Mental Health Medications Study Guide

Medications for Mental Health

General Considerations

  • When discussing mental health medications, it's helpful to categorize them by what they treat.
  • Many mental health medications have multiple uses (indications).
  • Example: Alprazolam (benzodiazepine) is used for anxiety and alcohol withdrawal.
  • Adding another indication doesn't change the medication itself.
  • Focus on:
    • What the medication is used for.
    • The side effects of the medication.

Medications for Insomnia

  • Medications:
    • Alprazolam (benzodiazepine).
    • Zolpidem (non-benzodiazepine).
    • Diazepam (benzodiazepine).
  • Benzodiazepines are not the first choice due to:
    • Risk of respiratory depression.
    • Risk of dependency and abuse.
    • Ideally, insomnia treatment should be short-term, addressing the root cause.
  • Avoid benzodiazepines, especially in patients with a history of substance abuse (even in remission).
Benzodiazepines - Side Effects
  • Respiratory depression.
  • Sedation, advise patients not to drive or operate heavy machinery.
  • Avoid alcohol due to additive effects.
  • Easy way to remember:
    • Don't drink and drive (same as alcohol).
Zolpidem
  • Non-benzodiazepine for insomnia.
  • Less potential for abuse than benzodiazepines, but still present.
  • Keep use short-term (ideally six months or less).
  • Risk of psychological dependence.

Medications for Anxiety

  • Medications:
    • Fluoxetine (antidepressant).
    • Alprazolam and diazepam (benzodiazepines).
    • Venlafaxine (antidepressant).
    • Buspirone (antianxiety).
Buspirone
  • Used for generalized anxiety disorder (chronic, low-level anxiety).
  • Non-sedating, can be good option for individuals that require alertness(e.g., school bus drivers).
  • Non-addictive.
  • Not effective for panic disorders (acute, overwhelming anxiety).
  • Takes 4-6 weeks to become fully effective.
Antidepressants
  • Fluoxetine, venlafaxine, amitriptyline, bupropion, phenelzine
  • Used for maintenance in chronic anxiety (generalized anxiety disorder).
  • Not effective for acute panic attacks.
  • Benzodiazepines are better for panic attacks (PRN use) unless patient has coping tools (counseling).

Antidepressants

  • It's helpful to classify medications by their primary drug class, then by other indications
  • Fluoxetine: Antidepressant (SSRI), also used as anxiolytic.
  • Grouping by the primary class helps understand shared mechanisms and side effects.
SSRIs (Selective Serotonin Reuptake Inhibitors)
  • Example: Fluoxetine.
  • Mechanism: Inhibit serotonin reuptake, increasing serotonin levels.
  • Side effects (the big three):
    • Changes in weight (some cause weight gain, some cause weight loss).
    • Changes in sleep (some cause insomnia, some cause sedation).
      • Example Fluoxetine (activating, take in the morning), Paroxetine (sedating, take at night)
    • Sexual dysfunction.
  • Avoid mixing with other medications that increase serotonin (e.g., St. John's Wort).
  • Cornerstone of depression management, start here unless contraindicated.
SNRIs (Selective Serotonin and Norepinephrine Reuptake Inhibitors)
  • Example: Venlafaxine, duloxetine.
  • Same side effects as SSRIs (changes in weight, changes in sleep, sexual dysfunction).
  • Additional side effect: Increase in blood pressure (due to norepinephrine).
  • Venlafaxine doses under 200 mg/day may not increase blood pressure.
Tricyclic Antidepressants (TCAs)
  • Example: Amitriptyline.
  • Mechanism: Increase serotonin and norepinephrine (same as SNRIs).
  • More side effects than SNRIs:
    • Anticholinergic effects: dry mouth, urinary retention, constipation, tachycardia.
    • Sedation (histamine receptor).
  • Overdose risk: Can cause fatal arrhythmia even with a one-week supply.
  • Initial management:
    • Prescribe only one week of supply at a time due to suicide risk.
    • Executive functioning may return before mood improves, increasing suicide risk.
    • Monitor closely during the first month of treatment.
Other Antidepressants
  • Bupropion: Does not affect serotonin.
  • MAOIs (Monoamine Oxidase Inhibitors):
    • Effective for resistant depression.
    • Significant dietary restrictions due to tyramine content:
      • Aged cheese.
      • Processed meats (beef jerky, salami, pepperoni).
      • Overripe fruit (bananas).
    • Tyramine increases blood pressure; MAOIs prevent its breakdown, leading to fatal hypertension.

