Psychotropic Medications and Nursing Considerations

Selective Serotonin Reuptake Inhibitors: Citalopram

• Mechanism of Action: This medication functions by blocking the reuptake of serotonin, which leads to increased levels of this neurotransmitter within the Central Nervous System (CNS).

• Therapeutic Uses: Primarily indicated for the treatment of depression. It is also utilized off-label for various anxiety-related disorders, including Generalized Anxiety Disorder (GAD), Post-Traumatic Stress Disorder (PTSD), and social anxiety.

• Nursing Assessment and Monitoring:

  • Vigilantly observe for suicidal thoughts and behaviors.
  • Monitor for electrolyte imbalances.
  • Assess for signs of serotonin syndrome.

• Physiological Effects on the Body: The introduction of this medication may result in insomnia, fatigue, nausea, and changes in body weight.

• Side Effects: Common occurrences include headache, gastrointestinal (GI) upset, decreased libido, sweating, and tremors.

• Adverse Effects: Significant risks include suicidal ideation, serotonin syndrome, serious alterations in heart rhythm, and rare, severe skin reactions.

• Administration Guidelines:

  • Administered orally (PO) once daily.
  • Importance of tapering: the medication must not be discontinued suddenly.

• Contraindications:

  • Concurrent use with MAOIs (Monoamine Oxidase Inhibitors) or linezolid.
  • Presence of certain cardiac conditions.

• Precautions: Use with caution in patients with a history of mania, seizure disorders, or renal and hepatic impairment.

• Client Teaching:

  • Report any new or worsening suicidal thoughts immediately.
  • Anticipate a timeframe of $1 \text{ to } 4$ weeks for full therapeutic effects to manifest.
  • Avoid the consumption of alcohol.
  • Do not combine with other serotonergic medications.

• Expected Medication Outcome: Enhancement of mood, reduction in anxiety levels, and improved functionality in daily living.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Venlafaxine

• Mechanism of Action: This class works by blocking the reuptake of both serotonin and norepinephrine in the brain.

• Therapeutic Indications: Used for the management of depression, clinical anxiety, panic disorder, and social phobia.

• Administration:

  • Taken orally.
  • Typically prescribed as an extended-release (XR) formulation administered once daily with food.

• Nursing Assessment:

  • Continuous monitoring of mood and potential suicidal thoughts.
  • Regular assessment of blood pressure (BP) and blood counts.

• Side Effects: Patients may experience GI symptoms, sexual dysfunction, headache, dizziness, and visual changes.

• Adverse Effects: Serious potential outcomes include serotonin syndrome, seizures, chest pain, hypertension, and suicidal ideation.

• Contraindications:

  • Do not use in conjunction with MAOIs.
  • Contraindicated during lactation.
  • Contraindicated for individuals with uncontrolled hypertension or acute glaucoma.

• Precautions: Heightened caution is required for patients with heart, liver, or kidney issues, those with a history of seizures, or those who are pregnant.

• Client Teaching:

  • Ensure the medication is taken with food.
  • Avoid alcohol and other CNS depressants.
  • Promptly report any significant mood shifts or eye pain.
  • Do not cease medication usage abruptly.

Benzodiazepines: Lorazepam

• Mechanism of Action: Enhances the inhibitory and calming effects of the neurotransmitter Gamma-Aminobutyric Acid (GABA) within the brain to reduce anxiety and induce sedation.

• Therapeutic Uses: Management of anxiety, sedation, insomnia, and seizure activity.

• Specific Indications:

  • Acute anxiety episodes.
  • Preoperative sedation.
  • Alcohol withdrawal syndrome.
  • Seizure disorders.

• Nursing Assessment:

  • Monitor anxiety levels, orientation, mood, and behavior.
  • Watch for CNS reactions, particularly in older adults who may be more sensitive.

• Physiological Effects: Promotes general relaxation, relieves anxiety, and induces sleep and sedation.

• Side Effects: Drowsiness, dizziness, nausea, constipation, and confusion.

• Adverse Effects: Respiratory depression, cardiac arrest, dependency, and seizures.

• Administration Routes: Available via oral (tablet, capsule, liquid), Intramuscular (IM), or Intravenous (IV) routes.

• Contraindications and Precautions:

  • Avoid use in patients with severe respiratory impairment or acute closed-angle glaucoma.
  • Avoid during pregnancy and lactation.
  • Contraindicated for those with alcohol use disorder.

