Psychotherapeutic Drugs

Psychotherapeutic Drugs
Chapter 16 Psychotherapeutic Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Psychotherapeutic Drugs
Used in the treatment of emotional and mental disorders Ability to cope with emotions can range from occasional depression or anxiety to constant emotional distress When emotions significantly affect an individual’s ability to carry out normal daily functions, treatment with a psychotherapeutic drug is a possible option Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Psychotherapeutic Drugs (cont’d)
Three main emotional and mental disorders: Anxiety Affective disorders Psychoses Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Psychotherapeutic Drugs (cont’d)
Types of psychotherapeutic drugs Anxiolytic drugs Mood-stabilizing drugs Antidepressant drugs Antipsychotic drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Anxiety Unpleasant state of mind, characterized by a sense of dread and fear May be based on actual anticipated experiences or past experiences May be exaggerated responses to imaginary negative situations Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Anxiety Disorders Six major anxiety disorders (persistent anxiety) Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder (PTSD) Generalized anxiety disorder (GAD) Panic disorder Social phobia (social anxiety disorder) Simple phobia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Affective Disorders (Mood Disorders)
Changes in mood that range from mania (abnormally pronounced emotions) to depression (abnormally reduced emotions) Some patients may exhibit both mania and depression: bipolar disorder (BPD) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Psychosis Severe emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in activities of daily living Hallmark: loss of contact with reality Examples Schizophrenia Depressive and drug-induced psychoses Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Anxiolytic Drugs Reduce anxiety by reducing overactivity in CNS Benzodiazepines Depress activity in the brainstem and limbic system Miscellaneous drug: buspirone (BuSpar) Nonsedating and non–habit forming May have drug interaction with SSRIs (serotonin syndrome) Do not administer with MAOIs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

alprazolam (Xanax) diazepam (Valium) lorazepam (Ativan)
Benzodiazepines alprazolam (Xanax) diazepam (Valium) lorazepam (Ativan) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Benzodiazepines: Adverse Effects
Benzodiazepine adverse effects are an overexpression of their therapeutic effects Decreased CNS activity, sedation Hypotension Drowsiness, loss of coordination, dizziness, headaches Nausea, vomiting, dry mouth, constipation Others Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Benzodiazepines: Overdose
Dangerous when taken with other sedatives or alcohol Treatment is generally symptomatic and supportive Flumazenil may be used to reverse benzodiazepine effects Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Miscellaneous Anxiolytic
buspirone (BuSpar) Unknown mechanism of action Administered on a scheduled basis Adverse effects Paradoxical anxiety Blurred vision Headache Nausea Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Mood-Stabilizing Drugs
Lithium carbonate and lithium citrate Other drugs may be used in combination with lithium Benzodiazepines Antipsychotic drugs Antiepileptic drugs Dopamine receptor agonists Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Mood-Stabilizing Drugs (cont’d)
Lithium is the drug of choice for the treatment of mania It is thought to potentiate serotonergic neurotransmission Narrow therapeutic range: maintenance serum levels should range between 0.6 and 1.2 mEq/L Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question
Before administering lithium to a patient, it is most important for the nurse to assess which laboratory value? Blood sugar Sodium Urine osmolality Hematocrit Correct answer: B Rationale: Lithium may become toxic if the patient has hyponatremia. The sodium level should be assessed in patients receiving lithium therapy to prevent toxicity. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antidepressants Tricyclic antidepressants Monoamine oxidase inhibitors (MAOIs) Second-generation antidepressants Selective serotonin reuptake inhibitors (SSRIs) Serotonin-norepinephrine reuptake inhibitors (SNRIs) Miscellaneous Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Tricyclic Antidepressants
Have largely been replaced by SSRIs as first-line antidepressant drugs Considered second line For patients who fail with SSRIs or other newer-generation antidepressants As adjunct therapy with newer-generation antidepressants amitriptyline (Elavil) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Tricyclic Antidepressants: Mechanism of Action
Block reuptake of neurotransmitters, causing accumulation at the nerve endings It is thought that increasing concentrations of neurotransmitters will correct the abnormally low levels that lead to depression Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Tricyclic Antidepressants: Indications
Depression Childhood enuresis (imipramine) Obsessive-compulsive disorders (clomipramine) Adjunctive analgesics for chronic pain conditions, such as trigeminal neuralgia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Tricyclic Antidepressants: Adverse Effects
Sedation Impotence Orthostatic hypotension Others Older patients Dizziness, postural hypotension, constipation, delayed micturation, edema, muscle tremors Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Tricyclic Antidepressants: Overdose
Lethal—70% to 80% die before reaching the hospital CNS and cardiovascular systems are mainly affected Death results from seizures or dysrhythmias Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Tricyclic Antidepressants: Overdose (cont’d)
No specific antidote Decrease drug absorption with activated charcoal Speed elimination by alkalinizing urine Manage seizures and dysrhythmias Basic life support Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Monoamine Oxidase Inhibitors (MAOIs)
Highly effective Considered second-line treatment for depression, not responsive to cyclics Disadvantage: potential to cause hypertensive crisis when taken with tyramine Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

