Psychotherapeutic Drugs

Neurotransmitters
 Serotonin (5HT)
 Dopamine
 Acetylcholine
 Glutamate
 Norepinephrine
 Gamma-aminobutyric Acid
 b- Endorphin (opiate)

Psychotherapeutic Drugs
 Types
o Antianxiety drugs
o Antimanic drugs
o Antidepressant drugs
o Antipsychotic drugs
 Disorders
o Anxiety Disorders
o Affective Disorders
o Thought Disorders

Antianxiety drugs
 Benzodiazepines (affect GABA receptors)
o Lorazepam
o Diazepam
o Alprazolam
 Miscellaneous
o Buspirone (BuSpar)
 Non benzodiazepine
 Administered with MAOIs causes serotonin syndrome
Serotonin Syndrome
 Symptoms
 Delirium, tachycardia, hyperreflexia, shivering, agitation, sweating, muscle
spasms, coarse tremors
 Symptoms of severe cases
 Hyperthermia, seizures, renal failure, dysrhythmias, disseminated intravascular
coagulation (DIC) metablic acidosis
 Treatment
 d/c medication, supportive measures, cooling blanket, benzodiazepines,
anticonvulsants, antihypertensives
 Monitor VS and I&O, prevent injury

Mood Stabilizers
 Mood stabilizers (antimanics)
o Bipolar disorder
 Lithium
 Antipsychotics
 Anticonvulsants
 Antidepressants
o Depression
 MAOIs
 Tricyclic Antidepressants (TCAs)
  SSRIs/SNRIs

Lithium
 Narrow therapeutic index: 0.6 and 1.2 mEq/L
 Early toxicity at 1.5 mEq/L
o Dose: 1800 to 2400 mg/day for acute mania
o 900 to 1200 mg for maintenance dose
 Increased toxicity with:
o Diuretics, NSAIDs
o Theophylline
o Sodium imbalance
 Severe Lithium Toxicity/OD
o Serum levels greater than 2.5 mEq/L
o Confusion, sedation, ataxia
o Coma, convulsions, death
o Treatment: hemodialysis
o Stop the med
 Monitor for side effects:
o Fine Tremors
o Acne
o GI upset
o Polyuria, polydipsia
o Weight gain
o Lethargy
o Watch sodium levels closely
Antiepileptics used as mood stabilizers
 Valproic acid (Depakote)
 Carbamazepine (Tegretol)
 Oxcarbazepine (Trileptal)
 Lamotrigine (Lamictal)
 Topiramate (Topamax)
 Gabapentin (Neurotin)
Client Education antimanics
 Lithium
o Take same time every day
o Blood levels drawn in am prior to am dose
o Any change in diet or exercise notify MD
o Symptoms of toxicity stop med notify MD
 Antiepileptics
o Do not stop abruptly
o Rash, unusual bleeding, bruising, sore throat, dark urine, yellow skin or eyes report to MD
o Avoid alcohol and non Rx meds
Depression Hypothesis
May be due to decreased amounts of or inadequate function of norepinephrine or serotonin
 Antidepressants
o increase concentration of these neurotransmitters
o If one fails try another…
 Tricyclic antidepressants (TCAs)
 Monoamine oxidase inhibitors (MAOIs)
 Selective serotonin reuptake inhibitors (SSRIs)
  Black box warning

 Common Tricyclics
o amitriptyline (Elavil, Endep)
o doxepin (Sinequan)
o imipramine (Tofranil)
o desipramine (Norpramin)
o nortriptyline (Aventyl, Pamelor)

Tricyclic's
Indications
o Depression
o Childhood enuresis
o Obsessive-compulsive disorders
o Adjunctive analgesics for chronic pain
 Use with caution elderly, hepatic
or renal disease or cardiac
insufficiency or seizure disorders
Side effects
o Anticholinergic effects
o Photosensitivity
o Weight gain
o Sedation
o Impotence
o Cardiac effects
o Reduction of seizure threshold
Overdose of Tricyclic's
o Lethal—70% to 80% die before reaching the hospital
o CNS and cardiovascular systems are
mainly affected
o Death results from seizures or dysrhythmias
o No specific antidote
 activated charcoal
 alkalinizing urine
 Manage seizures and dysrhythmias
 Basic life support

MAOIs monoamine oxidase inhibitors

 third-line treatment for depression, not responsive to cyclics/SSRIs
 hypertensive crisis when taken with tyramine
 Fatal adverse reactions (ss) may occur if taken with any/all other antidepressants (2-5 week washout
period)
 With opioids=death
 With insulin= hypoglycemia
o Avoid foods that contain tyramine! (hypertensive crisis)
 Aged, mature cheeses Smoked/pickled or aged meats, fish,
 Yeast extracts
 Red wines
 Italian broad beans (fava beans)
 No antidote OD=death
Serotonin Syndrome
 Confusion
 Agitation or restlessness
 Dilated pupils
 Headache
 Changes in blood pressure and/or temperature
 Nausea and/or vomiting
 Diarrhea
 Rapid heart rate
 Loss of muscle coordination or twitching muscles
 Shivering and goose bumps
 Heavy sweating  
 High fever
 Seizures
 Irregular heartbeat
 Unconsciousness 

