Nervous System Treatments

Benzodiazepines (anti-anxiety agents)

Indications: anxiety and panic disorders

Benzodiazepine mechanism of action

Binds to receptor sites on Y-amino butyric acid (GABA)

Benzodiazepine adverse reactions

Sedation, confusion, ataxia, and reduced motor skills

Benzodiazepine drug interactions

CNS depressants, anticoagulants, and corticosteroids

Benzodiazepine contraindications/cautions

Pulmonary impairment, sleep apnea, CNS depression, and seizure history

Benzodiazepine notes

May cause drowsiness.

May impair ability to drive.

May be habit forming.

Avoid alcohol.

Should be tapered on discontinuation.

Examples of anti-anxiety agents

1. alprazolam

2. buspirone

3. clorazepate

4. diazepam

5. lorazepam

6. meprobamate

Generic: alprazolam

Brand: Xanax

Dosage form: tablet

Dosage: 0.25-0.5 mg PO tid

Controlled substance: yes

Generic: buspirone

Brand: N/A

Dosage form: tablet

Dosage: 20-30 mg PO qd

Controlled substance: no

Generic: clorazepate

Brand: N/A

Dosage form: tablet

Dosage: 15-60 mg PO qd in divided doses

Controlled substance: yes

Generic: diazepam

Brand: Valium

Dosage form: tablet

Dosage: 2-10 mg PO bid-qid

Controlled substance: yes

Generic: lorazepam

Brand: Ativan

Dosage forms: tablet, IM solution, IV solution

Dosage: 2-3 mg PO qd in divided doses

Controlled substance: yes

Generic: meprobamate

Brand: N/A

Dosage form: tablet

Dosage: 400 mg PO tid-qid

Controlled substance: yes

Selective serotonin reuptake inhibitors (SSRIs)

Indications: Major depression, obsessive-compulsive behavior, and anxiety

SSRI mechanism of action

Blocks the reuptake of serotonin

SSRI adverse reactions

Nervousness, insomnia, nausea, diarrhea, weight loss, decreased libido, and ejaculatory disturbances

SSRI drug interactions

Anticholinergics, MAOIs, and digitalis

SSRI contraindications/cautions

Pregnancy, elderly patients, and hepatic impairment

SSRI notes

May cause dizziness.

May impair ability to drive.

Avoid alcohol.

Do not discontinue without medical supervision.

Onset of action is 10 to 21 days.

Examples of SSRIs

1. citalopram

2. escitalopram

3. fluoxetine

4. paroxetine

5. vortioxetine

6. sertraline

7. vilazodone

Generic: citalopram

Brand: Celexa

Dosage form: tablet

Dosage: 20-40 mg PO q AM

Generic: escitalopram

Brand: Lexapro

Dosage forms: tablet, solution

Dosage: 10 mg PO q AM

Generic: fluoxetine

Brand: Prozac

Dosage form: capsule

Dosage: 20-80 mg PO q AM

Generic: paroxetine

Brand: Paxil

Dosage forms: tablet, suspension

Dosage: 20-50 mg PO q AM

Generic: vortioxetine

Brand: Trintellix

Dosage form: tablet

Dosage: 25 mg PO qd

Generic: sertraline

Brand: Zoloft

Dosage forms: tablet, solution

Dosage: 50 mg PO q AM

Generic: vilazodone

Brand: Viibryd

Dosage form: tablet

Dosage: 20-40 mg PO qd

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Indications: Major depressive disorder, generalized anxiety disorder, and diabetic neuropathic pain

SNRI mechanism of action

Inhibits the reuptake of serotonin and norepinephrine

SNRI adverse effects

Suicidality, hypomania, and withdrawal syndrome

SNRI drug interactions

Benzodiazepines, Statins, and MAOIs

SNRI contraindications/cautions

Hepatic impairment or disease

SNRI notes

May cause dizziness or drowsiness.

May impair ability to drive.

Avoid alcohol.

Do not discontinue without medical supervision.

