Psychopharmacology

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Psychopharmacology

• Therapeutic vs. toxic dosage levels
• Side effects
• Adverse effects
• Interactions
• Use with the elderly, during Use during
  pregnancy
• Patient teaching
• nonpsychopharmacological interventions

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Neuroscience

• Nervous system
• Limbic system emotional control, memory,
  learning
• Hypothalamus releasing hormones -affect human
  behavior and keep bodys homeostasis
• Basic unit Neuron, contains cell body, nucleus,
  organelles, dentrites, and axons
• Neurotransmitter

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Neurotransmitter

• Neurotransmitter - combine with a specific
  receptor Relay a chemical message to the
  receptor cell
• Drugs act on neurotransmitters
• Agonist activating cell function to accelerate
  or slow cellular processes
• Antagonist prevent natural or other substances
  from activating cell function
• Affinity binding between drug and receptor
• Refractoriness - desensitization of cells to a
  drug over time

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Neurotransmitters and Related Mental Disorders

• Dopamine ?
• Norepinephrine ?
• Serotonin ?
• Acetylcholine ?
• Gamma-aminobutyric acid (GABA) ?

• Schizophrenia
• Depression
• Depression
• Alzheimers disease
• Anxiety

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Pharmacokinetics - Absorption

• PO, IV, IM,- Absorption
• qid, tid, bid, - drug level in the blood
• Individual condition -
• sex - female fat
• age - older
• health - congestive heart failure, GI,
• Others - exercise

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Pharmacokinetics - Distribution

• Target tissue
• Cardiac output - electric imbalance, CHF, chr
  pulmonary dis
• Serum protein binding
• Half-life of the drug
• Pregnancy

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Pharmacokinetics - Metabolism

• Break down or metabolize into other compound -
  liver
• convert into other active substance liver

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Pharmacokinetics - Excretion

• Proper excretion less toxicity
• Kidney - main excretion organ
• Others - GI, skin, lungs, sweat glands
• Tissue perfusion rate - shock, hemorrhage
• Diseases - renal, liver ...
• Urinary pH - acidic urine -amphetamine
• alkaline urine- barbiturates

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Phases of Treatment

• Initiation
• Stabilization
• Maintenance
• Medication-free

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Nursing Responsibilities

• Monitor the S S of the disease state
• Monitor for common, expected or worrisome side
  effects of medications
• Preventing adverse drug reactions
• Evaluate compliance
• Judge the appropriateness of the regimen
• Recommend needed changes
• Provide pt family education

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Patient Education

• Compliance - effectiveness, symptom control
• Side-effect - inevitable, unpleasant, temporary
  only a few are life threatening
• Education - encourages compliance Medications
  are not magic bullet
• Balance with information - too much
• or inappropriate
• Health beliefs model- what is the benefit of
  taking med
• Regular checkups and test

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Classes of psychotropic medication

• Antipsychotic medications
• Antidepressant medications
• Mood-stabilizing drugs
• Anti-anxiety medications
• Psychostimulants

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Antipsychotics - typical

• 1950 - Chlorpromazine (Thorazine)
• Mechanism - Block dopamine receptors
• effective in treating () symptoms
• ie. alterations of perception- hallucinations
• thought disturbance - delusion
• activity - agitation

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Atypical agents

• 1980s -
• Targets dopamine and serotonin, may work on both
  () (-) symptoms
• Better tolerated, less side effects, better
  compliance, less cognitive impairment, better
  efficacy in negative symptoms of schizophrenia

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Typical Atypical

• Clozaril
• 150-450 mg qd,
• watch for fever, agranulocytosis
• Risperdal
• 2-8 mg qd
• Less sedation
• Zyprexa
• 5-10 mg qd
• smaller dose for the elderly liver dis. pt
  

• Phenothiazines
• Thorazine
• 200-800 mg qd
• half-life 30 hours
• Peak 2-4 hours
• Non-phenothiazines
• Haldol
• 1-15 mg qd
• half-life 21-24 hours
• Higher risk of EPSs

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Neurological complications of antipsychotics

• Pseudoparkinsonism - muscle rigidity
• Extrapyramidal Side Effects (EPSEs)-
• Akathisia - motor restlessness
• Dyskinesia - jerky motion
• Dystonia -muscle rigidity life-threatening
• Tardive dyskinesia facial grimacing tics,
  tongue writhing, lip smacking, puckering
• - irreversible, high dose, older, females,

