goldberg chapter 10

Albia Dugger • Miami Dade College

Chapter 10 Psychotherapeutic

Drugs

Mental Illness

• The National Alliance on Mental Illness defines mental illnesses as: “medical conditions that disrupt a person’s thinking, feeling, mood, ability to relate to others and daily functioning”

• Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), and borderline personality disorder

Understanding Mental Illness

• One definition of a mental disorder is “an abnormal state of mind (whether of a continuous or an intermittent nature), characterized by delusions, or by disorders of mood or perception or volition or cognition”

Mental Illness and Medicine

• Medical model • The premise that a pathogen is responsible for a person’s

illness or disease

• Pathogen • Any organism that produces disease

• The application of the medical model to emotional problems gives rise to some concern – behaviors deemed inappropriate might not be the result of any given disease

Mental Illness and Special Populations

• Ethnic and racial minorities often face cultural and social stressors that pose greater risk factors for mental illness

• People of lowest socioeconomic status are more likely than those of higher strata to suffer from a mental illness

• American adolescents are experiencing major depressive episodes and dysthymia at an increasing rate

• Other groups affected by depression include postpartum women and the elderly

Types of Disorders

• Neurosis • Long-term disorder featuring the symptoms of anxiety

and/or exaggerated behavior dedicated to avoiding anxious feelings

• Includes obsessive-compulsive behaviors, psychosomatic ailments, phobias, and panic attacks

• Anxiety typically is treated with antianxiety drugs

Types of Disorders

• Psychosis • Severe mental condition marked by loss of contact with

reality

• Organic psychoses• Have physical causes such as excessive drug use, brain

infections, metabolic or endocrine disorders, brain tumors, and neurological diseases

• Functional psychoses • Have no known or apparent cause (e.g. schizophrenia)

Mood Disorders

• Mood disorders • Forms of psychosis that affect the person’s emotions• Can be depression or mania

• Depression • Dejection characterized by withdrawal or lack of response

to stimulation

• Mania • Characterized by inappropriate elation, an irrepressible

mood, and extreme cheerfulness

Mood Disorders

• Bipolar affective disorder • A mental condition characterized by alternating moods of

depression and mania• Formerly called manic-depression

• Unipolar depression • Mental disorder marked by alternating periods of

depression and normalcy

Mood Disorders

• Depression can cause substance abuse, but substance abuse also can lead to depression

• Clinical depression is a real illness that can be treated effectively

• Some individuals with substance abuse problems are misdiagnosed with bipolar illness

• A frequent problem among people with bipolar disorder is noncompliance with medications

Depression

• Women experience twice the rate of depression as men, regardless of race or ethnic background

Common Mood Disorders

Dual Diagnosis (Co-Occurring Disorders)

• Dual diagnosis (co-occurring disorders) describes a person with two or more existing mental illnesses, each of which can be diagnosed independent of the others

• Common co-occurring disorders include substance abuse/addiction or alcoholism and a mental illness such as depression, anxiety, or a personality disorder

• Major psychiatric disorders increases an individual’s risk for substance abuse

Major Psychiatric Disorders

Treatment of Mental Illness Before 1950

• Before 1950, mentally ill people were subjected to bloodletting, given sneezing powder, were flogged and starved, and had hot irons applied to their bodies

• Psychoanalysis grew in popularity starting with Freud – today, it seldom is used to treat mental problems

• Depression was treated with drugs such as amphetamines; other types of mental illnesses were treated with antihistamines, barbiturates and other depressants

Treatment of Mental Illness Before 1950

• Electroconvulsive therapy (ECT), first developed in 1938, was used to treat depression and psychosis

• Electrical activity in the brain is temporarily interrupted and a seizure within the brain is triggered

• Many patients experienced adverse cognitive effects

• Despite concerns, ECT is still a treatment option

Demographics of Drugs and Mental Disorders

• 10-15% of the general population receive drugs for emotional problems each year

