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Use as study guide if needed 1 Medications Commonly Prescribed in Psychiatric / Mental Health Settings ANXIOLYTIC AGENTS alprazolam (Xanax) buspirone (BuSpar) chlordiazepoxide (Librium) clorazepate (Tranxene) diazepam (Valium) lorazepam (Ativan) ANTICONVULSANTS clonazepam (Klonopin) carbamazepine (Tegretol) divalproex sodium (Depakote) gabapentin (Neurontin) valproic acid (Depakene) ANTIDEPRESSANTS amitriptyline (Elavil) citalopram (Celexa) desipramine (Norpramine) escitalopram oxalate (Lexapro) fluoxetine (Prozac) fluvoxamine (Luvox) imipramine (Tofranil) nefazodone (Serzone) paroxetine (Paxil) phenelzine (Nardil) sertraline (Zoloft) trazodone (Desyrel) venlafaxine (Effexor) usually used for sedating effect as a mood stabilizing agent as a mood stabilizing agent as a mood stabilizing agent as a mood stabilizing agent SSRI (selective serotonin reuptake inhibitor) SSRI SSRI SSRI SSRI SSRI MOOD STABILIZING AGENTS lithium carbonate / citrate ANTIPARKINSONIAN AGENTS benztropine mesylate (Cogentin) diphenhydramine (Benadryl) trihexyphenidyl (Artane) ANTIPSYCHOTICS aripiprazole (Abilify)* chlorpromazine (Thorazine) clozapine (Clozaril)* fluphenazine (Prolixin) haloperidol (Haldol) STIMULANT AGENTS methylphenidate (Ritalin) pemoline (Cylert) 2 olanzapine (Zyprexa)* quetiapine (Seroquel)* risperidone (Risperdal)* thioridazine (Mellaril) thiothixene (Navane) ziprasidone (Geodon) *ATYPICAL ANTIPSYCHOTICS Role of Drugs in Psychiatric Care I. Assumptions A. Not a "cure" B. Used to alleviate symptoms and therefore allow individual to participate more easily in other forms of treatment II. Seven major drug groups A. Major Tranquilizers ( also known as neuroleptics, ataractics, antipsychotics, or phenothiazines) B. Minor Tranquilizers (also known as anti-anxiety or anxiolytic agents) C. Antidepressants (also known as psychostimulants, or psychic-energizers) D. Lithium (also known as antimanic or a mood stabilizer) E. Antiparkinson Agents F. Anticonvulsants (used as mood stabilizers) G. Stimulants (usually used for attention deficit disorders) III. Major Tranquilizers - the "Antipsychotic agents" See previous page A. Characteristics: 1. Have an antipsychotic activity calm aggressive, overactive, highly disturbed people 2. Do not produce deep coma and anesthesia even with large doses 3. Are not addictive, either psychologically or physically 4. Produce extrapyramidal side effects (may be reversible or irreversible) Notes: Clozapine and olanzapine infrequently cause EPS and perhaps never tardive dyskinesia Weekly blood work must be performed on individuals taking clozapine to monitor for agranulocytosis B. Side effects: Will be marked variation in sensitivity from person to person. 1. Oversedation: a. Phenothiazines act like local anesthetics on sensory nerve endings, clouding out stimuli b. Most individuals will feel groggy the first few days when taking medication c. Usually disappears in one week 2. Extra-pyramidal effects (EPS) Four general types 3 a. Pseudo-parkinsonism Tremor - "pill-rolling" of fingers, especially first and thumb Mask-like facial expression Rigidity (esp. "lead-pipe" and "cog-wheel "types) Drooling Shuffling gait b. Akathisia Most prevalent EPS & most common side effect to cause individualsto discontinue medication Motor, inner-driven restlessness The “jitters,” “fidgety,” or “inner itch” Tapping feet incessantly, “restless legs” Shifting weight from side to side Rocking forward and backward in chair Ask if “muscle” or “head” feeling; head feeling more likely to be anxiety c. Akinesia Lack of spontaneous gestures or voluntary useful movements Apathy Rigid posture Diminished or total lack of conversation Decreased arm swing Feelings of fatigue and weakness, especially legs d. Dystonic reactions Onset is usually sudden, symptoms may come and go and are usually distressing to individual Acute contractions of tongue, face, neck, &/or back; may describe stiff, thick tongue Tongue, jaw and neck spasms are first to erupt - few hours to days Other symptoms Opisthotonos - tightening of entire body, head back, and belly up Oculogyric crisis - eyes locked upward Laryngospasm - can have breathing difficulties Torticollis - twisting of cervical muscles, unnatural head position Voluntary control does not mean individual faking More common with mania than with schizophrenia Prophylactic anticholinergics often prescribed with high-potency neuroleptics, especially in males < 30 years and females < 25 years NOTE: All of the above extra-pyramidal symptoms might be controlled by the use of antiparkinson medications or by lowering dosage, or by changing drug classification. 