Chapter 6 - Psycho Meds PDF

## 6.1 Introduction Notes - **Learning Objectives** - Relate the anatomy and physiology of the central nervous system (CNS) to mental health disorders and psychotropic medications. - Describe patient education for classes of psychotropic medications. - **Overview** - Psychotropic medications...

## 6.1 Introduction Notes - **Learning Objectives** - Relate the anatomy and physiology of the central nervous system (CNS) to mental health disorders and psychotropic medications. - Describe patient education for classes of psychotropic medications. - **Overview** - Psychotropic medications affect the mind, emotions, and behavior. - The chapter reviews: - The anatomy and physiology of the CNS in relation to mental health disorders and medications - Several classes of psychotropic medications. - **Important Considerations** - **Medication Information Updates** - Medication information frequently changes. - Nurses must consult evidence-based resources for up-to-date drug information, warnings, and patient education guidelines. - **Reliable Medication Resources** - **DailyMed** - Provided by the National Library of Medicine (NLM) - Contains current information from the Food and Drug Administration (FDA) about prescription and over-the-counter medications. - Includes essential details for health professionals, such as: - Indications - Dosage and administration - Contraindications - Boxed warnings and precautions - Adverse reactions - Drug interactions - Use in specific populations - **MedlinePlus** - An online health information resource for clients and their loved ones. - Provides easy-to-understand medication information. ## 6.2 Review of the Central Nervous System Notes - **Understanding the CNS** - Knowledge of CNS anatomy and physiology is essential to understanding psychotropic medications. - The nervous system is divided into: - **Central Nervous System (CNS)**: Includes the brain and spinal cord. - **Peripheral Nervous System (PNS)**: Includes all other parts of the nervous system. - **Components of the Peripheral Nervous System** - **Sensory Neurons** - Sense the environment and conduct signals to the brain. - Signals become conscious perceptions of the stimuli. - **Motor Neurons** - Conduct responses from the brain to the peripheral nervous system. - Two types of motor neuron systems: - **Somatic Nervous System**: Controls voluntary muscle movements. - **Autonomic Nervous System**: Controls involuntary functions ## Sympathetic and Parasympathetic Nervous System Notes - **Autonomic Nervous System (ANS)** - Divided into: - **Sympathetic Nervous System (SNS)** - **Parasympathetic Nervous System (PNS)** - **Homeostatic Regulation** - Body maintains balance through SNS and PNS stimulation. - **Effects of SNS Stimulation** - Increases heart rate. - Increases blood pressure via vasoconstriction. - Causes bronchodilation. - Associated with the "fight-or-flight" response. - **Effects of PNS Stimulation** - Slows heart rate. - Lowers blood pressure via vasodilation. - Causes bronchoconstriction. - Associated with the "rest-and-digest" system. ## SNS and PNS Receptor Notes - **SNS Receptors** - **Types of SNS Receptors** - Alpha-1, Alpha-2, Beta-1, Beta-2 receptors. - **Stimulated by** - Epinephrine and norepinephrine. - **Adrenergic Agonists** - Mimic the effects of natural SNS stimulation. - **Example:** - Methylphenidate: Treats ADHD. - **Adrenergic Antagonists** - Block SNS receptors - **Example:** - Propranolol: Beta-2 antagonist for severe anxiety (e.g., trembling, rapid heartbeat, sweating). - **PNS Receptors** - **Types of PNS Receptors:** - Nicotinic and Muscarinic receptors. - **Stimulated by:** - Acetylcholine (ACh). - **Cholinergics** - Stimulate nicotinic and muscarinic receptors. - **Examples:** - Nicotine: Stimulates nicotinic receptors. - Bethanechol: Muscarinic agonist used for urinary retention (increases bladder emptying). - **Anticholinergics** - Block the effects of PNS receptors. - **Example:** - Benztropine: Treats muscle spasms caused by extrapyramidal symptoms from antipsychotics. - **Anticholinergic Adverse Effects (SLUDGE Mnemonic)**: - **S**: Salivation decreased. - **L**: Lacrimation decreased. - **U**: Urinary retention. - **D**: Drowsiness/dizziness. - **G**: GI upset. - **E**: Eyes (blurred vision/dry eyes). ## Opioid System and Neurotransmitters - **Opioid System** - **Functions:** - Controls pain, reward, and addictive behaviors. - **Types of Opioid Receptors:** - Mu, Delta, and Kappa receptors. - **Stimulated by** - **Endogenous peptides** (e.g., endorphins). - **Exogenous opiates** (e.g., prescribed or illicit drugs). - **Examples of Opiates:** - **Prescribed:** Morphine, oxycodone (treat moderate to severe pain). - **Illicit:** Heroin. - **Addiction Potential:** - Chronic use of both prescribed and illicit opiates can be highly addictive. - Addiction linked to actions on the brain's reward system. ## Neurotransmitters Associated with Mental Health and Psychotropic Medications - **Acetylcholine** - Stimulates nicotinic and muscarinic receptors in the parasympathetic nervous system. - Substances that bind to these receptors: - Nicotine (tobacco) binds to nicotinic receptors. - Muscarine (hallucinogenic mushrooms) binds to muscarinic receptors. - **Glutamate** - Excitatory neurotransmitter. - Elevated levels linked to psychosis (schizophrenia, methamphetamine use). - Lamotrigine inhibits glutamate and treats bipolar disorder. - **Gamma-Aminobutyric Acid (GABA) and Glycine** - Inhibitory neurotransmitters that slow down overexcited nerve cells. - Low levels of GABA associated with: - Seizures, anxiety, mania, and impulse control. - Pregabalin mimics GABA's effects and is used for generalized anxiety disorder. - **Dopamine** - Plays an essential role in: - Learning, motor control, reward, emotion, and executive functions. - Abnormal levels linked to several mental health disorders. - Bupropion (antidepressant) inhibits dopamine reuptake to increase dopamine levels. - Chlorpromazine blocks dopamine receptors (used for psychosis but can cause extrapyramidal side effects). - **Serotonin** - Modulates mood, sleep, libido, and temperature regulation. - Abnormal levels linked to: - Depression, bipolar disorder, and anxiety. - Fluoxetine (SSRI antidepressant) prevents serotonin reuptake, helping relieve depression. - **Norepinephrine and Epinephrine** - Stimulate alpha- and beta-receptors in the sympathetic nervous system. - Affects stress, sleep, attention, and focus. - Venlafaxine (NRI antidepressant) prevents norepinephrine reuptake, boosting levels for depression treatment. - **Histamine** - Mediates homeostatic functions: - Promotes wakefulness, modulates feeding behavior, controls motivational behavior. - Diphenhydramine (histamine antagonist) ## 6.3 Antidepressants - **Overview of Antidepressants** - **Primary Use:** - Treat depression, but also used for conditions like: - Anxiety, chronic pain, and insomnia. - **Effectiveness:** - Generally, work well for improving depression symptoms and preventing relapse. - **Response Variability:** - Some individuals respond better to certain antidepressants - It may take 2 or more weeks to reach peak effectiveness. - **Types of Antidepressants** - SSRIs, SNRIs, NDRIs, serotonin antagonist and reuptake inhibitors, TCAS, MAOIs. - First-generation antidepressants (TCAS, MAOIs) have more side effects and are less commonly prescribed than newer antidepressants. - **Classes Of Antidepressants** - **1. Selective Serotonin Reuptake Inhibitors (SSRIs)** - **Action:** - Prevent the reuptake of serotonin at the synapse. - Increases serotonin levels in the brain. - **Primary Use:** - Treat depression and other disorders such as: - Bipolar disorder, obsessive-compulsive disorder (OCD), bulimia, panic disorder, PTSD, anxiety, premenstrual syndrome, and migraines. - **Examples:** - Fluoxetine, citalopram, sertraline, paroxetine, escitalopram. - **2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)** - **Action:** - Inhibit the reuptake of serotonin and norepinephrine. - Weak inhibition of dopamine reuptake. - **Examples:** - Venlafaxine, duloxetine. - **3. Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs)** - **Action:** - Inhibit the reuptake of norepinephrine and dopamine. - **Examples:** - Bupropion: Treats depression, seasonal affective disorder, attention deficit disorder (ADD), and helps people quit smoking. - **4. Serotonin Antagonist and Reuptake Inhibitor** - **Action** - Reduces neurotransmitters associated with arousal effects, including serotonin, norepinephrine, dopamine, acetylcholine, and histamine. - **Primary Use** - Antidepressant, but commonly prescribed off-label for anxiety or as a hypnotic. - **Exerts sedative effects (low-dose use typically administered in the evening)** ## Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs) -**Tricyclic Antidepressants (TCAs)** - **Overview** - Older first-generation antidepressants. - Block the reuptake of serotonin and norepinephrine in the synapse, leading to increased levels of these neurotransmitters in the brain. - Commonly used to treat neuropathic pain and insomnia. - **Example:** - Amitriptyline. - **Side Effects:** - Anticholinergic side effects (especially in older adults): - Tachycardia, urinary retention, constipation, dry mouth, blurred vision, confusion, psychomotor slowing, sedation, and delirium. - Cardiac