Nervous System, Mental Health, and Drug Therapy: Depression, Mood Disorders, and Drug Treatments

• Depression: feelings of pessimism worry, intense sadness, loss of concentration, slowing of mental processes, problems eating and sleeping

• Mania: mental and physical hyperactivity, disorganized behaviour, elevated mood; mood of extreme excitement, excessive elation, hyperactivity, agitation, increased psychomotor activity

• Bipolar disorder: alternating episodes of depression and mania; mood swings that alternate between periods of major depression and periods of mild to severe chronic agitation

• Post Traumatic Stress Disorder: Triggered by a traumatic event that leaves a person with intense, disturbing thoughts and feelings long after the event; Persistent anxiety or recurrent fear after a terrifying event

• Seasonal Affective Disorder: depression which occurs in the fall and winter and remits in the spring and summer

• Neurotransmitters

  • produced by a nerve cell and transmit information

  • i.e. serotonin, norepinephrine, dopamine

  • psychiatric and mood disorders

    • deficiency of neurotransmitters

    • dysfunction of neurotransmitters

• Antidepressants

  • goal of therapy is to change neurotransmitter levels

  • take 10-21 days to start working

  • medication Guide required

• Overview of Disorders

  • hard to diagnose

  • often occur together in same patient

  • Need multiple medications for treatment

  • Good communication essential among patient family or caregivers. prescriber, pharmacist

• Antidepressants

  • delay of onset of 10-21 days

  • not used on “as needed” basis

• Depression

  • underlying causes: exogenous vs. endogenous sources

  • signs: crying, loss of interest in life or social activities, increased focus on death, significant weight loss or gain

  • symptoms: low self-esteem, pessimism, sleep disturbances, loss of energy and ability to think, feelings of worthlessness and guilt, poor memory, thoughts of suicide

  • neurotransmitters involved in mood: norepinephrine, serotonin, dopamine

• Drug Regimens and Treatments for Depression

  • Patient response to drug therapy

    • response not immediate

    • may take 3-6 weeks for full response

    • drug therapy trial of at least 3-4 weeks

  • Risk for suicide

    • teens and young adults

    • highest risk is when starting drug therapy

    • monitor for worsening signs of depression, suicidal thoughts, unusual behaviors

  • Stopping Therapy

    • risk of acute withdrawal symptoms if stopped abruptly

    • worsened depression symptoms if dose not tapered

• Clinical depression is the most severe psychiatric disorder

• Women more likely than men to have depression

• Depression occurs later in life in men

• Selective Serotonin Reuptake Inhibitors (SSRI): block reuptake of serotonin, little effect on norepinephrine

• Serotonin Norepinephrine Reuptake Inhibitors (SNRI): increase both serotonin and norepinephrine

• Tricyclic Antidepressants (TCA): prevent reuptake of serotonin and/or norepinephrine

• Monoamine Oxidase Inhibitors (MAOIs): inhibit enzymes that break down serotonin and norepinephrine

Depression

• Serotonin syndrome

  • Cause: presence of too much serotonin

  • Signs: racing heart, fever, high blood pressure, headache

  • Risk factors: taking more than one antidepressant, taking St. John’s wort

  • Prognosis: potentially fatal

• Selective Serotonin Reuptake Inhibitors: block the reuptake of serotonin

  • classified effects: Nausea, vomiting, dry mouth, drowsiness, insomnia, headache, diarrhea, sexual dysfunction, serotonin syndrome

• Patients with antidepressants worked immediately, but it is important to realize that it may take four weeks for these medications to achieve full effect. Antidepressants should help with sleep problems within a week or so, but other psychiatric effects may take longer to achieve full efficacy.

• Additional uses for SSRIS Obsessive-compulsive disorder (OCD) A form of anxiety Obsessive thoughts impair function.

