Antipsychotic Drugs

y Neuroleptics y Use to treat the symptoms

of psychosis y Off Label uses: treatment of anxiety and insomnia; aggressive behavior; and delusions, hallucinations, and other disruptive behaviors that sometimes accompany Alzheimer s Disease

Mechanism of Action
y The major action of all antipsychotics in the nervous

system is to block receptors for the neurotransmmitter dopamine. Dopamine receptors are classified into subcategories (D1, D2, D3, D4, D5), and D2, D3, and D4 have been associated with mental illness.

Classifications of Antipsychotics
y Typical and atypical antipsychotics:
y Typical - e.g. phenothiazines (chlorpromazine),

thioxanthines (flupentixol), butyrophenones (haloperidol), diphenylbutylpiperidines (pimozide), substituted benzamides (sulpiride). y Atypical - e.g. amisulpiride, olanzapine, quetiapine, risperidone and zotepine. These are on the whole better tolerated with fewer extra-pyramidal side-effects.

y According to potency:
y High potency - e.g. haloperidol and fluphenazine. y Intermediate potency - e.g. perphenazine. y Low potency - e.g. chlorpromazine.

y Preparations:
y Oral - the majority. y Depot preparations

Side Effects
y Extrapyramidal Side effects y They include acute dystonia, pseudoparkinsonism, and akathisia. y Therapies for acute dystonia, pseudoparkinsonism, and akathisia are similar and include lowering the dosage of the antipsychotic or changing to a different antipsychotic or administering anticholenergic medication.

Acute dystonia
y includes acute muscular rigidity and cramping, a stiff

or thick tongue with difficulty swallowing, and in severe cases, laryngospasm and repiratory difficulties. y Spasms or stiffness in muscle groups can produce torticollis (twisted head and neck), opisthotonus (tightness in the entire body with the head back and an arched neck), or oculogyric crisis (eyes rolled back in a locked position).

y Immediate treatment with anticholinergic

drugs, such as intramuscular benztropines mesylate (Cogetin) or intramuscular or intravenous diphenhydramine (Benadryl) usually bring rapid relief.

Drug-induced parkinsonism or pseudoparkinsonism

y is often reffered to by the generic label of EPS. y Symptoms resemble those of Parkinson s disease and

include a stiff, stooped posture; mask-like facies; decreased arm swing; a shuffling, festinating gait (with small steps); cogwheel rigidity (rachet-like movements of joints); drooling; tremors; bradycardia; and coarse pill-rolling movement of the thumb and fingers while at rest.

Akathisia
yis reported by the client as an

intense need to move about.

Neuroleptic Malignant Sydrome

y NMS is a potentially fatal idiosyncratic reaction to

antipsychotic drugs. y Majors symptoms include rigidity, high fever, autonomic instability such as unstable blood pressure, diaphoresis, and pallor; delirium; and elevated levels of enzymes (creatinine phosphokinase).

Tardive Dyskinesia
y characterized by repetitive, involuntary,

purposeless movements, such as grimacing, tongue protrusion, lip smacking, puckering and pursing of the lips, and rapid eye blinking.

Anticholinergic Side Effects

y side effects includes orthostatic hypotension, dry

mouth, constipation, urinary retention, blurred near vision, dry eyes, photophobia, nasal congestion and decreased memory.

Client Teaching
y The nurse informs the client of the type of side effects

that may occur. y The nurse teaches the client methods of managing or avoiding unpleasant side effects (Drinking sugar-free fluids, eating sugar-free hard candy ease dry mouth. Exercise and increasing water and bulk forming foods may promote or relieve constipation. Avoid laxatives but use stool softeners) y Clients should monitor sleepiness or drowsiness they feel. y Clients should avoid driving and other potentially dangerous activities that requires alertness and reflexes.

ANTIDEPRESSANT DRUGS
y is a psychiatric medication used to alleviate mood

disorders, such as major depression and anxiety disorders such as social anxiety disorder , and dysthymia. y Although the mechanism of action is not completely understood, antidepressants somehow inact with the two neurotransmitters, norepinephrine and serotonin, that regulate mood, arousal, attention, sensory processing, and appetite.

y It is divided into four groups:

y Tricyclic and the related cyclic

antidrepessants y Selective serotonin reuptake inhibitors (SSRIs) y MAO inhibitors (MAOIs) y Other antidepressants such as venlafaxine (Effexor), bupropion (Wellbutrin), duloxetine (Cymbalta), trazodone (Desyrel), and nefazodone (Serzone)

Cyclic Compounds
y The cyclic compounds became available in 1950s and

for years were the first choice of drugs to treat depression even though the cause varying degrees of sedation, orthstatic hypotension, and anticholiergic effects. y Usually given orally, are typically well absorbed, and reach peak plasma concentrations in 2 to 6 hours; usually called the dirty drugs by psychiatrics and other mental health clinicians because they act on so many different receptors systems.

