psychiatric nursing - psycho pharmacology

8/6/2019 Psychiatric Nursing - Psycho Pharmacology

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PSYCHIATRIC NURSINGPSYCHIATRIC NURSING

PsychopharmacologyPsychopharmacologyLITERATURE:LITERATURE:--CONTEMPORARY PSYCHIATRICCONTEMPORARY PSYCHIATRIC--MENTAL HEALTH NURSING, Kneisl, Wilson &MENTAL HEALTH NURSING, Kneisl, Wilson &Trigoboff, Pearson Education Inc., New Jersey, 2004Trigoboff, Pearson Education Inc., New Jersey, 2004--PSYCHIATRIC MENTAL HEALTH NURSING, Fortinash & HolodayPSYCHIATRIC MENTAL HEALTH NURSING, Fortinash & Holoday--Worret,Worret,

MosbyMosby--Year Boock Inc., 1996Year Boock Inc., 1996--MENTAL HEALTH NURSING, 4th ed., Fontaine & Fletcher, Addison WesleyMENTAL HEALTH NURSING, 4th ed., Fontaine & Fletcher, Addison WesleyLongman Inc., 1999Longman Inc., 1999Instructor: Doris O. Aghazarian, M.A., B.Sc.N, R.N.Instructor: Doris O. Aghazarian, M.A., B.Sc.N, R.N.


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PsychopharmacologyPsychopharmacology

Bacground informationBacground information-- Prior to the 1950s psychopharmacology was notPrior to the 1950s psychopharmacology was not

availableavailable focus was on behaviouralfocus was on behaviouralinterventions and sedativesinterventions and sedatives

--

The advent of psychopharmacologic agentsThe advent of psychopharmacologic agentsdramatically lowered the numbers of inpatientsdramatically lowered the numbers of inpatients thousands were released from hospital carethousands were released from hospital care

-- Nowadays, psychopharmacology is a primaryNowadays, psychopharmacology is a primarytreatment mode of psychiatric illnessestreatment mode of psychiatric illnesses

-- -- Nurses are required to understand and updateNurses are required to understand and updatetheir knowlege on current advances intheir knowlege on current advances inpsychopharmacologic interventionspsychopharmacologic interventions


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Background information (contBackground information (contd)d) Discoveries of new medications to treatDiscoveries of new medications to treat

mental illnesses occur almost monthlymental illnesses occur almost monthly

This new frontier of psychiatric thought,This new frontier of psychiatric thought,research and treatment greatly affectsresearch and treatment greatly affectsnursing practicenursing practice

Medications are combined to find the mostMedications are combined to find the most

suitable ones on an individual basis, whichsuitable ones on an individual basis, whichmay require trying a number ofmay require trying a number ofalternatives before finding the right one/salternatives before finding the right one/s


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Psychotropics and neurolepticsPsychotropics and neuroleptics Although we still use classifications such asAlthough we still use classifications such as

antipsychotic and antidepressant, theantipsychotic and antidepressant, thenomenclaturenomenclature neurolepticneurolepticandand psychotropicpsychotropic

is used to indicate that the medication can beis used to indicate that the medication can beused across diagnostic groupsused across diagnostic groups

Many medications now have multiple indicationsMany medications now have multiple indications

For example, Antipsychotics are no more usedFor example, Antipsychotics are no more used

solely for their original purposesolely for their original purpose Psychotropic medications are medications thatPsychotropic medications are medications that

affect cognitive funcion, emotion and behaviour.affect cognitive funcion, emotion and behaviour.


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Psychotropics and neuroleptics (contPsychotropics and neuroleptics (contd)d) Recently, there has been a significant changeRecently, there has been a significant change

in the use of classes of medications forin the use of classes of medications forpsychiatric symptomatologypsychiatric symptomatology

Despite this, you will still encounter the mainDespite this, you will still encounter the mainclassification of psychotropics into four groups:classification of psychotropics into four groups:

1.1. AntipsychoticAntipsychotic

2.2. AntidepressantAntidepressant3.3. Antianxiety/AnxiolyticAntianxiety/Anxiolytic

4.4. MoodMood--stabilizingstabilizing


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Antipsychotic medicationsAntipsychotic medications Reducing as many of the psychotic symptoms asReducing as many of the psychotic symptoms as

possible, enables patient to participate morepossible, enables patient to participate moreeffectively in other forms of treatmenteffectively in other forms of treatment

