Neurotransmitters and Pharmacology

• Exam 2

Neurotransmitters (Monoamines)

• Includes dopamine, norepinephrine, serotonin, and histamine.

Dopamine

• Known as the "feel good" neurotransmitter and a "booster."
• Decreases in Parkinson's disease and depression.
• Increases in schizophrenia and mania.
• Functions: Cognition, motivation, movement, reward system, heart stimulation, and blood flow.
• Cocaine and amphetamines increase dopamine levels, potentially causing psychosis.
• Antipsychotics like haloperidol block dopamine, reducing psychosis.
• Dopamine hypothesis: Excess dopamine contributes to schizophrenia symptoms.

Norepinephrine

• Described as "flight or fight."
• Decreases in depression.
• Increases in mania, anxiety, and schizophrenia.
• Function: Regulates arousal; low levels lead to sedation/depression, and high levels lead to hyperarousal.
• Receptors: α1 and α2 adrenergic receptors.
• Prazosin blocks α1 to treat PTSD nightmares.
• FGAs (Conventional Antipsychotics) block α1, causing vasodilation, orthostatic hypotension, and ejaculation issues.

Serotonin

• Known as a "mood and sleep stabilizer."
• Decreases in depression.
• Increases in anxiety states.
• Function: Regulates mood, arousal, attention, behavior, and body temperature.
• Serotonin Syndrome:
  • Mild: Restlessness, shivering, diarrhea.
  • Severe: Muscle rigidity, fever, seizures.
  • Caused by excess serotonin from SSRIs combined with St. John's wort or dextromethorphan.
  • Treatment: Muscle relaxants, serotonin blockers.

SSRIs & SERT Blockade

• Effect: Increases serotonin and reduces platelet aggregation.
• Risk: Bleeding; caution with NSAIDs, aspirin, and warfarin.

Histamine

• Decrease leads to sedation and weight gain.
• Drugs: FGAs and other psychiatric medications block H1 receptors.
• Effects:
  • Sedation is useful for agitation.
  • Weight gain is beneficial for low appetite/weight.

Neurotransmitters (Amino Acids)

Gamma-Aminobutyric Acid (GABA)

• Described as "the calm down chemical"
• Decreases mania, anxiety, and schizophrenia.
• Increases reduction of anxiety.
• Function: Inhibitory neurotransmitter that regulates neuronal excitability and anxiety.
• Anxiolytics enhance GABA activity to reduce anxiety.
• Future antipsychotics may target GABA and dopamine for schizophrenia treatment.

Glutamate

• Described as a "brain booster."
• Decreased NMDA leads to psychosis.
• Increased NMDA causes neurotoxicity and neurodegeneration in Alzheimer's disease.
• Increased AMPA improves cognitive performance in behavioral tasks.
• Function: Excitatory neurotransmitter that activates NMDA receptors.
• Imbalance Effects:
  • Excess glutamate causes neurotoxicity and cell death, like in Alzheimer's.
  • NMDA antagonists (e.g., memantine) reduce excitability and neurotoxicity.
• Lumateperone (Caplyta) targets serotonin, dopamine, and glutamate in schizophrenia.
• Ketamine-like drugs modulate NMDA and AMPA receptors for rapid depression relief.

Neurotransmitters (Cholinergic)

• Includes Acetylcholine.

Acetylcholine

• Described as "mush, memory maker."
• Increases in depression.
• Decreases in Alzheimer's disease, Huntington chorea, and Parkinson disease.
• Function: Balances dopamine and regulates muscle movement, arousal, memory, and sleep-wake cycle.
• ACh & Alzheimer's:
  • Deficiency in ACh leads to cognitive decline.
  • AChE Inhibitors (e.g., donepezil, rivastigmine) delay cognitive decline.
• Nicotinic Receptors & Schizophrenia:
  • Nicotine stimulates ACh receptors and may help with cognition & sensory deficits.
  • New drug research targets nicotine receptors without harmful effects.

Peptides-Neuromodulators

• Substance P:
  • Regulates mood and anxiety.
  • Plays a role in pain management.
• Somatostatin:
  • Decreases in Alzheimer’s disease and in spinal fluid of some depressed patients.
  • Increases in Huntington chorea.
  • Function: Regulates cognitive function
• Neurotensin:
  • Decreased in spinal fluid of patients with schizophrenia.

