PSYCHOPHARMACOLOGI

CAGENTS

ANTI
ANXI
ETYAGENTS

Indi
cati
ons
Ant
ianxi
etydrugsarealsocaledanxi
l ol
yti
csandmi nortranquil
i
zer
s.Theyar
eusedinthetr
eatmentof
anxiet
ydisorder
s,anxi
etysymptoms, acut
ealcoholwi
thdrawal,skelet
almuscl
espasms,conv
ulsi
vedisor
ders,
stat
us
epil
epti
cus,andpreoperat
ivesedati
on.Thei
ruseandef f
icacyforper i
odsgr
eatert
han4monthshavenotbeen
eval
uated.

Act
ion
Anti
anxi
etydr
ugsdepresssubcort
icall
evelsoftheCNS, par
ticul
arl
ythel
imbicsyst
em andret
icular
formati
on.
Theymaypotenti
atetheeff
ectsofthepowerfulinhi
bit
oryneurotr
ansmit
terGABAinthebrai
n,thereby
produci
ngacalmati
veeff
ect.Al
l l
evel
sofCNSdepr essi
oncanbeef f
ected,f
rom mil
dsedati
ontohypnosistocoma.

Contr
aindicati
ons/Pr ecaut ions
Ant i
anxietydr ugsar econt r
aindicatedini
ndivi
dualswit hknownhy per
sensit
ivi
tytoanyofthedr ugswit
hin
thecl
assifi
cation(e.g., benzodi azepines).Theyshouldnotbet akenincombi nati
onwithotherCNSdepr essant
sand
arecontr
aindicatedinpr egnancyandl actati
on,nar
row-anglegl
aucoma, shock,andcoma.Cautionshoul
dbet akenin
administ
eringthesedr ugst oelderlyordebi l
itat
edcl
ientsandclientswithhepaticorr
enaldysfunct
ion.(
Thedosage
usual
lyhast obedecr eased. )
Caut i
oni salsor equiredwi t
hi ndivi
dualswhohav eahi stor
yofdr ugabuseoraddicti
onandwi t
ht hose
whoar edepressedorsui cidal.Indepressedcl i
ent
s,CNSdepr essant scanexacerbat
esy mptoms.

Interacti
ons
I
ncreasedeff
ectsofant i
anxiet
yagent scanoccurwhent akenconcomi t
antl
ywit
halcohol
,barbit
urat
es,
nar coti
cs,anti
psychot
ics,
antidepressant
s, ant
ihi
stamines,
neuromuscularblocki
ngagents,
cimeti
dine,ordi
sulf
ir
am.
Increasedef f
ectscanalsooccurwi thherbaldepressant
s(e.g.
,kava;v
aler
ian).Decr
easedeff
ectscanoccurwith
cigarettesmokingandcaf f
eineconsumpt ion.

EXCEPTION:
Buspir
one(BuSpar)doesnotdepresst
heCNS.Al
thoughit
sactioni
sunknown,t
hedrugisbel
iev
edto
producet
hedesi
redef
fect
sthroughint
eract
ionswit
hser
otoni
n,dopamine,
andotherneur
otr
ansmit
terr
ecept
ors.

EXAMPLESOFANTI
-ANXI
ETYDRUGS

Ant
ihi
stami
nes

Hy
droxy
zine(
Atar
ax)
(Vi
star
il
)

Benzodi
azepines
Alprazolam (Xanax)
Chlordiazepoxide(Li
bri
um)
Clonazepam( Klonopin)
Clorazepate(Tranxene)
Diazepam( Vali
um)
Lorazepam( Ativan)
Oxazepam ( Serax)

Carbamatederi
vat
ive:Mepr
obamate
Azaspi
rodecanedi
ones:Buspi
rone(
BuSpar
)

Si
deEf
fect
sandNur
singI
nter
vent
ions

1.Dr
owsi
ness,conf
usi
on,let
har
gy(
mostcommonsi deeffect
s)
I
nstr
uctthecl
ientnott
odr
iveoroper
atedanger
ousmachi
ner
ywhi
l
etaki
ngt
hemedi
cat
ion.

2.Tol
erance;physical
andpsychologicaldependence( doesnotapplytobuspi
rone)
Instr
uctthecli
entonlong-t
ermt herapynott oquittaki
ngthedrugabr
uptly.Abr
uptwithdr
awal
canbel
ife
threat
ening.Symptomsincludedepr ession,i
nsomni a,
incr
easedanxi
ety,
abdomi nal
andmusclecr
amps,
tremors,vomiti
ng,
sweating,convulsions,anddelir
ium.
3.Abi
l
ityt
opotent
iat
etheeffect
sofotherCNSdepressants
I
nst
ructt
hecli
entnottodr
inkalcohol
ort
akeot hermedi
cat
ionst
hatdepr
esst
heCNSwhi
l
etaki
ngt
his
medi
cati
on.

4.Possi
bil
it
yofaggr av
at i
ngsy mptomsi ndepressedpersons
Assesstheclient’
smooddai l
y.
Takenecessar yprecauti
onsforpotenti
alsuici
de.
5.Ort
hostat
ichypotension
Monitorl
yingandst andingbloodpressureandpulseateverynur
singshi
ft
.
I
nstructt
heclienttoar i
seslowlyfr
om al yi
ngorsitt
ingposi
ti
on.

6.Par
adoxi
calexci
tement(cl
i
entdevel
opssymptomsopposi
teoft
hemedi
cat
ion’
sdesi
redef
fect
)
Wi
thholddrugandnoti
fyt
hephysi
cian.

7.Dr
ymouth
Havet
hecl
i
entt
akef
requentsi
psofwat
er,
suckoni
cechi
psorhar
dcandy
,orchewsugar
lessgum.

8.Nauseaandvomi
ti
ng
Havet
hecl
ientt
aket
hedr
ugwi
thf
oodormi
l
k.

9.Bl
ooddyscr
asias
Symptomsofsorethr
oat,
fev
er,
mal
aise,
easybr
uisi
ng,
orunusual
bleedi
ngshoul
dber
epor
tedt
othe
physi
cianimmedi
atel
y.

10.Del
ayedonset( buspi
roneonly
)
Ensur
et hatthecli
entunder
standstherei
sal
agti
meof10daysto2weeksbetweenonsetoft
herapywit
h
buspi
roneandsubsi di
ngofanxiet
ysy mpt
oms.Cl
i
entshoul
dcont
inuet
otaket
hemedicati
onduri
ngthis
ti
me.

NOTE:Buspironeisnotrecommendedforp.
r.
n.admini
str
ati
onbecauseofthi
sdel
ayedther
apeut
iconset
.
Ther
eisnoev i
dencethatbuspi
ronecr
eat
estol
eranceorphy
sical
dependenceasdotheCNSdepressant
anxi
oly
tics.

Cl
i
ent
/Fami
l
yEducat
ion

Thecl
i
entshoul
d:

● Notdr iv
eoroper atedanger ousmachi nery.Drowsi nessanddi zzinesscanoccur .
● Notst opt aki ngt hedr ugabr uptl
y ,asthi
scanpr oduceser iouswi thdrawal sympt oms, suchasdepr ession,
i
nsomni a,anx iet y,abdomi nal andmuscl ecramps, t
remor s, v omi ti
ng, sweat i
ng,conv ulsions, del
iri
um.
●( Withbuspi roneonl y )
: Beawar eofl agtimebet weenst artoft herapyandsubsi dingofsy mptoms.Rel i
efisusual
ly
evidentwi thin10t o14day s.Thecl ientmustt aket hemedi cationr egul arl
y,asorder ed, sot hati
thassuf f
ici
entti
me
totakeef f
ect .Notconsumeot herCNSdepr essant s( i
ncludi ngal cohol ).
● Nott akenonpr escripti
onmedi cationwithoutappr ovalf rom t hephy sici
an.
● Ri seslowl yf rom si tti
ngorl yingposi t
iontopr eventsuddendr opi nbl oodpr essure.
●I mmedi atel yr eportsy mpt omsofsor ethroat,fever ,
mal aise,easybr uising,unusual bl eeding,ormot or
restl
essnesst ophy si
cian.
● Beawar eofr isksoft aki ngt hisdrugdur i
ngpr egnancy .(Congeni tal mal f
ormationshav ebeenassoci atedwi t
huse
duringthef irstt rimest er.
)Thecl i
entshouldnot ifythephy sicianoft hedesi r
abil
it
yt odi scont i
nuet hedrugi f
pregnancyi ssuspect edorpl anned.( Excepti
ons:Al thoughr iski slesswi thclonazepam, itcannotber uledout.With
buspi r
one, saf etyhasbeenest abli
shedonl yinani mal studi es.)
● Beawar eofpossi blesi deef fects.Theclientshoul dr efert owr i
ttenmat eri
alsfurnishedbyheal t hcar
epr ovi
ders
regardingt hecor r
ectmet hodofsel f-administr
ation.
● Car ryacar dorpi eceofpaperatal lti
messt atingt henamesofmedi cati
onsbei ngt aken.
 ANTI
DEPRESSANTS

Indi
cations
Antidepressantmedicati
onsareusedi nthet r
eatmentofdy sthymicdisorder;majordepressi
onwith
melanchol iaorpsy choti
csympt oms;depressionassociat
edwithorgani cdisease,alcohol
ism,schizophr
enia,or
ment alretardati
on; depr
essiv
ephaseofbi polardisor
der;anddepressi onaccompani edbyanxiety.Thesedrugs
elevatemoodandal l
evi
ateothersymptomsassoci at
edwi thmoderat e-t
o-sever
edepr essi
on.Selectedagentsare
alsousedt otreatanxiet
ydisorders,
buli
mianer vosa,andpremenstrual dysphori
cdisorder
.

Act
ion
Thesedr ugsulti
mat el
ywor ktoincr
easetheconcentrationofnor epi
nephri
ne,serotonin,
and/or
dopamineinthebody .Thisisaccompl i
shedinthebrai
nbybl ockingt hereuptakeoftheseneurotransmitt
ersbyt
he
neurons(
tri
cycl
ics,selecti
veserotoninreupt
akeinhi
bit
ors,
andot hers).I
talsooccurswhenanenzy me, monoamine
oxi
dase(MAO) ,thati
sknownt oinactiv
atenorepi
nephri
ne,serotonin,anddopami ne,i
sinhibit
edatv ar
ioussit
esi
nthe
nerv
oussystem (MAOi nhi
bit
orsorMAOI s]
.

Contraindi
cati
ons/ Precauti
ons
Anti
depressantdr ugsarecont
raindicatedi nindiv
idualswithhy persensi
tiv
ity
.Tr
icy
cli
csarecontrai
ndicat
ed
i
nt heacuterecov eryphasef ol
l
owingmy ocardialinfarcti
onandi nindiv
idual swit
h
angle-cl
osureglaucoma.
Cautionshoul dbeusedinadministeringt hesedrugst oelderl
yordebi li
tat
edcli
ent
sandt hosewithhepati
c,
renal,
orcardiacinsuf f
ici
ency.(
Thedosageusual lymustbedecr eased.)Caut i
onisalsor
equir
edwi t
hpsychoti
c
cli
ents,wit
hclientswhohav ebeni
gnprostati
chy pertr
ophy ,andwithindividualswhohaveahistor
yofseizures(may
decreaseseizurethreshold).

