PSYCHOPHARMACOLOGY MODULE 4 (copy)

What is mental illness ?

An interaction between a variety of neurobiological, genetic, and environmental factors

The brain functions by what?

Neurotransmitters

What impacts the brain’s ability to function?

Neurobiological and environmental factors

How does the brain process external and internal processes?

By cells called neurons which comprise the majority of the brain tissue

Neurons

Responsible for unconscious tasks, such as breathing and critical thinking. Neurons function directly correlate to mental health and illness.

How do neurons communicate?

Through neurotransmitters

Neurotransmitters

a function of electrochemical messages that are sent and received from various anatomical components of the neuron. It is chemical components that the neuron sends and receives and function as one of the main components of how the body communicates with itself.

The presynaptic neuron

Will send a key, or neurotransmitter, that will fit into a lock, or receptor site, that instructs the postsynaptic neuron on how to function. After the instruction is received, the neurotransmitter will either be stored for future use, through a process called reuptake, or inactivated by enzymes like monoamine oxidase.

Steps of the neurotransmitter

1.The neurotransmitter is released from the presynaptic neuron

2.Neurotransmitter binds to a specific receptor site on the postsynaptic neuron

3.Neurotransmitter then returns to the presynaptic cleft via reuptake channels either stored or deactivated by an enzyme

4.Enzyme degrades the neurotransmitter

5.Neurotransmitter is diffused away from the postsynaptic connection

6.Neurotransmitter binds to a specific receptor site on the presynaptic neuron for feedback regulation

Dopamine

is an excitatory neurotransmitter responsible for transmitting information about emotional responses, complex movements, and cognition.

Where does dopamine operate?

Primarily in the brainstem and is a product of the dietary amino acid, tyrosine.

Dopamine is responsible for:

individual experiencing pleasure and reward from behaviors and its neurotransmission can be affected by stress.

Schizophrenia

Manifestations is related to levels of dopamine and other neurochemicals of the brain

Dopamine and antipsychotic medications

Used to treat schizophrenia, aim to regulate the neurotransmission of dopamine.

Serotonin

an inhibitory neurotransmitter that is responsible for emotional regulations, sexual behaviors, temperature regulation, sleep, and pain management. Has more than 14 receptor sites.

Serotonin complexity

contributes to a variety of disorders such as anxiety, depression, and psychotic disorders.

Antidepressant medications

block the reuptake of serotonin in the pre-synaptic neuron to improve the chance of neurotransmission in the post-synaptic neuron. Regulating serotonin by this mechanism of action has been shown to improve mood.

Norepinephrine

an excitatory neurotransmitter that is responsible for learning, sleep, mood, memory, and attention. It is the most common neurotransmitter, is a derivative of epinephrine, and also responsible for our response to stress.

Low levels of epinephrine:

contribute to manifestations of anxiety, social withdrawal, depression, and memory loss.

Individuals with history of trauma

Have increased levels of norepinephrine, leading the individual to experience disorders like anxiety and depression.

Medications of norepinephrine

aims to block the reuptake in the pre-synaptic neuron.

Histamine

has a unique role in neuromodulation. The pre and postsynaptic receptors for histamine regulate the release of histamine, glutamate, serotonin, and gamma amino butyric acid (GABA).

Postsynaptic receptors for histamine

Mediate the effects of alertness and wakefulness. Also regulates the gastric secretions, allergic response, and cardiac stimulation.

Histamine Antagonists

Used to treat mental illness, resulting in side effects like sedation and weight gain

Gamma Amino Butyric Acid

an amino acid that serves as an inhibitory neurotransmitter. In addition to neuromodulation, GABA promotes neuronal development, improves sleeplessness, and minimizes manifestations of depression.

Benzodiazepines

Aim to enhance the binding of GABA to its associated receptor, reducing manifestations of anxiety and inducing sleep

Glutamate

An amino acid that serves as an excitatory neurotransmitter. Dopamine interacts with glutamate in various areas of the brain to regulate motor, affective, and cognitive functions.

High levels of glutamate leads to what?

Manifestations of psychosis.

Large amounts of glutamate:

Released in the brain in response to a head injury or stroke. When in excess, glutamate becomes toxic to neurons, causing permanent damage over time.

