Serotonin is a neurotransmitter abundant in brain regions that
ANITPSYCHOTIC AGENTS
• Are used primarily to treat most forms of psychosis, such as schizophrenia,
schizoaffective disorder, delusional disorder, mood disorder with psychosis,
and psychoses associated with delirium and dementia.
• Are used to manage confusion, behavior problems and behavior disorders
• Small doses may be used to treat anxiety, tension, agitation and dizziness.
• Contraindications and precautions:
o Angle-closure glaucoma and CNS depression
o Must be withheld 48 hours before and 24 hours after
myelography with metrizamide because atypical antipsychotics
may reduce the seizure threshold
o Used cautiously in patients with acute MI, heart disease, benign
prostatic hyperplasia and orthostatic hypotension
Two classifications of antipsychotics
1. Typical antipsychotics
• Produce significant neurologic adverse effects
• Provide symptom relief by blocking the dopamine receptors in
the brain.
Dopamine is a chemical messenger that regulates thinking,
emotion, behavior and perception. Excess amounts of dopamine
cause nerve impulses in the brain stem to be transmitted faster
than normal, resulting in strange thoughts, hallucinations, and
bizarre behavior.
• Low potency: Chlorpromazine, Procholorperazine, Thioridazine
• High potency: Fluphenazine, Haloperidol, Pimozide, Thiothixene
• Side effects of typcal antipsychotics: blurred vision, constipation,
drowsiness, dry mouth, hypo or hyperglycemia, orthostatic
hypertension, insomnia, tachycardia, weight gain
• Nursing responsibilities:
o If blurred vision continues after 1 to 2 weeks, notify
attending physician because a dosage reduction or change in
medication may be necessary.
o Promote increased fluid and fiber intake.
o Caution client to avoid driving.
o Advise to avoid caffeine.
o Encourage development of exercise programs
2. Atypical antipsychotics
• Block the activity of both dopamine and serotonin.
are associated with emotions. Serotonin helps balance mood,
assists with regulating emotions, appetite and sleep; helps to
form scabs and assists with other processes. In excess, it causes
intestinal disturbance, tremor, agitation, myoclonic jerking,
anxiety, shivering, hyperthermia, ataxia, headaches, confusion,
mania, hallucinations and other abnormal conditions and can
encourage suicide. Too little serotonin promotes impulsivity,
aggression, depression and can lead to suicide.
• To treat both the negative and positive symptoms of disorders
such as schizophrenia.
• To treat obsessive-compulsive disorder, bipolar disorder and risk
or recurrent suicidal behavior
• Produce fewer motor adverse effects than typical antipsychotics
• Include: Risperidone, Olanzapine, Clozapine, Quetiapine,
Ziprasidone, Aripiprazole
• Adverse reactions:
o Extrapyramidal reactions, tardive dyskinesia, sedation, blurred
vision, dry mouth, constipation, blood dyscrasias,
photosensitivity reaction, sunburn, heat intolerance
o Agranulocytosis, which requires close monitoring of WBC
(clozapine)
o Possible cataract development and increased liver function test
values (quetiapine)
• Interactions
o May potentiate the effects of alcohol and CNS depressants
o Concurrent use with anithypertensives and nitrates causes
additive hypotension
o Use with antacids decreases drug absorption
o Use with neuroleptics decreases the seizure threshold; increases
doses of anticonvulsants may be needed
o Counteracts the effect of levodopa and other dopamine agonists
• Nursing responsibities:
o Assess the patient’s mental status; loss of contact with reality
may signal noncompliance with drug therapy
o Monitor the patient for extrapyramidal symptoms and other
adverse effects such as tardive dyskinesia, which is irreversible
o Monitor the patient for orthostatic hypotension after parenteral
doses
