Psychopharmacology

MR. JAYESH PATIDAR

www.drjayeshpatidar.blogspot.com

INTRODUCTION…

• Psychopharmacology is the study of

drugs used to treat psychiatric disorders.

• Medications that affect psychic function,

behavior or experience are called

psychotropic medications.

• They have significant effect on higher

mental functions.

• Psychopharmacological agents are first

line treatment for almost all psychiatric

ailments now a days.

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• With the growing availability of a wide

range of drugs to treat mental illness, the

nurse practicing in modern psychiatric

settings needs to have a sound

knowledge of the pharmacokinetics

involved, the benefits & potential risks of

pharmacotherapy, as well as her own

role & responsibility.


DEFINITION OF PSYCHOTROPIC

DRUGS

Psychotropic drug is any drug

that has primary effects on behavior,

experience, or other psychological functions

(Logman Dictionary of Psychology &

Psychiatry). Psychotropic or psychoactive

drugs can also be defined as chemical that

affects the brain & nervous system, alter

feelings & emotions. These drugs also affect

the consciousness in various ways. A broad

range of these drugs is used in emotional &

mental illnesses.


GENERAL GUIDELINES REGARDING

DRUG ADMINISTRATION IN PSYCHIATRY

• The nurse should not administer any drug unless

there is a written order. Do not hesitate to consult

the doctor when in doubt any medication.

• All medications given must be charted on the

patient‘s case record sheet.

• In giving medication:

– Always address the patient by name & make certain of

his identification.

– Do not leave the patient until the drug is swallowed.

– Do not permit the patient to go to the bathroom to take

medication.

– Do not allow one patient to carry medicine to another.

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• If it is necessary to leave the patient to get

water, do not leave the tray within the reach of

the patient.

• Do not force oral medication because of the

danger of aspiration. This is especially

important in stuporous patients.

• Check drugs daily for any change in color, odor

& number.

• Bottle should be tightly closed & labeled. Labels

should be written legibly & in bold lettering.

Poison drugs are to be legibly labeled & to be

kept in separate cupboard.


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• Make sure that an adequate supply of drugs

is on hand, but do not overstock.

• Make sure no patient has access to the drug

cupboard.

• Drug cupboard should always be kept

locked when not in use. Never allow a

patient or worker to clean the drug

cupboard. The drug cupboard keys should

not be given to patients.


PATIENT EDUCATION RELATED TO

PSYCHOPHARMACOLOGY…

• Nurses assess for drug side effects, evaluate

desired effects, & make decisions about prn

(pro re neta) medication.

• Nurses must understand general principles of

psychopharmacology & have specific

knowledge related to psychotropic drugs.

• Teaching patients can decrease the incidence

of side effects while increasing compliance

with the drug regimen.


Specific areas of education include

the following…

1. Discussion of side effects: Side effects can

directly affect the patient‘s willingness to

adhere to the drug regimen. The nurse should

always inquire about the patient‘s response to

a drug, both therapeutic responses & adverse

responses

2. Drug interactions: Patients & families must

be taught to discuss the effects of the addition

of over-the-counter drugs, alcohol & illegal

drugs to currently prescribed drugs.


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3. Discussion of safety issues: Because some

drugs, such as tricyclic antidepressants, have a

narrow therapeutic index, thoughts of self harm

must be discussed.

• Discuss on abruptly discontinued effects.

• Many psychotropic drugs cause sedation or

drowsiness, discussions concerning use of

hazardous machinery, driving must be reviewed

4. Instructions for older adult patients: Because

older individuals have a different

pharmacokinetic profile than younger adults,

special instructions concerning side effects &

drug-drug interactions should be explained. 4/24/2013 10

JAYESH PATIDAR

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5. Instructions for pregnant or breastfeeding

patient: As pregnant or breastfeeding patients

have special risks associated with

psychotropic drug therapy, special

instructions should be tailored for these

individuals. Teaching patients about their

medications enables them to be mature

participants in their own care & decreases

undesirable side effects


CLASSIFICATIONS OF PSYCHOTROPIC

DRUGS

1. Antipsychotic agents

2. Antidepressant agents

3. Mood stabilizing drug

4. Anxiolytics & hypnosedatives

5. Antiepileptic drug

6. Antiparkinsonian drugs

7. Miscellaneous drugs which include stimulants,

drugs used in eating disorders, drugs used in

deaddiction, drugs uses in child psychiatry,

vitamins, calcium channel blockers etc.


ANTIPSYCHOTIC AGENTS


DESCRIPTION:-

• Antipsychotic agents are also known as

neuroleptic, major tranquillizers, or

phenothaiazines.

• This group of drugs has a major clinical

use in the treatment of psychosis.

• Psychosis is a state in which a person‘s

ability to recognize reality to

communicate & to relate to others is

severely impaired.


MODE OF ACTION:-

• Antipsychotic agents are thought to block the

dopamine receptors.

• Dopamine is a chemical which is released in

the brain & causes psychotic thinking.

• Increased production of dopamine transmits the

nerve impulses to the brainstem faster than

normal. This result in strange thoughts ,

hallucination & bizarre behavior.

• Antipsychotics helps in blocking or reducing the

activity of dopamine.

• Antiemetic is another property of antipsychotic

agents. They are also used in hiccoughs.