Acetylcholine

a neurotransmitter that has inhibitory and excitatory properties. Receptors for acetylcholine are found in skeletal muscle. It regulates the sleep-wake cycle and is a primary neurotransmitter for muscle functioning.

Alzheimer’s disease

are found to have decreased amounts of acetylcholine-secreting neurons.

Neurobiology

studies how the functioning of the brain impacts behavior and attempts to answer questions related to mental health.

Genetics

is associated with mental illness.

Identifiable mental health disorders according to mutation in genetic composition:

Early-onset Alzheimer’s disease. However, most mental health disorders cannot be detected by analyzing genetic composition.

Twin study:

Mental illness is examined between two genetically identical people over long periods of time. Despite living separate lives and being exposed to different stressors, manifestations of mental illness may still be present among the twins.

Adoptive studies:

For example, a parent may be diagnosed with addiction. The biological child of the parent is much more likely to also exhibit manifestations of addictions when compared to the child who was adopted. Despite being raised in the same household and being exposed to the same stressors, the biological child is more susceptible to mental illness than the adopted child when there is a family history.

Psychiatric pharmacogenomic testing

a strategy that improves the likelihood of selecting an effective psychotropic medication based on the client’s genes. provides the health care provider insight into the severity of side effects the client may experience with certain psychotropic medications.

psychiatric pharmacogenomic testing

The International Society of Psychiatric Genetics

provides prescribing guidelines on how to best use published evidence and product labels to best serve the client when genetic data is available.

Psychoimmunology

a field of science that attempts to expand knowledge related to the impact of psychosocial stress on the body’s immune system.

Stress and the immune system

May be related to the presentation of some manifestations of mental illness.

The immune system

may directly affect the processes of neurotransmission. For example, manifestations of depression and mood dysregulation are common when the body is experiencing an inflammatory response.

Infection

mental illness can be described according to previous or current infection. It is theorized that viral infection possibly alters genetic composition in the central nervous system leading to the presentation of mental illness. EX:infection during pregnancy and the occurrence of manifestations related to schizophrenia.

Neuroplasticity

Refers to the brain’s ability to adapt synaptic connections, particularly in response to stress, learning, or after experiencing an injury. However, the adaptive process of neuroplasticity is not instantaneous. It may take weeks or months for the brain to reconfigure neuronal pathways.

Neuroplasticity explains what?

Why some manifestations of mental illness increase in severity over time, such as Major Depressive Disorder, and cannot be cured through a single dose of medication. Current medication treatment for chronic anxiety and manifestations of major depression takes weeks for the client to notice a relief in manifestations.

When is important for nurses to discuss neuroplasticity with clients?

When starting antidepressant medication therapy for trauma or stress-related disorders

Neuroplasticity chemical change

Neurons first respond to a new stimulus by making chemical changes. This may be elicited by medications.

Neuroplasticity structural change

As the chemical change is sustained, a structural change then occurs to better support the new stimulus.

Neuroplasticity functional change

Once the structural change has been established, the brain experiences functional change through the utilization of new neuronal pathways

Prescribing medications:

The health care provider will consider the severity of manifestations and for how long the client has been experiencing them

Benzodiazepines anxiolytics

the most prescribed medications to treat anxiety.

Most common formulas for benzodiazepines

Alprazolam, chlordiazepoxide, diazepam, and lorazepam.

The mechanism of action for benzodiazepines

To regulate the function of the neurotransmitter GABA.

-Benzodiazepines bind to GABA receptor sites, causing an influx of chloride to enter the neuron, producing a major inhibitory effect

-A cascade effect occurs when benzodiazepines are introduced into the brain, causing a large amount of dopamine to be released in the limbic system. This effect greatly increases the potential for physical dependence on benzodiazepines.

Adverse effects/ manifestations of benzodiazepines

central nervous system depression are noted, such as sedation, poor concentration, impaired memory, and drowsiness.

Diazepam (type of benzodiazepine)

has a quick speed of onset and a half-life of up to 100 hr

Lorazepam (type of benzodiazepine)

has a moderately slow speed of onset and a half-life of up to 20 hr.

