Psychotropic Medications Practice Flashcards

Benzo-Based Pharmacology: Action, Indications, and Management

• Mechanism of Action: Benzodiazepines (Benzos) increase the levels of GABA ($\text{Gamma-Aminobutyric Acid}$), which is often referred to by the mnemonic "Gabby." GABA acts as a calming agent in the brain, slowing down firing when the brain is "firing too fast."
• GABA Function: GABA induces a state of calm and relaxation, effectively slowing down anxiety levels. It is described as "pumping the brakes" on the brain's activity.
• General Classification: These drugs are sedatives, often characterized by the phrase "low and slow."
• Indications for Use:
  • Anxiety.
  • Muscle spasms.
  • Seizure activity.
  • Panic disorder.
  • Acute alcohol withdrawal (this is a high-priority indication for exams).
• Side Effects (The "Low and Slow" Effects):
  • Drowsiness and lightheadedness.
  • Central Nervous System (CNS) depression.
  • Respiratory depression ($\text{Respiratory rate} < 12\,bpm$) due to sedative properties.
  • Blurred vision.
  • Lethargy.
  • Sedation and Amnesia.
  • Cognitive effects: Dementia and confusion.
  • Gastrointestinal: Constipation.
  • Physical safety: High risk of falls.
  • Withdrawal syndrome.
• Serious Adverse Reactions:
  • Amnesia.
  • Severe respiratory depression.
  • Dependency: Benzos are intended for short-term use only.
• Contraindications and Precautions:
  • Patients with current respiratory infections.
  • Use with other CNS depressants (e.g., alcohol, opioids).
  • Acute narrow-angle glaucoma.
  • Pregnancy.
  • Hepatic (liver) failure.
  • Sleep apnea.
  • Older adults (increased risk of falls, delirium, and varied metabolism).
  • Clients with a history of substance use disorder.
• Toxicity and Interactions:
  • Grapefruit Juice: Absolutely contraindicated as it increases diazepam levels, leading to significant toxicity risk and enhanced CNS depression.
• Nursing Interventions and Client Education:
  • Take the medication at bedtime.
  • Do not discontinue abruptly; life-threatening withdrawal symptoms (e.g., seizures, irritability) can occur.
  • Long-term therapy leads to both tolerance and dependency.
  • No alcohol consumption while on therapy.
  • Advice for activities: Patients should not drive (due to sedation).
• Benzodiazepine Antidote: The reversal agent is Flumazenil ($F-L-U-M-A-Z-E-N-I-L$).
• Mnemonics:
  • "Pam takes lorazepam for her anxiety. She doesn't drive her Benz anymore because BenzOs cause sedation."
  • "Pam and Lamb": Diazepam, Lorazepam, and Alprazolam.
  • "GABA does yoga": Used to remember the calming effect of the neurotransmitter.

Non-Benzodiazepine Sedative-Hypnotics: Zolpidem (Ambien)

• Mechanism of Action: This drug enhances GABA rather than binding directly like benzodiazepines do.
• Indications: Specifically and solely for sleep (insomnia).
• Administration Requirements:
  • Take immediately before bed.
  • Ensure the client has at least $7-8\,hours$ available for sleep.
  • Intended for short-term use only.
• Side Effects and Risks:
  • Sleepwalking (noted as a specific "crazy" side effect).
  • Dizziness and fatigue.
  • GI tract upset.
• Interactions: Avoid alcohol, which increases sedative effects.
• Mnemonics: "Gabby got the Zs" or "Zol has Zs."

Melatonin Agonists: Ramelteon

• Mechanism of Action: Mimics the body's natural melatonin to regulate sleep. It does not directly enhance GABA.
• Indications: Insomnia/Sleep.
• Administration Nursing Care:
  • Take within a $30\,minute$ window before bedtime.
• Dietary Precautions: High-fat meals significantly delay absorption.
• Mnemonic: "Get Rammed to sleep, but you can't eat ham" (to remember the drug name Ramelteon and the contraindication of fatty foods).

