Psychoactive DrugsPsychoactive Drugs

Professor Lana Chase

Psychoactive Drug Psychoactive Drug CategoriesCategories

Anti-psychotics: Schizophrenia, AgitationAnti-depressants: Depression, OCD,

AnxietyMood Stabilizers: Bipolar DisorderAnti-Anxiety: Anxiety /Panic DisordersPsycho-stimulants: ADHD, Narcolepsy

Purposes and AdvantagesPurposes and Advantages

Used to affect the brain & behaviorTo treat psychiatric disorders /symptomsUsed in conjunction with other treatments

such as psychosocial rehabilitation, psychotherapy, crisis intervention

To control symptoms & allow consumer to participate in therapy & re-enter job market

NeurohormonesNeurohormonesNeurotransmittersNeurotransmitters

Dopamine

Serotonin

Norepinepherine

AntipsychoticsAntipsychotics

Mainly cause blockade of Dopamine & Serotonin in post synaptic membrane of CNS

Also act on other neurotransmitters which may cause increase in side effects (movement disorders)

Antipsychotics: Antipsychotics: Conditions TreatedConditions Treated

Psychosis: Schizophrenia /Thought Disorders

SedationHiccoughsDementia- Organic Psychosis / AgitationBipolar Disorder (acute mania)

Anti-psychotic UseAnti-psychotic Use

Treat Positive Symptoms of Schizophrenia– Delusions- false beliefs

– Hallucinations- false sensory perceptions: – auditory, visual, tactile, olfactory,somatic,

gustatory

– Illusions- mistaken sensory perception

PhenothiazinesPhenothiazines

Developed in 1950’s 1st . Tranquilizer

Thorazine (Chlorpromazine)sedation, anticholinergic side effects

Prolixin Decanoate (Fluphenazine)– IM for Non-compliant patients– Viscous liquid – use 21 gauge needle ,– Z track – Q 2-4 week admin.(absorbs slowly)

Non PhenothiazinesNon Phenothiazines

Haldol (haloperidol): used extensively in psychiatric emergencies to

sedate patient frequently with Ativan and Benadryl I M or PO

Haldol Decanoate IM – For non-compliant pts. – Absorbed slowly over 2-4 weeks– Large gauge needle, Z track

Non Traditional AntipsychoticsNon Traditional Antipsychotics

Less side effectsMore effective with: Negative Symptoms of Schizophrenia.

– flat affect (mood), alogia(poverty of speech), avolition(apathy), anhedonia(no pleasure), asociality(loner), attentional impairment (poor concentration).

Non Traditional AntipsychoticsNon Traditional Antipsychotics

Clozaril(clozapine)– Biweekly WBC--risk agranulocytosis– Stop med for WBC below 2.5 (do not restart)– Start low dose 25 mg (max dose 900 mg)– Benefits: low side effect profile, pts. like how

they feel on it.– Effective antipsychotic especially for neg. s/s

Non Traditional AntipsychoticsNon Traditional Antipsychotics

Zyprexa (olanzapine)– Dopamine and serotonin blocking agent– Effective antipsychotic and for bipolar pts– Serious Side effects: weight gain , diabetes

Seroquel (quetiapine)– Little or no EPS(same as placebo)– Effective antipsychotic, sedative

Antipsychotic Side EffectsAntipsychotic Side Effects

Less side effects with newer medications Older meds not very user friendlynon

compliance– Sedation: drowsiness– Weight Gain– Photosensitivity– Dizziness (Orthostatic Hypotension)– Sexual Dysfunction

– Elevation in Prolactin Levels

AntipsychoticsAntipsychotics(continued)(continued)

Side Effects– Tardive Dyskenesia: irreversible

Snake like tongue movements /thrusting, invol. movements

– Anticholinergic: from acetylcholine blockade blurred vision, dry mouth,constipation,GI distress, urinary ret.

– Extrapyramidal (EPS): movement disorders Dystonia,akathesia , tremors, shuffling gait, muscle stiffness

(stiff neck, cogwheel rigidity), masked facies, oculogyric crisis (eyes roll back), diff. swallowing

Nursing Interventions for EPSNursing Interventions for EPS

Notify MD & Obtain order for: Cogentin or Artane (anticholinergics)

– PO or IM

Symmetrel (dopamine agonist)

Benadryl (antihistamine)

Side Effects Antipsychotics Side Effects Antipsychotics (cont.)(cont.)

Tardive Dyskinesia (irreversible) – Wormlike tongue movements, ataxia, lip

smacking, involuntary arm & leg movements, fever. Tx. Decrease dosage or D/C

Side Effects AntipsychoticsSide Effects Antipsychoticscont.cont.

Neuroleptic Malignant Syndrome (rare)– 14-30 % mortality– Tachicardia, high fever, muscle rigidity – risk for cardiovascular collapse

Nursing Measures:

discontinue medication, Notify MD,

treat symptomatically: cooling blanket, Bromocriptine, cardiac meds if necessary.

