PSYCHOPHARMACOLOGY – Do not allow one patient to carry medicine to
another.
Psychopharmacology is the study of drugs used to
treat psychiatric disorders.
• Medications that affect psychic function, behavior
or experience are called psychotropic medications.
• They have significant effect on higher mental
functions.
• Psychopharmacological agents are first line
treatment for almost all psychiatric ailments now a
days
• With the growing availability of a wide range of
drugs to treat mental illness, the nurse practicing in
modern psychiatric settings needs to have a sound
knowledge of the pharmacokinetics benefits &
potential involved, risks the of pharmacotherapy, as
well as & responsibility
DEFINITION OF PSYCHOTROPIC DRUGS
Psychotropic drug is any drug that has
primary effects on behavior, experience, or other
psychological functions (Logman Dictionary of
Psychology & Psychiatry).
Psychotropic or psychoactive drugs can
also be defined as chemical that affects the brain &
nervous system, alter feelings & emotions.
These drugs also affect the consciousness
in various ways. A broad range of these drugs is
used in emotional & mental illnesses
GENERAL GUIDELINES REGARDING DRUG
ADMINISTRATION IN PSYCHIATRY
• The nurse should not administer any drug unless
there is a written order. Do not hesitate to consult
the doctor when in doubt any medication.
• All medications given must be charted on the
patient‘s case record sheet.
• In giving medication:
– Always address the patient by name & make
certain of his identification.
– Do not leave the patient until the drug is
swallowed.
– Do not permit the patient to go to the bathroom
to take medication.
• If it is necessary to leave the patient to get water, do
not leave the tray within the reach of the patient.
• Do not force oral medication because of the danger
of aspiration. This is especially important in stuporous
patients.
• Check drugs daily for any change in color, odor &
number.
• Bottle should be tightly closed & labeled. Labels
should be written legibly & in bold lettering. Poison
drugs are to be legibly labeled & to be kept in separate
cupboard.
• Make sure that an adequate supply of drugs is on
hand, but do not overstock.
• Make sure no patient has access to the drug
cupboard
• Drug cupboard should always be kept locked when
not in use. Never allow a patient or worker to clean the
drug cupboard. The drug cupboard keys should not be
given to patients
PATIENT EDUCATION RELATED TO
PSYCHOPHARMACOLOGY
Nurses assess for drug side effects, evaluate desired
effects, & make decisions about prn (pro re neta)
medication.
• Nurses must understand general principles of
psychopharmacology & have specific knowledge
related to psychotropic drugs.
• Teaching patients can decrease the incidence of side
effects while increasing compliance with the drug
regimen.
SPECIFIC AREAS OF EDUCATION INCLUDE THE
FOLLOWING
1.Discussion of side effects: Side effects can directly
affect the patient‘s willingness to adhere to the
drug regimen. The nurse should always inquire
about the patient‘s response to a drug, both
therapeutic responses & adverse responses
2. Drug interactions: Patients & families must be taught
to discuss the effects of the addition of overthe-
counter drugs, alcohol & illegal drugs to currently
prescribed drugs.
3. Discussion of safety issues: Because some drugs,
such as tricyclic antidepressants, have a narrow
 therapeutic index, thoughts of self harm must be
discussed.
• Discuss on abruptly discontinued effects.
• Many psychotropic drugs cause sedation or
drowsiness, discussions concerning use of
hazardous machinery, driving must be reviewed

