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information regarding psychopharmacology especially for nursing students and community. covers all group like anti psychotic, anti anxiety, antidepressants, mood stabilizing agents etc.

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  1. 1. Psychopharmacology Aashish Parihar Lecturer College Of Nursing AIIMS, Jodhpur
  2. 2. • Psychopharmacology is the study of the effects of drugs on affect, cognition, and behavior • Efficacy refers to the maximal therapeutic that a drug can achieve. • Potency describe the amount of the drug needed to achieve the maximum effect. • Half life is the time taken for half of the drug to be removed from the blood stream. • Agonist a drug that binds to and activates a receptor • Antagonist a drug that binds to but does not activate (block) a receptor Psychopharmacology
  3. 3. • Neurotransmitters are the chemical messengers that travel from one brain cell to another and are synthesized by enzymes from certain dietary amino acids or precursors Receptors are molecules situated on the cell membrane that are binding sites for neurotransmitters. Psychopharmacology
  4. 4. Psychopharmacology
  5. 5. Drug Action on Synaptic Transmission Psychopharmacology Agonist drugs are in red, Antagonists are in blue
  6. 6. Presynaptic Drug Actions • Presynaptic autoreceptors regulate the amount of NT released from the axon terminal • Drugs that activate presynaptic autoreceptors reduce the amount of NT released, an antagonistic action • Drugs that inactivate presynaptic autoreceptors increase the amount of NT released, an agonistic action • Presynaptic heteroreceptors are sensitive to NT released by another neuron, can be inhibitory or facilitatory Psychopharmacology
  7. 7. Effect of drug in neurotransmission • Release • Blockade • Changes in receptor sensitivity • Blocked reuptake • Interference with storage vesicles • Precursor chain interference Psychopharmacology
  8. 8. Classifications of psychotropic drugs • Antipsychotics • Antidepressants • Mood stabilizing agents • Anxiolytics • Antiepileptic drugs • Antiparkinsonian drugs • Miscellaneous (stimulants, drugs used for de addiction, drugs used in child psychiatry) Psychopharmacology
  9. 9. Antiparkinsonian drugs
  10. 10. Antiparkinsonian drugs
  11. 11. Antiparkinsonian drugs
  12. 12. Antiparkinsonian drugs
  13. 13. Antiparkinsonian drugs • Classification of antiparkinsonian Drugs: • Drugs acting on dopaminergic system: • Dopamine precursors – Levodopa (l-dopa) • Peripheral decarboxylase inhibitors – carbidopa and benserazide • Dopaminergic agonists: Bromocriptyne, Ropinirole and Pramipexole • MAO-B inhibitors – Selegiline, Rasagiline • Dopamine facilitator - Amantadine • Drugs acting on cholinergic system • Central anticholinergics – Teihexyphenidyl (Benzhexol), Procyclidine, Biperiden • Antihistaminics – Orphenadrine, Promethazine
  14. 14. Antiparkinsonian drugs • Dopamine and Tyrosine Are Not Used for Parkinson Disease Therapy, Why? – Dopamine Doesn't Cross the Blood Brain Barrier – Huge amount of tyrosine decreases activity of rate limiting enzyme Tyrosine Hydroxylase
  15. 15. Antiparkinsonian drugs • Levodopa • Single most effective agent in PD • Inactive by itself but immediate precursor of Dopamine • Peripherally - 95% is decarboxylated in peripheral tissues in gut and liver to dopamine – This dopamine acts on peripheral organs like heart, blood vessels and CTZ etc. (NOT CNS) • 1 - 2% crosses BBB, taken up by neurons and DA is formed – Stored and released as neurotransmitter
  16. 16. Antiparkinsonian drugs • Levodopa • Actions of Levodopa – CNS • Effective in Eliminating Most of the Symptoms of Parkinson Disease (initially motor) – Bradykinesia and Rigidity Respond Quickly – Reduction in Tremor Effect with Continued therapy • Secondary symptoms - Handwriting , speech, facial expression and interest in life improves gradually • L -Dopa less Effective in Eliminating Postural Instability and Shuffling Gait Meaning Other Neurotransmitters are Involved in Parkinson Disease • Behavioural Effects: – Partially Changes Mood by elevating mood, and increases Patient sense of well being - General alerting response – Disproportionate increase in sexual activity – No improvement in dementia – psychiatric symptoms
  17. 17. Antiparkinsonian drugs • Levodopa • Actions of Levodopa – CVS: –Cardiac Stimulation Due to Beta adrenergic effect on Heart –Though stimulates peripheral adrenergic receptor – no rise in BP –Orthostatic Hypotension - some individuals – central DA and NA action –In elderly cardiovascular problems - transient tachycardia, cardiac arrhythmias and hypertension –Tolerance to CVS action develops within few weeks • CTZ: DA receptors cause stimulation – nausea and vomiting – tolerance • Endocrine: Decrease in Prolactin level and increase in GH release
  18. 18. Antiparkinsonian drugs • Levodopa Pharmacokinetics • Absorbed rapidly from small intestine • High First Pass Effect – Competition for amino acids present in food competes for the carrier – Also depends on gastric emptying and pH • Peak plasma conc. 1-2 hrs. and half life - 1 to 3 Hrs • Metabolized in liver and peripherally - secreted in urine unchanged or conjugated with glucoronyl sulfate • Central entry into CNS (1%) - mediated by membrane transporter for aromatic amino acids – competition with dietary protein • In CNS – Decarboxylated and DA is formed – therapeutic effectiveness • Transport back by presynaptic uptake or metabolized by MAO.