Neurotransmitter Systems & Psychotropic Drugs

• Affected neurotransmitter systems:
  • Antidepressants
  • Antianxiety agents
  • Sedative hypnotics
  • Mood stabilizers
  • Antipsychotic agents
  • Anticholinesterase agents

Antidepressant Drugs: MAOI's

• Monoamines: Organic compounds include catecholamines (NE, dopamine) and indolamines (serotonin).
• MAO: Enzyme that breaks down monoamines.
• MAOIs: Inhibits MAO, increasing monoamine concentrations.
• Use: Treats intractable depression by increasing serotonin & NE.
• SSRIs & SNRIs are preferred due to fewer side effects.
• Hypertensive Crisis: Combining MAOIs with OTC medications containing sympathomimetics or foods containing tyramine (aged/fermented foods, some beverages).
• Dietary Restriction: Avoid tyramine for 2 weeks after stopping MAOIs.
• Selegiline via patch lowers hypertensive risk compared to oral MAOIs (e.g., phenelzine, tranylcypromine).
• Takes 4 weeks to have effect

Serotonin Antagonist/Reuptake Inhibitors (SARIs)

• Trazodone (Desyrel):
  • Less preferred for antidepressant treatment; useful for insomnia.
  • Can cause priapism.

Selective Norepinephrine Reuptake Inhibitors (NRIs)

• Atomoxetine (Strattera)
  • Treats ADHD when stimulants are not tolerated.

Selective Serotonin Reuptake Inhibitor (SSRI)

• Stops uptake in the brain
• Take in the morning
• SSRIs: Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) Increase serotonin, improves mood.
• Side effects include fewer anticholinergic effects (N/V).

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)

• Venlafaxine (Effexor), duloxetine (Cymbalta):
  • Increases serotonin and norepinephrine.
  • Fewer anticholinergic side effects

Serotonin-Norepinephrine Disinhibitors (SNDIs)

• Mirtazapine (Remeron): increase serotonin and norepinephrine.
• Combined with SSRIs to augment efficacy or counteract serotonergic side effects (serotonin syndrome side effects).

Norepinephrine–Dopamine Reuptake Inhibitors (NDRIs)

• Bupropion (Wellbutrin)
  • Does not act on serotonin system.
  • Inhibits nicotinic acetylcholine receptors to reduce addictive effects.

Tricyclic (Cyclic) Antidepressants (TCAs)

• Amitriptyline (Elavil), nortriptyline (Pamelor)
  • Increase norepinephrine, block serotonin.
  • Side effects: anticholinergic effects, constipation, dry mouth, blurred vision, urinary retention.

Antianxiety Drugs

• Buspirone (Buspar):
  • Described as "long term use."
  • Reduces anxiety without the sedative and euphoric effects of benzodiazepines.

Benzodiazepines

• Described as "Enas in pam."
• Used short-term for anxiety. Enhances GABA acitivity. Antidote = Flumazil
• Types of Benzodiazepines:
  • Hypnotic (sleep-inducing): Flurazepam, Triazolam.
  • Anxiolytic (reduces anxiety): Lorazepam, Alprazolam.

Melatonin-Receptor Agonist

• Hypnotic drug similar to melatonin, regulates circadian rhythms.
  • Ex: Ramelteon (Rozerem).

Short-Acting Sedative-Hypnotic sleep agents

• Primarily for sedation (sleep-inducing) without affecting anxiety or muscle tone.
  • Zolpidem (Ambien)
  • Zaleplon (Sonata)
  • Eszopiclone (Lunesta)

Mood Stabilizer: Lithium

• Bipolar disorder
• Affects multiple steps in cellular signaling
• Therapeutic Level: 0.5-1.5 mEq/L Toxic Level: >1.5 mEq/L
• Signs of Toxicity:
  • Early signs: Vomiting, diarrhea, GI discomfort.
  • Levels >2 mEq/L: tremors, sedation, confusion.
  • Levels >3.5 mEq/L: delirium, seizures, coma, death. Long-Term Risks: Kidney disease, thyroid disease. Additional Safety Issues: Hyponatremia, headache, dizziness, hypotension, QT prolongation, leukocytosis, polyuria.

