Vandenberg Psychopharmacology/ 2007 Anti-Depressants: SSRI Tricyclics MAO inhibitors SSNRI Others Dry mouth Sexual side effects

(SSRI) Watch for serotonin syndrome Discontinuation syndrome At risk for suicide MAOI- avoid tyramine HTN crisis when given with MAOI

Anti- Anxiety: Benzodiazepines Buspirone (Buspar) Benzos = dependence Buspar- takes up to 2 weeks Benzo abrupt withdrawal = seizures Sedation- effect CNS (benzos)

Anti- Psychotics: Phenothiazines (typical) Other typicals Atypical Watch for EPS Watch for NMS ( EPS, high fever) Long-term: Tardive Dyskinesia Clozaril = agranulocytosis, hypersalivation Risk for emergent hyperglycemia

Mood Stabilizers: Anitmanic Anticonvulsants Calcium Channel Blocker (Verapamil) Antipsychotics Lithium toxicity > 1.5 mEq Lithuim- adequate fluids & sodium Neurontin- chronic pain

Antiparkinsonian Agents: Anticholinergics Antihistamines Dopaminergic agonists

Cogentin, Benadryl & Symmetrel most common Watch for orthostatic hypotension

Vandenberg Psychopharmacology/ 2007 Serotonin and Norepinephrine 1- Antidepressants works with 3 different neurotransmitters. Serotonin, Dopamine, and Norepinephrine. You will notice when you read about each medicine that you see the mechanism of action has to do with one of these neurotransmitters.***** It should be noted that most antidepressants take a few weeks to take effect !!! ***** 2. SSRI- Selective Serotonin Reuptake Inhibitors- 3 big side effects are sexual dysfunction, GI upset and dry mouth. Anytime someone is started on a SSRI, they are at risk to having GI upset due to the gut containing about 80% of serotonin. The other 20% is in the CNS- these are the ones we are trying to alter/adjust to help with depression. However, by default we affect the ones in the gut which is why the GI upset with SSRI often occur. Usually if the patient waits awhile, the gut will adjust and this will go away. Sexual dysfunction can occur as a decreased libido, inorgasmic, or inability to obtain or sustain erection. Typically when this happens, the only way to correct it is to come off the SSRI. All patients should be educated about this side effect. Imagine feeling depressed then starting a medicine that may cause this side effect and not know it? You would think it was something other than medicine. For some patients, adding Wellbutrin (another type of antidepressant, the side effect will go away. However, most research is saying that this is very rare). Dry mouth is often a side effect. Patients are encouraged to increase their fluid intake and use sugarless gum or candy. However, on most of the psych units, candy and gum or not allowed. . SSRI: Celexa, Prozac, Luvox, Lexapro, Paxil, Zoloft 3. MAOI- Monoamine Oxidase Inhibitors- These are antidepressants that are very effective but often are given as a last option. MAO is an enzyme. Keeps the MAO from breaking down neurotransmitters because you are already lacking them and the MAO keeps eating them. The MAOI keeps the enzyme from breaking them down. Cant have foods high in tyramine because it will make you hypertensive. The biggest problems with the MAOI medications are the dietary restrictions. Patients taking MAOI can not eat foods with tyramine. Sometimes it is impossible to avoid all tyramine so the patients must be educated on foods that are high in tyramine. Ingesting tyramine while taking a MAOI may result in hypertensive crisis. This high blood pressure can result in death. **Refer to book page 293 to be familiar with foods with tyramine ** Why does hypertensive crisis occur when ingesting tyramine? The exact mechanism which tyramine causes a hypertensive reaction is not well understood, but it is assumed that tyramine displaces norepinephrine from the storage vesicles. This may trigger a cascade in which excessive amounts of norepinephrine can lead to a hypertensive crisis. Another theory suggests that proliferation and accumulation of catecholamines causes hypertensive crisis There is now a patch called Emsam that is a MAOI. Because the medicine does not go through the GI tract, patients do not have the same dietary restrictions.

