ANTIPSYCHOTICS

Psychosis
 symptomatic thought disorder.
 chemical imbalance within brain

Schizophrenia
 MC psychosis
 characterized by:

a. positive symptoms
 exaggeration of normal function
 incoherent speech
 hallucination
 delusion
 paranoia

b. negative symptoms
 loss in function & motivation
 poverty of speech content
 poor self-care
 social withdrawal

Antipsychotics
• block dopamine receptor  improve thought processes & behavior , EPS
• block chemoreceptor trigger zone & vomiting  antiemetic effect
SE:
1. drowsiness
2. hypotension
3. anticholinergic effects

4. extrapyramidal side effects (EPS)

a. dystonia
 spasms of tongue, neck, back & legs
 facial grimacing
 involuntary upward eye movement
 unnatural positioning of the neck
 excessive salivation

b. akathisia
 uncontrolled restlessness
 inability to sit & stand still
 foot tapping
 hand movements

c. pseudoparkinsonism
 muscle tremors at rest
 rigidity
 bradykinesia
 shuffling gait
 stooped posture
 pill-rolling motion of hand
  drooling

 anticholinergics
o trihexyphenidyl (Artane)
o biperiden (Akineton)
o benztropine (Cogentin)

 benzodiazepine ie lorazepam

 beta-blockers ie propanolol

d. tardive dyskinesia
• lip smacking, tongue darting, chewing
• involuntary movements of body & extremities
• facial dyskinesia

• stop antipsychotic drug

 tx: benzodiazepines
Ca channel blocker
Beta blocker
Vitamin E
Clozapine

3. blood dyscrasias

4. pruritus & marked photosensitivity

5. neuroleptic malignant syndrome (NMS)

I. Typical Antipsychotics

A. Phenothiazines
1. alipathic
• chlorpromazine (Thorazine)
• promazine (Sparine)
• triflupromazine (Vesprin)

2. piperazines
• fluphenazine (Prolixin)
• perphenazine (Trilafon)
• prochlorperazine (Compazine)
• trifluoperazine (Stelazine)

3. piperidines
• thioridazine ( Mellaril)
• mesoridazine (serentil)

B. Non-phenothiazines
1. butyrophenone
• haloperidol (Haldol)
 • droperidol (Inapsine)

2. dibenzoxazepine
• loxapine (Loxitane)

3. dihydroindolone
• molindone (Moban)
4. thioxanthenes
• chlorprothixene (Taractan)
• thiothixene (Navane)

5. diphenylbutylpiperidine
• pimozide (Orap)

II. Atypical antipsychotics

• clozapine (Clozaril)
• olanzapine (Zyprexa)
• quetiapine (Seroquel)
• risperidone (Risperdal)
• ziprasidone (Geocodon)

I. Typical Antipsychotics

A. Phenothiazines
 block Dopaminergic 2 (D2) receptor  EPS
 block NE  sedative & hypotensive effect

 indications:
1. treat psychosis
2. tx of intractable hiccups
3. preoperative sedation
4. behavioral problems in children
5. control N & V

1. Alipathic
• chlorpromazine (Thorazine)
 cause sun-sensitive skin
 low potency antipsychotic
• promazine (Sparine)
• triflupromazine (Vesprin)

 strong sedative effect

 BP
 moderate EPS
 strong antiemetic effect

 SE:
o sedation & dizziness
o headache
o dry mouth & eyes
 o urinary retention
o EPS

2. Piperazines
• fluphenazine (Prolixin)
• perphenazine (Trilafon)
• prochlorperazine (Compazine)
• trifluoperazine (Stelazine)

 low sedative effect

 strong antiemetic effect
 little effect on BP
 more EPS

 SE: same as chlorpromazine +

o blurred vision
o restlessness
o pink-reddish urine
o euphoria & depression

3. Piperidines

• thioridazine ( Mellaril)
• mesoridazine (serentil)

 strong sedative effect

 low to moderate effect on BP
 few EPS
 no antiemetic effect

 drug/ food interactions:

1. alcohol,CNS depressants, narcotics, sedatives CNS depression
2. tricyclic antidepressants  increase hypotensive & anticholinergic fxs
3. antacids & antidiarrheals  decrease absorption

B. Non-phenothiazines
 block dopaminergic 2  severe EPS & less sedation

 indications:
1. treat psychosis
2. tx children with severe behavior problems
3. tx schizophrenia resistant to other drugs
4. tx of Tourette’s disorder

1. butyrophenone
 • haloperidol (Haldol)
 high-potency antipsychotic

 has anticholinergic activity

 strong EPS effects
 photosensitivity
 induce neuroleptic malignant syndrome

• droperidol (Inapsine)

2. dibenzoxazepine
• loxapine (Loxitane)
 moderate sedative & orthostatic hypotension
 strong EPS effects

3. dihydroindolone
• molindone (Moban)
 low sedative & hypotension
 strong EPS

4. thioxanthenes
• chlorprothixene (Taractan)
• thiothixene (Navane)
 highly potent
 same SE with molindone

