PSYCHOTROPIC DRUGS

Chapter 2, page 19 Videbeck 3rd Ed. I. ANTIPSYCHOTIC DRUGS also known as neuroleptics used to treat symptoms of psychosis, such as delusions and hallucinations seen in schizophrenia, schizoaffective disorder, and manic phase of bipolar disorder work by blocking receptors of the neurotransmitter dopamine examples (table 2.3, p. 30) Extrapyramidal side effects: o acute dystonia o pseudoparkinsonism o akathisia * although collectively referred to as EPS (extrapyramidal symptoms which are serious neurologic symptoms and are major side effects of antipsychotic drugs), each of these reactions has distinct features * therapy for acute dystonia, pseudoparkinsonism, and akathisia are similar and include the following: lowering dosage of antipsychotic changing to a different antipsychotic, or administering anticholinergic medication o Acute dystonia includes acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties most likely to occur in the first week of treatment, in clients younger than 40 years, in males, and in those receiving high-potency drugs (such as haloperidol and thiothexine) spasms or stiffness in muscle groups can produce torticollis, opisthotonus, or oculogyric crisis (p.30) reactions can be painful and frightening to the client immediate treatment with anticholinergic drug such as diphenhydramine IM or IV usually brings rapid relief * drugs used to treat EPS (table 2.4 p.30) o Pseudoparkinsonism, or drug-induced parkinsonism often referred to by the generic label of EPS symptoms resemble those of Parkinsons disease and include a stiff and stooped posture, mask-like faces, decreased arm swing, a shuffling, festinating gait, cogwheel rigidity, drooling, tremors, bradycardia, and coarse pill-rolling movements of the thumb and fingers while at rest treated by changing to an antipsychotic drug that has a lower incidence of EPS, or by adding an oral anticholinergic agent o Akathisia as reported by clients, is an 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. treated by a change in antipsychotic medication or by the addition of an oral agent (such as beta-blocker, anticholinergic, oor benzodiazepine)

* although collectively referred to as EPS (extrapyramidal symptoms which are serious neurologic symptoms and are major side effects of antipsychotic drugs), each of these reactions has distinct features. * therapy for acute dystonia, pseudoparkinsonism, and akathisia are similar and include the following: lowering dosage of antipsychotic changing to a different antipsychotic, or administering anticholinergic medication o Neuroleptic Malignant Syndrome (NMS) potentially fatal reaction to antipsychotic drugs major symptoms of NMS are rigidity, high fever, autonomic instability (such as unstable BP, diaphoresis, and pallor), delirium, and elevated levels of enzymes (particularly creatinine phosphokinase) clients with NMS usually are confused and often mute, may fluctuate from agitation to stupor * all antipsychotics seem to have the potential to cause NMS, but high dosages of high-potency drugs increase the risk (most often occurs in first 2 weeks of therapy or after increase increasing dosage, but can occur anytime) * dehydration, poor nutrition, and concurrent medical illness all increase the risk for NMS treatment includes immediate discontinuance of all antipsychotic medications and the institution of supportive medical care to treat dehydration and hyperthermia

o Tardive Dyskinesia (TD) syndrome of permanent involuntary movements commonly caused by the long-term use of conventional antipsychotic drugs symptoms of TD include involuntary movements of the tongue , facial and neck muscles, and upper and lower extremities tongue thrusting and protruding, lip smacking, blinking, grimacing, and other excessive, unnecessary facial movements are characteristic once it has developed, TD is irreversible, although decreasing or discontinuing antipsychotic medication can arrest its progression preventing TD is one goal when administering antipsychotics and this can be done by keeping maintenance dosages as low as possible, changing medications, and monitoring the client periodically for initial signs of TD o Anticholinergic Side Effects side effects include: orthostatic hypotension, dry mouth, constipation, urinary hesitance or resistance, blurred near vision, dry eyes, photophobia, nasal congestion, and decreased memory Other side effects:

