1. Week 9 Seminar Chapter 31: Drugs for Mental Health and Behavioral Disorders, p Chapter 10: Calculating Doses of Nonparenteral Medications 1 1

2. Drugs for Mental Health chapter-31
“the Mentally Healthy person” – one who can perceive reality accurately and has control over expression of emotions Mental Health: not a concrete achievable goal …but a lifelong process resulting in a sense of harmony and balance in a person’s life -difficult to define, highly individualized -varies from person-to-person

3. Medication in Psychotherapy
Among the most prescribed drugs
Used to reduce/alleviate symptoms of STRESS …to allow the patient’s participation in other psychotherapies
DRUGS – temporarily change behavior, addiction/dependence are major concerns
PSYCHOTHERAPY – more long-term, but … the results are more permanent

4. Neurosis vs Psychosis
Neurosis: patient is still in contact with reality
Psychosis: patient is out of contact with reality, unable to communicate
DRUGs for Anxiety (see Table 31-1) known generally as ‘anxiolytics’ which literally means ‘to break apart, or dissolve anxiety’
Benzodiazepines – long and/or short-acting
Misc Anxiolytics – Buspar, Paxil, Effexor, Desyrel

5. Anxiolytics (cont) Benzodiazepines - introduced in the 1960’s
Generic names end in ‘-pam’ - diazepam, lorazepam, clonazepam (exception: alprazolam, whose brand name is Xanax)
‘drugs-of-choice’ – safer, lower abuse potential, less tolerance and dependence (again, except for Xanax!)
Effect: a calming-effect without extreme sedation
(2)general types: Short-acting and Long-acting

6. Questions? 6 6

7. Benzodiazepines Patient-education
Take with food if GI symptoms occur
Take exactly as directed (don’t modify dose)
DO NOT mix with alcohol!
Drowsiness occurs … careful in hazardous situations, driving, machinery, etc
Physical dependence is rare, except Xanax !
Benzo’s should NOT be used in pregnancy!

8. Misc Anxiolytics Buspar (buspirone)
Vistaril/Atarax (hydroxyzine pamoate/hcl)
Paxil (paroxetine)
Effexor (venlafaxine)
Desyrel (trazodone)
See “Facts about Anxiolytics” on p.662

9. Major tranquilizers/ Neuroleptics
Drugs used to treat Psychosis (see Table 31-2) are also known as “Antipsychotics”
Antipsychotics are effective in 3 main areas:
1)hallucinations,delusions,combativeness (psychosis)
2)relief of nausea/vomiting (chemo, narcotic s/e)
3)to increase potency of analgesics (ex: promethazine)
The two major forms of Psychosis are …
Schizophrenia and Depression

10. Anti-Mania & Bi-polar drugs
Bi-polar Disorder (formerly referred to as Manic-Depression)
common meds used in the bi-polar patient:
Lithium (Lithobid, Eskalith) – mainstay
carbamazepine (Tegretol) – developed as an anti-seizure drug
valproic acid (Depakote, Depakene) –also originally for seizure disorders

11. Questions? 11 11

12. Depression !(study Box 31-3 on p. 668)
aka ‘mood-disorders’ or ‘affective-disorders’
Among the most common psychiatric disorders, and is of (2) major types …
Exogenous – “the blues”, a response to ‘external’ factors, normally self-limiting
Endogenous (unipolar) – no apparent ‘external’ cause, basis is typically genetic or biochemical …

13. Exogenous/Endogenous Depression (cont)
Exogenous Depression:
Caused by external factors such as - divorce, loss of loved one, job loss, serious illness, etc
Drug therapy often successful w/ Exogenous
Endogenous: seems to come from ‘within’ the person, biochemical imbalance, hereditary
Endogenous type DOES NOT respond well to medication therapy

14. Anti-depressant Drugs (study Box 31-4 on p.669)
All major classes have a similar response rate …
So the choice-of-drug is based on things like: *side-effects *patient-history *if sedation is needed
MAOI’s (monoamine oxidase inhibitors)
TCA’s (tricyclic antidepressants)
SSRI’s (selective serotonin reuptake inhibitors)
SNRI’s (selective norepinephrine reuptake inhib)
NRI’s (natural reuptake inhibitors) –herbal, St.John’s wort for example