4.Instructions for older adult patients: Because older

individuals have a different pharmacokinetic profile
than younger adults, special instructions
concerning side effects & drug-drug interactions
should be explained.
5.Instructions for pregnant or breastfeeding patient: As
pregnant or breastfeeding patients have special
risks associated with psychotropic drug therapy,
special instructions should be tailored for these
individuals.
CLASSIFICATIONS OF PSYCHOTROPIC DRUGS
1.Antipsychotic agents
2.Antidepressant agents
3.Mood stabilizingdrug
4.Anxiolytics & hypnosedative
ANTIPSYCHOTIC AGENTS
• Antipsychotic agents are also known as neuroleptic,
major tranquillizers, or phenothaiazines.
• This group of drugs has a major clinical use in the
treatment of psychosis.
• Psychosis is a state in which a person‘s ability to
recognize reality to communicate & to relate to
others is severely impaired.
MODE OF ACTION
• Antipsychotic agents are thought to block the
dopamine receptors.
• Dopamine is a chemical which is released in the
brain & causes psychotic thinking.
• Increased production of dopamine transmits the
nerve impulses to the brainstem faster than normal.
This result in strange thoughts , hallucination &
bizarre behavior.
• Antipsychotics helps in blocking or reducing the
activity of dopamine.
• Antiemetic is another property of antipsychotic
agents. They are also used in hiccoughs
 PHARMACOKINETICS
• Antipsychotics when administered orally are
absorbed variably from the gastrointestinal tract,
with uneven blood levels.
• They are highly bound to plasma as well as tissue
proteins. Brain concentration is higher than the
plasma concentration.
• They are metabolized in the liver, & excreted
mainly through the kidneys. The elimination half-
life varies from 10 to 24 hours.
SIDE-EFFECTS
1) Extrapyramidal symptoms(EPS)
i. Neuroleptic-induced parkinsonism:- occur in 40%
of the patients presenting extrapyramidal
symptoms. There are two varieties of parkinsonia
symptoms:
a. Akinetic Form:-Appears in the first week of
characteristics of akinetic form administration of
antipsychotic drugs. The are: Difficulty in
masticating movements, weakness& muscle
fatigue.
b. Agitating Form of parkinsonian Symptoms
include:- Tremors at rest, rigidity & mask-like face.
Most characteristic features of parkinsonism are:-
 Rigidity of muscles
 Motor retardation
 Salivation
 Slurred Speech
 Mask like face
 Shuffling gait
ii. Akathisia:-
Akathisia occurs in 50% of all the patients
presenting extrapyrimidal symptoms. The common
characteristics: Restless ―walkingin
place‖.Difficulty in sitting still, or strong urge to
move aboutreferred to as
―Walkies& Talkies by haris .generally occurs after
two weeks of treatment. Before administering anti-
parkinsonian medication anxiety should be ruled
out.
iii. Dystonia:-
Dystonia occurs in 6% of total number of
patient‘s presenting EPS. The characteristic features
are: rapidly developing contraction of muscles of
the tongue, jaw, neck (producing torticollis) &
etraocular muscles. Combined torticolis &
extraocular spasm results in an oculogyric crisis in
which eyes looked upward, head is turned to one
side.
iv. Tardive Dyskinesia:- This occur termination or
reduction of the due to abrupt antipsychotic drug
after long-term-high-dose therapy. Tardive
dyskinesia is characterized by involuntary rhythmic,
stereotyped movements, protrusion of the tongue,
puffing of cheeks, chewing movements, involuntary
movements of extremities & trunk. These
symptoms occur in 3% of patients. Antipsychotics
should be stopped immediately. There is no
treatment, symptoms may appear for years. It is
irreversible.
v. Neuroleptic Malignant Syndrome (NMS):- This is
a complication of antipsychotic agents & is rare
usually fetal. Many develop within hours or after
years of continued drug use. Symptoms
hyperpyrexia, severe muscle rigidity,
consciousness,blood pressure include altered
changes, increased count of W.B.C. symptoms
appear suddenly when medication is started & can
persist for 10-14 days or longer. Symptomatic
treatment is given to patients.
2) Autonomic Nervous System:- Dry mouth,
blurred vision, constipation, urinary hesitance or
retention & under rare circumstances paralytic
ileus.
3) Cardio-Vascular:- Tachycardia, orthostatic
hypotension & reversible arrhythmias.
4) Blood or Hematopoietic:- Agrunulocytosis
(marked decrease in leukocytes system especially
with chlorpramozine) leucopenia, leukocytosis.
NURSE’S RESPONSIBILITY
Close observation, especially when the
antipsychotic are just started. The expected results
are reduction in aggressive hyperactive behavior &
disorganized thoughts. Look for the possible side-
effects.
Extrapyramidal reaction, i.e. Parkinsonism, akinesia,
akathisia, dystonia, & tardive dyskinesia. These
symptoms are reduced/treated with early
observation, reporting & use of anti-parkinsonion
or anticholinergic medication.
Observe drowsiness. Medicine should be
administered at bed time. Report if the drowsiness
persists for a very long time. The patient should be
advised not to drive & handle hazardous machinery
while taking antipsychotic drugs. Observe for sore
throat, fever due to agranulocytosis.
Record blood pressure of the patient on
antipsychotic drugs. If the BP is drops by 20 to30
mm of hg in the patient, immediate reporting &
intervention should be done.
Accurate route of medication- antipsychotic drugs
are not given subcutaneously unless specially
prescribed as they cause tissue irritation. These
drugs should be given deep IM.
have shown reduced levels of norepinephrine (NE)
& serotonin (5-HT) in the space between nerve
ending carrying message from one nerve cell to
another cause depression.
• Tricyclic antidepressants & MAO inhibitors
increase these neurotransmitters i.e.
norepinephrine & serotonin to the synaptic
receptors in the central nervous system. Tricyclic
inhibitors block the reuptake of NE & 5-HT & MAO
inhibitors block the action of MONOamine oxidize
in breaking down excess of NE & 5-HT at the
presynaptic neuron.

