anxiety, depression, and bipolar

excitatory

sodium

inhibitory

potassium enters/ chloride exits

glutamate

excitatory neurotransmission, modulation of synaptic plasticity, activation of second messenger system

GABA

inhibitory neurotransmission

acetylcholine

muscle contraction, autonomic functions, parasympathetic functions, neuromodulation

norepinephrine

sympathetic function, neuromodulation

dopamine

neuromodulation

serotonin

neuromodulation

histamine

excitatory neuromodulation

glycine

inhibitory neurotransmission

peptides

neuromodulation

depression pathology

• some evidence suggests an imbalance of norepinephrine, serotonin, and/or dopamine

• other evidence suggest decreased neurogenesis

depression symptoms

mood changes, sleep changes, less hungry, less energy, back pain, headaches

tricyclics

• triptyline, pramine

• used for depression

• ADRS

  • muscarinic- constipation, tachycardia

  • histamine- sedation

  • alpha 1 adrenoceptors- hypotension

  • cardiac K+ channels- arrythmia, lengthened QT interval

    • 2-4 week onset

selective serotonin reuptake inhibitors (SSRI)

• pram

• used for depression

• ADRS

  • minor nausea, anorexia, weight loss, serotonin syndrome if mixed with other antidepressants, withdrawal, anxiety, long half-life, sexual dysfunction

    • 1-4 week onset

serotonin and norepinephrine reuptake inhibitors (SNRI)

• faxine

• used for depression

• ADRS

  • GI problems, male sexual dysfunction, agitation or increased mania

bupropion (wellbutrin)

• used for depression

• ADRS

  • insomnia, tremors, induce psychotic symptoms

trazodone (desyrel)

• used for depression

• ADRS

  • orthostatic hypotension, serious problems related to priapism may occur in men (erectile dysfunction)

mirtazapine (remeron)

• used for depression

• ADRS

  • agitation, anxiety, mood changes

nefrazodone (serzone)

• used for depression

• ADRS

  • antagonist effects at alpha-1 receptors causing hypotension

monoamine oxidase inhibitors (MAOI)

• used for depression but may have anticholinergic effects

• ADRS

  • orthostatic hypotension, consuming foods with tyramine could lead to hypertension- sympathetic is overactive

PT for depression

blood pressure, increased ADR, pulse check for arrythmia, sedation, antidepression meds may be used to treat chronic pain

bipolar pathology

lower concentration of AcH, diminished effects of serotonin, electrolyte imbalance

litium

• used for bipolar

• general ADRS

  • narrow therapeutic index

    • small margin for ineffective vs toxic doses

lithium mild toxicity ADRS

• CNS

  • fine hand tremor, fatigue, weakness, dizziness, blurred vision, slurred speech

• GI

  • nausea, loss of appetite, dry mouth, abdominal pain

• cardiovascular

  • ECG changes, T wave flattening U waves

• renal

  • polyuria, polydipsia

lithium moderate to severe ADRS

• CNS

  • ataxia, fasciculations, nystagmus, confusion, stupor, seizures, coma

• GI

  • vomiting, diarrhea

• cardiovascular

  • syncope, bradycardia, A-V block, other arrythmias

• renal

  • renal insufficiency, decrease GFR

anxiety pathology

brainstem areas mediate the physiologic manifestations of anxiety

• mot drugs target the input to the brainstem that causes anxiety

• norepinephrine and serotonin levels may lead to anxiety

anxiety symptoms

restlessness, muscle aching, tension, fatigue, palpitations, chest pain, tremors, dizziness, poor concentration, panic, sweating, hyperventilation, increased heart rate

GABAa

inhibits neuron by allowing chloride into cell

• hyperpolarize post-synaptic

GABAb

inhibits by increasing potassium release and decrease calcium entry

• hyperpolarize post-synaptic

GABAc

inhibits neuron by allowing chloride into cell

• hyperpolarize post-synaptic

benzodiazepines

• lam/pam/clone

• used for anxiety

• ADRS

  • high doses result in dependence and withdrawals, sedation, can cause sleep walking

barbiturates

• barbital

• used for anxiety

• ADRS

  • confusion, ataxia, psychomotor functions, lipid soluble- increasing concentration, joint and muscle pain

buspirone (class azapriones)

• plus

  • does not produce sedation or dependence like the others

• minus

  • not universally effects, 3 week onset

• ADRS

  • headaches, dizziness, lightheadedness

antidepressants to treat anxiety

duloxetine, escitalopram, paroexetine, sertraline, vanalfaxine

other meds to treat anxiety

beta-blockers, antipsychotics, anticonvulsants, gabapentin, antihistamines

PT for anxiety

tolerance and dependence, balance, plan rehab for effective drug time, promote non-pharm interventions