psychotropic meds sv 8 15

8/6/2019 Psychotropic Meds SV 8 15

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Psychotropic Drugs

Mental Health Jene Hurlbut, RN, MSN, CFNP


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Objectives: Discuss the functions of the brain and the way this

can be altered by the use of psychotrophicmedications

Discuss how the neurotransmitters are affected byvarious psychotrophic medications

Discuss the application of the nursing process withvarious psychotrophic medications

Identify specific cautions to be aware of the variouspsychotrophic medications


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Psychotropic Drugs Locus of all mental activity is the brain

Origin of psychiatric illness caused bymany factors: Genetics

Neurodevelopment factors

Drugs Infections

Psychosocial experiences, etc.


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Psychotropic Drugs-continue Theories behind use of psychotropic drugs focuses on

neurotransmitters and their receptors

Psychotropic drugs act by modulating neurotransmitters

Go to: http://www.wisc-online.com/

Health: Nursing, activity #3503 (Psychotropic Medications andNeurotransmitters)

Or try: http://www.wisc-online.com/objects/index_tj.asp?objID=NUR3503


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Review: Cellular composition

of brain Neurons-nerve cells that conduct electrical

impulses

Neurotransmitter-chemical that is releasedin response to an electrical impulse(neuromessenger). Attaches to a receptors on cell surface and either

inhibits or excites Major target of psychotropic drugs

See table 3-1 on pg. 40 !!!!


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Use of psychotropic meds: Relieve or reduce s/s of dysfunctional

thoughts, moods, or actions, & mentalillness

Improve clients functioning

Increase compliance to other therapies


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Therapeutic Effects of

Psychotropic Meds Do not cure

Relieve or decrease

symptoms Prevent or delay return

of S/S

Cannot be used as the

sole tx for disorders Need informed consent

before starting

Are broad spectrum andhave effects on a large

number of S/S. Initial effects are

sedative in nature

May take weeks foreffects to be seen


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Reasons for Nonadherence: Meds are expensive

Unpleasant sideeffects

Feel better anddecide no longerneed

Stigma associatedwith having a

mental illness andtaking meds

Paranoia or fears

about med usage


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Services Encouraging Compliance

to Medication Regimen: Follow-up appts. With client to verify that client understands the

purpose, proper administration, intended effects, side and toxiceffects of, and how to treat problems associated with meds

Support persons can encourage and assist the client to complywith meds

Appropriate lab tests must be conducted to preventcomplications and assure correct levels of drugs

Encourage clients to participate in med groups

Can use injections of antipsychotics which will last from 2-4weeks if clients are non-compliant


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Efficacy of Psychotropics with

Children & Elderly Use with great caution

Startlow and go slow for both elders andchildren!!

Elders have decrease liver & renal function

Risk of injuries and falls with elderly


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Client & Family Teaching Purpose of the meds

and benefits, side

effects and how totreat SE.

What S/S indicate atoxic effect, and

how to treat, andwhom to call.

Specific instructionsabout how to takethe meds


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Psychotropic Meds

Classifications: Antipsychotics

(neuroleptics)

Mood Stabilizers

Antidepressants

Anxiolytics(antianxiety)

Sedatives

Hypnotics

Psychostimulants

Antihistamines,antimuscarinics,dopamine agonists


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Uses for

Antipsychotics/Neuroleptics Schizophrenia

Disorders

Bipolar-Manic Phase

Major Depressionwith psychoticfeatures

Tourettes Syndrome

Control ofintractable hiccups

Dementia, andDelusions

Aggressive behavior


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Antipsychotic Meds-

Neuroleptics First generation:

Phenothiazines=

Thorazine,Mellaril,Stelazine,Prolixin (highpotency)

NonPhenothiazines=

Haldol(butyrophenones)

(high potency)

Atypical Antipsychotics(2nd and 3rd gen)=

Clozaril,

Zyprexa,Risperdal,Geodon,Seroquel,

Zeldox

Invega,Abilify


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First Gen Antipsychotic Meds Block

predominantly

dopamine activity little effect on

serotonin

High incidence ofabnormalmovements

(Also blocks acetylcholine,norepinephrine to somedegree)

Blocks the Hreceptor for

histamine results in sedation

and weight gain


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Side Effects of 1st

Gen Drugs Dystonia

(EPS)=spasms of the

eye, neck-torticollis,back, tongue-happenswithin 72 hrs.reversible.

