1. Drugs for Depression, Anxiety, and Psychosis
Chapter 22
Drugs for Depression, Anxiety, and Psychosis 1

2. Chapter 22
Lesson 22.1 2 2

3. Objectives
Explain how different classes of drugs are used to treat depression, anxiety, and psychosis.
List the common names, actions, usual adult dosages, possible side effects, and adverse effects of drugs for depression and anxiety.
Describe what to do before and after giving drugs for depression and anxiety.
Explain what to teach patients taking drugs for depression and anxiety, including what to do, what not to do, and when to call the prescriber.
Describe life span considerations for drugs for depression and anxiety. 3 3

4. Psychiatric Disorders
Major depression, generalized anxiety disorder, bipolar disorder, schizophrenia
Depressive disorder forms:
Major depression
Dysthymia
Bipolar disorder
Cause may be imbalance of neurotransmitters (e.g., serotonin, dopamine, norepinephrine)
Treatment – counseling, antidepressant drugs
Depression is an illness characterized by persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life.
Major depression is a disabling mental disorder marked by a persistent low mood, lack of pleasure in life, and increased risk of suicide.
Dysthymia is a chronic but less severe form of depression characterized by moods that are persistently low. A person with dysthymia may experience episodes of major depression.
Bipolar disorder (formerly manic-depression) is characterized by cycling moods from severe highs (mania) to severe lows (depression). Mood changes may be sudden and dramatic, or gradual. 4

5. Antidepressant Drugs
Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), norepinephrine/dopamine reuptake inhibitors (NDRIs)
Intended responses:
Correct depression
Decrease symptoms of depressed mood
Side effects – hypotension, headache, dry eyes, dizziness, drowsiness
Adverse effects:
TCAs – serious cardiac effects
NDRIs – seizures; increased suicidal thoughts (children, adolescents, young adults)
Often used in conjunction with psychotherapy or counseling.
SSRIs have fewer side effects than TCAs.
It can take as long as 8 wk for symptoms of depression to improve.
Often, depression is chronic and patients must continue to take antidepressants even when they have no symptoms to keep the depression from returning.
SSRIs increase the amount of serotonin in the brain by inhibiting reuptake.
TCAs inhibit the reuptake of norepinephrine, dopamine, or serotonin by nerve cells.
NDRIs correct the imbalance of dopamine and norepinephrine. 5

6. How SSRIs Work
Figure Selective serotonin reuptake inhibitor drugs increase the amount of serotonin in the brain by blocking reuptake of neurotransmitters by neurons. 6

7. Administering Antidepressant Drugs
Check before:
Baseline BP; heart rate, rhythm
Mental status; presence of suicidal thoughts
Check after:
Vital signs, heart status
Mental status to determine response
Assess for suicidal thoughts
Patient teaching:
Take exactly as prescribed; do not double-dose
Medical follow-up
May take 1-8 wk for symptoms to improve
Take even when symptom-free
Avoid alcohol (increases drowsiness)
Patients taking TCAs should not smoke because it may decrease the effectiveness of these drugs.
If a dose is missed, take the dose as soon as possible unless it is almost time for the next dose.
Patients should report any side effects to their prescriber immediately.
Do not drive, operate machines, or do anything requiring alertness due to drowsiness, dizziness, and impaired vision until the drug’s effects are known. Change positions slowly because of hypotension and dizziness.
Frequent mouth rinses and good oral hygiene can minimize the effects of dry mouth.
Do not use SSRIs, TCAs, and other antidepressants for at least 14 days after discontinuing MAOI drugs because of the risk of serotonin syndrome.
Wear a medical alert bracelet or carry an ID card with the drug’s name and purpose. 7

8. Life Span Considerations for Antidepressant Drugs
Pediatric:
Risk of increased suicidal thoughts in depressed children/ adolescents
Fluoxetine (Prozac) may cause unusual excitement, restlessness, irritability, trouble sleeping
Venlafaxine (Effexor) may slow growth and weight gain; monitor growth carefully
Pregnancy and breastfeeding:
SSRIs – category C (not tested); avoid paroxetine (Paxil) in pregnancy
Some excreted in breast milk, may affect infant
Older adults:
May require lower doses, especially with kidney disease or liver failure
Unwanted effects in the breastfeeding infant include drowsiness, decreased feeding, and weight loss. 8

