008- Mental Health Medications: Antidepressants, Mood Stabilizers, and Antipsychotics

 
 
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Hundreds of thousands of people are on medications to address mood and mental health disorders.  Many people try one medication, and when it doesn't work, they feel hopeless.  What they do not realize is that, since we cannot accurately measure the levels of neurochemicals in your brain, diagnosis and prescribing is part art, and part science.  A variety of different chemical imbalances besides low serotonin can cause depressive symptoms, for example.    In this episode we will discuss three common classes of medications: Antidepressants, Mood Stabilizers and Antipsychotics, the neurotransmitters on which they are believed to work and the symptoms of insufficiency and excess of each of these neurotransmitters.

 

Show Notes

Psychopharmacology: Antidepressants, Antipsychotics and Mood Stabilizers
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Objectives
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
Dopamine
Mechanism of action/purpose
Altered dopamine neurotransmission is implicated in
Cognitive control (racing thoughts)
Attentional control
Impulse control
Working memory
Dopamine
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
Dopamine
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.
Dopamine
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
Dopamine
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

Serotonin
Mechanism of action/purpose
Helps regulate
Mood
Sleep patterns
Appetite
Pain
Serotonin
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
Serotonin
Insufficiency
Depression
Anxiety
Pain sensitivity

Norepinepherine
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
Norepinepherine
Excess
Anxiety
Increased startle reflex/jumpiness
Impaired concentration
Restless sleep,
Rapid fatigue
Muscle tension/cramps
Irritability/edginess
Norepinepherine
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.
Neurochemical Receptors
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

Homeostasis
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.
Antidepressants
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.

Finding the Right Antidepressant
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

What do Antidepressants Treat?
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
Atypical Antipsychotics
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)
Atypical Antipsychotics
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)

Atypical Antipsychotics Used to Treat
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
Side Effects
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

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

Mood Stabilizer Side Effects
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
Other Great Resources
Drug Interaction Checker URL
Review Drugs By Condition and Read Patient Reviews
Antipsychotic Side effect Checklist

Summary
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
References
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

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