Drugs Affecting Mental Health Flashcards by Kelsey Klipfel

All drugs manipulating neurotransitters in some way to treat disorder
Chemical messengers of NS
neurotransitters Exert actions through receptors in postsynaptic membrane; goals: increases/decrease neurotransitters in cleft; altering levels neurotransitters lot AE
Interaction of transmitter/receptor results in specific physiologic response
Rapid removal of transmitter needed to maintain precise control of neural transmission - body good at it
All drugs used treat mental disorders - not abruptly d/c - taper off
Receptors named for type of neurotransmitter with which they interact

Basic concepts neurophysiology: communication neurotransmitters

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Neurotransmitters, neuromodulators, neurotrophic or nerve growth factors

Chemical messengers of NS

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Enables muscle action, learning and memory

Acetylcholine

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Influences movement, learning, attention and emotion

Dopamine

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Affects mood, hunger, sleep, arousal

Serotonin

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Helps control alertness and arousal

Norepinephrine

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A major inhibitory NT

Gamma- aminobutyric acid (GABA)

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Major excitatory NT; involved in memory

Glutamate

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Pharmacological treatment for mental health and neuro disorders (discussed in this class) modulate neurotransmitters
Result in inhibition or excitation of the CNS
Adverse effects are often primary (related to action of medication; too much medication)
Medications discussed should not be discontinued abruptly if taken scheduled - tapered off - really sick if just d/c med; high risk for seizures if for seizures

Mental health and neuro pharmacology

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Break cycle anxiety and restore functining
Unpleasant reaction to stimulus
Feelings of:
Treatment goal:
Clinical manifestations (SNS):
Mild anxiety:
Overwhelming or severe:

Anxiety

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Actual or unknown

Unpleasant reaction to stimulus - Anxiety

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Tension
Nervousness
Apprehension
Fear

Feelings of: - Anxiety

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Break feelings
Restore functioning

Treatment goal: - Anxiety

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Sweating
Tachycardia
Rapid breathing
Elevated BP

Clinical manifestations (SNS): - Anxiety

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Helpful in certain situations

Mild anxiety: - Anxiety

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Concerning
Interfere with functioning

Overwhelming or severe: - Anxiety

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Depress activity of CNS through GABA receptors (inhibitory neurotransmitter) - slow down to decrease anxiety)

MoA: - Gen: benzodiazepines

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Pregnancy (X - cross barrier)/lactation - AE happen in mom and baby; COPD (get problematic - decrease resp drive CO2 retainers not lot reserve be cautious when admin meds that cause resp depression); older adults

Contraindications: - Gen: benzodiazepines

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Schedule IV (lower risk for dependence and abuse, careful with admin and doc since is scheduled drug); CNS depressants: alcohol, opioids (higher risk for CNS and resp depression), others

Black Box Warning: - Gen: benzodiazepines

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CNS depression - slow down activity brain to break manifestations of anxiety - reacts certain way/too much med can have this, major one monitor for; Overdose: respiratory depression, coma - slow down CNS slow down resp sys so imp monitor for this

AE: - Gen: benzodiazepines

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Caution with IV route: higher risk for AE; Long term use must taper discontinuation (withdrawal syndrome); some addictive properties but lower than seen with opioids

Nursing: - Gen: benzodiazepines

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anxiety disorders, acute agitation, acute alcohol withdrawal, pre-operative sedation

Use: - Benzodiazepines: Prototype: lorazepam (Ativan)

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oral or IVP (rate 2 mg/min)

Route: - Benzodiazepines: Prototype: lorazepam (Ativan)

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drowsiness, dizziness, lethargy, fatigue, hypotension; overdose: respiratory depression (more common when taken with other CNS depressants)

AE: - Benzodiazepines: Prototype: lorazepam (Ativan)

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Fall risk - anytime CNS depressant high fall risk - drowsy easier and fall easier

Nursing: - Benzodiazepines: Prototype: lorazepam (Ativan)