o increase blood prolactin levels causing breast enlargement and tenderness (both in men and women) o diminished libido o erectile and orgasmic dysfunction o menstrual irregularities o weight gain (obesity common in schizophrenic clients, increasing risk for DM II and CVD) o minor cardiovascular adverse effects such as postural hypotension, palpitations, and tachycardia NURSING RESPONSIBILITIES: inform client of side effects and encourage to report problems instead of discontinuing medication teach client methods of managing or avoiding unpleasant side effects and maintaining medication regimen: o dry mouth sugar-free fluids and sugar-free hard candy * client should avoid calorie-laden beverages and candy o constipation exercise, increase water and bulk-forming foods; stool softener permissible but avoid laxatives o photosensitivity sunscreen client should monitor amount of sleepiness and drowsiness they feel; avoid driving and potentially dangerous activities until response time and reflexes seem normal II. ANTIDEPRESSANT DRUGS primarily used in the treatment of major depressive illness, anxiety disorders, depressed phase of bipolar disorder, and psychotic depression somehow interact with norephinephrine and serotonin which regulate mood, arousal, attention, sensory processing, and appetite divided into 4 groups: examples (table 2.5, p. 33) 1. Tricyclic and the related cyclic antidepressants have more side effects than SSRIs block cholinergic receptors, resulting in anticholinergic effects: 1. dry mouth 2. constipation 3. urinary retention 4. dry nasal passages 5. blurred near vision 6. more severe, agitation, delirium, and ileus other common side effects: 1. orthostatic hypotension 2. sedation 3. weight gain 4. tachycardia clients may develop tolerance to anticholinergic side effects but these are common reasons of noncompliance ( (esp. weight gain and sexual dysfunction) 2. Selective Serotonin Reuptake Inhibitors (SSRI) have fewer side effects than cyclic compounds enhanced serotonin transmission can lead to several common side effects: 1. anxiety 2. agitation

3. akathisia (treated with beta-blocker) 4. nausea (taking with food lessens nausea) 5. insomnia (sedative hypnotic or low dosage trazodone) 6. sexual dysfunction (diminished drive or difficulty achieving erection or orgasm) 7. cause less weight gain than other antidepressants less common side effects: 1. sedation * 2. sweating * 3. diarrhea 4. hand tremor 5. headaches

3. MAO Inhibitors (MAOIs) most common side effects: 1. daytime sedation * 2. insomnia * 3. weight gain 4. dry mouth 5. orthostatic hypotension 6. sexual dysfunction of particular concern with MAOIs is the potential for a lifethreatening hypertensive crisis if client ingests food containing tyramine or sympathomimietic drugs (refer to table 2.1, p. 35 regarding food containing tyramine) increased serum tyramine levels causes: 1. severe hypertension 2. hyperpyrexia 3. tachycardia 4. diaphoresis 5. tremulousness 6. cardiac dysrhythmias potentially fatal drug interactions with MAOIs: 1. SSRI 2. certain cyclic compounds 3. buspirone (BuSpar) 4. dextromethorpan 5. opiate derivatives (meperidine) 4. Other novel antidepressant medication: nefadozone causes: o sedation o headache o dry mouth o nausea trazodone o sedation o headache mirtazapine o sedation bupropion o loss of appetite o nausea o agitation

o insomnia venlafaxine o loss of appetite o nausea o agitation o insomnia o dizziness o sweating o sedation sexual dysfunction is less common but, with one notable exception: trazodone can cause priapism ( sustained and painful erection) which may result in impotence NURSING RESPONSIBILITIES: for cyclic compounds: o should be taken at night to lessen side effects o if forgets a dose, can take it up within 3 hours after missed dose or omit for SSRis: o clients should take it first thing in the morning unless sedation is a problem o if forgets a dose, can take it up within 8 hours after missed dose o client should avoid driving or performing activities requiring sharp, alert reflexes until sedative effects wear off for MAOIs: o client should be aware of life-threatening hyperadrenergic crisis if dietary restrictions are not observed. o provide a written list of foods to avoid while taking MAOIs o make client aware of serious and fatal drug interactions when taking MAOIs; instruct not to take additional medications, even OTC drugs without consulting doctor III. MOOD STABILIZERS used to treat bipolar disorders by stabilizing clients mood, preventing highs and lows characterizing bipolar illness, and treat acute mania examples: o Lithium most established mood stabilizer; first-line agent in treating bipolar normalizes reuptake of serotonin, norepinephrine, acetylcholine, and dopamine serum lithium level 1.0 mEq/L; should be monitored every 23 days toxicity is closely related to serum lithium levels and can occur at therapeutic doses. common side effects of lithium therapy: mild nausea or diarrhea (taking medication with food may help nausea) anorexia fine hand tremor (propranolol improves fine tremor) polydipsia polyuria a metallic taste in the mouth fatigue or lethargy