MAOIs: Mechanism of Action
Inhibit the MAO enzyme system in the CNS Amines (dopamine, serotonin, norepinephrine) are not broken down, resulting in higher levels in the brain Result: alleviation of symptoms of depression Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

MAOIs: Indications Depression, especially types characterized by reverse vegetative symptoms such as increased sleep and appetite Depression that does not respond to other drugs such as tricyclics Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

MAOIs: Adverse Effects
Few adverse effects—orthostatic hypotension most common Tachycardia Dizziness Insomnia Anorexia Blurred vision Palpitations Drowsiness Headache Nausea Impotence Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

MAOIs: Overdose Symptoms appear 12 hours after ingestion Tachycardia, circulatory collapse, seizures, coma Treatment: protect brain and heart, eliminate toxin Urine acidification Hemodialysis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

MAOIs and Tyramine Ingestion of foods or drinks with tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death Avoid foods that contain tyramine! Aged, mature cheeses (cheddar, blue, Swiss) Smoked/pickled or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté) Yeast extracts Red wines (Chianti, burgundy, sherry, vermouth) Italian broad beans (fava beans) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Second-Generation Antidepressants
Fewer adverse effects than tricyclics and MAOIs Very few drug-drug or drug-food interactions Still take about 4 to 6 weeks to reach maximum clinical effectiveness Now considered first-line drugs for depression Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Second-Generation Antidepressants (cont’d)
SSRIs fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) fluvoxamine (Luvox) citalopram (Celexa) escitalopram (Lexapro) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Second-Generation Antidepressants (cont’d)
SNRIs venlafaxine (Effexor) duloxetine (Cymbalta) desvenlafaxine (Pristiq) Miscellaneous trazodone (Desyrel, Oleptro) bupropion (Wellbutrin) nefazodone (Serzone) mirtazapine (Remeron) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Second-Generation Antidepressants: Mechanism of Action
SSRIs Selectively inhibit serotonin reuptake Little or no effect on norepinephrine or dopamine reuptake Result in increased serotonin concentrations at nerve endings SNRIs Inhibit reuptake of both serotonin and norepinephrine Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Second-Generation Antidepressants: Indications
Depression Bipolar disorder Obesity Eating disorders Obsessive-compulsive disorder Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Second-Generation Antidepressants: Indications (cont’d)
Panic attacks or disorders Social anxiety disorders Posttraumatic stress disorders (PTSDs) Myoclonus Treatment of various substance abuse problems (bupropion [Zyban] is used for smoking cessation treatment) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Second-Generation Antidepressants: Adverse Effects
Body System Effects CNS Headache, dizziness, tremor, nervousness, insomnia*, fatigue GI Nausea, diarrhea, constipation, dry mouth Other Sexual dysfunction, weight gain*, weight loss*, sweating *Most common and bothersome Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

When patients are taking selective serotonin reuptake inhibitors (SSRIs) for the first time for depression, which is most important to monitor for during the first few weeks of therapy? Hypertensive crisis Suicidal thoughts Convulsions Orthostatic hypotension Correct answer: B Rationale: Some studies have indicated a higher risk for suicide during the first few weeks of antidepressant therapy. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Serotonin Syndrome Symptoms Delirium, tachycardia, hyperreflexia, shivering, agitation, sweating, muscle spasms, coarse tremors Symptoms of severe cases Hyperthermia, seizures, renal failure, rhabdomyolysis, dysrhythmias, disseminated intravascular coagulation (DIC) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

