Week 13 & 14 - Mental Health

insomnia

lack of adequate sleep.

• sleep-onset insomnia: difficulty falling asleep

• sleep-maintenance insomnia: difficulty staying asleep

• sleep-offset insomnia: waking up too early

• non-restorative sleep: adequate sleep but sleepy during day

• can be associated with forms of anxiety (depression, manic disorders, chronic pain)

narcolepsy

severe daytime sleepiness.

• client may also fall asleep at inappropriate times

• other symptoms: cataplexy, hypnagogic hallucinations, muscular paralysis, automatic behaviour

drug classes used to treat anxiety and sleep disorders

CNS depressants:

• Benzodiazepines

• Barbiturates

• Other agents:

Zopiclone => IDEALLY for short-term (7-14 days) treatment of insomnia in adults)

→ inhibition of GABAa activity leads to a calming, sedative, and hypnotic effect, promoting sleep

→ similar action to benzodiazepines but chemically distinct

Act on continuum in terms of effects:

• anxiolytic - reduce anxiety

• sedative - promote relaxatoin

• hypnotic - promote sleep

Benzodiazepines

• tolerance develops with repeated use

• dependency can develop as well

• decrease time to fall asleep for clients with insomnia, reduce sleep interruptions

• Interactions → Respiratory depression can occur when mixed with other CNS depressants

paradoxical drug reactions

a drug reaction that constitutes an outcome that is exactly opposite from the outcome that would be expected from the drug’s known actions.

Example: Benzodiazepines are characterized by increased talkativeness, excitement and excessive movement and occur in less than 1% of patients

Barbiturates

Cross-tolerance - tolerance to barbiturates can promote tolerance to opioids and other CNS depressants

Interactions:

• increase the activity of some liver enzymes which can alter metabolism of other drugs

SSRIs MOA

• Prevent reuptake of 5HT, primarily

• Therapeutic effects with increased sensitivity of post-synaptic receptors, usually 4-6 weeks after start of treatment

• Same efficacy as TCAs and MAO inhibitors

Serotonin syndrome

Serotonergic overactivity in patients with exposure to serotonergic drugs.

• Altered mental status - anxiety, delirium, agitation, seizure, coma, psychomotor

• Autonomic dysfunction - mydriasis, hyperthermia, diaphoresis, tachycardia, hypertension, labile blood pressure

• Neuromuscular excitability - hyperreflexia, myoclonus, rigidity, tremor

Risk factors:

• concurrent use of multiple serotonergic drugs or combination use with CYP450 inhibitors

• overdose

• switching serotonergic drugs without tapering

Monoamine Oxidase Inhibitors

Indication:

• depression, for clients that do not respond to TCAs or SSRIs

• equal efficacy to TCAs and SSRIs but smaller margin of safety

e.g., Selegiline

Monoamine Oxidase Inhibitors: Drug-Drug Interactions

Insulin and oral hypoglycemic → enhances hypglycemia

Antihypertensive agents → profound hypertension

When used with SRRIs → Serotonin syndrome

Food containing tyramine:

• MAO inhibitors prevent breakdown of dietary tyramine

• Tyramine promotes release of NE which causes acute hypertension, palpitations, occipital headache, flushing, sweating, nausea

Atypical Antidepressants have used beyond depression

• Duloxetine is also indicated for fibromyalgia and other nerve pain disorders (e.g., diabetic peripheral neuropathy)

• Bupropion is used in smoking cessation

• Atomoxetine and methylphenidate are commonly used inADHD

• Trazodone is more often used as a sedative/sleep aid

mania is associated with

too much NE and glutamate or too little inhibitory NTs such as GABA

Lithium Carbonate

• Action: uncertain, crosses cell membranes, altering sodium transport, not protein bond

• side effects: thirst, metallic taste, increased frequency of urination, find head-and-hand tremor, drowsiness, diarrhea

• Blood levels monitored (lithium toxicity -severe diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination, withhold)

• Monitor creatinine concentrations, thyroid hormones, and CBC every 6 months

• Kidney damage may be a risk

• Thyroid function may be altered usually after 6 to 18 months. Observe for dry skin, constipation, bradycardia, hair loss, and cold intolerance

• Avoid during pregnancy

Symptoms of Schizophrenia

Positive symptoms — behaviours in addition to normal behaviours

• hallucinations, delusions

• disorganized thought, speech pattern

• movement disorders

Negative symptoms — behaviours that take away from normal behaviours

• lack of interest in social activities

• lack of emotion, responsiveness

• lack of pleasure in daily activities

• reduced or repetitive speech

• lack of desire to care for personal hygiene

Cognitive symptoms — often not noticed as part of condition until positive or negative behaviours emerge

• significant learning and memory problems

• decreased ability to concentrate

Neuroleptic

term given to CNS drug that can cause Parkinson-like symptoms

acute dystonia

Dystonic movement result from a slow sustained muscular spasm that lead to an involuntary movement

• can involve neck, jaw, tongue & entire body (opisthotonus)

• There is also involvement of eyes leading to upward lateral movement of known occulogyric crisis

akathisia

A subjective feeling of muscular discomfort that can cause patients to be agitated, restless, and feel generally dysphoric

Treated with propanolol, benzodiazepines, and clonidine.

Tardive Dyskinesia

It is a delayed one with abnormal, irregular movements of the muscle of the head, limb & trunk

Characterized by chewing, sucking, grimacing and perioral movements

Neuroleptic Malignant Syndrome (NMS)

• Rare but serious

• Onset is often in 1st 10 days of treatment

• rapid onset of sever motor, mental & autonomic disorders

• prominent muscular symptom is muscular tonicity

• stiffness of the muscles in throat & chest may cause dysphasia & dyspnea

Cannabinoids

Most frequently used class of addictive substances, derived from Cannabis sativa

THC is responsible for most of the psychoactive properties in cannabinoids

Psychological dependence.

Addiction — decreased coordination, disconnected thoughts, paranoia, euphoria, bloodshot eyes

Hallucinogens

• Produced an altered, dream-like state of consciousness; all are Schedule 1 drugs, no medial use

• Prototype substance is LSD

Addiction — laughter, visions, deep personal insights, religious revelations, afterimages, bright lights, vivid colours

Example — LSD, Mescaline, MMDA, PCP, Ketamine, Psilocybin

Addictive, Psychological Dependence, Tolerance — Yes.

CNS Stimulants

Example: Cocaine

• Increase the activity of the CNS some available by prescription (e.g., Adderall / Ritalin)

Physical dependence, Psychological dependence, Tolerance.

Addiction — increased blood pressure and respiratory rate euphoria, alertness confidence, restless, anxiety

Examples — cocaine, caffeine, amphetamines, methylphenidate

Nicotine

• Strongly addictive, highly carcinogenic

• Can cause effects to those nearby as well

• some effects similar to CNS stimulants

Physical dependence, Psychological dependence, Tolerance.

Addiction — increased alertness an focus, relaxation, lightheadedness, increased HR and blood pressure

Inhalants

• Vaporize or form a gas at room temperature

• Usually placed in paper/plastic bag or soaked in cloth and inhaled

• Some can be easily found

Tolerance - Unknown

Addiction - lightheadedness, drowsiness, exhilaration, euphoria, hallucinations

Examples - adhesives and glues, aerosol, cleaning agents, solvents, fuels, nitrous oxide

Anabolic Steroids

• Unlike other substances; effects may be delayed for weeks, months

• Provide a boost in athletic performance, similar to testosterone

• Long-term effects can cause the opposite

Addiction - substance adds to skeletal muscle mass and increased strength at first