Anticonvulsants:

• Valproate (Depakote/Depakene): Increases GABA
  • Helpful in bipolar patients unresponsive to lithium. Increases concentrations of lamotrigine.
• Lamotrigine (Lamictal): Decreases Mania
  • Effective in bipolar depression. May trigger Stevens-Johnson syndrome.
• Carbamazepine (Tegretol): Decreases Mania
  • Effective for rapid-cycling bipolar disorder.
  • CBC monitoring required due to potential blood problems (aplastic anemia and agranulocytosis).

Off-Label Mood Stabilizers

• Oxcarbazepine (Trileptal): Similar to carbamazepine, stabilizes sodium channels.
• Gabapentin (Neurontin): Increases GABA activity.
• Topiramate (Topamax): Inhibits glutamate release and enhances GABA activity.

First-Generation Antipsychotic Drugs (Typical) Category

• Mechanism of Action
  • Binds to and blocks D2 receptors reducing dopamine transmission leading to EPS.
• Examples
  • High-potency
    • Haloperidol, Fluphenazine
  • Low-potency
    • Chlorpromazine
  • Moderate-potency
    • Perphenazine
• Extrapyramidal Side Effects
  • High risk including dystonia, akathisia, & tardive dyskinesia and drug induced Parkinsonism.
• EPS Symptoms
  • Dystonia
  • Akathisia
  • Tardive dyskinesia
  • NMS
• Neuroleptic Malignant Syndrome (NMS)
  • Higher risk of NMS.
• Management of EPS
  • Anticholinergic agents such as benztropine are used, but may cause confusion and memory problems in older adults.
• Safety Profile
  • Higher incidence of EPS, NMS, and sedation. More likely to cause movement disorders.
• Clinical Use
  • Primarily used for acute episodes and positive symptoms of schizophrenia.

Second-Generation Antipsychotic Drugs (Atypical) Category

• Mechanism of Action
  • Binds to both dopamine D2 and serotonin 5-HT2 receptors resulting in fewer EPS.
• Examples
  • Clozapine, Olanzapine, Risperidone, Quetiapine, Ziprasidone, Aripiprazole, Iloperidone, Lurasidone HCI, Cariprazine.
• Extrapyramidal Side Effects
  • Lower risk of EPS at high doses.
• EPS Symptoms
  • Less frequent, if occurs, milder.
• Neuroleptic Malignant Syndrome (NMS)
  • Lower risk of NMS
• Management of EPS
  • EPS may still be managed with anticholinergics, but this risk is lower compared to FGAs
• Safety Profile
  • Fewer EPS and lower risk of NMS but still associated with metabolic side effects like weight gain, diabetes, and dyslipidemia
• Clinical Use
  • For both positive and negative symptoms, long-term management for schizophrenia

Antipsychotic Safety: Specific Adverse Reactions

• Blocking muscarinic cholinergic receptors
  • Blurred vision, dry mouth, constipation, and urinary hesitancy.
• Antagonism of the histamine1 receptors
  • Sedation and weight gain.
• Blocking α1 receptors for norepinephrine
  • Affects vasodilation and drop in blood pressure, or orthostatic hypotension
• Antagonism of either α1 receptors or 5-HT2 receptors
  • Ejaculatory dysfunction

Nonverbal behaviors

• Body behaviors, facial expressions. eye cast, voice related behaviors, observable autonomic physiological responses, personal appearance, physical characteristics.