NOTE:Asthesedr
ugstakeeff
ect,
andmoodbegi nstol
ift
,theindiv
idual
mayhaveincr
easedener
gy
wit
hwhichtoimpl
ementasuici
deplan.Sui
cidepot
enti
aloftenincr
easesasl
evel
ofdepressi
ondecr
eases.Thenur
se
shoul
dbeparti
cul
arl
yal
ertt
osuddenlift
sinmood.

EXAMPLESOFANTI
DEPRESSANTS

Tr
icy
cli
cs( TCA)
Ami t
riptyli
ne( Elavil
;Endep)
Amoxapi ne( Asendin)
Cl
omi prami ne(Anaf r
anil)
Desiprami ne( Nor pr
ami n)
Doxepi n(Sinequan)
I
mi prami ne( Tofranil
)
Nortri
pty l
ine( Aventyl;
Pamelor
)
Protr
ipty l
ine( Vivact
il
)
Tri
mi prami ne( Surmont i
l)

Sel
ect
iveSer otoninReupt akeI nhi
bit
ors(
SSRI
)
Cit
alopr am (
Cel exa)
Escital
opram ( Lexapro)
Fl
uoxet ine(Prozac; Seraf
em)
Fl
uv oxami ne(Luv ox)
Paroxet i
ne(Paxi l
)
Sert
r al
ine(Zoloft)

Monoami
neOxi daseInhi
bit
ors(MAOI )
I
socarboxazid(Marpl
an)
Phenelzi
ne(Nardil
)
Tranyl
cypromine(Parnate)
Selegi
l
ineTransdermal Syst
em (
Emsam)

Ot
her
s
Bupr opi
on(Zyban;(
Wellbut
ri
n)
Mapr oti
li
ne(Ludi
omil)
Mirtazapi
ne(Remeron)
Trazodone
 Nefazodone
Venlafaxi
ne( Eff
exor)
Duloxeti
ne( Cymbalta)
Desvenlafaxine(Pr
isti
q)

Psy
chot
herapeuti
cCombi nat
ions
Olanzapi
neandf l
uoxeti
ne(Symbyax)
Chlordi
azepoxi
deandf l
uoxeti
ne(Li
mbi t
rol
DS)
Perphenazi
neandami tr
ipt
yli
ne(Etr
afon)

I
nter
act
ions

1.Tr
icy
cli
cAntidepressant s
●Increasedef f
ectsoft r
icyclicanti
depressantswi t
hbupr opion,cimetidine, hal
operidol
,SSRIs,
and
val
proicaci d.
● Decreasedef fectsoftricycli
cantidepressant
swi thcarbamazepi ne,bar bit
urates,andri
famyci
ns.
● Hyperpyreticcri
sis,conv ulsi
ons,anddeat hcanoccurwi thMAOi nhi
bitor s.
● Co-administrati
onwi thclonidinemaypr oducehy pertensivecrisi
s.
● Decreasedef fectsoflev odopaandguanet hi
dinewi t
ht r
icycli
cant i
depr essants.
● Potenti
ationofpr essorr esponsewi t
hdi r
ect-
actingsy mpat homimet i
cs.
●Increasedant i
coagulationef f
ectswithdicumar ol.
●Increasedser um l
evelsofcar bamazepi nesoccurwi thconcomi t
antuseoft r
icycl
ics.
●Increasedr i
skofseizureswi t
hconcomi tantuseofmapr otil
ineandphenot hi
azines.

2.MAOI
nhibitor s
● Ser ious, potent i
all
yf atal adv ersereact i
onsmayoccurwi t
hconcur r
entuseofot herant idepr essants,
car bamazepi ne, cy cl
obenzapr i
ne, bupropion, SSRI s,
SARI s, buspi rone, sympat homi met i
cs,tryptophan, dextromethor phan, anest heticagent s,CNS
depr essant s,andamphet ami nes.Av oidusi ngwi t
hi n2weeksofeachot her( 5weeksaf tert herapywi th
fluoxet ine).
● Hy per tensivecr isi
smayoccurwi thamphet ami nes, methyl
dopa, lev odopa, dopami ne, epinephr i
ne,
nor epinephr i
ne, guanet hidine, guanadr el,reserpine, vasoconstrictor s,ori ngest i
onoft yrami necont aini
ng
foods
● Hy per tensionorhy pot ension, coma, conv ulsions, anddeathmayoccurwi thopi oids( avoiduseof
meper idinewi t
hin14t o21day sofMAOi nhibitorther apy).
● ExcessCNSst imulat i
onandhy pert
ensi onmayoccurwi thmet hy lpheni date.
● Addi t
ivehy pot ensionmayoccurwi thant ihyper t
ensi ves,t
hiazidedi uretics,orspi nalanest hesia.
● Addi t
ivehy pogl ycemi amayoccurwi thinsul i
nsoror alhypogly cemi cagent s.
● Doxapr am mayi ncreasepr essorr esponse.
● Ser otoninsy ndromemayoccurwi t
hconcomi tantuseofSt .John’ swor t.
● Consumpt ionoff oodsorbev erageswi thhi ghcaf fei
necont enti ncr easest her i
skofhy per t
ensionand
ar r
hy thmi as.
● Br ady cardiamayoccurwi thconcur r
entuseofMAOI sandbet abl ocker s.

3.Sel
ect
iveSer otoninReupt akeInhibitors(SSRI s)
● Toxi c,somet imesf atal,reacti
onshav eoccur r
edwi thconcomi tantuseofMAOI s.
●I ncreasedef f ectsofSSRI swithcimet idine,Ltryptophan,li
thium, li
nezolid,andSt .John’swor t
.
● Ser otoninsy ndromemayoccurwi t
hconcomi tantuseofSSRI sandmet ocloprami de,si
butrami ne,
tr
amadol ,or5-HT- receptoragoni sts(tri
ptans) .
● Concomi tantuseofSSRI smayi ncreaseef fectsofhy dantoi ns,tri
cycli
cant idepressants,cyclospori
ne,
benzodi azepines, betablocker s,methadone, carbamazepi ne, clozapine,ol
anzapi ne,pimozi de,haloperi
dol
,
phenot hiazi
nes, St.John’swor t,
sumat ri
ptan,sy mpat homimet i
cs,tacri
ne,theophy lli
ne,andwar f
arin.
● Concomi tantuseofSSRI smaydecr easeef fectsofbuspi roneanddi goxin.
● Lithium levelsmaybei ncreasedordecr easedbyconcomi tantuseofSSRI s.
● Decr easedef fectsofSSRI swi thconcomi tantuseofcar bamazepi neandcy proheptadine.

4.Ot
her
s
● Concomit
antusewi t
hMAOI sresult
sinseri
ous, somet i
mesfatal
,ef
fectsresembli
ngneur
olepti
c
mali
gnantsy
ndr ome.Coadmini
strat
ioniscont
raindicated.
● Serot
oni
nsy ndromemayoccurwhenanyoft hef oll
owingareusedtogether:
St.John’
swort,
sumat
ri
ptan,
si
butr
amine,t
razodone,nef
azodone,venlaf
axi
ne, duloxeti
ne.
 ●I ncreasedef fectsofhal oper idol,cl
ozapi ne,anddesi prami newhenusedconcomi t
antl
ywithvenlaf
axi
ne.
●I ncreasedef fectsofv enlaf axinewithci met i
dine.
●I ncreasedef fectsofwar farinwi t
hv enlafaxineanddul oxetine.
●I ncreasedef fectsofdul oxet inewi t
hCYP1A2i nhibi
t ors(e.g.,fl
uvoxami ne, quinol
oneanti
bioti
cs)and
CYP2D6i nhi
bitors(e.g.,fluoxet ine,quinidine,paroxetine).
●I ncreasedr i
skofl i
v eri njurywi thconcomi tantuseofal cohol anddul oxeti
ne.
●I ncreasedr i
skoft oxi cityoradv erseef fectsfrom drugsext ensivelymet abolizedbyCYP2D6( e.g.
,
fl
ecainide,phenot hi
azines, propaf enone, tri
cycli
cant i
depr essant s,thi
oridazine)whenusedconcomi t
ant
ly
wit
hdul oxetineorbupr opi on.
● Decr easedef fect
sofbupr opionandt razodonewi t
hcar bamazepi ne.
● Alteredant i
coagulantef f
ectofwar farinwi thbupropi on,venlafaxine,duloxetine,ort
razodone.

Si
deEf
fect
sandNur
singI
nter
vent
ions

1.Mayoccurwi
thal
lchemi
cal
classes:

a.Drymout h
Of f
ert hecl i
entsugar l
esscandy , i
ce, fr
equentsipsofwat er.
Stri
ctor al hy gienei sver yimpor tant .
b.Sedation
Requestanor derf rom t hephy sicianf ort
hedr ugtobegi venatbedt ime.
Requestt hatt hephy siciandecr easet hedosageorper hapsor deralesssedatingdrug.
Instructthecl ientnott odr i
veorusedanger ousequipmentwhi l
eexperienci
ngsedat i
on.
c.Nausea
Medi cationmaybet akenwi thf oodt ominimizeGIdi stress.
d.Discontinuationsy ndr ome
Allclassesofant i
depr essant shav ev aryi
ngpot enti
alstocausedi sconti
nuati
onsy ndromes.
Abr uptwi thdr awal f
oll
owi ngl ong-termt herapywi t
hSSRI s,venl
afaxine,
desv enlafaxi ne, anddul oxetinemayr esul
tindizziness, l
ethargy,headache,andnausea.Fluoxetinei sl
ess
li
kelytor esul ti nwi t
hdr awal sympt omsbecauseofi tslonghal f-l
i
fe.Abruptwithdr
awal fr
om tri
cy cl
icsmay
producehy pomani a,akat hi
sia,car diacarrhythmias,gast roi
ntesti
nalupset,andpanicattacks.The
discont i
nuat ionsy ndromeassoci atedwi t
hMAOI sincludesf lul
ikesympt oms,confusi
on,hypomani a,and
wor seningofdepr essivesy mpt oms.

Al
lant
idepr
essantmedi
cat
ionshoul
dbet
aper
edgr
adual
l
ytopr
eventwi
thdr
awalsy
mpt
oms.

