PSYCHOPHARMACOTHERAPY

Neurotransmitters chemical messengers that conduct impulses from one neuron to another Stored in synaptic vesicles Manufactured in the neuron (nerve cells) Either inhibitory or excitatory Functions (DANGS) DA: regulation of movements/ coordination, integration of thoughts/emotions Ach: memory acquisition/retention /learning Ne: sleep, arousal, mood regulation, energy GABA: calmness 5ht: sleep, arousal, libido, appetite, mood, aggression, temperature

Neurotransmitters and disorders Neurotransmitter (DANGS) Excess Dopamine (DA) Schizophrenia (+)sym Acetylcholine (Ach) Norephinephrine (NE/NA) Mania GABA Serotonin (5HT) Schizophrenia (-)sym

Deficient P.D,depression A.D Depression Anxiety Depression

TYPES ANTI ANXIETY / ANXIOLYTICS/ MINOR TRANQUILIZERS REMEMBER: A.N.X.I.E.T.Y A= ACTION: Decrease BENZODIAZEPINES(BZAs) =CNS depressant , increase anxiety, sleep disorder, for GABA, sedation vaginismus and rapid Calming effect ejaculation NON BENZODIAZEPINES= Interacts with serotonin / dopamine, less adverse effect, given to px prone to substance abuse SSRIs= for GAD, Ocd, Panic attacks, Ptsd, Social phobia N= NO TO(ACALA RA) ..(ACALA RA) ALCOHOL (FATAL and impairs liver function) CAFFEINE (decrease drug effect) ANTACIDS (interferes absorption) LONG TERM USE (abuse and dependence) ACTIVITIES that requires concentration or handling complex machineries, driving RISING immediately (hypotension: mgmt; Levarterenol(Levophed). ABRUPT stopping (Switch from BZA to non BZA ,Use tapering (if not :seizures, insomnia, vomiting to px) X= CONTRAINDICATIONS pregnant hypersensitive client with COPD renal/ hepatic dysfunction I= INDICATIONS BZAs- anxiety, sleep disorder, sedation, Clonazepam (Klonopin)- anti convulsant Non BZAs Buspirone( BuSpar) therapeutic effect; 3-6 weeks treatment E= EFFECTS OF THE BZAS DRUG SHOULD BE CNS DEPRESSION 4DS(over dosage manifestations) OBSERVED Drowsiness, dizziness, decrease BP, diminished reflex, dry mouth + it can lead to drug dependence

T= TYPES (VLAB VSeX K TAE)

Mgmt: gastric lavage followed by activated charcoal, Flumazenil (Romazicon)IV, recline position (VLAB VSeX K TAE) Diazepam (Valium)- mst. Prescribed, pre surgery jitters Chlordiazepoxide (Librium) 1st BZA Lorazepam (Ativan) elderly, px with impaired liver function Buspirone (BuSpar)*non BZAs, GAD Hydroxyzine (Vistaril)* non BZAs,antihistamine Oxazepam (Serax) elderly,same as ativan (BEH) Alprazolam (Xanax)- GAD,PD Clonazepam (Klonopin)- anti convulsant Clorazepate (Tranxene) Hydroxyzine (Atarax)*non BZAs, antihistamine Meprobamate(Equanil)*non BZAs, 1st anxiolytic drug

(V)alium (L)ibrium (A)tivan (B)uspar (V)istaril (Se)rax (X)anax (K)lonopin (T)ranxene (A)tarax (E)quanil Y= YOU should know that this drug is used for short time (BZA thera effect by 1 week or less, non BZA by 2-4 weeks ), (Non BZA is non prn drug) BEST GIVEN BEFORE MEALS TYPES ANTI DEPRESSANTS Remember: S.A.D. P.E.R.S.O.N S= STUDY DEPRESSION AND DRUG MECHANISM OF ACTION