Class Examples of

drugs

Trade name Oral dose

mg/day

Parenteral

dose (mg)

Phenothiazines Chlorpromazine

Triflupromazine

Thioridazine

Trifluoperazine

Fluphenazine

decanoate

Megatil

Largactil

Tranchlor

Siquil

Thioril, Melleril

Ridazin

Espazine

prolinate

300-1500

100-400

300-800

15-60

-

50-100 IM

only

30-60 IM only

1-5 IM

25-50 IM

every 1-3

weeks.

Thioxanthenes flupenthixol fluanxol 3-40

CLASSIFICATION:-


Class Examples of

drugs

Trade name Oral dose

mg/day

Parenteral

dose (mg)

Diphenylbutyl Pimozide orap 4-20

piperidines penfluridol flumap 20-60 weekly -

Indolic

derivatives

molindone mobam 50-225 -

Dibenzoxazepines loxapine loxapac 25-100 -

Atypical

antipsychotics

Clozapine

Risperidone

Olanzapine

Quetiapine

Ziprasidone

Sizopine, Lozapin

Sizodon, sizomax

Oleanz

Qutan

Zisper

50-450

2-10

10-20

150-750 mg

20-80 mg

Others reserpine serpasil 0.5-50

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INDICATIONS

Organic psychiatric

disorders:

• Delirium

• Dementia

• Delirium tremens

• Drug-induced psychosis &

other organic mental

disorders

Functional disorders:

• Schizophrenia

• Schizoaffective disorders

• Paranoid disorders

Mood disorders:

• Mania

• Major depression with

psychotic symptoms

Childhood disorders:

• Attention-deficit

hyperactivity disorder

• Autism

• Enuresis

• Conduct disorder

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Neurotic & other

psychiatric disorders:

• Anorexia nervosa

• Intractable obsessive-

compulsive disorder

• Severe, intractable &

disabling anxiety

Medical disorders:

• Huntington‘s chorea

• Intractable hiccough

• Nausea & vomiting

• Tic disorder

• Eclampsia

• Heart stroke severe

pain in malignancy

tetanus


PHARMACOKINETICS

• Antipsychotics when administered orally are absorbed

variably from the gastrointestinal tract, with uneven

blood levels.

• They are highly bound to plasma as well as tissue

proteins. Brain concentration is higher than the

plasma concentration.

• They are metabolized in the liver, & excreted mainly

through the kidneys. The elimination half-life varies

from 10 to 24 hours.

• Most of the antipsychotics tend to have a therapeutic

window. If the blood level is below this window, the

drug is ineffective. If the blood level is higher than the

upper limit of the window, there is toxicity or the drug

is again ineffective.


SIDE-EFFECTS

1) Extrapyramidal symptoms (EPS)

i. Neuroleptic-induced parkinsonism:- occur

in 40% of the patients presenting

extrapyramidal symptoms. There are two

varieties of parkinsonia symptoms:

a. Akinetic Form:- Appears in the first week of administration of antipsychotic drugs. The characteristics of akinetic form are: Difficulty in masticating movements, weakness & muscle fatigue.


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b. Agitating Form of parkinsonian Symptoms

include:- Tremors at rest, rigidity & mask-like

face. Most characteristic features of parkinsonism

are:-Rigidity of muscles

Motor retardation

salivation

slurred speech

mask-like face

shuffling gait

Anticholinergi drugs are given as treatments.


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ii. Akathisia:-

Akathisia occurs in 50% of

all the patients presenting

extrapyrimidal symptoms. The common

characteristics: Restless ―walking in

place‖. Difficulty in sitting still, or strong

urge to move about- referred to as

―Walkies & Talkies‖ by haris . generally

occurs after two weeks of treatment.

Before administering anti-parkinsonian

medication anxiety should be ruled out. 4/24/2013 JAYESH PATIDAR 23

Count…iii. Dystonia:-

Dystonia occurs in 6% of total number

of patient‘s presenting EPS. The characteristic

features are: rapidly developing contraction of

muscles of the tongue, jaw, neck (producing

torticollis) & etraocular muscles. Combined

torticolis & extraocular spasm results in an

oculogyric crisis in which eyes looked upward,

head is turned to one side. Dystonia is painful

& gives a frightening experience to the patient.

Constant observation of the patient should be

made. Dystonia occurs within a few minutes of

giving medicine or after several hours.


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iv. Tardive Dyskinesia:-

This occur due to abrupt

termination or reduction of the antipsychotic

drug after long-term-high-dose therapy.

Tardive dyskinesia is characterized by

involuntary rhythmic, stereotyped movements,

protrusion of the tongue, puffing of cheeks,

chewing movements, involuntary movements

of extremities & trunk. These symptoms occur

in 3% of patients. Antipsychotics should be

stoped immediately. There is no treatment,

symptoms may appear for years. It is

irreversible. 4/24/2013 JAYESH PATIDAR 25

Count…V. Neuroleptic Malignant Syndrome (NMS):-

This is a rare

complication of antipsychotic agents & is

usually fetal. Many develop within hours or

after years of continued drug use. Symptoms

include hyperpyrexia, severe muscle rigidity,

altered consciousness, blood pressure

changes, increased count of W.B.C.

symptoms appear suddenly when medication

is started & can persist for 10-14 days or

longer. Symptomatic treatment is given to

patients.


