UNDERSTANDING PSYCHOTROPIC MEDICATIONS

Psychotropic medications are a group of medications that are used to treat behavioral/mental health disorders.

Drugs are classified in several ways. They may be classified according to their clinical structure, clinical use or mechanism of action and their therapeutic effect.

There are numerous classification of medications:

  • Cardiac
  • Cancer
  • Sleep Disorders/Hypnotics
  • Fluid/Electrolyte Balance
  • Pain Management
  • Antinflammatory
  • Antiviral/Antibacterial
  • Pulmonary

ANTIDEPRESSANTS: classification of medications to treat depression.

SSRI’s First introduced in the 1980’s. Selective Serotonin Reuptake Inhibitors. SSRI’s concerned first line medication for treatment of depression. However it has a broad spectrum of applications. It is also used to treat anxiety disorders, bipolar depression, eating disorders and premenstrual dysphoria.

It is well tolerated in both long term and short term use. It has a low risk for seizures, low lethality with overdose, usually low weight gain with the expection of Paxal/Paroxetine.

SSri’s tend to be highly protein bound and have significant differences in half-lives. Prozac has a long half like good for tapering off other SSRI’s.

COMMON SIDE EFFECTS; SSRI’s

  • GI
  • Dizziness
  • Anxiety
  • Agitation
  • Headaches
  • Insomnia
  • Sexual dysfunction

LESS COMMON SIDE EFFECTS

  • Rash
  • Swollen joints

SSRI’s do not have cholinergic, (acetylcholine), histaminergic (effects B/P) and andrenegic.

Patients who discontinue one SSRI may be successfully treated with another.

SEROTONIN SYNDROME

Serious and potentially fatal side effect. That may occur when mixing an SSRI with an MAIO, St. Johns Wort , certain ingredient in cough syrup (dextrometnorphan Robitussin DM), Medication for migraine treatment: Amerge, Axert, Frova, Initrex, Maxalt, Naraming, Relpax and Zomig, diet pill Meridia, pain relivers: Demerol, Ultram.

SIDE EFFECTS SEROTONIN SYNDROME

  • Tachycardia/rapid heart rate
  • Anxiety
  • Sweating
  • Nausea
  • Vomiting
  • Diarrhea
  • Uncontrollable tremors/muscle contractions
  • Lack of coordination
  • Confusion
  • Hypertension/high pressure
  • Hallucinations
  • Coma

ANTIDEPRESSANTS

ATYPICALS

  • Nefazodone/Serzone
  • Mitazapine/Remeron
  • Venlafaxine/Effexor
  • Bupropion/Wellbutrin
  • Duloxetine/Cymbalta

Serzone: seldom used, increased liver disease

Cymbalta: Duel reuptake of both serotonin and norepinephrine, good pain relief. Side Effects similar to Effexor.

Effexor: Inhibits serotonin and norepinephrine reuptake, absorbed rapidly. Side effects: somnolence, dry mouth, dizziness, constipation, nervousness, sweating, anorexa. May effect B/P with high doses, does inhibit cytocrome P450 so it has a low potential for drug interactions. It has little effect on Lithium, benzos. It is good with treatment resistant, chronically depressed patients, bipolar depression, depression with ADHD, depression with general symptoms of anxiety and pain.

Remeron: potent 5HT2 & 5HT3 antagonist, causing enhancement of serotonergic transmission. Side effects: somnolence, increase appetite, weight gain, dizziness. It has a long ½ life (30hrs). Do not give with MAOI.

ANTIDEPRESSANTS

TRICYCLICS/HETEROCYCLICS

Tricyclics are well absorbed from the GI tract, have a half-life of about 24 yrs, and are metabolized in the liver. Some metabolites have active antidepressant effects: Desipramine is a metabolite of Imipramine, Nortriptyline is a metabolite of Amitriptyline.

SIDE EFFECTS

Include anticholinergic effects on the peripheral autonomic nervous system. Effects include dry mouth, visual disturbances (blurred vision and photosensitivity). These medications can also precipitate an acute attack of glaucoma. Anticholinergic effects on the cardiovascular system are common and include tachycardia, arrhythmias, which can lead to myocardial infarction, heart block or both. Pts with a history of glaucoma or cardiac problems should be evaluated.

Tricyclics also effect the central nervous system including sedation (histamine blockade), condusion, disorientation, delusions, agitation and hallucinations.

Overdose of Tricyclics was a real concern. In the 1980’s 25-50% of admissions were for psychotropic overdos of TCA’s. The difference is slight between a therapeutic dose and a health impairing or lethal dose. As little as a one week supply can be fatal.