5. diphenylbutylpiperidine
• pimozide (Orap)

II. Atypical antipsychotics

 weak affinity to D2 receptors
 stronger affinity to D4 receptors
 block serotonin receptor
 2 adv:
o fewer EPS
o treat both + & - Sxs of schizophrenia

1. clozapine (Clozaril)
 SE:
 Blood dyscrasias
 seizures
 dizziness & sedation
 tachycardia
 orthostatic hypotension
 constipation
 sialorrhea

 Indication:
  tx of severe schizophrenia unresponsive to
typical antipsychotics

2. olanzapine (Zyprexa)
3. quetiapine (Seroquel)
4. risperidone (Risperdal)
5. ziprasidone (Geocodon)
 few or no EPS
 target + & - sxs of schizophrenia

Nursing implications:
 Monitor VS
 Remain with client while he takes the medication.
 Avoid skin contact with liquid concentrates.
 Protect liquid prep from light & dilute with juice.
 Administer oral dose with food or milk.
 Administer IM drug deep.
 Observe for EPS.
 Monitor for signs of neuroleptic malignant syndrome.

 Client teachings:
• Take drug exactly as ordered.
• Meds take 6 wks or longer to achieve full clinical effect.
• WBC monitored for 3 months. (WOF signs of infection)
• Avoid driving & operating machineries.
• Avoid direct sunlight.
• Avoid extremes in temperatures & increased exercise.
• Change positions slowly.
• Alipathic phenothiazines  pink-red brown urine.
• Suggest lozenges, hard candy for dry mouth.
• Changes to sexual functioning & menstruation.

ANXIOLYTICS

Anxiolytics
 drugs used to induce sedation, relax muscles & inhibit convulsions.
 Major uses:
o Tx anxiety
o Tx insomnia

2 types of anxiety:
1. Primary anxiety
• not caused by medical condition or drug use.
• if severe & disabling  anxiolytic may be prescribed.

2. Secondary anxiety
• related to medical or psychiatric disorders, drug use.

S/Sxs:
 dyspnea
  choking sensation
 chest pain
 palpitations
 sweating
 trembling

Nonpharmacologic measures:
 relaxation techniques
 psychotherapy
 support groups

Pharmacologic measures:
I. Benzodiazepines
1. chlordiazepoxide (Librium)
2. diazepam (Valium) *
3. clorazepate (Tranxene)
4. lorazepam (Ativan) *
5. oxazepam (Serax)
6. alprazolam (Xanax) *
7. prazepam (Centrax)

II. Nonbenzodiazepines
A. Antihistamines
1. hydroxyzine (Vistaril, Atarax)
2. diphenyhramine (Benadryl)

B. Propanediol
1. meprobamate (Equanil, Miltown)

C. Azapirones
1. buspirone (BuSpar)

I. Benzodiazepines
1. chlordiazepoxide (Librium)
2. diazepam (Valium) *
3. clorazepate (Tranxene)
4. lorazepam (Ativan) *
5. oxazepam (Serax)
6. alprazolam (Xanax) *
7. prazepam (Centrax)

 safer & more common

 indications:
i. depression
ii. panic
iii. obsessive-compulsive DO
 controlled substances schedule IV (CSS IV) drugs
  Side Effect:
o drowsiness & HA
o dry mouth
o blurred vision
o habituation & increased tolerance
o blood dyscrasias
o withdrawal sxs (with prolonged use & high doses)

 Drug interactions:
• Alcohol & other CNS depressants  respiratory depression
• Tobacco, caffeine & sympathomimetics  decrease effect of benzod.

 CI : pregnancy

II. Nonbenzodiazepines

A. Antihistamines
1. hydroxyzine (Vistaril, Atarax)
2. diphenyhramine (Benadryl)
• short-term relief of anxiety

B. Propanediol
1. meprobamate (Equanil, Miltown)
• short-term relief of anxiety
• muscle relaxant effect

C. Azapirones
1. buspirone (BuSpar)
• newest
• lesser SE

Nursing implications:
 Administer by IM route slowly in large muscle mass.
 Observe for SE.
 Monitor VS (hypotension, bradycardia)
 Donot mix diazepam with other drugs  forms precipitate.

 For benzodiazepine overdose

• antagonist: flumazenil IV (Romazicon)
• if conscious administer emetic, follow with activated charcoal .
• if unconscious  gastric lavage.
• maintain airway, give O2

 Client teachings
• Donot drive or operate machineries
• Donot consume alcohol, CNS depressants (narcotics).
• Effective response may take 1-2 wks.
• Strictly follow drug regimen  withdrawal symptoms.
 ANTIDEPRESSANTS (Mood Elevators)

3 types of Depression:
1. Reactive (Exogenous) depression
• sudden onset
• “blues”
• results from a precipitating event
• tx: benzodiazepines

2. Major (Unipolar or endogenous) depression

• loss of interest in work & home
• inability to complete tasks
• deep depression
• tx: antidepressants

3. Bipolar affective (Manic-depressive) disorder

• swings bw manic (euphoria) & depressive (dysphoria)
• tx: lithium & divalproex

I. Tricyclic Antidepressants (TCAs)

1. amitriptyline (Elavil)
2. trimipramine (Surmontil)
3. doxepin (Sinequan)
4. imipramine (Tofranil)

 MOA: blocks uptake of NE & serotonin.

