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Chapter 16
Psychotherapeutic Drugs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Psychotherapeutic Drugs

Used in the treatment of emotional and mental
disorders


Ability to cope with emotions can range from
occasional depression or anxiety to constant
emotional distress
When emotions significantly affect an individual’s
ability to carry out normal daily functions, treatment
with a psychotherapeutic drug is a possible option
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2
Psychotherapeutic Drugs (cont’d)

Three main emotional and mental disorders:



Anxiety
Affective disorders
Psychoses
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3
Psychotherapeutic Drugs (cont’d)

Types of psychotherapeutic drugs

Anxiolytic drugs
 Mood-stabilizing drugs
 Antidepressant drugs
 Antipsychotic drugs
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4
Anxiety



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
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5
Anxiety Disorders

Six major anxiety disorders (persistent anxiety)

Obsessive-compulsive disorder (OCD)
 Posttraumatic stress disorder (PTSD)
 Generalized anxiety disorder (GAD)
 Panic disorder
 Social phobia (social anxiety disorder)
 Simple phobia
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6
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)
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7
Psychosis



Severe emotional disorder that impairs the
mental function of the affected individual to the
point that the individual cannot participate in
activities of daily living
Hallmark: loss of contact with reality
Examples


Schizophrenia
Depressive and drug-induced psychoses
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8
Anxiolytic Drugs

Reduce anxiety by reducing overactivity in CNS


Benzodiazepines
• Depress activity in the brainstem and limbic system
Miscellaneous drug: buspirone (BuSpar)
• Nonsedating and non–habit forming
• May have drug interaction with SSRIs (serotonin syndrome)
• Do not administer with MAOIs
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9
Benzodiazepines



alprazolam (Xanax)
diazepam (Valium)
lorazepam (Ativan)
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10
Benzodiazepines: Adverse Effects

Benzodiazepine adverse effects are an
overexpression of their therapeutic effects

Decreased CNS activity, sedation
 Hypotension
 Drowsiness, loss of coordination, dizziness,
headaches
 Nausea, vomiting, dry mouth, constipation
 Others
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11
Benzodiazepines: Overdose



Dangerous when taken with other sedatives or
alcohol
Treatment is generally symptomatic and
supportive
Flumazenil may be used to reverse
benzodiazepine effects
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12
Miscellaneous Anxiolytic

buspirone (BuSpar)



Unknown mechanism of action
Administered on a scheduled basis
Adverse effects
• Paradoxical anxiety
• Blurred vision
• Headache
• Nausea
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13
Mood-Stabilizing Drugs


Lithium carbonate and lithium citrate
Other drugs may be used in combination with
lithium

Benzodiazepines
 Antipsychotic drugs
 Antiepileptic drugs
 Dopamine receptor agonists
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14
Mood-Stabilizing Drugs (cont’d)

Lithium is the drug of choice for the treatment of
mania

It is thought to potentiate serotonergic
neurotransmission
 Narrow therapeutic range: maintenance serum
levels should range between 0.6 and 1.2 mEq/L
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15
Classroom Response Question
Before administering lithium to a patient, it is most
important for the nurse to assess which laboratory
value?
A. Blood sugar
B. Sodium
C. Urine osmolality
D. Hematocrit
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16
Antidepressants



Tricyclic antidepressants
Monoamine oxidase inhibitors (MAOIs)
Second-generation antidepressants



Selective serotonin reuptake inhibitors (SSRIs)
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
Miscellaneous
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17
Tricyclic Antidepressants


Have largely been replaced by SSRIs as firstline antidepressant drugs
Considered second line



For patients who fail with SSRIs or other newergeneration antidepressants
As adjunct therapy with newer-generation
antidepressants
amitriptyline (Elavil)
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Tricyclic Antidepressants:
Mechanism of Action


Block reuptake of neurotransmitters, causing
accumulation at the nerve endings
It is thought that increasing concentrations of
neurotransmitters will correct the abnormally low
levels that lead to depression
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Tricyclic Antidepressants:
Indications




Depression
Childhood enuresis (imipramine)
Obsessive-compulsive disorders (clomipramine)
Adjunctive analgesics for chronic pain
conditions, such as trigeminal neuralgia
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20
Tricyclic Antidepressants:
Adverse Effects





Sedation
Impotence
Orthostatic hypotension
Others
Older patients

Dizziness, postural hypotension, constipation,
delayed micturation, edema, muscle tremors
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21
Tricyclic Antidepressants:
Overdose



