2. Antidepressants, Antipsychotics, Antianxiety Agents, and Alcoholism
Chapter 7
Antidepressants, Antipsychotics, Antianxiety Agents, and Alcoholism

3. Chapter 7 Topics Antidepressants Antipsychotics Antianxiety Agents
Panic Disorders
Sleep Disorders
Alcoholism

4. Learning Objectives
Differentiate the antidepressant, antipsychotic, and antianxiety agents.
Be prepared to discuss the antidepressant classes, their uses, and their side effects.
Know why and how lithium and other drugs are used in treating bipolar disorders.

5. Learning Objectives
Be familiar with antipsychotics and the drugs that prevent their side effects.
Define anxiety, learn its symptoms, and know the drugs used in its treatment.
Recognize the course and treatment of panic disorders, insomnia and alcoholism.

6. Antidepressants Used to treat depression Depression, common feelings
Pessimism
Worry
Intense sadness
Loss of concentration
Slowing of mental processes
Problems with eating and sleeping

7. Antidepressants Common Symptoms of Depression
Loss of interest in usual activities
Low self-esteem
Self-pity
Significant weight loss or gain
Insomnia or hypersomnia
Extreme restlessness
Loss of energy
Feelings of worthlessness
Diminished ability to think
Feelings of guilt
Recurrent thoughts of death
Suicide attempts

8. Antidepressants Depression Women are affected more often than men
When men are affected, it is usually later in life
Levels of neurotransmitters in the brain may be a causative factor

9. Mood Disorders
Mania
Bipolar Disorder
Unipolar Disorder

10. Mood Disorders Mania Bipolar Disorder Unipolar Disorder
Mood of extreme excitement, excessive elation, hyperactivity, agitation, and increased psychomotor activity
Bipolar Disorder
Unipolar Disorder

11. Mood Disorders Mania Bipolar Disorder Unipolar Disorder
Mood swings alternate between major depression and mania
Unipolar Disorder

12. Mood Disorders Mania Bipolar Disorder Unipolar Disorder
Major depression with no previous occurrence of mania

13. Discussion
Describe the differences that may be seen in patients with unipolar and bipolar disorders.

14. Discussion
Describe the differences that may be seen in patients with unipolar and bipolar disorders.
Answer
Unipolar – Depression Symptoms Bipolar – Depression and Mania Symptoms

15. Treatment for Depression
Electroconvulsive Therapy
Introduction of brief, but convulsive electrical stimulation through the brain
Can induce seizures
Effective for major and delusional depression

16. Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs)
Cyclic Antidepressants
Monoamine Oxidase Inhibitors (MAOIs)

17. Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs)
Block the reuptake of serotonin, with little effect on norepinephrine
Fewer side effects than older meds

18. Treatments Cyclic Antidepressants Two Types
Tricyclic antidepressants (TCAs)
Tetracyclic antidepressants
Prevent reuptake of norepinephrine and/or serotonin
Agents in this class differ in adverse effects, cost, and response

19. Treatments Monoamine Oxidase Inhibitors (MAOIs)
Allows for buildup of norepinephrine at the synapse

20. Drug List SSRIs for Depression citalopram (Celexa)
escitalopram (Lexapro)
fluoxetine (Prozac,)
paroxetine (Paxil)
sertraline (Zoloft)
venlafaxine (Effexor)

21. Dispensing Issues Warning! Look-Alike Drugs
Prozac and Proscar (urinary drug)
Zoloft and Zocor (high cholesterol)
Celexa and Cerebyx (seizures) and Celebrex (arthritis)

22. SSRI Dispensing Issues
Warning!
Do not discontinue abruptly
Alcohol consumption should be avoided while taking these medications

23. fluoxetine (Prozac)
Indicated for major depression and obsessive-compulsive disorder (OCD)
Anorexia is a possible adverse effect
Take in the morning to avoid insomnia

24. paroxetine (Paxil)
Indicated for depression, obsessive-compulsive disorder, and panic disorder

25. venlafaxine (Effexor)
Blocks reuptake of serotonin and norepinephrine
Indicated for depression
May cause increase in blood pressure and blurred vision

26. sertraline (Zoloft)
Indicated for depression and obsessive-compulsive disorder
Primary side effect is nausea
May also cause drowsiness

27. citalopram (Celexa)
Indicated for depression and obsessive-compulsive disorder
Minimal drug interactions

28. escitalopram (Lexapro)
Similar to Celexa
More potent with fewer side effects

29. Cyclic Antidepressants
Drug List
Cyclic Antidepressants
Tricyclic
amitriptyline (Elavil)
nortriptyline (Pamelor)

30. Tricyclic Antidepressants Dispensing Issues
Warning!
Improvements are usually seen in 10 to 21 days
Can be cardiotoxic in high doses
May cause postural hypotension

31. Tricyclic Antidepressants Dispensing Issues
Warning!
Do not discontinue abruptly.

32. Cyclic Antidepressants Side Effects
Sedation is common, but tolerance usually occurs
Have many anticholinergic effects

33. Discussion
Why would cyclic antidepressants be prescribed for bed wetting in children?

34. Discussion
Why would TCAs be prescribed for bed wetting in children?
Answer
They may be prescribed because of their anticholinergic side effects.

