Neuro

Anxiolytic and Hypnotic Agents

1. Introduction

• Anxiety: A feeling of tension, nervousness, apprehension, or fear involving unpleasant reactions to a stimulus.

2. Psychological States Affecting Anxiolytic and Hypnotic Drugs

• Sedation: Loss of awareness and reaction to environmental stimuli.

• Hypnosis: Extreme sedation leading to further CNS depression and sleep.

3. Benzodiazepines Overview

• Definition:

  • Benzodiazepines are a class of central nervous system (CNS) depressants.

  • Used to manage anxiety, insomnia, muscle spasms, seizure disorders, and alcohol withdrawal.

• Prescriptive Popularity & Advantages:

  • Among the most commonly prescribed sedative-hypnotic agents.

  • Noted for effectiveness, rapid onset, and relatively high safety margin compared with older barbiturates.

4. Benzodiazepines: Mechanism of Action

• Working Process:

  • Benzodiazepines enhance the effects of gamma-aminobutyric acid (GABA), the main inhibitory neurotransmitter in the CNS.

  • Binding occurs on specific benzodiazepine receptors on the GABA-A receptor complex, increasing the frequency of chloride channel opening.

  • Chloride ion influx hyperpolarizes the neuron (less excitable), leading to CNS depression—producing sedation, anxiolysis, and muscle relaxation.

• Key Concept:

  • Benzodiazepines do not directly activate GABA receptors; they potentiate GABA's natural inhibitory effect.

5. Pharmacologic Uses of Benzodiazepines

• Categories:

  • Anxiolytic: Reduces anxiety and agitation.

  • Sedative-hypnotic: Promotes relaxation and sleep.

  • Anticonvulsant: Controls seizure activity.

  • Muscle relaxant: Decreases skeletal muscle tension.

  • Amnesic: Causes short-term memory loss (useful for medical procedures).

6. Actions & Indications of Benzodiazepines

• Actions:

  • Lower doses assist with anxiety; higher doses induce sedation and hypnosis.

• Indications:

  • Anxiety disorders, alcohol withdrawal, hyperexcitability, agitation, and preoperative relief of anxiety and tension for balanced anesthesia.

7. Common Benzodiazepines and Uses

• Drug Name (Generic) | Common Brand | Primary Clinical Uses

  • Diazepam | Valium | Anxiety, muscle spasms, seizure disorders, alcohol withdrawal.

  • Lorazepam | Ativan | Anxiety, sedation before surgery, status epilepticus.

  • Alprazolam | Xanax | Generalized anxiety and panic disorders.

  • Clonazepam | Klonopin | Panic disorders, seizure disorders.

  • Temazepam | Restoril | Short-term treatment of insomnia.

  • Midazolam | Versed | Sedation and amnesia before procedures or surgery.

8. Pharmacokinetics of Benzodiazepines

• Absorption:

  • Well absorbed from the GI tract.

• Peak Levels:

  • Achieved in 30 minutes to 2 hours.

• Distribution:

  • Lipid soluble, distributes well throughout the body, crosses the placenta, enters breast milk.

• Metabolism:

  • Primarily metabolized in the liver; excretion is mainly in the urine.

9. Adverse Effects of Benzodiazepines

• Common Adverse Effects:

  • Sedation, drowsiness, lethargy.

  • Depression.

  • Blurred vision.

  • Confusion.

  • Dry mouth.

  • Constipation.

  • Nausea/vomiting.

  • Hypotension.

  • Urinary retention.

10. Nursing Considerations for Benzodiazepines

10.1 Assessment

• Obtain medication history regarding other CNS depressants (e.g., opioids, alcohol).

• Assess level of anxiety, sleep patterns, or seizure activity prior to therapy.

• Monitor vital signs, specifically respiratory rate and level of consciousness.

10.2 Implementation

• Administer at bedtime for sleep aid.

• Avoid abrupt discontinuation (can cause withdrawal symptoms such as tremors, seizures, anxiety).

• Use the lowest effective dose for the shortest duration.

• For IV preparations (e.g., lorazepam, diazepam), monitor for respiratory depression.

10.3 Patient Teaching

• Avoid alcohol, opioids, and other sedatives while on benzodiazepines.

• Caution against driving or operating machinery until effects are known.

• Rise slowly to prevent orthostatic hypotension.

• Do not stop suddenly; taper under provider supervision.

• Secure medications due to the risk of misuse and dependence.

10.4 Evaluation

• Observational outcomes: reduction in anxiety, improved sleep without excessive sedation, no signs of dependence or withdrawal.

11. Contraindications of Benzodiazepines

11.1 Absolute Contraindications

• Conditions:

  • Known hypersensitivity/allergy (risk of severe allergic reaction).

  • Severe respiratory insufficiency or sleep apnea (further CNS depression may cause respiratory arrest).

  • Severe hepatic impairment (toxic accumulation for long-acting agents like diazepam).

  • Acute narrow-angle glaucoma (increases intraocular pressure).

  • Shock, coma, or acute intoxication (risk of respiratory and cardiovascular depression).

11.2 Relative Contraindications

• Conditions:

  • Chronic obstructive pulmonary disease (COPD): may worsen hypoventilation; caution advised.

  • Elderly or debilitated patients: higher CNS sensitivity and fall risk.

  • Pregnancy and lactation: risks to the fetus or infant.

  • Substance use disorder (alcohol or drug dependence): high risk of tolerance and dependence.

  • Renal impairment: may prolong effects.

  • Depression/suicidal ideation: increased risk of mood worsening; appropriate mental health support required.

