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Psychotropic Drugs Mental Health Jene’ Hurlbut, RN, MSN, CFNP.

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Presentation on theme: "Psychotropic Drugs Mental Health Jene’ Hurlbut, RN, MSN, CFNP."— Presentation transcript:

1 Psychotropic Drugs Mental Health Jene’ Hurlbut, RN, MSN, CFNP

2 Objectives: Discuss the functions of the brain and the way this can be altered by the use of psychotrophic medications Discuss how the neurotransmitters are affected by various psychotrophic medications Discuss the application of the nursing process with various psychotrophic medications Identify specific cautions to be aware of the various psychotrophic medications

3 Psychotropic Drugs Locus of all mental activity is the brain Origin of psychiatric illness caused by many factors: Genetics Neurodevelopment factors Drugs Infections Psychosocial experiences, etc.

4 Psychotropic Drugs-continue Theories behind use of psychotropic drugs focuses on neurotransmitters and their receptors Psychotropic drugs act by modulating neurotransmitters Go to: Health: Nursing, activity #3503 (Psychotropic Medications and Neurotransmitters) Or try: online.com/objects/index_tj.asp?objID=NUR3503

5 Review: Cellular composition of brain Neurons-nerve cells that conduct electrical impulses Neurotransmitter-chemical that is released in response to an electrical impulse (neuromessenger). Attaches to a receptors on cell surface and either inhibits or excites Major target of psychotropic drugs See table 3-1 on pg. 40 !!!!

6 Use of psychotropic meds: Relieve or reduce s/s of dysfunctional thoughts, moods, or actions, & mental illness Improve client’s functioning Increase compliance to other therapies

7 Therapeutic Effects of Psychotropic Meds Do not “cure” Relieve or decrease symptoms Prevent or delay return of S/S Cannot be used as the sole tx for disorders Need informed consent before starting Are broad spectrum and have effects on a large number of S/S. Initial effects are sedative in nature May take weeks for effects to be seen

8 Reasons for Nonadherence: Meds are expensive Unpleasant side effects Feel better and decide no longer need Stigma associated with having a mental illness and taking meds Paranoia or fears about med usage

9 Services Encouraging Compliance to Medication Regimen: Follow-up appts. With client to verify that client understands the purpose, proper administration, intended effects, side and toxic effects of, and how to treat problems associated with meds Support persons can encourage and assist the client to comply with meds Appropriate lab tests must be conducted to prevent complications and assure correct levels of drugs Encourage clients to participate in med groups Can use injections of antipsychotics which will last from 2-4 weeks if clients are non-compliant

10 Efficacy of Psychotropics with Children & Elderly Use with great caution Start low and go slow for both elders and children!! Elders have decrease liver & renal function Risk of injuries and falls with elderly

11 Client & Family Teaching Purpose of the meds and benefits, side effects and how to treat SE. What S/S indicate a toxic effect, and how to treat, and whom to call. Specific instructions about how to take the meds

12 Psychotropic Meds Classifications: Antipsychotics (neuroleptics) Mood Stabilizers Antidepressants Anxiolytics (antianxiety) Sedatives Hypnotics Psychostimulants Antihistamines, antimuscarinics, dopamine agonists

13 Uses for Antipsychotics/Neuroleptics Schizophrenia Disorders Bipolar-Manic Phase Major Depression with psychotic features Tourette’s Syndrome Control of intractable hiccups Dementia, and Delusions Aggressive behavior

14 Antipsychotic Meds- Neuroleptics First generation: Phenothiazines= Thorazine, Mellaril, Stelazine, Prolixin (high potency) Non Phenothiazines= Haldol (butyrophenones) (high potency) Atypical Antipsychotics (2 nd and 3 rd gen)= Clozaril, Zyprexa, Risperdal, Geodon, Seroquel, Zeldox Invega, Abilify

15 First Gen Antipsychotic Meds Block predominantly dopamine activity little effect on serotonin High incidence of abnormal movements (Also blocks acetylcholine, norepinephrine to some degree) Blocks the H receptor for histamine results in sedation and weight gain

16 Side Effects of 1 st Gen Drugs Dystonia (EPS)=spasms of the eye, neck-torticollis, back, tongue-happens within 72 hrs. reversible. Akathisia (EPS)= restlessness Pseudoparkinson- S/S similar to Parkinson's-see in 1-2 weeks. May disappear. TX. With Cogentin Tardive Dyskinesia- bizarre facial and tongue movements- irreversible.

