PSYCHOPHARMACOLOGY

ANTI-PSYCHOTIC DRUGS
Or neuroleptics or major tranquilizers; For acute and chronic psychosis; For bipolar I disorder, manic phase; Paranoid disorder; Severe nausea and vomiting*; Severe or pathologic hiccups*;

Classification (Traditional Classification)

or

Typical

1. Chlorpromazine (Thorazine) EARLIEST 2. Fluphenazine (Prolixin) 3. Thioridazine (Mellaril) 4. Trifluoperazine (Stelazine) 5. Haloperidol (Haldol) 6. Loxapine (Loxitane)

 Atypical Anti-psychotics:

1. Clozapine* (Clozaril) 2. Olanzapine* (Zyprexa) 3. Risperidone* (Risperdal)

Mechanisms of Action:
Blocks dopamine receptors in the nigrostriatal system causing pseudoparkinsonism; Inhibits dopamine receptors the tubuloinfundibular system; in

Antagonizes serotonin receptors in the cerebral cortex (Risperidone)

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Typical Anti-psychotics

Decrease dopamine

Atypical Anti-psychotics Decrease serotonin

Desired Drugs:

Effects

of

Antipsychotic

1. CNS Effects a. sedation b. emotional quieting c. slowing of psychomotor functions 2. Modification of Psychiatric Symptoms a. Resolution of positive symptoms Hallucinations Illusions Delusions Excitement Suspiciousness
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b. Resolution of negative symptoms Accomplished by antipsychotic agents ATYPICAL

1.Attention deficit 2.Asocial behavior 3.Blunted or flat affect 4.Communication difficulties 5.Difficulty with abstraction

SIDE EFFECTS
A. PNS Effects (anticholinergic effects) B. PNS Effects (anti-adrenergic effects)

1. Orthostatic hypotension
2. Reflex tachycardia due to lower extremity vasodilatation;

Anti-cholinergic effects are the same irregardless of what medication.

A urinAry retention Blurring of vision due to dilated pupils. Constipation Dry mouth and nasal passages Elevated heart rate (tachycardia)

C. CNS Effects (or EPSE)

1. Akathisia it is the most common EPSE; inability to sit still;

px is restless, jittery or uneasy and may report a lot of nervous energy; Tx: Anticholinergic antiparkinson drugs (Artane, Biperiden, Cogentin)

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2. Acute Dystonic Reactions (dystonia)

rigidity of the muscles of the tongue, face, neck or back;

results to abnormality in posture, gait or ocular movements; Torticollis Oculogyric crisis rolling of eyes backward in a fixed stare; Laryngeal-pharyngeal dystonia Tx: IM anticholinergic antiparkinson drug (Benztropine or Cogentin)
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3. Tardive Dyskinesia (TD) potential permanent complication;

refers to abnormal voluntary skeletal muscle movements usually jerky motion; appears after months or years of drug use but may occur sooner; caused by dopamine hypersensitivity and cholinergic deficit; anticholinergics may aggravate TD;
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usually affects the muscles of the mouth and face: 1. Lip smacking 2. Grinding of the teeth 3. Rolling or protrusion of the tongue 4. Tics 5. Excessive facial movements Grimacing and blinking Chewing and lateral jaw movement Puffing of the cheeks;
Tx: Bromocriptine (Parlodel); Reduction of dose; Discontinuation of the drug;
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4. Drug-induced Parkinsonism
or pseudoparkinsonism; motor retardation (bradykinesia) and rigidity; difficulty in initiating or carrying out motor activity; shuffling gait; resting tremors of the hands and feet; hypersalivation; Tx: Dosage reduction Antiparkinson drug (Akineton)

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5. Neuroleptic Malignant Syndrome

is a rare but life-threatening reaction to neuroleptic drugs (1% of clients) 3-9 days after starting anti-psychotic (Haldol)

manifestations: a. hyperthermia cardinal symptom. b. rigidity c. impaired consciousness d. hypertension e. cardiac arrhythmias
Tx: Immediate discontinuation of the drug; Cooling blankets; Dantrolene or Bromocriptine

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6.

