PsychopharmacolPsychopharmacologyogy

Manuel D. Reich, DOManuel D. Reich, DO

PsychopharmacologyPsychopharmacology The study and practice of the effects that The study and practice of the effects that

drugs have on mood and behaviordrugs have on mood and behavior A wide range of substances from plant A wide range of substances from plant

sources to metalssources to metals Neuropsychopharmacology: the Neuropsychopharmacology: the

relationship between drugs and the cells in relationship between drugs and the cells in the nervous system that casue change in the nervous system that casue change in mood and behaviormood and behavior

Psychoactive drugs cause chemical Psychoactive drugs cause chemical interactions between target receptors in interactions between target receptors in the CNSthe CNS

HistoryHistory India: Fly Agaric 10,000 BCEIndia: Fly Agaric 10,000 BCE Hunter/Gather/Tribes: Hallucinogenic Hunter/Gather/Tribes: Hallucinogenic

DrugsDrugs Farming: cannabis, opium herbs, Farming: cannabis, opium herbs,

farming societies fermentation farming societies fermentation alcohol alcohol Scientific Revolution: rejection of herbs Scientific Revolution: rejection of herbs

and natural preparationsand natural preparations 2020thth Century: psychiatric drugs as a by- Century: psychiatric drugs as a by-

product of organic compounds and product of organic compounds and reassessment of traditional remediesreassessment of traditional remedies

Psychoactive Categories Psychoactive Categories Antidepressants: TCA, MAOI, SSRI, SNRI, Antidepressants: TCA, MAOI, SSRI, SNRI,

OtherOther Alcohol; a depressant Alcohol; a depressant Anxiolytic: BenzodiazepinesAnxiolytic: Benzodiazepines Antipsychotic: 1* , 2*, 3*Antipsychotic: 1* , 2*, 3* Stimulants : Amphetamines Stimulants : Amphetamines Mood Stabilizer: Anti-seizure Mood Stabilizer: Anti-seizure HypnoticHypnotic CannabisCannabis Opiates: Narcotic analgesic Opiates: Narcotic analgesic HallucinogensHallucinogens HormonesHormones NeurotransmittersNeurotransmitters

Research & DevelopmentResearch & Development

Chemical Models: Chemical Models:

In relation to CNS anatomy and In relation to CNS anatomy and physiology physiology

Designed based on organic properties Designed based on organic properties Physical propertiesPhysical properties Mechanical propertiesMechanical properties NeurotransmittersNeurotransmitters Re-evaluation of existing medicationsRe-evaluation of existing medications

Specific TestingSpecific Testing

FDA GuidelinesFDA Guidelines Lab chemical analysisLab chemical analysis Animal modelsAnimal models Human testingHuman testing

Benefit over placeboBenefit over placebo Distinct number of studiesDistinct number of studies

Mental Illness and Mental Illness and MedicationsMedications

Significant percentage Americans Significant percentage Americans suffers a diagnosable mental illness in suffers a diagnosable mental illness in any six month periodany six month period

Significant percentage of these Significant percentage of these people will improve or recover if they people will improve or recover if they get treatmentget treatment

All medicines have effects based on All medicines have effects based on their positive and negative effectstheir positive and negative effects

Chemical properties:Chemical properties:

Therapeutic effect

Side effect

Mental Illnesses and Mental Illnesses and MedicationsMedications

People suffering from many mental People suffering from many mental illnesses have imbalances in brain illnesses have imbalances in brain physiology physiology

The neurotransmittersThe neurotransmitters

↓↓ TransmissionTransmission

↑↑ Re-up takeRe-up take

∆ ∆ ProductionProduction

? Anatomy ? Receptor – Neuroreceptor ? Anatomy ? Receptor – Neuroreceptor function function

NomenclatureNomenclature

DiagnosisDiagnosis Anti-depressantAnti-depressant Anti-anxietyAnti-anxiety Anti-psychoticAnti-psychotic Anti-epilepticAnti-epileptic

Physiological Action/ Administration Physiological Action/ Administration

SSRISSRI StimulantStimulant TransdermalTransdermal

NSRINSRI OralOral DepotDepot

TypicalTypical AtypicalAtypical ODTODT

Chemical FormulaChemical Formula Receptor Receptor Clinical EffectClinical Effect Mood StabilizerMood Stabilizer Pain Pain AnxiolyticAnxiolytic HypnoticHypnotic AnesthesiaAnesthesia RecreationRecreation Ritual/SpiritualRitual/Spiritual Military Military

Generic NameGeneric Name Trade Name ®Trade Name ® Clinical UtilizationClinical Utilization

FDA IndicationFDA Indication AgeAge DiagnosisDiagnosis

““Off Label” UseOff Label” Use PharmaPharma MedicalMedical

Anti-DepressantsAnti-Depressants Depression afflicts millions Americans in any six-month Depression afflicts millions Americans in any six-month

periodperiod Profound and unremitting sadness, hopelessness, Profound and unremitting sadness, hopelessness,

helplessness, guilt and fatigue, no happiness or joy in helplessness, guilt and fatigue, no happiness or joy in activities once enjoyed or being irritable for greater activities once enjoyed or being irritable for greater than 2 weeksthan 2 weeks