TRICYCLIC ANTIDEPRESSANTS-TCAS blocking reuptake of NA, 5ht desired effect; improved appetite, sedation, anxiety reduction With cardiovascular effects; elderly alert 2. SELECTIVE SEROTONIN REUPTAKE INHIBITORSSSRIS blocks reuptake of serotonin fewer side effects than TCAs first drug of choice in treating depression Unfortunately , they can cause sexual dysfunction and GI symptoms 3. MONOAMINE OXIDASE INHIBITORS-MAOIS inhibits MAO that breaks down/inactivates NA,5ht TCAs- depression, childhood enuresis, OCD, panic attacks SSRIs- depression, OCD, panic disorder, bulimia nervosa , social anxiety disorders MAOIs- atypical depression, panic disorders 1. T.C.A Si ATE Vi at ANA (Si) Sinequan: orthostatic hypotension
(A)nafranil: 1st TCA, panic attacks, OCD (T)ofranil: childhood enuresis, bulimia nervosa,

A= ALLOWED/ INDICATION

D= DIFF. CLASSIFICATION Doxepin (Sinequan) Clomipramine (Anafranil) Imipramine (Tofranil) Amitryptiline (Elavil) Protriptyline (Vivactyl) Amoxapine (Asendin) Desipramine (Norpramin)

panic,oldest TCAs (E)lavil: most cardiotoxic (Vi)Vivactyl: for elderly

(A)sendin: can cause tardive dyskinesia, for

Nortriptyline (Aventyl)

psychotic/depressed
(N)orpramine: panic, dysthymia, elderly depressed

pt, bulimia nervosa

(A)ventyl: good choice for elderly

SSRI Citalopram (Celexa) Fluvoxamine (Luvox) Sertraline (Zoloft) Escitalopram (Lexapro) Fluoxetine (Prozac) Panoxetine (Paxil)

2. SSRI Ce-Lo-Zo na, may Le-Pro-Pa (Ce)lexa (Lu)vox:newest SSRIs, OCD (Zo)loft: can cause sexual dysfunction (Le)xapro (Pro)zac: 1st SSRIs,bulimia (Pa)xil: panic 3. MAOIS (PaMaNa) Tranylcypromine ( Parnate) Isocarboxacid (Marplan) Phenelzine (Nardil) atypical depression xxxxxxReversible type xxxxxx Moclobemide (Manerix)*TYRAMINE rich food OK to eat!!!!!! Consult your provider of care TCAS- HATS= Hypotension, Anticholinergic effects, Tachycardia, Sedation TCA poisoning/overdosage (anticholinergic toxicity) vs. use Physostigmine (Antilirium) 2.MAOIS ORTHOSTATIC HYPOTENSION-common side effect HYPERTENSIVE CRISIS- if tyramine rich food is eaten: (CABSS) Cheddar/ aged cheese Avocado Banana, beer Soy sauce, salami, preserved foods occipital headache initial sign of hypertensive crisis MANAGEMENT: 3Ms for MAOI 1. MAOI D/C, inform physician 2. Monitor V/S 3. MEDS: Nifedipine( Procardia) Phentolamine (Regitine) A.for TCAS 1. Check BP- hypotension 2. Given at PM 3. Lag period of 2-4 weeks 4. TCAS + MAOIS= FATAL B. for SSRIS 1. Antacids decrease absorption 2. Given at AM; (insomnia) 3. Lag period(therapeutic effect can be felt) of 2-4 weeks 4. SSRIS + MAOI= FATAL 5. Serotonin syndrome SSRIs + MAOIs= serotonin syndrome signs and symptoms;

P= PLANNING PREGNANCY E= Effects/ Side effects

R= REMEMBER (usually taken with meals)

mental status changes: confusion/hypomania Restlessness/agitation Diaphoresis Tremors/shaking chills Nausea, abdominal cramps Ataxia (incoordination) headache