Akathisia (EPS)=

restlessness

Pseudoparkinson-S/S similar to

Parkinson's-see in 1-2weeks. May disappear.TX. With Cogentin

Tardive Dyskinesia-bizarre facial andtongue movements-irreversible.


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Other S/E of 1stgen

Antipsychotics Amenorrhea

Galactorrhea

Blurred vision, dry mouth,constipation and urinaryretention, tachycardia-anticholinergic S/E

Sexual dysfunction

Severe dysrhythmias

In men can lead togynecomastia

photosensitivity & skinrashes (i.e. haldol)

Reduction is seizurethreshold

Orthostatic hypotension

Agranulocytosis


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Contraindications of Traditional

Antipsychotics (1stGen): Blood dyscrasias

Liver, renal, or cardiac insufficiency

CNS depressants, including ETOH

Tegretol in conjunction withantipsychotics causes up to 50%reduction in antipsychoticconcentrations

SSRIs in conjunction withantipsychotics may cause suddenonset of EPS

Dont give if have: Parkinson'sdisease, prolactin dependent cancerof the breast

Cigarette smoking causes reducedplasma concentrations ofantipsychotics

Luvox in conjunction withantipsychotics causes increasedconcentrations of Haldol and Clozaril

Beta Blockers in conjunction withantipsychotics cause severehypotension

Antidepressants in conjunction withantipsychotics may cause increasedantidepressant concentrations


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First Generation Antipsychotic

MedsAre useful in getting out of control

behavior under control quickly.

These can be given with lithium to gettreat acute mania.


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Atypical AntipsychoticsAction:

Blocks serotonin and to a lesser degree,dopamine receptors

Also block receptors for norepinephrine ,histamine, acetylcholine


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Atypical Antipsychotics- 2nd

and 3rd

generation drugs Nicer drugs and are

used more!!

Decrease positive andnegative S/S ofSchizophrenia

These drugs blockserotonin as well asdopamine

Incidence of abnormalmovements is lower!

Biggest SE is wt. gain


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Positive & Negative S/S of

Schizophrenia Positive:

Hallucinations

Delusions

Abnormal thoughts

Bizarre behavior

Confused thoughts

Negative:

Blunted affect

Poverty of speech

Social withdrawal

Poor motivation


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Atypical Antipsychotics-2nd and 3rd

generation:

Clozaril (clozapine)

low incidence ofabnormal

movements

possible fatal sideeffect:

bone marrowsuppression &agranulocytosis(rare)

Most common S/E: sedation &

drowsiness, wt. gain

Other S/E are: hypersalivation,

tachycardia, &dizziness, seizure risk


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generation: continue

Risperidone

Does not cause bone

marrow suppression Can cause at higher

doses motordifficulties

Available as a longacting injection

Can be used to tx.mania

Seroquel(Quetiapine)

S/E sedation, weightgain and headache

Not associated withabnormalmovements


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generation: continue Zyprexa (olanzapine)

does not cause bone marrow suppression Can cause weight gain & hyperglycemia Adverse effects-Drowsiness, insomnia restlessness

Geodan (ziprasidone) Binds to multiple receptor sites Main S/E are hypotension & sedation Can prolong the QT interval-can be fatal if hx of cardiac arrhythmias

Abilify (Aripiprazole) Dopamine stabilizer Partial agonist at the D2 receptor In areas of the brain with excess dopamine, it lowers dopamine In areas of low dopamine, it stimulates receptors to raise the dopamine

level Main S/E are sedation, hypotension, and anticholinergic effects Adverse effects-headache, anxiety insomnia, GI upset


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Contraindications for Atypical

