NRG 305: Psychiatric-Mental Health Nursing Lecture Notes PDF

NRG 305: PSYCH LEC THIRD YEAR - SECOND SEMESTER | SY. 2024 - 2025 ​ Interpersonal- e.g. excessive dependency on or withdrawal...

NRG 305: PSYCH LEC THIRD YEAR - SECOND SEMESTER | SY. 2024 - 2025 ​ Interpersonal- e.g. excessive dependency on or withdrawal CHAPTER 1 - Foundations of ​ from relationships Social/Cultural- e.g. discrimination Psychiatric-Mental such as stigma, racism, classism, ageism, and sexism Health Nursing DSM-5 ​ Diagnostic and Statistical Manual of Mental Disorders, MENTAL HEALTH AND MENTAL ILLNESS fifth edition(DSM-5) ​ As long as people can carry out their social ​ taxonomy published by the American Psychiatric responsibilities and they behave appropriately are Association and revised as needed. viewed HEALTHY ​ describes all mental disorders, outlining specific ​ Those who fail to fulfill roles and shows inappropriate diagnostic criteria for each based on clinical behaviors are viewed as ILL experience and research ​ How a society views the mental health of a person will ​ All mental health clinicians who diagnose psychiatric be based on its culture, beliefs and values disorders use this diagnostic taxonomy. “What one society may view as acceptable PURPOSE OF DSM5 & appropriate may view by another society differently” ​ provide a standardized nomenclature and language for all mental health professionals WHAT IS MENTAL HEALTH? ​ Present defining characteristics or symptoms that ​ WHO defines health as a state of complete physical, differentiate specific diagnoses mental, and social wellness, not merely the absence ​ assist in identifying the underlying causes of disorders of disease or infirmity. ​ The classification system allows the practitioner to ​ Mental health has no UNIVERSAL definition. identify all the factors that relate to a person’s ​ It comprises of several factors and it is dynamic or condition ever-changing state. ​ One of the biggest changes in the DSM-5 is the removal of the multiaxial assessment system to FACTORS THAT CAN INFLUENCE MENTAL HEALTH categorize diagnoses. ​ Individual /Personal– e.g. biologic make up, coping ​ This evaluation method was based on multiple abilities factors, specifically five “axes”: ​ Interpersonal- e.g. ability to help others, effective ○​ Axis I - clinical disorders communication ○​ Axis II - personality disorders ​ Social/Cultural- e.g. access to adequate resources, ○​ Axis III - general medical disorders diversity of people ○​ Axis IV- psychosocial and environmental factors MENTAL ILLNESS ○​ Axis V - global assessment of functioning ​ includes disorders that affect mood, behavior, and ​ EX: thinking ○​ Axis I - Bipolar, Manic type ​ often cause significant distress or impaired ○​ Axis II - Borderline Personality disorder functioning or both. ○​ Axis III - Hypertension ​ These individuals feel: ○​ Axis IV- Poor environmental conditions; poor ○​ Dissatisfied with self and relationship with support systen others ○​ Axis V - 50-41 ○​ Have ineffective coping and view their daily lives as unbearable MENTAL ILLNESS IN THE 21ST CENTURY ○​ May view their situation as hopeless ​ In the US 44.7 M has mental illness (NIH,2018) ​ 19.2 received treatment within the past years FACTORS CONTRIBUTING TO MENTAL ILLNESS ​ 18-25 group highest prevalence but lowest % ​ Individual /Personal– e.g. intolerance of life’s receiving treatment uncertainties ​ 15.M adults and 4M children and adolescents are mentally and emotionally disturbed JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 1 ​ The economic burden of mental illness in the US OBJECTIVES FOR THE FUTURE exceeds the economic burden caused by all kinds of ​ Increase number of people identified, diagnosed, cancer. treated, helped to live healthier lives ​ Mental disorders are the leading cause of disability in ​ Decrease rates of suicide, homelessness the United States and Canada for persons 15 to 44 ​ Increase employment for those with serious mental years of age. illness ​ Yet, only 1 in 4 adults and 1 in 5 children and ​ Provide more services for incarcerated persons with adolescents requiring mental health services get the mental health problems care they need. ​ Deinstitutionalization - deliberate shift from HEALTHY PEOPLE 2020 MENTAL HEALTH OBJECTIVES institutional care in state hospitals to community ​ Reduce the suicide rate. facilities ​ Reduce suicide attempts by adolescents. ○​ Resulted to an 80% decrease in the bed ​ Reduce the proportion of adolescents who engage in capacity of public hospitals but the number disordered eating behaviors in an attempt to control of admission also increased by 90%. their weight. ○​ Led to the term revolving door effect ​ Reduce the proportion of persons who experience ○​ Patients are often boarded or kept in the ED major depressive episode. while waiting to see if the crisis deescalates ​ Increase the proportion of primary care facilities that or until an inpatient bed can be located or provide mental health treatment onsite or by paid becomes available. referral. ○​ This practice of boarding leads to frustration ​ Increase the proportion of juvenile residential facilities of health care personnel, dissatisfaction with that screen admissions for mental health problems. care for clients and their families, and some ​ Increase the proportion of persons with serious believe an increase in suicide. mental illness who are employed. ○​ Provision of an adequate number of ​ Increase the proportion of adults with mental health psychiatric inpatient beds could better meet disorders who receive treatment. the needs of clients and might even ​ Increase the proportions of persons with co-occurring decrease homelessness, incarceration, and substance abuse and mental disorders who receive violence (Allison et al., 2018). treatment for both disorders. ​ One result of deinstitutionalization is the revolving ​ Increase depression screening by primary care door of repetitive hospital admission without adequate providers. community follow-up ​ Increase the number of homeless adults with mental ​ People with severe and persistent mental illness may health problems who receive mental health services show signs of improvement in a few days but are not stabilized. COMMUNITY BASED CARE ​ Thus, they are discharged into the community without ​ Persons with severe and persistent mental illness being able to cope with community living. were either ignored ​ Dual problem of both mental and substance abuse ​ Lack of appropriate number of community mental are common health centers to provide services ​ Substance