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Mental Health/Psych

Psychopharmacology

TermDefinition
Psychotropic Drugs antipsychotics, antidepressants, mood stabilizers, anxiolytics and stimulants
Off-label use A drug that proves effective for a disease that differs from the one involved in the original testing and FDA approval
Black box warning When a drug is found to have serious or life-threatening side effects, even if such side effects are rare. Package inserts must have a highlighted box, separate from the text containing a warning
Tricyclic antidepressants can require 4 to 6 weeks before optimal therapeutic benefit
As a rule, older adults require lower dosages of medications than do younger clients to experience therapeutic effects; may take the drug longer to achieve full therapeutic effects in older adults
Psychotropic medications are decreased gradually (tapered) rather than decreased abruptly
Rebound Temporary return of symptoms or recurrence of the original symptoms or withdrawal
Withdrawal New symptoms resulting from discontinuation of the drug
Antipsychotic drugs (neuroleptics) Used the treat the symptoms of psychosis, such as the delusions and hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorder.
Off-label uses of antipsychotics Treatment of anxiety and insomnia; aggressive behavior; and delusions, hallucinations, and other disruptive behaviors that sometimes accompany Alzheimer's disease.
Second-generation antipsychotics Can increase mortality rates in elderly clients with dementia-related psychosis
Conventional or First-Generation Antipsychotics Chlorpromazine, Fluphenazine, Thioridazine, Haloperidol
Atypical or Second-Generation Antipsychotics Clozapine, Risperidone, Olanzapine, Quetiapine, Ziprasidone, Paliperidone
Third-Generation Antipsychotic Aripiprazole
Fluphenazine deconoate Depot injection that has a duration of 7 to 28 days. Uses sesame oil as the vehicle for injection so the medication is slowly absorbed over time
Haloperidol deconoate Depot injection that has a duration of 4 weeks. Uses sesame oil as the vehicle for injection so the medication is slowly absorbed.
Depot injection maintenance After client's condition has stabilized with oral doses of medications, administration of depot injection is required every 2 to 4 weeks to maintain therapeutic effect
Extrapyramidal Side Effects (EPS) Serious neurologic symptoms, are major side effects of antipsychotic drugs. They include dystonia, pseudoparkinsonism, and akathisia.
Acute dystonia Acute muscular rigidity and cramping, stiff or thick tongue with difficulty swallowing, and in severe cases, largyngospasm and respiratory difficulties. Spasms or stiffness in muscle groups can produce torticollis, opisthotonus, and oculogyric crisis
Dystonia is most likely to occur In first week of treatment, in clients younger than 40, in males and those receiving high potency drugs, such as haloperidol and thiothixene.
Torticollis Twisted head and neck
Opisthotonus tightness in the entire body with the head back and arched neck
Oculogyric crisis Eyes rolled back in a locked position
Treatment of Dystonia Immediate anticholinergic drugs: IM benztropine or IM/IV diphenhydramine usually brings rapid relief
Drug-induced parkinsonism or Psedoparkinsonism Resemble those of Parkinson's disease and include a stiff, stooped posture; mask like facies; decreased arm swing, shuffling, festinating gait; cogwheel rigidity, drooling, tremor, bradycardia, coarse pill movmements
Treatment of Parkinsonism Changing to an antipsychotic medication that has a lower incidence of EPS or by adding an oral anticholinergic or amantadine
Akathisia Intense need to move about. Client appears restless or anxious and agitated, often with a rigid posture or gait and a lack of spontaneous gestures.
Treatment of akathisia Change in psychotic medication or addition of an oral agent such as a beta-blocker, anticholinergic or benzodiazepine
Neuroleptic Malignant Syndrome (NMS) Potentially fatal idiosyncratic reaction to an antipsychotic (neuroleptic) drug. Major symptoms: rigidity, high fever, autonomic instability (fluctuating BP), diaphoresis, pallor, delirium, elevated level of CPK
NMS Most often occurs in the first 2 weeks of therapy or after an increase in dosage, but can occur anytime. Dehydration, poor nutrition and concurrent medical illness all increase risk for NMS.
Treatment of NMS Immediate discontinuance of all antipsychotic medications and the institution of supportive medical care to treat dehydration and hyperthermia until the client's physical condition stabilizes
Tardive Dyskinesia (TD) Syndrome of permanent involuntary movements, most commonly caused by long-term use of conventional antipsychotic drugs.