Management for serotonin syndrome: D/c the involve drug, the condition will usually resolve in its own within 24 hours Provide supportive measure E.g; headache; give analgesics *2 weeks- stopping MAOI and starting SSRI *4/ 5 weeks- stopping SSRI and starting MAOI C.for MAOIS 1. Given at AM 2. Lag period of 2-4 weeks at least 2-3 weeks interval when shifting from one antidepressants to another FOR SUICIDAL TENDENCIES(suicidal monitoring) PREGNANT, HYPERSENSITIVE, SEIZURES, ALCOHOLICS, CVD

S= SHIFTING O= OBSERVE N= NOT ALLOWED/ CONTRAINDICATED;

TYPES Antipsychotic/ neuroleptic/major tranquilizer Remember: A.N.T.I. P.S.Y.C.H.O.T.I.C A- ACTION blocks dopamine receptors sites in the brain= decrease psychotic symptoms ex: hallucinations, delusions, rage IM- dorsogluteal= drug route N-NEUROLEPTIC fatal reaction/side effect to antipsychotic drugs( sympathetic n.s MALIGNANT SYNDROME hyperactivity). Common in high potency anti psychotic drugs. (NMS) Haloperidol- common cause muscular rigidity, tremors, altered consciousness, increase temperature (cardinal sign 42.2 C) T- TARDIVE DYSKINESIA side effect, involuntary, irreversible stereotyped movement of face and neck generally manifested by lip smacking, tongue twitching, grinding of teeth, blinking, smacking, foot tapping, abnormal movements, tremors of the arms and legs. Appears after months or years of drug use. I- Inability to sit or I feel as if ants in my pants. (AKATHISIA) the most common EPSE. Appears 50-60 days after initiation of the therapy P- PARKINSONISMS- SUN EXPOSURE SHOULD BE AVOIDED Y- YES FOR A NURSE: like tremors, rigidity, akinesia (muscle weakness). (1-5 days after initiation of the therapy) PHOTOSENSITIVITY MANAGEMENT: SSS: sun protection, shades, sunscreen 1.Monitor V/S: BP: orthostatic hypotension (systolic decr. 30 mmHg),

C- CHLORPROMAZINE (Thorazine) H- HALOPERIDOL (Haldol) O- OBSERVE FOR DESIRED EFFECT T- TYPES:

TEMP: NMS, CBC(WBC) SUGAR LEVELS( incr. insulin-hyperglycemia(metabolic disturbance)- wt. gain) 2. Instruct client to avoid operating heavy machineries- sedation, drowsiness 3. Given at bedtime, with meals or after meals 4.EPSEs vs. ANTICHOLINERGIC DRUGS 5. OVERDOSE: gastric lavage 6. Pregnancy considerations 7. Do not stop abruptly. Leads to (EPSE) 1st anti psychotic drug, sedating and can cause wt.gain Watch out for NMS sedation, emotional quieting, effective for positive symptoms; AND SIDE EFFECTS: anti- cholinergic effects, tachycardia, hypotension, EPSEs, parkinsonism Trifluoperazine (Stelazine) HP Mesoridazine (Serentil) LP Olanzapine (Zyprexia)Atyp - for + and symptoms, no agranulocytosis Chlorpromazine (Thorazine)LP, 1st antipsych Perphenazine (Trilafon) MP - used with anti depressants for patients who are both psychotic and depressed Trilafon+ Elavil= Triavil Clozapine (Clozaril)- 1st Atyp - major side effect: agranulocytosis Thioridazine (Mellaril) LP - short term treatment for marked depression accompanied by anxiety, effective in children with severe behavioral problem. Impairs night vision Risperidone (Risperidal) Atyp -orthostatic hypotension Haloperidol (Haldol)HP Fluphenazine (Prolixin) HP ANTACIDS= decrease absorption; take antacids 1 hour before or 2 hours after taking antipsychotics ALCOHOL, ANXIOLYTICS, ANTIDEPRESSANTS, BARBITURATES- profound CNS depression Pregnant Severe CNS depression Parkinsons dis. Hepatic ,renal, coronary disease

