Clinical Judgment and Psychopharmacology

Wolters Kluwer: When You Have to Be Right

Concept: Clinical Judgment

  • Definition:

    • Clinical judgment is described as the thought process (clinical reasoning) by which healthcare professionals arrive at a conclusion (decision-making) using both objective and subjective data about a patient.

    • According to Cascella (2018) a nurse utilizes both automatic, intuitive reasoning and analytic, reflective reasoning when applying clinical judgment.

Exemplar: Psychopharmacology

  • Reference material: Reading from Videbeck: Chapter 2 and Professor Hamilton Service.

NCSBN Clinical Judgment Model

Overview of Layers in Clinical Judgment

  • Layer 0: Client Needs

  • Layer 1:

    • Clinical Judgment not satisfied

    • Form hypotheses

    • Refine hypotheses

  • Layer 2:

    • Nursing Process Steps

    • Recognize Cues

    • Analyze Cues

    • Prioritize Hypotheses

    • Generate Solutions

    • Take Actions

    • Evaluate Outcomes

Environmental Factors Affecting Judgment

  • Examples:

    • Client Observation

    • Resources

    • Evaluation

    • Environmental Factors (e.g., physical surroundings)

Individual Factors Affecting Judgment

  • Examples:

    • Medical Knowledge

    • Complexity of Conditions

    • Cultural Considerations

    • Time Pressure

    • Consequences

Clinical Decisions and Actions

  • The clinical decisions made and actions taken based on the analysis and evaluation are critical to ensure effective outcomes.

Topic Outcomes Related to Psychopharmacology

  1. Neurotransmission Process:

    • Explain the basic process of neurotransmission and synaptic transmission concerning psychotropic medications such as antidepressants, antianxiety agents, mood stabilizers, antipsychotic agents, and anticholinesterase agents.

  2. Risks & Safety Concerns:

    • Discuss associated risks and safety concerns (including side and adverse effects) when providing pharmacologic and other therapeutic care to patients with mental health issues across the lifespan.

  3. Ethical Principles and Legal Considerations:

    • Apply ethical principles and legal considerations related to patients’ rights, confidentiality, duty to warn, duty to intervene, and documentation in mental health care provision.

Neurotransmitters

  • Definition of Neurotransmitters:

    • Chemical substances that facilitate neurotransmission and are important in the right proportions to relay messages in the brain.

  • Study Evidence:

    • Studies have shown differences in the brains of individuals with certain mental disorders confirming their role in psychiatric illness and the mechanism of action of psychotropic medications.

  • Types of Effects:

    • Neurotransmitters can be either excitatory or inhibitory, functioning as modulators in neuronal activity.

Neurobiological Causes of Psychiatric Symptoms

  • Genetics and Heredity:

    • Genetics play a significant role but are not solely responsible for psychiatric conditions.

    • Twin, adoption, and family studies are utilized to understand genetic contributions.

  • Psychoimmunology:

    • Compromised immune systems may contribute to psychiatric disorders, especially among genetically vulnerable populations.

  • Infections:

    • There are theories positing that certain viruses can alter human genes or affect fetal development leading to mental health issues.

Nurse’s Role in Research and Education

  • Nurses help distinguish between facts and hypotheses regarding patient care.

  • Facilitate understanding of how new research may affect treatment strategies or prognoses for clients.

  • Verify information and clarify treatment options for patients and their families, ensuring accurate communication.

Psychopharmacology Overview (NURS 129)

  • Psychotropic Drugs:

    • Medications that affect the mental state and behavior of the client.

  • Key Concepts:

    • Efficacy: The maximum therapeutic effect achievable from a medication.

    • Potency: The amount of drug required for a maximum effect.

    • Half-life: The time taken for the blood concentration of a drug to reduce to half its original value.

    • FDA Role: In playing the regulatory role concerning drug approvals and safety.

    • Off-label Use: Drugs used effectively for treats other conditions different from those for which the drug was originally tested.

    • Black Box Warning: A warning about serious or life-threatening side effects of a medication.

