Psychopharmacology

Eve Karpinski, APHN-BC, RN-BC

Psychotherapeutics

The treatment of emotional and mental disorders

Mental Health

• Defined as “The successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-

appropriate and congruent with local and cultural norms.” • Stages are identified by age. However, personality is

influenced by temperament (inborn personality characteristics) and the environment.

• It is possible for behaviors from an unsuccessfully completed stage to be modified and corrected in a later stage.

Mental Illness• Defined as “Maladaptive responses to stressors

from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and interfere with the individual’s social, occupational, or physical functioning.”

• Horwitz describes cultural influences that affect how individuals view mental illness. These include– Incomprehensibility – the inability of the general population to understand the motivation behind the behavior. – Cultural relativity – the “normality” of behavior is

determined by the culture.

10 Leading Causes of Disability in the World (WHO, 1997)

• Unipolar Depression• Iron-deficiency Anemia• Falls• Alcohol Use• COPD• Bipolar disorder• Congenital anomalies• Osteoarthritis• Schizophrenia• Obsessive-compulsive disorder

• 10.7%• 4.7• 4.6• 3.3• 3.1• 3.0• 2.9• 2.8• 2.6• 2.2

Historical Perspectives

• Before 1950, sedatives and amphetamines were the only significant psychotropic drugs available.

• Since the 1950s, psychopharmacology has expanded to include antipsychotic, antidepressant, and antianxiety drugs.

• Psychotropic drugs are intended to be used as an adjunct to individual or group psychotherapy.

How Do Psychotropics Work?

• Neurotransmitters (chemical messages that transmit electrical signals between brain cells)– Chemicals that are stored in the axon terminals of

the presynaptic neuron.– An electrical impulse through the neuron

stimulates its release into the synaptic cleft, which in turn determines whether another electrical impulse is generated.

• Receptors– Molecules situated on the cell membrane that are

binding sites for neurotransmitters.

ReceptorsMolecules situated on the cell

membrane that are binding sites for neurotransmitters.

ReuptakeThe process of neurotransmitter inactivation by

which the neurotransmitter is reabsorbed into the presynaptic neuron from which it had been released.

• Antidepressants – Block reuptake of neurotransmitters

• Antipsychotics– Block dopamine and other receptors

• Benzodiazepines– Facilitate transmission of GABA

• Psychostimulants– Increase release of neurotransmitters

Anxiety Disorders• 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

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

The Nursing Process: Antianxiety Agents

Background Assessment Data• Indications: anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation

• Action: depression of the CNS

• Contraindications/Precautions – Contraindicated in known hypersensitivity; in combination with other CNS depressants; in pregnancy and lactation, narrow-angle glaucoma, shock, and coma– Caution with elderly and debilitated clients, clients with renal or hepatic dysfunction, those with a history of drug abuse or addiction, and those who are depressed or suicidal

• Interactions– Increased effects when taken with alcohol,

barbiturates, narcotics, antipsychotics antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, or disulfiram

– Decreased effects with cigarette smoking and caffeine consumption

– DO NOT USE WITH ALCOHOL

Nursing Diagnosis• Risk for injury• Risk for activity intolerance• Risk for acute confusion

Planning/Implementation• Monitor client for these side effects

– Drowsiness, confusion, lethargy; tolerance; physical and psychological dependence; potentiation of other CNS depressants; aggravation of depression; orthostatic hypotension; paradoxical excitement; dry mouth; nausea and vomiting; blood dyscrasias; delayed onset (with buspirone only)

• Educate client/family about the drugOutcome Criteria/Evaluation

Common Benzodiazepine Anxiolytics

Genericdiazepam lorazepam alprazolam clonazepam chlordiazepoxide oxazepam

BrandValiumAtivanXanaxKlonopinLibriumSerax*Non- Anxiolytic: BusSparNon-sedating, non habit forming

and not a prn. Good for the elderly

Non-benzodiazepine Hypnotic

GenericZolpidemZaleponEszopicloneRamelteon

BrandAmbien, *Ambien CRSonataLunestaRozerem

*contains a two layer coatOne layer releases it s immediataely

and other layer has a slow release of additional drug

Benzodiazepines–overdose

Dangerous when taken with other sedatives or alcohol

Treatment is generally symptomatic and supportive

Flumazenil (Romazicon) may be used to reverse benzodiazepine effects

Affective Disorders (Mood 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)

