Pharmacology in Psychiatry

Antonietta Rosemelinda Edra

Pharmacology

Goal - To administer the medication and dosage that will maximize the therapeutic effects and minimize the side effects.

Pharmacology
Psychotropic medications chemicals that produced profound effects on mind, emotions and body. 3 major psychotropic drugs. includes
antimanic, anti psychotic, anti depressant anti anxiety/ anxiolytics antipsychotic/ neuroleptics anti depressant anti manic mood stabilizing agents sedative hypnotic agents

psychotropic drugs during pregnancy

Pharmacology
Anti anxiety/ anxiolytic drugs Uses: Treatment of anxiety, alcohol withdrawal, induction of sleep Effects : depresses the CNS Preparation: oral and IV preparations Benzodiazepines ( inhibitory neurotransmitter in CNS) opening Cl ion channel inhibition of neuronal activity firing rate of neurons anxiety.

Pharmacology
Types A. Benzodiazepines Short acting Alprazolam (Xanax) Estazolam ( Prosan) Midazolam ( Versed) Oxazepam ( Serax) Triazolam ( Halcion) Medium acting Lorazepam ( Ativan) Temazepam ( Restoril) Long acting Chlordiazepoxide ( Librium) Clonazepam ( Klonopin) Clorazepate ( Tranxene) Diazepam ( Valium) Flurazepam ( Dalmane) Quazepam ( Doral)

Pharmacology
B. Non barbiturate
Buspirone ( Buspar) Chloral hydrate ( Noctec) Diphenhydramine ( Benadryl) Doxylamine ( Unisom) Hydromxyzine ( Atarax. Vistaril) Zolpidem ( Ambien) Clomipramine ( Anafranil) Fluoxetine ( Prozac) Fluvoxamine ( Luvox) Paroxetine ( Paxil) Sertarline ( Zoloft) Venlafaxine ( Effecxor XR)

C. Antidepressant for anxiety

Pharmacology
Precautions 1.potentiate effects of alcohol and other sedatives. 2. adverse effects: Decrease mental alertnesscaution driving , operating vehicles. 3.Tolerance- physical and emotional 4.a drop in b/p 20 mmHg standing notify physician 5.Withdrawal symptoms- when stopped abruptly 6. caffeine worsen the symptom of anxiety.

Pharmacology
Neuroleptics/ Antipsychotic Uses- used to treat agitated behavior and psychotic symptoms. Actions: Acts by blocking dopamine receptors in the CNS. They also block muscarinic receptors for acetylcholine, and alpha receptors for acetylcholine. Preparation: IV, IM, Oral Effective in treating symptoms of psychosis, May be taken with benzodiazepines to lessen the dose of neuroleptics Effects seen within 1-2 weeks of treatment

Pharmacology
These drugs are beneficial for 1. Positive symptoms ( Type I) schizophrenia Hallucinations and delusions Respond to newer and traditional antipsychotic drugs. 2. Negative symptoms ( Type II) Apathy, flat affect are more responsive to Newer atypical anti psychotic drugs.

Pharmacology
Types: Traditional drugs/ Typical drugs Phenothiazines aliphatics- Chlorpromazine ( Thorazine) Piperidines - Mesoridizine ( serentil), Thioridazine ( Melleril) Piperazines- a. Fluphenazine ( prolixin, permitil) b. Perphenazine ( triaflon) c. Prochlorperazine- ( Compazine) d. Trifluoperazine ( Stelazine) B. Butyrophenones : Droperidol ( Inapsine) Haloperidol ( Haldol) C. Thioxanthines : Chlorprothixene ( Taractan) Thiothixene ( Navane) D. Dibenzoxapine : Loxapine ( loxitane) E. Dihydroindolone Molindone ( Moban) F. Diphenylbutylpiperidine Pimozide ( orap)

Pharmacology
Atypical drugs A. DibenzodiazepineClozapine ( Clozaril) Quetiapine ( Seroquel) B. Benzisoxazole- Respiradone ( Resperdal) Ziprasidone ( Zeldox, Geodon) C.Thienobenzodiazepine- Olanzapine ( Zyprexa)

Pharmacology
Precaution: Drug interactions
Potentiate action of alcohol barbiturates, antihypertensives and anti cholinergics- must be avoided Should be temporary discontinued when spinal and epidural anesthesia will be used.

