Week 3 Psychotherapeutics Class Slides PDF

Psychotherapeutics NUR 2403 – Week 3  Questions from last week Housekeeping Review of quiz Glossary Dopamine hypothesis of psychosis Dysregulation hypothesis of depression and mood Permissive hypothesis of mood Extrapyramidal Symptoms Akathisia Dystonias Parkinson’s traits...

Psychotherapeutics NUR 2403 – Week 3  Questions from last week Housekeeping Review of quiz Glossary Dopamine hypothesis of psychosis Dysregulation hypothesis of depression and mood Permissive hypothesis of mood Extrapyramidal Symptoms Akathisia Dystonias Parkinson’s traits Tardive dyskinesia Anxiety An unpleasant state of mind characterized by a sense of dread and fear May be based on anticipated experiences or actual past experiences May be exaggerated responses to imaginary negative situations 4 Anxiety Disorders Separation anxiety disorder Selective mutism Specific phobia Social anxiety disorder (social phobia) Panic disorder Panic attack Agoraphobia Generalized anxiety disorder Substance- or medication-induced anxiety disorder 5 Affective (Mood) Disorders Changes in mood that range from mania (abnormally pronounced emotions) to depression (abnormally reduced emotions) Some patients may exhibit both mania and depression: bipolar disorder (BPD) 6 Psychosis Severe emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in activities of daily living. Hallmark: loss of contact with reality Examples: Schizophrenia Depressive and drug-induced psychoses 7 Psychotherapeutic Drugs Anxiety Affective (mood) disorders Psychotic disorders 8 Types of Psychotherapeutic Drugs Anxiolytic drugs Mood-stabilizing drugs Antidepressant drugs Antipsychotic drugs 9 Anxiolytic Drugs Reduce anxiety by reducing overactivity in the central nervous system (CNS) First line - antidepressants Benzodiazepines Depress activity in the brainstem and limbic system Miscellaneous drug: buspirone (BuSpar®) Nonsedating and non–habit forming May have drug interaction with selective serotonin reuptake inhibitors (SSRIs) (serotonin syndrome) Do not administer with monoamine oxidase inhibitors (MAOIs) 10 Benzodiazepines alprazolam (Xanax®) diazepam (Valium®) lorazepam (Ativan®) 11 Benzodiazepines: Adverse Effects Benzodiazepines’ adverse effects are an overexpression of their therapeutic effects. Decreased CNS activity, sedation, amnesia Hypotension Drowsiness, loss of coordination, dizziness, headaches Nausea, vomiting, dry mouth, constipation 12 Benzodiazepines: Overdose Dangerous when taken with other sedatives or alcohol Treatment is generally symptomatic and supportive Flumazenil may be used to reverse benzodiazepines’ effects 13 Benzodiazepines: Interactions Alcohol and CNS depressants can result in additive CNS depression and even death. Interactions are more likely to occur in patients with renal or hepatic compromise. 14 alprazolam (Xanax) Most used as an anxiolytic Indicated for generalized anxiety disorder (GAD), short-term relief of anxiety symptoms, panic disorder and anxiety associated with depression Adverse effects: confusion, ataxia, headache, and others Interactions: alcohol, antacids, oral contraceptives 15 diazepam (Valium) Indications: relief of anxiety, management of alcohol withdrawal, reversal of status epilepticus, preoperative sedation, and as an adjunct for the relief of skeletal muscle spasms Avoid in patients with hepatic dysfunction. Adverse effects: headache, confusion, slurred speech, and others Interactions: alcohol, oral contraceptives 16 lorazepam (Ativan) Intermediate-acting benzodiazepine Can be given intravenously or intramuscularly; useful in the treatment of an acutely agitated patient Continuous infusion for agitated patients who are undergoing mechanical ventilation Used to treat or prevent alcohol withdrawal 17 Miscellaneous Anxiolytic buspirone hydrochloride Unknown mechanism of action (? agonist of dopamine and serotonin) Administered on a scheduled basis Adverse effects: Paradoxical anxiety Blurred vision Dizziness Headache Nausea Interact with ketoconazole and Clarithromycin 18 Mood-Stabilizing Drugs Lithium carbonate and lithium citrate Other drugs may be used in combination with lithium Benzodiazepines Antipsychotic drugs Antiepileptic drugs Dopamine receptor agonists 19 Lithium Drug of choice for the treatment of mania Thought to potentiate serotonergic neurotransmission Narrow therapeutic range: acute mania—lithium serum level of 1 to 1.5 mmol/L. Maintenance serum levels should range between 0.6 mmol/L and 1.2 mmol/L. Levels exceeding 1.5 to 2.0 mmol/L begin to produce toxicity (severe reaction exceeding 2.0 mmol/L), including gastrointestinal (GI) discomfort, tremor, confusion, somnolence, seizures, and death. Keeping the sodium level in the normal range (135 to 145 mmol/L) helps maintain therapeutic lithium levels. Caution in kidney impairment. Half life 18-24 hours (measure level 8-12 hours after dose) 20 Lithium Adverse effects Most serious adverse effect is cardiac dysrhythmia. Other effects: drowsiness, slurred speech, epilepsy-type seizures, choreoathetotic movements (involuntary wavelike movements of the extremities), ataxia (generalized disturbance of muscular coordination), and hypotension Long-term treatment may cause hypothyroidism. 