PSYCHOTROPIC DRUGS

Chapter 2, page 19 Videbeck 3rd Ed. I. ANTIPSYCHOTIC DRUGS also known as neuroleptics used to treat symptoms of psychosis, such as delusions and hallucinations seen in schi ophrenia, schi oaffecti!e disorder, and manic phase of bipolar disorder work by blocking receptors of the neurotransmitter dopamine e"amples #table 2.3, p. 3$% E"trapyramidal side effects& o acute dystonia o pseudoparkinsonism o akathisia ' although collecti!ely referred to as E() #e"trapyramidal symptoms which are serious neurologic symptoms and are ma*or side effects of antipsychotic drugs%, each of these reactions has distinct features ' therapy for acute dystonia, pseudoparkinsonism, and akathisia are similar and include the following& lowering dosage of antipsychotic changing to a different antipsychotic, or administering anticholinergic medication o Acute dystonia includes acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in se!ere cases, laryngospasm and respiratory difficulties most likely to occur in the first week of treatment, in clients younger than +$ years, in males, and in those recei!ing high,potency drugs #such as haloperidol and thiothe"ine% spasms or stiffness in muscle groups can produce torticollis, opisthotonus, or oculogyric crisis #p.3$% reactions can be painful and frightening to the client immediate treatment with anticholinergic drug such as diphenhydramine -. or -V usually brings rapid relief ' drugs used to treat E() #table 2.+ p.3$% o Pseudoparkinsonism, or drug,induced parkinsonism often referred to by the generic label of E() symptoms resemble those of (arkinson/s disease and include a stiff and stooped posture, mask,like faces, decreased arm swing, a shuffling, festinating gait, cogwheel rigidity, drooling, tremors, bradycardia, and coarse pill,rolling mo!ements of the thumb and fingers while at rest treated by changing to an antipsychotic drug that has a lower incidence of E(), or by adding an oral anticholinergic agent o Akat isia as reported by clients, is an intense need to mo!e about client appears restless or an"ious and agitated often with a rigid posture or gait and a lack of spontaneous gestures. treated by a change in antipsychotic medication or by the addition of an oral agent #such as beta,blocker, anticholinergic, oor ben odia epine%

' although collecti!ely referred to as E() #e"trapyramidal symptoms which are serious neurologic symptoms and are ma*or side effects of antipsychotic drugs%, each of these reactions has distinct features. ' therapy for acute dystonia, pseudoparkinsonism, and akathisia are similar and include the following& lowering dosage of antipsychotic changing to a different antipsychotic, or administering anticholinergic medication o Neuro!eptic "a!i#nant Syndrome $N"S% potentially fatal reaction to antipsychotic drugs ma*or symptoms of 0.) are rigidity, high fe!er, autonomic instability #such as unstable 1(, diaphoresis, and pallor%, delirium, and ele!ated le!els of en ymes #particularly creatinine phosphokinase% clients with 0.) usually are confused and often mute, may fluctuate from agitation to stupor ' all antipsychotics seem to ha!e the potential to cause 0.), but high dosages of high,potency drugs increase the risk #most often occurs in first 2 weeks of therapy or after increase increasing dosage, but can occur anytime% ' dehydration, poor nutrition, and concurrent medical illness all increase the risk for 0.) treatment includes immediate discontinuance of all antipsychotic medications and the institution of supporti!e medical care to treat dehydration and hyperthermia

o Tardi&e Dyskinesia $TD% syndrome of permanent in!oluntary mo!ements commonly caused by the long,term use of con!entional antipsychotic drugs symptoms of 23 include in!oluntary mo!ements of the tongue , facial and neck muscles, and upper and lower e"tremities tongue thrusting and protruding, lip smacking, blinking, grimacing, and other e"cessi!e, unnecessary facial mo!ements are characteristic once it has de!eloped, 23 is irre!ersible, although decreasing or discontinuing antipsychotic medication can arrest its progression pre!enting 23 is one goal when administering antipsychotics and this can be done by keeping maintenance dosages as low as possible, changing medications, and monitoring the client periodically for initial signs of 23 o Antic o!iner#ic Side '((ects side effects include& orthostatic hypotension, dry mouth, constipation, urinary hesitance or resistance, blurred near !ision, dry eyes, photophobia, nasal congestion, and decreased memory 4ther side effects&