Use Antipsychotics CautiouslyUse Antipsychotics Cautiously

DiabeticsChildren under 6GlaucomaUlcersElderly

– Lower doses, hypotension

Drug InteractionsDrug Interactions

Potentiates action of CNS Depressants:

e.g.. narcotics, alcohol

Nursing ImplicationsNursing Implications

Baseline assessment: EKG, liver function Long term use: assess for adverse effects Assess for movement disorder: EPS, T.D. Observe for hording /”cheeking” meds Administer liquid med in juice Is it effective? monitor mental status Safety : orthostatic hypotension, monitor for

seizures D/C or switch to new med gradually (cont)

Antianxiety DrugsAntianxiety DrugsBenzodiazapinesBenzodiazapines

Action– Increase action of GABA that inhibits nerve

transmission in the CNS– Depresses activity in brainstem

Sedative Hyponotic Anticonvulsant

Antianxiety DrugsAntianxiety Drugs

Therapeutic Uses:– sedative agent/conscious sedation– Treat psychiatric emergencies /agitation– Treat panic disorder, social phobia, anxiety– Treat alcohol withdrawal & seizures– Treat anxiety assoc with medical disorders

COPD

– **use should be brief except with panic disorders due to risk of addiction

Commonly Prescribed Commonly Prescribed Antianxiey DrugsAntianxiey Drugs

Ativan PO or IM– Used for psych emergencies / severe agitation

Valium (diazepam) PO or IV– good IV anticonvulsant 2-40 mg qd– Muscle relaxant action used for neck & back pain

Xanax Versed –conscious sedation, anesthesia induction Tranxene, Librium

– freq. Used for alcohol detoxification in tapering doses Dalmane/Restoril

– sedative sleeping medications

Antianxiety MedicatonsAntianxiety Medicatons

Common Side Effects– Sedation, impaired consciousness,daytime

sedation (hangover), ataxia, dizziness, feelings of detachment, rebound insomnia, amnesia, euphoric mood

– TOLERANCE MUST INCREASE DOSE FOR SAME EFFECT

– PHYSIOLOGICAL DEPENDENCY

Antianxiety Drug OverdoseAntianxiety Drug Overdose

– Overdose alone almost never fatal (safe)– Benzo + alcohol respiratory depression

Treatment for Benzodiazapine Overdose:– Romazicon(flumazenil)

(Antagonist) benzodiazapine receptor blocker

Teaching for Antianxiety Teaching for Antianxiety DrugsDrugs

Drugs should be tapered to prevent withdrawal symptoms / DT’s

Drugs can store in fat cells and prolong withdrawal symptoms

Dosages ½ to 1/3rd. for elderlyInstruct about risk of addiction /safety from

falls

Antianxiety DrugsAntianxiety Drugs

Buspar (buspirone)– Potent antianxiety drug – no muscle relaxant, anticonvulsant or sedative,

or alcohol potentiating action– Takes several weeks for antianxiety effects

** works best with people who never took benzo’s because they are accustomed to immediate effect.

Antianxiety DrugsAntianxiety Drugs

Inderal (propranolol)– Beta Blocker

Used to decrease symptoms that lead to anxiety like tachicardia rather than centrally acting on anxiety

– Treatment for “performance anxiety” found in social phobia.

AntidepressantsAntidepressants

Uses:– Major Depressive Disorder– Premenstrual Dysphoric Disorder– Anorexia /Bulimia– Anxiety Disorders

GAD (Generalized Anxiety Disorder) OCD (Obsessive Compulsive Disorder)

Target Patrticular SymptomsTarget Patrticular Symptoms

Goal: to normalize transmission of impulses at the synapse

Amine Hypothesis: low norepinepherine (catacholamine) at synapse

Permissive Hypothesis: deficiency of serotonin at the synapse

Dysregulation Hypothesis: Failure to regulate catacholomine system

Tricyclic AntidepressantsTricyclic Antidepressants

NorpramineElavilTofranil

Uses: panic disorder, depression, GAD, enuresis, sedation (for insomnia)

***2-4 weeks for antidepressant effect

AntidepressantsAntidepressants

Trazadone– Drug of choice for sedation (sleep disturbances)– **Can cause priapism in males

Antidepressant TX

4-9 mos tx or may be lifetime if depression recurrent

Anxiety Disorders: SSRI (Paxil) now treatment of choice

22ndnd Generation Generation AntidepressantsAntidepressants

SSRI’sSelective Serotonin Reuptake Inhibitors

increases serotonin reuptake at receptor siteless SE than TCI’s

less anticholinergic, no wt. Gain, safer for cardiac pts.& pregnant women

Prozac

Zoloft

Paxil

Other Newer AntidepressantsOther Newer Antidepressants

Celexa & LexaproSerzoneEffexorVestraRemeronWellbutrin /Zyban

Side Effects of Side Effects of AntidepressantsAntidepressants

**Overdose of TCA’s can be fatal due to Cardiac arrhythmias Anticholinergic Side Effects

SSRI’s Psychomotor excitement / insomnia (take in morning), tremor,headache, nervousness

