PH 11 Drug Therapy for Mental Health.pdf

10 Drug Therapy for Mental Health LEARNING OUTCOMES 1. List the names, actions, possible side effects, and adverse effects of drugs for anxiety and sleep. 2. Explain what to teach patients and families about drugs for anxiety and sleep. 3. List the names, actions, possible side effects, and adverse...

10 Drug Therapy for Mental Health LEARNING OUTCOMES 1. List the names, actions, possible side effects, and adverse effects of drugs for anxiety and sleep. 2. Explain what to teach patients and families about drugs for anxiety and sleep. 3. List the names, actions, possible side effects, and adverse effects of typical and atypical antipsychotic drugs. 4. Explain what to teach patients and families about typical and atypical antipsychotic drugs. 5. List the names, actions, possible side effects, and adverse effects of antidepressant drugs and mood stabilizers. 6. Explain what to teach patients and families about antidepressant drugs and mood stabilizers. KEY TERMS anxiolytic (p. 188) A description for any drug that can reduce anxiety. atypical antidepressants (p. 196) Drugs that affect the neurotransmitters dopamine, norepinephrine, and/or serotonin to help reduce depression. atypical antipsychotics (p. 193) These drugs are usually a combination of dopamine and serotonin (5-HT) blockers used to reduce positive symptoms and improve negative symptoms of some types of psychosis without causing severe extrapyramidal effects. benzodiazepines (BNZs) (p. 185) A class of sedating-hypnotic drugs that depresses the central nervous system (CNS) by binding to benzodiazepine receptors, which then act with gamma-aminobutyric acid (GABA) receptors to enhance GABA effects. The results of these effects can reduce anxiety, induce sleep, and relax skeletal muscles depending on drug dose and concentration. benzodiazepine agonists (p. 185) Drugs that have a different chemical structure from the benzodiazepines (BNZs) but still bind strongly to BNZ receptors and act in the same ways as BNZs to initiate sleep and promote longer sleep with less risk for dependence. dopamine system stabilizers (DSSs) (p. 194) Drugs that affect dopamine and serotonin receptors slightly differently than other atypical antipsychotics. They partially activate dopamine 2 and 5-HT1A receptors and block 5-HT2A receptors. As a result, they have fewer motor side effects and adverse effects. 340 hypnotics (p. 185) Drugs that have the main purpose of promoting sleep by changing signals in the CNS and reducing responses to stimulation. Same as sedative. monoamine oxidase inhibitors (MAOIs) (p. 188) Drugs that inhibit the enzyme monoamine oxidase that is responsible for breaking down certain neurotransmitters, including dopamine, norepinephrine, and serotonin. Blocking this enzyme increases the available neurotransmitters and results in reduction of depressive symptoms. mood stabilizers (p. 204) Drugs used in treating patients with bipolar illness. They have a variety of actions that help to reduce the symptoms associated with mania, as well as improve the symptoms of depression. Several drugs in this category are also used as antiseizure drugs. nonphenothiazines (p. 190) Drugs that are chemically different from the phenothiazines but have similar actions, side effects, and adverse effects. phenothiazines (p. 190) Drugs that block transmission of dopamine at the dopamine receptors and other neurotransmitters at acetylcholine and alphaadrenergic receptors. These actions allow patients to receive the benefits of reducing positive symptoms but have significant side and adverse effects. sedatives (p. 185) Drugs that have the main purpose of promoting sleep by changing signals in the CNS and reducing responses to stimulation. Same as hypnotic. selective serotonin reuptake inhibitors (SSRIs) (p. 188) Drugs that act by inhibiting the cellular reuptake of serotonin, increasing the concentration of active serotonin that is available to bind to postsynaptic receptors and improve a patient's sense of well-being and reduce depression. serotonin norepinephrine reuptake inhibitors (SNRIs) (p. 188) This class of drugs inhibits the reuptake of both serotonin and norepinephrine, increasing the concentration of both neurotransmitters available to postsynaptic receptors. These actions can improve a patient's sense of well-being and reduce depression. tricyclic antidepressants (TCAs) (p. 196) Older drugs used to reduce depression. The precise action is not known, but they are thought to interfere with the reuptake of norepinephrine and serotonin. typical antipsychotics (p. 190) These drugs are thought to block dopamine 2 (D2) receptors in the brain. The blocking of dopamine receptors can help treat the positive symptoms of psychosis such as with schizophrenia (e.g., hallucinations and delusions). Blocking dopamine can also result in a variety of side and adverse effects, including pseudoparkinsonism and other extrapyramidal symptoms. Drug Therapy and Mental Illness Before we talk about mental illness, we need to think about the concepts of mental health and mental illness. According to the World Health Organization, mental health is a state of well-being and includes the ability to cope with normal life 341 stresses, to work productively, to be aware of personal abilities, and to contribute to the community. A person's mental health is influenced by a variety of factors including environment, culture, economic status, as well as biological factors. Mental illness is a condition in which an individual experiences significant changes in the ability to think, as well as changes in behaviors and emotions. The person often has difficulty in coping with normal stressors, interacting with others, and otherwise functioning within his or her own cultural norms. Bookmark This! The National Alliance for Mental Illness is a wonderful resource for caregivers, patients, and families: https://www.nami.org/. You can access information that can be helpful to you and your agency. You may even have a local group that provides support groups for your patients and their families. Rather than categorizing any individual as having mental health or mental illness, it is important to consider the mental health/illness continuum (Fig. 10.1). At any given time, we may be coping very well with normal stressors, but at a later time a significant life event can trigger emotional problems or concerns. In contrast, some people experience far greater emotional problems or concerns to common normal stressors and have marked distress or impairment. This more severe impairment is consistent with mental illness. FIG. 10.1 The mental health and mental illness continuum. (From University of Michigan: Understanding U. In What is mental health? 