M9: Psychopharmacology Lecture

Antidepressants 

Can be used to treat depression as well as anxiety disorders, pain, and insomnia.

Eg. Prozac, Zoloft, Lexapro, Luvox, and Paxil

Antipsychotics

A class of drugs used to treat disorders such as schizophrenia and bipolar disorder to help prevent or lessen the severity of mania, delusions, and hallucinations.

Eg. Thorazine, Trilafon, Serentil, and others.

Stimulants

Primarily used for the treatment of ADHD and the most commonly prescribed stimulants are Ritalin, Adderall, and Dexedrine.

Mood Stabilizers

Used to help patients diagnosed with bipolar disorder, borderline personality disorder, and schizophrenia. Can also be used to treat seizure disorders. 

Eg. Lithium and Lamictal.

Tricyclics and Monoamine Oxidase Inhibitors (MAOIs)

• older generation antidepressants

• associated with more side effects

• they may be the best option for some people

Tricyclics

• Inhibit the reuptake of neurotransmitters (serotonin and norepinephrine)

• Modulate mood, attention, and pain in individuals

• Orthostatic hypotension is a frequent side effect

Monoamine Oxidase Inhibitors (MAOIs)

• Prevent the breakdown of serotonin and neurotransmitters

• Treat different forms of depression as well as other nervous system disorders such as panic disorder, social phobia, and depression with atypical features.

• Dry mouth

• Nausea

• Diarrhea or constipation

• Headache

• Drowsiness

• Insomnia

• Dizziness or lightheadedness

• Skin reaction at the patch site

MAOIs: Most COMMON side effects

• Involuntary muscle jerks

• Low blood pressure

• Reduced sexual desire or difficulty reaching orgasm

• Weight gain

• Difficulty starting a urine flow

• Muscle cramps

• Prickling or tingling sensation in the skin (paresthesia)

MAOIs: Other POSSIBLE side effects

Food and beverage interactions.

• Avoid foods containing high levels of tyramine — an amino acid that regulates blood pressure

• Aged cheeses, chocolate, sauerkraut, banana, cured meats, draft beer, wine, fermented soy products (soy sauce, miso and tofu)

• The interaction of tyramine with MAOIs can cause dangerously high blood pressure.

MAOIs: Safety Concerns

Drug-drug / drug-supplement interactions

Combining antidepressants with other medications or supplements that act on the serotonin system can cause a rare but life-threatening illness called serotonin syndrome.

What are the symptoms associated with Serotonin Syndrome?

• anxiety, agitation / restlessness

• muscle twitches / tremors

• lack of coordination

• hallucinations, confusion, restlessness

• fever / sweating

• unusual blood pressure changes and tachycardia.

• For most people, the risk of such extreme reactions is low.

How long do Antidepressants take time to work?

up to 4-8 weeks to work

• Problems with sleep, appetite, energy, and concentration often improve before mood lifts.

What are common side effects of SSRIs and other antidepressants?

• Upset stomach

• Headache

• Sexual dysfunction
  - Side effects are usually mild and go away with time.

How can people minimize the side effects of SSRIs and antidepressants?

• Start with a low dose

• Increase slowly

• Adjust timing (e.g., take at bedtime or with food)

Discontinuation Syndrome

• Has been associated with anxiety

• Agitation and insomnia (vivid dreams)

• Flu-like symptoms such as sweating, chills, nausea, headache and feeling generally unwell (malaise)

• Electric shock sensations

Examples of Selective Serotonin Reuptake Inhibitors (SSRIs)?

• Citalopram (Celexa)

• Escitalopram oxalate (Lexapro)

• Fluoxetine (Prozac)

• Sertraline (Zoloft)

Examples of Selective Serotonin & Norepinephrine Reuptake Inhibitors (SNRIs)?

Venlafaxine (Effexor)

Example of a novel serotonergic drug?

Vortioxetine (Trentellix -formerly called Brintellix)

Examples of older tricyclic antidepressants (TCAs)?

• Amitriptyline (Elavil)

• Imipramine (Tofranil)

• Nortriptyline (Pamelor)

• Doxepin (Sinequan)

Bupropion (Wellbutrin)

Drugs that are thought to affect mainly dopamine and norepinephrine

Examples of Monoamine Oxidase Inhibitors (MAOIs)?

• Isocarboxazid (Marplan)

• Phenelzine (Nardil)

Example of a Tetracyclic antidepressant / NaSSA (Noradrenergic and Specific Serotonergic Antidepressant)?

• Mirtazapine (Remeron)

L-methylfolate (Deplin)

• A medical food / nutraceutical (not a medication)

• Active form of folate (Vitamin B)

• Regulates neurotransmitters that control mood

• Used in treating depression

Does L-methylfolate (Deplin) require a prescription?

