Chapter 13 Psychiatric Medications

1. Psychotherapeutic Medications
Chapter 13

2. Historical Overview
Psychoactive substances have been used to treat
mental illness for centuries
In the 1840s, a French physician working in a mental
hospital, attempted to treat mental illness with
marijuana. He found that depressed patients became
happy and talkative while manic patients calmed down
and relaxed. The effects tended to be only temporary
Manic – Relating to mania, a mood disturbance that
typically includes hyperactivity, agitation, excessive
elation, and pressured speech
Amphetamines were used in the treatment of
depression and narcolepsy and carbon dioxide
inhalation for various psychotic and neurotic conditions

3. Narcoleptic – A state characterized by brief but
uncontrollable episodes of sleep
Neuroses – Nonpsychotic emotional disturbance, pain,
or discomfort beyond what is appropriate in the
conditions of one’s life
Antihistamines, insulin shock, and psychosurgery were
also used to treat psychosis
Psychosurgery – Surgery that entails the cutting of
fibers connecting particular parts of the brain or the
removal or destruction of areas of brain tissue with the
goal of modifying severe behavioral or emotional
disturbances

4. Electroshock therapy was used to treat severe
depression and is still used on a limited basis today
It is important to remember that in the past the
motivation to administer psychopharmacological
agents to the mentally ill was largely to subdue them.
Thus many of the approaches were actually cruel,
including bloodletting, hot irons, flogging, revolving
chairs, starvation, and sneezing powder
The intention today is to provide persons with some
relief and ideally with the opportunity to function better
in their environments

5. In 1949, John Cade, an Australian physician,
discovered the alkali metal lithium and it became one
of the first of what are now called psychotropic drugs
Psychotropic – Exerting a special or unique action on
psychological functioning
Lithium was found to successfully moderate manic
conditions and remains a mainstay in the treatment of
bipolar illnesses today
The greatest advance in psychopharmacology was the
use, starting around 1950 in Paris, of the drug
chlorpromazine (Thorazine). Initially used as an
anesthetic due to its calming effects

6. Chlorpromazine was adopted throughout the world and
prompted the deinstitutionalization movement, thus
significantly decreasing the number of hospitalized
psychiatric patients
In 1955 there were 600,000 and today despite an
increase in the mentally ill population, there are
approximately 150,000 hospitalized psychiatric patients
Unfortunately, there have been downsides to this
deinstitutionalization. What are they ?
A host of other drugs were introduced in the years
following including antidepressant and antianxiety
medications

7. Epidemiology
Most prevalent mental disorders are anxiety disorders
(18%), mood disorders (10%), impulse-control
disorders (9%), and substance abuse (15%)
About 25% of the U.S. population experience some
form of mental disorder in any given year. Most have
symptoms associated with anxiety, depression, or
alcohol abuse
An additional 15% seek clinical services for various
symptoms that affect their life-functioning but may not
meet the diagnostic criteria for a particular disorder
Almost half of U.S. adults met the criteria for a mental
illness at some point in their lives. Most of these cases
were mild and did not require treatment

8. Comorbidity was common as (45%) of adults with one
mental disorder met the criteria for at least one other
disorder
Fewer than half in need get treatment, and those who
do often wait many years before doing so
Half with a mental disorder showed signs of the
disease by age 14 and three quarters by age 24. Few
sought help
Prevalence rates may be underestimates of mental
illness in the U.S. because sample did not draw from
homeless or institutionalized individuals and did not
assess less common psychiatric disorders as
schizophrenia and autism.

9. Most mental health disorders are treated with
prescription medications, most commonly antianxiety
and antidepressant medications, and three fourths of
people who receive these medications report some
degree of symptomatic relief
More than 200 million prescriptions for the lawful use
of psychotherapuetics are written yearly
 Approximately 10-15% of the general population in
any given year are given a prescription for some
psychotropic drug, usually an antidepressant or
antianxiety agent

10. Psychotropic drug use is more likely among women,
older persons, persons living alone, the more
educated, and those with higher incomes
Abuse of psychiatric drugs and Illicit use of such
prescription medications is a serious problem. Abuse
can range from exceeding recommended dosages, not
taking drugs as prescribed, taking multiple
prescriptions to street sale and diversion
Prescription drugs are a factor in a large number of
drug-related emergency room cases and drug-related
deaths
Drugs most often abused or misused in Western
cultures are depressants and stimulants