Principles of Psychopharmacology

  • Treatment Guidelines:

    • Focus on the effect on target symptoms in patients.

    • Ensure adequate dosage is provided for sufficient periods of treatment.

    • Administer the lowest effective dose, especially in older adults to minimize potential adverse effects.

    • Implement tapering of medications instead of abrupt cessation to avoid withdrawal effects.

    • Follow-up care is vital to monitor patient response and compliance.

    • A simplified medication regimen is encouraged to enhance adherence and compliance to treatment plans.

Psychotropic Medications: Antipsychotics

List of Antipsychotic Medications

  1. Chlorpromazine

  2. Fluphenazine

  3. Haloperidol

  4. Clozapine

  5. Risperidone

  6. Aripiprazole

  7. Quetiapine

  8. Ziprasidone

  9. Quetiapine (listed twice)

Antipsychotic Drugs Overview:

  • Use: Treat symptoms of psychosis in patients.

  • Mechanism of Action: Block dopamine receptors in the brain.

  • Categories:

    • First Generation (Conventional):

    • Examples include chlorpromazine, fluphenazine, and haloperidol.

    • Second Generation (Atypical):

    • Examples include clozapine, risperidone, and olanzapine.

    • Third Generation:

    • Includes dopamine system stabilizers such as aripiprazole.

Side Effects of Antipsychotics

Common Side Effects

  1. Extrapyramidal Symptoms (EPS):

    • Acute dystonia (e.g., torticollis, opisthotonus, oculogyric crisis)

      • Treatment: Anticholinergic drugs or diphenhydramine.

    • Pseudoparkinsonism (e.g. stooped posture, masklike facies, shuffling gait).

    • Akathisia (characterized by restlessness, anxiety, agitation).

  2. Neuroleptic Malignant Syndrome (NMS):

    • A potentially life-threatening condition characterized by fever, muscle rigidity, altered mental status.

  3. Tardive Dyskinesia:

    • Permanent involuntary movements, often requiring discontinuation of the drug.

  4. Anticholinergic Side Effects:

    • Examples include dry mouth, constipation, urinary retention.

Other Notable Side Effects

  • Increased prolactin levels.

  • Weight gain (especially relevant with second-generation agents).

  • Metabolic syndrome and cardiovascular issues.

  • Lengthening of the QT interval (especially with thioridazine, droperidol).

  • Risk of agranulocytosis (for clozapine).

Client Education on Antipsychotics

  • Adherence to Medication Regimen:

    • Encourage clients to follow prescribed dosages.

  • Management of Side Effects:

    • Strategies for thirst/dry mouth (e.g., sugar-free candies, increased fluids).

    • Dietary fiber and exercise to manage constipation.

    • Safety measures for sleepiness/drowsiness.

  • Instruction for Missed Doses:

    • If within 4 hours of the usual time, take the missed dose; otherwise, skip it.

Antidepressants

Classes of Antidepressants

  • Primary Uses in Psychiatry:

    • Anxiolytics:

    • Benzodiazepines: Treat anxiety disorders, insomnia, OCD, PTSD, depression, and alcohol withdrawal.

    • Cyclic Antidepressants:

    • Examples: Amitriptyline, Imipramine.

    • Monoamine Oxidase Inhibitors (MAOIs):

    • Examples: Phenelzine, Selegiline.

    • Selective Serotonin Reuptake Inhibitors (SSRIs):

    • Examples: Fluoxetine, Sertraline, Paroxetine, Escitalopram, Citalopram.

    • Atypical Antidepressants:

    • Examples: Duloxetine, Venlafaxine, Bupropion, Mirtazapine, Trazodone.

Antidepressants: Mechanism of Action

  • The precise mechanisms of antidepressants are not fully known.

  • Uses: Include treating major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression.

Groups of Antidepressants:

  1. Selective Serotonin Reuptake Inhibitors (SSRIs).

  2. Cyclic Compounds.

  3. Other Antidepressants.

  4. Monoamine Oxidase Inhibitors (MAOIs).

Major Interactions

  • Antidepressants interact primarily with monoamine neurotransmitter systems, with special emphasis on norepinephrine and serotonin.