Selective Serotonin Reuptake Inhibitors (SSRIs): Fluoxetine (Prozac)

• Mechanism of Action: Inhibits the reuptake of serotonin by blocking receptors in the first neuron. This increases the amount of serotonin available in the synaptic gap, which stabilizes mood.
• Indications:
  • Major Depression.
  • Obsessive-Compulsive Disorder (OCD).
  • Panic disorder.
  • Bulimia.
  • Premenstrual Dysphoric Disorder (PPMD).
• Side Effects:
  • Sexual dysfunction (e.g., inability to orgasm, low libido).
  • Weight changes.
  • Insomnia.
• Life-Threatening Risks:
  • Serotonin Syndrome (FAST): Fever ($\text{Hyperthermia}$), Agitation (anxiety, confusion), Sweating ($\text{Diaphoresis}$, shivering), and Tremors (hyperreflexia, muscle rigidity, specifically in the legs).
  • Suicide Risk: Medications can provide a depressed person with the energy needed to act on suicidal ideations before their mood fully recovers.
• Drug Interactions:
  • Contraindicated with MAOIs (causes potential for Serotonin Syndrome).
  • No Tricyclic Antidepressants (TCAs).
  • No St. John's wort.
  • No Tramadol.
  • No NSAIDs (increases bleeding risk).
• Medication Switching Timeline:
  • Requires a "two-week flush" before starting an MAOI after most SSRIs.
  • Fluoxetine requires a five-week ($5\,week$) waiting period after discontinuation before starting an MAOI due to its long half-life.
• Mnemonic: "Flo from the diner" is depressed, OCD, and panics.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Venlafaxine ($Ven-la-fax-ine$)

• Action: Increases energy and focus by raising both serotonin and norepinephrine levels. This triggers the sympathetic nervous system ("fight or flight").
• Indications:
  • Major depressive disorder.
  • Severe anxiety and panic disorders.
  • Duloxetine (a related SNRI) is specifically indicated for fibromyalgia and chronic pain.
• Side Effects:
  • Low libido/sexual dysfunction.
  • Sweating and insomnia.
  • Ocular issues: Dilated pupils ($\text{Mydriasis}$), angle-closure glaucoma, and eye pain.
  • Dose-dependent hypertension (increased heart rate due to norepinephrine).
  • Hyponatremia (low salt levels).
• Adverse Risks: Suicidal thoughts and serotonin syndrome if mixed with St. John's wort.
• Mnemonic: "Vinnie the tough guy" is depressed and can't focus.

Atypical Antidepressants: Bupropion (Wellbutrin)

• Indications:
  • Depression.
  • Smoking cessation (makes cigarettes taste horrible and removes the craving).
• Side Effects:
  • Increased thirst/Dry mouth.
• Major Contraindications:
  • Seizure disorders (greatly lowers the seizure threshold).
  • Past or current diagnosis of Anorexia Nervosa or Bulimia (affects appetite/metabolism).
  • Abrupt withdrawal from alcohol or sedatives.
• Mnemonic: "Well-used friend" for quitting smoking.

Tricyclic Antidepressants (TCAs): Amitriptyline

• Indications: Depression, chronic nerve pain, migraines, insomnia, and fibromyalgia.
• Side Effects (Anticholinergic Effects): Remember the phrase "Can't see, can't pee, can't spit, can't sh*t."
  • Dry mouth.
  • Blurry vision.
  • Urinary retention.
  • Constipation.
• Cardiac Risks: Causes prolonged QT intervals; nursing must monitor for mental status changes and cardiac issues (Potential for MI).
• Contraindications: Glaucoma (because it affects vision and can't see anyway).
• Timeline: Must be off MAOs for $14\,days$ before starting TCAs.
• Mnemonic: "Amy tripped on her bike and has pain/headaches."

Monoamine Oxidase Inhibitors (MAOIs): Phenelzine

• Action: Inhibits the enzyme that breaks down neurotransmitters like serotonin and norepinephrine.
• Critical Interactions:
  • Cannot be taken with virtually any other antidepressants.
  • Dietary restriction: No Tyramine (found in salami, aged meats, aged cheeses, etc.) or high-fat foods.
  • Long half-life requiring a flush period ($2-5\,weeks$ depending on the prior drug).

Questions & Discussion

• Interviewer/Participants: Discussion regarding the difference between delirium and dementia.
• Response: Dementia is permanent/staying; delirium is acute and potentially reversible.
• Speaker Anecdote: One speaker shared their success using Wellbutrin for smoking cessation, noting it worked in about three months and made cigarettes taste disgusting.
• Personal Experience: A speaker mentioned they had to stop taking Lexapro due to the deal-breaker side effect of being unable to achieve orgasm.
• Question: Is it safe to take grapefruit juice with Benzos?
• Answer: No, it increases the levels of the drug in the system, increasing toxicity risk and CNS depression.