2.Mostcommonl
yoccurwi
tht
ri
cycl
i
csandot
her
s,suchasbupr
opi
on,
mapr
oti
l
ine,
mir
tazapi
ne,
trazodone,
and
nef
azodone:

a.Bl
urredvision
Offerr eassurancethatthissy mptom shoul dsubsideaft
eraf ewweeks.
Instructthecl i
entnottodr i
veuntilvisi
oni sclear
.
Clearsmal l
itemsf r
om routinepathwayt opreventfal
ls.
b.Consti
pation
Orderf oodshi ghinfiber
;increasefluidintakeifnotcontr
aindicat
ed;
andencour
aget
hecl
i
entt
o
increasephy sicalexerci
se,ifpossible.

c.Ur
inar
yretenti
on
I
nstructt
heclienttor
epor
thesi
tancyorinabi
li
tyt
our
inat
e.
Monitori
ntakeandoutput
.
Tryvari
ousmet hodstost
imul
ateuri
nati
on,suchasr
unni
ngwat
eri
nthebat
hroom orpour
ingwat
erov
ert
he
peri
nealarea.

d.Or
thostat
ichy pot
ension
I
nstructthecli
enttori
sesl
owlyfr
om al y
ingorsi
tt
ingposit
ion.
Monitorbloodpressur
e(l
yi
ngandst andi
ng)fr
equentl
y,anddocumentandr
epor
tsi
gni
fi
cantchanges.
Avoidlonghotshowersortubbaths.

e.Reduct
ionofseizurethreshold
Observecli
entswi thhist
oryofsei
zur
esclosely
.
I
nsti
tuteseizur
epr ecauti
onsasspecif
iedinhospi
talpr
ocedur
emanual
.
Bupropi
on( Wellbutri
n)shoul
dbeadmi ni
ster
edindosesofnomor
ethan150mgandshoul
dbegi
venat
 l
east4hour
sapart
.Bupropionhasbeenassoci
atedwi
thar
elat
ivel
yhi
ghi
nci
denceofsei
zur
eact
ivi
tyi
n
anor
exi
candcachect
iccli
ents.

f
.Tachy
cardi
a;arr
hythmias
Caref
ull
ymoni t
orbloodpr
essur
eandpul
ser
ateandr
hyt
hm,
andr
epor
tanysi
gni
fi
cantchanget
o
thephysi
cian.

g.Phot
osensit
ivi
ty
Ensur
et hatcl
i
entwear
ssunbl
ockl
oti
on,
prot
ect
ivecl
othi
ng,
andsungl
asseswhi
l
eout
door
s.

h.Wei
ghtgai
n
Provi
deinst
ructi
onsforreduced-
calori
ediet
.
Encouragei
ncreasedlev
el ofact
ivi
ty,
ifappr
opr
iat
e.

3.Mostcommonl
yoccurwi
thSSRI
s:

a.I
nsomni a;
agit
ation
Admi ni
sterorinstructcli
enttotakedoseear
lyintheday.
Instr
uctcli
enttoav oidcaffei
natedfoodanddri
nks.
Teachrelaxati
ont echniquestousebeforebedti
me.
b.Headache
Admi ni
steranalgesics,asprescri
bed.
Requestthatthephy si
cianorderanot
herSSRIoranothercl
assofant
idepr
essant
s

c.Wei
ghtl
oss(mayoccurear l
yinther
apy)
Ensur
et hatcli
enti
sprovi
dedwi t
hcalori
cint
akesuff
ici
entt
omaintai
ndesir
edweight.
Cauti
onshoul dbetakeninpr
escri
bingthesedr
ugsforanor
ect
iccl
ients.
Weighclientdai
lyorever
yotherday,att
hesamet i
me,andonthesamescale,
ifpossi
ble.
Aft
erprolongeduse,someclient
smaygai nwei
ghtonSSRIs

d.Sexual
dysfunct
ion
Menmayr epor
tabnor
mal ejacul
ati
onorimpotence.
Womenmayexper i
encedelayorlossoforgasm.
I
fsideeff
ectbecomesintolerabl
e,aswit
chtoanotherant
idepr
essantmaybenecessar
y.

e.Ser
otoninsyndrome( mayoccurwhentwodr ugsthatpot
enti
ateserotoner
gicneurot
ransmissi
onare
usedconcurrentl
y
Mostf requentsymptomsi
ncludechangesinmentalstat
us,restl
essness,
my ocl
onus,hyper
ref
lexi
a,
tachycardia,
labi
l
ebloodpressur
e,di
aphoresis,
shi
ver
ing,andtremors.

Di
scont
inuet
heof
fendi
ngagenti
mmedi
atel
y.

Thephy sici
anwillpr
escr
ibemedicati
onstoblockserotoninrecept
ors,
rel
ievehypert
hermiaandmuscle
ri
gidi
ty,andpreventsei
zures.I
nseverecases,art
if
ici
alventi
l
ationmayber equir
ed.Thehist
amine-
1recept
or
antagonistcypr
oheptadi
neiscommonl yusedt otr
eatthesympt omsofserotoninsyndr
ome.

Suppor
ti
venursi
ngmeasur esincl
udemonit
ori
ngvitalsigns,pr
ovidi
ngsafetymeasur
estoprev
ent
i
njur
ywhenmuscl er
igi
dit
yandchangesi nmentalstat
usar epresent
,cool
ingbl
anketsandt
epidbat
hst
o
assi
stwit
htemperat
ureregulati
on,andmoni
tor
ingintakeandout put
.

Thecondi
ti
onwill
usual
l
yr esol
veonitsownoncetheof
fendi
ngmedi
cat
ionhasbeendiscont
inued.However
,
i
fthemedicat
ioni
snotdiscont
inued,
thecondi
ti
oncanprogr
esst
oamor eser
iousst
ateandbecomef at
al.

4.Mostcommonl
yoccurwi
thMAOI
s:

a.Hy
per
tensivecri
sis
Hy pert
ensiv
ecrisi
soccursiftheindi
vidualconsumesfoodscontai
ningtyr
aminewhilerecei
vi
ngMAOI
therapy(NOTE: Hyper
tensivecri
sishasnotshownt obeaproblem withsel
egil
i
netransdermalsyst
em at
the6mg/ 24hrdosage,anddietaryr
estri
cti
onsatthi
sdoseisnotrecommended. Di
etarymodifi
cati
onsar
e
recommended, however,atthe9mg/ 24hrand12mg/ 24hrdosages.)

Sy
mpt
omsofhy
per
tensi
vecr
isi
sincl
udesev
ereocci
pit
alheadache,
pal
pit
ati
ons,
ausea/
vomi
ti
ng,
 nuchal
rigi
dit
y,f
ever
,sweat
ing,
mar
kedi
ncr
easei
nbl
oodpr
essur
e,chestpai
n,andcoma.

Treat
mentofhy per
tensiv
ecrisi
s:discont
inuedrugimmedi
ately
; moni
torvi
tal
signs;admini
stershor
t-
acting
anti
hyper
tensi
vemedi cat
ion,
asor deredbyphysici
an;
useexternal
cooli
ngmeasur estocontr
olhyperpy
rexia.

b.Appl
i
cationsi
tereacti
ons(wit
hselegil
inetransdermal syst
em [ Emsam] )
Themostcommonr eacti
onsincluderash, i
tchi
ng,ery
thema, redness,
irr
it
ati
on,swel
li
ng,orur
ti
cari
all
esi
ons.
Mostreacti
onsresol
vespontaneousl y
,requiri
ngnot reatment.Howev er
,ifr
eacti
onbecomesprobl
emati
c,i
t
shoul
dber epor
tedtothephysician.Topicalcorti
costeroidshavebeenusedi nt
reat
ment.

Foodanddr
ugr
est
ri
cti
onswhi
l
eonMAOIt
her
apy
:

Hi
ghTy
rami
neCont
ent(
Avoi
dwhi
l
eonwhi
l
eonMAOIt
her
apy
)

Agedcheeses(cheddar
,Swi
ss,Camembert
,bl
uecheese,
Par
mesan,
prov
olone,
Romano,
bri
e)Rai
sins,
fav
a
beans,
flatI
tal
i
anbeans,Chi
nesepeapods

Redwi
nes(
Chi
ant
i,bur
gundy
,caber
netsauv
ignon)

Smokedandpr
ocessedmeat
s(sal
ami
,bol
ogna,
pepper
oni
,summersausage)

Cav
iar
,pi
ckl
edher
ri
ng,
cor
nedbeef
,chi
ckenorbeefl
i
ver

Soysauce,
brewer
’sy
east
,meatt
ender
izer(
MSG)

Moder
ateTy
rami
neCont
ent(
Mayeatoccasi
onal
l
ywhi
l
eonMAOIt
her
apy
)

Goudacheese,processedamericancheese,
mozzarel
la.y
ogur
t,sourcr
eam, avocados,
bananas,
beer
,whi
te
wine,
coff
ee,colas,t
ea,hotchocolat
e,meatext
ract
s,suchasbouil
l
on,chocolat
e

LowTy
ramineContent(Li
mitedquant
it
iesper
mi ssibl
ewhileonMAOIt her
apy)
Past
eur
izedcheeses(cr
eam,cheese,cottagecheese,
ricot
ta)
,fi
gs,di
sti
l
ledspi
ri
ts(
inmoder
ati
on)

5.Mi
scel
l
aneoussi
deef
fect
s:

a.Pr
iapi
sm ( withtrazodone)
Priapism isar aresi deeffect,buti
thasoccurredinsomement akingtr
azodone
Iftheclientcompl ainsofpr ol
ongedorinappropri
atepenileerecti
on,withhol
dmedicationand
notifythephy siciani mmedi at
ely.
Priapism canbecomev eryproblemati
c,r
equiri
ngsur gi
cali
nterventi
on,and,i
fnottr
eatedsuccessf
ull
y,
can
resultinimpot ence.
b.Hepat
icfailure(withnef azodone)
Casesofl if
e-t
hr eateninghepat i
cfai
lur
ehavebeenr eport
edincl i
entstr
eatedwit
hnefazodone.
Adv i
secl i
entst obeal er
tforsignsorsymptomssuggest i
veofl i
verdysfunct
ion(e.
g.,
jaundi
ce,
anor exi
a,GIcompl ai
nts,ormal ai
se)andtoreportthem tophy si
cianimmediatel
y.

