RN Psychopharm

Historical Context of Mental Illness Treatment

• Historically, responses to mental illness ranged from benign involvement to inhumane mistreatment due to fear and association with the supernatural.
• The late 18th century marked the beginning of "moral reform" with the establishment of community and state hospitals focused on the needs of people with mental illness.
• These institutions, although well-intentioned, fostered custodial care, providing food and shelter but limited hope for recovery or reintegration into the community.
• The early 20th century introduced somatic therapies, including insulin-shock therapy, wet sheet packs, ice baths, electroconvulsive therapy, and psychosurgery for mental illness.
• Before 1950, sedatives and amphetamines were the primary psychotropic medications, limited by their toxicity and potential for physical dependence.
• The development of psychopharmacology in the 1950s led to widespread use of antipsychotic, antidepressant, antianxiety, and mood-stabilizer medications, enhancing the understanding of biochemical influences in mental disorders.
• Psychotropic medications primarily alleviate physical and behavioral symptoms rather than eliminating mental disorders and are often used with psychotherapy.

Ethical and Legal Implications of Psychopharmacology for Nurses

• Nurses need a full understanding of ethical and legal considerations in psychotropic medication administration, varying by state, but emphasizing the patient's right to refuse treatment.
• Emergency situations allow treatment if patients are likely to harm themselves or others.
• Some states have laws enabling courts to mandate outpatient treatment, including medication, for individuals not seeking treatment but with a history of violent behavior, as exemplified by Kendra's Law in New York.
• Laws like Kendra's Law may include medication grant clauses to ensure uninterrupted medication during transitions from hospitals or correctional facilities.

Assessment in Psychopharmacology

• A complete baseline assessment is essential prior to initiating psychopharmacological therapy.
• Key components of this database include a nursing history and assessment and a comprehensive medication and ethnocultural assessment.
• Ethnocultural assessments are essential because genetic and cultural factors, including dietary preferences, can influence medication response via CYP450 isoenzyme variations.
• Pharmacogenetic testing may be conducted to identify poor metabolizers at higher risk of adverse drug reactions and toxicity.

Nurse's Role in Medication Administration and Evaluation

• Nurses are key professionals in the administration of psychotropic medications in various settings, including inpatient facilities, partial hospitalization programs, day treatment centers, and home healthcare.
• Monitoring for side effects and adverse reactions, along with evaluating the therapeutic effectiveness of medications, is part of their role.
• A thorough knowledge of psychotropic medications is needed to anticipate potential problems and outcomes associated with their administration.

Patient Education in Psychopharmacology

• It is a nursing responsibility to translate complex information about psychotropic medications so patients can easily understand it.
• Patients need to know why medication is used, when it is to be taken, and what to expect in terms of effects, side effects, and adverse reactions and whom to contact if questions arise.
• Medication education promotes patient collaboration, enabling effective management of the treatment regimen.
• Providing pregnancy risk information is an essential aspect of patient education for women of childbearing age; since 2015 drug labeling includes specific narrative information on pregnancy-associated risks.
• Nurses are expected to use the latest informatics resources to stay updated on medication-related topics and patient education.

Neurotransmitters and Psychotropic Medications

• Neurotransmitters are chemicals stored in the axon terminals of the presynaptic neuron: an electrical impulse causes their release into the synaptic cleft and determines whether another electrical impulse is generated.
• Receptors are molecules on the cell membrane which act as binding sites for neurotransmitters.
• Psychotropic medications mainly affect the neuronal synapse affecting neurotransmitter release and their receptors.
• Antagonist drugs dampen biological reactions by blocking receptors
• Agonist drugs activate receptors.
• It is hypothesized that most antidepressants blocking serotonin or norepinephrine reuptake.
• Reuptake is the process of neurotransmitter inactivation, which allows more neurotransmitters to be available to the synapse for neuronal transmission. -Unwanted side effects can also result from this action.
• Blocking alpha-adrenergic, histaminergic, and muscarinic cholinergic receptors can cause side effects like postural hypotension with tricyclic antidepressants.