abuse issues cannot be dealt within the 3 ​ Many people needing services were and still are in to 5 days the general population with their needs unmet ​ In the US, homelessness is a major problem, 33% of ​ Development of community support programs- the population have a severe mental issue with programs focus on rehabilitation, vocational needs, chronic substance abuse disorder education, and socialization as well as on ​ Those who are homeless are found everywhere. It management of symptoms and medication may be in the streets, park, bus terminals or they may ​ Availability, quality of services highly variable occasionally rent a house or room when they can ​ Inaccurate anticipation of extent of people’s needs afford it ​ Despite flaws, positive aspects making them ​ Homelessness worsens psychiatric problems for preferable for treatment many people with mental illness who end up on the streets, contributing to a vicious cycle. PSYCHIATRIC NURSING PRACTICE AND MENTAL ​ Inpatient psychiatric treatment still accounts for most HEALTH SERVICES IN THE PHILIPPINES of the spending for mental health in the US, so ​ Mental health remains poorly resourced: only 3–5% of community mental health has never been given the the total health budget is spent on mental health, and financial base it needs to be effective 70% of this is spent on hospital care (WHO & Department of Health, 2006). JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 2 ​ Despite the legal bases of the Mental Health Act (Republic Act no. 11036), which seeks to establish G.​ Cholinesterase inhibitor→ donepezil access to comprehensive and integrated mental H.​ NMDA receptor antagonist → memantine health services, while protecting the rights of people with mental disorders and their family members (Lally ​ Psychiatry remains a less popular specialty for et al, 2019). medical graduates in the Philippines, and the ​ Overcrowding, poorly functioning units, chronic staff numbers being trained are inadequate to meet a shortages and funding constraints are ongoing growing need. problems, particularly in peripheral facilities. ​ Increased investment is urgently needed to improve ​ There are no dedicated forensic hospitals, although the training and recruitment of psychiatrists, nurses, psychologists, social workers and other forensic beds are located at the National Center for multidisciplinary team members, particularly as large Mental Health. numbers of skilled professionals continue to emigrate. ​ Mental Health Staff shortage is also indicated as in the country it is only 2 – 3 per 100, 000 population PSYCHIATRIC-MENTAL HEALTH NURSES ASSOCIATION ratio compared to the standard 10 is to 100, 000 OF THE PHILIPPINES, INC population set by WHO. ​ The Psychiatric-Mental Health Nurses Association of ​ Not later than 5 years back, diagnosis and treatment the Philippines, Inc. (PMHNAP) is a duly recognized of mental health illness were truly undervalued as less nursing specialty organization of nurses working in than 15% - 50% were diagnosed and treated the area of psychiatry and mental health. The organization was established in 2010 thru the able particularly for those with depression, schizophrenia leadership of Professor Nenita Y. Davadilla. and suicide. ​ MISSION: Our mission is defined by the following ​ Prohibitive economic conditions and the objectives: inaccessibility of mental health services limit access ​ Education to mental healthcare in the Philippines. ○​ To promote advance studies in ​ Stigma is one barrier to help – seeking behavior Psychiatric-Mental Health and allied behavioral health sciences. among Filipinos ​ Training ​ A strong sense of family in the Philippines and so, ○​ To promote effective, equitable and when problems are thought to be socially related, evidenced-based nursing interventions for Filipinos will turn to family and peer networks before individuals, families, population groups, and seeking medical help (Tuliao, 2014) further limiting the communities. urgency of seeking proper mental health assistance. ○​ To enhance knowledge, skills and attitudes by providing education and training. ​ Research ​ The Philippines Department of Health Medication ○​ To engage in research work and promote Access Program for Mental Health list of essential effective, equitable and evidence-based psychotropic medications. These medications are nursing interventions. available at all service levels, but funding issues limit ​ Advocacy patient access, particularly access to newer ○​ To unite Filipino nurses by forming creating medications. The most commonly used antipsychotics linkages and collaboration with government, in clinical practice are chlorpromazine and private, and non-government institutions aimed towards a mentally healthy nation. haloperidol; escitalopram and fluoxetine are the most commonly used antidepressants. A.​ First-generation/typical antipsychotics → chlorpromazine, haloperidol (oral and long-acting injectable), fluphenazine decanoate B.​ Second-generation/atypical antipsychotics → clozapine, olanzapine, quetiapine, risperidone C.​ Antidepressants → fluoxetine, sertraline, escitalopram D.​ Mood stabilisers → lithium carbonate, valproic acid, carbamazepine, lamotrigine E.​ Anticholinergics → biperiden, diphenhydramine F.​ Benzodiazepine → clonazepam JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 3 CHAPTER 2 - Neurobiologic Theories & movements in diseases such as Parkinson disease and dementia. Psychopharmacology NEUROBIOLOGIC THEORIES & PSYCHOPHARMACOLOGY ​ The cause of mental illnesses remains to be unknown For the past 30 years, Science played a big role in analyzing how the brain works and explaining the possible causes and how every individual’s brain function differently ​ What does this imply? ○​ These neurobiologic advances created a big impact on the clinical practice. ​ Psychiatric nurses must be knowledgeable on the basic understanding on the bran functions and on the current theories regarding mental illness ​ Medulla, contains vital centers for respiration and cardiovascular functions ​ The pons bridges the gap both structurally and functionally, serving as a primary motor pathway ​ Midbrain connects the pons and cerebellum with the cerebrum ​ The reticular activating system influences motor activity, sleep, consciousness, and awareness ​ The Extrapyramidal system relays information about movement and coordination from the brain to the spinal nerves. ​ locus coeruleus, a small group of norepinephrine producing neurons in the brain stem, is associated with stress, anxiety, and impulsive behavior. CEREBRUM ​ divided in 2 hemispheres. The left controls the right side of the body and is the center for logical reasoning and analytic functions (e.g. Reading, writing, and mathematical tasks) ​ right hemisphere controls the left side of the body and is the center for creative thinking, intuition, and artistic abilities. ​ The frontal lobes control the organization of thought, body movement, memories, emotions, and moral behavior. The integration of all this information regulates arousal, focuses attention, and enables problem-solving and decision-making. ​ Abnormalities in the frontal lobes are associated with schizophrenia, attention deficit/hyperactivity disorder (ADHD), and dementia ​ Thalamus regulates activity, sensation, and emotion ​ The parietal lobes interpret sensations of taste and ​ The hypothalamus is involved in temperature touch and assist in spatial orientation. The temporal regulation, appetite control, endocrine function, sexual lobes are centers for the senses of smell and hearing drive, and impulsive behavior associated with feelings and for memory and emotional expression. of anger, rage,or excitement. ​ The occipital lobes assist in coordinating language ​ Hippocampus and amygdala are involved in generation and visual interpretation, such as depth emotional arousal and memory. perception ​ Disturbances are linked to variety of mental illnesses, such as the memory loss that accompanies dementia CEREBELLUM and the poorly controlled emotions and impulses seen ​ the center for coordination of movements and postural with psychotic or manic behavior. adjustments ​ Research has shown that inhibited transmission of dopamine, a neurotransmitter, in this area is associated with the lack of smooth coordinated JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 4  NEUROTRANSMITTERS (noradrenaline) attention, learning and ​ chemical substances manufactured in the neuron that memory, sleep and aid in the transmission of information throughout the wakefulness, mood body. They either excite or stimulate an action in the cells (excitatory) or inhibit or stop an action Epinephrine Excitatory Controls fight or flight (inhibitory). (adrenaline) response ○​ necessary in just the right proportions to relay messages across the synapses. Serotonin Inhibitory Controls food intake, sleep and wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions Histamine Neuromodulator Controls alertness, gastric secretions, cardiac stimulation, peripheral allergic responses Acetylcholine Excitatory or Controls sleep and inhibitory wakefulness cycle; signals muscles to become alert Neuropeptides Neuromodulator Enhance, prolong, inhibit, or s limit the effects of principal ​ Schematic illustration of (1) neurotransmitter (T) neurotransmitters release; (2) binding of transmitter to postsynaptic receptor; termination of transmitter action by (3a) Glutamate Excitatory Results in neurotoxicity if reuptake of transmitter into the presynaptic terminal, levels are too high (3b) enzymatic degradation, or (3c) diffusion away from the synapse; and (4) binding of transmitter to y-Aminobutyric Inhibitory Modulates other presynaptic receptors for feedback regulation of acid neurotransmitters transmitter release. DOPAMINE ​ is implicated in schizophrenia and other psychoses as well as in movement disorders such as Parkinson disease. Antipsychotic medications work by blocking dopamine receptors and reducing dopamine activity. NOREPINEPHRINE ​ Excess norepinephrine has been implicated in several anxiety disorders; deficits may contribute to memory loss, social withdrawal, and depression. Some antidepressants block the reuptake of norepinephrine, while others inhibit MAO from metabolizing it. ​ Major neurotransmitters have been found to play a SEROTONIN role in psychiatric illnesses as well as in the actions ​ plays an important role in anxiety, mood disorders, and side effects of psychotropic drugs. and schizophrenia. It has been found to contribute to the delusions, hallucinations, and withdrawn behavior seen in schizophrenia. Some antidepressants block MAJOR NEUROTRANSMITTERS serotonin reuptake, thus leaving it available longer in the synapse, which results in improved mood Mechanism of Type Physiologic Effects HISTAMINE Action ​ Some psychotropic drugs block histamine, resulting in Dopamine Excitatory Controls complex weight gain, sedation, and hypotension movements, motivation, cognition; regulates ACETYLCHOLINE emotional response ​ Studies have shown that people with Alzheimer disease have decreased acetylcholine secreting Norepinephrine Excitatory Causes changes in neurons, and people with myasthenia gravis (a JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 5  muscular disorder in which impulses fail to pass the LIMITATIONS OF BRAIN IMAGING TECHNIQUES myoneural junction, which causes muscle weakness) ​ The use of radioactive substances in PET and have reduced acetylcholine receptors. SPECT limits the number of times a person can undergo these tests. GLUTAMATE ​ risk that the client will have an allergic reaction to the ​ implicated in the brain damage caused by stroke, substances. Some clients may find receiving IV doses hypoglycemia, sustained hypoxia or ischemia, and some degenerative diseases such as Huntington or of radioactive material frightening or unacceptable. Alzheimer. ​ Imaging equipment is expensive to purchase and maintain, so can be limited availability GAMMA-AMINOBUTYRIC ACID (GABA) ​ Some persons cannot tolerate these procedures ​ found to modulate other neurotransmitter systems because of fear claustrophobia. rather than to provide a direct stimulus. Drugs that ​ Researchers are finding that many of the changes in increase GABA function, such as benzodiazepines, disorders such as schizophrenia are at the molecular are used to treat anxiety and to induce sleep. and chemical levels and cannot be detected with current imaging techniques (Gur & Gur, 2017). Brain Imaging Technology NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS ​ Genetics and heredity Procedure Imaging Method Results Duration ○​ Current theories and studies indicate that several mental disorders may be linked to a Computed Serial x-rays of Structural 20-40 specific gene or combination of genes but tomography brain image minutes that the source is not solely genetic; (CT) nongenetic factors also play important roles. ​ 3 types of studies are commonly conducted to Magnetic Radio waves from Structural 45 minutes investigate the genetic basis of mental illness: resonance brain detected image ○​ Twin Studies - Fraternal twins have the