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Chapter 7
Antidepressants,
Antipsychotics, Antianxiety
Agents,
and Alcoholism
Chapter 7 Topics
• Antidepressants
• Antipsychotics
• Antianxiety Agents
– Panic Disorders
– Sleep Disorders
• Alcoholism
Learning Objectives
• Differentiate the antidepressant,
antipsychotic, and antianxiety agents.
• Be prepared to discuss the antidepressant
classes, their uses, and their side effects.
• Know why and how lithium and other
drugs are used in treating bipolar
disorders.
Learning Objectives
• Be familiar with antipsychotics and the
drugs that prevent their side effects.
• Define anxiety, learn its symptoms, and
know the drugs used in its treatment.
• Recognize the course and treatment of
panic disorders, insomnia and
alcoholism.
Antidepressants
• Used to treat depression
• Depression, common feelings
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Pessimism
Worry
Intense sadness
Loss of concentration
Slowing of mental processes
Problems with eating and sleeping
Antidepressants
Common Symptoms of Depression
– Loss of interest in
usual activities
– Low self-esteem
– Self-pity
– Significant weight loss
or gain
– Insomnia or
hypersomnia
– Extreme restlessness
– Loss of energy
– Feelings of
worthlessness
– Diminished ability to
think
– Feelings of guilt
– Recurrent thoughts of
death
– Suicide attempts
Antidepressants
Depression
• Women are affected more often than men
• When men are affected, it is usually later in
life
• Levels of neurotransmitters in the brain may
be a causative factor
Mood Disorders
• Mania
• Bipolar Disorder
• Unipolar Disorder
Mood Disorders
• Mania
Mood of extreme excitement, excessive elation,
hyperactivity, agitation, and increased
psychomotor activity
• Bipolar Disorder
• Unipolar Disorder
Mood Disorders
• Mania
• Bipolar Disorder
Mood swings alternate between major depression
and mania
• Unipolar Disorder
Mood Disorders
• Mania
• Bipolar Disorder
• Unipolar Disorder
Major depression with no previous occurrence of
mania
Discussion
Describe the differences that may
be seen in patients with unipolar
and bipolar disorders.
Discussion
Describe the differences that may be seen in
patients with unipolar and bipolar disorders.
Answer
Unipolar – Depression Symptoms
Bipolar – Depression and Mania
Symptoms
Treatment for Depression
Electroconvulsive Therapy
• Introduction of brief, but convulsive
electrical stimulation through the brain
• Can induce seizures
• Effective for major and delusional
depression
Antidepressants
• Selective Serotonin Reuptake
Inhibitors (SSRIs)
• Cyclic Antidepressants
• Monoamine Oxidase Inhibitors
(MAOIs)
Antidepressants
Selective Serotonin Reuptake
Inhibitors (SSRIs)
– Block the reuptake of serotonin, with
little effect on norepinephrine
– Fewer side effects than older meds
Treatments
Cyclic Antidepressants
– Two Types
• Tricyclic antidepressants (TCAs)
• Tetracyclic antidepressants
– Prevent reuptake of norepinephrine
and/or serotonin
– Agents in this class differ in adverse
effects, cost, and response
Treatments
Monoamine Oxidase Inhibitors
(MAOIs)
Allows for buildup of norepinephrine at the
synapse
Drug List
SSRIs for Depression
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citalopram (Celexa)
escitalopram (Lexapro)
fluoxetine (Prozac,)
paroxetine (Paxil)
sertraline (Zoloft)
venlafaxine (Effexor)
Dispensing Issues
Warning!
Look-Alike Drugs
– Prozac and Proscar (urinary drug)
– Zoloft and Zocor (high cholesterol)
– Celexa and Cerebyx (seizures) and
Celebrex (arthritis)
SSRI
Dispensing Issues
Warning!
• Do not discontinue abruptly
• Alcohol consumption should be avoided
while taking these medications
fluoxetine (Prozac)
• Indicated for major depression and
obsessive-compulsive disorder (OCD)
• Anorexia is a possible adverse effect
• Take in the morning to avoid insomnia
paroxetine (Paxil)
• Indicated for depression, obsessivecompulsive disorder, and panic disorder
venlafaxine (Effexor)
• Blocks reuptake of serotonin and
norepinephrine
• Indicated for depression
• May cause increase in blood pressure and
blurred vision
sertraline (Zoloft)
• Indicated for depression and obsessivecompulsive disorder
• Primary side effect is nausea
• May also cause drowsiness
citalopram (Celexa)
• Indicated for depression and obsessivecompulsive disorder
• Minimal drug interactions
escitalopram (Lexapro)
• Similar to Celexa
• More potent with fewer side effects
Drug List
Cyclic Antidepressants
Tricyclic
• amitriptyline (Elavil)
• nortriptyline (Pamelor)
Tricyclic Antidepressants
Dispensing Issues
Warning!