Antiepileptics

  • Recognize drug names: Phenytoin, carbamazepine, lamotrigine, levetiracetam, gabapentin, pregabalin, valproic acid.
  • Used to prevent seizures.
General side effects
  • Risk of rash and bone marrow suppression.
  • Potential to lower the immune system.
  • Carbamazepine: Monitor for fevers.
  • Lamotrigine: Highest risk of Steven Johnson syndrome.
Phenytoin
  • Used to be a common medication for seizures.
  • Monitor drug levels (blood work) to ensure efficacy and avoid toxicity.
  • Symptoms of toxicity:
    • Nystagmus (rapid eye movement).
    • Confusion (slurred words, slowed movements).
  • Gingival hyperplasia (gum overgrowth) is a side effect of prolonged use, not toxicity.
Valproic Acid
  • Effective, but with significant side effects.
  • Weight gain.
  • Monitor drug levels, liver function tests (AST, ALT), and pancreatic enzymes (amylase, lipase).
  • Can cause hepatotoxicity and pancreatitis.
Lamotrigine and Valproic Acid - Combination
  • Valproic acid inhibits enzymes that break down lamotrigine, increasing lamotrigine concentrations and the risk of Steven Johnson syndrome.
  • When used together:
    • Doses are reduced by 50% of lamotrigine
    • Typically managed by a neurologist, psychiatrist, and/or psychiatric pharmacist.
    • Used together most of the time for bipolar disorder

Bipolar Disorder

  • Fluctuation between mania (illogical elevated mood) and depression.
  • Medications stabilize mood.
Lithium
  • Primary indication: Bipolar disorder.
  • Side effects:
    • Lithium toxicity: Symptoms mistaken for being drunk (vomiting, confusion, sedation, unsteady gait).
    • Tremors (fine hand resting tremor).
  • Monitoring:
    • Lithium levels (therapeutic range: 0.8-1.2; toxicity above 1.5).
    • Serum creatinine (kidney function; lithium is eliminated through the kidneys).
    • Sodium levels (maintain consistent levels as lithium and sodium don't play nice in the sandbox; lithium is a positive ion).
    • Thyroid hormone (TSH; lithium can affect the thyroid gland).
  • If medication type and dose are correct there should not be manic episodes, but hypomania can be experienced.

Schizophrenia

  • Issue of too much dopamine in the mesolimbic and mesocortical pathways.
  • Symptoms: Delusions, psychosis, hallucinations.
  • Two groups of medications:
    • First generation antipsychotics (FGAs).
    • Second generation antipsychotics (SGAs).
  • Difference are the side effects.
  • Both groups are good at managing the sumptoms.
  • FGAs: Movement-related side effects.
  • SGAs: Metabolic side effects.
FGAs (First Generation Antipsychotics)
  • Examples: Chlorpromazine and Haloperidol.
  • Side effects (DEPART):
    • Dystonia: Muscle rigidity.
    • EPS (Extrapyramidal Symptoms): Mimic Parkinson's disease (muscle rigidity, lip smacking, spasms).
    • Pseudo parkinsonism: Goes with EPS.
    • Akathisia: External result of an internal feeling of restlessness (pacing, shaking leg).
    • Restlessness: Goes with Akathisia.
    • Tardive Dyskinesia: Irreversible; monitor closely and stop medication if symptoms arise.
SGAs (Second Generation Antipsychotics)
  • Examples: Olanzapine, Risperidone, Clozapine.
  • Metabolic side effects: Increase in weight, glucose (leading to type 2 diabetes), and cholesterol.
  • First choice between first and second generation will be second generation (we have better ways of managing the metabolic side effects.
  • Clozapine monitoring: White blood cells (due to risk of agranulocytosis).
EPS Management
  • Diphenhydramine and benztropine can be used to manage EPS side effects.

ADHD Medications

  • Methylphenidate: Stimulant.
  • Atomoxetine: Non-stimulant.
  • Stimulants:
    • Potential for abuse.
    • Decrease in appetite and insomnia, potentially affecting growth in children.