12. Drug Interactions for Benzodiazepines

• Interacting Substances:

  • Alcohol: profound CNS and respiratory depression; contraindicated.

  • Opioids: increased risk of fatal respiratory depression.

  • Antihistamines, barbiturates, antipsychotics, antidepressants: additive sedation risk.

• Drugs affecting metabolism:

  • Valproate, cimetidine, oral contraceptives can lead to increased drug levels.

  • Smoking can induce metabolism, potentially reducing effectiveness.

13. Symptoms of Benzodiazepine Withdrawal

• Aches/pains, abnormal body sensations, grand mal seizures, nausea, insomnia, delirium/detachment from reality, muscle spasms, anxiety/panic attacks, depression.

14. Other Anxiolytic and Hypnotic Drugs

14.1 Antihistamines

• Examples:

  • Promethazine (Promethegan), diphenhydramine (generic).

• Uses: Preoperative and postoperative medications; decrease narcotic need.

• Note: Cause drowsiness but do not induce sleep.

14.2 Buspirone (Buspar) (Generic) 

• Reduces anxiety signs/symptoms without severe CNS effects and adverse effect .

14.3 Dexmedetomidine (Precedex)

• Used for sedation in intubated/mechanically ventilated patients.

14.4 Eszopiclone (Lunesta)

• FDA approved for insomnia management.

15. Non-benzodiazepine Anxiolytics

15.1 Buspirone Overview

• Definition: Prototype and most commonly used non-benzodiazepine anxiolytic.

• Mechanism of Action:

  • Works on serotonin (5-HT1A) and dopamine (D2) receptors.

  • Does not affect GABA, causing minimal sedation and no dependence.

• Onset: Takes 2–4 weeks for full effect (not for acute anxiety).

15.2 Common Side Effects

• Dizziness, light-headedness, nausea, headache, nervousness/excitement at treatment start.

15.3 Contraindications / Cautions

• Avoid use with MAO inhibitors (risk of hypertensive crisis).

• Grapefruit juice can increase drug levels.

• Use caution in liver/kidney impairment.

15.4 Nursing Considerations for Buspirone

• Emphasize consistent use; not a PRN medication. must be taken consistenly 

• Gradual relief expectations (2–4 weeks).

• No alcohol/sedatives concurrently; monitor dizziness, especially in older adults.

• Reinforce adherence, even if anxiety improves.

16. Other Anxiolytics

16.1 Sedating Antihistamines

• Examples: Hydroxyzine (Vistaril, Atarax), Diphenhydramine (Benadryl).

• Mechanism of Action: Block histamine (H1) receptors producing sedation/anxiolytic effects.

• Uses: Short-term anxiety management or sleep promotion when benzodiazepines contraindicated.

16.2 Side Effects

• Drowsiness, dry mouth, blurred vision, urinary retention (anticholinergic effects).

16.3 Nursing Considerations for Antihistamines

• Avoid driving/operating machinery.

• Encourage hydration/oral care for dry mouth.

• Caution against concurrent alcohol/CNS depressants.

17. Hypnotics (Non-Benzodiazepines)

17.1 Overview of Hypnotics

• Definition: Medications inducing and maintaining sleep, closely related to sedatives.

17.2 Sedatives vs. Hypnotics

• Sedative: Reduces anxiety and promotes relaxation. Lower doses 

• Hypnotic: Induces drowsiness and maintain sleep, usually at higher doses than sedatives.

• Subclass of CNS depressants, often related to sedatives (clam with nessarily cauing sleep) 

17.3 Non-Benzodiazepine Hypnotics

• Examples:

  • Zolpidem (Ambien), Zaleplon (Sonata), Eszopiclone (Lunesta).

• Mechanism of Action: Act on GABA-A receptors but at different subunits than benzodiazepines.

  • Produce sedation with minimal anxiolytic/muscle-relaxant effects.

17.4 Therapeutic Uses of Non-Benzodiazepines

• Short-term insomnia management, preoperative sedation, adjunct to anesthesia, control of anxiety, and treatment of nocturnal awakenings.

17.5 Advantages of Non-Benzodiazepine Hypnotics

• Lower risk of dependence.

• Minimal next-day sedation if used correctly.

• Short half-life is beneficial for sleep onset.

17.6 Side Effects

• Drowsiness, dizziness, headache, sleepwalking/sleep-driving (complex sleep behaviors), rare hallucinations/confusion (especially in older adults).

17.7 Nursing Considerations for Non-Benzodiazepine Hypnotics

• Administer right before bedtime.

  • Patient must have at least 6–8 hours to sleep.

• Avoid alcohol/CNS depressants.

• Educate about potential sleep-related behaviors.

• Caution in elderly to reduce the risk of confusion and falls.

18. Melatonin Receptor Agonists

18.1 Examples

• Ramelteon (Rozerem), Tasimelteon (Hetlioz).

• Mechanism of Action: Mimics the body’s natural melatonin by acting on melatonin receptors (MT1 and MT2) in the hypothalamus to regulate the sleep-wake cycle.

• Uses: Sleep-onset insomnia and Tasimelteon for “non-24-hour sleep disorder” in blind individuals.

• Advantages: No dependence or withdrawal, not a controlled substance.

18.2 Side Effects

• Dizziness, fatigue, endocrine effects (elevated prolactin, decreased testosterone).

• Nursing Considerations: Administer 30 minutes before bedtime.

• Avoid high-fat meals (delays absorption).

• Effects may take several days to become noticeable.

19. Barbiturates

19.1 Examples

• Secobarbital, Pentobarbital.

