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Psychopharmacology : Monitoring for the intended and the unintended effects of psychotropic medications.


Prozac, fluoxetine Paxil, paroxetine Zoloft, sertraline * Lexapro, escitalopram Celexa, citalopram * Older medications amines The tricyclic's: imipramine ... – PowerPoint PPT presentation

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Title: Psychopharmacology : Monitoring for the intended and the unintended effects of psychotropic medications.

Psychopharmacology Monitoring for the intended
and the unintended effects of psychotropic
  • My goal today is to talk about different classes
    of medications that you might see prescribed for
    children with mental disorders.

  • Barbara Noordsij APRN, ND, PMHNP, BC
  • Psychiatric Mental Health Nurse Practitioner for
    Washington County Mental Health Services Inc.
  • No, I do not work for or participate in any
    pharmaceutical research or development. Never
    have. I am biased about kids and horses.

Here we go
If you need a break take a break.
  • 100 - 230 PM
  • 245 - 415 PM

  • This next slide shows that approximately half,
    50.6 of children with mental disorders had
    received treatment for their disorder within the
    past year.
  • There were some differences between treatment
    rates depending on the category of mental
  • Children with anxiety disorders were the least
    likely (32.2 percent) to have received treatment
    in the past year.

(No Transcript)
  • Prescribed psychotropic medications are not being
    misused or overused among U.S. youth, according
    to a study using nationally representative data
    sponsored by NIMH.
  • This study was published December 3, 2012.
  • Archives of Pediatric and Adolescent Medicine.

Among those youth who met criteria for any mental
disorder, 14.2 percent reported that they had
been treated with a psychotropic medication.
Teens with ADHD had the highest rates of
prescribed medication use at 31 percent, while
19.7 percent of those with a mood disorder like
depression or bipolar disorder were taking
psychotropic medication. Among those with
eating disorders, about 19 percent were taking a
psychotropic medication, and 11.6 percent of
those with anxiety disorders reported taking
medication. Very few youth reported use of
antipsychotic medications. They were most
frequently used by youth with severe bipolar
disorder (1.7 percent) or a neurodevelopmental
disorder such as autism (2.0 percent). Approximat
ely 2.5 percent of teens without a diagnosed
mental disorder were prescribed a psychotropic
medication. Among these youth, 78 percent
reported having a previous mental or
neurodevelopmental disorder and associated
psychological distress or impairment.
  • Neuron

The synapse, where it all happens
A word about genetics
  • It is not nature versus nature
  • It is not genes versus environment
  • It is
  • Genetics and the Environment
  • It is
  • Vulnerability

Etiology of mental illness
  • Prenatal environment
  • Attachment
  • Temperament
  • Parenting
  • Exposure
  • All of these interact with a persons
  • genetics , vulnerabilities,
  • phenotype and leads to illness.

Treatment with medications
  • Some medications treat the underlying cause of
    the illness.
  • Some medications treat symptom clusters of the
  • Some medications really just try to make the
    client more available for the real treatment such
    as your behavioral strategies and support.
  • (NAMI video clips)

Considerations for all medications
  • Consent
  • What is the parents perspective?
  • Do they want their child on medications.
  • Do they feel that the prescriber knows their
    child well enough to make recommendations.
  • AKA trust.

More considerations
  • How to initiate the drug
  • How to terminate the drug
  • Cautions to clients
  • Contraindications to the use of this drug
  • Instructions
  • Drug interactions
  • Food interactions

More considerations
  • Monitoring the medication after starting the
  • Frequency of follow-up
  • Is it approved for use in children?

  • Early in treatment there are some side effects
    that may disappear over time.
  • Fatigue, anorexia or no appetite, headache,
    stomach ache, sleep problems, irritability,
  • If severe, dose may be too high

Stimulant dose is too high?
  • May cause dysphoria, depression, irritability
  • Moodiness when dose wears off
  • The child may seem to be too flat
  • Insomnia that is worse
  • Significant weight loss

Continued adverse effects of stimulants
  • Cardiovascular (tachycardia,
    hypertension/hypotension, palpitations)
  • Exacerbate psychosis or mania
  • Lower seizure threshold (not usually significant
    risk, can be used cautiously in patients with

Stimulants -what we want to know
  • Is the child more focused and attending.
  • Is the child experiencing side effects.
  • Is the child getting the medication regularly.

