Chapter 16 Psychotherapeutic Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc

Chapter 16

Psychotherapeutic Drugs

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Used in the treatment of emotional and mental disorders Ability to cope with emotions can range from

occasional depression or anxiety to constant emotional distress

When emotions significantly affect an individual’s ability to carry out normal daily functions, treatment with a psychotherapeutic drug is a possible option

Psychotherapeutic Drugs

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 2

Three main emotional and mental disorders: Anxiety Affective disorders Psychoses

Psychotherapeutic Drugs (cont’d)


Types of psychotherapeutic drugs Anxiolytic drugs Mood-stabilizing drugs Antidepressant drugs Antipsychotic drugs

Psychotherapeutic Drugs (cont’d)


Unpleasant state of mind, characterized by a sense of dread and fear

May be based on actual anticipated experiences or past experiences

May be exaggerated responses to imaginary negative situations

Anxiety


Six major anxiety disorders (persistent anxiety) Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder (PTSD) Generalized anxiety disorder (GAD) Panic disorder Social phobia (social anxiety disorder) Simple phobia

Anxiety Disorders


Changes in mood that range from mania (abnormally pronounced emotions) to depression (abnormally reduced emotions)

Some patients may exhibit both mania and depression: bipolar disorder (BPD)

Affective Disorders (Mood Disorders)


Severe emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in activities of daily living

Hallmark: loss of contact with reality Examples

Schizophrenia Depressive and drug-induced psychoses

Psychosis


Reduce anxiety by reducing overactivity in CNS Benzodiazepines

• Depress activity in the brainstem and limbic system

Miscellaneous drug: buspirone (BuSpar)• Nonsedating and non–habit forming

• May have drug interaction with SSRIs (serotonin syndrome)

• Do not administer with MAOIs

Anxiolytic Drugs


alprazolam (Xanax) diazepam (Valium) lorazepam (Ativan)

Benzodiazepines


Benzodiazepine adverse effects are an overexpression of their therapeutic effects Decreased CNS activity, sedation Hypotension Drowsiness, loss of coordination, dizziness,

headaches Nausea, vomiting, dry mouth, constipation Others

Benzodiazepines: Adverse Effects


Dangerous when taken with other sedatives or alcohol

Treatment is generally symptomatic and supportive

Flumazenil may be used to reverse benzodiazepine effects

Benzodiazepines: Overdose


buspirone (BuSpar) Unknown mechanism of action Administered on a scheduled basis Adverse effects

• Paradoxical anxiety

• Blurred vision

• Headache

• Nausea

Miscellaneous Anxiolytic


Lithium carbonate and lithium citrate Other drugs may be used in combination with

lithium Benzodiazepines Antipsychotic drugs Antiepileptic drugs Dopamine receptor agonists

Mood-Stabilizing Drugs


Lithium is the drug of choice for the treatment of mania It is thought to potentiate serotonergic

neurotransmission Narrow therapeutic range: maintenance serum

levels should range between 0.6 and 1.2 mEq/L

Mood-Stabilizing Drugs (cont’d)


Before administering lithium to a patient, it is most important for the nurse to assess which laboratory value?

A.Blood sugar

B.Sodium

C.Urine osmolality

D.Hematocrit

Classroom Response Question


Tricyclic antidepressants Monoamine oxidase inhibitors (MAOIs) Second-generation antidepressants

Selective serotonin reuptake inhibitors (SSRIs) Serotonin-norepinephrine reuptake inhibitors (SNRIs) Miscellaneous

Antidepressants


Have largely been replaced by SSRIs as first-line antidepressant drugs

Considered second line For patients who fail with SSRIs or other newer-

generation antidepressants As adjunct therapy with newer-generation

antidepressants amitriptyline (Elavil)

Tricyclic Antidepressants


Block reuptake of neurotransmitters, causing accumulation at the nerve endings

It is thought that increasing concentrations of neurotransmitters will correct the abnormally low levels that lead to depression

Tricyclic Antidepressants: Mechanism of Action


Depression Childhood enuresis (imipramine) Obsessive-compulsive disorders (clomipramine) Adjunctive analgesics for chronic pain

conditions, such as trigeminal neuralgia

Tricyclic Antidepressants: Indications


Sedation Impotence Orthostatic hypotension Others Older patients

Dizziness, postural hypotension, constipation, delayed micturation, edema, muscle tremors

