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CHAPTER 17
Psychotherapeutic Drugs
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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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Psychotherapeutic Drugs (cont’d)
Three main emotional and mental disorders:
 Anxiety
 Affective disorders
 Psychoses
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Psychotherapeutic Drugs (cont’d)

Types of psychotherapeutic drugs

Antianxiety drugs
 Antimanic drugs
 Antidepressant drugs

Antipsychotic drugs
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Biochemical Imbalance

Other biochemicals are necessary for normal
mental function



GABA
Acetylcholine (ACh)
Sodium, potassium, magnesium
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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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Anxiety Disorders
Six major anxiety disorders (persistent anxiety)






Obsessive-compulsive disorder (OCD)
Posttraumatic stress disorder (PTSD)
Generalized anxiety disorder (GAD)
Panic disorder
Social phobia
Simple phobia
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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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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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Psychotherapeutics:
Pathophysiology

Biochemical imbalance theory

Mental disorders are associated with
abnormal levels of endogenous chemicals,
such as neurotransmitters, in the brain
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Psychotherapeutics:
Pathophysiology
Biochemical imbalance theory (cont’d)


Brain levels of certain neurotransmitters play an
important role in maintaining mental health
Catecholamines



Dopamine
Norepinephrine
Indolamines


Serotonin
Histamine
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Antianxiety 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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Antianxiety Drugs (cont’d)

Barbiturates and carbamates


Previously used to treat anxiety
Replaced by newer drugs
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Antianxiety Drugs: Indications
Anxiety
 Insomnia
 Sedation
 Muscle spasms
 Seizure disorders
 Adjuncts in anesthesia
 Adjuvant therapy for depression
 Alcohol (ethanol) withdrawal

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Common Benzodiazepines
diazepam (Valium)
 lorazepam (Ativan)
 alprazolam (Xanax)
 clonazepam (Klonopin)
 chlordiazepoxide (Librium)

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Common Benzodiazepines
(cont’d)

Midazolam (Versed)*


Reduces anxiety and patient’s memory of painful
procedures that do not require general anesthesia
(moderate sedation)
Injection only
*Limited to use as sedative and anesthetic during invasive medical or
surgical procedures
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Benzodiazepines


Potentially habit-forming and addictive
Should be used at lowest effective dosages
and frequencies needed for symptom control
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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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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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Affective Disorder Drugs

Mood stabilizers


Used to treat bipolar disorder
• Involves cycles of mania, hypomania, and depression
Antidepressants

Used to treat depression
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Mood Stabilizers:
Antimanic Drugs
Lithium is the drug of choice for the treatment
of mania
It is thought to potentiate serotonergic
neurotransmission
 May be used with other medications to stabilize
mood
 Narrow therapeutic range: maintenance serum
levels should range between 0.6 and 1.2 mEq/L
 Monitor sodium levels

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Depression
Etiology

Biogenic amine hypothesis

Depression and mania are caused by an alteration
in neuronal and synaptic catecholamine
concentration at adrenergic receptor sites in the
brain
• Depression: deficiency of catecholamine, especially
norepinephrine
• Mania: excess amines
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Depression (cont’d)
Etiology (cont’d)

Permissive hypothesis

Affective disorders are caused by decreased
concentrations of serotonin
• Depression results from decreases in both serotonin and
catecholamine levels
• Mania results from increased catecholamine but
decreased serotonin levels
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Depression (cont’d)
Etiology

Dysregulation hypothesis

Depression and other affective disorders result
from a failure in the regulation of catecholamine
activity
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Antidepressants



Tricyclic antidepressants
Monoamine oxidase inhibitors (MAOIs)
Newer-generation antidepressants


Selective serotonin reuptake inhibitors (SSRIs)
Second- and third-generation antidepressants
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Tricyclic Antidepressants:
First-Generation Antidepressants


Have largely been replaced by SSRIs as
first-line antidepressant drugs
Considered second-line


For patients who fail with SSRIs or other newergeneration antidepressants
As adjunct therapy with newer-generation
antidepressants
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Common Tricyclics






amitriptyline (Elavil, Endep)
doxepin (Sinequan)
imipramine (Tofranil)
desipramine (Norpramin)
nortriptyline (Aventyl, Pamelor)
Others
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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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Drug Effects