 weight gain and acne occur later in lithium therapy * lethargy and weight gain difficult to minimize leading to noncompliance toxic effects: severe diarrhea vomiting drowsiness muscle weakness lack of coordination * if symptoms left untreated, it worsens and can lead to renal failure, coma, and death * when toxic signs occur, discontinue lithium immediately if lithium levels exceed 3.0 mEq/L, dialysis may be indicated o some anticonvulsants are effective * and good mood stabilizers: carbamazepine (Tegretol) * - SE: drowsiness, sedation, dry mouth, and blurred vision; rashes and orthostatic hypotension; aplastic anemia and agranulocytosis valproic acid (Depakote, Depakene) * - SE: drowsiness, sedation, dry mouth, and blurred vision; weight gain, alopecia, and hand tremor; hepatic failure, pancreatitis; teratogenic gabapentin (Neurontin) topiramate (Topamax) SE: dizziness, sedation, weight loss, and increased incidence of renal calculi oxcarbazepine (Trileptil) lamotrigine (Lamictal) serious rashes requiring hospitalization (esp. below yrs of age), Steven-Johnson syndrome, and rarely, life-threatening toxic epidermal necrolysis o antianxiety agent clonazepam (Klonopin) is occasionally used to treat mania NURSING RESPONSIBILITIES: for clients taking lithium and anticonvulsants, monitor blood levels periodically; plasma levels can be checked 12 hours after last dose encourage client to take medications with meals to minimize nausea instruct client not to attempt to drive until dizziness, lethargy, fatigue, or blurred vision has subsided IV. ANTIANXIETY DRUGS also known as anxiolytic drugs used to treat anxiety and anxiety disorders, insomnia, OCD, depression, posttraumatic stress disorder, and alcohol withdrawal examples (table 2.6, p.37) benzodiazepines have proved to be the most effective in relieving anxiety and are the drugs most frequently prescribed ( also may be prescribed for their anticonvulsant and muscle relaxant effects o mediate the actions of a.a. GABA (major inhibitory neurotransmitter in the brain) o SE: tendency to cause physical dependence SE associated with CNS depression ( drowsiness, sedation, poor coordination, and impaired memory or clouded sensorium)

when used for sleep, may complain of next-day sedation or a hangover effect buspirone is a nonbenzodiazepine often used for the relief of anxiety o acts as partial agonist at serotonin receptors, which decreases serotonin turnover o common side effects: dizziness, sedation, nausea, and headache * elderly clients may have more difficulty managing the effects of CNS depression; more prone to falls from the effects on coordination and sedation; may have more pronounced memory deficit and may have problems with urinary incontinence particularly at night NURSING RESPONSIBILITIES: make client aware that antianxiety agents are aimed at relieving symptoms such as anxiety or insomnia but do not treat the underlying problems that cause the anxiety instruct client not to drink alcohol (benzodiazepines strongly potentiate the effects of alcohol) make client aware of decreased response time, slower reflexes, and possible sedative effects of these drugs when attempting activities such as driving or going to work inform client never discontinue drug abruptly once started without supervision of physician because benzodiazepines withdrawal can be fatal

Commonly Used Drugs in Psychiatric Ward (Pavilion 5 Unit 3 Big Hall)