35. Drug List MAOIs phenelzine (Nardil) selegiline (Eldepryl)
tranylcypromine (Parnate)

36. MAOI Dispensing Issues
Warning!
Be cautious of many interactions with foods such as aged cheeses, concentrated yeast extracts, pickled fish, sauerkraut, broad bean pods, chocolate, and alcohol.

37. MAOI Dispensing Issues
Warning!
If changing to another class of antidepressant, patient must have a two-week “wash out” period before starting the new medication.

38. Other Antidepressants
Drug List
Other Antidepressants
bupropion (Wellbutrin, Zyban)
mirtazapine (Remeron)
trazodone (Desyrel)

39. trazodone (Desyrel) Prevents reuptake of serotonin and norepinephrine
Has a better side effect profile than TCAs
Caution: possible interaction with Ginkgo

40. bupropion (Wellbutrin, Zyban)
Dopamine-uptake inhibitor
Does not cause sedation, blood pressure changes, or ECG changes
Do not discontinue abruptly
Approved in the aid of smoking cessation

41. Other Antidepressant Dispensing Issues
Warning!
Wellbutrin SR = BID dosing
Wellbutrin XL = QD dosing

42. Bipolar Disorders Signs or Symptoms Decreased need for sleep
Elevated or irritable mood
Excessive involvement in pleasurable activities with a big potential for painful consequences
Grandiose ideas
Pressure to keep talking
Racing thoughts

43. Discussion
What is the drug of choice for treating bipolar disorders?

44. Discussion Answer Lithium
What is the drug of choice for treating bipolar disorders?
Answer
Lithium

45. Discussion
What is the two-fold objective of drug therapy for bipolar disorder?

46. Discussion Answer Treat acute episodes Prevent subsequent attacks
What is the two-fold objective of drug therapy for bipolar disorder?
Answer
Treat acute episodes
Prevent subsequent attacks

47. Drugs to Treat Bipolar Disorders
Drug List
Drugs to Treat Bipolar Disorders
carbamazepine (Tegretol)
divalproex (Depakote)
lithium (Lithobid)
olanzapine-fluoxetine (Symbyax)
valproic acid (Depakene)

48. Lithium Side Effects Gastrointestinal Dermatologic Hematologic
Neuromuscular
Weight
Renal
Teratogenic

49. Lithium Dispensing Issues
Warning!
Lithobid tablets are only effective for 6 months. Be sure to highlight expiration dates on containers.

50. divalproex (Depakote)
Beneficial for patients with rapid mood changes
Take with food or milk, but not carbonated drinks
Beware of symptoms of thrombocytopenia

51. Antipsychotics Also called neuroleptics
Schizophrenia is the primary indication
Retreat from reality
Delusions
Hallucinations
Ambivalence
Withdrawal
Bizarre or regressive behavior

52. Antipsychotics
Helps with thought disorders, hallucinations, and delusions
Does not help with emotional and social withdrawal, ambivalence, or poor self-care

53. Drug List Antipsychotics aripiprazole (Abilify) clozapine (Clozaril)
fluphenazine (Prolixin)
haloperidol (Haldol)
loxapine (Loxitane)

54. Drug List Antipsychotics molindone (Moban) olanzapine (Zyprexa)
prochlorperazine (Compazine)
quetiapine (Seroquel)

55. Drug List
Antipsychotics
risperidone (Risperdal)
thioridazine

56. Antipsychotic Side Effects
Anticholinergic
Cardiovascular
Dermatologic
Endocrine
Hematologic
Ophthalmologic

57. Antipsychotic Side Effects
Withdrawal
Neurologic
Dystonia
Akathisia
Pseudoparkinsonism
Tardive dyskinesia

58. Atypical Antipsychotics
Have improved efficacy and reduced side effects
Better tolerated, but associated with metabolic side effects

59. risperidone (Risperdal)
Indicated for management of psychotic disorders and dementia in the elderly
It is a serotonin-dopamine antagonist

60. Dispensing Issues Warning!
Clozaril (antipsychotic) and Clinoril (antibiotic) are look-alike/sound-alike drugs.

61. olanzapine (Zyprexa) Used for schizophrenia
Blocks dopamine and serotonin receptors
Causes fewer movement disorders and is more effective
Alcohol must be avoided

