Introduction: Psychopharmacology

1. SEE pg ~33-38 Blue text- added by me Italics- another student Introduction: Psychopharmacology

2. Learning Outcomes • Discuss the categories of drugs used to treat mental illness • Discuss the drugs mechanisms of action and side effects • Describe the nurse’s role in educating patients and families about medication management • Identify special nursing considerations related to medication adverse reactions

3. Neurobiologic Theories Great strides are being made in understanding the brain and mental illness, but much is still unknown; nurses need to keep abreast of developments to provide effective teaching

5. Cerebral Lobes • Frontal lobe: thought, body movement, memories, emotions, moral behavior • Parietal lobe: taste, touch, spatial orientation • Temporal lobe: smell, hearing, memory, emotional expression • Occipital lobe: language, visual interpretation • Consider medications that affect these areas

6. Neurotransmitters • Chemical substances manufactured in the neuron to aid in transmission of information • Are necessary in just the right proportions to relay messages • Major neurotransmitters play a role in mental illness • Major neurotransmitters play a role in the actions and side effects of psychotropic drugs

7. Neurotransmitter Drugs(Dopamine & Serotonin are 2 of the biggest neurotransmitters in psych) • Dopamine: control of complex movements, motivation, cognition, regulation of emotional responses (Largely used) key in psych medicine • Norepinephrine: attention, learning, memory, sleep, wakefulness, mood regulation • Epinephrine: flight or fight response • Serotonin: a NT and vasoconstrictor. food intake, sleep, wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions are key in psych medicine • Dopamine- It has an inhibitory effect on movement. A depletion of dopamine produces the symptoms of rigidity, tremors, and bradykinesia that are characteristic of Parkinson's disease. • Norepinephrine- vasoconstricts • Epinephrine- adrenal hormone • Serotonin- vasoconstricts

8. Neurotransmitter Drugs • Histamine(dilation of capillaries) alertness, control of gastric secretions, cardiac stimulation, peripheral allergic responses • Acetylcholine(vasodilator): sleep and wakefulness cycle, signals muscles to become alert • Glutamate: an excitatory amino acid, promotes memory and learning • GABA: modulates other neurotransmitters, results in neurotoxicity if levels are too high. • Leads & controls the others & regulates them • The “big daddy” neurotransmitter • Inhibitory neurotransmitter,anticonvulsant

9. Psychopharmacology • Psychopharmacology and medication management are important in the treatment of many mental illnesses • Approved uses • Off-label uses • Black box warnings • warnings that appear on prescription medications informing patients of serious side effects • Consider that it may not be the med that causes suicides but maybe the pt already had intentions/desire and the new med “helped” them fulfill their thru feelings.

10. Principles of Psychopharmacology • Principles that guide the use of medications: • Effect on target symptom • Adequate dosage for sufficient time • Lowest dose needed for maintenance • Lower doses for the elderly • Tapering rather than abrupt cessation to avoid rebound or withdrawal • Follow-up care • Simplify the regimen for increased compliance

11. Antipsychotic Drugs-2 classes 1) Conventional 2) Atypical • 2 classes: conventional (typical) & atypical • Atypical drugs are DOC for clients who have just been diagnosed & are receiving treatment • Uses: • Schizophrenia, acute mania, psychotic depression, drug-induced psychosis, and other psychotic symptoms • Action: • Treat psychotic symptoms, such as delusions and hallucinations, by blocking dopamine receptors Term Neuroleptic- Having antipsychotic properties

12. Conventional Antipsychotic 1) Phenothiazines- supress the (+) sxms of psychosis (Thorazine, Prolixin, Mellaril, Stelazine, Navane, Haldol, Loxitane, Moban) • Side effects: - Sedation - Seizures - Anticholinergic effects - Photosensitivity - Neuroendocrine effects*** - Dysrhythmia - Orthostatic hypotension - Sexual dysfunction • ***S/S-Galactorrhea -discharge of breast milk, Gynecomastia- man boobs, Orthostatic Hypotension, Seizures, Sexual dysfunction, Bruxism- teeth grinding.