Yes - even though it’s not technically a medication, it requires a prescription.

Anxiety

Help reduce the symptoms of anxiety, such as panic attacks or extreme fear and worry.

Benzodiazepines

Most common anti-anxiety medications used to treat short-term anxiety symptoms (like in Generalized Anxiety Disorder). They enhance GABA activity in the brain, helping you feel calm, but can also cause drowsiness.

Common side effects of Benzodiazepines

• drowsiness • sedation • dizziness • loss of balance

Rare side effects of benzodiazepines

Agitation, hallucinations, and nightmares (extremely rare). Reducing the dose can help lessen side effects.

Cognitive and physical effects of benzodiazepines

Can make it harder to learn, remember new information, or perform certain physical and mental tasks these abilities return to normal once the drug wears off.

Hangover effects of benzodiazepines

When used for sleep, may cause morning or daytime drowsiness.

Are benzodiazepines addictive?

Low risk when used occasionally or for a few weeks. Risk increases with regular use for more than a few weeks or high doses. People with a history of substance abuse are at greater risk.

Individuals with a higher risk of benzodiazepine addiction

Individuals with a history of substance abuse should avoid or minimize use, as they are more likely to become addicted.

Signs of benzodiazepine addiction

• Strong cravings for the drug’s effects

• Taking more than intended

• Continuing use despite problems caused by the drug

Benzodiazepine drug interactions

May interact with over-the-counter medications, including herbal products, cold or allergy tablets, and cough syrups.

Risk of benzodiazepine overdose

When taken alone, the risk of overdose is low.

Interaction between benzodiazepines and alcohol

Benzodiazepines increase the sedative effects of alcohol, causing sleepiness, dizziness, or lightheadedness.

Dangers of mixing benzodiazepines with alcohol

• Increased risk of stumbling, falling, and injury

• Increased risk of overdose

• Both are respiratory depressants, which can slow or stop breathing

Effect of caffeine on benzodiazepines

Caffeine counteracts the anti-anxiety effects of benzodiazepines.

Dangerous drug combinations with benzodiazepines

Combining benzodiazepines with other sedatives (e.g., alcohol, codeine, or other opioids) can cause overdose and possible death.

Symptoms of benzodiazepine overdose

Slurred speech, confusion, severe drowsiness, weakness, staggering, slow heartbeat, breathing problems, and unconsciousness.

Addiction and physical dependence on benzodiazepines

Addiction may develop with or without physical dependence. Physical dependence is marked by tolerance and withdrawal symptoms.

Tolerance to benzodiazepines

• Sleep-inducing tolerance can develop within a few weeks of regular use (not with occasional use).

• Anxiety-relieving tolerance is less likely to develop.

• Tolerance to one benzodiazepine causes cross-tolerance to other benzodiazepines and similar drugs (including alcohol).

Benzodiazepine withdrawal

Severity depends on the type, dose, duration of use, and whether it was stopped abruptly.

Common withdrawal symptoms of benzodiazepines

Headache, insomnia, anxiety, tension, sweating, poor concentration, tremor, sensory disturbances, fatigue, stomach upset, and loss of appetite.

Severe withdrawal symptoms of benzodiazepines

Agitation, paranoia, delirium, and seizures — more likely after regular high-dose use.

Stimulants

Medications most often used to treat ADHD and sometimes narcolepsy. They help manage short attention span, impulsive behavior, and hyperactivity. May be used alone or with behavior therapy.

Effectiveness of stimulants in treating ADHD

Stimulants ease ADHD symptoms in about 70% of adults and 70–80% of children.

Benefits of stimulant medications for ADHD

Reduce hyperactivity, interrupting, and fidgeting; help improve attention span, task completion, and relationships while medication is active.

Methylphenidate – age and cardiac precautions

• Typically prescribed to patients over age 6

• Avoid in patients with structural cardiac abnormalities, cardiomyopathy, serious arrhythmias, or coronary artery disease

Methylphenidate – monitoring requirements

Monitor blood pressure and heart rate in all patients; observe for signs of abuse and dependence during therapy.

Methylphenidate – pediatric considerations

May cause weight loss and slowed growth rate in children; monitor growth and weight regularly.

Methylphenidate – risk of peripheral vasculopathy (Raynaud’s phenomenon)

Watch for numbness, pain, coolness, or color changes in fingers/toes (pale → blue → red).

Methylphenidate – administration instructions

Given orally once daily in the morning as an extended-release capsule; do not crush, chew, or divide the capsule.

What are antipsychotic medications used for?

Used to treat psychosis, a condition involving loss of contact with reality, delusions, and hallucinations. Psychosis may be linked to drug use or mental disorders like schizophrenia, bipolar disorder, or psychotic depression.