conduction disturbances and hypotension due to adrenergic receptor blockage. - Elderly clients are more sensitive to these side effects and should start with low doses and be closely monitored due to the increased risk for falls. - **Overdose Risks:** - Overdose can be fatal due to cardiac effects and toxicity. - Common in deliberate ingestion with multiple drugs, including alcohol. - **Emergency Response:** - Call 911 or rapid response for inpatient settings. - Consult Certified Poison Control Center (1-800-222-1222) or visit https://www.poisonhelp.org/help for treatment guidance. - **Monoamine Oxidase Inhibitors (MAOIs)** - **Overview:** - Older first-generation antidepressants. - Inhibit the enzyme monoamine oxidase that breaks down norepinephrine, serotonin, and dopamine in the brain, leading to increased levels of these neurotransmitters. - **Example:** - Tranylcypromine. - **Contraindications:** - MAOIs are contraindicated with all other classes of antidepressants due to the risk of dangerous drug interactions. - **Significant Disadvantages:** - MAOIs is their potential to cause a hypertensive crisis when taken with stimulant medications or foods or beverages containing tyramine. - Examples of foods containing tyramine: aged cheese, cured or smoked meats, alcoholic beverages, and soy sauce. - Older adults are at increased risk for postural hypotension and serious adverse effects. ## 6.4 Mood Stabilizers - Mood stabilizers are primarily used to treat bipolar disorder but are also utilized in the treatment of depression (usually in combination with an antidepressant), schizoaffective disorder, and disorders of impulse control. - Lithium is one of the most well-known mood stabilizers, and anticonvulsant medications are also used for this purpose. - In addition, antipsychotics, antianxiety medications, and antidepressants may also be prescribed to help manage symptoms of bipolar disorder. - **Lithium** - **Mechanism of Action:** - Reduces excitatory neurotransmission (dopamine and glutamate). - Increases inhibitory neurotransmission (GABA). - Alters sodium transport in nerve and muscle cells. - Causes a shift in metabolism of catecholamines. - **Therapeutic Use:** - When administered to a client experiencing a manic episode, lithium may reduce symptoms within 1 to 3 weeks. - Lithium has unique antisuicidal properties, which set it apart from other medications like antidepressants. - **Toxicity and Monitoring:** - Lithium toxicity can occur at doses close to 0.8 to 1.2 mEq/L. Levels above this range cause lithium toxicity. ## 6.5 Antianxiety Medications - Antianxiety medications help reduce symptoms of anxiety, panic attacks, or extreme fear and worry. - The most common class of antianxiety medications is benzodiazepines. - While SSRIs or other antidepressants are typically used to treat panic disorder or social phobia (i.e., social anxiety disorder), beta-blockers and buspirone may also be prescribed for anxiety management. - **Benzodiazepines** - **Mechanism of Action:** - Benzodiazepines bind to GABA receptors and stimulate the effects of GABA, an inhibitory neurotransmitter, leading to a calming effect on the brain and nervous system. - **Uses:** - Primarily prescribed for generalized anxiety disorder. - Also used for sedation and anticonvulsant effects. - Commonly prescribed for short-term anxiety symptoms or acute anxiety episodes. - **Common Medications:** - Clonazepam, Alprazolam, Lorazepam. - **Controlled Substance:** - Benzodiazepines are classified as Schedule IV controlled substances due to their potential for misuse and the risk of dependence. - **Short-Acting Benzodiazepines:** - Medications like Lorazepam are used for short-term anxiety management and can be administered orally, intramuscularly, or intravenously. - **Beta-Blockers** - **Mechanism of Action:** - Beta-blockers like propranolol block the Beta-1 receptors in the sympathetic nervous system, reducing the physical effects of anxiety (e.g., trembling, rapid heartbeat, and sweating). - **Uses:** - Often prescribed to manage the physical symptoms of anxiety for a short period or to be used on an "as-needed" basis to alleviate acute symptoms. ## 6.6 Antipsychotics - Antipsychotic medications are primarily used to manage psychosis, a condition characterized by a loss of contact with reality, which may include delusions or hallucinations. - Psychosis can result from physical conditions (e.g., fever, head injury, or substance intoxication) or mental disorders (e.g., schizophrenia, bipolar disorder, or severe depression). - Antipsychotics may also be used in combination with other medications to treat conditions such as attention deficit hyperactivity disorder (ADHD), eating disorders, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, and conduct disorder. - Antipsychotic medications are classified into two main categories: - **1. First-Generation (Typical) Antipsychotics** - **2. Second-Generation (Atypical) Antipsychotics** - **First-Generation (Typical) Antipsychotics** - **Common Medications:** - Chlorpromazine, haloperidol, perphenazine, fluphenazine. - **Mechanism of Action:** - First-generation antipsychotics block dopamine receptors in certain areas of the CNS, such as the limbic system and basal ganglia, which are involved in emotions, cognitive function, and motor function. - This leads to a tranquilizing effect in psychotic patients. - **Adverse Effects:** - These medications may cause extrapyramidal side effects (e.g., involuntary movements, tremors, muscle contractions). - Tardive dyskinesia, a syndrome of persistent movement disorders, can develop, sometimes lasting for years despite discontinuation of the medication. - **Second-Generation (Atypical) Antipsychotics** - **Common Medications:** - Risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, lurasidone. - **Mechanism of Action:** - These medications block specific D2 dopamine receptors and serotonin receptors. - Atypical antipsychotics have a broader spectrum of action and are used for bipolar depression or depression not responsive to antidepressants alone. - **Benefits:** - They have a significantly reduced risk of extrapyramidal side effects. - **Adverse Effects:** - Weight gain and the development of metabolic syndrome are common. - Metabolic syndrome includes symptoms like high blood glucose, increased thirst and urination, fatigue, blurred vision, obesity (especially abdominal), hypertension, elevated triglycerides, and lower HDL. - Metabolic syndrome increases the risk of heart disease, stroke, and type 2 diabetes. - **Clozapine** - **Indication:** - Clozapine is prescribed for clients with treatment-resistant schizophrenia. - **Mechanism of Action:** - It binds to both serotonin and dopamine receptors. - **Adverse Effects:** - It has strong anticholinergic, sedative, cardiac, and hypotensive properties. - Clozapine also has a higher potential for drug-drug interactions. ## 6.7 Stimulants - Stimulant medications are primarily prescribed to treat attention deficit hyperactivity disorder (ADHD) in children, adolescents, and adults. - Despite being stimulants, these medications have a paradoxical calming effect in individuals with ADHD. This effect helps improve focus and concentration by blocking the reuptake of norepinephrine and dopamine in the synapse, thus increasing their levels in the brain. - **Common Stimulant Medications Used for ADHD:** - Methylphenidate - Amphetamine - Dextroamphetamine - Lisdexamfetamine dimesylate - **Safety and Concerns:** - Stimulants are generally safe when prescribed with close supervision. - They are classified as Schedule II controlled substances due to their high potential for misuse and dependence. ## 6.8 Psychoactive Substances and Medications to Treat Substance Use and Withdrawal - The effects of various psychoactive substances such as alcohol, cannabis, and illicit drugs are discussed in the "Substances: Use, Intoxication, and Overdose" section of the Substance Use Disorders chapter. - **Medications to Treat Alcohol Use Disorder and Opioid Use Disorder:** - Buprenorphine-naloxone - Methadone - Naltrexone - Acamprosate - Disulfiram. - **Medications Used for Substance Withdrawal/Detoxification:** - Buprenorphine - Methadone ## Glossary - **Acetylcholine:** A neurotransmitter that stimulates nicotinic and muscarinic receptors in the parasympathetic nervous system. - **Adrenergic agonists:** Substances that stimulate SNS receptors and cause effects similar to epinephrine and norepinephrine. - **Adrenergic antagonists:** Substances that block SNS receptors. - **Agranulocytosis:** Extremely low white blood cell count and an adverse effect of clozapine and antipsychotic medication. - **Anticholinergics:** Substances that block the effects of PNS receptors. - **Black Box Warning:** A significant warning from the Food and Drug Administration (FDA) that alerts the public and health care providers to serious side effects, such as injury or death. - **Catecholamines:** Substances that include epinephrine, norepinephrine, and dopamine and are responsible for the body's "fight-or-flight" response. - **Central nervous system (CNS):** The brain and spinal cord. - **Cholinergics:** Substances that stimulate nicotinic and muscarinic receptors and cause effects similar to acetylcholine (ACh). - **Controlled substance:** Drugs regulated by federal law that can cause dependence and