Antipsychotics: Known hypersensitivity

CNS depression, including ETOH

Blood dyscrasias in clients with

Parkinsons disease

Liver, renal, or cardiac insufficiency

Use with caution in diabetics, elderly, ordebilitated

SSRIs in conjunction with antipsychotics

may cause sudden onset of EPS

Cigarette smoking causes reducedplasma concentrations

Tegretol(carbamazepine) in conjunction withantipsychotics causes up to 50%reduction in antipsychotic levels

Luvox (fluvoxamine) in conjunction withantipsychotics causes increasedconcentrations of Haldol & Clozaril

Beta Blockers in conjunction withantipsychotics cause severe hypotension

Antidepressants in conjunction withantipsychotics may cause increasedantidepressant concentrations


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Antipsychotics Can be given be given as an IM

injection (depot preparations) if have

difficulty taking oral meds.

Can use lower doses when given IM, so

less risk of tardive dyskinesia


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Neuroleptic Malignant

Syndrome Rare, but fatal

complication from allantipsychotic drugs

See more with 1stgendrugs

Severe muscle rigidity

High temp up to 107

Tachycardia

Tachypnea

Stupor

Coma


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Mood Stabilizers Used in the

treatment of Manic

(Bipolar) disorder,and in some formsof depression

Drugs used Lithiumand Antiepileptic

Drugs


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Lithium Mechanism of action

unknown

Interacts with sodiumand K+

Alters electricalconductivity potential threat to all

body functions that areregulated by electricalcurrents

Can cause polyuria andpolydipsa due to Na andK alterations

Has the lowesttherapeutic index of allpsych drugs

Have to monitor bloodlevels of this drug


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Lithium Maintenance blood levels of

lithium are usually 0.4-1.3 mEq(toxicity occurs with levels > 1.5mEq/L)

Sign of toxicity is a fineintention tremor that becomesmore pronounced and coarse.

Risk of thyroid & kidney disease

If toxic s/s occur discontinue thedrug and notify health careprovider

Lithium should be taken withfood

Client must eat a balanced dietwith normal sodium intake andtake in adequate fluid (about 2-3 liters/day).

Excretion is dependent on this.

Dehydration and salt restrictioncan increase lithium levels &cause toxicity.

Takes 2-3 weeks for lithium tobecome effective (may useantipsychotic until therapeuticlevels are reached)


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Signs & symptoms of lithium

toxicity: Fine hand tremors

that progress of

coarse tremors Mild GI upset

progressing topersistent upset

Slurred speech andmuscle weaknessprogressing tomental confusion

Severe Toxicity:

decrease level of

consciousness tostupor and finallycoma

Seizures, severehypotension, severepolyuria with diluteurine


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Lithium:

Lithium serum concentrations are increased byfluoxetine (Prozac), ACE inhibitors, diuretics, andNSAIDs

Lithium serum concentrations are decreased bytheophylline, osmotic diuretics, and urine alkalinizers


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Contraindications for Lithium: Renal disease

Cardiac disease

Severe dehydration

Sodium depletion

Brain damage

Pregnancy or lactation

Use with caution in the elderly or clients with diabetics, thyroiddisorders, urinary retention, and seizures


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Anticonvulsants/Antiepileptic

Drugs Causes an increase in GABA in the CNS-which

causes a decrease in anxiety.

Reduce the mood swings with bipolar


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Anticonvulsants/Antiepileptic

Drugs Tegretol (carbamazepine)-also used to treat

severe pain (i.e. trigeminal neuralgia)

Depakote (valproic acid)-can cause hepaticfailure, pancreatitis, & thrombocytopenia.Watch for liver failure

Klonopin (clonazepam)

Lamictal (Lamotrigine)-can have a rare butfatal dermatological condition


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Toxic Effects of

Anticonvulsants: Tegretol can cause agranulocytosis and

aplastic anemia

Depakote can cause liver dysfunction, hepaticfailure, and blood dyscrasias includingthrombocytopenia