Vandenberg Psychopharmacology/ 2007 Another problem with MAOI are the inability to take a patient off the medicine and start another category of antidepressants immediately if the medicine is not working. When coming off a MAOI or staring a MAOI- patients must have at least a 14 day washout period between a MAOI and another antidepressant. Otherwise, hypertensive crisis can occur. MAOI: Marplan, Nadil, Parnate, Emsam 4. Tricyclics- These are the oldest of the antidepressants. They are still used, however they often cause undesirable side effects (anticholinergic). These are blurred vision, constipation, urinary retention, orthostatic hypotenision, and drowsiness. Often they are prescribed to help people sleep. They are not addictive and they cause drowsiness. Plus- it can also help increase mood. A few tricyclics have the added benefit of helping with chronic pain and may be prescribed for that reason alone. Anafranil is often used for OCD. Cant give these to people who are suicidal because it can cause death if you take the whole bottle. Tricyclics- Elavil, Asendin, Anafranil, Norpramin, Sinequan, Tofranil 5. SNRI/Other- There are some other antidepressants that do not fit the categories of the above. They have varying side effects. These are for people who have anxiety and depression because it works on serotonin and norepinephrine. They are similar to SSRIs in side effects. Others: Wellbutrin, Trazadone, Effexor, Pristiq, and Cymbalta. Wellbutrin also comes under the name Zyban and is used for smoking cessation. Trazadone is often prescribed for sleep due to its sedative effects. Cymbalta is the first FDA approved treatment for fibromyalgia. Trazadone can cause priapism. 6. Serotonin Syndrome- this can occur with any medications that cause too much serotonin in the synapses. An example would be when a patient is taking more than one antidepressant (one for mood and one for sleep). All patients taking antidepressants should be observed for this syndrome. This link on Mayo clinic describes it in detail: http://www.mayoclinic.com/health/serotonin-syndrome/DS00860 7. Discontinuation Syndrome- this can occur when a patient takes themselves off a medication without tapering. Symptoms include flu like symptoms. It is not life threatening. All antidepressants should be tapered to avoid this syndrome.

GABA 1- Often antidepressants are used to treat anxiety, however they are not considered anxiolytics. The main type of anxiolytics is a benzodiazepine and another medication called Buspar. 2. Benzodiazepines- these work on the GABA neurotransmitter to help calm a person. The GABA neurotransmitter is an inhibitory neurotransmitter, the chill out neurotransmitter. Benzos increase the affect of GABA, making a person chill out more. The problems with Benzos is that they are very addictive. The body develops a tolerance and needs more to function. Benzos are very similar to alcohol. That is why benzos are used to get someone off of alcohol. They also cause very sedating affects and taking concurrently with other drugs or alcohol can be lethal. The ideal is for benzos to

Vandenberg Psychopharmacology/ 2007 be used short term, for example, as long as it takes for an antidepressant to work. However, often you will see that people are on benzo for many years due to the tolerance. Benzos must be tapered- coming off a benzo cold turkey will often result in seizure activity. 3. Buspirone (Buspar)- is a anxiolytic used for anxiety. It takes a few weeks to work and does not have the same effect as Benzos. It is very similar to an antidepressant, though the mechanism of action is unknown. Grapefruit must be avoided. Dopamine 1. Antipsychotics are thought to work on the neurotransmitter, dopamine. It is believed that too much dopamine causes psychotic symptoms. Therefore-it is believed that these medicines block dopamine receptors at the postsynaptic receptor. There are two types: typical (older) and atypical (newer). 2. Typical antipsychotics are not as selective with the dopamine they block and therefore they cause more side effects (they affect more parts of the brain). These side effects are called : EPS (extrapyramidal symptoms), NMS (neuroleptic malignant syndrome like EPS with rigid, high temperature, stupor, confusion), and TD (tardive dyskinesia abnormal movement, worm-like movement mainly of the tongue)- You MUST read about these in your book. They also cause more anticholinergic side effects. The benefit is they are cheap! 3. Atypical antipsychotics are more selective to the parts of the brain and cause less side effects. However, lately they have been proven to contribute significantly to metabolic syndrome (weight gain, high lipids and glucose intolerance). They rarely cause EPS or TD but must be watched as this can happen. 4. Clozaril (clozapine)- has been known to cause significant agranulocytosis. This can happen with other antipsychotics but patients or clozaril must be registered nationally and their WBC count must be monitored often. However, it is a great medication that does a lot of good! 5. EPS can be treated with anticholinergic medications. TD is often irreversible when noticed. Typical: Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Navane, Haldol, Loxitane, Movan, Clozaril Atypical: Zyprexa, Abilify, Seoquel, Risperdal, Geodon, Invega, Saphris Antiparkinsons drugs help the take away the EPS symptoms. Cogentin, Benadryl & Symmetrel most common Watch for orthostatic hypotension

Vandenberg Psychopharmacology/ 2007

Anticonvulsants / Mood Stablizers Patients with mood disturbances (Bipolar and Schizoffective) are often prescribed medication to help stabilize their mood. They are given either Lithium or an anticonvulsant. The mechanism of action for both of these is unknown. 1. Lithium- Read about this in book. However we will discuss it more when studying Bipolar disorder. 2. Anticonvulsants- These are often used to help stabilize mood. They must be tapered when discontinuing to avoid seizure activity. Tegretol, Depakote, Lamictal, Neurontin, Topamax, Trileptal