• Mechanism of Action: Depress CNS by enhancing GABA and directly opening chloride channels.

• Uses: Occasionally used for anesthesia induction, seizure control (not typical for insomnia).

• Risks: High potential for tolerance, dependence, and fatal overdose (respiratory depression).

20. Summary Table of Drugs

Antidepressant Agents

21. Signs & Symptoms of Depression

• Low energy levels.

• Disturbances in sleep patterns.

• Lack of appetite.

• Limited libido.

• Inability to perform activities of daily living (ADLs).

• Overwhelming feelings of sadness, despair, hopelessness, disorganization.

22. Biogenic Amine Theory of Depression

• Theory posits that depression results from deficiency in norepinephrine (NE), dopamine, or serotonin (5-HT) due to:

  • Monoamine oxidase (MAO) may degrade these neurotransmitters affecting recycling/restoration.

  • Rapid neuronal firing may lead to depletion of neurotransmitters.

  • Increased number/sensitivity of postsynaptic receptors depletes neurotransmitter levels.

23. Actions of Antidepressant Therapy

• Mechanisms:

  • Inhibit the effects of MAO, increasing NE or 5-HT in the synaptic cleft.

  • Block reuptake by the releasing nerve, increasing neurotransmitter levels in the synaptic cleft.

  • Regulate receptor sites and neurotransmitter breakdown leading to increased concentrations in the synaptic cleft.

24. Classifications of Antidepressants

• Selective serotonin reuptake inhibitors (SSRIs).

• Tricyclic antidepressants (TCAs).

• MAO inhibitors (MAOIs).

• Serotonin norepinephrine inhibitors (SNRIs).

25. Selective Serotonin Reuptake Inhibitors (SSRIs)

25.1 Overview

• Definition: Major class of antidepressant and anxiolytic medications increasing serotonin levels in the brain.

• Advantages:

  • Effective for depression and anxiety.

  • Safer than older antidepressants (TCAs, MAOIs).

  • Better tolerated with fewer cardiovascular/anticholinergic effects.

25.2 Mechanism of Action

• Process: SSRIs block the reuptake of serotonin (5-HT) into the presynaptic neuron, increasing serotonin availability at the synaptic cleft, enhancing mood, energy, and emotional regulation.

• Key Concept for Nursing: SSRIs selectively affect serotonin, not norepinephrine or dopamine minimizing side effects compared to older antidepressants.

25.3 SSRIs Action & Indications

• Actions:

  • Specifically block the reuptake of 5-HT with minimal known effect on norepinephrine or other receptors. (USUALLY TIRED FIRST) 

• Indications:

  • Depression, OCDs, panic attacks, bulimia, premenstrual dysphoric disorder, post-traumatic stress disorder, social phobias, social anxiety disorders.

26. Common SSRIs and Brand Names

27. SSRI Pharmacologic Profile

• Onset of Action: 2–4 weeks for mood improvement, up to 6–8 weeks for full therapeutic effect.

• Metabolism: Primarily hepatic (CYP450).

• Elimination: Renal.

• Dosing: Generally once daily (morning preferred to avoid insomnia).

28. Common Adverse Effects of SSRIs

29. Life-Threatening Reactions with SSRIs

29.1 Serotonin Syndrome

• Cause: Excessive serotonin, can occur from SSRI combinations with other serotonergic drugs (MAOIs, St. John's wort, triptans, tramadol).

• Symptoms: Agitation, confusion, tremor, muscle rigidity, hyperreflexia, diaphoresis, fever, tachycardia; severe cases can lead to seizures, coma, or death.

• Nursing Priority:

  • Stop SSRI immediately.

  • Notify provider.

  • Provide supportive care (IV fluids, cooling, benzodiazepines for agitation).

29.2 Suicidal Ideation

• Monitor especially in children, adolescents, and young adults during early treatment for mood changes, agitation, or self-harm thoughts; report changes immediately.

30. Contraindications and Precautions for SSRIs

• Conditions:

  • Concurrent use with MAOIs or within 14 days of stopping.

  • Liver disease (reduced metabolism; dose adjustment needed).

  • Pregnancy (especially paroxetine; possible teratogenic effects).

  • Bipolar disorder (may trigger mania; requires mood stabilizer co-therapy).

  • Seizure disorder; glaucoma (SSRIs lower seizure threshold slightly).

31. Nursing Considerations for SSRIs

• Before Administration: Assess baseline mood, suicidal thoughts, anxiety levels.

• Obtain medication history (especially MAOIs, herbal supplements).

• Monitor liver/renal function as indicated.

32. During Therapy Considerations for SSRIs

• Check clinical improvement after 2–4 weeks.

• Watch for serotonin syndrome with new medications.

• Reinforce adherence—missed doses reduce effectiveness.

• Educate that energy may improve before mood, increasing suicide risk.

33. Patient Education for SSRIs

• Take daily at the same time, preferably morning.

• Do not stop abruptly without provider supervision.

• Avoid alcohol and other CNS depressants.

• Report increased anxiety, agitation, or suicidal thinking.

• Avoid St. John’s wort (increases serotonin levels).

• Continue even if better; full effect takes time.

34. Tricyclic Antidepressants (TCAs)

34.1 Overview

• Definition: Older antidepressants introduced in the 1950s; largely replaced by SSRIs and SNRIs due to side effects but still used for specific conditions.

• Key Point: TCAs effective but have more side effects and higher toxicity risk in overdose.

34.2 Mechanism of Action of TCAs

• Inhibit reuptake of norepinephrine and serotonin at synapses, thereby improving mood and emotional stability.