Side Effects of Antidepressants

  1. SSRIs:

    • Potential side effects: Anxiety, agitation, akathisia, nausea, insomnia, sexual dysfunction, and weight gain.

  2. Cyclic Antidepressants:

    • Anticholinergic effects, orthostatic hypotension, sedation, weight gain, tachycardia, and sexual dysfunction.

  3. MAOIs:

    • Daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, sexual dysfunction.

    • Risk of hypertensive crisis with tyramine-containing foods.

  4. Other Antidepressants:

    • Side effects include sedation, headaches (e.g., nefazodone, trazodone), loss of appetite, nausea, agitation, insomnia (e.g., bupropion, venlafaxine).

    • Priapism (specific to trazodone).

Antidepressants: Drug Interactions

  • Serotonin Syndrome:

    • Possible interaction when MAOIs are combined with SSRIs leading to agitation, sweating, fever, tachycardia, hypotension, rigidity, and hyperreflexia; potentially extreme reactions can lead to coma or death.

Client Education on Antidepressants

  • Timing of Dosage:

    • SSRIs should typically be taken first thing in the morning, while cyclic compounds are best administered at night.

  • Instructions for Missed Doses:

    • SSRIs may be taken up to 8 hours after a missed dose, while cyclic antidepressants should either be taken within 3 hours of missing or omitted for the day.

  • Safety Measures:

    • Awareness of side effects and dietary restrictions (especially with MAOIs).

Mood-Stabilizing Drugs

Primary Uses

  • Lithium and Anticonvulsants (e.g., carbamazepine, valproic acid):

    • Used for treating bipolar illness.

Mechanism of Action:

  • Lithium:

    • Normalizes neurotransmitter reuptake.

  • Valproic Acid and Topiramate:

    • Increase GABA levels.

  • Carbamazepine:

    • Inhibits the kindling process in mood disorders.

Drugs List:

  • Lithium, Carbamazepine, Divalproex (Valproic Acid & Sodium Divalproex), Lamotrigine, Topiramate.

Mood-Stabilizing Drugs: Side Effects

  • Lithium:

    • Common side effects: Nausea, diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, metallic taste, fatigue, lethargy, and potential for weight gain and acne (in the later stages of therapy).

    • Toxicity Symptoms:

    • Severe diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination.

  • Carbamazepine and Valproic Acid:

    • Common side effects: Drowsiness, dry mouth, sedation, blurred vision.

    • Carbamazepine can cause a rash and orthostatic hypotension.

    • Valproic acid can lead to weight gain, alopecia, and hand tremor.

  • Topiramate:

    • Side effects include dizziness, sedation, and weight loss.

Mood-Stabilizing Drugs: Client Teaching

  • Monitoring Requirements:

    • Clients should have blood levels monitored 12 hours after the last dose taken.

  • Dosage Guidelines:

    • Taking medication with meals is encouraged for improved absorption and adherence.

  • Safety Measures:

    • Educate on the necessity of periodic monitoring and adherence to the prescribed regimen.

Anxiolytics Overview

Primary Uses in Psychiatry

  • Anxiolytics:

  • Utilized for treating anxiety disorders, insomnia, OCD, depression, PTSD, and alcohol withdrawal.

  • Types include Benzodiazepines and Buspirone.

Mechanism of Action:

  • Benzodiazepines:

    • Function through mediation of GABA.

    • Buspirone:

    • Acts as a partial agonist activity at serotonin receptors.

Side Effects of Anxiolytics

  • Benzodiazepines:

    • Risk of physical and psychological dependence; CNS depression; potential hangover effect; tolerance.

  • Buspirone:

    • Dizziness, sedation, nausea, headache.

Client Education:

  • Discuss safety measures and avoidance of alcohol and abrupt discontinuation of medications.

Stimulants Overview

Primary Uses in Psychiatry

  • Stimulants (e.g., Amphetamines):

    • Used for treating ADHD in children, adolescents, adults, and narcolepsy.

Mechanism of Action:

  • Release norepinephrine, dopamine, and serotonin pre-synaptically; Block reuptake of neurotransmitters.