2007. Retrieved from http://www.hr.umich.edu/mhealthy/programs/mental_emotional/understandingu/learn/mental_health.html.) https://hr.umich.edu/sites/default/files/resource_guide_final.pdf According to the National Institute of Mental Health, nearly 18% of the adult population experiences some degree of mental illness, and about 4% suffer from serious mental health problems. Fortunately, as we learn more about the brain, drug therapy is able to reduce some of the suffering associated with living with mental illness. As you learned in Chapter 9, chemical neurotransmitters have important roles in transmitting messages between the brain and other areas of the nervous system. A 342 number of neurotransmitters are involved in memory, mood, and affect. A basic understanding of what these neurotransmitters do will help you to understand how drugs impact your patients. The main neurotransmitters affected by psychiatric drugs include serotonin, dopamine, norepinephrine, as well as gamma-amino butyric acid (GABA), acetylcholine, and histamine. Table 10.1 provides a basic description of these neurotransmitters and how they typically affect mental health and mental illness. This chapter focuses on drugs that are related to sleep, anxiety, depression, and other mood disorders, as well as psychosis. Table 10.1 Examples of Neurotransmitters and Their Function in Mental Health NEUROTRANSMITTER AFFECTS POSSIBLE CHANGES IN MENTAL HEALTH AND ILLNESS Norepinephrine Decreased in depression Serotonin Dopamine Gamma-Aminobutyric acid (GABA) Acetylcholine Sympathetic nervous system (fight-or-flight response) Alertness and arousal Sleep, appetite, pain, mood Learning, movement, motivation and drive, attention, pleasure and reward Inhibitory neurotransmitter Sleep, muscle tension, sedation Parasympathetic nervous system (rest or repose) Decreased in depression Increased in schizophrenia Decreased in anxiety Decreased in Alzheimer's disease Drugs for Sleep and Anxiety Sedatives-Hypnotics Sleep is a state of rest for the mind and body in which conscious awareness is reduced partially or completely. Sufficient amounts of sleep are needed daily to restore energy levels and promote optimum mental and physical functioning. Adults vary in how much sleep any one person needs daily, and whether it must occur over a 6- to 8-hour time or can occur over multiple shorter times throughout the day. Most adults have experienced occasions when they either cannot get to sleep or do not remain asleep during an expected time period. This problem is known as insomnia. Many people have occasional insomnia, but others struggle with this problem almost daily. When sleep is insufficient for adequate rest, all aspects of functioning are affected. Areas of obvious impairment include learning, remembering, concentration, judgment, reaction time, coordination, and general social interactions. You probably have been around someone who is sleep-deprived or have had this problem on occasion yourself. People who suffer from sleep deprivation may feel irritable, impatient, or unable to concentrate. People who have chronic insomnia usually require a more complex behavioral and pharmacologic approach to help the problem. For those who have intermittent problems with insomnia, drug therapy can be helpful. Sedatives are drugs that have the main purpose of promoting sleep by changing signals in the central nervous system (CNS) and reducing responses to stimulation. Hypnotic is another term for the same action as sedative. At times, people may also use or be prescribed one of many other drugs that have a side effect of sedation, such as antihistamines or muscle relaxants. This discussion is focused only on sedatives. Action and Uses 343 The two main drug categories prescribed for sleep are the benzodiazepines (BNZs) and benzodiazepine agonists (BNZ agonists, also called non-benzodiazepines). BNZs are sedating-hypnotic drugs that depress the CNS by binding to BNZ receptors that act with gamma-aminobutyric acid (GABA) receptors to enhance GABA effects, resulting in sleep and muscle relaxation. Sleep begins in a shorter time after going to bed, and total sleep time is increased. Recall from Chapter 9 that GABA is an inhibitory neurotransmitter, so when GABA receptors are stimulated, CNS activity is reduced. Depending on which type of BNZ receptor a specific BNZ binds to, other responses include reduced seizure activity and reduced anxiety. So depending on dose, drug concentration, and added chemicals, specific drugs from the BNZ class are approved for use as sedatives, but not to relieve anxiety. Others are approved to reduce anxiety but are not approved for sedation. BNZ agonists have a different chemical structure from the BNZs but still bind strongly to BNZ receptors and act in the same ways. These drugs are more specific for sedative effects and have less muscle-relaxing or antiseizure actions. Table 10.2 lists the names, adult dosages, and nursing implications for the most common BNZ and BNZ agonists prescribed to induce sleep. Table 10.2 also lists the BNZs most commonly used to reduce anxiety. Check with a drug reference guide or a pharmacist for information about other sedative-hypnotic drugs. Table 10.2 Examples of Common Drugs for Sleep and Anxiety DRUGS FOR SLEEP Benzodiazepines approved for sleep: drugs that induce and prolong sleep or reduce anxiety by binding to benzodiazepine receptors to enhance the inhibitory effects of GABA and make the CNS less responsive to stimuli DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS estazolam 0.5–2 mg orally at bedtime • Teach patients not to take sedatives with alcohol or any other CNS depressant to avoid flurazepam 15–30 mg orally at bedtime severe CNS depression, coma, or death. temazepam (Restoril) 7.5–15 mg orally at bedtime. Maximum • Ask women if they are pregnant because these drugs have a high risk for causing birth dose is 30 mg defects. • Tell patients not to drive, operate dangerous equipment, or make serious decisions while under the influence of these drugs because impaired judgment and memory are possible. • Tell patients to only take the drug if they have sufficient sleep time available, to prevent confusion and other effects while awake. Benzodiazepine agonists: drugs that have a different chemical structure from BNZs and act as agonists at the BNZ receptors to induce and prolong sleep or reduce anxiety by enhancing the inhibitory effects of GABA and making the CNS less responsive to stimuli DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS eszopiclone (Lunesta) 1–3 mg orally at bedtime • Suggest that patients have a family member or close friend with them when they first lorazepam (Ativan) 2–4 mg orally at bedtime start taking the drug because incidences of sleep-walking, sleep-eating, and sleepzaleplon (Sonata) 5–20 mg orally at bedtime driving have occurred. zolpidem (Ambien) 5–10 mg orally at bedtime • Tell patients not to drive, operate dangerous equipment, or make serious decisions while under the influence of these drugs because impaired judgment and memory are possible. • Teach patients that eszopiclone may cause a metallic taste in the mouth. • Teach patients not to take sedatives with alcohol or any other CNS depressant to avoid severe CNS depression, coma, or death. • Tell patients to only take the drug if they have sufficient sleep time available, to prevent confusion and other effects while awake. • Report agitation to the healthcare provider as this may be a side effect of eszopiclone. • Monitor patient's level of consciousness carefully because higher doses can lead to greater risk of daytime memory impairment and decreased alertness. DRUGS FOR ANXIETY Benzodiazepines approved for anxiety: drugs that induce and prolong sleep or reduce anxiety by binding to BNZ receptors to enhance the inhibitory effects of GABA and make the CNS less responsive to stimuli DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS alprazolam (Xanax) 0.25–0.5 mg orally two to three times per • These drugs may cause drowsiness, so advise patients to avoid driving, operating any day; maximum of 4 mg/day in divided doses; often used heavy