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Psychotropic Drugs

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Psychotropic Drugs Mental Health Jene Hurlbut, RN, MSN, CFNP * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Contraindications for ... – PowerPoint PPT presentation

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Title: Psychotropic Drugs


1
Psychotropic Drugs
  • Mental Health
  • Jene Hurlbut, RN, MSN, CFNP

2
Objectives
  • Discuss the functions of the brain and the way
    this can be altered by the use of psychotrophic
    medications
  • Discuss how the neurotransmitters are affected by
    various psychotrophic medications
  • Discuss the application of the nursing process
    with various psychotrophic medications
  • Identify specific cautions to be aware of the
    various psychotrophic medications

3
Psychotropic Drugs
  • Locus of all mental activity is the brain
  • Origin of psychiatric illness caused by many
    factors
  • Genetics
  • Neurodevelopment factors
  • Drugs
  • Infections
  • Psychosocial experiences, etc.

4
Psychotropic Drugs-continue
  • Theories behind use of psychotropic drugs focuses
    on neurotransmitters and their receptors
  • Psychotropic drugs act by modulating
    neurotransmitters
  • Go to http//www.wisc-online.com/
  • Health Nursing, activity 3503 (Psychotropic
    Medications and Neurotransmitters)
  • Or try http//www.wisc-online.com/objects/index_
    tj.asp?objIDNUR3503

5
Review Cellular composition of brain
  • Neurons-nerve cells that conduct electrical
    impulses
  • Neurotransmitter-chemical that is released in
    response to an electrical impulse
    (neuromessenger).
  • Attaches to a receptors on cell surface and
    either inhibits or excites
  • Major target of psychotropic drugs
  • See table 3-1 on pg. 40 !!!!

6
Use of psychotropic meds
  • Relieve or reduce s/s of dysfunctional thoughts,
    moods, or actions, mental illness
  • Improve clients functioning
  • Increase compliance to other therapies

7
Therapeutic Effects of Psychotropic Meds
  • Do not cure
  • Relieve or decrease symptoms
  • Prevent or delay return of S/S
  • Cannot be used as the sole tx for disorders
  • Need informed consent before starting
  • Are broad spectrum and have effects on a large
    number of S/S.
  • Initial effects are sedative in nature
  • May take weeks for effects to be seen

8
Reasons for Nonadherence
  • Meds are expensive
  • Unpleasant side effects
  • Feel better and decide no longer need
  • Stigma associated with having a mental illness
    and taking meds
  • Paranoia or fears about med usage

9
Services Encouraging Compliance to Medication
Regimen
  • Follow-up appts. With client to verify that
    client understands the purpose, proper
    administration, intended effects, side and toxic
    effects of, and how to treat problems associated
    with meds
  • Support persons can encourage and assist the
    client to comply with meds
  • Appropriate lab tests must be conducted to
    prevent complications and assure correct levels
    of drugs
  • Encourage clients to participate in med groups
  • Can use injections of antipsychotics which will
    last from 2-4 weeks if clients are non-compliant

10
Efficacy of Psychotropics with Children Elderly
  • 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

11
Client Family Teaching
  • Purpose of the meds and benefits, side effects
    and how to treat SE.
  • What S/S indicate a toxic effect, and how to
    treat, and whom to call.
  • Specific instructions about how to take the meds

12
Psychotropic Meds Classifications
  • Antipsychotics (neuroleptics)
  • Mood Stabilizers
  • Antidepressants
  • Anxiolytics (antianxiety)
  • Sedatives
  • Hypnotics
  • Psychostimulants
  • Antihistamines, antimuscarinics, dopamine agonists

13
Uses for Antipsychotics/Neuroleptics
  • Schizophrenia Disorders
  • Bipolar-Manic Phase
  • Major Depression with psychotic features
  • Tourettes Syndrome
  • Control of intractable hiccups
  • Dementia, and Delusions
  • Aggressive behavior

14
Antipsychotic Meds-Neuroleptics
  • First generation Phenothiazines Thorazine,
    Mellaril, Stelazine, Prolixin (high potency)
  • Non Phenothiazines Haldol
    (butyrophenones)
  • (high potency)
  • Atypical Antipsychotics (2nd and 3rd gen)
  • Clozaril, Zyprexa, Risperdal, Geodon,
    Seroquel,
  • Zeldox
  • Invega,
  • Abilify

15
First Gen Antipsychotic Meds
  • Block predominantly dopamine activity
  • little effect on serotonin
  • High incidence of abnormal movements
  • (Also blocks acetylcholine, norepinephrine to
    some degree)
  • Blocks the H receptor for histamine
  • results in sedation and weight gain

16
Side Effects of 1st Gen Drugs
  • Dystonia (EPS)spasms of the eye,
    neck-torticollis, back, tongue-happens within 72
    hrs. reversible.
  • Akathisia (EPS)
  • restlessness
  • Pseudoparkinson- S/S similar to Parkinson's-see
    in 1-2 weeks. May disappear. TX. With Cogentin
  • Tardive Dyskinesia-bizarre facial and tongue
    movements-irreversible.

