Drugs Used in Mental Health

1. Drugs Used in Mental Health Antianxiety Drugs

2. Antianxiety Drugs • Anxiety – a feeling of apprehension, worry, or uneasiness that may or may not e based on reality • Anxiolytics – another name for antianxiety medications

3. Antianxiety Drugs • Block neurotransmitter receptor sites preventing anxious feelings from reaching brain • Also prevents body’s physical reaction to anxiety

4. Antianxiety Drugs Common Uses • Anxiety disorders and panic attacks • Preanesthetic sedation and muscle relaxants • Convulsions or seizures - diazepam (Valium) • Alcohol withdrawal

5. Antianxiety Drugs • Benzodiazepines • diazepam (Valium) half life: 36-200 hr • clonazepam (Klonopin) half life: 18-50 hr • chlordiazepoxide (Librium) half life: 5-25 hr • alprazolam (Xanax) half life: 6-12 hr • lorazepam (Ativan) half life: 10-20 hr

6. Antianxiety Drugs • Nonbenzodiazepines • doxepin (Sinequan) half life: 28-52 hr • buspirone HCl (BuSpar) half life: 2-3 hr * buspirone (BuSpar) drug of choice with elderly because it does not cause excessive drowsiness and poses less fall risk

7. Antianxiety Drugs Side Effects / Adverse Reactions • Drowsiness / sedation • Lightheadedness / dizziness • Headache, visual disturbances • Lethargy, apathy, fatigue • Confusion, restlessness, agitation • GI disturbances, dry mouth

8. Antianxiety Drugs • Benzodiazepine Toxicity • Results from overdose • Sedation, respiratory depression, coma, death • Antidote: flumazenil (Romazicon) • Parenteral Alert • IM, IV route may lead to apnea and cardiac arrest • Use care with elderly, debilitated, respiratory compromised

9. Antianxiety Drugs High Risk for Physical Dependence • Long term use • Tolerance • Physical dependence • Withdrawal symptoms After 3 months of use, do NOT discontinue abruptly

10. Antianxiety Drugs Withdrawal Symptoms • Increased symptoms of anxiety • Fatigue, hypersomnia • Metallic taste, nausea, sweating • Headache, difficulty concentrating • Cramps, tremors • Hallucinations, convulsions

11. Contraindications • Psychoses • Acute narrow angle glaucoma • Pregnancy • Floppy infant syndrome • Lactation • Infant becomes lethargic and loses weight • Significant hypotension / bradycardia

12. Precautions • Use cautiously with elderly • Initial Low Dose: excreted more slowly, high risk for toxic levels • Exception: lorazepam (Ativan), safe for elderly at usual ranges • Use cautiously in patients with • Impaired liver function • Impaired kidney function • Overall debilitation • Avoid alcohol

13. Interactions • Other CNS depressants: Increased risk of sedation, confusion, convulsions • Alcohol • Narcotic Analgesics • Other Psychotropics • Digoxin • Increased risk for Digitalis Toxicity

14. Antidepressants • Depression – feelings of hopelessness that interfere with daily functioning

15. Antidepressants • Neurotransmisson • Important Neurotransmittors • Dopamine • Epinephrine • Norepinephrine • Serotonin

16. Antidepressants Types of Antidepressants • Tricyclic Antidepressants (TCA’s) • Monoamine Oxidase Inhibitors (MAOI’s) • Selective Serotonine Reuptake Inhibitors (SSRI’s) • Miscellaneous

17. Antidepressants • Tricyclic Antidepressants (TCA’s) • Earliest antidepressants • Enhances movement of serotonin from one neuron to the next • Examples • Doxepin (Sinequan) • Imipramine (Tofranil)

18. Antidepressants • Tricyclic Antidepressants (TCA’s) • Uses • Depressive episodes • Bipolar disorder • Obsessive – compulsion disorder • Chronic neuropathic pain • Depression accompanied by anxiety • Enuresis

19. Antidepressants • Tricyclic Antidepressants (TCA’s) • Side Effects • Anticholinergic-like side effects (insomnia, dry mouth, lethargy, confusion, blurred vision, urinary retention) • Constipation • Photosensitivity • Sedation (best given at night)

20. Antidepressants • Tricyclic Antidepressants (TCA’s) • Contraindications and Precautions • Use with caution in patients with cardiac history • Do not give during pregnancy or lactation • Use with caution with hyperthyroid disease • Use with caution with seizure disorder • Use with caution with hepatic / renal impairment

21. Antidepressants • Tricyclic Antidepressants (TCA’s) • Interactions • Avoid other CNS depressants, including alcohol • Dicumarol (similar to warfarin): increased bleeding times • Cimetidine (Tagamet): increased anticholinergic-like effects • MAOI’s: hypertension, convulsions, fever • Adrenergics: arrhythmias, hypertension

22. Antidepressants • Monoamine Oxidase Inhibitors (MAOI’s) • No longer in common use • Inhibit the enzyme responsible for inactivating (destroying) certain neurotransmittors • Example • Phenelzine (Nardil)

23. Antidepressants • Monoamine Oxidase Inhibitors (MAOI’s) • Uses • Depressive episodes • Unlabelled used: bulemia, night terrors, migraines, seasonal affective disorder (SAD), multiple sclerosis

24. Antidepressants • Monoamine Oxidase Inhibitors (MAOI’s) • Side Effects • Orthostatic hypotension • Anticholinergic-like side effects (insomnia, dry mouth, lethargy, confusion, blurred vision, urinary retention) • Constipation • Hypertensive Crisis

