Psychotropic Drugs

1. Psychotropic Drugs • Mental Health • Jene’ Hurlbut, RN, MSN, CFNP

2. Objectives: • Discuss the functions of the brain and the way this can be altered by the use of psychotrophic medications • Discuss how the neurotransmitters are affected by various psychotrophic medications • Discuss the application of the nursing process with various psychotrophic medications • Identify specific cautions to be aware of the various psychotrophic medications

3. Psychotropic Drugs • Locus of all mental activity is the brain • Origin of psychiatric illness caused by many factors: • Genetics • Neurodevelopment factors • Drugs • Infections • Psychosocial experiences, etc.

4. Psychotropic Drugs-continue • Theories behind use of psychotropic drugs focuses on neurotransmitters and their receptors • Psychotropic drugs act by modulating neurotransmitters Go to: http://www.wisc-online.com/ • Health: Nursing, activity #3503 (Psychotropic Medications and Neurotransmitters) • Or try: http://www.wisc-online.com/objects/index_tj.asp?objID=NUR3503

5. Review: Cellular composition of brain • Neurons-nerve cells that conduct electrical impulses • Neurotransmitter-chemical that is released in response to an electrical impulse (neuromessenger). • Attaches to a receptors on cell surface and either inhibits or excites • Major target of psychotropic drugs Seetable 3-1on pg. 40 !!!!

6. Use of psychotropic meds: • Relieve or reduce s/s of dysfunctional thoughts, moods, or actions, & mental illness • Improve client’s functioning • Increase compliance to other therapies

7. Do not “cure” Relieve or decrease symptoms Prevent or delay return of S/S Cannot be used as the sole tx for disorders Need informed consent before starting Are broad spectrum and have effects on a large number of S/S. Initial effects are sedative in nature May take weeks for effects to be seen Therapeutic Effects of Psychotropic Meds

8. Meds are expensive Unpleasant side effects Feel better and decide no longer need Stigma associated with having a mental illness and taking meds Paranoia or fears about med usage Reasons for Nonadherence:

9. Services Encouraging Compliance to Medication Regimen: • Follow-up appts. With client to verify that client understands the purpose, proper administration, intended effects, side and toxic effects of, and how to treat problems associated with meds • Support persons can encourage and assist the client to comply with meds • Appropriate lab tests must be conducted to prevent complications and assure correct levels of drugs • Encourage clients to participate in med groups • Can use injections of antipsychotics which will last from 2-4 weeks if clients are non-compliant

10. Efficacy of Psychotropics with Children & Elderly • Use with great caution • Start low and go slow for both elders and children!! • Elders have decrease liver & renal function • Risk of injuries and falls with elderly

11. Purpose of the meds and benefits, side effects and how to treat SE. What S/S indicate a toxic effect, and how to treat, and whom to call. Specific instructions about how to take the meds Client & Family Teaching

12. Antipsychotics (neuroleptics) Mood Stabilizers Antidepressants Anxiolytics (antianxiety) Sedatives Hypnotics Psychostimulants Antihistamines, antimuscarinics, dopamine agonists Psychotropic Meds Classifications:

13. Schizophrenia Disorders Bipolar-Manic Phase Major Depression with psychotic features Tourette’s Syndrome Control of intractable hiccups Dementia, and Delusions Aggressive behavior Uses for Antipsychotics/Neuroleptics

14. First generation: Phenothiazines=Thorazine, Mellaril, Stelazine, Prolixin (high potency) Non Phenothiazines= Haldol (butyrophenones) (high potency) Atypical Antipsychotics (2nd and 3rd gen)= Clozaril, Zyprexa, Risperdal, Geodon, Seroquel, Zeldox Invega, Abilify Antipsychotic Meds-Neuroleptics

15. Block predominantly dopamine activity little effect on serotonin High incidence of abnormal movements (Also blocks acetylcholine, norepinephrine to some degree) Blocks the H receptor for histamine results in sedation and weight gain First Gen Antipsychotic Meds

16. Dystonia (EPS)=spasms of the eye, neck-torticollis, back, tongue-happens within 72 hrs. reversible. Akathisia (EPS)= restlessness Pseudoparkinson- S/S similar to Parkinson's-see in 1-2 weeks. May disappear. TX. With Cogentin Tardive Dyskinesia-bizarre facial and tongue movements-irreversible. Side Effects of 1st Gen Drugs

17. Amenorrhea Galactorrhea Blurred vision, dry mouth, constipation and urinary retention, tachycardia-anticholinergic S/E Sexual dysfunction Severe dysrhythmias In men can lead to gynecomastia photosensitivity & skin rashes (i.e. haldol) Reduction is seizure threshold Orthostatic hypotension Agranulocytosis Other S/E of 1st gen Antipsychotics

18. Blood dyscrasias Liver, renal, or cardiac insufficiency CNS depressants, including ETOH Tegretol in conjunction with antipsychotics causes up to 50% reduction in antipsychotic concentrations SSRI’s in conjunction with antipsychotics may cause sudden onset of EPS Don’t give if have: Parkinson's disease, prolactin dependent cancer of the breast Cigarette smoking causes reduced plasma concentrations of antipsychotics Luvox in conjunction with antipsychotics causes increased concentrations of Haldol and Clozaril Beta Blockers in conjunction with antipsychotics cause severe hypotension Antidepressants in conjunction with antipsychotics may cause increased antidepressant concentrations Contraindications of Traditional Antipsychotics (1st Gen):

19. First Generation Antipsychotic Meds • Are useful in getting out of control behavior under control quickly. • These can be given with lithium to get treat acute mania.