17 Other S/E of 1 st gen Antipsychotics Amenorrhea Galactorrhea Blurred vision, dry mouth, constipation and urinary retention, tachycardia- anticholinergic S/E Sexual dysfunction Severe dysrhythmias In men can lead to gynecomastia photosensitivity & skin rashes (i.e. haldol) Reduction is seizure threshold Orthostatic hypotension Agranulocytosis

18 Contraindications of Traditional Antipsychotics (1 st Gen): Blood dyscrasias Liver, renal, or cardiac insufficiency CNS depressants, including ETOH Tegretol in conjunction with antipsychotics causes up to 50% reduction in antipsychotic concentrations SSRI’s in conjunction with antipsychotics may cause sudden onset of EPS Don’t give if have: Parkinson's disease, prolactin dependent cancer of the breast Cigarette smoking causes reduced plasma concentrations of antipsychotics Luvox in conjunction with antipsychotics causes increased concentrations of Haldol and Clozaril Beta Blockers in conjunction with antipsychotics cause severe hypotension Antidepressants in conjunction with antipsychotics may cause increased antidepressant concentrations

19 First Generation Antipsychotic Meds Are useful in getting out of control behavior under control quickly. These can be given with lithium to get treat acute mania.

20 Atypical Antipsychotics Action: Blocks serotonin and to a lesser degree, dopamine receptors Also block receptors for norepinephrine, histamine, acetylcholine

21 Atypical Antipsychotics- 2 nd and 3 rd generation drugs Nicer drugs and are used more!! Decrease positive and negative S/S of Schizophrenia These drugs block serotonin as well as dopamine Incidence of abnormal movements is lower! Biggest SE is wt. gain

22 Positive & Negative S/S of Schizophrenia Positive: Hallucinations Delusions Abnormal thoughts Bizarre behavior Confused thoughts Negative: Blunted affect Poverty of speech Social withdrawal Poor motivation

23 Atypical Antipsychotics-2 nd and 3 rd generation: Clozaril (clozapine) low incidence of abnormal movements possible fatal side effect: bone marrow suppression & agranulocytosis (rare) Most common S/E: sedation & drowsiness, wt. gain Other S/E are: hypersalivation, tachycardia, & dizziness, seizure risk

24 Atypical Antipsychotics-2 nd and 3 rd generation: continue Risperidone Does not cause bone marrow suppression Can cause at higher doses motor difficulties Available as a long acting injection Can be used to tx. mania Seroquel (Quetiapine) S/E sedation, weight gain and headache Not associated with abnormal movements

25 Atypical Antipsychotics-2 nd and 3 rd generation: continue Zyprexa (olanzapine) does not cause bone marrow suppression Can cause weight gain & hyperglycemia Adverse effects-Drowsiness, insomnia restlessness Geodan (ziprasidone) Binds to multiple receptor sites Main S/E are hypotension & sedation Can prolong the QT interval-can be fatal if hx of cardiac arrhythmias Abilify (Aripiprazole) Dopamine stabilizer Partial agonist at the D2 receptor In areas of the brain with excess dopamine, it lowers dopamine In areas of low dopamine, it stimulates receptors to raise the dopamine level Main S/E are sedation, hypotension, and anticholinergic effects Adverse effects-headache, anxiety insomnia, GI upset