9. Anxiety Disorders Feelings of apprehension, fear, worry
Can occur without cause; may escalate through “feedback circle”
Panic disorder, generalized anxiety disorder (GAD), phobic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD)
Treatment depends on cause – calming interventions, coping strategies, healthy lifestyle, group therapy, antianxiety drugs
Physical symptoms:
Heart (increased rate, pounding)
Lungs (increased rate, depth; shortness of breath)
Nervous system (tremors, headaches)
Emotional symptoms – apprehension, dread, irritability, restlessness, difficulty concentrating
Panic disorders are separate and intense periods of fear or feelings of doom that develop over a short period of time. A panic attack is characterized by anxiety or terror, and usually lasts between 15 and 30 min.
In GAD, a person experiences excessive, almost daily anxiety and worry for more than 6 months.
Phobic disorders are intense, persistent, recurrent fears of certain objects (e.g., snakes) or situations (e.g., heights) that can cause a panic attack.
OCD is characterized by obsessive thoughts and compulsive actions.
PTSD leads to anxiety and is caused by exposure to death or near-death experiences such as floods, fires, earthquakes, shootings, automobile accidents, or war. 9

10. Anxiety Feedback Circle
Figure The circle of anxiety. 10

11. Antianxiety Drugs Benzodiazepines, SSRIs
Fun fact – beta blockers used for anxiety-producing events (e.g., stage fright)
Intended responses:
Relieve anxiety without too much sedation
Decrease symptoms of anxiety
Improve sense of well being
Side effects – dizziness, drowsiness, headache, fatigue, rash
Adverse effects:
Benzodiazepines – seizures and coma; life-threatening withdrawal symptoms with sudden discontinuation
Buspirone (BuSpar) – hallucinations, heart failure
Benzodiazepines are CNS depressants; SSRIs affect serotonin.
Moderate to severe anxiety is a symptom of psychiatric disorders such as phobia, panic disorder, OCD, and PTSD.
What are other terms for antianxiety drugs? Anxiolytics or minor tranquilizers
Can also cause sedation or sleep, and are likely to cause dependence when taken for an extended period.
The major benefit of benzodiazepines is that they act within 30 min and may be given as needed, while SSRIs can take from 3 to 5 wk to control anxiety.
Benzodiazepines also decrease symptoms of alcohol withdrawal and prevent delirium tremens (DTs).
Suicidal ideation may occur with patients taking clonazepam (Klonopin). 11

12. Administering Antianxiety Drugs
Check before:
Baseline BP; heart rate, rhythm
Anxiety level, mental status, presence of suicidal thoughts
Check after:
Vital signs, heart status, gait
Level of anxiety to determine response
Monitor for signs of dependency
Patient teaching:
Take exactly as prescribed; do not discontinue
Medical follow-up
Take even when symptom free
Avoid dangerous activities (drowsiness)
Avoid alcohol, other CNS depressants (sedation)
Because of the risk for benzodiazepine dependency, give these drugs only as prescribed.
Instruct patients to call for help when getting out of bed and ensure that the call light is within easy reach.
Teach patients about the signs of dependence and to report these signs immediately to their prescriber.
What are the signs of dependence on benzodiazepines? Strong desire/need to continue taking the drug, need to increase the dose to feel the drug’s effects
What are some withdrawal effects? Irritability, nervousness, trouble sleeping, abdominal cramps, trembling
Patients should not take benzodiazepines with antacids; antacids will decrease the absorption of these drugs.
Avoid grapefruit juice with benzodiazepines or buspirone (BuSpar)
Wear a medical alert bracelet or carry an ID card with the drug name and its purpose. 12

13. Life Span Considerations for Antianxiety Drugs
Pediatric:
Benzodiazepines – sensitive to effects; side effects more likely
Clonazepam (Klonopin) – may cause decreased mental/ physical growth; do not use in those younger than 18 years
Pregnancy and breastfeeding:
Benzodiazepines – category D/X
Excreted in breast milk; avoid breastfeeding
Older adults:
More sensitive to effects; greater risk for side effects
Use lower doses
Monitor for respiratory depression
What does pregnancy category D/X mean? The drugs should not be used during pregnancy
Chlordiazepoxide (Librium) and diazepam (Valium) have caused birth defects when used during the first trimester.
Benzodiazepines should not be used during pregnancy because the fetus can become dependent on these drugs and they can cause withdrawal symptoms after birth.
Not recommended during breastfeeding because they can cause drowsiness, difficulty with feeding, and weight loss in the infant.
Chlordiazepoxide and clorazepate (Tranxene) are not recommended for older adults because they each have a long half-life. 13