imaging (MRI) from magnet same genetic similarities and differences as nontwin siblings. Positron Radioactive tracer Functional 2-3 hours ○​ Adoption studies - used to determine a trait emission injected into among biologic versus adoptive family tomography bloodstream and members. (PET) monitored as client ○​ Family studies - used to compare whether a performs activities trait is more common among first-degree relatives (parents, siblings, and children) Single-photon Same as PET Functional 1-2 hours than among more distant relatives or the emission general population. computed ​ Investigation continues about the influence of tomography inherited traits versus the influence of the (SPECT) environment—the “nature versus nurture” debate. ​ Before the brain could be studied only through STRESS AND THE IMMUNE SYSTEM surgery or autopsy Now several brain imaging (PSYCHOIMMUNOLOGY) techniques have been developed that now allow ​ Psychoimmunology, a relatively new field of study, visualization of the brain’s structure and function. examines the effect of psychosocial stressors on the ​ These techniques are useful for diagnosing some body’s immune system. A compromised immune system could contribute to the development of a disorders of the brain and have helped correlate variety of illnesses, particularly in populations already certain areas of the brain with specific functions. genetically at risk. ​ Brain imaging techniques are also useful in research ​ So far, efforts to link a specific stressor with a specific to find the causes of mental disorders. disease have been unsuccessful ​ However, immune system and the brain can influence neurotransmitters. When the inflammatory response is critically involved in illnesses such as multiple sclerosis or lupus erythematosus, mood dysregulation and even depression are common(Raison & Miller, 2017). INFECTION AS A POSSIBLE CAUSE ​ Most studies involving viral theories have focused on schizophrenia, but so far, none has provided specific or conclusive evidence. JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 6  ​ Theories that are being developed and tested include target symptoms, while lower dosages can be used to the existence of a virus that has an affinity for tissues sustain those effects over time. of the CNS, the possibility that a virus may actually ​ As a rule, older adults require lower dosages of alter human genes, and maternal exposure to a virus medications than do younger clients to experience during critical fetal development of the nervous therapeutic effects. It may also take longer for a drug system. to achieve its full therapeutic effect in older adults. ​ Prenatal infections may impact the developing brain Psychotropic medications are often decreased of the fetus, giving rise to a proposed theory that gradually (tapering) rather than abruptly. This is inflammation may causally contribute to the pathology because of potential problems with rebound of schizophrenia (DeBost et al., 2017). (temporary return of symptoms), recurrence (of the original symptoms), or withdrawal (new symptoms WHAT IS YOUR ROLE IN RESEARCH AND EDUCATION? resulting from discontinuation of the drug). ➔​ Nurse must ensure that clients and families are well ​ Follow-up care is essential to ensure compliance with informed about progress in these areas and must also the medication regimen, to make needed adjustments help them to distinguish between facts and in dosage, and to manage side effects. hypotheses ​ Compliance with the medication regimen is often ➔​ Explain if or how new research may affect a client’s enhanced when the regimen is as simple as possible treatment or prognosis. in terms of both the number of medications prescribed ➔​ You should be a good resource for providing and the number of daily doses. information and answering questions. ANTIPSYCHOTIC DRUGS PSYCHOPHARMACOLOGY ​ have been in clinical use since the 1950s. ​ Medication management is a crucial issue that greatly ​ formerly known as neuroleptics, are used to treat the influences the outcomes of treatment for many clients symptoms of psychosis, such as the delusions and with mental disorders hallucinations seen in schizophrenia, schizoaffective ​ Efficacy refers to the maximal therapeutic effect that disorder, and the manic phase of bipolar disorder a drug can achieve ​ They are the primary medical treatment for ​ Potency describes the amount of the drug needed to schizophrenia and are also used in psychotic achieve that maximum effect; low-potency drugs episodes of acute mania, psychotic depression, and require higher dosages to achieve efficacy, while high drug-induced psychosis. potency drugs achieve efficacy at lower dosages ​ Off-label uses of antipsychotics include treatment of ​ Half-life is the time it takes for half of the drug to be anxiety and insomnia; aggressive behavior; and removed from the bloodstream. Drugs with a shorter delusions, hallucinations, and other disruptive half-life may need to be given three or four times a behaviors that sometimes accompany Alzheimer day, but drugs with a longer half-life may be given disease once a day ​ The time that a drug needs to leave the body MECHANISM OF ACTION: completely after it has been discontinued is about five ​ Block receptors for the neurotransmitter dopamine; times its half-life. however, the therapeutic mechanism of action is only ​ The FDA approves each drug for use in a particular partially understood population and for specific diseases ​ conventional, or first-generation, antipsychotic drugs ​ off-label use a drug will prove effective for a disease are potent antagonists (blockers) of D2, D3, and D4. that differs from the one involved in original testing This not only makes them effective in treating target and FDA approval symptoms but also produces many extrapyramidal ​ FDA also monitors the occurrence and severity of side effects drug side effects ​ atypical or second-generation such as clozapine ​ black box warning contains a warning about the (Clozaril), are relatively weak blockers of D2, which serious or life-threatening side effects. may account for the lower incidence of EPS ​ Atypical antipsychotics inhibit the reuptake of PRINCIPLES THAT GUIDE PHARMACOLOGIC serotonin-similar with some anti-depressant, making ​ A medication is selected based on its effect on the them more effective in addressing the depressive client's target symptoms such as delusional thinking, state of schizophrenia panic attacks, ог hallucinations. The medication's ​ newest second-generation agents: Paliperidone effectiveness is evaluated