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2) Autonomic Nervous System:-

Dry mouth, blurred vision,

constipation, urinary hesitance or retention & under

rare circumstances paralytic ileus.

3) Cardio-Vascular:-

Tachycardia, orthostatic hypotension &

reversible arrhythmias.

4) Blood or Hematopoietic:-

Agrunulocytosis (marked decrease in

leukocytes system especially with chlorpramozine)

leucopenia, leukocytosis.


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5) Endocrine Disruptions:-

Menstrual irregularities, including

amenorrhea & false positive pregnancy tests, breast

enlargement, lactation, weight gain, changes in libido,

impotence, glycosuria, hyperglycemia.

6) Gastro-Intestinal:-

Anorexia, constipation, diarrhea, hypersalivation,

nausea, vomiting, obstructive jaundice.

7) Allergic effects:-

Dermatitis, photosensitization, pigment

deposits.


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8) Occular Effcts:-

Blurring of vision, pigmentation of

cornea & lens & retinopathy.

9) Hepatic Side-effects:-

Liver toxicity occurs in 0.5% of cases

presenting EPS. It is a hypersensitivity reaction &

dose dependent. Onset of symptoms is within the

first one month of treatment. Symptoms may be

fever, chills, nausea, malaise, prurites & jaundice.


NURSE’S RESPONCIBILITY

Close observation, especially when the antipsychotic are

just started. The expected results are reduction in

aggressive hyperactive behavior & disorganized thoughts.

Look for the possible side-effects.

Extrapyramidal reaction, i.e. Parkinsonism, akinesia,

akathisia, dystonia, & tardive dyskinesia. These symptoms

are reduced/treated with early observation, reporting &

use of anti-parkinsonion or anticholinergic medication.

Observe drowsiness. Medicine should be administered at

bed time. Report if the drowsiness persists for a very long

time. The patient should be advised not to drive & handle

hazardous machinery while taking antipsychotic drugs.

Observe for sore throat, fever due to agranulocytosis.


Count… Record blood pressure of the patient on

antipsychotic drugs. If the BP is drops by 20 to30

mm of hg in the patient, immediate reporting &

intervention should be done. The patient should be

made aware of the possibility of dizziness & injuries

after receiving medication & injection due to

orthostatic hypotension.

Accurate rout of medication- antipsychotic drugs are

not given subcutaneously unless specially prescribed

as they cause tissue irritation. These drugs should

be given deep IM.

Dry mouth may be may be reduced by encouraging

the patient to rinse his or her mouth frequently. Give

a piece of lemon or chewing gum. Good oral hygiene

should also be maintained.


Count… Blurred or impaired vision in the patient causes anxiety

& annonyance to him. The patient should be

encouraged to inform these symptoms immediately.

Blurred vision or brown coloured vision, night blindness

can be permanent due to pigmentary retinopathy.

The patient on antipsychotic drugs may have weight

gain. Weight record should be maintained. The patient

may be encouraged on a low salt & planned caloric diet.

The patient may complain of gastric irritation. He should

be discouraged to take antacid as there will be

decreased absorption of antipsychotic drugs.

An intake output chart should be maintained specially

for male patients who are confined to bed & have an

enlarged prostate gland. Encourage at least 2500 ml of

liquid intake.4/24/2013 JAYESH PATIDAR 32

Count… The patient should be advised to protect his skin, by not going

in the sun & to wear protective clothing & sunglasses.

The patient should be explained not to increase or decrease

or stop taking drugs without discussing with his doctor. The

drugs should be withdrawn slowly to avoid nausea or

seizures.

The nurse should find out menstrual changes from the female

patient. Sometimes the patient may complain of fever, upper

abdominal pain, nausea, jaundice & diarrhea. These

symptoms can be due to cholestatic jaundice. The nurse

should stop the medicine immediately & inform the doctor.

Reassurance to relatives- The patient & his relatives should

be explained that desired effects will be achieved after weeks

of medication, so the relatives need to wait for the effects of

the drugs.


ANTIDEPRESSANTS

AGENTS


DESCRIPTION

• Antidepressant agents are used in

affective disorders or disturbances

mainly to treat depressive disorders

caused by emotional or environmental

stressors.

• Several groups of affective

disturbances are treatable by

antidepressants.


MODE OF ACTION• Antidepressant drugs are classified as Tricyclics,

Tetracyclics & MAO inhibitors. Research studies

have shown reduced levels of norepinephrine (NE) &

serotonin (5-HT) in the space between nerve ending

carrying message from one nerve cell to another

cause depression.

• Tricyclic antidepressants & MAO inhibitors increase

these neurotransmitters i.e. norepinephrine & sertinin

to the synaptic receptors in the central nervous

system. Tricyclic inhibitors block the reuptake of NE

& 5-HT & MAO inhibitors block the action of

MONOamine oxidize in breaking down excess of NE

& 5-HT at the presynaptic neuron.4/24/2013 JAYESH PATIDAR 36

CLASSIFICATION

CLASS EXAMPLES OF

DRUGS

TRADE NAME ORAL DOSE

(mg/day)

Tricyclic

antidepressants (TCAs)

Imipramine

Amitriptyline

Clomipramine

Dothiepin

mianserin

Antidep

Tryptomer

Anafranil

Prothiaden

depnon

75-300

75-300

75-300

75-300

30-120

Selective serotonin

reuptake inhibitors

(SSRIs)

