Chapter 8
Drug for Psychiatric and Mood
Disorders
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Chapter 8
Topics
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Anatomy and Physiology of Neurotransmission
Depression
Anxiety
Insomnia
Bipolar Disorder
Schizophrenia and Psychosis
Herbal and Alternative Therapies
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Anatomy and Physiology of Neurotransmission
Neurotransmitters
• Are chemicals that transmit signals from nerve cell to
nerve cell within the brain
• Includes serotonin, norepinephrine, and dopamine
• Are released from a cell, cross the synaptic cleft, connect
with receptors on membranes of adjacent cells
 Are then either taken back up into presynaptic nerve
cell (a process called reuptake) or broken down by
metabolic enzymes while in the cleft
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Anatomy and Physiology of Neurotransmission
Neurotransmitters (continued)
• Monoamine oxidase
 Is an enzyme that breaks down neurotransmitters in
neurons
• Disorders affecting mood and mental function are related
to deficiency or dysfunction of neurotransmitters
• Drug therapy manipulates levels of neurotransmitters
 Mimics their actions or alters the processes that
eliminate them from the synaptic cleft
 Allows them to remain in the synaptic cleft longer and
activate more receptors
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Anatomy and Physiology of Neurotransmission
Signal
Conduction
Across the
Synaptic Cleft
Drug therapy
either blocks
reuptake or
breakdown of
neurotransmitters
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Depression
About Depression
• Treatment accounts for several of the top 50 prescription
medications in the United States
• Two types
 Exogenous (external) sources, such as the
response to the death of a loved one
 Endogenous (internal) causes that do not have logical,
observable reasons for happening
Is more likely to require drug therapy to control
• Neurotransmitters involved in mood include
norepinephrine, serotonin, and dopamine
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Depression
Signs
Crying (often no cause), no interest in life
or social activities, increased focus on
death, and significant weight loss or gain
Symptoms
Low self-esteem, pessimism, difficulty
sleeping, loss of energy and ability to think,
confusion, poor memory, feeling worthless
and guilty, and thoughts of suicide
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Depression
Antidepressants
• Includes SSRIs, SNRIs, TCAs, MAOIs, bupropion, and
trazodone
• Takes 3–6 weeks for patients to feel effects
 Takes time for the number of receptors for transmitters
to increase and cells to adapt
• Drug therapy trial should last 3–4 weeks
• Doses should only be changed once a month by prescriber
• Caution: do not stop use abruptly because it may worsen
symptoms
 Gradually decrease doses
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Depression
Antidepressants: SSRIs and SNRIs
• Indications: first-line therapy for depression
• Indications (other) for SSRIs: OCD, PMDD, anxiety, and
panic disorders
 OCD
Is a form of anxiety where obsessive thoughts
intrude daily life and impair function
 PMDD
Is emotional and behavioral changes in the second
half of menstrual cycle; more severe than PMS
• Indication for Duloxetine (primary): nerve pain that
accompanies depression
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Depression
Antidepressants: SSRIs and SNRIs (continued)
• Mechanism of Action
 SSRIs block serotonin reuptake into presynaptic neuron
 SNRIs block reuptake of serotonin and norepinephrine
• Side Effects (frequent): sexual dysfunction causes many
patients to stop therapy
• Side Effects of SSRIs: nausea, vomiting, dry mouth,
drowsiness, insomnia, headache, and diarrhea
• Side Effect of Fluvoxamine: can cause weight loss;
sometimes used for eating disorders including bulimia
• Routes: all are oral
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Depression
Antidepressants: SSRIs and SNRIs Cautions
• Possible increased risk of suicide in early weeks of therapy,
especially in pediatric and adolescent patients
 Patients require close monitoring and should be offered
counseling and psychotherapy
• Increase risk for serotonin syndrome; potentially fatal
 Occurs if too much serotonin is present
 Can cause changes in cardiovascular function and heart
attacks
 Risk very high if patient is taking more than one
antidepressant or St. John’s wort (herb product)
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Depression
Antidepressants: TCAs
• Name comes from three-ring structure
• Mechanism of Action: block reuptake of norepinephrine
and/or serotonin
• Indications: depression, insomnia, and nerve conditions
• Tetracyclic agent is a TCA but has a four-ring structure
• Side Effects: drowsiness, anticholinergic effects (dry
mouth, blurred vision, constipation, and urinary retention)
 Some also cause priapism (erection more than 4 hours)
• Routes: All are oral; amitriptyline is also IM
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Depression