• Repetitive behaviors relieve fears and anxiety. Premenstrual dysphoric disorder (PMDD) Emotional and behavioral changes during second half of a woman's menstrual cycle Similar symptoms to PMS but more severe Posttraumatic stress disorder (PTSD), fibromyalgia, anxiety, panic disorder, nerve pain (duloxetine)

• Often confused

  • Celexa

  • Celebrex (arthritis)

• Look-a-like

  • Prozac

  • Proscar (prostrated enlargement)

• Do not drink alcohol

• Do not stop abruptly

• Serotonin and norepinephrine Reuptake inhibitors work by blocking the reuptake of serotonin and norepinephrine

  • Side effects: nausea, vomiting, insomnia, agitation, drowsiness

Chapter 8 day 2

Depression and Mood Disorders

• 2 Weeks washout period before starting new class of antidepressants

• Severe hypertensive reactions with food containing high levels of tyramine

Bipolar Disorder

• Periods of depression alternating with periods of mania, a state of overly high energy, excitement, hyperactivity, optimism, and increased psychomotor activity

• Increased psychomotor activity can involve irritability, excessive involvement in work or other activities, grandiose ideas, racing thoughts, decreased need for sleep

• Goals of Therapy

  • Treat acute episodes and prevent subsequent attacks

• Mania: mood of extreme excitement, excessive elation, hyperactivity, agitation, and increased psychomotor activity

• Bipolar Disorder: mood swings that alternate between major depression and mania

• Unipolar Depression: major depression with no previous occurrence of mania

• Post-traumatic stress disorder: Disorder characterized by persistent agitation or persistent,
  recurrent fear after the end of a traumatic event and lasting for over a month or impairing work or relationship

• Seasonal Affective Disorder: Form of depression that recurs in the fall and winter and remits in the spring and summer

• The two-fold objective of drug therapy is to treat acute episodes and prevent subsequent attacks

Schizophrenia, Psychosis and drug Treatments

• Schizophrenia: A chronic mental health disorder characterized by delusions, disorganized speech and behavior, decrease in emotional range, neurocognitive deficit

  • Cause excessive dopamine levels in the limbic system

  • Positive symptoms include hallucinations and delusions

  • Negative symptoms are withdrawal, ambivalence, behaviour changes, memory loss and confusion

• Treatment

  • Typical antipsychotic

    • Block dopamine receptors in all four dopamine pathways

    • Lead to unfavorable side effects extrapyramidal symptoms (EPS)

  • Atypical antipsychotics

    • Block dopamine receptors in the limbic system pathway instead of all four pathways

    • Improved efficacy and fewer side effects

• Goals of Therapy: reduce symptoms such as thought disorder, hallucination, delusions

Anxiety and Drug Treatments

• Anxiety: a state of uneasiness characterized by apprehension and worry about possible events

• Symptoms

  • tension, apprehension, easy startling, uneasiness and nervous at your work or with people, nagging uncertainty about the future

  • can lead to chronic fatigue, headaches, insomnia

• Exogenous anxiety: Develops in response to external stresses

• Endogenous anxiety: Not related to any identifiable external factors

  • Occurs as a result of a cellular function abnormality in the CNS

• Antianxiety agents:

• SSRIs and SNRIs

  • citalopram (Celexa)

  • duloxetine (Cymbalta)

  • escitalopram (Cipralex)

  • paroxetine (Paxil)

  • sertraline (Zoloft)

  • venlafaxine (Effexor)

• Benzodiazepines

• Other antianxiety agents

• Treatment Principles

  • monitor closely for depression

  • Taper to avoid withdrawal symptoms

Panic Disorder

• Panic Disorder: A form of intense, overwhelming, and uncontrollable anxiety

  • Intense fear or apprehension, may involve anticipation of a serious illness or life-threatening attack

• Symptoms: Dyspnea, palpitations, chest pain, choking sensation, dizziness, feelings of unreality, tingling in hands or feet, hot or cold flashes, sweating, numbness, trembling

