BH Medications

benzodiazepines (anxiolytics)

Diazepam

Clonazepam

Alprazolam

Lorazepam

Chlordiazepoxide

Z-hypnotics

Zolpidem

Melatonin receptor agonists

Buspirone

Tricyclic Antidepressants (TCA)

Amitriptyline

Nortriptyline

Selective Serotonin Reuptake Inhibitors (SSRI)

Fluoxetine

Sertraline

Paroxetine

Citalopram

Escitalopram

Fluvoxamine

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Venlafaxine

Duloxetine

Serotonin antagonists & reuptake inhibitors

Trazodone

Norepinephrine & serotonin-specific antidepressant (NSSA)

Mirtazapine

Norepinephrine dopamine reuptake inhibitor (NDRI)

Bupropion

Mood Stabilizer

Lithium Carbonate

Anticonvulsant drugs used to stabilize mood

Valproate/Valproic Acid

Carbamazepine

Lamotrigine

Gabapentin

Topiramate

Oxcarbazepine

Antipsychotic Drugs: Generation I (Typical)

Haloperidol

Chlorpromazine

Fluphenazine

Pimozide

Antipsychotic Drugs: Generation II (Atypical)

Clozapine

Risperidone

Quetiapine

Olanzapine

Ziprasidone

Paliperidone

Lurasidone

Antipsychotic Drugs: Generation III (Atypical)

Aripiprizole

Brexpiprazole

ADHD Drug Treatment

Methylphenidate

Dextroamphetamine

Guanfacine

Clonidine

Alpha-2-Agonist

Prazosin

Clonidine

GABA

ANXIETY, SCHIZOPHRENIA, MANIA, HUNTINGTON’S

reduces aggression, excitation, & anxiety

pain perception

anticonvulsant

impairs cognition

norepinephrine

DEPRESSION, SCHIZOPHRENIA, ANXIETY, MANIA

mood

attention/arousal

“fight or flight”

serotonin

DEPRESSION

sleep regulation

hunger

hormonal activity

aggression, pain, & sexual behavior

dopamine

PARKINSON’S, DEPRESSION, SCHIZOPHRENIA, MANIA

fine motor movement

decision making

emotions & thoughts

hormone release

diazepam

class: benzodiazepine

used for: anxiety, acute alcohol withdrawal, seizures, muscle spasm, or pre-surgical sedative

S/E: highly addictive, sedation, ataxia, dizziness, confusion, dependence

nsg considerations: High potential for physical dependence/abuse. Monitor respiratory status (especially IV). Taper dose slowly. Avoid alcohol and other CNS depressants

clonazepam

class: benzodiazepine

used for: seizures/epilepsy, panic disorder

S/E: drowsiness, impaired coordination, dizziness, behavioral changes (paradoxical agitation)

nsg considerations: seen as standing order (poor choice), need a lot of it to work, Long half-life (less rebound anxiety). Risk for tolerance and dependence. Implement fall precautions. Do not stop abruptly

alprazolam

class: benzodiazepine

used for: generalized anxiety disorder (GAD), panic disorder

S/E: drowsiness, lightheadedness, dependence, rebound anxiety with abrupt cessation

nsg considerations: short half-life means high abuse potential and more severe withdrawal. Caution against driving/operating machinery. Educate on the risk of withdrawal seizures.

lorazepam

class: benzodiazepine

used for: anxiety, agitation, catatonia, alcohol withdrawal, cardiac complaints, insomnia, pre-op sedation, status epilepticus

S/E: Sedation, dizziness, anterograde amnesia (forgetfulness during drug action)

nsg considerations: preferred for alcohol withdrawal or anxiety in liver-impaired patients (safer metabolism). IV route requires close monitoring for respiratory depression

chlordiazepoxide

class: benzodiazepine

used for: Acute alcohol withdrawal (to prevent seizures), anxiety

S/E: drowsiness, confusion, incoordination, lethargy

nsg considerations: key treatment for acute alcohol withdrawal (longer half-life provides smoother detox). Monitor for excessive sedation/overdose

zolpidem

class: z-hypnotic

used for: Short-term treatment of insomnia

S/E: drowsiness/dizziness (daytime hangover), bizarre sleep-related behaviors (sleepwalking, sleep-driving), memory impairment

nsg considerations: take immediately before bed (ensure 7-8 hours for sleep). Should not be taken with food (delays onset). Report any unusual nocturnal behaviors

buspirone

class: melatonin-receptor agonist

used for: Generalized Anxiety Disorder (GAD)

