Psychopharmacology

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. ReceptorsMolecules 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 levodopaandguanethidine • 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 • Delirium Agitation • Tachycardia Sweating • Hyperreflexia Muscle spasms • Shivering Coarse tremors More severe cases • Hyperthermia Seizures • Renal failure Rhabdomyolysis • Dysrhythmias DIC

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 • 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 adequatesodium and fluid in diet

39. Tegretol • Depakote/Depakene • 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, tardivedyskinesia, 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