Week 6 Part 1: Psychopharmacology Flashcards
What is the predominant goal for medication getting to the public
Safety
Before 1950s what drugs were usually used for psychiatric illnesses? What has it expanded to since then?
1950s - Sedatives and Amphetamines
Now - antipsychotics, antidepressants, anti anxiety meds
Psychotropic medications are intended to be utilized…
with adjunct therapies - individual and group psychotherapy
combo therapies and meds lead to best results
___ have become the dominant treatment of psychiatric disorders
medications
What is the purposes of psychotropic drugs
relieve or reduce symptoms of dysfunctional thoughts, moods, or actions, mental illness or disorder
improve client functioning
increase clients adhered or compliance to other therapies
increase productivity and independence - the end goal!
Reasons for Nonadherence to Psychotropic Med Regimen
Expensive - Unaffordable
Unpleasant or distressing SE
Stopping because they feel they no longer need them
May not believe they have an illness warranting the meds
Stigma
denial or fears about medication usage from mental illness like paranoia
Pharmocodynamnics
study of mechanisms of acton and biochemical and physiologic effects of drugs
What is the main basic principle of psychopharmacology
mental illness symptoms result from chemical imbalances within the nervous system (CNS - brain and spinal cord)
Neurotransmission
process in which the interactive systems help the brain navigate the internal and external stimuli and allows the brain to create consciousness awareness of sensory perceptions
the brain decides how to respond to the stimuli, stores the memories of the response, and then subsequent responses are usually behavioral with some accompanied emotions
Any disruption in neurotransmission…
can affect cognition or the ability to accurately perceieve, or process incoming information or stimuli
4 Sites of Pharmacodynamic Action
Receptors
Ion Channels
Enzymes
Carrier Proteins: Uptake Receptors
Where are neurotransmitters stored and release
in the axon terminals of the presynaptic neuron
electrical impulses through the neuron wil; stimulate NT release into the synaptic cleft which determines whether another electrical impulse is generated
Reuptake
the process of NT inactivation by which the NT is reabsorbed into the presynaptic neuron form which it had been released
The funamental action of psychotropic medications is to…
alter either the transmission or reception of nerve impulses resulting in the increasing or slowing of nervous system functions
3 types of Psychotropic Meds
- Antidepressants
- Antipsychotics
- Benzodiazepines (Anti-Anxiety)
Antidepressants
class of psychotropic drugs that block reuptake of NT
Antipsychotics
class of psychotropic drugs that block dopamine and other receptors
Benzodiazepines
class of anti anxiety drugs
facilitates transmission of GABA to decrease excitability
How long does relief of symptoms take with antidepressants
initial improvement for some in 7 days but takes several weeks to get complete relief
Why should antidepressants never be discontinued abruptly
uncomfortable symptoms such as depression and anxiety from withdrawal, which are often worse than the original depression leading to a vicious cycle
Why is there an increased risk of suicidal behavior sometimes associated with anti depressants
increased in children and adolescents
but risk for suicide increases because they feel better and gain energy before they are fully relieved of depression
Types of Antidepressants
SSRI
SNRI
NDRI
NaSSA
SARI
SSRIs
selective serotonin reuptake inhibitors - antidepressant
inhibit serotonin reuptake by blocking presynaptic neuron increasing serotonin concentration
ex: Prozac, Selexa, Lexapro, Zoloft, Paxil, Luvox
SE of SSRIs
HA
anxiety
insomnia
transient nausea and vomiting
diarrhea
sedation
sexual dysfunction
diastolic HTN
increased perspiration
SNRIs
serotonin norepinephrine reuptake inhibitors - antidepressant
prevent reuptake of serotonin and NEP at presynaptic site
ex: Effexor, Serzone, Cymbalta, Norpramin
Side Effects of SNRIs
same as SSRIs + increased blood pressure
NDRI
NEP Dopamine Reuptake INhibitor - antidepressant
INhibits reuptake of dopamine NEP and serotonin
ex: Wellbutrin, Zyban
SE of NDRIs
agitation
anxiety
insomnia
appetite suppression
psychosis
increased seizures
It is very important to do what prior to giving NDRIs
VERIFYING PREVIOUS SEIZURE HX SINCE IT INCREASES INCIDENCE
NaSSA
alpha 2 antagonists - antidepressants
boosts NEP/Noradrenaline serotonin by blocking alpha 2 adrenergic presynaptic receptors on a serotonin receptor
ex: Remeron
SE of NaSSA
sedation (at lower doses)
dizziness
weight gain
dry mouth
constipation
change in urinary fxn
SARI
serotonin 2 antagonist/reuptake inhibitor - antidepressant
blocks serotonin 2A receptor potently and serotonin reuptake less potently
ex: Deyrel
SE of SARIs
sedation
weight gain
NV
constipation
dizziness
fatigue
incoordination!
