Pathopharmacology II = Mental health

Mental health is?

Able to recognize own potential

Cope with normal stress

Work productively; make contribution to community

Think rationally, communicate appropriately, learn, grow emotionally

Be resilient; maintain a healthy self-esteem

Mental illness is?

Disorders with definable diagnosis

Significant dysfunction in mental functioning related to:

◦     Developmental, biological, or physiological disturbances

Key Neurotransmitters Involved in disturbances of mental function?

Norepinephrine (NE)

Serotonin (5HT)

Dopamine

Glutamate

γ-Aminobutyric acid (GABA)

What is the mechanism of action for Benzodiazepines?

Act on the limbic system and the Reticular Activating System (RAS)

Enhance the effect of GABA (inhibitory neurotransmitter

Cause interference with neuronal firing

Benzodiazepines pharmacokinetics?

•     Well absorbed orally from GI tract

•     Peak level in 30 min to 2 hours

•     Lipid soluble — widely distributed; cross placenta, enter breast milk

•     Metabolized in liver; excreted in urine

Interactions of Benzodiazepines

Anxiety disorders, panic disorders, alcohol withdrawal

Restless leg syndrome, seizure disorders, insomnia

Preoperative sedation

Lorazepam (ativan)

Type of Benzodiazepines

Inhibits GABA neurotransmission by binding to specific benzodiazepine receptors

Uses=Anxiolytic, antiseizure, sedative-hypnotic, preoperative, substance abuse withdrawal

Side effects-Drowsiness, dizziness, ataxia, restlessness, weakness, headache, confusion, amnesia, blurred vision, GI distress, bradycardia, hypotension/hypertension, seizures, suicidal ideation, NMS, respiratory depression

Alprazolam (Xanax)

Onset/Half-life= Fairly fast onset; short half-life (12–15 hours)

Type of Benzodiazepines

Diazepam (Valium)

Onset/Half- Fast onset; longer half-life (20-50 hours)

Type of Benzodiazepines

Clonazepam (Klonopin)

Onset/Half-life= Slow onset; longer half-life (18–50 hours)

Watch spelling- close to clozapine (antipsychotic)

Type of Benzodiazepines

Benzodiazepines should be taken as?

PRN use only!- Soap box

-Due to high risk of abuse and dependency, benzodiazepines SHOULD only be used as needed (PRN). Other medications such as Buspar and various antidepressants are indicated for daily use.

Benzodiazepine adverse effects are?

Sedation, drowsiness, depression, lethargy, blurred vision

"Sleep driving" and other complex behaviors

Headaches, apathy, light-headedness, amnesia, confusion

Mild paradoxical excitatory reactions (first 2 weeks)

GI, CV, hematological, and genitourinary conditions

Withdrawal syndrome

Benzodiazepine Withdrawal

Gradually decrease dose over several days

Withdrawal develops slowly — 2 to 10 days; may last several weeks

Symptoms: Tremor, agitation, nervousness, sweating, insomnia, anorexia, muscle cramps

What are Nursing considerations with Benzodiazepines?

•     Assess for suicidal ideation

•     Obtain history of anxiety reactions; determine patient support system

•     Monitor vital signs; observe for side effects

•     Advise patient NOT to drive or operate dangerous equipment

•     Warn patient NOT to consume alcohol or other CNS depressants

Buspirone (Buspar)

Action- Binds to serotonin and dopamine receptors

Onset- May NOT be effective until 1–2 weeks after continuous use

Advantages= Fewer side effects; less sedation; less physical/psychological dependency than benzos

Side effects-Drowsiness, dizziness, headache, excitement, nausea, nervousness

Drug interactions- Grapefruit juice can lead to toxicity

Buspirone sould NOT be taken as?

NOT PRN

Buspirone is NOT for PRN use. It must be taken daily and requires 1–2 weeks to reach full effect. It is indicated for daily, scheduled dosing only.

Hydroxyzine (Atarax/Vistaril)

Actually, an antihistamine — safe and moderately effective

Use- Typically used acutely as needed; often given when patient has history of drug dependency/abuse

Can be sedating

What are Antihistamines (promethazine, diphenhydramine) given for?

preoperative / postoperative

What are Dexmedetomidine (Precedex) taken for?

sedation of ventilated ICU patients or before surgical procedures

What are Eszopiclone (Lunesta) and Suvorexant (Belsomra) taken for?

insomnia

What is Ramelteon (Rozerem) taken for?

insomnia with difficulty with sleep onset

What is Zaleplon (Sonata) / Zolpidem (Ambien) taken for?

short-term treatment of insomnia

Signs & Symptoms of Depression

Low energy level, sleep disturbances, altered appetite, altered libido

Reduced ability to perform ADLs

Overwhelming feelings of sadness, despair, hopelessness, disorganization

How Antidepressants Work?

