1. Psychopharmacology Eve Karpinski, APHN-BC, RN-BC

2. Psychotherapeutics The treatment of emotional and mental disorders

3. 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.

4. 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.

5. 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

6. 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.

7. 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.

8. Receptors Molecules situated on the cell membrane that are binding sites for neurotransmitters.

9. Reuptake The process of neurotransmitter inactivation by which the neurotransmitter is reabsorbed into the presynaptic neuron from which it had been released.

10. Antidepressants – Block reuptake of neurotransmitters Antipsychotics – Block dopamine and other receptors Benzodiazepines – Facilitate transmission of GABA Psychostimulants – Increase release of neurotransmitters

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

12. 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

13. 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

14. 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 drug Outcome Criteria/Evaluation

15. Common Benzodiazepine Anxiolytics Generic diazepam lorazepam alprazolam clonazepam chlordiazepoxide oxazepam Brand Valium Ativan Xanax Klonopin Librium Serax *Non- Anxiolytic: BusSpar Non-sedating, non habit forming and not a prn. Good for the elderly

16. Non-benzodiazepine Hypnotic Generic Zolpidem Zalepon Eszopiclone Ramelteon Brand Ambien, *Ambien CR Sonata Lunesta Rozerem *contains a two layer coat One layer releases it s immediataely and other layer has a slow release of additional drug

17. 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

18. 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)

19. Antidepressants Newer-generation antidepressants – Selective serotonin reuptake inhibitors (SSRIs) – Second- and third-generation antidepressants Tricyclic antidepressants Monoamine oxidase inhibitors (MAOIs)

20. 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)

21. 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).

22. – 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

23. 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)

24. 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

25. Nursing Diagnosis Risk for suicide Risk for injury Social isolation Constipation

26. 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

27. 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

28. Antidepressants- SSRI Generic Fluoxetine Paroxetine Sertraline Citalopram Escitalopram Fluvoxamine Brand Prozac Paxil Zoloft Celexa Lexapro Luvox

29. Serotonin Syndrome DeliriumAgitation TachycardiaSweating HyperreflexiaMuscle spasms ShiveringCoarse tremors More severe cases Hyperthermia Seizures Renal failure Rhabdomyolysis DysrhythmiasDIC

30. Antidepressants Generic Bupropion Mirtzapine Venlafaxine Duloxetine Amitriptyline Imipramine Phenelzine Selegiline Brand Wellbutrin Remeron Effexor Cymbalta Elavil Tofranil Nardil Emsam

31. Monoamine Oxidase Inhibitor Nardil Parnate Marplan Selegiline* *Available in a patch form called EMSAM

32. 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

33. Mood Stabilzers Generic Lithum Valproic acid Carbamazepine Oxcarbazepine Lamotrigine Topiramate Brand Eskalith, Lithobid Depakote, Depakene Tegretol, Equetro Trileptal Lamictal Topamax

34. Mood-Stabilizing Agents Background 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)

35. 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

36. Nursing Diagnosis Risk for injury Risk for self-directed or other-directed violence Risk for activity intolerance

37. 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 toxicity Symbyax is a combination of Prozac an antidepressant and Zyprexa an atypical major tranquilizer.

38. 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 adequate sodium and fluid in diet

39. 1.Tegretol 2.Depakote/Depakene 3.Valproic Acid Monitor 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)

40. 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

41. Planning/Implementation (cont.) Educate client and family about the medication Outcome Criteria/Evaluation

42. Conventional Antipsychotics Generic Haloperidol Chlorpromazine Fluphenazine Thiothixene Trifluoperazine Thioridazine Perphenazine Loxapine Brand Haldol Thorazine Prolidixin Navane Stelazine Mellari Trilafon Loxitane

43. 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.

44. Atypical Antipsychotics Generic Clozapine Olanzapine Risperidone Quetiapine Ziprasidone Aripiprazole Paliperidonen Brand Clozaril, FazaClo Zyprexa (Aydis) Risperdal (Consta, M-tab) Seroquel, Seroquest XR Geodon Abilify Invega (newest)

45. 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

46. 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.

47. 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

48. 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

49. Nursing Diagnosis Risk for other-directed violence Risk for injury Risk for activity intolerance Noncompliance

50. 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

51. 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

52. 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

53. 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

54. 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

55. Planning/Implementation Monitor client for these side effects – Anticholinergic effects, nausea, GI upset, sedation, dizziness, exacerbation of psychoses, orthostatic hypotension Educate client/family about drug Outcome Criteria/Evaluation

56. 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

57. 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.

58. Neuroleptic Malignant Syndrome Signs and symptoms of NMS are: muscle rigidity, hyperthermia, decreased ventilation, cardiovascular collapse, and an elevate CPK

59. Dyskinesia and Tardive 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.

61. Anti-Parkinson's They are used in the treatment of drug induced movement disorders or Extrapyramidal Side Effects (EPSE)

62. Anti-Parkinson Medications – Cogentin – Symmetrel – Artane