20. Atypical Antipsychotics • Action: • Blocks serotonin and to a lesser degree, dopamine receptors • Also block receptors for norepinephrine , histamine, acetylcholine

21. Nicer drugs and are used more!! Decrease positive and negative S/S of Schizophrenia These drugs block serotonin as well as dopamine Incidence of abnormal movements is lower! Biggest SE is wt. gain Atypical Antipsychotics- 2nd and 3rd generation drugs

22. Positive: Hallucinations Delusions Abnormal thoughts Bizarre behavior Confused thoughts Negative: Blunted affect Poverty of speech Social withdrawal Poor motivation Positive & Negative S/S of Schizophrenia

23. low incidence of abnormal movements possible fatal side effect: bone marrow suppression & agranulocytosis (rare) Most common S/E: sedation & drowsiness, wt. gain Other S/E are: hypersalivation, tachycardia, & dizziness, seizure risk Atypical Antipsychotics-2nd and 3rd generation: Clozaril (clozapine)

24. Risperidone Does not cause bone marrow suppression Can cause at higher doses motor difficulties Available as a long acting injection Can be used to tx. mania Seroquel (Quetiapine) S/E sedation, weight gain and headache Not associated with abnormal movements Atypical Antipsychotics-2nd and 3rd generation: continue

25. Atypical Antipsychotics-2nd and 3rd generation: continue • Zyprexa (olanzapine) • does not cause bone marrow suppression • Can cause weight gain & hyperglycemia • Adverse effects-Drowsiness, insomnia restlessness • Geodan (ziprasidone) • Binds to multiple receptor sites • Main S/E are hypotension & sedation • Can prolong the QT interval-can be fatal if hx of cardiac arrhythmias • Abilify (Aripiprazole) • Dopamine stabilizer • Partial agonist at the D2 receptor • In areas of the brain with excess dopamine, it lowers dopamine • In areas of low dopamine, it stimulates receptors to raise the dopamine level • Main S/E are sedation, hypotension, and anticholinergic effects • Adverse effects-headache, anxiety insomnia, GI upset

26. Known hypersensitivity CNS depression, including ETOH Blood dyscrasias in clients with Parkinson’s disease Liver, renal, or cardiac insufficiency Use with caution in diabetics, elderly, or debilitated SSRIs in conjunction with antipsychotics may cause sudden onset of EPS Cigarette smoking causes reduced plasma concentrations Tegretol (carbamazepine) in conjunction with antipsychotics causes up to 50% reduction in antipsychotic levels Luvox (fluvoxamine) in conjunction with antipsychotics causes increased concentrations of Haldol & Clozaril Beta Blockers in conjunction with antipsychotics cause severe hypotension Antidepressants in conjunction with antipsychotics may cause increased antidepressant concentrations Contraindications for Atypical Antipsychotics:

27. Antipsychotics • Can be given be given as an IM injection (depot preparations) if have difficulty taking oral meds. • Can use lower doses when given IM, so less risk of tardive dyskinesia

28. Rare, but fatal complication from all antipsychotic drugs See more with 1st gen drugs Severe muscle rigidity High temp up to 107 Tachycardia Tachypnea Stupor Coma Neuroleptic Malignant Syndrome

29. Used in the treatment of Manic (Bipolar) disorder, and in some forms of depression Drugs used Lithium and Antiepileptic Drugs Mood Stabilizers

30. Mechanism of action unknown Interacts with sodium and K+ Alters electrical conductivity potential threat to all body functions that are regulated by electrical currents Can cause polyuria and polydipsa due to Na and K alterations Has the lowest therapeutic index of all psych drugs Have to monitor blood levels of this drug Lithium

31. Maintenance blood levels of lithium are usually 0.4-1.3 mEq (toxicity occurs with levels > 1.5 mEq/L) Sign of toxicity is a fine intention tremor that becomes more pronounced and coarse. Risk of thyroid & kidney disease If toxic s/s occur discontinue the drug and notify health care provider Lithium should be taken with food Client must eat a balanced diet with normal sodium intake and take in adequate fluid (about 2-3 liters/day). Excretion is dependent on this. Dehydration and salt restriction can increase lithium levels & cause toxicity. Takes 2-3 weeks for lithium to become effective (may use antipsychotic until therapeutic levels are reached) Lithium

32. Signs & symptoms of lithium toxicity: • Fine hand tremors that progress of coarse tremors • Mild GI upset progressing to persistent upset • Slurred speech and muscle weakness progressing to mental confusion • Severe Toxicity: • decrease level of consciousness to stupor and finally coma • Seizures, severe hypotension, severe polyuria with dilute urine

