13 Psychopharmacology

PSYCHOPHARMACOLOGY TAN, Abegail TAN, Kristina TIRO, Noel TOMAGAN, Angela TOMBOC, Jude Carlo N3C Psychopharmacology Is the study of the regulation and stabilization of emotions, behavior, and cognition through the interactions of endogenous signaling substances or chemicals in the brain. Studies a wide range of substances with various types of psychoactive properties, focusing primarily on the chemical interactions with the brain. Brief history of psychopharmacology Ancient World: Alcohol has been nearly universal in use, and was already presenting itself as a problem among ancient Greeks and Romans. There are records of cannabis use in the ancient Middle East. An extract of the nightshade or belladonna plant called atropine was used everywhere from Rome to India as a poison and as a cosmetic device. Middle Ages: Early 1250 in the Middle Ages, Arab traders and warriors introduced the use of the opium poppy to India and China. In China, it was used primarily as a medicine. But in India, it became a widespread habit of the rich, and soldiers used it to booster their fighting spirit. At this time, opium was ingested primarily as a drink; sometimes it was eaten. Modern Psychopharmacology: A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic drugs. Chlorpromazine, and Lithium known for antimanic were the first drugs to be developed. Over the following 10 years there drugs introduced to reduced agitation, psychotic thinking and depression. Hospital stays were shortened, and many people were well enough to go home. Central nervous system and neurotransmitters Neurons Receive stimuli and transmit action potentials to other neurons or to target tissues. The functional unit of nerve cells. Neurotransmitter Are chemical substance manufactured in the neuron that aid in the transmission of information throughout the body. They either excite or stimulate an action cells or inhibit or stop an action. Approximately 100 billion brain cells forms group of neurons that are arrange in networks. Neurons communicate with one another by sending chemical messages. Major neurotransmitters: source and action ACETYLCHOLINE: Found in many areas of the brain. Usually excitatory, Inhibitory effect in some parasympathetic nervous system (heart) Control sleep and wakefulness cycle, signals muscle to become alert. SEROTONIN: Nuclei originating from the brain stem and projecting to many areas specially to the dorsal horn of the spinal cord. Usually Inhibitory, Control food intake, sleep and wakefulness, temperature, pain control, sexual behaviors, regulation of emotions. NOREPINEPHRINE: Located in brain stem and hypothalamus Usually excitatory, sometimes inhibitory. Causes changes in attention, learning and memory, sleep and wakefulness, and mood

DOPAMINE: Found in the substantia nigra. Usually excitatory, control complex movements and fine movements, motivation, cognition, regulates emotional response. GLUTAMIC ACID/GLUTAMATE: Found in the presynaptic terminals in many sensory Usually excitatory, causes neurotoxicity if levels are too high. Pharmacodynamics: The study of drug concentration and its effect on the body.

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Drugs can be an agonist for a receptor and stimulate the specific biologic activity of the receptor, or an antagonist that inhibits biologic activity. Terms to describe the effect of a drug on the body: Potency refers to the relative dosage of a drug that is required to achieve a desire effect. Clinical efficacy refers to the maximal therapeutic effect that a drug can achieve Median effective dose is the dosage at which 50% of clients experience a specific therapeutic effect when prescribed a certain psychotropic drug. Median toxic Dose is the dosage at which 50% of clients experience a specific toxic effect when taking a prescribed drug. Therapeutic index has been defined as a ration of the median effective dose to median toxic dose. Tolerance refers to the need for markedly increase amounts top specific drug over time to achieve the sane desired effect. Pharmacokinetics Is the study of the movement of drugs and their metabolites through the body by the process of drug absorption, distribution, metabolism, and excretion or elimination. After the drug is ingested it is absorbed into the bloodstream and distributed to various parts of the body in the form of a free or a protein bound drug. Peak plasma concentration Defined of drug as the greatest accumulation of the drug in the plasma. It varies depending upon the route of administration and rate absorption of the drug. Parenteral administration generally achieves peak plasma concentration more rapidly than oral administration. Drug half-life Refers to the amount of time it takes for metabolism and excretion to reduce the plasma concentration of a specific drug by half. The liver is the principal organ for site of metabolism. First pass effect Describe the initial metabolism of an orally administration drug within the hepatic circulation and fraction of the absorbed drug that reaches systemic circulation unmetabolized. For example drugs administered sublingually enter the blood stream directly and avoid first pass effects. Drug polymorphism Refers to the pharmacodynamic and pharmacokinetic variations that occur on the basis of several factors such as clients age, gender, size and body composition or genetic endowment. Environmental, cultural and genetic factors contribute to drug polymorphism among various ethnic groups Discontinue syndrome (withdrawal) Abrupt discontinue or reduction in the dosage of a number of psychotropic drugs can precipitate a transient emergence of clinical symptoms. With rebound or relapse of original symptoms, uncomfortable new physical and psychological symptoms. MEDICATING THE PSYCHIATRIC-MENTAL HEALTH CLIENT According to a 1997 study of 1,228 psychiatric clients, close to 90% were treated with medication. approximately 75% had psychiatric management Which is: the monitoring of clinical status client and family education the prescription of medication the monitoring of medication the adjustment of medication and treatment the establishment of therapeutic relationship and the development or a modification of a treatment plan Approximately 45% (significantly lower percentage) underwent psychotherapy. The findings clearly show the psychiatric communitys current reliance on medication in treating clients. The decision to medicate a client exhibiting clinical symptoms of a psychiatric disorder is often based on consideration of several guidelines. PSYCHOPHARMACOLOGIC GUIDELINES in MEDICATING THE CLIENT: Rational pharmacotherapy requires decisions regarding when and when not to medicate.

