Psychopharmacology Notes PDF

PSYCHOPHARMACOLOGY PRESENTER: DR. O.DAVIDSON BROWN’S TOWN COMMUNITY COLLEGE NURSING DEPARTMENT TUESDAY, NOVEMBER 16, 2021  Objectives Classification of psychotropic medications. Mechanism of action of psychotropic medications. Choo...

PSYCHOPHARMACOLOGY PRESENTER: DR. O.DAVIDSON BROWN’S TOWN COMMUNITY COLLEGE NURSING DEPARTMENT TUESDAY, NOVEMBER 16, 2021  Objectives Classification of psychotropic medications. Mechanism of action of psychotropic medications. Choose a psychotropic medication rationally. Know common & dangerous adverse effects. Manage failure of response to a therapeutic trial. Principles Medications are prescribed for target symptoms of psychiatric disorders No drug just affects target symptoms All drugs have unwanted effects some worse then others; side effects versus adverse reactions Pay careful attention to black box warning  Psychopharmacologic Drugs Work over A Spectrum Antipsychotics Antidepressants Mood stabilizing agents Anxiolytics/sedatives Others  Why Medications ? Dopaminergic theory of Schizophrenia Monoaminergic theory of Mood Disorders Terms Psychotropic medication: – Medications that affects psychic function, behavior or experience Neurotransmitter: – A chemical that is stored in the axon terminals of the presynaptic neuron Receptor: – Molecules situated on the cell membrane that are binding sites for neurotransmitters Antipsychotics  Antipsychotics Treat psychotic symptoms. Divided into: Typical/1st generation = D2 receptor antagonist Effective against +ve > -ve Atypicals/2nd generation = Serotonin-dopamine antagonists Effective against both +ve & -ve sx Requires ~ one month for significant antipsychotic effect Antipsychotic Drugs; sometimes called neuroleptics For the treatment of schizophrenia and bipolar psychosis For acute exacerbations For prevention/mitigation of relapse When a client stops taking a med, psychotic symptoms usually reoccur. With each relapse it takes longer to gain a remission leading to a possibility that client becomes unresponsive to treatment ANTIPSYCHOTIC AGENTS Indications: – These are also called major tranquilizers and neuroleptics. – They are used in the treatment of acute and chronic psychoses particularly when accompanied by increased psychomotor activity – Selected agents are used as antiemetics in the treatment of intractable hiccoughs and for the control of tics and vocal utterances in Tourette’s disorder Antipsychotics Average Daily Doses in mg Typicals Atypicals Risperidone (4-8) Haloperidol (5-15) Olanzapine (10-20) Thioridazine(100-300) Quetiapine (600-1200) Chlorpormazine (50-400) Clozapine (100-600) Lower numbers indicate higher potency Examples Chemical class Generic (trade) name Phenothiazines Chlorpromazine, Fluphenazine, Perphenazine, Prochlorperazine, Thioridazine, Trifluoperazine Thioxanthene Thiothixene Benzisoxazole Risperidone Dibenzoxazepine Loxapine Dihydroindolone Molindone Dibenzodiazepine Clozapine Diphenylbutylpiperidine Pimozide Thienobenzodiazepine Olanzapine Dibenzothiazepine Quetiapine Benzothiazolylpiperazine Ziprasidone Dihydrocarbostyril Aripiprazole Cont… Side effects of antipsychotics: – Anticholinergic effects such as dry mouth, blurred vision, constipation, urinary retention – Nausea, GI upset – Skin rash – Sedation – Orthostatic hypotension – Photosensitivity – Hormonal effects – ECG Changes – Reduction of seizure threshold – Agranulocytosis – Hypsersalivation Cont… Extrapyramidal symptoms (EPS) – Pseudoparkinsonism – Akinesia – Akathisia – Dystonia – Oculogyric crisis Tardive dyskinesia Neuroleptic malignant syndrome Hyperglycemia and diabetes Indications And Evidence For Effectiveness Positive Symptoms Of Schizophrenia – Hallucinations, delusions, disorganized thought processes and paranoia Negative Symptoms Of Schizophrenia – Withdrawal, lack of initiative, failure to maintain hygiene, lack of interest – Traditional antipsychotics do not help well with the negative symptoms First Generation Haldol, Prolixin Deconate, Thorazine Block dopamine in both the limbic and basal ganglia Dystonia (muscle stiffness) antiparkinson meds can help (benzatropine) Conventional (First-Generation) Antipsychotic Drugs Strong antagonists (blocking agents) – Bind to D2 receptors – Block attachment of dopamine – Reduce dopaminergic transmission – Amphetamines/cocaine/ritalin/levodopa