Lethal—70% to 80% die before reaching the
hospital
CNS and cardiovascular systems are
mainly affected
Death results from seizures or dysrhythmias
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Tricyclic Antidepressants:
Overdose (cont’d)

No specific antidote

Decrease drug absorption with activated charcoal
 Speed elimination by alkalinizing urine
 Manage seizures and dysrhythmias
 Basic life support
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23
Monoamine Oxidase Inhibitors
(MAOIs)



Highly effective
Considered second-line treatment for
depression, not responsive to cyclics
Disadvantage: potential to cause hypertensive
crisis when taken with tyramine
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MAOIs (cont’d)




isocarboxazid (Marplan)
phenelzine (Nardil)
tranylcypromine (Parnate)
selegiline (Emsam)
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MAOIs: Mechanism of Action



Inhibit the MAO enzyme system in the CNS
Amines (dopamine, serotonin, norepinephrine)
are not broken down, resulting in higher levels in
the brain
Result: alleviation of symptoms of depression
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26
MAOIs: Indications


Depression, especially types characterized by
reverse vegetative symptoms such as increased
sleep and appetite
Depression that does not respond to other drugs
such as tricyclics
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MAOIs: Adverse Effects

Few adverse effects—orthostatic hypotension
most common

Tachycardia
Dizziness
Insomnia
Anorexia
Blurred vision
Palpitations
Drowsiness
Headache
Nausea
Impotence









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MAOIs: Overdose



Symptoms appear 12 hours after ingestion
Tachycardia, circulatory collapse, seizures,
coma
Treatment: protect brain and heart, eliminate
toxin


Urine acidification
Hemodialysis
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29
MAOIs and Tyramine


Ingestion of foods or drinks with tyramine leads
to hypertensive crisis, which may lead to
cerebral hemorrhage, stroke, coma, or death
Avoid foods that contain tyramine!





Aged, mature cheeses (cheddar, blue, Swiss)
Smoked/pickled or aged meats, fish, poultry (herring,
sausage, corned beef, salami, pepperoni, paté)
Yeast extracts
Red wines (Chianti, burgundy, sherry, vermouth)
Italian broad beans (fava beans)
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Second-Generation
Antidepressants




Fewer adverse effects than tricyclics and MAOIs
Very few drug-drug or drug-food interactions
Still take about 4 to 6 weeks to reach maximum
clinical effectiveness
Now considered first-line drugs for depression
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31
Second-Generation
Antidepressants (cont’d)

SSRIs

fluoxetine (Prozac)
 paroxetine (Paxil)
 sertraline (Zoloft)
 fluvoxamine (Luvox)
 citalopram (Celexa)
 escitalopram (Lexapro)
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Second-Generation
Antidepressants (cont’d)

SNRIs




venlafaxine (Effexor)
duloxetine (Cymbalta)
desvenlafaxine (Pristiq)
Miscellaneous




trazodone (Desyrel, Oleptro)
bupropion (Wellbutrin)
nefazodone (Serzone)
mirtazapine (Remeron)
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Second-Generation
Antidepressants: Mechanism of
Action

SSRIs




Selectively inhibit serotonin reuptake
Little or no effect on norepinephrine or dopamine
reuptake
Result in increased serotonin concentrations at nerve
endings
SNRIs

Inhibit reuptake of both serotonin and norepinephrine
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Second-Generation
Antidepressants: Indications





Depression
Bipolar disorder
Obesity
Eating disorders
Obsessive-compulsive disorder
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Second-Generation
Antidepressants: Indications
(cont’d)





Panic attacks or disorders
Social anxiety disorders
Posttraumatic stress disorders (PTSDs)
Myoclonus
Treatment of various substance abuse problems
(bupropion [Zyban] is used for smoking
cessation treatment)
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Second-Generation
Antidepressants: Adverse Effects
Body System
CNS
Effects
Headache, dizziness,
tremor, nervousness,
insomnia*, fatigue
Nausea, diarrhea,
constipation, dry mouth
Sexual dysfunction,
weight gain*, weight
loss*, sweating
GI
Other
*Most common and bothersome
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Classroom Response Question
When patients are taking selective serotonin
reuptake inhibitors (SSRIs) for the first time for
depression, which is most important to monitor for
during the first few weeks of therapy?
A. Hypertensive crisis
B. Suicidal thoughts
C. Convulsions
D. Orthostatic hypotension
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Serotonin Syndrome

Symptoms


Delirium, tachycardia, hyperreflexia, shivering,
agitation, sweating, muscle spasms, coarse tremors
Symptoms of severe cases