machinery, or making any important decisions while taking these drugs. PRN • Provide patients with the call light and remind them to ask for help if getting out of bed diazepam (Valium) 2–10 mg orally two to four times per day because these drugs can cause dizziness and drowsiness. IM: 2–5 mg for moderate anxiety; for severe anxiety, 5–10 • Patients who are taking these drugs should be assessed using your agency fall risk mg, may repeat in 3–4 hours if necessary protocols because these drugs increase the risk for falls. lorazepam (Ativan) initially, 1–3 mg/day orally given in two • These drugs are intended for short-term use because they can cause physical to three divided doses; usual dose is 2–6 mg daily in dependence. Notify the healthcare provider if you have a patient admitted to your divided dose; maximum dose is 10 mg/day facility who has been using these drugs for more than 2–4 weeks. • Teach patients who have been taking BNZs for more than 2–3 weeks not to stop them 344 suddenly to avoid physical withdrawal symptoms. If they need to discontinue, they may require gradual and individualized taper. • BNZs should not be used in older adults because they are known to increase the risk for falls and mortality. • Assess your patients for any history of alcohol or other substance use disorder because they are at increased risk for BNZ dependence. • Teach the patient to avoid using nicotine products (such as cigarettes or chewing tobacco) or drinking caffeinated beverages (e.g., coffee, tea, and cola) because they can decrease the effect of anxiolytic drugs. DRUGS FOR Anxiety Miscellaneous benzodiazepine agonists approved for anxiety: newer drugs that reduce anxiety through a variety of actions that affect the serotonin and dopamine neurotransmitters DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS buspirone (BuSpar) usual dose is 15–30 mg/day given in two • Teach patients to avoid driving or operating machinery until they are certain that to three divided doses; maximum dose is 60 mg/day buspirone does not cause them to feel sleepy or dizzy. • Tell patients that the drug may be taken with or without food but should be taken the same way each time to avoid inconsistency in the dosage. • Remind patients to avoid eating grapefruit or drinking grapefruit juice while taking buspirone because it can increase the effect of the drug. BNZ, Benzodiazepine; GABA, gamma-aminobutyric acid. Expected Side Effects and Adverse Reactions Both classes of sedatives can cause mild daytime drowsiness and some memory loss. Both drug classes are metabolized by the liver and should not be used by anyone who has a liver disorder or impairment. The BNZs have a higher risk for addiction and dependency than do BNZ agonists. They also carry a black box warning for CNS depression. Overdoses are possible and serious. These drugs have a high risk for causing birth defects. BNZ agonists have been found to induce physical activity during sleep for some people. Such activities include sleep-walking, sleep-eating, and even sleep-driving— all without the person's awareness or remembrance of the action! Lifespan Considerations Pregnancy Pregnancy is an absolute contraindication for the BNZs because they have a high risk for causing birth defects. Although the chemical structure of the BNZ agonists is different, these drugs bind to the same receptors and have similar actions. As a result, they are not recommended during pregnancy. Drug Interactions Caffeine reduces the effectiveness of sedative drugs from both classes. The BNZs interact with any drug that causes CNS depression and can make the depression deeper, which can lead to death. Other drugs known to increase the action of the BNZs and the BNZ agonists include cimetidine, fluoroquinolone antibiotics, some oral contraceptives, and many others. Be sure to consult a drug reference or a pharmacist to avoid possible drug interactions. Top Tip for Safety The drug flumazenil (Romazicon) is a BNZ receptor antagonist and is an antidote used to reverse an overdose of either a BNZ sedative or a BNZ agonist sedative. For 345 adults, it is given intravenously with an initial dose of 0.2 mg. If there is no response after 45 seconds, the dose can be repeated. After that, it can be repeated every minute for a total of four doses. Nursing Implications and Patient Teaching Assessment. Ask the patient about all other drugs he or she takes, including over-the-counter drugs, to determine whether there are any other drugs that depress the CNS. Assess the patient's level of consciousness and ask whether he or she has a history of depression, confusion, falls, and pain. Also ask about common use of alcohol. These drugs should not be taken with any type of alcoholic beverage. Ask whether a woman of childbearing age may be pregnant. These drugs should not be used during pregnancy. Evaluation. Usually, sedatives begin to take effect in 15 to 30 minutes. Check the patient (without waking him or her) at this time for drug effectiveness and for changes in respiratory rate and depth. If this is the patient's first time taking a sedative, recheck at least hourly for about 4 hours and assess for any unusual reactions, especially sleepwalking or other activity. Patient and family teaching. Tell the patient and family the following: • Take these drugs for no longer than 2 to 3 weeks and only when needed, to avoid physical or psychological dependency. • Only take a drug for sleep if you have at least 5 to 6 hours immediately available to sleep, to avoid excessive drowsiness when you are supposed to be awake. • Do not drive, operate dangerous equipment, or make important decisions while under the influence of these drugs because they may alter your ability to reason clearly. • Do not take a sedative with alcohol or any other drug that depresses the CNS, to prevent severe side effects, coma, and death. • Do not take any other drug without the approval of your healthcare provider, to avoid dangerous 346 interactions. • When taking a BNZ agonist, be aware that drugs from this class can cause you to be physically active at night, even going for a drive, without your knowledge or memory of the event. It is best to have a family member or friend watch out for these effects when you first start taking the drug. • Report any new or unusual side effects to your healthcare provider. • Drinking excessive amounts of caffeinated beverages can reduce the effectiveness of the sedative. Antianxiety Drugs We can all identify with feelings of anxiety at certain times in our lives. We may describe it in terms of feelings of unease, worry, or apprehension. When we are anxious, we may experience both physical and behavioral symptoms. Perhaps our heart rate rises and we may feel a headache or breathe a little more rapidly. In some cases we may find ourselves being a little more irritable, pacing, or our muscles feel tense. These are all symptoms of anxiety. Anxiety is very common, particularly in times when you feel a little more stress. Anxiety can be mild, moderate, or severe depending on the situation. A person who has chronic or disabling anxiety may be experiencing an anxiety disorder. Advanced practice nurses or healthcare providers may diagnose the patient with the anxiety disorder. Examples include general anxiety disorder, social anxiety disorder, panic disorder, obsessive-compulsive disorder, or posttraumatic stress disorder. Although detailed discussion of each of these disorders is