14. Chapter 22
Lesson 22.2 14 14 14

15. Objectives
List the common names, actions, usual adult dosages, possible side effects, and adverse effects of drugs for psychosis.
Describe what to do before and after giving drugs for psychosis.
Explain what to teach patients taking drugs for psychosis, including what to do, what not to do, and when to call the prescriber.
Describe life span considerations for drugs for psychosis. 15 15 15

16. Psychosis Loss of contact with reality May be brief or long-term
Treatment:
Decrease hallucinations, delusions; stabilize thinking, behavior
Psychological therapies
Antipsychotic drugs
Hospital care may be needed – person with psychosis may harm self or others
Many symptoms controlled with long-term treatment
What are some common symptoms of psychosis? Delusions (false ideas about what is occurring or who one is), illusions (mistaken perceptions), hallucinations (seeing or hearing things that are not there)
What psychological therapies are used to treat psychosis? Counseling, guided discussion, cognitive behavior therapy to help change or eliminate unwanted thoughts or beliefs 16

17. Antipsychotic Drugs
Major tranquilizers, lithium carbonate, thiothixene
Produce tranquilizing effect, helps relax CNS
Intended responses:
Decrease signs/symptoms of psychosis (hallucinations, delusions)
Improve social behavior
Decrease schizophrenic, suicidal behavior
Side effects – sedation/drowsiness, dizziness, agitation, headache, hypotension, tachycardia, restlessness, muscle spasms, tremor, weakness, dry mouth, dry eyes, blurred vision, constipation, weight gain, photosensitivity, diarrhea, constipation, nausea
Adverse effects – tardive dyskinesia, seizures, neuroleptic malignant syndrome
Sometimes called neuroleptics or major tranquilizers.
Antipsychotic drugs block dopamine receptors in the dopamine pathways in the brain.
The tranquilizing effect allows patients to function appropriately and effectively. They also control the symptoms of other psychiatric disorders that may lead to psychosis such as bipolar disorder.
Several days to weeks may pass before therapeutic effects begin.
What is tardive dyskinesia? A disorder characterized by involuntary movements most often affecting the mouth, lips, and tongue, and sometimes the trunk or other parts of the body such as arms and legs
Neutropenia can result from taking clozapine or prochlorperazine. Clozapine can also cause myocarditis.
Quetiapine, risperidone, and ziprasidone cause increased risk of death in older adults with dementia. 17

18. Administering Antipsychotic Drugs
Check before:
Baseline vital signs, daily weight
Mental status, level of psychosis
Check after:
Vital signs, daily weight, I&O
Mental state, presence of suicidal thoughts
Monitor for signs of dependency
Patient teaching:
Take exactly as prescribed; do not discontinue
Medical follow-up
Take even when symptom-free
Avoid dangerous activities (drowsiness)
Avoid alcohol, other CNS depressants (sedation)
Be sure to observe that patients swallow these drugs.
Smoking may decrease the effectiveness of olanzapine and clozapine.
Watch for signs of side effects or life-threatening adverse effects and report these immediately.
Patients should know about the side/adverse effects of these drugs and report them if they occur. Immediately report sore throat, unusual bleeding or bruising, rash, tremors.
Remind patients about the importance of psychotherapy to help keep psychosis under control.
Increase activity, fluid intake, and bulk foods to prevent constipation. Take these drugs and antacids at least 2 hr apart to prevent decreased absorption. Take with food if GI upset occurs. 18

19. Life Span Considerations for Antipsychotic Drugs
Pediatric:
More sensitive to effects
Side/adverse effects more likely
Pregnancy and breastfeeding:
Category C
Do not use during breastfeeding
Older adults:
More sensitive to effects; side/adverse effects more likely
Start with lower doses, especially with renal insufficiency
These drugs may cross the placenta and cause unwanted side effects in the newborn infant such as involuntary movements. 19