S/E: dizziness, headache, nausea, nervousness

nsg considerations: NOT a PRN!! and taken daily, takes 1-2 wks for therapeutic effect, Avoid grapefruit juice (increases drug levels)

amitriptyline

class: tricyclic antidepressant (TCA)

used for: depression, chronic pain, migraines, insomnia

S/E: significant Anticholinergic effects (dry mouth, constipation, blurred vision, urinary retention), Orthostatic Hypotension, sedation, cardiotoxicity (QT prolongation)

nsg considerations: give at bedtime due to sedation. Monitor ECG and heart rate. Highly lethal in overdose (suicide risk assessment is critical). Teach patient to manage anticholinergic effects (sips of water, fiber)

nortriptyline

class: tricyclic antidepressant (TCA)

used for: depression, chronic pain, anxiety

S/E: less anticholinergic and less sedating than Amitriptyline, but still present. Orthostatic hypotension, dry mouth

nsg considerations: monitor for cardiac changes. Can be given in divided doses or at night. Takes several weeks for full antidepressant effect.

fluoxetine

class: SSRI

used for: MDD, OCD, Bulimia Nervosa, Panic Disorder

S/E: nausea, diarrhea, insomnia/agitation (initial), sexual dysfunction, H/A, anxiety

nsg considerations: longest half-life of SSRIs (less severe withdrawal). May cause initial anxiety/agitation. Take in the morning (to prevent insomnia). Monitor for Serotonin Syndrome.

sertraline

class: SSRI

used for: MDD, Panic Disorder, OCD, PTSD, PMDD

S/E: GI upset (nausea, diarrhea), sexual dysfunction, H/A

nsg considerations: take with food to minimize GI upset. High risk for GI side effects. Monitor for SS. Effective for a wide range of anxiety/depressive disorders

paroxetine

class: SSRI

used for: MDD, Panic Disorder, OCD, Social Anxiety Disorder

S/E: High rate of sexual dysfunction/anorgasmia, sedation, weight gain, most difficult SSRI to discontinue (severe withdrawal/discontinuation syndrome)

nsg considerations: Avoid in pregnancy. High anticholinergic activity among SSRIs. Taper very slowly upon discontinuation

citalopram

class: SSRI

used for: MDD, anxiety

S/E: Nausea, dry mouth, drowsiness, dose-dependent QT prolongation risk

nsg considerations: Maximum dose restriction (usually 40 mg/day, lower in the elderly) due to cardiac risk. Monitor electrolytes (hyponatremia risk in older adults)

escitalopram

class: SSRI

used for: MDD, GAD

S/E: Nausea, insomnia, sexual dysfunction, dizziness.

nsg considerations: Considered the most selective SSRI, generally well-tolerated. Similar to Citalopram but with lower risk for QT prolongation at therapeutic doses.

fluvoxamine

class: SSRI

used for: primarily OCD and depression

S/E: Nausea, somnolence, headache, insomnia

nsg considerations: Strong inhibitor of CYP450 enzymes (many drug interactions)

venlafaxine

class: SNRI

used for: MDD, GAD, Social Anxiety Disorder, Panic Disorder

S/E: Nausea, H/A, insomnia, dose-dependent HTN, sexual dysfunction, severe discontinuation syndrome

nsg considerations: Monitor BP regularly (especially with higher doses). Taper dose slowly to avoid severe withdrawal symptoms (flu-like symptoms, dizziness, electric-shock sensations)

duloxetine

class: SNRI

used for: MDD, GAD, Neuropathic Pain (diabetic peripheral pain), Fibromyalgia

S/E: Nausea, dry mouth, somnolence, constipation. Risk of hepatotoxicity

nsg considerations: Monitor LFTs. Useful for co-morbid depression and chronic pain conditions. Avoid in pts w/ substantial alcohol use

trazodone

class: SARI

used for: Insomnia (low dose), MDD (high dose, less common)