  19. 19. Antiparkinsonian drugs • Levodopa Pharmacokinetics
  20. 20. Antiparkinsonian drugs • Levodopa ADRs • Initial Therapy: Nausea and vomiting - 80% of patients Postural hypotension , but asymptomatic : 30 % of patients tolerance develops – disappear after prolonged treatment Cardiac arrhythmias (due to beta adrenergic action and peripheral CA synthesis) - tachycardia, ventricular extrasystoles and, rarely, atrial fibrillation Exacerbation of angina
  21. 21. Antiparkinsonian drugs • Levodopa ADRs • Prolonged therapy: 1. Abnormal movements: Facial tics, grimacing, tongue thrusting, choreoathetoid movements of limb after few months of treatment 2. Behavioural effects: – 20 to 25% of Population – Trouble in Thinking (Cognitive Effects) – L- dopa can induce: Anxiety, psychosis, confusion, hallucination, delusion – Hypomania - Inappropriate Sexual Behavior; "Dirty Old Man", "Flashers“ - Drug Holiday (1 - 3 weeks)
  22. 22. Antiparkinsonian drugs • Levodopa ADRs • Prolonged therapy – contd : Fluctuation in Motor Performance:  Initial therapy – each dose - good duration of action 9more than half-life) Suggesting Nigrostriatum retains capacity to store and release  Prolonged therapy – “buffering” capacity is lost – each dose causes fluctuation of motor state - each dose has short duration of action– short therapeutic effect (1 – 2 Hrs) – bradykinesia and rigidity comes back quickly - "On-off" Phenomenon Like a Light Switch: Without Warning  DYSKINESIA – excessive abnormal involuntary movements even in on phase (more troublesome)  Dyskinesia often with high plasma conc. of levodopa  Dyskinesia = Bradykinesia and Rigidity in terms of patient comfortness
  23. 23. Antianxiety drugs • Anti-anxiety medications, as the name implies, are prescribed to reduce anxiety. • They are prescribed for a number of illnesses: • Generalized Anxiety (GAD) • Post-Traumatic Stress Disorder (PTSD) • Phobias • Obsessive Compulsive Disorder (OCD) • Panic Disorder • Insomnia related to Anxiety
  24. 24. Antianxiety drugs • Classification Barbiturates: Benzodiazepines Non barbiturates and non benzodiazepines
  25. 25. Antianxiety drugs • Benzodiazepines are considered CNS depressants. • How do they work? Enhance the actions of the neurotransmitter, GABA, which slows down brain activity. This produces a drowsy or calming affect. • They are used to produce sedation, induce sleep, relieve anxiety and muscle spasms, and to prevent seizures.