21 Question Before administering lithium to a patient, it is most important for the nurse to assess which laboratory value? A. Blood sugar B. Sodium C. Urine osmolality D. Hematocrit 22 Antidepressants First Generation Tricyclics Tetracyclics MAOIs Second-generation antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs) Serotonin-norepinephrine reuptake inhibitors (SNRIs) Miscellaneous Therapy failure after 6 weeks on appropriate dose Warning for all classes: increased suicidal potential 23 Tricyclic Antidepressants Have largely been replaced by SSRIs as first-line antidepressant drugs Considered second line drugs For patients for whom SSRIs or other newer generation antidepressants fail As adjunct therapy with newer-generation antidepressants amitriptyline (Elavil®) 24 Tricyclic Antidepressants: MOA Block reuptake of neurotransmitters, causing accumulation at the nerve endings It is thought that these drugs may help regulate malfunctioning neurons. 25 Tricyclic Antidepressants: Indications Neuropathic pain, insomnia Childhood enuresis (imipramine) Obsessive compulsive disorders (OCDs) (clomipramine) Anorexia Adverse Effects: Sedation Impotence Orthostatic hypotension 26 Tricyclic Antidepressants: Overdose Lethality: 70 to 80% die before reaching the hospital CNS and cardiovascular systems are mainly affected Death results from seizures or dysrhythmias No specific antidote Decrease drug absorption with activated charcoal Speed elimination by alkalinizing urine Manage seizures and dysrhythmias Provide basic life support 27 amitriptyline (Elavil) Oldest and most widely used of all the tricyclic antidepressants Original indication: depression Commonly used to treat insomnia and neuropathic pain Contraindications: known drug allergy, pregnancy, and recent myocardial infarction. Adverse effects: dry mouth, constipation, blurred vision, urinary retention, and dysrhythmias 28 mirtazapine (Remeron®) Tetracyclic Promotes the presynaptic release of serotonin and norepinephrine in the brain Indications: depression (including that associated with BPD), sexual adverse effects in male patients receiving SSRI therapy, and an appetite stimulant Contraindications: drug allergy and MAOIs Adverse effects: drowsiness, abnormal dreams, dry mouth, constipation, increased appetite, and asthenia Drug interactions: additive CNS depressant effects with alcohol and cytochrome P-450 (CYP) inhibitors 29 Monoamine Oxidase Inhibitors (MAOIs) Nonselective: phenelzine sulphate and tranylcypromine sulphate Selective: selegiline hydrochloride Rarely used for depression Used for Parkinson’s disease Disadvantage: potential to cause hypertensive crisis when taken with tyramine 30 MAOIs and Tyramine Ingestion of foods or drinks with tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death Patients must avoid foods that contain tyramine Aged, mature cheeses (cheddar, blue, Swiss) Smoked, pickled, and aged meats, fish, and poultry (herring, sausage, corned beef, salami, pepperoni, paté) Yeast extracts Red wines (e.g., Chianti, burgundy, sherry, vermouth) Italian broad beans (fava beans) Hemodialysis 31 Second-Generation Antidepressants SARI SNRIs trazodone duloxetine (Cymbalta) NDRI desvenlafaxine (Prestiq) bupropion (Wellbutrin®) venlafaxine (Effexor) levomilnacipran (Fetzima) SSRIs fluoxetine (Prozac®) sertraline (Zoloft®) paroxetine (Paxil®) fluvoxamine (Luvox®) citalopram (Celexa®) escitalopram (Cipralex®) 32 2nd Gen Antidepressants: Indications depression premenstrual dysphoric BPD disorder obesity/eating disorders myoclonus OCD various substance misuse problems - alcoholism panic disorders social anxiety disorder post-traumatic stress disorder 34 2nd Gen Antidepressants: Adverse Effects Insomnia (partly caused by reduced rapid eye movement sleep) Weight gain Sexual dysfunction – inability to achieve orgasm Dry mouth Many clients stop taking due to the above effects 35 bupropion hydrochloride (Wellbutrin) NDRI Originally indicated for treatment of depression; now also indicated as an aid in smoking cessation Added as an adjunct antidepressant for patients experiencing sexual adverse effects secondary to SSRI therapy Zyban®: approved for smoking cessation treatment and was the first nicotine-free prescription medication used to treat nicotine dependence 36 duloxetine hydrochloride (Cymbalta®) SNRI Indications: depression, generalized anxiety disorder (GAD), and pain resulting from diabetic peripheral neuropathy or fibromyalgia, chronic back pain, and osteoarthritis Adverse effects: dizziness, drowsiness, headache, GI upset, anorexia, and hepatotoxicity. Drug interactions: SSRIs and triptans (increased risk of serotonin syndrome) and alcohol (increased risk of liver injury) Can worsen uncontrolled angle-closure glaucoma. 