tremor!
What can cause a toxic, sometimes fatal, reaction when used with an SSRI
MAOIs
SSRI use can boost the effects of what drugs
Tricycle antidepressants
hydantoin
clozapine
haloperidol
beta blockers
st johns worts (EVEN OTC!!!)
warfarin
etc
SSRI can decrease effects of ___ and ___
digoxin and buspirone
What popular psych drug can increase effects of SSRI
lithium
What can occur when SSRIs are used with other drugs that increase serotonin
Serotonin Syndrome - emergency!
S/S of Serotonin Syndrome
mental status change - hallucination, agitation, coma
Autonomic instability - tachycardia, hyperthermia, BP changes
Neuromuscular problems - hyperreflexia, incoordination
GI disturbance - NVD
Serotoning syndrome can be __ ___
life threatening
The effects of SSRIs are generally not seen for ___-___ days and it will take how long to reach full client benefit?
10-21 days
takes weeks longer after the first 10-21 days to reach full benefit
What is important to teach the patient regarding SSRI/SNRI
relief not immediate - will be experienced in time
skipping a dose can cause withdrawal symptoms
low to medium dose may cause sexual SE
Tricyclic Antidepressants
TCAs
Made in 60s - first drug to treat major depression
blocks NEP and serotonin and AcH - works on a lot of NT systems and serotoning reuptake
ex: Elavil, Tofranil, Asendin, Norpramin, Vivactil
TCA S/S
Early Morning Wakening, Anxiety, Weight Loss Panic, Compulsive Disorders - for those responding well
Blocking NEP, Serotonin and AcH has cholinergic effects = dry mouth, blurred vision, Urinary retention, delayed micturation, confusion, constipation, hypotension
others: tremors, restlessness, insomnia, NV, confusion, pedal edema, HA, seizures, blood dyscrasia
The most common side effects of TCAs are
sedation
orthostatic Hypotension
anticholinergic SE like dry mouth, blurry vision, urinary retention and delay, confusion, constipation, and hypotension
the biggest s/s of TCAs is
early morning awakening
TCAs are as effective as ___, but…
SSRIs, but have more serious side effects and a higher lethal potential
If the TCA causes sedation….