o increase blood prolactin le!els causing breast enlargement and tenderness #both in men and women% o diminished libido o erectile and orgasmic dysfunction o menstrual irregularities o weight gain #obesity common in schi ophrenic clients, increasing risk for 3. -- and CV3% o minor cardio!ascular ad!erse effects such as postural hypotension, palpitations, and tachycardia NURSING R'SPONSI)I*ITI'S+ inform client of side effects and encourage to report problems instead of discontinuing medication teach client methods of managing or a!oiding unpleasant side effects and maintaining medication regimen& o dry mouth 5 sugar,free fluids and sugar,free hard candy ' client should a!oid calorie,laden be!erages and candy o constipation 5 e"ercise, increase water and bulk,forming foods6 stool softener permissible but a!oid la"ati!es o photosensiti!ity 5 sunscreen client should monitor amount of sleepiness and drowsiness they feel6 a!oid dri!ing and potentially dangerous acti!ities until response time and refle"es seem normal II. ANTID'PR'SSANT DRUGS primarily used in the treatment of ma*or depressi!e illness, an"iety disorders, depressed phase of bipolar disorder, and psychotic depression somehow interact with norephinephrine and serotonin which regulate mood, arousal, attention, sensory processing, and appetite di!ided into + groups& e"amples #table 2.7, p. 33% 1. Tricyc!ic and the related cyclic antidepressants ha!e more side effects than ))8-s block cholinergic receptors, resulting in antic o!iner#ic e((ects+ 1. dry mouth 2. constipation 3. urinary retention +. dry nasal passages 7. blurred near !ision 9. more se!ere, agitation, delirium, and ileus other common side effects& 1. orthostatic hypotension 2. sedation 3. weight gain +. tachycardia clients may de!elop tolerance to anticholinergic side effects but these are common reasons of noncompliance # #esp. weight gain and se"ual dysfunction% 2. Se!ecti&e Serotonin Reuptake In i,itors #))8-% ha!e fewer side effects than cyclic compounds enhanced serotonin transmission can lead to se!eral common side effects& 1. an"iety 2. agitation

3. akathisia #treated with beta,blocker% +. nausea #taking with food lessens nausea% 7. insomnia #sedati!e 5hypnotic or low dosage tra odone% 9. se"ual dysfunction #diminished dri!e or difficulty achie!ing erection or orgasm% :. cause less weight gain than other antidepressants less common side effects& 1. sedation ' 2. sweating ' 3. diarrhea +. hand tremor 7. headaches

3. "AO In i,itors #.;4-s% most common side effects& 1. daytime sedation ' 2. insomnia ' 3. weight gain +. dry mouth 7. orthostatic hypotension 9. se"ual dysfunction of particular concern with .;4-s is the potential for a life, threatening hypertensi!e crisis if client ingests food containing tyramine or sympathomimietic drugs #refer to table 2.1, p. 37 regarding food containing tyramine% increased serum tyramine le!els causes& 1. se!ere hypertension 2. hyperpyre"ia 3. tachycardia +. diaphoresis 7. tremulousness 9. cardiac dysrhythmias potentially fatal drug interactions with .;4-s& 1. ))82. certain cyclic compounds 3. buspirone #1u)par% +. de"tromethorpan 7. opiate deri!ati!es #meperidine% -. Ot er no&e! antidepressant medication+ nefado one causes& o sedation o headache o dry mouth o nausea tra odone o sedation o headache mirta apine o sedation bupropion o loss of appetite o nausea o agitation

o insomnia !enlafa"ine o loss of appetite o nausea o agitation o insomnia o di iness o sweating o sedation se"ual dysfunction is less common but, with one notable e"ception& tra odone can cause priapism # sustained and painful erection% which may result in impotence NURSING R'SPONSI)I*ITI'S+ for cyclic compounds& o should be taken at night to lessen side effects o if forgets a dose, can take it up within 3 hours after missed dose or omit for ))8is& o clients should take it first thing in the morning unless sedation is a problem o if forgets a dose, can take it up within < hours after missed dose o client should a!oid dri!ing or performing acti!ities re=uiring sharp, alert refle"es until sedati!e effects wear off for .;4-s& o client should be aware of life,threatening hyperadrenergic crisis if dietary restrictions are not obser!ed. o pro!ide a written list of foods to a!oid while taking .;4-s o make client aware of serious and fatal drug interactions when taking .;4-s6 instruct not to take additional medications, e!en 42C drugs without consulting doctor III. "OOD STA)I*I.'RS used to treat bipolar disorders by stabili ing client/s mood, pre!enting highs and lows characteri ing bipolar illness, and treat acute mania e"amples& o >ithium most established mood stabili er6 first,line agent in treating bipolar normali es reuptake of serotonin, norepinephrine, acetylcholine, and dopamine serum lithium le!el 1.$ mE=?>6 should be monitored e!ery 2, 3 days to"icity is closely related to serum lithium le!els and can occur at therapeutic doses. common side effects of lithium therapy& mild nausea or diarrhea #taking medication with food may help nausea% anore"ia fine hand tremor #propranolol impro!es fine tremor% polydipsia polyuria a metallic taste in the mouth fatigue or lethargy

