DRUGS IN PSYCHIATRIC NURSING

Objectives.
Describe the physiological & therapeutic effects of psychotropic medications. Describe the side effects & toxic effects of psychotropic medications. Describe the use of psychotropic medication with special populations. Describe the process of client education/ teaching.

ACTIONS OF PSYCHOTROPHIC DRUGS

Mainly there are two concept in psychopharmacology they are neurotransmitters & blood-brain barrier. Lipid solubility is the most important of the chemical properties that determine whether a molecule may pass through BBB. Neurotransmitters are synthesized from natural precursors which are extracted from the blood stream &are synthesized in the cells and stored in storage vesicles in the presynaptic terminals of the cells.

Classifications of Psychotrophic medications

1. 2. 3. 4. The anti-anxiety drugs/anxiolytics. Antidepressants. Mood stabilizers Antipsychotics/neuroleptics

Antianxiety drugs.
(Benzodiazepines.) (NonBenzodiazepines. Azapirones. Beta-blockers. benzodiazepines.)
Alprazolam. Diazepam. Chlordiazepoxide. Lorazepam. Buspirone. Propanolol.

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Anti-anxiety drugs can be divided into benzodiazepenes& nonbenzodiazepines. Benzodiazapines are Diazepam& Alprazolam Action: clinically decreases the anxiety by inhibiting the neurotransmitter. Indications: they are used to treat anxiety, insomnia,alcohol withdrawal,psychotic agitation. Side effects: they are common,dose related, usually

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Include drowsiness,reduced mental acuity& impaired motor activity. Other effects such as headache, dizziness, feeling of detachment, nausea, hypotension & restless ness may be experienced. Addiction may not occur but physical dependency can cause development of tolerance & onset of withdrawal syndromes. Contraindications/precautions: dont take any CNS depressants including alcohol &avoid in

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Interactions: interaction may occur with alcohol,MAOinhibitor,antacids & agents with anticholinergic activity. Patient education: Driving or operating machinery should be avoided until tolerance develop. Alcohol and other CNS depressants potentiate the effects of benzodiazepines, so they should be avoided.

 Non-benzodiazepine are propanalol& buspiron. Propanalol is a betablocker that is useful in the treatment of anxiety. They reduce certain symptoms of anxiety,especially tachycardia,rather than working directly on the anxiety. Buspiron is a potent anxiolytic drug with no sedative or addictive properties. It is effective in the treatment of

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Antidepressant drugs.
Drug groups & examples.
Tricyclics. Amitriptyline. Trandazon. Lofepramine. SSRIs Flouxetine. Paroxetine. Venlafaxine. MAOIs Isocarboxazid. Phenelzine. Tranylcypromine.

Contantidepressants

Depression are thought to be deregulation of neurochemicals ,particularly serotonin& norepinephrine. Tricyclic antidepressants, selective serotonin reuptake inhibitor& mono-amine oxidase inhibitors. Action: Block the reuptake of neurotransmitters (tricyclic), inhibit their metabolism /destruction(MAOI`s) & enhances the activity of receptors (SSRI`s) in short they elevate the mood.

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Indications: in the treatment of major depression, dysthymic disorder & prevent its relapse,& in some anxiety disorders as panic disorders and OCD. Side effects: Tricyclic antidepressantsamitriptyline, fluxetine. Sedation, dry mouth, constipation, blurred vision, seizures& urinary retention& an over dose can cause life threatening emergencies.

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Mono-amine oxidase inhibitorphenelzine, isocarboxazid. Drowsiness/insomnia,agitation,fatigu e, GI disturbances,weight gain, hypotension& dizziness,dry mouth, skin & sexual dysfunction, constipation & blurred vision. Major concern is the interaction with specific food that contain tyramine& other amine drugs such as found in any cough preparation.

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Foods & drugs to be avoided in patients taking MAOIs Cheeses, especially matured one. Pickled herrings, cured meat& beef extracts. Liver& chicken liver. Whole broad beans,soybean paste,&figs. Alcoholic drinks especially red vine. Other antidepressant drugs, nasal/ sinus decongestants, narcotics, epinephrine.

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Selective serotonin reuptake inhibitors-fluoxetine,paroxetine. Side effects are similar to tricyclics but they don't cause cardiovascular, sedative & anticholenergic side effects,they can cause withdrawal syndrome such as paraesthesia,dizziness, anxiety, sleep disturbances, agitation & tremor if stop abruptly.

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Contraindication/precautions: caution is warranted in all antidepressants since once the drugs start to take effects & the patient`s mood lifts, they can be at the risk of suicide. SSRIs shouldnt be given with MAOIs& MAOIs shouldnt be started within one week of tricyclic therapy & conversely. Interactions: they can cause hypertensive crisis since they prevent antihypertensive action of certain drugs.

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Patient education: Mark commencing time & instruct them that action may start within 23 weeks,even though they may not be able to notice any change. Warn the problems when driving or operating machineries if sedation is experienced. Warn about the effect that alcohol & possible interaction of foods and medicines to the drugs. Declare the pregnancy to the treating doctor and if intend to breast feed.

Mood stabilizers.
Drug group & examples.
Lithium. Lithium carbonate. Anticonvulsants. Carbamazepine. Sodium Valporate.

Cont
main mood stabilizers used are lithium &anticonvulsants. Lithium is the naturally occurring salt, & is the drug of choice for the treatment of acute mania & ongoing maintenance of patients with history of mania. Action: the action is unknown but it is believed to regulate the catecholamine release in the CNS.