When providing teaching for a patient who is prescribed a selective serotonin reuptake inhibitor (SSRI), which statement will the nurse include? The SSRI will work faster than the older tricyclic antidepressants. The SSRI will have an immediate beneficial effect on the patient’s depression symptoms. The SSRI will not work well for severe cases of depression. The SSRI may take several weeks to have a beneficial effect. Correct answer: D Rationale: It may take several weeks to see the therapeutic effects of SSRIs. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Antipsychotics Drugs used to treat serious mental illness Behavioral problems or psychotic disorders Have been known as tranquilizers or neuroleptics Conventional drugs Atypical antipsychotics Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antipsychotics (cont’d)
Thioxanthenes: thiothixene (Navane) Butyrophenones: haloperidol (Haldol) Dihydroindolones: molindone (Moban) Dibenzoxazepine: loxapine (Loxitane) Phenothiazines: three structural groups Atypical antipsychotics: new class Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antipsychotics: Mechanism of Action
Block dopamine receptors in the brain (limbic system, basal ganglia)—areas associated with emotion, cognitive function, motor function Dopamine levels in the CNS are decreased Result: tranquilizing effect in psychotic patients Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Atypical Antipsychotics
clozapine (Clozaril) risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel) ziprasidone (Geodon) aripiprazole (Abilify) paliperidone (Invega) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Atypical Antipsychotics: Mechanism of Action
Block specific dopamine receptors: dopamine-2 (D2) receptors Also block specific serotonin receptors: serotonin 2 (5-HT2) receptors This is responsible for their improved efficacy and safety profiles Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antipsychotics: Adverse Effects
Body System Adverse Effects CNS Sedation, delirium Cardiovascular Orthostatic hypotension, syncope, dizziness, ECG changes Dermatologic Photosensitivity, skin rash, hyperpigmentation, pruritus Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antipsychotics: Adverse Effects (cont’d)
Body System Adverse Effects GI Dry mouth, constipation GU Urinary hesitancy or retention, impaired erection Hematologic Leukopenia and agranulocytosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Neuroleptic malignant syndrome (NMS) Potentially life threatening High fever, unstable BP, myoglobinemia Extrapyramidal symptoms (EPS) Involuntary muscle symptoms similar to those of Parkinson’s disease Akathisia (distressing muscle restlessness) Acute dystonia (painful muscle spasms) Treated with benztropine (Cogentin) and trihexyphenidyl (Artane) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Tardive dyskinesia (TD) Involuntary contractions of oral and facial muscles Choreoathetosis (wavelike movements of extremities) Occurs with continuous long-term antipsychotic therapy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Herbal Products: St. John’s Wort
Used for depression, anxiety, sleep disorders, nervousness May cause GI upset, fatigue, dizziness, confusion, dry mouth, photosensitivity Severe interactions if taken with MAOIs and SSRIs; many other drug interactions Food-drug interaction with tyramine-containing foods Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Herbal Products: Ginseng
Three varieties; has been used for over 5000 years Uses: stress reduction, improvement of physical endurance and concentration May cause elevated BP, chest pain, palpitations, anxiety, insomnia, headache, GI symptoms Interactions with anticoagulants, immunosuppressants, anticonvulsants, antidiabetic drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Psychotherapeutic Drugs: Nursing Implications
Before beginning therapy, assess physical and emotional status of patients Obtain baseline vital signs, including postural BP readings Obtain liver and renal function tests Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Psychotherapeutic Drugs: Nursing Implications (cont’d)
Assess for possible contraindications to therapy, cautious use, and potential drug interactions Assess for level of consciousness, mental alertness, potential for injury to self and others Check the patient’s mouth to make sure oral doses are swallowed Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Provide simple explanations about the drug, its effects, and the length of time before therapeutic effects can be expected Advise patients to avoid abrupt withdrawal Advise patients to change positions slowly to avoid postural hypotension and possible injury Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