17
Other S/E of 1st gen Antipsychotics
  • Amenorrhea
  • Galactorrhea
  • Blurred vision, dry mouth, constipation and
    urinary retention, tachycardia-anticholinergic
    S/E
  • Sexual dysfunction
  • Severe dysrhythmias
  • In men can lead to gynecomastia
  • photosensitivity skin rashes (i.e. haldol)
  • Reduction is seizure threshold
  • Orthostatic hypotension
  • Agranulocytosis

18
Contraindications of Traditional Antipsychotics
(1st Gen)
  • Blood dyscrasias
  • Liver, renal, or cardiac insufficiency
  • CNS depressants, including ETOH
  • Tegretol in conjunction with antipsychotics
    causes up to 50 reduction in antipsychotic
    concentrations
  • SSRIs in conjunction with antipsychotics may
    cause sudden onset of EPS
  • Dont give if have Parkinson's disease,
    prolactin dependent cancer of the breast
  • Cigarette smoking causes reduced plasma
    concentrations of antipsychotics
  • Luvox in conjunction with antipsychotics causes
    increased concentrations of Haldol and Clozaril
  • Beta Blockers in conjunction with antipsychotics
    cause severe hypotension
  • Antidepressants in conjunction with
    antipsychotics may cause increased antidepressant
    concentrations

19
First Generation Antipsychotic Meds
  • Are useful in getting out of control behavior
    under control quickly.
  • These can be given with lithium to get treat
    acute mania.

20
Atypical Antipsychotics
  • Action
  • Blocks serotonin and to a lesser degree, dopamine
    receptors
  • Also block receptors for norepinephrine ,
    histamine, acetylcholine

21
Atypical Antipsychotics- 2nd and 3rd generation
drugs
  • Nicer drugs and are used more!!
  • Decrease positive and negative S/S of
    Schizophrenia
  • These drugs block serotonin as well as dopamine
  • Incidence of abnormal movements is lower!
  • Biggest SE is wt. gain

22
Positive Negative S/S of Schizophrenia
  • Positive
  • Hallucinations
  • Delusions
  • Abnormal thoughts
  • Bizarre behavior
  • Confused thoughts
  • Negative
  • Blunted affect
  • Poverty of speech
  • Social withdrawal
  • Poor motivation

23
Atypical Antipsychotics-2nd and 3rd generation
Clozaril (clozapine)
  • low incidence of abnormal movements
  • possible fatal side effect
  • bone marrow suppression agranulocytosis (rare)
  • Most common S/E
  • sedation drowsiness, wt. gain
  • Other S/E are
  • hypersalivation, tachycardia, dizziness,
    seizure risk

24
Atypical Antipsychotics-2nd and 3rd generation
continue
  • Risperidone
  • Does not cause bone marrow suppression
  • Can cause at higher doses motor difficulties
  • Available as a long acting injection
  • Can be used to tx. mania
  • Seroquel (Quetiapine)
  • S/E sedation, weight gain and headache
  • Not associated with abnormal movements

25
Atypical Antipsychotics-2nd and 3rd generation
continue
  • Zyprexa (olanzapine)
  • does not cause bone marrow suppression
  • Can cause weight gain hyperglycemia
  • Adverse effects-Drowsiness, insomnia restlessness
  • Geodan (ziprasidone)
  • Binds to multiple receptor sites
  • Main S/E are hypotension sedation
  • Can prolong the QT interval-can be fatal if hx of
    cardiac arrhythmias
  • Abilify (Aripiprazole)
  • Dopamine stabilizer
  • Partial agonist at the D2 receptor
  • In areas of the brain with excess dopamine, it
    lowers dopamine
  • In areas of low dopamine, it stimulates receptors
    to raise the dopamine level
  • Main S/E are sedation, hypotension, and
    anticholinergic effects
  • Adverse effects-headache, anxiety insomnia, GI
    upset