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Indications: acute mania, aggression, conduct disorder& schezoaffective disorder. Side effects: Lithium- drowsiness,metallic taste in mouth, difficulty in concentration,increased thirst,dizziness,head ache,GIT upset,fine hand tremor,hypotension, arrhythmias, polyuria, dehydration& weight gain.

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Contraindications/precautions: Lithium:-should not be used in cardiac or renal disease,sodium depletion,brain damage, pregnancy& lactation. Therapeutic level for lithium in the blood is between .6-1.2 mmols/L for acute mania &.6-.8/L in maintenance of mania.the toxic level is if it exceed 1.5 mmols/L,if so next dose should be with held.

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Signs of Lithium toxicity. Early stages:anorexia,nausea,vomiting, diarrhea, hand tremor,twitching,lethargy, dyarrthmia, ataxia hypercaptive deep tendon reflexes,tinnitus,vertigo,drowsiness . Later stages:fever,decreased urinary output,low BP,irregular

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Patient education: Lithium- educate the patient about the side effects & signs of toxicity. Encourage a regular intake of about 10 glasses of water every day. Take medications everyday even when feeling well. Don't operate machinery until initial drowsiness subsides. Discuss risk of pregnancy while taking lithium.

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Anticonvulsants-inform about avoiding sudden cessation of the drugs. Encourage to report unusual symptoms such as unusual bleeding/bruise,jaundice etc. Take medications with meals to avoid GI symptoms. Avoid alcohol,consult doctor for any medication. Avoid pregnancy during medication ,use other than OC pills for family planning while taking

 Drug types & examples.

Typical/traditional. Butriphenoneseg.Haloperidol. Phenothiazineeg.Thioridazine. Thioxanthineseg. Flupenthixol. Diphenylbutylpiperidine Eg. Pimozide.

Antipsychotic/neuroleptic s.
Atypical/newer. Risperidone. Clozapine. Olazipine. Quetiapine.

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two types of antipsychotics traditional antipsychotics or typical antipsychotics newer antipsychotics or atypical antipsychotics The atypical antipsychotics are better tolerated & less likely to lead to problems with medical adherence.

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Action: Typical -are dopamine antagonists.They block postsynaptic D2 receptors primarily but also exert other synaptic effects& reduce positive symptoms of schizophrenia. Atypical -have dopamine receptor subtype 2 (5HT2) blocking action.They reduce both positive & negative symptoms without

 Indications: Acute &chronic psychosis, delusional disorder, severe depression, schizophrenia & schizoaffective disorder. Phenothiazine : group of antipsychotics have other uses such as antiemetic (prochlorperazine) & in the treatment of intractable hiccoughs (chlorpromazine) Side effects: Typical affects every system& CNS disorders (movement disorder, sedation & seizures), extrapyramidal reactions, tardive dyskynesia &

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Atypical- May cause some annoying side effects such as weight gain,constipation, dizziness&paradoxical hypersalivation.on higher doses they can cause EPS. Contraindications/precautions: Typical- older adults,medically ill or diabetic.Avoid extremes of temperature. Atypical:- risk of agranulocytosis &

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Interactions: Typical- alcohol may cause additional CNS depression,antacids &antidiarrhoeals can disrupt the absorption .concurrent use with antidepressants, antihistamines& antiparkinsonians may result in additional anticholinergic action. Atypical- enhance the effect of alcohol& other CNS depressants.drugs that can depress bone marrow should be

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Patient education: Typical- educate the client about the side effects and help with improving adherence. They should be careful about the sun & extremes of temperature. Atypical- regular blood level checking.important of seeking a doctor immediately for any flu like symptoms(while taking clozapine).

 The need to reduce agitation,distress or aggression rapidly often result in prescription & administration of PRN antipsychotics. The drug most often prescribed for PRN have been typical antipsychotics,particularly Halloperidol & benzodiazepines. When nurses give PRN medication they are often required to make decisions of what to give from a range of medications,as well as the

PRN antipsychotics.

 They have been introduced in 1960s due to the problems in compliance with oral medications. They are long acting, injectable forms of a typical antipsychotic, produced mostly in decanoate esters dissolved in an oily base. When administered in deep IM, the drug is de-esterifies to release the active drug, which slowly diffuse in to the circulation. The injection is usually given every 2-4 weeks. Eg.Flupenazine decanoate,IM,200-400mg,2-

Depot preparations.

Psychotropics&special population.

Pregnant & lactating women: Risk to the unborn or to the new born. untreated psychiatric disorders during pregnancy must be weighed against the risk of prenatal exposure to drugs,as antenatal psychological distress is known to be linked to premature labor,LBWB,microcephali etc. Tetragenic effects should be assessed.

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Children: They are to be monitored while on psychotropic as they are prone for cardio toxicity & seizures. Death has been reported after overdose of as little as few mgs. Old age: Adverse reaction are more common due to slower drug metabolism& excretion. Polypharmacy.

Tutorial outline.
Group-1; Discuss the legal & ethical issues in psychotropic drug administration. Group-2; Discuss about the problems of drug complaints /adherence in psychiatric patients. Group-3; Discuss the adjuvant therapies used along with psychotropic. Group-4; Discuss about CNS stimulants used in practice.

Tutorial activity
Discuss mental disorders due to the following Stimulants Hallucinogens Cannabinoids Alcohol Opioids

Substance dependence Acute intoxication Tolerance withdrawal