  26. 26. Antianxiety drugs • Side Effects: drowsiness, dizziness, loss of coordination, fatigue, mental slowing, confusion. • Withdrawal reactions are possible. S/S: anxiety, shakiness, headache, dizziness, seizures. • Precautions: with elderly, lung disease, liver disease, kidney disease, sleep apnea • Contraindications: acute narrow angle glaucoma
  27. 27. Antianxiety drugs • Safety Concerns: • risk of addiction: should be only used short term. • Patient should not drive or operate heavy machinery. • Not to be mixed with ETOH, opiates, OTC cough/allergy medications, dental anesthetics – can be life threatening (resp. depression) • Discuss use of OTC medications and supplements and other prescribed drugs with MD before taking them with this type of medication. • MUST NOT be discontinued abruptly. Taper schedule is prescribed.
  28. 28. Antipsychotic drugs Synonymous • Neuroleptic drugs • Anti-schizophrenic drugs • Major tranquilizers • Dopamine receptor antagonists
  29. 29. Antipsychotic drugs Classification: TYPICAL ANTIPSYCHOTICS a. Phenothiazine derivatives • Aliphatic Derivative: CHLORPROMAZINE • Piperidine Derivative: THIORIDAZINE • Piperazine Derivative: FLUPENAZINE, PERPHENAZINE, TRIFLUOPERAZINE b. Thioxanthene Derivative: THIOTHIXENE c. Butyrophenone: HALOPERIDOL
  31. 31. Antipsychotic drugs Difference between Typical Antipsychotics and Atypical Antipsychotics • 1. The side effects • 2. The efficacy • 3. Atypical anti psychotics are excreted faster. • 4. Atypical anti psychotics are less likely to cause extra pyramidal motor control and tardive dyskinesia • 5. Atypical anti psychotics are easier to discontinue and are less addictive.
  32. 32. Antipsychotic drugs Difference between Typical Antipsychotics and Atypical Antipsychotics • 6. Atypical anti psychotic drugs are recommended over typical psychotic drugs. • 7. Atypical anti psychotics fail to produce prolactin in the serum. • 8. Withdrawal symptoms are less likely with atypical anti psychotic drugs • 9. Akathesia to be less intense with these drugs than the typical antipsychotic.
  33. 33. Antipsychotic drugs
  34. 34. Antipsychotic drugs
  35. 35. Antipsychotic drugs Mechanism of action: (Typical Antipsychotics)
  36. 36. Antipsychotic drugs Mechanism of action: (Typical Antipsychotics)
  37. 37. Antipsychotic drugs Pharmacological action of Anti psychotic drugs: CNS- • Reduction in irrational behavior, agitation, aggressiveness. • Disturbed thoughts and behavior gradually normalized • Relives anxiety • Hyperactivity , hallucination and delusions are suppressed • Sedation • Lowers seizures threshold level • Extrapyramidal motor disturbances
  38. 38. Antipsychotic drugs Pharmacological action of Anti psychotic drugs: CNS- • Reduction in irrational behavior, agitation, aggressiveness. • Disturbed thoughts and behavior gradually normalized • Relives anxiety • Hyperactivity , hallucination and delusions are suppressed • Sedation • Lowers seizures threshold level • Extrapyramidal motor disturbances
  39. 39. Antipsychotic drugs Pharmacological action of Anti psychotic drugs: ANS- • Exerts  adrenergic blocking activity results in-  postural hypotension Palpitation Inhibition of ejaculation • Exerts anticholinergic activity results in-  dry mouth Blurring of vision Constipation Urinary hesitancy
  40. 40. Antipsychotic drugs Pharmacological action of Anti psychotic drugs: CVS- • Hypotension due to  adrenergic blocking action • Reflex tachycardia • Q-T prolongation and T wave suppression Endocrine- • Increases secretion of prolactin hormone results in gynecomastia and galactorrhea • Reduction of gonadotropin hormone results in amenorrhea, infertility.
  41. 41. Antipsychotic drugs Pharmacokinetics: • Most neuroleptic drugs are highly lipophilic, bind avidly to proteins, and tend to accumulate in highly perfused tissues. • Oral absorption is incomplete and erratic. • IM injection is more reliable. With repeated administration, variable accumulation occurs in body fat and possibly in brain myelin. • Half-lives are generally long, and so a single daily dose is effective. • After long-term treatment and drug administration is stopped, therapeutic effects may outlast significant blood concentrations by days or weeks. This may result from tight binding of parent drug of active metabolites in the brain. • Metabolites are excreted in urine and bile.