dose should be given at bedtime
The more sedating the TCA…
the more anticholinergic properties it has
TCA dosage for elderly is ___ adult dose
1/2
Alcohol intake in conjunction with TCA causes ___ and ___
sedation and ataxia
Why can’t suicidal clients take TCAs
because of fatal cardiac and cerebral toxicity in overdoses of TCA
___ and ___ are effective in treating depression, but are not as safe or well tolerated as antidepressants like SSRI, SNRI, NDRI
MAOI and TCAs
2 Important OTC Anti Depressants
St Johns Wort
Kava
St Johns Wort (SJW)
used for depression, pain anxiety, insomnia, and premenstrual syndrome
modulates serotonin, dopamine, and NEP
Risk of developing serotonin syndrome when taken with other serotonergic drugs
Kava
used for anxiety reduction
interacts with dopaminergic transmission, inhibits MAO-B enzyme system and modulates GABA receptors
risk for severe liver injury, thrombocytopenia, leukopenia, and hearing impairment
MAOIs
Antidepressant
Monoamine oxidase inhibitors
Inhibits MAO, an enzyme that breaks down serotoning, NEP, and others - by inhibiting this enzyme serotonin and NEP activity is increased in the synapse
SE of MAOIs
dizziness
HA
insomnia
dry mouth
blurred vision
constipation
NV
peripheral edema
urinary hesitancy
muscle weakness
forgetfulness
weight gain
sexual dysfunction
Never eat what kinds of foods when taking MAOIs
Tyramine Rich Foods
Why do you never eat tyramine rich foods with MAOIs
it will result in hypertensive crisis
What are some tyramine rich foods to avoid with MAOIs
Cheeses
Herbal Extracts (Palmetto, Ginseng)
Fruits (avoacdos, overripe and dried fruit, egg plant, grapes, figs, organes, pineapple, plum, prune, raisin)
Process foods (yeast extract, sauerkraut, shrimp paste, pickled meats and vegis)
Meat and Fish (liver, game birds, meat by products)
Soy
Chocolate (in hihg quantities it causes HA NV)
What other than tyramine rihc foods causes hypertensive crisis with MAOI use
amphetamines, methyldopa, levodopa, EP, NEP, Dopamine, vasoconstrictors, narcotic analgesics
some other antidepressants
How long should you avoid other antidepressant use when having taken an MAOI
avoid use within 2 weeks of each other
Important Nursing Considerations for MAOI use
extensive instruction about foods and medications to avoid with MAOI use like cheese, cold and decongestant medication and nasal sprays
severe HA, excess perspiration, lightheaded, vomiting, increased HR - MAOI hyptensive crisis liekly hold meds and contact physician + ER
MAOIs can never be combined with ____
SSRIs
Action of Antidepressants
increase concentration of NEP and serotonin in the body by blocking reuptake - TCA, SSRI
or
inhibiting release of MAO - MAOIs
Mood Stabilizers (Anti Mania Drugs)
Lithium
Anticonvulsants
Calcium Channel Blockers
Adrenergic Blocking Agents
Atypical Antipsychotics
Lithium
med for bipolar disorder - 40% effectiveness
Action of Lithium
uncertain - crosses cell membranes altering sodium transport, not protein bound
Onset of Lithium
5-7 days may take as long as 2 weeks
Therapeutic Lithium Blood Levels are…
0.8 to 1.5 mEq/L
SE of Lithium
thirst
metallic taste
increased frequency of urination
fine head and hand tremor
drowsiness
mild diarrhea
Nursing Considerations for Lithium
Lithium Toxicity - monitor blood levels
Monitor Creatinine concen, thyroid hormones and CBC every 6 months
Kidney damage risk
thryoid function alteration after 6-18 months including potentia dry skin, bradycardia, constipation, hair loss, and cold intolerance
Lithium Toxicity S/S
severe diarrhea
vomiting
drowsiness
muscular weakness and lack of coord
Lithium toxicity occurs when…
sodium levels are low and absorption is disrupted - excessive hear, diaphoresis, diuretic
Lithium Toxicity signs below 1.5 mEq/L
lethargy slurred speech muscle weakness hand tremors NVD
LIthium Toxicity signs between 1.5 and 2 mEq/L
coarse hand tremor, mental confusion, drowsiness, lack of coord, GI distress, EKG changes
Lithium toxicity signs between 2-2.5 mEq/L
ataxia, blurred vision, stupor, coma, resp failure
What lithium level is life threatening
above 2.5 mEq/L
Important Teaching Needs for Patients Taking Lithium
- Several weeks for full benefit - if a dose is missed DO NOT DOUBLE UP
- Do not change salt intake consumption
- Do not take pain meds, alcohol, sleeping pills as this will enhance sedation effects