Other Side Effects a. Hyperglycemia b. Jaundice c. Blood dyscrasias or agranulocytosis (Clozapine) d. Orthostatic hypotension (Risperidone) e. Retinal pigmentation (Thioridazine) f. Galactorrhea and gynecomastia (Increase secretion of prolactin) g. Amenorrhea and impaired ejaculation h. Sun burn

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ANTI-PARKINSON DRUGS
Major

cause of EPS malfunction is a DEFICIENCY in the neurotransmitter DOPAMINE (substantia nigra) and a subsequent decrease in dopamine transmission in the basal ganglia;

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Mechanisms of Actions:
Increases dopamine by increasing its precursor. Levodopa Carbidopa-levodopa (Sinemet) Stimulates the release of dopamine. Amantadine (Symmetrel) Increases the action of the dopamine receptors (Dopamine agonists) Bromocriptine (Parlodel) Pergolide (Permax)
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 Blocks the metabolism of dopamine by inhibiting MAO type b. Selegiline (Eldepryl)

Anti-parkinsons with anti-cholinergic properties. Benztropine (Cogentin) Biperiden (Akineton) Diphenhydramine (Benadryl) Ethopropazine (Parsidol) Procyclidine (Kemadrin) Trihexyphenidyl (Artane)

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ANTI-PARKINSON DRUGS
A Artane , Amantadine B Biperiden, Bromocriptine C Cogentin D Diphenhydramine, Dopamine precursors (Levodopa, Sinemet) E Eldepryl F Pergolide

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ANTIDEPRESSANTS
DEPRESSION is caused by an imbalance or decreased availability of certain neurotransmitters (deficiencies of norepinephrine, serotonin, and possibly dopamine)

Norepinephrine Serotonin Dopamine

DEPRESSION

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Goals in the tx of Depression:

1. Reduce or remove all signs and symptoms of

depression the most important.

2. Restore

occupational incident

and of

psychosocial relapse and

function;
3. Reduce

the recurrence;

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A. TRICYCLIC ANTIDEPRESSANTS
Blocks reuptake of norepinephrine and serotonin; Also increases receptor sensitivity to these neurotransmitter;

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Desirable Effects: Sedation. Others increase psychomotor activity. Improved appetite. Side Effects: 1. Anti-cholinergic side effects 2. Orthostatic hypotension

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Nursing Implications: Take medications at night.

Reassure that symptoms will decrease in Increase fiber and fluid diet. Assess for adverse drug reactions. 2 - 4 weeks

Assess for suicide potential.

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 Classifications:
Tertiary Amines Imipramine (Tofranil) Amitriptyline (Elavil) Clomipramine (Anafranil) used in OCD.

Secondary Amines - Amoxapine (Asendin) - Nortriptyline (Aventyl) - Desipramine (Norpramin)

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 Classifications Novel Cyclic Antidepressants Bupropion (Wellbutrin) Trazodone (Desyrel) Venlafaxine (Effexor)

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B. SELECTIVE SEROTONIN INHIBITORS (SSRI)

Fewer side effects that TCA; First choice in treating depression.

REUPTAKE

MOA: inhibits reuptake of serotonin in neurons which later increases the availability of serotonin in several neurons; Therapeutic lag time is approximately 1 4 weeks;

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Side Effects: GIT Symptoms Nausea Diarrhea Weight loss

CNS Symptoms Headache Dizziness Tremors Nervousness Decreased libido and orgasms

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Side Effects: GIT Symptoms Nausea Diarrhea Weight loss

CNS Symptoms Headache Dizziness Tremors Nervousness Decreased libido and orgasms

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 Nursing Implications: Avoid incorporating with MAOI because of the danger of serotonin syndrome (coma, hyperreflexia, hyperthermia, death) 14 days stopping MAOI and starting SSRI: 5 weeks stopping SSRI and starting MAOI;
Avoided during the 1st trimester of pregnancy. WOF: Increase activities and mood of patients because these are signs of suicidal ideations;

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 Classification: Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxel) Sertraline (Zoloft)

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C. MONOAMINE OXIDASE INHIBITORS (MAOI)

Monoamine Oxidase involved in the metabolic decomposition and inactivation of amines (norepinephrine, dopamine and serotonin); Administered to hospitalized patients or px that can be closely monitored or supervised at home; It takes 2 4 weeks for these drugs to take effect;

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 Side Effects:
CNS Hyperstimulation Hypomania Agitation Insomnia Restlessness and euphoria Acute Anxiety Attack Hypertensive crisis (tachycardia, palpitations, occipital headache, chest pain, elevated BP, diaphoresis, and dilated pupils; sudden epistaxis)

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 Nursing Implications:
Take the medication EARLY IN THE DAY to avoid insomnia;

Caution client to avoid OTC drugs because these contain AMINES and can cause HYPERTENSIVE CRISIS. Cold remedies Decongestants Antihistamines Sleeping aids Stimulants
Instruct the px TO AVOID FOODS HIGH IN TYRAMINE (tyramine-restricted diet)
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 Foods high in TYRAMINE: A aged cheese and avocado B bananas, beer C chocolate, coffee, chicken and pork D dried and preserved foods (pickles) E etc (yogurt, sausage) F fermented foods (beer, wine)

liver

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 Classifications:

Phenelzine (Nardil)
Tranylcypromine (Parnate) Moclobemide (Manerix) atypical MAOI.