Dosage Considerations:

  • Divided doses; may require higher doses for narcolepsy in adults; doses for ADHD patients vary widely.

Side Effects:

  • Include anorexia, weight loss, nausea, irritability, and potential growth suppression.

Client Teaching:

  • Encourage dosing after meals and avoidance of substances like caffeine, sugar, and chocolate; proper storage of medications out of reach of children.

Medications for Substance Use Disorders

List by Substance Type:

  • Alcohol Treatment Medications:

    • Disulfiram, Acamprosate, Naltrexone, Barbiturates, Vitamins.

  • Stimulant Treatment:

    • Modafinil.

  • Opioid Treatment Medications:

    • Methadone, Naltrexone, Suboxone, Naloxone.

Disulfiram Overview

  • Use:

    • Aversion therapy for alcoholism; mechanism includes inhibition of alcohol metabolism enzyme, leading to adverse reactions upon alcohol ingestion.

  • Side Effects:

    • Fatigue, drowsiness, halitosis, tremor, impotence.

  • Drug Interactions:

    • Can interact with phenytoin, isoniazid, warfarin, barbiturates, and long-acting benzodiazepines.

  • Client Teaching:

    • Avoidance of alcohol in all forms, including consumer products that may contain it (e.g., shaving cream, deodorant, OTC cough preparations).

Adherence Issues in Psychiatric Treatment

Reasons for Nonadherence:

  • Nonadherence exists on a continuum from full to partial, or nil.

  • Common reasons include:

    • Side effects of medications (most common).

    • Lack of awareness or denial of illness.

    • Stigma associated with mental illness.

    • Improvement in symptoms leading to discontinuation of medication.

    • Confusion regarding dosage or treatment timing.

    • Difficulties accessing treatment services.

    • Substance abuse issues.

Role of Registered Nurses:

  • RN advocates for patients through psychoeducation to improve adherence to treatment plans and medication regimens.

Other Biological Treatments

  1. Light Therapy (Phototherapy):

    • Used for resetting circadian rhythms in cases of seasonal depression.

  2. Transcranial Magnetic Stimulation (TMS):

    • Alternative for managing depressive symptoms, especially when Electroconvulsive Therapy (ECT) is not suitable.

  3. Vagus Nerve Stimulation (VNS):

    • An adjunct treatment for severe, treatment-resistant depression.

Electroconvulsive Therapy (ECT)

  • Use:

    • Indicated for severe depression, mania, and schizophrenia when other treatments have failed.

  • Procedure:

    • Involves the induction of generalized seizures through electrical current; repeated 2-3 times a week for a total of 6-15 treatments.

  • Efficacy:

    • Provides rapid relief from depressive symptoms.

  • Side Effects:

    • Hypo- or hypertension, bradycardia or tachycardia, minor arrhythmias, headache, nausea, muscle pain immediately post-procedure; memory loss can occur for months afterward.

Cultural Considerations in Mental Health Treatment

  • Responses to Medication:

    • Research indicates faster response rates to antipsychotic medications and tricyclic antidepressants in African Americans compared to Whites, coupled with a higher risk of side effects.

    • Slower metabolism of the same medications noted in Asians compared to Whites, suggesting lower required doses for efficacy.

  • Herbal Medicine Use:

    • Increased frequency of use of herbal medicines (e.g., St. John’s Wort, Kava, Valerian, Ginkgo biloba) may raise the risk of interactions with prescribed medications.

Self-Awareness Issues in Clinical Practice

  • Communication Needs:

    • Clients and families require clear and straightforward information, comprehensively explaining treatment modalities and expectations.

  • Mental Illness Perspective:

    • Chronic mental illness should be approached akin to chronic physical illnesses, recognizing patterns of remission and exacerbation.

  • Openness to New Ideas:

    • Mental health practitioners should remain open to innovative ideas and research that may provide breakthroughs in treatment approaches.

  • Compliance and Misunderstanding:

    • Noncompliance with medication is often a result of distorted thinking related to the illness rather than willful wrongdoing.