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Other adverse effects (I)

• Anticholinergic effect
• dry mouth, blurred vision, constipation,
• Neuroleptic maliganant syndrome (NMS) - rare,
  life-threatening
• altered consciousness, hyperthermia, muscle
  rigidity, tachycardia, sweating
• discontinue the medication
• reverse the dopamine-blocking effects of
  antipsychotics (ie bromocriptine) or muscle
  relaxant (ie dantrolene)

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Other adverse effects (II)

• Seizures - threshold ?
• Hyperprolactinemia - breast engorgement,
  falactorrhea, amenorrhea, impotence, azospermia
• Hepatic changes - jaundice, nausea, fever, chill,
  general malaise, itching
• Photosensitivity
• Weight gain - 3-9 lbs

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Interventions for EPSEs

• Tolerance usually ? by the 3rd month
• Lower dose of drug
• Add a drug to treat EPSE, then taper after 3 M on
  the antipsychotics
• Use a drug with a lower EPSE profile
• Pt education and support

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Interventions for Dystonia

• Occur suddenly frightening painful
• Common in children and young males
• With high potency drugs
• Medication - IV PO
• Have respiratory support available
• taper antipsychotics gradually to prevent
  withdrawal dyskinesia

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Neuroleptic Malignant Syndrome

• Drug-induced disorder
• Be recognized in 1980s
• Incidence 0.2 uncommon but potentially
  life-threatening
• Risk factors- dehydration, agitation, catatonia,
  mood disorders, organic brain syndromes, drug or
  alcohol withdrawal states, previous NMS episodes,
  drugs given by injection

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Characteristics of NMS

• Disturbances in mental status, temperature
  regulation, autonomic and extrapyramidal
  functions
• Mental Status catatonia
• Vital signs tachycardia, unstable BP
• Extrapyramidal functions tremors, dysarthria,
  dysphagia, drooling
• Lab increased WBC, elevated blood enzymes ie.
  Creatine phosphokinase,

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Interventions for NMS

• Potential fatal - tachycardia, fever, sweating,
  muscle rigidity, incontinence, stupor, aspiration
  pneumonia, leukocytosis, renal failure,
• Common with high potency drugs and in dehydrated
  pts
• Discontinue all drugs,
• supportive symptomatic care (H2O BT?
  hemodialysis)
• antipsychotics can be reintroduced later

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Interventions for Agranulocytosis

• Emergency case occur abruptly
• Fever, malaise, ulcerative sore throat,
  leukopenia
• High incidence with clozapine (1-2) - 1wk
  prescription a time - check CBC
• Discontinue drug immediately
• May need isolation and antibiotics

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Interventions for Photosensitivity

• Use sunscreen and sunglasses
• Cover body with clothing
• Reassurance
• normal vision typically returns in a few days
• tolerance develops

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Interventions for Anticholinergic effect

• S/S constipation, dry mouth, blurred vision,
  orthostatic hypotension, tachycardia, urinary
  retention, nasal congestion
• Avoid hazard task
• Fluid, mouth rinse, hard candy, sugar-free gum.
  Check mouth sore
• Fluid, fiber, exercises, monitor BM habits, use
  stool softeners,

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Interventions for Weight Gain

• Increase exercises
• Reduce calorie diet if indicated
• May need to change class of drug

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AIM- Abnormal Involuntary Movement

• incidence of TD has been relatively low in recent
  years, changes in prescribing may result in
  increased occurrence.
• AIMS (Abnormal Involuntary Movement Scale)
• http//www.psychiatrictimes.com/scales/movement_di
  sorders/AIMS_LandingPage.jhtml

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Drug interactions

• Central nervous system depressants i.e. opiates,
  barbiturates, alcohol - sedative effective ?
• Antihypertensives - hypotensive effects ?
• Caffeine - antipsychotic drug effect ?
• Cigarette smoking -blood level of
• antipsychotics ?
• Lithium - possible additive toxic effect
• Anticholinergic - absorption of antipsychotics ?

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Anticholinergic drugs - for EPSEs

• Benztropine (Cogentin) 1-4mg, qd or bid.
• PO or IM
• Biperiden (Akineton) 2-6mg, qd, bid, tid
• Trihexyphenidyl (Artane) 5-15mg/d
• Procyclidine (Kemadrin) 6-20mg/d
• Ethopropazine (Parsidol) 600mg/d
• Anticholinergic drugs ? acetylcholine?