Fluoxetine

Sertraline

Fludac

Serenata

10-80

50-200

Dopaminergic

antidepressants

fluvoxamine faverin 50-300

Atypical

antidepressants

amineptine survector 100-400

Monoamine oxidase

inhibitors (MAOIs)

Trazodone

isocarboxazid

Trazalon

Marplan

150-600

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INDICATIONS Depression

• Depressive episode

• Dysthymia

• Reactive depression

• Secondary depression

• Abnormal grief reaction

Childhood psychiatric

disorders

• Enuresis

• Separation anxiety disorder

• Somnambulism

• School phobia

• Night terrors

Other psychiatric disorders

• Panic attack

• Generalized anxiety disorder

• Agrophobia, social phobia

• OCD with or without depression

• Eating disorder

• Borderline personality disorder

• Post-traumatic stress disorder

• Depersonalization syndrome

Medical disorder

• Chronic pain

• Migraine

• Peptic ulcer disease4/24/2013 JAYESH PATIDAR 38

PHARMACOKINETICS

• Antidepressants are highly

lipophilic & protein-bound. The

half-life is long & usually more

than 24 hours.

• It is predominantly metabolized in

the liver.


CONTRAINDICATION

• Antidepressants are given with caution

to patients with cardiovascular disorder

because they cause arrhythmias.

• They increase symptoms of psychosis

& mania in cases of manic-depressive

psychosis.

• Drugs are given with caution to

prevents with liver disorders.


SIDE EFFECTS1) Autonomic side-effects:

Dry mouth, constipation,

cycloplegia, mydriasis, urinary retention, orthostatic

hypotension, impotence, impaired ejaculation,

delirium & aggravation of glaucoma.

2) CNS effects:-

Sedation, tremor & other extrapyramidal

symptoms, withdrawal syndrome, seizures,

jitteriness syndrome, precipitation of mania.

3) Cardiac side-effects:-

Tachycardia, ECG changes, arrhythmias,

direct myocardial depression, quinidine-like

action(decreased conduction time).


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4) Allergic side-effects:-

Agranulocytosis, cholestatic

jaundice, skin rashes, systemic vasculitis.

5) Metabolic & endocrine side-effects:-

weight gain

6) Special effects of MAOI drugs:-

Hypertensive crises, severe

hepatic necrosis, hyperpyrexia.


NURSE’S RESPONSIBILITY

Observation of the side-effects & monitoring the

changes noted are very significant to prevent

complications due to antidepressant agents.

Encourage the patient to take medicine at bed

time due to a sedative effect. Dryness of mouth to

decrease.

Give plenty of fluids orally. Lemonade or chewing

gum should be given. A few sips of water also

help the patient.

Do not give medicine empty stomach as the

patient complains of nausea & vomiting.


Count… Accurate recording of intake & output of the patient

should be maintained to check if he has retention of

urine.

If the patient complains of dizziness or light headedness

he/she should be encouraged to get up slowly & sit in the

bed before standing. These symptoms may due to

orthostatic hypotension. The patient should be reassured

that these symptoms are for a short period only. Some

patients may present hypertension.

Accurate recording of vital signs like B.P. & pulse.

The nurse should be able to interpret the blood reports

specially blood sugar level & W.B.C. count. If the patient

complains of sore throat, fever, malaise, it should be

reported to the physician on duty. These symptoms may

be due to agranulocytosis or hyperglycemia. 4/24/2013 JAYESH PATIDAR 44

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To relieve constipation plenty of fluids &

roughage should be encouraged in the diet.

If the patient complains of sexual dysfunction

inform the physician immediately & stop the

drug.

If the patient is presenting symptoms of

pressure of speech, increased motor activity &

elated mood, the physician should be informed

& the drug should be stopped immediately.

Antidepressant tricyclic drugs begin

therapeutic effects within four to eight weeks.

Accurate recording of the observation made.


MOOD

STABILIZING

DRUGS


Mood stabilizers are

used for the treatment of bipolar

affective disorders. Some commonly

used mood stabilizers are:-

1. Lithium

2. Carbamazepine

3. Sodium Valproate


LITHIUM


DESCRIPTION

• Lithium is an element with atomic

number 3 & atomic weight 7.

• It was discovered by FJ Cade in

1949, & is a most effective &

commonly used drug in the

treatment of mania.


MODE OF ACTION

The probable mechanisms of action can be:

• It accelerates presynaptic re-uptake &

destruction of catecholamines, like

norepinephrine.

• It inhibits the release of catecholamines at the

synapse.

• It decreases postsynaptic serotonin receptor

sensitivity.

All these actions result in decreased

catecholamine activity, thus ameliorating

mania.


INDICATION

Acute mania

Prophylaxis for

bipolar & unipolar

mood disorder.

Schizoaffective

disorder

Cyclothymia

Impulsivity &

aggression

Other disorders:

– Premenstrual

dysphoric disorder

– Bulimia nervosa

– Borderline

personality disorder

– Episodes of binge

drinking

– Trichotillomania

– Cluster headaches4/24/2013 JAYESH PATIDAR 51

PHARMACOKINETICS

• Lithium is readily absorbed with peak plasma

levels occurring 2-4 hours after a single oral

dose of lithium carbonate.