S/E: significant sedation/drowsiness, orthostatic hypotension, dizziness, Priapism (rare, but severe side effect—prolonged, painful erection)

nsg considerations: Primarily used off-label for sleep. Take at bedtime (due to sedation). Instruct male patients to seek immediate medical attention if they experience an erection lasting hours

mirtazapine

class: NaSSA (Norepinephrine and Serotonin-Specific Antidepressant)

used for: depression, especially with insomnia/low appetite

S/E: Sedation, weight gain/increased appetite, dry mouth. Low sexual dysfunction risk

nsg considerations: Give at bedtime due to pronounced sedation. Monitor weight. Monitor for agranulocytosis

bupropion

class: NDRI

used for: Depression, Smoking Cessation

S/E: Insomnia, H/A, dry mouth, appetite suppression, lowers seizure threshold. Low sexual dysfunction risk

nsg considerations: Contraindicated in patients with seizure disorder or eating disorders. Take in the morning (r/o insomnia). Monitor for anxiety/agitation

lithium carbonate 

class: mood stabilizer

used for: Bipolar Disorder (manic and maintenance)

S/E: Tremor, polyuria/polydipsia, nausea, diarrhea, weight gain, fatigue. Toxicity: Nausea, vomiting, ataxia, confusion, seizures

nsg considerations: Monitor serum levels closely (therapeutic range). Maintain adequate salt and fluid intake. Monitor renal and thyroid function

valproate/valproic acid

class: anticonvulsant (used to stabilize mood)

used for: bipolar disorder (mania), seizures, migraine prevention

S/E: Hepatotoxicity, pancreatitis, GI upset, tremor, thrombocytopenia, weight gain. Teratogenic (neural tube defects)

nsg considerations: Monitor LFTs and platelet counts (CBC). Monitor therapeutic serum levels. Advise women of childbearing age about risks/necessity of folic acid

carbamazepine

class: anticonvulsant (used to stabilize mood)

used for: bipolar disorder (mania), seizures, trigeminal neuralgia

S/E: agranulocytosis/Aplastic Anemia (rare, serious), vertigo, blurry vision, dry mouth, autoinduction of metabolism

nsg considerations: monitor CBC weekly during first months (risk for blood dyscrasias). Monitor therapeutic serum levels. Monitor LFTs. Risk of Steven Johnson Syndrome (SJS) (more common in Asian descent)

lamotrigine 

class: anticonvulsant (used to stabilize mood)

used for: Bipolar depression, seizure

S/E: Serious risk of rash (Steven Johnson Syndrome/Toxic Epidermal Necrolysis), dizziness, diplopia

nsg considerations: Educate patient to report any rash immediately. Titrate dose very slowly to minimize SJS risk. Not effective for acute mania.

gabapentin

class: anticonvulsant (used to stabilize mood)

used for: Seizures, neuropathic pain, anxiety (off-label)

S/E: Sedation, dizziness, ataxia, peripheral edema

nsg considerations: Used adjunctively for anxiety/mood. Monitor for CNS depression. Dose adjust in renal impairment

topiramate

class: anticonvulsant (used to stabilize mood)

used for: Seizures, migraine prophylaxis, weight loss (off-label)

S/E: cognition slowing, paresthesia (tingling), weight loss, kidney stones

nsg considerations: Encourage adequate fluid intake (to prevent kidney stones). Monitor cognitive changes

oxcarbazepine 

class: anticonvulsant (used to stabilize mood)

used for: Seizures, bipolar disorder

S/E: Hyponatremia, dizziness, sedation

nsg considerations: Monitor serum sodium levels, especially in first 3 months. Less risk of blood dyscrasias than Carbamazepine

haloperidol

class: Gen I Antipsychotic (Typical)

used for: Schizophrenia, acute psychosis, Tourette's

S/E: High risk for EPS (dystonia, parkinsonism, akathisia), NMS, sedation, anticholinergic effects

nsg considerations: Monitor for and treat EPS with benztropine or diphenhydramine. Monitor for NMS (fever, rigidity, altered mental status).