33. Lithium: • Lithium serum concentrations are increased by fluoxetine (Prozac), ACE inhibitors, diuretics, and NSAIDs • Lithium serum concentrations are decreased by theophylline, osmotic diuretics, and urine alkalinizers

34. Contraindications for Lithium: • Renal disease • Cardiac disease • Severe dehydration • Sodium depletion • Brain damage • Pregnancy or lactation • Use with caution in the elderly or clients with diabetics, thyroid disorders, urinary retention, and seizures

35. Anticonvulsants/Antiepileptic Drugs • Causes an increase in GABA in the CNS-which causes a decrease in anxiety. • Reduce the mood swings with bipolar

36. Anticonvulsants/Antiepileptic Drugs • Tegretol (carbamazepine)-also used to treat severe pain (i.e. trigeminal neuralgia) • Depakote (valproic acid)-can cause hepatic failure, pancreatitis, & thrombocytopenia. Watch for liver failure • Klonopin(clonazepam) • Lamictal (Lamotrigine)-can have a rare but fatal dermatological condition

37. Toxic Effects of Anticonvulsants: • Tegretol can cause agranulocytosis and aplastic anemia • Depakote can cause liver dysfunction, hepatic failure, and blood dyscrasias including thrombocytopenia • Depakote interacts with drugs that are hepatically metabolized

38. Contraindications for Anticonvulsants : • Hepatic or renal disease • Pregnancy • Lactation • Presence of blood dyscrasias

39. Unique teaching needs with anticonvulsants: • Monitor blood levels of mood stabilizers to prevent toxicity • Monitor liver, renal function tests and CBCs • Depakote must be swallowed whole, not cut, chewed, or crushed to prevent irritation

40. Antidepressants • Tx of depressive moods, including bipolar disease • 4 categories: • Tricyclics • MAOI’s • SSRI’S • Atypical Antidepressants

41. Antidepressant Drugs • Tricyclics- Elavil, Tofranil • SSRI’s-Zoloft, Paxil • MAOI’s- Nardil, Parnate, Marplan

42. Atypical Antidepressants • Inhibits selective reuptake of serotonin: Trazodone (desyrel) • Norepinephrine Dopamine Reuptake Inhibitor (NDRI):Wellbutrin (Bupropion) • Serotonin & norepinephrine reuptake inhibitor: Cymbalta (duloxetine) • SertoninNorepineprine Reuptake Inhibitor-(SNRI): Effexor(venlafaxine) • Increases release of serotonin & norepinephrine : Remeron (mirtazapine)

43. Trazodone= alternative to TCA’s Can cause orthostatic hypotension, sedation, & priapism in males Remeron= causes sedation, weight gain, dry mouth, constipation Wellbutrin (zyban)= rarely causes sedation, wt. Gain, or sexual dysfunction. Used for smoking cessation. Most common S/E are headaches, insomnia & nausea Can lower seizure threshold –causes seizures Atypical Antidepressants

44. SNRI-blocks uptake of serotonin and norepinephrine Good for clients with anxiety also SE=sexual dysfunction, insomnia, agitation Skipping 1 dose can cause withdrawal S/S Drug here is Effexor & Cymbalta Very effective in treating severe depression Atypical Antidepressants: serotonin norepinephrine reuptake inhibitor (SNRI):

45. Major Depressive disorder Bipolar depression Obsessive-Compulsive Anxiety Panic disorder PTSD Substance Abuse Chronic Pain Tourette’s Disorder ADHD Eating disorders Sleep disorders Migraines Enuresis Major Indications for Antidepressants

46. Blocks the reuptake of norepinephrine and sertonin Tricyclic drugs block the muscarine receptors (so anticholinergic effects) Other side effects: orthostatic hypotension sedation wt. gain confusion-esp. elderly arrhythmias Tricyclics: Elavil, Pamelor, Tofranil, Anafranil, Aventyl, Asendin, Sinequan

47. Do not mix with ETOH (none of the psych drugs should be mixed with ETOH) Dementia Suicidal clients Cardiac disease Pregnancy Seizure disorders Urinary retention Dose for elderly should be ½ of adult dose TCA’s and MAOIs are effective in tx. depression are not as safe or as well tolerated as the newer antidepressants Toxic Effects: possibility of cardiac toxicity and are toxic in overdose Tricyclics Contraindications

48. SSRI’s • Prozac, Zoloft, Paxil, Celexa, Luvox, Serzone, Lexapro • Action-blocks the reuptake of sertonin into the neuron • Side-effect: • biggest is sexual dysfunction & wt. gain • Contraindication: • Cardiac dysrhythmias

49. SSRI’s • Are very safe and are not lethal in overdose • Good choice with the elderly-very few side effects • If used with MAOI’s may cause Serotonin Syndrome=seizure, death • If used with TCA’s may cause TCA toxicity • Takes 2 weeks to feel effects

50. Nardil, Parnate, Marplan Inhibits MAO, thus interfering with breakdown of norepinephrine, dopamine, and serotonin Toxic effects= hypertensive crises Avoid foods with tyramine (aged cheese, red wine, beer, chocolate, etc.) MAOI’s don’t play well with other drugs!! MAOI’s