o Know that the patient who receives long-term antipsychotic
therapy should undergo regular evaluation of RBC and WBC
counts to detect blood dyscrasias.
o Warn the patient not to consume alcohol or other CNS
depressants while taking these drugs.
o Don’t give antacids within 1 hour of administering these drugs.
 o Caution the patient to avoid driving and other activities requiring
alertness until response to drug is known.
o Urge the patient to use sunscreen and protective clothing to
avoid photosensitivity reaction.
ANXIOLYTICS
• Are medications with a calming action that are used in states of
unrest, anxiety and tension of many types such as panic disorder,
generalized anxiety disorder, substance-related disorders and their
withdrawal and insomnias.
• Anxiolytics used today almost all belong to benzodiazepine
group and have the advantage of lower toxicity and generally better
tolerability than other sedative drugs.
• Drugs include benzodiazepine and buspirone
Benzodiazepine
• Mechanism of action: enhances GABA recognition, potentiating
inhibitory action
GABA is the major inhibitory neurotransmitter in the CNS.
• Safe in overdose if used alone
• Side effects: behavioral disinhibition, confusion, ataxia,
excitement, agitation, transient hypotension, vertigo, GI distress,
physical dependence
• Withdrawal symptoms: diaphoresis, various GI symptoms,
tremor, lethargy, dizziness, headaches, increased acuity for smell
and sound, seizures (especially with abrupt withdrawal of high-
potency benzodiazepine)
• It is important to taper benzodiazepine dose to avoid withdrawal
symptoms. It is necessary for patients who have taken
benzodiazepine for more than 4 months.
Buspirone
• Can relieve some symptoms of anxiety that do not cause
sedation, dependency or psychomotor retardation
• Safe in overdose.
• Mechanism of action: It acts as a partial agonist of 5HT1A.
5HT1A binds endogenous neurotransmitter serotonin.
• Side effects: headache, GI distress, dizziness
• Drug interactions:
o Avoid use with MAOs because it may increase blood
pressure.
o Grapefruit juice, diltiazem, erythromycin and
itraconazole may elevate levels of buspirone
• Disadvantages:
o Less useful in people who have been on benzodiazepine
o Takes around 2 weeks before patients notice results
• Nursing management:
o Avoid alcohol and other CNS depressants.
o Inform patient that results may be noticed after 2
weeks.
o Warn patients against operating heavy machinery until
they know the effects of the medication.
o Blood pressure should be monitored.
ANTABUSE (DISULFIRAM)
• It is used only if the client is preoccupied with alcohol or is
craving alcohol and has had multiple failed treatments in the past.
• It is a drug which blocks the enzyme that degrades the first
breakdown product of alcohol known as acetyldehyde.
• Client must be motivated to stop dinking and agree to fully
cooperate with the treatment program.
• It may also be court ordered.
• People who are taking antabuse drugs will experience an
accumulation of acetyldehyde. High blood acetyldehyde levels
induce an uncomfortable state. For them, drinking alcohol causes
nausea and vomiting, cramps, hypotension, vertigo, pulsating
headache, sweating and weakness.
• It is contraindicated in patients with heart disease, liver disease,
hypothyroidism, cerebral damage and diabetes.
• The maintenance dosage can range from 125 mg/day to
500mg/day of oral tablets and should not exceed 500mg/day.
Nursing considerations: Antabuse Therapy
• Do not give antabuse within 12 hours of alcohol ingestion. A
reaction may occur up to 2 weeks after antabuse is stopped.
• Adverse interactions occur with several other drugs, in addition
to alcohol.
• The drug is contraindicated during pregnancy and in the nursing
mother.
• The client’s liver function and CBC must be regularly monitored.

