Psychopharmacological Therapies & Nursing ImplicationsAntianxiety agentsAntidepressant AgentsMood stabilizersAntipsychotic agents

Psychotropic medications & usage

Anxiolytics- Antianxiety agentsUsed for treatment of anxiety disorders Panic disorder (++++ efficacy)Generalized Anxiety Disorder (GAD)(++++ efficacy)Obsessive-Compulsive Disorder (OCD) (+ efficacy)Posttraumatic Stress Disorder (PTSD) (+ efficacy)Simple PhobiasSocial Phobias

BenzodiazepinesAction CNS depressantsDepress activity in the brain stem and limbic systemIncrease action of gamma-aminobutyric acid GABA (inhibitory neurotransmitter) thus inhibiting nerve transmission is the CNSBenzos bind with receptor proteins> effects of sedation/muscle relaxation.

Anxiolytics Nursing implicationsBenzodiazepines(CNS depressants)Alprazolam(Xanex)Lorazepam(Ativan)Clonazepam(Klonopin)Diazepam(Valium)Oxazepam (Serax)

Do not give with other CNS depressantsUse cautiously in elderlyMonitor for physical & psychological dependence with long term useMonitor confusion, memory impairment & motor coordination- ataxic gaitDecreased effects with cigarettes/caffeine

Benzodiazepines - Hypnotic-sleep agentsTemazepam(restoril)Triazolam(halcion)Flurazepam ( Dalmane)Chlordiazepoxide (Librium)Diazepam(Valium)

NonbenzodiazepineBuspirone(Buspar)

Monitor drowsiness, sedation the day following use hangover effectElderly have more difficulty with side effects i.e. confusion, unsteady gait, urinary incontinence.

Assess for nausea, headache, dizzinessNot for immediate relief

Anti-convulsants-Mood stabilizersUsed for treatment of manic episodes and Bipolar disorder

Mood stabilizer --Nursing ImplicationsValproic Acid(Depakote) etc.

Carbamazepine(Tegretol)

Check liver functions (at start & q 6 mos.)Can cause hepatic failure/life threatening pancreatitisCan cause aplastic anemia & agranulocytosis (5-8xs greater than population)

Mood stabilizer --Nursing ImplicationsLamotrigine (Lamictal)(3rd generation anti-convulsant)

Topiramate(Topamax)Gabapentin (Neurontin)Oxcarbazepine (Trileptal)

Can cause serious rashes > in children; eg.Stevens-Johnson syndrome (severe form of erythemia multiforme)

Common side effects of all mood stabilizers: Dizziness, hypotension, ataxia- Monitor gait, & B/P ;give w/food; Pt. teaching re: s/es

Antidepressant ---Nursing ImplicationsSSRIs:Fluoxetine(Prozac) give in AMSertaline (Zoloft) give in PM if drowsyParoxetine (Paxil) give in PM if drowsyCitalopram(Celexa)Escitalopram (Lexapro)Fluvoxamine (Luvox)

Monitor for:Hyponatremia/sexual dysfunction; orthostatic B/PGive w/food;encourage adequate fluids

Selective Serotonin Reuptake Inhihibitors

Atypical Antidepressant ActionsMirtazapine(Remeron) promotes presynaptic release of two neurotransmitters(norepinephrie & seratonoin) No inhibition of neurotransmitters in pre-synaptic or post synaptic reuptake.Bupropion(Wellbutrin); Venlafaxine (Effexor)Affect all 3 major neurotransmitters Seratonin, norepinephrine & dopamine.

Atypical antidepressants- -Nursing ImplicationsVenlafaxine(Effexor)

Duloxetine(Cymbalta)

Bupropion(Wellbutrin)Nefazodone(Serzone)

Mirtazapine(Remeron)

May alter labs: AST ALT, alk phos, Createnine,gluc,lytes;Monitor for inc B/P & HR Can lower seizure threshold; inc. B/P,HR(as above)Check labs:AST,ALT LDH,chol,gluc,HctSedation: Give in PM,Monitor wt. gain,Monitor: sex dysfunction,constipation

Tricyclic Antidepressants--Nursing ImplicationsAmitriptyline(elavil)Amoxapine(Asendin)Doxepin(Sinequan)Imipramine(Tofranil)Desipramine(Norpramine)Nortriptyline (Pamelor)

