Chapter 14: Drugs for Anxiety and Insomnia

Anxiety disorders are the most common mental health illnesses encountered in clinical practice Anxiety : state of apprehension, tension, or uneasiness resulting from imminent or perceived danger, the source of which is largely UNKNOWN. Situational anxiety: temp anxiety experienced by people faced w a stressful environment . NOT considered major bc its not disabling or persistent * → BENEFICIAL bc it makes ppl get the task done, to END anxiety GAD (General anxiety disorder) – EXCESSIVE anxiety that lasts 6+ MONTHS. * interferes w day-to-day life . MOST COMMON TYPE OF STRESS DISORDER ^^ S/S of GAD- restlessness, fatigue, muscle tension, nervousness, inability to focus/concentrate, overwhelming sense of dread, sleep disturbances. SNS S/S- high BP, heart palpitations, RR change, dry mouth Parasympathetic S/S- abdominal cramping, diarrhea, fatigue, urinary urgency 20-35 yr old women more likely to have GAD than men Panic disorder- anxiety characterized by INTENSE feelings of immediate apprehension, fear, terror, impending doom, increased autonomic NS activity. ;Last < 10 mins For DX of panic disorder→ pt must have at least 1 month of ongoing concern or worry about experiencing subsequent episodes. Women affected more than men Phobias- fear to situations or object (heights/spiders/dark. Etc) Social anxiety disorder – persistent/unreasonable fear of being judged, ridiculed, or embarrassed by others Performing anxiety- fear of public speaking OCD (Obsessive compulsive disorder) – recurrent intrusive thoughts or repetitive behaviors → to be dx: behavior or though must occupy >1HR/day and negatively impact normal daily activities or relationships PTSD- extreme situational anxiety that develops in response to re-experiencing a previous life event (Rape/war/mva/etc) → nightmares, hallucinations, flashbacks, tachy, extreme nervousness/panic attacks) → = increase r/o suicide Stress is usually JUST a SYMPTOM of an underlying problem Nonpharmacological tx for underlying cause : cognitive behavioral therapy, counseling, biofeedback, meditation, herbal products. When anxiety s is severe and interferes w ADLS→ MEDS are started Short term anxiety→ stressful event will end OR behavioral coping mechanism is implemented; NO MEDS here * Anxiolytics- drugs that have the ability to relieve anxiety Anxiolytics provide tx for → phobias, PTSD, GAD, OCD, panic attacks INSOMNIA A condition in which a pt is unable to fall asleep or STAY asleep → tx w meds IF it interferes w ADLS Sleep is needed bc - Inactivity gives body time to repair itself Protective mechanism “electrical” charging and discharging of the brain; time for processing and filing new info collected in the day → more info remains in memory Circadian rhythm- body temp, bp, hormones and RR that fluctuate throughout the day; SLEEP-WAKE cycle When circadian rhythm becomes disrupted→ meds may be needed Insomnia → connected w anxiety Short term insomnia/ aka behavioral insomnia- r/t stress caused by hectic lifestyle or inability too resolve day to day conflicts. (worries abt work, marriage, kids, health) → MIND is TOO ACTIVE at night Narcolepsy- overwhelming daytime drowsiness and sudden attacks of sleep during the day; can last secs-30mins → TX w MODAFINIL (Provigil) Modafinil- preferred med for narcolepsy, well tol. → but classified as stimulant and schedule IV Sodium oxybate (Xyrem) – schedule class III ; also used for narcolepsy Sleep apnea and Restless leg syndrome- also cause daytime sleepiness Caffeine and tabacco- also keep you up Alcohol – causes vivid dreams→ enables freq awakenings that prevent restful sleep. Large meals (^ Proteins/^ fats) close to bedtime→ increase GI metabolic rate→ interfere w sleep Certain meds→ cause CNS stimulation Too much light, temp, snoring, nightmares → interrupt sleep Long term insomnia – lasts 30 days or longer; often caused by depression, manic disorders, chronic pain Nonpharmacological interventions should always be attempted BEFORE trying/starting meds Rebound insomnia- worsening sleeplessness and s/s anxiety caused by LT use of sleep meds/or dc abruptly Valerian and Kava- herbal products help w sleep→ OTC aids w antihistamines also help some ppl EEG (electroencephalogram) – used to dx sleep disorders, seizures, depression and dementia 4 types of brain waves- alpha, beta, delta