mental health drugs

SSRI

SSRI (selective serotonin reuptake inhibitor)

• increase concentration of serotonin in brain by blocking the reuptake of serotonin

• helps regulate mood, memory, pleasure, sleeping, eating and cell communication

SILLY COWS EAT FLUFFY PIGS

• EXAMPLES

  • Sertraline

  • Citalopram

  • Escitalopram

  • Fluoxetine

  • Paroxetine

SNRI

• serotonin-norepinephrine reuptake inhibitor

• stronger side effects and can be more toxic to overdose

• can affect QTC

• Norepinephrine- adrenaline - slows down

• EXAMPLES

  • Venlafaxine

  • duloxetine

Tricyclics

• Amitriptyline

• Trazadone

other antidepressants

Monoamine Oxidase Inhibitors (MAOIs) - Rarely ever prescribed

Noradrenaline and specific serotonergic antidepressants (NASSAs) - Mirtazapine

side effects of antidepressants

• feeling agitated, shaky or anxious

• feeling and being sick

• Indigestion and stomach ache

• Diarrhoea and constipation

• loss of appetite

• Dizziness

• not sleeping well or feeling very sleepy

• Headaches

• Loss of libido

• difficulties achieving orgasm during sex or masturbation

• difficulties obtaining or maintaining an erection(erectile dysfunction)

first line for less severe depression

1. Guided self-help

2. Group cognitive behavioural therapy

3. Group behavioural activation

4. Individual cognitive behavioural therapy

5. Individual behavioural activation

6. Group exercise

7. Group mindfulness and meditation

8. Interpersonal psychotherapy

9. SSRI antidepressants

10. Counselling

first line for more severe depression

1. Individual CBT and antidepressant

2. individual CBT

3. individual behavioural activation

4. antidepressant medication

5. individual problem solving

6. counselling

7. short term psychodynamic psychotherapy

8. interpersonal psychotherapy

9. Guided self help

10. group excersise

what history is important - with antidepressants?

• Many depressive symptoms may be due to physical health

  • low libido/erectile dysfunction

  • thyroid problems

  • high cholesterol

  • hormone issues

  • Vitamin D deficiency

antipsychotics

• Regulates dopamine - decreases

• First generation antipsychotics - stronger side effects - movement disorders

• Second generation antipsychotics - 'newer’

• too little dopamine can cause parkinsons

• postsynaptic,

• prevents signal from moving

extra pyramidal side effects - FSA

• Dystonia (muscle spasm)

• Parkinsonian tremor

• Akathisia (restlessness)

• Tardive Dyskinesia

• Slurred speech

• Management:

  • Dose reduction

  • Procyclidine

  • Switch to SGA

SGA side effects

• Sexual side effects

• Drowsiness

• Weight gain

• Restlessness

Dopamine agonist

activates dopamine receptors

Dopamine antagonist

Block dopamine receptors

depot vs rapid tranquilisation

• IM - Z track technique

• much bigger dose

• designed to last weeks

• Oil solution means it breaks down slowly whereas a RT act quickly

mood stabilisers

• Lithium

• Sodium valproate

• Carbamazepine

  used for:

  • Bipolar disorder

  •  personality disorder and severe self-harm

  • Used to treat epilepsy

benzodiazepines

• Diazepam (Valium), Lorazepam, Temazepam (CD), Clonazapam

• Should only be used short-term and reserved for severe / disabling anxiety

• conjunction with an SSRI.

• addictive

• build tolerance very quickly

• a street value

• Used recreationally

• Cause CNS depression

• Treat with naloxone

physical health monitoring - antidepressants

• ECG are beneficial as many antidepressants cause prolonged QTC, which can result in - fainting, ventricular fibrilation and death

• escalation!!

  • men over 340

  • women over 450

• can also cause hyponatremia - low sodium, which results in:

  • Nausea and vomiting

  • headache

  • confusion

  • loss of energy, drowsiness and fatigue

  • restlessness and irritability

  • muscle weakness, spasm or cramps

  • seizures

  • coma

physical health checks/problems - antipsychotics

• prolonged QTC

• weight gain

• diabetes

• liver function

• sexual side effects

• prolactin - men produce breast milk

shared care

• Prescriber to carry out baseline observations - bloods, bp, weight, waist circumference, lifestyle screen, ECG

• Repeat at 6 weeks, 3 months

• Primary care to review at 12 months, then annually

psychotropic in elderly - risk/considerations

• Need to be mindful of kidney function

• More sensitive to side effects

• Start low and go slow

• Falls risk - medication can be sedating

• Physical health co-morbidity - balancing Parkinson and psychosis

• Drugs for other treatment can cause more problems

dementia

• acetylcholinesterase (AChE) inhibitors:

  • Donepezil

  • Rivatigmine

  • Galantamine

  • Memantine - for severe dementia

    Can slow down the progression of disease, slowing down the breakdown of acetylcholine, a substance which helps nerve communication

 

vascular dementia

• Different process so ACE inhibitors not useful

• Treatment of underlying conditions are sensible

• Includes:

  • Diabetes

  • Stroke

  • High blood pressure

  • High cholesterol

  • Heart problems

  • Lifestyle changes - smoking/alcohol consumption

BPSD

Behavioral and psychological symptoms of dementia

• Increased agitation

• Anxiety

• Wandering

• Aggression

• Delusions

• Hallucinations

• Support/copying strategies should be given

antipsychotic prescribing in elderly

• associated with an increase risk of stroke

• reassessed every 6 weeks

• initated with a consultant psychiatrist

serotonin syndrome

• Too much serotonin in brain

• Drugs such as SSRI,  SNRI (Venlafaxine), lithium

• Recreational substances

• St johns wort

• Symptoms

  • Agitation or restlessness

  • Insomnia

  • Confusion

  • Rapid heart rate/high blood pressure

  • Dilated pupils

  • Loss of muscle coordination or twitching muscles

  • Muscle rigidity

  • Heavy sweating

  • Diarrhoea

  • Headache

  • Shivering

  • Goose bumps

  • High fever

  • Tremor

  • Seizures

  • Irregular heartbeat

  • Unconsciousness

causes of sexual dsyfunction

• Urological infections or cancer

• Diabetes

• Cardiovascular disease (heart disease and blood vessel disease)

• High blood pressure

• High cholesterol

• Hormonal imbalances

• Alcoholism

• Drug abuse

• Neurological disorders

• Chronic diseases, such as kidney failure

• Nerve damage

• psychological causes

  • guilt

  • depression

  • stress

  • anxiety

  • self-esteem

  • body image

  • past trauma

serotonergic agents

• drugs that increase serotonin

  • Opiates/opioids

  • Some cough medicines - dextromethorphan

  • Migraine medications - any triptans

  • HIV/AIDS medication - Ritonavir

  • Antibiotics

  • Anti-nausea medication

overdose

• High quantities excerbate cardiotoxic effect

• Signs:

  • Confusion

  • Drowsiness

  • Altered consciousness

  • Tremors

  • Disorientated

  • Agitation / aggression

• Treatment NAC (N-acetylcysteine) - 3 bags over 21 hours

PSSD

Post SSRI sexual dysfunction - sexual side effects persist even when medication stops

BNF warning

Should be disclosed

how do SSRI’S work?

• A neuron releases serotonin into the synapse
  (The synapse is the gap between two neurons.)

• Serotonin travels across the synapse and binds to receptors on the next neuron
  (This helps pass along the signal.)

• After the signal is delivered, serotonin is reabsorbed (reuptaken) by the original neuron
  (This process is called reuptake.)