Tricyclic Antidepressants: Adverse Effects


Lethal—70% to 80% die before reaching the hospital

CNS and cardiovascular systems are mainly affected

Death results from seizures or dysrhythmias

Tricyclic Antidepressants: Overdose


No specific antidote Decrease drug absorption with activated charcoal Speed elimination by alkalinizing urine Manage seizures and dysrhythmias Basic life support

Tricyclic Antidepressants:Overdose (cont’d)


Highly effective Considered second-line treatment for

depression, not responsive to cyclics Disadvantage: potential to cause hypertensive

crisis when taken with tyramine

Monoamine Oxidase Inhibitors (MAOIs)


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

MAOIs (cont’d)


Inhibit the MAO enzyme system in the CNS Amines (dopamine, serotonin, norepinephrine)

are not broken down, resulting in higher levels in the brain

Result: alleviation of symptoms of depression

MAOIs: Mechanism of Action


Depression, especially types characterized by reverse vegetative symptoms such as increased sleep and appetite

Depression that does not respond to other drugs such as tricyclics

MAOIs: Indications


Few adverse effects—orthostatic hypotension most common

Tachycardia Dizziness Insomnia Anorexia Blurred vision Palpitations Drowsiness Headache Nausea Impotence

MAOIs: Adverse Effects


Symptoms appear 12 hours after ingestion Tachycardia, circulatory collapse, seizures,

coma Treatment: protect brain and heart, eliminate

toxin Urine acidification Hemodialysis

MAOIs: Overdose


Ingestion of foods or drinks with tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death

Avoid foods that contain tyramine! Aged, mature cheeses (cheddar, blue, Swiss) Smoked/pickled or aged meats, fish, poultry (herring,

sausage, corned beef, salami, pepperoni, paté) Yeast extracts Red wines (Chianti, burgundy, sherry, vermouth) Italian broad beans (fava beans)

MAOIs and Tyramine


Fewer adverse effects than tricyclics and MAOIs Very few drug-drug or drug-food interactions Still take about 4 to 6 weeks to reach maximum

clinical effectiveness Now considered first-line drugs for depression

Second-Generation Antidepressants


SSRIs fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) fluvoxamine (Luvox) citalopram (Celexa) escitalopram (Lexapro)

Second-Generation Antidepressants (cont’d)


Second-Generation Antidepressants (cont’d)

SNRIs venlafaxine (Effexor) duloxetine (Cymbalta) desvenlafaxine (Pristiq)

Miscellaneous trazodone (Desyrel, Oleptro) bupropion (Wellbutrin) nefazodone (Serzone) mirtazapine (Remeron)


SSRIs Selectively inhibit serotonin reuptake Little or no effect on norepinephrine or dopamine

reuptake Result in increased serotonin concentrations at nerve

endings SNRIs

Inhibit reuptake of both serotonin and norepinephrine

Second-Generation Antidepressants: Mechanism of

Action


Depression Bipolar disorder Obesity Eating disorders Obsessive-compulsive disorder

Second-Generation Antidepressants: Indications


Panic attacks or disorders Social anxiety disorders Posttraumatic stress disorders (PTSDs) Myoclonus Treatment of various substance abuse problems

(bupropion [Zyban] is used for smoking cessation treatment)

Second-Generation Antidepressants: Indications

(cont’d)


Body System Effects CNS Headache, dizziness,

tremor, nervousness, insomnia*, fatigue

GI Nausea, diarrhea,constipation, dry mouth

Other Sexual dysfunction, weight gain*, weightloss*, sweating

*Most common and bothersome

Second-Generation Antidepressants: Adverse Effects



When patients are taking selective serotonin reuptake inhibitors (SSRIs) for the first time for depression, which is most important to monitor for during the first few weeks of therapy?

A.Hypertensive crisis

B.Suicidal thoughts

C.Convulsions

D.Orthostatic hypotension


Symptoms Delirium, tachycardia, hyperreflexia, shivering,

agitation, sweating, muscle spasms, coarse tremors Symptoms of severe cases

Hyperthermia, seizures, renal failure, rhabdomyolysis, dysrhythmias, disseminated intravascular coagulation (DIC)

Serotonin Syndrome



When providing teaching for a patient who is prescribed a selective serotonin reuptake inhibitor (SSRI), which statement will the nurse include?A.The SSRI will work faster than the older tricyclic antidepressants.

