CH15: Drugs for CNS Disorders (Psychotherapeutic agents)

Learning objectives

⚫ Name and describe the three categories of functional disorders discussed in this chapter.

⚫ Outline some basic precautions that the dental health care professional should keep in mind when treating patients with psychiatric disorders.

⚫ Summarize the basic mechanism of action, pharmacologic effects, adverse reactions, drug interactions, and uses of the antipsychotic agents.

⚫ Describe the mechanism of action, pharmacologic effects, adverse reactions, drug interactions, uses, and dental implications of the tricyclic antidepressants.

⚫ Describe the mechanism of action, pharmacologic effects, adverse reactions, drug interactions, uses, and dental implications of the selective serotonin reuptake inhibitors.

⚫ Name several other types of antidepressants.

⚫ List several drugs used to treat bipolar disorder.

Psychiatric disorders

Organic-Congenital or caused by injury or a disease

Functional- Psychogenic origin

⚫ Categories

• Psychoses

• Affective Disorder

• Neurose

Pscyhoses

Schizophrenia

⚫ Loss of perception of reality

⚫ Positive Symptoms (excitation)

• Hallucinations, delusions, unwanted thoughts, disorganized behavior, agitation, distorted speech

⚫ Negative Symptoms (low)

• Flat affect, unemotional, apathetic, abstract thinking, spontaneity, thought and speech impaired, lack of pleasure, social withdrawal

Affective disorders

Unipolar Depression

⚫ Endogenous- unrelated to external events

⚫ Exogenous- related to specific external events

Bi-Polar (Manic-Depressive Disorder)

⚫ Alternating periods of depression and excitation

Neuroses

⚫ Anxiety

⚫ Panic Disorder

⚫ Phobias

⚫ Obsessive-Compulsive Disorder

General precautions for health care professional

⚫ Communication - Difference in perception

⚫ Compliance - Are they taking their meds?

⚫ Suicide Potential - Children and teens at higher risk

Antipsychotic agents

conventional and atypical

Conventional antipsychotics

Haloperidol (Haldol)

Trifluoperazine (Stelazine)

Thiothixene (Navane)

Chlorpromazine (Thorazine)

Thioridazine (Mellaril)

Lower potency- more sedation, peripheral side effects, autonomic effects

Higher potency- more extrapyramidal effects and less sedation

Primarily dopamine antagonists

Atypical antipsychotics

Have action at more than one receptor-dopamine, serotonin, and norepinephrine

⚫ Aripiprazole (Abilify)

⚫ Clozapine (Clozaril)

⚫ Olanzapine (Zyprexa)

⚫ Quetiapine (Seroquel)

⚫ Risperidone (Risperdal)

⚫ Ziprasidone (Geodon)

Antipsychotics agents: pharmacologic effects

Antipsychotic Effect

⚫ Conventional-Effective against positive effects

⚫ Atypical-Effective against positive and negative effects

Antiemetic Effect

⚫ Depression of the chemoreceptor trigger zone

⚫ Prochlorperazine (Compazine)

Potentiation of Opioids

Antipsychotic agents: adverse reactions

Sedation- tolerance develops

Extrapyramidal Effects

⚫ Acute dystonia

⚫ Parkinsonism

⚫ Akathisia

⚫ Tardive dyskinesia

Orthostatic Hypotension

Tachycardia;

⚫ Ziprasidone (Geodon)- ECG changes

Seizures

⚫ Buproprion (Wellbutrin)

Anticholinergic Effects- blurred vision, xerostomia, constipation

Agranulocytosis -Clozapine (Clozaril)

Metabolic Effects- hyperglycemia

Other Effects- blood dyscrasias, cholestatic jaundice, skin eruptions, photosensitivity

Antipsychotic agents: drug interactions

⚫ CNS Depressants

⚫ Epinephrine

⚫ Anticholinergic Agents

Antipsychotic agents: uses

⚫ Antipsychotic Effects

⚫ Antiemetic Effects

⚫ Possible drug withdrawals; hiccups

Antipsychotic agents: dental implications

⚫ Sedation

⚫ Anticholinergic effects

⚫ Orthostatic hypotension

⚫ Epinephrine

⚫ Temporomandibular Joint Pain

⚫ Tardive Dyskinesia

Tricyclic antidepressants

⚫ Amitriptyline (Elavil)

⚫ Clomipramine (Anafranil)

⚫ Desipramine (Norpramin, Pertofrane)

⚫ Doxepin (Adapin, Sinequan)

⚫ Imipramine (Tofranil)

⚫ Nortriptyline (Pamelor, Aventyl)

⚫ Protriptyline (Vivactil)

Tricyclic antidepressants: pharmacologic effects

Tricyclic antidepressants: adverse reactions

⚫ CNS- sedation

⚫ ANS- anticholinergic effects

⚫ Cardiac Effects

⚫ Dependence or Withdrawal

Tricyclic antidepressants: drug interactions

Amphetamines, CNS stimulants, sympathomimetics, MAOIs, drugs inducing the hepatic microsomal enzymes

Poisoning - Overdose can be lethal!

Triycyclic antidepressants: uses

⚫ Depression

⚫ Sedation (amitriptyline); less sedation (nortriptyline)

⚫ Nocturnal enuresis- imipramine

⚫ OCD- clomipramine

⚫ Antianxiety- doxepin

Dental implications

⚫ Sympathomimetic Amines

• Local anesthetic solution

⚫ Xerostomia- additive effect

Trazodone (Desyrel)

Serotonin modulator

⚫ Fewer anticholinergic effects

⚫ Less cardiotoxic

⚫ Highly sedative

⚫ Painful priapism

Selective serotonin reuptake inhibitors

⚫ Fluoxetine (Prozac), Sertraline (Zoloft),

Paroxetine (Paxil), fluvoxamine (Luvox)

⚫ Adverse Reactions

• CNS- stimulation

• GI

• Oral

• Sexual dysfunction

• Excessive sweating

Buproprion (Wellbutrin)

⚫ Dopamine-NE reuptake inhibitor

⚫ Adverse Reactions

• Seizures

• GI

• Xerostomia

• HA

• Excessive Sweating

• Agitation

• Dizziness

Stay in brain longer and longer effect

regulate mood

Other agents

⚫ Serotonin Modulator

• Nafazodone (Serzone)- *Black-box warning*- life threatening hepatic failure

⚫ Serotonin- NE Reuptake Inhibitors

• Venlafaxine (Effexor)

⚫ NE-Serotonin Modulator

• Mirtazapine (Remeron)

Still work on serotonin or epinephrine

Monoamine oxidase inhibitors (MAOI)

⚫ Lots of drug interactions!!!

⚫ Interactions with food (cheeses, wine, fish)

⚫ Phenelzine (Nardil), tranylcypromine (Parnate)

last choice for treatment of depression

inhibit enzyme that breakdown epinephrine

can result in hypertensive crisis, cardiac issues

Bipolar depression drugs

Lithium (Eskalith, Lithobid)

⚫ Polyuria, fine hand tremor, thirst, slurred speech, ataxia, N/V, diarrhea

⚫ CNS symptoms- muscle rigidity, excessive tremor

⚫ Changes in sodium levels

⚫ NSAIDs- decreased lithium clearance

Anticonvulsants- valproate, carbamazepine, gabapentin

Atypical Antipsychotics