It's document containing drugs suitable for psychiatry patient.

1. Psychopharmacology

2. Psychopharmacology
Introduction
• Psychopharmacology is the study of the regulation and stabilization of
emotions, behavior, and cognition through the interactions of
neurotransmitters and drugs
• These drugs are referred to as psychotropic agents or psychoactive or
psychotherapeutic drugs.

3. Classification of psychotropic drugs
1. Antipsychotic agents
2. Antianxiety agents (anxiolytics) and hypnotics
3. Antidepressants
4. Antimanic agents
5. Anticonvulsants
6. Anticholinergic or antiparkinsonism agents, which are used to alleviate extrapyramidal
symptoms or adverse effects of psychotropic agents

4. The science of psychopharmacology
• The science of psychopharmacology focuses on neurotransmission.
• Neurotransmitters undergo six steps, each of which offers a potential target for therapeutic
intervention by a drug;
1. Synthesis
2. Vesicular uptake
3. Transmitter release
4. Receptor binding
5. Cellular re-uptake
6. Transmitter metabolism.

6. Antipsychotic Medication
• Antipsychotic drugs are also called major tranquillizers or neuroleptics.
• Antipsychotic drugs are derived from several chemical groups and broadly categorized as;
1. Typical or traditional phenothiazines
2. Atypical newer drugs.
Mode of action
• They occupy or block dopamine receptors in the brain thereby decreasing the effects of
dopamine.
• Antipsychotic effects occur when the drug has been given for a few weeks.

7. Indications
• Treatment of schizophrenia and other psychotic disorders.
• Selected agents are used in the treatment of bipolar mania
• Others uses include;
Antiemetics (chlorpromazine, perphenazine, promethazine)
Treatment of intractable hiccoughs (chlorpromazine)
Control of tics and vocal utterances in Tourette’s disorder (haloperidol, pimozide).

8. Antipsychotic Medication
• Manifestations of hyperarousal e.g. anxiety, agitation, hyperactivity, insomnia, aggressive
or combative behaviour are relieved more quickly than hallucinations, delusions and
thought disorders.
• These agents also have antiemetic properties.
• Drugs should be given using the following time frame:
Six months for first psychotic episode.
One year period for second psychotic episode.
Indefinite period for third and later psychotic episodes.

9. Categories of antipsychotic drugs
1. Phenothiazines
2. Butyrophenones
3. Thioxanthenes
4. Phenothiazine like
5. Atypical

10. 1. Phenothiazines
Generic Name Trade Name Daily Dose Range
Chlorpromazine Largactil 300-1000mgs
Thioridazine Melleril 50-800mg
Acetophenazine Tindal 80-120mg
Mesoridazine serentil 100-400mg
Promazine sprine 10-200mg
Fluphenazine Moditen 2.5-20mg
Trifluoperazine Stelazine 5-30mg

11. 2. Butyrophenones
Generic Name Trade Name Daily Dose Range
Haloperidol Haldol, Serenace 1-20mg
3. Thioxanthenes
Thiothixene Navane 6-60mgs
Flupenthixol Depixol 6-18mg
Zuclopenthixol Clopixol 20-150mg

12. 2. Phenothiazine like
Generic Name Trade Name Daily Dose Range
Sulpride Domatil,Sulparex 200-2400mg
Molindone Lidone 50-400mgs
Loxapine Loxitane 60-250mgs
Pimozide Orap 2-10mg

13. 5. Atypical
Generic Name Trade Name Daily Dose Range
Clozapine clozaril 50-900mg
olanzapine zyprexa 5-10mg
Quetiapine Seroquel 25-50mg
Risperodone Risperdal 2-8mg

14. 6. Deport injections
Generic Name Trade Name Daily Dose Range Group
Fluphenazine
decanoate
Modecate 12.5-100mg(IM 2
Weekly)
Phenothiazines
Zuclopenthixol
Acetate
Clopixol
Acuphase
50-150mg every
2-3 days
Thioxanthenes
Haloperidol
decanoate
Haldol
decanoate
50-300mg (IM 4
weekly)
Butyrophenon

