Psychopharmacology Notes

Review of the Central Nervous System

• To understand how psychotropic medications work, it is important to understand the anatomy and physiology of the central nervous system.

• The nervous system is divided into the central and peripheral nervous systems.

• The central nervous system includes the brain and spinal cord. The peripheral nervous system includes sensory and motor neurons.

• Sensory neurons sense the environment and conduct signals to the brain, leading to conscious perception.

• Conscious perception may lead to responses conducted from the brain to the peripheral nervous system via motor neurons.

Sympathetic and Parasympathetic Nervous System

• The autonomic nervous system is divided into the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS).

• Homeostatic mechanisms are regulated by the body through a balance of SNS and PNS stimulation.

• Stimulation of SNS receptors increases heart rate and blood pressure (via vasoconstriction) and causes bronchodilation.

• Alpha-1, Alpha-2, Beta-1, and Beta-2 receptors are stimulated by epinephrine and norepinephrine.

• Stimulation of the PNS slows the heart, lowers blood pressure (due to vasodilation), and causes bronchoconstriction.

• PNS receptors include nicotinic and muscarinic receptors, which are stimulated by acetylcholine.

Neurotransmitters

• Neurotransmitters are chemical substances released at the end of a neuron by the arrival of an electrical impulse.

• Can be manipulated through nonpharmacological and pharmacological interventions.

Neuron Communication with Neurotransmitters

• Acetylcholine: Stimulates nicotinic and muscarinic receptors in the parasympathetic nervous system.

• Glutamate: An excitatory neurotransmitter.

• Gamma-Aminobutyric Acid (GABA) and Glycine: Inhibitory neurotransmitters that slow down overexcited nerve cells.

• Dopamine: Plays an essential role in learning, motor control, reward, emotion, and executive functions.

• Serotonin: Modulates multiple neuropsychological processes such as mood, sleep, libido, and temperature regulation.

• Norepinephrine and Epinephrine: Stimulate alpha- and beta-receptors in the sympathetic nervous system.

• Histamine: Mediates homeostatic functions, promotes wakefulness, modulates feeding behavior, and controls motivational behavior.

Mental Health Treatment

• Mental health conditions often treated by manipulating neurotransmitters to create neuroplasticity.

• Examples of conditions: Depression, Insomnia, Mood disorders, Anxiety, Psychosis, Attention Deficit Hyperactivity Disorder (ADHD), and Pain

• This manipulation creates chemical changes to elicit structural changes, which result in functional changes. Neurons change production or response to neurotransmitters.

• Structure changes to support chemical changes, and behavior changes due to new stimulus pathways.

Individual Considerations

• Etiologies of mental health disorders involve genetic, biophysical, and environmental factors.

• Genetic differences are more likely to cause slower drug metabolism than racial or ethnic background.

• In the future, a person’s genes may be linked with the most efficacious treatment.

• Avoid making assumptions based on race or ethnicity; ask patients about their past experiences.

Black Box Warning

• Manipulation of neurotransmitters can have serious health effects.

• The Black Box Warning from the FDA alerts the public and healthcare providers to serious side effects (e.g., injury or death).

Antidepressants

• Uses: depression, anxiety, chronic pain, and insomnia.

• Agency for Healthcare Research and Quality aims to improve symptoms and prevent recurrence.

• Several classes and types:

  • Selective serotonin reuptake inhibitors (SSRIs)

    • neurotransmitters involved:

  • Serotonin and norepinephrine reuptake inhibitors (SNRIs)

    • neurotransmitters involved:

  • Norepinephrine and dopamine reuptake inhibitors

    • neurotransmitters involved:

  • Serotonin antagonist and reuptake inhibitors

    • neurotransmitters involved:

  • Tricyclic antidepressants (TCAs)

    • neurotransmitters involved:

  • Monoamine oxidase inhibitors (MAOIs)

    • neurotransmitters involved:

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Prevent the uptake of serotonin at the synapse, increasing serotonin levels in the brain.