HETEROCYCLICS

Amoxapine/Asendin, is a secondary amine heterocyclic, is a novel compound not related to the TCA’s. It is a metabolite of the antipsychotic drug loxapine and flocks dopamine receptors (D1 and D2). Amoxapine poteniates norepinephrine. It has the faster rate of onset of action than other antidepressant. However, extrapyramidal and neuroleptic side effects are common.

Maprotiline/Ludiomil: It potentiates norepinephrine, has relatively mild potential for anticholinergic effects and is sedating. This is a potent drug and increases are made slowly.

Trazodone/Desyrel: potentiates serotonin reuptake inhibition and is a 5HT2 receptor antagonist. It has virtually low anticholinergic effects and low potential for cardiac effects. Trazodone’s absorption is increased by 20% if taken with a meal. Trazodone may cause priapism (prolonged penile erection). This side effects tends to occur in higher doses in younger men.

MAOI’s

Another class of antidepressant, are prescribed as last line agent after the other classes have been tried. MAOI are particulary effective in treating atypical depression. May also be effective in treating certain types of anxiety syndromes. These drugs block monoamine oxidase, a major enzyme involved in the metabolic decomposition and thus the inactivation of norepinephrine, serotonin, and dopamine. The increased level of these neurotransmitters in the PNS and CNS can be dramatic. This mechanism is in contrast to mechanisms of TCA’s and other agents, which achieve the normal level or restore the relative deficiency by preventing the reuptake of amines, increasing the release of amines.

MAOI’s are absorbed from the GI tract and metabolized in the liver.

SIDE EFFECTS

PNS, the slow release of norepinephrine causes decreased heart rate, decrease vasoconstriction and hypotension. It may also lead to elevated levels of other drugs because MAOI’s inhibit monoamine oxidase in the liver.

Hypotention is the most common side effect. It may also cause anticholinergic effects: dry mouth, blurred vision, constipation, urinary retention. Because MAOi’s increase the availability of biogenic amines in the brain, CNS hyperstimulation may also occur, causing agitation, acute anxiety, restlessnessm insomnia and euphoria. Full schizophrenic episodes as a response to MAOI’s may also develop. Hypomania is also a common effect.

MAOI’s should not be given with other antidepressants: SSRI’s, TCA’s and a wash out period of 2 weeks is recommended.

Dietary restrictions: avoid foods rich in Tyramine

  • Alcoholic beverages: Beer and ale, chianti and sherry wine.
  • Dairy products: Cheese (cheddar, bleu, brie and mozzarella), sour cream, Yogurt
  • Meats: Bolongam chicken liver, fish, fried, liver, meat tendieizer, pickled herring salami, sausage
  • Fruits and Vegetables: Avocados, bananas, fava beans, canned figs
  • Other foods: caffeinated coffee, colas, tea, chocolate, licorice, soy sauce, yeast

HYPERTENSIVE CRISIS: palpations, tightness in the chest, stiff neck, and throbbing, radiating headache. Extremely high blood pressure with elevated heart rate is common.

MOOD STABILIZERS

Lithium: first line treatment, naturally occurring salt. Side effects: ataxia, confusion, hand tremors, increased deep tendon reflexes, joint pain, muscle stiffness, nystagmus, sedation and visual changes. The condition may progress to include movement abnormalities, tremors, seizures, coma and CV collapse.

ANTIPSYCHOTICS:

Typicals vs Atypicals

Typical: Developed in the 1950’s, classified based on chemical structure. These drugs are classified based on potency, or the ability to antagonize (occupy) dopamine D2 receptors. Clinical effectiveness occurs when about 60-70% of these receptors are blocked.

Atypical: Agents developed and released since the 1990’s. First atypical marketed in the US was Clozapine in the 1990.

Side Effects: Hypokinetic types

  • EPS/Extra pyramidal: caused by hypodopaminergic state, offending agents, tyupically high-potency antipsychotics. Side effects; akathisia (restlessness, agitation), akinesia (abnormal motor and psychic hypoactivity or muscular paralysis), dystonia (impairment of muscle tone, commonly involves the head, neck and tongue), drug induced parkinsonism.
  • Hyperkinetic type: caused by nigrostriatal receptor supersensitivity, offending agents: typically high potency antipsychotics: EPSE tardive dyskinesia (involuntary, repetitious movements of the muscles of the face, the limbs, and the trunk)

Kava:tranquilizer, sedative, narcotic, analgesic. Banned in Germany, US other countries.

SaMe: treat depression, increases the synthesis of neurotransmitters such as serotonin and norepinephrine. Side effect: mania