• The client must avoid all sources of alcohol, including cooking
sauces, vinegars, cough syrup and possible transdermal sources, such as
after-shave lotion, liniments and rubbing alcohol.
• Some adverse side effects may occur, including impotence,
decreased libido, fatigue, and unpleasant taste in the mouth. These
usually disappear within a few weeks.
• If the client experiences any alcohol-disulfiram reaction, seek
medical help immediately. Report any unusual bleeding/ bruising,
jaundice, chest pain, difficulty breathing, or any alcohol ingestion.
ANTIDEPRESSANTS
• Used for treatment of major depressive disorder, anxiety disorder, the
depressed phase of bipolar disorder and psychotic depression
• Off label uses: chronic pain, migraine headaches, sleep apnea, peripheral
and diabetic neuropathies, panic disorder, dermatologic disorder and
eating disorders
Mechanism of Action: interacts with 2 neurotransmitters, norepinephrine and
serotonin that regulate mood, arousal, attention, sensory processing and
appetite.
4 Groups of Antidepressants
1. Tricyclic antidepressants
-blocks the reuptake of norepi primarily and serotonin to some degree
-may take 4-6weeksto be effective
-blocks cholinergic receptors resulting in anticholinergic effects such as
dry mouth, constipation, urinary hesitancy and blurred vision. Agitation,
delirium and ileus may occur in older adults.
-common side effects: orthostatic hypotension, sedation, weight gain and
tachycardia, sexual dysfunction
-lethal if taken overdose
Ex: impiramine, clomipramine, amitriptyline, despiramine
2. Selective Serotonin Reuptake Inhibitors (SSRIs)
-blocks the reuptake of serotonin
-may take 2-3 weeks to be effective
-has fewer side effects compared to cyclic compounds
-common side effects: anxiety, agitation, akathisia, nausea,
insomnia,sexual dysfunction
Ex: fluxoetine (Prozac)
3. MAO inhibitors (MAOIs)
-interfere with enzyme metabolism
-needs 2-4weeks for effectiveness
-common side effects: daytime sedation, insomnia, weight gain, dry
mouth, orthostatic hypotension and sexual dysfunction
-may cause hypertensive crisis when ingest with tyramine containing
foods
4. Other antidepressants such as venlafaxine, bupropion, duloxetine, trazodone,
nefadozone
-common side effects: sedation, headaches, loss of appetite, nausea,
agitation, insomnia
-nefadozone: may cause liver damage
-bupropion: can cause seizures 4x greater than other antidepressants
Serotogenic Syndrome- can result from taking MAOI and SSRI at the same time
-symptoms: agitation, sweating,fever, tachycardia, hypotension, rigidity,
hyperreflexia
Client Teaching for Antidepressants
1. SSRI should taken in the morning unless sedation is a problem
2. If missed dose of SSRI, wait after 8hours before taking the missed dose.
3. Cyclic compunds should be taken at night in a single daily dose.
4. If missed dose of cyclic, wait after 3hours before taking the missed dose.
5. Caution in driving or performing activities
MOOD STABILIZING DRUGS
• Used to treat bipolar disorder
• Stabilizing the client’s mood, preventing or minimizing the highs
and lows of bipolar illness
Lithium- most established mood stabilizerand 1st line agent in treating bipolar
illness.
-normalizes the reuptake of certain neurotransmitters such as serotonin,
norepinephrine, acetylcholine, and dopamine
- reduces release of norepinephrine through competition with calcium
-produces effects intracellularly rather than within neural synapses
- available in tablets, capsules, liquid, no parenteral form
-common side effects: mild nausea, diarrhea, anorexia, fine hand tremor,
polydipsia, polyuria, metallic taste in the mouth, fatigue
-toxic effects; severe diarrhea, vomiting, drowsiness, muscle weakness
and lack of coordination
*Lithium can’t be given if the patient cannot have regular blood tests.
Increase in salt intake can increase excretion of lithium—could lead to return to
mood symptoms.
Sufficient water intake to promote adequate lithium excretion.
Evidence of toxicity should be watch out for.
Lithium may impair mental and physical functioning.
ANTICONVULSANT
Valproic Acid -increase levels of GABA
- can cause hepatic failure
Carbamazepine - inhibits the kindling process (when minor seizures
become more frequent and severe)
-can cause aplastic anemia and agranulocytosis
Lamotrigine- for mood stabilization
- can cause serious rashes requiring hospitalization
Client Teaching:
1. Monitor blood levels periodically.
 2. take medications with meals
3. Do not attempt to drive if under medication.

STIMULANTS
o Pronounced effect of CNS stimulation
o Used for ADHD in children and adolescents, residual Attention Deficit in
older adults and narcolepsy

Mechanism of Action: indirectly acting amines that cause the release of

neurotransmitters from presynaptic nerve terminals as opposed to having
direct presynaptic effect on the post synaptic receptors

Examples: Amphetamines, Methylphenidate, Dextroamphetamine

Common Side effects: anorexia, weight loss, nausea and irritability

Client teaching:
1. Client should avoid intake of caffeine, sugar and chocolate.
2. Take doses after meals
3. Watch out for potential substance abuse.