• Uses: depression (primary), bipolar disorder, obsessive-compulsive disorder, bulimia, panic disorder, post-traumatic stress disorder, anxiety, premenstrual syndrome, and migraines.

• Examples: fluoxetine, citalopram, sertraline, paroxetine, and escitalopram.

• Most common side effects: nausea, agitation, and sexual dysfunction.

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

• Prevent the reuptake of serotonin and norepinephrine, with weak inhibition of dopamine reuptake.

• Examples: venlafaxine and duloxetine.

• Most common side effects: appetite suppression.

Serotonin Antagonist and Reuptake Inhibitor

• Trazodone is an example.

• Reduces levels of neurotransmitters associated with arousal effects (serotonin, noradrenaline, dopamine, acetylcholine, and histamine).

• Low-dose trazodone has a sedative effect for sleep and is typically administered in the evening.

Serotonin Syndrome

• Caused by the combination of multiple medications that affect serotonin.

• Signs: mental status changes, autonomic instability, incoordination, or gastrointestinal symptoms.

• Severe forms can resemble neuroleptic malignant syndrome.

Norepinephrine and Dopamine Reuptake Inhibitor

• Bupropion is an example.

• Used to treat depressive disorders, seasonal affective disorder, attention deficit disorder, and to help people stop smoking.

Tricyclic Antidepressants (TCAs)

• Block the reuptake of serotonin and norepinephrine in the synapse, increasing neurotransmitter concentrations in the brain.

• Older, first-generation antidepressants.

• Amitriptyline.

• Most common side effects: anticholinergic (dry mouth, constipation, orthostatic hypotension).

• SLUDGE (Salivation decreased, Lacrimation decreased, Urinary retention, Drowsiness/dizziness, GI upset, Eyes) mnemonic for anticholinergic side effects.

• Older adults are particularly sensitive and should be started on low doses.

Monoamine Oxidase Inhibitors (MAOIs)

• Monoamine oxidase is an enzyme that removes norepinephrine, serotonin, and dopamine from the brain.

• Older, first-generation antidepressant.

• Contraindicated with all other classes of antidepressants.

• Common side effects: weight gain, daytime sedation, sexual dysfunction, insomnia.

• Interacts with many medications and foods.

• Dietary restrictions with MAOIs (foods containing Tyramine - aged cheese, cured meats, pickled/fermented foods, dried fruits, etc).

• Dangerous side effects: hypertensive crisis.

Hypertensive Crisis

• A condition that can be caused by MAOIs, with severe hypertension and evidence of organ dysfunction.

• Symptoms may include occipital headache, palpitations, neck stiffness or soreness, nausea or vomiting, sweating, dilated pupils, photophobia, shortness of breath, or confusion.

Antidepressants: Client Teaching

• Time of dosage:

  • SSRI first thing in morning

  • Cyclic compounds at night

• Actions for missed dose:

  • Take SSRI up to 8 hours after missed dose

  • Take cyclic within 3 hours of missed dose or omit the day’s dose

• Can take several weeks to see response.

• Monitor for worsening symptoms.

• Some cause suicidal thoughts.

• Safety measures

Mood Stabilizers

• Used primarily to treat bipolar disorder.

• Also used to treat depression, schizoaffective disorder, and disorders of impulse control.

• Anticonvulsant medications are also used as mood stabilizers.

Lithium

• Reduces excitatory neurotransmission and increases inhibitory neurotransmission.

• Alters sodium transport in nerve and muscle cells and causes a shift in metabolism of catecholamines( excitatory neurotransmitters), which contributes to its efficacy in mood stabilization.

• May reduce symptoms of mania within 1 to 3 weeks.

Mood-Stabilizing Drugs: Client Teaching

• Periodic monitoring of blood levels:

  • On initiation and every 2 weeks until therapeutic.

• Lithium has a narrow therapeutic range of $0.8$ to $1.2$ mEq/L.

  • 12 hours after last dose taken.

  • Signs of early lithium toxicity: diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination.

  • At higher levels: giddiness, ataxia(imbalence), blurred vision, tinnitus(ringing in ears) , and a large output of dilute urine may occur.