First-generation (typical) antipsychotics

Older medications (neuroleptics) used to treat psychosis. Long-term use may cause tardive dyskinesia, an involuntary muscle movement disorder ranging from mild to severe.

Tardive dyskinesia

A condition with uncontrollable muscle movements caused by long-term use of typical antipsychotics. Patients should consult a healthcare provider before stopping medication.

Second-generation (atypical) antipsychotics

Newer drugs that treat a broader range of symptoms than older ones. May also be used for bipolar depression or depression unresponsive to antidepressants.

Monitoring while taking atypical antipsychotics

Patients should have regular checks of weight, glucose levels, and lipid levels due to metabolic side effects.

Mechanism of action of antipsychotic medications

All antipsychotics block dopamine receptors in the brain. The exact mechanism is not fully understood but helps reduce psychotic symptoms.

Mechanism of conventional (typical) antipsychotics

Drugs like haloperidol block dopamine receptors in the limbic system and basal ganglia, areas controlling emotion, cognition, and movement, producing a tranquilizing effect in psychotic patients.

Adverse effects of dopamine blockade

Blocking dopamine can lead to movement-related side effects and other adverse reactions.

Indications for haloperidol

Used to treat schizophrenia and Tourette’s disorder.

Indications for risperidone

Used to treat schizophrenia, acute manic episodes, and irritability associated with autism.

Other uses of atypical antipsychotics

Some atypical antipsychotics are used as adjunct therapy for depression.

Haloperidol is contraindicated for…

Patients with Parkinson’s Disease or Lewy Body Dementia

Tardive Dyskinesia

Causes involuntary movements in the face, mouth, lips, trunk, and extremities.

Neuroleptic Malignant Syndrome

Causes tachycardia, raised BP, hyperthermia, diaphoresis rigidity, delirium, hyporeflexia.

Extrapyramidal Symptoms

Refers to the localization of the motor dysfunction in the spinal tracts. EPS are motor problems that include Parkinsonian-like symptoms (stiffness, tremor, shuffling gait), acute dystonia (abrupt spasms of head and neck), and akathesia (physical restlessness).

Metabolic side effects of antipsychotics

Some antipsychotics can cause weight gain, altered blood sugar regulation, and changes in blood lipids (cholesterol and triglycerides).

Agranulocytosis (antipsychotic side effect)

A serious condition with a sharp decrease in infection-fighting white blood cells (granulocytes), making patients prone to infection and at higher risk of death.

Antipsychotic most associated with agranulocytosis

Clozapine (Clozaril) — occurs in about 1 in 100 patients.

Monitoring for agranulocytosis

Patients taking Clozaril must have regular CBC tests to monitor white blood cell and differential counts.

Mood stabilizers

• Are typically used to treat bipolar disorder and mood changes associated with other mental disorders.

• Lithium, an effective mood stabilizer, is approved for the treatment of mania and bipolar disorder.

What is lithium used for?

A mood-stabilizing medication used to treat mania, hypomania, and bipolar disorder (mood swings between mania and depression). It can also be used for schizophrenia and certain types of depression.

Purpose of lithium in bipolar disorder

Helps stabilize mood and reduce episodes of mania and depression.

Mechanism of action of lithium

Exact mechanism is unknown; may work by altering the release of neurotransmitters such as dopamine and serotonin in the brain.

Onset of lithium’s therapeutic effect

Takes several weeks to months before full effects are seen.

Medications used at the start of lithium therapy

Other temporary medications may be prescribed initially to help the patient stay calm until lithium becomes effective.

Hospitalization during initiation of lithium therapy

Patients are often admitted to the hospital when starting lithium to ensure safe monitoring of dosage and side effects.

Lithium is contraindicated for…

Renal or cardiovascular disease, severe dehydration or sodium depletion, and to patients receiving diuretics due to an increase risk of lithium toxicity.

Lithium can cause fetal harm in pregnant women (CONGENITAL ANOMALIES AND HEART DEFECTS).

Nursing Consideration for Lithium

Lithium toxicity

Toxicity is closely related to serum lithium levels and can occur even at therapeutic doses around 1.5 mEq/L.

Cardiac risks of lithium

Lithium may cause abnormal ECG findings and increase the risk of sudden death.

Warning signs requiring emergency attention while on lithium

Fainting, lightheadedness, abnormal heartbeats, or shortness of breath — patients should seek immediate medical help if these occur.

Antidote for Lithium Poisoning

No specific antidote for lithium poisoning is known; treatment focuses on the elimination of the medication. Fine hand tremors, polyuria, and mild to excessive thirst may also persist throughout treatment. Patients should be advised that weight gain may likely occur.