It may take 2It may take 2--4 weeks to see improvement4 weeks to see improvement Some people respond better to one drug than toSome people respond better to one drug than to

anotheranother idiosyncracyidiosyncracy Choosing the medication also depends on itsChoosing the medication also depends on its

sideside--effectseffects again, idiosyncraticagain, idiosyncratic Half of the medicated people get sideHalf of the medicated people get side--effectseffects

because of which they discontinue thebecause of which they discontinue themedication (loss of compliance or adherence)medication (loss of compliance or adherence)


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Antipsychotic medications (contAntipsychotic medications (contd)d) There are conventional and newThere are conventional and new--generation orgeneration or

atypical antipsychoticsatypical antipsychotics

Some patients respond better to conventionalSome patients respond better to conventionalmedication (e.g. Chlorpromazine), althoughmedication (e.g. Chlorpromazine), althoughatypical agents (e.g. Zyprexa, Risperdal) haveatypical agents (e.g. Zyprexa, Risperdal) havebeen found to be more effective and safe inbeen found to be more effective and safe inlonglong--term treatmentterm treatment

Conventional (as well as some atypical) agentsConventional (as well as some atypical) agentscan have very serious sidecan have very serious side--effectseffects


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Antipsychotic medicationsAntipsychotic medications

SideSide--effectseffects The most common sideThe most common side--effects ofeffects of

conventional antipsychotic medicationsconventional antipsychotic medications

include:include:-- Anticholinergic effectsAnticholinergic effects (an anticholinergic is a drug that inhibits(an anticholinergic is a drug that inhibits

the action of acetylcholine, the chemical transmitter by which the vagus nervethe action of acetylcholine, the chemical transmitter by which the vagus nervestimulates the stomach and intestines.)stimulates the stomach and intestines.)

-- PhotosensitivityPhotosensitivity-- Extrapyramidal sideExtrapyramidal side--effects (EPS)effects (EPS)


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Antipsychotic medicationAntipsychotic medication

sideside--effects (conteffects (contd)d) Extrapyramidal sideExtrapyramidal side--effects (EPS)effects (EPS)-- Akathisia:Akathisia: (Gk. Not being able to sit). Feeling restless or jittery, needing to(Gk. Not being able to sit). Feeling restless or jittery, needing to

fidget, pace around, be aboutfidget, pace around, be about

-- Dystonia:Dystonia: sudden muscle spasm characterized by torticollis (twisting of neck),sudden muscle spasm characterized by torticollis (twisting of neck),opisthotonos (spasm of the neck and back forcing the head backwards), oculogyricopisthotonos (spasm of the neck and back forcing the head backwards), oculogyriccrisis (a fixed gaze that cannot return to lateral)crisis (a fixed gaze that cannot return to lateral)

-- Parkinsonism:Parkinsonism: tremor, stiffness, rigidity, stooped posture, shuffling gait,tremor, stiffness, rigidity, stooped posture, shuffling gait,akinesia (feeling slowed down), pillakinesia (feeling slowed down), pill--rolling movement of fingers, oscillations of distalrolling movement of fingers, oscillations of distalparts of extremitiesparts of extremities

-- Neuroleptic malignant syndrome:Neuroleptic malignant syndrome: muscle rigidity,muscle rigidity,hyperpyrexia, hypertension, confusion, deliriumhyperpyrexia, hypertension, confusion, delirium-- Tardive dyskinesia:Tardive dyskinesia: involuntary movements of face and body (lipinvoluntary movements of face and body (lip

smacking, tongue protrusion, rocking, foot tapping), impaired gait andsmacking, tongue protrusion, rocking, foot tapping), impaired gait andpostureposture