• Lithium is distributed rapidly in liver & kidney &

more slowly in muscle, brain & bone. Steady

state levels are achieved in about 7 days.

• Elimination is predominately via tubules & is

influenced by sodium balance. Depletion of

sodium can precipitate lithium toxicity.


DOSAGES

Lithium is available in the market in the form of the

following preparation:

– Lithium carbonate: 300mg tablet (eg. Licab);

400mg sustained release tablets (eg.

Lithosun-SR).

– Lithium citrate: 300mg/5ml liquid.

The usual range of dose

per day in acute mania is 900-2100mg given in

2-3 divided doses. The treatment is started after

serial lithium estimation is done after a loading

dose of 600mg or 900mg of lithium to determine

the pharmacokinetics.


BLOOD LITHIUM LEVEL

• Therapeutic levels = 0.8-1.2 mEq/L

(for treatment of acute mania)

• Prophylactic levels = 0.6-1.2 mEq/L

(for prevention of relapse in bipolar

disorder)

• Toxic lithium levels>2.0 mEq/L


SIDE EFFECTS• Neurological: Tremors, motor hyperactivity,

muscular weakness cogwheel rigidity, seizures,

neurotoxicity (delirium, abnormal involuntary

movements, seizures, coma).

• Renal: Polydipsia, polyuria, tubular enlargement,

nephritic syndrome.

• Cardiovascular: T-wave depression.

• Gastrointestinal: Nausea, vomiting, diarrhea,

abdominal pain & metallic taste.

• Endocrine: Abnormal thyroid function, goiter &

weight gain.

•


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• Dermatological: Acneiform eruptions,

popular eruptions & exacerbation of

psoriasis.

• Side-effect during pregnancy &

lactation: Teratogenic possibility,

increase incidence of Ebstein‘s anomaly

(distortion & downward displacement of

tricuspid value in right ventricle) when

taken in first trimester. Secreted in milk

& can cause toxicity in infant.


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• Sign & symptoms of

lithium toxicity (serum

lithium level>2.0

mEq/L):

– Ataxia

– Coarse tremor (hand)

– Nausea & vomiting

– Impaired memory

– Impaired concentration

– Nephrotoxicity

– Muscle weakness

– Convulsions

– Muscle twitching

– Dysarthria

– Lethargy

– Confusion

– Coma

– Hyperreflexia

– Nystagmus


MANAGEMENT OF LITHIUM TOXICITY:-

• Discontinue the drug immediately.

• For significant short-term ingestions, residual

gastric content should be removed by induction of

emesis, gastric lavage adsorption with activated

charcoal.

• If possible instruct the patient to ingest fluids.

• Assess serum lithium levels, serum electrolytes,

renal functions, ECG as soon as possible.

• Maintenance of fluid & electrolyte balance.

• In a patient with serious manifestations of lithium

toxicity, hemodialysis should be initiated.


CONTRAINDICATION OF LITHIUM:-

• Cardiac, renal, thyroid or neurological

dysfunctions

• Presence of blood dyscrasias

• During first trimester of pregnancy &

lactation

• Severe dehydration

• Hypothyroidism

• History of seizures


NURSE’S RESPONSIBILITY:-

• The pre—lithium work up: A complete

physical history, ECG, blood studies (TC, DC,

FBS, BUN, Creatinine, electrolytes) urine

examination (routine & microscopic) must be

carried out. It is important to assess renal

function as renal side-effects are common &

the drug can be dangerous in an individual

with compromised kidney function. Thyroid

functions should also be assesses, as the

drug is known to depress the thyroid gland.


Count…To achieve therapeutic effect & prevent lithium toxicity,

the following precaution should be taken:

• Lithium must be taken on a regular basis,

preferably at the same time daily (for example, a

client taking lithium on TID schedule, who forget

a dose should wait until the next scheduled time

to take lithium & not take twice the amount at one

time, because toxicity can occur).

• When lithium therapy is initiated, mild side-effects

such as fine hand tremors, increased thirst &

urination, nausea, anorexia etc may develop,

Most of them are transient & do not represent

lithium toxicity. 4/24/2013 JAYESH PATIDAR 61

Count…• Serious side-effects of lithium that necessitate its

discontinuance include vomiting, extreme hand tremor,

sedation, muscle weakness & vertigo. The psychiatrist

should be notified immediately if any of these effects

occur.

• Since polyuria can lead to dehydration with risk of lithium

intoxication, patients should be advised to drink enough

water to compensate for the fluid loss.

• Various situations may require an adjustment in the

amount of lithium administered to a client, such as the

addition of the new medicine to the client drug regimen, a

new diet or an illness with fever or excessive sweating.

They must be advised to consume large quantities of

water with salts, to prevent lithium toxicity due to

decreased sodium levels.


Count…• Frequent serum lithium level evaluation is

important. Blood for determination of lithium

levels should be drawn in the morning

approximately 12-14 hours after the last dose

was taken.

• The patient should be told about the importance

of regular follow up. In every six months, blood

sample should be taken for estimation of

electrolytes, urea, creatinine, a full blood count

& thyroid function test.


CARBAMAZEPINE


DESCRIPTION

• It is available in the market under

different trade names like Tegretol,

Mazetol, Zeptol & Zen Retard.


MECHANISM OF ACTION

• Its mood stabilizing mechanism is

not clearly established. Its

anticonvulsant action may

however be by decreasing

synaptic transmission in the CNS.