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Other drugs to treat EPSEs

• Antihistamine
• Diphenhydramine (Benadryl) 25-300/d PO, IM, IV
• Dopamine Agonist
• Amantadine (Symmetrel) 100-3000mg/d PO
• Benzodiazepines
• Diazepam (Valium) 2-6 mg/d PO, IV
• Lorazepam (Ativan) 0.5-2 mg/d PO, IM
• Clonazepam (Klonopin) 1-4 PO

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Types of Antidepressants

• Monoamine Oxidase inhibitors (MAO inhibitors)
• TCAs (Tricyclic Antidepressants)
• SSRI (Selective Serotonin Reuptake
• inhibitor)

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Antidepressants - MAO Inhibitors Drug
Trade name Daily dose Isocarboxazid
Marplan 45-90 mg Phenylzine Nardil 10-30
mg Tranylcypromine Parnate 10-30 mg
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Side Effects of MAO Inhibitors Common Less
common Constipation Agitation Dizziness Blurred
vision Dry mouth Headache Hypotension Hyperten
sion Insomnia Hypomania Nausea Impaired
muscle Sexual difficulties coordination Weight
gain Muscle cramps
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Foods Drugs to be avoided Foods Drugs Aged
cheeses Amphetamine Beer Cocaine Broad-bean
pods Decongestants Caffeined beverages
Epinephrine Canned figs L-dopa
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S/S of Hypertensive Crisis on MAOIs

• Warning S - BP? palpitations Headache
• Symptoms - sudden BP?
• Explosive occipital headache
• Head and face are flushed feel full
• Palpitation, chest pain
• Sweating, fever, nausea, vomiting
• Dilated pupils, photophobia

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TX of Hypertensive Crisis on MAOIs

• Hold MAOIs doses
• Do not lie down (elevates BP in head)
• IM chlorpromazine 100mg, repeat if necessary (to
  block norepinephrine)
• IV phentolamine, (to bind with norepinephrine
  receptor sites, blocking norepinephrine)
• Manage fever by external cooling techniques
• Evaluate diet, adherence, and teaching

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Cyclic Antidepressants Drug Trade
name Daily dosage Amitriptyline Elavil
100-200 mg Clomipramine Anafranil
150-200 mg Imipramine Tofranil 100-200
mg Nortriptyline Aventyl 75-150 mg
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Common Side effects of TCAs

• Mechanism blockade of acetylcholine
• Drowsiness, dizziness, tachycardia, skin rashes,
  dry moth, constipation, and urinary retention,
• Risk of mortality with overdose is high

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Drug Interactions with Cyclic Antidepressants Drug
Possible effect Alcohol
Sedation, antidepressant blood level
? Antiparkinsonians Additive anticholinergic
effects Antipsychotics Sedation Fluoxetine(Prozac)
Antidepressant blood level ? Phenobarbitol
Antidepressant blood level ? Sedatives Sedation
? Antidepressant blood level ?,
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The SSRI antidepressant Drug
Trade name Daily dosage/starting Bupropion
Wellbutrin 100-300 mg/150 mg Fluoxetine
Prozac 10-80 mg/20 mg Paroxetine Paxil
10-60 mg/ 20 mg Sertraline Zoloft
50-200 mg/50 mg
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Side effects of the SSRI

• Anxiety restlessness
• Constipation
• Dry mouth
• Headache
• Nausea vomiting
• Sedation
• Sexual dysfunction

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Overview of antidepressants

• 1st choice - SSRI
• Take 2-4 weeks to be effective of TCAs
• Abrupt withdrawal of TCAs ?headache, nausea,
  malaise
• MAOIs uses could not take tyramine related food
  ? hypertensive crisis
• 14 days - change drugs from TCAs to MAOIs