• Taking medication with meals; staying well hydrated (LFTs, kidney function).

• Safety measures.

Antianxiety Medications

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

• The most common class is benzodiazepines.

• Benzodiazepines are used to treat generalized anxiety disorder, although SSRIs or other antidepressants are typically used to treat panic disorder or social phobia.

Benzodiazepines

• Used to treat anxiety and also for their sedation and anticonvulsant effects because they bind to GABA receptors and stimulate the effects of GABA.

• Schedule IV controlled substance due to misuse potential and can cause dependence due to increased dopamine.

• Short-acting benzodiazepines and beta-blockers are used to treat the short-term symptoms of anxiety.

Antianxiety Drugs: Client Teaching

• Safety measures

• CNS depressant: poor concentration, impaired memory, drowsiness.

• Avoidance of alcohol (potentiates).

• Avoidance of abrupt discontinuation (taper).

Beta-Blockers

• Block sympathetic nervous system stimulation of Beta-1 receptors.

• May be prescribed to manage the physical symptoms of anxiety for a short period or used “as needed” to reduce acute physical symptoms.

Antipsychotics

• Primarily used to manage psychosis, which can be a symptom of a physical condition or a mental disorder.

• Also used in combination with other medications to treat the symptoms of other mental health conditions (ADHD, eating disorders, post-traumatic stress disorder, obsessive-compulsive disorder, and generalized anxiety disorder).

• Common first-generation antipsychotic medications include chlorpromazine, haloperidol, perphenazine, and fluphenazine.

• First-generation antipsychotics work by blocking dopamine receptors in certain areas of the CNS, such as the limbic system and the basal ganglia.

• Adverse effects are caused by dopamine blockade, such extrapyramidal side effects and tardive dyskinesia.

Extrapyramidal Side Effects

• Involuntary or uncontrollable movements, tremors, and muscle contractions (can be painful) that can occur with antipsychotic medications.

Tardive Dyskinesia

• A syndrome of movement disorders

  • associated with antipsychotic medications that persists for at least one month and can last up to several years despite discontinuation of the medications.

Second-Generation Antipsychotics

• Also called atypical antipsychotics:

  • how does the drug work: These medications primarily work by modulating neurotransmitter systems in the brain, particularly dopamine and serotonin receptors, leading to reductions in psychotic symptoms.

    • work by blocking specific D2 dopamine receptors and serotonin receptors.

      • Examples: risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, and lurasidone.

• Adverse Effects:

  • Metabolic syndrome increases the risk of heart disease, stroke, and type 2 diabetes. Clinical symptoms include high blood glucose, symptoms of diabetes (i.e., increased thirst and urination, fatigue, and blurred vision), obesity with a large abdominal girth, hypertension, elevated triglyceride, and lower levels of HDL.

  • Increased Prolactin:

    • This can lead to symptoms such as galactorrhea, amenorrhea, and gynecomastia, particularly seen with medications like risperidone and paliperidone.

  • Cardiovascular side effects (prolonged QT interval, torsades de pointes, Agranulocytosis)

Neuroleptic Malignant Syndrome

• A rare but fatal adverse effect that can occur at any time during treatment with antipsychotics.

• Typically develops over days to weeks and resolves in approximately nine days with treatment.

• Signs

  • increased temperature, severe muscular rigidity, confusion, agitation, hyperreflexia, elevation in white blood cell count, elevated creatinine phosphokinase, elevated liver enzymes, myoglobinuria, and acute renal failure (AKI).

Antipsychotics: Client Teaching

• Adherence to regimen

• Management of side effects:

  • Thirst/dry mouth (sugar-free candy, liquids)

  • Constipation (dietary fiber, exercise)

  • Sleepiness/drowsiness (safety measures)

• Actions for missed dose (take dose if within 4 hours of usual time)

Stimulants

• Treat attention deficit hyperactivity disorder (ADHD).

• Block the reuptake of norepinephrine and dopamine in the synapse and increase the overall level of these substances in the brain.

• Paradoxical calming effect and improve the ability to focus and concentrate for individuals diagnosed with ADHD.

