Chapter 16
Psychotherapeutic Drugs
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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
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Three main emotional and mental disorders: Anxiety Affective disorders Psychoses
Psychotherapeutic Drugs (cont’d)
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Types of psychotherapeutic drugs Anxiolytic drugs Mood-stabilizing drugs Antidepressant drugs Antipsychotic drugs
Psychotherapeutic Drugs (cont’d)
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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
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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
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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)
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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
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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
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alprazolam (Xanax) diazepam (Valium) lorazepam (Ativan)
Benzodiazepines
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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
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Dangerous when taken with other sedatives or alcohol
Treatment is generally symptomatic and supportive
Flumazenil may be used to reverse benzodiazepine effects
Benzodiazepines: Overdose
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buspirone (BuSpar) Unknown mechanism of action Administered on a scheduled basis Adverse effects
• Paradoxical anxiety
• Blurred vision
• Headache
• Nausea
Miscellaneous Anxiolytic
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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
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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)
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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
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Tricyclic antidepressants Monoamine oxidase inhibitors (MAOIs) Second-generation antidepressants
Selective serotonin reuptake inhibitors (SSRIs) Serotonin-norepinephrine reuptake inhibitors (SNRIs) Miscellaneous
Antidepressants
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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
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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
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Depression Childhood enuresis (imipramine) Obsessive-compulsive disorders (clomipramine) Adjunctive analgesics for chronic pain
conditions, such as trigeminal neuralgia
Tricyclic Antidepressants: Indications
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Sedation Impotence Orthostatic hypotension Others Older patients
Dizziness, postural hypotension, constipation, delayed micturation, edema, muscle tremors
Tricyclic Antidepressants: Adverse Effects
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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
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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)
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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)
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isocarboxazid (Marplan) phenelzine (Nardil) tranylcypromine (Parnate) selegiline (Emsam)
MAOIs (cont’d)
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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
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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
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Few adverse effects—orthostatic hypotension most common
Tachycardia Dizziness Insomnia Anorexia Blurred vision Palpitations Drowsiness Headache Nausea Impotence
MAOIs: Adverse Effects
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Symptoms appear 12 hours after ingestion Tachycardia, circulatory collapse, seizures,
coma Treatment: protect brain and heart, eliminate
toxin Urine acidification Hemodialysis
MAOIs: Overdose
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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
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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
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SSRIs fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) fluvoxamine (Luvox) citalopram (Celexa) escitalopram (Lexapro)
Second-Generation Antidepressants (cont’d)
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Second-Generation Antidepressants (cont’d)
SNRIs venlafaxine (Effexor) duloxetine (Cymbalta) desvenlafaxine (Pristiq)
Miscellaneous trazodone (Desyrel, Oleptro) bupropion (Wellbutrin) nefazodone (Serzone) mirtazapine (Remeron)
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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
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Depression Bipolar disorder Obesity Eating disorders Obsessive-compulsive disorder
Second-Generation Antidepressants: Indications
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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)
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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
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Classroom Response Question
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
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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
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Classroom Response Question
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.
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Drugs used to treat serious mental illness Behavioral problems or psychotic disorders
Have been known as tranquilizers or neuroleptics
Conventional drugs Atypical antipsychotics
Antipsychotics
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Thioxanthenes: thiothixene (Navane) Butyrophenones: haloperidol (Haldol) Dihydroindolones: molindone (Moban) Dibenzoxazepine: loxapine (Loxitane) Phenothiazines: three structural groups Atypical antipsychotics: new class
Antipsychotics (cont’d)
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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
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clozapine (Clozaril) risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel) ziprasidone (Geodon) aripiprazole (Abilify) paliperidone (Invega)
Atypical Antipsychotics
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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
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Body System Adverse Effects
CNS Sedation, delirium
Cardiovascular Orthostatic hypotension, syncope, dizziness, ECG changes
Dermatologic Photosensitivity, skin rash, hyperpigmentation, pruritus
Antipsychotics: Adverse Effects
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Antipsychotics: Adverse Effects (cont’d)
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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
Antipsychotics: Adverse Effects (cont’d)
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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)
Antipsychotics: Adverse Effects (cont’d)
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Tardive dyskinesia (TD) Involuntary contractions of oral and facial muscles Choreoathetosis (wavelike movements of extremities) Occurs with continuous long-term antipsychotic
therapy
Antipsychotics: Adverse Effects (cont’d)
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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
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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
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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
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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)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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Antianxiety drugs In elderly patients, monitor closely for oversedation
and profound CNS depression
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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Monitor for therapeutic effects (cont’d) For lithium
• Less mania
• Therapeutic lithium levels of 0.6 to 1.2 mEq/L
Psychotherapeutic Drugs: Nursing Implications (cont’d)
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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?
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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)
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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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