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Mood-stabilizing medications Drug Trade name
Daily dosage Lithium Lithium carbonate
900-2100 mg Lithonate Valproic acid Depakote
1200-1500 mg
Depakene Carbamazepine Tegretol 400-1600
mg cant be used with Lithium
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Side Effects of Lithium Carbonate Common
Less common Potential serious (toxic) Confusion
Acne Diarrhea(severe) Diarrhea Edema
Dizziness Fatigue Hair loss Drowsiness
(severe) Hand tremor Muscle
weakness Increased thirst
Nausea/vomiting(severe) Increased urination
Slurred speech Muscle weakness Marked
tremor/twitching Nausea/vomiting Spastic
movements in limbs Weight gain
or face muscles
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Signs of Lithium Toxicity Mild
Moderate Severe (1.5-2.0mEq/L) 2.0-2.5
mEq/L Over 2.5 mEq/L Abdominal pain
Anorexia Coma Dry mouth Urination
? Nausea/vomiting kidney failure Dizziness Blu
rred vision Drowsiness Convulsions Lethargy/
Coordination excitement
impairment Marked tremor/ Delirium
twitching Stupor Slurred speech
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Use of Lithium

• Thyroid kidney screening
• Regular levels - prophylactic
• Drink a lot of water
• No pregnancy - fetal heart problems
• 1st trimester - birth defects
• no nursing - excrete from milk
• blood volume increase - hard to measure
• no use in age under 8 or in seniors, accumulation
  in bone tissue, effect of renal thyroid
  function meta? in seniors

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Side-effect of Lithium

• Body Image- weight gain ( 60 of pt)
• Cardiac - ECG change but not significant
• CNS - fine hand tremor (50 of pt) fatigue,
  headache, mental dullness, lethargy
• Skin - acne, rash
• Endocrine - hypothyroid (5 of pt) DM
• Renal - Polyuria (60 of pt) - H2O?

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Common causes for Li?

• Decrease sodium intake
• Fluid and electrolyte loss, sweating,
• diarrhea, dehydration, fever, vomiting
• Exercise marathons
• Medical illness ie poor renal function
• Overdose
• Nonsteroidal anti-inflammatory drug therapy

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Ways to maintain Li level

• Stabilize dosing schedule - dividing doses or use
  of sustained-release capsules
• Ensure adequate dietary sodium and fluid intake
  (2-3 L/day)
• Replace fluid electrolytes lost during exercise
  or gastrointestinal illness.
• Monitor S/S of lithium side effects and toxicity
• Forget dose - retake if 2hr
• Never double up

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Side effects of other mood stabilizing
med. Carbamazepine (Tegretol) Confusion, memory
disturbance Dizziness WBC ? (benign)
Nausea Skin rash Valproic Acid - used with
Lithium- additive Hair loss Nausea/vomiting
Sedation BW ?
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Anti-anxiety Medications Benzodiazepine
group Drug Trade Name Daily
dosage Alprazolam Xanax 0.5-6
mg Chlordiazepoxide Librium 15-100
mg Diazepam Valium 2-60
mg Lorazepam Ativan 2-6
mg Dependence, withdrawal, tolerance Most
appropriate for the elderly
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Anti-Anxiety drugNon benzodiazepines- Buspirone

• Buspirone (BuSpar)
• not a CNS depressant
• less danger of interaction with other CNS
  depressant i.e. alcohol
• no strong sedative-hypnotic effect
• Less drowsiness
• better tolerated than the benzodiazepines
• less potential for addiction

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Adverse Effects of Anti-Anxiety
Med. Confusion Dizziness Drowsiness Headache Impa
ired muscle coordination Irritability/restlessness
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Benzodiazepine Withdrawal Symptoms Transient
True withdrawal Agitation Delirium Anxiety
Depression Blurred vision
Hypothermia Diarrhea Impaired
concentration Dizziness Nausea Headache
Paranoid Insomnia Seizure Muscle aches
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Intervention for Benzodiazepine Withdrawal
Symptoms

• Careful with tolerance, dependency, rebound
  insomnia/anxiety
• Tapered weekly at a rate of 25
• Short-term use
• Contraindicated with drug or alcohol abuse

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Patient Education

• What the most important thing in medication
  counseling?
• What How Why
• Common side-effects/ poorly controlled
• Health beliefs model what is the benefits of
  taking the medication

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Non-compliance

• Knowledge - purpose, side-effect,
• Pts beliefs, wishes, ideas of taking med
• Multiple daily dosing schedule
• Polypharmacy
• History of noncompliance
• Social isolation Expense of drugs
• Lack of continuity of care

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Non-compliance (II)

• Increased restrictions of pts lifestyle
• Unsupportive sig. others
• Remission of target symptoms
• unrealistic expectations
• Concurrent substance use
• potential stigmatization

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Have a nice weekend