beyond the scope of this text, many can be well managed with a combination of nonpharmacologic strategies (including counseling) and pharmacologic therapy. Major categories of antianxiety agents (also called anxiolytics) include BNZs, BNZ agonists, and certain antidepressants (selective serotonin reuptake inhibitors [SSRIs] and serotonin norepinephrine reuptake inhibitors [SNRIs]). In general, the choice of drug varies according to the need of the patient, including whether the anxiety is an acute or a chronic condition. Action and Uses The BNZ and BNZ agonist classes of drugs for sedation (discussed earlier) can also be used as anxiolytics. These drugs act with GABA receptors to enhance GABA effects leading to a reduction in anxiety and decrease in muscle tension. BNZs are recommended primarily for short-term use, such as during alcohol withdrawal before a patient has surgery. They generally should not be prescribed on a PRN basis because irregular use can actually cause an increase in anxiety with variation in blood drug levels. Long-term use of BNZs can result in physical dependence and withdrawal symptoms if the drug is stopped suddenly. 347 A newer drug from the BNZ agonist class, buspirone, reduces anxiety through a variety of actions that affect the serotonin and dopamine neurotransmitters. This results in a decrease of anxiety, muscle tension, sweating, and rapid heart rate. The onset of the anxiolytic effect is slower than with the BNZs and may take 1 to 2 weeks. Maximal effects of buspirone may take up to 3 to 6 weeks. This drug can reduce anxiety without the risk for physical dependence and the sedation that is often associated with BNZ drugs. Certain drugs often considered antidepressants are commonly used to relieve symptoms of anxiety. A number of SSRIs and SNRIs are also effective in a variety of anxiety disorders. These drugs will be discussed in more detail in the section on mood disorders. Expected Side Effects and Adverse Reactions The expected side effects and adverse reactions are very similar to those presented in the section on sleep. BNZs and BNZ agonists may cause some drowsiness and memory loss when used for anxiety. Other side effects include dizziness, headache, or hypotension. Adverse effects include confusion, apnea, and seizures. Remember, the BNZs have a higher risk for addiction and dependency than the BNZ agonists. Drug Interactions Do not give BNZs to patients who are taking sodium oxybate (a drug specifically prescribed for narcolepsy, a sleep-wake disorder). This combination can result in serious respiratory depression, even coma. Avoid giving BNZs to patients who are taking opioids or any other drug that can result in CNS depression. Do not give buspirone with monoamine oxidase inhibitors (MAOIs), opioids, or drugs for tuberculosis. Drinking grapefruit juice can significantly increase the blood levels of buspirone, which increases the risk for adverse reactions. Nursing Implications and Patient Teaching Assessment. Check vital signs, including blood pressure, heart rate, and respiratory rate, before giving the drug. Patients with a history of lung, liver, or kidney problems may be more sensitive to the effects of the drug. Assess the mental status of the patient before giving the drug. Is he or she oriented to time, place, and person? If not oriented, contact the healthcare provider before giving the drug. Assess the patient for any history of alcohol or other chemical dependency because there is an increased risk for BNZ dependence. This is less likely with the BNZ agonists. Ask patients to describe their feelings of anxiety to determine effectiveness after you have given the drug. Lifespan Considerations Older Adults 348 BNZs are not recommended to treat insomnia, agitation, or delirium in patients 65 years or older, and they are avoided in all patients with cognitive impairment, dementia, or a history of falls or fractures. Planning and implementation. Many BNZs have a rapid onset and short duration of action, requiring multiple doses per day. They can be used very effectively for patients with acute anxiety or panic attacks. Buspirone, a BNZ agonist, and other antidepressants used for anxiety have much longer onsets of action and may take several weeks for the patient to notice an effect. Monitor the patient for side effects of drowsiness or dizziness because these can cause an increased risk for falls. Report any changes in mental status, such as confusion or agitation, to the registered nurse (RN) or healthcare provider. If patients have respiratory depression after BNZ use, flumazenil (Romazicon), a BNZ receptor antagonist, can quickly reverse the effects. For long-term mental health, nonpharmacologic therapies such as counseling, mindfulness training, yoga, or other interventions are essential. Provide the patient and their family with information for local resources including crisis lines, support groups, and websites such as the National Association of Mental Illness (NAMI). Evaluation. Ask the patient whether he or she has experienced any relief from anxiety. Explore how the drug affects the ability to focus, make decisions, and function. If the patient is still having symptoms, contact the healthcare provider for next steps. If the patient has been using BNZs for more than 2 to 4 weeks, suddenly stopping the drug will result in severe withdrawal symptoms including panic, vomiting, sweating, abdominal and muscle cramps, and even seizures. The risk for seizures is greatest during the first 24 to 72 hours after starting to withdraw the drug. Slow tapering of the drug dosage can decrease the risk of the withdrawal symptoms. Patient and family teaching. Tell the patient and family the following: • Take this drug exactly as prescribed. Withdrawal symptoms can occur if the drug is used for longer than 2 to 4 weeks. If used for longer than that time, contact your healthcare provider because you will need to taper the dosage. • Do not use this drug if you are pregnant or breastfeeding because the effects can be passed to the fetus or infant. • Avoid drinking grapefruit juice while taking these drugs because it may cause an increase in effect. 349 • Avoid driving, operating hazardous machinery, or performing activities that require alertness until your response to the drug has been determined. • Change positions slowly to minimize dizziness that may occur. • Avoid drinking alcohol with these drugs to reduce the risk for severe sedation and respiratory depression. • Do not use nicotine products (such as cigarettes or chewing tobacco) or drink caffeinated beverages (e.g., coffee, tea, and cola) because these can decrease the effect of anxiolytic drugs. Antipsychotics Before we discuss antipsychotic drugs, we need a good understanding about what we mean when we use the term psychosis. In general, psychosis involves a loss of contact with reality. How the psychosis occurs and the types of symptoms produced may vary. Psychosis may develop over a few hours or days (usually called delirium), or over months or years such as in schizophrenia. It is important to distinguish between acute psychosis (as in delirium) and chronic psychosis (as in schizophrenia or bipolar illness) because you can see both conditions in your clinical practice. Delirium is considered an acute condition; patients experience a sudden change in their awareness and attention that is related to problems in the brain. Delirium can occur in a patient who has