Psychopharmacological Therapies & Nursing Implications

1. Psychopharmacological Therapies & Nursing Implications Antianxiety agents Antidepressant Agents Mood stabilizers Antipsychotic agents

2. Psychotropic medications & usage

3. Anxiolytics- Antianxiety agents Used for treatment of anxiety disorders – • Panic disorder (++++ efficacy) • Generalized Anxiety Disorder (GAD) (++++ efficacy) • Obsessive-Compulsive Disorder (OCD) (+ efficacy) • Posttraumatic Stress Disorder (PTSD) (+ efficacy) • Simple Phobias • Social Phobias

4. Benzodiazepines Action – CNS depressants • Depress activity in the brain stem and limbicsystem • Increase action of gamma-aminobutyric acid GABA (inhibitory neurotransmitter) thus inhibiting nerve transmission is the CNS • Benzo’s bind with receptor proteins> effects of sedation/muscle relaxation.

5. Benzodiazepines (CNS depressants) Alprazolam(Xanex) Lorazepam(Ativan) Clonazepam(Klonopin) Diazepam(Valium) Oxazepam (Serax) Do not give with other CNS depressants Use cautiously in elderly Monitor for physical & psychological dependence with long term use Monitor confusion, memory impairment & motor coordination- ataxic gait Decreased effects with cigarettes/caffeine Anxiolytics –Nursing implications

6. Hypnotic-sleep agents Temazepam(restoril) Triazolam(halcion) Flurazepam ( Dalmane) Chlordiazepoxide (Librium) Diazepam(Valium) Nonbenzodiazepine Buspirone(Buspar) Monitor drowsiness, sedation the day following use “hangover effect” Elderly have more difficulty with side effects i.e. confusion, unsteady gait, urinary incontinence. Assess for nausea, headache, dizziness Not for immediate relief Benzodiazepines -

7. Anti-convulsants-Mood stabilizers Used for treatment of manic episodes and Bipolar disorder

8. Valproic Acid(Depakote) etc. Carbamazepine (Tegretol) Check liver functions (at start & q 6 mos.) Can cause hepatic failure/life threatening pancreatitis Can cause aplastic anemia & agranulocytosis (5-8x’s greater than population) Mood stabilizer --Nursing Implications

9. Lamotrigine (Lamictal) (3rd generation anti-convulsant) Topiramate(Topamax) Gabapentin (Neurontin) Oxcarbazepine (Trileptal) Can cause serious rashes > in children; eg. Stevens-Johnson syndrome (severe form of erythemia multiforme) Common side effects of all mood stabilizers: Dizziness, hypotension, ataxia- Monitor gait, & B/P ;give w/food; Pt. teaching re: s/e’s Mood stabilizer --Nursing Implications

10. SSRI’s: Fluoxetine(Prozac) give in AM Sertaline (Zoloft) give in PM if drowsy Paroxetine (Paxil) give in PM if drowsy Citalopram(Celexa) Escitalopram (Lexapro) Fluvoxamine (Luvox) Monitor for: Hyponatremia/sexual dysfunction; orthostatic B/P Give w/food;encourage adequate fluids Antidepressant –---Nursing Implications

11. Selective Serotonin Reuptake Inhihibitor’s

12. Atypical Antidepressant Actions Mirtazapine(Remeron) – • promotes presynaptic release of two neurotransmitters(norepinephrie & seratonoin) • No inhibition of neurotransmitters in pre-synaptic or post synaptic reuptake. Bupropion(Wellbutrin); Venlafaxine (Effexor) • Affect all 3 major neurotransmitters – Seratonin, norepinephrine & dopamine.

13. Venlafaxine(Effexor) Duloxetine(Cymbalta) Bupropion(Wellbutrin) Nefazodone(Serzone) Mirtazapine(Remeron) May alter labs: AST ALT, alk phos, Createnine,gluc,lytes; Monitor for inc B/P & HR Can lower seizure threshold; inc. B/P,HR (as above) Check labs:AST,ALT LDH,chol, gluc,Hct Sedation: Give in PM, Monitor wt. gain, Monitor: sex dysfunction, constipation Atypical antidepressants- -Nursing Implications

14. Amitriptyline(elavil) Amoxapine(Asendin) Doxepin(Sinequan) Imipramine(Tofranil) Desipramine(Norpramine) Nortriptyline (Pamelor) Monitor & educate re: cholinergic s/e’s: dry mouth, blurred vision, constipation,Ortho-B/P, **cardiac dysrhythmias/functionlethal in OD *caution use in elderly Tricyclic Antidepressants--Nursing Implications