largely by its ability to (Invega),iloperidone (Fanapt), asenapine (Saphris), diminish oг eliminate the target symptoms. and lurasidone (Latuda) ​ Many psychotropic drugs must be given in adequate dosages for some time before their full effects are realized. For example, tricyclic antidepressants can require 4 to 6 weeks before the client experiences optimal therapeutic benefit. ​ The dosage of medication is often adjusted to the lowest effective dosage for the client. Sometimes a client may need higher dosages to stabilize his or her JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 7  ​ Second-generation antipsychotics can increase mortality rates in elderly clients with dementia-related psychosis ​ Short-term therapy with antipsychotics may be useful for transient psychotic symptoms such as those seen in some clients with borderline personality Antipsychotic Drugs Extreme Generic (Trade) Forms Daily Dosage Dosage Name Ranges CONVENTIONAL OR FIRST-GENERATION ANTIPSYCHOTICS PHENOTHIAZINES Chlorpromazine T, L, INJ 200-1,600 25-2,000 (Thorazine) Perphenazine T, L, INJ 16-32 4-64 (Trilafon) Fluphenazine T, L, INJ 2.5-20 1-60 (Prolixin) Thioridazine T, L 200-600 40-800 (Mellaril) Mesoridazine T, L, INJ 75-300 30-400 (Serentil) Trifluoperazine T, L, INJ 6-50 2-80 (Stelazine) Thioxanthene Thiothixene C, L, INJ 6-30 6-60 (Navane) Butyrophenones Haloperidol T, L, INJ 2-20 1-100 (Haldol) Droperidol INJ 2.5 (Inapsine) Dibenzazepine Loxapine C, L, INJ 60-100 30-250 (Loxitane) ​ Conventional (e.g., chlorpromazine, fluphenazine, Dihydroindole thioridazine, haloperidol, loxapine) Second generation (e.g., clozapine, risperidone, olanzapine) – Third Molindone T, L 50-100 15-250 generation (dopamine system stabilizers; e.g., (Moban) aripiprazole) ​ Clients with dementia who have psychotic symptoms sometimes respond to low dosages of conventional ATYPICAL OR SECOND-GENERATION ANTIPSYCHOTICS antipsychotics Clozapine T 150-500 75-700 JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 8  Antipsychotics- used for schizophrenia, manic (Clozaril) episodes, and as adjunct medication in both bipolar disorder and depression. Most common S/E are Fazaclo DT 150-500 75-700 sedation, weight gain, akathisia, headache, anxiety, (clozapine) and nausea ​ Six antipsychotics are available in depot injection, a Risperidone T, L, DT 2-8 1-16 time-release form of intramuscular medication for (Risperdal) maintenance therapy ​ Decanoate fluphenazine (Prolixin) has a duration of 7 Olanzapine T 5-15 5-20 to 28 days, and decanoate haloperidol (Haldol) has a (Zyprexa) duration of 4 weeks. ​ After the client's condition is stabilized with oral doses Quetiapine T 300-600 200-750 of these medications, administration by depot (Seroquel) injection is required every 2 to 4 weeks to maintain the therapeutic effect. Ziprasidone C, INJ 40-160 20-200 ​ Risperidone (Risperdal, Consta), paliperidone (Invega (Geodon) Sustenna), and olanzapine pamoate (Zyprexa Relprevv), second-generation antipsychotics, Paliperidone T 6 3-12 encapsulate active medication into polymer-based (Invega) microspheres that degrade slowly in the body, gradually releasing the drug at a controlled rate. Iloperidone T 12-24 2-24 Risperdal Consta, 25 mg, is given every 2 weeks. (Fanapt) Invega Sustenna, 117 mg, is given every 4 weeks. ​ Zyprexa Relprevv has the potential to cause post Asenapine T (SL) 10-20 10-20 injection delirium/sedation syndrome, including (Saphris) sedation, confusion, disorientation, agitation, and cognitive impairment that can progress to ataxia, Lurasidone T 40-80 20-160 convulsions, weakness, and HPN, which can lead to (Latuda) arrest ​ client must be directly observed by a health care professional for 3 hours after the injection and must THIRD-GENERATION ANTIPSYCHOTICS be alert, oriented, and symptom-free before he or she can be released Aripiprazole T 15-30 10-40 ​ Aripiprazole (Abilify Maintena), a third generation (Abilify) antipsychotic, is slowly absorbed into the bloodstream because of insolubility of aripiprazole particles Cariprazine C 3-6 1.5-6 (Otsuka America Pharmaceuticals, 2018).After (Vraylar) initiation with oral medication, Abilify Maintena 400 mg is given monthly. Brexpiprazole T 1-3 5-4 (Rexulti) ATYPICAL ANTIPSYCHOTICS ​ *Values are in milligrams per day for oral doses only. ​ Elderly patients with dementia-related psychosis C, capsule; DT, orally disintegrating tablet; INJ, treated with atypical antipsychotic drugs are at an injection for IM (usually prn) use; L, liquid for oral use; increased risk for death. Causes of death are varied, SL, sublingual; T, tablet. but most appear to be either cardiovascular or ​ Paliperidone (Invega) is chemically similar to infectious in nature. risperidone (Risperdal); however, it is an extended-release preparation. This means the client SIDE EFFECTS can take one daily dose in most cases, which may be ​ Extrapyramidal Side Effects. Extrapyramidal a factor in increased compliance symptoms (EPSs), serious neurologic symptoms, are ​ Asenapine (Saphris) is a sublingual tablet, so clients the major side effects of antipsychotic drugs. must avoid food or drink for 10 to 15 min after the ​ They include acute dystonia, pseudo parkinsonism, medication dissolves. and akathisia ​ third generation of antipsychotics, called dopamine ​ One client can experience all the reactions in the system stabilizers, is being developed same course of therapy, which makes distinguishing ​ These drugs are thought to stabilize dopamine output; among them difficult that is, they preserve or enhance dopaminergic ​ First-generation antipsychotic drugs cause a greater transmission when it is too low and reduce it when it incidence of EPSs is too high. This results in control of symptoms without some of the side effects of other antipsychotic medications ​ Aripiprazole (Abilify), first drug of this type, was approved for use in 2002. Cariprazine (Vraylar) and brexpiprazole (Rexulti) are newer third-generation JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 9  ​ These are vesicular monoamine transporter 2 (VMAT2) inhibitors believed that these drugs decrease activity of monoamines, such as dopamine, serotonin, and norepinephrine, thereby decreasing the abnormal movements associated with Huntington chorea and TD. ​ Valbenazine has a dosage range of 40 to 80 mg daily, and deutetrabenazine ranges from 12 to 48 mg daily. ​ Pseudo parkinsonism, is often referred to by the ​ Both drugs cause somnolence, QT prolongation, generic label of EPS akathisia, and restlessness. In addition, valbenazine ​ treated by changing to an antipsychotic