13. More of them having s/s, because now the trend is to try the “new” meds. • These are the older drugs • Mainly suppress the positive symptoms of psychosis (hallucinations, hearing voices, delusions, agitation) • These drugs have a lot of side effects • Neuroendocrine effects: gynecomastia, galactorrhea, menstrual irregularities, increased prolactin levels • Greatest risk is if pt. already has an existing seizure disorder b/c these drugs increase seizure threshold • Bruxism – grinding of the teeth at night • Dysrhythmias – tachycardia

14. Conventional Antipsychotic Drugs Neuroleptic Malignant Syndrome“life threatening” (a potentially life threatening reaction to antipsychotic drugs) • Symptoms: - Dysrhythmias - Muscle rigidity - Autonomic instability- sudden change in BP/HR - Sudden high grade fever - Changes in level of consciousness Term: Neuroleptic Malignant Syndrome- Nerve-Seizure+Bad+Syndrome Poor nutrition is a contributing factor

15. Conventional Antipsychotic Drugs Neuroleptic Malignant Syndrome- NMS Neg effects usually start w/in 7d of starting new med • Nursing interventions: • A spike in temp and the following = stop meds - Stop antipsychotic medication - Monitor physical and mental status - Apply cooling blankets - Administer antipyretics - Increase fluid intake - Dantruim (Dantrolene) “muscle relaxant” as ordered • Dantrium – muscle relaxant (helps treat muscle rigidity & aggressiveness) • NMS usually occurs during the first 7 days of starting the medication, but it can occur at any time • IV Valium is often used to treat NMS

16. Extrapyramidal Symptoms (EPS) EPS = Serious Neurologic Symptoms • Early EPS: - Dystonia- neck/tongue muscle spasms, respiratory problems - Pseudoparkinsonism- stooped posture, shuffling gait, cog-wheel rigidity, pill-rolling movements - Akathisia- “without-sit”; inability to sit or stand still. (internal restlessness), patients “want to jump/crawl out of their skin” - Treat with anticholinergic medications, when caught early, can be turned around • Late EPS: - Tardive dyskinesia (TD)- “late+bad-movement”;disorder, abnormal involuntary movements. (Kind of all the above rolled into one) - No treatment, not reversible Cogentin- reduce rigidity, tremor, and drooling Symmetrel- assist with rigidity and other parkinsonian symptoms Artane- assist with rigidity and other parkinsonian symptoms Inderal- non-selective beta blocker Valium- relieve anxiety and relax muscles Ativan- sedative

17. Extrapyramidal- pertaining to the function of these tissues and structures. • Most of the times can be reversed if caught in the early stages • No going back if condition progresses to late EPS • Treated with Cogentin (Benztropine)& Artane, sometimes will use a low dose of Benadryl, may see Inderal, Valium, or Ativan

18. Extrapyramidal Symptoms Nursing interventions: - Monitoring for early symptoms is key (screening exam is the AIMS test) Abn Invol Movement Scale - Manage symptoms with medication as ordered - Maintain safe environment - Provide reassurance to patient • Encourage patients to tell nurse if they notice anything different • If Cogentin or another med is given & symptoms do not clear up then need to call the physician

19. Long-acting Antipsychotics Available in depot “long acting” injection: • Prolixin (fluphenazine decanoate)- treatment of psychoses such as schizophrenia and acute manic • Duration of 1 to 4 weeks • Haldol (haloperidol decanoate)- a tranquilizing medication that can cause Parkinson-like symptoms. • Duration of 2 to 4 weeks • Risperdal Consta (risperidone)- atypical antipsychotic used to treat schizophrenia • Duration of 2 weeksMay see an order written for Prolixin or Prolixin decanoate (this one is long-acting) – Must know the difference between the two forms • A lot of psych patients mismanage their meds

