Psychotropic Medications

1. Psychotropic Medications What are they? What do they treat? What should you know?

2. What are Psychotropic Medications • Psychotropic drugs is a term used to describe psychiatric medicines that alter chemical levels in the brain which impact mood and behavior • Typically these drugs interact with the release and reuptake or absorption of neurotransmitters in the brain and central nervous system

3. Neurotransmitters in action

4. What are Neurotransmitters anyway? • Norepinephrine • Serotonin • Dopamine • Gamma amino-butyric acid (GABA) • Acetylcholine • Glutamate

5. What do Neurotransmitters control? • Anxiety • Mood • Learning • Memory • Appetite • Sleep • Pain • Pleasure • Anger • Aggression

6. Disorders • Anxiety • PTSD • OCD • Mood Disorders • Depression • Bipolar • ADHD • Psychotic spectrum disorder

7. Types of Anxiety Disorders • Generalized anxiety disorder (GAD) • Social phobia • Panic disorder • Agoraphobia • Adjustment Disorder (AD) • Obsessive-Compulsive Disorder (OCD) • Posttraumatic Stress Disorder (PTSD)

8. Obsessive-Compulsive Disorder • Chronic condition, often incapacitating, characterized by persistent thoughts and compulsions

9. Posttraumatic Stress Disorder • Developed after surviving unusual and severe mental or physical trauma. Person may feel fear, helplessness, or that they are in danger

10. Antianxiety Medication SSRIs • Zoloft (sertraline) • Paxil (paroxetine) • Prozac (fluoxetine) • Anafranil (clomipramine) • Luvox (fluvoxamine)

11. What is an SSRI • SSRIs increase effectiveness of serotonin • Regulating mood • Decreased anxiety • Regulate sleep and appetite • Reduce primitive OCD-like urges • Preferred for treatment of OCD

12. How safe are SSRIs? • Death by overdose is incredibly rare, occurring about two for every one million people using them

13. SSRI side effects • Increased anxiety • Sedation • Insomnia • Sexual dysfunction • Weight gain

14. Antianxiety Medication Benzodiazepines • Valium (diazepam) • Klonopin (clonazepam) • Xanax (alprazolam) • Ativan (Lorazepam)

15. What do Benzodiazepines do? • Acting through the central nervous system • Muscle relaxation • Sedative • Anxiolytic • anti convulsant • Do not repress obsessions in OCD

16. Benzodiazepine side effects • Significant risk for dependence • Dangerous overdose risk when mixed with alcohol • Drowsiness, dizziness, potential for physical and psychological dependence

17. Antianxiety medications and children • About 13 out of 100 children and adolescents, ages 9-17, have some sort of anxiety disorder • There are few conclusive studies or guidelines for the use of antianxiety medications in pediatrics • Therapy, however, has been shown to be effective among children and adolescents with anxiety disorders

18. Mood Disorders

19. Types of Depression • Unipolar depression is synonymous with clinical depression and major depressive disorder

20. Types of Depression • Atypical depression is the most common and typically coexists with an anxiety disorder • Dysthymic depression differs from Unipolar depression in that the symptoms are long lasting and milder

21. Antidepressants: Cyclics • Tofranil (imipramine) • Elavil (amitriptyline) • Anafranil (clomipramine) • Desyrel(trazodone)

22. Antidepressants:What do cyclics do? • Cyclics increase effectiveness of both serotonin and norepinephrine • Decreased anxiety • Decreased anger/aggression • Increase positive feelings • Increased ability to learn and concentrate

23. Strattera (atomoxetine) Vestra (reboxetine) Remeron (mirtazapine) Antidepressants: NRIs

24. Antidepressants:What do NRIs do? • NRIs increase effectiveness of norepinephrine. • Provide an energy boost and increase attention span • Decrease anxiety • Increased positive feelings

25. Antidepressants: SSRIs • Prozac (fluoxetine) • Zoloft (sertraline) • Paxil (paroxetine) • Celexa (citalopram) • Lexapro (escitalopram) • Luvox (fluvoxamine)

26. Antidepressants:A review of SSRIs • SSRIs selectively increase effectiveness of serotonin • Decreased anxiety • Decreased anger/aggression • Increased ability to learn and concentrate

27. Antidepressants: SNRIs • Cymbalta (duloxetine) • Effexor (venlafaxine) • Pristiq (desvenafaxine)

28. Antidepressants:What do SNRIs do? • SNRIs increase effectiveness of both serotonin and norepinephrine • Decreased anxiety • Decreased anger/aggression • Increase positive feelings • Increased ability to learn and concentrate

29. Antidepressants: Atypical • Wellbutrin (bupropion HCL) • Zyban (bupropion HCL) • Aplenzin (bupropion hydrobromide) • Oleptro (trazodone ER)