  42. 42. Antipsychotic drugs Uses: : • Schizophrenia • Schizoaffective disorder • Mania • Organic brain syndrome • Anxiety • Preanaesthtic medication • Intractable hiccough • Tetanus • Alcoholic hallucination • Huntington’s disease • Tourette’s syndrome
  43. 43. Antipsychotic drugs Contraindications: These drugs are contraindicated in • Hypersensitivity • CNS depression • Blood dyscrasias • Parkinson’s disease • Liver, renal, or cardiac insufficiency
  44. 44. Antipsychotic drugs Precautions: • Elderly, severely ill, or debilitated, and to diabetic clients or clients with respiratory insufficiency, prostatic hypertrophy, or intestinal obstruction. • Individuals should avoid exposure to extremes in temperature while taking antipsychotic medication. • Safety in pregnancy and lactation has not been established.
  45. 45. Antipsychotic drugs Adverse drug reactions: Anticholinergic effects- • Dry mouth • Blurred vision • Constipation • Urinary retention Nausea, GI upset Skin rashes Sedation Photosensitivity Orthostatic hypotension
  46. 46. Antipsychotic drugs Adverse drug reactions: Hormonal effects • Decreased libido, gynecomastia • Amenorrhea • Infertility • Weight gain ECG changes • Q-T prolongation and T wave suppression Decreased threshold level  Agranulocytosis  Hypersalivation
  47. 47. Antipsychotic drugs Adverse drug reactions:  Extrapyramidal symptoms • Pseudo-parkinsonism (tremor, shuffling gait, drooling, rigidity) • Akinesia (muscular weakness) • Akathisia (continuous restlessness and fidgeting) • Dystonia (involuntary muscular movements [spasms] of face, arms, legs, and neck) • Oculogyric crisis (uncontrolled rolling back of the eyes)
  48. 48. Antipsychotic drugs Extrapyramidal symptoms • Pseudo-parkinsonism (tremor, shuffling gait, drooling, rigidity) Akinesia Akathisia
  49. 49. Antipsychotic drugs Extrapyramidal symptoms • Dystonia Oculogyric crisis
  50. 50. Antipsychotic drugs Adverse drug reactions:  Tardive dyskinesia (bizarre facial and tongue movements, stiff neck, and difficulty swallowing)
  51. 51. Antipsychotic drugs Adverse drug reactions:  Neuroleptic malignant syndrome (NMS) Symptoms include - Severe parkinsonian muscle rigidity, Hyperpyrexia up to 107 f, Tachycardia, Tachypnea, Fluctuations in blood pressure, Diaphoresis, Rapid deterioration of mental status Stupor and coma.
  52. 52. Antipsychotic drugs Nursing management of ADR: For Anticholinergic effects : • Provide the client with sugarless candy or gum, ice, and frequent sips of water. • Ensure that client practices strict oral hygiene. • Explain that this symptom will most likely subside after a few weeks. • Advise client not to drive a car until vision clears. • Clear small items from pathway to prevent falls. • Order foods high in fiber • Encourage increase in physical activity and fluid intake if not contraindicated. • Instruct the client to report any difficulty urinating; monitor intake and output.
  53. 53. Antipsychotic drugs Nursing management of ADR: For Nausea and GI upset: • Tablets or capsules may be administered with food to minimize GI upset. • Concentrates may be diluted and administered with fruit juice or other liquid. • They should be mixed immediately before administration.
  54. 54. Antipsychotic drugs Nursing management of ADR: For Skin Rash: • Report appearance of any rash on skin to physician. • Avoid spilling any of the liquid concentrate on skin • Contact dermatitis can occur with some medications.
  55. 55. Antipsychotic drugs Nursing management of ADR: For Sedation: • Discuss with the physician the possibility of administering the drug at bedtime. • Discuss with the physician a possible decrease in dosage or an order for a less sedating drug. • Instruct client not to drive or operate dangerous equipment while experiencing sedation.
  56. 56. Antipsychotic drugs Nursing management of ADR: For Orthostatic hypotension : • Instruct the client to rise slowly from a lying or sitting position • Monitor blood pressure (lying and standing) each shift • Document and report significant changes.
  57. 57. Antipsychotic drugs Nursing management of ADR: For Photosensitivity: • Ensure that the client wears a protective sunblock lotion, clothing, and sunglasses while spending time outdoors.