Hyperthermia, seizures, renal failure, rhabdomyolysis,
dysrhythmias, disseminated intravascular coagulation
(DIC)
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39
Classroom Response Question
When providing teaching for a patient who is
prescribed a selective serotonin reuptake inhibitor
(SSRI), which statement will the nurse include?
A. The SSRI will work faster than the older tricyclic
antidepressants.
B. The SSRI will have an immediate beneficial effect on
the patient’s depression symptoms.
C. The SSRI will not work well for severe cases of
depression.
D. The SSRI may take several weeks to have a beneficial
effect.
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40
Antipsychotics

Drugs used to treat serious mental illness




Behavioral problems or psychotic disorders
Have been known as tranquilizers or
neuroleptics
Conventional drugs
Atypical antipsychotics
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Antipsychotics (cont’d)






Thioxanthenes: thiothixene (Navane)
Butyrophenones: haloperidol (Haldol)
Dihydroindolones: molindone (Moban)
Dibenzoxazepine: loxapine (Loxitane)
Phenothiazines: three structural groups
Atypical antipsychotics: new class
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Antipsychotics: Mechanism of
Action



Block dopamine receptors in the brain (limbic
system, basal ganglia)—areas associated with
emotion, cognitive function, motor function
Dopamine levels in the CNS are decreased
Result: tranquilizing effect in psychotic patients
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43
Atypical Antipsychotics







clozapine (Clozaril)
risperidone (Risperdal)
olanzapine (Zyprexa)
quetiapine (Seroquel)
ziprasidone (Geodon)
aripiprazole (Abilify)
paliperidone (Invega)
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Atypical Antipsychotics:
Mechanism of Action


Block specific dopamine receptors: dopamine-2
(D2) receptors
Also block specific serotonin receptors:
serotonin 2 (5-HT2) receptors

This is responsible for their improved efficacy and
safety profiles
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45
Antipsychotics: Adverse Effects
Body System
Adverse Effects
CNS
Cardiovascular
Sedation, delirium
Orthostatic hypotension,
syncope, dizziness,
ECG changes
Photosensitivity, skin
rash, hyperpigmentation,
pruritus
Dermatologic
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46
Antipsychotics: Adverse Effects
(cont’d)
Body System
GI
GU
Hematologic
Adverse Effects
Dry mouth, constipation
Urinary hesitancy or
retention, impaired
erection
Leukopenia and
agranulocytosis
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47
Antipsychotics: Adverse Effects
(cont’d)
Body System
Metabolic/endocrine
Adverse Effects
Galactorrhea,
irregular menses,
increased appetite,
polydipsia
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Antipsychotics: Adverse Effects
(cont’d)

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)
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Antipsychotics: Adverse Effects
(cont’d)

Tardive dyskinesia (TD)



Involuntary contractions of oral and facial muscles
Choreoathetosis (wavelike movements of extremities)
Occurs with continuous long-term antipsychotic
therapy
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50
Herbal Products: St. John’s Wort




Used for depression, anxiety, sleep disorders,
nervousness
May cause GI upset, fatigue, dizziness,
confusion, dry mouth, photosensitivity
Severe interactions if taken with MAOIs and
SSRIs; many other drug interactions
Food-drug interaction with tyramine-containing
foods
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51
Herbal Products: Ginseng




Three varieties; has been used for over 5000
years
Uses: stress reduction, improvement of physical
endurance and concentration
May cause elevated BP, chest pain, palpitations,
anxiety, insomnia, headache, GI symptoms
Interactions with anticoagulants,
immunosuppressants, anticonvulsants,
antidiabetic drugs
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52
Psychotherapeutic Drugs:
Nursing Implications



Before beginning therapy, assess physical and
emotional status of patients
Obtain baseline vital signs, including postural BP
readings
Obtain liver and renal function tests
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53
Psychotherapeutic Drugs:
Nursing Implications (cont’d)



Assess for possible contraindications to therapy,
cautious use, and potential drug interactions
Assess for level of consciousness, mental
alertness, potential for injury to self and others
Check the patient’s mouth to make sure
oral doses are swallowed
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54
Psychotherapeutic Drugs:
Nursing Implications (cont’d)



Provide simple explanations about the drug, its
effects, and the length of time before therapeutic
effects can be expected
Advise patients to avoid abrupt withdrawal
Advise patients to change positions slowly to
avoid postural hypotension and possible injury
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55
Psychotherapeutic Drugs:
Nursing Implications (cont’d)