3. Tardive Dyskinesia (TD) - most serious side effect of long-term use of neuroleptics 4 Arises after 3-6 months of treatment a. May appear when antipsychotic lowered or stopped b. May be irreversible c. Three major types of symptoms Facial-lingual-oral involuntary hyperkinesis (most common) Limb choreoathetoid movements Trunk movements See AIMS Scale must complete test in clinical rotation 1-4 4. Anticholinergic effects on the autonomic nervous system. Most decrease in weeks but don’t completely remit Hypotension Dry mouth Constipation Paralytic ileus Urinary hesitancy or retention Blurred near vision Dry eyes Narrow angle glaucoma Photophobia Nasal congestion Confusion and decreased memory 5. Endocrine effects: Breast enlargement and tenderness Galactorrhea Diminished libido Amenorrhea, menstrual irregularities, delayed ovulation Increase breast cancer growth 6. Skin, Allergies and Temperature Effects Photosensitivity - Chlorpromazine (Thorazine) highest; may have severe sunburn after 30-60 minutes of direct sunlight Skin rashes Hyperthermia more common than hypothermia Decreased sweating 7. Other types of side effects: Decrease the convulsive threshold - persons with seizure disorders are more likely to have seizures 5 Antiemetic drugs (e.g. Compazine) Potentiate alcohol barbiturates, and analgesics - individual should be cautioned Neuroleptic Malignant Syndrome -Can be fatal Characterized by severe muscle rigidity, hyperthermia, stupor, elevated CPK IV. Minor Tranquilizers - the "Anti-anxiety agents" or “anxiolytic agents” (See list of Medications Commonly Prescribed) A. Characteristics 1. Used to treat: Generalized anxiety disorders Acute panic disorders To augment treatment in bipolar disorder, especially during the manic phase 2. Tolerance can develop and physical addiction can result from use; HIGH POTENTIAL FOR ABUSE 3. Most have strong muscle relaxing effect 4. Strong sedative effect with decreased mental alertness. Side effects: Drowsiness Dizziness Dry mouth Headache 5. Larger doses may cause slurred speech, ataxia, mental confusion 6. Sometimes may cause paradoxical reactions of excitement or rage 7. May cause withdrawal symptoms if stopped abruptly after prolonged use: Tremors Muscle twitching Vomiting Confusional states Convulsions 8. Buspirone differs from benzodiazepines: Lacks anticonvulsant, sedative, or muscle relaxant properties Not effective in panic disorder or acute anxiety Used for generalized anxiety disorders Not known to develop drug dependency One to 2 week onset IV. V. Anti-Depressants A. Characteristics 1. Are used in the treatment of depressive states 2. Create an energy producing action that results in Elevation of mood Increased physical activity and mental alertness Improved appetite and sleep patterns Reduction in preoccupations and delusions 6 3. Typically require 10 -14 days on a therapeutic dose to start working and full effect may take 6 weeks 4. Four types of drugs in this classification: Tricyclics (TCAs) Monoamine oxidase inhibitors (MAOIs) Selective serotonin reuptake inhibitors (SSRIs) Atypical (bupropion, nefazodone, trazodone, venlafaxine) *Look up individual medications 5. Overall, all yield same improvement rates 6. Danger of suicide is highest when antidepressants first begin to work.Be aware and monitor individual’s closely B. Tricyclic Antidepressants 1. Much more anticholinergic than neuroleptics (see above list of SEs) 2. Contraindicated in individuals with history of cardiovascular