Psychopharmacology Flashcards
Components of CNS
brain and spinal cord cerebrum cerebellum brain stem limbic system
Cerebrum
cerebral hemispheres
- frontal
- temporal
- parietal
- occipital
Frontal Lobe
Prefrontal cortex (PFC)
“executive center”
-regulation of attention, behavior, and emotion, decision making
-cognition, perception, affect, behavior (predominant dysfunction in the PFC w/ schizophrenia)
-inattention, impulsivity, motor hyperactivity (weaker function and structure of PFC w/ ADHD)
Temporal Lobe
center for sense of smell and hearing
deficits of auditory processing (w/ schizophrenia)
Occipital Lobe
language generation
visual interpretation (depth perception)
memory processing
Parietal Lobe
interpret sensations of taste and touch
Cerebellum
coordination of movements
Limbic System
includes: thalamus, hypothalamus, hippocampus, and amygdala
emotional regulation
Neurobiologic Causes of Mental Illness
- genetics
- stress and the immune system (inflammatory response)
- infection (viral theories and schizophrenia)
chemical imbalance
- serotonin and depression
- dopamine and schizophrenia
Neurotransmitters
dopamine serotonin norepinephrine epinephrine histamine acetylcholine glutamate GABA
Serotonin
derived from: tryptophan
involved in: control of food intake, sleep and wakefulness, temperature regulation, pain control, sexual behavior, and regulation of emotions
role in: anxiety, schizophrenia, and mood disorders
SSRI
selective serotonin reuptake inhibitors
block the reuptake of serotonin from the synaptic cleft, and thus this NT stays longer in the gap than normal > increase in serotonergic activity
hallmark med = fluoxetine (Prozac)
equally as efficacious as TCAs, but w/ fewer SEs
takes 4-6wks to see full therapeutic effect
Dopamine
involved in: control of complex movements, motivation, cognition, regulation of emotional responses
antipsychotics block dopamine receptors > reduce dopamine activity
Histamine
function: chemical messenger responsible for allergic response, control of gastric secretions, cardiac stimulations, alertness
implications: schizophrenia, sleep disorders, Alzheimer’s
psychiatric medications (diphenhydramine, hydroxyzine, Doxepin, amitriptyline (TCA), antipsychotics) block histamine and result in: -weight gain, sedation, hypotension, constipation, cognitive
Acetylcholine
- controls sleep and wakefulness
- implications in Alzheimer’s disease
Glutamate
workin in an excitatory capacity in the brain
major mediator of cognition, memory, and learning
implication in Alzheimer’s
GABA (Gamma-aminobutyric acid)
involved in the inhibition of vigilance, anxiety, muscle tension and memory enhancement
implication: anxiety, sleep
* benzodiazepines: increase GABA function and induce sleep
Norepinephrine/Epinephrine
attention, learning, memory, sleep, wakefulness
implications: mood, person’s ability to concentrate, anxiety
Brain Imaging
Computed tomography (CT) - radiation
Magnetic resonance imaging (MRI) - risk from magnetic field
Positron emission tomography (PET) - radiation
Single-photon emission computed tomography (SECT) - radiation
- brain imagining alone cannot be used to dx a mental health condition
- used to r/o another medical condition
Psychopharmacology Med Classes
Antipsychotics Antidepressants Mood stabilizers Anxiolytics Simulants Medications for substance use disorders
Efficacy
maximal therapeutic effect that a drug can achieve
Potency
amount of drug needed to achieve maximum effect
Half-life
amount of time for half of the drug to be removed from the bloodstream
Off label use
use of a drug for a condition not approved by the FDA
Black box warning
separate warning which contains serious or life-threatening side effects
Discontinuation withdrawal
many medications need to be tapered before stopped (shorter half life might need to give more often)
Antipsychotics: Use
- psychosis (positive symptoms)
- mood stabilization
off label: anxiety, insomnia, aggressive behavior
Antipsychotic Meds
first generation (older, more associated w/ TD and EPS SEs)
- chlorpromazine (Thorazine)
- perphenazine (Trilafon)
- fluphenazine (Prolixin)*
- haloperidol (Haldol)*
second generation: have more metabolic SEs
- clozapine (Clozaril)
- risperidone (risperdal)*
- olanzapine (Zyprexa)*
- quetiapine (Seroquel)
- Ziprasidone (Geodon)
- Paliperidone (Invega)*
- Iloperidone (Fanapt)
- asenapine (Saphris)
- lurasidone (Latuda)
second generation meds that can used for mood disorder like bipolar depression:
-aripiprazole (Abilify)*
*available as depot
Depot Injection
long acting injectables (LAI)
six antipsychotic meds are available as depot
Antipsychotics: Black Box Warnings
elderly patients with dementia related psychosis: increased mortality risk w/ conventional (first generation) or atypical antipsychotics
most deaths d/t cardiovascular or infectious events
EPS
Dystonia: seen in the neck, emergency, give IM benztropine
Drug-induced parkinsonism: tremors, shuffling gait, flat affect/ mask like face, slower movements in general
Akathisia: restlessness, can’t sit, pt will report this subjectively as well
TD: oral/facial movements (tongue protruding)
-in assessment of this ensure they do not have denture or gum and then distract them by having them touch their thumb to each finger.