Antidepressants: TCAs Cautions
• Causes cardiotoxicity and heart arrhythmias; do not take if
preexisting heart conditions or recent heart attack
• Causes postural hypotension
• Do not take if have seizure disorders (for most patients)
• Do not take if liver problems; can cause liver toxicity
• Do not take with MAOIs due to serotonin syndrome risk
 Washout required if switching from TCA to MAOI
• Overdose can be fatal
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Depression
Antidepressants: MAOIs
• Indication: last resort for intractable depression symptoms
• Mechanism of Action: inhibit a primary enzyme that
metabolizes neurotransmitters, so levels rise in cleft
• Side Effects: heart palpitations, postural hypotension,
dizziness, headache, tremors, insomnia, anxiety,
restlessness, agitation, and anticholinergic effects
• Cautions: interact with many drugs; interact with
tyramine-rich foods such as aged cheeses, beer,
wine, sauerkraut, and pickled foods
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Depression
Antidepressants: Bupropion
• Mechanism of Action: mainly blocks dopamine reuptake;
also weakly blocks serotonin and norepinephrine reuptake
• Indication: depression symptoms, adjunct therapy for
smoking cessation, and anxiety
• Side Effects: headache, agitation, weight gain, insomnia
• Cautions
 Do not chew or crush extended-release form
 Do not take if have seizure disorders
 Do not take with alcohol or CNS depression drugs
• Route: all are oral
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Depression
Antidepressants: Trazodone
• Mechanism of Action: not fully understood, but it may
affect serotonin reuptake
• Indication: depression with insomnia, neuralgic pain, and
anxiety that affects sleep
• Side Effect: drowsiness
• Route: oral
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Anxiety
About Anxiety
• Is the abnormal function of the neurotransmitters that
regulate brain activity, mood, and the fear response
• Two types
 Panic disorder
Causes chest pain, difficulty breathing, palpitations,
dizziness, sweating, choking sensation, trembling,
and unrealistic feelings of doom
Symptoms occur without typical stimuli; onset of
symptoms is sudden and quick; called an attack
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Anxiety
About Anxiety (continued)
• Two types (continued)
 Generalized anxiety disorder
Is excessive worry that causes significant distress or
disturbs normal functioning
Causes restlessness, irritability, difficulty
concentrating, muscle tension, and fatigue
Symptoms are constant, can become debilitating
• PTSD
 Is a variation of anxiety
 Occurs in response to a traumatic event and
reexperiencing syndrome continues for at least a
month
 Symptoms include avoidance behavior and irritability
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Anxiety
Sedatives and Hypnotics
• Anxiety often requires drug therapy and counseling
• Hypnotics
 Are medications that causes sedation and relaxation
• Sedatives (another word for hypnotics)
 Used to induce sleep
• Agents with sedatives or hypnotics like benzodiazepines
may be useful for short-term treatment for panic disorder
 Benzodiazepines typically are necessary for generalized
anxiety disorder
• SSRIs are also used for PTSD and anxiety
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Anxiety
Sedatives and Hypnotics: Benzodiazepines
• Indications: first-line drug for generalized anxiety disorder,
panic disorder, and PTSD
• Indications (other): preanesthetic medications, alcohol
withdrawal symptoms, and status epilepticus
• Mechanism of Action: stimulate omega receptors in the
CNS, causing drowsiness and relaxation
 Used for anxiety and has calming and euphoria effect
 Used for sleep to improve sleep quality
• Routes: all are oral; a few are IM and IV
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Anxiety
Sedatives and Hypnotics: Benzodiazepines
(continued)
• Side Effects (common): constipation, muscle weakness,
and impaired reflexes
• Side Effects (other): difficulty waking up in the morning
and leftover drowsiness the following day
• Side Effects (severe): oversedation and respiratory
depression
• Cautions: do not take with alcohol or other sedatives; can
increase heart rate; all are controlled substances Schedule
IV and require special handling and storage
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Anxiety
Sedatives and Hypnotics: Buspirone
• Mechanism of Action: blocks serotonin receptors
• Indication: preferred antianxiety medication because is not
a controlled substance and doesn’t cause euphoria
• Route: oral; must be taken regularly
• Side Effects: drowsiness, dizziness, headache, and nausea
• Side Effects (severe): hostility, depression, serotonin
syndrome, and extrapyramidal symptoms
• Cautions: may cause depression and increase suicidal
tendencies; do not take with MAOIs
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Your Turn
Question 1: A physician is writing an order for a patient who has
depression. The patient also has nerve pain. What is the likely
order?
