Psychopharmacological Therapies

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Psychopharmacological Therapies Nursing
Implications

• Antianxiety agents
• Antidepressant Agents
• Mood stabilizers
• Antipsychotic agents

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Psychotropic medications usage
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Anxiolytics- Antianxiety agents

• Used for treatment of anxiety disorders
• Panic disorder ( efficacy)
• Generalized Anxiety Disorder (GAD)
• ( efficacy)
• Obsessive-Compulsive Disorder (OCD)
• ( efficacy)
• Posttraumatic Stress Disorder (PTSD)
• ( efficacy)
• Simple Phobias
• Social Phobias

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Benzodiazepines

• Action CNS depressants
• Depress activity in the brain stem and limbic
  system
• Increase action of gamma-aminobutyric acid GABA
  (inhibitory neurotransmitter) thus inhibiting
  nerve transmission is the CNS
• Benzos bind with receptor proteinsgt effects of
  sedation/muscle relaxation.

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Anxiolytics Nursing implications

• Benzodiazepines
• (CNS depressants)
• Alprazolam(Xanex)
• Lorazepam(Ativan)
• Clonazepam(Klonopin)
• Diazepam(Valium)
• Oxazepam (Serax)

• Do not give with other CNS depressants
• Use cautiously in elderly
• Monitor for physical psychological dependence
  with long term use
• Monitor confusion, memory impairment motor
  coordination- ataxic gait
• Decreased effects with cigarettes/caffeine

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Benzodiazepines -

• Hypnotic-sleep agents
• Temazepam(restoril)
• Triazolam(halcion)
• Flurazepam
• ( Dalmane)
• Chlordiazepoxide (Librium)
• Diazepam(Valium)
• Nonbenzodiazepine
• Buspirone(Buspar)

• Monitor drowsiness, sedation the day following
• use hangover effect
• Elderly have more difficulty with side effects
  i.e. confusion, unsteady gait, urinary
  incontinence.
• Assess for nausea, headache, dizziness
• Not for immediate relief

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Anti-convulsants-Mood stabilizers

• Used for treatment of manic episodes and Bipolar
  disorder

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Mood stabilizer --Nursing Implications

• Valproic Acid(Depakote) etc.
• Carbamazepine
• (Tegretol)

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

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Mood stabilizer --Nursing Implications

• Lamotrigine (Lamictal)
• (3rd generation
• anti-convulsant)
• Topiramate(Topamax)
• Gabapentin (Neurontin)
• Oxcarbazepine
• (Trileptal)

• Can cause serious rashes gt 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

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Antidepressant ---Nursing Implications

• SSRIs
• Fluoxetine(Prozac)
• give in AM
• Sertaline (Zoloft)
• give in PM if drowsy
• Paroxetine (Paxil)
• give in PM if drowsy
• Citalopram(Celexa)
• Escitalopram (Lexapro)
• Fluvoxamine (Luvox)

• Monitor for
• Hyponatremia/sexual dysfunction orthostatic B/P
• Give w/foodencourage adequate fluids

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Selective Serotonin Reuptake Inhihibitors
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Atypical Antidepressant Actions

• Mirtazapine(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.

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Atypical antidepressants- -Nursing Implications

• Venlafaxine(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 labsAST,ALT LDH,chol,
• gluc,Hct
• Sedation Give in PM,
• Monitor wt. gain,
• Monitor sex dysfunction,
• constipation

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Tricyclic Antidepressants--Nursing Implications

• Amitriptyline(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

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MonoamineOxidase Inhibitors-----Nursing
Implications

• Used in treatment resistant depression
• Work to increase levels of norepinephrine,
  seratonin tyramine dopamine
• Isocarboxazid (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

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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 hours
• Negative( Affective symptoms)- may take up to 2-4
  weeks to respond.

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Use/clinical efficacyAntipsychotic medications
cont

• Cognitive/Perceptual symptoms i.e.
  hallucinations, delusions, thought broadcasting
  2 to 8 weeks to respond
• Increasing meds will not hasten relief of slow
  responding symptoms
• Usually start with divided doses
• (minimizes s/es)
• Once effective change to Daily or BID dosing
  (increases med compliance)

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Use/clinical efficacyAntipsychotic medications
cont

• Absorption absorbed well in GI tract
• Metabolism metabolized in the liver
• Half Life Adults (20 40 hours)
• Half Life Elderly client may be doubled
• Adult steady state 4-7 days
• Monitor liver functions esp. elderly and
  physically compromised

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Use/clinical efficacyAntipsychotic medications
cont

• INJECTABLE 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 Ativan
• LIQUID form-used when client has hx. of
  non-compliance or has been suspected of
  cheeking meds.

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Antipsychotic medications

• LONG ACTING INJECTABLE
• Used to increase compliance
• Eg. Haldol Decanoate/Prolixin Decanoate
• Given monthly or bi-weekly
• Half life Haldol decanoate- 21 days
• Half-life for Prolixin decanoate 14 days
• Monitor carefully as out patient

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Extrapyramidal Side Effects- EPS

• Serious neurological symptoms that are major side
  effects of antipsychotic drugs.
• Cause Blockade of D2(dopamine)in midbrain region
  of the brainstem

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EPS- Acute dystonia

• Symptoms 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

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EPS Parkinsonism symptoms

• Tremors
• Bradykinesia/akinesia slowness, absence of
  movement
• Cogwheel rigidityslow regular muscular jerks
• Postural instability
• Stooped/hunched posture
• Shuffling gait
• Restricted movements
• Masked faceloss of mobility in facial muscles
• Hypersalivation drooling

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EPS Akathesia symptoms

• AKATHISIA not sitting
• Pacing, Motor restlessness,Rocking, Foot taping
• Subjective c/o inner restlessness, irritability,
  inability to sit still or lie down.
• Need to differentiate between Akathisia and
  psychomotor agitation or restlessness

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Neuroleptic Malignant Syndrome

• A rare but potentially fatal complication of
  treatment with neuroleptic drugs.
• Can occur within first 2 weeks of use
• Increased 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)

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Neuroleptic Malignant Syndrome

• Severe Opisthotonos severe dorsal arching of
  neck and back
• As seen in NMS

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TARDIVE DYSKINESIA( late occurring abnormal
movements)

• Effects 4 of persons taking antipsychotics
• Choreoathetoid movements rapid,jerky and
  slow,writhing movements may occur anywhere in
  the body arms,feet,legs,trunk
• Classic descriptionoral,buccal, lingual,
  masticatory movements tongue thrusting,lip
  pursing smacking,facial grimaces and chewing
  movements.