Psychopharmacology

1. Psychopharmacology Khalid Bazaid, MB BS, FRCPC Assistant Professor Child & Adolescent Psychiatrist Department of Psychiatry College of Medicine King Saud University

2. Outlines The role of psychotropic medications in the mental health and its therapeutic indications Identify specific cautions to be aware of the various psychotropic medications Discuss the adherence to medication treatment Overview Psychotropic Medications Classifications

3. Psychopharmacology • The aim is learn how to choose a psychotropic drug that is more: • Less toxic • Effective • Better-tolerated • The most targeted therapeutic agents

4. Use of psychotropic medications Relieve or reduce symptoms/signs of dysfunctional thoughts, moods, or actions of mental illness Improve client’s functioning Increase compliance to other therapies

5. Psychotropic Drugs Focus of all mental activity is the CNS (brain) Origin of psychiatric illness caused by many factors: Genetics Neurodevelopment factors Endocrinologic e.g. Hypothyroidism Autoimmune system (infections) Drugs Psychosocial experiences, stressors … etc. To date …Theories behind use of psychotropic drugs focuses on neurotransmitters and their receptors Psychotropic drugs act by modulating neurotransmitters

6. Therapeutic Effects of Psychotropic Medications Do not “cure” Relieve or decrease symptoms Prevent or delay return of S/S Cannot be used as the sole treatment for disorders Need informed consent before starting Are broad spectrum and have effects on a large number of S/S Initial effects are sedative in nature May take weeks for effects to be seen

7. Reasons for Non- adherence: Medications are expensive Unpleasant side effects Feel better and decide no longer need Stigma associated with having a mental illness and taking medications Paranoia or fears about medication usage particularly addition

8. Encouraging Compliance to Medication Regimen Follow-up appointments With client to verify that client understands: the purpose, proper administration, intended effects, side and toxic effects of, and how to treat problems associated with medications Appropriate lab tests must be conducted to prevent complications and assure correct levels of drugs Encourage clients to participate in medication groups Can use injections of antipsychotics which will last from 2-4 weeks if clients are non-compliant

9. Efficacy of Psychotropics with Children & Elderly Use with great caution Start low and go slow for both elders and children Children are faster metabolizer whereas elders have decrease liver & renal function Risk of injuries and falls with elderly

10. Client & Family Teaching Purpose of the meds and benefits, side effects and how to treat SE What S/S indicate a toxic effect, and how to treat, and whom to call. Specific instructions about how to take the medications

11. Psychotropic Medications Classifications Antipsychotics (Neuroleptics) Mood Stabilizers Antidepressants Anxiolytics (antianxiety) Sedatives Hypnotics Psychostimulants Antihistamines, antimuscarinics, dopamine agonists

12. AntipsychoticsNEUROLEPTICS / MAJOR TRANQUILIZERS • Block D2 receptors in the mesolimbic system • Not addictive • Treat all psychoses & psychotic symptoms Tourette’s Syndrome Delirium, Dementia, and Delusions Control of intractable hiccups Aggressive behavior Schizophrenia Disorders Bipolar disorder Major Depression with psychotic features

13. ANTIPSYCHOTIC DRUGSNEUROLEPTICS / MAJOR TRANQUILIZERS Mechanism of action • In typical antipsychotics • Blockage of D2 – receptors in: • Nigro-strial (psychiatric tract) • SubstantiaNigra (Neurological tract) • Tubero-infundibular tract (Endocrine tract) • In atypical antipsychotics: • Blockage of 5HT2A/D2 receptors

14. ANTIPSYCHOTIC DRUGSSide effects (hint) • High Potency typical antipsychotics: Neurological side effects e.g. Haloperidol • Low Potency typical antipsychotics: other side effects e.g. Chlorpromazine

15. Due to D2 blockade Parkinsonian syndrome Position & gait Apathy Drooling Fine tremor Staring eyes ANTIPSYCHOTIC DRUGSNeurologic Side effects

16. Due to D2 blockade Parkinsonian syndrome Akathesia (Motor restlessness) Subjective feelings of restlessness Objective signs of restlessness Feelings of anxiety, inability to relax, jitteriness, pacing, rocking motions while sitting, rapid alterations of position. More in middle aged women ANTIPSYCHOTIC DRUGSNeurologic Side effects

17. Due to D2 blockade Parkinsonian syndrome Akathesia (Motor restlessness) Brief or prolonged muscle contraction leading to abnormal movements or postures e.g. Occulogyric crises, tongue protrusion, torticollis, laryngeal pharyngeal dystonias and dystonic Postures Early onset, more in young men and high doses of typical neurosleptics Acute dystonia ANTIPSYCHOTIC DRUGSNeurologic Side effects

