Post on 08-Apr-2018
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Psychotropic Drugs
Mental Health Jene Hurlbut, RN, MSN, CFNP
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Objectives: Discuss the functions of the brain and the way this
can be altered by the use of psychotrophicmedications
Discuss how the neurotransmitters are affected byvarious psychotrophic medications
Discuss the application of the nursing process withvarious psychotrophic medications
Identify specific cautions to be aware of the variouspsychotrophic medications
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Psychotropic Drugs Locus of all mental activity is the brain
Origin of psychiatric illness caused bymany factors: Genetics
Neurodevelopment factors
Drugs Infections
Psychosocial experiences, etc.
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Psychotropic Drugs-continue Theories behind use of psychotropic drugs focuses on
neurotransmitters and their receptors
Psychotropic drugs act by modulating neurotransmitters
Go to: http://www.wisc-online.com/
Health: Nursing, activity #3503 (Psychotropic Medications andNeurotransmitters)
Or try: http://www.wisc-online.com/objects/index_tj.asp?objID=NUR3503
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Review: Cellular composition
of brain Neurons-nerve cells that conduct electrical
impulses
Neurotransmitter-chemical that is releasedin response to an electrical impulse(neuromessenger). Attaches to a receptors on cell surface and either
inhibits or excites Major target of psychotropic drugs
See table 3-1 on pg. 40 !!!!
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Use of psychotropic meds: Relieve or reduce s/s of dysfunctional
thoughts, moods, or actions, & mentalillness
Improve clients functioning
Increase compliance to other therapies
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Therapeutic Effects of
Psychotropic Meds Do not cure
Relieve or decrease
symptoms Prevent or delay return
of S/S
Cannot be used as the
sole tx for disorders Need informed consent
before starting
Are broad spectrum andhave effects on a large
number of S/S. Initial effects are
sedative in nature
May take weeks foreffects to be seen
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Reasons for Nonadherence: Meds are expensive
Unpleasant sideeffects
Feel better anddecide no longerneed
Stigma associatedwith having a
mental illness andtaking meds
Paranoia or fears
about med usage
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Services Encouraging Compliance
to Medication Regimen: Follow-up appts. With client to verify that client understands the
purpose, proper administration, intended effects, side and toxiceffects of, and how to treat problems associated with meds
Support persons can encourage and assist the client to complywith meds
Appropriate lab tests must be conducted to preventcomplications and assure correct levels of drugs
Encourage clients to participate in med groups
Can use injections of antipsychotics which will last from 2-4weeks if clients are non-compliant
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Efficacy of Psychotropics with
Children & Elderly Use with great caution
Startlow and go slow for both elders andchildren!!
Elders have decrease liver & renal function
Risk of injuries and falls with elderly
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Client & Family Teaching Purpose of the meds
and benefits, side
effects and how totreat SE.
What S/S indicate atoxic effect, and
how to treat, andwhom to call.
Specific instructionsabout how to takethe meds
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Psychotropic Meds
Classifications: Antipsychotics
(neuroleptics)
Mood Stabilizers
Antidepressants
Anxiolytics(antianxiety)
Sedatives
Hypnotics
Psychostimulants
Antihistamines,antimuscarinics,dopamine agonists
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Uses for
Antipsychotics/Neuroleptics Schizophrenia
Disorders
Bipolar-Manic Phase
Major Depressionwith psychoticfeatures
Tourettes Syndrome
Control ofintractable hiccups
Dementia, andDelusions
Aggressive behavior
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Antipsychotic Meds-
Neuroleptics First generation:
Phenothiazines=
Thorazine,Mellaril,Stelazine,Prolixin (highpotency)
NonPhenothiazines=
Haldol(butyrophenones)
(high potency)
Atypical Antipsychotics(2nd and 3rd gen)=
Clozaril,
Zyprexa,Risperdal,Geodon,Seroquel,
Zeldox
Invega,Abilify
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First Gen Antipsychotic Meds Block
predominantly
dopamine activity little effect on
serotonin
High incidence ofabnormalmovements
(Also blocks acetylcholine,norepinephrine to somedegree)
Blocks the Hreceptor for
histamine results in sedation
and weight gain
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Side Effects of 1st
Gen Drugs Dystonia
(EPS)=spasms of the
eye, neck-torticollis,back, tongue-happenswithin 72 hrs.reversible.