cause increase of dopamine. Can cause signs of psychosis – Newer drugs; less side effects, increase neurocognitive functioning – Disadvanatages Side effects; EPS, zombie feeling, affective flattening, sedation, Advantages, low cost, available in depot form, improve positive symptoms Side Effects EPS symptoms (akathisia, dystonia, and pseudoparkinsonism) tardive dyskinesia Lower seizure threshold Neuroleptic malignant syndrome EPS symptoms Acute dystonia; muscle cramps of the head, neck Akathisia; internal restlessness, and external restlessness (pacing inability to remain at rest) Pseudoparkinsonism; stiffening of muscular activity in the face, body, arms and legs (frequently appears within first month, mimics parkinsons disease) Treatment; change/lower drug, Give Artane, or benztropine, or benadryl, or symmetrel. Patients on typical antipsychotics are prescribed an anticholinergic to mitigate the EPS symptoms Side Effects of Anti-Psychotic Drugs Management of weigt gain by a patient Tardive Dyskinesia Result of Prolonged treatment More serious usually not reversible Involuntary tonic muscular spasms (tongue, fingers, toes, neck) AIMS scale (page 411) Agranulocytosis Signs of infection should be reported to physician ASAP. Clients on therapy should initially have WBC’s measured weekly Atypical Antipsychotics Bind to dopamine receptors in the limbic system – Binds Preferentially over dopamine receptors in the basal ganglia – Fewer motor side effects – Also acts as antagonists for 5HT2 receptors (treats negative symptoms) Clozapine first atypical – Possibly fatal side effects Agranulocytosis, convulsions, myocarditis – Other side effects Drowsiness, sedation, hypersalivation, tachycardia, dizziness Risperidone Side effects orthostatic hypertension, sedation Now available in long acting Consta (a good choice over prolixn deconate; traditional antipsychotic) Long Acting preparations Consta (risperdal) Haldol fluphenazine Others Quetiapine: seroquel, sometimes diverted Zyprexa: Olanzapine (now available in injectable; zydis) SE weight gain, good for agitation Ziprasidone: geodon (take with food) Aripiprazole; Ablifiy , less metabolic syndrome Drug choice Factors to be considered; Side effect profile Ease of administration What would be benefit of long acting drug for a client with schizophrenia? History of past response Co-morbid conditions What drug is contraindicated for a patient with pre-existing heart disease? Cost Basis of Side Effects of Psychotropic Drugs A particular transmitter is often used by different neurons to carry out different activities Alterations in mental status, whether arising from disease or medication, are often accompanied by changes in basic drives, sleep patterns, body movement, and autonomic functions Drugs come with side effects some can be beneficial, others not Effects of psychotropic medications on neurotransmitters Medication Action on NT/ Physiological Side effects Receptor effects SSRI’s Inhibit reuptake of Reduce Nausea, agitation, seretonin depression headache, sexual Control anxiety dysfunction Control obsessions Tricyclic Inhibit reuptake of Reduce Sexual dysfunction antidepressants seretonoin depression (NE & 5 – HT) Inhibit reuptake of Relief of severe Sedation, weight norepinephrine pain gain (H1) (NE) Prevent panic Dry mouth, Block NE receptor attacks constipation, Block ACh blurred vision, receptor urinary retention Block histamine (ACh), postural receptor hypotension and tachycardia  Cont… Medication Action on NT/ Physiological Side effects Receptor effects MAO inhibitors Increase NE & 5 – Reduce Sedation, HT by inhibiting depression dizziness the enzyme that Control anxiety Sexual degrades them dysfunction (MAO – A) Hypertensive crisis (interaction with tyramine) Trazodone & 5 – HT2 receptor Reduce Nausea, sedation, nefazadone antagonism depression orthostasis, Adrenergic Reduce anxiety priapism receptor blockade SSNRI’s: Potent inhibitor of Reduce Nausea, venlafaxine and seretonin & depression increased duloxetine norepinephrine Relieve pain of sweating, reuptake neuropathy insomnia, tremors, Weak inhibitor of (duloxetine) sexual dysfunction dopamine Relieve anxiety reuptake (venlafaxine) Bupropion Inhibits reuptake Reduce Insomnia, dry of 5-HT. NE & depression, aid in mouth, tremor, dopamine smoking seizures cessation, reduce