26
Contraindications for Atypical Antipsychotics
  • Known hypersensitivity
  • CNS depression, including ETOH
  • Blood dyscrasias in clients with Parkinsons
    disease
  • Liver, renal, or cardiac insufficiency
  • Use with caution in diabetics, elderly, or
    debilitated
  • SSRIs in conjunction with antipsychotics may
    cause sudden onset of EPS
  • Cigarette smoking causes reduced plasma
    concentrations
  • Tegretol
  • (carbamazepine) in conjunction with
    antipsychotics causes up to 50 reduction in
    antipsychotic levels
  • Luvox (fluvoxamine) in conjunction with
    antipsychotics causes increased concentrations of
    Haldol Clozaril
  • Beta Blockers in conjunction with antipsychotics
    cause severe hypotension
  • Antidepressants in conjunction with
    antipsychotics may cause increased antidepressant
    concentrations

27
Antipsychotics
  • Can be given be given as an IM injection (depot
    preparations) if have difficulty taking oral
    meds.
  • Can use lower doses when given IM, so less risk
    of tardive dyskinesia

28
Neuroleptic Malignant Syndrome
  • Rare, but fatal complication from all
    antipsychotic drugs
  • See more with 1st gen drugs
  • Severe muscle rigidity
  • High temp up to 107
  • Tachycardia
  • Tachypnea
  • Stupor
  • Coma

29
Mood Stabilizers
  • Used in the treatment of Manic (Bipolar)
    disorder, and in some forms of depression
  • Drugs used Lithium and Antiepileptic Drugs

30
Lithium
  • Mechanism of action unknown
  • Interacts with sodium and K
  • Alters electrical conductivity
  • potential threat to all body functions that are
    regulated by electrical currents
  • Can cause polyuria and polydipsa due to Na and K
    alterations
  • Has the lowest therapeutic index of all psych
    drugs
  • Have to monitor blood levels of this drug

31
Lithium
  • Maintenance blood levels of lithium are usually
    0.4-1.3 mEq (toxicity occurs with levels gt 1.5
    mEq/L)
  • Sign of toxicity is a fine intention tremor that
    becomes more pronounced and coarse.
  • Risk of thyroid kidney disease
  • If toxic s/s occur discontinue the drug and
    notify health care provider
  • Lithium should be taken with food
  • Client must eat a balanced diet with normal
    sodium intake and take in adequate fluid (about
    2-3 liters/day).
  • Excretion is dependent on this.
  • Dehydration and salt restriction can increase
    lithium levels cause toxicity.
  • Takes 2-3 weeks for lithium to become effective
    (may use antipsychotic until therapeutic levels
    are reached)

32
Signs symptoms of lithium toxicity
  • Fine hand tremors that progress of coarse tremors
  • Mild GI upset progressing to persistent upset
  • Slurred speech and muscle weakness progressing to
    mental confusion
  • Severe Toxicity
  • decrease level of consciousness to stupor and
    finally coma
  • Seizures, severe hypotension, severe polyuria
    with dilute urine

33
Lithium
  • Lithium serum concentrations are increased by
    fluoxetine (Prozac), ACE inhibitors, diuretics,
    and NSAIDs
  • Lithium serum concentrations are decreased by
    theophylline, osmotic diuretics, and urine
    alkalinizers

34
Contraindications for Lithium
  • Renal disease
  • Cardiac disease
  • Severe dehydration
  • Sodium depletion
  • Brain damage
  • Pregnancy or lactation
  • Use with caution in the elderly or clients with
    diabetics, thyroid disorders, urinary retention,
    and seizures

35
Anticonvulsants/Antiepileptic Drugs
  • Causes an increase in GABA in the CNS-which
    causes a decrease in anxiety.
  • Reduce the mood swings with bipolar

36
Anticonvulsants/Antiepileptic Drugs
  • Tegretol (carbamazepine)-also used to treat
    severe pain (i.e. trigeminal neuralgia)
  • Depakote (valproic acid)-can cause hepatic
    failure, pancreatitis, thrombocytopenia. Watch
    for liver failure
  • Klonopin (clonazepam)
  • Lamictal (Lamotrigine)-can have a rare but fatal
    dermatological condition

37
Toxic Effects of Anticonvulsants
  • Tegretol can cause agranulocytosis and aplastic
    anemia
  • Depakote can cause liver dysfunction, hepatic
    failure, and blood dyscrasias including
    thrombocytopenia
  • Depakote interacts with drugs that are
    hepatically metabolized

38
Contraindications for Anticonvulsants
  • Hepatic or renal disease
  • Pregnancy
  • Lactation
  • Presence of blood dyscrasias

39
Unique teaching needs with anticonvulsants
  • Monitor blood levels of mood stabilizers to
    prevent toxicity
  • Monitor liver, renal function tests and CBCs
  • Depakote must be swallowed whole, not cut,
    chewed, or crushed to prevent irritation