26 Contraindications for Atypical Antipsychotics: Known hypersensitivity CNS depression, including ETOH Blood dyscrasias in clients with Parkinson’s disease Liver, renal, or cardiac insufficiency Use with caution in diabetics, elderly, or debilitated SSRIs in conjunction with antipsychotics may cause sudden onset of EPS Cigarette smoking causes reduced plasma concentrations Tegretol (carbamazepine) in conjunction with antipsychotics causes up to 50% reduction in antipsychotic levels Luvox (fluvoxamine) in conjunction with antipsychotics causes increased concentrations of Haldol & Clozaril Beta Blockers in conjunction with antipsychotics cause severe hypotension Antidepressants in conjunction with antipsychotics may cause increased antidepressant concentrations

27 Antipsychotics Can be given be given as an IM injection (depot preparations) if have difficulty taking oral meds. Can use lower doses when given IM, so less risk of tardive dyskinesia

28 Neuroleptic Malignant Syndrome Rare, but fatal complication from all antipsychotic drugs See more with 1 st gen drugs Severe muscle rigidity High temp up to 107 Tachycardia Tachypnea Stupor Coma

29 Mood Stabilizers Used in the treatment of Manic (Bipolar) disorder, and in some forms of depression Drugs used Lithium and Antiepileptic Drugs

30 Lithium Mechanism of action unknown Interacts with sodium and K+ Alters electrical conductivity potential threat to all body functions that are regulated by electrical currents Can cause polyuria and polydipsa due to Na and K alterations Has the lowest therapeutic index of all psych drugs Have to monitor blood levels of this drug

31 Lithium Maintenance blood levels of lithium are usually mEq (toxicity occurs with levels > 1.5 mEq/L) Sign of toxicity is a fine intention tremor that becomes more pronounced and coarse. Risk of thyroid & kidney disease If toxic s/s occur discontinue the drug and notify health care provider Lithium should be taken with food Client must eat a balanced diet with normal sodium intake and take in adequate fluid (about 2- 3 liters/day). Excretion is dependent on this. Dehydration and salt restriction can increase lithium levels & cause toxicity. Takes 2-3 weeks for lithium to become effective (may use antipsychotic until therapeutic levels are reached)

32 Signs & symptoms of lithium toxicity: Fine hand tremors that progress of coarse tremors Mild GI upset progressing to persistent upset Slurred speech and muscle weakness progressing to mental confusion Severe Toxicity: decrease level of consciousness to stupor and finally coma Seizures, severe hypotension, severe polyuria with dilute urine

33 Lithium: Lithium serum concentrations are increased by fluoxetine (Prozac), ACE inhibitors, diuretics, and NSAIDs Lithium serum concentrations are decreased by theophylline, osmotic diuretics, and urine alkalinizers

34 Contraindications for Lithium: Renal disease Cardiac disease Severe dehydration Sodium depletion Brain damage Pregnancy or lactation Use with caution in the elderly or clients with diabetics, thyroid disorders, urinary retention, and seizures

35 Anticonvulsants/Antiepileptic Drugs Causes an increase in GABA in the CNS-which causes a decrease in anxiety. Reduce the mood swings with bipolar

36 Anticonvulsants/Antiepileptic Drugs Tegretol (carbamazepine)-also used to treat severe pain (i.e. trigeminal neuralgia) Depakote (valproic acid)-can cause hepatic failure, pancreatitis, & thrombocytopenia. Watch for liver failure Klonopin (clonazepam) Lamictal (Lamotrigine)-can have a rare but fatal dermatological condition

37 Toxic Effects of Anticonvulsants: Tegretol can cause agranulocytosis and aplastic anemia Depakote can cause liver dysfunction, hepatic failure, and blood dyscrasias including thrombocytopenia Depakote interacts with drugs that are hepatically metabolized

38 Contraindications for Anticonvulsants : Hepatic or renal disease Pregnancy Lactation Presence of blood dyscrasias

39 Unique teaching needs with anticonvulsants: Monitor blood levels of mood stabilizers to prevent toxicity Monitor liver, renal function tests and CBCs Depakote must be swallowed whole, not cut, chewed, or crushed to prevent irritation