• Also block acetylcholine (anticholinergic effects), histamine (sedation), and alpha-adrenergic receptors (hypotension)—explains their side effects.

• Nursing Tip: Think of TCAs as “nonselective reuptake inhibitors.”

34.3 Common TCAs and Uses

35. Therapeutic Uses of TCAs

• Treat major depressive disorder (MDD) when SSRIs/SNRIs ineffective.

• Used for anxiety disorders, obsessive-compulsive disorder (OCD), chronic neuropathic pain, fibromyalgia, insomnia, migraine prophylaxis, and nocturnal enuresis in children (imipramine) IN CHILDREN).

36. Pharmacokinetics of TCAs

• Absorption: From the GI tract.

• Peak: 2-4 hours.

• Binding: To plasma proteins, lipid soluble.

• Metabolism: In liver; excreted in urine.

• Half-Life: 8-46 hours.

37. Contraindications of TCAs

• Known allergy, recent MI, myelography, pregnancy, and lactation.

38. Adverse Effects of TCAs

• 1. Anticholinergic Effects:

• (Drying mouth” symptoms due to ACh blockade) 

  • Dry mouth, blurred vision, constipation, urinary retention, tachycardia, confusion (especially in elderly).

• 2. Cardiovascular Effects:

  • Orthostatic hypotension, dysrhythmias, tachycardia (especially in overdose).

  • Nursing Tip: Monitor BP and heart rate, especially in older patients.

• 3. CNS Effects:

  • Sedation, drowsiness, dizziness, confusion, tremors, seizures (in high doses).

  • Nursing Tip: Administer at bedtime to minimize daytime drowsiness and fall risk.

• 4. Weight and Metabolic Effects: Weight gain (common) and increased appetite.

• 5. Sexual Dysfunction: Decreased libido, erectile or orgasmic dysfunction.

(GIVE AT BEDTIME, TO REDUCE DAYTIME DROWSINESS & FALL RISK) 

39. Nursing Considerations for TCAs

• Before Administration: Obtain mental health history, vital signs, cardiac history, baseline ECG (if older adult) (always monitor BP and HR). 

• Assess for suicidal ideation—risk highest when energy improves but mood remains low.

• Review medication list for interactions.

• During Administration:

  • Administer at bedtime due to sedating effects.

• Monitor orthostatic BP changes; teach the patient to rise slowly.

• Evaluate for dry mouth, constipation, urinary retention; ensure adequate fluid/fiber intake.

• For enuresis, administer 1 hour before bedtime (imipramine).

40. Patient Education for TCAs

• Take exactly as prescribed; do not double doses if missed.

• Therapeutic effects may take weeks.

• Avoid alcohol/CNS depressants.

• Report cardiac symptoms (palpitations/chest pain) or urinary retention immediately.

• Do not stop abruptly: withdrawal symptoms possible.

• Store medications securely due to overdose risk (especially important for suicidal patients).

41. SNRIs (Serotonin–Norepinephrine Reuptake Inhibitors)

41.1 Overview

• Definition: Increase serotonin (5-HT) and norepinephrine (NE) levels in the brain; used for treating depression, anxiety disorders, and certain chronic pain conditions.

• Mechanism of Action: Inhibit reuptake of serotonin and norepinephrine at the presynaptic neuron, improving mood and reducing anxiety/pain sensitivity.

• Its similar to SSRIs but also boost norepinephrine, which improve energy, concentration and pain perception

41.2 Common Drugs in SNRI Class

41.3 Common Side Effects of SNRIs

• Nausea, dry mouth, dizziness, headache, insomnia or somnolence, sweating, increased blood pressure (from norepinephrine), sexual dysfunction.

41.4 Serious or Cautionary Effects

• Hypertension: Regular BP monitoring is critical.

• Serotonin Syndrome: Particularly with SSRIs or MAOIs; symptoms include agitation and increased autonomic instability.

• Withdrawal symptoms can occur if discontinued abruptly; taper slowly.

• Suicidal Ideation: Early treatment phase requires close mood monitoring.

41.5 Nursing Considerations for SNRIs

• Monitor vital signs regularly—especially blood pressure.

• Inform patients about therapeutic effects taking 2–4 weeks.

• Avoid sudden cessation; gradual taper needed to prevent withdrawal.

• Instruct against concurrent alcohol/CNS depressants.

• Look for signs of serotonin syndrome.

41.6 Adverse Effects of SNRIs

• Nausea, constipation, hyperhidrosis, erectile dysfunction, tachycardia, vomiting, palpitations, serotonin syndrome, hypertension, abnormal bleeding, angle closure glaucoma, urinary retention.

• Drug Interactions: Be cautious with MAOIs, SSRIs, TCAs, serotonergic drugs, aspirin, and NSAIDs.

42. Monoamine Oxidase Inhibitors (MAOIs)

42.1 Overview

• Definition: An older antidepressant class for major depressive disorder, particularly for unresponsive cases; requires strict dietary precautions due to hypertensive crisis risk.

• Mechanism of Action: Block monoamine oxidase, increasing norepinephrine, serotonin, and dopamine in the brain for improved mood stabilization.

42.2 Common MAOIs

42.3 Contraindications for MAOIs

• Known allergy, pheochromocytoma, cardiovascular (CV) diseases, headaches, renal or hepatic impairment.

42.4 Major Adverse Effects of MAOIs

• Hypertensive crisis (tyramine-rich food interactions).

• Orthostatic hypotension, headache, dizziness, insomnia, weight gain, sexual dysfunction.