Assessment Interventions Evaluation

Nursing care plan: benzodiazepines

Focus on neuro and respiratory (major AE) - adequate baseline imp; VS

Assessment

Give parenteral only if oral forms are not feasible/available - try oral if can Taper dose after long term therapy Fall risk Teach client: drug name, dose, AE, non-pharm therapy for anxiety, can make them drowsy - avoid operating heavy machinery until know how react to med

Interventions

Therapeutic response, AE, teaching, compliance

Evaluation

Benzodiazepines would not be beneficial in which situation? A.A client with extreme fear B.A client with moderate anxiety C.A client who is a truck driver D.A client who is experiencing stress

Answer: C Rationale: Benzodiazepines can cause drowsiness which is problematic for a truck driver. Benzodiazepines are indicated to treat fear, anxiety and stress.

The nurse is caring for a client prescribed lorazepam. When reviewing the client's medication list, what other medication causes the most concern for the nurse? A.Oxycodone/Morphine B.Lisinopril C.Ondansetron D.Metoprolol

Answer: A Sedation and resp depression - ondansetron causes sedation; benzo can lower BP - concerning with antihypertensives but more concerned with sedation and resp depression Rationale: Opioids are the most concerning due to their ability to also cause sedation and respiratory depression. There is a black box warning regarding the drug-drug interaction between benzodiazepines and opioids. Although antihypertensives like lisinopril and metoprolol could increase the risk for hypotension, this is less concerning than respiratory depression. Ondansetron could increase the risk for drowsiness and hypotension, but most patients are taking it on a PRN basis and the risks to the client are lower than that of opioids.

Imbalance of neurotransmitters and drugs trying to restore that Inhibit effects of monoamine oxidase (monoamine oxidase is an enzyme breaks down neurotransmitters - so not broken down and more available for use) Block reuptake of neurotransmitters back to neurotransmitter released them; less neurotransmitters available to exert effect on next neurotransmitters in cleft Regulate receptor sites and/or breakdown - helping increase receptor sites available for neurotransmitters and/or breakdown allowing more regardless type drug give Goal: More neurotransmitter in synaptic cleft

Depression: drug therapy

Indication: depression (Allow 4-6 weeks for therapeutic effect); some off-label uses: fibromyalgia Black box warning: Increased risk for suicidal ideation when start them (esp. children and young adults) Contraindications: Pregnancy (X - cross barrier)/lactation - excreted in milk; seizure disorders - increases risk for underlying seizures Caution: older adult more susceptible to AE - esp anticholinergic Drug-drug: More than 1 antidepressant increases risk for AE and serotonin syndrome; Serotonergic drugs - increase serotonin levels: fentanyl, St. John’s Wort Serotonin syndrome: Initiation, increased dose, or overdose on drug; usually self-limiting after discontinuing drug; multiple antidepressants - more on higher risk; first line treatment stop drug and monitor; severe: dialysis

Gen: antidepressants

Delirium Agitation - imp monitor for in combo Tachycardia/HTN Sweating - imp monitor for in combo Clonus (muscle spasms) - imp monitor for in combo Hyperreflexia - imp monitor for in combo Tremors - imp monitor for in combo Shivering

Common: - most self-limiting - Serotonin syndrome CM

Hyperthermia Seizures Rhabdomyolysis Renal failure Cardiac dysrhythmias

Severe: - Serotonin syndrome CM

Tricyclic MAOI's More significant and severe adverse effects Toxicity lethal Pregnancy Category D/X

First generation - Antidepressant classifications

SSRI SNRI More tolerable adverse effects, but still bothersome - same AE but much less severe Usually first line treatment - sim efficacy but more tolerable because AE not as severe Pregnancy Category C

Second generation - Antidepressant classifications

Orthostatic hypotension first week of therapy GI effects (n/v/d) Drowsiness or insomnia Anticholinergic effects Weight loss or gain Sexual dysfunction Prolonged QTc

Antidepressants: gen adverse effects

- Tricyclic Antidepressants (TCA): Prototype: amitriptyline

Reduce reuptake of serotonin and NE into nerves (block cholinergic, histaminergic, adrenergic, dopaminergic receptors) - block lot diff receptor sites resulting in all diff factors