15. Contraindications/Precautions
Typical antipsychotics are contraindicated in:
 Clients with known hypersensitivity (cross-sensitivity may exist among phenothiazines).
 Patients in comatose states or when central nervous system (CNS) depression is evident
 Blood dyscrasias
 Clients with Parkinson’s disease
 Narrow angle glaucoma
 Liver, renal, or cardiac insufficiency; or those with poorly controlled seizure disorders

16. Side Effects
• The effects of these medications are related to blockage of a number of receptors for which
they exhibit various degrees of affinity.
• Dopamine blockage results in extrapyramidal symptoms (EPS) and prolactin elevation
(galactorrhea; gynecomastia).
• Cholinergic blockade causes anticholinergic side effects (dry mouth, blurred vision,
constipation, urinary retention and tachycardia).
• Blockage of the alpha1-adrenergic receptors produces dizziness, orthostatic hypotension,
tremors, and reflex tachycardia.

17. Side Effects
• Histamine blockade is associated with weight gain and sedation.
• Skin reactions such as urticaria, dermatitis, and pigmentation of the skin
• Photosensitivity
• Gastrointestinal distress such as nausea, heartburn, and jaundice
• Decreased libido, retrograde ejaculation, and gynecomastia (men)
• Amenorrhea

18. Extrapyramidal side effects
• The extrapyramidal system is a biological neural network that is part of the motor system
causing involuntary actions.
• The system is called extrapyramidal to distinguish it from the tracts of the motor cortex that
reach their targets by traveling through the pyramids of the medulla
• Antipsychotic medications commonly produce extrapyramidal symptoms as side effects,
especially typical ones.
• Extrapyramidal symptoms are caused by dopamine blockade or depletion in the basal
ganglia; this lack of dopamine often mimics idiopathic pathologies of the extrapyramidal
system.

19. Functions of extrapyramidal tract
• Control the movement of the eye balls
• Control of tone, posture and equilibrium
• Control of complex movements of the body and limbs e.g. coordinated movement of
arms and legs during walking
• Exert tonic inhibition control over the lower centres

20. Extrapyramidal side effects
Side Effect Symptoms Onset and prevalence
Parkinsonism Motor retardation or akinesia,
characterized by masklike appearance,
rigidity, tremors, pill rolling, excessive
salivation(sialorrhea)
Generally occurs after first
week of treatment or
before second month
Akathisia (motor
restlessness)
Constant state of movement,
characterized by restlessness, difficulty
sitting still, or strong urge to move
about
Generally occurs 2 weeks
after treatment begins
Acute dystonic
reactions (disturbance
of movement involving
the muscles of the
head, neck, trunk, or
limbs)
Irregular, involuntary spastic muscle
movement, wryneck or torticollis, facial
grimacing, abnormal eye movements,
backward rolling of eyes in the sockets
(oculogyric crisis)
May occur anytime from a
few minutes to several
hours after first dose of
antipsychotic drug

21. Extrapyramidal side effects
Side Effect Symptoms Onset and prevalence
Tardive dyskinesia
(abnormal movements)
Most frequent serious side effect resulting
from termination of the drug, during
reduction in dosage, or after long-term, high-
dose therapy. Characterized by involuntary
rhythmic, stereotyped movements, tongue
protrusion, cheek puffing, involuntary
movements of extremities and trunk
Occurs in approximately 3% to 5%
of clients taking antipsychotics in
first 10 years
Neuroleptic malignant
syndrome (NMS)
Severe parkinsonian muscle rigidity, very high
fever, tachycardia, tachypnea,
fluctuations in blood pressure, diaphoresis,
and rapid deterioration of mental status to
stupor and
It is a relatively rare, but
potentially fatal, complication of
treatment with neuroleptic drugs.
Onset can occur within hours or
even years after drug initiation, and
progression is rapid over the
following 24 to 72 hours

22. Management of extrapyramidal effects
• Reduce or discontinue antipsychotic agent; irreversible adverse effect
Give vitamin E,
• Administer anticholinergic agent, such as benztropine mesylate
• Monitor vital signs, degree of muscle rigidity, intake and output, level of
consciousness.