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Emotional responses to ordinary life situations should generally not be medicated. Psychiatric illnesses such as depression and psychosis generally required pharmacotherapy. Failure to medicate properly may prolong the clients illness suffering. Irrational use of medications may lead to simultaneous adverse reactions to multiple drugs. Detailed medical and psychiatric history, as well as the assessment of clients attitudes toward medication is needed. Appropriate medication must be carefully chosen. The dose must be titrated according to response and adverse effects; the standard dose is seldom optimal. All medications should be temporarily withheld if unexplained adverse effect occurs. Start only one medication at a time to observe client before others are added. Lack of desired response may indicate that client is not taking medication as directed. The addicting potential of sedatives such as benzodiazepines should be kept in mind Physician must be aware of increased sensitivity and persistence of various drugs in elderly clients, and the interactions between underlying medical conditions and psychotropic drugs. Before medication is prescribed, the potential risks and benefits of treatment must be discussed with the client. Special treatment considerations are given to: Children Older adult clients Pregnant Nursing women Person with hepatic or renal insufficiency Person with co morbid medical illnesses However, even in the most ideal situations, psychopharmacology can result in adverse effects affecting the clients treatment. COMMON ADVERSE EFFECTS OF PSYCHOTROPIC DRUGS WITH THE FOLLOWING NURSING INTERVENTIONS Blurred vision Constipation Drowsiness Dry mouth Gastrointestinal disturbance Hypo- or hyperglycemia Hypotension, orthostatic Insomnia Libido changes (sexual dysfunction) Tachycardia Weight gain

Blurred vision Interventions: Explain that anticholinergic effects of medication can occur initially, but should If blurred vision continues after 1 to 2 weeks, notify attending practitioner CAUTION: client about driving or operating hazardous machinery. Constipation Interventions: Assess and monitor bowel movement Promote adequate fluid intake (2500-3000 cc daily of not medically contraindicated) Increase intake of fresh fruits, vegetables, and bran products Provide stool softeners or bulk-forming agents prescribed by practitioner Drowsiness Intervention: CAUTION: avoid driving or operating hazardous equipment Give entire daytime dose of medication at bedtime if symptoms persists Explain that this is usually a transient symptom Dry mouth Intervention: Encourage to use low-calorie or sugarless hard candy, mints, gums or beverages Gastrointestinal disturbance Intervention: Explain that anorexia, nausea and vomiting, or irritation may occur as transient adverse effect Encourage taking medication with food Refer to attending practitioner if not improved Hypo- or hyperglycemia Intervention: Monitor blood sugar routinely if the client is taking a TCA or antipsychotic medication Report any irregular results Hypotension, orthostatic Intervention:

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Monitor blood pressure before start of medication and during period of dosage adjustments Instruct client to rise slowly when changing position Instruct client to avoid showers or baths (promotes vasodilation) Insomnia Intervention: Advise against use of caffeine Assess sleep pattern and hygiene practice Take medication as prescribed Libido changes (sexual dysfunction) Intervention: Conduct a sexual history Provide emotional support Tachycardia Intervention: Monitor pulse rate if taking TCA, lithium, or anti-cholinergic medication Educate client about effects of caffeine Report any irregularities Weight gain Intervention: Instruct client to monitor weight weekly Educate about dietary measures to avoid weight gain Refer to dietitian or nutritionist Encourage development of an exercise program ANTIPSYCHOTIC AGENTS -ROLE OF THE NURSE The psychiatric nurse has a wealth of knowledge and competencies that make the nursing care provided to people with psychiatric disorders unique in many ways. Following are some examples of the nurses role in psychopharmacological treatment of persons with neurobiological illness. ANTIPSYCHOTIC AGENTS Are used primarily to treat most forms of psychosis such as: Schizophrenia Schizoaffective disorder Delusional disorder Mood disorder with psychosis Psychoses associated with delirium and dementia Symptoms: Impaired communication or inability to relate with others Delusions Hallucinations Lack of responsiveness to external stimuli Inability to identify reality SMALL DOSES may be used to treat: Anxiety Tension Agitation Dizziness Hiccups Nausea and vomiting Control pain when combined TYPICAL or CONVENTIONAL Original drugs from 1950s that is used to treat psychosis They revolutionized the treatment of schizophrenia and other psychotic disorders. Provide symptom control by blocking the dopamine receptors in the brain. *DOPAMINE is a chemical messenger that regulates thinking, emotion, behavior and perception. Excess amount of dopamine cause nerve impulses in the brain stem to be transmitted faster than normal, resulting in strange thoughts, hallucinations and bizarre behavior. Blocking dopamine activity lessens or prohibits the development of such thoughts behaviors. TYPICAL ANTIPSYCHOTIC DRUGS Phenothiazines Chlorpromazine (Thorazine) Thioridazine (Mellaril) Mezoridazine (Serentil) Non Phenothiazines Haloperidol (haldol) ATYPICAL or NOVEL New-generation antipsychotic Blocks the activity of both serotonin and dopamine have been developed They are used to treat both positive and negative symptoms of disorders (schizophrenia) ATYPICAL ANTIPSYCHOTIC DRUGS Clozapine (Clozaril) Risperidon (Risperdal, consta) Olanzapine (Zyprexa) Quetiapine (Seroquel) CONTRAINDICATIONs and precautions:

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History of drug hypersensitivity Severe depression Bone marrow depression Brain damage Client with history of: Impaired liver function Cardiovascular disorder Hypertension Glaucoma Diabetes Parkinsons disease Peptic ulcer disease Seizure disorder Pregnancy MAJOR ADVERSE EFFECTS: Anti-cholinergic effect Drowsiness Nasal congestion Blurred vision Constipation Urinary retention Skin reaction Dermatitis urticaria Pigmentation of the skin Photosensitivity or phototoxicity Gastrointestinal distress Nausea Heartburn Cholestatic jaundice st Orthostatic hypotension during the 1 two weeks of treatment Weight gain and possible edema Seizure due to a lowering of the seizure threshold Alteration in sexual functioning due to diminished sex drive Mild ECG changes; sinus tachycardia NEUROLOGIC ADVERSE EFFECTS: Acute dystonia Abnormal positioning or spasm of muscles of the head, neck, trunk or limbs SYMPTOMS: Wryneck or torticollis Facial grimacing Abnormal eye movements Parkinsonism Motor retardation or akinesia Characterized by: Masklike appearance Rigidity Tremors pill rolling Salivation Akathisia (motor restlessness) Constant state of movement Characterized by: Restlessness Difficulty sitting still Or strong urge to move Tardive dyskinesia (abnormal movements) Most frequent serious adverse effect resulting from termination of the drug, during reduction in dosage, or after longterm, high dosage therapy. Characterized by: Involuntary rhythmic Tongue protrusion Cheek puffing Involuntary movement of extremities and trunk Neuroleptic malignant syndrome (NMS) Rare syndrome Characterized by: Severe muscle rigidity Altered concsiousness Alteration in blood pressure NURSING IMPLICATIONS When administering antipsychotic drugs, keep in mind the following: If antacids are needed, administer 2 hours before or 1 hour after administration the antipsychotic medication. If a single daily dose is ordered, administer oral form within 1 or 2 hours of bedtime, whenever possible, to aid sleep. Avoid contact with concentrated solutions while preparing them. DO NOT administer antipsychotic drugs subcutaneously unless specifically ordered. Change needles after filling the syringe and before injecting the medication to avoid tissue irrigation. Be aware that both olanzapine (zyprexa) and risperidone (risperidal-M-TAB)come in an orally disintegrating form. Therefore, monitor the clients compliance to insure adequate absorption. Know that antipsychotic agents may provoke seizures in client with seizure disorders. Closely observe the client receiving antipsychotic drugs with the following:

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Therapeutic effects of the drugs, such as decreased agitation, decreased hallucinations, and increased socialization. A decrease in nausea and vomiting if the drugs administered as an antiemetic Drug-induced EPS, and signs of TD, and NMS Signs of weight gain, high fever, upper abdominal pain, nausea, diarrhea, and skin rash. -certain antihistamines, betablockers, SSRIs and atypical anti-depressants 1. HYPNOTICS -used to induce state of natural sleep -reduce periods of involuntary awakenings during night -increases total sleep time Benzodiazepine Anxiolytics and Hypnotics Used as antianxiety agents May also be used to treat insomnia Examples: (Librium) Clonazepam (Klonopin) Diazepam (Valium) Oxazepam (Serax) Clorazepate (Tranxene) Lorazepam (Ativan) Prazepam (Centrax) Alprazolam (Xanax) Triazolam (Halcion) Effect: -works on limbic system of brain, which is responsible for emotions such as rage and anxiety -produce tranquilizing effects with possible sedation -may numb emotions, taking away ones enthusiasm -adverse effects may include ataxia (incoordination) and slurred speech Take Note: 1) Individuals who take >40mg of Diazepam (Valium) daily for several months may experience seizures 2) A rebound phenomenon called Paradoxical Excitation may occur after abrupt discontinuation It can occur anytime up to 3 weeks after stopping a long acting Benzodiazepine, but may occur within a few hours after abrupt cessation of short acting Benzodiazepines 3. When used with alcohol, serum levels of Benzodiazepines increase, resulting in respiratory distress. 4. It may also interfere with normal coping mechanisms -Increase irritability, aggressiveness and hostility - Increase risk for depression

CLIENT EDUCATION Nurses need to inform client about the planned drug therapy, drug dosage, length of time it takes to achieve therapeutic results. And possible adverse effects of drug therapy. Clients are instructed to report any physical illnesses or unusual adverse effects. Instructions about antipsychotic drugs therapy when teaching a client and family: Avoid alcohol and sleeping pills, which can cause drowsiness and decrease ones awareness of environmental hazards, and other medication during therapy. Refrain from driving or operating hazardous machinery while taking antipsychotic drugs. DO NOT increase, decrease, or cease taking drugs without discussing this step with the physician. Expect to be taken off the drug slowly to avoid nausea and vomiting. Avoid taking antacids during antipsychotic therapy. Practice good oral hygiene to minimize the risk of mouth infections, dental caries, and ill-fighting dentures. Follow up with the dentist yearly. Keep the drugs in a safe place, especially if the children are at home. ANTIANXIETY AGENTS -CNS depressants -used to primarily treat daytime stress -Larger doses may be used to promote sleep -also called Anxiolytics -used to manage withdrawal symptoms associated with chronic alcoholism >control convulsions >produce skeletal muscle relaxation -classified as Benzodiazepines and Nonbenzodiazepines