• 43% of people with mental disorders reside in the US and Europe

• 1 in 3 Americans suffer from a mental disorder

• Antidepressants are the medication most frequently used by people aged 18–44

Mood Stabilizers

• Depression is treated with five major classes of drugs:• Monoamine oxidase inhibitors (MAOIs)• Tricyclic antidepressants• Selective serotonin reuptake inhibitors (SSRIs)• Serotonin and norepinephrine reuptake inhibitors (SNRIs)• Atypical antidepressants that do not fall into one of the

above categories

Many Available Antidepressants

Monoamine Oxidase Inhibitors

• Monoamine oxidase (MAO) is an enzyme on the outer membranes of mitochondria – inactivates the neurotransmitters serotonin, dopamine, and norepinephrine

• MAOIs block the action of monoamine oxidase

• Four principal MAOIs in the US:• Tranylcypromine (Parnate)• Phenelize (Nardil)• Isocarboxazid (Marplan)• Selegiline (Emsam)

Monoamine Oxidase Inhibitors

• Work well for neurotic conditions such as acute anxiety, obsessive-compulsive behavior, phobias, panic attacks

• Toxic effects occur when MAOIs interact with foods containing tyramine – release of catecholamines produces sympathomimetic effects

• MAOIs interact dangerously with certain medications, especially dextromethorphan, Demerol, and other antidepressants that affect serotonin such as Prozac

Tricyclic Antidepressants

• Amitriptyline (Elavil) is used for depression accompanied by agitation

• Imipramine (Tofranil) is given for depression involving psychomotor retardation, as well as for agoraphobia, panic attacks, and obsessive-compulsive behavior

• Clomipramine (Anafranil) also has been used to treat obsessive-compulsive behaviors

Tricyclic Antidepressants

Tricyclic Antidepressants

• Antidepressant action takes 3-4 weeks

• Tricyclics are also effective in moderating pain, and can be beneficial in treatment of the eating disorder bulimia

• Common side effects are distorted vision, tachycardia, dry mouth, constipation, sleepiness, and urinary retention

• With alcohol, risk of a deadly reaction increases – overdose causes coma, cardiac difficulties, and respiratory problems

Tricyclic Antidepressants

• If patients cease taking tricyclics abruptly, they demonstrate withdrawal symptoms

• Even at low dosage, tricyclics can be toxic – excessive levels can be fatal

• Another side effect is development of type 2 diabetes, especially when taken with the newer antidepressants

Side Effects of Tricyclic Antidepressants

• Tachycardia• Dry mouth• Confusion• Hypotension• Disorientation• Impotence• Glaucoma• Distorted vision• Sleepiness

• Constipation• Urinary retention• Tremors• Rashes• Jaundice• Respiratory problems• Coma• Death

Selective Serotonin Reuptake Inhibitors

• Selective serotonin reuptake inhibitors (SSRIs) • Antidepressant medications that increase the

concentration of serotonin in the brain• Reduce aggressive and violent behavior• Adverse effects include sexual dysfunction, increase in

weight, and altered sleep patterns• Not much more effective than placebos

Selective Serotonin Reuptake Inhibitors

• Prozac (fluoxetine)• Fewer serious side effects• Also used for bulimia, obesity, anxiety, and OCD• Implicated in a number of suicides

• Zoloft (sertraline)• Especially effective with elderly patients• Prescribed for patients with acute coronary syndrome• Also used to treat OCD

Selective Serotonin Reuptake Inhibitors

• Paxil (paroxetine)• Increased risk of suicides in children• When taken during pregnancy, increases risk of cardiac

malformations and neonatal complications• New version: PaxilCR

• Lexapro (escitalopram)• Also used for OCD, panic disorder, social anxiety disorder,

PTSD, premenstrual dysphoric disorder, menstrual mood swing and irritability, and compulsive gambling

Atypical Antidepressants

• Nefazodone (Serzone)• No longer available in the US• Reported as causing severe liver failure

• Trazodone • Mood elevator• Side effects may include confusion, concentration

difficulties, headaches, and nervousness

Atypical Antidepressants

• Mirtazapine • May cause mood changes, unusual thought processes,

seizures, lowered libido, and changes in menstrual cycle

• Bupropion (Wellbutrin)• Inhibits uptake of dopamine and norepinephrine.• Also used for smoking cessation and seasonal affective

disorder• Side effects are usually mild

SNRIs

• Serotonin and norepinephrine reuptake inhibitors (SNRIs)• Work by decreasing the reabsorption of both serotonin and

norepinephrine in the brain• Side effects may include pain in the eyes, vision blurring,

or blindness• May cause a variety of other side effects, from diarrhea

and agitation to irregular heartbeats and convulsion

SNRIs

• Venlafaxine (Effexor XR)• Side effects similar to SSRIs• Overdose can be dangerous or fatal