MAOIs
 Examples
o phenelzine (Nardil)
o tranylcypromine (Parnate)
o isocarboxazid(Marplan)
o selegiline( Emsam) Transdermal

Newer-Generation Antidepressants
 Fewer adverse effects
 Very few drug-drug or drug-food interactions
 about 4 to 6 weeks to reach maximum clinical effectiveness
 Now considered first-line drugs for depression
 trazodone (Desyrel)
 bupropion (Wellbutrin)
SSRIs  escitalopram (Lexapro)
o fluoxetine (Prozac)  venlafaxine (Effexor)
o paroxetine (Paxil)  nefazodone (Serzone)
o sertraline (Zoloft)  mirtazapine (Remeron)
o fluvoxamine (Luvox)  duloxetine (Cymbalta)
o citalopram (Celexa)  desvenlafaxine (Pristiq)
Newer-Generation Antidepressants: Indications
 Depression
 Bipolar disorder
 Obesity
 Eating disorders
 Obsessive-compulsive disorder
 Panic attacks or disorders
 Social anxiety disorders
 Posttraumatic stress disorders (PTSDs)
 Myoclonus
 bupropion [Zyban] is used for smoking cessation treatment)

Newer-Generation Antidepressants: Adverse Effects

 HA, dizziness, tremor, nervousness, insomnia fatigue, nausea, diarrhea, constipation, dry mouth,
weight gain, weight loss, sexual dysfunction, sweating

Client Education antidepressants

 Monitor for response
 Monitor for side effects
 Discontinuation syndrome
 Photosensivity
 SS
 Orthostatic hypotension
 Diet
 Smoking issues
 Sexual function issues
 No double up on meds
 Patch application
 Pregnancy risks
 Suicide risks
 Fall risks
 ID card

Antipsychotics, Neuroleptics, major tranquilizers

Indications
 Psychosis
 Movement disorders
 Bipolar disorder
 Autism
 Nausea, intractable hiccups
 Decrease dopamine levels in CNS
 Black box warning

Antipsychotics Typical, first generation

 Chlorpromazine (Thorazine)
 Thioxanthenes: thiothixene (Navane)
 Butyrophenones: haloperidol (Haldol)
 Dihydroindolones: molindone (Moban)
 Dibenzoxazepine: loxapine (Loxitane)
 Fluphenazine (Prolixin)
Atypical Antipsychotics: Second-Generation
 clozapine (Clozaril)
 risperidone (Risperdal)
 olanzapine (Zyprexa)
 quetiapine (Seroquel)
 ziprasidone (Geodon)
 aripiprazole (Abilify)
 paliperidone (Invega)

Antipsychotics Injectable’s (2 to 4 week duration)

 Fluphenazine
 Haloperidol
 Olanzapine
 Risperidone
 Paliperidone

Adverse effects
 EPS
o Pseudoparkinsonism
o Akathisia
o Akinesia
o Dystonia
o Oculogyric crisis
 Tx. anticholinergics
 Tardive dyskinesia
 Hyperglycemia and diabetes
 Anticholinergic
 Postural hypotension
 Weight gain
 sedation
 Photosensitivity
 Galactorrhea and gynecomastia
 Seizures
 Agranulocytosis
 Hypersalivation

Adverse Effects: Neuroleptic malignant syndrome (NMS)

 Potentially life threatening
 High fever, unstable BP
 Decreased LOC, muscle rigidity
 Tachypnea, diaphoresis and drooling
Treatment
 d/c meds
 Monitor VS
 Administer Rx bromocriptine (Parlodel) or dantrolene (Dantrium)
Client Education antipsychotics
 Photosensitivity
 Medication compliance
 S&S NMS
 Avoid alcohol
 Pregnancy risks
 ID card
 When to call the PCP
Psychotherapeutic Drugs: Nursing Implications
 Before beginning therapy
o assess physical and emotional status
o Obtain baseline vital signs
o Obtain liver and renal function tests
o California law
 signed consent needed
o Assess for possible contraindications to therapy, cautious use, and potential drug interactions
o Assess for LOC, mental alertness, potential
for injury to self and others
 During Therapy

o Check the client’s mouth to make sure oral doses are swallowed
o Only small amounts of medications should be dispensed at a time
o Simultaneous use of these drugs with alcohol or other CNS depressants can be fatal
o Provide simple explanations about the drug
o Advise clients to avoid abrupt withdrawal
o Advise clients to change positions slowly