Dry mouth may be may be reduced by encouraging

the patient to rinse his or her mouth frequently.
Give a piece of lemon or chewing gum. Good oral
hygiene should also be maintained.

Blurred or impaired vision in the patient causes

anxiety & annonyance to him. The patient should
be encouraged to inform these symptoms
immediately.

The patient on antipsychotic drugs may have weight

gain. Weight record should be maintained. The
patient may be encouraged on a low salt & planned
caloric diet.

The patient may complain of gastric irritation. He

should be discouraged to take antacid as there will
be decreased absorption of antipsychotic drugs.

An intake output chart should be maintained

specially for male patients who are confined to bed
& have an enlarged prostate gland. Encourage at
least 2500 ml of liquid intake.

ANTIDEPRESSANTS AGENTS
Antidepressant agents are used in affective
disorders or disturbances mainly to treat depressive
disorders caused by emotional or environmental
stressors.
PHARMACOKINETICS
• Antidepressants are highly lipophilic & protein-
bound. The half-life is long & usually more than 24
hours.

Several groups of affective disturbances are • It is predominantly metabolized in the liver.

treatable by antidepressants. CONTRAINDICATION
MODE OF ACTION • Antidepressants are given with caution to
• Antidepressant drugs are classified as Tricyclics, patients with cardiovascular disorder because they
Tetracyclics & MAO inhibitors. Research studies cause arrhythmias.
• They increase symptoms of psychosis & mania in sore throat, fever, malaise, it should be
cases of manic-depressive psychosis. reported to the physician on duty.