medication can cause nausea, vomiting, headache, and balance that has a lower incidence of EPS or by adding an oral anticholinergic agent or amantadine, which is a disturbances. Deutetrabenazine can also cause NMS dopamine agonist that increases transmission of and increased depression and suicidality in patients dopamine blocked by the antipsychotic drug. with Huntington chorea ANTICHOLINERGIC SIDE EFFECTS Drugs Used to Treat Extrapyramidal Side Effects ​ usually decrease within 3 to 4 weeks but do not entirely remit Generic ​ often occur with the use of antipsychotics and include Oral Dosages IM/IV orthostatic hypotension, dry mouth, constipation, (Trade) Drug Class (mg) Doses (mg) urinary hesitance or retention, blurred near vision, dry Name eyes, photophobia, nasal congestion, and decreased memory. Amantadine 100 bid or tid Dopaminergic ​ Client taking anticholinergic agents for EPSs may (Symmetrel) agonist have increased problems with anticholinergic side effects Benztropine 1-3 bid 1-2 Anticholinergic ​ calorie-free beverages or hard candy may alleviate (Cogentin) dry mouth, and stool softeners, adequate fluid intake, and theinclusion of grains and fruit in the diet may Biperiden 2 tid-qid 2 Anticholinergic prevent constipation. (Akineton) OTHER SIDE EFFECTS Diazepam 5 tid 5-10 Benzodiazepine ​ increase blood prolactin levels- may cause breast (Valium) enlargement and tenderness in men and women, diminished libido, erectile and orgasmic dysfunction, Diphenhydra 25-50 tid or qid 25-50 Antihistamine and menstrual irregularities; and increased risk for mine breast cancer and WEIGHT GAIN. (Benadryl) ​ Weight gain can accompany most antipsychotic medications, but it is most likely with the Lorazepam 1-2 tid Benzodiazepine second-generation antipsychotic drugs, with (Ativan) ziprasidone (Geodon) being the exception. Weight increases are most significant with clozapine Procyclidine 2.5-5 tid Anticholinergic (Clozaril) and olanzapine (Zyprexa). (Kemadrin) ​ Since 2004, the FDA has made it mandatory for drug manufacturers that atypical antipsychotics carry a Propranolol 10-20 tid, up to Beta-Blocker warning of the increased risk for hyperglycemia and (Inderal) 40 qid diabetes ​ Mechanism of weight gain is UNKNOWN Trihexypheni 2-5 tid Anticholinergic ​ it is associated with increased appetite, binge eating, dyl (Artane) carbohydrate craving, food preference changes, and decreased satiety in some clients ​ The addition of a regularly scheduled oral anticholinergic, such as benztropine, may allow the ➔​ Penninx and Lange (2018) found that genetics can client to continue taking the antipsychotic drug with no also make clients more prone to weight gain and further dystonia. Recurrent dystonic reactions would metabolic syndrome. necessitate a lower dosage or a change in the ➔​ Metabolic syndrome is a cluster of conditions that antipsychotic drug increase the risk for heart disease, DM, and stroke. This is diagnosed when three or more of the ff are ​ In 2017, the FDA approved valbenazine (Ingrezza) present: and deutetrabenazine(Austedo, Teva) as the first ◆​ Obesity—excess weight, increased (BMI), drugs to treat TD. and abdominal girth because of fat deposits ◆​ Increased blood pressure JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 10  ◆​ High blood sugar level ​ encourages clients who have difficulty remembering ◆​ High cholesterol—with at least 150 mg/dL of to take their medication to use a chart and to record triglyceride; less than 40 mg/dL of doses when taken or to use a pillbox that can be high-density lipoprotein for women and 50 prefilled with accurate doses for the day or week. mg/dL for men common with schizophrenia, further increasing the risk for DM II & ANTIDEPRESSANTS cardiovascular disease ​ primarily used in the treatment of major depressive ◆​ Recommended to be part of a weight control illness, anxiety disorders, the depressed phase of program to decrease BMI. bipolar disorder, and psychotic depression ➔​ Most antipsychotic drugs cause relatively minor ​ Off-label uses of antidepressants include the cardiovascular adverse effects such as postural treatment of chronic pain, migraine headaches, hypotension, palpitations, and tachycardia peripheral and diabetic neuropathies, sleep apnea, ➔​ antipsychotic drugs, such as thioridazine (Mellaril), dermatologic disorders, panic disorder, and eating droperidol (Inapsine), and mesoridazine (Serentil), disorders. can also cause a lengthening of the QT interval ​ divided into: ➔​ Thioridazine and mesoridazine are used to treat ○​ Tricyclic and the related cyclic psychosis; droperidol is most often used as an antidepressants adjunct to anesthesia or to produce sedation. ○​ Selective serotonin reuptake inhibitors Sertindole (Serlect) was never approved in the United (SSRIs) States to treat psychosis but was used in Europe and ○​ MAO inhibitors (MAOIs) was subsequently withdrawn from the market ○​ Other antidepressants such as because of the number of cardiac dysrhythmias and desvenlafaxine (Pristiq), venlafaxine deaths that it caused. (Effexor), bupropion (Wellbutrin), duloxetine ➔​ Clozapine produces fewer traditional side effects than (Cymbalta), trazodone (Desyrel), and do most antipsychotic drugs, but it has the potentially nefazodone (Serzone) fatal side effect of agranulocytosis- potentially life threatening ➔​ develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia. This side effect may not manifest immediately and can occur up to 24 weeks after the initiation of therapy. ➔​ Clients who are being treated with clozapine must have a baseline WBC count and differential before initiation of treatment and a WBC count every week throughout treatment and for 4 weeks after discontinuation of clozapine. CLIENT TEACHING ​ Educate patients taking antipsychotics on the different side effects that might occur while taking these drugs. ​ Encourage patients to report these SE to physician rather than discontinuing the medication ​ teach methods of managing or avoiding unpleasant side effects and maintaining the medication regimen ​ Drinking sugar-free fluids and eating sugar-free hard candy ease dry mouth ​ avoid calorie-laden beverages and candy because they promote dental caries, contribute to weight gain, and do little to relieve dry mouth. ​ prevent or relieve constipation include exercising and increasing water and bulk forming foods in the diet. Stool softeners are permissible, but the client should avoid laxatives. ​ use of sunscreen is recommended because photosensitivity can cause the client to sunburn easily. ​ monitor the amount