30. Antidepressants:What do atypicals do? • Atypical antidepressants increase effectiveness of both dopamine and norepinephrine • Decrease anxiety • Increased positive feelings • Increased ability to concentrate and learn • Increased motivation and desire • Increased pleasure

31. Antidepressants: MAOIs • Parnate (tranylcypromine) • Nardil (phenelzine) • Emsam patch (selegline)

32. Antidepressants:What about MAOIs? • Side effects • Orally, rarely used due to many serious drug-drug and drug-food interactions • Patch is associated with fewer side effects • MAOIs should NEVER be combined with SSRIs as this may result in a coma or even death

33. What do antidepressants do? • Used to restore normal biological functioning • Studies suggest that with quality care, the same outcomes may be achieved with a primary care physician as with a psychiatrist

34. Side effects of antidepressants • Cyclics • Dangerous in overdose and enhance effects of alcohol, very sedating, dry mouth, constipation, drop in blood pressure, rapid hear rate, weight gain, decreased libido • Atypical • Anxiety and insomnia

35. Side effects of antidepressants • SSRIs • Increased serotonin activity, weight gain, decreased libido, anxiety, sedation, insomnia • NRIs • Weight gain, rare decreased white blood cell count (Remeron)

36. Action times • How long does it take for Zoloft, Paxil, Effexor, and Wellbutrin to take effect? • At least 50% of those who will eventually respond to the above mentioned antidepressants will begin to demonstrate improvement within one week of beginning treatment.

37. Antidepressants and children • According to the NIMH one in three children suffer from depression. • SSRIs are the choice treatment for pediatric depression. • All antidepressants carry a warning indicating possible risk of suicide with use in teens and children

38. Are older cyclic antidepressants as effective as newer SSRIs, SNRIs and atypicals? • Most likely, yes. • Most cyclics are dual-action, meaning they assist at increasing the effectiveness of norepinephrine and serotonin to the “emotional brain”.

39. Are certain ethnicities more likely to be depressed than others? • Apparently so… • Approximately 30% of Hispanics report suffering from depression compared to 26% for whites, 20% for blacks, and 16% for Asians.

40. Bipolar Disorder • Characterized by intense mood swings (mania and depression) • Disruptive behaviors include delusional thinking, binges, recklessness • Classified as a mood disorder • Cyclothymia: mood swings lasting at least two years • Chronic disorder with less intense mood swings

41. Discussion Point • Is Bipolar disorder underdiagnosed or over diagnosed in children and adolescents?

42. Mood-Stabilizing Agents Anticonvulsants • Depakote (divalproex) • Lamictal (lamotrigine) • Tegretol (carbamazepine) • Topamax (topiramate)

43. Mood-Stabilizing Agents Atypical Antipsychotics • Zyprexa (olanzapine) • Abilify (aripiprazole) • Symbyax (fluoxetine)

44. Lithium • Lithium reduces suicide risk and attempts • Decreases anxiety and manic episodes • Lithium commonly causes nausea, diarrhea, vomiting, thirst, weight gain, acne and fine-hand tremors • Lithium may pose long term health risks. For this reason, children or adolescents should have blood drawn and analyzed several times a year

45. What do mood-stabilizing agents do? • The exact way remains unclear, perhaps interaction with GABA • Decrease mania • Decrease disruptive behaviors • Stabilize mood • Depakote may work quicker than Lithium • Decreases rapid cycling mania • Decreases rage reactions • Topamax is more effective in treating migraines than as a mood stabilizer

46. Side effects of mood-stabilizing agents • Depakote may cause sedation, dizziness, drowsiness, blurred vision, and coordination problems • Depakote may pose long term health risks. For this reason, children or adolescents should have blood drawn and analyzed several times a year • Lamictal may cause serious rash development

47. Mood stabilizing agents and children • Lithium and Depakote are most often used in this age group • Both drugs require frequent blood tests to monitor thyroid and kidney functioning • The use of mood stabilizers in children is a balancing act between possible impact of side effects and the severity of the disorder

48. Is the diagnosis of pediatric bipolar disorder on the rise? • Absolutely. • According to the December 2007 Harvard Mental Health Letter, office visits by children diagnosed with bipolar disorder multiplied 40-fold from 1994 to 2003.

49. Diagnosing children vs. adults • Is bipolar disorder more difficult to diagnose in children than in adults? • Yes, bipolar disorder is actually very hard to diagnose in children. This is mainly due to the high incidence of multiple co-existing disorders, often with symptom overlap.

50. ADHD • Effects 5-8% of all children in the USA • Characterized by difficulty focusing, sitting still and often impulsive tendencies • 4-9 times more common in boys