Akathisia (EPS)=
restlessness
Pseudoparkinson-S/S similar to
Parkinson's-see in 1-2weeks. May disappear.TX. With Cogentin
Tardive Dyskinesia-bizarre facial andtongue movements-irreversible.
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Other S/E of 1stgen
Antipsychotics Amenorrhea
Galactorrhea
Blurred vision, dry mouth,constipation and urinaryretention, tachycardia-anticholinergic S/E
Sexual dysfunction
Severe dysrhythmias
In men can lead togynecomastia
photosensitivity & skinrashes (i.e. haldol)
Reduction is seizurethreshold
Orthostatic hypotension
Agranulocytosis
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Contraindications of Traditional
Antipsychotics (1stGen): Blood dyscrasias
Liver, renal, or cardiac insufficiency
CNS depressants, including ETOH
Tegretol in conjunction withantipsychotics causes up to 50%reduction in antipsychoticconcentrations
SSRIs in conjunction withantipsychotics may cause suddenonset of EPS
Dont give if have: Parkinson'sdisease, prolactin dependent cancerof the breast
Cigarette smoking causes reducedplasma concentrations ofantipsychotics
Luvox in conjunction withantipsychotics causes increasedconcentrations of Haldol and Clozaril
Beta Blockers in conjunction withantipsychotics cause severehypotension
Antidepressants in conjunction withantipsychotics may cause increasedantidepressant concentrations
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First Generation Antipsychotic
MedsAre useful in getting out of control
behavior under control quickly.
These can be given with lithium to gettreat acute mania.
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Atypical AntipsychoticsAction:
Blocks serotonin and to a lesser degree,dopamine receptors
Also block receptors for norepinephrine ,histamine, acetylcholine
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Atypical Antipsychotics- 2nd
and 3rd
generation drugs Nicer drugs and are
used more!!
Decrease positive andnegative S/S ofSchizophrenia
These drugs blockserotonin as well asdopamine
Incidence of abnormalmovements is lower!
Biggest SE is wt. gain
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Positive & Negative S/S of
Schizophrenia Positive:
Hallucinations
Delusions
Abnormal thoughts
Bizarre behavior
Confused thoughts
Negative:
Blunted affect
Poverty of speech
Social withdrawal
Poor motivation
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Atypical Antipsychotics-2nd and 3rd
generation:
Clozaril (clozapine)
low incidence ofabnormal
movements
possible fatal sideeffect:
bone marrowsuppression &agranulocytosis(rare)
Most common S/E: sedation &
drowsiness, wt. gain
Other S/E are: hypersalivation,
tachycardia, &dizziness, seizure risk
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Atypical Antipsychotics-2nd and 3rd
generation: continue
Risperidone
Does not cause bone
marrow suppression Can cause at higher
doses motordifficulties
Available as a longacting injection
Can be used to tx.mania
Seroquel(Quetiapine)
S/E sedation, weightgain and headache
Not associated withabnormalmovements
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Atypical Antipsychotics-2nd and 3rd
generation: continue Zyprexa (olanzapine)
does not cause bone marrow suppression Can cause weight gain & hyperglycemia Adverse effects-Drowsiness, insomnia restlessness
Geodan (ziprasidone) Binds to multiple receptor sites Main S/E are hypotension & sedation Can prolong the QT interval-can be fatal if hx of cardiac arrhythmias
Abilify (Aripiprazole) Dopamine stabilizer Partial agonist at the D2 receptor In areas of the brain with excess dopamine, it lowers dopamine In areas of low dopamine, it stimulates receptors to raise the dopamine
level Main S/E are sedation, hypotension, and anticholinergic effects Adverse effects-headache, anxiety insomnia, GI upset
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Contraindications for Atypical
Antipsychotics: Known hypersensitivity
CNS depression, including ETOH
Blood dyscrasias in clients with
Parkinsons disease
Liver, renal, or cardiac insufficiency
Use with caution in diabetics, elderly, ordebilitated
SSRIs in conjunction with antipsychotics
may cause sudden onset of EPS
Cigarette smoking causes reducedplasma concentrations
Tegretol(carbamazepine) in conjunction withantipsychotics causes up to 50%reduction in antipsychotic levels
Luvox (fluvoxamine) in conjunction withantipsychotics causes increasedconcentrations of Haldol & Clozaril
Beta Blockers in conjunction withantipsychotics cause severe hypotension
Antidepressants in conjunction withantipsychotics may cause increasedantidepressant concentrations
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Antipsychotics Can be given be given as an IM
injection (depot preparations) if have
difficulty taking oral meds.