abuse. - **Dopamine:** A neurotransmitter that plays an essential role in several brain functions, including learning, motor control, reward, emotion, and executive functions. - **Extrapyramidal side effects:** Involuntary or uncontrollable movements, tremors, and muscle contractions that can occur with antipsychotic medications. - **Gamma-aminobutyric acid and Glycine:** Inhibitory neurotransmitters that act like brakes in a car by slowing down overexcited nerve cells. Low levels of GABA are associated with seizures, anxiety, mania, and impulse control. Pregabalin is an anticonvulsant that mimics the effects of GABA and is used to treat generalized anxiety disorder. - **Glutamate:** An excitatory neurotransmitter. Elevated levels of glutamate are associated with psychosis that can occur with schizophrenia, as well as with illicit drug use such as methamphetamines. Conversely, lamotrigine, a medication used to treat bipolar disorder, inhibits glutamate. - **Histamine:** A substance that mediates homeostatic functions in the body, promotes wakefulness, modulates feeding behavior, and controls motivational behavior. For example, diphenhydramine, a histamine antagonist, causes drowsiness. - **Hypertensive crisis:** A condition that can be caused by MAOIs with severe hypertension (blood pressure greater than 180/120 mm Hg) and evidence of organ dysfunction. Symptoms may include occipital headache (which may radiate frontally), palpitations, neck stiffness or soreness, nausea or vomiting, sweating, dilated pupils, photophobia, shortness of breath, or confusion. - **Lithium toxicity:** Lithium has a narrow therapeutic range of 0.8 to 1.2 mEq/L. Levels above this range cause lithium toxicity. Signs of early lithium toxicity include diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination. At higher levels, giddiness, ataxia, blurred vision, tinnitus, and a large output of dilute urine may occur. - **Neuroleptic malignant syndrome (NMS):** A rare but fatal adverse effect that can occur at any time during treatment with antipsychotics. It typically develops over a period of days to weeks and resolves in approximately nine days with treatment. Signs include increased temperature, severe muscular rigidity, confusion, agitation, hyperreflexia, elevation in white blood cell count, elevated creatinine phosphokinase, elevated liver enzymes, myoglobinuria, and acute renal failure. - **Neurotransmitters:** Chemical substances released at the end of a neuron by the arrival of an electrical impulse. They diffuse across the synapse and cause the transfer of the impulse to another nerve fiber, a muscle fiber, or other structure. Neurotransmitters interact with specific receptors like a key and a lock. - **Norepinephrine and Epinephrine:** Substances that stimulate alpha- and beta-receptors in the sympathetic nervous system. - **Opiates:** Powerful analgesics prescribed to treat moderate to severe pain (such as morphine and oxycodone). Opiates also include illicit drugs (such as heroin). - **Opioid receptors:** Mu, delta, and kappa receptors that are stimulated by endogenous peptides released by neurons (such as endorphins) and exogenous opiates. - **Opioid system:** A system in the brain that controls pain and reward and addictive behaviors. - **Parasympathetic Nervous System (PNS) receptors:** Nicotinic and muscarinic receptors that are stimulated by acetylcholine (ACh). - **Serotonin:** A neurotransmitter that modulates multiple neuropsychological processes such as mood, sleep, libido, and temperature regulation. Abnormal levels of serotonin have been linked to many mental health disorders such as depression, bipolar disorder, and anxiety. Many psychotropic medications target serotonin. - **Serotonin syndrome:** A syndrome caused by the combination of multiple medications that affect serotonin. It typically develops within 24 hours from the combination of medication and can range from mild to a life-threatening syndrome. Signs of serotonin syndrome include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), incoordination, or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Serotonin syndrome, in its most severe form, can resemble neuroleptic malignant syndrome (NMS). - **SLUDGE:** A mnemonic for anticholinergic side effects: Salivation decreased, Lacrimation decreased, Urinary retention, Drowsiness/dizziness, GI upset, Eyes (blurred vision/dry eyes). - **Sympathetic Nervous System (SNS) receptors:** Alpha-1, Alpha-2, Beta-1, and Beta-2 receptors that are stimulated by epinephrine and norepinephrine. - **Tardive dyskinesia:** A syndrome of movement disorders associated with antipsychotic medications that persists for at least 3 months, and often longer.