06 Psychotherapeutic Agents Upd

Psychotherapeutic Agents
Antidepressants and Antipsychotics
Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.
Psychotherapeutics
The therapy of emotional and mental disorders
Psychotherapeutics
Anxiety
Grief Depression are normal human emotions
Psychotherapeutics
The ability to cope with these emotions can range from occasional depression or anxiety to constant emotional distress to the point ofinterfering with the ability to carry on normal daily living.
Psychotherapeutics
When these emotions significantly affect an individuals ability to carry out normal daily functions, treatment with a psychotherapeutic drug is a possible option.
Psychotherapeutics
Three main emotional and mental disorders:
Psychoses Affective disorders Anxiety
Psychotherapeutics
Psychosis
A major emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in everyday life. Hallmark: loss of contact with reality
Psychotherapeutics
Affective Disorders
Major emotional disorders that impair the mental function of the affected individual to the point that the individual cannot participate in everyday life.
Psychotherapeutics
Affective Disorders
Mania: abnormally pronounced emotions Depression: abnormally reduced emotions Bipolar affective disorder: exhibits both mania and depression
Psychotherapeutics
Pathophysiology
Biochemical Imbalance
Mental disorders are associated with abnormal levels of endogenous chemicals, such as neurotransmitters, in the brain.
Psychotherapeutics
Pathophysiology
Brain levels of certain catecholamines play an important role in maintaining mental health. Dopamine Serotonin Histamine
Psychotherapeutics
Pathophysiology
Other biochemicals are necessary for normal mental function. GABA acetylcholine lithium
Etiology of Depression
Biogenic Amine Hypothesis
Depression and mania are due to an alteration in neuronal and synaptic catecholamine concentration at adrenergic receptor sites in the brain. Depression: deficiency of catecholamine, especially norepinephrine Mania: excess amines
Instructors may wish to insert EIC Image #45: Biogenic Amine Hypothesis
Affective Disorders
Drug Categories
Antidepressants tricyclics, tetracyclics, SSRIs, MAOIs Antimanic Agents lithium
Antidepressants
Cyclic antidepressants
tricyclics tetracyclics Monoamine oxidase inhibitors (MAOIs) Second-generation antidepressants and SSRIs
Cyclic Antidepressants
Tricyclic antidepressantsprimary: amitriptyline (Elavil), doxepin (Sinequan), imipramine (Tofranil) Tricyclic antidepressantssecondary: desipramine (Norpramin), nortriptyline (Aventyl), protriptyline (Vivactil) Tetracyclic antidepressants: amoxapine (Asendin), maprotiline (Ludiomil)
Cyclic Antidepressants Mechanism of Action

Block reuptake of neurotransmitters, causing accumulation at the nerve endings.
It is thought that increasing concentrations of neurotransmitters will correct the abnormally low levels that lead to depression.
Cyclic Antidepressants Mechanism of ActionDrug Effects

Blockade of norepinephrine:
antidepressant, tremors, tachycardia, additive pressor effects with sympathomimetic drugs
Blockade of serotonin:
antidepressant, nausea, headache, anxiety, sexual dysfunction
Cyclic Antidepressants Therapeutic Uses

Depression
Childhood enuresis (imipramine) Obsessive-compulsive disorders (clomipramine) Adjunctive analgesics
Trigeminal neuralgia
Cyclic Antidepressants Side Effects

Sedation
Impotence Orthostatic hypotension Older patients:
dizziness, postural hypotension, constipation, delayed micturation, edema, muscle tremors
Tricyclic Antidepressants Overdose

Lethal70 to 80% die before reaching the hospital CNS and cardiovascular systems are mainly affected Death results from seizures or dysrhythmias No specific antidote
Decrease drug absorption with activated charcoal Speed elimination by alkalinizing urine Manage seizures and dysrhythmias Basic life support
Antidepressants
Monoamine Oxidase Inhibitors: MAOIs
Highly effective
Considered second-line treatment for depression not responsive to cyclics Disadvantage: potential to cause hypertensive crisis when taken with tyramine
Antidepressants: MAOIs
phenelzine (Nardil)
tranylcypromine (Parnate) isocarboxazid (Marplan)
Antidepressants: MAOIs Mechanism of Action

Inhibit the MAO enzyme system in the CNS
Amines (dopamine, serotonin, norepinephrine) are not broken down, resulting in higher levels in the brain Result: alleviation of symptoms of depression
Antidepressants: MAOIs Therapeutic Uses