• Drugs are given with caution to prevents with MOOD STABILIZING DRUGS
liver disorders.
Mood stabilizers are used for the treatment of
SIDE EFFECTS bipolar affective disorders. Some commonly used
mood stabilizers are:-
1) Autonomic side-effects: Dry mouth, constipation,
cycloplegia, mydriasis, urinary retention, orthostatic 1. Lithium
hypotension, impotence, impaired ejaculation,
2. Carbamazepine
delirium & aggravation of glaucoma.
3.Sodium Valproate
2) CNS effects:- Sedation, tremor & other
extrapyramidal symptoms, withdrawal syndrome, LITHIUM
seizures, precipitation of mania.
• Lithium is an element with atomic number 3 &
3) Cardiac side-effects:- Tachycardia, ECG changes, atomic weight 7.
arrhythmias, direct myocardial depression.
• It was discovered by FJ Cade in 1949, & is a most
4) Allergic side-effects:- Agranulocytosis, effective & commonly used drug in the treatment
cholestatic jaundice, skin rashes, systemic vasculitis. of mania.
5) Metabolic & endocrine side-effects:- weight gain MODE OF ACTION
6) Special effects of MAOI drugs:- Hypertensive The probable mechanisms of action can be:
crises, severe hepatic necrosis, hyperpyrexia.
• It accelerates presynaptic re-uptake & destruction
NURSE’S RESPONSIBILITY of catecholamines, like norepinephrine.
 Observation of the side-effects & • It inhibits the release of catecholamines at the
monitoring the changes noted are very synapse.
significant to prevent complications due to
antidepressant agents. • It decreases postsynaptic serotonin receptor
 Encourage the patient to take medicine at sensitivity. All these actions result in decreased
bed time due to a sedative effect. Dryness catecholamine activity, thus ameliorating mania.
of mouth to decrease.
 Give plenty of fluids orally. Lemonade or
chewing gum should be given. A few sips of
water also help the patient.
 Do not give medicine empty stomach as the
patient complains of nausea & vomiting.
 Accurate recording of intake & output of
the patient should be maintained to check
if he has retention of urine.
 If the patient complains of dizziness or light
headedness he/she should be encouraged
to get up slowly & sit in the bed before
standing. These symptoms may due to
orthostatic hypotension. PHARMACOKINETICS
 Accurate recording of vital signs like B.P. &
• Lithium is readily absorbed with peak plasma
pulse.
levels occurring 2-4 hours after a single oral dose of
 The nurse should be able to interpret the
lithium carbonate.
blood reports specially blood sugar level &
W.B.C. count. If the patient complains of
• Lithium is distributed rapidly in liver & kidney &
more slowly in muscle, brain & bone. Steady state
levels are achieved in about 7 days.
• Elimination is predominately via tubules & is
influenced by sodium balance. Depletion of sodium
can precipitate lithium toxicity.
DOSAGES
Lithium is available in the market in the form of the
following preparation:
– Lithium carbonate: 300mg tablet (eg. Licab);
400mg sustained release tablets (eg. Lithosun-SR).
– Lithium citrate: 300mg/5ml liquid. The usual
range of dose per day in acute mania is 900-
2100mg given in 2-3 divided doses. The treatment
is started after serial lithium estimation is done
after a loading dose of 600mg or 900mg of lithium
to determine the pharmacokinetics.
BLOOD LITHIUM LEVEL
• Therapeutic levels = 0.8-1.2 mEq/L (for treatment
of acute mania)
• Prophylactic levels = 0.6-1.2 mEq/L (for
prevention of relapse in bipolar disorder)
• Toxic lithium levels>2.0 mEq/L
SIDE EFFECTS
• Neurological: Tremors, motor hyperactivity,
seizures, neurotoxicity (delirium, abnormal
involuntary movements, seizures, coma).
• Renal: Polydipsia, polyuria, tubular enlargement,
nephritic syndrome.
• Cardiovascular: T-wave depression.
• Gastrointestinal: Nausea, vomiting, diarrhea,
abdominal pain & metallic taste.
• Endocrine: Abnormal thyroid function, goiter &
weight gain.
MANAGEMENT OF LITHIUM TOXICITY:-
• Discontinue the drug immediately.
• For significant short-term ingestions, residual
gastric content should be removed by induction of
emesis, gastric lavage adsorption with activated
charcoal.
• If possible instruct the patient to ingest fluids.
• Assess serum lithium levels, serum electrolytes,
renal functions, ECG as soon as possible.
• Maintenance of fluid & electrolyte balance.
• In a patient with serious manifestations of lithium
toxicity, hemodialysis should be initiated.
CONTRAINDICATION OF LITHIUM:-
• Cardiac, renal, thyroid or neurological
dysfunctions
• Presence of blood dyscrasias
• During first trimester of pregnancy & lactation
• Severe dehydration
• Hypothyroidism
• History of seizures
NURSE’S RESPONSIBILITY:-
• The pre—lithium work up: A complete physical
history, ECG, blood studies (TC, DC, FBS, BUN,
Creatinine, electrolytes) urine examination (routine
& microscopic) must be carried out. It is important
to assess renal function as renal side-effects are
common & the drug can be dangerous in an
individual with compromised kidney function.
Thyroid functions should also be assesses, as the
drug is known to depress the thyroid gland.
To achieve therapeutic ef ect &prevent lithium
toxicity,the following precaution should be taken:
• Lithium must be taken on a regular basis,
preferably at the same time daily (for example, a
client taking lithium on TID schedule, who forget a
dose should wait until the next scheduled time to
take lithium & not take twice the amount at one
time, because toxicity can occur).
• When lithium therapy is initiated, mild side-
effects such as fine hand tremors, increased thirst &
urination, nausea, anorexia etc may develop, Most
of them are transient & do not represent lithium
toxicity.
• Since polyuria can lead to dehydration with risk of
lithium intoxication, patients should be advised to
drink enough water to compensate for the fluid
loss.
• Various situations may require an adjustment in
the amount of lithium administered to a client,
such as the addition of the new medicine to the
client drug regimen, a new diet or an illness with
fever or excessive sweating. They must be advised
to consume large quantities of water with salts, to
prevent lithium toxicity due to decreased sodium
levels.=
• Frequent serum lithium level evaluation is
important. Blood for determination of lithium levels
should be drawn in the morning approximately 12-
14 hours after the last dose was taken.
• The patient should be told about the importance
of regular follow up. In every six months, blood
sample should be taken for estimation of
electrolytes, urea, creatinine, a full blood count &
thyroid function test.
CARBAMAZEPINE
• It is available in the market under different trade
names like Tegretol, Mazetol, Zeptol & Zen Retard.
MECHANISM OF ACTION
• Its mood stabilizing mechanism is not clearly
established. Its anticonvulsant action may however
be by decreasing synaptic transmission in the CNS.
INDICATIONS
• Seizures-complex partial seizures, GTCS, seizures
due to alcohol withdrawal.
• Psychiatric disorders- rapid cycling bipolar
disorder, acute depression, impulse control
disorder, aggression, psychosis with epilepsy,
schizoaffective disorders, borderline personality
disorder, cocaine withdrawal syndrome.
• Paroxysmal pain syndromes- trigeminal neuralgia
& phantom limb pain.
DOSAGE
• The average daily dose is 600-1800 mg orally, in
divided doses. The therapeutic blood levels are 6-
12 µg/ml. toxic blood levels are attained at more
than 13µg/ml.
SIDE EFFECTS
• Drowsiness, confusion, headache, ataxia,
hypertension, arrhythmias, skin rashes, steven-
Johnson syndrome, nausea, vomiting, diarrhea, dry
mouth, abdominal pain, jaundice, hepatitis,
oliguria, leucopenia, thrombocytopenia, bone
marrow depression leading to aplastic anemia.
NURSE’S RESPONSIBILITY
• Since the drug may cause dizziness & drowsiness
advise him to avoid driving & other activities
requiring alertness?
• Advise patient not to consume alcohol when he is
on the drug.
• Emphasize the importance of regular follow-up
visits & periodic examination of blood count &
monitoring of cardiac, renal, hepatic & bone
marrow functions.
SODIUM VALPROATE (ENCORATE CHRONO,
VALPARIN, EPILEX, EPIVAL) MECHANISM OF
ACTION
• The drugs acts on gamma- aminobutyric acid
(GABA) an inhibitory amino acid neurotransmitters.
GABA receptors activation serves to reduce
neuronal excitability.
INDICATION
• Acute mania, prophylactic treatment of bipolar-I
disorder, rapid cycling bipolar disorder.
• Schizoaffective disorder.
• Seizures.
• Other disorders like bulimia nervosa, obsessive-
compulsive disorder, agitation & PTSD.
DOSAGE
• The usual dose is 15 mg/kg/day with a maximum
of 60mg/kg/day orally.
SIDE EFFECTS
• Nausea, vomiting, diarrhea, sedation, ataxia,
dysarthria, tremor, weight gain, loss of hair,
thrombocytopenia, platelet dysfunction.
NURSE’S RESPONSIBILITY
 Explain to the patient to take the drug
immediately after food to reduce GI
irritation.
 Advise to come for regular follow-up &
periodic examination of blood count,
 hepatic function & thyroid function.
Therapeutic serum level of valproic acid is
50-100 micrograms/ml.