Symptoms of TD Involuntary movements of the tongue, facial and neck muscles, upper and lower extremities, and truncal musculature. Tongue thrusting and protruding, lip smacking, blinking, grimacing and other excessive unnecessary facial movements are characteristic
Treatment of TD TD is irreversible, although decreasing or discontinuing antipsychotic medications can arrest its progression
Anticholinergic Side Effects Occur with use of antipyschotics and include orthostatic hypotension, dry mouth, constipation, urinary hesitance or retention, blurred near vision, dry eyes, photophobia, nasal congestion, and decreased memory
Treatment of anticholinergic side effects Side effects usually decrease within 3 to 4 wks; do not entirely remit. Using sugar-free beverages or hard candy may alleviate dry mouth; stool softeners, adequate fluid intake, inclusion of grains and fruit in diet my prevent constipation
Other side effects Antipsychotic drugs may increase blood prolactin levels; causing breast enlargement and tenderness in men and women; diminished libido, erectile and orgasmic dysfunction and menstrual irregularities and increased risk for breast cancer; weight gain
Weight gain increases most significant in clozapine and olanzapine
Metabolic Syndrome Cluster of conditions that increase the risk for heart disease, diabetes, and stroke. DX when three or more are present: Obesity, Increased BP, High blood sugar level, High cholesterol
Antipsychotic drugs that can cause a lengthening of the QT interval thioridazine, droperidol, mesordizaine; can cause torsade de pointes
Clozapine produces fewer traditional side effects than most antipsychotic drugs, but has the potentially fatal side effect of agranulocytosis
Agranulocytosis Occurs suddenly; characterized by fever, malaise, ulcerative sore throat, and leukopenia. May not be manifested immediately and can occur up to 24 wks after initiation of therapy
Initially with Clozapine Clients need to have a weekly WBC count that is above 3500 per mm3 to obtain the next wks supply. Currently, all must have wkly WBCs drawn for first 6 months. ANC must also be above 2000 mm3. Monitored every 2 wks for 6 months then every 4 wks
If a dose is forgotten With antipsychotic medication: can take missed dose if it is only 3 or 4 hours late. If more than 4 hrs you omit forgotten dose
Antidepressant drugs Primarily used in treatment of major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression.
Off-label uses of antidepressants Include tx of chronic pain, migraine headaches, peripheral and diabetic neuropathies, sleep apnea, dermatologic disorders.
Antidepressants divided into four groups Triclyclic and related cyclic antidepressants; SSRIs; MAOIs; Other depressants: desvenlafaxine, venlafaxine, bupropion, duloxetine, trazadone, and nefazadone
SSRIs fluoxetine, sertraline, paroxetine
Cyclics Imipramine, Amitriptyline, Mirtazapine, Clomipramine
Other Compounds Bupropion, Venlafaxine, Trazodone, Nefazodone, Duloxetine
MAOIs Phenelzine, Trancyclopromine, Isocarboxazid
Cyclic compounds Cause varying degrees of sedation, orthostatic hypotension and anticholinergic side effects. Potentially lethal if taken in an overdose
MAOIs Must be used with extreme caution: Life-threatening SE hypertensive crisis; cannot be given in combination with other MAOIs, tricyclic antidepressants, meperdine, CNS depressants, many hypertensives or general anesthetics; potentially lethal in overdose
SSRIs First choice in treating depression; equal in efficacy and produce fewer troublesome side effects. Effective ONLY for mild and moderate depression
SSRIs and clomipramine Effective in treatment of OCD
Clients at high risk for suicide SSRIs, venlafaxine, nefazadone, and bupropion are often better choices for those who are potentially suicidal or highly impulsive; they carry no risk for lethal overdose
Cyclic compounds may take 4 to 6 weeks to be effective
MAOIs may take 2 to 4 weeks for effectiveness. Should be taken in the morning
SSRIs may take 2 to 3 weeks to be effective
Akathisia usually treated with A beta blocker (propranolol) or a benzodiazepine
Side Effects of SSRIs Common: anxiety, agitation, akathisia, nausea, insomnia, and sexual dysfunction, specifically diminished sexual drive or difficulty achieving erection or orgasm. Weight gain.
Side Effects of Cyclic antidepressants Anticholinergic effects: dry mouth, constipation, urinary hesitancy or retention, dry nasal passages, blurred near vision. Older adults: agitation, delirium and ileus may occur. Other common SE: orthostatic hypotension, sedation, weight gain, tachycardia
Side Effects of MAOIs Most common: daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension and sexual dysfunction.