MoA: - Tricyclic Antidepressants (TCA): Prototype: amitriptyline

refractory to other treatment for depression; not used as first line - hinders compliance

Use: - Tricyclic Antidepressants (TCA): Prototype: amitriptyline

CV disease, seizure disorder

Caution: - Tricyclic Antidepressants (TCA): Prototype: amitriptyline

MAOI’s

Drug-drug: - Tricyclic Antidepressants (TCA): Prototype: amitriptyline

sedation, anticholinergic effects, see general; overdose: cardiac arrhythmias and seizure

AE: - Tricyclic Antidepressants (TCA): Prototype: amitriptyline

admin at HS since highly sedating; see general

Nursing: - Tricyclic Antidepressants (TCA): Prototype: amitriptyline

Irreversibly inhibits MAO (enzyme breaks down neurotransmitter so no longer there in synaptic cleft) allowing neurotransmitters to accumulate in synaptic cleft (including dopamine) - break down in neurotransmitters and tyramine

MoA: - Monoamine Oxidase Inhibitors (MAOI): Prototype: Phenelzine

depression refractory to other treatment - not first line; Parkinson's disease

Use: - Monoamine Oxidase Inhibitors (MAOI): Prototype: Phenelzine

CV disease

Caution: - Monoamine Oxidase Inhibitors (MAOI): Prototype: Phenelzine

sympathomimetic, serotonergic drugs; many others; anything raise BP

Drug-drug: - Monoamine Oxidase Inhibitors (MAOI): Prototype: Phenelzine

Tyramine increases BP and risk for HTN crisis

Drug-food: - Monoamine Oxidase Inhibitors (MAOI): Prototype: Phenelzine

severe: hypertensive crisis; see general

AE: - Monoamine Oxidase Inhibitors (MAOI): Prototype: Phenelzine

teach avoid high tyramine-containing foods; wait 2-6 weeks MAOI to SSRI (inc. risk SS); see general

Nursing: - Monoamine Oxidase Inhibitors (MAOI): Prototype: Phenelzine

Aged cheeses (cheddar, blue, swiss) Smoked/pickled/cured meats (sausage, pepperoni) Yeast extracts (Brewer's yeast) Red wines

High - must avoid - Tyramine-containing foods

Avocado Pasteurized light and pale beer Distilled spirits (vodka, gin) Non-aged cheeses Chocolate and caffeinated beverages Fruit (bananas, grapes, pineapple)

Moderate-Low - can eat low - Tyramine-containing foods

Blocks reuptake of serotonin increasing levels in the synaptic cleft

MoA: - Selective Serotonin Reuptake Inhibitors (SSRI): Prototype: citalopram (Celexa)

First line treatment of depression; OCD, panic attacks, PTSD; off-label: chronic pain, neuropathies

Use: - Selective Serotonin Reuptake Inhibitors (SSRI): Prototype: citalopram (Celexa)

highly protein bound (warfarin, phenytoin) risk toxicity

Drug-drug: - Selective Serotonin Reuptake Inhibitors (SSRI): Prototype: citalopram (Celexa)

Less CV, anticholinergic, drowsiness affects than others (1st gen); sexual dysfunction, prolonged QTc

AE: - Selective Serotonin Reuptake Inhibitors (SSRI): Prototype: citalopram (Celexa)

slowly taper due to withdrawal syndrome; see general

Nursing: - Selective Serotonin Reuptake Inhibitors (SSRI): Prototype: citalopram (Celexa)

Blocks reuptake of NE and serotonin

MoA: - Selective Norepinephrine Reuptake Inhibitor (SNRI): Prototype: duloxetine (Cymbalta)

depression, anxiety; off-label: neuropathic pain, fibromyalgia; not as affective as SSRIs - not used as much as those but more than 1st gen since not as many AE

Use: - Selective Norepinephrine Reuptake Inhibitor (SNRI): Prototype: duloxetine (Cymbalta)

highly protein bound (warfarin, phenytoin) risk toxicity

Drug-drug: - Selective Norepinephrine Reuptake Inhibitor (SNRI): Prototype: duloxetine (Cymbalta)

GI effects; see general

AE: - Selective Norepinephrine Reuptake Inhibitor (SNRI): Prototype: duloxetine (Cymbalta)

see general

Nursing: - Selective Norepinephrine Reuptake Inhibitor (SNRI): Prototype: duloxetine (Cymbalta)

Notice that there is a drug-drug interaction with the SSRIs and SNRIs with highly protein bound drugs like warfarin that may lead to SSRI/SNRI toxicity. Knowing this information, what must also be true regarding SSRIs?

