Psychotherapeutic Drugs

What are the different psychological disorders?

* Anxiety, trauma, stress related disorders
* Depressive disorders
* Bipolar disorders
* Psychotic disorders
* Substance use disorders

Types of disorders under the umbrella terms of Anxiety, Trauma, Stress, and Depression?

* Generalized anxiety disorder
* Panic disorder
* Obsessive-compulsive disorder
* Social anxiety disorder
* Post-traumatic stress disorder (PTSD)
* Depression

The practice of giving medications to treats these disorders is known as the -- approach

biomedical

With any class of anti-depressant medications you are NOT allowed to -- them with each other

combine/mix

If you want to switch anti-depressant medications you must…

slowly taper use of current medication

What is the main priority with anti-depressant medications?

SAFETY

What are different safety protocols we can perform with anti-depressant medications?

* ==make sure that the environment is completely free of anything that the patient can harm themselves with==
* no curtains, strings, glass items
* ==do NOT round on a regular interval== because the patient may being to time when you are leaving and how long they have before you return - this may be the time they try to harm themselves

If a patient starts to show signs of medication effectiveness with anti-depressants (talking more, perky, upbeat), watch out for….

suicide attempts

Selective Serotonin Reuptake Inhibitors (SSRIs) antidepressant medications?

* paroxetine
* sertraline
* fluoxetine
* citalopram
* escitalopram

SSRIs perform which action?

* Inhibits serotonin reuptake, allowing more serotonin to stay at the junction of neurons
* Produces CNS stimulation

==GOAL: increase serotonin levels==

Educate patient to take SSRI medications in the…

morning

Educate patient that SSRI medications need -- to become effective

4 weeks

* patients may wonder why the effects are not occurring

SSRIs can be used to treat…

* generalized anxiety
* panic disorder
* OCD
* depressive disorders ==(primary use)==
* PTSD

Initial complications of SSRIs?

* nausea
* fatigue
* tremors

Other complications of SSRIs?

* weight gain
* GI bleeding
* ==protect patient from trauma or invasive procedures==
* hyponatremia
* ==clients on diuretics==
* ==messes up neuromuscular function==
* serotonin syndrome
* bruxism
* ==grinding teeth==
* suppression of platelet aggregation
* ==increased bleeding risk==

What is serotonin syndrome and what do we see with it?

* An accumulation of serotonin in the brain stem or brain tissues
* Leads to a hyperstimulation of the body
* increased BP, PR, Temp
* Fever or Tremors seen
* This condition will usually subside on its own but if it does not, administer benzodiazepine

What is the antidote for serotonin syndrome?

Cyproheptadine

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) medications?

* Venlafaxine
* Duloxetine

What is the action of SNRIs?

They block reuptake of norepinephrine and serotonin

What disorders are SNRIs used for?

* Major depression
* Generalized anxiety disorder
* Social anxiety disorder
* Panic disorder
* ==Pain due to fibromyalgia, osteoarthritis, low back pain, diabetic neuropathy==

Tricyclic Antidepressant medications?

* amitriptyline
* nortriptyline
* imipramine

What is the action of Tricyclic Antidepressants?

blocks reuptake of norepinephrine and serotonin

Advantage of Tricyclic Antidepressants?

it works quicker than SSRIs

* 10-14 days before it takes effect
* maximum effects in 4-8 weeks

What are Tricyclic Antidepressants used for?

**Depression**

* Depressive episodes of bipolar disorder
* Neuropathic pain
* Fibromyalgia
* ADHD

Complications of Tricyclic Antidepressants?

* Orthostatic Hypotension
* Anticholinergic Effects
* dry mouth, constipation, urinary retention

How to prevent orthostatic hypotension?

* move slowly with the patient
* do not make abrupt changes in position
* monitor VS

How to minimize anti-cholingeric effects?

* chew sugarless gum
* increase fluids
* 2-3L/day
* 6-8 glasses/day is normal amount so we want >8 glasses of water/day
* eat foods high in fiber
* wear sunglasses outside

Monoamine Oxidase Inhibitor (MAOI) medications?

* phenelzine
* isocarboxazid
* selegiline (transdermal)

MAOI action on the brain?

Blocks MAO in the brain; thus increasing amount of norepinephrine, dopamine, serotonin and tyramine available for impulse transmission

* used less frequently d'/t its SE

What are MAOIs used for?

* depression
* bulimia
* panic disorder
* social anxiety disorder
* OCD
* PTSD

Complications of MAOIs?

**CNS Stimulation:**

* anxiety
* agitation
* mania
* hypertensive crisis
* HA
* tachycardia

\-- is the most common sign of an increase in BP

HA

With MAOI medications, it can be dangerous to give them to patients with a history of…

* HTN
* heart disease
* angina
* stroke

Be careful with -- rich foods because they can trigger a hypertensive crisis in patients using MAOIs

tyramine

* cheese
* pepperoni
* salami
* avocados
* figs
* soups
* soy sauce
* red wine
* protein supplements

Atypical or 2nd Generation Antidepressant medications?