Antianxiety Agents

• They are also called anxiolytics or historically were known as minor tranquilizers, these typically include benzodiazepines, buspirone, and some SSRIs.
• Off-label uses include anticonvulsants, beta blockers, antihistamines, and quetiapine.
• They treat anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation.
• They’re best for acute anxiety states, as use beyond 4 months is unevaluated; antidepressants are preferred for long-term mgmt due to non-addictive properties.
• They depress subcortical CNS levels, especially the limbic system and reticular formation.
• All levels of CNS depression can be affected from mild sedation to hypnosis to coma
• They potentiate GABA in the brain, causing calmative effects;
• Benzodiazepines (clonazepam, lorazepam, diazepam, alprazolam), schedule IV controlled substances, are like alcohol, thus used for alcohol withdrawal.
• Buspirone is not a benzodiazepine, doesn't depress the CNS, and affects serotonin, dopamine, and other neurotransmitter receptors.
• It has a lag period of 7-10 days, but may be better for anxiety disorders/substance use disorders due to, it not having the physical dependence potential of other antianxiety agents.
• Benzodiazepines use is risky in older adults due to psychomotor/cognitive impairment increase of anxiety for long term use.

Antianxiety Interactions

• Increased effects can occur if taken with alcohol, barbiturates, narcotics, antipsychotics, antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, or disulfiram.
• Increased effects also occur with herbal depressants (kava, valerian, lemon verbena, I-tryptophan, melatonin, chamomile).
• There are decreased effects with cigarette smoking and caffeine consumption.

Antidepressants

• Some also treat anxiety disorders.
• The first "antidepressant" was isoniazid (an MAOI) which treated tuberculosis.
• Tricyclics were a first-line treatment, but about 70% of people with depression improved with treatment.
• Increasing norepinephrine leads to anticholinergic effects (rapid heart rates and increases potential for postural hypotension; use is limited in the elderly with cardiovascular problems.

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Serotonin is an antianxiety hormone & neurotransmitter; was the latest biochemical believed to improve depression and anxiety w/o significant anti-cholinergic issues.
• SSRIs and SNRIs decrease reuptake of serotonin and norepinephrine; SNRIs include desvenlafaxine, duloxetine, levomilnacipran, and venlafaxine SSRIs and SNRIs are the preferred first-line treatment for depression.

Atypical Antidepressants

• Atypical antidepressants act indifferent ways. FDA-approved ones include:
• Bupropion decreases reuptake of dopamine, and serotonin and norepinephrine),.
• Mirtazapine potentiates norepinephrine & serotonin.
• Nefazodone inhibits serotonin & NE by acting as antagonist at the central 5-HT2 receptor.
• vortioxetine action not under well understood
• Vilazodone; partial agonist at serotonergic 5-HT1A receptors
• Trazodone, unknown but alters Serotonin.

Safety Issues and Nursing Interventions for Antianxiety Agents

• Tolerance and physical dependence may develop; abrupt withdrawal may lead to life-threatening. *Instruct patient not to stop the drug abruptly.
• Assess the patient for signs of developing tolerance (requiring higher doses of medication to achieve effects) or symptoms of withdrawal.
• Educate the patient about symptoms of withdrawal. Contact the doctor immediately if symptoms of withdrawal are assessed.
• The most common side effects are drowsiness, confusion, and lethargy and should be reported.
• *Instruct patient not to drive or operate dangerous machinery while taking this medication. Effects of other CNS depressants are increased.
• The FDA warns against mixing with opioid pain or cough medicines.
• Anti-anxiety agents may aggravate signs of depression and risks for suicide risk.
• Orthostatic hypotension may occur, instruct the patient to rise slowly from sitting to standing to minimize risk for falls. Monitor lying and standing blood pressures to assess for orthostatic hypotension.

Food and Mood in Patients Taking Mood Stabilizers

• A patient-centered, collaborative team approach can explore options in safe management of anxiety and insomnia (lower dose, shorter-acting benzodiazepines; psychological interventions, etc.)
• Assess for sore throat, fever, bruising, or unusual bleeding. Hold medication and report these symptoms immediately to the doctor.
• In 2019 the FDA approved the nasal spray esketamine (Spravato) along with an oral antidepressant for people with treatment-resistant depression.
• Drugs working on melatonin receptors are in clinical trials for depression use.
• High tyramine content foods should be avoided for clients on MAOI therapy and can cause hypertensive crisis.
• Moderate tyramine, and low tyramine content foods should be eaten occasionally/limited quanitities.