Cl
i
ent
/Fami
l
yEducat
ion

● Continuet ot aket hemedi cati

onev enthought hesy mptomshav enotsubsided.Thet herapeuti
cef fect
maynotbeseenf orasl ongas4weeks.I faftert hi
slengthoftimenoi mpr ovementi snoted,thephy sici
an
maypr escr ibeadi ffer
entmedi cati
on.
● Usecaut i
onwhendr i
vingoroper ati
ngdanger ousmachi nery.Drowsinessanddi zzinesscanoccur .If
thesesi deef f
ect sbecomeper sistentorinterf
er ewithacti
vit
iesofdailyli
ving,t
hecl ientshouldr eport
them tot hephy sician.Dosageadj ustmentmaybenecessar y.
● Notst opt akingt hedr ugabruptly.Todosomi ghtproducewi t
hdrawal symptoms, suchasnausea, v ert
igo,
i
nsomni a,headache, malai
se,andni ghtmares.
● Usesunbl ockl otionandwearpr otecti
veclothingwhenspendi ngt i
meout doors.Theski nmaybesensi tivet
o
sunbur n.
● Repor toccur renceofanyoft hef oll
owingsy mpt omst othephy si
cianimmedi ately:sorethroat,fever,
malaise, yell
owi shski n,unusualbleeding,easybr ui
sing,
persi
stentnausea/ vomi t
ing, sev
ereheadache,
rapidhear trate, diff
icul
tyuri
nat i
ng,anorexia/weightloss,sei
zureact i
vi
ty,sti
fforsor eneck, andchest
 pain.
● Risesl owlyf rom asi ttingorl yingposi tiont opr ev entasuddendr opi nbl oodpr essur e.
● Takef requentsi psofwat er,chewsugar lessgum, orsuckonhar dcandyi fdrymout hisapr oblem.Goodor alcare
(fr
equentbr ushi ng, f
lossi ng)i sv eryi mpor tant.
Av oidsmoki ngwhi l
er ecei vi
ngt ricy cli
ct her apy .
Smoki ngincr easest hemet abol i
sm oft ricy cli
cs, requi ri
nganadj ust menti ndosaget oachiev et het her apeutic
ef f
ect .
● Notdr inkal cohol whi l
et akingant idepr essantt her apy .Thesedr ugspot ent i
atetheef fectsofeachot her .
● Notconsumeot hermedi cations( includi ngov er -the-count ermedi cations)wi t
houtt hephy sician’s
appr ov alwhi ler eceivingant i
depr essantt her apy.Manymedi cat ionscont ai nsubst ancest hat, i
ncombi nationwith
antidepr essantmedi cat i
on, couldpr ecipitat eal ife- threateni nghy per tensi vecrisis.
● Not ifyphy siciani mmedi atelyifi nappr opr iateorpr olongedpeni leer ectionsoccurwhi letakingt razodone.I fthe
erectionper sist slongert han1hour ,seekemer gencyr oom t r
eat ment .Thi scondi ti
oni srare, buthasoccur r
edin
somemenwhohav et akent razodone.I fmeasur esar enoti nstitutedi mmedi ately,impot encecanr esul t.
● Not“ doubleup”onmedi cat i
oni fadoseofbupr opi on( Wel lbut rin)ismi ssed, unlessadv isedt odosobyt he
phy sician.Taki ngbupr opi onindi v i
deddoseswi l
l decr easet her i
skofsei zuresandot heradv erseef fect s.
● Followt hecor rectpr ocedur eforappl yingt hesel egi l
inet ransder mal pat ch:•Appl ytodr y,intactski nonuppert or
so,
uppert high,orout ersur faceofupperar m.•Appl yappr oximat el ysamet imeeachdayt onewspotonski n,aft
er
remov inganddi scardi ngol dpat ch.
Washhandst hor oughl yaf terappl yingt hepat ch.
Av oi
dexposi ngappl i
cationsi tetodi rectheat( e.g.heat ingpads, elect r
icbl anket s,heatl amps, hott ub,or
prolongeddi rectsunl i
ght ).
Ifpat chf allsof f,appl ynewpat cht oanewsi teandr esumepr eviousschedul e.
● Beawar eofpossi bler isksoft aki ngant idepr essant sdur i
ngpr egnancy .Saf eusedur ingpr egnancyandl actati
on
hasnotbeenf ullyest abl i
shed.Thesedr ugsar ebel ievedt or eadi l
ycr osst heplacent al barri
er ;i
fso, t
hef etuscould
exper ienceadv erseef f ectsoft hedr ug.I nf ormt hephy sici
ani mmedi atelyi fpregnancyoccur s, issuspect ed,oris
planned.
● Beawar eoft hesi deef fectsofant idepr essant s.
● Car ryacar dorot heri dent ifi
cationatal ltimesdescr ibingt hemedi cationsbei ngt aken.

MOODSTABI
LIZI
NGAGENTS

Formanyy ears,t
hedrugofchoicefort
reat
mentandmanagementofbipol
armaniawasli
thi
um carbonat
e.
However,i
nr ecentyears,anumberofinv
esti
gatorsandcl
ini
ciansinpr
act
icehav
eachi
evedsat
isf
actor
yresult
swith
sev
eralothermedi cat
ions,ei
theral
oneorincombinati
onwit
hl i
thi
um.

1.Ant
imani
c I
ndi
cat
ions Mechani
sm ofAct
ion Cont
rai
ndi
cat
ons

Lit
hium car
bonate Indicati
on: Prev
ention Notful
lyunderst ood,but Hy persensiti
vit
y.Cardiac
(Eskal
it
h,Li
thane;Li
thobi
d) andt reat
mentofmani c mayenhancer euptakeof orr enaldisease,
episodesofbipolar nor
epinephrineand dehy drati
on;sodium
disorder. ser
otonin,decreasingthe depl et
ion;brai
ndamage;
l
evel
sint hebody , pregnancyandl actat
ion.

resul
tingindecreased
Unl
abel
eduses: hyperacti
vit
y(mayt ake
1–3weeksf orsymptoms Caut i
onwi ththyroid
•Neut
ropeni
a tosubside). disorders,diabetes,ur
inar
y
retenti
on,historyof
•Clust
erheadaches seizures,andwi ththe
(pr
ophylaxi
s) elderl
y.

•Al
cohol
dependence

•Bul
i
mia

•Postpar
tum af
fect
ive
psychosi
s
 •Corti
cost
eroi
dinduced
psychosi
s

2.Ant
iconv
ulsant
s Epi
l
epsy Act
ioni
nthe Hy
per
sensi
ti
vi
ty.

•Tr
igemi
nal t
reat
mentof Wi
thMAOI
s,

a.Carbamazepi
ne neur
algi
a bi
pol
ardi
sor
deri
s l
act
ati
on.Caut
ion
(Tegr
etol
)
Unl
abel
eduses: uncl
ear
. wi
thel
der
ly,

•Bi
pol
ardi
sor
der l
i
ver
/renal
/car
diac

•Resi
stant di
sease,
pregnancy

schi
zophr
eni
a

•Managementof

al
cohol
wit
hdr
awal

•Rest
lessl
egs

sy
ndr
ome

•Post
her
pet
ic

neur
algi
a

b.Cl
onazepam (
Klonopi
n) Pet
itmal
,aki
net
ic, Act
ioni
nthe Hy
per
sensi
ti
vi
ty,

andmy
ocl
oni
c t
reat
mentof gl
aucoma,
li
ver

sei
zur
es bi
pol
ardi
sor
deri
s di
sease,
lact
ati
on.

•Pani
cdi
sor
der uncl
ear Caut
ioni
nel
der
ly,

l
i
ver
/renal
disease,

Unl
abel
eduses: pr
egnancy
.

•Acut
emani
c

epi
sodes

•Uncont
rol
l
edl
eg

mov
ement
sdur
ing

sl
eep

•Neur
algi
as

c.Val
proi
caci
d(Depakene; Epi
l
epsy Act
ioni
nthe Hy
per
sensi
ti
vi
ty;
Depakot
e) •Mani
cepi
sodes t
reat
mentof l
i
verdi
sease.

•Mi
grai
ne bi
pol
ardi
sor
deri
s Caut
ioni
nel
der
ly,

pr
ophy
laxi
s uncl
ear
. r
enal
/car
diac

•Adj
unctt
her
apyi
n di
seases,
pregnancy

schi
zophr
eni
a andl
act
ati
on.

d.Lamot
ri
gine(
Lami
ctal
) •Epi
l
epsy Act
ioni
nthe Hy
per
sensi
ti
vi
ty.

Unl
abel
eduse: t
reat
mentof Caut
ioni
nrenal

•Bi
pol
ardi
sor
der bi
pol
ardi
sor
deri
s andhepat
ic

uncl
ear i
nsuf
fi
ciency
,

pr
egnancy
,

l
act
ati
on,
and

chi
l
dren<16

y
ear
sol
d.

e.Gabapent
in(
Neur
ont
in; Epi
l
epsy Act
ioni
nthe Hy
per
sensi
ti
vi
tyand

Gabar
one) •Post
her
pet
ic t
reat
mentof chi
l
dren<3y
ear
s.

neur
algi
a bi
pol
ardi
sor
deri
s Caut
ioni
nrenal

Unl
abel
eduses: uncl
ear i
nsuf
fi
ciency
,

•Bi
pol
ardi
sor
der pr
egnancy
,

•Mi
grai
ne l
act
ati
on,
chi
l
dren,

pr
ophy
laxi
s andt
heel
der
ly.

•Neur
opat
hicpai
n

•Tr
emor
sassoci
ated

wi
thmul
ti
ple

scl
erosi
s

f
.Topi
ramat
e(Topamax) •Epi
l
epsy Act
ioni
nthe Hy
per
sensi
ti
vi
ty.

•Mi
grai
ne t
reat
mentof Caut
ioni
nrenal

pr
ophy
laxi
s bi
pol
ardi
sor
deri
s andhepat
ic

Unl
abel
eduses: uncl
ear i
mpai
rment
,

•Bi
pol
ardi
sor
der pr
egnancy
,

•Cl
ust
erheadaches l
act
ati
on,
chi
l
dren,
 •Bul
i
mia andt
heel
der
ly.

•Bi
ngeeat
ing

di
sor
der

•Wei
ghtl
ossi
n

obesi
ty

3.Cal
cium Channel •Angi
na Act
ioni
nthe Hy
per
sensi
ti
vi
ty;

Bl
ocker •Ar
rhy
thmi
as t
reat
mentof sev
erel
eft

Ver
apami
l(Cal
an; •Hy
per
tensi
on bi
pol
ardi
sor
deri
s v
ent
ri
cul
ar

I
sopt
in) Unl
abel
eduses: uncl
ear dy
sfunct
ion,
hear
t

•Bi
pol
armani
a bl
ock,
hypot
ensi
on,

•Mi
grai
neheadache car
diogeni
cshock,

pr
ophy
laxi
s congest
ivehear
t

f
ail
ure.Caut
ioni
n

l
i
verorr
enal

di
sease,

car
diomy
opat
hy,

i
ntr
acr
ani
al

pr
essur
e,el
der
ly

pat
ient
s,pr
egnancy

andl
act
ati
on.

4.Ant
ipsy
chot
ics •Schi
zophr
eni
a Al
lant
ipsy
chot
ics: Al
lant
ipsy
chot
ics:

a.Ol
anzapi
ne •Acut
emani
c Ef
fi
cacyi
n Hy
per
sensi
ti
vi
ty,

(
Zypr
exa) epi
sodes schi
zophr
eni
ais chi
l
dren,
lact
ati
on.