chlorpromazine 

class: Gen I Antipsychotic (Typical)

used for: Schizophrenia, severe behavioral problems, hiccups

S/E: High sedation, significant orthostatic hypotension, anticholinergic effects, low EPS risk compared to haloperidol

nsg considerations: Monitor BP and HR (risk of orthostasis). Sun sensitivity (photosensitivity)

fluphenazine

class: Gen I Antipsychotic (Typical)

used for: Schizophrenia (maintenance)

S/E: High risk for EPS (especially with the Decanoate/depot form), sedation, anticholinergic effects

nsg considerations: Depot form is for non-adherent patients. Monitor for severe EPS

pimozide

class: Gen I Antipsychotic (Typical)

used for: Severe Tourette's Disorder

S/E: Tardive Dyskinesia (TD) risk, QT prolongation (cardiac)

nsg considerations: Requires baseline and periodic ECG monitoring. Monitor for TD (abnormal involuntary movements mostly of neck & up)

clozapine

class: Treatment-resistant Schizophrenia

used for: Agranulocytosis (severe WBC drop), seizures, excessive sedation, orthostasis, significant weight gain, drooling

S/E: Weekly monitoring of ANC (Absolute Neutrophil Count) is mandatory due to agranulocytosis risk. Not a first-line agent

nsg considerations:

risperidone

class: Gen II Antipsychotic (Atypical)

used for: Schizophrenia, Bipolar mania, irritability in Autism

S/E: High risk for hyperprolactinemia (gynecomastia, lactation, sexual dysfunction), orthostasis, moderate weight gain

nsg considerations: Monitor for signs of prolactin elevation. Depot form is available

quetiapine

class: Gen II Antipsychotic (Atypical)

used for: Schizophrenia, Bipolar disorder (mania/depression)

S/E: High sedation, prolongs QT interval, high orthostatic hypotension, moderate to high weight gain, cataracts (less common)

nsg considerations: Give at night due to high sedation. Monitor BP. Monitor blood glucose/lipids

olanzapine

class: Gen II Antipsychotic (Atypical)

used for: Schizophrenia, Bipolar mania

S/E: Highest risk for metabolic syndrome (significant weight gain, hyperglycemia, dyslipidemia), sedation

nsg considerations: Monitor weight, blood sugar, and lipids diligently. High abuse potential in certain populations (quick calming effect)

ziprasidone

class: Gen II Antipsychotic (Atypical)

used for: Schizophrenia, Bipolar mania

S/E: QT prolongation risk, somnolence, low risk of weight gain

nsg considerations: Must be taken with food (at least 500 calories) for proper absorption. Monitor ECG

paliperidone 

class: Gen II Antipsychotic (Atypical)

used for: Schizophrenia, Schizoaffective disorder

S/E: High risk for hyperprolactinemia, orthostasis

nsg considerations: Active metabolite of Risperidone. Available in long-acting injectable forms

lurasidone

class: Gen II Antipsychotic (Atypical)

used for: Schizophrenia, Bipolar depression

S/E: Lower metabolic risk than Olanzapine/Quetiapine, akathisia (restlessness), somnolence

nsg considerations: Must be taken with food (at least 350 calories) for proper absorption. Low risk of weight gain

aripiprazole

class: Gen III Antipsychotic (Atypical)

used for: Schizophrenia, Bipolar disorder, adjunct for MDD

S/E: Akathisia (severe restlessness), H/A, nausea, low risk for weight gain/sedation

nsg considerations: Known as a "dopamine system stabilizer." Lower risk of metabolic and prolactin side effects. Monitor for akathisia

brexpiprazole

class: Gen III Antipsychotic (Atypical)

used for: Schizophrenia, adjunct for MDD

S/E: Similar to Aripiprazole: Akathisia, weight gain

nsg considerations: Newer agent, generally well-tolerated with low EPS/metabolic risk. Monitor for restlessness.