Depression can be lethal, patients are at high risk for Depression can be lethal, patients are at high risk for suicidesuicide

80% of patients suffering from major illness respond 80% of patients suffering from major illness respond well to treatmentwell to treatment

Psychiatrists usually recommend treatment with anti-Psychiatrists usually recommend treatment with anti-depressant medications for a minimum of six months depressant medications for a minimum of six months after a 3 month stabilization period ( 9-12-18 months)after a 3 month stabilization period ( 9-12-18 months)

Longer for multiple episodes especially after age 40 Longer for multiple episodes especially after age 40

Anti-Depressant Anti-Depressant MedicationMedication

The classes of medication are used as The classes of medication are used as anti-depressantsanti-depressants TricyclicsTricyclics MAOIsMAOIs SSRI (Specific Serotonin Re-Uptake SSRI (Specific Serotonin Re-Uptake

Inhibitors)Inhibitors) SNRI (Norepinephine Serotonin Re-uptake SNRI (Norepinephine Serotonin Re-uptake

Inhibitors)Inhibitors) TetracyclicTetracyclic OtherOther

Tricyclic Anti-Tricyclic Anti-DepressantsDepressants

Elavil (Amitryptiline)Elavil (Amitryptiline) Norpramin (Despiramine)Norpramin (Despiramine) Tofranil (Imipramine)Tofranil (Imipramine) Pamelor (Nortryptiline)Pamelor (Nortryptiline)

Tricyclic AntidepressantsTricyclic Antidepressants Side EffectsSide Effects

Blurred visionBlurred vision ConstipationConstipation Light-headednessLight-headedness Dry mouthDry mouth Retention of urineRetention of urine

Side effects generally disappear after a few Side effects generally disappear after a few weeksweeks

More serious side effects: More serious side effects: narrow-angle glaucoma narrow-angle glaucoma seizuresseizures

ConfusionConfusion SweatingSweating Racing heartbeatRacing heartbeat Low blood pressureLow blood pressure Allergic skin Allergic skin

reactionsreactions Sensitivity to sunSensitivity to sun

MAOI’sMAOI’s

NardilNardil MarplanMarplan EmsamEmsam

Diet ConsiderationsDiet Considerations

Serotonin-Specific Serotonin-Specific AgentsAgents

ProzacProzac ZoloftZoloft Less effect on the cardiovascular system Less effect on the cardiovascular system

(safer if overdose)(safer if overdose) Generally have fewer effects than other Generally have fewer effects than other

classes of anti-depressantsclasses of anti-depressants Side EffectsSide Effects

Anxious or nervous, sleep disturbances, Anxious or nervous, sleep disturbances, stomach cramps, nausea, skin rash and, rarely, stomach cramps, nausea, skin rash and, rarely, sleepinesssleepiness

Extremely rare cases may develop a seizureExtremely rare cases may develop a seizure Discontinuation syndromeDiscontinuation syndrome Serotonin syndromeSerotonin syndrome

CelexaCelexa PaxilPaxil

LuvoxLuvox LexaproLexapro

FetzimaFetzima EffexorEffexor PristiqPristiq CymbaltaCymbalta

Serotonin – Norepinephrine Serotonin – Norepinephrine Reuptake Inhibition (dual Reuptake Inhibition (dual

action)action)

RemeronRemeron LudiomilLudiomil ViibrydViibryd BrintellixBrintellix

Tetracyclics and OthersTetracyclics and Others

Mood StabilizersMood Stabilizers

Bipolar Disorder patients have Bipolar Disorder patients have symptoms of severe depression that symptoms of severe depression that alternate with periods of feeling normal alternate with periods of feeling normal and/or periods of excessive excitement and/or periods of excessive excitement and activity known as maniaand activity known as maniaManic Phases may include:Manic Phases may include:

Extremely high energyExtremely high energy Grandiose and unrealistic ideasGrandiose and unrealistic ideas Spending spreesSpending sprees Go for days without sleepingGo for days without sleeping Thoughts become chaotic, speak rapidlyThoughts become chaotic, speak rapidly

Mood Stabilizer – Anti-Mood Stabilizer – Anti-EpilepticEpileptic

DepakoteDepakote TegretolTegretol LithiumLithium TrileptalTrileptal LamictalLamictal NeurontinNeurontin TopomaxTopomax Atypical Anti-psychoticsAtypical Anti-psychotics

Treats manic Treats manic symptoms in symptoms in seven to ten days seven to ten days and reduces and reduces depressive depressive symptoms symptoms

Effective in Effective in controlling wild controlling wild thoughts and thoughts and behaviors of behaviors of maniamania