Can use lower doses when given IM, so
less risk of tardive dyskinesia
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Neuroleptic Malignant
Syndrome Rare, but fatal
complication from allantipsychotic drugs
See more with 1stgendrugs
Severe muscle rigidity
High temp up to 107
Tachycardia
Tachypnea
Stupor
Coma
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Mood Stabilizers Used in the
treatment of Manic
(Bipolar) disorder,and in some formsof depression
Drugs used Lithiumand Antiepileptic
Drugs
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Lithium Mechanism of action
unknown
Interacts with sodiumand K+
Alters electricalconductivity potential threat to all
body functions that areregulated by electricalcurrents
Can cause polyuria andpolydipsa due to Na andK alterations
Has the lowesttherapeutic index of allpsych drugs
Have to monitor bloodlevels of this drug
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Lithium Maintenance blood levels of
lithium are usually 0.4-1.3 mEq(toxicity occurs with levels > 1.5mEq/L)
Sign of toxicity is a fineintention tremor that becomesmore pronounced and coarse.
Risk of thyroid & kidney disease
If toxic s/s occur discontinue thedrug and notify health careprovider
Lithium should be taken withfood
Client must eat a balanced dietwith normal sodium intake andtake in adequate fluid (about 2-3 liters/day).
Excretion is dependent on this.
Dehydration and salt restrictioncan increase lithium levels &cause toxicity.
Takes 2-3 weeks for lithium tobecome effective (may useantipsychotic until therapeuticlevels are reached)
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Signs & symptoms of lithium
toxicity: Fine hand tremors
that progress of
coarse tremors Mild GI upset
progressing topersistent upset
Slurred speech andmuscle weaknessprogressing tomental confusion
Severe Toxicity:
decrease level of
consciousness tostupor and finallycoma
Seizures, severehypotension, severepolyuria with diluteurine
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Lithium:
Lithium serum concentrations are increased byfluoxetine (Prozac), ACE inhibitors, diuretics, andNSAIDs
Lithium serum concentrations are decreased bytheophylline, osmotic diuretics, and urine alkalinizers
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Contraindications for Lithium: Renal disease
Cardiac disease
Severe dehydration
Sodium depletion
Brain damage
Pregnancy or lactation
Use with caution in the elderly or clients with diabetics, thyroiddisorders, urinary retention, and seizures
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Anticonvulsants/Antiepileptic
Drugs Causes an increase in GABA in the CNS-which
causes a decrease in anxiety.