42.5 Drug-Drug Interactions of MAOIs

• Concurrent antidepressants lead to hypertensive crisis or coma.

• Increased sympathomimetic effects with Methyldopa (sympathomimetic effects increase).

• Risk of hypoglycemia with insulin/oral antidiabetic agents (additive hypoglycemia).

42.6 Food Interactions with MAOIs

• Tyramine-rich foods: Can cause severe hypertension due to norepinephrine release.

  • Foods to Avoid: Aged cheeses, cured meats, smoked/pickled foods, red wine, beer, soy products, avocados, overripe fruits, yeast extracts.

  • Hypertensive Crisis Signs: severe headache, neck stiffness, palpitations, nausea/vomiting, chest pain → medical emergency 

42.7 Nursing Interactions for MAOIs

• Educate on strict tyramine-free diet.

• Avoid concurrent SSRIs, SNRIs, TCAs, or St. John's wort due to serotonin syndrome risk.

• Ensure 14 days gap between MAOI and other antidepressants.

• Regularly monitor blood pressure.

• Teach to rise slowly to prevent orthostatic hypotension.

• Do not stop suddenly; taper under supervision.

43. Other Antidepressants

• Used when first-line treatments (SSRIs, SNRIs, TCAs, MAOIs) are ineffective, poorly tolerated, or to meet special clinical needs (e.g., smoking cessation, insomnia).

• Examples:

  • Bupropion (Wellbutrin, Zyban)

  • Milnacipran (Savella)

  • Mirtazapine (Remeron)

  • Nefazodone (generic)

  • Selegiline (Emsam)

  • Trazodone (Desyrel).

43.1 Bupropion (Wellbutrin, Zyban)

• Mechanism: Inhibits norepinephrine and dopamine reuptake; does not affect serotonin.

• Uses: Depression, seasonal affective disorder, smoking cessation (Zyban), off-label ADHD treatment.

• Nursing Considerations: Contraindicated in seizure disorders/eating disorders (anorexia/bulimia); side effects include dry mouth, insomnia, tremor, weight loss; minimal sexual side effects compared to SSRIs. Take in the morning to avoid insomnia 

43.2 Milnacipran (Savella)

• Mechanism: SNRI used primarily for fibromyalgia (not in the U.S. for major depression).

• Nursing Considerations: Monitor for suicidal thoughts, potential serotonin syndrome, and avoid abrupt discontinuation to prevent withdrawal symptoms; possible side effects include nausea/constipation/increased heart rate.

43.3 Mirtazapine (Remeron)

• Mechanism: Enhances norepinephrine and serotonin release by blocking presynaptic α-₂ adrenergic receptors; also blocks histamine receptors.

• Key Features: Causes sedation and weight gain; beneficial in depressed patients needing improved appetite.

• Side Effects: Increased appetite, drowsiness, dry mouth, elevated cholesterol.

• Teaching: Take at bedtime to aid sleep  

43.4 Trazodone

• Mechanism: Serotonin antagonist and reuptake inhibitor (SARI) with sedative effects from histamine blockade.

• Clinical Use: Low doses for sleep for sleep aid ; higher doses for antidepressant effects.

• Key Adverse Effects: Sedation, dizziness, orthostatic hypotension, priapism (requires emergency care).

44. Psychothera peutic Agents

• Functions: Used to treat psychoses such as schizophrenia, bipolar disorder, narcolepsy, and attention deficit disorder (ADD). * Drug do not cure the disorder 

• Effectiveness: Help patients manage symptoms, enabling more acceptable functioning and improved ADLs; utilized in both children and adults.

45. Schizophrenia Characteristics

• Signs: Hallucinations, paranoia, delusions, speech abnormalities, affective problems.

• Causes: Strong genetic association; may indicate a fundamental biochemical abnormality.

46. Bipolar Disorder Characteristics

• Signs: Extremes of depression followed by hyperactivity and excitement.

• Causes: Reflects a biochemical imbalance leading to neuronal instability.

47. Narcolepsy Characteristics

• Symptoms: Daytime sleepiness, sudden loss of wakefulness.

• Causes: Relate to stimulation problems by the reticular activating system (RAS).

48. Attention Deficit Disorders

• Signs: Inability to focus on one activity for long; characterized by hyperkinesis (excessive involuntary, and often uncontrollably muscular activity or movement); usually diagnosed in school-aged children but can persist into adulthood.

49. Select Antipsychotic Agents

49.1 Traditional (First Generation) Antipsychotics

• Examples:

  • Chlorpromazine (Thorazine), Fluphenazine (Prolixin, Permitil), Haloperidol (Haldol), Loxapine (Loxitane), Mesoridazine besylate (Serentil), Molindone (Moban).

49.2 Atypical (Second Generation) Antipsychotics

• Examples:

  • Aripiprazole (Abilify), Clozapine (Clozaril), Iloperidone (Fanapt), Olanzapine (Zyprexa), Paliperidone (Invega), Quetiapine (Seroquel), Risperidone (Risperdal), Ziprasidone (Geodon).

49.3 Antipsychotic Drugs

• Definition: Utilized primarily to treat schizophrenia; effective for more than just psychosis, assisting in manic episodes characterized by grandiosity, paranoia, and delusions.

• Efficacy: These agents decrease hallucinations and delusions, aiding functional levels.

50. Overview of Antipsychotic Drugs

• Functionality: Treating psychotic disorders (schizophrenia, bipolar disorder, severe depression).

• Classification:

  • Typical (First-Generation): e.g., Haloperidol (Haldol), Chlorpromazine (Thorazine).

  • Atypical (Second-Generation): e.g., Clozapine (Clozaril), Risperidone (Risperdal).