Antidepressants

• Newer-generation antidepressants– Selective serotonin reuptake inhibitors (SSRIs)– Second- and third-generation antidepressants

• Tricyclic antidepressants• Monoamine oxidase inhibitors (MAOIs)

The Nursing Process: Antidepressants

Background Assessment Data• Indications: dysthymic disorder; major depression;

depression associated with organic disease, alcoholism, schizophrenia, or mental retardation;

depressive phase of bipolar disorder; and depression accompanied by anxiety

• Action: increase concentration of nor-epinephrine and serotonin in the body, either by blocking their reuptake by the neurons (tricyclics, tetracyclics, SSRIs) or by inhibiting the release of monoamine oxidase (MAOIs)

• Contraindications/precautions– Contraindicated in known hypersensitivity (SSRIs,

MAOIs, tricyclics); acute phase of recovery from myocardial infarction; angle-closure glaucoma (tricyclics); and concomitant with MAOIs (SSRIs and tricyclics).

– Caution with elderly or debilitated clients; clients with hepatic, cardiac, or renal insufficiency; psychotic clients; clients with benign prostatic hypertrophy; and those with history of seizures (tricyclics, MAOIs).

– Interactions (with tricyclics)• Increased effects of tricyclics with bupropion,

cimetidine, haloperidol, SSRIs, and valproic acid• Decreased effects of tricyclics with rifamycin,

carbamazepine, and barbiturates• Hyperpyretic crisis, convulsions, and death can

occur with MAO inhibitors• Hypertensive crisis can occur with clonidine• Decreased effects of levodopa and

guanethidine• Potentiation of pressor response with direct-

acting sympathomimetics

• Interactions (MAOIs)– Hypertensive crisis with amphetamines, methyldopa,

levodopa, dopamine, epinephrine, norepinephrine, reserpine, vasoconstrictors, or foods with tyramine

– Hypertension, hypotension, coma, convulsions, and death with narcotic analgesics

– Additive hypotension with antihypertensives– Additive hypoglycemia with antihyperglycemic agents– Potentially fatal reactions with other antidepressants,

carbamazepine, cyclobenzaprine, maprotiline, furazolidone, procarbazine, or selegiline (avoid use within 2 weeks of each other)

• Interactions (SSRIs)– Toxic, sometimes fatal, reactions have occurred with

concomitant use of MAOIs – Increased effects of SSRIs with cimetidine, L-tryptophan, and

lithium– Concomitant use of SSRIs may increase effects of hydantoin,

tricycle antidepressants, benzodiazepine, beta-blockers, carbamazepine, clozapine, haloperidol, phenothiazine, St. John’s wort, sumatriptan, sympathomimetics, tacrine, theophylline, and warfarin.

– Concomitant use of SSRIs may decrease effects of buspirone and digoxin

– Serotonin syndrome can occur with concurrent use of other drugs that increase serotonin

Nursing Diagnosis

• Risk for suicide• Risk for injury• Social isolation• Constipation

Planning/Implementation• Monitor client for the following side effects

– May occur with all chemical classes• Dry mouth, sedation, nausea• Discontinuation syndrome

– Most commonly occur with tricyclics • Blurred vision, constipation, urinary retention,

orthostatic hypotension, reduction of seizure threshold, tachycardia, arrhythmias, photosensitivity, weight gain

Planning/Implementation (cont.)• Side effects (cont.)

– Most commonly occur with SSRIs• Insomnia, agitation, headache, weight loss, sexual dysfunction,

serotonin syndrome– Most commonly occur with MAOIs

• Hypertensive crisis

– Miscellaneous side effects• Priapism (with trazadone)• Hepatic failure (with nafazodone)

• Educate client/family about drug

Outcome Criteria/Evaluation

Antidepressants- SSRI

• GenericFluoxetineParoxetineSertralineCitalopramEscitalopramFluvoxamine

• BrandProzacPaxilZoloftCelexaLexaproLuvox

Serotonin Syndrome

• Delirium Agitation• Tachycardia Sweating• Hyperreflexia Muscle spasms• Shivering Coarse tremors

More severe cases• Hyperthermia Seizures• Renal failure Rhabdomyolysis• Dysrhythmias DIC