Depression, especially types characterized by reverse vegetative symptoms such as increased sleep and appetite Depression that does not respond to other agents such as tricyclics
Antidepressants: MAOIs Side Effects

Few side effectsorthostatic hypotension most common
Tachycardia Palpitations
Dizziness
Insomnia Anorexia
Drowsiness
Headache Nausea
Blurred vision
Impotence
Antidepressants: MAOIs Overdose

Symptoms appear 12 hours after ingestion
Tachycardia, circulatory collapse, seizures, coma
Treatment: protect brain and heart, eliminate toxin

Gastric lavage
Urine acidification
Hemodialysis
Antidepressants: MAOIs Hypertensive Crisis and Tyramine

Ingestion of foods and/or drinks with the amino acid TYRAMINE leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death
Antidepressants: MAOIs Hypertensive Crisis and Tyramine

Avoid foods that contain tyramine!
Aged, mature cheeses (cheddar, blue, Swiss) Smoked/pickled or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, pat) Yeast extracts
Red wines (Chianti, burgundy, sherry, vermouth)

Italian broad beans (fava beans)
Second-Generation Antidepressants
Newer
Fewer side effects than tricyclics, but not superior in overall efficacy or onset of action
trazodone (Desyrel) bupropion (Wellbutrin, Zyban)
selective serotonin reuptake inhibitors (SSRIs)
Second-Generation Antidepressants and SSRIs Mechanism of Action

Selectively inhibit serotonin reuptake Little or no effect on norepinephrine or dopamine reuptake Results in increased serotonin concentrations at nerve endings
Advantage over tricyclics and MAOIs: Little or no effect on cardiovascular system

Second-Generation Antidepressants Therapeutic Uses

Used for depressionvery few serious side effects Bipolar affective disorder Obesity Eating disorders Obsessive-compulsive disorder Panic attacks Myoclonus Treatment of various substance abuse problems (bupropion [Zyban] is used for smoking cessation treatment)
Second-Generation Antidepressants Side Effects

Body System
CNS
Effects
Headache, dizziness, tremor, nervousness, insomnia, fatigue Nausea, diarrhea, constipation, dry mouth
GI
Other
Sweating, sexual dysfunction
Second-Generation Antidepressants Drug Interactions

Highly bound to plasma proteins
Compete with other protein-binding drugs, resulting in more free, unbound drug to cause a more pronounced drug effect
Antipsychotics
Drugs used to treat serious mental illness
Behavioral problems or psychotic disorders
Antipsychotics
Thioxanthenes: chlorprothixene, thiothixene (Navane)
Butyrophenones: haloperidol (Haldol) Dihydroindolones: molindone (Moban) Dibenzoxazepine: loxapine (Loxitane)
Phenothiazines: three structural groups
Antipsychotics Phenothiazine Structural Groups

Aliphatic: chlorpromazine (Thorazine), triflupromazine (Vesprin)
Piperidine: mesoridazine (Serentil), thioridazine (Mellaril) Piperazine: fluphenazine (Prolixin), perphenazine (Trilafon), prochlorperazine (Compazine), trifluoperazine (Stelazine) Largest group of psychotropic agents
Antipsychotics Atypical Antipsychotics

clozapine (Clozaril)
risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel)
Antipsychotics: Mechanism of Action

Block dopamine receptors in the brain (limbic system, basal ganglia)areas associated with emotion, cognitive function, motor function
Dopamine levels in the CNS are decreased Result: tranquilizing effect in psychotic patients
Antipsychotics: Mechanism of Action

The newer, atypical antipsychotics also block specific serotonin receptors (serotonin-2 [5HT2] receptors). This is responsible for their improved efficacy and safety profiles.
Antipsychotics: Drug Effects

Block dopamine receptors in CNS
Block alpha receptors (causing hypertension, other cardiovascular effects)
Block histamine receptors (causing anticholinergic effects)

Block serotonin
Also function as antiemetics

Antianxiety effects
Antipsychotics: Therapeutic Uses

Treatment of serious mental illnesses:
Bipolar affective disorder Depressive and drug-induced psychoses
Schizophrenia Autism
Movement disorders (such as Tourettes syndrome) Some medical conditions

Nausea, intractable hiccups
Antipsychotics: Side Effects

Body System
CNS Cardiovascular
Effects
Sedation, delirium Orthostatic hypotension, syncope, dizziness, ECG changes Photosensitivity, skin rash, hyperpigmentation, pruritus
Dermatologic
Antipsychotics: Side Effects

