Medications & Psychopharmacology
(4-12-23)

Why should a counselor or psychologist worry about medications?

1) medications affect the quality of life of many of our clients

While they are probably not the magic bullets we would like them to be--well managed pharmacotherapy can be of benefit to many clients.

2) we spend (usually) more time with clients than any of their other service providers and, hence, have more opportunity to learn about the experience and educate them about how to get the most benefit from other providers and services

a) consistently the most common reason cited by patients for discontinuing a psychotropic medication is displeasure with side effects

b) most of these same patients have not spoken with their physician/prescriber about these side effects, but will do so if asked/prompted to

c) certain clients will have difficulty speaking about certain side effects with certain providers (middle aged male needing to discuss sexual side effects with younger, attractive, female physician's assistant)

3) studies usually find that most people do not take medications as prescribed (majority of deviations are trivial but some are not), fail to report this to prescribing agents; and physicians (and, I suspect, NP's, PA's, and all other prescribing agents) tend to act/believe that the patient is always taking the medication just as directed

4) patients (perhaps influenced by all those overly optimistic advertisements) tend to expect medications to work immediately if not sooner, want to suffer no side effects at all, and believe that their experience by the end of the week reflects what their experience will always be like.

Failure of life to conform to these expectations often lead to phone calls to the doctor's office with complaints. Enough complaints will cause physicians, who usually really do know better, to change medications before a reasonable trial at a certain dosage level, etc., etc., until God herself would have no idea what might be going on inside the patient's body. A certain amount of hand holding and independent discussion (we usually do not have a dog in this particular fight) can help patients understand and tolerate a "fair trial" of a medication.

Classification of drugs and representative agents (originally adapted from Julien,1995).

Some preliminary, general thoughts:

How drugs work: in general, drugs will cause our body to do more or less of something it already does/is doing

stimulant vs. depressant chemicals

Or, "If alcohol is a depressant, why do I feel so good after having a drink?"

stimulating an inhibitor and inhibiting an excitatory pathway

stimulate manufacture/release neurotransmitter
block reuptake of a neurotransmitter
stimulate manufacture/release of a neurotransmitter metabolizer
bind to without activating/or without disengaging from (block) a receptor site for a neurotransmitter
stimulate an inhibitory neuron influencing a signal neuron
stimulate an excitatory neuron influencing a signal neuron
decrease number of receptor sites on receiving neuron
increase number of receptor sites on receiving neuron

Effects and side effects--why all classifications systems break down at some point: All psychoactive chemicals tend to have multiple effects within the CNS.

Today's side effect is tomorrows treatment effect: imipramine and enuresis.

Take this and all simple classificatory schemes cautiously and with a huge grain of salt.

Individual differences: Why even "good" drugs will hurt some people

On wanting simple answers in a very complex world: doing watch repair with a sledge hammer and blow torch

the FDA, "indications", "off label use", generic drugs, and the economics of health and health research in the 21st century

Yes, drug companies are the agents of Satan but only in the nicest possible way

I. Traditional, nonselective CNS depressants

Normal--Relief from anxiety--Disinhibition--Sedation--Sleep--General anesthesia--Coma--Death

effects additive, may be supra-addative

"Mickey Finn": chloral hydrate added to an alcoholic drink was a useful tool for "shanghai'ing" sailors in past centuries or robbing naive newcomers to the city

multiple large doses may lead to rebound hyperexcitability

risk of inducing psychological dependence and tolerance

A. Barbiturates: phenobarbital (Luminal), amobarbital (Amytal), pentobarbital (Nembutal), thiopental (Pentothal)

B. Nonbarbiturate, nonbenzodiazepine hypnotics: meprobamate (Equanil), gluthimide (Doriden), methyprylon (Noludar), methaqualone, chloral hydrate

C. Ethyl alchohol

D. General anesthetics

E. Inhalants of abuse

II. Antianxiety agents (“anxiolytic”)

A. Benzodiazepines: diazepam (Valium), lorazepam (Ativan), triazolam (Halcion), chlordiazepoxide (Librium), oxazepam (Serax)

abuse potential greatest for benzodiazepines with more rapid onset of action and shorter half-life