• Improvements are usually seen in 10 to
21 days
• Can be cardiotoxic in high doses
• May cause postural hypotension
Tricyclic Antidepressants
Dispensing Issues
Warning!
Do not discontinue abruptly.
Cyclic Antidepressants Side Effects
• Sedation is common,
but tolerance usually
occurs
• Have many
anticholinergic
effects
Discussion
Why would cyclic
antidepressants be prescribed for
bed wetting in children?
Discussion
Why would TCAs be prescribed for bed
wetting in children?
Answer
They may be prescribed because
of their anticholinergic side
effects.
Drug List
MAOIs
• phenelzine (Nardil)
• selegiline (Eldepryl)
• tranylcypromine (Parnate)
MAOI
Dispensing Issues
Warning!
Be cautious of many interactions with foods
such as aged cheeses, concentrated yeast
extracts, pickled fish, sauerkraut, broad
bean pods, chocolate, and alcohol.
MAOI
Dispensing Issues
Warning!
If changing to another class of
antidepressant, patient must have a twoweek “wash out” period before starting
the new medication.
Drug List
Other Antidepressants
• bupropion (Wellbutrin, Zyban)
• mirtazapine (Remeron)
• trazodone (Desyrel)
trazodone (Desyrel)
• Prevents reuptake of serotonin and
norepinephrine
• Has a better side effect profile than TCAs
• Caution: possible interaction with Ginkgo
bupropion (Wellbutrin, Zyban)
• Dopamine-uptake inhibitor
• Does not cause sedation, blood pressure
changes, or ECG changes
• Do not discontinue abruptly
• Approved in the aid of smoking cessation
Other Antidepressant
Dispensing Issues
Warning!
• Wellbutrin SR = BID dosing
• Wellbutrin XL = QD dosing
Bipolar Disorders
Signs or Symptoms
– Decreased need for sleep
– Elevated or irritable mood
– Excessive involvement in pleasurable activities
with a big potential for painful consequences
– Grandiose ideas
– Pressure to keep talking
– Racing thoughts
Discussion
What is the drug of choice for
treating bipolar disorders?
Discussion
What is the drug of choice for treating
bipolar disorders?
Answer
Lithium
Discussion
What is the two-fold objective of
drug therapy for bipolar disorder?
Discussion
What is the two-fold objective of drug
therapy for bipolar disorder?
Answer
Treat acute episodes
Prevent subsequent attacks
Drug List
Drugs to Treat Bipolar
Disorders
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carbamazepine (Tegretol)
divalproex (Depakote)
lithium (Lithobid)
olanzapine-fluoxetine (Symbyax)
valproic acid (Depakene)
Lithium Side Effects
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Gastrointestinal
Dermatologic
Hematologic
Neuromuscular
Weight
Renal
Teratogenic
Lithium Dispensing Issues
Warning!
Lithobid tablets are only effective for 6
months. Be sure to highlight expiration
dates on containers.
divalproex (Depakote)
• Beneficial for patients with rapid mood
changes
• Take with food or milk, but not carbonated
drinks
• Beware of symptoms of thrombocytopenia
Antipsychotics
• Also called neuroleptics
• Schizophrenia is the primary indication
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Retreat from reality
Delusions
Hallucinations
Ambivalence
Withdrawal
Bizarre or regressive behavior
Antipsychotics
• Helps with thought disorders,
hallucinations, and delusions
• Does not help with emotional and social
withdrawal, ambivalence, or poor self-care
Drug List
Antipsychotics
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aripiprazole (Abilify)
clozapine (Clozaril)
fluphenazine (Prolixin)
haloperidol (Haldol)
loxapine (Loxitane)
Drug List
Antipsychotics
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molindone (Moban)
olanzapine (Zyprexa)
prochlorperazine (Compazine)
quetiapine (Seroquel)
Drug List
Antipsychotics
• risperidone (Risperdal)
• thioridazine
Antipsychotic Side Effects
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Anticholinergic
Cardiovascular
Dermatologic
Endocrine
Hematologic
Ophthalmologic
Antipsychotic Side Effects
• Withdrawal
• Neurologic
– Dystonia
– Akathisia
– Pseudoparkinsonism
• Tardive dyskinesia
Atypical Antipsychotics
• Have improved efficacy and reduced side
effects
• Better tolerated, but associated with
metabolic side effects
risperidone (Risperdal)
• Indicated for management of psychotic
disorders and dementia in the elderly
• It is a serotonin-dopamine antagonist
Dispensing Issues
Warning!
Clozaril (antipsychotic) and Clinoril
(antibiotic) are look-alike/sound-alike
drugs.
olanzapine (Zyprexa)
• Used for schizophrenia
• Blocks dopamine and serotonin receptors
• Causes fewer movement disorders and is
more effective
• Alcohol must be avoided
Dispensing Issues
Warning!