37 fluoxetine (Prozac) SSRI Indications: depression, bulimia, OCD, panic disorder, and premenstrual dysphoric disorder Contraindications: known drug allergy and concurrent MAOI therapy Adverse effects: anxiety, dizziness, drowsiness, insomnia, and others 38 Question When patients are taking selective SSRIs for the first time for depression, which is most important to monitor for during the first few weeks of therapy? A. Hypertensive crisis B. Suicidal thoughts C. Convulsions D. Orthostatic hypotension 39 Antipsychotics Drug-induced psychoses, schizophrenia, and autism Also used to treat extreme mania (as an adjunct to lithium), BPD, depression that is resistant to other therapy, certain movement disorders (e.g., Tourette’s syndrome), and certain other medical conditions (e.g., nausea, intractable hiccups) Conventional, or first-generation antipsychotics: phenothiazines Second-generation antipsychotics - ASD in children Atypical antipsychotics – newer, better side effect profile 40 Antipsychotics: MOA Block dopamine receptors in the brain (limbic system, basal ganglia), areas associated with emotion, cognitive function, motor function Dopamine levels in the CNS are decreased. Result: tranquilizing effect in psychotic patients 41 Antipsychotic Drugs: Indications Psychotic illness, most commonly schizophrenia Anxiety and mood disorders prochlorperazine (antiemetics) 42 Schizophrenia Positive symptoms: hallucinations, delusions, and conceptual disorganization Negative symptoms: apathy, social withdrawal, blunted affect, poverty of speech, and catatonia All antipsychotics show efficacy in improving the positive symptoms of schizophrenia. Less effective in managing negative symptoms. Atypical antipsychotics have greater efficacy in treating both positive and negative symptoms. 43 Antipsychotic Drugs: Adverse Effects Agranulocytosis and hemolytic anemia CNS effects: Drowsiness Neuroleptic malignant syndrome (NMS) Extrapyramidal symptoms (EPS): pseudoparkinsonism-akathisia, acute dystonia treated with benztropine (Kynesia®) and trihexyphenidyl hydrochloride Tardive dyskinesia 44 Antipsychotic Drugs: Adverse Effects Neuroleptic malignant syndrome NMS Muscular rigidity Potentially life threatening High fever, unstable blood pressure, myoglobinemia, dysrhythmia Rhabdomyolysis Extrapyramidal Symptoms EPS Involuntary muscle symptoms like those of Parkinson’s disease Akathisia (distressing muscle restlessness) Acute dystonia (painful muscle spasms) Treated with benztropine (Cogentin®) and trihexyphenidyl (Artane®) 45 Adverse Effects: Antipsychotic Drugs Tardive dyskinesia Involuntary contractions of oral and facial muscles Choreoathetosis (wavelike movements of extremities) Occurs with continuous long-term antipsychotic therapy Insulin resistance Weight gain Changes in serum lipid levels Cardiometabolic syndrome (most common cause of mortality) 46 haloperidol Indications: long-term treatment of psychosis Contraindications: hypersensitivity, Parkinson’s disease, large amounts of CNS depressants taken Oral, intramuscular Long duration of action (clients with schizophrenia who are nonadherent to their drug regimen) 47 Atypical Antipsychotics clozapine (Clozaril®) aripiprazole (Abilify®) risperidone (Risperdal®) paliperidone (Invega®) olanzapine (Zyprexa®) asenapine (Saphris®) quetiapine (Seroquel®) lurasidone (Latuda®) ziprasidone (Zeldox®) 48 Atypical Antipsychotics: MOA Block specific dopamine receptors: dopamine-2 (D2) receptors Also block specific serotonin receptors: serotonin-2 (5-HT2) receptors This is responsible for their improved efficacy and safety profiles Lower incidence of neuromuscular malignant syndrome and tardive dyskinesia Available in disintegrating tablets and/or sublingual 49 clozapine (Clozaril®) Selectively blocks the dopaminergic receptors in the mesolimbic region of the brain Associated with minor or no EPS Adverse effects: blood dyscrasias 50 risperidone (Risperdal®) Indication: schizophrenia (including negative symptoms) Adverse effect: minimal EPS at therapeutic dosages of 1 to 6 mg/day. Oral and long-acting injectable forms Risperdal Consta injection dosed every 2 weeks Invega Sustenna injection lasts 1 month 51 quetiapine (Seroquel) Schizophrenia, bipolar disorder Not indicated in elderly with dementia – increased risk of death Oral dosing Caution with