• Cause: Heightened sensitivity to signals entering the brain; Amplification of incoming messages to a part of the brain stem resulting in excessive arousal, excessive autonomic discharges, and increased respiratory drive

• Treatment

  • Psychotherapy

  • Short-Term anxiety agents

    • SSRIs

    • Benzodiazepines buspirone

  • Other agents

    • beta-adrenergic agents

    • diphenhydramine

    • hydroxyzine

    • TCAs

8.5 Sleep Disorders and Drug Treatments

Insomnia

• Difficulty falling asleep or staying asleep

• May be chronic condition, a short term problem or transient

  • Transient not considered a sleep disorder but a response to an acute stressful event that is expected to improve with time

• Causes

  • Situational: job stress, hospitalization, travel

  • Medical: pain, respiratory problems, GI problems

  • Psychiatric: schizophrenia, depression, mania

  • Drug induced: alcohol, caffeine, sympathomimetic agents

• Non Drug Therapy

  • Normalizing the sleep schedule

  • Increasing physical activity during the day

  • Discontinuing the use of alcohol as a sedative

  • Sleeping a total of only seven or eight hours in a 24-hr period

  • Reducing caffeine and nicotine intake

  • Eliminating any drug that could lead to insomnia

Stimulants of Narcolepsy

• A sleep disorder involving recurrent inappropriate episodes of sleep during daytime hours

• Characteristics symptoms

  • Sleepy feeling during daytime with quick progression to REM sleep

  • Cataplexy or short periods of muscle tone loss

  • Sleep paralysis when falling asleep or waking up

  • Vivid hallucinations at onset of sleep

• Nondrug therapy

  • constant sleep schedule

  • Avoiding of shift work

  • Avoidance of Alcohol

Alcohol Dependence and Drug treatment

• Alcohol dependence (alcoholism): Pattern of alcohol use that involves problems controlling drinking, preoccupation with alcohol, use of alcohol even when it causes problems, drinking more to get the same effect, or having withdrawal symptoms upon rapidly decreasing or stopping drinking

• Ethanol (alcohol)

  • The intoxicating agent in liquor, is an anesthetic

  • Deaths from alcohol due to cirrhosis or aspiration of vomitus

• Impacts on health

  • Obesity, vitamin deficiency, gastritis, organic brain damage, alcoholic psychosis and dementia, cirrhosis

Alcohol Dependance

• Alcohol dependence

  • Pattern of alcohol use involving problems controlling drinking, preoccupation with alcohol, use of alcohol even when it causes problems, drinking more to get the same effect, or having withdrawal symptoms with rapidly decreasing or stopping drinking

• Alcohol tolerance

  • Increased ability to rapidly metabolize ethanol

  • Neurons in the CNS adapt to the presence of alcohol

• Impact on health

  • Obesity

  • Vitamin deficiency

  • Gastritis

  • Organic brain damage

  • Alcoholic psychosis and dementia

  • Cirrhosis

Alcohol Dependance

• Dependence

  • The inability to control the use of a physical substance.

  • A physical condition that cannot be controlled by willpower

• Alcohol withdrawal symptoms

• Agitation, circulatory disturbances, convulsions, delirium tremens, digestive disorders, disorientation, extreme fear, hallucinations, mental disturbances, nausea and vomiting, restlessness, sweating, temporary suppression of REM sleep, tremor, weakness

• Treatment of alcohol withdrawal

  • May include benzodiazepine, anticonvulsant, beta blocker, antipsychotic

  • Folic acid, thiamine, multipurpose vitamin to treat underlying deficiencies

Complimentary and Alternative Therapy

• Melatonin: Used for insomnia and benzodiazepine and nicotine withdrawal

  • Helps regulate circadian rhythms

• Kava: Affects GABA and dopamine in the brain

  • Used for anxiety and insomnia

  • Risk of liver toxicity and liver failure

• St. John’s Worts: Work similarly to SSRIs

  • Used for mild depression, psychological symptoms of menopause

  • Multiple drug interactions