Antidepressants• Generic Bupropion Mirtzapine Venlafaxine Duloxetine Amitriptyline Imipramine Phenelzine Selegiline

• Brand Wellbutrin Remeron Effexor Cymbalta Elavil Tofranil Nardil Emsam

Monoamine Oxidase Inhibitor

• Nardil• Parnate• Marplan • Selegiline**Available in a patch form called EMSAM

Hypertensive Crisis and Tyramine• Ingestion of foods and/or drinks with

the amino acid tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death

• Ingestion of foods and/or drinks with the amino acid tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death

Mood Stabilzers

• GenericLithumValproic acidCarbamazepine OxcarbazepineLamotrigineTopiramate

• BrandEskalith, LithobidDepakote, DepakeneTegretol, EquetroTrileptalLamictalTopamax

Mood-Stabilizing AgentsBackground Assessment Data• Indications: prevention and treatment of manic

episodes associated with bipolar disorder

• Examples: *lithium carbonate, clonazepam, carbamazepine, valproic acid, lamotrigine, gabapentin, topiramate, verapamil, various antipsychotics.

• Blood levels are needed for Lithium (0.4-1.2mEg/ml)

Depakote (4-12 mEg/ml) Tegretol (4-12 meg/ml)

• Action• Lithium enhances the reuptake of

norepinephrine and serotonin in the brain, lowering levels in the body and resulting in decreased hyperactivity

• The role of anticonvulsants, verapamil, and antipsychotics in the treatment of bipolar mania is not fully understood.

• Interactions• Contraindications/precautions

Nursing Diagnosis

• Risk for injury• Risk for self-directed or other-directed violence• Risk for activity intolerance

Planning/Implementation

• Monitor for side effects of lithium– Drowsiness, dizziness, headache– Dry mouth; thirst; GI upset; nausea/vomiting– Fine hand tremors– Hypotension; arrhythmias, pulse irregularities– Polyuria; dehydration– Weight gain--Potential for toxicitySymbyax is a combination of Prozac an antidepressant and

Zyprexa an atypical major tranquilizer.

• Lithium Toxicity– Therapeutic range: 1.0–1.5 mEq/L– Narrow therapeutic range: maintenance serum

levels should range between 0.6 and 1.2 mEq/L

– Initial symptoms of toxicity include• Blurred vision, ataxia, tinnitus, persistent nausea and

vomiting, and severe diarrhea

– Ensure that client consumes adequatesodium and fluid in diet

1. Tegretol2. Depakote/Depakene3. Valproic AcidMonitor for side effects of anticonvulsants

– Nausea and vomiting– Drowsiness; dizziness– Blood dyscrasias– Prolonged bleeding time (with valproic acid)– Risk of severe rash (with lamotrigine)– Decreased efficacy with oral contraceptives (with topiramate)

• Monitor for side effects of verapamil– Drowsiness; dizziness– Hypotension; bradycardia– Nausea– Constipation

• Monitor for side effects of antipsychotics– Drowsiness; dizziness– Dry mouth; constipation– Increased appetite; weight gain– ECG changes– Extrapyramidal symptoms– Hyperglycemia and diabetes

Planning/Implementation (cont.)• Educate client and family about the medication

Outcome Criteria/Evaluation

Conventional Antipsychotics

GenericHaloperidolChlorpromazineFluphenazineThiothixeneTrifluoperazineThioridazinePerphenazineLoxapine

BrandHaldolThorazineProlidixinNavaneStelazineMellariTrilafonLoxitane

Conventional Antipsychotics

• Advantage-Effective for positive symptoms of schizophrenia- Available in IM formulation for acute psychosis/agitation- Cheap

• Disadvantage- Could worsen cognitive function- Minimally effective for negative symptoms of schizophrenia- Higher incidence of side effects (EPS, NMS, tardive dyskinesia, etc.