• Stimulant medications are safe when prescribed with close supervision but are a Schedule II controlled substance because they have a high potential for misuse and dependence.

Stimulants: Side Effects and Client Teaching

• Side effects:

  • Anorexia, weight loss, nausea, irritability

  • Growth and weight suppression

• adverse side effects:

  • Insomnia, agitation, anxiety, headache

  • dry mouth, dizziness, fatigue, blurred vision.

• Client teaching:

  • Dose after meals

  • Avoidance of caffeine, sugar, chocolate

  • Proper storage out of reach of children

Opioid System

• The opioid system in the brain controls pain, reward, and addictive behaviors.

• Opioid receptors are stimulated by endogenous peptides released by neurons and exogenous opiates.

• Opiates include powerful analgesics prescribed to treat moderate to severe pain.

• Mu, delta, and kappa receptors are stimulated by endogenous peptides released by neurons and exogenous opiates.

• Opiates also include illicit drugs.

  • heroin

Psychoactive Substances and Medications to Treat Substance Use and Withdrawal

• Medications to treat alcohol use disorder and opioid disorder include buprenorphine-naloxone, methadone, naltrexone, acamprosate, and disulfiram.

• Medications used to manage symptoms of substance withdrawal/detoxification include buprenorphine, methadone, and Alpha-2 adrenergic agonists.

Complementary and Alternative Medicine (CAM)

• Complementary medicine is used along with conventional practices.

• Alternative medical systems are used in place of conventional treatment.

• Integrative medicine combines conventional and CAM practices.

• Variety of therapies:

  • Alternative medical systems (nutrition, exercise, acupuncture)

  • Mind–body interventions (meditation, art, music therapy)

  • Biologically based therapies (herbs, foods, vitamins)

  • Manipulative and body-based therapies (therapeutic massage, chiropractic manipulation)

  • Energy therapies (therapeutic touch, qi-gong, pulsed fields, magnetic fields)

Cultural Considerations

• Increased frequency of herbal medicine use:

  • St. John’s Wort

  • Kava

  • Valerian

  • Ginkgo biloba

  • Ginseng

  • Chamomile

  • Echinacea

• Increased risk for interactions with herbal medicine

Self-Awareness Issues

• Clients and families need more than factual information; they need simple and thorough explanations.

• View chronic mental illness as having remissions and exacerbations, just as chronic physical illnesses do.

• Remain open to new ideas that may lead to future breakthroughs.

• Understand that medication noncompliance is often a result of faulty thinking and reasoning related to the illness, not willful misbehavior.

Chat GBT Cheat Sheet Notes

1. Overview: How the Brain and Medications Work Together

• The brain and spinal cord make up the central nervous system (CNS).

• Messages move through neurons using neurotransmitters—chemical messengers.

• Mental health meds work by adjusting these neurotransmitters to bring balance.

2. Nervous System Basics

• Sympathetic Nervous System (SNS): “Fight or flight”

  • Increases heart rate, raises blood pressure, opens airways

  • Activated by epinephrine and norepinephrine

• Parasympathetic Nervous System (PNS): “Rest and digest”

  • Slows heart rate, lowers blood pressure, tightens airways

  • Activated by acetylcholine (ACh)

3. Important Neurotransmitters

• Acetylcholine (ACh) – affects memory, attention, and muscle control

• Glutamate – main excitatory (activating) chemical

• GABA and Glycine – calming, slow things down

• Dopamine – affects mood, motivation, movement

• Serotonin – affects mood, sleep, appetite, and temperature

• Norepinephrine/Epinephrine – energizing, "adrenaline"

• Histamine – involved in alertness and appetite

4. Treating Mental Illness with Meds

• Mental illness is treated by adjusting neurotransmitters.

• Medications create chemical changes → lead to brain structure changes → result in behavior changes.

5. Important Warnings

• Black Box Warning: The strongest FDA warning. Highlights risk of death or serious side effects.