Depakote interacts with drugs that arehepatically metabolized


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Contraindications for

Anticonvulsants : Hepatic or renal disease

Pregnancy

Lactation

Presence of blood dyscrasias


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Unique teaching needs with

anticonvulsants: Monitor blood levels of mood stabilizers to

prevent toxicity

Monitor liver, renal function tests and CBCs

Depakote must be swallowed whole, not cut,chewed, or crushed to prevent irritation


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Antidepressants Tx of depressive moods, including

bipolar disease

4 categories: Tricyclics

MAOIs SSRIS

Atypical Antidepressants


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Antidepressant Drugs Tricyclics- Elavil, Tofranil

SSRIs-Zoloft, Paxil

MAOIs- Nardil, Parnate, Marplan


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Atypical Antidepressants Inhibits selective

reuptake of serotonin:Trazodone (desyrel)

NorepinephrineDopamine ReuptakeInhibitor (NDRI):Wellbutrin (Bupropion)

Serotonin &norepinephrinereuptake inhibitor:

Cymbalta (duloxetine)

Sertonin NorepineprineReuptake Inhibitor-(SNRI): Effexor

(venlafaxine)

Increases release ofserotonin &norepinephrine :Remeron (mirtazapine)


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Atypical Antidepressants Trazodone=

alternative to TCAs Can cause orthostatic

hypotension, sedation, &priapism in males

Remeron= causessedation, weight gain,dry mouth, constipation

Wellbutrin (zyban)=rarely causes sedation,wt. Gain, or sexualdysfunction. Used for smoking cessation.

Most common S/E areheadaches, insomnia &nausea

Can lower seizure thresholdcauses seizures

A i l A id


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Atypical Antidepressants:serotonin norepinephrine reuptake

inhibitor (SNRI): SNRI-blocks uptake of

serotonin andnorepinephrine

Good for clients withanxiety also

SE=sexual dysfunction,insomnia, agitation

Skipping 1 dose cancause withdrawal S/S

Drug here is Effexor

& Cymbalta

Very effective in

treating severedepression


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Major Indications for

Antidepressants Major Depressive

disorder

Bipolar depression Obsessive-

Compulsive

Anxiety Panic disorder

PTSD

Substance Abuse

Chronic Pain

Tourettes Disorder

ADHD

Eating disorders

Sleep disorders Migraines

Enuresis


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Tricyclics:Elavil, Pamelor, Tofranil, Anafranil,

Aventyl, Asendin, Sinequan

Blocks the reuptake ofnorepinephrine andsertonin

Tricyclic drugs block themuscarine receptors (soanticholinergic effects)

Other sideeffects:

orthostatichypotension

sedation

wt. gain

confusion-esp.elderly

arrhythmias


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Tricyclics Contraindications Do not mix with ETOH (none

of the psych drugs should bemixed with ETOH)

Dementia

Suicidal clients

Cardiac disease

Pregnancy

Seizure disorders Urinary retention

Dose for elderly should be of adult dose

TCAs and MAOIs areeffective in tx. depression are not as safe or as well

tolerated as the newerantidepressants

Toxic Effects:possibility of cardiactoxicity and are toxic inoverdose


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SSRIs Prozac, Zoloft, Paxil, Celexa, Luvox, Serzone,Lexapro

Action-blocks the reuptake of sertonin into theneuron

Side-effect: biggest is sexual dysfunction & wt. gain

Contraindication: Cardiac dysrhythmias


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SSRIs Are very safe and are not lethal in overdose

Good choice with the elderly-very few side effects

If used with MAOIs may cause SerotoninSyndrome=seizure, death

If used with TCAs may cause TCA toxicity

Takes 2 weeks to feel effects


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MAOIs Nardil, Parnate,Marplan

Inhibits MAO, thusinterfering withbreakdown ofnorepinephrine,dopamine, andserotonin

Toxic effects= hypertensive crises

Avoid foods withtyramine (aged cheese,red wine, beer,

chocolate, etc.)

MAOIs dont play wellwith other drugs!!