Zyprexa (antipsychotic) and Zyrtec
(antihistamine) are look-alike/soundalike drugs.
quetiapine (Seroquel)
• Related to Clozaril
• Lower incidence of hematologic toxicities
Drug List
Minimizes Side Effects of
Antipsychotics
• benztropine (Cogentin)
• diphenhydramine (Benadryl)
• meclizine (Antivert)
Antianxiety Agents
Anxiety
State of uneasiness characterized by
apprehension and worry about possible events
Antianxiety Agents
Two Types of Anxiety
• Exogenous
Response to external stresses
• Endogenous
Not related to external stresses, result of
abnormality in cellular function in the CNS
Discussion
What is the most common selfprescribed treatment for anxiety?
Discussion
What is the most commonly self-prescribed
treatment for anxiety?
Answer
Alcohol
Antianxiety Agents
• Benzodiazepines
• Other Controlled Medications
• Some Non-Controlled Medications
Drug List
Antianxiety Agents
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amoxapine
buspirone (BuSpar)
hydroxyzine (Vistaril), antihistamine
paroxetine (Paxil), SSRI
Drug List
Antianxiety Agents
• propranolol (Inderal), beta blocker
• venlafaxine (Effexor)
Drug List
Antianxiety Agents
Benzodiazepines, C-IV
• alprazolam (Xanax)
• chlordiazepoxide (Librium)
• clorazepate (Tranxene)
• diazepam (Valium)
• lorazepam (Ativan)
• oxazepam (Serax)
Antianxiety Agnets
Benzodiazpines
• May cause physical dependence, C-IV
• Should not be stopped abruptly
• Side Effects
– Muscle relaxation
– Paradoxical excitement
– Sedation
Dispensing Issues
Warning!
Xanax (antianxiety) and Zantac (H2
Antagonist for the stomach) are lookalike/sound-alike drugs.
propranolol (Inderal)
• Beta blocker used to treat physical
symptoms of anxiety
• Not officially indicated for this use
• Lowers heart rate which decreases
nervousness due to stage fright or test
anxiety
buspirone (Buspar)
• Selectively antagonizes serotonin receptors
• Take with food
• Report changes in the senses
Dispensing Issues
Warning!
Buspirone (antidepressant/antianxiety)
and bupropion (antidepressant) are lookalike/sound-alike drugs.
Panic Disorders
Panic
• Intense, overwhelming, and uncontrollable
anxiety
• Neither a controllable voluntary emotion
nor a condition that can be avoided by
ignoring it or wishing it away
Panic Disorders
• Can occur anywhere at anytime
• Criteria for Diagnosis
– Three attacks in a three-week period
– At least four qualifying symptoms
Panic Disorders
Pathophysiology
• Result from a neurochemical defect
• The brain stem is a pathway for sensory
information
• If there is a defect in the brain stem, stimuli
can be excessively amplified and cause an
overreaction
Panic Disorders
Treatment
• Combination of antipanic medication and
behavioral therapy
• Psychotherapy is preferred treatment when
symptoms cause significant discomfort or
impairment
• Antianxiety medications are indicated for
short-term treatment
Discussion
What fraction of Americans 18
and older have a sleep disorder?
Discussion
What fraction of Americans 18 and older
have a sleep disorder?
Answer
1/3
Sleep Disorders
Insomnia
• Difficulty falling or staying asleep or not
feeling refreshed on awakening
• Treated with hypnotics (to induce sleep)
Sleep Disorders
Causes
– Situational
Sleep Disorders
Causes
– Situational
– Medical
Sleep Disorders
Causes
– Situational
– Medical
– Psychiatric
Sleep Disorders
Causes
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Situational
Medical
Psychiatric
Drug induced
Sleep Disorders
Stages of Sleep
Stage 1
Somewhat aware of surroundings, but relaxed
Sleep Disorders
Stages of Sleep
Stage 1
Somewhat aware of surroundings, but relaxed
Stage 2
Unaware of surroundings, but can easily be
awakened
Sleep Disorders
Stages of Sleep
Stage 1
Somewhat aware of surroundings, but relaxed
Stage 2
Unaware of surroundings, but can easily be
awakened
Stage 3
Deep sleep (REM sleep); dreams occur
Sleep Disorders
Narcolepsy
• Involves recurring, inappropriate episodes
of sleep during the daytime hours
• No known cause
• Occurs four times more in men than women
Sleep Disorders
Characteristic Symptoms
1. Patient feels sleepy during the daytime
and then enters into REM sleep
Sleep Disorders
Characteristic Symptoms
1. Patient feels sleepy during the daytime
and then enters into REM sleep
2. Patient experiences cataplexy with sudden
emotions
Sleep Disorders
Characteristic Symptoms
1. Patient feels sleepy during the daytime
and then enters into REM sleep
2. Patient experiences cataplexy with sudden
emotions
3. Sleep paralysis
Sleep Disorders
Characteristic Symptoms
1. Patient feels sleepy during the daytime
and then enters into REM sleep
2. Patient experiences cataplexy with sudden
emotions
3. Sleep paralysis
4. Very vivid hallucinations at the onset of
sleep
Sleep Disorders
Treatment of Narcolepsy
• Nondrug Therapy
Lifestyle changes
• Drug Therapy
– Stimulants
– Tricyclic antidepressants
– SSRIs
Sleep Disorders
• Pharmacological Treatment
Hypnotics
• Nonpharmacological Treatment
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Normalizing sleep schedule
Increases physical exercise
Discontinuing alcohol use as a sedative
Sleep only 7-8 hours/24 hr
Reducing caffeine and nicotine intake
Sleep Disorders
Treatment
• Hypnotics should be used in conjunction
with other medical therapeutics
• Benzodiazepines are the preferred agents
• Hypnotics should not be taken every night,
only as needed
Dispensing Issues
Warning!