• Client Teaching:

  • Adhere strictly to the prescribed dosage.
  • Avoid alcohol and other CNS depressants.
  • Report severe side effects immediately.
  • Do not discontinue use abruptly and never share the medication with others.

• Medication Outcome: An increased sense of well-being and decreased anxiety without the presence of excessive sedation.

Non-Benzodiazepine Anxiolytics: Buspirone

• Mechanism of Action: Primarily targets serotonin receptors with minor dopamine action. Notably, it does not cause sedation or lead to physical dependence.

• Therapeutic Uses: Treatment of Generalized Anxiety Disorder (GAD) and short-term relief of anxiety symptoms.

• Indications: Specifically indicated for GAD and for clients who are intolerant to the side effects of SSRIs or SNRIs.

• Nursing Assessment: Monitor for anxiety levels and potential CNS effects such as dizziness or headaches.

• Physiological Effects: Successfully reduces anxiety without inducing significant drowsiness.

• Side Effects: Dizziness, drowsiness, headache, and nausea.

• Adverse Effects: Potential for movement disorders, chest pain, palpitations, and rare but severe CNS effects.

• Administration:

  • Taken orally.
  • Must be taken consistently either always with food or always without food to maintain steady levels.
  • Dosage must not exceed $60\,\text{mg/day}$.

• Contraindications and Precautions:

  • Contraindicated with hypersensitivity, severe hepatic or renal impairment, and use of MAOIs.
  • Use caution when consuming grapefruit juice or other psychotropic medications.

• Client Teaching:

  • Inform the patient that the medication takes several weeks to reach full effectiveness.
  • Avoid alcohol.
  • Do not stop the medication abruptly.
  • Report any worsening symptoms and consult a provider before starting new meds or supplements.

• Outcome: Improved sense of well-being and a reduction in anxiety.

Antihistamines for Anxiety: Hydroxyzine

• Mechanism of Action: Blocks H1 receptors, resulting in a calming effect on the CNS to provide anxiety relief.

• Therapeutic Use: Reduction of anxiety and tension.

• Indications: Acute anxiety and as an adjunct treatment for insomnia.

• Nursing Assessment:

  • Periodically check anxiety levels.
  • Monitor for sedation level and cardiac side effects.

• Physiological Effects: Causes sedation, dry mouth, and occasionally confusion.

• Side Effects: Drowsiness, headache, and xerostomia (dry mouth).

• Adverse Effects: QT prolongation, Torsades de pointes, hallucinations, seizures, and respiratory depression.

• Administration Routes:

  • Oral (tablet, capsule, syrup).
  • Intramuscular (IM) injection. Note: Never administer via IV.

• Contraindications: Prolonged QT interval, early pregnancy, and lactation.

• Precautions: Increased risk with cardiac issues, CNS depression, and in older populations.

• Client Teaching:

  • Be aware of sleepiness; avoid alcohol and other sedatives.
  • If used for insomnia, take as prescribed, usually at bedtime.

Beta-Adrenergic Blockers: Propranolol

• Mechanism of Action: Blocks beta-adrenergic receptors, which reduces the heart rate and physical symptoms of anxiety like tremors and palpitations.

• Therapeutic Use: High efficacy for situational or performance anxiety and off-label use for PTSD.

• Indication: Specifically for performance anxiety and social phobia.

• Nursing Assessment:

  • Monitor blood pressure and pulse rate.
  • Watch for signs of orthostatic hypotension and skin rash.

• Physiological Effects: Lowers physiological hyperarousal by affecting the heart and blood vessels.

• Side Effects: Fatigue, weakness, dizziness, drowsiness, and mild hypotension.

• Adverse Effects: Arrhythmias, severe bradycardia, heart failure, and anaphylaxis.

• Administration: Taken orally as needed (PRN) prior to the anxiety-provoking event.

• Contraindications: Heart failure, bradycardia, asthma, and severe pulmonary disease.

• Precautions:

  • Diabetes: The drug can mask signs of hypoglycemia.
  • Renal or hepatic impairment; pregnancy.

• Client Teaching:

  • Monitor pulse and blood pressure.
  • Change physical positions slowly to avoid dizziness.
  • Diabetic patients must monitor blood sugar levels closely.

• Medication Outcome: Reduction in anxiety and Sympathetic Nervous System (SNS) symptoms during social or performance situations.