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Antianxiety/Anxiolytic Drugs GABA exerts an

inhibitory effect on

neurons These drugs

enhance this effectand produce a

sedative effect Therefore reduce

anxiety

The most commonused drugs here are

theBenzodiazepines


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Benzodiazepines Valium, Xanax, Ativan ,

Librium , Klonopin,Serax

Dalmane, Halcion (usedas sleep aides mostly-short term!!)

Used for anxiety, panicdisorders, ETOH withdrawal,muscle spasm, sedation,insomnia, andepileptics/seizures

Use only short term becauseof dependency issues

Avoid ETOH

Causes sedation-dont drive!!


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Benzodiazepines Side Effects;

Drowsiness, confusion, sedation, and lethargy

Toxic Effects; Respiratory depression esp. with ETOH use!

Contraindications; Combination with other CNS depressants Renal or hepatic dysfunction History of drug abuse or addiction Depression and suicidal tendencies

Teaching; Use short term due to drug dependency issues Avoid ETOH and other CNS depressants Can impair ability to drive Do not use with someone who has a hx of drug dependency DC meds can cause withdrawal s/s


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Nonbenzodiazepine Aniolytic BuSpar (Buspirone)=

reduces anxiety without

strong sedative-hypnotic properties.

Not a CNS depressant

No potential foraddiction

Takes 2 weeks tofeel effects


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Nonbenzodiazepine Aniolytic Side Effects;

Dizziness, dry mouth, nervousness, diarrhea, headache, excitement

Toxic Effects; Lethal dose is 160-550 times the daily recommended dose

Contraindications; Use with caution in PG women Nursing mothers Clients with renal or hepatic disease Anyone taking MAOs

Teaching; Buspar is not associated with sedation, cognitive problems or withdrawal Takes 2-4 weeks to feel effects Some clients might feel restless, which could be incompleted anxiety


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Sedative/Hypnotic Drugs Used to reduce

anxiety and

insomnia

Can lead totolerance and

dependency

Use short term

Drugs used

benzodiazepines,i.e. Dalmane,Restoril, Halcion

Non-benzodiazepines,i.e. Ambien,Sonata, Lunestra


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Sedative/Hypnotic

Benzodiazepine Teaching: Use short term(1-2 weeks)

Carefully need to taper these off-never stopcold turkey

Do not take with other meds without talking

to provider first

Do not drive if sedated on these!!


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Client Teaching for

Nonbenzodiazepines Long term use not recommended

Do not drive when taking

Can repeat Sonata up to 4 hours beforearising


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ADD/ADHD-Psychostimulants Ritalin, Adderall,Dexedrine, Concerta,Focalin, Metadate,

Methylin

Action=

increasing the release

and blocking thereuptake ofmonoamines(dopamine,norepinephrine)

S/E: wt. loss,anorexia, insomnia,headache, long-term

growth suppression

Potential for abuse

Also used to treatnarcolepsy


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ADD/ADHD-Psychostimulants Intended effects:

Increased attention span & concentration Decreased distractibility, hyperactivity, and impulsivity Treatment of ADHD, ADD, & narcolepsy

S/E: Anorexia Wt. loss Growth retardation in children Insomnia Headache Cardiovascular effects-high blood pressure, dysrhythmias

Contraindications: Hx of drug abuse & dependency, severe anxiety, anorexia, MAIOIs


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ADD/ADHD- Non-Stimulants Strattera (atomoxetine)

Controls symptoms thru selective inhibition

of norepinephrine

Takes 1-3 weeks to feel effects

No abuse potential and is not considered acontrolled substance


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Herbal Medicines Ginkgo biloba-helps with memory

Kava-Kava

St. Johns Wart


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PETScan=positron-emission tomography

(PET) scans

Useful in identifying physiological andbiochemical changes as they occur in living

tissue i.e. clients with schizophrenia PET scans show a

decrease of glucose in the frontal lobes ofunmedicated clients, also can indicate mooddisorders,ADHD

Radioactive substance is injected, travels tothe brain, and illuminates the brain. Have 3Dvisualizations of the CNS

psychotropic meds sv 8 15

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