Drugs for Mental Health chapter-31

1. Drugs for Mental Healthchapter-31 “the Mentally Healthy person” – one who can perceive reality accurately and has control over expression of emotions Mental Health: not a concrete achievable goal …but a lifelong process resulting in a sense of harmony and balance in a person’s life -difficult to define, highly individualized -varies from person-to-person

2. Medication in Psychotherapy • Among the most prescribed drugs • Used to reduce/alleviate symptoms of STRESS …to allow the patient’s participation in other psychotherapies • DRUGS – temporarily change behavior, addiction/dependence are major concerns • PSYCHOTHERAPY – more long-term, but … the results are more permanent

3. Neurosis vs Psychosis • Neurosis: patient is still in contact with reality • Psychosis: patient is out of contact with reality, unable to communicate • DRUGs for Anxiety (see Table 31-1) known generally as ‘anxiolytics’ which literally means ‘to break apart, or dissolve anxiety’ • Benzodiazepines – long and/or short-acting • Misc Anxiolytics – Buspar, Paxil, Effexor, Desyrel

4. Anxiolytics (cont) • Benzodiazepines - introduced in the 1960’s • Generic names end in ‘-pam’ - diazepam, lorazepam, clonazepam (exception: alprazolam, whose brand name is Xanax) • ‘drugs-of-choice’ – safer, lower abuse potential, less tolerance and dependence (again, except for Xanax!) • Effect: a calming-effect without extreme sedation • (2)general types: Short-acting and Long-acting

5. Benzodiazepines Patient-education • Take with food if GI symptoms occur • Take exactly as directed (don’t modify dose) • DO NOT mix with alcohol! • Drowsiness occurs … careful in hazardous situations, driving, machinery, etc • Physical dependence is rare, except Xanax ! • Benzo’s should NOT be used in pregnancy!

6. Misc Anxiolytics • Buspar (buspirone) • Vistaril/Atarax (hydroxyzine pamoate/hcl) • Paxil (paroxetine) • Effexor (venlafaxine) • Desyrel (trazodone) • See “Facts about Anxiolytics” on p.662

7. Major tranquilizers/ Neuroleptics • Drugs used to treat Psychosis(see Table 31-2) are also known as “Antipsychotics” • Antipsychotics are effective in 3 main areas: 1)hallucinations,delusions,combativeness (psychosis) 2)relief of nausea/vomiting (chemo, narcotic s/e) 3)to increase potency of analgesics (ex: promethazine) • The two major forms of Psychosis are … • Schizophrenia and Depression

8. Anti-Mania & Bi-polar drugs • Bi-polar Disorder (formerly referred to as Manic-Depression) • common meds used in the bi-polar patient: • Lithium (Lithobid, Eskalith) – mainstay • carbamazepine (Tegretol) – developed as an anti-seizure drug • valproic acid (Depakote, Depakene) –also originally for seizure disorders

9. Depression • !(study Box 31-3 on p. 668) • aka ‘mood-disorders’ or ‘affective-disorders’ • Among the most common psychiatric disorders, and is of (2) major types … • Exogenous – “the blues”, a response to ‘external’ factors, normally self-limiting • Endogenous (unipolar) – no apparent ‘external’ cause, basis is typically genetic or biochemical …

10. Exogenous/Endogenous Depression (cont) • Exogenous Depression: • Caused by external factors such as - divorce, loss of loved one, job loss, serious illness, etc • Drug therapy often successful w/ Exogenous • Endogenous: seems to come from ‘within’ the person, biochemical imbalance, hereditary • Endogenous type DOES NOT respond well to medication therapy

11. Anti-depressant Drugs(study Box 31-4 on p.669) • All major classes have a similar response rate … • So the choice-of-drug is based on things like: *side-effects *patient-history *if sedation is needed • MAOI’s(monoamine oxidase inhibitors) • TCA’s(tricyclic antidepressants) • SSRI’s (selective serotonin reuptake inhibitors) • SNRI’s (selective norepinephrine reuptake inhib) • NRI’s(natural reuptake inhibitors) –herbal, St.John’s wort for example

12. MAOI – patient ed • Very high number of potentially dangerous DRUG and FOOD interactions! • Avoid TYRAMINE containing foods, such as *cheese *wine *beans *chocolate (31-4, p.672) • See DDI (Dangerous-Drug-Interactions) (31-5,p.672) • MAOI must be ‘cleared’ from body before starting any new antidepressant (taper)

13. ‘Atypical’ Antidepressants (2nd generation) • Introduced in the 1980’s • These will treat --- major depressions, reactive depressions, and anxiety disorders • Wellbutrin (bupropion) • Remeron (mirtazapine) • Desyrel (trazodone)

14. Alzheimer’s disease ~ 250,ooo new cases per year! • Progressive (worsening) illness • Degradation of nerve pathways (cholinergic) • Impaired thinking, confusion, disorientation, ‘sundowning’ = symptoms worse in evening • No specific ‘test’ for this , can only be diagnosed with certainty by autopsy • Drugs are used to slow the deterioration and/or improve patient’s nerve function