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5. Long term use is not recommended because it produces dependency 6. Associated with phenomenon of tolerance Drug to Drug Interaction Alcohol, narcotic analgesics, TCAs, and CNS depressants can cause an increase used concurrently with this classification of psychotropic medication. Displacement of digoxin from serum proteins can occur when taken concurrently Hypertension can occur when buspirone and MAOIs are combined during Prothrombin times may vary during anticoagulant therapy. Nonbenzodiazepine Anxiolytics Examples: Meprobamate (Equanil) Used to relieve muscle tension associated with anxiety or for insomnia that causes CNS depression Buspirone (BuSpar) An azasperone or novel anxiolytic and blocks release of serotonin and prevents uptake of dopamine Antihistamines as Anxiolytics One of the most common classes of sleepinducing agents Used to treat anxiety and insomnia Examples: Hydroxyzine hydrochloride (Atarax) Hyrdoxyzibe pamoate (Vistaril) Diphenhydramine hydrochloride (Benadryl) Common Adverse Effects: -drowsiness -gastritis -dizziness -paradoxical excitement -dry mouth -blurred vision Betablockers as Anxiolytics Used to diminish tachycardia, benign essential tremors, impulsitivity, agitation associated with anxiety Examples: Propranolol (Inderal) Atenolol (Tenormin) Metoprolol (Lopressor) Nadolol (Corgard) Common Adverse Effects hypotension bronchospasm bradycardia fatigue dizziness depression Selective Serotonin Reuptake Inhibitors and Atypical Antidepressants as Antixiolytics Examples: Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa) Fluoxetine (Prozac) Escitalopram (Lexapro) Contraindications: -acute narrow angle or open angle untreated glaucoma -severe renal or hepatic impairement -blood dyscrasias -pregnancy/lactation -acute post-myocardial infarction -psychosis -use of MAOIs Nursing Implications: -Before administering antianxiety agents or hypnotics, assess the clients mental and physical status to avoid the risk of possible adverse effects. -Pregnant women are contraindicated to take because of the risk of adverse effects -If a client complains of a sleep disturbance, the cause should be identified, if possible. Appropriate nursing interventions such as sleep hygiene measures, relaxation therapy, sleep restriction therapy, and stimulus control are to be tried first as alternatives to the administration of hypnotics When administering antianxiety or hypnotic drugs, keep in mind the following: Administer daily dose at bedtime to promote sleep, minimize adverse effects, and allow more normal daytime activities to occur. Administer intramuscular dosages deeply and slowly into the large muscle masses Observe for therapeutic effects Observe for adverse effects such as oversedation, hypotension, pain at the injection site, skin rashes, and paradoxical excitement such as

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hostility, rage, confusion, depersonalization, or hyperactivity. Monitor for adverse effect of beta blockers, especially hypotension, bronchospasm, bradycardia, and depression Know that alprazolan (Xanax) is available as an orally disintegrating tablet that has been labeled Niravam; clonazepam (Klonopin) is available in wafer form labeled Rivotril; and lorazepam (Ativan) can be administered sublingually for rapid absorption When administering antianxiety agents parenterally, do not administer solutions that are cloudy or contain a precipitate Be alert for possible drug-drug interactions Explain rebound insomnia, which is the worsening of insomnia that may occur after discontinuation of medication

Client Teaching: Review adverse effects of prescribed meds and instruct client to report onset of these as well as symptoms such as fever, malaise, sore throat, petechiae, easy bruising or bleeding, and skin rash Instruct client to avoid use of alcoholic beverages with antianxiety agents because alcohol can increase depressant effects of these agents, possibly causing death Instruct to avoid ingesting large amounts of beverages with caffeine, a stimulant, because it can decrease effects of hypnotic agents and increase effects of beta blockers Instruct that grapefruit juice interacts with alprazolam (Xanax), flvoxamine (Luvox), buspirone (BuSpar), sertraline (Zoloft), and triazolam (Halcion), inhibiting enzyme metabolism that may result in fatal consequences Explain that sudden cessation of benzodiazepines can cause rapid eye movement or rebound effects such as insomnia, nightmares, hyperexcitability, agitation, or convulsions and sudden death Instruct to avoid excessive use of these drugs to prevent onset of substance abuse or addiction Instruct clients who take hypnotics to keep a sleep diary to determine efficacy of prescribed hypnotic

ANTIDEPRESSANT DRUGS Used to treat depressive disorders caused by emotional or environmental stressors; losses; drugs disease states such as cerebral vascular accidents; or depression that cannot be related to an identifiable cause. Primarily used in the treatment of major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression. Interact with the two neurotransmitters, norepinephrine and serotonin, that regulate mood, arousal, attention, sensory processing, and appetite. 4 Groups of Antidepressants Tricyclic and the related cyclic antidepressants Selective serotonin reuptake inhibitors (SSRIs) Monoamine oxidase inhibitors (MAOIs) Novel or other antidepressants such as venlafaxine (Effexor), bupropion (Wellbutrin), trazodone (Desyrel), and nefazodone (Serzone) TRICYCLIC ANTIDEPRESSANT Increases the level of a neurotransmitter, either serotonin or norepinephrine, in the space between nerve endings. A deficiency in either of these transmitters is thought to cause depression. Used to treat symptoms of depression such as insomnia, decreased appetite, decreased libido, excessive fatigue, indecisiveness, difficulty thinking and concentrating, somatic symptoms, irritability, and feelings of worthlessness. Considered effective in 85% of those people who exhibit symptoms of depression Clients receiving this show increased mental alertness and physical acitivity with mood elevation with a few days after therapy is initiated Increases the level of a neurotransmitter, either serotonin or norepinephrine, in the space between nerve endings. A deficiency in either of these transmitters is thought to cause depression.