ANTIANXIETY AGENTS, INCLUDING SEDATIVES

AND HYPNOTICS

• Anxiety is a state which occurs in all human being

at sometime or the other.

• It is also a cardinal symptoms of many psychiatric

conditions.

• The drugs used to relieve anxiety are called

ANTIANXIETY OR ANXIOLYTIC AGENTS. Antianxiety
drugs relieve moderate-to-severe anxiety &
tension.

MODE OF ACTION

• These non-barbiturate benzodiazepines act as

CNS depressants.

• It is believed that these drugs increase or help the

inhibitory neurotransmitter action of gama-
aminobutyric inhibitor in all areas of CNS. So, there
is inhibition or control on the cortical & limbic
system of the brain, which is responsible for
emotions such as rage & anxiety.

INDICATIONS

• Antianxiety agents are used to relieve mild,

moderate & severe anxiety associated with:
emotional disorders

• For control of alcohol withdrawal symptoms.

• To control convulsions.

• To produce skeletal muscle relaxation.

• To provide short-term sleep preoperatively, prior

to diagnosis & insomnia.

CONTRAINDICATIONS

• Patients with renal or liver & respiratory

impairment are given antianxiety drugs with
caution.
 NURSE’S RESPONSIBILITY

 Assessment of the patient, prior to the use

of antianxiety, sedative-hypnotic agents. If
the patient complains of sleep disturbance
the causative factor should be identified.
 Appropriate nursing measures to induce
sleep should be taken such as a calm &
quite environment, a cup of hot milk, good
back care, allowing the patient to read
magazines, sitting with the patient for some
time for reassurance purpose.
 While administering the drug daily dose
should be given at bed time to promote a
normal sleep pattern, so that day-time
activities are not affected.
 Give IM injection
 Look for side-effects, record & report
immediately.
 If the patient complains of drowsiness tell
him to avoid using knife or any other
dangerous equipment. He should be
instructed not to drive.
 Instruct the patient not to take any
stimulant like coffee, alcohol as they alter
the effect of drugs.
 Avoid excessive use of these drugs to
prevent the onset of substance abuse or
addiction