Psychopharmacology Outline

Psychopharmacology

Historical Perspectives

  • Before 1950, sedatives and amphetamines were the only significant psychotropic drugs available.
  • Since the 1950’s, psychopharmacology has expanded to include antipsychotic, antidepressant, and antianxiety drugs.
  • Psychotropic drugs are intended to be used as an adjunct to individual or group psychotherapy.

Function and Activities of the Brain

  • Maintenance of homeostasis
  • Regulation of autonomic nervous system (ANS) and hormones
  • Control of biological drives and behavior
  • Cycle of sleep and wakefulness
  • Circadian rhythms
  • Conscious mental activity
  • Memory
  • Social skills

Review: Cellular Composition of Brain

  • Neurons-nerve cells that conduct electrical impulses
  • Neurotransmitter-chemical that is released in response to an electrical impulse (neuro-messenger).  
    • Psychotropic drugs act by modulating neurotransmitters
    • Attaches to a receptor on cell surface and either inhibits or excites

Theories behind use of psychotropic drugs focuses on neurotransmitters and their receptors

Visualizing the Brain

  • Structured imaging techniques
    • Computed tomography (CT)
      • X-rays to produce images for instance bones and tumors
    • Magnetic resonance imaging (MRI)
      • Use magnetic field and radio frequency pulses to produces detailed pictures of organs and body structures
  • Functional imaging techniques
    • Positron emission tomography (PET)
    • Single photon emission computed tomography (SPECT)

Therapeutic effects of Psychotropic meds

It’s important to remember that psychotropic medications (inform the client):-

  • Do not “cure” but relieve or decrease symptoms
  • Prevent or delay return of signs and symptoms
  • Cannot be used as the sole treatment for disorders
  • Need informed consent before starting
  • Are broad spectrum and have effects on a large number of signs and symptoms.
  • Initial effects are sedative in nature
  • May take weeks for effects to be seen

There are many reasons why the client may not adhere to the medications which may include:-

  • Meds are expensive
  • Unpleasant side effects such as nausea, mood swings, etc.
  • Feel better and decide no longer need
  • Stigma associated with having a mental illness and taking meds
  • Paranoia or fears about med usage

Things to consider when giving medications

  • Use with great caution
  • Start low and go slow for both elders and children!!
  • Elders have decrease liver & renal function
  • Risk of injuries and falls with elderly

Role of the Nurse

  • Ethical and legal implications
    • Nurses must understand the ethical and legal implications associated with the administration of psychotropic medications.
    • Most states adhere to the client’s right to refuse treatment, except in emergency situations.
  • Assessment
    • A thorough baseline assessment must be conducted before a client is placed on a regimen of psychopharmacological therapy.
  • Medication administration and evaluation
    • The nurse is the key healthcare professional in contact with the individual receiving medication. The nurse monitors for side effects and adverse reactions and evaluates the therapeutic effectiveness of the medication.
  • Patient education
    • The nurse translates the complex information related to the medication into terms that can be easily understood by the client.
    • Nurses should use the latest informatics resources to provide current and relevant education on medication-related topics.
  • It is important for the client (and family/SO to understand-
    • What the expected benefit hopefully will be
    • When the client should expect to see results
    • What are the potential side effects
    • What symptoms to report to provider
    • What things to do or not to do while taking medications

Antianxiety Agents (Anxiolytics)

  • Also referred to as minor tranquilizers

Clinical indications

  • Anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation

Medication action

  • Depression of the central nervous system (C N S; exception: buspirone)

Interactions

  • Increased effects when taken with alcohol, barbiturates, narcotics, antipsychotics, antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, disulfiram, or herbal depressants
  • Decreased effects with cigarette smoking and caffeine consumption

Nursing diagnosis

  • Risk for injury
  • Anxiety
  • Risk for activity intolerance
  • Disturbed sleep pattern

Drug Classification

Drug trade/ Generic names

Actions

Side effects

Nursing implication

Benzodiazepines

-Most widely prescribed in the world.

-Concerns of physiological dependence.

-Treatment with BZs generally should be brief, during time of specific stress or for specific indication.