of sleepiness or drowsiness they feel. They should avoid driving and performing other potentially dangerous activities until their response times and reflexes seem normal. ​ If the client forgets a dose of antipsychotic medication, he or she can take the missed dose if it is only 3 or 4 hours late ​ If the dose is more than 4 hours overdue or the next dose is due, the client can omit the forgotten dose JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 11  and tired of waiting to feelbetter, which can result in suicidal behavior ​ an FDA-required warning for SSRIs and increased suicidal risk in children and adolescents. SIDE EFFECTS OF OTHER ANTIDEPRESSANTS ​ other or novel antidepressant medications, nefazodone, trazodone, and mirtazapine commonly cause sedation also cause dry mouth and nausea. ​ Bupropion, venlafaxine, and desvenlafaxine may cause loss of appetite, nausea, agitation, and insomnia. ​ Venlafaxine may also cause dizziness, sweating, or sedation ​ Sexual dysfunction is much less common with the FOODS (CONTAINING TYRAMINE) TO AVOID WHEN novel antidepressants, with one notable exception: TAKING MONOAMINE OXIDASE INHIBITORS Trazodone can cause priapism (a sustained and ​ Mature or aged cheeses or dishes made with cheese, painful erection that necessitates immediate treatment such as lasagna or pizza. All cheese is considered and discontinuation of the drug)-which can result to aged except cottage cheese, cream cheese, ricotta impotence cheese, and processed cheese slices. ​ Nefazodone may cause rare but potentially ​ Aged meats such as pepperoni, salami, mortadella, life-threatening liver damage, which could lead to liver summer sausage, beef logs, meat extracts, and failure. similar products. Make sure meat and chicken are ​ Bupropion Can cause seizures at a rate four times fresh and have been properly refrigerated. that of other antidepressants. The risk for seizures ​ Italian broad beans (fava), bean curd (tofu), banana increases when doses exceed 450 mg/day (400 mg peel, overripe fruit, and avocado. SR); dose increases are sudden or in large ​ All tap beers and microbrewery beer. Drink no more increments; the client has a history of seizures, than two cans or bottles of beer (including cranial trauma, excessive use of or withdrawal from nonalcoholic beer) or 4 oz of wine per day. alcohol, or addiction to opiates, cocaine, or ​ Sauerkraut, soy sauce ог soybean condiments, stimulants; the client uses over-the-counter (OTC) (concentrated yeast). ог marmite stimulants or anorectics; or the client has diabetes ​ Yogurt, sour cream, peanuts, brewer's yeast, and being treated with oral hypoglycemics or insulin. monosodium glutamate (MSG). DRUG INTERACTIONS ​ uncommon but potentially serious drug interaction called serotonin syndrome (or serotonergic syndrome) can result from taking an MAOI and an SSRI at the same time. ​ can also occur if the client takes one of these drugs too close to the end of therapy with the other ​ Symptoms –similar with SSRI overdose which include agitation, sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia, and, in extreme reactions, even coma and death CLIENT TEACHING ​ Clients should take SSRIs first thing in the morning unless sedation is a problem; generally, paroxetine DRUGS FOR CLIENTS AT HIGH RISK FOR SUICIDE most often causes sedation ​ Suicide is always a primary consideration when ​ If the client forgets a dose of an SSRI, they can take it treating clients with depression up to 8 hours after the missed dose. ​ SSRIs, venlafaxine, nefazodone, and bupropion are ​ To minimize SE, clients generally should take cyclic often better choices for those who are potentially compounds at night in a single daily dose when suicidal or highly impulsive because they carry no risk possible. of lethal overdose in contrast to the cyclic compounds ​ If the client forgets a dose of a cyclic compound, they and the MAOIs. should take it within 3 hours of the missed dose or ​ SSRIs are effective only for mild and moderate omit the dose for that day. depression. Evaluation of the risk for suicide must ​ Clients should exercise caution when driving or continue even aftertreatment with antidepressants is performing activities requiring sharp, alert reflexes initiated until sedative effects can be determined. ​ takes weeks before the medications have a full ​ Clients taking MAOIs need to be aware that a therapeutic effect, clients may become discouraged life-threatening hyperadrenergic crisis can occur if they do not observe certain dietary JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 12  restrictions.-should receive a written list of foods to avoid while taking MAOIs. ​ Educate patients on the possible risks when taking MAOIs and instruct them not to take an additional medication unless consulted or approved by physician. ANTIANXIETY DRUGS (ANXIOLYTICS) ​ among the most widely prescribed medications today ​ used to treat anxiety and anxiety disorders, insomnia, obsessive-compulsive disorder (OCD), depression, posttraumatic stress disorder, and alcohol withdrawal ​ Benzodiazepines have proved to be the most effective in relieving anxiety and are the drugs most frequently prescribed. May also be prescribed for their anticonvulsant and muscle relaxant effects ​ Buspirone is a nonbenzodiazepine often used for the relief of anxiety SIDE EFFECTS ​ one chief problem encountered with the use of benzodiazepines is their tendency to cause physical dependence. ​ Significant discontinuation symptoms occur when the drug is stopped; these symptoms often resemble the original symptoms for which the client sought treatment. ​ This is especially a problem for clients with long-term benzodiazepine use, such as those with panic disorder or generalized anxiety disorder ​ Psychological dependence on benzodiazepines is common; clients fear the return of anxiety symptoms or believe they are incapable of handling anxiety without the drugs. ​ This can lead to overuse or abuse of these drugs. Buspirone does not cause this type of physical dependence ​ Side effects most commonly reported with benzodiazepines are those associated with CNS depression, such as drowsiness, sedation, poor coordination, and impaired memory or clouded sensorium ​ When used for sleep, clients may complain of next-day sedation or a hangover effect. Clients often develop a tolerance to these symptoms, and they generally decrease in intensity. ​ Common side effects from buspirone include dizziness, sedation, nausea, and headache ​ Elderly clients may have more difficulty managing the effects of CNS depression. They