I- INTERACTION OF ANTI PSYCHOTIC DRUG TO OTHER DRUG C- CONTRAINDICATIONS:

ADD ONS BATTLE OF THE ANTI PSYCHOTIC DRUGS Typical Atypical Or traditional/conventional/standard Old drug s(discovered in 50s) For (+) symp

Or nontraditional/unconventional/novel New drugs (discovered 90s) Discovered in 2000s For (+) and (-) symp

Dopamine(DA) System Stabilizer DSS

MOA: decrease DA (anti dopamine) S/E: high risk for EPSE e.g: Chlorpromazine (Thorazine

MOA: decrease 5HT (anti serotonin) S/E: low risk for EPSE e.g: Clozaril

MOA: increase DA in areas with less DA, decrease DA in areas with more DA S/E: low risk for EPSE e.g: Aripiprazole (Ablify)

ADD ONS Atypical antipsychotics; (5HT, NE) Reduced or no risk for EPSE Effective in treating negative symptoms Minimal risk of TD Usual side effect; weight gain (idiopathic) CloRZ (clozaril, risperidal, zyprexa) E.g : clozapine (Clozaril), risperidone (Risperidal), olanzipine (Zyprexa) Clozapine (Clozaril); agranulocytosis Fatal side effect, can occur 24 weeks after the initiation of the therapy Characterized by fever, malaise, sore throat, leukopenia Management; a. Once started; monitor WBC weekly for 6 mos. b. If WBC drops below 2000/mm3 D/C permanently

ADD ONS EXTRAPYRAMIDAL SIDE EFFECTS (EPSE) major cause is a deficiency in dopamine Antipsychotics effect: decrease dopamine CNS effects. 1. Dystonia- rigidity in muscles that control posture, gait, or ocular movement DOC: Benztropine (Cogentin), anti cholinergic agents 2.. Akathisia- Inability to sit or I feel as if ants in my pants. , most common EPSE DOC: Benztropine (Cogentin), Trihexyphenidyl (Artane) 3.. Drug-induced parkinsonism/ pseudoparkinsonism (false) symptoms resemble those of Parkinsons disease (idiopathic Parkinsons Disease) drooling, lack of facial responsiveness, shuffling gait and fine tremors DOC: Biperiden (Akineton) 4.TARDIVE DYSKINESIA: side effect, involuntary, irreversible stereotyped movement of face and neck generally manifested by lip smacking, tongue twitching, grinding of teeth, blinking, smacking, foot tapping, abnormal movements, tremors of the arms and legs. Appears after months or years of drug use.(hence, tardive; late onset,appearance) dyskinesia; abnormal voluntary skeletal muscle movements usually jerky motions Drug of choice : Bromocriptine ( Parlodel) 5.NMS: fatal reaction/side effect to antipsychotic drugs( sympathetic n.s hyperactivity). Common in

high potency anti psychotic drugs. Symptoms: muscular rigidity, tremors, altered consciousness, increase temperature (cardinal sign 42.2 C)

Neuroleptic/Antipsychotic S/E Remember: Anti A HOPE Anti cholinergic side effects Agranulocytosis Hyperglycemia Orthostatic hypotension Photosensitivity Extrapyramidal side effects TYPES Anti Parkinsons Drug Remember: A.N.T.I .P.A.R.K. A- ACTION:

MANAGEMENT:NMS(neuroleptic malignant syndrome) 1. Monitor V/S 2. Meds: Dantrolene ( Dantrium), muscle relaxant Bromocriptine (Parlodel), Da agonist 3. D/c meds(haloperidol)- stat, notify physician, should not reinstitute meds for at least 2 weeks after resolution of NMS symptoms