 weight gain and acne occur later in lithium therapy ' lethargy and weight gain difficult to minimi e leading to noncompliance to"ic effects& se!ere diarrhea !omiting drowsiness muscle weakness lack of coordination ' if symptoms left untreated, it worsens and can lead to renal failure, coma, and death ' when to"ic signs occur, discontinue lithium immediately if lithium le!els e"ceed 3.$ mE=?>, dialysis may be indicated o some anticon!ulsants are effecti!e ' and good mood stabili ers& carbama epine #2egretol% ' , )E& drowsiness, sedation, dry mouth, and blurred !ision6 rashes and orthostatic hypotension6 ap!astic anemia and a#ranu!ocytosis !alproic acid #3epakote, 3epakene% ' , )E& drowsiness, sedation, dry mouth, and blurred !ision6 weight gain, alopecia, and hand tremor6 epatic (ai!ure/ pancreatitis0 terato#enic gabapentin #0eurontin% topiramate #2opama"% 5 )E& di iness, sedation, weight loss, and increased incidence of renal calculi o"carba epine #2rileptil% lamotrigine #>amictal% 5 serious rashes re=uiring hospitali ation #esp. below yrs of age%, )te!en,@ohnson syndrome, and rarely, life,threatening to"ic epidermal necrolysis o antian"iety agent clona epam #Alonopin% is occasionally used to treat mania NURSING R'SPONSI)I*ITI'S+ for clients taking lithium and anticon!ulsants, monitor blood le!els periodically6 plasma le!els can be checked 12 hours after last dose encourage client to take medications with meals to minimi e nausea instruct client not to attempt to dri!e until di iness, lethargy, fatigue, or blurred !ision has subsided I1. ANTIAN2I'TY DRUGS also known as an"iolytic drugs used to treat an"iety and an"iety disorders, insomnia, 4C3, depression, posttraumatic stress disorder, and alcohol withdrawal e"amples #table 2.9, p.3:% ben odia epines ha!e pro!ed to be the most effecti!e in relie!ing an"iety and are the drugs most fre=uently prescribed # also may be prescribed for their anticon!ulsant and muscle rela"ant effects o mediate the actions of a.a. B;1; #ma*or inhibitory neurotransmitter in the brain% o )E& tendency to cause physical dependence )E associated with C0) depression # drowsiness, sedation, poor coordination, and impaired memory or clouded sensorium%

when used for sleep, may complain of ne"t,day sedation or a hango!er effect buspirone is a nonben odia epine often used for the relief of an"iety o acts as partial agonist at serotonin receptors, which decreases serotonin turno!er o common side effects& di iness, sedation, nausea, and headache ' elderly clients may ha!e more difficulty managing the effects of C0) depression6 more prone to falls from the effects on coordination and sedation6 may ha!e more pronounced memory deficit and may ha!e problems with urinary incontinence particularly at night NURSING R'SPONSI)I*ITI'S+ make client aware that antian"iety agents are aimed at relie!ing symptoms such as an"iety or insomnia but do not treat the underlying problems that cause the an"iety instruct client not to drink alcohol #ben odia epines strongly potentiate the effects of alcohol% make client aware of decreased response time, slower refle"es, and possible sedati!e effects of these drugs when attempting acti!ities such as dri!ing or going to work inform client ne!er discontinue drug abruptly once started without super!ision of physician because ben odia epines withdrawal can be fatal

Commonly Csed 3rugs in (sychiatric Dard #(a!ilion 7 Cnit 3 1ig Eall%

;ntipsychotic ? 0euroleptic 3rugs o haloperidol #)erenase, Ealdol% 7 ? 2$ mg. o chlorproma ine #2hora ine, (synor, Fycloran% 1$$ ? 2$$ mg. o risperidone o clo apine o le!omeproma ine #0o inan% 1$$ mg. o olan apine ' )hort,;cting , haloperidol #Ealdol, )erenase, (sycotil% 7 mg?ml ' >ong,;cting , haloperidol decanoate 7$ mg?ml , fluphena ine decanoate 27 mg?ml , fluphenti"ol decanoate 27 mg?ml ;nticon!ulsants o carbama epine #2egretol, 2egrilol% 2$$ mg. o phenytoin #)odium #0a%, 3ilantin% 1$$ mg. o !alproic acid 27$ mg. o di!alproe" 0a #Epi!al% 27$ mg. ;ntidepressants o fluo"etine #(ro ac% 2$ mg. o sertraline #Foloft% 7$ mg. ;nti,parkinsonism o biperiden lactate #;kineton% 7 mg. o biperiden ECl #;kineton% 2 mg. ;nti,an"iety o hydro"y ine dihydrochloride #-tera"% 27 mg. 4ther .edications& o ;nithypertensi!es nifedipine, metropolol, captopril o ;nti,21 -0E, rifampicin, pyra inamide o ;nti,asthma