Diazepam, lorazepam, and alprazolam
can be misread and misheard.
Drug List
Sleep Agents
Benzodiazepines, C-IV
• alprazolam (Xanax)
• chlordiazepoxide (Librium)
• clorazepate (Tranxene)
• diazepam (Valium)
• estazolam (ProSom)
• flurazepam (Dalmane)
Drug List
Sleep Agents
Benzodiazepines, C-IV
• lorazepam (Ativan)
• oxazepam (Serax)
• temazepam (Restoril)
• triazolam (Halcion)
Drug List
Sleep Agents
Barbiturates
• amobarbital (Amytal), C-II
• butabarbital (Butisol), C-III
• secobarbital (Seconal), C-II
Antihistamines
• diphenhydramine (Benadryl)
• hydroxyzine (Vistaril)
Drug List
Sleep Agents
Hypnotic
• chloral hydrate
Others
• zaleplon (Sonata)
• zolpidem (Ambien)
zolpidem (Ambien)
• Targets benzodiazepine receptors with less
effects on skeletal muscles and seizure
threshold
• Short-term treatment only
– Should not be used for more than 10 days
– Alert the pharmacist, but realize there are
exceptions
Alcoholism
• Denial is one of the major roadblocks for a
patient to overcome before getting help
• Linked to genetics
• No cure, but can be arrested
Alcoholism
Effects on Metabolism and Excretion
• Alcohol is an anesthetic and can cause loss
of consciousness
• Emetic action prevents death by preventing
absorption of lethal concentrations
• Habitual drinkers metabolize ETOH
quicker, which increases tolerance
Alcoholism Side Effects
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Vitamin deficiency
Gastritis
Organic brain damage
Alcoholic psychosis and dementia
Cirrhosis of the liver (irreversible damage)
Alcoholism
Symptoms of Dependence on Alcohol
• Blackouts or lapses of memory
• Concerns of family, friends, and employers
about the substance use
• Doing things that cause regret afterwards
• Financial or legal problems from substance
use
• Loss of pleasure with the substance
Alcoholism
Symptoms of Dependence on Alcohol
• Neglecting responsibilities
• Trying to cut down or quit using a
substance, but failing
• Using alone; hiding evidence
• Using to forget about problems
• Willingness to do almost anything to get the
substance
Alcoholism
Steps Towards Recovery
1. Acknowledge the problem
2. Limit the time spent with substance
abusers
3. Seek professional help
4. Seek support from recovering alcoholics
Alcoholism
Withdrawal Symptoms
• Agitation
• Circulatory disturbances
• Convulsions
• Delirium treatments
• Digestive disorders
• Disorientation
• Extreme fear
Alcoholism
Withdrawal Symptoms
• Hallucinations
• Mental disturbances
• Nausea and vomiting
• Restlessness
• Sweating
• Temporary suppression of REM sleep
• Tremor and weakness
Drug List
Alcohol Antagonists
• disulfiram (Antabuse)
• naltrexone (Revia)
• topiramate (Topamax) – not approved yet
disulfiram (Antabuse)
• Stops the metabolism of alcohol
• Upon consumption of alcohol, side effects
are immediate:
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Blurred vision
Difficulty breathing
Severe headache
Severe vomiting
Face becomes hot & scarlet
– Confusion
– Chest pain
– Nausea
– Uneasiness
– Thirst
disulfiram (Antabuse)
• Patients must read labels to avoid ETOH:
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Cough medicines
Mouthwashes
Flavorings
Salad dressings
topiramate (Topamax)
• Anticonvulsant that can reduce cravings for
alcohol
• Takes six weeks to be effective
• Topamax mixed with behavioral therapy
looks promising in the treatment of
alcoholism