15. Used in treatment resistant depression Work to increase levels of norepinephrine, seratonin tyramine & dopamine Isocarboxazid (Marplan) Phenelzine (Nardil) Tranlcypromine (Parnate) Educate re: low tyramine diet; *Hypertensive crisis if diet is contains tyramine foods. potentially fatal drug to drug interactions i.e. Meperidine, SSRI’s,TCA’s, Amphetamines *can be lethal in OD MonoamineOxidase Inhibitors-----Nursing Implications

16. CLINICAL USE //EFFICACYAntipsychotic medications • *MOST TOXIC DRUGS USED IN PSYCHIATRY!! • Use lowest possible dose –especially in Geriatric client –start low go slow! • Positive (aggressive symptoms) –most responsive-relieved within hours • Negative( Affective symptoms)- may take up to 2-4 weeks to respond.

17. Use/clinical efficacyAntipsychotic medications con’t • Cognitive/Perceptual symptoms i.e.: hallucinations, delusions, thought broadcasting –2 to 8 weeks to respond • Increasing meds will not hasten relief of slow responding symptoms • Usually start with divided doses (minimizes s/e’s) • Once effective –change to Daily or BID dosing (increases med compliance)

18. Use/clinical efficacyAntipsychotic medications con’t • Absorption– absorbed well in GI tract • Metabolism – metabolized in the liver • Half Life –Adults (20 – 40 hours) • Half Life – Elderly client may be doubled • Adult steady state 4-7 days • Monitor liver functions esp. elderly and physically compromised

19. Use/clinical efficacyAntipsychotic medications con’t • INJECTABLE form– I M use for emergencies only (client imminent danger to self/others) • Simultaneous use of a benzodiazepine may help client to gain control more rapidly ie: combination of Haldol and Ativan • LIQUID form-used when client has hx. of non-compliance or has been suspected of “cheeking” meds.

20. Antipsychotic medications • LONG ACTING INJECTABLE – • Used to increase compliance • Eg. Haldol Decanoate/Prolixin Decanoate • Given monthly or bi-weekly • Half –life Haldol decanoate- 21 days • Half-life for Prolixin decanoate –14 days • Monitor carefully as out patient

21. Extrapyramidal Side Effects- EPS • Serious neurological symptoms that are major side effects of antipsychotic drugs. • Cause: Blockade of D2(dopamine)in midbrain region of the brainstem

22. Symptoms may include: Blepharospasm [eye closing] Torticolis [neck muscle contraction –pulling head to side] Oculogyric Crisis [severe upward deviation of eyeballs] Opisthotonos [severe dorsal arching of neck and back] Larngospasm/involve-ment of tongue [dysphasia- difficulty swallowing] EPS- Acute dystonia

23. EPS –Parkinsonism symptoms • Tremors • Bradykinesia/akinesia [slowness, absence of movement] • Cogwheel rigidity[slow regular muscular jerks] • Postural instability • Stooped/hunched posture • Shuffling gait • Restricted movements • Masked face[loss of mobility in facial muscles] • Hypersalivation &drooling

24. EPS – Akathesia symptoms • AKATHISIA – “not sitting” • Pacing, Motor restlessness,Rocking, Foot taping • Subjective c/o inner restlessness, irritability, inability to sit still or lie down. • Need to differentiate between Akathisia and psychomotor agitation or restlessness

25. A rare but potentially fatal complication of treatment with neuroleptic drugs. Can occur within first 2 weeks of use Increased risk with high dose- high potency drugs, concurrent medical conditions (dehydration, poor nutrition) Assessment – check elevation of-B/P, high fever-(hyperpyrexia), rigidity, diaphoresis, pallor, delirium LABS – elevated CPK (createnine phosphokinase) Neuroleptic Malignant Syndrome

26. Severe Opisthotonos [severe dorsal arching of neck and back] As seen in NMS Neuroleptic Malignant Syndrome

27. TARDIVE DYSKINESIA( late occurring abnormal movements) • Effects 4% of persons taking antipsychotics • Choreoathetoid movements [rapid,jerky and slow,writhing movements] may occur anywhere in the body – arms,feet,legs,trunk • Classic description—oral,buccal, lingual,& masticatory movements[ tongue thrusting,lip pursing & smacking,facial grimaces and chewing movements.