Psychiatric Management Medication & ECT PDF

Medication Therapy and Electroconvulsive Therapy Asst. Prof. Dr. Siriporn Poonruksa, RN Objectives: Students will be able to ⚫ Explain neurological anatomy and its function related to mental illness ⚫ Identify medication treatment for mental health and psychiatri...

Medication Therapy and Electroconvulsive Therapy Asst. Prof. Dr. Siriporn Poonruksa, RN Objectives: Students will be able to ⚫ Explain neurological anatomy and its function related to mental illness ⚫ Identify medication treatment for mental health and psychiatric client ⚫ Identify nursing intervention related to action and side effect of medication and rational drug use ⚫ Describe the action of electroconvulsive therapy (ECT) ⚫ Identify nursing intervention for client with ECT  Topic 2.2 Medication Therapy or Psychopharmacology (DSM-V-TR, 2023) ⚫ Neuroscientists now view behavior, and cognitive functions are as results of complex interactions within the CNS and its ability to adapt and change in both structure and function. Neuroanatomy ⚫ The cerebrum, a largest part of the human brain, can be divided into two halves or hemispheres. ⚫ Each hemisphere of the brain is divided into four lobes; frontal lobes, parietal lobes, temporal lobes, and occipital lobes. www.adamimages.com Frontal lobes ⚫ Control motor speech function, personality, and memory ⚫ Frontal lobes often called as the executive functions that govern one’s ability to plan and initiate action of human. Parietal lobes ⚫ Control the sensory functions Temporal lobes ⚫ Contain the primary auditory and olfactory areas Occipital lobes ⚫ Controls visual integration of information Subcortical structures ⚫ Beneath the cortex, outermost surface of the cerebrum which composes of six layers thick, has many structures. - basal ganglia: involves with motor functions, association in both learning and the programming of behavior or activities that are repetitive, done over time, and become automatic. ⚫ Limbic system: includes hippocampus, thalamus, and hypothalamus - Hippocampus: involves in storing information, especially the emotions attached to a memory - Thalamus: acts as a regulatory structure to relay all sensory information, except smell, thus prevents cortex from becoming overloaded with sensory stimulus  - Hypothalamus: regulates sleep-rest patterns, body temperature, and physical drive such as hunger and sex ⚫ Neurons, the smallest cells of the brain communicate with each others through synaptic transmission. ⚫ The science of psychopharmacology focuses on neurotransmission, the sending of impulses from one neuron to another across the synapse (the region surrounding the point of contact between two neurons) via the aid of specific substances called neurotransmitters. www.adamimages.com www.adamimages.com Neurotransmitters ⚫ There are small molecules that directly and indirectly control the opening or closing of ion channels. ⚫ There excite or inhibit a response at the receptor sites and have been linked to certain mental disorders. Function of Neurotransmitters Neurotransmitters Function Acetylcholine Important role in learning and memory, some roles in wakefulness, and basic attention, peripherally activities muscles and is the major neurochemical in the autonomic system Monoamines -Dopamine* Involved in involuntary motor movement Some roles in mood states, pleasure component in reward systems, and complex behavior such as judgment, reasoning, and insight -Norepinephrine Proposed role in learning and memory, attributing value in reward systems, fluctuates in sleep and wakefulness, major component of the sympathetic nervous system responses including “fight or flight” -Serotonin* Proposed role in the control of appetite, sleep, mood states, hallucinations, pain