cat: C
    • Alert: Avoid for elderly or dementia
    • MOA: Blocks dopamine, serotonin and alpha adrenergic receptors
    • Indications: Schizophrenia, bipolar, autism, elderly, depression.
    • Contraindications: hypersensitivity
    • Adverse: Obesity, diabetes, stroke, EPS-less often than typical. Possible for agranulocytosis(clozaril)
    • Interactions: numerous
  38. Atypical antipsychotics examples
    • Risperdal - Risperidone
    • Olanzepine - Zyprexia
    • Quetiapine - Seroquel
    • Ziprasidone – Geodon
    • Aripiprazole – Abilify
    • Paliperidone - Invega
  39. Serious side effects of antipsychotics
    • Tardive dyskinesia
    • Anti-ACH
    • Anti-histamine
  40. Schizophrenia
    • Most common psychotic disorder
    • associated with dopamine type 2 receptor-too much dopamine due to basal ganglia in brain-(antipsychotics/neuroleptic-blocks this receptor and reduces symptoms of schizophrenia.)
    • Abnormal thoughts and thought process
    • disordered communication
    • social isolation
    • severe depression
    • high risk for suicide
  41. Extrapyramidal symptoms (EPS)
    • Tardive dyskinesia: Lip smacking, bizarre movements of head and neck.
    • Acute dystonias: face spams, tongue or back, facial grimace, nystagmus/ upward eye movement, jerking motions. Benadryl can be given for this. 
    • Akathisia: extreme restlessness
    • Parkinsonism symptoms: stooped gestures, shuffling gait, tremors at rest.
  42. Neuroleptic Malignant Syndrome (NMS)
    • Toxic reaction to therapeutic doses of antipsychotics.
    • potentially life threatening
    • S&S: elevated temp, unstable blood, profuse sweating, dyspnea, muscle rigidity, incontinence.
    • Discontinue drug
  43. Atypical antipsychotics
    • Helps to control + and - symptoms
    • Fewer side effects.
    • Aripiprazole (Abilify)
    • Clozapine (Clozaril)
    • Olanzapine (Zyprexa)
    • Olanzapine/Fluoxetine (Symbyax) Risperidone (Risperdal)
    • Quetiapine (Seroquel)
    • Ziprasidone (Geodon)
  44. aripiprazole (Abilify)
    dopamine system stabilizer
    • Treats both + and -
    • Grapefruit juice leads to toxic level
    • Advertised for depression but also used for schizophrenia
    • SE: hypotension, hypertension, NMS possible, less likely for EPS, little to no weight gain, anxiety can occur.
  45. Patient teaching for Atypical and Typical
    • medications take 6 weeks or longer to take effect
    • Teach for S&S of tardive dyskinesia, NMS, parkinsonian syndrome.
    • explain about the weight gain, orthostatic hypotension.
    • Do not take alcohol or other depressants with antipsychotics.
    • teach smoking cessation
    • Follow up visits for Blood draw: WBC's Agranulocytosis-Decrease in WBC-leading to increased risk of infection.
  46. Naltrexone (Revia)
    blocks pathways in the brain that trigger the feelings of pleasure- reducing the cravings for alcohol.
  47. Disulfiram (Antabuse)
    Form of aversion therapy that prevents the breakdown of alcohol. causing the symptoms for physical illness when consumed with alcohol
Card Set
Mental Health Pharm
Mental health