 salbutamol o ;ntipyeretic paracetamol o ;ntibiotic amo"icillin, do"ycycline, clo"acillin, sultamicillin o ;ntiamoebics metronida ole o ;ntihistamine 3iphenhydramine ECl #1enadryl% 7$ mg.

SCHI.OPHR'NIA
Chapter 1+, page 2:9 Videbeck 3rd Ed. causes distorted and bi arre thoughts, perceptions, emotions, mo!ements, and beha!ior can/t be defined as a single illness6 rather, is thought of as a syndrome or disease process with many different !arieties and symptoms onset may be abrupt or insidious, but most clients slowly and gradually de!elop signs and symptoms such a social withdrawal, unusual beha!ior, loss of interest in school or work, and neglected hygiene peak incidence of onset& o male 5 17,27 years of age o female 5 27,37 years of age usually diagnosed in late adolescence or early adulthood #rarely manifests in childhood% the diagnosis usually is made when the person begins to display more acti!ely positi!e symptoms of delusions, hallucinations, and disordered thinking #psychosis% symptoms are di!ided into two ma*or categories& #refer to table on p. 2:9% o positi!e or hard symptoms?signs ambi!alence associati!e looseness delusions echopra"ia flight of ideas hallucinations ideas of reference perse!eration o negati!e or soft symptoms alogia anhedonia apathy blunted affect catatonia flat affect lack of !olition those who de!elop the illness earlier show worst outcomes that those who de!elop it later6 younger client display a poorer pre,morbid ad*ustment, more prominent negati!e signs, and greater cogniti!e impairment than do

older clients6 those who e"perience a gradual onset of the disease #about 7$G% tend to ha!e both a poorer immediate and long,term course than those who e"perience a acute and sudden onset appro"imately 3$G of clients with schi ophrenia relapse within 1 year of an acute episode the intensity tends to diminish with age6 o!er time, the disease becomes less disrupti!e to the person/s life and easier to manage, but rarely can the client o!ercome the effects of many years of dysfunction medication can control the positi!e symptoms, but fre=uently the negati!e symptoms persist after positi!e symptoms ha!e abated6 the persistence of these negati!e symptoms o!ertime presents a ma*or barrier to reco!ery and impro!ed functioning in the client/s daily life types of schi ophrenia according to the 3).,-V,28 #3iagnostic and )tatistical .anual of .ental 3isorder, +th edition, 2e"t 8e!ision%& o Sc i3op renia/ paranoid type& characteri ed by persecutory #feeling !ictimi ed or spied on% or grandiose delusions, hallucinations, and, occasionally, e"cessi!e religiosity #delusional religious focus% or hostile and aggressi!e beha!ior o Sc i3op renia/ disor#ani3ed type& characteri ed by grossly inappropriate or flat affect, incoherence, loose associations, and e"tremely disorgani ed beha!ior o Sc i3op renia/ catatonic type& characteri ed by marked psychomotor disturbance, either motionless or e"cessi!e motor acti!ity motor immobility may be manifested by catalepsy # wa"y fle"ibility% or stupor e"cessi!e motor acti!ity is apparently purposeless and is not influenced by e"ternal stimuli other features include e"treme negati!ism, mutism, peculiarities of !oluntary mo!ement, echolalia, and echopra"ia o Sc i3op renia/ undi((erentiated type& characteri ed by mi"ed schi ophrenic symptoms #of other types% along with disturbances of thought, affect, and beha!ior o Sc i3op renia/ residua! type& Characteri ed by at least one pre!ious, though not a current episode6 social withdrawal6 flat affect6 and looseness of associations antipsychotic medications play a crucial role in the course of the disease and indi!idual outcomes6 they do not cure the disorder, howe!er, they are crucial to its successful management the more effecti!e the client/s response and adherence to his or her medication regimen, the better the client/s outcome indi!idual and group therapies, family therapy, family education, and social skills training can be instituted for clients in both inpatient and community settings