perception, cognitive effects, sexual function. (And it interacts with many dopamine pathways and has the ability to inhibit dopamine release.) Neurotransmitters Function Amino Acids -Gamma-Aminobutyric Fast inhibitory response post-synaptically, inhibits Acid (GABA) the excitability of the neurons and therefore contributes to seizure, agitation, and anxiety control Neuropeptides -Endogeneous opioids Suppresses pain, modulates mood and stress (i.e., endorphins) Likely involvement in reward systems and addiction -Melatonin Secreted in dark and suppressed in light, helps regulate the sleep-wake cycle as well as other biologic rhythm From McCabe and Boyd. (2008). The biological foundations of psychiatric nursing. www.imagine.com ⚫ Six groups of medication for mental health and psychiatric clients. 1. Antipsychotic medication 2. Antidepressant medication 3. Mood stabilizers 4. Anti-anxiety medications 5. Stimulants 6. Anti-cholinergic or anti-parkinsonism medications  Antipsychotic medications (Major tranquilizers) ⚫ The old term is Neuroleptic medication but in placed with antipsychotic medication in DSM-V. ⚫ There are two types of antipsychotic medication) (Typical and Atypical groups). 1. Conventional or typical antipsychotic: block D2 receptors in the limbic region of the brain (It has been found that the increasing of dopamine causes strange thought, bizarre behavior, and hallucination.)  2. Atypical antipsychotic: block serotonin postsynaptic receptors and other varieties of dopamine receptors (e.g., D1 and D5) -It has less side effect than typical antipsychotic but more expensive, normally is prescribed for psychiatric patients in the special wards. Antipsychotic medications use to treat most forms of psychosis. ⚫ Schizophrenia, Schizoaffective disorder, Delusional disorder, Mood disorder with psychosis, and Psychosis associated delirium and dementia ⚫ Symptoms of these disorders may include impaired communication or inability to related to others, delusion, behavior problems, and personality disorders ⚫ Small doses may be used to treat anxiety, tension, agitation, dizziness, intractable hiccups, nausea and vomiting, and control pain when combined with other drugs.  Antipsychotics: Names and usual range of daily doses for adults Generic name Trade name mg/day Chlorpromazine (CPZ) Thorazine, Largactil, Chlozapine 200-1,000 Thioridazine Melleril 25-600 Thiothixine Navane 10-30 Trifluoperazine Stelazine 6-40 Fluphenazine Prolixin, Fendec 5-40 Haloperidol Haldol 2-40 Molindone Moban 10-100 Loxapine Loxitane 10-100 Perphenazine Trilafon, Pernazine 8-32 Pimozide Orap 4-10 Clozapine* Clozaril, Clopaze*(Agranulocytosis) 200-900 Risperidone* Risperdal* 4-8 Olanzapine* Zyprexa* (Weight gain) 5-20 Quetiapine* Seroquel* 150-800 Ziprasidone* Geodon* 80-160 Aripiprazole* Abilify* 10-30 Paliperidone* Invega* 3-12 *Atypical antipsychotic  Contraindication (Cannot use in these cases) ⚫ Drug hypersensitivity, Severe depression, Bone marrow depression, Blood dyscrasias, Brain damage, Impaired liver function, Cardiovascular disease (take with other drugs may cause prolongation of Q-T interval), Hypertension, Glaucoma, DM, Parkinson’s disease, Peptic ulcer, Seizure, and Pregnancy (need for close observation by psychiatrist and pharmacist) Side effect ⚫ Neurological side effect: drowsiness, extrapyramidal side effect (EPS)** ⚫ EPS causes by taking high-potency conventional (typical) antipsychotic medications. ⚫ Five EPS symptoms include* (see attached document) -Parkinsonism -Akathisia -Acute dystonia -Tardive dyskinesia -Neuroleptic Malignant Syndrome (NMS) ⚫ Effect on alpha adrenergic blocker: general orthostatic hypotension* (BP drop while changing position rapidly that may occur 1-2 weeks after taking medication.) ⚫ Effect on anticholinergic