  • Goals: controls symptoms such as hallucinations, delusions, agitation, and disorganized thought  

50.1 Mechanism of Action

• Typical Antipsychotics: Blocks D2 dopamine receptors—reduces positive symptoms of psychosis.

• Mechanism: block dopamine D2 receptors in the brain→ reduced postive symptoms of psychosis 

• Atypical Antipsychotics: Block D2 and 5-HT2 serotonin receptors—addresses both positive and negative symptoms.

50.2 Risks of Antipsychotic Medications

• Adverse Effects: Extrapyramidal symptoms (EPS): dystonia, akathisia, parkinsonism, tardive dyskinesia; neuroleptic malignant syndrome (NMS): fever, rigidity, altered mental status; sedation, hypotension, anticholinergic effects.

• Nursing Care: Monitor adverse reactions like EPS and NMS; intervene immediately if NMS occurs.

Atypical (Second-Generation)
Antipsychotics
❖ Examples: Clozapine (Clozaril), Risperidone (Risperdal),
Olanzapine (Zyprexa), Quetiapine (Seroquel),
Aripiprazole (Abilify).
❖
Mechanism: Block dopamine (D2) and serotonin (5-
HT2) receptors → treat both positive and negative
symptoms.
❖
Advantages: Fewer EPS, improved mood and cognition.
❖
Major Risks: Weight gain, metabolic syndrome,
diabetes, hyperlipidemia.
❖
Teaching: Encourage healthy diet, monitor glucose and
lipids.

Contraindications
o Underlying diseases that could be exacerbated by
dopamine-blocking effects of these drugs
o CNS depression
o Circulatory collapse
o Parkinson’s disease
o Coronary disease
o Severe hypotension
o Prolonged QT interval

Clozapine (Clozaril)
❖ Special Considerations:
o Reserved for treatment-resistant schizophrenia.
❖ Risk of agranulocytosis (decreased WBCs).
❖ Monitor: CBC weekly for first 6 months, then biweekly.
o Report signs of infection (fever, sore throat)
immediately.
❖
Other effects: Weight gain, sedation, hypotension.

Haloperidol (Haldol)
❖ Use: Acute psychosis, agitation, Tourette’s syndrome.
❖
Adverse Effects:
❖ High risk for EPS and NMS.
❖
Nursing Interventions:
❖ Assess for muscle stiffness, rigidity, fever, and confusion.
❖ If NMS suspected → stop drug, maintain airway, apply
cooling measures, administer dantrolene or
bromocriptine per protocol.

Adverse Effects
o Sedation
o Weakness
o Tremors
o Constipation
❖ Drug-Drug Interactions
o Beta blockers, alcohol, anticholinergics, ziprasidone,
thioridazine
o Drowsiness
o Extrapyramidal
effects
o Dry mouth
o Nasal congestion

51. Common Adverse Effects of Antipsychotics

• Sedation, weakness, tremors, constipation; specific drug-drug interactions (e.g., beta blockers, alcohol may enhance sedative effects).

52. Extrapyramidal Symptoms (EPS)

• Types:

  • Dystonia: Involuntary muscle spasms (face, neck).

  • Akathisia: Restlessness, inability to remain still.

  • Pseudoparkinsonism: Tremors, rigidity, bradykinesia.

  • Tardive Dyskinesia: Involuntary movements (e.g., lip smacking).

• Treatment: Introduce anticholinergic drugs (benztropine, diphenhydramine) for management; education on early recognition is critical for prevention.

53. Neuroleptic Malignant Syndrome (NMS)

• Definition: A life-threatening emergency characterized by symptoms such as high fever, muscle rigidity, altered mental state, and autonomic instability.

• Management: Immediate medication immediately , supportive therapies (fluids, cooling). Administer dantrolene or bromocriptine as necessary. Monitor: vitals signs, Ck levels, renal functions 

54. Nursing Responsibilities for Antipsychotic Therapies

• Baseline Assessment: Include mental status, vital signs, weight, lab values (glucose, lipids, CBC).

• Monitoring: Observe for EPS, orthostatic hypotension, sedation, and metabolic changes.

• Educations: adherence is critical, sudden withdrawal may worsen symptoms 

• Promote Safety: slow position changes, fall precautions 

55. Overview of Bipolar Disorder

• Definition: A chronic mood disorder with alternating episodes of mania and depression.

• Goals of Treatment: Mood stabilization, relapse prevention, functional improvement.

• Medication Classes: Include mood stabilizers, anticonvulsants acting as mood stabilizers, atypical antipsychotics, cautiously administered antidepressants.

56. Drugs for Bipolar Disorders

57. Mood Stabilizer: Lithium Carbonate

• Mechanism: Alters sodium transport in neurons, stabilizing neurotransmission.

• Therapeutic Range: 0.6–1.2 mEq/L; toxicity signs begin above >1.5 mEq/L.

• Nursing Interventions: Regularly monitor lithium serum levels, renal, and thyroid function; maintain consistent sodium and fluid intake; educate on hydration to avoid dehydration.