15. MAOI Medication Phenelzine (Nardil), Tranylcypromine (Parnate)
Selegiline (Selegiline, Eldepryl, Emsam),
MOA: increases the concentration of epinephrine, norepinephrine, and serotonin in storage sites throughout the nervous system

16. MAOI – patient ed
Very high number of potentially dangerous DRUG and FOOD interactions!
Avoid TYRAMINE containing foods, such as *cheese *wine *beans *chocolate (31-4, p.672)
See DDI (Dangerous-Drug-Interactions) (31-5,p.672)
MAOI must be ‘cleared’ from body before starting any new antidepressant (taper)

17. ‘Atypical’ Antidepressants (2nd generation)
Introduced in the 1980’s
These will treat --- major depressions, reactive depressions, and anxiety disorders
Wellbutrin (bupropion)
Remeron (mirtazapine)
Desyrel (trazodone)
MOA: increase of norepinephrine and dopamine, and does not inhibit monoamine oxidase or the reuptake of serotonin

18. Questions? 18 18

19. Alzheimer’s disease ~ 250,ooo new cases per year!
Progressive (worsening) illness
Degradation of nerve pathways (cholinergic)
Impaired thinking, confusion, disorientation, ‘sundowning’ = symptoms worse in evening
No specific ‘test’ for this , can only be diagnosed with certainty by autopsy
Drugs are used to slow the deterioration and/or improve patient’s nerve function

20. Drug therapy for Alzheimer’s
See Table 31-6 on p.675
Cognex, Aricept: increases nerve-function only
increasing the concentration of acetylcholine through reversible inhibition of its hydrolysis by acetylcholinesterase
Reminyl: slows disease progression AND improves nerve function (increased Ach)
Namenda: newest agent – ‘anti-Alzheimer’ agent, reduces deterioration of cholinergic nerve pathways in moderate-severe cases

21. ADHD
Common behavioral disorder (average of one ADHD child per classroom) – cause unknown!
Diagnosis usually based on symptoms that occur before age 7, and last > 6 months
Symptoms (begin from 3 – 7 yo, thru teenage)
Inattention
Hyperactivity
Impulsivity

22. Drugs for ADHD (study Table 31-7 on p.677)
CentralNervousSystem (CNS) Stimulants
Not to be given >1 year without a ‘break’ from the drug! …may suppress child’s growth
Break is known as ‘Drug-Holiday’
Suggested Drug-Holiday opportunities …
Weekends, summer-breaks, vacations, etc

23. ADHD drug names Methylphenidate (Ritalin) – CII (schedule-2)
Dextroamphetamine (Dexedrine) -CII
Amphetamine (Adderall) -CII
Lisdexamfetamine (Vyvanse) -CII
Atomoxetine (Strattera) only one that’s not a ‘scheduled’ drug, also used as antidepressant

24. ADHD drug side-effects
CII’s (methylphenidate, etc) – insomnia, growth suppression, headache, abdominal pain, lethargy, weight loss, dry mouth, irritability
Strattera (Atomoxetine) – headache, dyspepsia, nausea/vomiting, fatigue, decreased appetite, dizziness, altered mood
Clonidine (HTN agent) – hypotension, sedation

25. Questions? 25 25

26. Dosing calculations review (chapter-9)
LET’S REVIEW !!!
ANY QUESTIONS are fine …

27. Basic Rules for confident calculating (see Box 9-1 on p
Basic Rules for confident calculating (see Box 9-1 on p.166 … dosage-forms)
Always check UNIT’s (numerator/denominator)
Always work the problem ON PAPER, even the math seems EASY
Check and RE-CHECK all Decimals, Fractions
LOOK at the RESULT! …does it look reasonable?
Take ONE LAST LOOK to make sure you calculated dose in the correct units

28. Let Review Examples

29. Ordered: Docusate sodium syrup 60mg PO prn to soften stool Available : Docusate sodium syrup 20mg/5ml Dose to be given :
Steps
We need to find out how many ml we need to equal 60mg(ordered)
We have Doscusate sodium syrup 20mg/5ml (Available)
So set up the ratio
Ensure units are equal in numerator/denominator

30. Cont. 20mg 60mg 5ml x ml Cross multiply 20mg(xml)=5ml*60mg)
Solve for X find out how many ml’s are required per dose (60mg)
X= 15ml

31. Length Conversions
An abdominal cavity was opened with a 14-inch incision. Convert this measurement into cm (centimeters)
Use this conversion factor: 2.5 cm = 1 inch
2.5 cm / 1 in = x cm / 14 in
2.5 x 14 = 35
1 x x = 35
x = 35
14 inches = 35 cm
2.5 cm x cm
1 in in

