Depression

1
Depression Alzheimer's
NAPLEX
p. 109
2

• Hypnotics
• Barbiturates (phenobarbital, etc.)
• better anticonvulsant then sedative hypnotic
• Nonbarbiturates
• Glutethimide (Doriden)
• Chloral Hydrate (Noctec) dosage forms
• Benzodiazepines (see table)
• Other
• Natural Products

3
(No Transcript)
4

• Antidepressants
• Types of depression
• Major depressive disorder, single episode
• Major depressive disorder, recurrent
• Dysthymic disorder
• Dysthymic disorder, not otherwise specified
• Secondary mood disorder due to nonpsychiatric
  medical condition
• Biochemical basis of endogenous depression
  reduced / imbalance of NE / 5-HT in CNS
• Drug selection/adequate therapeutic trial

5
Antidepressant Selection Factors

• Patient factors
• Age, comorbid conditions, medication profile,
  preference, previous successes and failures of
  specific agents
• Other factors
• Cost, convenience, adverse-effect profile, safety
• Typical response rate 4 to 6 weeks
• Adequate trail is 6 month on effective dose

6

• Antidepressants (contd)
• Common Adverse Effects by Receptor Subtype
• H-1 receptor blockade
• Sedation, drowsiness, weight gain
• Acetylcholine blockade
• dry mouth, blurred vision, tachycardia,
  constipation, urinary retention, memory
  impairment
• Norepinephrine blockade
• Tremors, jitteriness, tachycardia, diaphoresis,
  HTN, erectile dysfunction
• 5-HT blockade
• sexual dysfunction, N/V/D, anorexia, anxiety,
  asthenia, insomnia, EPS

7

• Antidepressants (contd)
• Common Adverse Effects by Receptor Subtype
• 5-HT2 blockade
• sexual dysfunction, hypotension
• Alpha-1 blockade
• orthostasis, drowsiness
• Alpha-2 blockade
• priapism
• Withdrawal syndrome
• Flu-like syndromes, dizziness, adverse GI
  effects, paresthesias, mood, appetite, and sleep
  changes

8
Antidepressants (contd)
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12

• Antidepressants (contd)
• Monoamine Oxidase (MAO) Inhibitors
• - effective in refractory depression
• Isocarboxazid (Marplan)
• Phenelzine sulfate (Nardil)
• Tranylcypromine sulfate (Parnate)

13

• Antidepressants (contd)
• Substances to be avoided when using MAO
  inhibitors
• Food with Tyramine Content
• Aged cheeses
• Sauerkraut
• Smoked aged, or pickled meat or fish
• Yeast extracts
• Fava beans
• Beer, red wine
• Avocados
• Meat extracts

14

• Antidepressants (contd)
• Substances to be avoided when using MAO
  inhibitors (contd)
• Medications
• Phenylpropanolamine
• Pseudoephedrine
• Meperidine (Demerol)
• Methyldopa (Aldomet)
• Morphine
• Reserpine

15

• Anxiolytic Agents
• Anxiolytic Agents
• Types of anxiety
• GAD, Panic disorders, Phobic disorders, OCD,
  PTSD
• Anxiety as a normal and useful response
• back to fight or flight too little GABA, excess
  5-HT and NE

16

• Anxiolytic Agents (contd)
• Anxiolytic Drugs
• Antidepressants
• Beta-adrenergic blocking agents (e.g.,
  propranolol)
• Benzodiazepines
• Buspirone (BuSpar)

17
Anxiolytic Agents (contd)
Metabolized to dimethyldiazepam (active
metabolite)
18
Antipsychotic Drugs
NAPLEX
19

• An example of an antipsychotic agent
• that is likely to cause extrapyramidal side
  effects is
• a. risperidone (Risperdal)
• b. pramipexole (Mirapex)
• c. thiothixene (Navane)
• d. thioridazine (Mellaril)
• e. clozapine (Clozaril)
  

20

• An example of an antipsychotic agent
• that is likely to cause extrapyramidal side
  effects is
• a. risperidone (Risperdal)
• b. pramipexole (Mirapex)
• c. thiothixene (Navane)
• d. thioridazine (Mellaril)
• e. clozapine (Clozaril)
  

21
Characteristics

• Schizophrenia is a disorder that consists of at
  least 2 of the following symptoms lasting at
  least 1 month
• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms

22
Symptoms

• Positive
• Delusions
• Hallucinations
• Disorganized thinking
• Agitation

• Negative
• Lack of drive or initiative
• Social withdrawal
• Apathy
• Emotional unresponsiveness

23
Types

• Paranoid
• Disorganized
• Catatonic
• Residual

24

• Antipsychotic Drugs
• Mechanism of action
• D2 - dopamine receptor antagonism relief of
  positive symptoms, e.g., phenothiazine
• Combination of D2 and 5HT2A antagonism relief of
  positive and negative symptoms, e.g., newer
  antipsychotic drugs