23. Nursing Implications/ Considerations in administering
Antipsychotics
• Evaluation of blood pressure, complete blood count, liver function tests, and vision tests
before starting therapy and at periodic intervals thereafter as determined by the
prescribing clinician
• If antacids are needed, give them either 2 hours prior to or 1 hour after administration of
the antipsychotic medication(decrease potency)

24. Nursing Implications/ Considerations in administering
Antipsychotics
• If a single daily dose is ordered, give oral neuroleptics within 1 or 2 hours of bedtime,
whenever possible, to aid sleep.
• Do not give antipsychotic drugs subcutaneously; Administer them as deep intramuscular
injections.
• Use manufacturers specifications in parenteral administration
• Know that antipsychotic agents may provoke seizures in clients with seizure disorders.

25. Nursing Implications/ Considerations in administering
Antipsychotics
• Closely observe the client receiving antipsychotic drugs for the following:
Therapeutic effects of the drugs, such as decreased agitation, decreased hallucinations,
and increased socialization
A decrease in nausea and vomiting if the drug is given as an antiemetic
Drug-induced EPS
Anticholinergic effects, respiratory depression, and hypersensitivity
Signs of agranulocytosis (eg, sore throat, fever, and discomfort)

26. Antidepressants

27. Antidepressants
• Drugs used in the pharmacologic management of depressive disorders are derived three
main chemical groups:
1. Tricyclic antidepressants (TCAs)
2. Monoamine oxidase inhibitors (MAOIs).
3. Selective serotonin reuptake inhibitors (SSRIs)
• SSRI are first line followed by TCA. MAOIs are third line due to interactions with food
containing tyramine and tryptophan
• TCAs can also be used for treating neurotic disorders like nocturnal enuresis.

28. Mechanisms of Action
• Antidepressant drugs generally act by normalizing abnormal neurotransmission
systems in the brain by altering the amounts of neurotransmitters and the number
or sensitivity of receptors.
SSRIs selectively inhibit the reuptake of serotonin.
MAOIs prevent the metabolism of neurotransmitter molecules..
Tricyclic antidepressants inhibit reuptake of norepinephrine and serotonin.
• These mechanisms thereby increase the amount of neurotransmitter available to
bind to receptors

30. Mechanisms of Action
For the drugs to be effective:
• Dosage may be divided, but the total dose can be given at bed time due to the sedative
effects.
• Minimum dose should be given then increased gradually.
• Four to six weeks must be allowed to pass for therapeutic effects to be observed.
• Medication needs to be continued for 6 months after patient is free from depression.

31. Examples of antidepressants
Major Groups Generic Name Trade Name Daily Dosage (range)
Tricyclic antidepressants Amitriptyline Elavil (laroxyl) 75-300mg
Imipramine Tofranil 100-300mg
Monoamine Oxidase
Inhibitors
Isocarboxacid Marplan 10-60mg
Phenelzine Nardil 45-90mg
Selective Serotonin
Reuptake Inhibitors
Fluoxetine Prozac 20mg
Citalopram Cipramil 20-60mg

32. Side Effects of antidepressants: Some of the side effects that might be
experienced include mild anticholinergic effects from tricyclic and monoamine
oxidase inhibitors: Include;
Dry mouth
 Constipation
 Blurred vision
 Tachycardia
Nausea
 Oedema
Hypotension
Urinary retention

33. Side Effects of antidepressants
Side effects that are specific to tricyclics are:
• Allergic reactions manifested as skin rash and jaundice.
• Tachycardia.
• Tremors.
• Long term treatment may depress bone marrow, predispose to sore throat and
aching, and fever.

34. Side Effects of antidepressants
Specific side effects of monoamine oxidase inhibitors include:
• Liver damage that is rare but fatal.
• Precipitation of manic episodes.
• Hypertension crisis characterized by severe headache palpitation, neck stiffness, nausea,
vomiting, increased Bp, chest pain and collapse. It occurs 30 minutes to 24 hours after
eating food containing tyramine and tryptophan. These foods include cheese, wine, beer,
sour cream, liver, chocolate, bananas, avocadoes, soy sauce, and beans.