Adverse Effects Agranulocyctosis- sore throat, colds Hepatotoxicity- Jaundice Drowsiness- CNS depression Orthostatic hypotension- CNS depression Constipation and urinary retention- anticholinergic effect Anorexia- depressed appetite centers Hypersensitivity reactions Cardiac toxicity

Pharmacology
Extrapyramidal Side effects (EPS) Manifestation- grimacing , torticollis, intermittent muscle spasms. Manisfestation- tremor, mask like facies, drooling , restlessness, festinating gait, rigidity.
Pseudoparkinsonism- resembles true parkinsonism Dystonia- Occurs early in treatment after initial dosage

Akathisia- motor agitation- restlessness , festinating gait, rigidity. Akinesia- fatigue, weakness, ( hypotonia, painful muscles, lack of energy ( anergy) Tarditive Dyskinesia- Late appearing after prolonged use of antipsychotic drugs.- involuntary movement of face ,jaw and tongue , lip smacking, grinding of teeth , rolling or protrusion of tongue.

Pharmacology
Conditions disappears with sleep- all anti psychotics should be discontinued to see if symptoms subside. Symptoms- Hyperthermia ( cardinal symptom) Muscular rigidity Tremors Impaired ventilation Unstable blood pressure Anti Parkinson drugs Blocks the extrapyramidal symptoms. Anti cholinergics- Benztropin ( Cogentin), Biperiden (Akineton) Trihexyphenidyl ( Artane) Antihistamine- Diphenhydramine ( Benadryl)
Neuroleptic malignant syndrome- results from dopamine blockade in the hypothalamus- associated with high dosage of anti psychotic drugs.

Pharmacology
Others drugs Amantadine ( Symmetrel)- neuroleptic malignant syndrome Benzodiazepine- for akinesia, akathisia Bromocriptine ( Parlodel)- NMS Clonidine ( Catapres)- EPS Nifedipine- tarditive dyskinesia Propranolol- EPS Verapamil( Calan) Tarditive dyskinesia

Pharmacology
Nursing Care monitor for signs of hepatotoxicity- Jaundice monitor for signs of infection colds and sore throat monitor B/P in supine and standing position assist in ambulation- sit first before standing CBC- for long term theraphy Avoid alcohol intake with concurrent medication esp. if taking benzodiazepines avoid hazardous activities Avoid exposure to direct sunlight provide sunscreens EPS noted report to physician water and high fiber diet- prevent constipation Avoid mixing neuroleptics with certain juices and beverages ( Coffee, tea, cola beverages) - effectiveness of the drug. Avoid antacids- or take them 1-2 hours after administration of anti psychotics- decreases absorption of antipsychotics. Avoid smoking- decrease levels of anti psychotics.

Pharmacology
Anti depressants Indication- Major depressive illness For treatment of Panic disorder, Narcolepsy, ADHD, Enuresis Mechanism of action: it affects the neurotransmitter serotonin and norepinephrine - by partially blocking their reuptake- down regulation Preparation: oral, IM preparations Selective Serotonin Reuptake Inhibitors- use in eating disorders and OCD It takes 2-3 weeks before therapeutic responses is felt occurs. Monoamine Oxidase Inhibitors- Elevates norepinephrine levels , by interfering with the enzyme mao, rarely used due to food interaction resulting to hypertensive crises.

Pharmacology
1.TCA nonselective/ Cyclic 1. Amitirptyline ( Elavil, Endep) 2. Clomipramine ( Anafril) 3. Desipramine ( Norpramin) 4. Doxepin ( Sinequan, Triadapin) 5. Imipramine ( Tofranil) 6. Nortrptyline ( Aventyl, Pamelor) 7. Protriptyline ( Vivactil, Triptal) 8. Trimipramine ( Surmontil) 2. Monoamine Oxidase Inihibitors 1. Phenelzine sulfate ( Nardil) 2. Selegiline ( Eldepryl) 3. Tranycypromine sulfate ( Parnate) 3. Selective serotonin reuptake inhibitors 1. Citaprolam ( Celexa) 2. Fluoxetine ( Prozac, Saralem) 3. Fluvoxamine ( Lexapro, Luvox) 4. Paroxetine ( Paxil) 5. Sertraline ( Zoloft)

Pharmacology
Atypical New Generation
Amoxapine ( Ascendin) Bupropion (Wellbutrin) - tx smoking Maprotiline ( Ludiomil) Mirtazapine ( Remeron) Nefazodone ( Remeron) Trazodone ( Desyrel) Venlafaxine (Effexor)

Drug Interactions- TCA Potentiates effects of anticholinergics and CNS depressant Adverse effects Orthostatic hypotension, skin rash, drowsiness, dry mouth, blurred vision, constipation, urine retention, tachycardia, CNS stimulation older patients restlessness, incoordination, fine tremors, night mares , delusions disorientation. TCA should not be given with narrow angle glaucoma TCA contraindicated to patients with or during recovery from MI or with history of cardiac dysrythmias and conduction defects. Minimum of 14 days between switching TCA to MAOI to avoid hypertensive crises. Abrupt discontinuation can produce- nausea, head ache, malaise.