15. Drug therapy for Alzheimer’s • See Table 31-6 on p.675 • Cognex, Aricept: increases nerve-function only • Reminyl: slows disease progression AND improves nerve function (increased Ach) • Namenda: newest agent – ‘anti-Alzheimer’ agent, reduces deterioration of cholinergic nerve pathways in moderate-severe cases

16. ADHD • Common behavioral disorder (average of one ADHD child per classroom) – cause unknown! • Diagnosis usually based on symptoms that occur before age 7, and last > 6 months • Symptoms (begin from 3 – 7 yo, thru teenage) • Inattention • Hyperactivity • Impulsivity

17. Drugs for ADHD(study Table 31-7 on p.677) • CentralNervousSystem (CNS) Stimulants • Not to be given >1 year without a ‘break’ from the drug! …may suppress child’s growth • Break is known as ‘Drug-Holiday’ • Suggested Drug-Holiday opportunities … • Weekends, summer-breaks, vacations, etc

18. ADHD drug names • Methylphenidate (Ritalin) – CII (schedule-2) • Dextroamphetamine (Dexedrine) -CII • Amphetamine (Adderall) -CII • Lisdexamfetamine (Vyvanse) -CII • Atomoxetine (Strattera) only one that’s not a ‘scheduled’ drug, also used as antidepressant

19. ADHD drug side-effects • CII’s (methylphenidate, etc) – insomnia, growth suppression, headache, abdominal pain, lethargy, weight loss, dry mouth, irritability • Strattera (lisdexamfetamine) – headache, dyspepsia, nausea/vomiting, fatigue, decreased appetite, dizziness, altered mood • Clonidine (HTN agent) – hypotension, sedation

20. Dosing calculations review (chapter-9) • LET’S REVIEW !!! • ANY QUESTIONS are fine …

21. Calculating Doses (oral, nonparenteral) • 3 calculation methods --- Ratio-and-Proportion method --- Formula-Method --- Dimensional-analysis • Choose the ONE method that you’re most comfortable with … and stick with it !

22. Why just ONE method ? • …you will become very familiar with your ‘chosen’ method • … this will reduce the chance of medication errors that may occur from switching between calculation methods !

23. Basic Rules for confident calculating (see Box 9-1 on p.166 … dosage-forms) • Always check UNIT’s (numerator/denominator) • Always work the problem ON PAPER, even the math seems EASY • Check and RE-CHECK all Decimals, Fractions • LOOK at the RESULT! …does it look reasonable? • Take ONE LAST LOOK to make sure you calculated dose in the correct units

24. Box 9-1(p.166) Dosage-forms • What type of dosage-forms can be divided ? • Scored tablets • Oral – syrups, liquids • Time-release (sustained, delayed)

25. “labeling” the math • “DA” = dose-available, what is ‘on-hand’ • “DO” = dose-ordered, what you ‘want’ • “DF” = dosage-form, of the ‘on-hand’ • “DG” = dose-given, this is the unknown-amount of the on-hand drug that we are calculating

26. Ratio-and-Proportion • Units must match … numerator/denominator • Ratio examples: 60-minutes/1-hour • Proportion examples: 60min/1hr = 120min/2hr • Let’s try one!: how many minutes in 2.5 hours ? a) we are looking for x minutes/2.5 hours b) we know that60min/hr(60min = 1hr, written as fraction) ( … see next slide … )

27. ratio-and-proportion • Let’s try one!: how many minutes in 2.5 hours ? 1st: we are looking for x minutes/2.5 hours 2nd:we know that60min/hr…(60min = 1hr, written as fraction) so set-up the problem as xmin/2.5hr = 60min/hr 3rd: now we cross-multiplyx-min x 1-hr = 2.5hr x 60min 4th: ‘hr’s cancel, leaving: x = (2.5)(60min) = 180 minutes … our final answer, which makes sense! 2-1/2 hours is 60min + 60min + 30min = 180 minutes.

28. Formula - method • “DA” = dose-available, what is ‘on-hand’ • “DO” = dose-ordered, what you ‘want’ • “DF” = dosage-form, of the ‘on-hand’ • “DG” = dose-given, this is the unknown-amount of the on-hand drug that we are calculating • Always check that the strengths of the drug-ordered (DO) and the drug-available (DA) are in the same-unit-of-measure!

29. Formula-method cont. • Look at page-171 • Example #3, then Example #4 • Ask yourself … (also, page-171) --what the Dr. ordered (DO)? --what strength is available (DA)? --what is the unit of measure (DF)? --how much do we need to give (DG)? • REMEMBER … 1-grain = 60-mg (gr i = 60 mg)

30. Dimensional - analysis • Look at page-173 of Textbook • Once learned, this is a very good system • Try a few examples in your Textbook • May be the ‘one for you’ !