1. Psych Mental Health Nursing
Must Know Drugs

2. Haldol (Haldoperidol)
Class: High Potency Neuroleptic (butyrophenone)
Conventional Antipsychotic Agent
Mechanism: Block receptors for dopamine, acetylcholine, histamine and norepinephrine. Therapeutic effect from blocking D2 receptors in mesolimbic region.
Therapeutic Use: Schizophrenia, Bipolar Disorder, Tourette’s Syndrome.
Adverse effects: Extrapyramidal Symptoms (EPS)- Acute Dystonia, (oculogyric crisis, laryngeal dystonia) Parkinsonism, Akathisia, Tardive Dyskinesia (TD), Neuroleptic Malignant Syndrome (NMS), Anticholinergic effects, orthostatic hypotension, sedation, neuroendocrine effects, lowers seizure threshold, sexual dysfunction, severe dysrhythmias from prolongation of QT interval.
Interactions: Alcohol or other CNS depressants. Possible neurotoxicity with lithium. Caution with drugs that prolong QT interval (ketoconazole, paroxetine). Monitor anticoagulants.
Nursing Actions: Assess and monitor for EPS (AIMS - Assessment of Involuntary Movement Scale). Monitor for EKG changes. Administer anticholinergic for treatment of EPS prn. Encourage sugarless candy for dry mouth. Monitor for orthostatic hypotension.

3. Thorazine (Chlorpromazine)
Class: Low Potency Neuroleptic (phenothiazine)
Conventional Antipsychotic Agent
Mechanism: Block receptors for dopamine, acetylcholine, histamine and norepinephrine. Therapeutic effect from blocking D2 receptors in mesolimbic region.
Therapeutic Use: Schizophrenia, Bipolar Disorder.
Adverse effects: Extrapyramidal Symptoms (EPS)- Acute Dystonia, (oculogyric crisis, laryngeal dystonia) Parkinsonism, Akathisia, Tardive Dyskinesia (TD), Neuroleptic Malignant Syndrome (NMS), Anticholinergic effects, orthostatic hypotension, sedation, neuroendocrine effects, lowers seizure threshold, sexual dysfunction, severe dysrhythmias from prolongation of QT interval. Photosensitivity.
Interactions: Alcohol or other CNS depressants. Possible neurotoxicity with lithium. Caution with drugs that prolong QT interval (ketoconazole, paroxetine). Monitor anticoagulants. Risk for Agranulocytosis – life threatening.
Nursing Actions: Assess and monitor for EPS – AIMS (Assessment of Involuntary Movement Scale). Monitor for EKG changes. Administer anticholinergic for treatment of EPS prn. Encourage sugarless candy for dry mouth. Monitor for orthostatic hypotension. Educate patient for need for sunscreen and sunglasses due to photosensitivity. Monitor White Blood Cell Counts, and educate patient about signs of agranulocytosis: ie sore throat and fever. Neuroloptic must be withdrawn if develops agranulocytosis.

4. Abilify (Aripiprazole)
Class: Atypical Antipsychotic (Thienobenzodiazepine) Mechanism: (Dopamine system stabilizer) Blocks H1, 5HT2 and alpha1 receptors, mixed effects on 5HT1 and D2 receptors. Therapeutic Use: Psychosis, Bipolar Disorder, adjunctive treatment for resistant depression Adverse effects: Extrapyramidal symptoms (EPS) (less likely, but possible) Neuroleptic Malignant Syndrome (NMS) – few cases reported. Anticholinergic effects, Orthostatic Hypotension, sedation, neuroendocrine effects, lower seizure threshold. Most common include headache, anxiety, or agitation. Interactions: Barbituates, carbamazepine, phenytoin or rifampin can decrease abilify levels. Ketoconazole, itraconozole, fluconazole, erythromycin, quinidine, fluoxetine or paroxetine can increase abilify levels. Nursing Actions: Mental status assessment, assess for suicidality, educate and monitor adherence, assess for orthostatic hypotension, Inform patient about risk for weight gain, monitor weight and abdominal girth, reduce caloric intake in response to weight gain, educate patient about small potential for sexual dysfunction. Assess for metabolic syndrome – monitor triglycerides, blood glucose and cholesterol levels.