and thetha are seen Alpha waves- indicate awake but drowsy pt – Alpha (A little awake) Beta- alert pt whose mind is active NREM & REM sleep can be distinguished on EEG NREM STG 1 ; Lasts 5-10 mins, pt can be easily awakened NREM STG 2 ; still in LIGHT sleep, HR < , body temp < NREM STG 3 ; deepest stage of sleep, hard to wake up. Disoriented for brief time REM SLEEP ; eye movement and loss of muscle tone. DREAMING takes place here. Mind is active and resembles nml waking state. AKA PARADOXICAL SLEEP * brain wave is the same if pt was awake → but pt is asleep NREM STG3- Associated w repair/restoration of physical body (w/out this stg patients are depressed/feeling of apathy and fatigue) REM sleep- associated w learning, memory, and capacity to adjust to changes in the environment Lack of REM sleep → leads to SLEEP DEBT In SLEEP DEBT→ become frightened. Irritable, paranoid and emotionally disturbed –> also causes impaired judgement and slowed reaction time. To make up for lack of sleep→ > daydreaming & fantasizing in the day CNS DRUGS Produce profound activity in the brain and the spinal cord Anxiolytic drugs- have the ability to reduce anxiety s/s by altering 2 NEUROTRANSIMTTERS -NOREPINEPHRINE -SERETONIN Sedatives- medications that depress the CNS; sedate or relax a patient HIGHER doses → HYPNOTICS; ability to induce SLEEP Sedative-hypnotic- describes drug that has ability to produce calming effect at lower doses and induce sleep at higher doses Tranquilizer- ability to produce tranquil feeling CNS depressants can cause physical and psychological dependence Withdrawals → can cause life threatening neurologic reactions ; fever, psychosis, seizures , > HR , effects of GABA One of the MOST POTENT benzos Extended half life of 10-20 HRS → allows 1-2 day dosing PO Used as anxiolytic Used as PRE-anesthetic med to provide sedation used to provide management of status epilepticus off label tx- chemo induced n/v IV ADMIN- monitor RR Q 5-15 mins; have airway and resuscitative equipment available* PREGNANCY CAT- D a/e: most common → drowsiness/sedation (can < over time) high doses IV→ more severe s/e → amnesia , weakness, disorientation, ataxia (poor muscle control ) , sleep disturb , BP changes, blurred vision, double vision, N/V DON’T USE in pts w acute narrow angle glaucoma, closed angle glaucoma, misuse or excess use of drugs, liver disease, impaired brain function or thoughts of suicide Use w CNS depressants/alcohol → > sedative effects , >r/o RR depression and death; s/s vision changes, N/V, dizziness, confusion Can > anti parkinsonism effects of levodopa and > phenytoin levels TX OVERDOSE: FLUMAZENIL (ROMAZICON) a benzo receptor antagonist is admin to reverse CNS depression ________________________________ TX anxiety w ANTIDEPRESSANTS Antidepressants→ used to tx major depression and variety of anxiety conditions Work by altering levels of 2 neurotransmitters NOREPINEPHRINE SEROTONIN Panic s/s come in 2 stages 1st STAGE- anticipatory anxiety; pt begins to think about an upcoming challenge and starts to experience a feeling of drea 2nd STAGE- ACTUAL s/s → SOB, tachy, muscle tension (ANS s/s ) ANTIDEPRESSANT MEDS used to tx anxiety/insomnia disorders include SSRIS, ATYPICAL ANTIDEPRESSANTS, SNRI AND TCA’s SSRI’s- safer than other classes ;Less common sympathomimetic s/e ;< anticholinergic effects; Can cause WEIGHT GAIN and SEXUAL DYSUFNCTION ; overdose s/s : confusion, anxiety, restless, HTN, tremors, sweating, fever, lack of muscle coordination; CAREFULLY monitor for behavior changes + suicidal tendencies ATYPICAL ANTIDEPRESSANTS/ SNRI’s- a/e include abnormal dreams, sweating, constipation , dry mouth, loss of appetite, wt loss, tremors, vision disturb, HA, N/V, dizziness, loss of sexual desire. CAREFULLY monitor for behavior changes + suicidal tendencies TCA’s- not recommended for ppl w heart problems (MI, heart block, arrythmia) ; s/e include annoying anticholinergic effects → dry mouth, blurred vision, urine retention HTN; most preg cat C-D ; avoid use w alcohol or other CNS depressants ; caution in use w pts that have asthma, GI disorder, alcoholism, schizo, bipolar. Most antidepressants have BLACK BOX WARNINGS→ r/o suicidal behavior in adults/kids in beginning of tx or when doses are changed. Can have s/s → irritability, panic attacks, agitation, insomnia , hostility. ESCITALOPRAM (Lexapro) Antidepressant; anxiolytic/ SSRI Increases the availability of SERETONIN at specific post synaptic receptor sites located w/in CNS Results in sympathomimetic s/s OR anticholinergic s/s Indicated for conditions of GAD & major depression Off label tx- tx of panic disorder < doses for ppl w < renal/hepatic impairment Dose increments separated by at least 1 wk PREG CAT-C Onset – 1-4 WEEKS ; peak 5HRS → LONG ONSET OF ACTION a/e : dizziness, nausea, insomnia, somnolence, confusion , seizures (if overdose) BLACK BOX WARNING- increase r/o sucidial ideation/behavior in kids, adolescents, youn adults w depression and psych disorders. Not approved for kids <12YRS ** Not used in pts who breastfeeding or w/in 14 days of MAOI therapy MAOIS should be avoided d/t SERETONIN SYNDROME (condition in which high levels of serotonin accumulate in the body) S/S → hyperactivity , hyperthermia, rigidity, diaphoresis, neuroleptic malignant syndrome ; can result in HTN crisis, hyperthermia, autonomic instability MAOI’S are the first type of antidepressants that were developed. ** Escitalopram will > levels of metoprolol and cimetidine (stomach acid reducer) Use w alcohol will > antidepressant effects ; AVOID No tx for overdose. Tx s/s as indicated . Miscellenaous anxiolytics for anxiety and sleep disorders Valrproic acid- anti seizure med with off label tx of agitation in older adults or anxiety in bipolar pts Atenolol, metoprolol, propranolol(beta blockers)- reduce ANS s/s of anxiety such as nervousness, tremor and tachy Clonidine- adrenergic antagonist that blocks ANS s/s that accompany anxiety Buspirone- agonist effects on presynaptic dopamine receptors and high afiinity for serotonin receptors Less likely than bezos to affect cognition and motor performance and RARELY interacts w other CNS depressants. Common s/e → dizziness, HA, drowsiness. ; < problems w dependence and withdrawals ; takes week to achieve effects Eszopiclone(Lunesta)- similar to zolpidem; long half life. More likely to cause daytime sedation; schedule IV controlled substance. Ramelteon- melatonin receptor AGONIST – improves sleep induction; short onset (30mins) , short duration Suvorexant(Belsomra) – tx ppl w diff falling and staying asleep ; receptor agonist that blocks action of orexin, chemical involved in sleep wake cycle of brain; caution w alcohol and CNS depressant use d/t additive sedation risk. Main S/E → daytime drowsiness. ; take 30 mins before sleep Tasimelteon (Hetlioz) – second melatonin receptor agonist; used for tx of 24 hr sleep wake disorders, that happens in blind ppl. ; s/e HA, abnormal dreams. Ramelteon, Zolpidem, Tasimelteon don’t have to be SHORT TERM USE bc they have no r/o dependence or tolerance *** Zaleplom (Sonata) – used for ppl who wake up early 2-3am. Benadryl/hydroxyzine(Vistaril) – antihistamines OTC that help w sleep ZOLPIDEM (ambien, Edluar, Intermezzo) Sedative-hypnotic / non benzo GABA receptor agonist; nonbenzo/ nonbarbiturate CNS depressant Non benzo but acts similar to GABA mediated CNS depression in the limbic, thalamic, and hypothalamic regions. Preserves stage 3 of sleep + only minor effects on REM Only indication → short term insomnia management (7-10 days) Avail SL (Edular), PO sray (Solpimist) RAPID ONSET 7-27 mins ; take right before sleep PREG CAT – B S/E – daytime sedation, confusion, amnesia, dizziness, depression, suicidal thoughts, N/V Neuropsychiatric reactions- hallucinations , sensory distortion, sleepwalking, nocturnal eating. Other s/e amnesia , somnambulism (sleepwalkin) , sleepdriving.. etc other activities BLACK BOX WARNING- can be abused and lead to dependency ; store in safe place → NOT AT BEDISDE TO AVOID SOMEONE TAKING THEM WHILE THEY ARE DEROWSY LACTATING women should not take Use w other CNS depressants –increased sedation Food SLOWS absorption and delays onset TX OVERDOSE – gen symptomatic and supportive measures should be applied w IMMEDIATE gastric lavage. Give IV fluids PRN. Flumanezil (Romazicon) As a benzo receptor agonist may help. BARBITURATES Not used anymore bc there is safer drugs Have high risk of psychologic and physical dependence Withdrawal can be fatal Overdose results In PROFOUND respiratory depression, hypotension and shock Have been used to commit suicide Intensify GABA levels throughout NS Low dose → cause drowsiness Mod doses → promote sleep High doses→ induce anesthesia