40 Antidepressants Tx of depressive moods, including bipolar disease 4 categories: Tricyclics MAOI’s SSRI’S Atypical Antidepressants

41 Antidepressant Drugs Tricyclics- Elavil, Tofranil SSRI’s-Zoloft, Paxil MAOI’s- Nardil, Parnate, Marplan

42 Atypical Antidepressants Inhibits selective reuptake of serotonin: Trazodone (desyrel) Norepinephrine Dopamine Reuptake Inhibitor (NDRI): Wellbutrin (Bupropion) Serotonin & norepinephrine reuptake inhibitor: Cymbalta (duloxetine) Sertonin Norepineprine Reuptake Inhibitor- (SNRI): Effexor (venlafaxine) Increases release of serotonin & norepinephrine : Remeron (mirtazapine)

43 Atypical Antidepressants Trazodone= alternative to TCA’s Can cause orthostatic hypotension, sedation, & priapism in males Remeron= causes sedation, weight gain, dry mouth, constipation Wellbutrin (zyban)= rarely causes sedation, wt. Gain, or sexual dysfunction. Used for smoking cessation. Most common S/E are headaches, insomnia & nausea Can lower seizure threshold –causes seizures

44 Atypical Antidepressants: serotonin norepinephrine reuptake inhibitor (SNRI): SNRI-blocks uptake of serotonin and norepinephrine Good for clients with anxiety also SE=sexual dysfunction, insomnia, agitation Skipping 1 dose can cause withdrawal S/S Drug here is Effexor & Cymbalta Very effective in treating severe depression

45 Major Indications for Antidepressants Major Depressive disorder Bipolar depression Obsessive- Compulsive Anxiety Panic disorder PTSD Substance Abuse Chronic Pain Tourette’s Disorder ADHD Eating disorders Sleep disorders Migraines Enuresis

46 Tricyclics: Elavil, Pamelor, Tofranil, Anafranil, Aventyl, Asendin, Sinequan Blocks the reuptake of norepinephrine and sertonin Tricyclic drugs block the muscarine receptors (so anticholinergic effects) Other side effects: orthostatic hypotension sedation wt. gain confusion-esp. elderly arrhythmias

47 Tricyclics Contraindications Do not mix with ETOH (none of the psych drugs should be mixed with ETOH) Dementia Suicidal clients Cardiac disease Pregnancy Seizure disorders Urinary retention Dose for elderly should be ½ of adult dose TCA’s and MAOIs are effective in tx. depression are not as safe or as well tolerated as the newer antidepressants Toxic Effects: possibility of cardiac toxicity and are toxic in overdose

48 SSRI’s Prozac, Zoloft, Paxil, Celexa, Luvox, Serzone, Lexapro Action-blocks the reuptake of sertonin into the neuron Side-effect: biggest is sexual dysfunction & wt. gain Contraindication: Cardiac dysrhythmias

49 SSRI’s Are very safe and are not lethal in overdose Good choice with the elderly-very few side effects If used with MAOI’s may cause Serotonin Syndrome=seizure, death If used with TCA’s may cause TCA toxicity Takes 2 weeks to feel effects

50 MAOI’s Nardil, Parnate, Marplan Inhibits MAO, thus interfering with breakdown of norepinephrine, dopamine, and serotonin Toxic effects= hypertensive crises Avoid foods with tyramine (aged cheese, red wine, beer, chocolate, etc.) MAOI’s don’t play well with other drugs!!

51 Antianxiety/Anxiolytic Drugs GABA exerts an inhibitory effect on neurons These drugs enhance this effect and produce a sedative effect Therefore reduce anxiety The most common used drugs here are the Benzodiazepines

52 Benzodiazepines Valium, Xanax, Ativan, Librium, Klonopin, Serax Dalmane, Halcion (used as sleep aides mostly- short term!!) Used for anxiety, panic disorders, ETOH withdrawal, muscle spasm, sedation, insomnia, and epileptics/seizures Use only short term because of dependency issues Avoid ETOH Causes sedation-don’t drive!!