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Used to treat symptoms of depression such as insomnia, decreased appetite, decreased libido, excessive fatigue, indecisiveness, difficulty thinking and concentrating, somatic symptoms, irritability, and feelings of worthlessness. Considered effective in 85% of those people who exhibit symptoms of depression Clients receiving this show increased mental alertness and physical acitivity with mood elevation with a few days after therapy is initiated Contraindications: Pregnant or breast-feeding women Persons recovering from a myocardial infarction or with severe liver or kidney disease should not receive TCAs. Caution is necessary to clients with asthma, urinary retention, hyperthyroidism, glaucoma, cardiovascular prostatic hypertrophy, alcoholism, epilepsy, and schizophrenia. Adverse Effects: Dry mouth blurred vision tachycardia urinary retention constipation Potentially dangerous adverse effects include agranulocytosis, jaundice, increased seizure susceptibility to clients with epilepsy, and prolongation of atrioventricular conduction time. Drug to Drug Interaction: Several drugs increase the effects of TCAs; they include antihistamines, atropine, alcohol, narcotic analgesics, benzodiazepines, and urinary alkalizers (eg, sodium bicarbonate). Barbiturates, decrease the effects of TCAs Nursing Implications Assess clients level or severity of depression, including the presence of suicidal ideation; note any adverse effects; monitor for drug interactions; and observe for therapeutic effects of TCAs. Within 2-3 weeks after initial dose, it should reach a serum plasma level at which optimal response occurs. Therefore, if no therapeutic response is observed within 4-8 weeks, another drug is usually prescribed. Because these agents cause urinary retention and constipation, assess client for abdominal retention Also assess for VS and cardiac status closely Client Education Take drugs exactly as prescribed. Never attempt to alter dosage Be aware that therapeutic effects may not occur 2-3 weeks after initial therapy. Check with physician for follow-up lab testing for drug levels to monitor dosage Avoid taking OTC cold remedies without physicians knowledge Inform other professionals such as dentist or surgeon, of the drug therapy Report adverse effects such as fever, malaise, sore throat, mouth sores, urinary retention, fainting Avoid excessive exercise and high temperpatures because these drugs block perspiration Know that these drugs are not addictive, but some clients may have a chronic deficiency in neurotransmitters, requiring them to take these agents over an extended period MAOIs Prescribed for clients with treatmentresistant depression; clients who have depression associated with anxiety attacks, phobic attacks, or many somatic complaints; clients who fail to respond to TCAs or who cannot tolerate SSRIs; and clients who are in the depressive phase of bipolar disorder Prevents the metabolism of neurotransmitters, but are used less frequently than the TCAs because they are less effective, must be given for longer periods before they are beneficial, are more toxic, have al longer duration of action, and may cause severe adverse reactions if taken with tyramine-rich foods. Contraindications Asthma Cerebral vascular disease Congestive heart failure Hypertension Hypernatremia Impaired kidney function Cardiac arrhythmias Pheochromocytoma

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Hyperthyroidism Liver disease Abnormal liver function tests Severe headaches Alcoholism Glaucoma Atonic colitis Paranoid schizophrenia Debilitated clients Clients over age 60 Pregnancy Age younger than 16 years MAOIs are potentially lethal in overdose and pose a potential risk for clients with depression who may be considering suicide. Nursing Implications MAOIs are nonaddictive and are considered safe and effective if taken as directed. Monitor client for signs of therapeutic effects, adverse effects, and drug or food interactions. To reach a maximum therapeutic effect, MAOIs may require 2 to 6 weeks of should be evident within 3 to 4 weeks. Monitor the client closely for possible readily available should signs and symptoms occur. Medication for overdose excessive pressor response (dilation of blood vessels and lowering of arterial excessive agitation. Client Education Take drugs exactly as prescribed Avoit intake of foods with tyramine and tryptophan, caffeine-containing beverages, and beer and wine Report symptoms such as headache or heart palpitations that may indicate a hypertensive crisis requiring immediate attention Avoid overactivity because these agents may suppress angina pain, a warning of myocardial ischemia Have vision checked periodically because optic toxicity may occur if therapy is administered over an extended period. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) A popular class of antidepressants now considered the first line of therapy for treating depression. Although this class of drugs is relatively safe and useful for a broad spectrum of potential indications, the FDA recently recommended that a black box warning be added to drug labels stating that SSRIs increase the risk of suicidal behavior in depressed children and teens. Examples: Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa)

FOODS AND BEVERAGES THAT CONTAIN TYRAMINE AND TRYPTOPHAN Hypertensive crisis may occur if MAOIs are taken with the following: Aged cheese Avocados Bananas Beer Caffeine Canned figs Chicken livers Chocolate Fava bean pods Guacamole dip Meat tenderizers Pickled herring Raisins Sauerkraut Sour cream Soy sauce Wine Yeast supplements Yogurt Adverse Effects Frequently seen adverse effects include abnormal heart rate, orthostatic hypotension, headache, dizziness, blurred vision, vertigo, constipation, weakness, dry mouth, appetite. A life-threatening side effect, hypertensive crisis, may occur if the client ingests foods containing tyramine (an amino acid) while taking MAOIs. Because of the risk of potentially fatal drug interactions, MAOIs cannot be given in combination with other MAOIs, tricyclic antidepressants, meperidine (Demerol), CNS depressants, many antihypertensives, or general anesthetics.

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Escitalopram (Lexapro) Mode of Action SSRIs decreases the reuptake of serotonin at selected nerve terminals in the CNS. They also have a weak effect on the reuptake of norepinephrine and dopamine. Increased availability of serotonin at the receptors results in mood elevation and reduced anxiety. Indications Used in the treatment of depression alone or in the presence of concurrent disorders such as anxiety, panic attacks, eating disorders, sleep disorders, alcoholism or schizophrenia. Contraindications -Hypersensitivity to SSRIs -Concurrent use of MAOIs If the client has been taking an MAOI, a 14-day drug clearance is required before initiating SSRI therapy to avoid an accumulation of serotonin and subsequent serotonin syndrome. This phenomenon occurs as a result of central and peripheral serotogenic hyperstimulation. Symptoms of Serotonin syndrome: Confusion, delirium, agitation, irritability, ataxia, incoordination, tremor, seizures, hyperreflexia, diaphoresis, nausea, vomiting, diarrhea, abdominal pain, hypotension or hypertension, tachycardia, hyperthermia, cyanosis, severe respiratory depression and coma. Precautions and Drug-Drug Interactions Caution is needed when SSRIs are prescribed concurrently with anticoagulants. Monitor prothrombin times closely. The dosages of theophylline and alprazolam are reduced to avoid excessive plasma concentrations of both drugs. Diazepam, alcohol, and tryptophan should be avoided. Adverse Effects -Nausea, diarrhea, constipation, tremor, insomnia, somnolence, dry mouth, headache, nervousness, anorexia, weight loss, sweating and sexual dysfunction, and mild or moderate hyponatremia. Nursing Implications Treatment of depression places the client at increased risk for suicide; monitor client for mood changes. Client should advise health care provider if she might be pregnant; SSRIs should not be used during pregnancy or lactation. Discourage use of NSAIDs because of aggravation of bleeding problems. Patient Education Do not stop taking medication; withdrawal should be gradual, not abrupt. Take the drugs exactly as prescribes. Never attempt to alter the dosage. Avoid taking grapefruit juice with fluvoxamine (Luvox) and sertraline (Zoloft). Report any unusual symptoms such as tremors, nausea and vomiting, anorexia, weight loss nervousness or sexual dysfunction. Avoid the use of diazepam, alcohol, and tryptophan. Inform the physician if taking an anticoagulant or theophylline. Avoid operating hazardous machinery, including an automobile, if drowsiness occurs. Keep the medication out of reach of children. Notify the physician if symptoms of depression worsen. Atypical Antidepressants -They represent a conglomeration of agents that elude traditional classification. When clients do not respond to the use of SSRIs or TCAs, atypical antidepressants are considered to be alternatives or second-line therapy. Examples include: - Bupropion (Wellbutrin) - Maprotiline (Ludiomil) - Mirtazapine (Remeron) - Reboxetine (Edronax, Vestro) - Trazodone (Desyrel) - Venlafaxine (Effexor) Contraindications: Venlafaxine is contraindicated in presence of uncontrolled HTN because of its potential to increase blood pressure. Buspropion is contraindicated in the presence of seizure disorder, bulimia, anorexia, trauma, or lactation Caution is exercised with the use of bupropion in clients with renal or liver disease, heart disease, or history of a myocardial infarction. Trazodone is contraindicated in the presence of a recent myocardial infarction

