Transcript Psychotherapeutic Drugs

CHAPTER 15
Psychotherapeutic Drugs
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Types of Drugs
Antianxiety drugs
Antidepressants
Antimanic drugs
Antipsychotics
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Psychotherapeutics
The treatment of emotional
and mental disorders
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Psychotherapeutics (cont’d)
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Normal human emotions
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
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Anxiety
Grief
Depression
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Psychotherapeutics (cont’d)
The ability to cope with these emotions can
range from occasional depression or anxiety
to constant emotional distress to the point of
interfering with the ability to carry on normal
activities of daily living
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Psychotherapeutics (cont’d)
When these emotions significantly affect an
individual’s ability to carry out normal daily
functions, treatment with a psychotherapeutic
drug is a possible option
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Psychotherapeutics (cont’d)
Three main emotional and mental disorders:
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Psychoses
Affective disorders
Anxiety
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Psychosis
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
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A 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
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Affective Disorders
(Mood Disorders)
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
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)
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Anxiety
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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
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Anxiety Disorders
Six major anxiety disorders (persistent anxiety)
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Obsessive-compulsive disorder (OCD)
Posttraumatic stress disorder (PTSD)
Generalized anxiety disorder (GAD)
Panic disorder
Social phobia
Simple phobia
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Psychotherapeutics:
Pathophysiology
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Biochemical imbalance theory
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Mental disorders are associated with
abnormal levels of endogenous chemicals,
such as neurotransmitters, in the brain
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Pathophysiology
Biochemical imbalance theory (cont'd)
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Brain levels of certain neurotransmitters play an
important role in maintaining mental health
Catecholamines
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Dopamine
Norepinephrine
Indolamines
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Serotonin
Histamine
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Biochemical Imbalance

Other biochemicals are necessary for normal
mental function
 GABA
 Acetylcholine (ACh)
 Sodium, potassium, magnesium
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Antianxiety Drugs
All reduce anxiety by reducing overactivity in
the CNS
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Benzodiazepines
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Depress activity in the brainstem and limbic system
Antihistamines
Depress CNS by sedation
 Primarily used for allergic conditions
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Misc. drug: buspirone (BuSpar)
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Nonsedating and non–habit forming
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Antianxiety Drugs (cont’d)
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Barbiturates and carbamates
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Previously used to treat anxiety
Replaced by newer drugs
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Antianxiety Drugs:
Indications
Anxiety
 Sedation
 Muscle relaxation
 Seizure control
 Adjuvant therapy for depression
 Alcohol withdrawal

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Common Benzodiazepine
Anxiolytics
diazepam (Valium)
 lorazepam (Ativan)
 alprazolam (Xanax)
 clonazepam (Klonopin)
 chlordiazepoxide (Librium)

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Common Benzodiazepine
Anxiolytics (cont’d)
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midazolam (Versed)*
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Reduces anxiety and patient’s memory of painful
procedures that do not require general anesthesia
(moderate sedation)
Injection only
* Limited to use as sedative and anesthetic during invasive medical
or surgical procedures
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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

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Benzodiazepines
Potentially habit-forming and addictive
 Should be used at lowest effective dosages and
frequencies needed for symptom control
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Benzodiazepines–overdose
Dangerous when taken with other sedatives or
alcohol
 Treatment is generally symptomatic and supportive
 Flumazenil may be used to reverse benzodiazepine
effects

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Antimanic Drugs
Lithium is the drug of choice for the
treatment of mania
It is thought to potentiate serotonergic
neurotransmission
 May be used with other medications to stabilize
mood
 Narrow therapeutic range: maintenance serum
levels should range between 0.6 and 1.2 mEq/L