Examples of SNRIs

1. venlafaxine

2. desvenlafaxine

3. duloxetine

4. mirtazapine

5. trazodone

6. levomilnacipran

Generic: venlafaxine

Brand: Effexor XR

Dosage form: timed-release capsule

Dosage: 75-150 mg PO with food

Generic: desvenlafaxine

Brand: Pristiq

Dosage form: tablet

Dosage: 50 mg PO qd

Generic: duloxetine

Brand: Cymbalta

Dosage form: capsule

Dosage: 40-60 mg PO q AM

Generic: mirtazapine

Brand: Remeron

Dosage form: tablet

Dosage: 15-45 mg PO qd

Generic: trazodone

Brand: N/A

Dosage form: tablet

Dosage: 150 mg PO TID with food

Generic: levomilnacipran

Brand: Fetzima

Dosage form: capsule

Dosage: 40-120 mg PO qd

Tricyclic antidepressants (TCAs)

Indications: depression and enuresis

TCA mechanism of action

Blocks the reuptake of serotonin or norepinephrine

TCA adverse reactions

Anticholinergic effects, cardiotoxic in high doses, drowsiness, and postural hypotension in elderly adults

TCA drug interactions

Antiseizure meds, antiarrhythmics, and MAOIs

TCA contraindications/cautions

Patients experiencing seizure, patients with history of myocardial infarction, and caution with elderly adults

TCA notes

May cause drowsiness; alcohol may intensify this effect.

May impair ability to drive.

Do not discontinue without medical supervision.

Avoid prolonged exposure to sunlight.

Noticeable results may not occur for several weeks.

Examples of TCAs

1. amitriptyline

2. nortriptyline

3. desipramine

4. imipramine

5. doxepin

Generic: amitriptyline

Brand: N/A

Dosage form: tablet

Dosage: 75-150 mg PO qd in divided doses

Note: may discolor urine to blue-green

Generic: nortriptyline

Brand: Pamelor

Dosage forms: capsule, oral solution

Dosage: 25 mg PO tid-qid

Generic: desipramine

Brand: Norpramin

Dosage form: tablet

Dosage: 100-200 mg PO qd

Generic: imipramine

Brand: Tofranil

Dosage forms: tablet, capsule

Dosage: 75-150 mg PO qd

Generic: doxepin

Brand: Silenor

Dosage forms: capsule, oral liquid

Dosage: 75-150 mg PO qd

Monoamine oxidase inhibitors (MAOIs)

Indication: atypical depression

MAOI mechanism of action

Prevents enzymes from breaking down catecholamines

MAOI adverse reactions

Postural hypotension, blurred vision, dry mouth, constipation, and urinary retention

MAOI drug interactions

Antidepressants, hypoglycemic agents, and opioids

MAOI contraindications/cautions

Cerebrovascular disease, cardiovascular disease, and hypertension

MAOI notes

May cause dizziness or drowsiness.

Avoid alcohol.

Should be discontinued for 2 weeks before starting a new therapy.

Patients should avoid certain tyramine-containing foods, such as aged cheeses, certain wines, and certain yeast products.

MAOIs should not be prescribed if the patient is taking ephedrine, amphetamine, methylphenidate, levodopa, or meperidine.

Examples of MAOIs

1. phenelzine

2. tranylcypromine

Generic: phenelzine

Brand: Nardil

Dosage forms: tablet, patch

Dosage: 15 mg PO tid

Generic: tranylcypromine

Brand: Parnate

Dosage forms: tablet, patch

Dosage: 30 mg PO qd in divided doses

Bipolar agents

Indication: bipolar disease

Bipolar agent mechanism of action

Unknown

Bipolar agent adverse reactions

1. Bloating and abdominal distress

2. bloody stools

3. acne

4. leukocytosis

5. hand tremor

6. increased body weight

7. polyuria

8. polydipsia

9. nocturia

10. abnormal fetus development during pregnancy

Bipolar agent drug interactions (lithium, carbamazepine)

Lithium interacts with anticholinergics, antithyroid meds, diuretics, and NSAIDs.

Carbamazepine interacts with multiple drugs, including benzodiazepines, corticosteroids, MAOIs, oral contraceptives, thyroid meds, and TCAs.

Bipolar agent contraindication/caution

No MAOI use within 10 days of taking bipolar medications

Bipolar agent notes

May cause dizziness or drowsiness.

May impair ability to drive.

Take with food and plenty of water.

Avoid pregnancy.

Do not discontinue without medical supervision.

Salt content must be monitored and alcohol avoided.