Serious side effect of MAOI Hypertensive crisis; If patient ingests food containing tyramine or takes sympathomimetic drugs
Signs of Hypertensive Crisis Hypertension, hyperpyrexia, tachycardia, diaphoresis, tremulousness, and cardiac dysrhythmias
Fatal interactions with MAOIs SSRIs, certain cyclic compounds, buspirone, dextromethorphan and opiate derivatives such as Meperdine
Side Effects of other Antidepressants sedation, headache, dry mouth and nausea, loss of appetite, agitation, and insomnia. Venlafaxine: dizziness, sweating or sedation.
Novel antidepressants (nefazadone, trazadone, mirtazapine, buproprion, venlafaxine, desvenlafaxine) Sexual dysfunction is less common; Trazadone CAN cause priapism (sustained and painful erection), may result in impotence
Serotonin Syndrome Uncommon but potentially serious drug interaction that can result from taking an MAOI and an SSRI at the same time. Can also occur if one of the drugs is taken too close to end of therapy with the other.
Symptoms of Serotonin Syndrome agitation, sweating, fever, tachycardia, hypotension, rigidity, hyperreflxia, and in extreme reactions, coma and death
When should SSRIs be taken? First thing in the morning unless sedation is a problem, generally, paroxetine most often causes sedation.
When should cyclic compounds be taken? At night in a single daily dose to minimize sedation effects
Mood-stabilizing drugs Used to treat bipolar disorder by stabilizing the client's mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania.
Lithium Most established mood stabilizer. Available in tablet, capsule, liquid and sustained-release forms. Effective dosage determined by monitoring serum lithium levels and clinical response to drug. Dosages range from 900 to 3600 mg
Serum Lithium levels Should be 1.0 mEq/L. Levels 1.5 and higher are considered toxic. Monitored q2 to 3 days when dosage is being determined. Then monitored weekly until condition is stable and then monthly or less frequently
Side Effects of Lithium therapy Common: mild nausea or diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, metallic taste, fatigue or lethargy. Weight gain and acne occur later in therapy
Toxic Effects of Lithium Severe diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination. Lithium should be d/c immediately. If levels are 3.0 or > dialysis may be indicated
Propranolol Often improves fine tremor with lithium therapy
Valproic Acid Available in liquid, table, capsule forms and sprinkles with dosages ranging from 1000 to 1500 mg/day; Serum drug levels obtained 12 hrs after last dose
Side Effects of Valproic Acid Drowsiness, sedation, dry mouth and blurred vision
Lamotrigine Can cause rashes including Stevens-Johnson syndrome or life-threatening (rare) toxic epidermal necrolysis
Kindling Process Snowball-like effect seen when minor seizure activity seems to build up into more frequent and severe seizures.
Anxiety drugs or Anxiolytics Used to treat anxiety and anxiety disorders, insomnia, OCD depression, PTSD and alcohol withdrawal. Most widely prescribed medications today.
Benzodiazepines Proved to be the most effective in relieving anxiety and most frequently prescribed. May be prescribed for their anticonvulsant and muscle relaxant effects
Buspirone Nonbenzodiazepine often used for the relief of anxiety. Does not cause physical dependence
Benzodiazepines Alprazolam, Chlordiazepoxide, Clonazepam, Diazepam, Lorazepam
Anxiolytics used to manage alcohol withdrawal Diazepam, chlordiazepoxide and clonazepam
Side Effects of Benzodiazepines One chief problem is the tendency to cause physical dependence
Most common Side effects of benzodiazepines CNS depression, drowsiness, sedation, poor coordination, impaired memory or clouded sensorium. If used for sleep, may complain of next-day sedation or hangover effect
Common side effects of buspirone Dizziness, sedation, nausea, and headache
Benzodiazepine withdrawal Can be fatal. Taper drug down!
Stimulant drugs Dextroamphetamine, methylphenidate, amphetamine and dextromethamphetamine
Treatment of narcolepsy Both dextroamphetamine and methylphenidate are given in doses totaling 20 to 200 mg/day. Higher doses may be needed due to tolerance.
Side Effects of stimulants Most common: anorexia, weight loss, nausea, and irritability. Client should avoid caffeine, sugar and chocolate. Most common with long-term is growth and weight suppression that occurs in some children.; "drug holidays" can prevent this
"Drug Holidays" Times when children do not take their stimulant medication such as on weekends and holidays or during summer vacation, helps restore normal eating and growth patterns
Disulfiram (Antabuse) Sensitizing agent that causes an adverse reaction when mixed with alcohol in the body. It's only use is as a deterrent to drinking alcohol in persons receiving treatment for alcoholism. Useful for persons motivated to abstain and not impulsive.