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sideside--effects (conteffects (contd)d) TARDIVE DYSKINESIA (contTARDIVE DYSKINESIA (contd)d)-- Many of the cases are mild but the disorder can beMany of the cases are mild but the disorder can be

socially disfiguring. The symptoms of frowning, blinking,socially disfiguring. The symptoms of frowning, blinking,

grimacing, puckering, blowing, smacking, licking,grimacing, puckering, blowing, smacking, licking,chewing, tongue protrusion and spastic facial distortionschewing, tongue protrusion and spastic facial distortionsare very troubling. Abnormal movements of the armsare very troubling. Abnormal movements of the armsand legs also occur, including rapid, purposelessand legs also occur, including rapid, purposelessirregular movements; tremors and foot tapping. Bodyirregular movements; tremors and foot tapping. Bodysymptoms include dramatic movements of the neck andsymptoms include dramatic movements of the neck and

shoulders, rocking, twisting pelvic gyrations and thrusts.shoulders, rocking, twisting pelvic gyrations and thrusts.-- Because tardive dyskinesia is often irreversible, the goalBecause tardive dyskinesia is often irreversible, the goal

is prevention.is prevention.-- If symptoms begin to appear, the medication is reducedIf symptoms begin to appear, the medication is reduced

or the person is switched to a newer antipsychotic.or the person is switched to a newer antipsychotic.


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sideside--effects (conteffects (contd)d) Interference with sexual functioning is fairly common.Interference with sexual functioning is fairly common.

Almost half report weight gain.Almost half report weight gain.

Identifying and managing side effects is important.Identifying and managing side effects is important.

Some people stop taking their medication and relapseSome people stop taking their medication and relapsewhereas others relapse first, and as a result, stop takingwhereas others relapse first, and as a result, stop takingtheir medication.their medication.

Monitoring white blood cells is essential with someMonitoring white blood cells is essential with somemedications as agranulocytosis is common with somemedications as agranulocytosis is common with some

drugs and can be fatal, since the patient can easilydrugs and can be fatal, since the patient can easilysuccumb to an overwhelming infection.succumb to an overwhelming infection.


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Toxicity and overdoseToxicity and overdose The primary symptom of overdose is CNS depression,The primary symptom of overdose is CNS depression,

which may extend to the point of coma.which may extend to the point of coma.

Other symptoms include agitation, restlessness, seizures,Other symptoms include agitation, restlessness, seizures,

fever, EPS, arrhythmias, and hypotension.fever, EPS, arrhythmias, and hypotension. Caring for a client with overdose includes monitoringCaring for a client with overdose includes monitoring

vital signs, especially of cardiac function; maintaining avital signs, especially of cardiac function; maintaining apatent airway and gastric lavage.patent airway and gastric lavage.

Antiparkinsonian medications may be given for EPS.Antiparkinsonian medications may be given for EPS.

Valium (Diazepam) may be given for seizures.Valium (Diazepam) may be given for seizures.


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Antidepressant medicationAntidepressant medication

Physiological effectsPhysiological effects The neurotransmitters involved in depressionThe neurotransmitters involved in depression

are dopamine (DA), serotonin (5are dopamine (DA), serotonin (5--HT),HT),norepinephrine (NE) and acetylcholine (ACH).norepinephrine (NE) and acetylcholine (ACH).

It is believed that during depressive episode,It is believed that during depressive episode,there is a functional deficiency of thesethere is a functional deficiency of theseneurotransmitters or hyposensitive receptors.neurotransmitters or hyposensitive receptors.

Antidepressant medications increase the amountAntidepressant medications increase the amount

of available neurotransmitters by inhibitingof available neurotransmitters by inhibitingneurotransmitter reuptake, by inhibitingneurotransmitter reuptake, by inhibitingmonoamina oxidase (MAO) or by blockingmonoamina oxidase (MAO) or by blockingcertain receptors.certain receptors. (Thase and Howland, 1995)(Thase and Howland, 1995)


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Therapeutic effectsTherapeutic effects Antidepressant medications can be classified as:Antidepressant medications can be classified as:

Older generation agents: multicyclics andOlder generation agents: multicyclics andmonoamine oxidase inhibitors (MAOIs)monoamine oxidase inhibitors (MAOIs)

New generation agents: selective serotoninNew generation agents: selective serotoninreuptake inhibitors (SSRIs) and serotoninreuptake inhibitors (SSRIs) and serotonin--norepinephrine reuptake inhibitors (SNRIs).norepinephrine reuptake inhibitors (SNRIs).

The new generation medications haveThe new generation medications have

dramatically changed the treatment ofdramatically changed the treatment ofdepression, with more effective action and fewerdepression, with more effective action and fewerside effects.side effects.


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Therapeutic effects (contTherapeutic effects (contd)d) Depressions are heterogenous in terms of whichDepressions are heterogenous in terms of which

neurotransmitters are depleted, which is why differentneurotransmitters are depleted, which is why differentpeople respond differently to various antidepressants.people respond differently to various antidepressants.