Stimulants, some more common drug names
  • Adderall amphetamine
  • Adderall XR
  • Concerta methylphenidate
  • Focalin (dexmethyphenidate)
  • Focalin XR
  • Metadate methylphenidate
  • Ritalin methylphenidate
  • Vyvance lisdexamfetamine

  • Another class of medications for ADHD.
  • In addition these medications may also be used
    for aggressive behavior which may be due to
    hypervigilance, or emotionally reactive children.
  • They are

Alpha-adrenergic medications
  • These medications are alpha 2- noradrenergic
    receptor agonists (stimulating agents) that
    inhibit endogenous release of nor -epinephrine in
    the brain.
  • Clonidine hydrochloride (clonidine)
  • Guanfacine (Tenex, Intuniv)

Alpha adrenergic medications
  • Adverse effects of these medications concern
    the effects these medications can have on the
    cardiovascular system.
  • Lower blood pressure
  • Slowed heart rate or heart block

  • One more medication for ADHD, which is in a group
    unto itself

Strattera ,atomoxetine
  • Chemically similar to older tricyclic
    medications. (in the old days we used imipramine
    for kids with ADHD a tricyclic)
  • Adverse effects
  • Sedation
  • Cardiovascular (electrocardiogram)

Signs a child is having cardiovascular issues.
  • Cant catch his breath.
  • Feels like his heart is pounding.
  • Passes out or is dizzy.
  • Describes a funny feeling and points to his
  • Color is blue or dusky.

  • Recently published results from the National
    Comorbidity StudyAdolescent Supplement reveal a
    lifetime prevalence of major depressive disorder
    or dysthymia of 11.2 of 13- to 18-year-olds,
    with a 3.3 lifetime prevalence of a severe
    depressive disorder in that same age group.
  • The 2008 National Survey on Drug Use and Health,
    sponsored yearly by the Substance Abuse and
    Mental Health Services Administration, shows the
    prevalence of depression among 12- to
    17-year-olds to be 8.3, with girls showing 3
    times the prevalence as boys.
  • One-year prevalence rates for major depression
    are approximately 2 in childhood and 4 to 7 in

  • Suicide risk is significantly increased in youth
    with depressive disorders and is the third
    leading cause of death in adolescents.
  • Data published by the Centers for Disease Control
    and Prevention report that over a 1-year period
    of time studied
  • 13.8 of American adolescents considered
    killing themselves
  • 10.9 had made plans, and
  • 6.3 actually reported attempting suicide.

Antidepressant medications
  • SSRIs -serotonin reuptake inhibitor
  • Common initial side effects go away after a
    couple of weeks.
  • If severe side effects may need to slow the
  • They are
  • nausea, stomach upset, decreased appetite, and

  • Anti-depressant medications
  • Anti-Anxiety medications

(No Transcript)
  • Prozac, fluoxetine
  • Paxil, paroxetine
  • Zoloft, sertraline
  • Lexapro, escitalopram
  • Celexa, citalopram

More on Antidepressants
  • Older medications amines
  • The tricyclic's imipramine, amitriptyline,
    clomipramine, desipramine.
  • Concerns re cardiac reactions
  • chest pain, shortness of breath, heart racing,
  • Dangerous risk of overdose. Heart block which is
    difficult to reverse with medications.

Antidepressants- what we want to know
  • These medications take several weeks to work.
  • A bad reaction would be a sudden change in
    personality or behavior. Off the charts, out of
    the norm. Euphoria, happiness a sudden change
    could mean mania.
  • If what you see, is just a continuation of
    target behaviors, it may just mean that an
    effective dose has not been achieved.

AntidepressantsMonoamine Oxidase Inhibitors
  • MAOIs
  • Nardil, phenelzine
  • Parnate ,tranylcypromine
  • Food and OTC drug interactions major concern
  • Which can cause a hypertensive crisis.
  • Tend to be used rarely. Generally for treatment
    resistant depression and anxious individuals

Antidepressants Dual agents
  • Effexor ,venlafaxine
  • Cymbalta, duloxetine
  • Pristiq, desvenlafaxine
  • Work on two receptors

  • Dual agent usually implies that the medication is
    effective at two receptor sites.

  • Dual agents
  • Adverse effects, similar to SSRIs
  • andIncreased concern about sensitivity to
    cardiovascular side effects, increased BP,
    agitation, sleep issues

Anxiety a little more on this.
  • Buspirone. This anti-anxiety medication may be
    used on an ongoing basis. As with most
    antidepressants, it typically takes up to several
    weeks to become fully effective. A common side
    effect of buspirone is a feeling of
    lightheadedness shortly after taking it. Less
    common side effects include headaches, nausea,
    nervousness and insomnia.