11. Classes of Drugs and Their Actions
Like other drugs, psychiatric drugs can be classified in
different ways but the most common way is by
therapeutic use
The four major categories are: antipsychotics which
include the phenothiazines such as chlorpromazine
and fluphenazine and nonphenothiazines such as
haloperidol (See Table 13.1 for complete list);
antidepressants which include cyclic antidepressants
and MAOIs (See Table 13.2 for complete list);
antianxiety agents such as barbiturates and
nonbarbiturate sedatives, benzodiazepines, and
general anesthetics (See Tables 13.3 & 13.4), and
antimanic medications or mood-stabilizers

12. Antipsychotics
Antipsychotic medications, also known as neuroleptics
or major tranquilizers, are used to treat schizophrenia
and other disorders such as mania, agitated
depression, toxic (drug-induced) psychosis,
emotionally unstable personalities, and psychosis
associated with old age.
Neuroleptic – Tranquilizing drugs used to treat
psychoses; a synonym is major tranquilizer
Agitated Depression – Depressed mood accompanied
by a state of tension or restlessness. Person shows
excessive motor activity, as he or she may, for
example, be unable to sit still, pace, wring the hands,
or pull at his or her clothes

13. Schizophrenia – An array of thought disorders,
including disturbances in areas of functioning such as
language, affect, perception, and behavior.
Disturbances may include distortions of reality (such
as delusions and hallucinations), profoundly blunted
mood, and withdrawn or bizarre behavior
Symptoms most likely to respond to antipsychotic
medications are agitation, mania, hallucinations,
delusions, fury, and accelerated and disorganized
thinking processes
Paranoid Schizophrenia – A type of schizophrenia
distinguished by systematic delusions or auditory
hallucinations related to one theme

14. Antipsychotic medications affect primarily the reticular
activating system by moderating spontaneous activity
and decreasing reactivity to stimuli, the limbic system
by moderating or blunting emotional arousal, and the
hypothalamus by modulating metabolism, alertness,
and muscle tone
The dopamine hypothesis is the most accepted
explanation for the action of antipsychotic medications.
Two core elements of the dopamine hypothesis are:
psychosis is caused by increased levels of dopamine
in the brain, and most antipsychotics block dopamine
receptors inhibiting their transmission

15. Although the antipsychotics have produced many
positive effects in the treatment of mental disorders,
their use comes with significant side effects
Chief among the acute side effects are motor
disturbances which give the appearance of a
Parkinsonian syndrome
Extrapyramidal symptoms are the most apparent
motor disturbances and include dyskinesia and
akinesia,
Extrapyramidal – Outside the pyramidal tracts, with
origin in the basal ganglia. These cell bodies are
involved with starting, stopping, and smoothing out
movements

16. Dyskinesia – Disordered movements
Akinesia – Slowness of movement and underactivity
The most common side effect assocaited with long-
term use (2 years or more) of antipsychotics is tardive
dyskinesia
Tardive Dyskinesia – An extrapyramidal complication
characterized by involuntary movements of the mouth
and tongue, trunk, and extremities; a side effect of
long-term (two or more years) use of antipsychotic
drugs
Such effects can be controlled or eliminated now with
medications such as Cogentin designed to treat them

17. Antidepressants
Depression is one of the most common psychiatric
disorders in the United States with 20% of the U.S.
population experiencing a major depressive episode in
their lifetime.
It is often classified as one of two major types:
endogenous or exogenous
Endogenous – Developed from within. When applied to
depression, the term means that depressive symptoms
seem to be due to genetic factors
Exogenous – Developed from without. When applied to
depression, the term means that depressive symptoms
seem to be in reaction to a particular situation or event

18. Two major classes of antidepressant medications now
are prescribed: cyclic antidepressants and monoamine
oxidase inhibitors (MAOIs).
The cyclics are prescribed more frequently in the united
States and include SSRIs such as Paxil, Prozac, and
Zoloft
A newer group of antidepressants have mechanisms of
action that are not yet well understood or have
therapeutic effects that mirror both the tricyclis and
SSRIs and include Wellbutrin, Celexa, Effexor, and
Desyrel
The biochemical hypothesis for depression is that it
results from a deficiency in catecholamines, specifically
norepinephrine, and serotonin

19. One disadvantage in the use of antidepressants is that
their clinical action frequently takes two to three weeks
to be apparent in the patient’s functioning.
Unfortunately it is during this initial period when most
of the undesired side effects are experienced and
patients terminate their use
Common side effects of the cyclics are drowsiness,
dry mouth, constipation, difficulty urinating, blurred
vision, dizziness, weight gain, and rapid heart rate
Side effects for the MAOIs are the same as above but
may also include temporay low blood pressure when
changing positions and impaired sexual functioning

