Psychopharmacology

Rosemary Bender, MS, RNBC,LPC

Objectives
 Discuss historical perspectives related to psychopharmacology  Describe indications, actions, contraindications, precautions, side effects, and nursing implications for psychotropic medications

Historical Perspective
 Before 1950, sedatives & amphetamines were the only psychotropics available.  Since the 1950s, psychopharmacology has expanded to include antipsychotic, antidepressant and antianxiety drugs.  Psychotropic drugs are intended to be used as an adjunct to individual or group psychotherapy.

PSYCHOPHARMACOLOGY
 The 101st Congress of the US designated the 1990s as the Decade of the Brain with the challenge for studying the biological basis of behavior.  In keeping with the neuroscientific revolution, greater emphasis is placed on the study of the organic basis for psychiatric illness.

Principles of Psychopharmacology
 Principles that guide the use of Rx include:
Effect on target symptom Adequate dosage for sufficient time Lowest dose needed for maintenance Lower doses for elderly Tapering rather than abrupt cessation to avoid rebound or withdrawal Follow-up care Simplify the regimen for increased compliance

Implications for Nursing

Emphasis in psychiatric nursing is on a smooth transition from a psychosocial approach to a biopsychosocial focus. New science and technology must be incorporated into nursing practice, education, and research.

 Neurotransmitters play an important role in human emotions and behavior and are the target for the mechanism of action in many psychotropic medications.  Major categories of neurotransmitters  Cholinergics  Monoamines  Amino acids  Neuropeptides

Neurotransmitters
 Chemicals that are stored in the axon terminals of the presynaptic neuron  An electrical impulse through the neuron stimulates its release into the synaptic cleft, which in turn determines whether another electrical impulse is generated.

Important Neurotransmitters
 Acetylcholine- important in pathology and treatment of Alzheimers and parkinsonism  Dopamine- important in pathology and treatment of schizophrenia & parkinsonism  GABA- important in pathology & treatment of anxiety  Glutamate-important in pathology & treatment of Alzheimers  Serotonin- important in pathology & treatment of mania and depression  Norepinephrine- important in pathology & treatment of mania & depression

Receptors
Molecules situated on the cell membrane that are binding sites for neurotransmitters.

Psychotropics
 Antianxiety agents  Antidepressants  Mood Stabilizing agents  Antipsychotics  Antiparkinsonism agents  Sedative-hypnotics  ADHD agents

How do psychotropics work?

 Antidepressants- block reuptake of neurotransmitters  Antipsychotics- block dopamine & other receptors  Benzodiazepines- facilitate transmission of GABA  Psychostimulants increase release of neurotransmitters

Key Terms
 Agranulocytosis  Akathisia  Amenorrhea  Dystonia  Extrapyramidal symptoms  Gynecomastia  Hypertensive crisis  Neuroleptic Malignant  Syndrome (NMS)  Oculogyric crisis  Priapism  Retrograde ejaculation  Serotonin syndrome  Tardive dyskinesia

Antianxiety Agents
 Benzodiazepines- used for anxiety Xanax, Librium, Klonopin, Valium, Ativan, Serax, Tranxene
Non-benzodiazepines used for anxiety Buspar, Atarax, Vistaril, Inderal

Sleep Medication
Benzodiazepines used for sleep Dalmane, Restoril, Halcion, ProSom Non-benzodiazepines used for sleep Ambien, Sonota, Lunesta, Rozerem

Antidepressants Agents
 Tricyclics- Elavil, Pamelor, Norpramin, Ascendin, Sinequan, Tofranil, Vivactil, Surmontil  MAOIs- Nardil, Parnate, Marplan, Emsan  SSRIs -Prozac, Paxil, Zoloft, Luvox, Celexa, Lexapro  SNRIs- Effexor, Cymbalta, Pristiq

Priority Interaction Considerations

 Tricyclics- Fatal in overdose. Potentially fatal with MAOI inhibitors.  MAOIs- hypertensive crisis occurs with the ingestion of foods containing tyramine(aged cheeses, red wines, smoked & processed meats, pickled fish, corned beef, liver, soy sauce, brewers yeast & MSG) or sympathomimetic drugs(dopamines, epinephrine, norepinephrine, reserpine, amphetamines and vasoconstrictors)  SSRIs- Potentially fatal with MAOIs, Serotonin Syndrome can occur with concurrent use of other drugs that increase serotonin.