Double-bind messages

• The verbal message is not reinforced by the communicator's actions; ambiguous message

Techniques that can obstruct communication

• Giving premature advice
• Minimizing feelings
• Falsely reassuring
• Making value judgments
• Asking "why" questions
• Asking excessive questions
• Giving approval; agreeing
• Disapproving; disagreeing
• Changing the subject

Communication Techniques

• Appropriate, Sensitive Use of Silence:
  • Allows space for reflection, processing, and expression of emotions.
• Active Listening:
  • Ensures full attention, and helping the nurse understand the patientís needs.
• Clarifying:
  • Ensures clear understanding the message received.
• Paraphrasing (Reflection of Content):
  • Restating the patientís message in different words to confirm understanding.
• Restating:
  • Repeating key words or phrases to delve deeper.
• Reflection of Feelings:
  • Identifies and acknowledges the emotional tone of the patientís message.
• Exploring:
  • Encourages the patient to provide more details/expand.
• Projective Questions ("What if..."):
  • Helps the patient reflect on hypothetical scenarios to gain insights.
• Presupposition Questions (Miracle Question):
  • Helps the patient envision the future.

Active listening includes:

• Observing the patient's nonverbal behaviors
• Listening and understanding the patient's verbal message
• Listening and understanding a person in the social context, and listening for “false notes"
  • “False notes” = inconsistencies or things the patient says that need more clarification Providing feedback Most people want (in communication) the other person to be there for them psychologically, socially, and emotionally

Cultural Competence

• Involves gaining knowledge about another individual's culture.
• This is the most necessary competence when caring for a client from a diverse background

Barriers

• Communication Styles - Some cultures use expressive, emotional communication, others prefer reserved, indirect styles.
• Eye Contact - In some cultures, contact is respect, but for others it is inappropriate.
• Perception of Touch – Cultures may either value physical contact as warmth or see it as intrusive Cultural Filters – Personal biases

Factors that can Impede Accurate Communication

• Personal Factors:
  • Emotional: Mood, personal bias
  • Social: Cultural, lifestyle, and language differences.
  • Cognitive: Problem solving, knowledge level. Environmental Factors:
  • Physical factors: backgrounds noise, lack of privacy
  • Societal determinants: economic factors, expectations of others Relationship Factors:
  • Symmetrical relationship: Equal friends or colleagues
  • Complementary relationship: Difference in status and power

Techniques That Enhance Communication

• Using silence
• Accepting
• Giving recognition
• Offering self
• Offering general leads
• Giving broad openings
• Placing the events in time or sequence
• Offering observations
• Encouraging description, of perception
• Encouraging comparison
• Restating
• Reflecting
• Focusing
• Exploring
• Giving information
• Seeking clarification
• Presenting reality
• Voicing doubt
• Seeking consensual validation
• Verbalizing the implied
• Encouraging evaluation
• Attempting to translate into feelings
• Suggesting collaboration
• Summarizing
• Encouraging formulation of a plan of action

Telehealth

• Allow for establishing and maintaining therapeutic relationships
• Can help relieve the nursing shortage

Why mental health issues are not being addressed

• Fear of stigma.
• Scarcity of health care providers in remote areas.
• Problems with transportation.

The U.S. Department of Defense (DOD) uses telehealth for:

• Telepsychiatry appointments
• Health assessments, diagnoses, treatments and interventions
• Clinical consultations for all DOD members

Mobile apps

• Cell phones are the most quickly adopted consumer technology in human history.
• Psychiatric patients own smartphones and are interested in using them to monitor their mental health.
• There are thousands of apps that target psychiatric conditions, however, there is less clinical research on these apps.
• There is growing interest in using “passive data” information

Therapeutic Relationship: ATI chapter 5

• A patient-centered partnership, helps the patient take part in health decisions.
• Is the basis of all psychiatric nursing treatment approaches, regardless of the specific aim.
• Is a creative process and unique to each nurse.
• Main Goals Include: Facilitating communication of thoughts and feelings, Assisting patients to find solutions and help and encouraging self-care and independence.
• Social Relationship
  • Includes friendship and socialization.
  • Mutual needs are met.
• Therapeutic Relationship
  • Focuses on the patient's goals/needs.
  • Nurse maximizes communication and uses personal strengths

Phases of the nurse patient relationship

• Orientation: when the nurse and patient first meet
  • Key Aspect
    • Establishing rapport and a trusting environment.
    • Defining the nurse's role and responsibilities.
• Working: nurse and patient actively engage in addressing identified concerns
  • Key Aspect
    • Exploring the patient's thoughts.
    • Encouraging problem-solving. Monitoring for the patient's feelings
• Termination: Conclusion of the nurse-patient relationship.
  • Key Aspects
    • Reviewing the progress the patient has made.
    • Addressing feelings of loss or separation.
    • Ensuring a smooth transition to other sources of support if needed.