•Managementof achi
evedt
hrougha Caut
ionwi
th

bi
pol
ardi
sor
der combi
nat
ionof hepat
icor

•Agi
tat
ion dopami
neand car
diov
ascul
ar

associ
atedwi
th ser
otoni
nty
pe2 di
sease,
hist
oryof

schi
zophr
eni
aor (
5-HT2) sei
zur
es,
comat
ose

mani
a ant
agoni
sm. orot
herCNSdepr
essi
on,

Unl
abel
eduses: Mechani
sm of pr
ost
ati
c
 •Obsessi
vecompul
siv
e act
ioni
nthe hy
per
trophy
,

di
sor
der t
reat
mentofmani
a nar
row-
angl
e

i
sunknown. gl
aucoma,
diabet
es

orr
iskf
act
orsf
or

di
abet
es,

pr
egnancy
,el
der
ly

anddebi
l
itat
ed

pat
ient
s.

b.Ol
anzapi
neand •Fort
het
reat
mentof

f
luoxet
ine depr
essi
veepi
sodes

(
Symby
ax) associ
atedwi
th

bi
pol
ardi
sor
der

c.Ar
ipi
prazol
e •Bi
pol
armani
a

(
Abi
l
ify
) •Schi
zophr
eni
a

d.Chl
orpr
omazi
ne •Bi
pol
armani
a

(
Thor
azi
ne) •Schi
zophr
eni
a

•Emesi
s/hi
ccoughs

•Acut
eint
ermi
tt
ent

por
phy
ria

•Pr
eoper
ati
ve

appr
ehensi
on

Unl
abel
eduses:

•Mi
grai
neheadaches

e.Quet
iapi
ne •Schi
zophr
eni
a

(
Ser
oquel
) •Acut
emani
c

epi
sodes

f
.Ri
sper
idone •Bi
pol
armani
a

(
Risper
dal
) •Schi
zophr
eni
a

Unl
abel
eduses:
 •Sev
erebehav
ior
al

pr
obl
emsi
n

chi
l
dren

•Behav
ior
al

pr
obl
emsassoci
ated

wi
thaut
ism

•Obsessi
ve–

compul
siv
e

di
sor
der

g.Zi
prasi
done •Bi
pol
armani
a

(
Geodon) •Schi
zophr
eni
a

•Acut
eagi
tat
ioni
n

Schi
zophr
eni
a

Si
de/
Adv
erseEf
fect
sandNur
singManagement

Li
thium Toxicit
y
Themar gi
nbet weent hetherapeut icandt oxi clev el
sofl ithi
um carbonat eisv er
ynarrow.The
usualrangesoft herapeut i
cserum concent r
ationsar e:
Foracut emani a:1.0to1.5mEq/ L
Formai ntenance: 0.6t
o1.2mEq/ L
Serum li
thi
um lev el
sshoul dbemoni t
or edonceort wiceaweekaf terini
ti
altreatmentunt i
ldosageandser um levels
arestable,
thenmont hlydur i
ngmai ntenancet herapy .
Bloodsampl esshoul dbedr awn12hour saf t
erthel astdose.
Sympt omsofl i
t hium toxicit
ybegint oappearatbl oodl evelsgr eaterthan1.5mEq/ Landaredosagedet erminate.
Sympt omsi ncl
ude:
● Atser um levelsof1. 5t o2.0mEq/ L: blurr
edv ision,ataxia,ti
nni tus,persi
stentnauseaandv omiti
ng,severediarrhea.
● Atser um levelsof2. 0t o3.5mEq/ L: excessiveout putofdi luteur i
ne,increasingtremors,muscularir
ri
tabil
it
y ,
psychomot orret ardati
on, mentalconf usi
on, gi
ddi ness.
● Atser um levelsabov e3. 5mEq/ L:impai redconsci ousness, nystagmus, seizures,coma,
oli
guri
a/anur i
a,
ar rhythmi as,myocardial i
nfarct
ion, cardiov ascularcol l
apse.

Lithi
um l evelsshoul dbemoni tor
edpr iortomedi cationadmi nist
rat
ion.Thedosageshouldbewi thhel
dand
thephy si
ciannot ifi
edift helevelreaches1.5mEq/ Loratt heear li
estobserv
ationorr epor
tbythecl
ientofeventhe
mildestsy mpt om.I fleftuntreated,lit
hium toxicit
ycanbel if
et hreat
ening.
Lit
hi um issimilarinchemi calstructuretosodi um, behavingint hebodyi nmucht hesamemannerandcompet ingat
vari
oussi t
esi nthebodywi t
hsodi um.I fsodium i nt
akeisr educedort hebodyi sdepletedofit
snormalsodium (
e.g.
,
duet oexcessiv esweat ing,fever,ordiuresi
s),lit
hium isreabsor bedbyt heki
dneys,increasi
ngthepossibi
l
ityof
toxicity
.Ther efore,thecl i
entmustconsumeadi etadequat einsodi um aswellas2500t o3000mLoff lui
dperday .
Accur aterecor dsofi ntake,output,andcl i
ent’swei ghtshoul dbekeptonadai l
ybasis.

Si
deEf
fect
s Nur
singI
nter
vent
ions

Ant
imani
c 1.Drowsi
ness,
dizzi
ness, 1.Ensur
ethatcl
i
entdoesnotpar
ti
cipat
einact
ivi
ti
es
headache
Li
thi
um car
bonat
e t
hatr
equi
real
ert
ness,
oroper
atedanger
ous
(
Eskal
i
th,
Lit
hane, 2.Dr
ymout
h;t
hir
st machi
ner
y.

Li
thobi
d) 3.GIupset
;nausea/
vomi
ti
ng 2.Pr
ovi
desugar
lesscandy
,ice,
frequentsi
psofwat
er.

4.Fi
nehandt
remor
s Ensur
ethatst
ri
ctor
alhy
gienei
smai
ntai
ned.

5.Hypot
ensi
on;arr
hyt
hmi
as; 3.Admi
nist
ermedi
cat
ionswi
thmeal
stomi
nimi
zeGI
pul
seirr
egul
ari
ti
es
upset
.
6.Pol
yur
ia;
dehy
drat
ion
4.Repor
ttophy
sici
an,
whomaydecr
easedosage.
7.
Wei
ghtgai
n
Somephy
sici
anspr
escr
ibeasmal
ldoseofbet
a

bl
ockerpr
opr
anol
olt
ocount
eractt
hisef
fect
.

5.Moni
torv
ital
signst
woort
hreet
imesaday
.

Phy
sici
anmaydecr
easedoseofmedi
cat
ion.

6.Maysubsi
deaf
teri
nit
ial
weekort
wo.Moni
tordai
l
y

i
ntakeandout
putandwei
ght
.Moni
torski
ntur
gor

dai
l
y.

7.Pr
ovi
dei
nst
ruct
ionsf
orr
educedcal
ori
edi
et.

Emphasi
zei
mpor
tanceofmai
ntai
ningadequat
e

i
ntakeofsodi
um.

Ant
iconv
ulsant
s 1.Nausea/
vomi
ti
ng 1.Maygi
vewi
thf
oodormi
l
ktomi
nimi
zeGIupset
.

Cl
onazepam (
Klonopi
n) 2.Dr
owsi
ness;
dizzi
ness 2.Ensur
ethatcl
i
entdoesnotoper
atedanger
ous

Car
bamazepi
ne 3.Bl
ooddy
scr
asi
as machi
ner
yorpar
ti
cipat
einact
ivi
ti
est
hatr
equi
re

(
Tegr
etol
) 4.Pr
olongedbleedi
ngt
ime al
ert
ness.
(wi
thvalpr
oicacid)
Val
proi
caci
d(Depakene; 3.Ensur
ethatcl
i
entunder
standst
hei
mpor
tanceof
5.Ri
skofsever
erash(
wit
h
Depakot
e) l
amotri
gine) r
egul
arbl
oodt
est
swhi
l
erecei
vi
ngant
iconv
ulsant

Gabapent
in(
Neur
ont
in) 6.Decr
easedeff
icacywi
th t
her
apy
.
oral
contr
acept
ives(wi
th
Lamot
ri
gine(
Lami
ctal
) 4.Ensur
ethatpl
atel
etcount
sandbl
eedi
ngt
imear
e
t
opi
ramat
e)
Topi
ramat
e(Topamax) det
ermi
nedbef
orei
nit
iat
ionoft
her
apywi
thv
alpr
oic

aci
d.Moni
torf
orspont
aneousbl
eedi
ngorbr
uisi
ng.

5.Ensur
ethatcl
i
enti
sinf
ormedt
hatheorshemust

r
epor
tev
idenceofski
nrasht
ophy
sici
an

i
mmedi
atel
y.
 6.Ensur
ethatcl
i
enti
sawar
eofdecr
easedef
fi
cacyof

or
alcont
racept
iveswi
thconcomi
tantuse.

Cal
cium Channel 1.Dr
owsi
ness;
dizzi
ness 1.Ensur
ethatcl
i
entdoesnotoper
atedanger
ous

Bl
ocker 2.Hy
pot
ensi
on;
brady
car
dia machi
ner
yorpar
ti
cipat
einact
ivi
ti
est
hatr
equi
re

Ver
apami
l(Cal
an; 3.Nausea al
ert
ness.

I
sopt
in) 4.Const
ipat
ion 2.Takev
ital
signsj
ustbef
orei
nit
iat
ionoft
her
apyand

bef
oredai
l
yadmi
nist
rat
ionoft
hemedi
cat
ion.

Phy
sici
anwi
l
lpr
ovi
deaccept
abl
epar
amet
ersf
or

admi
nist
rat
ion.Repor
tmar
kedchangesi
mmedi
atel
y.

3.Maygi
vewi
thf
oodt
omi
nimi
zeGIupset
.

4.Encour
agei
ncr
easedf
lui
d(i
fnotcont
rai
ndi
cat
ed)

andf
iberi
nthedi
et.

Ant
ipsy
chot
ics 1.Dr
owsi
ness;
dizzi
ness 1.Ensur
ethatcl
i
entdoesnotoper
atedanger
ous

Ol
anzapi
ne(
Zypr
exa) 2.Dr
ymout
h;const
ipat
ion machi
ner
yorpar
ti
cipat
einact
ivi
ti
est
hatr
equi
re

Ar
ipi
prazol
e(Abi
l
ify
) 3.I
ncr
easedappet
it
e;wei
ght al
ert
ness.
gai
n
Chl
orpr
omazi
ne 2.Pr
ovi
desugar
lesscandyorgum,
ice,
andf
requent
4.ECGChanges
(
Thor
azi
ne) si
psofwat
er.Pr
ovi
def
oodshi
ghi
nfi
ber
;encour
age
5.Ext
rapy
rami
dal
Sympt
oms
Quet
iapi
ne(
Ser
oquel
) phy
sical
act
ivi
tyandf
lui
difnotcont
rai
ndi
cat
ed.
6.Hypergl
ycemi
aand
Ri
sper
idone(
Risper
dal
) di
abetes. 3.Pr
ovi
decal
ori
e-cont
rol
l
eddi
et;
prov
ideoppor
tuni
ty

Zi
prasi
done(
Geodon) f
orphy
sical
exer
cise;
prov
idedi
etandexer
cise

i
nst
ruct
ion.

4.Moni
torv
ital
signs.Obser
vef
orsy
mpt
omsof

di
zzi
ness,
pal
pit
ati
ons,
syncope,
orweakness.

5.Moni
torf
orsy
mpt
oms.Admi
nist
erpr
nmedi
cat
ion

atf
ir
stsi
gn.