  58. 58. Antipsychotic drugs Nursing management of ADR: For Hormonal effects: • Provide an explanation of the effects and reassurance of reversibility. • If necessary, discuss with the physician the possibility of ordering alternate medication. • Offer reassurance of reversibility • Instruct the client to continue use of contraception, because amenorrhea does not indicate cessation of ovulation. • Weigh client every other day • Order a calorie controlled diet • Provide an opportunity for physical exercise • Provide diet and exercise instruction.
  59. 59. Antipsychotic drugs Nursing management of ADR: For ECG Changes: • Caution is advised in prescribing this medication to individuals with history of arrhythmias. • Conditions that produce hypokalemia and/or hypomagnesemia, such as diuretic therapy or diarrhea, should be taken into consideration when prescribing. • Routine ECG should be taken before initiation of therapy and periodically during therapy. • Monitor vital signs every shift. • Observe for symptoms of dizziness, palpitations, syncope, or weakness.
  60. 60. Antipsychotic drugs Nursing management of ADR: For Reduction of seizure threshold: • Closely observe clients with history of seizures.
  61. 61. Antipsychotic drugs Nursing management of ADR: For Agranulocytosis: • There is a significant risk of agranulocytosis with clozapine. • A baseline white blood cell (WBC) count and absolute neutrophil count (ANC) must be taken before initiation of treatment with clozapine and weekly for the first 6 months of treatment. • Only a 1-week supply of medication is dispensed at a time. • If the counts remain within the acceptable levels (i.e., WBC at least 3,500/mm3 and the ANC at least 2,000/mm3) during the 6-month period, blood counts may be monitored biweekly, and a 2-week supply of medication may then be dispensed • If the counts remain within the acceptable level for the biweekly period, counts may then be monitored every 4 weeks thereafter. • When the medication is discontinued, weekly WBC counts are continued for an additional 4 weeks.
  62. 62. Antipsychotic drugs Nursing management of ADR: For Hyper salivation (with clozapine) : • A significant number of clients receiving clozapine therapy experience extreme salivation. • Offer support to the client because this may be an embarrassing situation. • It may even be a safety issue (e.g., risk of aspiration) if the problem is very severe.
  63. 63. Antipsychotic drugs Nursing management of ADR: For Extrapyramidal symptoms (EPS) : • Pseudoparkinsonism (tremor, shuffling gait, drooling, rigidity) may appear 1 to 5 days following initiation of antipsychotic medication; occurs most often in women, the elderly, and dehydrated clients. • Akathisia (continuous restlessness and fidgeting) occurs most frequently in women, symptoms may occur 50 to 60 days following initiation of therapy. • Dystonia (involuntary muscular movements [spasms] of face, arms, legs, and neck) and oculogyric crisis occurs most often in men and in people younger than 25 years of age. • Pseudoparkinsonism and akathisia can be treated with anticholinergics, antihistamine and dopaminergic agents. • Dystonia and oculogyric crisis should be treated as an emergency situation. • The physician should be contacted, and intravenous or intramuscular benztropine mesylate (Cogentin) is commonly administered. • Stay with the client and offer reassurance and support during this frightening time.
  64. 64. Antipsychotic drugs Nursing management of ADR: For Tardive dyskinesia : • All clients receiving long-term (months or years) antipsychotic therapy are at risk. • The symptoms are potentially irreversible. • The drug should be withdrawn at the first sign, which is usually vermiform movements of the tongue • Prompt action may prevent irreversibility.
  65. 65. Antipsychotic drugs Nursing management of ADR: For Neuroleptic malignant syndrome (NMS) : • This is a rare, but potentially fatal, complication of treatment with neuroleptic drugs. • Routine assessments should include temperature and observation for parkinsonian symptoms. • Onset can occur within hours or even years after drug initiation, and progression is rapid over the following 24 to 72 hours. • Discontinue neuroleptic medication immediately. • Monitor vital signs, degree of muscle rigidity, intake and output, level of consciousness. • The physician may order bromocriptine (Parlodel) or dantrolene (Dantrium) to counteract the effects of neuroleptic malignant syndrome
  66. 66. Antidepressants Indications • Dysthymic disorder • Major depression with melancholia or psychotic symptoms • Depression associated with organic disease, alcoholism, schizophrenia, or mental retardation • Depressive phase of bipolar disorder • Depression accompanied by anxiety.