may be more prone to falls from the effects on coordination and sedation. They may also have more pronounced memory deficits and may have problems with urinary incontinence, particularly at night. JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 13  CLIENT TEACHING ​ Clients need to know that antianxiety agents are aimed at relieving symptoms such as anxiety or insomnia but do not treat the underlying problems that cause the anxiety ​ Benzodiazepines strongly potentiate the effects of alcohol; one drink while on a benzodiazepine may have the effect of three drinks- NO ALCOHOL ​ Clients should be aware of decreased response time, slower reflexes, and possible sedative effects of these drugs when attempting activities such as driving or going to work. ​ Benzodiazepine withdrawal can be fatal. After the client has started a course of therapy, he or she should never discontinue benzodiazepines abruptly or without the supervision of the physician MOOD STABILIZING DRUGS ​ used to treat bipolar disorder by stabilizing the client’s mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania ​ Lithium is the most established mood stabilizer ​ some anticonvulsant drugs, particularly carbamazepine (Tegretol) and valproic acid (Depakote, Depakene), are effective mood stabilizers ​ Other anticonvulsants, such as gabapentin (Neurontin), topiramate (Topamax), oxcarbazepine (Trileptal), and lamotrigine (Lamictal), are also used for mood stabilization ​ Occasionally, clonazepam (Klonopin) is also used to treat acute mania. MECHANISM OF ACTION ​ Although lithium has many neurobiologic effects, its mechanism of action in bipolar illness is poorly understood. Considered a first-line agent in the treatment of bipolar disorder ​ normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. Also reduces the release of norepinephrine through competition with calcium and produces its effects intracellularly rather than within SIDE EFFECTS neuronal synapses; it acts directly on G-proteins and certain enzyme subsystems such as cyclic adenosine ​ Common side effects of lithium therapy include mild monophosphates and phosphatidylinositol nausea or diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, a metallic taste in the mouth, and fatigue or lethargy. ​ Weight gain and acne are side effects that occur later in lithium therapy; both are distressing for clients ​ Toxic effects of lithium are severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination. Untreated, these symptoms worsen and can lead to renal failure, coma, and death. When toxic signs occur, the drug should be discontinued immediately. If lithium levels exceed 3 mEq/L, dialysis may be indicated ​ mechanism of action for anticonvulsants is not clear because it relates to their off-label use as mood stabilizers ​ Valproic acid and topiramate are known to increase the levels of the inhibitory neurotransmitter GABA. Both valproic acid and carbamazepine are thought to stabilize mood by inhibiting the kindling process.- JULIANNA G. JOVENIR ♡ XANDRIXMIL ANGELOU PRIETO 14  can be described as the snowball-like effect seen STIMULANTS when minor seizure activity seems to build up into ​ specifically amphetamines, were first used to treat more frequent and severe seizures. psychiatric disorders in the 1930s for their ​ In seizure management, anticonvulsants raise the pronounced effects on CNS stimulation. level of the threshold to prevent these minor seizures. ​ In the past, they were used to treat depression and It is suspected that this same kindling process may obesity, but those uses are uncommon in current also occur in the development of full-blown mania with practice stimulation by more frequent minor episodes. This ​ Dextroamphetamine(Dexedrine) has been widely may explain why anticonvulsants are effective in the abused to produce a high or to remain awake for long treatment and prevention of mania as well. periods. Today, the primary use of stimulants is for ADHD in children and adolescents, residual attention-deficit disorder in adults, and narcolepsy (attacks of unwanted but irresistible daytime sleepiness that disrupt the person's life). MECHANISM OF ACTION ​ Amphetamines and methylphenidate are often termed indirectly acting amines because they act by causing release of the neurotransmitters (norepinephrine, dopamine, and serotonin) from presynaptic nerve terminals as opposed to having direct agonist effects on the postsynaptic receptors ​ They also block the reuptake of these neurotransmitters. ​ Carbamazepine is available in liquid, tablet, and ​ Atomoxetine helps block the reuptake of chewable tablet forms. Dosages usually range from norepinephrine into neurons, thereby leaving more of 800 to 1,200 mg/day; the extreme dosage range is the neurotransmitter in the synapse to help convey 200 to 2,000 mg/day electrical impulses in the brain ​ Valproic acid is available in liquid, tablet, and capsule forms and as sprinkles with dosages ranging from DOSAGE 1,000 to 1,500 mg/day; the extreme dosage range is 750 to 3,000 mg/day. ​ narcolepsy in adults both dextroamphetamine and ​ Serum drug levels, obtained 12 hours after the last methylphenidate are given in divided doses totaling dose of the medication, are monitored for therapeutic 20 to 200 mg/day levels of both these anticonvulsants. ​ Stimulant medications are also available in ​ Lithium Toxicity is closely related to serum lithium sustained-release preparations so that once-a day levels and can occur at therapeutic doses. Facilities dosing is possible. Tolerance is not seen in persons for serum lithium determinations are required to with ADHD monitor therapy. ​ ADHD in children- dosages vary widely depending on ​ Valproic Acid and Its Derivatives Can cause the physician; the age, weight, and behavior of the hepatic failure, resulting in fatality. Liver function tests child; and the tolerance of the family for the child’s should be performed before therapy and at frequent behavior intervals thereafter, especially for the first 6 months. ​ Arrangements must be made for the school nurse or Can produce teratogenic effects such as neural tube another authorized adult to administer the stimulants defects (e.g., spina bifida). Can cause life-threatening to the child at school. Sustained release preparations pancreatitis in both children and adults. Can occur eliminate the need for additional dosing at school. shortly after initiation or after years of therapy ​ Carbamazepine Can cause aplastic anemia and SIDE EFFECTS agranulocytosis at a rate five to eight times greater ​ most common: anorexia, weig