Severe cases of anxiety or severe central nervous system agitation:

Seen in alcohol withdrawal; the health care provider may choose to use a benzodiazepine with a short half-life to manage acute manifestations.

Long half-life prescribed (aka next-day sedation)

Client may report feelings of sedation for hours after the medication

When to stop the long-half life formula:

If an individual begins to experience increased agitation, hallucinations, or seizures after taking a benzodiazepine. This opposite of the intended effect is known as a paradoxical response.

Benzodiazepines risk fall

be mindful of the client’s tolerance for CNS depressant side effects. If necessary, place the client on fall risk precautions.

Benzodiazepine toxicity

The nurse should obtain a provider prescription to administer the benzodiazepine receptor antagonist, flumazenil, which can reverse the sedative effects. Flumazenil may induce seizures in clients who have a history of seizure disorders or who are taking tricyclic antidepressants.

Buspirone

-treats chronic anxiety and is a partial serotonin receptor agonist and a weak dopamine receptor antagonist. It does not affect GABA receptors.

-The clinical effects of buspirone are not experienced for a few weeks and are thought to be related to the adaptive response of the brain.

Buspirone adverse affects:

serotonin receptors, causing side effects like sedation, nausea, headaches, and dizziness. 

Client education on anti anxiety medication:

-The nurse should emphasize that these medications are only treating the manifestations of anxiety and not the cause.

-Alcohol should not be consumed at the same time.

-The sedating effects of benzodiazepines can be disruptive for some individuals, so they should plan their activities accordingly. After prolonged use of benzodiazepines, the body adapts to tolerance and becomes dependent on the substance. The client should not discontinue benzodiazepines after prolonged use and should be placed on a taper schedule.

-Benzodiazepines cause an influx of dopamine to be released in the limbic system of the brain, causing the individual to feel rewarded after use. The nurse should educate the client on the risk of developing an addiction to benzodiazepines with prolonged use.

-The nurse should consider the client’s ability to complete activities of daily living, such as ambulation and grooming

Antidepressants

used to treat a variety of manifestations that present in depression and anxiety.

People on antidepressants should be watched for what?

for worsening depression or unusual behavior, including increased risk for suicide.

The DSM-5-TR

Identifies various disorders that present with manifestations of depression and anxiety, such as major depressive disorder, bipolar disorder, generalized anxiety disorder, and posttraumatic stress disorder.

Clients who attend psychotherapy and use antidepressants

often have a better prognosis than those who only use either psychotherapy or antidepressants. However, in some cases, psychotherapy, like cognitive behavioral therapy (CBT), may be the only effective treatment for reducing manifestations of anxiety or depression.

Five types of antidepressants:

-monoamine oxidase inhibitors (MAOIs)

-tricyclic antidepressants (TCAs)

- selective serotonin reuptake inhibitors (SSRIs)

-serotonin norepinephrine reuptake inhibitors (SNRIs)

-neurosteroid antidepressants.

MAOIs (phenelzine)

a type of antidepressant in which the mechanism of action inhibits the function of the enzyme monoamine oxidase. Disabling monoamine oxidase increases the amount of time that monoamine transmitters, like serotonin and dopamine.

MAOI causes higher concentrations of serotonin to be released into the synaptic gap for neurotransmission which leads to what?

Relieved depression manifestations.

MAOI adverse effects:

-weight gain

-daytime sedation

-sexual dysfunction

-insomnia

MAOI teaching:

client needs to refrain from eating foods that contain tyramine as they will be at a high risk of developing a hypertensive crisis.

-Foods that are aged or fermented have high levels of tyramine such as smoked meats, red wine, beer, aged cheeses. chocolate, avocado, and soy products like tofu.

-A client should avoid taking MAOIs with other TCAs and over-the-counter drugs that contain ephedrine.

Specific MAOI food to avoid:

Swiss and blue cheese

Cured and processed meats with nitrate, nitrite, and salt (like hot dogs, bacon, and sausage)

Sauces like teriyaki, fish, shrimp,

Fruits like raisins, prunes, avocado, and bananas

TCAs(amitriptyline)

antidepressant in which the mechanism of action affects serotonin and norepinephrine by blocking their reuptake in presynaptic receptors.