Atypical Antipsychotics

• GenericClozapineOlanzapineRisperidoneQuetiapineZiprasidoneAripiprazolePaliperidonen

• BrandClozaril, FazaCloZyprexa (Aydis)Risperdal (Consta, M-tab)Seroquel, Seroquest XRGeodonAbilifyInvega (newest)

Atypical Antipsychotics• Advantage- Effective for positive of symptoms of schizophrenia- May improve negative symptoms of schizophrenia- Lower incidence of side effects compared to

conventional antipsychotics

• Disadvantage- Higher incidence of weight gain- Higher incidence of diabets- Expensive

Antipsychotics

Background Assessment Data• Indications: Treatment of acute and chronic

psychoses; selected agents are also used as antiemetics in the treatment of intractable hiccoughs and for control of tics and vocal utterances in Tourette’s disorder

• Actions: Unknown; thought to block postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. Newer antipsychotics may block action on receptors specific to dopamine, serotonin, and other neurotransmitters.

• Contraindications/precautions– Contraindicated with known hypersensitivity; with CNS

depression; when blood dyscrasias exist; in clients with Parkinson’s disease; or those with liver, renal, or cardiac insufficiency

– Caution with elderly, debilitated, or diabetic clients or those with respiratory insufficiency, prostatic hypertrophy, or intestinal obstruction

• Interactions– Additive anticholinergic effects with other drugs that produce

these properties– Additive hypotensive effects with beta-blockers– Decreased absorption of antipsychotics with antacids and

antidiarrheals– Decreased effectiveness of antipsychotics with barbiturates– Additive CNS depression with alcohol, antihistamines,

antidepressants, sedative-hypnotics, and anxiolytics

Nursing Diagnosis

• Risk for other-directed violence• Risk for injury• Risk for activity intolerance• Noncompliance

• Monitor client for these side effects– Anticholinergic effects, nausea, GI upset, skin rash, sedation,

orthostatic hypotension, photosensitivity, hormonal effects, ECG changes, reduction of seizure threshold, agranulocytosis (especially with clozapine), hypersalivation (with clozapine), extrapyramidal symptoms (EPS), tardive dyskinesia, neuroleptic malignant syndrome (NMS), hyperglycemia and diabetes

• Educate client/family about drug

Outcome Criteria/Evaluation

Side effects• 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

• Indications: treatment of parkinsonism of various causes, including degenerative, toxic,

infective, neoplastic, or drug-induced

• Action: work to restore the natural balance of acetylcholine and dopamine in the CNS

• Contraindications/precautions– Contraindicated in known hypersensitivity; angle-

closure glaucoma; pyloric, duodenal, or bladder neck obstructions; prostatic hypertrophy; or myasthenia gravis

– Caution with hepatic, renal, or cardiac insufficiency; elderly and debilitated clients; those with a tendency toward urinary retention; those exposed to high environmental temperatures

• Interactions– Additive anticholinergic effects and potentially fatal paralytic

ileus with other drugs that possess these properties– Concurrent use with haloperidol or phenothiazine may result in

decreased effect of the antipsychotic and increased incidence of anticholinergic side effects.

– Additive CNS effects with CNS depressants

Planning/Implementation• Monitor client for these side effects

– Anticholinergic effects, nausea, GI upset, sedation, dizziness, exacerbation of psychoses, orthostatic hypotension

• Educate client/family about drugOutcome Criteria/Evaluation

Side effects• 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

• Examples of drug induced movement disorders are:– AkathisiaIt-An absence of movement.– Akinesia- is restlessness or an inability to sit still – Dyskinesia and Tardive Dyskinesia– Chorieoform, worm-like movements– Dystonias-Rigidity in the muscles that control posture,

gait, eye rolling (occulogyro crisis), laryngeal spasms (gagging), cyanosis, and respiratory distress.

– Cog-wheel rigidity-Joints such as at the elbow do not move freely but have a jerking type motions much like two wheels that have projections or cogs that can get caught and cause a stop and start action.

Neuroleptic Malignant Syndrome

• Signs and symptoms of NMS are: muscle rigidity, hyperthermia, decreased ventilation, cardiovascular collapse, and an elevate CPK

Dyskinesia andTardive Dyskinesia

• It is abnormal involuntary muscle movement (jerky), pill rolling, lip smacking, tongue protrusion and an impaired gag reflex (Places the individual at risk for choking).

• Abnormal Involuntary Movement Scale or AIMS is performed every three months for patient s receiving antipsychotic medication that can cause a drug induced movement.

Anti-Parkinson's

• They are used in the treatment of drug induced movement disorders or Extrapyramidal Side Effects (EPSE)

Anti-Parkinson Medications

– Cogentin– Symmetrel– Artane