TCA’s: Sedation, drowsiness especially 1st week (instruct to start on weekend), often added as nighttime dose for insomnia

Sexual Side Effects– Ejaculatory disturbances & decreased libido, priapism (Deseryl)

AntidepressantsAntidepressants

MAOI’s– Monoamine Oxidase Inhibitors

Action: Inhibit enzyme activity resulting in decreased amount of MAO in the body

Used for non responders to other antidepressant tx. Effective for atypical depression, panic, and phobias

Monoamine Oxidase InhibitorsMonoamine Oxidase Inhibitors

Role of Tyramine and Dietary Restrictions– MAO metabolizes neurotransmitters related to

depression. Also linked to control of BP due to inhibition of norepinepherine.

– Need to avoid norepinepherine agonists like dietary TYRAMINE.

– HYPERTENSIVE CRISIS (life threatening) can occur from increased levels of norepinepherine ie risk of strokes (CVA)

MAOI’s Side EffectsMAOI’s Side Effects

Life Threatening if taken with drugs or foods containing TYRAMINE

Hypertensive Crisis (Malignant Hypertesion)– Sudden elevation of BP, palpitations,chest

pain,sweating , fever, N&V– HOLD MAOI : do not lie down (inc. BP in brain)– Treatment: Thorazine 100 mg IM (blocks

norepinepherine), Cooling blanket, – Phentolamine IV in 5 mg doses (binds with

norepinepherine)– Cooling blanket

Seratonin SyndromeSeratonin Syndrome

Risk– May occur when SSRI’s are administered too close to the

discontinuation of MAOI’s or other drugs affecting serotonin reuptake are taken together

Signs and Symptoms

confusion , disorientation, mania, restlessness, diaphoresis, shivering, diarrhea, nausea.

Treatment:

D/C all serotonergic drugs including

SSRI’s, MAOI’s, anticonvulsants, Ativan, Klonapin

** do not reintroduce serotonin drugs

MAO InhibitorsMAO Inhibitors

Only 3 Drugs in this Class– Nardil– Parnate– Marplan– Side effects: extreme hypotension– Toxic effect : malignant hypertension (if taken

with sympathomimetic substance (Tyramine)

Nursing Interventions MAOI’sNursing Interventions MAOI’s

Careful teaching on diet and drug reactions Dietary Restrictions: aged cheese (blue, brick, brie),

organ meats, pickled herring, bologna, pepperoni, salami, fava beans,avacado,red wine (Chianti), beer, tofu, miso soup– over ripe fruit (banana, raisons)

In moderation: chocolate, soy sauce, yogurt Drug Restrictions

OTC drugs with epinepherine like effects: sudafed, sinus , allergy remedies

Narcotics (Demerol especially), other antidepressant drugs, Cocaine, amphetamines

Mood Stabalizing DrugsMood Stabalizing Drugs

Lithium Carbonate– Classic Drug for Bipolar Disorder (Manic Depression)– Action: lithium replaces sodium in the cells– **Dosage adjusted by Serum Lithium Level (weekly

then monthly levels), not by symptoms– Narrow Therapeutic Index: Risk of toxicity

Toxic and Theraputic serum levels are close

.5-1.5 meq./l therapuetic above 2 meq. toxic Usual dosage 900 mg. but depends on rate of excretion

Lithium CarbonateLithium Carbonate

Side Effects – : fine hand tremor,mental dullness,weight gain,

polyuria, kidney impairment– Secondary hypothyroidism: give Synthroid

Lithium Toxicity (Flu like Symptoms)– ataxia(may look intoxicated),diarrhea,GI

distrubance (N &V)

Lithium CarbonateLithium Carbonate

Nursing ConsiderationsHold Lithium, Notify MD, get serum lithium level to confirminstruct patient in S/S of toxicity

excessive sweating: will raise serum lithium levels (caution for people who have outdoor jobs in the heat (roofer)

contraindicated/caution with diuretics such as Hydrodiuril (HCTZ)

Mood StabalizersMood Stabalizers

Anticonvulsant Mood Stabalizers– Enhances effect of GABA– 2nd. Line treatment for lithium intolerant pts.– Use is increasing –less Side Effects

Used to Treat:– Bipolar disorder (rapid cyclers),Schizoaffective Disorder,

BorderlinePersonality Disorder, Schizophrenia

Given in combo with other meds **Give Mood Stabalizer with SSRI to avoid Mania

– Tegretal (carbamazapine) most studied– Depakote (valproic acid) most studied– Neurontin,Lamictal, Topramax (newer)

Mood StabilizersMood Stabilizers

Anticonvulsant Mood Stabilizers– Response in 1-2 weeks– Side effects:

sedation, dizziness (subside over time), skin reaction may require D/C, Depakote-pancreatitis risk (liver func. Tests)

– Nursing Implications Monitor serum levels, WBC,hepatic/renal function Can be lethal in overdose