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Etiology of Depression
Biogenic amine hypothesis
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Depression and mania are due to an alteration in
neuronal and synaptic catecholamine concentration
at adrenergic receptor sites in the brain
 Depression: deficiency of catecholamine,
especially norepinephrine
 Mania: excess amines
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Etiology of Depression (cont’d)
Permissive hypothesis
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Affective disorders are due to decreased
concentrations of serotonin
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Depression results from decreases in both serotonin and
catecholamine levels
Mania results from increased catecholamine but decreased
serotonin levels
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Etiology of Depression (cont’d)
Dysregulation hypothesis
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Depression and other affective disorders result from
a failure in the regulation of catecholamine activity
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Antidepressants
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Newer-generation antidepressants
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Selective serotonin reuptake inhibitors (SSRIs)
Second- and third-generation antidepressants
Tricyclic antidepressants
Monoamine oxidase inhibitors (MAOIs)
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Newer-Generation
Antidepressants
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Fewer adverse effects than tricyclics and MAOIs
Very few drug-drug or drug-food interactions
Still takes about 4 to 6 weeks to reach maximum
clinical effectiveness
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Second-Generation
Antidepressants
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trazodone (Desyrel)
bupropion (Wellbutrin)
SSRIs
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fluoxetine (Prozac)
paroxetine (Paxil)
sertraline (Zoloft)
citalopram (Celexa)
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SSRI Antidepressants
fluoxetine (Prozac)
paroxetine (Paxil)
sertraline (Zoloft)
citalopram (Celexa)
escitalopram (Lexapro)
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Third-Generation
Antidepressants
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venlafaxine (Effexor)
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mirtazapine (Remeron)
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SSRIs
Mechanism of action
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Selectively inhibit serotonin reuptake
Little or no effect on norepinephrine or dopamine
reuptake
Result in increased serotonin concentrations at
nerve endings
Advantage over tricyclics and MAOIs: little or no
effect on cardiovascular system
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Newer-Generation
Antidepressants:
Indications
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Depression
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Bipolar disorder
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Obesity
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Eating disorders
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Obsessive-compulsive disorder
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Newer-Generation
Antidepressants:
Indications (cont’d)
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Panic attacks or disorders
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Social anxiety disorders
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Posttraumatic stress disorders (PTSD)
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Myoclonus
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Treatment of various substance abuse problems (bupropion
[Zyban] is used for smoking cessation treatment)
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Other uses
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Newer-Generation
Antidepressants: Adverse Effects
Body System
Effects
CNS
Headache, dizziness,
tremor, nervousness,
insomnia,* fatigue
Nausea, diarrhea,
constipation, dry mouth
Sexual dysfunction,
* weight gain,* weight
loss, sweating
GI
Other
* Most common and bothersome
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Serotonin Syndrome
Delirium
Tachycardia
Hyperreflexia
Shivering
Agitation
Sweating
Muscle spasms
Coarse tremors
More severe cases
Hyperthermia
Renal failure
Dysrhythmias
Seizures
Rhabdomyolysis
DIC
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Newer-Generation
Antidepressants:
Drug Interactions
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Highly bound to plasma proteins
Compete with other protein-binding drugs,
resulting in more free, unbound drug to cause
a more pronounced drug effect
Inhibition of cytochrome P-450 system
MAOIs
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Tricyclic Antidepressants:
First-Generation Antidepressants
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Have largely been replaced as first-line
antidepressant drugs by SSRIs
Considered second-line
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For patients who fail with SSRIs or other newergeneration antidepressants
As adjunct therapy with newer antidepressants
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Common Tricyclics
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amitriptyline (Elavil, Endep)
doxepin (Sinequan)
imipramine (Tofranil)
nortriptyline (Aventyl, Pamelor)
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Mechanism of Action
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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
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Drug Effects
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Blockade of norepinephrine reuptake
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Antidepressant,* tremors, tachycardia, others
Blockade of serotonin reuptake
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Antidepressant,* nausea, headache, anxiety,
sexual dysfunction
*Desired therapeutic effects
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Indications
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Depression
Childhood enuresis (imipramine)
Obsessive-compulsive disorders
(clomipramine)
Adjunctive analgesics for chronic pain
conditions, such as trigeminal neuralgia
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Adverse Effects
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Sedation
Impotence
Orthostatic hypotension
Others
Older patients
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Dizziness, postural hypotension, constipation,
delayed micturation, edema, muscle tremors
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Overdose
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Lethal—70% to 80% die before reaching the
hospital
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CNS and cardiovascular systems are
mainly affected
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Death results from seizures or dysrhythmias
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Overdose (cont’d)
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No specific antidote
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Decrease drug absorption with activated charcoal
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Speed elimination by alkalinizing urine
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Manage seizures and dysrhythmias
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Basic life support
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MAOIs
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Highly effective
Considered second-line treatment for
depression not responsive to cyclics
Disadvantage: potential to cause
hypertensive crisis when taken with tyramine
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MAOIs (cont’d)
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phenelzine (Nardil)
tranylcypromine (Parnate)
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MAOIs: Mechanism of Action
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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
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MAOIs: Indications
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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
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MAOIs: Adverse Effects
Few adverse effects—orthostatic hypotension most
common
Tachycardia
 Dizziness
 Insomnia
 Anorexia
 Blurred vision
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Palpitations
Drowsiness
 Headache
 Nausea
 Impotence
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MAOIs: Overdose
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Symptoms appear 12 hours after ingestion
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Tachycardia, circulatory collapse,
seizures, coma
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Treatment: protect brain and heart,
eliminate toxin
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Gastric lavage
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Urine acidification
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Hemodialysis
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Hypertensive Crisis and Tyramine
Ingestion of foods and/or drinks with
the amino acid tyramine leads to
hypertensive crisis, which may lead
to cerebral hemorrhage, stroke,
coma, or death
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Hypertensive Crisis and Tyramine
(cont’d)
Avoid foods that contain tyramine!
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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)
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Antidepressants: MAOIs
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Concurrent use of MAOIs and SSRIs may lead to
serotonin syndrome
If the decision is made to switch to an SSRI, there
must be a 2- to 5-week “wash-out” period between
MAOI therapy and SSRI therapy
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Antipsychotics
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Drugs used to treat serious mental illness
Behavioral problems or psychotic disorders
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Antipsychotics (cont’d)
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Thioxanthenes: thiothixene (Navane)
Butyrophenones: haloperidol (Haldol)
Phenothiazines: three structural groups
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Mechanism of Action
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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
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Atypical Antipsychotics:
Second-Generation Antipsychotics
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risperidone (Risperdal)
olanzapine (Zyprexa)
quetiapine (Seroquel)
aripiprazole (Abilify)
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Newer Antipsychotics:
Mechanism of Action