problems, hypertension and acute myocardial infarction 3. Potentiate the effects of alcohol 4. Do not provoke dependence, tolerance or addiction but may have a Flu-like withdrawal syndrome 5. High risk of mortality with overdose C. MAO Inhibitors (MAOIs) 1. Potentiate alcohol, barbiturates, and sedatives - incompatible with insulin, Cogentin, diuretics, phenothiazines, tricyclic antidepressants 2. Must wait 10 days after taking MOA drugs to use these other drags 3. Main problem is danger of Hypertensive Crisis with subsequent intracranial hemorrhage and possible death 4. Onset of Hypertensive Crisis is signaled by headache (either generalized or occipital) Diaphoreses Increased restlessness Nausea and vomiting Muscle twitching. 5. To avoid hypertensive crisis the individual must not eat anything containing pressor amines Six - 8 mg of tyramine usually needed to precipitate crisis Four major food groups: Aged cheeses Air-dried sausages Fava pods (beans are okay, pod contains dopamine) Sauerkraut Tap and microbrewery beers Chianti wine Concentrated yeast extracts - powdered protein diet supplements Pickled herring Chinese foods 7 Phenylalanine No longer at risk: Chocolate Figs, raisins, overripe fruit avocados, bananas (not skin) < 3 oz. red or white wine Bottled or canned US or Canadian beer (< 4 servings) Many drug interactions, always check D. Selective Serotonin Reuptake Inhibitors (SSRIs) 1. Chemically unrelated to and have fewer side effects than other antidepressants 2. Most common side effects (always check individual medication) Headache Nausea, vomiting, diarrhea Nervousness Sleep disturbance Sexual dysfunction 3. Also used to treat other disorders such as Eating disorders Obsessive-compulsive disorders Tourette’s syndrome Social phobia 4. Powerful serotonergic effects are potentiated when tryptophan or lithium concurrently prescribed. Watch for: Nausea Headache Diarrhea Ataxia Seizures Agitation VI. Lithium A. Characteristics 1. Lithium salts prevent and treat manic and depressive swings in bipolar disorders 2. Drugs modulating “highs” and “lows” are called “mood stabilizers.” Mood stabilizers are lithium and some anticonvulsants 3. Lithium aborts 60-80% of acute manic and hypomanic episodes in 10-21 days. 4. Therapeutic and toxic blood plasma levels are close. Extreme plasma level range is 0.5-1.5 mEq/L. Monitor closely when level > 1.0 mEq/L 5. Maximum daily dose is usually 1800 mg. in divided doses B. Side Effects 1. Most common at beginning of treatment Hand tremor Dyspepsia 8 Diarrhea Polyuria and/or polydipsia 2. Most common in later treatment Weight gain Polyuria Thirst Edema Hair loss Acne 20% of lithium individual develop thyroid abnormalities 3. Contraindicated in: Renal disease Cardiovascular disease Febrile conditions Pregnancy 4. Signs of developing toxicity: increasing Sluggishness and lethargy Fine tremor or muscle twitching Ataxia Nausea, vomiting, and diarrhea. 5. Severe toxicity includes: Excessive thirst with polyuria Gradual development of coma Seizures Can lead to death C. Nursing Concerns 1. Follow mental status carefully 2. Individuals started on lithium that are already on salt-restricted diets or diuretics 3. Individuals already on lithium who are started on a diuretic, salt-restricted diet or vigorous exercise program 4. The ability to excrete lithium dwindles with age, use reduce doses in the elderly Note: The individual on lithium must maintain an adequate sodium intake along with adequate fluid intake. In the absence of sufficient sodium in diet or with conditions that deplete sodium, the individual will become rapidly toxic. VII. Anticonvulsants A. Carbamazepine, valproic acid, gabapentin and clonazepam are anticonvulsants that treat the symptoms and prevent the recurrence of bipolar disorders, especially mania B. Carbamazepine is structurally similar to the TCA imipramine and should be monitored for the same side effects C. Carbamazepine and valproic acid may cause massive hepatic cellular necrosis. Baseline and regular hepatic function tests are essential 9 D. Clonazepam is a benzodiazepine is also