6.Moni
torbl
oodgl
ucoser
egul
arl
y.Obser
vef
ort
he

appear
anceofsy
mpt
omsofpol
ydi
psi
a,pol
yur
ia,

pol
yphagi
a,andweaknessatanyt
imedur
ing

t
her
apy
 ANTI
PSYCHOTI
CAGENTS

Ant ipsychoticdrugsar ealsocalledmaj ortr

anquili
zersandneur olepti
cs.Theywerei nt
roducedintothe
Unit
edSt atesint he1950swi tht hephenot hiazi
nes.Otherdrugsi nthisclassifi
cati
onsoonf oll
owed.Sincethatti
mea
secondgener ationofmedi cationshasbeendev el
oped.Thef irstgenerati
on
anti
psychot i
csar ecall
ed“ t
ypical”andincludet hephenothiazines,haloperi
dol ,
loxapi
ne,molindone,
pimozi
de, andt hiothi
xene.Thesecond- gener ati
onantipsychoticsar ecal
led“ atypi
cal
”or“novel”anti
psychoti
csand
i
ncludear i
piprazole,cl
ozapine, ol
anzapine, quet
iapi
ne,ri
speridone, pal
iperi
done, andzipr
asidone.

Indi
cations
Antipsychot i
csar eusedi nthetreatmentofschizophreniaandotherpsychot
icdi
sorder
s.Select
edagent
s
areusedi nthetreatmentofbi polarmania( seeprevi
oussectionon“ mood-st
abil
izi
ngagents”
).Othersar
eusedas
antiemetics(chl
orpromazi ne,perphenazi
ne,prochlor
per
azine),
i
nt hetreatmentofi ntractablehiccoughs( chl
orpromazi
ne),andf ort
hecontrolofti
csandvocalutter
ancesi
n
Tour et
te’
sdisorder( haloperidol
,pimozide).

Act
ion
Theexactmechani sm ofactioni snotknown.Thesedr ugsar ethoughtt oworkbybl ocki
ngpostsynapti
c
dopaminer eceptorsint hebasal ganglia,hypothalamus,li
mbicsy stem, brai
nstem, andmedul l
a.Affi
nit
yalsoexist
s
forchol
iner gic,
adr energic,andhistami nicreceptors.Newermedicat ionsmayexer tant
ipsy
chot i
cpropert
iesby
blocki
ngact i
ononr eceptorsspecifictodopami ne,serot
onin,
andot herneurot
r ansmitt
ers,
includi
ngcholiner
gic,
adrener
gi c,andhi staminic.Ant i
psychot i
cef f
ectsmayal soberelatedt oinhi
biti
onofdopami ne-mediat
ed
transmissionofneur ali
mpul sesatthesy napses.

EXAMPLESOFANTI
PSYCHOTI
CDRUGS

Chemi cal Classes

Phenot hiazines:
Chlorpromazi ne( Thor azine)
,Fluphenazine( Proli
xi
n).Perphenazi
ne(
Tri
l
afon),Pr
ochlor
per
azine(Compazi
ne)
Thiori
dazi ne,Tr ifl
uoper azi
ne(St el
azi
ne)
Pheny l
but yl
pi peradines: Hal
operidol(
Hal dol)Pimozide(Orap)
Thioxanthene: Thiothixene( Nav ane)
Benzisoxazol esRi sper i
done(Risperdal)
.,Pal i
peri
done(Invega)
Dibenzepi nes: Loxapi ne( Loxi
tane),Cl
ozapi ne( Cl
ozari
l)
,Olanzapi
ne(
Zyprexa)
,Quet
iapi
ne(Seroquel
)
Dihydroindol ones: Mol indone(Moban) ,Ziprasidone(Geodon)
Quinoli
none: Ar i
piprazol e(Abil
ify)

Si
de/
Adv
erseEf
fect
sofAnt
ipsy
chot
icandNur
singManagement

1.Ant
ichol
i
ner
gicef
fect
s

a.Drymouth
Provi
dethecl
ientwi
thsugar
lesscandyorgum,ice,
andf
requentsi
psofwat
er.
Ensuret
hatcl
ientpr
act
icesstr
ictor
alhygi
ene.

b.Blurr
edvisi
on
Explai
nthatthi
ssymptom wil
lmostli
kelysubsideaf
teraf
ewweeks.
Adv i
secli
entnott
odriveacarunt
ilv
isi
oncl ears.
Clearsmalli
temsfrom pat
hwaytopreventfall
s.

c.Consti
pati
on
Orderfoodshi
ghi
nfi
ber
;encour
agei
ncr
easei
nphy
sical
act
ivi
tyandf
lui
dint
akei
fnotcont
rai
ndi
cat
ed.

d.Ur
inar
yretent
ion
I
nstr
uctcli
enttorepor
tanydi
ff
icul
tyur
inat
ing;
moni
tori
ntakeandout
put
.

2.Nausea;GIupset(mayoccurwithal
lcl
assi
ficati
ons)
Tablet
sorcapsulesmaybeadmi ni
steredwithfoodtominimizeGIupset.
Concentrat
esmaybedi l
utedandadmi ni
ster
edwi t
hfrui
tjui
ceorotherl
iqui
d;t
heyshoul
dbe
mixedimmediatelybef
oreadmini
str
ation.
3.Ski
nr ash( mayoccurwi t
hallcl
assi f
icati
ons)
Repor tappear anceofanyr ashonski ntot hephy sici
an.
Av oidspi l
li
nganyoft heli
qui dconcent rateonski n;contactder
mat i
ti
scanoccurwi thsomemedi cat
ions.
4.Sedation
Discusswi ththephysici
ant hepossi bil
ityofadmi nist
eringthedrugatbedtime.
Discusswi thphysici
anapossi bl
edecr easeindosageoranor derforal
esssedat i
ngdr ug.
Instructclientnottodriv
eoroper atedanger ousequi pmentwhi l
eexperi
encingsedation.
5.Ort
host atichy potension
Instructclienttori
seslowlyf rom alyingorsi t
tingposi t
ion
Moni torbl oodpressure(l
yingandst anding)eachshi ft;
documentandr eportsigni
fi
cant
changes.
6.Photosensi ti
vity(mayoccurwi thall cl
assif
ications)
Ensur et hatthecli
entwearsasunbl ockl oti
on,protecti
veclothi
ng,andsunglasseswhilespendi
ng
timeout doors.
7.Hormonal effects( mayoccurwi t
hal lcl
assi f
icati
ons, butmor ecommonwi tht
ypical
s)

a.Decreasedli
bido,r
etr
ogradeejacul
ati
on,gynecomast
ia(men)
Provi
deexplanationoft
heef f
ect
sandr eassuranceofr
eversi
bil
i
ty.I
fnecessar
y,di
scusswi
thphy
sici
an
possi
bili
tyoforderi
ngalt
ernatemedicat
ion.

b.Amenorrhea(women)
Off
erreassuranceofrev
ersi
bil
i
ty;i
nst
ructcl
i
entt
ocont
inueuseofcont
racept
ion,
becauseamenor
rheadoes
noti
ndicat
ecessationofovul
ati
on.

c.Weightgai
n(mayoccurwithal lcl
assif
icat
ions;
hasbeenprobl
ematicwit
htheatypicals)
Weighcli
entever
yotherday;ordercalori
econtrol
l
eddiet
;pr
ovideopport
uni
tyforphysical
exer
cise;pr
ovi
dedietandexerciseinstr
ucti
on.

8.ECGchanges.ECGchanges, incl
udingpr olongationoft heQTi nterval,ar
epossi blewi thmostofthe
anti
psychoti
cs.Thi sisparti
cularlytr
uewi thzi prasi
done, t
hiori
daz i
ne, pimozide,haloperidol
,and
pal
iperi
done.Caut ionisadv i
sedi nprescribingthismedi cati
ont oindividual
swi t
hahi storyofar
rhyt
hmias.
Conditi
onsthatpr oducehy pokalemiaand/ orhy pomagnesemi a,
suchasdi ureti
cther apyor
di
arrhea,shouldbet akenintoconsi derati
onwhenpr escri
bing.Rout i
neECGshoul dbet akenbefor
e
i
niti
ati
onoft herapyandper iodicall
ydur i
ngt herapy.
Monitorvitalsi
gnsev eryshift
.
Observef orsymptomsofdi zziness, palpi
tati
ons,syncope, orweakness.

9.Reduct
ionofseizurethr
eshold(morecommonwi ththetypicalst
hant heatypical
s,wit
htheexcepti
onofcl
ozapi
ne)
Closel
yobservecli
entswithhi
storyofseizures.
NOTE: Thisi
sparti
cularl
yimport
antwithclientst
akingclozapine(Clozari
l)
,wit
hwhichseizur
eshavebeen
fr
equentlyassoci
ated.Doseappearstobeani mportantpr
edictor,wit
hagr eat
erli
kel
ihoodofsei
zur
es
occurri
ngathigherdoses.Ext
remecautioni sadvi
sedi nprescri
bingclozapi
neforcli
entswit
hahist
oryof
seizur
es.

10.Agr
anul ocytosis(mor ecommonwi t
hthet ypicalsthanwi t
ht heatypicals,witht heexceptionofcl ozapi ne)
Itusual l
yoccur swi thint
hef i
rst3mont hsoft reatment .
Obser vef orsy mpt omsofsor ethroat,fever,mal aise.Acompl etebloodcountshoul dbemoni toredi fthese
sy mptomsappear .
EXCEPTI ON: Ther eisasignifi
cantriskofagr anul ocy t
osiswithcl ozapine( Clozari
l)
.Agr anul
ocy tosi sisa
pot enti
allyfatal blooddisorderinwhi cht hecl i
ent’swhi t
ebloodcel l(
WBC)countcandr optoext remel ylow
l
ev els.Abasel i
neWBCcountandabsol ut eneutrophi lcount(ANC)mustbet akenbef oreini
tiationof
treatmentwi t
hcl ozapineandweekl yf orthef ir
st6mont hsoft r
eatment .Onl ya1-week’ ssuppl yof
medi cationisdi spensedatat i
me.Ift hecount sr emai nwithintheaccept ablelevel
s( i
.e.,
WBCatl east
3500/ mm3andt heANCatl east2000/ mm3)dur ingthe6- mont hperiod,bl oodcount smaybemoni t
ored
biweekl y,anda2- weeksuppl yofmedi cat i
onmayt henbedi spensed.I fthecount sremai nwi thint he
accept ablelev el f
ort he
biweekl yper i
od, count smayt henbemoni tored every4weekst hereafter.Whent hemedi cat i
oni s
discont i
nued, weekl yWBCcount sarecont i
nuedf oranaddi t
ional 4weeks.