5. Geodon (Ziprasidone HCl)
Class: Atypical Antipsychotic (Serotonin and Dopamine antagonist)
Mechanism: Blocks D2, 5-HT2, H1 and alpha-adrenergic receptors. Also blocks reuptake of serotonin and norepinephrine.
Therapeutic Use: Treatment of Schizophrenia or other mood disorders.
Adverse effects: Prolongs Q-T interval, increases risk of torsades de pointes. Sedation, orthostatic hypotension. Low risk of EPS, TD or NMS. Less risk of weight gain than other atypicals, but still may contribute to weight gain and metabolic syndrome. Increased risk of mortality with use in elderly with dementia.
Interactions: Do not combine with any other drugs that prolong QT interval – (TCAs, Mellaril, several antidysrhythmic drugs, several antibiotics – clarithromycin, moxiffloxacin, gatifloxacin, sparfloxacin.
Nursing Actions: Mental status assessment, assess for suicidality, educate and monitor adherence, assess for orthostatic hypotension, Inform patient about risk for weight gain, monitor weight and abdominal girth, reduce caloric intake in response to weight gain, educate patient about small potential for sexual dysfunction. Monitor for EKG changes. Monitor triglyceride, glucose and cholesterol levels.

6. Invega (Paliperidone)
Class: Atypical Antipsychotic (Benzisoxazole)
Mechanism: Blocks D2, 5HT2, and alpha 2 adrenergic receptors. An extended release preparation for once daily dosing.
Therapeutic Use: Schizophrenia
Adverse effects: Headache, somnolence, anxiety. Cardiac effects – may prolong QT interval. Lower risk of EPS, TD or NMS. Orthostatic hypotension or syncope. Increased risk of death for use in elderly with dementia. Monitor for metabolic syndrome.
Interactions: Avoid alcohol, drugs that prolong QT interval, caution with other CNS drugs or drugs that cause orthostatic hypotension. May be antagonized by carbamazepine. May antagonize levodopa or other dopamine agonists.
Nursing Actions: Mental status assessment, assess for suicidality, educate and monitor adherence, assess for orthostatic hypotension, Inform patient about risk for weight gain, monitor weight, reduce caloric intake in response to weight gain, educate patient about small potential for sexual dysfunction. Monitor for EKG changes.

7. Fanapt (Piperidinyl-benzisoxasole)
Class: Atypical Antipsychotic (Piperidinyl-benzisoxazole)
Mechanism: Unknown. Theoretical - Blocks D2, 5HT2, and alpha 2 adrenergic receptors.
Therapeutic Use: Schizophrenia in adults
Adverse effects: May prolong QT interval. Increased mortality in elderly with dementia. EPS, TD and NMS. Metabolic syndrome. Decreased seizure threshold. Blood dyscrasias. Hyperprolactinemia. Dysphagia. Suicide risk. Priaprism.
Interactions: Do not combine with any other drugs that prolong QT interval – (TCAs, Mellaril, several antidysrhythmic drugs, several antibiotics – clarithromycin, moxiffloxacin, gatifloxacin, sparfloxacin. Use with fluoxetine, paroxetine or ketoconazole can cause increased blood levels of Fanapt.
Nursing Actions: Monitor for EKG changes. Monitor CBC. Monitor for metabolic syndrome, (cholesterol, triglycerides and glucose). Assess for EPS.

8. Seroquel (Quitiapine)
Class: Atypical Antipsychotic (Dibenzothiazepine)
Mechanism: Blockade of 5-HT2 (Seratonin) receptors, and weak blockade of D2 (Dopamine) receptors. Also blocks H1 (Histamine) receptors and alpha-adrenergic receptors.
Therapeutic Use: Schizophrenia and Bipolar Disorder.
Adverse effects: Sedation, orthostatic hypotension, weight gain. Metabolic syndrome. Low risk of EPS. TD has not been reported, but theoretically is possible. Increase risk of Diabetes and increased mortality in elderly with dementia has been reported. Lens changes and increased risk of cataracts.
Interactions: Metabolism of drug is increased by phenytoin, barbituates, carbamazepine or rifampin. Inhibitors of CYP3A4 (Ketoconazole, itraconazole, fluconazole, erythromycin may increase levels of quitiapine and pose risk of toxicity.
Nursing Actions: Mental status assessment, assess for suicidality, educate and monitor adherence, assess for orthostatic hypotension, Inform patient about risk for weight gain, monitor weight, reduce caloric intake in response to weight gain, monitor blood glucose level. Educate patient about small potential for sexual dysfunction.