agent (block the action of acetylcholine neurotransmitter that inhibits the parasympathetic system), clients have dry mouth, mild salivation, blurred vision, nasal congestion, constipation, abdominal distention, urinary retention, and denture caries ⚫ Weight gain , cardiotoxicity, jaundice, hepatological effects (agranulocytosis), Ophthalmological effects* (thioridazine > 800 mg/day disturbs pigmentation of the eyes and cause photosensitivity, phototoxicity), so, wearing long-sleeved shirt and pants, apply sunblock, and umbrella are needed when going outdoor. Dermatological effect, epilepsy, and retrograded ejaculation of sperm Antidepressant medication ⚫ It is used to treat depressive disorders caused by emotional or environmental stressors, losses, drugs (steroids), disease states such as cerebral vascular accident, or depression that cannot be related to an identifiable cause. ⚫ There are four groups of antidepressant medication; SSRls, TCAs, Atypical antidepressant, and MAOls Selective Serotonin Reuptake Inhibitors (SSRIs) ⚫ It inhibits the 5-hydroxytrptamine (5-HT) system uptake of indoleamine (serotonin). ⚫ Abnormalities in 5-HT function can result in mood disturbances, anxiety, altered cognition, aggressive behavior, or altered sexual drive. SSRIs: Names and usual range of daily dose for adults Generic name Trade name mg/day Citalopram Celexa 10-60 Escitalopram oxalate Lexapro 10-20 Fluoxetine Prozac, Fulox* 10-80 Fluvoxamine* Luvox 50-300 Paroxetine Paxil 10-60 Sertraline* Zoloft 25-200 -do not prescribe with anticoagulant and need to monitor prothrombin time closely -avoid the use of diazepam, alcohol, and tryptophan -avoid operating hazardous machinery, including automobile, if drowsiness occurs -avoid taking grapefruit juice with fluvoxamine* and sertraline* -*check v/s if client receive drug overdose or has hypersensitivity because it may have respiratory depression (Wrycraft, 2012). ⚫ Side effect: - nausea, diarrhea, constipation, tremor, insomnia, somnolence (sleepy), dry mouth, headache, nervousness, anorexia, weight loss, sweating, and sexual dysfunction Tricyclic antidepressants (TCAs) ⚫ Increase the level of a neurotransmitter either serotonin or norepinephrine, in the space between nerve ending ⚫ A deficiency of either of these transmitters is thought to cause depression. TCAs: Names and usual range of daily doses for adults Generic name Trade name mg/day Amitriptyline Amitril, Elavil, Endep 50-300 Desipramine Norpramin, Protofrane 75-300 Dexepin Sinequan, Adapin 75-300 Imipramine Tofranil 75-300 Nortriptyline Aventyl, Psmelor 50-150 Potriptyline Vivactil 15-60 Trimipramine Surmontil 75-300 Contraindication: -pregnant or breast-feeding -myocardial infraction -severe liver or kidney diseases ⚫ Side effect -dry mouth, blurred vision, tachycardia, urinary retention, and constipation - agranulocytosis, jaundice, increased seizure in client with epilepsy, prolongation of atrioventricular conduction Atypical antidepressants ⚫ They are considered to be alternatives or second-line therapy when clients do not respond to the use of SSRIs or TCAs.  Atypical antidepressants: Names and usual range of daily doses for adults Generic name Trade name mg/day Bupropion Wellbutrin 200-450 Maprotiline Ludiomil 25-225 Mirtazapine Remeron 15-45 Reboxetine Edronex, Vastro 4-12 Trazodone Desyrel 25-600 Venlafaxine Effexoe 75-375 ⚫ Contraindication: -cardiac or neuroleptic disorders -uncontrolled hypertension -seizure, lactation -abnormal liver function test ⚫ Side effect: -drowsiness, dizziness, dry mount, GI upset -weight gain, sexual dysfunction Monoamine Oxide (Oxidase) Inhibitors (MAOIs) ⚫ Inhibit MAO enzyme, so the serotonin is increased. ⚫ Normally prescribed for client with treatment resistant depression.  