Mood stabilizers

Gold Standard

Treats Manic Phase

Low Therapuetic Index

Nausea, Bomiting, diarrhea

Morot incoordination

Slurred Speech

Confusion

Coma

Death

Weight GAin

Hyperdipsia

Hyperuria

Hand Tremors

Depression

Biological Intervensions

Medication (antidepressants)

ECT

Deep Brain STimulation

Sleep deprivation

Transcranial Magnetic Stimulation(TMS)

• Antidepressant technique
• Placing a small coil of wires on the scalp and applying a brief but powerful electric current that induces a strong, localized magnetic field.
• excite the brain or inhibit neural activity 

• Antidepressent Intervention 
• Resetting the normal phase relationship between the sleep-waking cycle and the other rhythms
• Respond more quickly then using antidepressant drugs alone.

• Euphorics- cocaine to treat melancholia
• Shock Treatment: insulin injection 

• Resperine for hypertension
• Resperine depletes monoamines- interferes with packing into synaptic vesicles

• Reserpine
• Monoaminergic of Depression

• Monoaminergic Antagonist
• tx Hypertension
• Pts reported Depression
• decreases release of Serotonin and NE

• changes first seen in sleep and eating patterns
• Mood improvement seen later
• Maximum efficacy seen 4-6 weeks 

Low abuse potential

Do NOT elevate mood in nondepressed individuals

medication maintenance- 6-8 months

• Antidepressant Medication Modalities

• Tricyclic Antidepressants (TCA)
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Monoamine Oxydase Inhibitors (MAOIs)
•  Serotonin-NE Reuptake Inhibitors (SNRIs)
• Augmenters and Add-Ons

• Inhibit Reuptake of Monoamines
• prolongs presence of NT at synaptic cleft
• primary NE agonist, secondary 5-HT agonist
• Acts of multiple systems
• Narrow Therapeutic Index

• "Dirty Drugs"
• Narrow Therapeutic Index
• Serious toxicity can occur 2-6X within therapeutic range
• Death occurs with overdose of 10 Xs normal dose
• Prolongation of QT interval

TCA side Effects

Anticholinergic

• Dry mouth
• Constipation
• Urinary retention
• Blurred Vision (mydriasis- large pupil)
• Memory problems
• Confusion 

TCA side Effects

Alpha-Adrenergic

• Orthostatic Hypotension
• Tachycardia
• Headache
• Nausea 

• Decrease in blood pressure when changing postures quickly (sitting to standing)
• Side effect of TCA's
• Alpha-Adrenergic Blockade 

TCA side effects (antidepressant)

Anti-Histaminergic

• Dizziness
• Upset stomach
• Drowsiness 

• Serotinergic Agonist
• Antidepressant
• D/C SSRIs results in withdrawal
• safer than TCAs 

Drowsiness

Sleep disturbance

Nausea and vomiting

Abdominal discomfort

Weight gain

*Sexual dysfunction

*Increased suicidal ideation (children-black box warning)

• Fluoxetine-prozac
• Sertaline-Zoloft
• Paroxetine-Paxil
• Fluvoxamine-Luvox
• Ditalopram-Celexa
• Escitalopram-Lexapro 

LUVOX

SSRI

ANTIDEPRESSANT

CELEXA

SSRI

ANTIDEPRESSANT

LEXAPRO

SSRI

ANTIDEPRESSANT

• GAD
• Panic Disorder
• OCD
• Social Anxiety
• PTSD
• Eating Disorders 

• when combined with other medications that increase serotonin
• Autonomic
• Somatic
• Cognitive

Serotonergic Syndrome

Autonomic

• fever
• shivering
•  sweating
• hyperthermia
• hypertension
•  tachyccardia
• nausea
•  diarrhea 

Serotinergic Syndrome

Somatic

• myoclonus (motor disturbance)
• Clonus (muscular contractions and relaxation)
• Tremors 

Serotinergic Syndrome

Cognitive

• agitation
• mental confusion
• hallucinations
• coma 

Serotonin Norepinephrine Reuptake

SNRIs

• Antidepressant
• NE and 5-HT
• less side effects than TCAs
• more withdrawal than SSRIs 

• Venlafaxine (Effexor)
• Desvenlafaxine (Pristiq)
• Duloxetine (Cymbalta)
• Mirtazapine (Remeron) 

Effexor

SNRI

Antidepressant

PRISTIQ

SNRI

ANTIDEPRESSANT

CYMBALTA

SNRI

ANTIDEPRESSANT

REMERON

SNRI

ANTIDEPRESSANT

MONOAMINE OXYDASE INHIBITORS

(MAOIs)

• Antidepressant
• used in atypical depression
• - atypical depression- characterized by overeating, hypersomnia 

• changes in blood pressure
• sleep disturbance
• overeating and weight gain 

• tyramine- amino acide that helps regulate blood pressure
• can't eat cheese, wine, meats, chocolate 

• Hypertension
• stroke
• confusion
• headaches
• heart problems
• nausea and vomiting 

• MAO agonist
• MAO degrades Monoamines that are in the synaptic clef
• Not contained in synaptic vesicles 

• Phenelzine (Nardil)
• Tranylcypromine (Parnate)
• Isocarboxzaid (Marplan) 