20. Conventional Antipsychotic • Patient teaching: - Avoid alcohol - Adhering to medication regimen - Ideas to help with dry mouth anticholinergic effects- chew gum, candy -Report any changes to physician - Avoid direct contact with medication if liquid - Avoid excessive exposure to sun, use sunscreen

21. Atypical Antipsychotic Drugs2) Clozaril, Risperdal, Seroquel, Zyprexa, Zyprexa Zydis, Geodon, Abilify, Invega • Side effects: - Weight gain • Fewer or no EPS- little no Serious Neurologic Symptoms (good thing) • Headache, sleepiness, anxiety • Less anticholinergic adverse effects ( higher drooling) • Treat (+) and (-) sxms • Treats lack of energy, no motivation, social withdrawal • Positive sxms- things that shouldn’t be there (hallucinations) • Neg sxms- having things that should be there (withdrawal)

22. Clozaril (After one has tried all other meds/options) • Has to be monitored closely. Causes drooling at night. Incr in seizure risk b/c it incr seizure threshold. • Need a wkly CBC for 6m. Checking WBC- checking for agranulocytosis, leading to no defense against infection. (fatal, char: fever, sore throat) • Caution: Clozaril pt w/ sore throat • Zyprexa • Problem swallowing pills or refusing to take meds. Treat agitation. • Dissolves on tongue. Injectable. • Geodon (Need an EKG before admit b/c it can make changes in one’s Q-Wave • Injectable, short acting • Invega • Only once a day (expensive, not usually covered by ins)

23. Positive symptoms: having things that shouldn’t be there • Negative symptoms: having things that should be there • Clozaril (more cholinergic effects) – usually won’t see patients take this drug unless they have tried all the other medications; has to be monitored very carefully (weekly CBC for 6 months – clozaril registry that tracks CBC: won’t get prescription if you haven’t gotten weekly CBC); clozaril patients may drool (worse at night); increases seizure risk • Agranulocytosis risk with clozaril – can be fatal; usually characterized by fever, sore throat • Zyprexa (tablet form) or Zyprexa Zydis (form that dissolves on tongue); also available as injectable IM (not long-acting) • Geodon – EKG recommended before using medication; can make changes in QT-wave; also available as injectable (not long-acting) • Invega – extended release tab (patients like this b/c they only have to take it once a day); very expensive (insurance usually doesn’t cover it)

24. Atypical Antipsychotic Drugs Patient teaching: • Adhering to medication regimen!!! • Psycho says he hasn’t been taking his med... Find out why (ins, money?) • Monitor weight gain, exercise • Observe for signs of diabetes mellitus • Some of these meds can cause a pt to gain 50-60lbs so important to report changes • Observe for sign of infection • Report any changes to physician • If a patient tells you that he has not been taking his medication, find out why (may be due to side effects) • May gain 50-60 pounds with Zyprexa

25. Antidepressant Drugs SSRIs Atypical TCAs MAOIs • Uses: • Major depression, panic disorder, other anxiety disorders, bipolar depression, psychotic depression • Antidepressant can be used for anxiety disorders • Action: • Interact with the monoamine neurotransmitter systems in the brain, particularly the neurotransmitters norepinephrine and serotonin • Consider: age, hx, pt preference, try to figure all angles of what is best for the pt.