Side EffectsSide Effects TremorTremor Weight gainWeight gain NauseaNausea DiarrheaDiarrhea ConfusionConfusion Slurred speechSlurred speech FatigueFatigue WeaknessWeakness Difficulty walkingDifficulty walking Blood count Blood count

changeschanges Liver changesLiver changes Steven Johnson Steven Johnson

SyndromeSyndrome

Atypical Anti-PsychoticAtypical Anti-Psychotic

AbilifyAbilify ZyprexaZyprexa GeodonGeodon SeroquelSeroquel RisperdalRisperdal RexultiRexulti

Metabolic SyndromeMetabolic Syndrome

Anti-Anxiety MedicationsAnti-Anxiety Medications Generalized anxietyGeneralized anxiety Phobias – a strong persistent fear of Phobias – a strong persistent fear of

objects, activities, persons and situations, objects, activities, persons and situations, which is excessive, and unreasonable and which is excessive, and unreasonable and interferes with life function and is beyond interferes with life function and is beyond self controlself control

Panic disorders: Panic disorders: Panic disorder has both physical and mental Panic disorder has both physical and mental

symptomssymptoms Obsessive-compulsive disorderObsessive-compulsive disorder

Repeated, unwanted and often very disturbing Repeated, unwanted and often very disturbing thoughts and/or ritualistic behaviors and actionsthoughts and/or ritualistic behaviors and actions

Post-traumatic stress disorderPost-traumatic stress disorder

AnxiolyticsAnxiolytics

SSRISSRI NSRINSRI Anti-psychoticAnti-psychotic TCATCA Azaspirodecanediones (Buspar)Azaspirodecanediones (Buspar) BenzodiazepinesBenzodiazepines BarbituratesBarbiturates Sedative hypnoticsSedative hypnotics

Variable drugs in all classesVariable drugs in all classes Chronic and acute indicationsChronic and acute indications Side EffectsSide Effects

Depends on class and typeDepends on class and type SedationSedation DependenceDependence

Antipsychotic DrugsAntipsychotic Drugs

Psychosis is a symptom, not a diseasePsychosis is a symptom, not a disease Part of several mental illnesses such as Part of several mental illnesses such as

schizophrenia, bipolar disorder, major schizophrenia, bipolar disorder, major depressiondepression

Psychosis alters person’s ability to test Psychosis alters person’s ability to test reality as shown by alteration of:reality as shown by alteration of: Any/all of the five senses (hallucination)Any/all of the five senses (hallucination) Thinking and communication (formal thought Thinking and communication (formal thought

disorder)disorder) Ideation (paranoia, delusions)Ideation (paranoia, delusions)

Example:Example: SchizophreniaSchizophrenia Bipolar DisorderBipolar Disorder Brief Reactive PsychosisBrief Reactive Psychosis Delusional DisorderDelusional Disorder Schizoaffective DisorderSchizoaffective Disorder

MedicationsMedications Abilify, Clozaril, Geodon, Haldol, Abilify, Clozaril, Geodon, Haldol,

Prolixin, Risperdal, Seroquel, Stelazine, Prolixin, Risperdal, Seroquel, Stelazine, Trilafon, Zyprexa, Navane, Loxitane, Trilafon, Zyprexa, Navane, Loxitane, Moban, MellarilMoban, Mellaril

Side Effects: dry mouth, blurred vision, Side Effects: dry mouth, blurred vision, constipation and drowsinessconstipation and drowsiness

Other Side Effects: photo sensitivity, Other Side Effects: photo sensitivity, blood cell count, low blood pressure, blood cell count, low blood pressure, parkinsonism, tardive dyskinesia, parkinsonism, tardive dyskinesia, movement disorder movement disorder

Metabolic syndrome, weight gainMetabolic syndrome, weight gain

InsomniaInsomnia Sedative hypnoticsSedative hypnotics

LunestaLunesta SonataSonata AmbienAmbien

BarbituratesBarbiturates NarcoticsNarcotics

StimluantsStimluants

Amphetamine productsAmphetamine products Methylphenidate productsMethylphenidate products These are named for the believed These are named for the believed

pharmacological action of stimulating pharmacological action of stimulating the neurotransmission in the CNSthe neurotransmission in the CNS

Long and short acting preparationsLong and short acting preparations Coverage is from 2 – 10 hours Coverage is from 2 – 10 hours

depending on the preparation; each depending on the preparation; each dose is discreet dose is discreet

Stimlulants IIStimlulants II

Methylphenidate products are for 5 Methylphenidate products are for 5 and olderand older

Amphetamine products: Dexedrine, Amphetamine products: Dexedrine, Adderall, VyvanseAdderall, Vyvanse

Methylphenidate products: Ritalin, Methylphenidate products: Ritalin, Focalin, ConcertaFocalin, Concerta

Listed short to long actingListed short to long acting

Non-StimulantsNon-Stimulants

StratteraStrattera Alpha agonists (short and long Alpha agonists (short and long

acting)acting) ClonidineClonidine Tenex Tenex

Q & AQ & A