MAOIs: Names and usual range of daily doses for adults Generic name Trade name mg/day Isocarboxazid Marplan 10-70 Phenelzine Nardil 15-90 Tranylcypromine Pranate 20-60 Contraindication: -asthma, cerebral vascular disease, congestive heart failure, hypertension, hypernatremia, impaired kidney function, cardiac arrhythmias, hyperthyroidism, liver disease, severe headache, alcoholism, glaucoma, and pregnancy ⚫ Side effect: -abnormal heart rate, orthostatic hypotension, drowsiness, headache, blurred vision, vertigo, constipation, weakness, dry mouth, and loss of appetite Mood stabilizers or Anti-manic agents ⚫ Prevent or diminish the frequency and intensity of manic behavior, mood swings, aggressive behavior, and dyscontrol syndrome ⚫ Drug of choice is Lithium which balances serotonergic neurotransmission, preventing a decreased activity of nerve impulses that causes depression and preventing an increased activity of nerve impulses that causes mania. ⚫ The lithium ion, similar to sodium ion, is thought to maintain a constant sodium concentration in the brain. ⚫ Since lithium behaves as a salt in the body, sodium intake by the client must remain relatively stable during treatment; otherwise, lithium levels will be altered and toxicity can occur. ⚫ Treatment dosage = 900-1,200 mg/day ⚫ Normal lithium level = 0.8-1.2 mEq/L (Thai client) ⚫ Blood lithium should be collected 12 hours after last time of this medication administration. ⚫ Contraindication: -pregnancy (cause cardiovascular anomaly in fetus) -severely impaired kidney function -heart disease ⚫ Side effect: -nausea, metallic taste, abdominal discomfort, polydipsia (drink a lot of water) *, polyuria, muscle weakness, hand tremors, fatigue, mild diarrhea, edema of the feet, hands, abdominal wall, and face, and lithium toxicity Lithium Toxicity ⚫ Lithium toxicity occurs when serum lithium levels exceed 1.5-2.0 mEq/L (1.0 for Thai client). ⚫ If > 1.5 mEq/L, client will have vomiting, diarrhea, stagger, slurred speech, and hand tremor. ⚫ If > 2.0-2.5 mEq/L, client will have blurred vision, reflex↑, and muscle spasms. ⚫ If > 2.5 mEq/L, client will have renal failure and death. ⚫ Nurse has to “STOP or Withhold” Lithium suddenly.***  **Psychosis Intermittent Hyponatremia and Polydipsia (PIP) ⚫ It happens because client taking lithium and Drink a lot of water (polydipsia) and cause hyponatremia and water intoxication symptoms including: -restlessness -polyuria -diarrhea -salivation -nausea & vomiting -muscle tremor & twitching -ataxia (abnormal gait/walk) -tonic-clonic convulsion -coma and death  Treatment (normal Na = 135-145 mmol/l) Level of Na Weight gain Rx (mmol/L) 134-140 0-3% No treatment 130-133 3-5% Seclusion 1 day, limit fluid intake < 3 L/day 126-129 5-7% NaCl oral 4.5 mg/day, seclusion, limit fluid intake < 3 L/day 120-125 7-10% NaCl oral 4.5 mg/day and repeat after 2 hrs, seclusion, limit fluid intake, record body weight every 2 hrs, repeat Na lab OD (morning) 115-120 > 10% NaCl oral 4.5 mg/day and repeat after 2 & 4 hrs, record body weight every 1 hr until Na = 125, seclusion, close observation from 1 staff and limit fluid intake < 115 Isolate client and take care him as critical case, give 3-5% NaCl drip or Lasix through intravenous slowly if generalized seizure present, limit fluid intake, control Na not > Antianxiety medications and hypnotics (minor tranquilizers) ⚫ Relieve moderate to severe anxiety and tension associated with emotional disorders, physical disorders, excessive environmental stress, neurosis, and mild depression status without excessive sedative or drowsiness ⚫ Two groups of antianxiety medications: -Benzodiazepine group -Nonbenzodiazepine group Benzodiazepine group ⚫ It works selectively on the limbic system of the brain, which is responsible to emotions such as rage (anger) and anxiety. ⚫ Commonly used benzodiazepines include chlordiazepoxide (librium), clonazepam (klonopin), diazepam (valium), oxazepam (serax), clorazepate (tranxene), lorazepam (ativan), praxepam (centrex), alprazolam (xenax), and triazolam (halcion) Nonbenzodiazepine group ⚫ Meprobamate (Equanil), it causes CNS depression. ⚫ Buspirone (BuSpar), blocks the release of serotonin and prevents the uptake of dopamine. ⚫ Contraindication: glucoma, severe renal/hepatic impairment, blood dyscrasias, pregnancy or lactation, acute post-myocardial infraction ⚫ Side effect: -drowsiness -tolerance -withdrawal symptom (nausea, vomiting, hypotension, fatigue, sleep disturbance, fever, delirium, potential fatal grandmal seizure within 12 hours to 2 weeks) -confusion -anterograded amnesia (Short term memory impairment) -abnormal behaviors: -dysinhibition syndrome, paradoxical excitement Stimulants ⚫ It acts as mood elevators that used in treatment resistant depression ⚫ Stimulants cause a release of norepinephine and dopamine into the system from the presynaptic nerve cell and block their reuptake. This action stimulates the sympathetic nervous system, resulting in alertness, wakefulness, vasoconstriction, suppressed appetite, and hypothermia. Stimulants: Names and usual range of daily doses for adults Generic name Trade name mg/day Dexmethylphenidate HCL Focalin 2.5-20 Dextroamphetamine Dexedrine 5-60 Dextroamphetamine and amphetamine Adderall 2.5-40 Metylphenidate Ritalin 10-60 Metylphenidate HCL Concerta 18-54 Metylphenidate HCL, USP Metadate CD 20-60 Modafnil Provigil 100-200 ⚫ Contraindication: (during or within 14 days of the administration of MAOIs) -glaucoma -advanced arteriosclerosis -cardiovascular diseases -moderate to severe hypertension -hyperthyroidism ⚫ Side effect: -appetite suppression -sleep disturbance (drowsiness or insomnia) -GI disturbance -increase in pulse and blood pressure -arrhythmias Anticholinergic or antiparkinsonism medications** ⚫ They have been used to treat medication-induced movement disorders (EPS). ⚫ Anticholinergic agents block the action of acetylcholine receptor in the brain and peripheral nervous system in an attempt to correct an imbalance between a deficiency of dopamine and an abundance of acetylcholine resulting in decreasing of salivation, spasticity, and tremors such as Benztropine* (Cogentine, Benzhexal, Aca), Trihexyphenidyl (Artane), and Biperiden (Akineton). ⚫ Antihistamine agents act by competitively antagonizing histamine at the H1 histamine receptor and function as hypnotics and anxiolytics such as diphenhydramine (benedryl) and orphenadrine (norflex). ⚫ Dopaminergic agonists increase the release of dopamine, therapy by helping to relieve symptom such as amantadine (symmetrell) and levodopa (larodopa). ⚫ Contraindication: -hypersensitivity reaction, prostatic hypertrophy, glaucoma, obstruction of GI tract or urinary tract ⚫ Side effect: -dry mouth, blurred vision, dizziness, drowsiness, constipation, tachycardia, and urinary retention  Topic 2.3 Electroconvulsive therapy (ECT) ⚫ Introduced in 1937 by two Italian physicians (Cerletti and Bini) ⚫ It’s the treatment that uses electric current to induce convulsive seizures in neurons in the entire brain to alleviate (improve) symptom such as major depression, acute manic episodes, or schizophrenia (Shives, 2008). Mechanism of ECT ⚫ Neurotransmitter theory ECT corrects the biochemical abnormalities of peptide and neurotransmitters such as serotonin and dopamine produce effect similar to that of tricyclic-antidepressants or selective serotonin reuptake inhibitors. ⚫ Neuroendocrine theory A release of hormones by the hypothalamus or pituitary produce antidepressant effects. ⚫ Anticonvulsant theory ECT produces convulsion that minimizes or