methylphenidate

class: CNS Stimulant

used for: ADHD, Narcolepsy

S/E: Insomnia, appetite suppression/weight loss, tachycardia, HTN, nervousness, abuse potential

nsg considerations: Give in the morning (avoid giving after 4 PM). Monitor HR, BP, and growth rate (height/weight) in children

dextroamphetamine

class: CNS Stimulant

used for: ADHD, Narcolepsy

S/E: Insomnia, appetite suppression/weight loss, high abuse potential, potential for sudden cardiac death (rare)

nsg considerations: Give in the morning. Monitor for signs of abuse. Instruct on taking drug holidays if prescribed (may help limit growth suppression).

guanfacine 

class: Adrenergic Agonist

used for: ADHD (non-stimulant), HTN

S/E: Sedation, hypotension, dry mouth, rebound hypertension if stopped abruptly

nsg considerations: Monitor BP and heart rate. Do not stop abruptly (risk of rebound HTN). Less abuse potential than stimulants

clonidine

class: Adrenergic Agonist

used for: ADHD (non-stimulant), HTN, managing withdrawal symptoms (substance abuse)

S/E: Significant sedation, hypotension, dizziness, dry mouth, rebound HTN if stopped abruptly

nsg considerations: Monitor BP and HR closely. Do not stop abruptly

prazosin 

class: Alpha 2 agonist, Adrenergic Agonist

used for: HTN, PTSD-related nightmares/hyperarousal (off-label)

S/E: Significant orthostatic hypotension (first-dose effect), dizziness, H/A

nsg considerations: Give the first dose at bedtime to minimize "first-dose" syncope/orthostasis. Monitor BP. Effective for sleep disturbances associated with hyperarousal.

MAOIs

used for: atypical depression, treatment-resistant depression

S/E: Hypertensive Crisis (when consuming tyramine), orthostatic hypotension, insomnia, weight gain, sexual dysfunction

nsg considerations: strict adherence to a tyramine-restricted diet (avoid aged cheese, cured meats, tap beer, soy sauce). High risk for drug-drug interactions (especially with SSRIs/TCAs—risk of Serotonin Syndrome). Monitor BP frequently

hydroxyzine

class: antihistamine

used for: fast Tx of anxiety (PRN, non-habit forming alternative to benzos), pruritus (itching), sedation

SE: usually doesn’t cause as much tiredness as benzos, but potential significant sedation, dry mouth, blurred vision, dizziness, H/A

nsg considerations: Non-addictive alternative to Benzodiazepines for anxiety (Vistaril is the anti-anxiety indication). Use smallest effective dose. Monitor for QT prolongation (risk is dose-dependent)

diphenhydramine

class: antihistamine

used for: Insomnia (OTC), mild anxiety (PRN), allergic reactions, acute EPS (dystonia)

SE: Significant sedation, pronounced Anticholinergic effects (dry mouth, constipation, urinary retention), dizziness, confusion (especially in older adults)

nsg considerations: Used often to treat extrapyramidal symptoms (EPS) from antipsychotics. Caution with the elderly (risk of confusion/falls). Give at bedtime for sleep. Monitor for urinary retention

disulfiram

class: Aldehyde Dehydrogenase Inhibitor

used for: Maintenance of abstinence from alcohol

SE: H/A, metallic/garlic taste, hepatotoxicity, Reaction includes flushing, throbbing headache, severe N/V, chest pain, and potentially death.

nsg considerations: ABSOLUTELY NO ALCOHOL! Educate pt to avoid all forms of alcohol (mouthwash, hand sanitizer, cologne, vinegar, cough syrup)

naltrexone

class: Opioid Receptor Antagonist

used for: Maintenance of abstinence from alcohol and opioids (to prevent relapse)