18. Due to D2 blockade Parkinsonian syndrome Akathesia (Motor restlessness) Involuntary choreiform, athetoid or rhythmic movements of the tongue, jaw, trunk or extremities More with long term typical neuroleptic treatment, old age, female sex, mood disorder, cognitive disorders. Acute dystonia Tardive Dykinesia ANTIPSYCHOTIC DRUGSNeurologic Side effects

19. Due to D2 blockade Parkinsonian syndrome Akathesia (Motor restlessness) Muscular rigidity, , Hyper-thermia , Akinesia, mutism, obtundation & agitation, sweating, tachycardia, Hypertension. Increased WBC, increased CPK, liver enzymes, and plasma myoglobulin. Myoglobulinuria, may occur and may lead to renal failure. Symptoms evolve in 1-3 days & may last 10-14 days. May occur at any time More common in young men Mortality: 20% - 30%( higher with depot) Acute dystonia Tardive Dyskinesia Neuroleptic malignant syndrome ANTIPSYCHOTIC DRUGSNeurologic Side effects

20. Muscarenic (anti-cholenergic): dry mouth Constipation Blurred vision, urinary retention Precipitation of narow angle glucoma Alpha–1–adrenergic blockade: Orthostatic hypotension Impotence Impaired ejaculation ANTIPSYCHOTIC DRUGSOther Side effects

21. CNS Side effects: Sedation Metabolic / Endocrine Side effects: weight gain Increased BS & lipids Galactorrhea Amenorrhea Allergic Side effects Cholestatic jaundice Agranulostasis Cardiac side effects: EKG changes Arrythmias Occular Side effects: Corneal Opacities Retinitis pigmentoza Dermatological Side effects: Photosensitivities Metallic discoloration Contact dermatitis ANTIPSYCHOTIC DRUGSOther Side effects

22. Antipsychotics-Long acting preparation Can be given be given as an IM injection (depot preparations) if have difficulty taking oral meds. Can use lower doses when given IM, so less risk of tardive dyskinesia

23. Antidepressants Treatment of depressive moods, including bipolar disease 4 categories: Tricyclics (TCA) MAOI’s SSRI’S Atypical Antidepressants

24. Major Indications for Antidepressants Major Depressive disorder Bipolar depression Anxiety disorders: Panic disorder Obsessive-Compulsive Phobic disorders PTSD Substance Abuse Chronic Pain Tourette’s Disorder ADHD Eating disorders Sleep disorders Migraines Enuresis

25. Antidepressant Drugs Tricyclics- Amitriptyline, Imipramine SSRI’s- Fluoxetine, Sertraline MAOI’s- Phenelzine , Tranycypramine

26. Atypical Antidepressants Inhibits reuptake of serotonin: desyrel (Trazodone) Norepinephrine Dopamine Reuptake Inhibitor (NDRI): Wellbutrin (Bupropion) Serotonin Norepinephrine Reuptake Inhibitor-(SNRI): Effexor (venlafaxine) Cymbalta (duloxetine) Increases release of serotonin & norepinephrine: Remeron (Mirtazapine)

27. Atypical Antidepressants Trazodone: alternative to TCA’s, may cause orthostatic hypotension, sedation, and priapism in males Remeron: causes sedation, weight gain, dry mouth, constipation Wellbutrin (zyban): rarely causes sedation, weight Gain, or sexual dysfunction Used for smoking cessation. Most common S/E are headaches, insomnia & nausea May lower seizure threshold

28. Atypical Antidepressants: Serotonin Norepinephrine Reuptake Inhibitor (SNRI) SNRI-blocks uptake of serotonin and norepinephrine Drugs include Effexor & Cymbalta Good for clients with anxiety S/E:GI, sexual dysfunction, insomnia, agitation Skipping 1 dose can cause withdrawal S/S Very effective in treating severe depression Cymbalta is effective in treating somatic symptoms e.g. pain

29. HETEROCYCLICS: Muscarenic (anti-cholenergic): Dry mouth Constipation Blurred vision, urinary retention Precipitation of narow angle glucoma Alpha–1–adrenergic blockade: Orthostatic hypotension Impotence Impaired ejaculation ANTIDEPRESSANT DRUGSSide effects

30. Delirium Coma seizures Agitation Hallucinations Severe hypotension Supra-ventricular tachycardia Flushing Mydriasis Dry skin Hyperthermia Decreased bowel sounds. ANTIDEPRESSANT DRUGSSide effects Management • Stop HCA immediately • Physostigmine (anticholinesterase inhibitor) 1-2 mg IV or IM every 20 – 60 minutes, until improvement occurs • Cardiac monitoring and life support (physostigmine may lead to severe BP drop and bronchial constriction) • Benzodiazepines may be used. Central anti-cholenergic syndrome:

31. ANTIDEPRESSANTSSide effects • HETEROCYCLICS: • SSRI: • have a much better side effect profile: • Agitation • Sexual problems • Stomach upset • Hypersomnia/insomnia

32. ANTIDEPRESSANTSSide effects • HETEROCYCLICS: • SSRI: • MAOI: • Cardiovascular (orthostatic hypotension, tyramine hypertensive crisis) • Sexual (Impotence & delayed ejaculation) • Neurologic (insomnia, seizure& euphoria) • Hepatic: (Cholestatic reaction).