- Weight increase common
- Avoid caffeine - impacts effectiveness
- Serum blood tests 2x weekly for initial beginning therapy
Higher salt concentrations do what to lithium
decreases absorption (and effectiveness)
Anticonvulsant
Mood Stabilizer Drug
Reduces repetitive firin og action potentials in the nerves
When are anti convulsants used as mood stabilizers
when patients have no responded well to lithium
Pharmacokinetics of Anticonvulsants
peak serum levels in 1-4 hours
patients need education on potential drug interactions
Carbamazepine (Tegretol)
anti convulsant/mood stabilizer
effective for aggressive and hostile symptoms
Lamotrigin (Lamictal)
anti convulsant / mood stabilizer
decreases manic behaviors
Oxcarbazepine (Trileptal)
useful in bipolar
What requires immediate medical intervention if experienced while on anticonvulsants
any rash
Carbamazepine SE
Dizziness
Drowsiness
Tremor
Visual Disturbances
NV
weight gain
alopecia
There is increased risk for what when taking Carbamazepine
increased risk for aplastic anemia and agranulocytosis
How to minimize carbamazepine SE
minimized by treating in low doses
given with food
SE of Lamotrigine (Lamictal)
benign skin rash
sedation
blurred or double vision
dizziness
NV
Other GI symptoms
In rare cases what can occur with Lamotrigine (Lamictal)
Stevens Johnson Syndrome - 15%
A severe life threatening rash that occurs within 2-8 weeks of treatment
Immediately discontinued if rash is noted
Indications for Mood Stabilizer/Anti Convulsant Use?
prevention and treatment of manic episodes associated with bipolar disorder
Nursing Dx potentials post anti psychotic/mood stabilizer/anti convulsant
risk for injury
risk for self directed or other direct violence
risk for activity intolerance
What mood stabilizers require blood monitoring to prevent toxicity
lithium
depakote
tegretol
When taking lithium, what should the client make sure to do
take in adequate 2-3 liters/day
eat a balanced diet with nL SODIUM INTAKE
Mood Stabilizers should be …
taken with food
Do not take mood stabilizers without docto permission, and report any ____, and do not use…
any bruising; not use heavy equipment if drowsy
When it comes to mood stabilizers, clients should understand the importance of…
regular blood monitoring
Anxiolytics
antianxiety medications used for generalized anxiety disorders, acute anxiety states, social phobia, performance anxiety, and even some short term insomnia relief
Buspirone (Buspar)
Anti Anxiety medication
binds to serotonin receptor via unknown mechanism of action
NOT an anticonvulsant, sedative or muscle relaxant
contraindicated in renal and liver impairment and in lactating women
Benzodiazepines
anxiolytics - antianxiety meds
sedation, muscle relaxant, elevation in seizure threshold
works on GABA receptors to dampen neural overstimulation
Examples of Benzodiazepines
Xanax
Ativan
Valium
Dalmane
Serax
Halcion
Benzodiazepines are used for…
short term relief of anxiety or anxiety associated with depression
SE of Benzos
drowsiness
intellectual impairment
memory impairment
ataxia
reduced motor coordination
sedation
hangover effects
tolerance development
alcohol potentiating CNS depression
abrup discontinuation may result in targe symptom recurrence (rebound)
Important Nonbenzodiazepine antianxiety medications to know
buspirone (Buspar)
zolpidem (Ambien)
Nonbenzodiazepines like Buspar and Ambien are useful in what way compared to benzodiazepines
effective for treating anxiety disorders without the CNS depression effects or the potential for abuse and withdrawal syndromes
Main SE of Nonbenzodiazepine antianxiety drugs
dizziness
drowsiness
nausea
Indications for Anti Anxiety Medications
short term management of various anxiety states and treatment of insomnia
Action of most anti anxiety meds
depression of the CNS
Contraindications and Precautions for Anti Anxiety Medications
those with known hypersensitivity
caution in those with hepatic dysfunction or severe renal impairment, those that are suicidal and those that have been addicted to drugs before
What interactions change anti anxiety med effects
- Additive CNS depression with alcohol, anti histamines, antidepressants, phenothiazine, or other CNS depressent drugs
- Barbituates decrease effectiveness of drugs metabolized by the liver