62. Dispensing Issues Warning!
Zyprexa (antipsychotic) and Zyrtec (antihistamine) are look-alike/sound-alike drugs.

63. quetiapine (Seroquel)
Related to Clozaril
Lower incidence of hematologic toxicities

64. Minimizes Side Effects of Antipsychotics
Drug List
Minimizes Side Effects of Antipsychotics
benztropine (Cogentin)
diphenhydramine (Benadryl)
meclizine (Antivert)

65. Antianxiety Agents Anxiety
State of uneasiness characterized by apprehension and worry about possible events

66. Antianxiety Agents Two Types of Anxiety Exogenous Endogenous
Response to external stresses
Endogenous
Not related to external stresses, result of abnormality in cellular function in the CNS

67. Discussion
What is the most common self-prescribed treatment for anxiety?

68. Discussion Answer Alcohol
What is the most commonly self-prescribed treatment for anxiety?
Answer
Alcohol

69. Antianxiety Agents Benzodiazepines Other Controlled Medications
Some Non-Controlled Medications

70. Drug List Antianxiety Agents amoxapine buspirone (BuSpar)
hydroxyzine (Vistaril), antihistamine
paroxetine (Paxil), SSRI

71. Drug List Antianxiety Agents propranolol (Inderal), beta blocker
venlafaxine (Effexor)

72. Drug List Antianxiety Agents Benzodiazepines, C-IV alprazolam (Xanax)
chlordiazepoxide (Librium)
clorazepate (Tranxene)
diazepam (Valium)
lorazepam (Ativan)
oxazepam (Serax)

73. Antianxiety Agnets Benzodiazpines May cause physical dependence, C-IV
Should not be stopped abruptly
Side Effects
Muscle relaxation
Paradoxical excitement
Sedation

74. Dispensing Issues Warning!
Xanax (antianxiety) and Zantac (H2 Antagonist for the stomach) are look-alike/sound-alike drugs.

75. propranolol (Inderal)
Beta blocker used to treat physical symptoms of anxiety
Not officially indicated for this use
Lowers heart rate which decreases nervousness due to stage fright or test anxiety

76. buspirone (Buspar) Selectively antagonizes serotonin receptors
Take with food
Report changes in the senses

77. Dispensing Issues Warning!
Buspirone (antidepressant/antianxiety) and bupropion (antidepressant) are look-alike/sound-alike drugs.

78. Panic Disorders
Panic
Intense, overwhelming, and uncontrollable anxiety
Neither a controllable voluntary emotion nor a condition that can be avoided by ignoring it or wishing it away

79. Panic Disorders Can occur anywhere at anytime Criteria for Diagnosis
Three attacks in a three-week period
At least four qualifying symptoms

80. Panic Disorders Pathophysiology Result from a neurochemical defect
The brain stem is a pathway for sensory information
If there is a defect in the brain stem, stimuli can be excessively amplified and cause an overreaction

81. Panic Disorders Treatment
Combination of antipanic medication and behavioral therapy
Psychotherapy is preferred treatment when symptoms cause significant discomfort or impairment
Antianxiety medications are indicated for short-term treatment

82. Discussion
What fraction of Americans 18 and older have a sleep disorder?

83. Discussion
What fraction of Americans 18 and older have a sleep disorder?
Answer
1/3

84. Sleep Disorders Insomnia
Difficulty falling or staying asleep or not feeling refreshed on awakening
Treated with hypnotics (to induce sleep)

85. Sleep Disorders
Causes
Situational

86. Sleep Disorders
Causes
Situational
Medical

87. Sleep Disorders
Causes
Situational
Medical
Psychiatric

88. Sleep Disorders
Causes
Situational
Medical
Psychiatric
Drug induced

89. Sleep Disorders Stages of Sleep Stage 1
Somewhat aware of surroundings, but relaxed

90. Sleep Disorders Stages of Sleep Stage 1 Stage 2
Somewhat aware of surroundings, but relaxed
Stage 2
Unaware of surroundings, but can easily be awakened

91. Sleep Disorders Stages of Sleep Stage 1 Stage 2 Stage 3
Somewhat aware of surroundings, but relaxed
Stage 2
Unaware of surroundings, but can easily be awakened
Stage 3
Deep sleep (REM sleep); dreams occur

92. Sleep Disorders Narcolepsy
Involves recurring, inappropriate episodes of sleep during the daytime hours
No known cause
Occurs four times more in men than women

93. Sleep Disorders Characteristic Symptoms
Patient feels sleepy during the daytime and then enters into REM sleep

94. Sleep Disorders Characteristic Symptoms
Patient feels sleepy during the daytime and then enters into REM sleep
Patient experiences cataplexy with sudden emotions