B.The SSRI will have an immediate beneficial effect on the patient’s depression symptoms.

C.The SSRI will not work well for severe cases of depression.

D.The SSRI may take several weeks to have a beneficial effect.


Drugs used to treat serious mental illness Behavioral problems or psychotic disorders

Have been known as tranquilizers or neuroleptics

Conventional drugs Atypical antipsychotics

Antipsychotics


Thioxanthenes: thiothixene (Navane) Butyrophenones: haloperidol (Haldol) Dihydroindolones: molindone (Moban) Dibenzoxazepine: loxapine (Loxitane) Phenothiazines: three structural groups Atypical antipsychotics: new class

Antipsychotics (cont’d)


Block dopamine receptors in the brain (limbic system, basal ganglia)—areas associated with emotion, cognitive function, motor function

Dopamine levels in the CNS are decreased Result: tranquilizing effect in psychotic patients

Antipsychotics: Mechanism of Action


clozapine (Clozaril) risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel) ziprasidone (Geodon) aripiprazole (Abilify) paliperidone (Invega)

Atypical Antipsychotics


Block specific dopamine receptors: dopamine-2 (D2) receptors

Also block specific serotonin receptors: serotonin 2 (5-HT2) receptors This is responsible for their improved efficacy and

safety profiles

Atypical Antipsychotics:Mechanism of Action


Body System Adverse Effects

CNS Sedation, delirium

Cardiovascular Orthostatic hypotension, syncope, dizziness, ECG changes

Dermatologic Photosensitivity, skin rash, hyperpigmentation, pruritus

Antipsychotics: Adverse Effects


Antipsychotics: Adverse Effects (cont’d)


Body System Adverse EffectsGI Dry mouth, constipationGU Urinary hesitancy or

retention, impaired erection

Hematologic Leukopenia andagranulocytosis

Body System Adverse EffectsMetabolic/endocrine Galactorrhea,

irregular menses,increased appetite, polydipsia



Neuroleptic malignant syndrome (NMS) Potentially life threatening High fever, unstable BP, myoglobinemia

Extrapyramidal symptoms (EPS) Involuntary muscle symptoms similar to those of

Parkinson’s disease Akathisia (distressing muscle restlessness) Acute dystonia (painful muscle spasms) Treated with benztropine (Cogentin) and

trihexyphenidyl (Artane)



Tardive dyskinesia (TD) Involuntary contractions of oral and facial muscles Choreoathetosis (wavelike movements of extremities) Occurs with continuous long-term antipsychotic

therapy



Used for depression, anxiety, sleep disorders, nervousness

May cause GI upset, fatigue, dizziness, confusion, dry mouth, photosensitivity

Severe interactions if taken with MAOIs and SSRIs; many other drug interactions

Food-drug interaction with tyramine-containing foods

Herbal Products: St. John’s Wort


Three varieties; has been used for over 5000 years

Uses: stress reduction, improvement of physical endurance and concentration

May cause elevated BP, chest pain, palpitations, anxiety, insomnia, headache, GI symptoms

Interactions with anticoagulants, immunosuppressants, anticonvulsants, antidiabetic drugs

Herbal Products: Ginseng


Before beginning therapy, assess physical and emotional status of patients

Obtain baseline vital signs, including postural BP readings

Obtain liver and renal function tests

Psychotherapeutic Drugs: Nursing Implications


Assess for possible contraindications to therapy, cautious use, and potential drug interactions

Assess for level of consciousness, mental alertness, potential for injury to self and others

Check the patient’s mouth to make sure oral doses are swallowed

Psychotherapeutic Drugs: Nursing Implications (cont’d)


Provide simple explanations about the drug, its effects, and the length of time before therapeutic effects can be expected

Advise patients to avoid abrupt withdrawal Advise patients to change positions slowly to

avoid postural hypotension and possible injury



The combination of drug therapy and psychotherapy is emphasized because patients need to learn and acquire more effective coping skills

Only small amounts of medications should be dispensed at a time to minimize the risk of suicide attempts