hepatic impairment Blood dyscrasias Herbal Products: St. John’s Wort Used for depression, anxiety, sleep disorders, nervousness May cause GI upset, fatigue, dizziness, confusion, dry mouth, photosensitivity Severe interactions if taken with MAOIs and SSRIs; many other drug interactions Food–drug interaction with tyramine-containing foods 53 Serotonin Syndrome ØDelirium ØSevere serotonin syndrome: Ø Hyperthermia ØAgitation Ø Seizures ØTachycardia Ø Rhabdomyolysis Ø Chronic kidney disease ØSweating Ø Cardiac dysrhythmias Ø DIC ØMyoclonus (muscle spasms) ØHyperreflexia ØShivering ØCoarse tremors ØExtensor plantar muscle (sole of foot) responses Psychotherapeutic Drugs: Implications Before beginning therapy, assess the physical and emotional status of patients. Obtain baseline vital signs, including postural blood pressure readings. Obtain liver and renal function tests. Assess for possible contraindications to therapy, cautious use, and potential drug interactions. 55 Psychotherapeutic Drugs: Implications Provide the patient with simple explanations about the drug, its effects, and the length of time before therapeutic effects can be expected. Advise patients to avoid abrupt withdrawal. Advise patients to change positions slowly to avoid postural hypotension and possible injury. Assess for level of consciousness, mental alertness, and potential for injury to self and others. Check the patient’s mouth to make sure oral doses are swallowed. 56 Psychotherapeutic Drugs: Implications The combination of drug therapy and psychotherapy is emphasized because patients need to learn and acquire more effective coping skills. Only small amounts of medications should be dispensed at a time to minimize the risk of suicide attempts. Simultaneous use of these drugs with alcohol or other CNS depressants can be fatal. 57 Psychotherapeutic Drugs: Implications Antianxiety drugs With older adult patients, monitor closely for oversedation and profound CNS depression. Antidepressants Many cautions, contraindications, and interactions exist pertaining to the use of antidepressants. Inform patients that it may take several weeks to see therapeutic effects. Monitor patients closely during this time, assess for suicidal tendencies, and provide support. Assist older adult and weakened patients with ambulation and other activities because falls may occur due to drowsiness or postural hypotension. 58 Psychotherapeutic Drugs: Implications Antidepressants To avoid interactions with anaesthetic drugs, tricyclics may need to be weaned and discontinued before a patient undergoes surgery. Monitor for adverse effects and discuss with patients. Caffeine and cigarette smoking may decrease the effectiveness of medication therapy. When MAOIs are given, teach the patient and family about tyramine- containing foods and the signs and symptoms of hypertensive crisis. Gum, saliva enhancers and oral rinses can be suggested for dry mouth. 59 Psychotherapeutic Drugs: Implications Antipsychotics Inform patients to avoid alcohol and other CNS depressants. Long-term haloperidol therapy may result in tremors, nausea, vomiting, or uncontrollable shaking of small muscle groups. Report these symptoms to the physician. Oral forms may be taken with meals to decrease GI upset. May cause drowsiness, dizziness, or fainting. Instruct patients to change positions slowly. 60 Psychotherapeutic Drugs: Implications Monitor mental alertness, cognition, affect, mood, ability to carry out activities of daily living, appetite, and sleep patterns. Monitor potential for self-injury during the delay between the start of therapy and symptomatic improvement. For anxiolytics: Improved mental alertness, cognition, and mood Fewer anxiety and panic attacks Improved sleep patterns and appetite Less tension and irritability; fewer feelings of fear, impending doom, and stress More interest in self and others 61 Psychotherapeutics: Implications For antidepressants: Improved sleep patterns and nutrition Increased feelings of self-esteem Decreased feelings of hopelessness Increased interest in self and appearance Increased interest in daily activities Fewer depressive manifestations or suicidal thoughts or ideations 62 Psychotherapeutics: Implications For antipsychotics: Improved mood and affect Alleviation of psychotic symptoms and episodes Decreased hallucinations, paranoia, delusions, garbled speech, and inability to cope For lithium: Less mania Therapeutic lithium levels of 0.6 to 1.2 mmol/L 63 Case Study Jane Gonzalez 28 YOF Admission: Acute exacerbation of major depressive disorder (MDD) with suicidal ideation and insomnia. See Moodle for fulsome case study and discussion questions Wrap-up Questions? Week 4: Accreditation observation Acid controllers and antidiarrheals Quiz #2: psychotherapeutics