Mood-Stabilizing Agents

• Lithium carbonate was a drug of choice for treatment and management of bipolar mania.
• In recent years, others have demonstrated effectiveness alone or in combination with lithium.
• Bipolar disorder is characterized by cycles of depression and manic episodes which effective medication lowers by “ups and downs”, acting as stabilizer.
• Today, the Lithium therapeutic range (0.6 to 1.2 mEq/L) allows for a blood level measure, for safety maintenance (and maintained in check).
• In 1995 the FDA approved valproate (Depakote) acting as a mood stabilizer; for mood stabilizer is unclear.
• First and second generation antipsychotics, have been used alone or as adjuncts to other medication treatment for bipolar mania.
• Those taking Lithium must maintain regular dietary sodium and fluid intake to avoid major fluctuations in lithium levels and their resulting effects.

Antipsychotic Agents

• Also called neuroleptics.
• Historically, they have been referred to major tranquilizers have a major depressive effect, alleviates psychotic issues (hallucinations).
• Since the 1950s with phenothiazines, are called typical/first generation antipsychotics.
• Typical antipsychotics include the phenothiazines, haloperidol, loxapine, pimozide, and thiothixene
• Second generation antipsychotic meds are known to have less EPS (extrapyramidal side effects - side effects, also called extrapyramidal symptoms (EPS), that interfere with normal movements).
• second generation medications that have less are as atypical antipsychotics
• Pimavanserin is for helps hallucinations/ delusions associated with Parkinson's ailment, alleviate (+) parts such as hallucinations/delusions, agitation, better at treating (-) signs.
• Aripiprazole (Abilify), has a little risk for EPS also known as dopamine stabilizer.
• Old folks are at risk from strokes, and all antipsychotic medications and need warnings (since they may get psychotic w/ a Nuero cognitive deficit).
• Ziprasidone, risperidone, paliperidone, asenapine, & iloperidone are can’t do given if there’s a history of cardiac, arrhythmia, etc.
• Some of them such as olanzapine, risperidone, & quetiapine, can cause birth issues(congenital malformations).

Sedative-Hypnotic Agents

• Are for short term used, in anxiety situations or to help insomnia.
• Clinical guidelines typically recommend CBT as the first choice of treatment for insomnia; medications include:
• Benzodiazepines (estazolam, flurazepam, quazepam, temazepam and triazolam)
• Alternative structured medications (eszopiclone, zaleplon and zolpidem) with benzodiazepine-like properties

Attention-Deficit Hyperactivity Disorder Agents

• Attention deficit-hyperactivity disorder (ADHD) agents include CNS stimulants and nonstimulants
• CNS stimulants increase neurotransmitters, and creates CNS/and/or/increase activity/decrease fatigue, increase attn and/ or memory in ADHD patients
• Atomoxetine blocks norepinephrine uptake/ and Bupropion will block it from uptaking serotonin/ norepinephrine/ dopamine or is to help by stimulating Alpha receptors/.
• FDA states “Not Drug”, for ADHD, yet has interactive video and studies (effective improving memory) and is advanced

General Study Points

• Medications are to be taken as adjunctive therapy
• Agents are to be used in the treatment of acute anxiety
• Drowsiness, confusion may occur. It lifts/alleviates with signs
• Meds work by increasing Nor/ and/ or Sero/Dopamine.
• Tricyclics do help by blocking Nor/ at the neurons level.
• Lithium Carbonate will be the mood stabilizer. There must blood test to check for the level.
• The atypical meds all will treat schizophrenia
• Be sure with what you are giving, that is long enough to take effect.
• There can be other symptoms of the mind when being taken
• Look at the safety and implementing it for the next round of care
• Check and confirm for an herb, or anything
• Make sure they take everything you give, to help better