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and should be used with caution in clients who have preexisting cardiac disease or abnormal liver function tests. Adverse Effects: Drowsiness or somnolence, dizziness, dry mouth, GI upset. Nursing Implications: Monitor VS to detect potential adverse effects such as HTN, hypotension, arrythmias, or infection during therapy Establish safety precautions if CNS changes such as confusion, drowsiness, incoordination, or weakness occur. Administer meds with food to decrease adverse GI effects such as anorexia and GI upset. Expect to administer lower doses or administer the drugs less frequently if the client is older or debilitated Do not administer atypical antidepressants within 40 days of MAOI administration Ensure that clients who are depressed and potentially suicidal have access to only limited quantities of the prescribed drug Nursing Implications: Monitor liver and hepatic function tests in clients with history of liver or renal impairment Client Education: Take meds exactly as prescribed Do not abruptly discontinue taking the drug Report any adverse effects or changes in medical condition Avoid the use of alcohol, sleep-inducing drugs and OTC drugs while taking this medication Avoid prolonged exposure to sunlight or sun lamps when taking mirtazapine Take drug with food or snack to enhance absorption and decrease likelihood of dizziness. Sustained Release Parenteral and Transdermal Antidepressants As a result of several studies that focused on the role of medication tolerability in treatment adherence, drug companies have developed various formulations of antidepressants Examples: Orally disintegrating mirtazapine; sustained release bupropion, methylphenidate hydrochloride, dextroamphetamine Parenteral administration includes the assurance of drug compliance, provides an option for clients who cannot tolerate oral meds, and is an alternative choice of treatment for severely ill, treatmentresistant clients before the use of ECD. Stimulants as Mood Elevators These are used to potentiate antidepressant meds in treatment resistant depression and treatment refractory depression. Indications: Stimulants have also been proven effective in reducing depression in medically ill clients, post stroke clients and clients with AIDS Other uses of stimulants include the treatment of narcolepsy, ADHD in children, residual ADHD in adults and obesity Mode of Action: Amphetamine stimulants cause a release of norepinephrine and dopamine into the synapse from the presynaptic nerve cell and block their reuptake. This action stimulates the sympathetic nervous system, resulting in alertness, wakefulness, vasoconstriction, supressed appetite, and hypothermia Contraindications: Contraindicated during or within 14 days of the administration of MAOIs Stimulants are not prescribed in the presence of glaucoma, advanced arteriosclerosis, CV disease, moderate to severe HTN, hyperthyroidism, marked anxiety or agitation, drug or alcohol abuse or the history of tics or tourette syndrome Adverse Effects: Appetite supression, sleep disturbances, GI disturbances, CNS overstimulation, mild increases in pulse and BP Nursing Implication: Assess BP, pulse, weight, height, and sleep habits initially Assess CNS activity, growth progression, and appetite of children and adolescent clients taking amphetamine stimulants Ensure that timed release tablets are swallowed whole, not chewed or crushed Monitor CBC and platelet counts periodically in clients undergoing long term therapy with methylphenidate Administer stimulants in the morning and at noon.