* bupropion
* ==helps with smoking cessation==
* mirtazapine
* ==causes sedation and is an appetite stimulant==
* nefazodone
* trazodone
* ==can help with depression and insomnia especially in older adults==
* vilazodone
* vortioxetine

Contraindications to the use of Bupropion?

* **patients with seizure disorders**
* lowers the seizure threshold which puts patients at increased risk for status epilepticus
* **MAOIs**
* do not administer the two medications together

Trazodone can cause --

priapism - painful sustained erection (hardening of penis)

Evaluating effectiveness of Atypical or 2nd Generation Antidepressant medications?

* Verbalizing improvement in mood
* Increased hopefulness and desire to live
* Ability to perform ADLs
* Improved sleeping and eating habits
* Increased interaction with peers

Benzodiazepine medications for anxiety?

* alprazolam (Xanax)
* diazepam (Valium)
* lorazepam (Ativan)
* lonazepam

Benzodiazepines induce -- and reduce --

sleep; anxiety

* ==they enhance the inhibitory effects of GABA in the CNS==

Benzodiazepines are used for…

* general anxiety disorder
* panic disorder
* PTSD
* insomnia
* alcohol withdrawal

Complications of Benzodiazepines?

* sedation
* lightheadedness
* ataxia
* ==difficulty walking==
* decreased cognitive function
* paradoxical response
* ==opposite effect==
* ==patient will be hyper==

We want to avoid giving Benzodiazepines with…

**CNS depressants**

* alcohol
* opioid analgesics

What do we see with acute toxicity from Benzodiazepines?

* Respiratory depression
* Hypotension
* Cardiac/respiratory arrest

Nursing considerations with benzodiazepines?

* Take as prescribed
* Taper the dose when discontinuing
* Administer at bedtime if possible
* Keep in a secure place

What is the antidote for Benzodiazepines?

Flumazenil

Atypical Non-barbiturate Anxiolytic medication?

Buspirone

Buspirone binds to…

serotonin and dopamine receptors

Advantages to the use of Buspirone?

* less dependency than benzodiazepines
* less sedation

Buspirone can be used for…

* panic disorders
* social anxiety disorder
* OCD
* PTSD

What things interact with Buspirone and why is this a bad thing?

* Erythromycin
* Ketoconzazole
* St. John’s Wort
* Grapefruit juice

\
* ==All of these things can cause an increase of medication levels in the blood!!==

S&S of Bipolar Disorder?

* Erratic behavior
* Great mood
* Rapid speech
* Irritability
* Inability to complete tasks
* Trouble at work
* Flight of ideas
* Depression
* Alcohol or drug use
* Difficulty sleeping

Bipolar disorder medications are known as --

“mood stabilizers”

Actions of Mood Stabilizers?

* Promote sleep
* Decrease anxiety and agitation
* Manage psychomotor agitation
* Useful during the depressive phase

Mood Stabilizing medication for Bipolar disorder?

Lithium carbonate

* prevents episodes of acute mania or return of mania/depression

Lithium carbonate blocks…

serotonin receptors

Complications of Lithium Carbonate?

* GI distress
* Fine hand tremors
* Polyuria, mild thirst
* Weight gain
* Renal toxicity
* perform a renal function assessment before and during administration
* Goiter/hypothyroidism
* Lithium toxicity
* monitor levels
* Watch for sodium balance
* overhydration (low Na)
* dehydration (high Na)

If a patient has hyponatremia while on lithium carbonate, this will…

increase their risk for toxicity

If a patient has hypernatremia while on lithium carbonate, this will…

reduce the effectiveness of the medication

* ==sodium and lithium carbonate both “attach” to the same receptors==

Lithium carbonate has a very narrow…

TI

Maintenance level for Lithium carbonate?

0\.6-1.0 mEq/L

* 1.1 or 1.3 is still okay

Lithium carbonate becomes toxic once it is over…

1\.5 mEq/L

There is no antidote for lithium carbonate so -- is used instead and is done -- times daily

hemodialysis; 2-3x

Mood Stabilizing Anti-epileptic drugs?

* carbamazepine
* valproic acid
* lamotrigine

What is the action of Mood Stabilizing Anti-epileptic drugs?

* Slows re-entrance of sodium and calcium back into the neuron: extends the time it takes for the nerve to return to its active state
* Potentiates inhibitory effects of GABA
* Inhibits CNS excitation

Mood Stabilizing Anti-epileptic drugs are used for…

* Treatment and prevention of relapse of mania and depressive episodes
* Also: mixed mania and rapid cycling bipolar disorders

Evaluation of effectiveness of Mood Stabilizing Anti-epileptic drugs?

* Relief of acute manic symptoms or depressive symptoms
* Mood stability
* Ability to perform ADLs
* Improved sleeping and eating habits
* appropriate interaction with peers

Psychotic Disorders: Schizophrenia spectrum disorders are?

psychotic disorder of thought process

Positive symptoms of Schizophrenia?