SE: Nausea, headache, dizziness, injection site pain (Vivitrol: monthly IM shot). Hepatotoxicity

nsg considerations: Must be opioid-free for 7-10 days before starting (to avoid severe immediate withdrawal). Monitor LFTs. Patients must carry ID stating they are on an opioid antagonist (opioids will not work in an emergency)

Acamprosate

class: GABA-A Agonist/NMDA Antagonist

used for: Maintenance of abstinence from alcohol

SE: Diarrhea, GI upset, depressed mood/suicidal ideation (rare)

nsg considerations: Primarily used to reduce craving and normalize brain function. Does not require abstinence prior to starting. Excreted renally—contraindicated in severe renal impairment

Methadone

class: Long-acting Opioid Agonist

used for: Opioid Use Disorder (OUD) treatment (Maintenance/Detox) and severe chronic pain

SE: Sedation, constipation, sweating, QT prolongation (cardiac risk), respiratory depression (risk in acute overdose)

nsg considerations: Administered only through licensed Opioid Treatment Programs (OTPs). Monitor for QT prolongation (require baseline ECG). Monitor for respiratory depression and signs of overdose

Buprenorphine

class: Partial Opioid Agonist

used for: Opioid Use Disorder treatment (Maintenance/Detox)

SE: H/A, nausea, insomnia, oral mucosal irritation (Suboxone film). Precipitated withdrawal (if given too soon)

nsg considerations: Initiate therapy only after mild to moderate withdrawal has begun (wait until COWS score is > or = 12). Combined with naloxone to prevent IV abuse

Benzodiazepines (general uses,SE, etc.)

uses: Anxiety, acute alcohol withdrawal, seizures, panic disorder, insomnia

SE: Sedation, dizziness, ataxia, dependence (risk of withdrawal), respiratory depression

CNS sedative, caution w/ substance abuse, take VS, fall risk, don’t operate heavy machinery, taper slowly

Z-Hypnotics (general uses, SE, etc.)

uses: Short-term treatment of insomnia

SE: Daytime drowsiness, dizziness, sleep-related behaviors (sleep-driving, sleep-eating)

Take immediately before bed (ensure 7-8 hrs sleep). Do not take with food (delays onset). Low risk of dependence compared to Benzos

TCAs (general uses, SE, etc.)

uses: Depression, chronic pain, insomnia (off-label)

SE: Anticholinergic effects (dry mouth, constipation, urinary retention), Orthostatic Hypotension, sedation, cardiotoxicity (QT prolongation)

Lethal in overdose. Monitor ECG/vitals. Give at bedtime (due to sedation). Slow onset (weeks)

MAOIs (general uses, SE, etc.)

uses: Atypical depression, treatment-resistant depression

SE: Hypertensive Crisis (when consuming Tyramine-rich foods), orthostatic hypotension, insomnia

Strict adherence to Tyramine-free diet is mandatory. High risk for Serotonin Syndrome (SS) if combined with other agents. Monitor BP frequently

SSRIs (general uses, SE, etc.)

uses: Depression, GAD, OCD, Panic Disorder, PTSD, Bulimia.

SE: Nausea/diarrhea, insomnia/agitation, sexual dysfunction, H/A

Black Box Warning for suicidal ideation (especially youth). Risk for SS. Do not stop abruptly (withdrawal syndrome). Slow onset (4-6 weeks)

SNRIs (general uses, SE, etc.)

uses: Depression, GAD, Chronic pain (neuropathic, fibromyalgia)

SE: Nausea, insomnia, headache, elevated blood pressure (especially Venlafaxine), sexual dysfunction

Monitor BP regularly. Severe discontinuation syndrome (taper very slowly). Duloxetine requires monitoring of LFTs (liver)

SARIs (general uses, SE, etc.)

uses: Insomnia (low dose), MDD (high dose, less common)

SE: Profound sedation, dizziness, orthostatic hypotension, Priapism

Primarily used for sleep. Instruct male pts to seek immediate attention for prolonged erection. Take at bedtime

NaSSAs (general uses, SE, etc.)

uses: Depression, especially with insomnia or low appetite

SE: Significant sedation, significant weight gain/increased appetite, dry mouth

Give at bedtime. Low risk of sexual dysfunction. Monitor weight

NDRIs (general uses, SE, etc.)