Answer: The order is probably for duloxetine, an
antidepressant that also is used for nerve pain that
accompanies depression.
Question 2: A patient is experiencing reoccurring, sudden attacks
in which she feels chest pain and has trembling, sweating, and
difficulty breathing. She also feels something horrible is about to
happen. What therapy will likely be prescribed?
Answer: Benzodiazepines are the first-line therapy for panic
attacks.
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Insomnia
About Insomnia
• Is the inability to fall asleep (sleep latency) or
stay asleep (sleep maintenance)
 Is usually a reaction to a stressful situation and a
disruption in the normal sleep cycle
• Can be symptom of depression, anxiety, or other mental
disorders
Drugs for Insomnia
• First identify and eliminate external or medical
causes and implement good sleep hygiene
 Drug therapy is last resort and used short term
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Insomnia
Drugs for Insomnia (continued)
• Drug therapy
 Begins with OTC antihistamines; short-term use
 Diphenhydramine, hydroxyzine, and TCAs
Can cause drowsiness as a side effect
• Sleep aids
 Ramelteon
Not a controlled substance
Mechanism of Action: Mimics melatonin, a
hormone of the body’s natural sleep/wake cycle
Cautions: do not take with or immediately after
high-fat meals; many drug interactions
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Insomnia
Drugs for Insomnia (continued)
• Sleep aids (continued)
 Eszopiclone, zaleplon, and zolpidem
used short-term only (2 weeks or less)
Side Effects (common): headache, drowsiness, dry
mouth, dizziness, nausea, hallucination, and
memory loss
Side Effects (severe): face and tongue swelling,
difficulty breathing, and sleepwalking (rare)
Cautions : controlled substances Schedule IV;
require special handling and storage
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Bipolar Disorder
About Bipolar Disorder
• Is related to the dysfunction of neurotransmitters such as
GABA, serotonin, and norepinephrine
• Is characterized by periods of depression with times of
mania
 Mania manifests as irritability, elevated mood,
excessive involvement in work or activities, grandiose
ideas, racing thoughts, a decreased need for sleep
• Varies in how much a patients experiences mania versus
depression
• Other psychoses often coexist with bipolar disorder
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Bipolar Disorder
Drugs for Bipolar Disorder: Lithium
• Is the first-line and primary drug therapy
 Anticonvulsants and several atypical antipsychotic
agents may be used instead of lithium
• Route: oral; dosed at 900–2,400 mg a day
• Is a mood stabilizer that accompanies antidepressants
• Side Effects (common): nausea, vomiting, dizziness,
tremors, fatigue, muscle weakness, increased thirst and
urination, and significant weight gain
• Side Effects (severe): hypothyroidism, heart arrhythmias,
and leukocytosis (an increase in white blood cells)
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Schizophrenia and Psychosis
About Schizophrenia and Psychosis
• Schizophrenia
 Is related to an imbalance of various neurotransmitters,
likely dopamine and serotonin
 Comprised of positive symptoms (hallucinations and
delusions) and negative symptoms (withdrawal,
ambivalence, behavior changes, memory loss, and
confusion)
 Onset usually during teen or young adult years
 Drug therapy often needed to maintain normal
thought and function
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Schizophrenia and Psychosis
About Schizophrenia and Psychosis (continued)
• Schizophrenia is one of a variety of psychotic disorders
Reactive
Psychosis
Occurs briefly, from a few hours to just
under a month, and then subsides
Delusional
Disorder
Schizophreniform
Disorder
Delusional thoughts longer than 1
month; do not impair normal function
Symptoms similar to schizophrenia but
less than 6 months; if symptoms
continue for more than 6 months then a
diagnosis of schizophrenia is made
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Schizophrenia and Psychosis
About Schizophrenia and Psychosis (continued)
• Psychotic symptoms
 Patients with bipolar disorder can have thought
disorders, hallucinations, or delusions
Half of patients with bipolar disorder will have at
least one psychotic symptom at least once in their
lifetime
 Displayed in patients with dementia
 Can be caused by drugs
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Schizophrenia and Psychosis
Drugs for Schizophrenia and Psychosis
• Drug therapy highly individualized and often requires
changing therapies over time
• Doses slowly increased over weeks to months, and then
adjusted to balance symptoms and side effects
• Atypical agents
 First-line therapy
• Antipsychotics
 Second-line therapy; have been available longer than
atypical agents
 Side effect profiles are problematic and often doselimiting
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Schizophrenia and Psychosis
Drugs: Typical Antipsychotics
• Mechanisms of Action: not fully understood
 Many drugs are phenothiazines or thioxanthenes,
which block dopamine receptors that control emotion
and thought
• Indications: reduces abnormal thoughts and hallucinations
 Does not always affect behaviors such as withdrawal
and ambivalence
 Haloperidol also for Tourette’s syndrome
 Prochlorperazine (low doses) also for nausea and
vomiting
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Schizophrenia and Psychosis
Drugs: Typical Antipsychotics (continued)
• Indications (other): used for agitation and delirium in
patients without schizophrenia
 Lower doses prescribed
 Given to elderly patients in long-term care that have
dementia and related effects like irritability, confusion,
and delirium
Can cause dizziness, blood pressure drop, and falls
Laws and regulations in place for use of
antipsychotic agents in long-term care settings
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Schizophrenia and Psychosis
Drugs: Typical Antipsychotics (continued)
• Side Effects (common): sedation, dizziness, constipation,
dry mouth, blurred vision, weight gain, photosensitivity,
and sexual function changes
• Side Effects (severe): EPS (tremors, muscular rigidity, and
difficulty initiating movement) and tardive dyskinesia
(uncontrollable tongue thrusting and lip smacking)
 Anticholinergics given to reduce EPS effects
• Routes: all are oral; some are also IM and IV
• Cautions: can cause arrhythmias and heart function
changes; do not drink alcohol
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Schizophrenia and Psychosis
Drugs: Atypical Antipsychotics
• Mechanisms of Action: not fully understood
 Some block dopamine and others enhance it
• Indications: first-line therapy for schizophrenia and other
psychoses
• Dosage: variable effectiveness for individual patients
• Side Effects (common): drowsiness, headache,
constipation, dry mouth, urinary incontinence or
retention, rash, excitation, hiccups, EPS (but less than
typical antipsychotics), and a decrease in blood pressure
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Schizophrenia and Psychosis
Drugs: Atypical Antipsychotics (continued)
• Side Effects (severe): arrhythmias, QT wave prolongation,
and significant weight gain, which often causes high
cholesterol levels and new-onset diabetes
 Medication for Type II diabetes will be needed
• Cautions: can lower seizure threshold; do not take if have
liver or kidney problems; bone marrow suppression; use
caution with elderly patients; do not drink alcohol
• Routes: all are oral; some are IM
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Your Turn
Question 1: A patient is having difficulty staying asleep at night.
He has tried OTC medications and follows good sleep hygiene.
He wants a nonaddictive sleep aid. What medication is the
prescriber likely to order?
Answer: The prescriber will likely order Ramelteon. This sleep
aid is not a controlled substance and does not cause
addiction.
Question 2: What is a restriction of typical antipsychotics?
Answer: Patients cannot consume alcohol while taking these
medications.
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Herbal and Alternative Therapies
• Melatonin
 Is taken for sleep and insomnia disorders,
benzodiazepine and nicotine withdrawal, and
headaches
• Kava
 Is taken for anxiety and insomnia
 Is effective but dangerous
• St. John’s wort
 Is taken for mild depression and psychological
symptoms of menopause
• SAMe
 Is taken for mild depression and osteoarthritis
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Summary
• SSRIs, TCAs, and MAOIs are used to treat depression
• Benzodiazepines are the first-line therapy for anxiety
• Benzodiazepines are also used for insomnia; typically
nonpharmacologic and OTC remedies are tried first
• Ramelteon is a new prescription agent for insomnia;
enhances melatonin
• Lithium is the drug of choice for bipolar disorder
• Typical and atypical antipsychotics are used for
schizophrenia and psychosis; have significant side effects
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