Reduce the mood swings with bipolar
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Anticonvulsants/Antiepileptic
Drugs Tegretol (carbamazepine)-also used to treat
severe pain (i.e. trigeminal neuralgia)
Depakote (valproic acid)-can cause hepaticfailure, pancreatitis, & thrombocytopenia.Watch for liver failure
Klonopin (clonazepam)
Lamictal (Lamotrigine)-can have a rare butfatal dermatological condition
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Toxic Effects of
Anticonvulsants: Tegretol can cause agranulocytosis and
aplastic anemia
Depakote can cause liver dysfunction, hepaticfailure, and blood dyscrasias includingthrombocytopenia
Depakote interacts with drugs that arehepatically metabolized
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Contraindications for
Anticonvulsants : Hepatic or renal disease
Pregnancy
Lactation
Presence of blood dyscrasias
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Unique teaching needs with
anticonvulsants: Monitor blood levels of mood stabilizers to
prevent toxicity
Monitor liver, renal function tests and CBCs
Depakote must be swallowed whole, not cut,chewed, or crushed to prevent irritation
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Antidepressants Tx of depressive moods, including
bipolar disease
4 categories: Tricyclics
MAOIs SSRIS
Atypical Antidepressants
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Antidepressant Drugs Tricyclics- Elavil, Tofranil
SSRIs-Zoloft, Paxil
MAOIs- Nardil, Parnate, Marplan
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Atypical Antidepressants Inhibits selective
reuptake of serotonin:Trazodone (desyrel)
NorepinephrineDopamine ReuptakeInhibitor (NDRI):Wellbutrin (Bupropion)
Serotonin &norepinephrinereuptake inhibitor:
Cymbalta (duloxetine)
Sertonin NorepineprineReuptake Inhibitor-(SNRI): Effexor
(venlafaxine)
Increases release ofserotonin &norepinephrine :Remeron (mirtazapine)
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Atypical Antidepressants Trazodone=
alternative to TCAs Can cause orthostatic
hypotension, sedation, &priapism in males
Remeron= causessedation, weight gain,dry mouth, constipation
Wellbutrin (zyban)=rarely causes sedation,wt. Gain, or sexualdysfunction. Used for smoking cessation.
Most common S/E areheadaches, insomnia &nausea
Can lower seizure thresholdcauses seizures
A i l A id
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Atypical Antidepressants:serotonin norepinephrine reuptake
inhibitor (SNRI): SNRI-blocks uptake of
serotonin andnorepinephrine
Good for clients withanxiety also
SE=sexual dysfunction,insomnia, agitation
Skipping 1 dose cancause withdrawal S/S
Drug here is Effexor
& Cymbalta
Very effective in
treating severedepression
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Major Indications for
Antidepressants Major Depressive
disorder
Bipolar depression Obsessive-
Compulsive
Anxiety Panic disorder
PTSD
Substance Abuse
Chronic Pain
Tourettes Disorder
ADHD
Eating disorders
Sleep disorders Migraines
Enuresis
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Tricyclics:Elavil, Pamelor, Tofranil, Anafranil,
Aventyl, Asendin, Sinequan
Blocks the reuptake ofnorepinephrine andsertonin
Tricyclic drugs block themuscarine receptors (soanticholinergic effects)
Other sideeffects:
orthostatichypotension
sedation
wt. gain
confusion-esp.elderly
arrhythmias
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Tricyclics Contraindications Do not mix with ETOH (none
of the psych drugs should bemixed with ETOH)
Dementia
Suicidal clients
Cardiac disease
Pregnancy
Seizure disorders Urinary retention
Dose for elderly should be of adult dose
TCAs and MAOIs areeffective in tx. depression are not as safe or as well
tolerated as the newerantidepressants
Toxic Effects:possibility of cardiactoxicity and are toxic inoverdose
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SSRIs Prozac, Zoloft, Paxil, Celexa, Luvox, Serzone,Lexapro
Action-blocks the reuptake of sertonin into theneuron
Side-effect: biggest is sexual dysfunction & wt. gain
Contraindication: Cardiac dysrhythmias
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SSRIs Are very safe and are not lethal in overdose
Good choice with the elderly-very few side effects
If used with MAOIs may cause SerotoninSyndrome=seizure, death
If used with TCAs may cause TCA toxicity
Takes 2 weeks to feel effects
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MAOIs Nardil, Parnate,Marplan
Inhibits MAO, thusinterfering withbreakdown ofnorepinephrine,dopamine, andserotonin
Toxic effects= hypertensive crises
Avoid foods withtyramine (aged cheese,red wine, beer,
chocolate, etc.)
MAOIs dont play wellwith other drugs!!