58. Lithium: Key Nursing Considerations

Lithium
❖Pharmacokinetics
o Absorbed from GI tract
o Peak in 30 minutes
o Distribution pattern in the body as water
o Slowly crosses the blood-brain barrier.
o Excreted from the kidney, 80% is
reabsorbed
o Crosses the placenta – associated with
congenital abnormalities
o Enters the breast milk
❖Contraindications
o Allergy, renal, cardiac disease, leukemia,
metabolic disorders, pregnancy, lactation

Assessment                         Action

Dehydration           →           Encourage fluids 

Diuretics/NSAIDs   →           Avoid- raises lithium levels 

Tremor, confusion   →          Assess for toxicity 

Renal/thyroid          →           Monitor every 6 months 

Nursing Considerations for
Antimanic Drugs
❖Assess:
o History and Physical Exam, known allergies
to lithium; renal or CV disease; dehydration;
sodium depletion, use of diuretics
o Protracted sweating, or diarrhea; suicidal
or impulsive patients with severe
depression; pregnancy or lactation; and
infection with fever CNS orientation, affect
o Urinary output, liver and renal function tests
o Serum Lithium levels

59. Nursing Responsibilities for Antimanic Drugs

• Assess: mental and physical health history, allergies, kidney disease, CV disease, dehydration status; monitor urine output and lab levels carefully.

60. Anticonvulsants as Mood Stabilizers

• Examples: Valproic acid (Depakote), Carbamazepine (Tegretol), Lamotrigine (Lamictal).

• Mechanism: Modulate GABA and glutamate levels to stabilize mood.

61. Valproic Acid (Depakote)

• Mechanism: Increases GABA levels for stabilize mood

• Adverse Effects: Monitor renal function due to hepatotoxicity and pancreatitis; report weight gain and GI upset in patients.

62. Carbamazepine (Tegretol)

• Mechanism: Reduces neuronal excitability via sodium channel inhibition.

• Adverse Effects: Monitor CBC for possible bone marrow suppression; report signs of rash or fever.

63. Lamotrigine (Lamictal)

• Mechanism: Modulates glutamate release in the brain.

• Adverse Effects: Beware of rashes; Stevens-Johnson syndrome risk requires immediate action if detected.

• Teaching: titrate slowly, stop immediately if rasg develops 

64. Atypical Antipsychotics Overview

• Examples: Olanzapine, Risperidone, Quetiapine, Aripiprazole.

• Mechanism: Block both dopamine and serotonin receptors for effective amenity.

• Uses: Treat acute mania, bipolar depression, and maintenance therapy.

• Adverse Effects: Pay attention to weight loss/gain, monitoring glucose for hyperglycemia /lipid changes in high-risk patients.

65. Antidepressants in Bipolar Disorder

• Use only short-term for depressive episodes and always in combination with mood stabilizers to prevent mania.

• Examples: Fluoxetine (Prozac), Sertraline (Zoloft).

66. Key Takeaways

• Be alert for lithium toxicity; withhold dose upon suspicion.

• Regularly monitor liver functions for those prescribed valproic acid.

• Report fever/sore throat in patients administered carbamazepine → possible agranulocytosis.

• Titrate lamotrigine slowly, with immediate discontinue if upon rash appearance.

Central Nervous System Stimulants

67. Actions of CNS Stimulants

• Mechanism of Action:

  • Act on cortical and the reticular activating system (RAS), potentially through releasing catecholamines from presynaptic neurons, leading to increased stimulation of postsynaptic neurons.

• Indications:

  • Treatment of attention-deficit syndromes; narcolepsy management.

68. Overview of CNS Stimulants

• Mechanism: Increase the levels of dopamine, norepinephrine, and serotonin in the CNS.

• Therapeutic Uses:

  • ADHD, narcolepsy, and short-term obesity treatments (appetite suppression).

• Note: These are controlled substances with a potential for high abuse.

69. Amphetamine and Dextroamphetamine (Adderall)

• Mechanism: Promotes norepinephrine and dopamine release, increasing alertness and focus.

• Uses: Effective for ADHD and narcolepsy.

• Side Effects: Insomnia, weight loss, tachycardia, hypertension, irritability.

• Teaching Points: [Take in the morning, monitor appetite/weight, avoid caffeine/stimulants, do not discontinue abruptly].

70. Methylphenidate (Ritalin, Concerta)

• Mechanism: Blocks reuptake of dopamine/norepinephrine.

• Uses: Indicates ADHD and narcolepsy; assess growth in children.

• Adverse Effects: Decreased appetite, insomnia, tachycardia, nervousness; follow signs of abuse.

71. Modafinil (Provigil)

• Mechanism: Enhances wakefulness by altering dopamine pathways.

• Uses: Effective for narcolepsy, shift-work sleep disorder.

• Side Effects: Headache, insomnia, nausea, anxiety.

• Teaching: Administer in the morning; caution for driving until side effects are clear.

72. Phentermine (Adipex-P, Suprenza)

• Mechanism: Enhances norepinephrine/dopamine release and suppresses appetite.

• Use: Short-term obesity management alongside dietary changes and exercise.

• Adverse Effects: Increased heart rate, elevated BP, insomnia, nervousness, dry mouth; contraindications include cardiovascular conditions and diabetes.

73. Phentermine Teaching Points

• Administration must be in the morning to preempt insomnia.

• Avoiding caffeine/stimulants; short use duration only (few weeks) with dietary/exercise integration needed.

74. Non-Stimulant ADHD Medications

• Example: Atomoxetine (Strattera).

• Mechanism: Functions as a selective norepinephrine reuptake inhibitor (SNRI).

• Advantages: Lower abuse potential; less controlled substance nature.

• Adverse Effects: Fatigue, GI upset, and potential suicidal ideation risks in children.

• Nursing Care: Monitor mood changes and liver toxicity.

75. Stimulants Nursing Implications

• Monitor: HR, BP, weight, overall growth.

• Assessment: Quality of sleep, appetite, psychiatric changes.

• Teaching: Restrict evening dosing, limit caffeine intake, report chest pain or palpitations.