previously been alert and oriented but has come in for surgery or taken a new drug. It can also occur in a patient who has been diagnosed with dementia who suddenly has a change in symptoms after being moved from his or her home into a new setting. Family may notice before you do as a nurse that the patient is confused or “different.” The previously calm patient may be trying to pull out tubes or get out of bed without help. The patient is suddenly agitated and confused, or may be unable to focus or may seem frightened. The patient's awareness can change over the course of the day —sometimes oriented, sometimes confused. He or she often may have more symptoms at night. We may think that because it is often temporary that it is not a big problem. Unfortunately, delirium can increase patient length of stay, mortality, and the risk for falls. Patients with chronic mental illnesses such as schizophrenia have symptoms that increase over a long period. In fact, it may be months or even years before the patient is accurately diagnosed. Families and friends may notice changes in behavior but may not be fully aware of the problems until the person has delusions and hallucinations. Many of these symptoms can be effectively managed with antipsychotic drugs and other therapies. This chapter predominantly reviews drugs that are used in patients with mental illness. Drugs that can be used in delirium may be mentioned, but the focus is on drugs for chronic mental illnesses. 350 In the past, antipsychotic drugs were used in patients with dementia. And while patients with dementia may exhibit confusion or agitation, use of antipsychotic drugs in these patients can cause an increased risk for stroke, a greater rate of cognitive impairment (decline in ability to think and remember), and even mortality. Symptoms of psychosis are classified as positive symptoms and negative symptoms (Box 10.1). This can be a bit confusing because we often think of positive as “good” and negative as “bad.” In mental health, the positive symptoms of psychosis are those that add to the person's normal behaviors. Positive symptoms include hallucinations (e.g., seeing things, hearing voices), delusions (e.g., ideas that they have special powers or are famous people), disorganized thoughts or speech (e.g., jumbled ideas or words that do not make sense to the listener). These are the conditions that we may think about right away when we hear the term psychotic. Negative symptoms are slightly different. These are the symptoms that subtract from the person's normal behavior. For example, negative symptoms include poor hygiene, difficulty with social relationships, lack of interest in activities, or lack of motivation. Box 10.1 Examples of Positive and Negative Symptoms Associated With Schizophrenia POSITIVE SYMPTOMS (SOMETHING THAT IS PRESENT THAT IS NOT NORMALLY PRESENT) NEGATIVE SYMPTOMS (SOMETHING THAT IS ABSENT THAT IS USUALLY PRESENT) Hallucinations (visual or auditory) Delusions (holds a belief without any evidence) Disordered thinking (unusual ways of thinking, speaking) Lack of motivation Flat affect (decreased facial expression or tones with emotion) Decrease in personal hygiene Lack of social interest Agitation or other bizarre behavior Drugs that treat symptoms of psychosis are grouped into two main categories: typical antipsychotics and atypical antipsychotics. These drugs are presented in reference for their use in the psychosis associated with schizophrenia. Typical Antipsychotic Drugs Action and Uses The typical antipsychotics are the first generation of this drug type. In general, these drugs treat the positive symptoms of psychosis. They appear to block dopamine 2 (D2) receptors in the brain. Blocking of dopamine receptors helps treat the positive symptoms of psychosis such as hallucinations and delusions. They do not affect the negative symptoms. Schizophrenia is considered to be a disease of overstimulation of dopamine receptors from the presence of too much dopamine (remember, Parkinson's disease is too little dopamine). The typical antipsychotic blocks dopamine; thus it can treat the positive symptoms but also creates a series of side and adverse effects including pseudoparkinsonism and other extrapyramidal symptoms (EPSs). Normally the extrapyramidal system, the part of the nervous system involved in movement, helps 351 ensure smooth or flowing movements of the body. EPSs, then, are associated with disordered movements. The two main categories of typical antipsychotics are the phenothiazines and the nonphenothiazines. Phenothiazines block transmission of dopamine at the dopamine receptors. They also block acetylcholine and alpha-adrenergic receptors. By blocking these receptors, the patients receive the benefits of reducing positive symptoms but have risks for significant side and adverse effects. The nonphenothiazines have a similar action but are chemically different from the phenothiazines. Side effects and adverse effects are basically the same. Which drug type is prescribed long term depends on the patient's responses. Table 10.3 lists the names, adult dosages, and nursing implications for the most common typical antipsychotic drugs. Check a drug reference or with a pharmacist for information about other typical antipsychotics. Table 10.3 Examples of Common Antipsychotic Drugs Typical antipsychotics: These drugs are thought to block D2 receptors in the brain. The blocking of dopamine receptors can help treat the positive symptoms of psychosis such as with schizophrenia (e.g., hallucinations and delusions). Blocking dopamine can also result in a variety of side effects and adverse reactions including pseudoparkinsonism and other extrapyramidal symptoms (EPSs). Phenothiazines: These drugs block transmission of dopamine at the dopamine receptors and other neurotransmitters at acetylcholine and alphaadrenergic receptors. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS chlorpromazine (Thorazine): for mild-to-moderate symptoms, 10 mg three • Recognize the signs of EPSs because many are severe and some may be to four times per day, or 25 mg two to three times per day orally, then irreversible. They can occur in as many as 10% of patients who take these adjusted to patients symptoms; IM: 25–50 mg every 4–6 hours. Higher drugs. doses may be required for severe symptoms. • Teach patients to avoid becoming dehydrated, participating in strenuous fluphenazine (Prolixin) exercise, or extremes in temperature because these drugs may affect the Oral dosage: 2.5–10 mg/day in divided doses; maximum dosage is 40 body's ability to regulate core body temperature. mg/day • Report sudden increases in blood pressure; increase in temperature and IM or subcutaneous dosage: the usual initial dose 12.5–25 mg IM or confusion may indicate signs of neuroleptic malignant syndrome. subcutaneously; maximum dosage is 100 mg as a depot injection; a • Know the specific onset of actions, peak effects, and durations when you single dose can last 3–6 weeks are giving these drugs. Some injectable drugs are used for rapid treatment of symptoms, whereas others are designed for long-term management. • Monitor changes in mental status with the healthcare team to determine the effectiveness of these drugs. • Teach the patient to avoid activities that require alertness particularly when first using the drug. This usually improves over time. Nonphenothiazines: These drugs have similar actions to the phenothiazines but are chemically different from the phenothiazines. Side effects and adverse effects are similar. Selection of drug is dependent on patient responses. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS haloperidol (Haldol) 0.5–5 mg orally two to three times per day depending • Recognize the signs of EPSs because many are severe and some may be on symptoms irreversible. They can occur in as many as 10% of patients who take these IM: doses of up to 2–10 mg IM every 4–8 hours. May also be given as a drugs. depot injection. • Teach patients to avoid becoming dehydrated, participating in strenuous exercise, or extremes in temperature because these drugs may affect the body's ability to regulate core body temperature. • Report sudden increases in blood pressure; increase in temperature and confusion may indicate signs of neuroleptic malignant syndrome. • Know the specific onset of actions, peak effects, and durations when you are giving these drugs. Some injectable drugs are used for rapid treatment of symptoms, whereas others are designed for long-term management. • Monitor changes in mental status with the healthcare team to determine the effectiveness of these drugs. • Teach the patient to avoid activities that require alertness particularly when first using the drug. Atypical antipsychotics: The majority of these drugs are a combination of dopamine and serotonin (5-HT) blockers. These drugs can reduce positive symptoms and improve negative symptoms without the severe extrapyramidal effects characteristic of the typical antipsychotics. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS risperidone (Risperdal) • Watch for signs and symptoms of extrapyramidal effects. This is less Initially 0.5–2 mg orally as a single or divided dose; Usual dosage is 4–16 common with atypical antipsychotics but must be monitored. mg/day orally • Teach patient about good nutrition and physical activity because these IM as depot drug 25–50 mg every 2 weeks drugs can cause weight gain. ziprasidone (Geodon) • Monitor blood sugars for patients with diabetes or those at risk for Initially 20 mg orally twice daily with food. Maximum of 80 mg orally diabetes because these drugs can increase blood sugar. twice daily with food. • Monitor vital signs because sudden changes in blood pressure or increase IM: 10–20 mg per dose; do not give IM dosage for more than 3 in temperature can indicate dangerous adverse effects. consecutive days. Maximum dose is 40 mg daily • Remind patients that they should not drink alcohol or take any sedating quetiapine (Seroquel) Initially 25 mg by mouth twice daily. May be drugs without talking to the healthcare provider. These drugs can cause increased to 300–400 mg in two to three divided doses daily. Maximum drowsiness or insomnia. dose is 800 mg daily. Extended release form (Seroquel XR): Initially at • Encourage patients to keep a diet high in fiber to avoid constipation 300 mg once daily in the evening. Maximum dose is 800 mg once daily. common with atypical antipsychotics. • For patients who have difficulty adhering to oral drug schedules, IM 352 depot drugs may allow less frequent dosing up to 2 weeks or even longer. • Work with healthcare team members to maintain a safe patient environment while they are experiencing symptoms of their psychosis. • Teach patients to avoid extremes in temperature because these drugs can affect the body's ability to adjust to changes in temperature. Dopamine system stabilizers: These drugs affect dopamine and serotonin receptors slightly differently than other atypical antipsychotics. They are partial D2 agonists and partial 5-HT1A agonists, 5-HT2A antagonists. As a result, they have fewer motor side and adverse effects. DRUG/ADULT DOSAGE RANGE aripiprazole (Abilify) 10–30 mg/day by mouth daily. IM: 30 mg/day for an immediate-release injection; 400 mg/month extended-release NURSING IMPLICATIONS • Teach patients that oral doses can be given with or without food. • Read drug information carefully when giving aripiprazole. In general the deltoid muscle can be used for IM doses ≤400 mg. Doses greater than 600 mg must be given in the gluteal muscles. Depending on the patient and dose, these drugs can be given every 6 weeks to 2 months. • See also nursing implications for atypical antipsychotics. D2, Dopamine 2; EPS, extrapyramidal symptom. Expected Side Effects and Adverse Reactions Expected side effects and adverse reactions of typical antipsychotics are primarily related to the blocking of key neurotransmitters. Examples of side effects include headache, drowsiness, nausea, constipation, and dry mouth. The main adverse effects are described as EPSs. These symptoms are related to the decrease in dopamine; many are severe and some may be irreversible, so it is important to recognize them very early in treatment. They can occur in as many as 10% of patients who take these drugs. The main EPSs are pseudoparkinsonism, acute dystonia, akathisia, and tardive dyskinesia. Fig. 10.2 describes these symptoms. FIG. 10.2 Characteristics of pseudoparkinsonism, acute dystonia, akathisia, and tardive dyskinesia. (From McCuistion LE, Yeager J, Winton M: Pharmacology, ed 9, St. Louis, 2017, Saunders.) Onset of EPSs varies, and treatment focuses on symptom management and altering the cause. Acute dystonia usually occurs within 1 to 4 days of the start of treatments. It is more common in younger men and patients who are taking large doses. It may be managed with anticholinergic drugs and BNZs. Akathisia usually develops several days to several weeks into therapy. Management may include decreasing drug dosage and/or adding a BNZ or beta blocker. Pseudoparkinsonism usually occurs 1 to 2 weeks after beginning antipsychotic therapy. It is more 353 common in women and older adults. Anticholinergics, antihistamines, and BNZs may be used to manage symptoms. Unlike the earlier onset of other EPSs, tardive dyskinesia can occur during long-term therapy or after stopping therapy. It occurs more frequently in older women. The disorder is characterized by involuntary movements of the tongue, jaw, mouth, or face. The patient's lips may be smacking, cheeks puffing, or other bizarre movements of the arms and shoulders. It is more likely to occur in patients with bipolar disorder than in patients with schizophrenia. These drugs may affect the body's ability to regulate core body temperature. The risk increases if patients become dehydrated, participate in strenuous exercise, or are in very hot environments. In rare cases, patients may experience hypothermia. This usually occurs in the presence of other risk factors such as hypothyroidism, brain injury, or cold environmental temperature. Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse effect. NMS is characterized by hyperpyrexia (an abnormally high body temperature above 104°F), confusion, changes in blood pressure (hypotension to hypertension), and EPSs, and can lead to coma and death. It occurs more often in men than women. Box 10.2 lists the common signs and symptoms associated with NMS. Box 10.2 Signs and Symptoms of Neuroleptic Malignant Syndrome • Sudden elevated temperature • Increased white blood cell count • Muscle rigidity • Unstable blood pressure • Elevated serum creatine kinase • Hyperkalemia Drug Interactions Typical antipsychotic drugs interact with a wide range of drugs including acetaminophen, diuretics such as furosemide or hydrochlorothiazide, certain calcium channel blockers, and several antidiabetic agents. Make sure to consult a pharmacist or other healthcare provider if you have any questions. Nursing Implications and Patient Teaching Assessment. Determine baseline level of consciousness. Is the patient agitated? Hallucinating? If you are in a behavioral health setting, you may be working with the RN who conducts a formal mental status exam. Components of the mental status exam include factors such as the patient's appearance, behavior, mood, affect, and thought 354 processes. This assessment is very helpful in determining a baseline to evaluate the effects of the drugs. Planning and implementation. Maintaining patient safety is vitally important in caring for patients who are experiencing psychosis. Whether the patient has acute delirium or chronic mental illness, the patient is at risk for injury to self or to others. Keeping the patient, caregivers, and others free from injury is a priority. As an LPN, you will work with other members of the healthcare team to keep the milieu (social environment or surroundings) safe and calm. Techniques for working with patients with psychosis is beyond the scope of this textbook, so make sure to consult professional resources in mental health, such as experienced mental health nurses, mental health nursing textbooks, or continuing education. Bookmark This! The National Institute of Mental Health is a great resource for nurses, patients, and families to learn more about mental health disorders: https://www.nimh.nih.gov. You can print or order free brochures, booklets, posters, and fact sheets for your agency. Monitor vital signs carefully for any significant changes. Increase in temperature or severe changes in blood pressure can indicate the severe adverse effect NMS. Recognize the classic characteristics of EPSs (see Fig. 10.2). Early recognition is essential in reducing the risk for long-term consequences. Any changes in motor function such as in muscle tone, gait, or fine motor movement can be warning signs of EPSs, especially tardive dyskinesia. Report these symptoms to the RN or healthcare provider immediately. Treatment often requires discontinuing the drug. In some cases, these problems are irreversible. Top Tip for Safety Recognize the classic characteristics of EPSs (see Fig. 10.2). Early recognition is essential in reducing the risk for long-term consequences. Know the specific onset of actions, peak effects, and durations when you are giving these drugs. Some oral injectable drugs are used for rapid treatment of symptoms, whereas others are designed for long-term management. For example, an oral form of haloperidol may take 4 to 6 hours for peak effects, whereas an oral form of chlorpromazine may take 6 weeks to 6 months for peak effects. A good understanding of these facts will help you to plan your care and recognize whether the drug is effective. Evaluation. Has the patient had any changes in mental status after beginning this drug? 355 Remember, these drugs affect only positive symptoms, so you may see a decrease in agitation, hallucinations, and delusions. Also note whether the patient has had any side effects from these drugs. For improvement in negative symptoms, the patient will need either addition of or substitution with atypical antipsychotics. In general typical antipsychotics are not used alone for an extensive period because of the possibility of EPSs. Patient and family teaching. Tell the patient and family the following: • Continue to take the drugs as prescribed even if you do not start feeling better right away. It may take several weeks before significant changes occur. Suddenly stopping these drugs can result in nausea, dizziness, and tremors. • Do not drink alcohol or use any sedatives while taking these drugs, to prevent deep sedation and other dangerous side effects. • Avoid activities that require alertness, particularly when first using the drug because these drugs can reduce clear thinking and induce drowsiness. This usually improves over time. • These drugs may affect your body's ability to adjust to changes in temperature. Avoid extremes of temperature, as well as situations that can affect your temperature, such as dehydration or strenuous exercise. • If you or your family member has difficulty remembering to take these drugs, check with your healthcare provider about long-acting injectable drugs. • These drugs may cause dryness of your mouth. You can try chewing sugarless gum, sucking on sugarless candy, or drinking sips of ice or water to reduce this sensation. • If you develop unusual muscle spasms or other types of movement problems, contact your healthcare provider right away. • Avoid getting liquid forms of these drugs on your skin 356 because they can cause irritation. • You can take many of these drugs with food to avoid GI upset. • Avoid using any herbal or other over-the-counter drugs without first checking with your healthcare provider because these can interact with your prescription drugs. • Wear a medical alert bracelet or carry a drug ID card to identify that you are taking these drugs. Atypical Antipsychotic Drugs Action and Uses Atypical antipsychotics are also known as second-generation antipsychotics. Whereas typical antipsychotics block the dopamine type 2 receptors in the brain, atypical antipsychotic drugs work in a variety of ways. Many block dopamine 2 or other subtypes of dopamine receptor, as well as certain subtypes of serotonin. They are used primarily for schizophrenia but also can be used for bipolar illnesses and schizoaffective disorder. The atypical antipsychotics have a lower risk for EPSs and have the benefit of treating the negative symptoms of psychosis, in addition to the positive symptoms (see Box 10.1) common in schizophrenia and some other mental illnesses such as bipolar disorder. Atypical antipsychotics are more commonly used for long-term management of chronic mental illnesses associated with psychosis. They are not recommended for any patient with psychosis from dementia. The newest category is called dopamine system stabilizers (DSSs). DSSs affect dopamine and serotonin receptors slightly differently than other atypical antipsychotics. They are partial dopamine 2 agonists and partial 5-HT1A agonists, 5HT2A antagonists. As a result they have even fewer motor side effects and adverse reactions. The DSSs can be used in schizophrenia and bipolar disorders. These drugs can also be used to relieve symptoms in some autistic disorders and in Tourette's syndrome. Table 10.3 lists the names, adult dosages, and nursing implications for the most common atypical antipsychotic drugs. Check a drug reference or with a pharmacist for information about other atypical antipsychotics. Memory Jogger Atypical antipsychotics are also known as second-generation antipsychotics. Expected Side Effects and Adverse Reactions The most common side effects of atypical antipsychotics are both insomnia and drowsiness. Although many drugs have sexual side effects, these are less common than with the typical side effects. Other common side effects include dizziness, 357 orthostatic hypotension, constipation, and dry mouth. A major advantage of atypical antipsychotics is significantly lower rates of EPSs than the typical antipsychotics. This means a reduced risk for adverse effects such as acute dystonia, akathisia, tardive dyskinesia, and pseudoparkinsonism. Although the risk is not totally eliminated, the reduced risk makes atypical antipsychotic