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Antidepressants and Antipsychotics www.indiandentalacademy.com
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The therapy of emotional and mental disorders
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Anxiety Grief Depression are normal human emotions
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The ability to cope with these emotions can range from occasional depression or anxiety to constant emotional distress to the point ofinterfering with the ability to carry on normal daily living.
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When these emotions significantly affect an individual’s ability to carry out normal daily functions, treatment with a psychotherapeutic drug is a possible option.
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Three main emotional and mental disorders:
Psychoses Affective disorders Anxiety
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Psychosis 
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A major emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in everyday life. Hallmark: loss of contact with reality
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Affective Disorders  Major emotional disorders that impair the mental function of the affected individual to the point that the individual cannot participate in everyday life.
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Affective Disorders
Mania: abnormally pronounced emotions Depression: abnormally reduced emotions Bipolar affective disorder: exhibits both mania depression
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Pathophysiology Biochemical Imbalance 
Mental disorders are associated with abnormal levels of endogenous chemicals, such as neurotransmitters, in the brain.
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Pathophysiology Biochemical Imbalance
Brain levels of certain catecholamines play an important role in maintaining mental health. Dopamine Serotonin Histamine
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Pathophysiology Biochemical Imbalance
Other biochemicals are necessary for normal mental function. GABA acetylcholine lithium
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Biogenic Amine Hypothesis 
Depression and mania are due to an alteration in neuronal and synaptic catecholamine concentration at adrenergic receptor sites in the brain. ď‚Ą Depression: deficiency of catecholamine, especially norepinephrine ď‚Ą Mania: excess amines
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Drug Categories
Antidepressants tricyclics, tetracyclics, SSRIs, MAOIs Antimanic Agents lithium
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Cyclic antidepressants tricyclics tetracyclics Monoamine oxidase inhibitors (MAOIs) Second-generation antidepressants and SSRIs
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Tricyclic antidepressants—primary: amitriptyline (Elavil), doxepin (Sinequan), imipramine (Tofranil) Tricyclic antidepressants—secondary: desipramine (Norpramin), nortriptyline (Aventyl), protriptyline (Vivactil) Tetracyclic antidepressants: amoxapine (Asendin), maprotiline (Ludiomil)
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Block reuptake of neurotransmitters, causing accumulation at the nerve endings. It is thought that increasing concentrations of neurotransmitters will correct the abnormally low levels that lead to depression.
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Blockade of norepinephrine: ď‚Ą
antidepressant, tremors, tachycardia, additive pressor effects with sympathomimetic drugs
Blockade of serotonin: ď‚Ą
antidepressant, nausea, headache, anxiety, sexual dysfunction
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Depression Childhood enuresis (imipramine) Obsessive-compulsive disorders (clomipramine) Adjunctive analgesics Trigeminal neuralgia
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Sedation Impotence Orthostatic hypotension Older patients:
dizziness, postural hypotension, constipation, delayed micturation, edema, muscle tremors
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Lethal—70 to 80% die before reaching the hospital CNS and cardiovascular systems are mainly affected Death results from seizures or dysrhythmias No specific antidote
Decrease drug absorption with activated charcoal Speed elimination by alkalinizing urine Manage seizures and dysrhythmias Basic life support www.indiandentalacademy.com
Highly effective Considered second-line treatment for depression not responsive to cyclics Disadvantage: potential to cause hypertensive crisis when taken with tyramine
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phenelzine (Nardil) tranylcypromine (Parnate) isocarboxazid (Marplan)
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Inhibit the MAO enzyme system in the CNS Amines (dopamine, serotonin, norepinephrine) are not broken down, resulting in higher levels in the brain Result: alleviation of symptoms of depression
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Depression, especially types characterized by reverse vegetative symptoms such as increased sleep and appetite Depression that does not respond to other agents such as tricyclics
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Few side effects—orthostatic hypotension most common Tachycardia
Impotence
Palpitations Dizziness
Drowsiness
Insomnia
Headache
Anorexia
Nausea
Blurred vision
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Symptoms appear 12 hours after ingestion
Tachycardia, circulatory collapse, seizures, coma
Treatment: protect brain and heart, eliminate toxin
Gastric lavage
Urine acidification
Hemodialysis
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Ingestion of foods and/or drinks with the amino acid TYRAMINE leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death
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Avoid foods that contain tyramine!