Side effects
y Anticholinergic effects. Include blurred vision, dry mouth, rapid heart rate, constipation, urinary retention, and impaired memory function. y Antihistaminic effects. Include weight gain, sedation, hypotension, and interaction with other drugs that cause CNS depression.

y Alpha-adrenergic effects. Include postural hypotension, dizziness. And potential interaction with some antihypertensive medications. y Antidopaminergic effects. Include movements disorders and endocrine changes.

Adverse effects
y Accidental or intentional overdose. Symptoms include CNS depression, widening of electrocardiogram (EKG) QRS complexes with associated heart blocks, shock, seizures, and dangerous temperature elevations. May also increase risk of suicide.

Nursing Responsibilities
y Assess suicidal risk y Assess how often prescription is being refilled y Assess if drug is taken daily. y Conduct pill counts to determine if take daily y Blood levels of the drug are indicated if there is a

concern about the dose. Therapeutic dose (300mg/daily), 3-4days supply is equivalent to lethal dose.

SSRIs
y Selective serotonin reuptake inhibitors or

serotonin-specific reuptake inhibitor (SSRIs) are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorder, and some personality disorder. y SSRIs boost levels of a substance called serotonin in the brain. When serotonin is released in the brain, it helps lift mood. It is thought that people with depression release only small amounts of serotonin.

y Enhanced serotonin transmission can lead

to several common side effects such anxiety, agitation, akathisia (motor restlessness), nausea, insomnia, sexual dysfunction, specially diminished sexual drive or difficulty achieving erection or orgasm. During the antidepressant therapy it can cause weight gain. Akathisia is usually treated with propanolol (Inderal).

Nursing Responsibilities
y SSRIs should be take first in the morning unless sedation is a problem. Clients should exercise caution when driving or performing activities that requires sharp, alert reflexes until sedatives effect.

MAOIs
y Monoamine Oxidase Inhibitors - commonly known as MAOIs - were the second type of antidepressants developed, after the tricyclics. Because of the way they work, MAOIs have significant dietary restrictions and important limitations on what other drugs may be taken at the same time. y The brain's neurotransmitters serotonin, norepinephrine, and dopamine are all monoamines, meaning they have a single amino acid group. In the gap between nerve cells the synapse - used neurotransmitters are destroyed by an enzyme called monoamine oxidase (MAO).

Why MAOIs Have Dietary Restrictions

y The enzyme monoamine oxidase has another role in

the brain - it controls levels of tyramine, which affects blood pressure. When an MAOI blocks the activity of the MAO enzyme, along with higher levels of neurotransmitters, it causes higher levels of tyramine, and blood pressure can go up.

Foods to Avoid
y Aged cheeses, some processed cheeses (cottage cheese,

y y y y y

cream cheese, pot cheese and ricotta cheese are allowed) Chianti, vermouth, sherry, red wines, tap beer, nonalcoholic beer and wine Broad (fava) beans Sauerkraut Italian green beans Snow pea pods

y Soy products, especially soy sauce and tofu y Aged or cured meats y Caviar y Liver y Concentrated yeast extract, brewer's yeast, yeast

supplements, yeast paste (marmite), miso (commercial leavened products with baker's yeast are allowed) y Acidophilus and products with acidophilus y Any food that is not fresh, overripe, close to expiration date

Drug Interactions
The most common of these include: y Allergy, cold, cough and sinus medications (including nasal sprays/drops) y Amphetamines y Antihistamines y Antipsychotics y Asthma drugs y Blood pressure medications y BuSpar y Cocaine*

y Demerol* y Other antidepressants not specifically listed, including

other MAOIs y Prozac* y Ritalin y Tegretol y Tricyclic antidepressant* y Tryptophan y Wellbutrin *Starred items are highly dangerous when combined with MAOIs

Side effects of Other antidepressant Drugs

y Of the other or novel antidepressant medication,

nefazodone, trazadone, mirtazapine (Remeron) commonly cause sedation. Both nefazodone and trazadone commonly cause headaches. y Bupropion and venlafaxine- loss of appetite, nausea, agitation and insomnia y Venlafaxine- sweating, dizziness, or sedation y Sexual dysfunction is much less common with the novel antidepressants , except Trazodone.

THE END