drugs preferable to the typical antipsychotics in most situations. Weight gain is common with many of the atypical antipsychotics. Beyond the weight gain, hypertriglyceridemia (increase in blood triglycerides) and a risk for insulin resistance and diabetes type 2 are associated with these drugs. These changes can significantly increase the risk for cardiovascular problems, even death. Use caution in starting these drugs for patients with preexisting hypertension, heart or cerebrovascular diseases, heart failure, or any dysrhythmias. Atypical antipsychotic drugs can also affect the ECG, prolonging the QT interval (part of the cardiac cycle). This is very important for any patients with heart disease because it can result in severe cardiac dysrhythmias. One drug, clozapine, is associated with agranulocytosis (decreased white blood cell count). This can result in a significantly increased risk for infection, even death. As a result, clozapine is usually reserved for patients who do not experience symptom relief from other antipsychotics. Drug Interactions Atypical antipsychotics interact with a wide range of drugs. Drugs that decrease dopamine, such as metoclopramide or any typical antipsychotics, increase the risk for EPSs. Use of these drugs with any SSRI or an SNRI can increase the risk for serotonin syndrome (Box 10.3). Box 10.3 Signs and Symptoms of Serotonin Syndrome • Confusion • Agitation • Restlessness • Stomach disturbances/diarrhea • Sweating • Extremely high blood pressure • Seizures • Dilated pupils • Tremors Alcohol or other CNS depressants increase the sedating and nervous system side effects of these drugs. In addition, these drugs affect specific enzymes in the liver that metabolize drugs. Make sure to check your drug references and/or contact your agency pharmacist or the patient's healthcare provider for other interactions with 358 additional drugs the patient takes. Nursing Implications and Patient Teaching Assessment. It is important to determine baseline level of consciousness for any patient prescribed an antipsychotic drug. Work with the RN and other healthcare team members to determine the patient's mental status. This includes assessment of appearance, behavior, mood, affect, and thought processes. A good baseline assessment is essential to determining whether the drugs are effective. Determining baselines for vital signs, weight, and blood glucose is very important for patients beginning therapy with atypical antipsychotic drugs. These data are useful in looking for side or adverse effects the patient may experience. Thorough assessment for any history of hypertension, diabetes, cardiovascular or cerebral vascular diseases, or dysrhythmia is needed. Also note if the patient is taking any prescriptions, over-the-counter drugs, or herbal drugs. Planning and implementation. As addressed above with typical antipsychotics, maintaining patient safety is very important. Make sure to work with members of the healthcare team to keep the patient, caregivers, and others free from injury. Monitor the patient carefully for side effects and adverse effects. Sudden changes in vital signs such as drop in blood pressure or severe and sudden increase in temperature can be indicators of complications of drug therapy. For patients who are taking clozapine, monitor white blood cell counts. Fewer white blood cells can indicate a life-threatening complication of agranulocytosis. This significantly affects the patient's ability to fight infection. Risk for EPSs is much lower with use of atypical antipsychotics than with the typical antipsychotics, but it can still occur. It is important to recognize any change in fine motor movement, gait, or muscle tone as potential adverse effects. Report these to the healthcare provider immediately. Monitor the patient's weight on a regular basis because weight gain is a very common side effect of drug therapy. You may need to consult your agency dietician or RN to help patients find strategies for managing their weight. Atypical antipsychotics can cause dry mouth, so make sure the patient has good oral hygiene. Sugar-free gums or candies, ice chips, or sips of water may be helpful in moistening the mouth. Remind the patient to avoid extremes of cold or heat, because the drug may affect the area of the brain responsible for temperature regulation. Evaluation. Determine whether the patient has had any changes in mental status since beginning this drug. Be sure of the individual drug's onset of action. Many of these drugs can take several weeks before they have significant impact on patient behaviors. Also remember that these drugs can impact both positive and negative symptoms. Assess whether the patient has an increase in the ability to interact with others, interest in activities and hygiene, as well as whether there has been a reduction in the positive 359 symptoms of hallucinations and delusions. Patient and family teaching. Tell the patient and family the following: • Continue to take the drugs as prescribed even if you do not start feeling better right away. It may take several weeks before significant changes occur. Suddenly stopping these drugs can result in nausea, dizziness, and tremors. • Do not drink alcohol or use any sedatives while using these drugs, to avoid oversedation and other dangerous nervous system side effects. • Avoid activities that require alertness, particularly when first using the drug, because the drug increases drowsiness and interferes with clear thinking. This usually improves over time. • These drugs may affect your body's ability to adjust to changes in temperature. Avoid temperature extremes and situations that can affect your temperature such as dehydration or strenuous exercise. • If you (or your family member) has difficulty remembering to take these drugs, check with your healthcare provider about long-acting injectable drugs. • These drugs may cause dryness of your mouth. You can try chewing sugarless gum, sucking on sugarless candy, or drinking sips of ice or water to reduce this problem. • If you have unusual muscle spasms or other types of movement problems, contact your healthcare provider right away. • You can take many of these drugs with food to avoid GI upset. • Avoid using any herbal or other over-the-counter drugs without checking with your healthcare provider first because these can interact with your prescription 360 drugs. • Wear a medical alert bracelet or carry a drug ID card to identify that you are taking these drugs. Antidepressants and Mood Stabilizers Antidepressants Depression, whether mild or so severe that it interferes with activities of daily living (ADLs), has been recognized for centuries. Most people have days when they feel “down” or “blue.” Sometimes depressive symptoms are triggered by difficult situations such as the loss of a loved one or by experiencing a sudden illness, which are normal responses to these life-changing events. However, intense and prolonged inability to interact with others, go to work, and keep up with the ADLs, as well as loss of interest in pleasurable activities, represent more significant depression (Box 10.4 lists common depressive symptoms). Depressive symptoms can go on for weeks, even months. Risk factors for depression include a family history of depression, substance abuse, history of abuse, certain drugs, or chronic illnesses. Fig. 10.3 shows some examples of people with depression. Box 10.4 Symptoms of Depression ?