Download Historical Perspectives

Psychopharmacology
Eve Karpinski, APHN-BC, RN-BC
Psychotherapeutics
The treatment of emotional
and mental disorders
Mental Health
• Defined as “The successful adaptation to stressors from
the internal or external environment, evidenced by
thoughts, feelings, and behaviors that are ageappropriate 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.
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.
10 Leading Causes of Disability in the
World (WHO, 1997)
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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
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.
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.
Receptors
Molecules situated on the cell
membrane that are binding sites for
neurotransmitters.
Reuptake
The process of neurotransmitter inactivation by
which the neurotransmitter is reabsorbed into the
presynaptic neuron from which it had been
released.
• Antidepressants
– Block reuptake of neurotransmitters
• Antipsychotics
– Block dopamine and other receptors
• Benzodiazepines
– Facilitate transmission of GABA
• Psychostimulants
– Increase release of neurotransmitters
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
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
• 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
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
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
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
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
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)
Antidepressants
• Newer-generation antidepressants
– Selective serotonin reuptake inhibitors (SSRIs)
– Second- and third-generation antidepressants
• Tricyclic antidepressants
• Monoamine oxidase inhibitors (MAOIs)
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)
• 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).
– 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 levodopa and
guanethidine
• Potentiation of pressor response with directacting sympathomimetics
• 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)
• 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
Nursing Diagnosis
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Risk for suicide
Risk for injury
Social isolation
Constipation
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
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
Antidepressants- SSRI
• Generic
Fluoxetine
Paroxetine
Sertraline
Citalopram
Escitalopram
Fluvoxamine
• Brand
Prozac
Paxil
Zoloft
Celexa
Lexapro
Luvox
Serotonin Syndrome
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Delirium
Agitation
Tachycardia
Sweating
Hyperreflexia
Muscle spasms
Shivering
Coarse tremors
More severe cases
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Hyperthermia
Seizures
•
Renal failure
Rhabdomyolysis
•
Dysrhythmias DIC
Antidepressants
• Generic
Bupropion
Mirtzapine
Venlafaxine
Duloxetine
Amitriptyline
Imipramine
Phenelzine
Selegiline
• Brand
Wellbutrin
Remeron
Effexor
Cymbalta
Elavil
Tofranil
Nardil
Emsam
Monoamine Oxidase Inhibitor
• Nardil
• Parnate
• Marplan
• Selegiline*
*Available in a patch form called EMSAM
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
Mood Stabilzers
• Generic
Lithum
Valproic acid
Carbamazepine
Oxcarbazepine
Lamotrigine
Topiramate
• Brand
Eskalith, Lithobid
Depakote, Depakene
Tegretol, Equetro
Trileptal
Lamictal
Topamax
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)
• 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
Nursing Diagnosis
• Risk for injury
• Risk for self-directed or
other-directed violence
• Risk for activity intolerance
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.
• 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 adequate
sodium and fluid in diet
1. Tegretol
2. Depakote/Depakene
3. Valproic Acid
Monitor for side effects of anticonvulsants
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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)
• Monitor for side effects of verapamil
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Drowsiness; dizziness
Hypotension; bradycardia
Nausea
Constipation
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Drowsiness; dizziness
Dry mouth; constipation
Increased appetite; weight gain
ECG changes
Extrapyramidal symptoms
Hyperglycemia and diabetes
• Monitor for side effects of antipsychotics
Planning/Implementation (cont.)
• Educate client and family about the medication
Outcome Criteria/Evaluation
Conventional Antipsychotics
Generic
Haloperidol
Chlorpromazine
Fluphenazine
Thiothixene
Trifluoperazine
Thioridazine
Perphenazine
Loxapine
Brand
Haldol
Thorazine
Prolidixin
Navane
Stelazine
Mellari
Trilafon
Loxitane
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,
tardive dyskinesia, etc.
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)
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
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.
• 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
• 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
Nursing Diagnosis
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•
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Risk for other-directed violence
Risk for injury
Risk for activity intolerance
Noncompliance
• 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
Side effects
• 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)
• Tardive dyskinesia (TD)
– Involuntary contractions of oral and facial muscles
– Choreoathetosis (wavelike movements of extremities)
– Occurs with continuous long-term antipsychotic therapy
• Indications: treatment of parkinsonism of
various causes, including degenerative, toxic,
infective, neoplastic, or drug-induced
• Action: work to restore the natural balance of
acetylcholine and dopamine in the CNS
• Contraindications/precautions
– Contraindicated in known hypersensitivity; angleclosure glaucoma; pyloric, duodenal, or bladder
neck obstructions; prostatic hypertrophy; or
myasthenia gravis
– Caution with hepatic, renal, or cardiac
insufficiency; elderly and debilitated clients; those
with a tendency toward urinary retention; those
exposed to high environmental temperatures
• Interactions
– Additive anticholinergic effects and potentially fatal paralytic
ileus with other drugs that possess these properties
– Concurrent use with haloperidol or phenothiazine may result in
decreased effect of the antipsychotic and increased incidence of
anticholinergic side effects.
– Additive CNS effects with CNS depressants
Planning/Implementation
• Monitor client for these side effects
– Anticholinergic effects, nausea, GI upset,
sedation, dizziness, exacerbation of psychoses,
orthostatic hypotension
• Educate client/family about drug
Outcome Criteria/Evaluation
Side effects
• 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)
• Tardive dyskinesia (TD)
– Involuntary contractions of oral and facial muscles
– Choreoathetosis (wavelike movements of extremities)
– Occurs with continuous long-term antipsychotic therapy
• Examples of drug induced movement disorders are:
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AkathisiaIt-An absence of movement.
Akinesia- is restlessness or an inability to sit still
Dyskinesia and Tardive Dyskinesia
Chorieoform, worm-like movements
Dystonias-Rigidity in the muscles that control posture,
gait, eye rolling (occulogyro crisis), laryngeal spasms
(gagging), cyanosis, and respiratory distress.
– Cog-wheel rigidity-Joints such as at the elbow do not
move freely but have a jerking type motions much like
two wheels that have projections or cogs that can get
caught and cause a stop and start action.
Neuroleptic Malignant Syndrome
• Signs and symptoms of NMS are: muscle
rigidity, hyperthermia, decreased ventilation,
cardiovascular collapse, and an elevate CPK
Dyskinesia and
Tardive Dyskinesia
• It is abnormal involuntary muscle movement
(jerky), pill rolling, lip smacking, tongue
protrusion and an impaired gag reflex (Places
the individual at risk for choking).
• Abnormal Involuntary Movement Scale or
AIMS is performed every three months for
patient s receiving antipsychotic medication
that can cause a drug induced movement.
Anti-Parkinson's
• They are used in the treatment of drug
induced movement disorders or
Extrapyramidal Side Effects (EPSE)
Anti-Parkinson Medications
– Cogentin
– Symmetrel
– Artane