Valium (Diazepam)

Klonopin (Clonazepam)

Xanax (Alprazolam)

Ativan (Lorazepam)

Dalmane (Flurazepam)

Restoril (Temazepam)

Halcion (Triazolam)

Prosom (Estazolam)

Doral (Quazepam)

Bind to specific GABA receptor sites resulting in a calming effect

Ataxia, drowsiness, confusion and orthostatic hypotension

Teach patient – do not combine with other anti-anxiety meds, and do not take with alcohol! 

Alcohol and BZ’s together can cause extreme sedation.

Sedative-hypnotics

Ambien (Zolpidem)

Sonata (Zaleplon)

Lunesta (Eszoplicone)

Bind selectively to GABA receptor sites

Amnesia, ataxia, rapid onset

Take just before going to bed.

Buspirone

BuSpar (Buspirone)

Not clearly understood; appears to be a serotonin agonist.

Takes 2-4 weeks for full therapeutic effect so cannot be taken prn (when necessary).

Headache, dizziness, light-headedness, nausea and insomnia.

(Not associated with sedation or withdrawal symptoms)

Take as directed; stand slowly.

Antidepressant agents

Clinical Indications

  • Dysthymia, major depressive disorder, depression associated with organic disease, alcoholism, schizophrenia, intellectual disability, depressive phase of bipolar disorder, and depression accompanied by anxiety

Medication action

  • Increase concentration of norepinephrine, serotonin, and/or dopamine in the body either by blocking their reuptake by the neurons (tricyclics, tetracyclic, SSRI’s, SNRI’s) or by inhibiting the release of monoamine oxidase inhibitors (MAOI’s).

Drug interactions

Drug Interactions with SSRI

Interacting Drugs

Adverse effects

Buspirone (BuSpar), TCA’s (especially clomipramine), Selegiline (Eldepryl), Saint John’s Wort

Serotonin syndrome

MAOI’s

Hypertensive crisis

Warfarin, NSAID’s

Increased risk of bleeding

Alcohol, benzodiazepines

Increased sedation

Antiepileptics

Lowered seizure threshold

Drug Interaction with TCA’s

Interacting Drugs

Adverse effects

MAOI’s

High fever, convulsions, death

Saint John’s Wort, tramadol (Ultram)

Seizures, serotonin syndrome

Clonidine (Catapres), epinephrine

Severe hypertension

Acetylcholine blockers

Paralytic ileus

Alcohol and carbamezipine (Tegretol)

Block antidepressant action, increases sedation

Cimetidine (Tagamet), bupropion (BuSpar)

Increased TCA blood levels, increased side effects

Drug Interactions with MAOI’s

Interacting Drugs

Adverse effects

SSRI’s, TCA’s, atomoxetine (Strattera), duloxetine (Cymbalta), dextromethorphan (an ingredient in many cough syrups), venlafaxine (Effexor), St. John’s Wort, Ginkgo

Serotonin syndrome

Morphine and other narcotic pain relievers, antihypertensive

Hypotension

All other antidepressants, pseudoephedrine, amphetamines, cocaine cyclobenzaprine (Flexeril), dopamine, methyldopa, levodopa, epinephrine, buspirone (BuSpar)

Hypertensive crisis (these side effects can occur even if take with 2 weeks of stopping MAOI’s)

Buspirone (BuSpar)

Psychosis, agitation, seizures

Antidiabetics

Hypoglycemia

Tegretol

Fever, hypertension, seizures

Nursing diagnosis

  • Risk for suicide
  • Risk for injury
  • Social isolation
  • Risk for constipation
  • Insomnia

Drug Classification

Drug trade/ Generic names

Actions

Side effects

Nursing implication

Tricyclic (TCAs)

Elavil (Amitriptyline)

Tofranil (Imipramine) Pamelor (Nortriptyline).

Blocks re-uptake of serotonin and nor-epinephrine.