33. ANTIDEPRESSANTSSide effects • HETEROCYCLICS: • SSRI: • MAOI: • Interaction: • Diet: Amphetamines Decongestants & nasal sprays (Ephedrine….) Epinephrine (local anesthesia) Aldomet Aged cheese Pickled herriag Raisin Alcohol Chicken liver Beans Figs Yeast products Chocolate

34. MOOD STABLIZERS • Lithium Carbonate • Sodium Valproate • Carbamazepine • Lamotrigine • Topiramate • Clozapine

35. MOOD STABLIZERS • Used in the treatment of Manic (Bipolar) disorder, and in some forms of depression • Drugs used: Lithium and Antiepileptic Drugs

36. Lithium Mechanism of action unknown Alters electrical conductivity potential threat to all body functions that are regulated by electrical currents Can cause polyuria and polydipsa due to Na and K alterations Has the lowest therapeutic index of all psych drugs Have to monitor blood levels

37. LITHIUM CARBONATESide effects • Neurological: Tremor (50%), weakness, cog-wheeling • Renal: Occur in 10-50 % e.g. polyuria, polydipsia, nephrogenic D.I., nephrotic syndrome, (tubular changes with chronic use and high levels) • Cardiac: Similar to those of hypokalimia e.g. U-wave and T-wave depression • Endocrine: Goiter, hypothyroidism, abnormal thyroid functions (30-40%) • Dermatological: Acne, exacerbation of psoriasis ), hair loss. • Pregnancy and lactation: Teratogenicity (level in milk=30-100% of maternal blood level) • Toxicity: (seizures, delirium, cerebellar signs, coma) occurs in blood level= 1.2 – 2 mEq/l. Lethal levels above that.

38. Signs & Symptoms of Lithium Toxicity Fine hand tremors that progress into coarse tremors Mild GI upset progressing to persistent upset Slurred speech and muscle weakness progressing to mental confusion • Severe Toxicity: • decrease level of consciousness to stupor and finally coma • Seizures, severe hypotension, severe polyuria with dilute urine

39. Contraindications for Lithium Renal disease Cardiac disease Severe dehydration Sodium depletion Brain damage Pregnancy or lactation Use with caution in the elderly or clients with diabetics, thyroid disorders, urinary retention, and seizures

40. Sedative/Hypnotic Drugs Anxiolytic and hypnotic Can lead to tolerance and dependency Use for short term Drugs used benzodiazepines: Dalmane, Restoril, Halcion Non-benzodiazepines: Ambien, Sonata, Lunestra

41. Benzodiazepines Valium, Xanax, Ativan , Librium, Lexotanil Dalmane, Halcion (used as sleep aides-short term) Used for anxiety disorders, ETOH withdrawal, muscle spasm, sedation, insomnia, and epileptics/seizures Risk of dependency Avoid ETOH Causes sedation-don’t drive!!

42. Benzodiazepines Side Effects Drowsiness, confusion, sedation, and lethargy Toxic Effects Respiratory depression esp. with ETOH use! Contraindications Combination with other CNS depressants Renal or hepatic dysfunction (may use Ativan) History of drug abuse or addiction Depression and suicidal tendencies Teaching Use short term due to risk of drug dependency Avoid ETOH and other CNS depressants Can impair ability to drive Sudden D/C of benzodiazepines might cause withdrawal s/s

43. Non-benzodiazepine Anxiolytic BuSpar (Buspirone) Reduces anxiety without strong sedative-hypnotic properties Not a CNS depressant Takes 2 weeks to feel effects No potential for addiction Side Effects Dizziness, dry mouth, nervousness, diarrhea, headache, excitement Toxic Effects Lethal dose is 160-550 times the daily recommended dose Contraindications Use with caution in PG women Nursing mothers Clients with renal or hepatic disease Anyone taking MAOs

44. Questions after lecture? Please e-mail (kbazaid@ksu.edu.sa) or call (01 467 1717) Interested in learning more about child and adolescent psychiatry? Arrange to attend OPD Consider an elective rotation during internship or otherwise 10/21/2019 44