53 Benzodiazepines Side Effects; Drowsiness, confusion, sedation, and lethargy Toxic Effects; Respiratory depression esp. with ETOH use! Contraindications; Combination with other CNS depressants Renal or hepatic dysfunction History of drug abuse or addiction Depression and suicidal tendencies Teaching; Use short term due to drug dependency issues Avoid ETOH and other CNS depressants Can impair ability to drive Do not use with someone who has a hx of drug dependency D’C meds can cause withdrawal s/s

54 Nonbenzodiazepine Aniolytic BuSpar (Buspirone)= reduces anxiety without strong sedative- hypnotic properties. Not a CNS depressant No potential for addiction Takes 2 weeks to feel effects

55 Nonbenzodiazepine Aniolytic Side Effects; Dizziness, dry mouth, nervousness, diarrhea, headache, excitement Toxic Effects; Lethal dose is times the daily recommended dose Contraindications; Use with caution in PG women Nursing mothers Clients with renal or hepatic disease Anyone taking MAOs Teaching; Buspar is not associated with sedation, cognitive problems or withdrawal Takes 2-4 weeks to feel effects Some clients might feel restless, which could be incompleted anxiety

56 Sedative/Hypnotic Drugs Used to reduce anxiety and insomnia Can lead to tolerance and dependency Use short term Drugs used benzodiazepines, i.e. Dalmane, Restoril, Halcion Non- benzodiazepines, i.e. Ambien, Sonata, Lunestra

57 Sedative/Hypnotic Benzodiazepine Teaching: Use short term(1-2 weeks) Carefully need to taper these off-never stop cold turkey Do not take with other meds without talking to provider first Do not drive if sedated on these!!

58 Client Teaching for Nonbenzodiazepines Long term use not recommended Do not drive when taking Can repeat Sonata up to 4 hours before arising

59 ADD/ADHD-Psychostimulants Ritalin, Adderall, Dexedrine, Concerta, Focalin, Metadate, Methylin Action= increasing the release and blocking the reuptake of monoamines (dopamine, norepinephrine) S/E: wt. loss, anorexia, insomnia, headache, long-term growth suppression Potential for abuse Also used to treat narcolepsy

60 ADD/ADHD-Psychostimulants Intended effects: Increased attention span & concentration Decreased distractibility, hyperactivity, and impulsivity Treatment of ADHD, ADD, & narcolepsy S/E: Anorexia Wt. loss Growth retardation in children Insomnia Headache Cardiovascular effects-high blood pressure, dysrhythmias Contraindications: Hx of drug abuse & dependency, severe anxiety, anorexia, MAIOIs

61 ADD/ADHD- Non-Stimulants Strattera (atomoxetine) Controls symptoms thru selective inhibition of norepinephrine Takes 1-3 weeks to feel effects No abuse potential and is not considered a controlled substance

62 Meds used to Tx Extrapyramidal SE Cogentin Benadryl Artane Symmetrel Requip Akineton Kemadrin These meds should be taken simultaneously with antipsychotic meds to prevent EPS

63 Meds for Alzheimer’s Drugs here are used to slow the progression of the disease Memantine (Namenda, Ebixa) Cognex (tacrine) Aricept (donepezil) Exelon (Rivastigmine) Razadyne (galantamine)

64 Herbal Medicines Ginkgo biloba-helps with memory Kava-Kava St. John’s Wart

65 PET Scan=positron-emission tomography (PET) scans Useful in identifying physiological and biochemical changes as they occur in living tissue i.e. clients with schizophrenia PET scans show a decrease of glucose in the frontal lobes of unmedicated clients, also can indicate mood disorders, ADHD Radioactive substance is injected, travels to the brain, and illuminates the brain. Have 3D visualizations of the CNS


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