*EPS is assessed via AIMS exam
Medications Used to Treat EPS
benztropine (2-8mg per day)
benadryl
NMS
neuroleptic malignant syndrome
infrequent/rare
potentially life-threatening condition
s/sx:
- fever
- rigid muscles
- altered consciousness
SE of Antipsychotics
- EPS
- TD
- elevated prolactin > breast enlargement or tenderness (can happen in men) and decreased libido
- common w/ risperidone (Risperdal)
- weight gain
- most significant w/ clozaril and olanzapine
Clozaril: SE
- wide Qtc (at risk for dysrhytmias)
- weight gain (metabolic syndrome)
- lower seizure threshold
- agranulocytosis! (look at ANC values)
- myocarditis (at onset of tx)
- constipation!
- low risk for EPS
baseline EKG before initiating tx
used when failed 4-6wk trial of two different antipsychotics at max dose
Antidepressants: Uses
depression, anxiety, OCD
off label uses: chronic pain, migraines
Antidepressants: Types
- Tricyclic
- SE: sedation, orthostatic HTN, anticholinergic - SSRI
- MAOIs
- SE: hypertensive crisis w/ foods containing tyramines, many drug interactions - Other antidepressants
TCA
- desipramine (Norpramin): used for children w/ bedwetting issues
- amitriptyline (Elavil)
- nortriptyline (Pamelor)
- Doxepin
- Mirtaxapine
- Clomipramine: more efficacious w/ treating OCD
MAOIs
Monoamine Oxidase Inhibitors
-phenelzine (Nardil)
potentially life-threatening hypertensive crisis w/ foods containing tyramine
Other Antidepressants
- bupropion (Wellbutrin)
- Venlafaxine
- Desvenlafaxine
- Duloxetine
- Trazodone (Nefazodone - avoided b/c of life-threatening liver damage that can occur)
- Vilazodone
SSRI/SNRI: SE
- GI upset at onset of tx
- Sexual SE (anorgasmia, impotence, decreased libido)
- sleep disturbances (take in morning to reduce this)
- weight gain
- akathisia
- sweating
- paroxetine (more sedation)
- withdrawal syndrome
- monitor for increases in BP
TCA: SE
anticholinergic effects: dry mouth, blurred vision, urinary retention, constipation, tachycardia
cholinergic blockade and cardiac toxicity in overdose situations
drug levels can be obtained
don’t give to someone who is high risk for suicide unless safety measures can be ensured (like handing them out daily to them)
Bupropion
Wellbutrin
- inhibit dopamin uptake
- aid to quit smoking
- used for depression and ADHD
- sex and drug
- weight loss
- SEIZURE RISK (don’t use w/ seizure hx/ eating disorder)
Trazodone
sleep
priapism
Serotonin Syndrome: S/Sx
in order of appearance:
- diarrhea
- restlessness
- extreme agitation
- hyperreflexia
- autonomic instability
- myoclonus
- seizures
- rigidity
- delirium, coma, death
Antidepressants: Black Box Warning
increased risk for suicidality in children, adolescents, and young adults w/ MDD or other psychiatric disorders
- observe all pt’s clinical worsening, sucidality, or unusual behavior changes
- may advise families or caregivers to closely observe and communicate w/ the prescriber as needed
Mood Stabilizers
used in tx of bipolar disorder
- lithium
- valproic acid
- gabapentin (used for neuropathic pain, anxiety, adjunct in opioid and alcohol withdrawal)
- carbamazepine (Tegratol)
- Topiramate
- Oxcarbamazepine (Trileptal)
- lamotrigine
- drug levels are important w/ mood stabilizers