- Adverse effect when taken with MAOI
Indications for antipsychotic med use
treatment of acute and chronic psychoses
selected agents are also used as antiemetics in the treatment of intractable hiccoughs and for control of tics and vocal utterances in tourettes
Action of Antipsychotic meds
unknown
though to block post synaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla
newer antipsychotics may block action on receptors specific to dopamine, serotonin and other NTs
Antipsychotic big benefit and negative when released
huge breakthrough but SE are significant with some irreversible
Nursing Diagnoses related to antipsychotic meds
risk for injury
disturbed sleep pattern
risk for activity intolerance
risk for acute confusion
Antipsychotic medications target symptoms of what
schizophrenia
mania
autism
symptoms of psychosis such as hallucination, delusion, bizarre behavior, disorganized thinking, agitation psychosis
Antipsyhotic meds mostly target what
the NT dopamine
Examples of Typical and Atypical Antipsychotic meds
typical: Prolixin, Navane, Loxitane, Haldol
atypical: Clozeril, Abilify, Geodon, Zyprexa
What is the big difference between typical and atypical antipsychotic meds
atypical meds have far fewer side effects
SE of Typical/Traditional Antipsychotic Meds
Cardiovascular / Orthostatic Hypotension - HIGH FALL RISK
Anticholinergic effects
weight gain
diabetes
sexual side effects
blood dyscrasias
neuroleptic malignant syndrome
photosensitivity
lowered seizure threshold
medication related movement disorders
SE of Atypical Antipsychotic Medications
sedation
weight gain
insomnia
agitation
minimal anticholinergic effects
MUCH LESS RISK OF DEVELOPING EPS AND/OR TARDIVE DYSKINISA
___ is an atypical antipsychotic with greater sedation, anticholinergic, and orthostatic hypotension effects than others
Clozaril
The importance of regular administration of antipsychotic medications is to …
provide treatment and prevent exacerbations of psychosis
While taking clozaril, what must a patient have done
They may need to have blood count monitored frequently because of the drugs potential for bone marrow toxicity (leads to low WBC)
Acute and Chronic Extrapyramidal Syndromes that can be Medication Related Movement Disorders
Dystonia, Pseudoparkinsonism, Akathisia - Acute
Tardive Dyskinisia - Chronic
Dystonia
involuntary muscle spasms
abnormal postures
oculogyric crisis
torticollis
acute movement disorder related to medication use
Pseudoparkinsonism
rigidity, akinesia (swlo movement)
tremor
masklike face
loss of spontaneous movements
acute movement disorder related to medication use
Akathisia
inability to sit still
restlessness
acute movement disorder related to medication use
Medication Related Movement Disorders sometimes occur as a result of using what type of medicine
anti psychotics
What is the etiology of medication related movement disorders
related to dopamine in nigrostrial pathway that increases cholinergic activity
Tx for Acute Medication Related Movement Disorders
Anticholinergic medication for dystonia and parkinsonism (Artane and Congentin)
Akathisia does not usually respond to anticholinergic meds, but beta blockers have best success
Tardive Dyskinesia
irregular, reptitive, involuntary movement sof mouth, face, and tongue, including chewing, tongue protrusion, lip smacking, puckering of the lips and rapid eye blinking
abnormal finger movements are common
a chronic medication related movement disorder syndrome
When do symptoms begin for medication related tardive dyskinesia and are they reversible?
potentially irreversible
begin 6 months after start of antipsychotic use or when they are withdrawn
Etiology of Tardive Dyskinesia
cause unclear
Tx for Tardive Dyskinesia
prevention by using atypical antipsychotics, using lowest possible dose, minimizine use of PRN, closely monitoring those in high risk groups
standardized assessments to monitor at a minimium of 3 to 6 month intervals
Nursing Diagnoses for Anti Psychotics and Medication Related Movement Disorders
risk for other directed violence
risk for injury
risk for activity intolerance
noncompliance
The most common reason for psych medication noncompliance is…
side effects!
Compliance to psych med regimens can be improved through…
education
Psychiatric nurses should actively…
address compliance concerns