40
Antidepressants
  • Tx of depressive moods, including bipolar disease
  • 4 categories
  • Tricyclics
  • MAOIs
  • SSRIS
  • Atypical Antidepressants

41
Antidepressant Drugs
  • Tricyclics- Elavil, Tofranil
  • SSRIs-Zoloft, Paxil
  • MAOIs- Nardil, Parnate, Marplan

42
Atypical Antidepressants
  • Inhibits selective reuptake of serotonin
    Trazodone (desyrel)
  • Norepinephrine Dopamine Reuptake Inhibitor
    (NDRI) Wellbutrin (Bupropion)
  • Serotonin norepinephrine reuptake inhibitor
    Cymbalta (duloxetine)
  • Sertonin Norepineprine Reuptake Inhibitor-(SNRI)
    Effexor (venlafaxine)
  • Increases release of serotonin norepinephrine
    Remeron (mirtazapine)

43
Atypical Antidepressants
  • Trazodone
  • alternative to TCAs
  • Can cause orthostatic hypotension, sedation,
    priapism in males
  • Remeron causes sedation, weight gain, dry
    mouth, constipation
  • Wellbutrin (zyban) rarely causes sedation, wt.
    Gain, or sexual dysfunction.
  • Used for smoking cessation. Most common S/E are
    headaches, insomnia nausea
  • Can lower seizure threshold causes seizures

44
Atypical Antidepressants serotonin
norepinephrine reuptake inhibitor (SNRI)
  • SNRI-blocks uptake of serotonin and
    norepinephrine
  • Good for clients with anxiety also
  • SEsexual dysfunction, insomnia, agitation
  • Skipping 1 dose can cause withdrawal S/S
  • Drug here is Effexor
  • Cymbalta
  • Very effective in treating severe depression

45
Major Indications for Antidepressants
  • Major Depressive disorder
  • Bipolar depression
  • Obsessive-Compulsive
  • Anxiety
  • Panic disorder
  • PTSD
  • Substance Abuse
  • Chronic Pain
  • Tourettes Disorder
  • ADHD
  • Eating disorders
  • Sleep disorders
  • Migraines
  • Enuresis

46
Tricyclics Elavil, Pamelor, Tofranil,
Anafranil, Aventyl, Asendin, Sinequan
  • Blocks the reuptake of norepinephrine and
    sertonin
  • Tricyclic drugs block the muscarine receptors (so
    anticholinergic effects)
  • Other side effects
  • orthostatic hypotension
  • sedation
  • wt. gain
  • confusion-esp. elderly
  • arrhythmias

47
Tricyclics Contraindications
  • Do not mix with ETOH (none of the psych drugs
    should be mixed with ETOH)
  • Dementia
  • Suicidal clients
  • Cardiac disease
  • Pregnancy
  • Seizure disorders
  • Urinary retention
  • Dose for elderly should be ½ of adult dose
  • TCAs and MAOIs are effective in tx. depression
  • are not as safe or as well tolerated as the
    newer antidepressants
  • Toxic Effects
  • possibility of cardiac toxicity and are toxic
    in overdose

48
SSRIs
  • Prozac, Zoloft, Paxil, Celexa, Luvox, Serzone,
    Lexapro
  • Action-blocks the reuptake of sertonin into the
    neuron
  • Side-effect
  • biggest is sexual dysfunction wt. gain
  • Contraindication
  • Cardiac dysrhythmias

49
SSRIs
  • Are very safe and are not lethal in overdose
  • Good choice with the elderly-very few side
    effects
  • If used with MAOIs may cause Serotonin
    Syndromeseizure, death
  • If used with TCAs may cause TCA toxicity
  • Takes 2 weeks to feel effects

50
MAOIs
  • Nardil, Parnate, Marplan
  • Inhibits MAO, thus interfering with breakdown of
    norepinephrine, dopamine, and serotonin
  • Toxic effects
  • hypertensive crises
  • Avoid foods with tyramine (aged cheese, red wine,
    beer, chocolate, etc.)
  • MAOIs dont play well with other drugs!!

51
Antianxiety/Anxiolytic Drugs
  • GABA exerts an inhibitory effect on neurons
  • These drugs enhance this effect and produce a
    sedative effect
  • Therefore reduce anxiety
  • The most common used drugs here are the
    Benzodiazepines

52
Benzodiazepines
  • Valium, Xanax, Ativan , Librium , Klonopin,
    Serax
  • Dalmane, Halcion (used as sleep aides
    mostly-short term!!)
  • Used for anxiety, panic disorders, ETOH
    withdrawal, muscle spasm, sedation, insomnia, and
    epileptics/seizures
  • Use only short term because of dependency issues
  • Avoid ETOH
  • Causes sedation-dont drive!!