Pharmacology

Pharmacology
MAO Inhibitors Drug interaction- MAO potentiates the effects of alcohol, barbiturates, anesthetic agents, cocaine , antihistamine, narcotics, corticoids, anticholinergics. Drug Foods interaction- Hypertensive crises- with vascular rupture, occipital head ache, palpitations , stiffness of neck muscles, emesis, sweating. Increase neuro-hormonal changes secondary to ingestion of food high in tyramine beer, wine , chicken livers, aged or natural cheese, chocolate caffeine cola, licorice avocado, bananas , bologna.

Pharmacology
Adverse EffectsCNS- orthostatic hypotension, Hypersensitivity resction- skin rash CNS depression- drowsiness Anticholinergic effects- dry mouth, blurred vision,tachycardia Autonomic effect- sexual disfunction CNS stimulation- nightmares, delusion, disorientation, insomnia

Pharmacology
Selective Serotonin Reuptake Inhibitor(SSRI`s) Drug interaction- may interact with tryptophan.. Diazepam, Warfarin, Digoxin should be discontinued 4-6 weeks before starting SSRI. Adverse Effect- insomnia, head ache, dry mouth sexual dysfunction, anxiety, diarrhea. SSRI`s are given at noon time to avoid insomnia, or sleep disturbances.

Pharmacology
Atypical New Generations drugs Adverse effects- increase appetite, weight gain and sleep disturbances. Bupropion- affect dopamine can result to agitation.
used in treatment of smoking cessation.

Pharmacology
Nursing Care for patients receiving Antidepressants monitor self destructive behavior esp. during the 2nd week of treatment when suicidal ideation remains and energy increases. Monitor serum glucose levels. Expect therapeutic effect to be delayed . < 3wks with MAOI , 3-4 wks with the other antidepressants. Avoid concurrent administration with adrenergics. , limit or eliminate caffeine use- to prevent exacerbation of depression.

Pharmacology
Anti Manic and Mood stabilizing Agents Action: Use to control manic episodes and mood disorders, it decrease psychomotor response/ activity to environmental stimuli. LITHIUM affects neurotransmitters of multiple systems including dopamine, serotonin, norepinephrine, GABAand acetylcholine. Preparation: oral tablets and capsules

Pharmacology
Types Anti manic agents and mood stabilizers Lithium Carbonate (Eskalith, Lithotabs, Lithane , Lithonate) Lithium Carbonate sustained released ( Eskalith C-R, Lithobid) Alternative anti manic and mood stabilizing agents Carbamazepine ( Tegretol) Gabapentin ( Neurontin) Lamotrigine ( Lamictal, Lamivtal cd) Topiramate ( Topimax) Valproate ( Depakene, Dapakote, Depacon, Epival)

Pharmacology
Precautions: Drug /Food interaction: Diuretics increase the reabsorption of lithium.- Toxicity When given with haloperidol and thioridazineencephalopathic syndrome Na bicarbonate, Na Cl Increases the excretion of Lithium. Daily intake of 250 mg of caffeine with lithium decreases effect of antimanic drugs. Thetapeutic level of Lithium- 0.5-1.5 mEq/L Clinical response is 1-2 wks after taking the first dose

Pharmacology
Nursing care Administer with meals- prevent gastric irritation Ensure that drug is not crushed nor chewed Medication should not be discontinued abruptly Maintain Na intake-Hyponatremia and dehydration- Lithium toxicity Monitor therapeutic levels of lithium Check for signs of toxicity- vomiting , diarrhea, tremors , weakness, severe thirst, tinnitus. visual disturbances and skin rashes.

Pharmacology
Sedative and Hypnotic drugs Uses: insominia, hypersomnias, narcolepsy, parasomnias, periodic leg movements (nocturnal myoclonus), sleep apnea. Preparations : Available in Oral, IM Hypnotic cause sleep and have a more potent effect on the CNS than sedatives. Sedative hypnotics are classified chemically into 3 groups Barbiturates, Benzodiazepins, non benzodiazepines

Pharmacology
Precautions/ nursing consideration Intended only for short term use- physiologic addiction, overdose Barbiturates- increase the metabolism of anti coagulants because they induce liver enzyme synthesis. Chloral hydrate and paraldehyde- not use in alcohol withdrawal- toxic Paraldehyde- status epilepticus when all drugs have failed Once tolerance have developed abrupt discontinuation could lead to withdrawal

Pharmacology
Withdrawal- insomnia, weakness, muscle tremors, anxiety, irritability, sweating, anorexia, fever, nausea and vomiting, head ache , incoordination. To avoid withdrawal- taper dosing of sedative hypnotic medications. Any of the sedative hypnotic when taken in excess could lead to unconsciousness, coma and death. Assess for signs of alcohol and suicide attempts. Assess for undesired effects such as respiratory depression. Evaluate clients response to medications and understanding of teaching.

Pharmacology
End of lecture Reference Mosby`s comprehensive review of Nursing for NCLEX RN 8th edition

Rosemelle C. Edra