Miscellaneous Antidepressants: Mirtazapine and Bupropion

Mirtazapine

• Mechanism of Action: Enhances serotonin and norepinephrine by blocking alpha-2 receptors.
• Therapeutic Use: Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and issues regarding sleep or appetite.
• Indications: Depression, anxiety, insomnia, and for clients who are underweight.
• Nursing Assessment: Monitor for mood changes, suicidal thoughts, and serotonin syndrome.
• Physiological Effects: Drowsiness, weight gain, and increased appetite.
• Side Effects: Drowsiness, dry mouth, and constipation.
• Adverse Effects: Suicidal ideation, serotonin syndrome, Neuroleptic Malignant Syndrome (NMS), and rare blood disorders.
• Administration: Oral, typically at bedtime; may be taken with or without food.
• Contraindications: Use with MAOIs or similar drugs.
• Precautions: History of seizures, hepatic/renal issues, or suicidal risks.
• Client Teaching: Take at bedtime, avoid alcohol, and manage dry mouth with hydration or gum.

Bupropion

• Mechanism of Action: A Norepinephrine-Dopamine Reuptake Inhibitor (NDRI) that increases levels of dopamine and norepinephrine.
• Therapeutic Use: MDD, Seasonal Affective Disorder (SAD), anxiety, and smoking cessation.
• Nursing Assessment: Monitor mood, suicidal thoughts, and liver/kidney function.
• Physiological Effects: Improved mood and energy; potential appetite suppression.
• Side Effects: Agitation, headache, insomnia, dry mouth, and nausea.
• Adverse Effects: Seizures, suicidal or homicidal thoughts, hypertension, and psychosis.
• Administration: Oral XR (extended-release) tablet; do not crush or chew.
• Contraindications: MAOI use, seizure disorders, bulimia, or anorexia.
• Precautions: Recent Myocardial Infarction (MI), glaucoma, pregnancy, and renal/hepatic impairment.
• Client Teaching: Take in the morning, swallow whole, and avoid alcohol.

Tricyclic Antidepressants (TCAs): Amitriptyline

• Mechanism of Action: Increases the concentration of serotonin and norepinephrine in the brain.

• Therapeutic Use: Primarily for depression; used off-label for anxiety.

• Nursing Assessment:

  • Monitor blood pressure, pulse, and ECG.
  • Track weight and glucose/cholesterol levels.
  • Monitor for suicidal thoughts and liver/blood abnormalities.

• Physiological Effects: Causes sedation and anticholinergic effects; can alter heart rhythm.

• Side Effects: Sedation, dry mouth, constipation, urinary hesitancy, and photosensitivity.

• Adverse Effects: Severe anticholinergic effects, dysrhythmias, blood dyscrasias, and suicidal thoughts.

• Overdose Risk: Extremely dangerous in overdose scenarios due to toxicity risk.

• Administration:

  • Oral, with or after meals.
  • Best taken at bedtime to utilize sedative effects.
  • Do not stop abruptly.

• Contraindications: Closed-angle glaucoma, QT prolongation, recent MI, heart failure, and lactation.

• Precautions: Cardiac disease, seizure history, elderly patients, and patients under $25$ due to increased suicide risk.

• Client Teaching:

  • Protect skin from sunburn (photosensitivity).
  • Avoid alcohol.
  • Expect effects to take $2\text{ to } 6$ weeks.

Anticonvulsants: Pregabalin

• Mechanism of Action: Binds to calcium channels in the CNS to regulate the release of neurotransmitters, effectively calming nerve activity.

• Therapeutic Use: Treatment of neuropathic pain and off-label use for anxiety.

• Nursing Assessment: Monitor renal function and watch for suicidal thoughts.

• Physiological Effects: Drowsiness, dizziness, and blurred vision.

• Side Effects: Dry mouth, GI upset, drowsiness, and dizziness.

• Adverse Effects: Suicidal thoughts, edema, and PR interval changes.

• Administration: Oral XR tablets.

• Contraindications: Severe renal impairment, myopathy, and lactation.

• Precautions: Heart failure, pregnancy, and use in older adults.

• Client Teaching:

  • Avoid alcohol and other CNS depressants.
  • Report muscle pain or weakness immediately.
  • Never stop the medication abruptly.

• Medication Outcome: Increased mood stability and reduced anxiety levels.