DEPRESSION
Antidepressants Target symptomsSleep disturbance, appetite disturbance, fatigue, dec’d sex
drive, psychomotor retardation or agitation, diurnal variations
in mood, impaired concentration or forgetfulness, anhedonia
Improvement may take 1-3 wks
Primary considerations:
Side effect profile, ease of administration, h/o past response,
safety & medical considerations, specific subtype of
depression
Secondary considerations:
Neurotransmitter specificity, family h/o response, blood level
considerations, cost
First-line agents:
Selective serotonin reuptake inhibitors (SSRI’s)
Newer atypical antidepressants
Cyclic antidepressants
Second-line interventions:
Monoamine oxidase inhibitors (MAOI’s)
Electroconvulsive therapy (ECT)
SSRI’s- block neuronal uptake of serotonin; first line for all
types except psychotic, melancholic & mild
-lower anticholinergic s/e (dry mouth, blurred vision, urinary
retention), less cardiotoxicity, faster onset than TCA’s
-effective w/ anxiety features & psychomotor agitation
-less dangerous when OD
Common adverse rx-agitation, anxiety, sleep disturbance,
tremor, sexual dysfunction, tension HA, autonomic rx (dry
mouth, sweating, wt change, mild nausea, loose bm)
Potential toxic effects- abd pain, diarrhea, sweating, fever,
tachycardia, elevated BP, altered mental state, myoclonus,
inc’d motor activity, irritability, hostility, mood change,
hyperpyrexia, cardiovascular shock, death
-risk inc when combined w/ 2nd serotonin-enhancing agent
such as MAOI
Serotonergic syndrome: inc HR, BP, fever, seizure
-citalopram (Celexa)
-fluoxetine (Prozac)
-fluvoxamine (Luvox)
-paroxetine (Paxil)
-sertraline (Zoloft)
-excitalopram (Lexapro)
New Atypical Antidepressant- different neurotransmitters &
side effects
-bupropion (Wellbutrin, Zyban)
-trazadone (Desryl)
-venlafaxine (Effexor)
-mirtazapine (Remeron)
-duloxetine (Cymbalta)
-roboxetine (Vestra, Endronax)
Tricylic antidepressants- inhibit reuptake of norepi &
serotonin; takes 10-14 days or longer to start, full effect may
not be seen for 4-8wks, start low go slow
Adverse rx- anticholinergic (dry mouth, blurred vision,
tachycardia, constipation, urinary retention, esophageal
reflux), postural hyptension
Potential toxic effects- dysrhythmias, tachycardia, MI, heart
block
Adverse drug interactions- contraindicated w/ MAOI
Contraindications- recent MI, narrow-angle glaucoma, h/o
seizures, pregnant women
-amitriptyline (Elavil, Endep)
-amoxapine (Ascendin)
-desipramine (Norpramin, Pertofrane)
-doxepin (Adapin, Sinequan)
-imipramine (Tofranil)
-nortriptyline (Aventyl, Pamelor)
-protriptyline (Vivactil)
-trimipramine (Surmontil)
-maprotiline (Ludiomil)
MAOI- inc norepi, serotonin dopamine
s/e-high BP, HTN crisis CVA
-not often given as first-line tx; particularly effective for
atypical depression
Adverse rx- orthostatic hypotension, wt gain, edema, change
in cardiac rate & rhythm, constipation, urinary hesitancy,
sexual dysfunction, vertigo, overactivity, muscle twitching,
hypomanic & manic behavior, insomnia, weakness, fatigue
Potential toxic effects- inc’d BP, intracranial hemorrhage,
hyperpyrexia, convulsion, coma, death, HTN crisis (starts w/
HA, stiff/sore neck, palpitations, inc/dec HR often w/ CP,
N&V, inc temp)
Contraindications- CVS, HTN, CHF, liver disease,
consumption of foods w/ tyramine, tryptophan, dopamine;
recurrent or severe HA; surgery previous 10-14days, <16yrs
-phenelzine (Nardil)
-tranylcypromine (Parnate)
-moclobemide (Manerix, Aurorix)
ECT-can achieve >90% remission rate w/in 1-2wks
Indications- need for rapid, definitive response when
suicidal/homicidal; extreme agitation/stupor; risks of other txs
outweigh risks of ECT; h/o poor drug response, h/o good ECT
response, or both; client prefers it
-major depressive & bipolar, esp w/ psychotic symptoms; &
clients w/ depression w/ marked psychomotor retardation &
stupor
-manics resistant to tx w/ litium & antipsychotic drugs & rapid
cyclers
-pregnant schizo
-Parkinson’s
Integrative approaches:
-light therapy; St. John’s Wort; exercise; transcranial magnetic
stimulation (TMS)
BIPOLAR
lithium (Lithobid)- acute tx of mania & depressive episodes
& prevention of recurrent mania/dep epidsodes
-less effective in people w/ mixed mania
-effective in reducing: elation, grandiosity, expansiveness;
flight of idea; irritability, manipulativeness; anxiety; (to a
lesser extent)-insomnia; psychomotor agitation; threatening or
assaultive behavior; distractibility; hypersexuality; paranoia
Therapeutic levels- 7-14 days; 0.4-1.3mEq/L (toxicity @ 1.5,
>2.0 is life threatening!)