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ANTI-MANIC (Mood Stabilizers)

LITHIUM

DRUGS

Is used for manic phase of manic-depressive illness and refractory depression; The exact action of lithium is UNKNOWN; Substitute for Na in neurons altering the release and attachment of certain neurotransmitters in most neurons; Increases the reuptake of NE and serotonin; Lithium has a lag time of 7 10 days;
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 Lithium is well absorbed from the GIT ORAL route)

(via

The typical dose for acute mania is 600 mg TID which produces a therapeutic blood dose of 0.6 1.2 mEq/L; Blood levels over 1.5 mEq/L can be toxic;

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Nursing Implications: WOF signs of early Li toxicity: Vomiting earliest; Diarrhea and Drowsiness Muscular weakness Lack of coordination Polyuria
Client may have mild exercise or activities.

Advise px not to drive during Li therapy;

Advise px to practice balanced diet and salt intake;

Increase Salt intake = decrease blood Li Decrease salt intake = increase blood Li

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 For Li determination, blood must be drawn at least 8-12 hrs after the last dose and performed in the morning (every 3 4 months of Li intake) Take Li with meals to avoid nausea and vomiting;

Increase fluid intake (2500-3000 ml) per day to reduce thirst and maintain normal fluid balance;

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CARBAMAZEPINE (Tegretol)
Used for px who do not respond to Li or for px Li is contraindicated; Used in px with bipolar disorders and for px with seizure disorders; Thought to inhibit the small abnormal activity in the brain; Side Effects:

Nausea and vomiting Anorexia Sedation and drowsiness Agranulocytosis

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VALPROIC ACID (Depakene)

Is an anticonvulsant with antimanic property; Effective in px with bipolar disorders; Rapid acting and with less effect on cognition; Side Effects:

Transient hair loss Weight gain Tremors GI Upset Thrombocytopenia

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ANTIANXIETY DRUGS
Are also known as anxiolytics; Classified into: a. Benzodiazepines b. Sedative-Hypnotics

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Benzodiazepines
are the major class of anxiolytics or minor tranquilizers; Are used in px: a. chronic anxiety b. acute anxiety or persons in crises c. presurgery d. panic attacks e. insomnia f. alcohol withdrawal syndrome g. bipolar disorders with Li therapy h. seizures

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 Types of Benzodiaze PAM PAM 1.Diazepam (Valium) 2.Lorazepam (Ativan) 3.Clonazepam (Klonopin) 4.Oxazepam (Serax) for elderly. 5.Alprazolam (Xanax) 6.Chlordiazepoxide (Librium) 7.Clorazepate (Tranxene) 8.Buspirone (BuSpar)

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Adverse Drug Reactions: 1. CNS Depression a. Drowsiness b. Fatigue c. Decreased coordination d. Mental impairment e. Slow reflexes f. Confusion g. Respiratory depression*** 2. Anticholinergic side effects

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3. Problems of dependence, withdrawal, and tolerance;

a. Dependence or addiction the person must take the drug to feel normal; b. Withdrawal physical signs and symptoms that occur when the addictive substance is reduced or withheld;

c. Tolerance the need to increase the amount of a substance to achieve the same effects;
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Nursing Interventions: Advise the px to avoid taking alcohol and other CNS depressants with the drug. WOF of overdose ( somnolence, confusion, coma, decreased reflexes, and hypotension) Advise the px to avoid driving; Monitor VS especially breathing;

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Sedative-Hypnotics
Are also used in the treatment of anxiety, insomnia, and prevention of alcohol withdrawal syndrome; Barbiturates: Phenobarbital Secobarbital Pentobarbital Antihistamines: Diphenhydramine

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THERAPEUTIC LAG TIME Anti-psychotics TCA MAOI

2 4 weeks

SSRI
Lithium Clomipramine

1 4 weeks
7 10 days 2-3 months
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