Anti-cholinergic effects : dry mouth, blurred vision, urinary retention, sedation, and drowsiness

Not a first line treatment! Can overdose on these, and can cause cardiac conduction disturbances.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Prozac (Fluoxetine)

Zoloft (Sertraline)

Paxil (Paroxetine)

Celexa (Citalopram), Lexapro (Escitalopram), Luvox (Fluvoxamine)

(Most widely prescribed)

Blocks the re-uptake and thus the destruction of serotonin.

Apathy and low libido.

Low lethality! 

Difficult to overdose.

Serotonin-  Norepinephrine Reuptake Inhibitors (SNRIs)

Effexor (Venlafaxine)

Cymbalta (Duloxetine).

In low doses blocks reuptake of Serotonin; in high doses blocks reuptake of Norepinephrine

Monoamine Oxidase Inhibitors (MAOIs)

Marplan (Isocarboxazid), Nardil (Phenelzine), Parnate (Tranylcpromine) Ensam (Selegiline).

Inhibits the action of Monoamine Oxidase (Oxidase destroys Monoamines such as Serotonin, Epinephrine, Dopamine, and Norepinephrine).

Do not take with other anti-depressants

Avoid foods containing tyramine such as wine, smoked fish and aged cheese!

Toxic effect can develop into hypertensive crisis. (headache, increased respirations, light headed, vomiting, and increased heart rate)

If so, hold med, call MD, and take client to the ER

Mood Stabilizers

Lithium, anticonvulsant medications, and second-generation atypical antipsychotics

Interactions

  • Because lithium is an imperfect substitute for sodium, anything that depletes sodium will make more receptor sites available to lithium and increase the risk for lithium toxicity

Common causes for Increased Lithium levels

  • Decreased sodium intake
  • Diuretic therapy
  • Decreased renal functioning
  • Fluid and electrolyte loss, sweating, diarrhea, dehydration, fever, vomiting
  • Medical illness
  • Overdose
  • Nonsteroidal anti-inflammatory therapy

Nursing diagnosis

  • Risk for injury
  • Risk for self-directed or other-directed violence
  • Risk for injury related to lithium toxicity
  • Risk for injury related to adverse effects of mood-stabilizing drugs
  • Risk for activity intolerance

Lithium Maintenance

  • Therapeutic range
    • 1.0 to 1.5 milliequivalents per liter (acute mania)
    • 0.6 to 1.2 milliequivalents per liter (maintenance)
  • Ensure that client consumes adequate sodium and fluid in diet.
  • Using Lithium
    • Needs initial and ongoing health assessment, laboratory monitoring
    • Excreted by kidneys, can adversely affect thyroid, has narrow therapeutic index
    • Blood levels can quickly become fatal
    • Need health teaching of patient, family, support system
    • Patients differentiate side effects from potentially life-threatening toxic effects, maintain stable lithium level

Educate client and family about the medication

Drug Classification

Drug trade/ Generic names

Actions

Side effects

Nursing implication

LiCO3

First-line treatment for acute mania and for long-term prevention of recurrences

Lithium (Eskalith, Lithane, Lithobid, and Lithonate).

Interacts with sodium and potassium ions to stabilize electrical activity.

Fine hand tremors, polyuria, mild thirst, weight gain.

Early toxic – N, V, and D, thirst, polyuria, lethargy, slurred speech, muscle weakness

Advanced toxic – Course hand tremors, GI upset, confusion, sedation, incoordination

Severe toxic – Ataxia, confusion, large output of dilute urine, blurred vision, clonic movements, seizures, HTN, stupor and coma.

Therapeutic range of <0.4 to 1.5mEq/L

Frequent levels drawn

Toxicity- withhold med and draw level

Vigorously hydrate; use emetic, GI suctioning if overdose

Provide supportive nursing care for bedridden patient; may need peritoneal dialysis or hemodialysis

Anticonvulsants

Depakote (Divalproex Sodium)

Tegretol (Carbamazapine) Lamictal (Lamotrigine).

Reduces the firing rate of high-frequency neurons. Is thought to reduce mood swings in patients with bipolar disorders.

Tremor, weight gain, sedation, anticholinergic side effects and rashes.

Liver panel and CBC with Depakote or Depakene.

CBC, electrolyte panel with Tegretol, along with an ECG.

Patients should report any rashes with Lamictal.