Anxiety and benzodiazepines Ativan lorazepam,
klonopin clonazepam
  • For short-term relief of anxiety symptoms.
  • Benzodiazepines are generally only used for
    relieving acute anxiety on a short-term basis.
  • school phobia, panic attacks severe
  • Concerns -
  • Habit forming
  • Other signs of mis use drowsiness, reduced
    muscle coordination, and problems with balance
    and memory.

Mood medications
  • Essentially two categories
  • Lithium
  • And
  • Anticonvulsants

  • Lithium is a salt.
  • So anything that upsets a fluid and salt balance
    in the body can increase risks.
  • Lithium has a narrow therapeutic range.
  • To low it doesnt work
  • To high toxic

Signs of lithium toxicity
  • If you see this (as below) , hold the dose, until
    you consult with a practitioner. Consult with
    provider immediately or take the child to the
    emergency room.
  • looks drunk ataxia unsteady gait, slurring of
    words, confusion, lethargy or tremors

Treatment with lithium and renal failure risks
  • Recently, McKnight and colleagues published a
    meta-analysis encompassing 5988 abstracts and 385
    studies from 1966 to 2010, concluding an absolute
    risk of renal failure of 0.5 (18/3369 patients).

  • In general
  • When these medications are started they cause
    some cognitive slowing and tiredness.
  • Usually this will abate as time goes by and it
    may take a few weeks. If severe consult with the

  • Depakote, valproic acid, divalproex
  • Tegretol, carbamazepine
  • Trileptal, oxycarbamazepine
  • Topomax , topiramate
  • Neurontin, gabapentin
  • Lamictal , lamotrogine

  • Several of them have a serious rash that can be
    associated with the start of treatment.
  • Any rash in the first few weeks of treatment is a
    concern and should be evaluated. Do not
    administer additional medication until it is
    evaluated by a provider.

  • Also common to many of the anticonvulsants early
    in treatment is a concern about liver problems or
  • Both liver problems and pancreatitis would
    present with nausea and vomiting and diarrhea.
    If severe it may be an emergency.

AHS Anticonvulsant Hypersensitivity Syndrome
  • AHS is characterized by fever, eosinophilia,
    rash, lymphadenopathy, coagulopathy, and internal
    organ involvement. In severe cases, AHS can
    progress to Stevens-Johnson syndrome or toxic
    epidermal necrosis. The onset of AHS classically
    begins with initiation of the medication and
    differs in onset by drug and is not related to a
    dosage or serum concentration of anticonvulsants.
  • AHS is reported to occur in approximately 1 in
    1000 to 1 in 10,000 exposures. Mansur and
    colleagues95 reported on 31 patients who
    presented with AHS in response to the following
    agents carbamazepine (48.38), phenytoin
    (35.48), lamotrigine (9.6), and combined
    valproic acid and lamotrigine (6.45).

Mood stabilizers what we want to know
  • The provider should hopefully identify the target
    symptoms for treatment at the outset of
  • We would look for those symptoms to decrease.
  • These might be episodes or duration of episodes
    of aggression, decrease lability of mood,
    improved sleep wake patterns, less risk taking

Antipsychotic medications
  • What to watch for early in treatment
  • Movement problems (EPS)
  • Stiffness
  • Dystonia can be an emergency (neck / shoulder)
  • Restlessness (Akesthesia)
  • Any sudden onset of high temperature or flu like
  • (video)

Side effects of antipsychotics
  • Drowsiness
  • Dizziness
  • Blurred vision
  • Rapid heart beat
  • Sensitivity to sun (can be severe)
  • Skin rash
  • Menstrual changes
  • Weight gain, metabolic changes (diabetes,
    elevated triyglycerides.

  • The relationship between antipsychotic use and
    the increased risk of insulin resistance, weight
    gain, type 2 diabetes, and dyslipidemia has been
    well documented in multiple pediatric studies.

Movement side effects of antipsychotic medications
  • What to watch for early in treatment
  • Complaints of rigidity, muscle complaints,
    tremors, stiffness.
  • Stiffness
  • Dystonia usually involves neck and shoulder
  • Restlessness (Akasthesia)

Time to relax and have a great weekend.