ANS: SSRIs/SNRIs are highly protein bound. If a patient is taking 2 drugs that are highly protein bound, both drugs are attempting to bind to proteins but there is limited protein available in the body. In this instance, less drug will bind to protein allowing more drug to remain in the bloodstream for distribution to tissues - increase risk for toxicity All want bind so less protein to bind to

Indication for drug (Depression > suicidal ideation (esp. children and adolescent age) - assess for SI - report to PCP/NP over pat) Related to AE (CNS, CV, GI, insomnia, sedation)

Assessment - Nursing care plan: antidepressants

Administer AM or HS (amiltriptolyne) depending on drowsiness or insomnia Teach: Report suicidal ideation - help PRN and care appropriately Drug name, dose, AE and non-pharm therapy for depression Therapeutic effect in 4-6 weeks

Intervention - Nursing care plan: antidepressants

Therapeutic response, AE, teaching, compliance Improving, more + thoughts, engaging in joyful activities

Evaluate - Nursing care plan: antidepressants

Long term effects not clearly understood Some studies – efficacy poor, increased risk for suicidal ideation Assess risk for suicide

Children - Drug therapy across the lifespan: antidepressants

Caution in pregnancy/lactation Neurological, cardiac, respiratory effects on fetus/baby

Adults - Drug therapy across the lifespan: antidepressants

More susceptible to adverse effects Reduce dose

Older Adults - Drug therapy across the lifespan: antidepressants

Which nursing intervention would help alleviate potential adverse effects of amitriptyline? A.Administer on an empty stomach B.Advise use of St. John’s Wort C.Limit fluid intake D.Administer at bedtime

Answer: D Rationale: Amitriptyline is highly sedating so the medication should be given at HS.

1.A 68-year-old patient has been taking an SSRI antidepressant for 3 weeks. His wife calls and expresses concern because he has started to give away some of his keepsakes. What is the nurse’s priority action at this time?

SI Meet with pat and if safe to go home The priority is to watch this patient closely for suicidal ideations, which may increase during the first weeks after antidepressant therapy is started. The nurse should instruct the wife to bring her husband in for a follow-up visit immediately and not to leave him alone.

2.A patient has been admitted to the hospital because of a suspected overdose of a TCA. What two problems are the nurse’s priority at this time?

Sedation Safety precautions - why OD The two priority problems that may occur after an overdose of tricyclic antidepressants are cardiac dysrhythmias and seizures, and both may lead to death. Overdoses of these medications can be lethal, especially if taken with alcohol.

Genetic association Hallucinations Paranoia Delusions Affective problems

Schizophrenia - Mental disorders and treatment goals

Extremes of depression alternating with hyperactivity/mania

Bipolar disorder - Mental disorders and treatment goals

Stabilize disorder Decrease debility Maintain functionality Limit adverse effects Maintain compliance

Goals: - Mental disorders and treatment goals

Differ in potency, severity of adverse effects, dose, route Med selection depends on desired potency and tolerance of adverse effects Varying therapeutic response Divided into typical and atypical categories Different mechanism of action Older adults Black box warning: not indicated for dementia behaviors (risk CV death)

Antipsychotics

Dopamine receptor blockers Due to blocking of dopamine receptor sites: result in Anticholinergic, antihistamine, alpha-adrenergic blocking effects - block variety receptor sites

Typical Antipsychotic: - Antipsychotis: MoA

Block both dopamine and serotonin receptors - not block as effectively - not see EPS as well, more metabolic effects Alleviate some of unpleasant neurological effects and depression associated with typical antipsychotics