• Desvenlafaxine (Pristiq)• Similar to venlafaxine and causes similar side effects

• Duloxetine (Cymbalta)• May help relieve physical pain in addition to depression• Side effects include nausea, dry mouth, constipation• Heavy drinkers or those with certain liver or kidney

problems should not take duloxetine

Antidepressant Medications

Lithium

• Lithium • A positively charged ion, similar to sodium• Used to treat symptoms associated with mania• Side effects include tremors, excessive thirst, frequent

urination, fluid retention, and weight gain• Inability to excrete lithium can lead to toxic levels in the

body

• Chlorpromazine• Alternative antimanic with fewer toxic effects

Effectiveness of Lithium

• Lithium is effective for acute mania and for preventing mania and depression from recurring

• Maximal benefit is achieved in one to two weeks

• Effective for people who have unipolar depression and do not respond to tricyclic antidepressant drugs

• The therapeutic window is small – three to four times the therapeutic level can cause grave consequences

Side Effects of Lithium

• Nausea• Excessive perspiration• Water retention• Vomiting• Confusion• Drowsiness• Tinnitus• Kidney dysfunction• Respiratory depression

• Polydipsia• Hand tremors• Polyuria• Diarrhea• Weight gain• Muscular weakness• Distorted vision• Coma• Death

Antipsychotic Drugs

• Antipsychotic drugs (major tranquilizers or neuroleptics) used particularly for schizoprenia

• Antipsychotic drugs, are pharmacologically different from minor tranquilizers and other sedative-hypnotic drugs

• Chlorpromazine – an anesthetic used to ameliorate anxiety and shock during surgery – was marketed for mental disorders in 1955 under the trade name Thorazine

Antipsychotic Drugs

• Well-known antipsychotic drugs:• Haloperidol (Haldol)• Trifluoperazine (Stelazine)• Fluphenazine (Prolixin)• Olanzipine (Zyprexa)• Quetiapine (Seroquel)• Promazine (Sparine)• Thioridazine (Mellaril)

Antipsychotic Drugs

• Schizophrenic patients have to take antipsychotic drugs for four to six weeks for maximum effectiveness

• One problem is that they are absorbed erratically

• Some patients receive injections of antipsychotic drugs so the drug can be released slowly into the bloodstream

• These drugs build up in fatty areas of brain and lungs, and cross the placenta to affect the fetus

Children and Antipsychotic Drugs

• Antipsychotic drugs are prescribed more often to children in the US than to children in other developed countries

• Adverse effects in children (particularly females):• Excessive weight gain• Type 2 diabetes• Neurological symptoms• Digestive problems• Cardiovascular conditions

Effectiveness of Antipsychotic Drugs

• Schizophrenics receiving antipsychotic drugs almost always show improvement, but a small percentage gets worse

• Improvement is most rapid during the first several weeks of treatment

• Although many people taking antipsychotic drugs relapse, it appears that these drugs reduce violent behavior

Side Effects of Antipsychotic Drugs

• Antipsychotic drugs produce undesirable motor problems (extrapyramidal symptoms)

• Inappropriate motor movements (acute dyskinesias) sometimes appear within a year after treatment:• Parkinsonism• Dystonia• Akathesia

Side Effects of Antipsychotic Drugs

• Tardive dyskinesia• Motor disorders such as involuntary repetitive facial

movements, lip smacking, involuntary movement of trunk and limbs, and twitching

• Less severe side effects:• Difficulty urinating, constipation, dry mouth• Altered skin pigmentation, jaundice, and extreme

sensitivity to sunlight• Changes in heart rate

Psychotherapeutic Drug Abuse

• About 7 million Americans over age 12 report recent use of psychotherapeutic drugs for nonmedical purposes

• Unintentional poisoning deaths involving psychotherapeutic drugs, such as sedative-hypnotics and antidepressants, increased by 84% from 1999 to 2004

• In many cases, individuals had been abusing multiple drugs of different classes, compounding the toxicity