9. Zyprexa (Olanzapine)
Class: Atypical Antipsychotic (Thienobenzodiazepine)
Mechanism: Blocks receptors for serotonin, dopamine, histamine, acetylcholine and norepinephrine. Therapeutic effects from blocking 5HT2 and D2 receptors.
Therapeutic Use: Schizophrenia and Bipolar Disorder. Adjunctive treatment of depression.
Adverse effects: Weight gain and metabolic syndrome (increased cholesterol, triglycerides and risk for diabetes). Lower risk of EPS, TD or NMS. Increase mortality in elderly with dementia. Sedation, constipation and orthostatic hypotension are also possible.
Interactions: Metabolism of drug is increased by phenytoin, barbituates, carbamazepine or rifampin. Inhibitors of CYP3A4 (Ketoconazole, itraconazole, fluconazole, erythromycin may increase levels of quitiapine and pose risk of toxicity. Alcohol or other centrally acting drugs may potentiate effects.
Nursing Actions: Mental status assessment, assess for suicidality, educate and monitor adherence, assess for orthostatic hypotension, Inform patient about risk for weight gain, monitor weight, reduce caloric intake in response to weight gain, monitor blood glucose level. Educate patient about small potential for sexual dysfunction

10. Prozac (Fluoxetine)
Class: SSRI Antidepressant (Selective Serotonin Reuptake Inhibitor)
Mechanism: Selective inhibition of serotonin reuptake, and intensifies transmission at serotonergic synapses.
Therapeutic Use: Depression, Anxiety Disorders – OCD, Bulimia nervosa and premenstrual dysphoric disorder.
Adverse effects: Sexual dysfunction, nausea, headache and nervousness or insomnia. Weight gain. Serotonin syndrome – usually on initiation – altered mental status, myoclonus, hyperreflexia, sweating, tremor and fever. Can cause EPS – ie akathisia or restlessness. Bruxism – clenching or grinding teeth – can cause dental problems. May impede platelet aggregation and increase risk of bleeding. Can cause hyponatremia – especially in elderly. Diarrhea or excess sweating may also occur.
Interactions: Stop MAOI 14 days before giving Prozac, and do not give MAOI for at least 5 weeks following Prozac administration. Monitor response to Warfarin closely. May increase plasma levels of TCAs or Lithium – use together with caution
Nursing Actions: Educate patient to taper dose before discontinuation. Educatie patient to reduce dose / take drug holiday intermittently to treat sexual dysfunction.

11. Cymbalta (Duloxetine)
Class: S/NRI Antidepressant (Serotonin and Norepinephrine Reuptake Inhibitor)
Mechanism: Block neuronal reuptake of serotonin and norepinephrine
Therapeutic Use: Major Depression, Anxiety Disorders, Pain management
Adverse effects: Nausea, dry mouth, insomnia, somnolence, reduced appetite, fatigue, increased sweating and blurred vision. May caused small increase in BP in some. May impact liver – rare hepatotoxicity - caution use with liver disease. Not recommended with renal insufficiency. Not recommended during pregnancy or lactation.
Interactions: Alcohol. Tryptophan, SSRIs, SNRIs, Thioridazine. Potentiated by cimetidine, fluvoxamine or quinolones, also paroxetine, fluoxetine, TCAs or phenothiazines. Caution with triptans, lithium, traomadol, or St. John’s Wort. Increased bleeding risk with ASA, anticoagulants or NSAIDs.
Nursing Actions: Monitor BP prior to therapy, and periodically thereafter. Monitor and assess for suicidal ideation.

12. Effexor (Venlafaxine)
Class: S/NRI Antidepressant (Serotonin and Norepinephrine Reuptake Inhibitor)
Mechanism: Block neuronal reuptake of serotonin and norepinephrine
Therapeutic Use: Depression and Anxiety Disorders
Adverse effects: Nausea, headache, anorexia, nervousness and insomnia. Abrupt discontinuation can cause intense withdrawal syndrome. May cause dose dependent diastolic hypertension. Sexual dysfunction. Caution use with heart disease, renal or hepatic dysfunction.
Interactions: MAOI – must discontinue 14 days before starting. Avoid alcohol use. Monitor for serotonin syndrome if used in combination with SSRIs. Caution use with cimetidine, haldol, or diuretics.
Nursing Actions: Warn patients not to stop abruptly. Montior BP before and during therapy. Assess and monitor for suicidal ideation.

13. Amitriptyline (Elavil)
Class: TCA – Tricyclic Antidepressant
Mechanism: Block neuronal reuptake of norepinephrine and seratonin.
Therapeutic Use: Depression. Off label use for pain management.
Adverse effects: Sedation, orthostatic hypotension and anticholinergic effects. May cause cardiac toxicity.
Interactions: During or within 5 weeks of PROZAC. Hyperpyretic crisis, seizure and death with MAOIs. Potentiates alcohol, barbituates and other CNS depressants. Delerium with disulfiram. Paralytic ileus with anticholinergics.
Nursing Actions: Assess and monitor for orthostatic hypotension. Monitor for EKG changes. Educate patient about sedation – patient should not drive, etc.