Adverse Rx- hypothyroidism, kidney impairment
Contraindications- CV disease, brain damage, renal disease,
thyroid disease, myasthenia gravis, pregnancy/breast feeding,
children<12yrs
Antiepileptic drugs: dysphoric manic, rapid cycling, EEG
abnormalities, substance abuse, progression in frequency &
severity of symptons, no family h/o
-carbamazepine (Tegretol)- monitor blood levels first 8 wks
-divalproex (Depakote)
-lamotrigine (Lamictal)
-gabapentin (Neurontin)
-topiramate (Topamax)- does not appear to cause wt gain
Anxiolytics-tx of acute mania w/ tx-resistant mania; should be
avoided w/ h/o substance abuse
-clonazepam (Klonopin)
-lorazepam (Ativan)
Antipsychotics- newer atypical have mood-stabilizing
properties
-olanzapine (Zyprexa)
-quetiapine (Seroquel)
ECT- severe manic behavior, esp w/ tx-resistant mania &
rapid cyclers
SCHIZOPHRENIA
Antipsychotics
-3-6wks for effect
Side effects: akathesia, dystonia, akinesia, dyskinesia/tardive
dyskinesia, neuroleptic malignant syndrome
Peripheral nervous system effects: constipation, dry mouth,
nasal congestion, clurred vision, mydriasis, photphobia,
orthostatic hypotension, tachycardia, urinary retention, urinary
hesitation, wt gain, inhibition of ejaculation or impotence in
men
Anticholinergic effects: dry mouth, urinary retention &
hesitancy, constipation, blurred vision, photosensitivity, dry
eyes, inhibition of ejaculation or impotence in men
Extrapyramidal Side Effects (EPS)-acute dystonic rx (opisthotonos, oculogyric crisis);
-akathisia(internal restlessness & external pacing/fidgeting);
-tardive dyskinesia (AIMS test); appears after prolonged tx,
not always reversible: involuntary tonic muscular spasms of
tongue, fingers, toes, neck, trunk or pelvis
-psuedoparkinsonism
Cardiovascular effects- hypotension, postural hypotension,
tachycardia
Rare & toxic effects- Agranulocytosis- sore throat, fever, malaise, mouth sores
- Neuroleptic malignant syndrome (NMS)- dec’d LOC,
greatly inc’d muscle tone, autonomic dysfxn: hyperpyrexia,
labile HTN, tachycardia, tachypnea, diaphoresis, drooling
-tx: early detection; bromocriptine (Parlodel) for mild;
dantrolene (Dantrium) for more severe; ECT
- cholestatic jaundice-
Traditional- dopamine antagonist
Advantages-target positive symptoms; becoming obsolete
because of side effects; less expensive
disadvantages-do not treat neg symptoms, EPS, tardive
dyskinesia, anticholineergic effects, lower seizure threshold
high potency= low sedation + low ACH + high EPS
-haloperidol (Haldol)- least sedating, often used in lg dose for
assaultive behavior
-trifluoperazine (Stelazine)
-fluphenazine (Prolixin)
-thiothixene (Navane)
Medium potency
-loxapine (Loxitane)
-molindone (Moban)
-perphenazine (Trilafon)
Low potency= high sedation + high ACH + low EPS
-chlorpromazine (Thorazine)
-thioridazine (Mellaril)
-mesoridazine (Serentil)
Decanoate= long acting
-haloperidol decanoate (Haldol)
-fluphenazine deconate (Prolixin)
AtypicalAdvantages-diminish neg symptoms as well; fewer side
effects; improve symptoms of anxiety/depression, dec suicidal
Disadvantages- wt gain, metabolic abnormalities
-clozapine (Clozaril)- s/e: agranulocytosis, seizures; weekly
WBC for first 6 mos & frequently after
-risperidone (Risperdal)-olanzapine (Zyprexa)
-quetiapine (Seroquel)
-ziprasidone (Geodon)
-aripiprazole (Abilify)
-paliperidone (Invega)
Antiparkinsonian drugs- to tx s/e
-trihexyphenidyl (Artane)
-benztropine mesylate (Cogentin)
-diphenhydramine hydrochloride (Benadryl)
Amantadine hydrochloride (Symmetrel)
Adjuncts:
Antidepressants; antimanic agents; benzos (can improve
symptoms by ~50%)
Snake root- source of reserpine in antipsychotics