Block specific dopamine receptors (dopamine
2 [D2] receptors
Also block specific serotonin receptors
(serotonin-2 [5HT2] receptors)

This is responsible for their improved efficacy and
safety profiles
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Indications

Treatment of serious mental illnesses
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Bipolar affective disorder
Depressive and drug-induced psychoses
Schizophrenia
Autism
Movement disorders (such as Tourette’s syndrome)
Some medical conditions

Nausea, intractable hiccups
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Adverse Effects
Body System
Adverse Effects
CNS
Cardiovascular
Sedation, delirium
Orthostatic hypotension,
syncope, dizziness,
EKG changes
Photosensitivity, skin
rash, hyperpigmentation,
pruritus
Dermatologic
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Adverse Effects (cont’d)
Body System
GI
Adverse Effects
Dry mouth, constipation
GU
Urinary hesitancy or
retention, impaired
erection
Hematologic
Leukopenia and
agranulocytosis
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Adverse Effects (cont’d)
Body System
Metabolic/endocrine
Adverse Effects
Galactorrhea,
irregular menses,
increased appetite,
polydipsia
MANY OTHER ADVERSE EFFECTS
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Adverse Effects (cont’d)
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Neuroleptic malignant syndrome (NMS)
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Potentially life threatening
High fever, unstable BP, myoglobinemia
Extrapyramidal symptoms (EPS)
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
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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)
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Adverse Effects (cont’d)
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Tardive dyskinesia (TD)
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Involuntary contractions of oral and facial muscles
Choreoathetosis (wavelike movements of
extremities)
Occurs with continuous long-term antipsychotic
therapy
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Psychotherapeutic Drugs:
Nursing Implications
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Before beginning therapy, assess both the
physical and emotional status of patients
Obtain baseline vital signs, including postural
BP readings
Obtain liver and renal function tests
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
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Assess for possible contraindications to
therapy, cautious use, and potential drug
interactions
Assess LOC, mental alertness, potential
for injury to self and others
Check the patient’s mouth to make sure
oral doses are swallowed
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
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Provide simple explanations about the drug, its
effects, and the length of time before therapeutic
effects can be expected
Abrupt withdrawal should be avoided
Advise patients to change positions slowly
to avoid postural hypotension and possible injury
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)

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
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
Antianxiety Drugs

In the elderly, monitor closely for oversedation and
profound CNS depression
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
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
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
Antidepressants (cont'd)

Assist elderly or weakened patients with ambulation
and other activities because falls may occur due to
drowsiness or postural hypotension
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
Antidepressants (cont'd)
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

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
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
Antidepressants (cont'd)


Caffeine and cigarette smoking may decrease
effectiveness of medication therapy
Instruct patients and family regarding tyraminecontaining foods and signs and symptoms of
hypertensive crisis
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
Antipsychotics—phenothiazines



Instruct patients to wear sunscreen due to
photosensitivity
Avoid taking antacids or antidiarrheal preparations
within 1 hour of a dose
Do not take alcohol or other CNS depressants with
these medications
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
Antipsychotics—phenothiazines (cont'd)

Long-term haloperidol therapy may result in tremors,
nausea, vomiting, or uncontrollable shaking of small
muscle groups; these symptoms should be reported
to the physician
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
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
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
Monitor for therapeutic effects


Monitor mental alertness, cognition, affect, mood,
ability to carry out activities of daily living, appetite,
and sleep patterns
Monitor the patient’s potential for self-injury during
the delay between the start of therapy and
symptomatic improvement
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Psychotherapeutic Drugs:
Nursing Implications (cont’d)
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
Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Psychotherapeutic Drugs:
Nursing Implications (cont’d)
Monitor for therapeutic effects (cont'd)

For antidepressants

Improved sleep patterns and nutrition, increased feelings of
self-esteem, decreased feeling of hopelessness, increased
interest in self and appearance, increased interest in daily
activities, fewer depressive manifestations or suicidal
thoughts or ideations
Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Psychotherapeutic Drugs:
Nursing Implications (cont’d)
Monitor for therapeutic effects (cont'd)

For antipsychotics


Improved mood and affect, alleviation of psychotic
symptoms and episodes
Decrease in hallucinations, paranoia, delusions, garbled
speech, inability to cope
Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Psychotherapeutic Drugs:
Nursing Implications (cont’d)
Monitor for therapeutic effects (cont'd)

For lithium


Less mania
Therapeutic lithium levels of 0.6 to 1.2 mEq/L
Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.