* agitation
* bizarre behavior
* ==delusions==
* ==hallucinations==
* flight of ideas
* illogical thinking patterns

Negative symptoms of Schizophrenia?

* social withdrawal
* lack of emotion
* lack of energy
* flat affect
* decreased motivation
* decreased pleasure in usual activities

Cognitive symptoms of Schizophrenia?

attention and focus deficit

Delusion is a…

belief

* it is caused by an external stimulation
* if someone sees a shadow they may interpret it differently

Hallucination is…

an alteration in thought process

* there is no specific stimulation
* comes from within

Goals of Schizophrenia therapy?

* Suppress acute episodes
* Prevent acute recurrences
* Maintain the highest possible level of functioning

Typical First generation Antipsychotic medications?

* chlorpromazine
* thiordiazine
* thiothixene
* haloperidol (Haldol)
* fluphenazine

First generation Antipsychotic medications will typically decrease the -- symptoms in patients

positive

First generation Antipsychotic medications action on the brain?

They block dopamine, acetylcholine, histamine and norepinephrine receptors in brain and periphery

Since First generation Antipsychotic medications block dopamine receptors this can cause…

Pseudoparkinsonism

* patients will mimic actions seen in parkinson disease

First generation Antipsychotic medications are used for…

* Acute and chronic psychotic disorders
* Schizophrenia spectrum
* Bipolar syndrome
* Tourette syndrome
* Agitation
* Violent or aggressive behavior - **specifically haloperidol**

Complications seen with first generation antipsychotic medications?

* Extrapyramidal side effects (EPSs)
* ==can fall, choke, or aspirate==
* Akathisia
* ==unable to stand still or sit, continually paced and agitated==
* Tardive dyskinesia
* ==involuntary movement of tongue & lips==
* Anticholinergic SE
* ==constipation, dry mouth, hypotension==
* Photosensitivity
* ==protect skin; sun screen, hats, wear long sleeves==
* Jaundice
* ==pay attention to LFTs==
* Agranual cytolysis
* ==will see recurring sore throat or infection==
* Neuroleptic malignant syndrome
* ==fever, tremors, tachycardia==

\-- can be given for management of Tardive dyskinesia

Valbenazine

Atypical 2nd and 3rd generation Antipsychotic medications?

* risperidone
* olanzapine
* quetiapine
* clozapine
* aripiprazole

Atypical 2nd and 3rd generation Antipsychotic medications block…

serotonin, dopamine, norepinephrine, histamine and acetylcholine receptors

* typically first line treatment since they have less SE

Atypical 2nd and 3rd generation Antipsychotic medications decrease both…

positive and negative symptoms

Atypical 2nd and 3rd generation Antipsychotic medications can be used for…

* Schizophrenia spectrum
* Psychotic episodes induced by levodopa therapy
* Bipolar disorders
* Impulse control disorders

Atypical 2nd and 3rd generation Antipsychotic medications can cause -- disorders

==blood==

* can mess up platelets or WBCs
* want to monitor blood levels to prevent anemia, bleeding, or infection

Substance use disorders include abuse towards…

* alcohol
* caffeine
* cannabis
* hallucinogens
* inhalants
* opioids
* sedatives/anxiolytics
* stimulants
* tobacco
* steroids

Withdrawal symptoms include…

* GI distress
* behavioral changes
* cardiovascular changes
* increase in VS - PR
* seizures

First -- hours after a person comes in with alcohol withdrawal, they may experience --

72

hallucinations and acute changes in mental status

Medications to support acute alcohol withdrawal?

* benzodiazepines
* ==chlordiazepoxide==
* ==helps to maintain VS, decrease seizures and withdrawal symptoms==
* carbamazepine
* clonidine
* propanolol
* atenolol
* “banana bag”
* ==IV infusion==
* ==combination of thiamine, folate, and multivitamins==
* ==for hangovers==

Medications to support maintenance alcohol withdrawal?

* disulfiram
* ==makes you nauseous if you drink alcohol==
* ==don’t give mouthwash because it has alcohol base properties in it==
* naltrexone
* ==suppresses craving for alcohol==

Medications supporting Opioid withdrawal/OD?

* methadone
* ==narcotic which doesn’t get the client high==
* clonidine
* ==decreases autonomic hyperactivity but not the craving==
* buprenorphine
* ==safer than methadone due to decreased risk of dependence==
* naloxone (Narcan): Antidote
* ==blocks the effects of opioids and reverses the overdose; available in nasal spray and IV in in patient settings==

Medications to support smoking withdrawal?

* Antidepressant: ==buproprion==
* Varenicline
* ==reduces cravings for nicotine by blocking the desired effects; also helps with withdrawal symptoms==

Nicotine replacement (relieves physical withdrawal symptoms so client can focus on the emotional aspect)

* lozenge (limit quantity to 20 QD
* Gum (limit: 6 months)
* patch (3 step)
* nasal spray (not for asthmatics)
* Inhaler (gradually taper)

Use caution with -- patients when giving Bupropion or Varenicline

cardiovascular

* can makes things worse