25

• Antipsychotic Drugs (contd)
• Side/Adverse effects
• Sedation
• Adrenergic antagonism Lowering of convulsive
  threshold
• Impaired temperature regulation Endocrine
  effects
• Eye/skin syndrome Extrapyramidal effects
• Pseudoparkinsonism - tremor and speech
  problems
• Dyskinesia - spasm of muscle groups
• Akathisia - restlessness, inability to sit
  still
• Tardive dyskinesia - rhythmic involuntary
  movements
• Anticholinergic Effects
• Hepatotoxicity
• Neuroleptic malignant syndrome (NMS)

26

• Antipsychotic Drugs (contd)
• Antimanic Drugs
• Lithium levels, drug interactions (looks like
  Na), renally eliminated
• AEs polyuria, polydipsia, tremor, GI upset,
  diarrhea, cognitive dysfunction, hypothyroidism,
  weight gain, dermatologic conditions
• Valproic Acid
• AEs GI upset, hepatotoxicity, thrombocytopenia,
  weight gain, hair loss, sedation, tremor

27
Alzheimer's Drugs
NAPLEX
p. 118
28

• Drugs for Alzheimers Disease
• Cholinesterase inhibitors all enhance
  cholinergic activity
• Donepezil (Aricept)
• Galantamine (Razadyne) (Reminyl D/C))
• Rivastigmine (Exelon)
• - Exelon patch approved 7-2007
• Glutamate antagonists
• Memantine (Namenda)
• Miscellaneous agents
• Vitamin E
• Selegiline (Eldepryl)

29
Cholinesterase Inhibitors Dosing

• Dose dependent side effects require titration
• Start low and take in steps to avoid side effects

30

• Drugs for Alzheimers Disease
• Adverse Effects
• Cholinesterase inhibitors
• Hepatotoxicity
• Cholinergic effects (N/D, anorexia,
  salivation)
• Bradycardia
• Headache
• Glutamate antagonists
• Hypertension
• Tachycardia
• Insomnia

31

• A prescription is presented for galatamine
  (Razadyne). The patient is most likely being
  treated for
• Alzheimer's
• Nocturnal enuresis
• Manic-depressive illness
• ADHD
• Insomnia

32

• A prescription is presented for galatamine
  (Reminyl). The patient is most likely being
  treated for
• Alzheimer's
• Nocturnal enuresis
• Manic-depressive illness
• ADHD
• Insomnia

33

• Orthostatic hypotension is characterized by which
  of the following symptoms?
• Peripheral vasoconstriction
• Increased urination
• Urinary retention
• Dizziness
• Dry mouth

34

• Orthostatic hypotension is characterized by which
  of the following symptoms?
• Peripheral vasoconstriction
• Increased urination
• Urinary retention
• Dizziness
• Dry mouth

35

• Which SSRI(s) is not required to be tapered when
  discontinued?
• I Fluoxetine (Prozac)
• II Paroxetine (Paxil)
• III Sertaline (Zoloft)
• I only
• III only
• I II only
• II III only
• I, II, III

36

• Which SSRI(s) is not required to be tapered when
  discontinued?
• I Fluoxetine (Prozac)
• II Paroxetine (Paxil)
• III Sertaline (Zoloft)
• I only
• III only
• I II only
• II III only
• I, II, III

37

• How long is an adequate continuation of an
  antidepressant before considering a different
  agent?
• I. 4 weeks
• II. 2 months
• III. 6 months
• I only
• III only
• I II only
• II III only
• I, II, III

38

• How long is an adequate continuation of an
  antidepressant before considering a different
  agent?
• I. 4 weeks
• II. 2 months
• III. 6 months
• I only
• III only
• I II only
• II III only
• I, II, III

39

• What is considered an optimal augmentation
  approach to someone not responding to SSRI
  therapy?
• I Add Lithium 600mg BID
• II Add Cytomel 25mcg/day
• III Add Bupropion 150mg/day
• I only
• III only
• I II only
• II III only
• I, II, III

40

• What is considered an optimal augmentation
  approach to someone not responding to SSRI
  therapy?
• I Add Lithium 600mg BID
• II Add Cytomel 25mcg/day
• III Add Bupropion 150mg/day
• I only
• III only
• I II only
• II III only
• I, II, III

41
Good Luck!

• You will all do great!

42
Attention-Deficit Hyperactivity Disorder (ADHD)

• Stimulants
• Methylphenidate (Ritalin, Concerta)
• Dexmethylphenidate
• Dextroamphetamine
• Magnesium pemoline
• Methamphetamine
• Nonstimulants
• SNRI atomoxetine (Strattera)