- can get 12 hours after last dose
Lithium
-gold standard
-suicide protective
-serum levels needed
monitor renal and thyroid function (hypothyroid)
-avoid use of NSAIDs to prevent toxic accumulation
black box warning: NARROW THERAPEUTIC RANGE (0.8-1.2)
Lithium: SEs
tremor polydipsia metallic taste fatigue acne alopecia worsens psoriasis
toxic effects: severe diarrhea vomiting drowsiness muscle weakness lack of coordination ataxia
Carbamazepine: SEs
- interferes w/ birth control
- hyponatremia
- check LFT’s
- sedation
- teratogenesis (risk to developing fetus so this med might be avoided in women of child bearing age)
- grapefruit juice = inhibitory > increase in blood levels
black box warning: aplastic anemia, agranulocytosis
Lamotrigine
black box warning: steven’s Johnson’s rash
pt education
start low and go slow w/ dosing
Valproic Acid: SE
can obtain level
black box warning: hepatotoxicity (check liver fxn), congenital malformations (caution in use w/ females or reproductive age), pancreatitis
most sedating so person might take at bedtime
bone marrow suppression (check CBC)
Topiramate: SE
weight loss
dizziness
sedation
increased risk for renal calculi
Anxiolytics
uses: pain, OCD, social anxiety, GAD
benzodiazepines:
- alprazolam
- chlordiazepoxide
- clonazepam
- diazepam (long half-life, used for alcohol withdrawal)
- oxazepam
- lorazepam
non-benzodiazepines:
- buspirone
- beta blockers
- centrally acting alpha blockers
- anticonvuslants
Benzodiazepines: SEs
- CNS depression (sedation, ataxia, decreased cognitive function)
- risk of combination of CNS depressants
- potentiation of the effects of alcohol
- special considerations in the elderly
- withdrawal secondary to dependency (potentially lethal - seizure, DTs)
- pregnancy category D
- controlled substance
- lorazepam used for alcohol WD in pts with liver dysfunction b/c no active metabolites
Zolpidem
benzo like med used for sleep
black box warning: sleep walking, sleep-driving, engagement in activities while not fully awake
Stimulants
use: ADHD, narcolepsy
methylphenidate (Concerta)
amphetamine
dextroamphetamine
nursing interventions:
- give early in the day (no later than 1600)
- monitor weight
- caffeine use
- monitor for tics
Other ADHD Medications
- bupropion
- atomoxetine (SNRI - FDA approved for ADHD)
- black box warning: increased risk for suicidality in children/adolescents w/ ADHD
- guanefacine
Stimulants: SE
- anorexia
- weight loss
- nausea
- irritability
-precautions: psychosis, severe anxiety, cardiovascular hx, substance use
Medications for Alcohol Use
Disulfiram - aversion therapy (prevent)
*works by making pt violently ill when they drink alcohol
Naltrexone - craving
Acamprosate - reduction in withdrawal symptoms
Medications for Opioid use Disorder
buprenophine - agonist/antagonist
methadone - agonist
naltrexone - antagonist
Medications for Tobacco Use Disorder
bupropion (branded as Zyban) - attenuating the effects of nicotine withdrawal
NRT
Varenicline:
- nicotine receptor agonist > promotes release of dopamine to stimulate the pleasurable effects of nicotine
- reduces craving and withdrawal
- don’t give with NRT
Medications for Stimulant Use Disorder
no FDA approved meds for stimulant use disorder