Empathy

• "Temporarily living in the other's life."
• In empathy, we understand the feelings of others.

Sympathy

• We feel the feelings of others; objectivity is lost.

Genuineness

• Self-awareness of one's feelings occurs.
• Develops the ability to communicate when appropriate.

Positive regard

• Displays respect; view another person as worthy of our time.

Transference

• Person unconsciously transfers emotional reactions.

Countertransference

• Tendency of the nurse to displace feelings related to people in his or her past onto a patient.

Boundary blurring

• The first connections between the nurse and patient are to establish an understanding which must be: safe, confidential, reliable, and consistent.

Clinical Interview

• Patient Goals:
  • Feel understood and comfortable.
  • Identify/explore problems relating to others.
• Nurses Role:
  • Better use communication skills to understand.

Depression Stats

• Early life trauma, active alcohol or substance use disorder, and family hx of depressive disorder

The individual experiencing is dealing with

• Being Stigmatized!
• Is just feeling down
• Risk Factors
  • History of prior episodes if depression
  • Member of LGBTQ+ community
  • Being Female
  • Age 40 or younger
  • Absence of social support

Theories of Depression

• Consist of genetic factors and biochemical ones

Assessment Categories

• Trigger:
  • Assess for trigger events
• Support:
  • Assess support systems
• History
  • Assess for history of depression

Detailed Assessment Findings

• Mood & Affect
  • Anxiety
  • Worthlessness and anger
• Thought Content & Processes
  • Slow and delusional thinking
• Physical Signs & Symptoms
  • Sleep pattern changes
• Characteristic Communication Styles
  • Monotone speech

• Nursing Concerns (priority hypothesis)*!
• DTS! #!*
• Self mutilation #!*
• Worthlessness!* Hopelessness!

• Self care guidelines*!
• Poor nutrition!*
• Interventions
• !

General Safety Guidelines

• Safety is always the highest priority Recognize and help patient tolerate medication side effects Facilitate a supportive nurse patient relationship Account for the presence of depressive conditions

Helpful Communication Guidelines

Person with depression may speak/ comprehend very slowly. This time spent can be meaningful to the depressed person. Provide comfort

Brain Stimulation Guidelines

Brief seizures by applying electrical current

Guideline Goals

• Helpful for treatment resistant depression and with patients experiencing threatening circumstances. Useful for patients with unremitting suicidal thoughts

Educate pt

• Must be NPO
• Include expected effects

Suicide (Overview)

• The intentional ending of one's own life.
• Is willful, self-inflicted, and the patient is a risk
• Must identify these risks carefully*

Always listen very carefully and take seriously

• "Are you thinking of harming yourself?" -"Are you thinking of killing yourself?"
• Take all factors into consideration

"Right To Die"

Requires the patient to make 2 verbal statements for treatment

Prevalence & Comorbidity Factors

• Consists of : People from various walks of life who are experiencing great loss, addiction or a high dose of anxiety!

Suicide Factors

• The presence of a plan and adverse life events (Loss etc)
• High rate of risk for mental disorders and family members.

Sudden Changes To Clue Into

• Clue include: Discontinuing daily routines and increased substance/ alcohol abuse.

Important cues

• Verbal clues*!
• "Life is not worth living"*!
• "Nothing feels good and never will again.*"!

Nursing concers

• Low self esteem and disturbed thought process*
• Distored thoughts*
• Spiritual distress*
• Substance and or alcohol and or any sort of dependence

Maintain Safety

Maintain Safe Protocols during the crisis.. Document

• In 15 minutes: what the patient is doing and with whom Construct a verbal or written"no suicide contract."

Post Crisis

• Post Crisis, follow-up with arrangement for the patient to contact family

Provide all the information the family will need and follow-up!

Quiz on neurotransmitters, SSRIs, and related pharmacology. Questions cover Parkinson's disease, PTSD treatment, serotonin's role in anxiety, and medication side effects like serotonin syndrome.