53
Benzodiazepines
  • Side Effects
  • Drowsiness, confusion, sedation, and lethargy
  • Toxic Effects
  • Respiratory depression esp. with ETOH use!
  • Contraindications
  • Combination with other CNS depressants
  • Renal or hepatic dysfunction
  • History of drug abuse or addiction
  • Depression and suicidal tendencies
  • Teaching
  • Use short term due to drug dependency issues
  • Avoid ETOH and other CNS depressants
  • Can impair ability to drive
  • Do not use with someone who has a hx of drug
    dependency
  • DC meds can cause withdrawal s/s

54
Nonbenzodiazepine Aniolytic
  • BuSpar (Buspirone)
  • reduces anxiety without strong sedative-hypnotic
    properties.
  • Not a CNS depressant
  • No potential for addiction
  • Takes 2 weeks to feel effects

55
Nonbenzodiazepine Aniolytic
  • Side Effects
  • Dizziness, dry mouth, nervousness, diarrhea,
    headache, excitement
  • Toxic Effects
  • Lethal dose is 160-550 times the daily
    recommended dose
  • Contraindications
  • Use with caution in PG women
  • Nursing mothers
  • Clients with renal or hepatic disease
  • Anyone taking MAOs
  • Teaching
  • Buspar is not associated with sedation, cognitive
    problems or withdrawal
  • Takes 2-4 weeks to feel effects
  • Some clients might feel restless, which could be
    incompleted anxiety

56
Sedative/Hypnotic Drugs
  • Used to reduce anxiety and insomnia
  • Can lead to tolerance and dependency
  • Use short term
  • Drugs used
  • benzodiazepines, i.e. Dalmane, Restoril, Halcion
  • Non-benzodiazepines, i.e. Ambien, Sonata,
    Lunestra

57
Sedative/Hypnotic Benzodiazepine Teaching
  • Use short term(1-2 weeks)
  • Carefully need to taper these off-never stop cold
    turkey
  • Do not take with other meds without talking to
    provider first
  • Do not drive if sedated on these!!

58
Client Teaching for Nonbenzodiazepines
  • Long term use not recommended
  • Do not drive when taking
  • Can repeat Sonata up to 4 hours before arising

59
ADD/ADHD-Psychostimulants
  • Ritalin, Adderall, Dexedrine, Concerta, Focalin,
    Metadate, Methylin
  • Action
  • increasing the release and blocking the reuptake
    of monoamines (dopamine, norepinephrine)
  • S/E wt. loss, anorexia, insomnia, headache,
    long-term growth suppression
  • Potential for abuse
  • Also used to treat narcolepsy

60
ADD/ADHD-Psychostimulants
  • Intended effects
  • Increased attention span concentration
  • Decreased distractibility, hyperactivity, and
    impulsivity
  • Treatment of ADHD, ADD, narcolepsy
  • S/E
  • Anorexia
  • Wt. loss
  • Growth retardation in children
  • Insomnia
  • Headache
  • Cardiovascular effects-high blood pressure,
    dysrhythmias
  • Contraindications
  • Hx of drug abuse dependency, severe anxiety,
    anorexia, MAIOIs

61
ADD/ADHD- Non-Stimulants
  • Strattera (atomoxetine)
  • Controls symptoms thru selective inhibition of
    norepinephrine
  • Takes 1-3 weeks to feel effects
  • No abuse potential and is not considered a
    controlled substance

62
Meds used to Tx Extrapyramidal SE
  • Cogentin
  • Benadryl
  • Artane
  • Symmetrel
  • Requip
  • Akineton
  • Kemadrin
  • These meds should be taken simultaneously with
    antipsychotic meds to prevent EPS

63
Meds for Alzheimers
  • Drugs here are used to slow the progression of
    the disease
  • Memantine (Namenda, Ebixa)
  • Cognex (tacrine)
  • Aricept (donepezil)
  • Exelon (Rivastigmine)
  • Razadyne (galantamine)

64
Herbal Medicines
  • Ginkgo biloba-helps with memory
  • Kava-Kava
  • St. Johns Wart

65
PET Scanpositron-emission tomography (PET) scans
  • Useful in identifying physiological and
    biochemical changes as they occur in living
    tissue
  • i.e. clients with schizophrenia PET scans show a
    decrease of glucose in the frontal lobes of
    unmedicated clients, also can indicate mood
    disorders, ADHD
  • Radioactive substance is injected, travels to the
    brain, and illuminates the brain. Have 3D
    visualizations of the CNS
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