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Antianxiety/Anxiolytic Drugs GABA exerts an
inhibitory effect on
neurons These drugs
enhance this effectand produce a
sedative effect Therefore reduce
anxiety
The most commonused drugs here are
theBenzodiazepines
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Benzodiazepines Valium, Xanax, Ativan ,
Librium , Klonopin,Serax
Dalmane, Halcion (usedas sleep aides mostly-short term!!)
Used for anxiety, panicdisorders, ETOH withdrawal,muscle spasm, sedation,insomnia, andepileptics/seizures
Use only short term becauseof dependency issues
Avoid ETOH
Causes sedation-dont drive!!
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Benzodiazepines Side Effects;
Drowsiness, confusion, sedation, and lethargy
Toxic Effects; Respiratory depression esp. with ETOH use!
Contraindications; Combination with other CNS depressants Renal or hepatic dysfunction History of drug abuse or addiction Depression and suicidal tendencies
Teaching; Use short term due to drug dependency issues Avoid ETOH and other CNS depressants Can impair ability to drive Do not use with someone who has a hx of drug dependency DC meds can cause withdrawal s/s
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Nonbenzodiazepine Aniolytic BuSpar (Buspirone)=
reduces anxiety without
strong sedative-hypnotic properties.
Not a CNS depressant
No potential foraddiction
Takes 2 weeks tofeel effects
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Nonbenzodiazepine Aniolytic Side Effects;
Dizziness, dry mouth, nervousness, diarrhea, headache, excitement
Toxic Effects; Lethal dose is 160-550 times the daily recommended dose
Contraindications; Use with caution in PG women Nursing mothers Clients with renal or hepatic disease Anyone taking MAOs
Teaching; Buspar is not associated with sedation, cognitive problems or withdrawal Takes 2-4 weeks to feel effects Some clients might feel restless, which could be incompleted anxiety
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Sedative/Hypnotic Drugs Used to reduce
anxiety and
insomnia
Can lead totolerance and
dependency
Use short term
Drugs used
benzodiazepines,i.e. Dalmane,Restoril, Halcion
Non-benzodiazepines,i.e. Ambien,Sonata, Lunestra
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Sedative/Hypnotic
Benzodiazepine Teaching: Use short term(1-2 weeks)
Carefully need to taper these off-never stopcold turkey
Do not take with other meds without talking
to provider first
Do not drive if sedated on these!!
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Client Teaching for
Nonbenzodiazepines Long term use not recommended
Do not drive when taking
Can repeat Sonata up to 4 hours beforearising
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ADD/ADHD-Psychostimulants Ritalin, Adderall,Dexedrine, Concerta,Focalin, Metadate,
Methylin
Action=
increasing the release
and blocking thereuptake ofmonoamines(dopamine,norepinephrine)
S/E: wt. loss,anorexia, insomnia,headache, long-term
growth suppression
Potential for abuse
Also used to treatnarcolepsy
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ADD/ADHD-Psychostimulants Intended effects:
Increased attention span & concentration Decreased distractibility, hyperactivity, and impulsivity Treatment of ADHD, ADD, & narcolepsy
S/E: Anorexia Wt. loss Growth retardation in children Insomnia Headache Cardiovascular effects-high blood pressure, dysrhythmias
Contraindications: Hx of drug abuse & dependency, severe anxiety, anorexia, MAIOIs
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ADD/ADHD- Non-Stimulants Strattera (atomoxetine)
Controls symptoms thru selective inhibition
of norepinephrine
Takes 1-3 weeks to feel effects
No abuse potential and is not considered acontrolled substance
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Herbal Medicines Ginkgo biloba-helps with memory
Kava-Kava
St. Johns Wart
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PETScan=positron-emission tomography
(PET) scans
Useful in identifying physiological andbiochemical changes as they occur in living
tissue i.e. clients with schizophrenia PET scans show a
decrease of glucose in the frontal lobes ofunmedicated clients, also can indicate mooddisorders,ADHD
Radioactive substance is injected, travels tothe brain, and illuminates the brain. Have 3Dvisualizations of the CNS