20. Antidepressants and Suicide Risk
An area of recent concern regarding some
antidepressants, primarily SSRIs (Paxil, Zolft, Prozac,
Luvox), is the possibility of suicide, especially in
children, and when dosages are being increased or
decreased
FDA urged manufacturers of 10 popular
antidepressants (listed in the text) to revise warning
labels to identify these concerns
Great Britain markedly increased restrictions on the
prescribing of antidepressants for children and in
2003, declared certain antidepressants as too risky for
any children under 18

21. History of Depressant Drugs
Depressant drugs are often classified by their most
common use but this can be misleading as the same
drug can have multiple effects depending on the dose
 For example, benzodiazepines such as Valium and
Librium reduce anxiety at moderate doses, they
produce sedative-hypnotic effects (calm and induce
sleep) in larger doses
Barbiturates are usually prescribed for sleep but are
anxiety-reducing in lower doses and can produce
surgical anesthesia in higher doses
Barbiturates – Depressant drugs formerly used as
sleeping pills; currently used in anesthesia and
treatment for epilepsy

22. All depressant drugs (including alcohol) produce similar
effects. At low doses they relieve anxiety, at moderate
doses they induce sleep, and at higher doses they
produce general anesthesia and eventually coma and
death.
The first depressants were drugs used for general
anesthesia such as nitrous oxide and ether.
Development of the barbiturates in 1862 led to the use
of depressants as sleeping pills and as treatment of
anxiety and epilepsy
Effects of barbiturates are generally similar, differing
primarily in potency and duration of action.

23. Pentobarbital and secobarbital are considered potent
and short-acting (2-4 hours), amobarbital is
intermediate (6-8 hours), and phenobarbital longer-
acting(8-10 hours)
Barbiturates with a rapid onset and short duration of
action such as pentobarbital are used as anesthetics,
whereas those with slower onset and longer duration
of action such as phenobarbital are preferred for the
treatment of epilepsy
Barbiturate use was limited when adverse effects were
discovered such as rapid development of tolerance,
severe withdrawal symptoms, high risk of overdose,
and high abuse potential

24. Antianxiety Agents
The discovery of benzodiazepines revolutionized the
medical use of depressant drugs because they relieve
anxiety with fewer side effects than previous
depressants
Librium and Valium were the first drugs in this group
marketed and they quickly came to dominate the
market as treatments for anxiety and insomnia
Because alcohol shows cross-dependence with
benzodiazepines, they are commonly used to withdraw
alcoholics from alcohol
They are believed to act at the GABA receptor site in
the central nervous system

25. The anxiolytic effects of benzodiazepines are more
selective than those of other depressants because
they relieve anxiety at doses that produce minimal
sedation and motor impairment
Although less problematic than barbiturates,
benzodiazepines may produce tolerance and
dependence and withdrawal symptoms may occur
Because the lethal dose is so high, suicide and
accidental overdose are far less of a risk than with
other depressant drugs. However, because of
potentiation with alcohol and other drugs, fatal
overdoses are not uncommon with such drug
combinations.

26. Benzodiazepines may interfere with the storage of
memories, a phenomenon called anterograde amnesia
Anterograde Amnesia – Loss or limitation of the ability
to form new memories
The drug Rohypnol (street name “roofies”) is called the
“date rape” drug due cases where men have slipped
the drug into a woman’s drink without her knowledge
and then raped her after the drug has “knocked her
out”. The drug has the ability to produce significant
memory loss and blackouts in its users
Barbiturates and methaqualone also produce
blackouts, which suggest some type of memory deficit
may be characteristic of any depressant drug

27. Mood-Stabilizing Drugs
The most specific treatment for the mood disorders of
mania and bipolar disorder is lithium
Mania is a state with pronounced elevations in mood
and increased activity
It is believed bipolar disorder is the result of
overactivity of neurotransmitters in the brain.
Serotonin, norepinephrine, and dopamine are all
affected
Other drugs available for the treatment of mania
include the antiepileptic drug Tegretol, and
anticonvulsants Klonopin and Depakote

28. Psychotropic Drugs and Pregnancy
No psychotropic drug is totally safe for use during
pregnancy
The best approach is that they be given only when
necessary and when nondrug therapies, such as
counseling, have been tried and failed
There are risks to both mother and fetus with the fetus
facing various teratogenic, neurobehavioral, and toxic
consequences
Teratogenic – Producing abnormalities in the fetus
The most widely recognized effect is the association of
lithium use during the first trimester and risk of
cardiovascular system impairment