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Client Education: Take the drug exactly as prescribed. Do not crush or chew sustained or time released tablets Report any unusual clinical symptoms such as insomnia, abnormal body movements, palpitations, nervousness, vomiting, diarrhea, fever, skin rash, pale stools or yellowing of the skin or eyes Avoid use of alcohol or OTC drugs Avoid pregnancy while taking stimulants because they may cause harm to the fetus. Antimanic Agents or Mood Stabilizers This refer to agents that prevent or diminish the frequency and intensity of manic behavior, mood swings, aggressive behavior, and dyscontrol syndrome. Lithium has long been considered the tretment of choice for the manic phase of bipolar disorder. It is also used in the treatment of major depressive disorder, schizo-affective disorder, therpay resistant schizophrenia and chronic aggression Mode of Action: Lithiums antidepressant effects result from the augmentation of serotonin function in the CNS. Lithium is thought to balance serotonergic neurotransmission, preventing a decreased activity of nerve impulses that causes depression and preventing an increased activity of nerve impulses that causes mania. In clients exhibiting the manic phase of bipolar disorder, lithium appears to enhance the thyrotropin-releasing hormonestimulated prolactin response and reduce dopamine transmission Contraindications: Should not be prescribed during pregnancy Presence of severely impaired kidney function Caution in using to people with heart disease; perspire profusely; are on a sodium-restricted diet; are hypotensive; have epilepsy, parkinsonism, or are dehydrated Adverse Effects: Nausea, metallic taste, abdominal discomfort, polydipsia, polyuria, muscle weakness, fine hand tremors, fatigue and mild diarrhea, edema of hands and feet Nursing Implications: Give prescribed drug during or after meals to decrease gastric irritation; Monitor serum lithium levels twice a week during initiation of therapy before stabilization of manic episode Obtain serum samples 12 hours after a lithium dose is administered. Observe for decreases in manic behavior and mood swings; adverse effects and drug interactions Recognize that diuretics and anti inflam agents such as indomethacin increase the effects of lithium To avoid lithium toxicity, obtain electrolyte levels, a thyroid profile, and a liver profile routinely as ordered depending upon established protocol Client Education: Take drug exactly as prescribed Do not alter dosage or cease taking the prescribed drug. Lithium may require 3-5 weeks to be effective Do not decrease dietary salt intake unless instructed to do so by a physician because it increases risk of adverse effects such as toxicity due to increased concentration of lithium. Maintain high intake of fluids, 8-10 glasses daily unless contraindicated because of physical disorder Avoid crash or fad diets Avoid excessive exercise in warm weather Have blood lithium levels monitored regularly Avoid taking other meds without physicians knowledge because these may increase or decrease effects of lithium Report unusual symptoms, illnesses, or loss of appetite Continue to take drug despite occasional relapse Notify doctor whenever a change in diet occurs as it affects lithium level ANTICONVULSANTS Drugs used to treat seizure disorders, which are uncommon to psychiatric disorders Suppress abnormal electric impulses from seizure focus to other cortical areas, thus preventing the seizure but not eliminating the cause of seizure Types of anticonvulsants: long-acting barbiturates, benzodiazepines, hydantoins and succinimides

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Anticonvulsants work in one of three ways: 1. preventing neuron firing 2. preventing electric current 3. increasing GABA Classifications Hydantoin Examples are: Phenytoin -Phenytoin Sodium, prompt -Phenytek - Dilantin Fosphenytoin - Cerebyx Mephenytoin -Mesantoin Ethotoin -Peganone Hydantoin Discovered in 1938 but is still the most common drug used for controlling seizures MOA: reduces repetitive neuronal firing and limits seizures; also an antidysrhythmic; has small effect on general sedation and is nonaddicting Indicated for: prevention of grand mal and complex partial seizures Contraindicated to: patients with heart block and pregnant women Decreases effects of anticoagulants, oral contraceptives, and antihistamines Side effects: drowsness, nausea, vomiting; gum hypertrophy; rashes Drug has increased effects with cimetidine, izoniacid, chlorampenicol; decreased effects with folic acid, calcium, antacids, sucralfate, vinblastine, and cisplatin Adverse effects: depression, nystagmus, osteoporosis, and hirsutism Special precaution to: newborn and elderly Nursing responsibilities -clients psychiatric assessment must be completed before taking drug -observe for signs of bleeding or hemorrhage(eg. Gingival hyperplasia) -be alert for elevation or decrease in lab findings (eg. Serum concentration levels) -instruct client to report any observed changes in body hair consistency -observe symptoms of folic acid deficiency -monitor diabetics for loss of glycemic control Patient Education Tell the client that drug makes urine pink or red to brown in color Do not breastfeed when taking Hydantoins Do not take alcohol with the drug because it may increase levels of Hydantoin and may lead to drug toxicity Do not alter drug regimen If advised to stop taking the drug, do not discontinue abruptly, taper. Benzodiazepine Examples include: clonazepam Klonopin clorazepate dipotassium Tranxene diazepam Valium MOA: increases chloride ion conductance and inhibits action potential. Indicated for: Epilepsy; petit mal; status epilepticus Contraindicated to: acute pulmonary insufficiency; acute narrow angle glaucoma Long-term use leads to tolerance and also physical dependence which may lead to withdrawal Side effects: dizziness, upset stomach, headache, confusion, depression, euphoria, impaired coordination, changes in heart rate, trembling, weakness, amnesia, grogginess, dreaming or nightmares, chest pain, vision changes, jaundice. Carbamazepine, phenobarbitone or phenytoin may accelerate clonazepam metabolism. Combining benzodiazepines with other sedating drugs such as alcohol, marijuana, barbiturates, and opiates can cause lifethreatening respiratory depression. Increased sedative effect with alcohol Adverse effects: Drowsiness, fatigue, muscular hypotonia, coordination disturbances, dizziness, vertigo, anorexia, visual disturbances, libido changes.

Nursing responsibilities -Monitor addiction-prone patients -Monitor liver function and blood counts periodically in patients on long-term therapy. -Arrange for patient to wear medical alert