The combination of drug therapy and psychotherapy is emphasized because patients need to learn and acquire more effective coping skills Only small amounts of medications should be dispensed at a time to minimize the risk of suicide attempts Simultaneous use of these drugs with alcohol or other CNS depressants can be fatal Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antidepressants Many cautions, contraindications, and interactions exist pertaining to the use of antidepressants Inform patients that it may take several weeks to see therapeutic effects Monitor patients closely during this time, assess for suicidal tendencies, and provide support Assist elderly or weakened patients with ambulation and other activities because falls may occur because of drowsiness or postural hypotension Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antidepressants (cont’d) Tricyclics may need to be weaned and discontinued before undergoing surgery to avoid interactions with anesthetic drugs Monitor for adverse effects, and discuss with patients Encourage patients to wear medication ID badges naming the drugs being taken Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antidepressants (cont’d) Caffeine and cigarette smoking may decrease effectiveness of medication therapy With MAOIs, instruct patients and family regarding tyramine-containing foods, and signs and symptoms of hypertensive crisis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antipsychotics—phenothiazines Instruct patients to wear sunscreen because of photosensitivity Tell patients to avoid taking antacids or antidiarrheal preparations within 1 hour of a dose Inform patients to avoid alcohol or other CNS depressants with these medications Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antipsychotics—phenothiazines (cont’d) Long-term haloperidol therapy may result in tremors, nausea, vomiting, or uncontrollable shaking of small muscle groups; report these symptoms to the physician Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antipsychotics—phenothiazines (cont’d) Oral forms may be taken with meals to decrease GI upset These drugs may cause drowsiness, dizziness, or fainting; instruct patients to change positions slowly Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Monitor for therapeutic effects Monitor mental alertness, cognition, affect, mood, ability to carry out activities of daily living, appetite, and sleep patterns Monitor potential for self-injury during the delay between the start of therapy and symptomatic improvement Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Monitor for therapeutic effects (cont’d) For anxiolytics Improved mental alertness, cognition, and mood Fewer anxiety and panic attacks Improved sleep patterns and appetite Less tension and irritability; fewer feelings of fear, impending doom, and stress More interest in self and others Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Monitor for therapeutic effects (cont’d) For antidepressants Improved sleep patterns and nutrition Increased feelings of self-esteem Decreased feelings of hopelessness Increased interest in self and appearance Increased interest in daily activities Fewer depressive manifestations or suicidal thoughts/ideations Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Monitor for therapeutic effects (cont’d) For antipsychotics Improved mood and affect Alleviation of psychotic symptoms and episodes Decreased hallucinations, paranoia, delusions, garbled speech, and inability to cope Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study A patient is admitted to the emergency department. The patient’s heart rate is 112 beats/min; he is sweating, has muscle tremors, and is agitated. The patient says, “I was depressed and took more of the pills the doctor gave me so I would feel better.” What does the nurse suspect is happening with this patient? What treatment does the nurse expect to implement? Along with completing a full assessment, the nurse would need to ask the patient what medication the patient was prescribed, how long the patient has been taking the medication, and how much of the medication the patient currently has taken. Based on the presenting signs and symptoms, the nurse would include serotonin syndrome as a highly possible reason for the patient’s presenting symptoms. The treatment for serotonin syndrome includes discontinuation of all serotonin reuptake inhibitors and supporting the patient to maintain homeostasis. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study (cont’d) The patient was admitted to the hospital for observation and has now recovered. Which information will the nurse include in patient teaching about SSRIs? It usually takes 4 to 6 weeks until you will experience benefits from the medication. The patient must avoid foods that contain tyramine. If the patient develops an upset stomach when taking this medication, he should discontinue use. The patient should take the medication at bedtime to enhance sleep. Correct answer: A Rationale: Patients should be taught that the time period for SSRIs to take effect is 4 to 6 weeks. These medications can cause GI upset and taking them with food is recommended. SSRIs should be taken in the morning to prevent any sleep disturbances. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study Several months later the patient returns to the health care provider’s office for follow-up regarding use of the SSRI. The patient tells the nurse that he is feeling better and stopped taking the SSRI yesterday. He doesn’t plan on taking the medication again. When talking with the patient, which knowledge should guide the nurse’s response? Drug dependency will develop, so it is appropriate to stop therapy after a few months. Drug therapy must be stopped as soon as the patient feels better to avoid serotonin syndrome. The patient is the best person to determine when the drug therapy should end. A 1- to 2-month taper period is indicated to prevent adverse effects of abrupt drug discontinuation. Correct answer: D Rationale: A taper period of 1 to 2 months is needed to prevent the development of adverse effects of withdrawal from the medication, which include dizziness, diarrhea, and a worsening of the depressive mood disorder. Serotonin syndrome is a result of taking too much of the medication. The patient and the provider should determine together when is the optimal time for drug discontinuation. There is no evidence of drug dependency associated with use of SSRIs. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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