symptoms of ADHD  Cont… Medication Action on NT/ Physiological Side effects Receptor effects Antipsychotics: Strong D, receptor Relief of psychosis Blurred vision, dry phenothiazines blockade Relief of anxiety mouth, decreased and haloperidol Weaker blockade (Some) provide sweating, of ACh, H1, alpha relief from nausea constipation, adrenergic & 5- and vomitting and urinary retention. HT2 receptors intractable Tachycardia hiccoughs EPS, increased plasma prolactin (D2), sedation, weight gain (H1), ejaculatory difficulty (5-HT2), orthostatic hypotension Antianxiety: Binds to BZ Relief of anxiety Dependency (with benzodiazepines receptor sites on Sedation long term use) the GABA receptor Confusion, complex, memory increases receptor impairment, motor affinity for GABA incoordination  Cont… Medication Action on NT/ Physiological Side effects Receptor effects Antipsychotics Receptor Relief of Potential with (novel): clozapine, antagonism of 5- psychosis (with some of the drugs olanzapine, HT minimal or no for mild EPS (D2) arip[iprazole, D1 – D5 (varies EPS) Sedation, weight quetiapine, with drug) Relief of anxiety gain (H1) risperidone, H1, alpha 1 Relief of acute Orthostasis & ziprasidone adrenergic, mania dizziness muscarinic (ACh) Blurred vision, dry mouth, decreased sweating, constipation, urinary retention, tachycardia (ACh) Antianxiety: 5-HT agonist Relief of anxiety Nausea, buspirone D2 agonist headache, D2 antagonist dizziness Restlessness ANTIANXIETY AGENTS Indications – These are also called anxiolytics and minor tranquilizers. – These are used in the treatment of anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus and preoperative sedation. Cont… Side effects: – Drowsiness, confusion, lethargy – Tolerance; physical & psychological dependence – Ability to potentiate the effects of other CNS depressants – Possibility of aggravating symptoms in depressed persons – Orthostatic hypotension – Paradoxical excitement – Dry mouth – Nausea & vomiting – Blood dyscrasias – Delayed onset Examples Chemical class Generic (trade) name Antihistamines Hydroxyzine (Atarax, Vistaril) Benzodiazepines Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Traxene) Diazepam (Valium) Lorazepam (Ativan) Oxazepam (Serax) Propanediols Meprobamate (Miltown) Azaspirodecanediones Buspirone (BuSpar) ANTIDEPRESSANTS Indications: – It is used in the treatment of dysthymic disorder, major depression with melancholia or psychotic symptoms, depression associated with organic disease, alcoholism, schizophrenia or mental retardation, depressive phase of bipolar disorder and depression accompanied by anxiety. – These drugs elevate mood and alleviate other symptoms associated with moderate-to-severe depression ANTIDEPRESSANTS:POSSIBLE EFFECTS OF RECEPTOR BINDING Cont… Side effects with all chemical classes: – Dry mouth – Sedation – Nausea – Discontinuation syndrome – Hepatic failure Side effects with MAOI’s: – Hypertensive crisis Cont… Side effects with tricyclics: – Blurred vision – Constipation – Urinary retention – Orthostatic hypotension – Reduction of seizure threshold – Tachycardia; arrhythmias – Photosensitivity – Weight gain Cont… Side effects with SSRI’s: – Insomnia, agitation – Headache – Weight loss – Sexual dysfunction – Seretonin syndrome Examples Chemical class Generic (trade) name Tricyclics Amitriptyline, Amoxapine, Clomipramine, Desipramine, Doxepin, Imipramine, Nortriptyline, Protriptyline, Trimipramine SSRI’s Citralopram, Fluoxetine, Fluvoxamine, Escitalopram, Paroxetine, Sertraline MAOI Isocarboxazid, Phenelzine, Tranylcypromine Others Bupropion, Maprotiline, Mirtazapine, Trazodone, Nefazodone, Venlafaxine, Duloxetine  Potential Adverse Effects of Antidepressant Therapy Cardiac Central Nervous System Dizziness, cognitive impairment, Orthostasis sedation, light-headedness, hypertension somnolence, nervousness, heart block, insomnia, headache, tremor, tachycardia changes in satiety and appetite Gastrointestinal Nausea, constipation, Urogenital vomiting, dyspepsia, Erectile dysfunction, diarrhea ejaculation disorder, anorgasmia, Autonomic Nervous System priapism Dry mouth, urinary retention, blurred vision, sweating MOOD STABILIZING AGENTS ANTIMANIC: Prevention and treatment of manic episodes of bipolar disorder, alcohol dependence, major depression ANTICONVULSANTS: All stages of seizures CALCIUM