•     Inhibit MAO → increased NE or 5HT in synaptic cleft

•     Block reuptake by releasing nerve → increased neurotransmitter levels

•     Regulate receptor sites and breakdown → accumulation of neurotransmitters

Antidepressants classifications are?

•     Tricyclic Antidepressants (TCAs)

•     Monoamine Oxidase Inhibitors (MAOIs)

•     Selective Serotonin Reuptake Inhibitors (SSRIs)

•     Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

•     Other antidepressants

Types of Tricyclic Antidepressants (TCAs)?

•     Amitriptyline (Elavil)

•     Nortriptyline (Pamelor)

•     Imipramine (Tofranil)

Note: May be used as part of a pain protocol, specifically for nerve pain

Contraindications & Cautions for Tricyclic Antidepressants (TCAs)?

Known allergy, recent MI, concurrent use of MAOI, pregnancy/lactation

Caution with preexisting CV disorders, manic-depressive patients, seizure history

Caution with hepatic or renal disease

Boxed warning: risk of suicidality

TCAs are CONTRAINDICATED in patients?

with cardiac issues — they are CARDIOTOXIC and can cause arrhythmias. Overdose can be FATAL. TCAs take 10–14 days to begin working.

Adverse Effects of Tricyclic Antidepressants (TCAs)?

CNS and peripheral nervous system effects

GI anticholinergic effects

Genitourinary effects

CV effects — cardiotoxic in overdose

Withdrawal syndrome

Drug-drug interactions: cimetidine, fluoxetine, ranitidine, oral anticoagulants

Types of Monoamine Oxidase Inhibitors (MAOIs)?

Isocarboxazid (Marplan)

Phenelzine (Nardil)

Selegiline (Emsam) — also used in Parkinson's Disease treatment

Tranylcypromine (Parnate)

Contraindications & Cautions for Monoamine Oxidase Inhibitors (MAOIs)?

Known allergy, pheochromocytoma, CV disease, history of headaches

Caution with bipolar disorder, elective surgery, pregnancy/breastfeeding

  Boxed warning: possible risk of suicidality

Drug & Food Interactions with MAOI

CNS stimulants (vasoconstrictors, cold meds with phenylephrine/pseudoephedrine) → hypertensive crisis

Tyramine-containing foods → hypertensive crisis

◦     Cheeses, cream, yogurt, coffee, chocolate, bananas, raisins, Italian green beans, liver

◦     Pickled foods, sausage, soy sauce, yeast, beer, red wines

Which medications are not approved by the FDA for depression?

MAOIs are NOT FDA approved for depression. They have more serious/potentially fatal adverse effects than other antidepressants.

Mechanism and indicators for Selective Serotonin reuptake inhibitors (SSRIs)?

•     Block reuptake of serotonin (5HT), increasing levels in the synaptic cleft

•     Indicated for: depression, OCDs, panic attacks, bulimia, PMDD, PTSD, social phobias, social anxiety

•     Period of up to 4 weeks necessary for full effect

•     Patients may respond to one SSRI but not another

•     Currently FIRST-LINE therapy for depression and anxiety disorders

Pharmacokinetics of SSRIs?

•     Well absorbed from GI tract

•     Metabolized in liver; excreted in urine and feces

Adverse effects of SSRIs?

•     CNS, GI, GU effects related to increased serotonin

•     Respiratory changes

•     SEROTONIN SYNDROME (life-threatening)

What are Drug-Drug Interactions for SSRIs?

•     MAOIs — dangerous combination

•     TCAs

•     Other drugs that raise serotonin levels

•     Aspirin, NSAIDs, antiplatelet drugs, anticoagulants

Bupropion (Wellbutrin / Zyban)

Uses- Depression, smoking cessation, weight loss

Advantages- Known for NOT causing sexual dysfunction

Which medication is least likely to cause sexual dysfunction?

Bupropion (Wellbutrin)

Mirtazapine (Remeron)

Known to cause significant weight gain (30–40 lbs); sedating

Trazodone (generic)

Use- Moderate antidepressant efficacy; often used as sleep aid

No potential for abuse; helpful in patients with addiction history