Monitor & educate re: cholinergic s/es: dry mouth, blurred vision, constipation,Ortho-B/P, **cardiac dysrhythmias/functionlethal in OD *caution use in elderly

MonoamineOxidase Inhibitors-----Nursing ImplicationsUsed in treatment resistant depressionWork to increase levels of norepinephrine, seratonin tyramine & dopamineIsocarboxazid (Marplan)Phenelzine (Nardil)Tranlcypromine (Parnate)

Educate re: low tyramine diet; *Hypertensive crisis if diet is contains tyramine foods.potentially fatal drug to drug interactions i.e. Meperidine, SSRIs,TCAs, Amphetamines*can be lethal in OD

CLINICAL USE //EFFICACYAntipsychotic medications*MOST TOXIC DRUGS USED IN PSYCHIATRY!!Use lowest possible dose especially in Geriatric client start low go slow!Positive (aggressive symptoms) most responsive-relieved within hoursNegative( Affective symptoms)- may take up to 2-4 weeks to respond.

Use/clinical efficacyAntipsychotic medications contCognitive/Perceptual symptoms i.e.: hallucinations, delusions, thought broadcasting 2 to 8 weeks to respondIncreasing meds will not hasten relief of slow responding symptomsUsually start with divided doses (minimizes s/es)Once effective change to Daily or BID dosing (increases med compliance)

Use/clinical efficacyAntipsychotic medications contAbsorption absorbed well in GI tractMetabolism metabolized in the liverHalf Life Adults (20 40 hours)Half Life Elderly client may be doubledAdult steady state 4-7 daysMonitor liver functions esp. elderly and physically compromised

Use/clinical efficacyAntipsychotic medications contINJECTABLE form I M use for emergencies only (client imminent danger to self/others)Simultaneous use of a benzodiazepine may help client to gain control more rapidly ie: combination of Haldol and AtivanLIQUID form-used when client has hx. of non-compliance or has been suspected of cheeking meds.

Antipsychotic medicationsLONG ACTING INJECTABLE Used to increase complianceEg. Haldol Decanoate/Prolixin DecanoateGiven monthly or bi-weeklyHalf life Haldol decanoate- 21 daysHalf-life for Prolixin decanoate 14 daysMonitor carefully as out patient

Extrapyramidal Side Effects- EPSSerious neurological symptoms that are major side effects of antipsychotic drugs.

Cause: Blockade of D2(dopamine)in midbrain region of the brainstem

EPS- Acute dystoniaSymptoms may include: Blepharospasm [eye closing]Torticolis [neck muscle contraction pulling head to side]Oculogyric Crisis [severe upward deviation of eyeballs]Opisthotonos [severe dorsal arching of neck and back]Larngospasm/involve-ment of tongue [dysphasia- difficulty swallowing]

EPS Parkinsonism symptomsTremorsBradykinesia/akinesia [slowness, absence of movement]Cogwheel rigidity[slow regular muscular jerks]Postural instabilityStooped/hunched postureShuffling gaitRestricted movementsMasked face[loss of mobility in facial muscles]Hypersalivation &drooling

EPS Akathesia symptomsAKATHISIA not sittingPacing, Motor restlessness,Rocking, Foot tapingSubjective c/o inner restlessness, irritability, inability to sit still or lie down.Need to differentiate between Akathisia and psychomotor agitation or restlessness

Neuroleptic Malignant SyndromeA rare but potentially fatal complication of treatment with neuroleptic drugs.Can occur within first 2 weeks of useIncreased risk with high dose- high potency drugs, concurrent medical conditions (dehydration, poor nutrition)Assessment check elevation of-B/P, high fever-(hyperpyrexia), rigidity, diaphoresis,pallor, delirium LABS elevated CPK(createnine phosphokinase)

Neuroleptic Malignant SyndromeSevere Opisthotonos [severe dorsal arching of neck and back]As seen in NMS

TARDIVE DYSKINESIA( late occurring abnormal movements)

Effects 4% of persons taking antipsychoticsChoreoathetoid movements [rapid,jerky and slow,writhing movements] may occur anywhere in the body arms,feet,legs,trunkClassic descriptionoral,buccal, lingual,& masticatory movements[ tongue thrusting,lip pursing & smacking,facial grimaces and chewing movements.