Simultaneous use of these drugs with alcohol or other CNS depressants can be fatal



Antianxiety drugs In elderly patients, monitor closely for oversedation

and profound CNS depression



Antidepressants Many cautions, contraindications, and interactions

exist pertaining to the use of antidepressants Inform patients that it may take several weeks to see

therapeutic effects Monitor patients closely during this time, assess for

suicidal tendencies, and provide support Assist elderly or weakened patients with ambulation

and other activities because falls may occur because of drowsiness or postural hypotension



Antidepressants (cont’d) Tricyclics may need to be weaned and discontinued

before undergoing surgery to avoid interactions with anesthetic drugs

Monitor for adverse effects, and discuss with patients Encourage patients to wear medication ID badges

naming the drugs being taken

Psychotherapeutic Drugs:Nursing Implications (cont’d)


Antidepressants (cont’d) Caffeine and cigarette smoking may decrease

effectiveness of medication therapy With MAOIs, instruct patients and family regarding

tyramine-containing foods, and signs and symptoms of hypertensive crisis



Antipsychotics—phenothiazines Instruct patients to wear sunscreen because of

photosensitivity Tell patients to avoid taking antacids or antidiarrheal

preparations within 1 hour of a dose Inform patients to avoid alcohol or other CNS

depressants with these medications



Antipsychotics—phenothiazines (cont’d) Long-term haloperidol therapy may result in tremors,

nausea, vomiting, or uncontrollable shaking of small muscle groups; report these symptoms to the physician



Antipsychotics—phenothiazines (cont’d) Oral forms may be taken with meals to decrease GI

upset These drugs may cause drowsiness, dizziness, or

fainting; instruct patients to change positions slowly



Monitor for therapeutic effects Monitor mental alertness, cognition, affect, mood,

ability to carry out activities of daily living, appetite, and sleep patterns

Monitor potential for self-injury during the delay between the start of therapy and symptomatic improvement



Monitor for therapeutic effects (cont’d) For anxiolytics

• Improved mental alertness, cognition, and mood

• Fewer anxiety and panic attacks

• Improved sleep patterns and appetite

• Less tension and irritability; fewer feelings of fear, impending doom, and stress

• More interest in self and others



Monitor for therapeutic effects (cont’d) For antidepressants

• Improved sleep patterns and nutrition

• Increased feelings of self-esteem

• Decreased feelings of hopelessness

• Increased interest in self and appearance

• Increased interest in daily activities

• Fewer depressive manifestations or suicidal thoughts/ideations



Monitor for therapeutic effects (cont’d) For antipsychotics

• Improved mood and affect

• Alleviation of psychotic symptoms and episodes

• Decreased hallucinations, paranoia, delusions, garbled speech, and inability to cope



Monitor for therapeutic effects (cont’d) For lithium

• Less mania

• Therapeutic lithium levels of 0.6 to 1.2 mEq/L



Case Study

A patient is admitted to the emergency department. The patient’s heart rate is 112 beats/min; he is sweating, has muscle tremors, and is agitated. The patient says, “I was depressed and took more of the pills the doctor gave me so I would feel better.”

1.What does the nurse suspect is happening with this patient?

2.What treatment does the nurse expect to implement?


The patient was admitted to the hospital for observation and has now recovered. Which information will the nurse include in patient teaching about SSRIs?A.It usually takes 4 to 6 weeks until you will experience benefits from the medication.

B.The patient must avoid foods that contain tyramine.

C.If the patient develops an upset stomach when taking this medication, he should discontinue use.

D.The patient should take the medication at bedtime to enhance sleep.

Case Study (cont’d)


Several months later the patient returns to the health care provider’s office for follow-up regarding use of the SSRI. The patient tells the nurse that he is feeling better and stopped taking the SSRI yesterday. He doesn’t plan on taking the medication again. When talking with the patient, which knowledge should guide the nurse’s response?A.Drug dependency will develop, so it is appropriate to stop therapy after a few months.

B.Drug therapy must be stopped as soon as the patient feels better to avoid serotonin syndrome.

C.The patient is the best person to determine when the drug therapy should end.

D.A 1- to 2-month taper period is indicated to prevent adverse effects of abrupt drug discontinuation.

Case Study


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Chapter 16 Psychotherapeutic Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc