Psychopharmacology of Antidepressants, Mood Stabilizers and Antipsychotics

Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC, NCC, CCDC

Executive Director, AllCEUs.com

For each of the following, antidepressants, antipsychotics and mood stabilizers◦ Examine their method of action◦ Explore the types of disorders they are used to treat◦ Review the most common medications in those classes

Identify where to get more information for patients

Discuss the benefits and drawbacks to off-label prescribing

Mechanism of action/purpose◦ Altered dopamine neurotransmission is implicated

in

Cognitive control (racing thoughts)

Attentional control

Impulse control

Working memory

Symptoms of excess & insufficiency◦ Excess of dopamine

Unnecessary movements, repetitive tics

Psychosis

Hypersexuality

Nausea

Most antipsychotic drugs are dopamine antagonists

Dopamine antagonist drugs are also some of the most effective anti-nausea agents

Symptoms of excess & insufficiency◦ Insufficient dopamine

Negative symptoms of schizophrenia Pain Parkinson’s Disease Restless legs syndrome Attention deficit hyperactivity disorder (ADHD) Neurological symptoms that increase in frequency with age,

such as decreased arm swing and increased rigidity. Changes in dopamine levels may also cause age-related

changes in cognitive flexibility.

Symptoms of excess & insufficiency◦ Insufficient dopamine

Lack of motivation Fatigue Apathy, Inability to feel pleasure Procrastination Low libido Sleep problems Mood swings Hopelessness Memory loss Inability to concentrate

Medications◦ Most common dopamine antagonists (positive

symptoms) Risperdone, Haldol, Zyprexa

Metoclopramide (Reglan) is an antiemetic and antipsychotic

◦ Most common dopamine AGONISTs (Parkinson’s, Restless Legs) (negative symptoms) Mirapex & Requip

Mechanism of action/purpose◦ Helps regulate

Mood

Sleep patterns

Appetite

Pain

Symptoms of excess◦ Depression◦ Apathy, Emotional flatness or dullness◦ Passivity◦ Insomnia and other sleep problems◦ Difficulty concentrating and learning◦ Poor memory; amnesia◦ Difficulty making decisions and acting on them◦ Sexual dysfunction

Insufficiency◦ Depression

◦ Anxiety

◦ Pain sensitivity

Mobilize the brain and body for action.

Norepinephrine release is lowest during sleep, rises during wakefulness, and reaches much higher levels during situations of stress (fight-or-flight)

Increases arousal, alertness, anxiety and restlessness; promotes vigilance, and focuses attention

Excess◦ Anxiety

◦ Increased startle reflex/jumpiness

◦ Impaired concentration

◦ Restless sleep,

◦ Rapid fatigue

◦ Muscle tension/cramps

◦ Irritability/edginess

Alpha-2 agonists often have a sedating effect, and are commonly used as anesthesia-enhancers in surgery, as well as in treatment of drug or alcohol dependence

Stimulants and antidepressants increase dopamine and serotonin as well as increasing levels of norepinephrine.

Medications bind to receptors to effect changes in the brain.◦ D1-D4 Receptors are associated with dopamine◦ 5-HT1-5HT7 with subtypes are associated with

serotonin◦ Alpha receptors are associated with adrenergic receptors

(norepinepherine/noradrenaline; epinepherine/adrenaline)

◦ M1-M3 are muscarinic receptors associated with acetylcholine

◦ H1 receptors are associated with histamines

Higher ACh and NE, together with lower SE, produces ◦ Anxiety, emotional lability, irritability, anger,

aggressiveness, negative rumination, impatience, and impulsiveness

When NE, DA, and SE are low and acetylcholine is high◦ The result is simply depression.

Increasing serotonin ◦ lowers acetylcholine levels, and norepinephrine and

dopamine.

SSRIs◦ Selective serotonin reuptake inhibitors (SSRIs)

decrease serotonin blockers in the brain. sertraline (Zoloft)

fluoxetine (Prozac)

paroxetine (Paxil, Pexeva)

citalopram (Celexa)

escitalopram (Lexapro)

fluvoxamine (Luvox)

trazodone (Oleptro)

SNRIs◦ Serotonin and norepinephrine reuptake inhibitors

(SNRIs)

◦ Options include: desvenlafaxine (Pristiq)

duloxetine (Cymbalta)

venlafaxine (Effexor XR)

◦ Duloxetine offers the added benefit of pain relief in addition to treating depression.

Tricyclics (-tryptaline, -amine)◦ Prescribed when other antidepressants don’t work.◦ Significant side effects◦ TCAs are available as:

amitriptyline clomipramine (Anafranil) desipramine (Norpramin) imipramine (Tofranil) nortriptyline (Pamelor) protriptyline (Vivactil) trimipramine (Surmontil)

Dopamine Reuptake Blocker◦ Bupropion (Wellbutrin) is a mild dopamine and

norepinephrine reuptake blocker

◦ Used for depression, seasonal affective disorder (SAD) and also smoking cessation.

◦ Not advised for eating disorders

MAOIs◦ Monoamine oxidase inhibitors (MAOIs) prevent the

breakdown of norepinephrine, dopamine, and serotonin.

◦ MAOIs have many side effects

◦ MAOIs include:

isocarboxazid (Marplan)

phenelzine (Nardil)

selegiline (Emsam), a transdermal patch

tranylcypromine (Parnate)

Noradrenergic Antagonist ◦ Mirtazapine (Remeron) is used primarily for

depression.

Symptoms◦ Depression can be caused by an imbalance on one

or more neurotransmitters

Side effects

Efficacy in close, blood relatives

Other medications

Health conditions & pregnancy

Anorexia/Feeding Problems

Anxiety/Panic

Anxiety and Stress

Binge Eating

Bipolar Disorder

Body Dysmorphic Disorder

Borderline Personality Disorder

Bulimia

Depression

Fibromyalgia

Generalized Anxiety

Hot Flashes

Intermittent Explosive Disorder

Irritable Bowel

Major Depression

Obsessive Compulsive Disorder

Post Traumatic Stress

Postpartum Depression

Premature Ejaculation

Premenstrual Dysphoric Disorder

Schizoaffective Disorder

Social Anxiety

Somatoform Pain Disorder

Generally known as◦ Major Tranquilizers

◦ Neuroleptics

Block receptors in the brain's dopamine pathways causing a reduction in dopamine stimulation

Antipsychotics, however, fail to significantly improve the negative symptoms and cognitive dysfunction (D3)

Types◦ Aripiprazole (marketed as Abilify)◦ Asenapine Maleate (marketed as Saphris)◦ Clozapine (marketed as Clozaril)◦ Lurasidone (marketed as Latuda)◦ Olanzapine (marketed as Zyprexa)◦ Olanzapine/Fluoxetine (marketed as Symbyax)◦ Paliperidone (marketed as Invega)◦ Quetiapine (marketed as Seroquel)◦ Risperidone (marketed as Risperdal)◦ Ziprasidone (marketed as Geodon)

Agitated State

Agitation

Anorexia

Anxiety

Autism

Bipolar Disorder

Body Dysmorphic Disorder

Borderline Personality Disorder

Depression

Generalized Anxiety

Insomnia

Intermittent Explosive Disorder

Nightmares

Obsessive Compulsive Disorder

Post Traumatic Stress Disorder

Psychosis

Schizoaffective

Disorder

Schizophrenia

Social Anxiety Disorder

Tic Disorder

Tourette's Syndrome

Antipsychotics have many side effects ◦ Drowsiness

◦ Dizziness

◦ Restlessness

◦ Weight gain

◦ Constipation

◦ Nausea/Vomiting

◦ Blurred vision

◦ Low blood pressure

◦ Uncontrollable movements, such as tics and tremors

Clozapine and olanzapine are associated with the greatest effects on weight gain and decreased insulin sensitivity, followed by risperidone and quetiapine

Comprised of a variety of drugs to reduce mood swings (GABA receptor agonist)

Types◦ Mineral (Lithium)◦ Anticonvulsants

Depakote (valporate semisodium)

Lamictal (Lamotrigine)

Tegretol (Carbamazepine)

◦ Atypical Antipsychotics (all) for acute mania

Itching, rash

Excessive thirst

Frequent urination

Tremor (shakiness) of the hands

Nausea and vomiting

Slurred speech

Fast, slow, irregular, or pounding heartbeat

Changes in vision

Seizures

Hallucinations Loss of coordination

Swelling of the eyes, face, lips, tongue, throat, hands, feet

Drug Interaction Checker URL

Review Drugs By Condition and Read Patient Reviews

Antipsychotic Side effect Checklist

There are a variety of different neurotransmitters involved in addiction and mental health disorders

It is not always about increasing a neurotransmitter. Sometimes you need to decrease it.

Human brains try to maintain homeostasis and too much or too little can be bad

Neuropsychopharmacology: The Fifth Generation of Progress Editors: Kenneth L. Davis et. Al. Publisher Lippincott, Williams, & Wilkins, Philadelphia, Pennsylvania, 2002 http://www.acnp.org/publications/neuro5thgeneration.aspx