Atypical Antipsychotic: - Antipsychotis: MoA

CNS effects: Anticholinergic effects CV effects: Gynecomastia Laryngospasm/bronchospasm Extrapyramidal symptoms - longer use more sig become Neuroleptic malignant syndrome (Rare)

Antipsychotics: gen AE

Sedation Tremor

CNS effects:

Hypotension (orthostatic) Arrhythmias (some prolong QTc) Heart failure (pulmonary edema)

CV effects:

Acute dyskinesia (tardive dyskinesia) Dystonia Pseudo parkinsonism

Extrapyramidal symptoms - longer use more sig become

Fever Altered mental status Muscle rigidity Autonomic dysfunction

Neuroleptic malignant syndrome (Rare)

Dystonia: spasms of tongue, neck, back, and legs Akathisia: continuous restlessness, constant movement –foot tapping Pseudo parkinsonism: muscle tremors, drooling, shuffling gait - blocking dopamine receptors give appearance have Parkinson’s disease because drug blocking dopamine Tardive dyskinesia: abnormal muscle movements - lip smacking, tongue darting, chewing movements

Neurologic AE - EPS from med; much can be reversed if slow down/stop med

CNS depression Parkinson’s disease - blocking dopamine receptors, exacerbate disease Cardiac disease/arrhythmias Bone marrow suppression/immunosuppressed Dementia Seizure disorders Conditions exacerbated by anticholinergic effects (constipation, BPH, etc.)

Antipsychotics: contraindications/cautions

Any exacerbate AE Increase risk for sedation: Increase anticholinergic effects Increase risk for serotonin syndrome Increase risk of prolonged QTc:

Antipsychotics: drug-drug interactions

CNS depressants Alcohol

Increase risk for sedation:

Anticholinergics

Increase anticholinergic effects

SSRI and SNRI

Increase risk for serotonin syndrome

Antidysrhythmic; any other med prolongs QTc

Increase risk of prolonged QTc:

The nurse is preparing to administer an antipsychotic to a client. Which additional prescribed medication puts the client at risk for increased sedation? A.Pseudoephedrine B.Loperamide C.Oxycodone D.Oxybutynin

Answer: C Rationale: Opioids can cause CNS depression and should be used in caution with antipsychotics. Opioids increase risk for sedation

The nurse is preparing to administer an antipsychotic to a client. Which additional prescribed medication puts the client at increased risk of constipation? A.Lactulose B.Docusate C.Oxybutynin D.Guaifenesin

Answer: C Rationale: Oxybutynin is an anticholinergic medication which increases the risk for constipation. Lactulose and docusate are indicated for the treatment of constipation. Guaifenesin decreases viscosity of respiratory tract secretions and does not cause constipation.

Block dopamine receptors, preventing stimulation of post-synaptic neurons; depresses reticular activating system of brain; anticholinergic, antihistaminic, alpha-adrenergic blocking - why variety AE

MoA: - Typical Antipsychotics: Prototype: haloperidol (Haldol)

Acute psychotic disorders/episodes

Use: - Typical Antipsychotics: Prototype: haloperidol (Haldol)

PO: 150% of parenteral dose: first pass effect affects bioavailability so need higher dose; IM: inject large muscle; IVP: 5 mg/min, monitor EKG (increased risk arrhythmias); switch to oral ASAP - less dangerous to pat

Route: - Typical Antipsychotics: Prototype: haloperidol (Haldol)

see general

AE: - Typical Antipsychotics: Prototype: haloperidol (Haldol)

see general; many other typical antipsychotics used for acute episodes and/or maintenance

Nursing: - Typical Antipsychotics: Prototype: haloperidol (Haldol)

Block dopamine and serotonin receptors, depresses the reticular activating system of brain; anticholinergic, antihistaminic, alpha-adrenergic blocking

MoA: - Atypical Antipsychotics: Prototype: clozapine (Clozaril)

Oral only; tablet, oral disintegrating, oral suspension

Route: - Atypical Antipsychotics: Prototype: clozapine (Clozaril)

increased blood glucose, weight gain, decreased WBC; see general

AE: - Atypical Antipsychotics: Prototype: clozapine (Clozaril)

periodically monitor blood glucose - induced T2DM because elevated BG; check WBC before starting therapy; see general