  67. 67. Antidepressants Classification • Tricyclics • SSRIs (Selective serotonin reuptake inhibitor) • MAOIs (Mono amine oxidase inhibitors) • Others
  68. 68. Antidepressants Classification • Tricyclics Amitriptyline, Nortriptyline Protriptyline Amoxapine, Doxepin Clomipramine, Desipramine, Imipramine, Trimipramine
  69. 69. Antidepressants Classification • SSRIs (Selective serotonin reuptake inhibitor) Citalopram, Escitalopram Flu , Par Fluvoxamine Sertraline
  70. 70. Antidepressants Classification • MAOIs (Mono amine oxidase inhibitors) Isocarboxazid Phenelzine Tranylcypromine
  71. 71. Antidepressants Classification • Others Bupropion Maprotiline Mirtazapine Trazodone Nefazodone Venlafaxine Duloxetine
  72. 72. Antidepressants Mechanism of action
  73. 73. Antidepressants Pharmacokinetics Lipophiloic and protein bound Half life long usually more than 1 day Metabolized in liver Excreted in urine
  74. 74. Antidepressants Contraindications/Precautions • Hypersensitivity. • Myocardial infarction and angle-closure glaucoma. • Caution- Elderly or debilitated clients Hepatic, renal, or cardiac insufficiency. (The dosage usually must be decreased.) Psychotic clients, prostatic hypertrophy History of seizures
  75. 75. Antidepressants Interactions • Tricyclic antidepressants Hyperpyretic crisis, hypertensive crisis, severe seizures, and tachycardia may occur when used with MAOIs. Additive CNS depression occurs with concurrent use of CNS depressants. Additive sympathomimetic and anticholinergic effects occur with use of other drugs possessing these same properties. Increased effects of tricyclic antidepressants may occur with bupropion, cimetidine, haloperidol, selective serotonin reuptake inhibitors (SSRIs), and valproic acid.
  76. 76. Antidepressants Interactions • SSRIs Use of SSRIs with cimetidine may result in increased concentrations of SSRIs. Hypertensive crisis can occur if SSRIs are used within 14 days of MAOIs. Impairment of mental and motor skills may be potentiated with use of alcohol. Serotonin syndrome may occur with concurrent use of MAOIs, and other drugs that increase serotonin, such as tryptophan, amphetamines or other psychostimulants
  77. 77. Antidepressants Interactions • MAOIs Hypertensive crisis may occur with concurrent use of amphetamines, methyldopa, levodopa, dopamine, epinephrine, norepinephrine, reserpine, vasoconstrictors, or ingestion of tyramine containing foods Hypertension or hypotension, coma, convulsions, and death may occur with meperidine or other narcotic analgesics when used with MAOIs. Additive hypotension may result with concurrent use of antihypertensives or spinal anesthesia and MAOIs. Additive hypoglycemia may result with concurrent use of insulin or oral hypoglycemic agents and MAOIs. Serious, potentially fatal adverse reactions may occur with concurrent use of other antidepressants, carbamazepine, cyclobenzaprine, maprotiline, furazolidone, procarbazine, or selegiline.
  78. 78. Antidepressants Adverse effects List of adverse effects with all classes of antidepressants • Dry mouth • Sedation • Nausea and GI upsets • Discontinuation syndrome
  79. 79. Antidepressants Adverse effects List of adverse effects with Tricyclics • Blurred vision • Constipation • Urinary retention • Orthostatic hypotension • Reduction of seizure threshold • Tachycardia; arrhythmias • Photosensitivity • Weight gain
  80. 80. Antidepressants Adverse effects List of adverse effects with SSRIs • Insomnia; agitation • Headache • Weight loss • Sexual dysfunction • Serotonin syndrome Symptoms include changes in mental status, restlessness, myoclonus, hyperreflexia, tachycardia, labile blood pressure, diaphoresis, shivering, and tremors.