11.Hy
per
sali
vat
ion(mostcommonwi thclozapine)
Asigni
fi
cantnumberofcli
entsrecei
vingclozapi
ne(
Cloz
aril
)ther
apyexper
ienceext
remesal
iv
ation.
Off
ersupportt
othecli
entbecausethismaybeanembar rassi
ngsit
uati
on.Itmayevenbeasafetyi
ssue
 (e.
g.,ri
skofaspi
rat
ion)i
ftheprobl
em i
sver
ysevere.
Managementhasi ncl
udedtheuseofsugar
-f
reegum toincreasetheswal
l
owingrat
e,aswel
lasthe
prescri
pti
onofmedicati
onssuchasananti
chol
inergi
c(e.g.
,scopolami
nepat
ch)or2-adr
enoceptoragoni
st
(e.
g.,cl
onodi
ne).

12.Ext
rapy
ramidal
symptoms(
EPS)
Obser
veforsy
mptomsandr
epor
t;admi
nist
erant
ipar
kinsoni
andr
ugs,
asor
der
ed(
Tabl
e21–9)
.

a.Pseudoparkinsonism (
tremor
,shuffl
inggai
t,
drool
ing,ri
gidit
y)
Symptomsmayappear1t o5daysfoll
owinginiti
ati
onofant
ipsy
chot
icmedi
cat
ion;
occur
smost
oft
eninwomen, t
heelder
ly,anddehydrat
edclients.
b.Akinesia(muscularweakness)*Sameasf orpseudoparkinsoni
sm.

c.Akat
hisi
a(cont inuousr estl
essnessandf i
dgeti
ng) .Thisoccur smostf requent
lyi
nwomen;
sympt omsmayoccur50t o60day sfoll
owi ngi nit
iati
onoft her
apy.
d.Dyst
onia(involunt ar
ymuscul armov ement s[spasms]off ace,ar
ms, l
egs,andneck)
Thisoccur smostof teninmenandi npeopl ey oungert han25y earsofage.
e.Ocul
ogyri
ccr isis(uncontroll
edroll
i
ngbackoft heey es)
Thismayappearaspar tofthesy ndromedescr ibedasdy stonia.I
tmaybemi stakenf or
sei
zur eact ivi
ty.Dyst
oniaandocul ogy r
iccrisisshoul dbet r
eatedasanemer gencysi t
uati
on.
Thephy sicianshouldbecont acted,andi nt
rav enousbenzt ropi
nemesy l
ate(Cogentin)iscommonly
admi ni
st ered.Staywi t
htheclientandof ferreassur anceandsuppor tduri
ngthi
sf r
ighteningt
ime.

13.Tar
div
edyski
nesia[bizar
ref aci
alandt onguemov ement s,st
if
fneck,anddif
ficul
tyswall
owing](may
occurwi
thal
lcl
assif
icati
ons, butmorecommonwi thtypi
cal anti
psychoti
cs)
Allcli
entsreceivi
ngl ong-t
erm( monthsory ears)anti
psychot
ictherapyar
eatr i
sk.
Thesy mpt omsar epot enti
all
yir
rever
sible.
Thedr ugshoul dbewi thdrawnatthef i
rstsign,whichi
susuall
yv ermif
orm movementsoft
he
tongue; pr
omptact ionmaypr ev
entirr
ev er
sibil
it
y.

14.Neur
olepticmal i
gnantsy ndr ome( NMS)( mor ecommonwi t
ht hetypi
calsthanwi t
ht heat ypicals)
Thisisar el
at i
velyrare, butpot enti
allyf atal,
compl icationoft reatmentwithneur olepticdr ugs.
Routineassessment sshoul dincludet emper at ur eandobser vati
onforparkinsoniansy mpt oms.
Onsetcanoccurwi thinhour sorev eny earsaft erdr ugi ni t
iati
on,andprogressionisr apidov erthefoll
owing
24t o72hour s.
Sympt omsi ncludesev erepar kinsoni anmuscl er i
gidity, hyperpyr
exi
aupt o107° F,t achycar dia,
tachypnea,fluctuati
onsi nbloodpr essur e,diaphor esis,andr apiddeteri
orati
onofment al statustostuporand
coma.
Discont i
nueneur olept i
cmedi cationimmedi atel y.
Moni torvitalsigns, degreeofmuscl er igidit
y ,intakeandout put,l
evelofconsci ousness.
Thephy si
cianmayor derbr omocr i
ptine( Parlodel )ordantr
olene(Dant ri
um)t ocount er
actthe
effectsofneur olepticmal ignantsy ndr ome.

15.Hypergly
cemiaanddi abet es(mor ecommonwi that ypicals)
.Studi eshav esuggest edani ncr
easedr i
skof
tr
eatment-emergenthy perglycemi a-
relatedadv erseev ent sinclientsusi ngat ypicalantipsychoti
cs(e.
g.,r
isperi
done,
cl
ozepine,ol
anzapine, queti
api ne,zi
prasidone, pali
peridone, andaripiprazole).
Clientswithdi abetesst arti
ngonat y
pi cal anti
psychot icdrugsbemoni t
oredregular
ly
forwor seningofgl ucosecont rol.
Clientswithr iskfactorsf ordiabetesshoul dunder gof astingbl ood
glucoset est i
ngatt hebegi nningoft reatmentandper i
odicallythereafter.
Allclient
st akingthesemedi cat i
onsshoul dbemoni toredf orsy mptomsofhy per
glycemi a
(polydipsi
a, polyuri
a, polyphagia,andweakness) .Ifthesesy mpt omsappeardur i
ngtreatment,the
cli
entshoul dunder gof asti
ngbl oodgl ucoset esting.

16.Increasedriskofmor t
ali
tyinelderl
ypati
entswi thdementi
a-r
elat
edpsychosis.Recentstudieshave
i
ndicatedt hatelderlypatientswithdementia-r
elatedpsychosi
swhoar etr
eatedwithatypi
cal anti
psychot
ic
drugs( e.
g.,cl
ozapi ne,olanzapine,queti
api
ne,ri
speridone,pal
i
peri
done,zi
prasi
done,andaripiprazol
e)
areatincreasedr iskofdeat h,compar edwithplacebo.Causesofdeatharemostcommonl yr el
ated
toinfecti
onsorcar diovascularprobl
ems.

Cl
i
ent
/Fami
l
yEducat
ion
● Usecaut i
onwhendr ivingoroper at i
ngdanger ousmachi ner y.Dr owsi nessanddi zzi nesscanoccur .
● Notst opt akingt hedr ugabr upt lyaf terlong- ter m use.Todosomi ghtpr oducewi t hdr awal sy mpt oms,
suchasnausea, v omi ting, di zziness, gast rit
is,headache, t
achy car dia, i
nsomni a,t remul ousness.
● Usesunbl ockl ot i
onandwearpr ot ectivecl othingwhenspendi ngt i
meout door s.Ski ni smor e
suscept i
bl et osunbur n, whi chcanoccuri nasl ittl
eas30mi nut es.
● Repor tweekl y( ifr eceiv ingcl ozapi net herapy )t ohav ebl oodl evelsdr awnandt oobt ainaweekl y
suppl yoft hedr ug.
● Repor ttheoccur renceofanyoft hef ol l
owi ngsy mpt omst ot hephy siciani mmedi at ely:soret hroat,
fever,mal aise, unusual bleedi ng, easybr uising, per si
st entnauseaandv omi ti
ng, sev ereheadache,
rapidhear tr ate,diff i
cult yur inat ing, muscl et witchi ng,tremor s, dar klycol oredur ine, excessi v eur inati
on,
excessi v et hir
st ,
excessi vehunger , weakness, pal est ools, yellowski norey es, muscul ari ncoor di
nation,
orski nr ash.
● Ri
sesl owl yf r
om asi t
tingorl yingposi ti
ont opr ev entasuddendr opi nbl oodpr essur e.
● Takef requentsi psofwat er ,chewsugar lessgum, orsuckonhar dcandy ,ifdrymout hi sapr obl em.
Goodor al care( frequentbr ushi ng, fl
ossi ng)i sv er yimpor tant .
● Consul tt hephy si cianr egar dingsmoki ngwhi l
eonneur olept i
ct her apy .Smoki ngi ncr easest he
met abol ism ofneur olept ics, requi ri
nganadj ust menti ndosaget oachi ev eat her apeut icef fect .
● Dresswar ml yincol dweat her ,andav oidext endedexposur et ov eryhi ghorl owt emper atures.Body
temper atur eishar dert omai nt ainwi t
ht hismedi cat i
on.
● Notdr inkal cohol whi leonneur olept i
ct her apy.Thesedr ugspot ent i
at eeachot her ’
sef f
ect s.
● Notconsumeot hermedi cat ions( includingov er -the-count erpr oduct s)wi t
houtt hephy sician’sappr oval
.
Manymedi cationscont ainsubst ancest hati nt eractwi thneur olept i
csi nawayt hatmaybehar mf ul
.
● Beawar eofpossi bler i
sksoft aki ngneur olepticsdur ingpr egnancy .Saf eusedur ingpr egnancyhasnot
beenest ablished.Neur olept i
csar et houghtt or eadi l
ycr osst hepl acent albarrier; ifso, afet uscoul d
exper i
enceadv erseef f ect soft hedr ug.I nfor mt hephy siciani mmedi atelyifpr egnancyoccur s,is
suspect ed, orispl anned.
● Beawar eofsi deef fect sofneur olept i
cdr ugsf orsaf esel f-admi nistration.
● Continuet ot aket hemedi cat ion, ev eni ffeel i
ngwel landast houghi tisnotneeded.Sy mpt omsmay
returni fmedi cat ioni sdi scont i
nued.
● Carryacar dorot heri dent ificat ionatal ltimesdescr i
bingmedi cat i
onsbei ngt aken.

SEDATI
VE/
HYPNOTI
CS

I
ndicati
ons
Sedativ
e-hypnoti
csareusedintheshort-t
erm managementofvar
iousanxiet
ystat
esandt otr
eat
i
nsomni a.Selectedagentsareusedasanticonvul
sants(mephobar
bit
al,
pentobar
bital
,andphenobarbi
tal
)and
pr
eoperat i
vesedat i
ves(pent
obarbi
tal
,secobarbi
tal
)andtoreduceanxi
etyassoci
atedwithdrugwit
hdrawal(chl
oral
hydrat
e).

Act
ion
Sedat
ive-
hypnot
icscausegener
ali
zedCNSdepressi
on.Theymaypr
oducet
oler
ancewi
thchr
oni
c
useandhav
ethepotenti
alf
orpsychol
ogi
calorphy
sical
dependence.

EXCEPTION: Ramelteon(
Rozer
em)isnotacontr
oll
edsubstance.Itdoesnotproducetol
eranceorphy
sical
dependence.Sleep-
promoti
ngpr
opert
iesar
etheresul
toframelteon’sagoni
stacti
vit
yonselecti
vemelat
oni
n
recept
ors.