BALANCE dopamine and acetylcholine *Balance is accomplished 1. Dopaminergic agents- increase DA Levodopa- (Dopar), (Larodopa) Carbidopa- Levodopa- (Sinemet) Amantadine- (Symmetrel) Bromocriptine- (Parlodel) Selegine- (Eldepryl) 2. Anti cholinergic drugs- decrease Ach Trihexyphenidyl (Artane) Benztropine (Cogentin) Biperidon (Akineton) Diphenhydramine (Benadryl) (ROACH.coach freddie ROACH) Rise slowly (hypotension) Observe therapeutic effect; (decrease tremor and salivation, improve balance and gait) Avoid alcohol, high protein foods, Vit B6(decrease absorption) Cautiously used during pregnancy (decr. lactation) Have a meal before taking meds (GI upset) TREMORS- first sign, pill rolling, shaking BRADYKINESIA- slow and retarded movements, mask like appearance because facial movements slow down, stiffness RIGIDITY- salivation, difficulty in dressing, bathing, handwriting Parkinsons disease, pseudoparkinsonism, EPSE

N- NURSING CONSIDERATIONS

T- TRIADS OF PDs (primary symptoms)

I- INDICATIONS

P- PRIMARY symptoms

A- ANTICHOLINERGIC DRUGS R-REMEMBER: CAPABLaDES

PRIMARY symptoms can lead to secondary symptoms .e.g dysphagia, excessive saliva accumulation, weight loss, choking, impair respiration, bladder and bowel function, compromise breathing, urinary retention, constipation are used alone in the treatment of Parkinsonism induced by anti psychotic drugs- so that balance of the two neurotransmitters will be restored CAPABLaDES Benztropine (Cogentin)- most prescribe anticholinergic drug Trihexyphenidyl (Artane)- 1st anticholinergic used for EPSEs Bromocriptine (Parlodel)- for NMS Biperiden (Akineton) Diphenhydramine (Benadryl) Levodopa (Larodopa) (Dopar) Selegiline (Eldepryl) Amantadine (Symmetrel) (C)ogentin (A)rtane (P)arlodel (A)kineton (B)enadryl (LA)rodopa,(D)opar, (E)ldepryl (S)ymmetrel CANT SEE: blurred vision; normal vision usually returns in a few weeks, sunglasses, caution when driving CANT SPIT; dry mouth; sugarless candy, frequent rinses, ice chips, sips of water CANT PEE; urinary retention; encourage frequent voiding, catheterization CANT SHIT; constipation; laxatives, 2500-3000 ml. of water/ day, high fiber diet CANT SWEAT; anhidrosis; take temperature, feversponge bath

K- KNOW the side effects

TYPES ANTI MANIC or mood stabilizers Remember: L.I.T.H.I.U.M L= LEVEL (therapeutic (0.6- 1.2 mEq/l) level) TOXICITY INDICATORS: NAVDAD Nausea, anorexia, (first indicators) followed by vomiting, diarrhea, abdominal pains, drowsiness I= INTERVENTIONS Take it with meals or after meals- prevent nausea.given PO Take 10-12 glasses of water- thirst/toxicity Sodium intake(3gm/day)-prevent toxicity Monitor serum level; must be drawn at least 8-12 hours after the last dose and performed in the morning. For toxicity-acetazolamide (Diamox), gastric lavage, PNSS ,for severe use hemodialysis T= TEN-14 DAYS TEN-14 DAYS BEFORE THERAPEUTIC EFFECT BECOMES EVIDENT

H= HOLD IT/ CONTRAINDICATIONS:

I= INDICATION U= UNCLEAR M= MANIA VS. ANTI MANIC AGENTS

pregnant renal diseases Hypersensitivity cardiovascular dis. treatment for manic; action: decrease hyperactivity Mechanism of action is unclear. Lithium alters sodium transport in the nerve and muscle cells and inhibits the release of NE and Da. Lithium Carbonate(Eskalith) Valproic acid (Depakene) Carbamazepine (Tegretol) (NAV- nausea, anorexia, vomiting) Anti manic types 1.Lithium carbonate 2.Anti convulsants; stimulates GABA which provides a calming effect Valproic acid (Depakene)WOF: hair loss, wt.gain, GI upset Carbamazepine (Tegretol)WOF(NAV), agranulocytosis Lamotrigine (Lamictal)WOF rashes

TYPES Anti Dementia Common approach to treatment attempts to restore neurotransmitter loss(focus on Ach) No known treatment can stop or reverse A.D Agents that restore acetylcholine For mild to moderate A.D (preserve cognitive function longer) Cholinesterase inhibitors targets Ach deficiency, inhibits cholinesterase which increase Ach 1.Tacrine (Cognex)

2. Donepezil (Aricept) 3. Rivastigmine (Exelon) 4. Galantamine(Razadyne) Agents that retard neurogeneration NMDA (N-methyl-D-Aspartate) receptors antagonist For moderate to severe A.D MEMANTINE: no to patient with renal problem Prevents glutamate from stimulating NMDA Often co prescribed with Donepezil Over dosage can lead to psychosis Drugs that prevent A.D (BENS) B vitamins (B6,B12 and folic acid) Estrogen: anti oxidants vs. beta amyloids, increase cholinergic function NSAIDS (Celebrex): WOF CVA, heart attacks Statins: dual benefit, lowers cholesterol + reduce risk of A.D

1st available for use Linked to hepatic effects, seldom prescribed Fewer peripheral S/E Absence of hepatotoxicity Problem includes G.I problem, bradycardia Given at bedtime (PO,OD at HS) With peripheral S/E Presents typically cholinergic S/E such as GI symptom MGMT: Take it with meals

Others Herbs: anti oxidants like grape seed extract, gingko, green tea, garlic, prunes, strawberries Omega 3 fish oil: salmon, mackerel, sardines Lecithin: soy beans, a major component of cell membranes, like nerve cells Music therapy: increase melatonin concentration (sleep) vs. A.D (sleep disturbance) Vit E/C: anti oxidants, slows/reverse the cognitive decline of A.D ANTI CHOLINERGIC MEDS SHOULD BE AVOIDED IN PATIENT WITH A.D Captopril (Capoten) Codeine Cimetidine (Tagamet) Digoxin (Lanoxin) Furosemide (Lasix) Nifedipine (Procardia) Ranitidine (Zantac) Warfarin (Coumadin)

ADD ONS Stages of A.D Stage Mild

Duration 2-3 years

Changes Denial Difficulty performing usual activities Decision making, concentration, judgment, problem solving Decreased short term memory(amnesia) ABCD 2 W Apraxia, agnosia, aphasia Blunt affect Changes in sleep patterns Disoriented/delusional 2LONG(assistance) for ADLs Wandering TOTAL bed bound TOTAL incontinence TOTAL gait disturbance TOTAL care needed (24 hours supervision)

Moderate

3-4 years

Severe

5-10 years

Restraints and Seclusion Persons are never restrained and left alone in a locked room. Seclusion and restraint should not be used as a means of coercion or punishment, for the convenience of the staff, or when less restrictive measures to manage behaviors are available. Seclusion is the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving. Seclusion may only be used for the management of violent or self destructive behavior Restraints A physical restraint is any manual method or physical or mechanical device, material or equipment that immobilizes or reduces the ability of a person to move his or her arms, legs, body or head freely; or A drug or medication when it is used as a restriction to manage the persons behavior or restrict the persons freedom of movement and is not a standard treatment or dosage for the persons condition Rs of Restraints Restraints: last resort (least restrictive interventions first) Requires special training and competency on staff members or person top decide or initiate this measure Review institutional policy or protocol FIRST Reassess patient every 10-15 minutes (face to face)

Record events/ interventions (documentation/ before-during-after the restraints)