25. Antidepressants • Monoamine Oxidase Inhibitors (MAOI’s) • Hypertensive Crisis with Foods Containing the amino acid Tyramine • Cheese • Wines (especially red) • Caffeine • Soy

26. Antidepressants • Monoamine Oxidase Inhibitors (MAOI’s) • Symptoms of Hypertensive Crisis • Headache (usually occipital) • Stiff, sore neck • Nausea, vomiting • Sweating, fever, chest pains, mydriasis • Severe hypertension

27. Antidepressants • Monoamine Oxidase Inhibitors (MAOI’s) • Contraindications and Precautions • Use with caution in patients with cerebrovascular disease • Use with caution in patients with history of hypertension and/or congestive heart failure • Do not give to pregnant women or children • Use with caution with hepatic / renal impairment

28. Antidepressants • Monoamine Oxidase Inhibitors (MAOI’s) • Interactions • Avoid other CNS depressants, including alcohol • Hydrochlorothiazide: increased hypotension • Tyramine, tryptophan: increased risk of hypertensive crisis • TCA’s: hypertension, convulsions, fever • Adrenergics: arrhythmias, hypertension

29. Antidepressants Inhibiting Serotonin Reuptake

30. Antidepressants • Selective Serotonin Reuptake Inhibitors (SSRI’s) • Widespread use • Inhibits reuptake of serotonin, thus allowing more serotonin to travel across neurons • Examples • Fluoxetine (Prozac) • Paroxetine (Paxil) • Sertraline (Zoloft)

31. Antidepressants • Selective Serotonin Reuptake Inhibitors (SSRI’s) • Uses • Depressive episodes • Obsessive – compulsion disorder • Bulemia nervosa • Unlabelled uses: menstrual disorders, post traumatic stress disorder (PTSD), phobias • Therapeutic Effect: 2-4 weeks

32. Antidepressants • Selective Serotonin Reuptake Inhibitors (SSRI’s) • Side Effects • Somnolence, insomnia, dizziness • Headache, tremors, weakness • Constipation, dry mouth, nausea • Pharyngitis, rhinitis • Loss of libido, erectile dysfunction • Serotonin syndrome

33. Antidepressants • Selective Serotonin Reuptake Inhibitors (SSRI’s) • Serotonin Syndrome (increased levels of serotonin) • Increased metabolism (diarrhea, vomiting, fever) • Increased cardiovascular (tachycardia, hypertension) • Increased neuromuscular (agitation, ataxia, muscle spasms)

34. Antidepressants • Selective Serotonin Reuptake Inhibitors (SSRI’s) • Contraindications and Precautions • Use with caution in patients with cardiac history • Use with caution in patients with diabetes • Do not give until two weeks after stopping MAOI • Best given in morning • Use with caution with hepatic / renal impairment • Monitor closely for serotonin syndrome during first two weeks of therapy or dosage increase

35. Antidepressants • Selective Serotonin Reuptake Inhibitors (SSRI’s) • Interactions • Avoid other CNS depressants, including alcohol • Other antidepressants: increased toxic effects • Cimetidine (Tagamet): increased anticholinergic effects • Aspirin, NSAID’s: increased risk of GI bleeding • Lithium: increased risk of lithium toxicity

36. Antidepressants • Miscellaneous • Brupropion HCl (Wellbutrin): often used for smoking cessation as well as depression • Duloxetine HCl (Cymbalta): often used for diabetic neuropathy discomfort as well as depression

37. Drugs Used in Mental Health Antipsychotic Drugs

38. Antipsychotic Drugs • Psychosis – affects mood and behavior • Characterized by hallucinations and / or delusions

39. Antipsychotic Drugs Common Uses • Acute and chronic psychoses • Bipolar illness (manic phase) • Agitated behaviors associated with dementia

40. Antipsychotic Drugs Common Medications • Aripiprazole (Abilify) • Haloperidol (Haldol) • Risperidone (Risperdal) • Lithium

41. Antipsychotic Drugs Side Effects / Adverse Reactions • Drowsiness / headache • Dry mouth / constipation • Photophobia / photosensitivity • Extrapyramidal symptoms • Tardive dyskinesia • Neuroleptic malignant syndrome

42. Antipsychotic Drugs Lithium Toxicity • High levels of lithium toxic to body • Medication titrated based upon blood levels • Antacids: decreased effectiveness of lithium • Loop diuretics: increased risk for lithium toxicity

43. Psychotropics: Patient Teaching • Take as directed • Do not discontinue abruptly • Avoid hazardous activity • Advise physician of all OTC medications and supplements • Do not drink alcohol • Mouth care, hard candies, sugarless gum for dry mouth • Fluids and fiber to prevent constipation

44. Psychotropics: General Nursing Considerations • Make sure they are swallowed, not pocketed • Concern with suicide-may hoard • Clients/patients may induce vomiting if paranoid • Need to continue counseling even after beginning to feel better • Avoid driving and operating machinery • Most very sedating in the beginning • Elderly usually require lower doses • Postural hypotension common side effect with many

45. Psychotropics: General Nursing Considerations • None of the antidepressants should be administered with herbal preparations containing St. John’s wort due to potential for adverse reactions • Read side effects for each particular antidepressants; some require a waiting period before switching to another anti-depressant (example-MAOIs must be discontinued 2 weeks before administration of SSRIs)