Blockade of norepinephrine reuptake


Antidepressant,* tremors, tachycardia, others
Blockade of serotonin reuptake

Antidepressant,* nausea, headache, anxiety,
sexual dysfunction
*Desired therapeutic effects
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Indications




Depression
Childhood enuresis (imipramine)
Obsessive-compulsive disorders
(clomipramine)
Adjunctive analgesics for chronic pain
conditions, such as trigeminal neuralgia
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Adverse Effects





Sedation
Impotence
Orthostatic hypotension
Others
Older patients

Dizziness, postural hypotension, constipation,
delayed micturation, edema, muscle tremors
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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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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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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)

Examples


phenelzine (Nardil)
tranylcypromine (Parnate)
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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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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

Gastric lavage

Urine acidification

Hemodialysis
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Hypertensive Crisis
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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MAOIs


Concurrent use of MAOIs and SSRIs may
lead to serotonin syndrome
If the decision is made to switch to an SSRI,
there must be a 2- to 5-week “wash-out”
period between MAOI therapy and SSRI
therapy
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Newer-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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Newer-Generation
Antidepressants (cont’d)



trazodone (Desyrel)
bupropion (Wellbutrin)
SSRIs






fluoxetine (Prozac)
paroxetine (Paxil)
sertraline (Zoloft)
fluvoxamine (Luvox)
citalopram (Celexa)
escitalopram (Lexapro)
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Newer-Generation
Antidepressants (cont’d)

venlafaxine (Effexor)

nefazodone (Serzone)

mirtazapine (Remeron)

duloxetine (Cymbalta)

desvenlafaxine (Pristiq)
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SSRIs

Mechanism of action




Selectively inhibit serotonin reuptake
Little or no effect on norepinephrine or dopamine
reuptake
Result in increased serotonin concentrations at
nerve endings
Advantage over tricyclics and MAOIs: little or
no effect on cardiovascular system
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Newer-Generation
Antidepressants: Indications

Depression

Bipolar disorder

Obesity

Eating disorders

Obsessive-compulsive disorder
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Newer-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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Newer-Generation
Antidepressants: Adverse Effects
Body System
Effects
CNS
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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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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Newer-Generation
Antidepressants: Drug
Interactions




Highly bound to plasma proteins
Compete with other protein-binding drugs,
resulting in more free, unbound drug to cause
a more pronounced drug effect
Inhibition of cytochrome P-450 system
MAOIs
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Antipsychotics

Drugs used to treat serious mental illness


Behavioral problems or psychotic disorders
Have been known as tranquilizers or
neuroleptics
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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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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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Atypical Antipsychotics:
Second-Generation
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 (5HT2) receptors

This is responsible for their improved efficacy and
safety profiles
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Antipsychotics: Indications

Treatment of serious mental illnesses


Bipolar affective disorder
Depressive and drug-induced psychoses
Schizophrenia

Autism



Movement disorders (such as Tourette’s
syndrome)
Some medical conditions

Nausea, intractable hiccups
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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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Adverse Effects (cont’d)
Body System
GI
Adverse Effects
Dry mouth, constipation
GU
Urinary hesitancy or
retention, impaired
erection
Hematologic
Leukopenia and
agranulocytosis
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Adverse Effects (cont’d)
Body System
Metabolic/endocrine
Adverse Effects
Galactorrhea,
irregular menses,
increased appetite,
polydipsia
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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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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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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 tyraminecontaining foods
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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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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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Psychotherapeutic Drugs:
Nursing Implications (cont’d)



Assess for possible contraindications to
therapy, cautious use, and potential drug
interactions
Assess for LOC, 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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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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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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Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Antianxiety drugs

In elderly patients, monitor closely for
oversedation and profound CNS depression
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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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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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)

Antidepressants (cont’d)


Caffeine and cigarette smoking may decrease
effectiveness of medication therapy
Instruct patients and family regarding tyraminecontaining foods and signs and symptoms of
hypertensive crisis
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
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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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
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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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
75
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
76
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
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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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
78
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
79
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
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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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
81