B. Nonbenzodiazepine, GABA-agonist hypnotic: zolpidem (Ambien)

C. Nonbenzodiazepine, “second-generation” anxiolytic: buspirone (BuSpar)

D. Antihistimine: hydroxyzine (Atarax, Marax, Vistaril)

E. propranalol (Inderal)--antihypertensive

Most antidepressant medications (Tricyclics, SSRI's, atypicals) have anxiolytic effects; Lithium does not to my knowledge

III. Antiepileptic drugs

A. Traditional agents: alcohol, phenobarbital; phenytoin (Dilantin), primidone (Mysoline)

B. Benzodiazepines: clonazepam (Klonopin), clorazepate (Tranxene)

C. Newer agents used in treating psychological disorders: carbamazepine (Tegretol), valproic acid (Depakene), alprazolam (Xanax), gabapentin (Neurontin), lamotrigine (Lamictal)

D. Newer meprobamate derivative: felbamate (Felbatol)

IV. Psychomotor stimulants (psychostimulants)

all are behavioral stimulants, all are behavioral reinforcers, all are subject to compulsive abuse, many have limited but continuing therapetic use

A. Dopamine reuptake blocker: cocaine

B. Dopamine-releasing agents

cognitive inhancement: sustained attention and volutional control of concentration

1. Amphetamines: d-amphetamine (Dexedrine, Adderall, Desoxyn, Dexedrine, DextroStat), methamphetamine

2. Amphetamine derivatives:

methylphenidate (Ritalin, Concerta, Adderall [combination of 4 amphetamines], Metadate)

several are now available in "extended release" or "controlled release" forms

pemoline (Cylert, PemADD) [largely abandoned due to risk of liver failure]

C. Adenosine receptor blocker: caffeine

D. Acetylcholine receptor stimulant (agonist): nicotine

V. Antidepressants

A. Tricyclic antidepressants (TCAs):

imipramine (Tofranil)
amitriptyline (Elavil)
amoxapine (Asendin)
nortiptyline (Pamelor, Aventyl)
protriptyline (Vivactil)

B. Second-generation antidepressants (some referred to as "tatracyclics"):

maprotiline (Ludiomil)
amoxapine (Asendin)
trazodone (Desyrel)
bupropion (Wellbutrin)
maprotiline (Ludiomil)
mertazapine (Remeron)
nefazodone (Serzone)
clomipramine (Anafranil)
venlafaxine (Effexor) [sometimes grouped with SSRI's, serotonin and norepinephrine reuptake inhibitor]

C. Serotonin-specific reuptake inhibitors:

citalopram (Celexa, Cipramil, Emocal, Sepram, Seropram)
escitalopram oxalate (Lexapro, Cipralex, Esertia)
fluoxetine (Prozac, Fontex, Seromex, Seronil, Sarafem, Fluctin (EUR)
fluvoxamine maleate (Luvox, Faverin)
paroxetine (Paxil, Seroxat, Aropax, Deroxat, Rexetin, Xetanor, Paroxat)
sertraline (Zoloft, Lustral, Serlain)
dapoxetine (no known trade name)

D. Monoamine oxidase (MAO) inhibitors:

tranylcypromine (Parnate)
phenelzine (Nardil)
isocarboxazid (Marplan)

VI. Mood stabilizers

A. Lithium salt

Lithium (Carbolith, Lithane, Lithobid, Lithonate, Lithotab, Eskalith)

supporters claim that Lithium fulfils all four criteria for mood stabilizers: prophylaxis against and treatment of mania and bipolar depression

1. treats acute mania
2. prevents/decreases future mania
3. treats acute depression
4. prevents.decreases future depression

tremor is common side effect and toxicity is a risk

the "mental dulness" complained of by some patients may reflect their not liking the feeling of a normal mood

B. anticonvulsants

Carbamazepine (Tegretol)
Valproic acid (Depakene, Dapakote)
gabapentin (Neurontin)
carbamazepine (Carbatrol)
phenytoin (Dilantin)
topiramate (Topamax)
oxcarbazepine (Trileptal)

C. adjunctive, nonspecific antimanic drugs

Benzodiazepines: clonazepam (Klonopin), lorazepam (Ativan)
Calcium-channel-blocking agents: Verapamil (Calan), nimodipine
clonidine (Catapres)