INDICATIONS

• Seizures-complex partial seizures, GTCS,

seizures due to alcohol withdrawal.

• Psychiatric disorders- rapid cycling bipolar

disorder, acute depression, impulse control

disorder, aggression, psychosis with

epilepsy, schizoaffective disorders,

borderline personality disorder, cocaine

withdrawal syndrome.

• Paroxysmal pain syndromes- trigeminal

neuralgia & phantom limb pain.


DOSAGE

• The average daily dose is 600-1800

mg orally, in divided doses. The

therapeutic blood levels are 6-12

µg/ml. toxic blood levels are attained at

more than µg/ml.


SIDE EFFECTS

• Drowsiness, confusion, headache,

ataxia, hypertension, arrhythmias, skin

rashes, steven-Johnson syndrome,

nausea, vomiting, diarrhea, dry mouth,

abdominal pain, jaundice, hepatitis,

oliguria, leucopenia, thrombocytopenia,

bone marrow depression leading to

aplastic anemia.


NURSE’S RESPONCIBILITY

• Since the drug may cause dizziness &

drowsiness advise him to avoid driving &

other activities requiring alertness?

• Advise patient not to consume alcohol

when he is on the drug.

• Emphasize the importance of regular

follow-up visits & periodic examination of

blood count & monitoring of cardiac,

renal, hepatic & bone marrow functions.


SODIUM

VALPROATE (ENCORATE CHRONO,

VALPARIN, EPILEX,

EPIVAL)


MECHANISM OF ACTION

• The drugs acts on gamma-

aminobutyric acid (GABA) an

inhibitory amino acid

neurotransmitters. GABA

receptors activation serves to

reduce neuronal excitability.


INDICATION

• Acute mania, prophylactic treatment of

bipolar-I disorder, rapid cycling bipolar

disorder.

• Schizoaffective disorder.

• Seizures.

• Other disorders like bulimia nervosa,

obsessive-compulsive disorder, agitation

& PTSD.


DOSAGE

• The usual dose is 15

mg/kg/day with a maximum of

60mg/kg/day orally.


SIDE EFFECTS

• Nausea, vomiting, diarrhea,

sedation, ataxia, dysarthria,

tremor, weight gain, loss of hair,

thrombocytopenia, platelet

dysfunction.



• Explain to the patient to take the drug

immediately after food to reduce GI

irritation.

• Advise to come for regular follow-up &

periodic examination of blood count,

hepatic function & thyroid function.

Therapeutic serum level of valproic

acid is 50-100 micrograms/ml.


ANTIANXIETY

AGENTS,

INCLUDING

SEDATIVES AND

HYPNOTICS


DESCRIPTION

• Anxiety is a state which occurs in all

human being at sometime or the other.

• It is also a cardinal symptoms of many

psychiatric conditions.

• The drugs used to relieve anxiety are

called ANTIANXIETY OR ANXIOLYTIC

AGENTS. Antianxiety drugs relieve

moderate-to-severe anxiety & tension.


MODE OF ACTION

• These non-barbiturate benzodiazepines

act as CNS depressants.

• It is believed that these drugs increase

or help the inhibitory neurotransmitter

action of gama-aminobutyric inhibitor in

all areas of CNS. So, there is inhibition

or control on the cortical & limbic system

of the brain, which is responsible for

emotions such as rage & anxiety.


INDICATIONS• Antianxiety agents are used to relieve mild, moderate &

severe anxiety associated with: emotional disorders

physical disorders excessive environmental stress

neuroses & mild depressive states without causing

excessive sedation or drowsiness.

• For control of alcohol withdrawal symptoms.

• To control convulsions.

• To produce skeletal muscle relaxation.

• To provide short-term sleep preoperatively, prior to

diagnosis & insomnia.

• Antianxiety agents should always be used in time-limited

regimen.


CONTRAINDICATIONS

• Patients with renal or liver &

respiratory impairment are

given antianxiety drugs with

caution.


CLASSIFICATION OF ANTIANXIETY

AGENTS:-CHEMICAL GROUP &

GENERIC NAME

TRADE NAME RANGE OF DAILY

DOSAGE IN mgm

ACTION

I. Non-Barbiturates

A. Benzodiazepines

Chlordiazepoxide

Diazepam

Oxazepam

Prazepam

Chlorazapate

Flurazepam

Nitrazepam

lorazepam

Librium,

Equibrome

Valium,

Calmpose

Serepax

Verstran

Tranzene

Azene

Dalmane,

Nitravet

Mogadon

ativan

15-100

6-50

30-120

20-60

11.25-60

15-60

10-30

2-6

These are non-

barbiturate

benzodiazepines.

They produce a

tranquillizing

effect without

much sedation.

These drugs are

potential for

abuse.4/24/2013 JAYESH PATIDAR 82

COUNT…CHEMICAL GROUP &

GENERIC NAME

TRADE NAME RANGE OF DAILY

DOSAGE IN mgm

ACTION

A.Non-

Benzodiazepine

Propanediols

Meprobamate

Equanil

Miltown

Tybamate

1.2-1.6

1.2-1.6

1.2-1.6

These drugs

have sedative

action &

present a high

risk of abuse &

physical

dependence.