Contraindicati
ons/Precauti
ons
Sedati
ve-
hypnoticsarecont r
aindicatedinindividualswi t
hhy per
sensi t
ivi
tytothe
drugort oanydr ugwi t
hinthechemi calclass;inpregnancy( exceptionsmaybemadei ncertai
ncasesbasedon
benefit-
to-ri
skrati
o);
lactati
on;andinsev erehepat i
c,cardiac, r
espiratory,
orr enaldisease.
Cauti
onshoul dbeusedi nadmi ni
steringthesedr ugstocl ientswithcar diac,hepatic,r
enal,
orrespir
ator
y
i
nsufficiency.Theyshouldbeusedwi thcaut i
oninclientswhomaybesui cidalorwhomayhav ebeenaddict
edto
drugspr eviousl
y.Hypnoticuseshoul dbeshor tt
erm.Elderlyclientsmaybemor esensiti
vetoCNSdepr essantef
fect
s,
anddosager educti
onmayber equired.

Bar
bit
urates
Amobarbit
al(Amy t
al)
Butabar
bit
al(Buti
sol)
Mephobarbit
al(Mebaral
)
 Pentobarbi
tal(Nembutal
)
Phenobarbit
al(Luminal
)
Secobarbit
al(Seconal
)

Benzodi
azepines
Est
azolam (ProSom)
Fl
urazepam (Dalmane)
Quazepam (Doral)
Temazepam (Rest or
il
)
Tri
azolam (
Halcion)

Mi
scel
l
aneous
Chloralhydrat
e( Noctec)
Zaleplon(Sonata)
Zolpidem (Ambien)
Eszopiclone(Lunesta)
Ramel teon(Rozerem)

NOTE:Ref
ert
othedi
scussi
onant
i-
anxi
etydr
ugsf
ort
henur
singmanagementf
ort
hesi
deef
fect
sofsedat
ive
hy
pnot
ics.

AGENTSFORATTENTI
ON-DEFI
CIT/
HYPERACTI
VITY
DI
SORDER(ADHD)

Indi
cations
Themedi cationsi nthi
ssectionar eusedforADHDi nchildr
enandadults.CNSst i
mul antsi
ncreaselev
elsof
neurotransmi tters(probabl ynorepi
nephrine,dopamine, andser otoni
n)
i
nt heCNS.Theypr oduceCNSandr espir
at or
ystimulati
on, dil
atedpupil
s,i
ncreasedmot oractivi
tyand
ment alalertness, di
mi nishedsenseoff atigue,andbrighterspiri
ts.Thei
racti
onint hetreatmentof
ADHDi suncl ear.
Atomoxet i
nei nhibit
sthereuptakeofnor epi
nephr ine,
andbupr opi
onblockst heneur onaluptakeof
serotonin,norepinephrine, anddopami ne.Theexactmechani sm bywhi chthesedrugspr oducet hetherapeut
iceff
ect
i
nADHDi sunknown.Theyar enotCNSst imulants.

Cont raindications/ Precaut ions

CNSst imulant sar econt raindi catedini ndividual swithhy persensi tiv
ityto
sympat homi met i
cami nes.Theyshoul dnotbeusedi nadv ancedar teriosclerosis,cardiov asculardisease,
hyper tension,hy perthyroidism, gl aucoma, agi
tatedorhy perexcitabil
it
yst ates, incli
ent swi thahi storyofdr ugabuse,
duringorwi t
hin14day sofr eceiv i
ngt her apywithMAOI s,inchi l
drenyoungert han3y ear sofage, andi npr egnancy
andl act ati
on.
Atomoxet i
neandbupr opi onar econt raindicat edi nclientswithhy persensiti
v i
tytot he
drugsort heircomponent s,inlact at ion, andinconcomi tantusewi t
h,orwi thin2weeksofusi ngMAO
i
nhibitor s.Atomoxet i
nei scont r
ai ndi catedi ncli
ent swi t
hnar row- anglegl aucoma.Bupr opioni scont raindicatedin
i
ndiv i
dual swi thknownorsuspect edsei zuredisorder ,acut ephaseofmy ocar diali
nfarction, andincl ientswi th
buli
mi aoranor exianer vosa.
Cautioni sadv isedi nusi ngCNSst imulant sinchi l
drenwi thpsy chot i
cdi sorders; inTour ett
e’sdi sorder;i
n
cl
ient swi thanor exi
aori nsomni a; inel der l
y,debili
tated, orast henicclients; andi ncli
ent swi thahi storyofsui cidalor
homi cidal tendenci es.Pr olongedusemayr esultint olerance
andphy sical orpsy chol ogical dependence.
Useat omoxet ineandbupr opioncaut i
ousl yincl i
entswi thuri
nar yr etenti
on; hyper tensi
on; hepat ic,r
enal,or
cardiov asculardi sease; sui cidalcl ients; pregnancy ;andel derlyanddebi li
tatedcl i
ents.

Si
de/
Adv
erseEf
fect
sandnur
singmanagement
1.Oversti
mul ation, r
est lessness, insomni a( CNSst i
mul ants)
Assessment al st atusf orchangesi nmood, lev elofact iv
ity ,degr eeofst i
mul ation, andaggr essiveness.
Ensur et hatt hecl ienti spr ot ect edf rom i njur y .
Keepst imul ilowandenv ironmentasqui etaspossi blet odi scour ageov ersti
mul at i
on.
Topr ev enti nsomni a, admi ni stert hel astdoseatl east6hour sbef or ebedt ime.Admi nistersust ai
ned- release
formsi nt hemor ning.
2.Pal
pitations, t achy car di a( CNSst imul ant s; at omoxet ine;bupr opi on)
Moni torandr ecor dv ital si gnsatr egul arint erv als( twoort hreet i
mesaday )thr oughoutt her apy .Repor t
significantchangest ot hephy sici ani mmedi at ely.
NOTE:
TheFDAr ecent lyi ssuedwar ningsassoci at edwi t
hCNSst imul ant sandat omoxet i
neoft her iskf orsudden
deat hi npat ient swhohav ecar diov ascul ardi sease. Acar ef ul per sonal andf ami l
yhi storyofhear t
disease, hear tdef ect s, orhy per tensi onshoul dbeobt ainedbef or et hesemedi cat ionsar epr escr i
bed.Car eful
moni tor ingofcar di ov ascul arf unct iondur i
ngadmi nist
rat i
onmustbeongoi ng.
3.Anorexia,wei ghtl oss( CNSst imul ant s; atomoxet i
ne; bupr opion)
Tor educeanor exi a, themedi cat ionmaybeadmi nisteredi mmedi at elyaf t
ermeal s.Thecl ientshoul dbe
weighedr egul ar l
y( atl eastweekl y)whenr ecei vingt herapywi thCNSst i
mul ant s, atomoxet ine, orbupr opi on
becauseoft hepot ent ial foranor exi aandwei ghtl oss, andt empor aryinterrupt i
onofgr owthand
dev elopment .
4.Tol
erance, phy si cal andpsy chol ogi cal dependence( CNSst imul ant s)
Toler ancedev elopsr api dly .
Inchi ldr enwi thADHD, adr ug“ hol iday ”shoul dbeat tempt edper iodi cal l
yunderdi recti
onoft hephy siciant o
deter mi net heef fect i
v enessoft hemedi cat i
onandt heneedf orcont inuat i
on.
Thedr ugshoul dnotbewi thdr awnabr upt l
y.Todosocoul di nitiatet hef oll
owi ngsy ndromeof
sympt oms: nausea, vomi ting, abdomi nal cr ampi ng, headache, fat i
gue, weakness, mental depr ession, suicidal
ideat i
on, i
ncr easeddr eami ng, andpsy choticbehav ior.
5.Nauseaandv omi ting( atomox et ineandbupr opion)
Maybet akenwi thf oodt omi nimi zeGIupset .
6.Constipation( at omoxet ineandbupr opi on)
Increasef iberandf l
ui di ndi et ,ifnotcont raindi cat ed.
7.Potentialforsei zur es( bupr opi on)
Prot ectcl ientf rom i nj uryi fsei zur eshoul doccur .
Instructf ami l
yandsi gni ficantot her sofcl ient sonbupr opiont her apyhowt opr ot ectclientdur i
nga
seizur ei foneshoul doccur .Ensur et hatdosesoft hemedi cat i
onar eadmi nister edatl east4t o6hour sapar t
.
8.Severel i
verdamage( wi that omoxet ine)
Moni torf ort hef ol lowi ngsi deef fect sandr epor tt ophy si
ci ani mmedi ately:it
chi ng, darkur i
ne, r
ightupper
quadr antpai n, yel lowski norey es, sor ethr oat , fever ,
mal aise.
9.Neworwor senedpsy chi at ricsy mpt oms( wi thCNSst i
mul antsandat omoxet ine)
Moni torf orpsy chot icsy mpt oms( e.g. ,hear ingv oices,par anoi dbehav iors,del usions)
Moni torf ormani csy mpt oms, incl udi ngaggr essi veandhost il
ebehav iors

Cl
i
ent
/Fami
l
yEducat
ion

● Usecaut ioni ndr ivi

ngoroper ati
ngdanger ousmachi nery.Dr owsiness, dizziness, andbl ur redv ision
canoccur .
● Notst opt akingCNSst i
mul antsabr uptly.Todosocoul dproduceser i
ouswi thdr awal sy mpt oms.
● Avoidt akingCNSst imul ant slateint hedayt opr eventinsomni a.Takenol at ert han6hour sbef or e
bedtime.
● Nott akeot hermedi cat ions( i
ncl
udi ngov er-the-counterdr ugs)wi thoutphy sician’sappr ov al.Many
medi cationscont ainsubst ancest hat ,i
ncombi nat i
onwi thagent sforADHD, canbehar mf ul.
● Diabeticcl ientsshoul dmoni torbloodsugart woort hreet imesadayorasi nst ructedbyt hephy sician.
Beawar eofneedf orpossi bleal t
erat i
oni ninsulinrequi r
ement sbecauseofchangesi nf oodi ntake,
weight ,andact ivity.
● Avoidconsumpt i
onofl ar geamount sofcaf feinatedpr oduct s(cof fee,t
ea, col as, chocol at e)
, ast hey
Mayenhancet heCNSst imul anteffect.
● Notifyphy siciani frestlessness, i
nsomni a,anor exia,ordrymout hbecomessev er eori fr apid, poundi ng
Heartbeatbecomesev ident .
● Repor tanyoft hef oll
owi ngsi deef fectstot hephy sicianimmedi at ely:
shor t
nessofbr eat h, chestpai n,jaw/leftarm pai n,fainti
ng, seizures, suddenv isionchanges,
weaknessononesi deoft hebody ,
slurredspeech, conf usion,it
ching, dar kur i
ne, ri
ghtupper
quadr antpai n,yellowski norey es,soret hroat,fever,mal aise, i
ncreasedhy peract i
v ity,believingthi
ngst
hat
ar enott rue,orhear ingv oices.
● Beawar eofpossibl
er i
sksoftaki
ngagentsforADHDdur ingpregnancy.Safeusedur i
ngpregnancy
andlactat
ionhasnotbeenest abli
shed.I
nformthephysici
animmedi atel
yifpregnancyissuspect
edor
planned.
● Beawar eofpotenti
alsideeff
ectsofagentsforADHDf orsaf
eself-admini
stration.
● Carryacardorotheridenti
fi
cati
onatallt
imesdescri
bingmedicationsbeingt aken.