CHANNEL BLOCKERS: Angina, arrhytmias, hypertension, bipolar mania, migraine headache ANTIPSYCHOTICS: Schizophrenia, bipolar mania  Common Mood Stabilizers Carbamazepine Valproic Acid Lithium 4-12 mg/ml Therapeutic Level 40-100 mg/ml 0.5-1.2 mEq/L nausea, Dizziness, sedation, nausea, diarrhea, hypothyroidism, ataxia, leukopenia, ataxia, dysarthria, tremors, dysarthria, Common S/E rash, weight gain, slight ataxia elevation of hepatic transaminases sinus node Agranulocytosis, dysfunction, T-wave teratogenicity (neural changes, teratogenic (neural teratogenic (cardiac Dangerous S/E tube defect), induction tube defects) anomalies) of hepatic metabolism Cont… Chemical class Generic (trade) name Antimanic Lithium carbonate Anticonvulsants Clonazepam, carbamazepine, valporic acid, lamotrigine, gabapentin, topiramate Calcium channel blocker Verapamil Antipsychotics Olanzapine, aripiprazole, chlorpromazine, quetiapine, risperidone, ziprasidone Cont… Side effects of antimanic: – Drowsiness, dizziness, headache – Dry mouth, thirst – GI upset, nausea/ vomiting – Fine hand tremors – Hypotension, arrhythmias, pulse irregularities – Polyuria, dehydration – Weight gain Side effects of calcium channel blockers: – drowsiness, dizziness – Hypotension, bradycardia – Nausea – constipation Cont… Side effects of anticonvulsants: – Nausea/ vomitting – Drowsiness, dizziness – Blood dyscrasias – Prolonged bleeding time – Risk of severe rash – Decreased efficacy with oral contraceptives Side effects of antipsychotics: – Drowsiness, dizziness – Dry mouth, constipation – Increased appetite, weight gain – ECG changes – Extra Pyramidal Symptoms – Hyperglycemia & diabetes Examples Chemical class Generic (trade) name Phenothiazines Chlorpromazine, Fluphenazine, Perphenazine, Prochlorperazine, Thioridazine, Trifluoperazine Thioxanthene Thiothixene Benzisoxazole Risperidone Dibenzoxazepine Loxapine Dihydroindolone Molindone Dibenzodiazepine Clozapine Diphenylbutylpiperidine Pimozide Thienobenzodiazepine Olanzapine Dibenzothiazepine Quetiapine Benzothiazolylpiperazine Ziprasidone Dihydrocarbostyril Aripiprazole Cont… Side effects of antipsychotics: – Anticholinergic effects such as dry mouth, blurred vision, constipation, urinary retention – Nausea, GI upset – Skin rash – Sedation – Orthostatic hypotension – Photosensitivity – Hormonal effects – ECG Changes – Reduction of seizure threshold – Agranulocytosis – Hypsersalivation Cont… Extrapyramidal symptoms (EPS) – Pseudoparkinsonism – Akinesia – Akathisia – Dystonia – Oculogyric crisis Tardive dyskinesia Neuroleptic malignant syndrome Hyperglycemia and diabetes SEDATIVE HYPNOTICS Indications: – They are used in the short term management of various anxiety states and to treat insomnia. – Selected agents are used as anticonvulsants and preoperative sedatives and to reduce anxiety associated with drug withdrawal Examples Chemical class Generic (trade) name Barbiturates Amobarbital, Butabarbital, Mephobarbital, Pentobarbital, Phenobarbital, Secobarbital Benzodiazipines Estazolam, Flurazepam, Quazepam, Temazepam, Triazolam Miscellaneous Chloral hydrate, Eszopiclone, Zaleplon, Zolpidem Cont… Side effects: – Drowsiness, confusion, lethargy – Tolerance; physical & psychological dependence – Ability to potentiate the effects of other CNS depressants – Possibility of aggravating symptoms in depressed persons – Orthostatic hypotension – Paradoxical excitement – Dry mouth – Nausea & vomiting – Blood dyscrasias – Delayed onset Newer trends – agents for ADHD Indications: – These are used for ADHD in children and adults Side effects: – Overstimulation, restlessness, insomnia – Palpitations, tachycardia – Anorexia, weight loss – Tolerance, physical and psychological dependence – Nausea and vomiting – Constipation – Potential for seizures Examples Chemical class Generic (trade) name Amphetamines Dextroamphetamine sulfate, Methamphetamine Amphetamine mixtures Dextroamphetamine/ amphetamine Miscellaneous Methylphenidate, Dexmethylphenidate, Pemoline, Atomoxetine, Bupropion Review of Nursing responsibilities Assess for expected effects Know safety profiles…contraindications Recognize SE and adverse reactions Reinforce teaching points Therapeutic drug monitoring Assess for undiagnosed illnesses… Drugs that can induce psych symptoms Drug interactions….inhibit or potentiate action Thank you