II. Antihistamines

Hydroxyzine

Atarax

vistaril

30-200

30-2004/24/2013 JAYESH PATIDAR 83

CLASSIFICATION OF SEDATIVES AND

HYPNOTICS:-CHEMICAL GROUP

& GENERIC NAME

TRDE NAME HYPNOTIC

DOSE RANGE-

DAILY IN mgm

SEDATIVE DOSE

DAILY IN mgm.

ACTION

III. Barbiturates

Amobarbidtal SA

Butabarbital SA

Pentobarbital LA

Phenobarbital LA

Thiopental USA

Amytal

Butisol

Nembutal

Luminal

pentothal

100-200

100-200

100-200

100-200

Used for

anasthesia

60-150

20-200

60-150

30-90

These drugs

cause drowsiness

lethargy,

decrased

alertness & sleep.

Tolerance to drug

can occur within

7-14 days,

resulting in

physical

dependence.

IV. Nonbarbiturates


COUNT…CHEMICAL GROUP &

GENERIC NAME

TRDE NAME HYPNOTIC

DOSE RANGE-

DAILY IN mgm

SEDATIVE DOSE

DAILY IN mgm.

ACTION

V. Quinazolines

Methaquualone Quaalude

Parest

Optimal

mandrax

150-300 250-300

VI. Acetylinic Alcohols

Ethchlorvynol placidyl

0.5gm-1gms 200-600mgm

VII. Chloral

Derivatives

Chloral hydrate

Chloral betaine

Noctaec

Beta-chlor

0.5gm-2gms

870mg-1gm

VIII. Monoureides

paraldehyde paral 3gm-8gms4/24/2013 JAYESH PATIDAR 85

SIDE – EFFECTS OF ANTIANXIETY,

SEDATIVES & HYPNOTICS

1)Central nervous system: drowsiness,

ataxia, confusion, depression, blurred

vision.

2)Cardiovascular system: hypotension,

palpitation, syncope.

3)Endocrine: change in libido.

4)Allergic: skin rash.


COUNT…

5) Physical/psychological dependence non-

benzodiazepines & barbiturate group of

drugs has a high risk of abuse & physical

dependence.

6) Acute toxicity of barbiturate that can be fetal when taken in excessive dosage usually for suicide attempts. Overdose can cause tachycardia, hypotension, shock, respiratory depression, coma & death.


NURSE’S RESPONSIBILITYAssessment of the patient, prior to the use of

antianxiety, sedative-hypnotic agents. If the patient

complains of sleep disturbance the causative factor

should be identified.

Appropriate nursing measures to induce sleep

should be taken such as a calm & quite

environment, a cup of hot milk, good back care,

allowing the patient to read magazines, sitting with

the patient for some time for reassurance purpose.

While administering the drug daily dose should be

given at bed time to promote a normal sleep

pattern, so that day-time activities are not affected.


COUNT…Give IM injection deep into muscles to prevent

irritation.

Look for side-effects, record & report immediately.

If the patient complains of drowsiness tell him to

avoid using knife or any other dangerous equipment.

He should be instructed not to drive.

Instruct the patient not to take any stimulant like

coffee, alcohol as they alter the effect of drugs.

Avoid excessive use of these drugs to prevent the

onset of substance abuse or addiction.

Drug should be reduced gradually, sudden stoppage of the

drug may cause REM (Rapid Eye Movements), insomnia,

dreams or nighmare, hyperexcitability, agitation or convulsions. 4/24/2013 JAYESH PATIDAR 89

ANTIPARKINSONIAN

AGENTS


DESCRIPTION

• Antiparkinsonian agents are the specific

drugs to treat the extrapyramidal side-

effects of antipsychotic agents.

• Side-effects are parkinsonism,

akathisia, acute dystonia & tardive

dyskinesia.

• Anticholinergics, antihistamines &

amantidne are used to treat these side-

effects.


MODE OF ACTION

• Anticholinergic drugs block the

secretion, thereby reducing the symptoms

of akathesia & acute dystonia. It is not

effective against tardive dyskinesia.

• Antihistamines have effects like

anticholinergic drugs. Amantadines are

dopamine-releasing agents from central

neurons. Studies show that this drug may

affect some clients with tardive

dyskinesia.


INDICATION

• Antiparkinsonian drugs are

used to treat the

extrapyramidal symptoms.


CONTRINDICATION

• Patient with history of closed angle glaucoma,

urinary or intestinal obstruction, hypersensitivity,

prostatic hypertrophy, tachycardia are not given

these drugs.

• The drugs are given with caution to patients with

mysthesia gravis, arthesclerosis & chronic

respiratory problems.

• Anticholinergic drugs: Amantadine is given with

caution to patients with renal impairment as

most of the medication is excreted through the

kidney.


CLASSIFICATIONCHEMICAL & GENERIC

NAME

TRADE NAME DOSE RANGE PER

DAY mgm/Day

FROM OF

AVAILABILITY

I. Anticholinergic

Benztropine

Biperiden HCL

Hydrochiride

Trihexyphenidyl

Hydrochiride

Procyclidine

hydrochiride

Cogentin

Akinetone

Dyskinon

Pacitane

Parbenz

kemadrin

0.5-6.0

2.0-8.0

2.0-12.0

5.0-20mg

Tab, injection

-do-

-do-

Tab.

Tab.