The combination of drug therapy and
psychotherapy is emphasized because patients
need to learn and acquire more effective coping
skills
Only small amounts of medications should be
dispensed at a time to minimize the risk of
suicide attempts
Simultaneous use of these drugs with alcohol or
other CNS depressants can be fatal
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56
Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Antianxiety drugs

In elderly patients, monitor closely for oversedation
and profound CNS depression
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57
Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Antidepressants




Many cautions, contraindications, and interactions
exist pertaining to the use of antidepressants
Inform patients that it may take several weeks to see
therapeutic effects
Monitor patients closely during this time, assess for
suicidal tendencies, and provide support
Assist elderly or weakened patients with ambulation
and other activities because falls may occur because
of drowsiness or postural hypotension
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58
Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Antidepressants (cont’d)



Tricyclics may need to be weaned and discontinued
before undergoing surgery to avoid interactions with
anesthetic drugs
Monitor for adverse effects, and discuss with patients
Encourage patients to wear medication ID badges
naming the drugs being taken
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59
Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Antidepressants (cont’d)


Caffeine and cigarette smoking may decrease
effectiveness of medication therapy
With MAOIs, instruct patients and family regarding
tyramine-containing foods, and signs and symptoms
of hypertensive crisis
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60
Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Antipsychotics—phenothiazines



Instruct patients to wear sunscreen because of
photosensitivity
Tell patients to avoid taking antacids or antidiarrheal
preparations within 1 hour of a dose
Inform patients to avoid alcohol or other CNS
depressants with these medications
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61
Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Antipsychotics—phenothiazines (cont’d)

Long-term haloperidol therapy may result in tremors,
nausea, vomiting, or uncontrollable shaking of small
muscle groups; report these symptoms to the
physician
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Antipsychotics—phenothiazines (cont’d)


Oral forms may be taken with meals to decrease GI
upset
These drugs may cause drowsiness, dizziness, or
fainting; instruct patients to change positions slowly
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63
Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Monitor for therapeutic effects


Monitor mental alertness, cognition, affect, mood,
ability to carry out activities of daily living, appetite,
and sleep patterns
Monitor potential for self-injury during the delay
between the start of therapy and symptomatic
improvement
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64
Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Monitor for therapeutic effects (cont’d)

For anxiolytics
• Improved mental alertness, cognition, and mood
• Fewer anxiety and panic attacks
• Improved sleep patterns and appetite
• Less tension and irritability; fewer feelings of fear, impending
doom, and stress
• More interest in self and others
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65
Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Monitor for therapeutic effects (cont’d)

For antidepressants
• Improved sleep patterns and nutrition
• Increased feelings of self-esteem
• Decreased feelings of hopelessness
• Increased interest in self and appearance
• Increased interest in daily activities
• Fewer depressive manifestations or suicidal
thoughts/ideations
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Monitor for therapeutic effects (cont’d)

For antipsychotics
• Improved mood and affect
• Alleviation of psychotic symptoms and episodes
• Decreased hallucinations, paranoia, delusions, garbled
speech, and inability to cope
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67
Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Monitor for therapeutic effects (cont’d)

For lithium
• Less mania
• Therapeutic lithium levels of 0.6 to 1.2 mEq/L
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68
Case Study
A patient is admitted to the emergency
department. The patient’s heart rate is 112
beats/min; he is sweating, has muscle tremors,
and is agitated. The patient says, “I was depressed
and took more of the pills the doctor gave me so I
would feel better.”
1. What does the nurse suspect is happening with
this patient?
2. What treatment does the nurse expect to
implement?
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69
Case Study (cont’d)
The patient was admitted to the hospital for
observation and has now recovered. Which
information will the nurse include in patient
teaching about SSRIs?
A. It usually takes 4 to 6 weeks until you will experience
benefits from the medication.
B. The patient must avoid foods that contain tyramine.
C. If the patient develops an upset stomach when taking
this medication, he should discontinue use.
D. The patient should take the medication at bedtime to
enhance sleep.
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70
Case Study
Several months later the patient returns to the health care
provider’s office for follow-up regarding use of the SSRI.
The patient tells the nurse that he is feeling better and
stopped taking the SSRI yesterday. He doesn’t plan on
taking the medication again. When talking with the patient,
which knowledge should guide the nurse’s response?
A.
B.
C.
D.
Drug dependency will develop, so it is appropriate to stop therapy
after a few months.
Drug therapy must be stopped as soon as the patient feels better
to avoid serotonin syndrome.
The patient is the best person to determine when the drug therapy
should end.
A 1- to 2-month taper period is indicated to prevent adverse effects
of abrupt drug discontinuation.
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71