Psychopharmacology Part 1 of 4 - Bipolar Disorder, Depression, PPMD, ETC.

Chapter 1: Introduction

List as lead three arguments in favor of and three arguments against the use of medication treatment for mental illness.

• Medication effectiveness can be studied more systematically and objectively
• Medications act relatively quickly
• Medications restore hope and reduce demoralization
• Medication effectiveness does not depend on the skill of a psychotherapist
• Medications treat symptoms but do not address psychological causes of symptoms
• Medications are more cost effective and available to the general public
• Drugs foster dependency rather than autonomy
• Psychotherapy honors free will and hard work
• Drugs often have nasty side effects or may be abused
• Medications do not teach coping skills, mend hearts, or fill empty lives

Ritalin received “bad press” in the late 1980’s. The result? A 40% reduction in prescriptions in the following two years. Was that good? Explain your answer.

• When Ritalin received “bad press” in the late 1980’s there was a negative impact due to the 40% reduction in prescriptions the following 2 years. 36% of those children who discontinued Ritalin experienced major academic maladjustment. Another 47% experienced mild to moderate academic problems. Many turned to drugs that had worse side-effects (though less publicized) for treatment of depression.

Why is it important for you to learn about clinical psychopharmacology?

• It is important to learn about psychopharmacology because over 80% of psychoactive medications are prescribed by general practitioners who have little training in complex psychological issues but still are able to prescribe medication for complex psychological disorders.

Chapter 4: Pharmacology

Define the terms Pharmacokinetics and Pharmacodynamics. List four major Pharmacokinetic factors.

• Pharmacokinetics refers to the movement of drugs while pharmacodynamics refers to the effects of the drug.
  There are 4 major pharmacokinetic factors including absorption, distribution, biotransformation, and excretion. Each drug has its own pharmacokinetic profile and awareness of these profiles significantly enhance clinical practice.
• Absorption is affected by stomach contents, drug structure, and barriers to its passage. Distribution is dependent on the circulatory system and depending on the drugs structure, some tissues attract the drug more than others which sometimes results in a build up of the drug in body tissue far greater than the levels found in the blood. Biotransformation is the process of metabolic breakdown of medication into by products that results in side effects and medicinal values. Lastly, excretion allows for the elimination of drugs from the body's, exit routes include the commonly used kidneys, and less commonly used sweat, saliva, and breast milk.

Define biotransformation? (you may need to review appendix) In your answer, distribution half-life, Elimination half-life, and steady state.

• Biotransformation is the process of metabolic breakdowns for medication. Enzymes that are mostly located within the liver break down the organic compounds into chemical by products. Some of these are responsible for unpleasant side effects while others have medicinal value. Some of these enzymes are also difficult to eliminate from the body.
  Related to the excretion of this enzymes is a half-life which is used to determine the amount and the frequency of drug intake.
• There are 2 types of half lives, distribution half life and elimination half life.
  Distribution half life is the amount of time required for the serum concentration to be reduced by 50%. Elimination half life is the amount of time required to remove 50% of the drug from the body which is often much longer the the distribution half life.
  When both half lives are equal the body experiences a steady state when the concentration of the medicine in the blood stream is fairly stable because the amount of the drug administered is equal to the amount of the drug eliminated. This state is typically attained after 4 half lives and is often reached before noticeable therapeutic effects.

Provide a general definition of a Drug Interaction. What is a common physiological mechanism by which such an interaction may occur? Provide an example.

• Each drug has a kinetic profile that is easily altered when co-administered with other medications, this is referred to drug interaction. Sometimes results are disastrous due to the metabolisms of several drugs continue to rely on the same liver enzyme for its metabolism.
• An example of a disastrous drug interaction is seen in an elderly man who is already taking a medication to maintain blood pressure, he is then prescribed prozac for depression which interferes with his current blood pressure medicine and causes his blood pressure to be low because both medications can not be properly metabolized on the same liver; especially since he is elderly and experiences a slowed metabolism.

Chapter 7: Depressive Disorders

List at least four core symptoms shared by most forms of clinical depression.

• Patients with clinical depression face multiple variations of symptoms including sadness, despair, emptiness, anhedonia*, low self esteem, apathy, low motivation, social withdrawal, excessive emotional sensitivity, irritability, and suicidal ideas.