  81. 81. Antidepressants Adverse effects List of adverse effects with MAOIs • Hypertensive crisis Symptoms of hypertensive crisis include severe occipital headache, palpitations, nausea/vomiting, nuchal rigidity, fever, sweating, marked increase in blood pressure, chest pain, and coma. • Priapism (With trazodone ) • Hepatic failure (with nefazodone)
  82. 82. Antidepressants Health education/ nursing management • Treatment adherence • Use caution when driving or operating dangerous machinery • Not stop taking the drug abruptly • If taking a tricyclic, use sunblock lotion and wear protective clothing • Report occurrence of any of the following symptoms to the physician immediately: sore throat, fever, malaise, yellowish skin, unusual bleeding, easy bruising, persistent nausea/vomiting, severe headache, rapid heart rate, difficulty urinating, anorexia/weight loss, seizure activity, stiff or sore neck, and chest pain.
  83. 83. Antidepressants Health education/ nursing management • Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure • Take frequent sips of water, chew sugarless gum, or suck on hard candy • Good oral care • Not consume the following foods or medications while taking MAOIs: Aged cheese, wine (especially Chianti), beer, chocolate, colas, coffee, tea, sour cream, beef/chicken livers, canned figs, soy sauce, overripe and fermented foods, pickled herring, preserved sausages, yogurt, yeast products, broad beans, cold remedies, diet pills. (TYRAMINE CONTAINING FOOD)
  84. 84. Antidepressants Health education/ nursing management • Avoid smoking while receiving tricyclic therapy. • Not drink alcohol while taking antidepressant therapy • Not consume other medications (including overthe-counter medications) without the physician’s approval • Notify the physician immediately if inappropriate or prolonged penile erections occur while taking trazodone • Establish seizure precaution especially with Bupripion
  85. 85. Antidepressants Health education/ nursing management Serotonin syndrome • May occur when two drugs that potentiate serotonergic neurotransmission such as tryptophan, amphetamines or other psychostimulants are used concurrently • Most frequent symptoms include changes in mental status, restlessness, myoclonus, hyperreflexia, tachycardia, labile blood pressure, diaphoresis, shivering, and tremors. • Discontinue offending agent immediately. • The physician will prescribe medications to block serotonin receptors, relieve hyperthermia and muscle rigidity, and prevent seizures. • Artificial ventilation may be required. • The condition will usually resolve on its own once the offending medication has been discontinued. • However, if the medication is not discontinued, the condition can progress to a more serious state and become fatal
  86. 86. Mood stabilizing agents • Any medication that is able to decrease vulnerability to subsequent episodes of mania or depression; and not exacerbate the current episode or maintenance phase of treatment.
  87. 87. Mood stabilizing agents Classification of mood stabilizing drugs • Antimanic- Lithium carbonate • Anticonvulsants- Carbamazepine, Clonazepam, Valproic acid, Lamotrigine, Gabapentin & Topiramate • Calcium channel blocker- Verapamil • Antipsychotics
  88. 88. Mood stabilizing agents Antimanic(Lithium carbonate) • Lithium as an antimanic drug was first discovered by FJ Cade in 1949. • Indications – Acute mania Prophylaxis for bipolar and unipolar mood disorder Schizoaffective disorder Cyclothymia Impulsivity and aggression Others like bulimia nervosa, trichotillomania, cluster headache, borderline personality disorder.
  89. 89. Mood stabilizing agents Antimanic(Lithium carbonate) Mechanism of action- • Exact mechanism is unknown, however it probably works by-  accelerating presynaptic reuptake and destruction of catecholamine. Inhibiting the release of catecholamine Decreasing postsynaptic serotonin receptor sensitivity.
  90. 90. Mood stabilizing agents Antimanic(Lithium carbonate) Interaction- • Increased renal excretion of lithium with acetazolamide, osmotic diuretics, and theophylline. • Decreased renal excretion of lithium with NSAIDsand thiazide diuretics. • There is an increased risk of neurotoxicity with carbamazepine, haloperidol, or methyldopa. • Fluoxetine or loop diuretics may result in increased serum lithium levels. • Increased effects of neuromuscular blocking agents or tricyclic antidepressants, • Use of lithium with phenothiazines may result in neurotoxicity,
  91. 91. Mood stabilizing agents Antimanic(Lithium carbonate) Dosage- • 900-2100 mg in 2-3 divided dose. Blood lithium level- • Therapeutic level- 0.8-1.2 mEq/litre • Prophylactic level- 0.6-1.2 mEq/litre • Toxic lithium level - >2.0 mEq/litre
  92. 92. Mood stabilizing agents Antimanic(Lithium carbonate) Pharmacokinetics- • Well absorbed orally • Neither protein bound nor metabolized • Kidney handles lithium in much same way as sodium. • Plasma half life is 16-30 hrs.