Antipsychotic / Neuroleptic Drugs o haloperidol (Serenase, Haldol) 5 / 20 mg. o chlorpromazine (Thorazine, Psynor, Zycloran) 100 / 200 mg. o risperidone o clozapine o levomepromazine (Nozinan) 100 mg. o olanzapine * Short-Acting - haloperidol (Haldol, Serenase, Psycotil) 5 mg/ml * Long-Acting - haloperidol decanoate 50 mg/ml - fluphenazine decanoate 25 mg/ml - fluphentixol decanoate 25 mg/ml Anticonvulsants o carbamazepine (Tegretol, Tegrilol) 200 mg. o phenytoin (Sodium (Na), Dilantin) 100 mg. o valproic acid 250 mg. o divalproex Na (Epival) 250 mg. Antidepressants o fluoxetine (Prozac) 20 mg. o sertraline (Zoloft) 50 mg. Anti-parkinsonism o biperiden lactate (Akineton) 5 mg. o biperiden HCl (Akineton) 2 mg. Anti-anxiety o hydroxyzine dihydrochloride (Iterax) 25 mg. Other Medications: o Anithypertensives nifedipine, metropolol, captopril o Anti-TB INH, rifampicin, pyrazinamide o Anti-asthma

 salbutamol o Antipyeretic paracetamol o Antibiotic amoxicillin, doxycycline, cloxacillin, sultamicillin o Antiamoebics metronidazole o Antihistamine Diphenhydramine HCl (Benadryl) 50 mg.

SCHIZOPHRENIA
Chapter 14, page 276 Videbeck 3rd Ed. causes distorted and bizarre thoughts, perceptions, emotions, movements, and behavior cant be defined as a single illness; rather, is thought of as a syndrome or disease process with many different varieties and symptoms onset may be abrupt or insidious, but most clients slowly and gradually develop signs and symptoms such a social withdrawal, unusual behavior, loss of interest in school or work, and neglected hygiene peak incidence of onset: o male 15-25 years of age o female 25-35 years of age usually diagnosed in late adolescence or early adulthood (rarely manifests in childhood) the diagnosis usually is made when the person begins to display more actively positive symptoms of delusions, hallucinations, and disordered thinking (psychosis) symptoms are divided into two major categories: (refer to table on p. 276) o positive or hard symptoms/signs ambivalence associative looseness delusions echopraxia flight of ideas hallucinations ideas of reference perseveration o negative or soft symptoms alogia anhedonia apathy blunted affect catatonia flat affect lack of volition those who develop the illness earlier show worst outcomes that those who develop it later; younger client display a poorer pre-morbid adjustment, more prominent negative signs, and greater cognitive impairment than do

older clients; those who experience a gradual onset of the disease (about 50%) tend to have both a poorer immediate and long-term course than those who experience a acute and sudden onset approximately 30% of clients with schizophrenia relapse within 1 year of an acute episode the intensity tends to diminish with age; over time, the disease becomes less disruptive to the persons life and easier to manage, but rarely can the client overcome the effects of many years of dysfunction medication can control the positive symptoms, but frequently the negative symptoms persist after positive symptoms have abated; the persistence of these negative symptoms overtime presents a major barrier to recovery and improved functioning in the clients daily life types of schizophrenia according to the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorder, 4th edition, Text Revision): o Schizophrenia, paranoid type: characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and, occasionally, excessive religiosity (delusional religious focus) or hostile and aggressive behavior o Schizophrenia, disorganized type: characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior o Schizophrenia, catatonic type: characterized by marked psychomotor disturbance, either motionless or excessive motor activity motor immobility may be manifested by catalepsy ( waxy flexibility) or stupor excessive motor activity is apparently purposeless and is not influenced by external stimuli other features include extreme negativism, mutism, peculiarities of voluntary movement, echolalia, and echopraxia o Schizophrenia, undifferentiated type: characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior o Schizophrenia, residual type: Characterized by at least one previous, though not a current episode; social withdrawal; flat affect; and looseness of associations antipsychotic medications play a crucial role in the course of the disease and individual outcomes; they do not cure the disorder, however, they are crucial to its successful management the more effective the clients response and adherence to his or her medication regimen, the better the clients outcome individual and group therapies, family therapy, family education, and social skills training can be instituted for clients in both inpatient and community settings