6. Antidepressants

Classes:

1. SSRIs (Selective Serotonin Reuptake Inhibitors)

   • Keeps serotonin in the brain longer

   • Used for: depression, anxiety, OCD, PTSD

   • Examples: fluoxetine, sertraline, escitalopram

   • Side effects: nausea, agitation, sexual issues

2. SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

   • Boosts both serotonin and norepinephrine

   • Examples: venlafaxine, duloxetine

   • Side effect: appetite suppression

3. Serotonin Antagonist/Reuptake Inhibitor

   • Example: trazodone

   • Used at low doses for sleep

   • Watch for: serotonin syndrome (a dangerous reaction to too much serotonin)

4. Norepinephrine and Dopamine Reuptake Inhibitor

   • Example: bupropion

   • Treats depression, ADHD, smoking addiction

5. Tricyclic Antidepressants (TCAs)

   • Boosts serotonin and norepinephrine

   • Older drugs like amitriptyline

   • Side effects: dry mouth, dizziness, constipation

   • Watch for anticholinergic side effects (use SLUDGE mnemonic)

6. MAOIs (Monoamine Oxidase Inhibitors)

   • Oldest class, increases serotonin, dopamine, norepinephrine

   • Dangerous food and drug interactions

   • Watch for: hypertensive crisis if patient eats tyramine-rich foods (e.g., aged cheese)

Key Antidepressant Facts:

• SSRIs should be taken in the morning; TCAs at night

• May take weeks to work

• Watch for worsening depression or suicidal thoughts

• Never stop suddenly; taper off

7. Mood Stabilizers

Lithium

• Used for bipolar disorder

• Balances excitatory and calming neurotransmitters

• Takes 1–3 weeks to work

• Requires blood level monitoring

  • Safe range: 0.8–1.2 mEq/L

  • Toxic signs: vomiting, diarrhea, drowsiness, tremors, blurred vision

• Stay hydrated and take with food

Anticonvulsants also help stabilize mood in bipolar disorder.

8. Antianxiety Medications

Benzodiazepines

• Work by increasing GABA

• Used short-term for anxiety, panic, seizures

• Can cause dependence, sedation, poor concentration

• Must avoid alcohol

• Do not stop suddenly

Beta-Blockers

• Block physical anxiety symptoms (shaky hands, fast heart rate)

• Used short-term or “as needed”

9. Antipsychotics

First-Generation (Typical)

• Block dopamine

• Examples: haloperidol, chlorpromazine

• Side effects:

  • Extrapyramidal symptoms (EPS): tremors, stiffness, spasms

  • Tardive dyskinesia: permanent twitching or movement

  • Neuroleptic malignant syndrome: rare, life-threatening (fever, muscle rigidity, confusion)

Second-Generation (Atypical)

• Block dopamine and serotonin

• Examples: risperidone, olanzapine, aripiprazole

• Side effects:

  • Metabolic syndrome: weight gain, high blood sugar, high cholesterol

  • Heart rhythm changes (prolonged QT)

  • Low white blood cells (agranulocytosis)

10. Stimulants

• Used for ADHD

• Increase norepinephrine and dopamine

• Examples: methylphenidate, amphetamines

• Side effects: appetite loss, weight loss, insomnia, irritability

• Teach patients:

  • Take after meals

  • Store safely

  • Avoid caffeine, sugar, chocolate

11. Substance Use Treatment Medications

• For alcohol or opioid use disorders:

  • Buprenorphine-naloxone, methadone, naltrexone, disulfiram

• For withdrawal symptoms:

  • Alpha-2 agonists (like clonidine)

  • Methadone, buprenorphine

12. Complementary & Alternative Medicine (CAM)

• Common CAM therapies:

  • Herbs: St. John’s Wort, Kava, Valerian

  • Mind–Body: meditation, music/art therapy

  • Manual therapies: massage, chiropractic

• Be cautious: Many interact with medications

13. Cultural and Self-Awareness Considerations

• Be mindful of herbal medicine use across cultures.

• Mental illness is chronic, with ups and downs.

• Medication noncompliance may be part of the illness, not disobedience.

• Avoid stereotypes; ask patients about personal experiences and needs.