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Transcript
Chapter 17
Psychotherapeutic Agents
Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Antipsychotic Agents



Antipsychotic drugs are divided into two
categories: conventional and atypical.
Conventional antipsychotics primarily treat
the positive symptoms associated with
schizophrenia.
Atypical antipsychotics have a much more
tolerable adverse effect profile and target
both the positive and negative symptoms
of schizophrenia.
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Antipsychotic Agents



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Conventional antipsychotics primarily block all
dopamine receptors as well as cholinergic,
norepinephrine, and histamine receptors.
Atypical antipsychotics are more specific for
dopamine2 receptors, serotonin, and
norepinephrine receptors which results in
improved efficacy and lower incidence of adverse
effects.
Conventional antipsychotics have antipsychotic
effects, antiemetic effects, and sedating effects.
Atypical antipsychotics possess antipsychotic
effects.
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3
Antipsychotic Agents

Adverse Reactions

Adverse reactions are many and are
dependent upon the drug itself. Atypical
antipsychotics have a lower incidence of
adverse effects.
 Several conventional antipsychotics are
sedating.
 Extrapyramidal Effects
• These are a result of dopamine blockade in the
nigrostriatal pathways of the brain.
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Antipsychotic Agents

Extrapyramidal Effects


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Acute dystonic reactions occur within 72 hours of
starting the drug or a dose increase.
It is characterized by muscle spasms of the face,
tongue, neck and back.
Parkinsonian symptoms consistent with resting
tremor, rigidity, and akinesia.
Akathisia which is defined as an inability to sit still.
Tardive dyskinesia which are defined as
involuntary, abnormal movements of the tongue,
lips, face, and jaw.
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Antipsychotic Agents



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Orthostatic hypotension is a result of peripheral αreceptor blockade. When the patient rises rapidly
his or her blood pressure falls.
Other cardiac effects include tachycardia.
Some antipsychotic drugs lower the seizure
threshold.
These drugs block cholinergic receptors and can
cause dry mouth, blurred vision, constipation, and
urinary retention.
Other adverse effects include photosensitivity and
blood dyscrasias.
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6
Antipsychotic Agents

Drug Interactions



Because these drugs can be sedating they
should be used with caution with other drugs
that are sedating.
A local anesthetic with epinephrine can be
used in patients taking antipsychotic drugs.
Anticholinergic drugs are used in combination
with antipsychotic drugs to treat drug-induced
extrapyramidal effects. The combination can
cause sedation and intense dry mouth.
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7
Antipsychotic Agents

Uses



These drugs are used for the treatment of
schizophrenia.
Atypical antipsychotics are used to treat bipolar
disorder.
Conventional antipsychotics are used as
antiemetic drugs.
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Antipsychotic Agents

Dental Concerns

Sedation
• Sedation is additive with other sedating drugs such as
antianxiety drugs and opioid analgesics.
• Patients may require someone to drive them to and from
dental appointments.
• They should avoid anything that requires thought or
concentration while taking this combination.

Orthostatic Hypotension
• Raise the dental chair slowly and have the patient sit for a
few minutes prior to getting out of the chair.
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Antipsychotic Agents

Dental Concerns

Anticholinergic Effects
• Patients should be encouraged to drink plenty of
water or suck on tart, sugarless gum or candy.
• They should avoid caffeine-containing fruit juices or
alcoholic beverages.

Epinephrine should not be used to treat acute
hypotensive crisis.
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Antipsychotic Agents

Extrapyramidal Effects


These effects can impair the patient’s ability to
perform home oral hygiene.
Akathisia may make it difficult for the patient to
sit in a dental chair.
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11
Antidepressant Agents


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Many different classes of antidepressants
are available.
They are similar in therapeutic effects.
They differ in their adverse effect profile.
Choice of antidepressant is usually based
upon adverse effect profile, history of use,
and patient response.
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Antidepressant Agents

Pharmacologic Effects


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These drugs block the reuptake of serotonin
and/or epinephrine to a varying extent.
Monoamine oxidase inhibitors block the
enzyme monoamine oxidase.
Pharmacologic effects include elevation of
mood, increased ability to concentrate,
improvement in sleep, and sedation.
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Antidepressant Agents

Adverse Effects – Tricyclic Antidepressants






The adverse effects of antidepressant drugs are many and
are dependent upon the chemical class of the drug.
Almost all of the tricyclic antidepressants cause sedation.
Patients should develop tolerance to it.
These drugs also block cholinergic receptors and cause dry
mouth, blurred vision, constipation, and urinary retention.
These drugs can also be cardiotoxic.
Acute poisoning or overdose can occur.
These drugs interact with other sedating and drying drugs,
monoamine oxidase inhibitors, and epinephrine.
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Antidepressant Agents
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Antidepressant Agents

Selective Serotonin Reuptake Inhibitors



These drugs are stimulating and can cause
insomnia. Headache, dizziness, tremor,
agitation, and sweating also occur.
These drugs also cause weight loss.
A small percentage of patients complain of
xerostomia.
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Antidepressant Agents

Bupropion


This drug has a higher propensity to cause
seizures than other antidepressants.
Because of its seizure potential it is only used
in patients who don’t respond to other drugs
and in those who are not at risk for seizures.
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Antidepressant Agents

Monoamine Oxidase Inhibitors (MAOIs)


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MAOIs interact with sympathomimetic or
adrenergic drugs.
This includes many over-the-counter cough
and cold products.
They also interact with foods that contain
tyramine and include aged cheeses, red wine,
yeast extracts, and smoked or aged meats.
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Antidepressant Agents

Monoamine Oxidase Inhibitors (MAOIs)

The interaction of MAOIs with
sympathomimetics or tyramine-containing
foods can precipitate a hypertensive crisis.
 A hypertensive crisis is characterized by a
headache, stiff neck, sweating, nausea,
vomiting, and hypertension.
 It is treated with antihypertensive drugs.
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Drugs for Treatment of
Bipolar Disorder

Lithium

Lithium is used to treat bipolar disorder, which
is characterized by cyclic recurrence of mania
alternating with depression.
 Lithium is a narrow therapeutic index drug that
requires 2-4 weeks before a positive
therapeutic effect is achieved.
 Its adverse effects are many and the drug must
be carefully monitored.
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20
Drugs for Treatment of
Bipolar Disorder

Lithium

Adverse Effects
• Adverse effects include polyuria, fine hand tremor,
thirst.
• More severe adverse effects include slurred speech,
coarse hand tremor, ataxia, nausea, vomiting, and
diarrhea.
• Sodium levels can alter lithium levels.
• Some nonsteroidal antiinflammatory drugs can
decrease lithium clearance leading to increased
lithium levels.
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Drugs for Treatment of
Bipolar Disorder

Lithium

Dental Concerns
• Polydipsia





Increased sugar and caffeine consumption
Lithium interacts with ibuprofen – end up with lower
lithium levels because of fluid retention
Elevated heart rate may indicate lithium toxicity
Be concerned about administering epinephrine
Use of aspirin and other NSAIDs with GI upset
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Drugs for Treatment of
Bipolar Disorder

Other Treatments for Bipolar Disorder

Carbamazepine and valproate are approved
for treating bipolar disorder. They have a much
more tolerable adverse effect profile.
 The atypical antipsychotics have been
approved for the treatment of bipolar disorder.
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