14. Nardil (Phenelzine sulfate)
Class: Monoamine oxidase inhibitor antidepressant (MAOI)
Mechanism: Inhibits monoamine oxidase, which normally inhibits the activity of epinephrine, norepinephrine, serotonin and dopamine, and may help depression by increasing amount of norepinephrine and serotonin thus available.
Therapeutic Use: Depression. Due to potential for serious interactions with food and other drugs, these drugs are usually reserved for patients who have not responded to SSRIs or TCAs.
Adverse effects: CNS stimulation may cause anxiety, dizziness, headache or agitation. Orthostatic hypotension. Risk for Hypertensive Crisis from Dietary Tyramine: headache, tachycardia, HTN, nausea and vomiting.
Interactions: Foods containing tyramine, caffeine. Sympathomimetic agents (ephedrine, amphetamine) and other antidepressants: TCAs and SSRIs. Use with SSRIs also poses risk of serotonin syndrome as well as hypertensive crisis. Alcohol or other CNS depressants – ie Demerol.
Nursing Actions: Assess for suicidal ideation. Assess mental status. Teach client about food and drug interactions, and educate to avoid foods containing tyramines. Assess and educate for orthostatic hypotension.

15. Wellbutrin (Bupoprion HCL)
Class: Atypical Antidepressant (Aminoketone)
Mechanism: Unknown. Theoretical blockade of dopamine uptake.
Therapeutic Use: Depression, smoking cessation.
Adverse effects: Agitation, headache, dry mouth, constipation, weight loss, GI upset, dizziness, tremor, insomnia, blurred vision and tachycardia. Does have risk for seizures, and is contraindicated for use in individuals with history of head injury, seizure disorder, bulima or anorexia nervosa.
Interactions: MAOIs – must be discontinued at least 2 weeks prior to initiation with bupropion. Caution use with other drugs that lower seizure threshold. Use with alcohol, opiates or cocaine may enhance these risks.
Nursing Actions: Assess and monitor for suicidal ideation. Educate patient about careful attention to dosing, increased amounts can contribute to increased risk for seizures – patient should not double dose.

16. Remeron (Mirtazapine)
Class: (Other) (Tetracyclic) Antidepressant
Mechanism: Blocks two serotonin receptors (5-HT2 and 5-HT3) as well as histamine receptors.
Therapeutic Use: Depression
Adverse effects: Sedation and weight gain are most common. Increased appetite, dizziness, nausea, dry mouth, edema, increase cholesterol levels, rare agranulocytosis and neutropenia may occur. Rare occurrences of NMS or serotonin syndrome. May lower seizure threshold.
Interactions: Sedation exacerbated by alcohol, benzodiazepine or other CNS depressants. MAOIs.
Nursing Actions: Educate patient about sedation, need for pm dosing, avoid driving etc. Counsel patient regarding risk for increased appetite and weight gain. Monitor cholesterol and CBCs. Monitor for suicidal ideation.

17. Lithium Carbonate Class: Lithium salt; Mood Stabilizer
Mechanism: Specific mechanism unknown. Theoretical balancing of calcium or sodium channels, and decreases sensitivity to neurotransmitters.
Therapeutic Use: Bipolar Disorder
Adverse effects: GI upset, nausea, diarrhea, anorexia, fatigue, muscle weakness, polyuria, tremor, hypothyroidism, acne, thinning hair and teratogenesis. Toxicity- nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness, tremor, ataxia, confusion, ECG changes, could progress rapidly and lead to death. Contraindicated with cardiac or renal disease.
Interactions: Diuretic use increases risk of lithium toxicity. NSAIDs can increase lithium levels, and also contribute to toxicity. (Note: exception aspirin does not increase Li levels) Anticholinergic drugs (antihistamines, phenothiazine antipsychotics or TCAs) could cause urinary hesitancy.
Nursing Actions : Monitor blood levels - therapeutic levels – 0.8 – 1.2mEq/L. (.4 to 1.0 for maintenance, and for acute mania) Assess and monitor for signs of Lithium toxicity. TID dosing is required due to short half life, so ensure adherence to dosing schedule. (BID dosing with extended release formulations – ie Lithobid) Assess for suicidal ideation. Obtain baseline ECG and monitor periodically for changes. Monitor thyroid and renal function via labs (TSH, T3, T4, BUN, BMP and CBC). Overdose may be fatal, requires gastric lavage.