classified a an anti-anxiety agent E. 20-30% of bipolar individuals do not respond to or tolerate lithium. F. Carbamazepine and valproic acid efficacy is 55-76% Can be prescribed with lithium but carbamazepine often triggers confusion Synergistic therapeutic and toxic effects are often seen Toxic effects can be seen when each medication is in the “normal” serum range. Petechiae, bruising, hemorrhage, nose bleeds, and anemia may occasionally occur on valproic acid. Avoid concurrent aspirin or blood thinners VIII. Antiparkinson agents A. Used primarily to treat and prevent side effects of the major tranquilizers B. Effects: Inhibits the contraction of smooth muscle Increases cardiac rate and conduction irritability Decrease in body secretions such as gastric, salivary, perspiration Pupillary dilatation C. Problem Side Effects: Constipation Urinary hesitancy and urinary retention Impotence Tachycardia Palpitations Dizziness Nervousness Blurred vision Photo-phobia ( light will bother eyes) Dryness of mouth Inability to sweat with resultant hyperthermia Serotonin Syndrome Because of possible side effects, many individuals will not be started on these drugs until extra-pyramidal symptoms develop Neuroleptic Malignant Syndrome Neuroleptic Malignant Syndrome (NMS) is a rare, underdiagnosed, and potentially fatal complication of neuroleptic treatment. Syndrome is not highly correlated with dosage and is considered to be an idiosyncratic reaction to neuroleptics. It may develop within hours, or even after. years of continued drug exposure. Underlying pathophysiology is not well understood. Syndrome is most commonly seen in individuals who are: Male (two to one ratio) Under 20 or over 60 years old Dehydrated Taking lithium Receiving decanoate injections Being prescribed rapid neuroleptization 10 Prescribed high neuroleptic dosages Mentally retarded, drug addicted or have CNS syndromes Anemic with low serum iron Exposed to high ambient temperatures Taking 2 or more neuroleptics Signs and Symptoms: The development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication Two or more of the item labeled * below (not accounted for by other conditions) Severe parknsonism with Muscle rigidity, catatonic appearance Tremors *, dyskinesias “Lead-pipe” muscle tone Flexor-extensor posturing Hyprerpyrexia (101˚ 107˚ F) Altered consciousness Alert look Dazed mutism * Agitated, confused, or comatose * Obtunded *, or incontinent * Autonomic dysfunction with Tachycardia (>130 beads/minute) * Increased BP (>20 pts diastolic) or labile * Profuse sweating *, more salivation Tachypnea (>25 respriations/minute) Pallor Dysphagia * Severe abnormalities on laboratory tests Evidence of severe muscle damage with high creatine phosphokinase (CPK 347-4286 U/ml) or myoglobinuria * Renal decline or failure Raised WBCs (15,000-30,000/mm) * Often elevated LFTs Mortality is estimated 15% to 30%. Death most often results from respiratory failure (especially laryngospasm) or kidney failure. Symptoms may mimic functional catatonia, heat stroke, and CNS infection Nursing Care: 1. Most important measure is recognition of the syndrome and stopping neuroleptics immediately. 2. No specific treatment, the nursing care is supportive. Areas of nursing concern will be: Potential for injury Impairment of physical mobility (may need eye patches and 11 3. 4. 5. 6. 7. 8. 9. lubricants) Monitoring and maintenance of fluid balance Monitoring and maintenance of respiratory status Emotional support Maintain hydration by oral or IV routes Correct electrolyte abnormalities Use antipyretic agents Cool body to reduce fever Keep room temperatures cool Monitor temperature and other vital signs frequently Check WBC and CPK regularly 沊Major Tranquilizers Side Effects Assessment (side effect or discomfort) Nursing intervention Blurred vision Reassurance (generally subsides in 2-6 weeks) Dry mouth Frequent rinsing of mouth Lozenges Constipation Mild laxative Roughage in diet Exercises Fluids Nasal congestion Nose drops Moisturizer. Decreased libido and inhibition of ejaculation Prepare individual