26. Worry about risk for suicide (we want to make sure to give pt. an antidepressant that is comparable to the type of depression they are in) • May see used for sleep apnea, eating disorders • Have to look at noncompliance – want a once a day medication if possible • Look at age, past history, patient preference, cost

27. SSRI Antidepressant Drugsnewer anti depress, and are 1st choice DOC. Prozac, Paxil, Zoloft, Celexa, Lexapro, Luvox • Side effects: - Tremor - Anxiety - Nausea - Dry mouth • Headache - Diarrhea • Insomnia, drowsiness • Sexual dysfunction (anorgasmia)- absence of an orgasm • Prozac- “ Zach” given in morn b/c of insomnia sxms. • Though they have fewer SE then other anti-depressants, w/ any of these meds consider N/V/D & impotence effects. • Decr cardio toxicity

28. Selective Serotonin Reuptake Inhibitors • Prozac is one of the oldest SSRI antidepressants & is used very often (also has a generic) • SSRIs are newer antidepressants – first choice in treatment of depression • Have to monitor side effects – Prozac often given in the morning r/t insomnia • Agitation & dizziness can also occur • Newer SSRIs have fewer side effects than other antidepressants & have lower cardiotoxicities – less chance of overdose

29. SSRI Antidepressant Drugs Serotonin Syndrome- SE of SSRI • Symptoms: - Fever - Diarrhea - Tremors - Sweating - Anxiety - Irritablility - Hyperreflexia - Bloating - Mood change - Altered mental state - Apnea, death - Wt gain Caution Serotonin Syndrome- serotonin level incr fever, life threatening. Wait 14day after if taking MAOIs

30. Serotonin syndrome: have too much medication on board; causes serotonin levels to become very high (very rare occurrence, but is life-threatening) can result in DEATH • Can also happen when you have an MAOI on board (need to clear one up one drug for at least 14 days – don’t want to take SSRI and MAOI together) • Sweating is one of the main things we notice in these patients • Altered mental state: not as quick as they were • Symptoms similar to flu-like symptoms (need to distinguish between the two)

31. SSRI Antidepressants Serotonin Syndrome- what do you do? • Nursing interventions: - Discontinue offending agent - Maintain safe environment - Monitor physical and mental status - Administer serotonin receptor blockade - Dantrolene, Valium for muscle rigidity - Provide reassurance to patient • Want to prevent falls, injuries due to hyperreflexia, mental status, etc. • May have to send pt. to ICU • May have to use cooling blankets, artificial ventilators

32. SSRI Antidepressant Drugs • Patient teaching: • Take with food (to prevent nausea) • Avoid alcohol and antihistamine else risk incr in CNS depression • Take in the morning (to prevent promblems w/ sleep) • Adhering to medication regimen (else risk serotonin withdrawal  sxms get worse) • Medication should not be discontinued abruptly (serotonin withdrawal) • Takes several weeks to be therapeutic (don’t quit after no results in 1st few days) • Tell doc if there's any incr thought/feelings about harming themselves (depression)

33. Atypical Antidepressants Wellbutrin (cannot OD, ideal for suicidal pt), Effexor (SE = incr BP), Remeron(for sleep dys, don’t use much), Cymbalta (treat major depression and pain), Desyrel aka “Trazodone”(oral antidepressant , sedative/sleep, caution for painful erection “priapism”) • Side effects: - Somnolence “sleepiness” - Changes in appetite (hunger vs no appetite) - Anticholinergic effects (dry mouth, urinary retention, blurred vision) - Cannot overdose on Wellbutrin, but increases seizure threshold & can make you very agitated • Very good for suicidal patients • Remeron – not used as often; used very often for sleep (but does have antidepressant feature) • Effexor – have to watch for high BP especially in elderly & cardiac compromised patients • Desyrel (Trazadone – generic) – given at night for sleep; AE: priaprism (very significant & painful)

34. Atypical Antidepressants • Patient teaching: - Avoid alcohol - Take with food/meals - Adhering to medication regimen - Takes several weeks to be therapeutic - Monitor BP

35. TCA Antidepressantscause many more/worse SE - Sedation - Tachycardia - Weight gain - Sexual dysfunction - Orthostatic hypotension • Anticholinergic effects • Mydriasis “pupillary dilation”  blindness • Cardiac effects (tachy) • Older antidepressants (making a comeback) – cause many more side effects; but may work much better on some patients • Monitor cardiac effects esp. in elderly (dysrhythmias) Tofranil, Norpramin, Elavil, Sinequan, Anafranil, Pamelor • Side effects:

36. TCA AntidepressantsLethal in OD Patient teaching: - Avoid alcohol - Lethal in overdose (understand on discharge not to take more than reg dose; (very narrow therapeutic range) - Take in the evening (can lead to better morning) - Use caution when driving (reflexes hampered) - Takes several weeks to be therapeutic (must talk to dr before stopping meds) - Adhering to medication regimen

37. MAOI Antidepressantsnot used much b/c of food interactions Nardil, Parnate, Marplan, Ensam • Side effects: - Sedation • Muscle cramps • Weight gain - Sexual dysfunction • Anticholinergic effects • Serious food/drug interactions • Tyramine- substance found in meats, all cheese and red wine, which can trigger migraine. Pg 34-5 • Nardil, Parnate, & Marplan not used very often • MAOIs have very serious interactions with drugs and foods (several have even been taken off the market) • Tyramine – aged cheeses, aged meats, beer/wine, dried beans, avocadoes • Ensam – newer medication that is a patch (very expensive); not as likely to have an AE if you eat something you aren’t supposed to (up to a point)

38. MAOI Antidepressants Hypertensive Crisis • Symptoms: - Nausea - Vomiting - Chills - Sweating - Fever - Hypertension - Restlessness - Nuchal rigidity - Dilated pupils - Occipital headache - Motor agitation - Severe nosebleeds • - Hypertensive crisis (Elevated temp/BP  Life threatening) severe HA, dilated pupils • Very serious, life-threatening effect (can occur with ingestion of tyramine foods) • If elevated BP is not treated pt. can have cerebral hemorrhage, stroke & even death

39. MAOI Antidepressants and Hypertensive Crisis • Nursing interventions: • 1st take VS- call doctor if BP is high • give sublingual Propranolol to lower BP • Immediate medical attention is crucial • Administer antihypertensives as ordered • Administer cooling blankets/ice packs • Monitor physical and mental status

40. Usually give sublingual Propanolol to bring down BP • Patient may have to be sent to ICU if BP won’t come down or if they have a really high fever • Comfort measures – IV medications to help pt. relax • SSRI- selective serotonin reuptake inhibitor (Serotonin- vasocontricts, so to inhibit reuptake will make more serotonin available) • Advantages over tricyclic antidepressant drugs include fewer anticholinergic side effects (dry mouth, blurred vision, urinary retention), and fewer antihistaminic side effects (sedation, weight gain). • MAOI-highly effective antidepressant and anti-panic agent • Remember: MAO s required to breakdown Tyramine (incr BP), so ingest food containing Tyramine  Hypertensive Crisis.

41. MAOI Antidepressants • Patient teaching: - Lethal in overdose (don’t give to suicidal pts) - Follow tyramine free diet (avoid aged cheeses, aged meats, foods with yeast, soy, beer, wines, avocados, etc.) • Notify physician before taking any other medication (i.e.-over the counter) • Use caution when driving • Don’t take Demerol “opioid analgesic” • Takes several weeks before TEs are seen • Must wait 14 days after discontinuing drug before starting other meds or eating tyramine foods • High risk for overdose – not given to suicidal patients SSRI- selective serotonin reuptake inhibitor (Serotonin- vasocontricts, so to inhibit reuptake will make more serotonin available) • Advantages over tricyclic antidepressant drugs include fewer anticholinergic side effects (dry mouth, blurred vision, urinary retention), and fewer antihistaminic side effects (sedation, weight gain). • MAOI-highly effective antidepressant and anti-panic agent • Remember: MAO s required to breakdown Tyramine (incr BP), so ingest food containing Tyramine  Hypertensive Crisis.