  93. 93. Mood stabilizing agents Antimanic(Lithium carbonate) Contraindication and precaution- • Hypersensitivity • Cardiac or renal disease • Dehydration • Sodium depletion • Brain damage • Pregnancy and lactation. • Caution with thyroid disorders, diabetes, urinary retention, history of seizures, and with the elderly
  94. 94. Mood stabilizing agents Antimanic(Lithium carbonate) Adverse drug reaction- • Neurological Tremors, Motor hyperactivity Muscular weakness • Renal Polydipsia Polyuria Nephrotic syndrome • CVS T-wave depression • Dermatological Acne eruption Exacerbation of psoriasis • Gastrointestinal Nausea, vomiting Diarrhea Abdominal pain Metallic taste • Endocrine Abnormal thyroid function Goiter Weight gain • Others Teratogenicity Ebstein’s anomaly Toxicity in infant
  95. 95. Mood stabilizing agents Antimanic(Lithium carbonate) Lithium toxicity- • The margin between the therapeutic and toxic levels of lithium carbonate is very narrow. • Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L • Symptoms include: At serum levels of 1.5 to 2.0 mEq/L: Blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea. At serum levels of 2.0 to 3.5 mEq/L: Excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness. At serum levels above 3.5 mEq/L: Impaired consciousness, nystagmus, seizures, coma, oliguria/ anuria, arrhythmias, myocardial infarction, cardiovascular collapse.
  96. 96. Mood stabilizing agents Antimanic(Lithium carbonate) Lithium toxicity- • Lithium levels should be monitored prior to medication administration. • The dosage should be withheld and the physician notified if the level reaches 1.5 mEq/L or at the earliest observation or report by the client of even the mildest symptom. • If left untreated, lithium toxicity can be life threatening. • The client must consume a diet adequate in sodium as well as 2500 to 3000 ml of fluid per day. • Accurate records of intake, output, and client’s weight should be kept on a daily basis.
  97. 97. Mood stabilizing agents Antimanic(Lithium carbonate) Nursing management- • Take medication on a regular basis • Not drive or operate dangerous machinery • Not skimp on dietary sodium intake. • Avoid “junk” foods. • The client should drink six to eight large glasses of water each day • Avoid excessive use of beverages containing caffeine (coffee, tea, colas), which promote increased urine output. • Notify the physician if vomiting or diarrhea occurs. • Carry a card or other identification noting that he or she is taking lithium. • Notify the physician as soon as possible if pregnancy is suspected or planned.
  98. 98. Mood stabilizing agents Antimanic(Lithium carbonate) Nursing management- • Be aware of side effects and symptoms associated with toxicity. • Notify the physician if any of the following symptoms occur: persistent nausea and vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive output of urine, increasing tremors, or mental confusion. • Refer to written materials furnished by health care providers while receiving self- administered maintenance therapy. • Keep appointments for outpatient follow-up; have serum lithium level checked every 1 to 2 months, or as advised by physician.
  99. 99. Drugs usedin child psychiatry Clonidine • Used to control withdrawal symptoms from opioids, Tourette’s disorder, aggression and autism • It is an alpha 2 adrenergic receptor agonist • Dose is 0.1 mg BD • Side effects are dry mouth, dryness of eye, fatigue, irritability, sedation, dizziness, nausea, vomiting, hypotension and constipation.
  100. 100. Drugs usedin child psychiatry Methylphenidate (Retalin) • Used in attention deficit and hyperkinetic disorder, narcolepsy, depressive disorder and obesity. • It is sympathomimetic drug • Dosage is 5-10 mg/day orally • Side effects are dyspepsia, weight loss, slowed growth, dizziness insomnia, nightmares, tics and psychosis
  101. 101. Drugs usedin child psychiatry Antabuse drugs (Disulfiram) • It is used in the de-addiction from alcohol. • Its main effect is to produce a rapid and violently unpleasant reaction in a person who ingests even a small amount of alcohol while taking disulfiram. • It cause flushing, headache, nausea and vomiting if a person drinks alcohol while taking drug • One dose of disulfiram usually effective for 1-2 weeks. • Overdose can be dangerous, causing low blood pressure, chest pain, shortness of breath and even death.