uses: Depression, smoking cessation

SE: Insomnia, dry mouth, headache, appetite suppression, lowers seizure threshold

Contraindicated in seizure and eating disorders. Low risk of sexual dysfunction. Take in the morning (risk of insomnia)

Mood Stabilizers (general uses, SE, etc.)

uses: Bipolar Disorder (manic and maintenance)

SE: Tremor, polyuria/polydipsia, nausea, diarrhea, weight gain, fatigue

Monitor serum levels (Therapeutic Range: 0.6-1.2 mEq/L). Monitor renal and thyroid function. Maintain consistent salt and fluid intake.

Anticonvulsants (general uses, SE, etc.)

uses: Bipolar disorder (mania/maintenance), seizures, pain

SE: Hepatotoxicity (Valproate), Blood Dyscrasias (Carbamazepine), sedation, SJS risk (Lamotrigine)

Requires frequent LFTs (liver) and CBC (blood) monitoring. Lamotrigine: Report rash immediately. Valproate is highly teratogenic. Monitor serum levels

Antipsychotics Gen I 

(general uses, SE, etc.)

uses: Schizophrenia, acute psychosis, severe behavioral problems

SE: High risk for EPS, (dystonia, akathisia, parkinsonism), TD, NMS, Anticholinergic SE, wt gain, sexual dysfunction, endocrine disturbances (metabolic syndrome)

Monitor for and treat EPS. Pimozide requires ECG monitoring (QT prolongation). Higher sedation/anticholinergic effects (Chlorpromazine)

Antipsychotics Gen II

(general uses, SE, etc.)

uses: Schizophrenia, Bipolar disorder

SE: Metabolic Syndrome (weight gain, hyperglycemia, dyslipidemia), sedation, orthostasis, hyperprolactinemia (Risperidone/Paliperidone)

Monitor weight, blood glucose, and lipid panel regularly. Clozapine requires mandatory weekly ANC (agranulocytosis risk). Ziprasidone/Lurasidone require food for absorption.

Antipsychotics Gen III

(general uses, SE, etc.)

uses: Schizophrenia, adjunct for MDD, Bipolar disorder

SE: Akathisia (restlessness), headache, nausea

Known as Dopamine System Stabilizers (lower risk of metabolic/prolactin side effects). Monitor for severe restlessness

ADHD Drug Treatments (Stimulants) (general uses, SE, etc.)

uses: ADHD, Narcolepsy

SE: Insomnia, appetite suppression/weight loss, tachycardia, HTN, abuse potential

Monitor BP, HR, and growth (height/weight) in children. Give early in the morning. Potential for abuse/diversion

Alpha 2 Agonists (general uses, SE, etc.)

uses: ADHD (non-stimulant), HTN, nightmares/hyperarousal (PTSD)

SE: Sedation, Hypotension, dizziness, dry mouth, rebound HTN (if stopped suddenly)

Monitor BP and HR before administration. Do not stop abruptly (risk of rebound hypertension). Prazosin: give first dose at bedtime (orthostasis)

Anticholinergic Toxicity (dry/fatal)

• life-threatening emergency caused by antipsychotics or other anticholinergic meds. Older adults & those on many anticholinergics are at higher risk. It blocks the neurotransmitter acetylcholine. 

• S/S: ANS instability, dilated pupils (mydriasis), urinary retention, reduced or absent peristalsis, delirium w/ altered mental status, hyperpyrexia w/o sweating, rapid HR, agitation, decreased responsiveness, seizure, repetitive motor movements

• Tx: hold meds ASAP, implement emergency cooling measures, give urinary cath., give benzo & physostigmine (reverses toxicity)

Neuroleptic Malignant Syndrome (wet/fatal)

• Rare, but acute life-threatening emergency caused by excessive dopamine receptor blockade, mostly from Gen I antipsychotics. 