18. Depakote (Valproic Acid)
Class: AED (Antiepileptic Drug) Mood Stabilizer
Mechanism: Suppression of high-frequency neuronal firing through blockade of sodium channels. Suppress Calcium influx through T-type calcium channels. Augment the inhibitory influence of GABA
Therapeutic Use: Seizure Disorders, Bipolar Disorder, Migraine.
Adverse effects: Minimal sedation or cognitive impairment. Nausea, vomiting or indigestion common, but transient. Rare hepatotoxicity or pancreatitis. Teratogenicity effects – Pregnancy risk category D. Rash, weight gain, tremor and blood dyscrasias (thrombocytopenia or clotting abnormalities).
Interactions: Phenobarbital or Phenytoin levels may be increased and could lead to toxicity. Monitor levels of Valproate with enzyme inducers – potentiated by ASA, levels reduced by rifampin, phenytoin, phenobarbital, carbamazepine.
Nursing Actions: Teach patients to watch for rare but serious symptoms of pancreatitis- (abdominal pain, nausea, vomiting or anorexia). Monitor for suicidal ideation. Educate patient to avoid abrupt cessation. Monitor platelets, bleeding time, CBC, Liver function tests. Educate females of childbearing potential of risks to fetus. Monitor for therapeutic level: mcg/ml.

19. Lamictal (Lamotrigine)
Class: Antiepileptic Drug (AED). Mood Stabilizer
Mechanism: Unknown. Theoretical - inhibits sodium channels, stabilizing neuronal membranes and modulating GABA.
Therapeutic Use: Seizure Disorder, Bipolar Disorder
Adverse effects: Headache, dizziness or double vision. Rare –serious, life threatening rash due to Stevens-Johnson syndrome).
Interactions: Valproate (potentiates Lamictal). Lamictal levels decreased by phenytoin, carbamazepine, phenobarbital or rifampin. Lamictal levels may be decreased by oral contraceptives, and may interfere with contraceptive efficacy.
Nursing Actions: Educate about risk for rash, and serious reaction which needs immediate attention and discontinuation of medication. Medication must be started at low dose and titrated slowly.

20. Busparone (Buspar) Class: Anti-Anxiety (Azaspirone)
Mechanism: Binds with high affinity to receptors for serotonin and with lower affinity to receptors for dopamine.
Therapeutic Use: Anxiety Disorders
Adverse effects: Dizziness, GI upset, headache, nausea.
Interactions: Hypertensive crisis with MAOIs. Avoid alcohol or large amounts of grapefruit juice. May potentiate haldol, valium, nefazodone. Potentiated by CUP3A3 inhibitors, erythromycin or ketoconazole. Antagonized by CYP3A4 inducers such as rifampin, phenytoin, phenobarbital or cabamazepine.
Nursing Actions: Educate patient regarding need for 1 – 2 weeks for therapeutic effects. No evidence of tolerance, physical dependence or withdrawal, so may be better choice than long term use of benzodiazepines, or for individuals with chemical dependency.

21. Vistaril (Hydroxyzine pamoate)
Class: Antihistamine (anti-anxiety)
Mechanism: H1 antagonist – block histamine receptors
Therapeutic Use: Anxiety (also sedation)
Adverse effects: anticholinergic side effects – blurred vision, dry eyes, dry mouth, urinary hesitancy.
Interactions: Alcohol and other CNS depressants potentiate effects.
Nursing Actions: Educate patient about potential for sedation, ie to avoid driving etc. , utilize pm dosing etc. Recommend sugarless candy and frequent sips of fluid for dry mouth.

22. Zoloft (Sertraline)
• Class: SSRI (Selective Serotonin Reuptake Inhibitor)
• Mechanism: inhibits neurons from reuptaking serotonin, making more available in synapse
• Therapeutic uses: Depression, Anxiety/OCD, PTSD, PMDD
• Adverse effects: H/A, sexual dys, weight gain, tremor, insomnia, agitation, N/D, Serotonin syndrome (<72hrs), discontinuation syndrome.
• Interactions: MAOI
• Nsg Actions: Assess adverse effects, educate 2 weeks before begins working; do not d/c suddenly

23. Ativan (Lorazepam)
• Class: benzodiazepine, anxiolytic (minor tranquilizers)
• Mechanism: makes GABA receptors more active, slowing neural activity
• Therapeutic uses: anxiety, insomnia, seizures, ETOH withdrawal
• Adverse effects: CNS depression (sedation), anterograde amnesia (blackout), Resp depression, abuse, paradoxical effects
• Interactions: other CNS depressants, esp opioids and ETOH
• Nsg Actions: assess, fall precautions, educate about interactions; monitor resp if on other CNS depressants