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ID indicating the patient has epilepsy and is receiving drug therapy -Thorough medical background assessment of client to avoid complications when drug is to be taken -Monitor vital signs and I & O Patient education Instruct not to alter drug regimen Avoid alcohol when taking drug Warn that drug has serious adverse effects on pregnant women Instruct that he/she may expect nervousness; depression, emotional changes; bed-wetting, urinary incontinence as a side effect of drug Instruct to report severe dizziness weakness, drowsiness that persists, rash or skin lesions, difficulty voiding, palpitations, and swelling in the extremities Barbiturates Examples include: Mephobarbital Mephal Phenobarbital Primidone Mysoline MOA: act by enhancing and/or mimicking the synaptic action of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter Indicated for: partial seizures and status epilepticus Contraindicated to: patients with severe renal and hepatic disorders, severe respiratory depression, dyspnea, and pregnant women Side effects: dizziness, light-headedness, drowsiness, and clumsiness or unsteadiness May increase depressant effects; whenused with phenytoin, may either increase or decrease effects of both; increase metabolism of corticosteroids and oral contraceptives; decreases anticoagulant response; Barbiturates cross the placental barrier. Adverse reactions: Bradycardia, hypotension, syncope; drowsiness, lethargy, CNS excitation or depression, impaired judgment, hangover effect, confusion Nursing responsibilities -Monitor patients blood levels -Administer in IV doses slowly -Monitor injection sites for irritation, because it is very irritating to tissues -Monitor vital signs -If in long-term therapy, arrange periodic lab tests for blood, kidneys and hepatic systems -Taper dosage gradually Patient education Instruct that drug makes patient drowsy so dont get up upon taking this drug or if not ask assistance when ambulating Do not alter drug dosages Observe and check for signs of drug toxicity Do not use contraceptives along the drug Teach sleep hygiene techniques (eg. Dark and quiet room, bedtime ritual, limit daytime napping, avoid caffeine before sleep) Succinimides Examples are: Ethosuximide Zarontin Methsuximide Celontin MOA: increase the seizure threshold ; effects may be due to direct modification of membrane function in excitable cells and/or alteration of chemically mediated neurotransmission Indicated for: absence seizures Contraindicated to: pregnant women Sides effects: dizziness, drowsiness, headache, hiccups, nausea or vomiting, stomach cramps, irritability, unusual tiredness or weakness Folic acid may be elevated with Succinimides Haloperidol, Phenacemide, Valproic acid, Carbamazepine, Phenobarbital, Phenytoin, and other antidepressants may either increase or decrease amounts of Succinimide concentrations Adverse reactions: Aggressiveness, difficulty in concentrating, mental depression, anorexia, ataxia Nursing responsibilities Administer drug with food to reduce GI irritation Expect to adjust dosage according to patients response to drug

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Monitor patients serum levels Check results of liver function studies Administer daily dose at bedtime to overcome sedation effect Patient education A missed dose may result in a seizure adopt a healthy life style. Do not stop meds without consulting doctor. Store drugs properly - out of reach of children. Keep a daily record of seizures Medic-Alert tag Report pregnancy to health care provider as associated with risk of birth defects Other Anticonvulsants Oxalidazones/ Oxalidinedione Trimethadione Tridione Paramethadione Paradione Iminostilbenes Carbamazepine Tegretol Oxycarbazepine Trileptal Valproate Valproic acid Depakene ANTIPARKINSONISM agents Acts by: -increasing dopaminergic activity -balancing dopaminergic and cholinergic activities -acting on neurotransmitter pathway other than dopaminergic pathway Anti-parkinsonian agents include anticholonergic agents, some antihistamininergic agents, and dopaminergic agonists and precursors. Classifications Dopaminergic agents Examples include: Dopaminergics carbidopa-levodopa Dopamine agonist amantadine Bromocriptine Paramipexole MAO-B Inhibitor selegiline rasagiline COMT Inhibitors entacapone tolcapone MOA: similar actions to dopamine, a neurotransmitter Indicated for: parkinsons; to relieve tremors and rigidity Contraindicated to: patients who have severe cardiac, renal or hepatic disease; allergy; have adrenal gland tumors Side effects: Fast heartbeat; headache; nausea; vomiting

Cyclopropane, droxidopa, ergot derivatives (eg, methylergonovine), furazolidone, halogenated hydrocarbon anesthetics (eg, halothane), tricyclic antidepressants or MAO inhibitors increase risk of side effects Alpha-blockers (eg, prazosin), beta-blockers (eg, propranolol), butyrophenones (eg, haloperidol), hydantoins (eg, phenytoin), or phenothiazines decrease effectiveness. Adverse reactions: Severe allergic reactions; chest pain; dizziness; irregular heartbeat; pain, redness, or swelling at the injection site; severe headache. Nursing responsibilities Obtain vital signs for future comparisons Assess patient for any history glaucoma, heart disease, peptic ulcers, kidney or liver disease, and resting tremors Observe for improvement in gait, balance, posture, speech, and self-care ability Administer with low-protein foods. High protein diet may interfere with drug transport to CNS Observe for therapeutic effects (eg. Decreased salivation, tremor, and drooling) Patient education Inform client that urine may be discolored and will darken in exposure to air; perspiration may also be dark Instruct client to report side effects and symptoms of dyskinesia. This may take weeks or months before symptoms are controlled Suggest that taking Levodopa with food may decrease GI upset, but food will slow the absorption rate

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Anticholinergic agents Examples are: Benzotripine mesylate Cogentin Beperiden Akineton Procyclidine Kemadrin Trihexyphenidyl Artane MOA: block nerve impulses that help control the muscles of the arms, legs, and body; also restrict the action of acetylcholine, an important chemical messenger in the brain that helps regulate muscle movement, sweat gland function, and intestinal function Indicated to: people with parkinsonism Contraindicated to: pediatric patient because it has side effects like that of atrophine; patients who are hypersensitive to this drug Side effects: Blurred vision; constipation; decreased sweating; difficult or painful urination; dry mouth, nose, or throat; increased sensitivity of the eyes to light; nausea or vomiting. may have interactions with certain foods, other medications, vitamins, herbal supplements, over the counter cold pills and other remedies Adverse reactions: seizures; severe drowsiness; fast heartbeat; hallucinations; mood or mental changes; unusual warmth, dryness, or flushing of the skin Nursing responsibilities Decrease dosage or discontinue temporarily if dry mouth makes swallowing or speaking difficult Provide sugarless lozenges, ice chips to suck for dry mouth Ensure patient voids before receiving each dose if urinary retention is a problem Give with meals if GI upset occurs Monitor or assess for constipation, abdominal pain, distention, or absence of bowel sounds Monitor intake and output ratios Patient education Advise patient to avoid driving or other activities that require alertness until response to the drug is known Instruct patient that frequent rinsing of mouth, good oral hygiene, and sugarless gum or candy may decrease dry mouth Caution patient to change positions slowly to minimize orthostatic hypotension Caution patient that this medication decreases perspiration. Overheating may occur during hot weather

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