• S/S: severe muscle pipelike rigidity, reduced consciousness & responsiveness (progresses to stupor, coma, delirium), hyperpyrexia (over 103 F), ANS dysfunction (HTN, sweating, tachycardia), incontinence, dysphagia, reduced speech & movement

• Tx: bromocriptine, dantrolene, give cooling blanket, maintain hydration (oral &/or IV), monitor for cardiac dysrhythmias, acute resp. failure, & AKI

Serotonin Syndrome (wet/fatal)

• life-threatening drug reaction caused by having too much serotonin in your body. Often d/t an interaction between different meds that increase serotonin levels.

• S/S: myoclonus (twitching/ jerking), mental status change (confusion, agitation, restlessness, anxiety), autonomic instability (high fever, tachycardia, HTN, dilated pupils, diaphoresis), muscle rigidity, tremors, overactive reflexes, shivering, loss of muscle coordination

• Tx: discontinue all serotonin meds ASAP, monitor VS, give IV fluids, give cooling measures, give benzo (controlled, agitation, spasms, & seizures), give cyproheptadine (serotonin antagonist), educate pts on r/o combining certain meds

Tardive Dyskinesia (TD/nonfatal)

• movement disorder that can be a side effect of Gen I antipsychotics. Develops after months to years of Tx & is serious b/c it may be irreversible, even after med is stopped. Early detection is important. Monitored using Abnormal Involuntary Movement Scale (AIMS)  

• S/S: involuntary movements of the face & jaw (lip-smacking, tongue protrusion), & sometimes the limbs

• Tx: discontinuing or reducing dose, switching to a Gen II antipsychotic, using VMAT2 inhibitors: Valbenazine, Congentin, paradoxically increasing dose can be helpful, assess pt’s environment for safety risks, educate pt on how to minimize risks

Extrapyramidal Symptoms (EPS; TD, akathisia, acute dystonic reaction)

• Acute dystonic reaction: A sudden, sustained, & painful contraction of one or several muscle groups, most commonly in head & neck. Caused by antipsychotics. 

• Akathasia: uncontrollable desire to move (restless leg in whole body)

• S/S: painful muscle contractions (in tongue, face, neck (torticollis), & back), spasms of muscles that can cause head, neck, & spine to arc backwards, cogwheel rigidity, eyes rolling back & fixed position (oculogyric crisis), larynx (laryngeal dystonia) could be life-threatening

• Tx: monitor & assure open airway, Use Antiparkinsonian drugs: Benztropine (IM), trinexyphenidyl (PO), Antihistamine: Diphenhydramine (IM), decrease drug dose, use newer atypical antipsychotic

benztropine

class: anticholinergic/antihistamine

Used for: Tx parkinsonism & control of EPS

S/E: Anticholinergic effects (dry mouth, blurred vision, constipation, urinary retention), sedation, confusion, dizziness, impaired memory, precipitate or worsen glaucoma or tachycardia

nsg considerations: Monitor for anticholinergic SE and mental status changes (especially in the elderly, as it can cause confusion/ psychosis), monitor for signs of TD, use with caution in hot weather (impaired sweating)

trihexyphenidyl

class: Anticholinergic/Antiparkinsonian

used for: Adjunctive Tx of parkinsonism, EPS control

SE: anticholinergic effects (dry mouth, blurred vision, constipation, urinary retention, dilated pupils), dizziness, nervousness, confusion, and memory impairment (especially in the elderly)

nsg considerations: Monitor for S/S of anticholinergic crisis (confusion, hyperthermia, flushed skin). Monitor I&O for urinary retention and bowel function for severe constipation/paralytic ileus. Use w/caution in pts w/ glaucoma, BPH, or cardiac conditions

valbenazine

class: VMAT2 inhibitor

used for: Tx TD & chorea associated w/ Huntington's disease

SE: somnolence, QT prolongation, parkinsonism-like symptoms (tremors, rigidity, unsteadiness), akathisia, & restlessness

nsg considerations: Assess for new or worsening signs of depression or SI, (esp. in pts w/ Huntington’s), monitor for QT prolongation, assess for signs of NMS, advise pt to not drive or operate heavy machinery