42. Mood Stabilizing Drugs Lithium (#1 for Bipolar, Cost effective, need blood lab), Tegretol (anticonvulsant, need blood lab), Depakote (anticonvulsant, need blood lab), Lamictal, Neurontin, Trileptal, Topamax • Uses: • Bipolar Disorder • Action: • Normalizes the reuptake of certain neurotransmitters and reduces the release of norepinephrine • Lithium is the #1 drug for bipolar disease, very cost effective, works very well on most bipolar patients • Tegretol & Depakote are also anti-convulsants • Lithium, Tegretol, & Depakote all require blood draws (must monitor serum levels) • With lithium must watch sodium & fluid levels because it can become toxic

43. Mood Stabilizing Drugs • Side effects: - Drowsiness - Rash - Hand tremors (toxicity, Lithium) - Fatigue - Anticholinergic effects - Weight changes -Toxicity, metal taste in mouth with Lithium - Alopecia “hair loss”, Hepatic failure with Depakote - Stevens-Johnson syndrome“skin separates” with Lamictal (med) - Aplastic anemia “deficient RBC from bone marrow” with Tegretol (med) Monitor sodium and fluids

44. Mood Stabilizing Drugs • Patient teaching: (see pg 34-5, lithium/mood stabilize- common vs uncommon/Toxicity; blood level/toxicity of Lithium) .4-1.3mEq/L - Take with food/meals - Monitor lab levels as ordered - Maintain adequate fluid intake - Adhering to medication regimen - Reporting any changes to physician - uncoordination, severe N/V/D, tinnitus, muscle weakness, drowziness - Read pg. 34 & 35 (difference between common symptoms & toxic symptoms of Lithium) • Must know the therapeutic level of Lithium (very narrow range: 0.4 to 1.3 mEq/L) • Nothing can be done to counteract lithium toxicity besides stopping the medication

45. Antianxiety (Anxiolytics) Benzodiazepines, BuSpar • Uses: • Anxiety disorders, insomnia, OCD, depression, PTSD, and alcohol withdrawal • Action: • They moderate the actions of GABA “aids sleep by naturally relaxing the muscles in the body and calming emotions” • Many used w/ antidepressants, caution for tolerance and dependence. • Valium, Ativan, Xanax • Main use is for anxiety in clients • Many are used along with antidepressants (can become dependant very quickly; tolerance can occur quickly)

46. Antianxiety Drugs • Side effects: • Sedation • Drowsiness • Impaired memory • Poor concentration “assoc amnesia effect” • Clouded sensorium “One's sensory environment” • Tolerance and dependence • Physical and psycho dependency, must be tapered off.

47. Antianxiety Drugs • Patient teaching: • Avoid alcohol, potentiate effects of alcohol • Caution during driving due to slower reflexes and response time • Never discontinue abruptly as withdrawal can be fatal • Medication does not treat the underlying problem • Treating the anxiety S/S, but not taking care of the underlying cause of the anxiety. Quick fix.

48. Stimulant Drugs Ritalin, Cylert, Adderall, Dexedrine, Newer:Concerta, Vyvanse (pedi med- learn later) • Uses: • ADHD, residual ADD in adults, and narcolepsy “chronic sleeping” • Action: • Cause release of neurotransmitters • Affect epinephrine & dopamine receptors, addicitive Strattera: not a CNS stimulant, not addictive • High abuse potential; stimulant drugs very addictive • Used with a lot of success in ADHD & residual ADD & narcolepsy

49. Stimulant Drugs • Side effects: • Nausea • Anorexia • Irritability • Weight loss • Restlessness • Cardiac effects • Dysrhythmias, chest pain, high BP • Growth retardation • Adjust dosage to decr. SE

50. Stimulant Drugs • Patient teaching: • Take after meals, else nausea • Avoid caffeine, sugar, and chocolate (cause they’re stimulant) • Long term use can cause dependency and tolerance • May need medication adjusted if develop a tolerance