List unique symptoms seen in atypical depression, not observed in other forms of depression.

• Atypical depression is also called hysteroid-dysphoria and faces symptoms such as reactive dysphoria-sadness or despair that comes and goes in response to psychological stressors, profound fatigue, low energy, hypersomnia, increased appetite, weight gain, phobias, and panic attacks.

Describe the difference between reactive sadness and reactive depression

• Reactive sadness is marked by sadness, disappointment and despair that comes with minor losses and disappointments. These often do not affect academic, occupational or social or interpersonal functioning.
• Reactive depression occurs in response to identifiable psychosocial stressors (either acute or enduring). It is marked by mild to severely depressed mood and very few, if any, vegetative or physiological symptoms.

Describe symptoms of psychotic depression and discuss the efficacies of various treatments for this type of depression.

• Those with psychotic depression tend to have hallucinations or delusions that are mood congruent. They might also think of themselves as disgusting or evil.
• Medication is warranted with mixed depression and psychosis, therefore ECT and/or hospitalization is often necessary and there is a greatly increased risk of suicide when the patient is actively psychotic.
• Treatment efficacy of psychotic depression is 90% with ECT, 60%-75% with antidepressants and antipsychotics, 25% with antidepressants alone, and 35% with antipsychotics alone.

Discuss what you can (demographics, symptoms, treatments...etc) about Premenstrual Dysphoric Disorder (PMDD).

• PMDD affects 5% of women and give them irritability, anxiety, and/or depression. It is noted by its regularity in onset and remission and typically shows no psychosocial stressors.
• During PMDD, female hormones destabilize serotonic functions in the limbic system. SSRI’S are most commonly used for PMDD.

Describe the course of treatment (# of sessions, pulse rates, brain targets) using Repetitive transcranial magnetic stimulation (rTMS). What advantages/disadvantages are there compared to using electroconvulsive therapy?

• This experimental procedure consists of a series of 20 treatments over a 2-4 week period that dramatically improves the condition of people with severe depression.
• In comparison to ECT, the only side effects with rTMS was a few reports of minor headaches and some redness where the electrode like coils were placed against the skull and the patients did not lose consciousness during the rTMS procedure.
  The full treatment course involved 10,000 to 20,000 magnetic pulses that were employed at a rate of 10 pulses a second. The patients received 20 long pulses lasting 5 seconds each and 30 seconds apart in each treatment session.

Describe the body (systemic) and brain (neurological) changes that occur with prolonged severe depression.

• There are multiple body and brain changes that occur with prolonged severe depression. When sustained, elevated levels of cortisol is associated with cell death in the hippocampus and also damages the interior walls of arteries. The elevated cortisol could also harm a fetus if the patient is pregnant since it is a teratogen.
• The brain could also face hypometabolism in the frontal lobes and hypermetabolism in the hypothalamus, amygdala, hippocampus, and infralimbic cingulate.
• Stress also leads to reduced growth hormones that is related to osteoporosis and the failure to thrive
• Stress causes immune suppression
• Stress reduced brain derived neurotrophic factors (BDNF) that is needed for neural maintenance and repairs.

Chapter 8: Bipolar Disorders

What are the general differences in duration and type of symptoms that lead to a differential diagnosis of Bipolar I, Bipolar II, and cyclothymia?
*Bipolar I Indicates one or more manic episodes with one or more major depressive episodes or subclinical major depressive episode. With age, episodes become more frequent and prolonged. Without treatment, most people will have great difficulty
Mixed mania may comprise 30% of all mania cases. Mixed episodes are more difficult to treat. Controversy over role of antidepressants in treating bipolar depression. Drug induced mania has been documented

• Bipolar II is defined as one or more major depressive or subclinical depressive episodes and at least one episode of hypomania. Often confused with major depression because patients don't view elevated mood as dysfunctional. The hypomania may present as irritability and viewed by the clinician as “characterological”
• Cyclothymia is alternating periods of depression and elation lasting 2 or more years that do not meet the criteria for major depression and manial social and occupational impairment is possible when depressed. A chronic condition with ⅓ developing a major affective disorder. Not due to any organic factors or substance abuse

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