Side Effects of Disulfiram Five to ten minutes after ingesting alcohol, SX appear: facial & body flushing from vasodilation, throbbing headache, sweating, dry mouth, nausea, vomiting, dizziness, & weakness. Severe cases: chest pain, dyspnea, severe hypotension, confusion and death
Additional Side Effects of Disulfiram Sx progress rapidly and last from 30 min to 2 hrs. most effective in persons whose liver enzymes are within normal range. Client must select products that are alcohol free while on this medication.
Other side effects of Disulfiram Fatigue, drowsiness, halitosis, tremor, and impotence. Can interfere with drugs such as phenytoin, isoniazid, warfarin, barbiturates and benzodiazepines: diazepam and chlordiazepoxide
Acamprosate Sometimes rx for persons in recovery from alcohol abuse or dependence. Helps reduce physical & emotional discomfort encountered during first few weeks or months of sobriety:sweating, anxiety & sleep disturbances. Dose is two tablets 333 mg each 3x daily
St. John's wort Used to treat depression and commonly purchased herbal product in the US
Kava Used to treat anxiety and can potentiate the effects of alcohol, benzodiazepines, and other sedative-hypnotic agents
Ginkgo biloba Primarily used to improve memory but is also taken for fatigue, anxiety and depression
Electroconvulsive Therapy (ECT) Used to treat depression in select groups, such as clients who do not respond to antidepressants or those who experience intolerable side effects at therapeutic doses. In addition, pregnant women can safely have an ECT with no harm to fetus
ECT Involves application of electrodes to the head of the client to deliver an electrical impulse to the brain causing a seizure.
Treatment schedule for ECT Usually a series of 6 to 15 treatments scheduled three times a week. Generally a minimum of six treatments are needed to see sustained improvement. Maximum benefit is achieved in 12 to 15 treatments
Preparation for ECT NPO after midnight, removal of any fingernail polish, voids just before procedure, IV line started for administration of medication.
During ECT Initially client receives short-acting anesthetic so not awake during the procedure. Receives a muscle relaxant/paralytic, usually succinylcholine. Electrodes placed on head bilateral/unilateral. Electrical stimulation delivered; monitered by EEG.
Clozapine (antipsychotic) Schizophrenia unresponsive to or intolerant of standard therapy. To reduce recurrent suicidal behavior in schizophrenic patients
Chlorpromazine (antipsychotic) Second line treatment for schizophrenia and psychoses after failure with atypical antipsychotics
What drink to avoid with Benzodiazepines? Grapefruit juice
Venlafaxine (SNRI) First SNRI approved for major depression
Foods that contain Tyramine Cheese, cream, yogurt, coffee, chocolate, bananas, raisins, Italian Green beans, liver, pickled foods, sausage, soy, yeast, beer and redwines
Important to remember with Lithium Monitor serum sodium levels. Use with caution with diuretics. Adequate intake of fluid intake of 1 to 2 L daily
Nursing Interventions for Benzodiazepines Observe for side effects, observe for physical and psychological dependency, can occur with most anxiolytics. Monitor V/S, especially BP and pulse; Orthostatic hypotension may occur. Do not consume alcohol. Teach ways to control stress and anxiety
Chlorpromazine common side effects May produce pronounced orthostatic hypotension. May cause a harmless pinkish to red-brown urine color
Contraindications with haloperidol Narrow-angle glaucoma, severe hepatic, renal and cardiovascular diseases; CNS depression
Atypical Antipsychotics Effective in treating both positive and negative symptoms of schizophrenia
Clozapine Only indicated for treatment of severely ill schizophrenic pts who have not responded to traditional antipsychotic drugs
Risperidone Treats positive and negative symptoms of schizophrenia. Action similar to clozapine, occurrence of EPS and TD is low. Does not cause agranulocytosis
Nursing Considerations for treating mood disorders Monitor BP q2 to 4 hrs during initial therapy; Assess pt taking MAOI for hypertensive crisis; Monitor liver function & CBC when pt is tkng trycyclic; Administer SSRIs in AM w/or w/out food; Advise pt to avoid alcohol; Monitor serum drug levels of lithium
Naloxone For opioid reversal. Administered IV or IM or subq every 2 to 3 minutes. Rapidly reverses opioid-induced CNS depression and increases respiratory rate within 1 to 2 minutes
Benztropine (anticholinergic) To decrease involuntary symptoms of parkinsonism or drug induced parkionsonism.
Side Effects of Benztropine N/V, dry mouth, constipation, restlessness, flushing, dizziness, blurred vision, photophobia, pupil dilation, amnesia, confusion, depression, hallucinations, anhidrosis, weakness, hyperthermia, paresthesia
Adverse Reactions of Benztropine Tachycardia, palpitations, urinary retention, Life-threatening: Paralytic ileus
Created by: JennG2017