TCAs adverse effects:

block cholinergic receptors resulting in anticholinergic effects like dry mouth and constipation, and at risk for hypotension.

TCAs teaching:

2-4 weeks for the client to experience a therapeutic benefit. I

-If the client experiences sedation, it may be better to take the medication at night.

What should clients be aware of when taking medications like antidepressants?

The side effects before engaging in any activities that require alert reflexes or operating heavy machinery, especially when taking bupropion, as it carries a higher risk for seizures.

Anticholinergics effects

blurry vision, urinary retention, and dry mouth.

-The nurse should be aware of the potential for orthostatic hypotension and the risk of falling. In some cases, bladder catheterization may be necessary for severe urinary retention.

Fluoxetine

an SSRI and antidepressant in which the mechanism of action affects serotonin by selectively blocking the reuptake of presynaptic receptors.

SSRI teaching:

Experience relief up to 4-6 weeks

SSRI adverse effect:

-nausea

-agitation

-sexual dysfunction

Venlafaxine

an SNRIs and antidepressant in which the mechanism of action affects serotonin and norepinephrine by selectively blocking the reuptake of presynaptic receptors.

SNRIs adverse effect:

includes appetite suppression.

Blocking the reuptake of serotonin and norepinephrine increases what?

the amount of time that serotonin and norepinephrine must find a receptor on the postsynaptic neuron to complete neurotransmission.

Improving the neurotransmission of serotonin may improve?

sleep regulation

Improving the neurotransmission of norepinephrine may improves?

Manifestations of anxiety.

Other medication used for antidepressant properties :

Trazodone, nefazodone, bupropion, and mirtazapine.

-In some cases, these alternative antidepressants are used when medications like SSRIs have been found to be ineffective or if the side effects are deemed intolerable by the client. 

Zuranolone

A neurosteriod antidepressant used for the treatment of postpartum depression (PPD). The FDA has approved it as a once daily oral medication for a 14-day course of treatment, and takes about 3 days to begin to manage manifestations of PPD.

Antipsychotics

used to treat a variety of manifestations that present in schizophrenia spectrum and other psychotic-related disorders. There are two generations of antipsychotic drugs: first and second.

What is a common antipsychotic medication for maintenance in a long-term intramuscular route?

depot injections.

First generation antipsychotics

known as conventional or typical, work by blocking the dopamine receptors. They are very potent dopamine antagonists and can be effective at treating severe manifestations of schizophrenia.

First generation antipsychotics medications

haloperidol, fluphenazine, loxapine, and chlorpromazine

Second generation antipsychotic

also known as unconventional or atypical, work by blocking dopamine receptors to a lesser degree and by inhibiting the reuptake of serotonin.

Three SGAs sometimes called third generation antipsychotics:

aripiprazole, brexpiprazole, and cariprazine

These medications are dopamine system stabilizers and work by regulating dopamine transmission when reception is too low or too high.

SGAs adverse effects:

Metabolic side effects are more common like increased levels of blood sugar, increased blood pressure, and increased cholesterol. The nurse should be aware of clients who are at high risk of developing type 2 diabetes mellitus or those who are already diagnosed with diabetes.

SGA’s teaching:

Instruct the client about the importance of routine laboratory testing that is required, such as monitoring blood glucose and lipid levels while taking an SGA and measuring the absolute neutrophil count when taking clozapine.

 Brexpiprazole

used for the treatment of agitation for clients who have dementia.

Antipsychotics overall side effects:

anticholinergic manifestations like dry mouth, constipation, blurred vision, and orthostatic hypotension.

-Antipsychotics increase levels of prolactin that may cause enlargement of breast tissue, decreased sex drive, menstrual irregularities, and weight gain.

Antipsychotics overall teaching:

-The nurse should consider using hard candies, drinking water, and chewing sugarless gum to minimize discomfort related to dry mouth, encourage fiber and fluid intake to minimize constipation, and consider fall risk precautions for those who experience blurry vision or orthostatic hypotension.

-If the client plans to be in direct sunlight, advise them to wear sunscreen as photosensitivity with antipsychotics is common.

Mood Stabilizers

used to help relieve manifestations of mood dysregulation found in disorders like bipolar disorder.