VII. Narcotic analgesics: opiates

A. Pure opioid agonists (e.g., morphine, codeine, heroin)

B. Partial opioid agonists (e.g., nalbuphine, pentazocine)

C. Opioid antagonists (e.g., naloxone, naltrexone)

VIII. Antipsychotic agents (neuroleptics)

suppression of positive psychotic symptoms usually associated with inhibition of Dopamine receptors, especially D2; side effects follow from same pathways

dopamine pathways in CHS associated with symptoms and side effects

Mesolimbic pathway: hyperactivity--positive symptoms

Nigrostriatal pathway: part of EP system (Parkinson symptoms)

Mesocortical pathway: hypoactivity--negative symptoms, cognitive impairment

Tuberoinfundibular pathway: inhibits prolactin release (sexual side effects)

hypothalmus signals pitutary to stop making prolactin with dopamine

Potential consequences of prolactin elevation:

sexual dysfunction
amenorrhea
loss of feeling feminine
low testosterone & impotence
galactorrhea

A. Phenothiazines: chlorpromazine (Thorazine), fluphenazine (Prolixin), mesoridazine (Serentil), perphenazine (Etrafon, Triavil, Trilafon)

B. Butyrophenones: haloperidol (Haldol)

C. Other antipsychotics:

atypical antispsychotics, "second generation antipsychotics"

D2 & 5-HT receptors; "partial agonists"

amoxapine (Asendin)

aripiprazole (Abilify)

FDA recognition for treatment of schizophrenia and bipolar mania

chlorprothixene (Taractan)

clozapine (Clozaril)
loxapine (Loxitane, Loxapine)
prochlorperazine (Compazine)
quetiapine (Seroquel)

Dopamine and serotonin antagonist:

risperidone (Risperdal)
thiothixene (Navane)
remoxipride (Remorin)
olanapine (Zyprexia)
ziprasidone (Geodon )

IX. Psychedelics and hallucinogens

A. Anticholinergic psychedelics: scopolamine

B. Norepinephrine psychedelics: mescaline, DOM (STP), MDA, MMDA, TMA, DMA, Myristin

C. Serotonin psychedelics: lysergic acid diethylamide (LSD); dimethyltryptamine (DMT); psilocybin, psilocin, bufotenine; ololiuqui (morning glory seeds); harmine

D. Psychedelic anesthetics: phencyclidine (Sernyl), ketamine (Ketalar)

E. Tetrahydrocannobinol: marijuana, hashish, cannabis

microdosing

X. Anti-Alzeheimer's (cognitive inhancement)

current focus on enhancing cholinergic function. agents that inhibit acetylcholinesterase--the enzyme that breaks down acetylcholine--are most widely used

donepezil (Aricept)
ergoloid (Hydergine)
glantamine (Reminyl, Razadyne)
tacrine (Cognex)
rivastigmine (Exelon)

dimebolin (Dimebon) in trials

phenserine: in trials; inhibits cholinesterase and decreases formation of AB1-42

XI. Antiparkinsonian (anticholinergic)

benztropine (Cogentin)

L-dopa, levodopa (Atamet, Larodopa, Dopar, Sinemet)

trihexyphenidyl (Artane)

XII. Antiaddiction

disulfiram (Antabuse)--alcohol

buprenorphine (Buprenex)

methadone (Dolophine)--opioid

Narcotic antagonist: nalmefene (Revex)

naloxone (Narcane)

Opioid antagonist (alcohol):

naltrexone (ReVia, Trexan, Vivitrol)

acamprosate sodium (Campral)

Zyban (Wellbutrin; bupropion) for smoking cessation

XII. anti-ADHD (cognitive ehancement/behavior control enhancement)

CNS stimulants

antihypertensives

clonidine (Catapres)
guanfacine (Tenex)

norepinephrine reuptake inhibitor

atomoxetine (Strattera)

SSRI's

XII. treatment of enuresis

imipramine (Tofranil)

desmopressin acetate (DDAVP)

oxybutinin chloride (Ditopan)

 

References:

Julien, R.M. (1995). A Primer of Drug Action, 7th Ed. New York: W.H. Freeman & Co.

Weiden, P. (2007). The pharmacodynamics of atypical antipsychotics: Focus on safety and functional outcome. Presentation at U.S. Psychiatric and Mental Health Congress, regional extension, Chicago, IL, March 10, 2007.