eliminates symptoms. ⚫ Frontal lobe theory ECT minimizes or eliminates symptoms of mood or behavioral disorders that originate in the frontal lobe. Indications ⚫ Client with depression ⚫ Schizophrenia ⚫ Obsessive compulsive disorder ⚫ Manic episode of bipolar disorder ⚫ Use as combine treatment with psychotropic drugs Two types of ECT ⚫ Unmodified ECT ⚫ Modified ECT (under anesthesia) ECT preparation ⚫ Client’s education about the process is given to clients and their significant others. -The videotape may be shown during the discussion. -The nurse emphasizes that the client will be asleep during the procedure and, although low voltage current is passed to the brain, the client will not be harmed or feel any pain. ⚫ Informed consent is needed. If a client has been deemed legally incapacitated to give an informed consent, the consent may be obtained by a court-appointed guardian and a designed health care surrogate. ⚫ Physical assessment including -Anterior and posterior of the spine and dental examination for elderly -EKG (client age > 45 years, Nitroderm 5 mg patches on the chest is needed.) -EEG -Chest x-ray -Vital signs ⚫ NPO/empty bladder ⚫ Removal of prostheses (dentures, contact lens, metal hair accessories, and etc.) ⚫ Apply electrocardiogram electrodes ⚫ Insert IV line ⚫ A sedative may be given to decrease anxiety. ⚫ An atropine-like drug, Roninul, is given to dry up body secretion and prevent aspiration. ⚫ The client is given a quick-acting anesthetic, such as Methohexital (Brevital), after being placed on a padded mat or table. ⚫ Medication such as Anectine (Succinylcholine) is given to produce muscle paralysis or relaxation and prevent severe muscle contractions that may observe from the “fasciculation” and Babinski’s sign. ⚫ O2 is administered by Ambu bag. ⚫ A plastic airway or bite block is usually in place to prevent airway obstruction or biting of tongue. ⚫ EEG electrodes are applied to deliver electric shock at bitemporal or unilateral area. http://psiquiatruras.blogspot.com http://psiquiatruras.blogspot.com http://psiquiatruras.blogspot.com http://psiquiatruras.blogspot.com ⚫ The limbs have to be restrained gently to prevent fractures during a severe clonic seizure. Usually the seizure is barely noticeable; slight toe twitching, finger twitching, or goose bumps may occur. ⚫ The client awakens approximately 20-30 minutes after treatment and appears groggy and confused. ⚫ Vital signs are taken during the recovery stage as well as O2 saturation. The nurse stays with the client until the client is oriented and able to care for himself/herself. ⚫ https://www.youtube.com/watch?v=9L2-B- aluCE Complication ⚫ Physical change-hypertension, bradycardia ⚫ Amnesia ⚫ Apnea ⚫ Fracture and dislocation of joint ⚫ Backache Reference Boyd, M. (2008). Psychiatric nursing: Contemporary practice (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Fortinash, P. G., Kennedy, W. Z., and Ballard, K. A. (2008). Psychiatric mental health nursing: An introduction to theory and practice. Massachusetts: Jones and Barlett Publishers. Shives, L. R. (2008). Psychiatric-mental health nursing (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Varcarolis, E. M. & Halter, J. (2014). Foundations of psychiatric mental health nursing: A clinical approach (7th ed.). Philadelphia: W.B. Saunders Company. Videbeck, S.,L. (2014). Psychiatric-mental health nursing (6th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. Wheeler, K. (2014). Psychotherapy for the advanced practice nurse: How to guide for evidence-based practice. USA: Springer. Wrycraft, N. (2012). Mental health nursing: case book. Maidenhead : McGraw Hill / Open University Press. http:/www.adamimages.com http://www.imagine.com http://www.manarom.com http://www.psiquiatruras.blogspot.com