95. Sleep Disorders Characteristic Symptoms
Patient feels sleepy during the daytime and then enters into REM sleep
Patient experiences cataplexy with sudden emotions
Sleep paralysis

96. Sleep Disorders Characteristic Symptoms
Patient feels sleepy during the daytime and then enters into REM sleep
Patient experiences cataplexy with sudden emotions
Sleep paralysis
Very vivid hallucinations at the onset of sleep

97. Sleep Disorders Treatment of Narcolepsy Nondrug Therapy Drug Therapy
Lifestyle changes
Drug Therapy
Stimulants
Tricyclic antidepressants
SSRIs

98. Sleep Disorders Pharmacological Treatment Nonpharmacological Treatment
Hypnotics
Nonpharmacological Treatment
Normalizing sleep schedule
Increases physical exercise
Discontinuing alcohol use as a sedative
Sleep only 7-8 hours/24 hr
Reducing caffeine and nicotine intake

99. Sleep Disorders Treatment
Hypnotics should be used in conjunction with other medical therapeutics
Benzodiazepines are the preferred agents
Hypnotics should not be taken every night, only as needed

100. Dispensing Issues Warning!
Diazepam, lorazepam, and alprazolam can be misread and misheard.

101. Drug List Sleep Agents Benzodiazepines, C-IV alprazolam (Xanax)
chlordiazepoxide (Librium)
clorazepate (Tranxene)
diazepam (Valium)
estazolam (ProSom)
flurazepam (Dalmane)

102. Drug List Sleep Agents Benzodiazepines, C-IV lorazepam (Ativan)
oxazepam (Serax)
temazepam (Restoril)
triazolam (Halcion)

103. Drug List Sleep Agents Barbiturates amobarbital (Amytal), C-II
butabarbital (Butisol), C-III
secobarbital (Seconal), C-II
Antihistamines
diphenhydramine (Benadryl)
hydroxyzine (Vistaril)

104. Drug List Sleep Agents Hypnotic chloral hydrate Others
zaleplon (Sonata)
zolpidem (Ambien)

105. zolpidem (Ambien)
Targets benzodiazepine receptors with less effects on skeletal muscles and seizure threshold
Short-term treatment only
Should not be used for more than 10 days
Alert the pharmacist, but realize there are exceptions

106. Alcoholism
Denial is one of the major roadblocks for a patient to overcome before getting help
Linked to genetics
No cure, but can be arrested

107. Alcoholism Effects on Metabolism and Excretion
Alcohol is an anesthetic and can cause loss of consciousness
Emetic action prevents death by preventing absorption of lethal concentrations
Habitual drinkers metabolize ETOH quicker, which increases tolerance

108. Alcoholism Side Effects
Vitamin deficiency
Gastritis
Organic brain damage
Alcoholic psychosis and dementia
Cirrhosis of the liver (irreversible damage)

109. Alcoholism Symptoms of Dependence on Alcohol
Blackouts or lapses of memory
Concerns of family, friends, and employers about the substance use
Doing things that cause regret afterwards
Financial or legal problems from substance use
Loss of pleasure with the substance

110. Alcoholism Symptoms of Dependence on Alcohol
Neglecting responsibilities
Trying to cut down or quit using a substance, but failing
Using alone; hiding evidence
Using to forget about problems
Willingness to do almost anything to get the substance

111. Alcoholism Steps Towards Recovery Acknowledge the problem
Limit the time spent with substance abusers
Seek professional help
Seek support from recovering alcoholics

112. Alcoholism Withdrawal Symptoms Agitation Circulatory disturbances
Convulsions
Delirium treatments
Digestive disorders
Disorientation
Extreme fear

113. Alcoholism Withdrawal Symptoms Hallucinations Mental disturbances
Nausea and vomiting
Restlessness
Sweating
Temporary suppression of REM sleep
Tremor and weakness

114. Drug List Alcohol Antagonists disulfiram (Antabuse) naltrexone (Revia)
topiramate (Topamax) – not approved yet

115. disulfiram (Antabuse)
Stops the metabolism of alcohol
Upon consumption of alcohol, side effects are immediate:
Blurred vision – Confusion
Difficulty breathing – Chest pain
Severe headache – Nausea
Severe vomiting – Uneasiness
Face becomes hot & scarlet – Thirst

116. disulfiram (Antabuse)
Patients must read labels to avoid ETOH:
Cough medicines
Mouthwashes
Flavorings
Salad dressings

117. topiramate (Topamax)
Anticonvulsant that can reduce cravings for alcohol
Takes six weeks to be effective
Topamax mixed with behavioral therapy looks promising in the treatment of alcoholism