Nursing: - Atypical Antipsychotics: Prototype: clozapine (Clozaril)

Head to toe (many AE to monitor): CNS, listen to heart, BP,; Vital signs Labs as appropriate - BG, WBC - not often monitor

Assessment - Nursing care plan for antipsychotics

Taper with long term use Manage AE of medications - need maintain compliance as best can: manage anticholinergic effects: laxatives, water always available, EPS: not lot can do: higher fall risk High fall risk Teach

Interventions - Nursing care plan for antipsychotics

Abrupt withdrawal: gastritis, nausea, vomiting, dizziness, arrhythmias, insomnia

Taper with long term use

Drug name, dose, AE and how to manage Do not abruptly discontinue medication once feel better; diff with AE find ways to manage AE nonpharm

Teach

Therapeutic response, AE, teaching, compliance

Evaluate: - Nursing care plan for antipsychotics

Alters Na2+ transport in nerve and muscle cells; inhibits release of NE and dopamine from neurons; vary effective Is a salt: Follows same distribution pattern in body as water; excreted in kidneys, 80% reabsorbed of drug in renal tubule of kidneys Narrow therapeutic window/index: Therapeutic level: 0.6-1.2 mEq/L - blood levels monitored constantly - more effort on part of pat Issues when up to 1.5 Life-threatening toxicity > 2.5 mEq/L - narrow window of safety

MoA: - Bipolar Disorder Agents: Prototype: Lithium

renal disease, cardiac disease, sodium depletion/altered sodium levels - alters where drug goes and how reabsorped - needs be consistently rehydrated because effects how moved throughout body, pregnancy (X)/lactation

Contraindications/cautions: - Bipolar Disorder Agents: Prototype: Lithium

diuretics (excess fluid - hyponatremia, dehydration); haloperidol (encephalopathic syndrome and could have irreversible brain damage)

Drug-drug: - Prototype: lithium

Related to serum levels of the medication - therapeutic level not lot AE, issue when levels rise; higher get more severe AE; teach to monitor for GI effects and increase urination if having lot of that

AE: - Prototype: lithium

GI effects (n/v/d) - early indication of increasing blood levels (1.5) CNS: lethargy, slurred speech, weakness, tremor, ataxia, clonic movements, hyperreflexia, seizures Renal: mild: polyuria; toxicity: Nephrogenic (originating from kidneys) diabetes insipidus - DI: large amounts urine output, toxic: large volumes output - monitor for CNS and how severe DI is Cardiac: life-threatening arrhythmias

AE: Related to serum levels of the medication - therapeutic level not lot AE, issue when levels rise; higher get more severe AE; teach to monitor for GI effects and increase urination if having lot of that

Neurologic status: LOC, gait, reflexes, tremors Monitor s/s toxicity - GI effects/renal first; see where at with bipolar: well controlled/not Serum lithium levels 2x’s/week initially and once levels stable and adequately treating levels, then every 2 months - quite a bit and struggle for those with issues with compliance Skin turgor daily Weigh daily Look for Edema - dehydration/disorder with water balance because effects med Kidney function - as declines excretion drug declines so at risk for toxicity

Assessment - Nursing care plan: lithium

Maintain consistent hydration and sodium intake! Fall risk if CNS effects associated with elevated lithium occur Teach

Interventions - Nursing care plan: lithium

Follows same distribution pattern in body as water; excreted in kidneys, 80% reabsorbed - not want alter Na and water intake and at risk for dehydration - higher risk for toxicity Sodium depletion or dehydration = more reabsorption lithium = toxicity

Maintain consistent hydration and sodium intake!

Drug name, dose, AE (minor vs. severe toxicity-ER), blood monitoring Therapeutic effects 1-3 weeks to become therapeutic Not to operate heavy machinery until levels are stable - not too sedated or CNS effects and stable before that Contraception as appropriate - Pregnancy category X Lot urine output/dysrhythmia - toxicity - ER

Teach