32. Length Conversions
Question for the class Would you be able to convert 35cm to Micometers?

33. cross-multiplying
A physician orders Tylenol 0.65 gram but when you check your inventory you notice you have Tylenol 325mg tablets. How can you fill this prescription?
1. How can we make our units equal?
0.65g => 650mg (move decimal 3 units to the right)
2.Cross multiply & divide (650mg*1tab / 325mg) to solve for X
X = 2 tab =dose
in other words, 2 of the (325mg tablets) = 650mg =0.65 grams
1 tab X tab x = 2 tab
325mg mg

34. MD orders penicillin 500mg tid
MD orders penicillin 500mg tid. You check your inventory and have 250mg/5mL solution available. How many teaspoonfuls of medication are needed per dose? Per day?
1. Ensure units are equal (both are mg’s)
2. Cross multiply to find out how many ml’s are required per dose (5mL * 500mg / 250mg =10ml’s)
5 ml x mL
250mg mg
X = 10 ml’s

35. 3. To find out how many teaspoonfuls are needed, convert mL to tsp
Remember 5mL=1 tsp, so 10mL = 2tsp
4. 2 tsp’s per dose
5. Since dose is 500mg (2tsp’s) tid  need 6 tsp’s per day

36. Volume Conversions 5 ml x mL 100mg 250mg
MD orders Zithromax 250mg po stat for 5year old child. You check the office inventory and have 100mg/5mL solution available. How many teaspoonfuls of medication are needed for dose?
1. Ensure units are equal (both are mg’s)
2. Cross multiply to find out how many ml’s are required per dose (5mL * 100mg / 250mg =10ml’s)
5 ml x mL
100mg mg
X = 12.5 ml’s
3. To find out how many teaspoonfuls are needed, convert mL to tsp
Remember 5mL=1 tsp, so 12.5mL = 2&1/2 tsp
4. 2 & ½ tsp’s per dose

37. Please solve this ? Ordered: Heparin 5000 units SC Q12h
Available: Heparin 2000 units/ml
How many ml do you have to draw to administer units?

38. Answer = 2.5ml
5oooUnits Units =
X ml
Step up
2000Units(X)= 5000Units(1ml)
Solve x= Units (ml)
2000Units

39. Practice Problems
Md writes prescription for metoprolol 12.5mg bid, you have on hand metoprolol 25mg scored tablets. How many tablets would be required for a one month supply (30 days)?
How can you make a 12.5mg dose from 25mg ‘scored’ tablets ? Split them in half each half ( ½ tab) =12.5mg
12.5mg bid x 30 days  ½ tablet bid x 30 days
½ tab* 2 (twice daily) = 1 whole tablet per day x 30days = 30 whole tablets for a one month supply

40. Do not forget to Review all your assignment on
Conversion between the metric
And the common conversion (ie 1m=1000mg,lbs to kg, ml to tsp)
Dosing calculation
Review all the example in my power point

41. Questions? 41 41

42. Measuring Liquid Medications
Pour at eye level
Read bottom of meniscus
Meniscus
Figure 9-3. The meniscus

43. Liquid Measurement Instruments
Oral dispenser (A)
Oral syringe (B)
Liquid dropper (C)
Figure 9-4.

44. Final Project
This Project is for you to use your Critical thinking Skills
There are 4 cases
Case One
Discuss the patient concern (question to ask)
Possible reason for difference
What resource to ID pills
Case Two
Review antibiotic
Review the calculation

45. Final Project Case Three Review Pepto Bismol ( ingredient)
Option for constipation
Rx vs OTC
Case Four
Review her concerns
Review her concerns about the medication

46. Final Exam Information
Access Date(s): See Announcement
Pharmacology Portion
Time allowed for Pharmacology: 1 Hour 30 minutes
Calculation Portion
Time allowed for Calculations:   1 Hour 15 minutes
Each portion of the exam can be completed on different days.
Both portion done by June 26, 2012 at 11:59 EST****

47. Thank you class It was great to have all of you in class
The weekly seminar and discussion board response goes by so quickly
A very interactive group of students
The best of luck in your education endeavors
Good luck on the final exam
Have all you material ready for the final
Books and PowerPoint , Quiz and assignments

48. Class dismissed