for effect. Reassurance (reversible) Ask physician about change to less antiadrenergic drug Postural hypotension Frequent monitoring of blood pressure during dosage adjustment period Advise individual to get up slowly. Elastic stockings if necessary 12 Photosensitivity Protective clothing Dark glasses Use of sunscreen Dermatitis Stop medication Request physician to change order and prescribe systemic antihistamine Initiate comfort measures Impaired psychomotor functions Advise individual to avoid dangerous tasks Drowsiness Give single daily dose at bedtime Weight gain Caloric control; exercise-diet teaching Edema Reassurance Request physician to prescribe diuretic Irregular menstruation and decreased sex drive Reassurance (reversible) Have physician change class of drugs Amennorhea Reassurance and counseling (does not indicate lack of ovulation) Instruct individual to continue birth control 13 ABNORMAL INVOLUNTARY MOVEMENT SCALE: AIMS Ratings are done on Likert type scale from 1- 5. 1 = None 2= Minimal 3 = Mild 4 = Moderate 5= Severe FACIAL AND ORAL MOVEMENTS: 1. Muscles of Facial Expression e.g., movements of forehead, eyebrows, periorbital area, cheeks; include frowning, blinking, smiling, grimacing 12345 2.. Lips and Perioral Area e.g.. puckering. pouting, smacking 12345 3. Jaw e.g., biting, clenching. chewing, mouth opening. lateral movement 12345 4. Tongue Rate only increase in movement both in and out of mouth, NOT inability to sustain movement 12345 5. Upper (arms, wrists, hands, fingers) Include choreic movements, (i.e., rapid, objectively purposeless. Irregular, spontaneous), athetoid movements (i.e., slow, irregular, complex, serpentine). Do NOT include tremor (i.e., repetitive, regular, rhythmic) 12345 6. Lower (legs, knees, ankles, toes) e.g., lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot 12345 7. Neck, shoulders, hips e.g., rocking, twisting, squirming, pelvic gyrations 12345 8. Severity of abnormal movements 12345 9. Incapacitation due to abnormal movements 12345 10. Individual's awareness of abnormal movements Rate only individual’s report 12345 11. no Current problems with teeth and/or dentures yes 12. no Does individual usually wear dentures? yes EXTREMITY MOVEMENTS: TRUNK MOVEMENTS: GLOBAL JUDGMENTS: DENTAL STATUS: 14 EXAMINATION PROCEDURE Either before or after completing the Examination Procedure observe the individual unobtrusively, at rest (e.g., in waiting room). The chair to be used in this examination should be a hard, firm one without arms. 1. Ask individual to remove shoes and socks. 2. Ask individual whether there is anything in his/her mouth (i.e.. gum, candy, etc.) and if there is, to remove it. 3. Ask individual about the current condition of his/her teeth. Ask individual if he/she wears dentures. Do teeth or dentures bother individual now? 4. Ask individual whether he/she notices any movements in mouth, face, hands, or feet. If yes, ask to describe and to what extent they currently bother individual or interfere with his/her activities. 5. Have individual sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at entire body for movements while in this position.) 6. Ask individual to sit with hands hanging unsupported. If male, between legs, if female and wearing a dress, hanging over knees. (Observe hands and other body areas.) 7. Ask individual to open mouth. (Observe tongue at rest within mouth.) Do this twice. 8. Ask individual to protrude tongue. (Observe abnormalities of tongue movement .) Do this twice. 9. Ask individual to tap thumb, with each finger, as rapidly as possible for 10-15 seconds; separately with right hand, then with left hand. (Observe facial and leg movements.) 10. Flex and extend individual's left and right arms (one at a time). (Note any rigidity.) 11. Ask individual to stand up. (Observe in profile. Observe all body areas again. hips included 12. Ask individual to extend both arms outstretched in front with palms down. (Observe trunk, legs, and mouth.) 13. Have individual walk a few paces, turn, and walk back to chair. (Observe hands and gait.) Do this twice. 15 16