Common Side Effects

 ALL Classes- dry mouth,sedation, nausea  Tricyclics-blurred vision, constipation, urinary retention, orthostatic hypotension, reduced seizure threshold, tachycardia, arrhythmias, weight gain  MAOIs- hypertensive crisis  SSRIs Insomnia, agitation, headache, GI upset, sexual dysfunction, serotonin syndrome, weight loss

Mood Stabilizing Agents

 Lithium Carbonate  Valproic Acid (Depakote)  Lamotrigine (Lamictal)  Carbamazepine (Tegretol)  Topiramate (Topomax)  Atypical Antipsychotics (Abilfy,Geodon, Zyprexa Risperdal & Seroquel)

Mood Stabilizing Agents

 Indications: prevention & treatment of manic episodes associated with bipolar disorder  Action: Lithium enhances the reuptake of norepinephrine and serotonin in the brain, lowering levels in the body and resulting in decreased hyperactivity.  The role of anticonvulsants and antipsychotics in the treatment of bipolar mania is not fully understood.

Lithium Side Effects

 Drowsiness, dizziness, headache  Dry mouth, thirst, GI upset, N/V  Fine hand tremors  Hypotension, arrhythmias  Polyuria, dehydration  Weight gain  Potential for toxicity  Therapeutic range 0.6 1.2mEq/L  Toxic levels equal to or greater than 1.5mEq/L

Lithium
 Initial symptoms of toxicity- blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea.  Ensure that client consumes adequate sodium and fluid in diet  Monitor renal function regularly

Depakote
 LFTs and CBC with Diff to prevent liver, kidney or blood cell complications.  Blood levels must be monitored regularly.  Therapeutic range is 50 110  Depakote can cause liver dysfunction, hepatic failure and blood dyscrasias.

Anticonvulsant Side Effects

 Nausea and vomiting  Drowsiness; dizziness  Blood dyscrasias  Prolonged bleeding time (Depakote)  Risk of severe rash (Lamictal)  Decreased efficacy of oral contraceptives (Topomax)

Antipsychotics
Indications: Treatment of acute and chronic psychosis. Action: Unknown; thought to block postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. Newer agents may block action on receptors specific to serotonin and other neurotransmitters.

Antipsychotic Agents
Typical (older) First Generation Thorazine Haldol Prolixin Stelazine Navane Loxitane Atypical (newer) Second Generation Clozaril Risperdal Zyprexa Seroquel Geodon Abilify

Side or Adverse Effects

Agranulocytosis- white bone marrow suppression associated with Clozaril Akathesia restlessness, an urgent need for movement. Amenorrhea cessation of menses. Dystonia-involuntary muscular movements (spasms) of the face, arms, legs & neck Extrapyramidal symptoms-responses that originate outside the pyramidal tracts Tardive dyskinesia-Syndrome of symptoms characterized by bizzare facial and tongue movements

Gynecomastia-enlargement of breast tissue in the male Hypertensive crisis- life threatening syndrome results when patient on MAOIs eats a product high in tyramine Neuroleptic Malignant Syndrome NMS- life threatening condition with muscle rigidity, extreme EPS, fever, HTN and tachycardia Oculogyric crisis-involuntary deviation and fixation of the eyeballs Priapism- prolonged, painful erection Serotonin Syndrome- occurs when two drugs that potentiate serotonergic neurotransmission are used

Long Acting Injections

There are 3 Antipsychotics available in Depot formulations for patients who experience problems with compliance:  Prolixin (decanoate) Duration 7 28 days  Haldol (Decanoate) Duration of 4 weeks  Risperdal Consta Duration of 2 weeks

ADHD Agents
 Indications: ADHD in children and adults  Action: The CNS stimulants increase levels of norepinephrine, dopamine, and serotonin in the CNS.  Straterra inhibits the reuptake of norepinephrine

ADHD Agents
 Dexadrine  Adderall (XR)  Focalin (XR)  Ritalin (LA,SR)  Concerta  Metadate(CD,ER)  Methylin(ER)  Straterra (non-stimulant)

Special Populations: Older Adults

o Higher risk for toxicity due to: - Increased proportion of adipose tissue - Decreased rate of excretion of medications in the liver - Decreased renal filtration o Greater risk of antipsychotic side effects: sedation, orthostatic hypotension, EPS, and tardive dyskinesia

Special Populations: Pregnant Women

 Goal of medication therapy: effect a balance between the risk to the fetus and the risk of mental illness to the mother.  Practices:  avoid during gestational weeks 6 to 10  monotherapy at lowest dose for shortest time  lower the dose before delivery  increase dose after delivery  Resume medication when finished breastfeeding

Nursing responsibilities for psychotropic drug administration..

 Demonstrate knowledge necessary to develop medication education and treatment plans.  Differentiate psychiatric symptoms from medication side effects.  Identify appropriate use of psychopharmacologic agents in special populations.  Involve clients & their families.  Identify factors that might prevent the active involvement of clients in their care.  Describe appropriate nonpharmacologic interventions.  Discuss the use of standardized rating scales.

Self Awareness Issues

 Viewing chronic mental illness as having remissions and exacerbations, just as chronic physical illnesses do  Remaining open to new ideas that may lead to future breakthroughs  Understanding that medication noncompliance is often part of the illness, not willful misbehavior.