Psychopharmacology in Psychiatry
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Transcript of Psychopharmacology in Psychiatry
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Psychopharmacology in Psychiatry
By : Dr SeddighHUMS
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Classification of antidepressants
Tricyclics (TCAs) Monoamine Oxidase Inhibitors (MAOIs) Selective Serotonin Reuptake Inhibitors
(SSRIs) Serotonin/Norepinephrine Reuptake
Inhibitors (SNRIs) Novel antidepressants
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Cyclic Antidepressants
Drug Trade name Daily dosage
Amitriptyline Elavil* 100-200 mg
Clomipramine Anafranil 150-200 mg
Imipramine Tofranil* 100-200 mg
Nortriptyline Aventyl* 75-150 mg
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Common Side effects of TCAs
Mechanism Complication overdose
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Drug Interactions with Cyclic Antidepressants
Drug
Alcohol
Antiparkinsonians
Antipsychotics
Fluoxetine(Prozac)
Phenobarbitol
Sedatives
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Antidepressants
Indications
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TCAs
effective & unacceptable Lethal in overdose QT lengthening
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Selective Serotonin Reuptake Inhibitors (SSRIs) Presynaptic reuptake Anxiety or depressive sx Side effects Overdose Discontinuation syndrome
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The SSRI antidepressant
Drug Trade name Daily dosage/starting
Fluoxetine Prozac 10-80 mg/20 mg
Paroxetine Paxil 10-60 mg/ 20 mg
Sertraline Zoloft 50-200 mg/50 mg
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Paroxetine (Paxil)
– half life & metabolite – Sedating – CYP2D6 inhibition– Complication – discontinuation syndrome
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Sertraline (Zoloft)
– interactions – Short half – Less sedating – absorption – GI adverse
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Fluoxetine (Prozac)
– Long half-life – Initially activating – taper someone – hepatic illness– interactions – increase anxiety and insomnia– induce mania
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Antidepressants -MAO Inhibitors
Drug Trade name Daily dose
Isocarboxazid Marplan 45-90 mg
Phenylzine Nardil 10-30 mg
Tranylcypromine Parnate 10-30 mg
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Foods & Drugs to be avoided
Foods Drugs
Aged cheeses AmphetamineBeer CocaineBroad-bean pods DecongestantsCaffeined beverages EpinephrineCanned figs L-dopa
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Overview of antidepressants
1st choice weeks effective → TCAs Abrupt withdrawal TCAs MAOIs “tyramine” TCAs to MAOIs
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Monoamine Oxidase Inhibitors (MAOIs) Bind to monoamine oxidase effective Side effects Hypertensive crisis
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MAOIs cont.
Serotonin Syndrome
Wait 2 weeks Fluoxetine
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Overview of antidepressants
1st choice weeks effective → TCAs Abrupt withdrawal TCAs MAOIs “tyramine” TCAs to MAOIs
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Serotonin/Norepinephrine reuptake inhibitors (SNRIs) v/s TCAS Indication
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Venlafaxine (Effexor)
– interactions – geriatric
– diastolic BP.– nausea – discontinuation – QT prolongation– Sexual side
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Duloxetine (Cymbalta)
depression
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Novel antidepressants Mirtazapine (Remeron) Pros
– Different mechanism of action may provide a good augmentation strategy to SSRIs. Is a 5HT2 and 5HT3 receptor antagonist
– Can be utilized as a hypnotic at lower doses secondary to antihistaminic effects
Cons– Increases serum cholesterol by 20% in 15% of patients and
triglycerides in 6% of patients– Very sedating at lower doses. At doses 30mg and above it
can become activating and require change of administration time to the morning.
– Associated with weight gain (particularly at doses below 45mg
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Buproprion (Wellbutrin)
Pros– Good for use as an augmenting agent– Mechanism of action likely reuptake inhibition of dopamine and
norepinephrine – No weight gain, sexual side effects, sedation or cardiac interactions– Low induction of mania– Is a second line ADHD agent so consider if patient has a co-
occurring diagnosis Cons
– May increase seizure risk at high doses (450mg+) and should avoid in patients with Traumatic Brain Injury, bulimia and anorexia.
– Does not treat anxiety unlike many other antidepressants and can actually cause anxiety, agitation and insomnia
– Has abuse potential because can induce psychotic sx at high doses
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Overview of antidepressants
1st choice weeks effective → TCAs Abrupt withdrawal TCAs MAOIs “tyramine” TCAs to MAOIs
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Anxiolytics
Used to treat many diagnoses including panic disorder, generalized Anxiety disorder, substance-related disorders and their withdrawal, insomnias and parasomnias. In anxiety disorders often use anxiolytics in combination with SSRIS or SNRIs for treatment.
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Benzodiazapines
Used to treat insomnia, parasomnias and anxiety disorders.
Often used for CNS depressant withdrawal protocols ex. ETOH withdrawal.
Side effects/cons– Somnolence– Cognitive deficits– Amnesia– Disinhibition– Tolerance– Dependence
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Drug
Dose Equivalency (mg)
Peak BloodLevel
(hours)
Elimination Half-Life1
(hours)Comments
Alprazolam (Xanax)
0.5 1-2 12-15 Rapid oral absorption
Chlordiazepoxide (Librium)
10.0
2-4 15-40
Active metabolites; erratic bioavailability from IM injection
Clonazepam (Klonopin)
0.25 1-4 18-50 Can have layering effect
Diazepam (Valium)
5.0
1-2 20-80
Active metabolites; erratic bioavailability from IM injection
Flurazepam (Dalmane)
30.01-2 40-100
Active metabolites with long half-lives
Lorazepam (Ativan)
1.0 1-6 10-20 No active metabolites
Oxazepam (Serax)
15.0 2-4 10-20 No active metabolites
Temazepam (Restoril)
30.0 2-3 10-40 Slow oral absorption
Triazolam (Halcion)
0.251 2-3
Rapid onset; short duration of action
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Buspirone (Buspar)
Pros: – Good augmentation strategy- Mechanism of action is
5HT1A agonist. It works independent of endogenous release of serotonin.
– No sedation Cons:
– Takes around 2 weeks before patients notice results.– Will not reduce anxiety in patients that are used to
taking BZDs because there is no sedation effect to “take the edge off.