 Lag period of 1-6 wks
 Indication: tx major depression

 SE:
• strong anticholinergic effects
• orthostatic hypotension
• sedation
• GI sxs
• Allergic reactions
• sexual dysfunction
• blood dyscrasias
• seizures
• cardiac toxicity  fatal cardiac dysrhythmias

II. Monoamine Oxidase inhibitors (MAOIs)

1. isocarboxazid (Marplan)
2. phenelzine (Nardil)
3. tranycypromine (Parnate)

 MOA: inhibit MAO (inactivates NE, dopamine & serotonin)  increase in NE,
 serotonin,dopamine.

 Indication:
o tx depression unresponsive to TCAs & atypical (2nd generation)
antidepressants.

 toxic, potent, many SE:

• hypertensive crisis
 esp if taken with tyramine rich foods &
 CNS stimulants (vasoconstrictors, cold preparations)
 DOC: phentolamine IV (Regitine)
• agitation, insomnia
• orthostatic hypotension
• anticholinergic effects

 must not be used in combination with TCAs.

III. Atypical ( 2nd generation or heterocyclic ) antidepressants

1. amoxapine (Asendin)
2. maprotiline (Ludiomil)
3. trazodone (Desyrel)

 MOA: inhibits reuptake of serotonin, dopamine, NE

 Indications:
1. major (unipolar) depression
2. reactive depression
3. anxiety

 SE:
• orthostatic hypotension
• drowsiness
• anticholinergic effects
 must not be taken with MAOIs

IV. Selective Serotonin Reuptake inhibitors (SSRIs)

1. fluoxetine (Prozac)
2. sertraline (Zoloft)
3. paroxetine (Paxil)
4. fluvoxamine (Luvox)
5. citalopram (Celexa)

 MOA: block reuptake of serotonin into nerve terminal  enhance transmission at

synapse.

 Indications:
1. major (unipolar) depression
2. anxiety d.o. (Obs.-Compulsive,phobias etc.)

 more costly but lesser SE

 SE:
 • nausea (MC)
• insomnia
• nervousness
• HA & drowsiness
• sexual dysfunction
• less anticholinergic effects & not cardiotoxic

Nursing Implications:
 check liver & renal function.
 Observe for s/sxs of depression.
 Monitor VS (orthostatic hypotension & anticholinergiclike effects)
 Monitor for suicidal tendencies when marked depression is present.
 Avoid tyramine-rich foods if taking MAOIs.
 Avoid alcohol & other CNS depressants  additive effect.
 Antidepressants lower seizure threshold  anticonvulsant dose might need to be increased.
 Compliance is very impt. Full effectiveness may not be evident 1-2 wks after start of tx.

ANTIMANICS (MOOD STABILIZERS)

1. lithium carbonate (Eskalith, Lithane, Lithonate)

2. divalproex (Depakote)
3. carbamazepine (Tegretol)

I. Lithium
 controls manic phase of bipolar disorder
 narrow therapeutic range : 0.6 -1.2mEq/L
 acute mania : 1 -1.5 mEq/L
 metabolized by kidney
 Na deficiency  increase lithium absorption increase risk of toxicity.
 Na excess  lower lithium below therapeutic range.

 > 1.5 mEq/ L  toxic effects

 1.5 -2.0 mEq/L
o persistent n & v
o severe diarrhea
o muscle weakness
o slurred speech
o ataxia
o blurred vision
o tinnitus

 2.0 – 3.5 mEq/ L

o excessive output of dilute urine
o increase tremors
o mental confusion
o psychomotor retardation
 >3.5 mEq/ L (CNS)
o impaired consciousness
o nystagmus
 o seizures
o coma
o oliguria/anuria
o cardiac dysrrhythmias
o MI

 Tx:of lithium toxicity:

1. gastric lavage
2. correction of fluid balance
3. mannitol

 Side Effects:
• dry mouth & thirst
• increase urination
• wt gain
• bloated feeling/ edema
• metallic taste
• hypothyroidism ( with prolonged use)

 Drug interactions:
o NSAIDS, diuretics, tetracyclines  increase risk of lithium toxicity.
o Caffeine products (coffee, tea cola)  aggravate manic phase

Nursing implications:

 Monitor VS.
 Monitor renal & hepatic function.
 Draw weekly blood levels (12hrs after last dose) initially, then every 1-2 months.
 Monitor UO & wt.
 Monitor for signs of lithium toxicity.
 Maintain adequate fluid intake 2-3L /day initially & 1-2L/day maintenance.
 Maintain adequate Na intake.