Body System
GI GU Hematologic
Effects
Dry mouth, constipation Urinary hesitancy or retention, impaired erection Leukopenia and agranulocytosis
Metabolic/endocrine
Galactorrhea, irregular menses increased appetite, polydipsia
Psychotherapeutic Agents: Nursing Implications

Before beginning therapy, assess both the physical and emotional status of patients
Obtain baseline VS, including postural BP readings Obtain liver and renal function tests (and baseline platelet levels for MAOIs)

Assess for possible contraindications to therapy, cautious use, and potential drug interactions Assess LOC, mental alertness, potential for injury to self and others
Check the patients mouth to make sure oral doses are swallowed

Provide simple explanations about the drug, its effects, and the length of time before therapeutic effects can be expected Abrupt withdrawal should be avoided
Advise patients to change positions slowly to avoid postural hypotension and possible injury

The combination of drug therapy and psychotherapy is emphasized because patients need to learn and acquire more effective coping skills Only small amounts of medications should be dispensed at a time to minimize the risk of suicide attempts Simultaneous use of these agents with alcohol or other CNS depressants can be fatal

Antidepressants
Many cautions, contraindications, and interactions exist pertaining to the use of antidepressants.
Inform patients that it may take 1 to 3, even 4, weeks to see therapeutic effects.
Monitor patients closely during this time and provide support.

Antidepressants
Sedation often occurs with tricyclic therapy; notify physician if this lasts more than 2 weeks.
Assist elderly or weakened patients with ambulation and other activities as falls may occur due to drowsiness or postural hypotension.

Antidepressants
Tricyclics may need to be weaned and discontinued before undergoing surgery to avoid interactions with anesthetic agents. Monitor for side effects and discuss with patients. Encourage patients to wear medication ID badges naming the agent being taken.

Antidepressants
Caffeine and cigarette smoking may decrease effectiveness of medication therapy
Instruct patients and family regarding tyraminecontaining foods and signs and symptoms of hypertensive crisis

AntipsychoticsPhenothiazines
Instruct patients to wear sunscreen due to photosensitivity
Avoid taking antacids or antidiarrheal preparations within 1 hour of a dose

Do not take alcohol or other CNS depressants with these medications

AntipsychoticsPhenothiazines
Long-term haloperidol therapy may result in tremors, nausea, vomiting, or uncontrollable shaking of small muscle groups; these symptoms should be reported to the physician Oral forms may be taken with meals to decrease GI upset These agents may cause drowsiness, dizziness, or fainting; instruct patients to change positions slowly

Monitor for therapeutic effects:
Monitor mental alertness, cognition, affect, mood,ability to carry out activities of daily living, appetite, and sleep patterns Monitor the patients potential for self-injury during the delay between the start of therapy and symptomatic improvement

Monitor for therapeutic effects
For antidepressants:
Improved sleep patterns and nutrition, increased feelings of self-esteem, decreased feeling of hopelessness, increased interest in self and appearance, increased interest in daily activities, fewer depressive manifestations or suicidal thoughts or ideations

Monitor for therapeutic effects
For antipsychotics:
Improved mood and affect, alleviation of psychotic symptoms and episodes Decrease in hallucinations, paranoia, delusions, garbled speech, inability to cope

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Psychotherapeutic Agents

Antidepressants and Antipsychotics

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Cyclic Antidepressants Mechanism of Action

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Cyclic Antidepressants Mechanism of ActionDrug Effects

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Cyclic Antidepressants Therapeutic Uses

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Cyclic Antidepressants Side Effects

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Tricyclic Antidepressants Overdose

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants: MAOIs Mechanism of Action

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants: MAOIs Therapeutic Uses

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants: MAOIs Side Effects

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants: MAOIs Overdose

Treatment: protect brain and heart, eliminate toxin

Antidepressants: MAOIs Hypertensive Crisis and Tyramine

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants: MAOIs Hypertensive Crisis and Tyramine

Red wines (Chianti, burgundy, sherry, vermouth)

selective serotonin reuptake inhibitors (SSRIs)

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Second-Generation Antidepressants and SSRIs Mechanism of Action

Advantage over tricyclics and MAOIs: Little or no effect on cardiovascular system

Second-Generation Antidepressants Therapeutic Uses

Second-Generation Antidepressants Side Effects

Sweating, sexual dysfunction

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Second-Generation Antidepressants Drug Interactions

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Phenothiazines: three structural groups

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics Phenothiazine Structural Groups

Antipsychotics Atypical Antipsychotics

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics: Mechanism of Action

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics: Mechanism of Action