Examples of bipolar agents

1. carbamazepine

2. divalproex

3. lamotrigine

4. lithium

5. olanzapine-fluoxetine

6. valproic acid

Generic: carbamazepine

Brand names: Tegretol, Tegretol XR

Dosage forms: tablet, chewable tablet, suspension

Dosage: 200 mg PO tid-qid

Generic: divalproex

Brand names: Depakote, Depakote ER

Dosage forms: tablet, ER tablet

Dosage: 250-500 mg PO tid

Generic: lamotrigine

Brand names: Lamictal, Lamictal ER

Dosage form: tablet

Dosage: 200 mg PO qd

Generic: lithium

Brand: Lithobid

Dosage form: ER capsule

Dosage: 900–1200 mg/day PO div bid/tid

Note: blood levels must be established for patients taking lithium and should be in the range of 0.6 to 0.8 mg/mL.

Generic: olanzapine-fluoxetine

Brand: Symbyax

Dosage form: capsule

Dosage: 1 cap PO q AM

Generic: valproic acid

Brand: Depakene

Dosage forms: capsule, syrup

Dosage: 250-500 mg PO tid

Antipsychotic agents

Indications: psychosis, schizophrenia, and bipolar disease

Antipsychotic agent mechanism of action

Blocks D2 dopamine receptors in the dopamine pathways of the brain

Antipsychotic agent adverse reactions

Sedation, anticholinergic responses, postural hypotension, hyperglycemia, dystonia, akathisia, and pseudo-parkinsonism

Antipsychotic agent drug interactions

Alcohol, paroxetine, and fluoxetine

Antipsychotic agent contraindication/caution

Cardiovascular disease

Antipsychotic agent notes

May cause drowsiness; may impair ability to drive.

Avoid alcohol.

Maintain adequate hydration.

Gains in reducing symptoms may take anywhere from 6 to 12 weeks.

Do not discontinue without medical supervision; discontinuation may lead to relapse of symptoms.

These drugs may minimize the adverse effects of antipsychotic meds: dimenhydrinate, benztropine, diphenhydramine, and trihexyphenidyl.

Examples of antipsychotic agents

1. aripiprazole

2. clozapine

3. haloperidol

4. iloperidone

5. loxapine

6. lurasidone

7. olanzapine

8. prochlorperazine

9. quetiapine

10. paliperidone

11. risperidone

12. thioridazine

13. ziprasidone

generic: aripiprazole

Brand: Abilify

Dosage form: tablet

Dosage: 10-15 mg PO qd

generic: clozapine

Brand: Clozaril

Dosage form: tablet

Dosage: 150-300 mg PO bid

Note: Clozaril requires prescribers, patients, and pharmacies to be enrolled in a restricted drug program.

generic: haloperidol

Brand: Haldol

Dosage form: tablet

Dosage: 0.5–5 mg PO bid–tid

generic: iloperidone

Brand: Fanapt

Dosage form: tablet

Dosage: 6–12 mg PO bid

generic: loxapine

Brand: Loxitane

Dosage form: capsule

Dosage: 30–50 mg PO bid

generic: lurasidone

Brand: Latuda

Dosage form: tablet

Dosage: 40–80 mg PO qd

generic: olanzapine

Brand: Zyprexa

Dosage form: tablet

Dosage: 10 mg PO qd

generic: prochlorperazine

Brand: N/A

Dosage forms: tablet, suppository

Dosage: 5 mg PO q6–8h

generic: quetiapine

Brand names: Seroquel, Seroquel ER

Dosage form: tablet

Dosage: 150–750 mg/day PO div bid–tid

generic: paliperidone

Brand: Invega

Dosage form: ER tablet

Dosage: 6 mg PO q AM

generic: risperidone

Brand: Risperdal

Dosage forms: tablet, oral solution

Dosage: 1–4 mg/day PO div qd–bid

Note: avoid carbonated beverages when taking risperidone.

generic: thioridazine

Brand: N/A

Dosage form: tablet

Dosage: 200-800 mg/day PO div bid-qid

generic: ziprasidone

Brand: Geodon

Dosage forms: capsule, powder for injection

Dosage: 20 mg PO bid

Sedatives

Indications: anxiety and sleep

Sedative mechanism of action

Interacts with Y-amino butyric acid (GABA)– benzodiazepine receptor complexes

Sedative adverse reactions

Dizziness, confusion, CNS depression, and impaired reflexes

Sedative drug interactions

Alcohol and cimetidine

Sedative contraindications/cautions

Alcohol use and CNS depressant use

Sedative notes

May cause drowsiness; may impair ability to drive.

Avoid alcohol.

May be habit forming.

Should be taken 30 minutes before bedtime.

Barbiturates are rarely used to treat insomnia; they have been replaced with benzodiazepines and imidazopyridines (zolpidem and zaleplon).