II. Antihistamine

Diphenhydramine Benadryl 75-100

Capsule & syrup

III. Dopamine Drugs

L. Dopa

Amantadine Hydrochiride

Selegline

Carbidopa & L.Dopa.

Larodopa

Symmetrel

Deprenyl

Sinemet

2 gms-3gms

100-200gms

5-10mg

10-100mg

Tab.

Tab .

Tab.

Tab.


SIDE-EFFECTS• Anticholinergic:- Side-effects are dry mouth,

flushed, dry skin, blurred vision, photophobia,

increased heart rate, constipation, urinary

retention, mental confusion & excitement.

• Antihistamines:- Side-effects are drowsiness,

dizziness, anorexia, nausea, vomiting, euphoria,

orthostatic hypotension, weight gain, weakness &

tingling of hands.

• Amantadine:- Side-effects are mood changes,

slurred speech, insomnia, inability to concentrate,

dry mouth, livedo reticularis that is a red-blue

netlike discolouration of the skin which becomes

worse in winter.4/24/2013 JAYESH PATIDAR 96


Observation- observation of the patient for side-

effects of anti-parkinsonian drugs such as

tachycardia, palpitation, sedation, drowsiness &

blurred vision.

Maintain an intake output chart in case the patient

has urinary retention or constipation.

Encourage adequate intake of fluids & roughage in

the diet.

Record vital sign such as B.P., pulse & respiration

every four hours.

Advise the patient not to get up quickly from a lying-

down position to sitting because of orthostatic

hypotension.4/24/2013 JAYESH PATIDAR 97

COUNT…

Educate the patient not to use hazardous

machinery or driving when he is on

anticholinergic drugs.

Encourage the patient to get his routine

eye check-up done for early detection of

blurred vision or glaucoma.

Record the medicine & side-effects

accurately.

Report & record any side-effects

observed to the physician.


DRUGS USED IN

CHILD

PSYCHIATRY


1. CLONIDINE

2. METHYLPHENIDATE (RITALIN):-


CLONIDINE


MECHANISM OF ACTION

• Alpha2- adrenergic receptors agonist.

• The agonist effects of clonidine on

presynaptic alpha 2-adrenergic

receptors result in a decrease in the

amount of neurotransmitters released

from the presynaptic nerve terminals.

This decrease serves generally to reset

the sympathetic tone at a lower level &

to decrease arousal.


INDICATION

• Control of withdrawal symptoms from

opioids.

• Tourette‘s disorder

• Control of aggressive or hyperactive

behavior in children

• Autism.


DOSAGE

• Usual starting dosage is 0.1mg

orally twice a day; the dosage can

be raised by 0.3 mg a day to an

appropriate level.


SIDE-EFFECTS

• Dry mouth, dryness of eyes,

fatigue, irritability, sedation,

dizziness, nausea, vomiting,

hypotension & constipation.



• Monitor BP, the drug should be

withheld if the patient becomes

hypotensive.

• Advise frequent mouth rinses &

good oral hygiene for dry mouth.


METHYLPHENIDATE

(RITALIN)


DESCRIPTION

• Methylphenidate ,

dextroamphetamine &

pemoline are

sympathominetics.


MECHANISM OF ACTION

• Sympathomimetics cause the stimulation of

alpha & beta-adrenergic receptors directly as

agonists & indirectly by stimulating the release

of dopamine & norepinephrine from

presynaptic terminals.

• Dextroamphetamine & methylphenidate are

also inhibitors of catecholamine reuptake,

especially dopamine reuptake & inhibitors of

monoamino oxidase.

• The net result of these activities is believed to

be the stimulation of the several brain regions.


INDICATION

• Attention-deficit hyperactivity disorder

• Narcolepsy

• Depressive disorders

• Obesity


DOSAGE

• Starting dose is 5-10 mg per

day orally, maximum daily

dose is 80mg/day.


SIDE-EFFECTS

• Anorexia or dyspepsia, weight

loss, slowed growth, dizziness,

insomnia or nightmares,

dysphoric mood, tics &

psychosis.



• Assess mental status for chang in mood, level of

activity, degree of stimulation & aggressiveness.

• Ensure that the patient is protected from injury.

• Keep stimuli low & environment as quiet as

possible to discourage over stimulation.

• To decrease anorexia, the medication may be

administered immediately after meals. The

patient should be weighed regularly during

hospitalization & at home while on therapy with

CNS stimulants, due to the potential for anorexia/

weight loss & temporary interruptions of growth &

development.


COUNT…

• To prevent insomnia administer last dose at

least 6 hours before bedtime.

• In children with behavioral disorders a drug

‗holiday‘ should be attempted periodically

under the direction of the physician to

determine effectiveness of the medication &

the need for continuation.

• Ensure that parents are aware of the delayed

effects of Ritalin. Therapeutic response may

not seen for 2-4 weeks; the drug should not be

discontinued for lack of immediate results.


COUNT…

• Inform parents that OTC (over-the-counter)

medications should be avoided while the child

is on stimulant medication. Some OTC

medications, particularly cold & hay fever

preparation contain certain sympathomimetic

agents that could compound the effects of the

stimulants & create drug interactions that may

be toxic to the child.

• Ensure that parents are aware that the drug

should not be withdraw abruptly. Withdrawal

should be gradual & under the direction of the

physician.



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Health & Medicine

Psychopharmacology