Aged, mature cheeses (cheddar, blue, Swiss) Smoked/pickled or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté) Yeast extracts Red wines (Chianti, burgundy, sherry, vermouth) Italian broad beans (fava beans)
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Newer Fewer side effects than tricyclics, but not superior in overall efficacy or onset of action
trazodone (Desyrel) bupropion (Wellbutrin, Zyban) selective serotonin reuptake inhibitors (SSRIs)
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Selectively inhibit serotonin reuptake Little or no effect on norepinephrine or dopamine reuptake Results in increased serotonin concentrations at nerve endings Advantage over tricyclics and MAOIs: Little or no effect on cardiovascular system
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Used for depression—very few serious side effects
Bipolar affective disorder
Obesity
Eating disorders
Obsessive-compulsive disorder
Panic attacks
Myoclonus
Treatment of various substance abuse problems (bupropion [Zyban] is used for smoking cessation treatment) www.indiandentalacademy.com
Body System
Effects
CNS
Headache, dizziness, tremor, nervousness, insomnia, fatigue Nausea, diarrhea, constipation, dry mouth Sweating, sexual dysfunction
GI Other
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Highly bound to plasma proteins Compete with other protein-binding drugs, resulting in more free, unbound drug to cause a more pronounced drug effect
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Drugs used to treat serious mental illness Behavioral problems or psychotic disorders
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Thioxanthenes: chlorprothixene, thiothixene (Navane) Butyrophenones: haloperidol (Haldol) Dihydroindolones: molindone (Moban) Dibenzoxazepine: loxapine (Loxitane) Phenothiazines: three structural groups
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Aliphatic: chlorpromazine (Thorazine), triflupromazine (Vesprin) Piperidine: mesoridazine (Serentil), thioridazine (Mellaril) Piperazine: fluphenazine (Prolixin), perphenazine (Trilafon), prochlorperazine (Compazine), trifluoperazine (Stelazine) Largest group of psychotropic agents
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clozapine (Clozaril) risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel)
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Block dopamine receptors in the brain (limbic system, basal ganglia)—areas associated with emotion, cognitive function, motor function Dopamine levels in the CNS are decreased Result: tranquilizing effect in psychotic patients
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The newer, atypical antipsychotics also block specific serotonin receptors (serotonin-2 [5HT2] receptors). This is responsible for their improved efficacy and safety profiles.
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Block dopamine receptors in CNS
Block alpha receptors (causing hypertension, other cardiovascular effects)
Block histamine receptors (causing anticholinergic effects)
Block serotonin
Also function as antiemetics
Antianxiety effects www.indiandentalacademy.com
Treatment of serious mental illnesses:
Bipolar affective disorder
Depressive and drug-induced psychoses
Schizophrenia
Autism
Movement disorders (such as Tourette’s syndrome)
Some medical conditions
Nausea, intractable hiccups www.indiandentalacademy.com
Body System
Effects
CNS Cardiovascular
Sedation, delirium Orthostatic hypotension, syncope, dizziness, ECG changes Photosensitivity, skin rash, hyperpigmentation, pruritus
Dermatologic
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Body System
Effects
GI GU
Dry mouth, constipation Urinary hesitancy or retention, impaired erection Hematologic Leukopenia and agranulocytosis Metabolic/endocrine Galactorrhea, irregular menses increased appetite, polydipsia
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Before beginning therapy, assess both the physical and emotional status of patients Obtain baseline VS, including postural BP readings Obtain liver and renal function tests (and baseline platelet levels for MAOIs)
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Assess for possible contraindications to therapy, cautious use, and potential drug interactions Assess LOC, mental alertness, potential for injury to self and others Check the patient’s mouth to make sure oral doses are swallowed
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Provide simple explanations about the drug, its effects, and the length of time before therapeutic effects can be expected Abrupt withdrawal should be avoided Advise patients to change positions slowly to avoid postural hypotension and possible injury
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The combination of drug therapy and psychotherapy is emphasized because patients need to learn and acquire more effective coping skills
Only small amounts of medications should be dispensed at a time to minimize the risk of suicide attempts
Simultaneous use of these agents with alcohol or other CNS depressants can be fatal www.indiandentalacademy.com
Antidepressants 
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Many cautions, contraindications, and interactions exist pertaining to the use of antidepressants. Inform patients that it may take 1 to 3, even 4, weeks to see therapeutic effects. Monitor patients closely during this time and provide support.
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Antidepressants 
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Sedation often occurs with tricyclic therapy; notify physician if this lasts more than 2 weeks. Assist elderly or weakened patients with ambulation and other activities as falls may occur due to drowsiness or postural hypotension.
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Antidepressants
Tricyclics may need to be weaned and discontinued before undergoing surgery to avoid interactions with anesthetic agents. Monitor for side effects and discuss with patients. Encourage patients to wear medication ID badges naming the agent being taken.
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Antidepressants 
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Caffeine and cigarette smoking may decrease effectiveness of medication therapy Instruct patients and family regarding tyraminecontaining foods and signs and symptoms of hypertensive crisis
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Antipsychotics—Phenothiazines
Instruct patients to wear sunscreen due to photosensitivity Avoid taking antacids or antidiarrheal preparations within 1 hour of a dose Do not take alcohol or other CNS depressants with these medications
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Antipsychotics—Phenothiazines
Long-term haloperidol therapy may result in tremors, nausea, vomiting, or uncontrollable shaking of small muscle groups; these symptoms should be reported to the physician Oral forms may be taken with meals to decrease GI upset These agents may cause drowsiness, dizziness, or fainting; instruct patients to change positions slowly
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Monitor for therapeutic effects:  Monitor mental alertness, cognition, affect, mood,ability to carry out activities of daily living, appetite, and sleep patterns  Monitor the patient’s potential for self-injury during the delay between the start of therapy and symptomatic improvement
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Monitor for therapeutic effects  For antidepressants: 
Improved sleep patterns and nutrition, increased feelings of self-esteem, decreased feeling of hopelessness, increased interest in self and appearance, increased interest in daily activities, fewer depressive manifestations or suicidal thoughts or ideations
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Monitor for therapeutic effects For antipsychotics:
Improved mood and affect, alleviation of psychotic symptoms and episodes Decrease in hallucinations, paranoia, delusions, garbled speech, inability to cope
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