35. Contraindications
• The use of antidepressants is contraindicated when the patient suffers from;
 Glaucoma
Agitated states
 Urinary retention
 Cardiac disorders
Seizure disorders

36. Antidepressant discontinuation syndrome
• Occurs in approximately 20 percent of patients after abrupt discontinuation of an
antidepressant medication that was taken for at least six weeks.
• It is more likely with a longer duration of treatment and a shorter half-life of the treatment
drug.
• All antidepressants are capable of producing symptoms.

37. Antidepressant discontinuation syndrome
Symptoms
• Flu-like symptoms, insomnia, nausea, imbalance, flashes of lights, "electric shock"
sensations, hyperresponsivity to noises or lights.
Prevention
• Patient education to include warnings about the potential problems associated with abrupt
discontinuation.
• Tailing off the drug

38. Mood- Stabilizing Agents
(Antimanic drugs)

39. 1. Lithium carbonate
• This is a naturally occurring metallic salt used in the management of bipolar affective
disorder.
• It is more effective in the treatment and prevention of mania than in preventing depression.
Mode of action
• Affect synthesis, release and reuptake of several neurotransmitters in the brain including
acetylcholine, dopamine, GABA and norepinephrine.
• It also stabilizes post synaptic receptor sensitivity to neurotransmitters.
Dose: PO 900-1200 mg daily in divided dosages
Side effects: metallic taste, hand tremors, nausea, polyuria, diarrhea, fatigue, edema and
weight gain.

40. 2. Other mood stabilizers
Valproic acid
• Valproic acid (sodium valproate) is an anticonvulsant indicated for bipolar disorders
Mode of action
• Regulate calcium and sodium channels function leading to enhanced GABA activity and
reduced glutamate activity in the brain
Indications
• Schizophrenic disorder, depression, bipolar disorder, impulse control disorder
Dose
• 10-15mg /KgBW/Day in 2 divided doses
Adverse effects
• Aplastic anemia, hepatitis, exfoliative dermatitis and hypothyroidism

41. 2. Other mood stabilizers
Carbamazine(Tegretol)
• An anticonvulsant chemically related to the tricyclic antidepressants
Indications
• Seizure disorders, neuralgia, unipolar and bipolar disorders
Dose
• 400-1000mg/day in two divided doses
Side effects
• CNS effects e.g. ataxia, drowsiness, sedation; GIT effects like anorexia, nausea,
vomiting; Skin disorders like urticaria, exfoliative dermatitis; blood dyscrasias
like anemia, thrombocytopenia, agranulocytosis; liver damage

42. Antiparkinsonian Agents Used to Treat Extrapyramidal
Side Effects of Antipsychotic Drugs
Indication
• Used to treat Parkinsonism of various causes and drug-induced extrapyramidal
reactions.
Action
• Restores the natural balance of acetylcholine and dopamine in the CNS.
Contraindications/Precautions
• Contraindicated in individuals with hypersensitivity, Angle-closure glaucoma;
pyloric, duodenal, or bladder neck obstructions; prostatic hypertrophy; or
myasthenia gravis.
• Caution should be used in administering these drugs to clients with hepatic,
renal, or cardiac insufficiency; elderly and debilitated clients; those with a
tendency toward urinary retention; or those exposed to high environmental
temperatures.

43. Antiparkinsonian Agents Used to Treat Extrapyramidal
Side Effects of Antipsychotic Drugs
Common side effects
• Anticholinergic effects (dry mouth, blurred vision, constipation, paralytic ileus, urinary
retention, tachycardia, elevated temperature, decreased sweating), nausea/GI upset,
sedation, dizziness, orthostatic hypotension, exacerbation of psychoses.
• Examples
• Benztropine (Cogentin) – 0.5-2mgPO,tid;2 mg IV/IM
• Biperiden (Akineton) – 2-6 MG PO tid, 2mg IV/IM
• Trihexyphenidyl (Artane) – 2-5mg PO tid