• Promote adherence: Safety protocols around controlled dosing.

76. Stimulants Contraindications & Precautions

• Contraindications: Severe anxiety, agitation, cardiac disease or arrhythmias, hyperthyroidism, history of substance abuse.

• Caution: MAO inhibitors risk of hypertensive crisis; standard protocol should be maintained.

77. Commercially Available Stimulants

78. Key Takeaways

• CNS stimulants significantly boost CNS activity, improving suspension.

• Major risks include adverse effects and the potential for abuse.

• Nurses play pivotal roles in monitoring growth, vitals, and mental health side effects, ensuring safe compliance.

Pain 

• Sensory and emotional
  experience associated
  with actual or potential
  tissue damage
  ❖ Acute or chronic
  ❖ Drugs Used to Relieve Pain
  o Narcotics: Opium
  derivatives used to treat
  many types of pain
  o Antimigraine Drugs:
  Reserved for the
  treatment of migraine
  headaches

Pain Receptors
❖ Opioid receptors
o CNS
o Nerves in the periphery
o Cells in the
gastrointestinal (GI) tract

Pain is a subjective experience mediated by nociceptors.
❖ Drug classes used for pain:
o Narcotic (opioid) agonists.
o Narcotic antagonists and mixed agents.
o Non-opioid analgesics (NSAIDs, acetaminophen).
o Anti-migraine agents (triptans, ergots).

Narcotic (Opioid) Agonists
❖ Examples: Morphine, Fentanyl, Hydromorphone,
Oxycodone, Codeine.
❖
Mechanism: Bind to mu and kappa opioid receptors,
altering perception and response to pain.
❖ Therapeutic Uses: Moderate to severe pain, anesthesia
adjunct, acute MI, cancer pain.
❖ Adverse Effects: Respiratory depression, constipation,
sedation, hypotension, urinary retention.

Nursing Responsibilities for Narcotics
❖ Assess pain level, respiratory rate, and sedation level
before administration.
❖ Hold if RR < 12/min; notify provider.
❖ Administer slowly IV to prevent respiratory depression.
❖ Encourage fluids, fiber, and ambulation to prevent
constipation.
❖ Use stool softeners as needed.

Narcotic Antagonists
❖ Example: Naloxone (Narcan).
❖
Mechanism: Competes with opioids at receptor sites,
reversing respiratory and CNS depression.
❖ Use: Opioid overdose, postoperative respiratory
depression, newborn resuscitation.
❖ Nursing Care:
o Administer IV, IM, or intranasal.
o Onset 1–2 min IV.
o Monitor for return of pain and withdrawal symptoms.

Mixed Agonist-Antagonist Opioids
❖ Examples: Butorphanol (Stadol), Pentazocine (Talwin).
❖
Mechanism: Stimulate kappa receptors, block or weakly
stimulate mu receptors.
❖ Use: Moderate pain, labor pain, pain with lower risk of
respiratory depression.
❖ Nursing Note: Can precipitate withdrawal in opioid-
dependent patients.

Opioid overdose- Key actions
❖ Signs: Respiratory rate < 10, pinpoint pupils,
unresponsiveness.
❖
Nursing Interventions:
❖ Administer Naloxone immediately.
❖ Support airway, oxygenation, and monitor vital signs.
❖ Reassess frequently—Naloxone’s half-life is shorter than
many opioids.

Migraine Headaches
o Severe, throbbing
headaches on one
side of the head
o Common
o Classic
❖ Cluster Headaches
o Begin during sleep; involve sharp, steady
eye pain, sweating, flushing, tearing, and
nasal congestion
❖ Tension Headaches
o Usually occur at times of stress; dull band
of pain around the entire head

Anti-Migraine Medications: Overview
❖ Pathophysiology: Migraine pain caused by cranial
vessel dilation and inflammation.
❖
Drug Classes:
o Triptans (Serotonin 5-HT1 agonists) – cause
vasoconstriction.
o Ergot derivatives – older drugs, constrict
intracranial vessels.
o Preventive agents – beta-blockers,
anticonvulsants, supplement “cocktails”

Triptans (Sumatriptan, Rizatriptan)
❖ Mechanism: Stimulate 5-HT1 receptors → cranial
vasoconstriction and decreased neuroinflammation.
❖ Use: Acute migraine attacks (not prevention).
❖
Adverse Effects: Chest tightness, dizziness, tingling,
hypertension.
❖ Contraindications: Coronary artery disease,
uncontrolled hypertension.

Ergotamine (Ergomar) and
Dihydroergotamine (DHE)
❖ Mechanism: Vasoconstriction of dilated cranial blood
vessels.
❖ Adverse Effects: Nausea, vomiting, muscle pain,
tingling in extremities.
❖ Toxicity (Ergotism): Peripheral ischemia—cold, pale
extremities, numbness.
❖ Teaching: Avoid use with triptans within 24 hours
(severe vasospasm risk).

Nursing Responsibilities for Pain
Medications
❖ Assess pain and sedation before/after administration.
❖ Monitor vital signs and level of consciousness.
❖ Evaluate for side effects: respiratory depression,
constipation, orthostatic hypotension.
❖ Educate on safe storage, use, and risk of dependence.
❖ Teach early intervention for migraine and avoidance of
triggers.

Key Takeaways
❖ Opioid agonists: effective for severe pain; monitor for
respiratory depression.
❖ Naloxone: life-saving reversal agent.
❖ Anti-migraine meds: triptans for acute attacks, ergots as
older options.
❖ Nurses play a vital role in assessment, safety, and
education.