NARDIL

MAOI

ANTIDEPRESSANT

PARNATE

MAOI

ANTIDEPRESSANT

MARPLAN

MAOI

ANTIDEPRESSANT

AUGMENTER OR ADD-ON MEDS

FOR DEPRESSION

• INCREASE POTENCY OF ANTIDEPRESSANTS WHEN USED IN COMBINATION 

• BUSPIRONE (BUSPAR)
•  NEFAZODONE (SERZONE)
• TRAZODONE (DESYREL)
• QUETIAPINE FUMARATE (SEROQUEL XR)

BUSPAR

AUGMENTER

ANTIDEPRESSANT

SERZONE

AUGMENTOR

ANTIDEPRESSANT

DESYREL

AUGMENTOR

ANTIDEPRESSANT

SEROQUEL XR

AUGMENTOR

ANTIDEPRESSANT

• Electrical Self-stimulation and Substance abuse
• Direct self brain stimulation produces pleasurable sensations in pts with severe depression

• DIMINISHED RESPONSE TO A DRUG AFTER REPEATED EXPOSURE TO THE DRUG.
• INCREASINGLY LARGER DOSES OF A GIVEN DRUG MUST BE ADMINISTERED TO REACH INTOXICATION OR THE DESIRED EFFECT.

• tolerance manifested in same environment in which drug administered
• tolerance reduced or eliminated in novel environment 

WITHDRAWAL/

ABRUPT DISCONTINUATION SYNDROME

• when drug is no longer present, neuro fx does not return to normal, it overshoots basal levels
• rebound effect 

• WHEN DRUG ABRUPTLY STOPS, SXS ARE MORE SEVERE 
• COCAINE=SPEEDS U UP, REBOUND=CRASH
• CAN BE INDUCED BY GIVING DRUG ANTAGONIST

Tolerance or Withdrawal

does NOT equal

Substance Dependence or Addiction

Physical dependence does not necessarily lead to abuse or addiction

Cancer and chronic pain patients do not develop addiction

• AFTER TOLERANCE TO ONE DRUG, OTHER CHEMICALLY0RELATED DRUGS ALSO SHOW REDUCED EFFECTIVENESS
• HEROIN-->CODIENE
• SMOKING HISTORY--> LOWER SENSITIVITY TO CAFFEINE
• ALCOHOL-->BDZs 

SENSITIZATION/

REVERSE TOLERANCE

• enhancement of drug effects following repeated admin of same dose of drug 
• cocaine- tolerance to euphoria, sensitization motor activity

• use of a substance that is chemically similar, but less addictive
• slower speed of onset
• longer duration of action
• less likelihood of high 
• stimulates same brain receptors as abused drug

• replacement medication blocks receptors associated with abused drug
• drug doesn't produce the same intensity of pleasurable effects 

• MEDICATION RESULT IN UNPLEASANT PHYSICAL SYMPTOMS IF ABUSED DRUG IS USED
• dISULFIRAM (ANTABUSE) FOR aLCOHOL 

• SUBSTANCE ABUSE IS ATTEMPT BY PATIENT TO SELF-MEDICATE FOR OTHER UNTREATED PSYCH PROBLEMS
• TREAT PSYCH PROBLEM DRUG ABUSE WILL BE ELIMINATED OR REDUCED 

1. DETOXIFICATION
2. REHABILITATION
3. CONTINUING/SUPPORTING CARE 

ALCOHOL

(ETOH)

• Most abused
• reinforceing effects-->DA release from VTA-->NA and EOP-->Periaqueductal Gray in midbrain

• Block reinforcing effects of alcohol
• Opiate antagonists
• used as an adjunt tx in alcohol abuse 

• sedative-hypnotic drug
• grayout and blackout- amnesia
• .15% BAC=vomiting
• .35% BAC=pass out
• .45% BAC=lethal

• metabolized- 95% liver, 5% lungs 
• CYTOCHROME p450 METABOLIZE ETOH
• Induction- liver enzymes increase in number with abuse ie alcohol tolerance
• Cytochrome P450 also metabolizes other drugs and will compete with alcohol to be metabolized 

• repeated heavy drinking produces intense withdrawal that starts within a few hours and continues over 2-4 days
• withdrawal signs can be eliminated by taking drug again or taking drug in same class (cross dependence, BNZs) 

DELIRIUM TREMENS

DTs

• Severe form of ETOH withdrawal that involves sudden and severe mental or neuro changes
• tremors,disorientation, agitation, convulsions, hallucinations, autonomic instability 

• alcohol detox should always be conducted medically
• 10% of patients in severe alcohol withdrawal can die w/o treatment

• REPLACEMENT MEDICATION THAT ACT ON gaba RECEPTORS
• BDZs USED:
•  DIAZEPAM (VALIUM)
• CLONAZEPAM (KLONOPIN)
• ALL HAVE ANTISEIZURE EFFECTS

• NALTREXONE(ReVia)
•  Disulfiram (Antabuse)
• Acamprosate (campral)

• Naltrexone
• ETOH treatment
• blocks opiod receptors
• Interference treatment 

• Disulfiram
• ETOH treatment
• only FDA approved medication for aversion treatment of ETOH abuse 
• Aversion treatment

• Campral
• moste recent med approved by FDA for ETOH abuse
• stimulate GABA receptors
• reduces cravings