Often, a period of trial and error is necessary toOften, a period of trial and error is necessary to

determine which medication is the most effective.determine which medication is the most effective. Maintenancecontinues until clients are free of symptomsMaintenancecontinues until clients are free of symptoms

from 4 months to 1 year. Then the drugs are slowyfrom 4 months to 1 year. Then the drugs are slowydiscontinued.discontinued.

The therapeutic purpose of antidepressants is toThe therapeutic purpose of antidepressants is todecrease as many of the depressive symptoms asdecrease as many of the depressive symptoms aspossible, THEREBY ENABLING THE CLIENT TOpossible, THEREBY ENABLING THE CLIENT TOPARTICIPATE MORE EFFECTIVELY IN OTHER FORMS OFPARTICIPATE MORE EFFECTIVELY IN OTHER FORMS OFTREATMENT.TREATMENT.


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Therapeutic effects (contTherapeutic effects (contd)d) Antidepressants do not cause dependence, tolerance,Antidepressants do not cause dependence, tolerance,

addiction or withdrawal.addiction or withdrawal. It takes an average of 10It takes an average of 10--14 days for the beginning14 days for the beginning

effect and full effect may not be apparent for 4effect and full effect may not be apparent for 4--6 weeks.6 weeks. When a client does not respond at all after a trial periodWhen a client does not respond at all after a trial period

of 4of 4--6 weeks, a different antidepressant is tried or a6 weeks, a different antidepressant is tried or acombination of other medications.combination of other medications.

A significant number of clients improve when 600mg ofA significant number of clients improve when 600mg oflithium is added to antidepressant treatment.lithium is added to antidepressant treatment.

Other clients improve when triiodothyronine (T3) isOther clients improve when triiodothyronine (T3) isadministered daily.administered daily.

For delusional or severely agitated clients antipsychoticFor delusional or severely agitated clients antipsychoticmedication may be indicated.medication may be indicated.


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Side effectsSide effects Both multicyclics and MAOIs may have anticholinergic effects suchBoth multicyclics and MAOIs may have anticholinergic effects such

as dry mouth, blurred vision, urinary retention and constipation.as dry mouth, blurred vision, urinary retention and constipation. CNS effects include drowsiness, lethargy, insomnia and restlessness.CNS effects include drowsiness, lethargy, insomnia and restlessness. Orthostatic hypotension and tachycardia may occur in the earlyOrthostatic hypotension and tachycardia may occur in the early

phases of treatmentphases of treatment The best know side effects are sexual dysfunction and weight gain.The best know side effects are sexual dysfunction and weight gain. Some medications cause great sexual impairment and excessiveSome medications cause great sexual impairment and excessive

weight gain, e.g. Elavil (amitriptyline), Adapin (doxepin) andweight gain, e.g. Elavil (amitriptyline), Adapin (doxepin) andAnafranil (clomipramine).Anafranil (clomipramine).

Least sexual side effects and weight gain is experienced withLeast sexual side effects and weight gain is experienced with

Norpramin (desipramine) and Pamelor (nortriptyline).Norpramin (desipramine) and Pamelor (nortriptyline). Weight gain with latter is 0Weight gain with latter is 0--10 pounds and with formerly mentioned10 pounds and with formerly mentioned

medications 5medications 5--40 pounds.40 pounds.


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Side effects (contSide effects (contd)d) The SSRIs and SNRIs have fewer anticholinergic effects,The SSRIs and SNRIs have fewer anticholinergic effects,

fewer cardiac effects, fewer sexual problems, lessfewer cardiac effects, fewer sexual problems, lesssedation and less weight gain.sedation and less weight gain.

MAOIs decrease the amount of monoamine oxidase inMAOIs decrease the amount of monoamine oxidase inthe liver, which breaks down the essential amino acidsthe liver, which breaks down the essential amino acidstyramine and tryptophan. If a person eats food that istyramine and tryptophan. If a person eats food that isrich in these substances he or she risks hypertensiverich in these substances he or she risks hypertensivecrisis.crisis.

The first sign of hypertensive crisis is a sudden andThe first sign of hypertensive crisis is a sudden andsevere headache, followed by neck stiffness, nausea,severe headache, followed by neck stiffness, nausea,vomiting and tachycardia. Death can result fromvomiting and tachycardia. Death can result fromcirculatory collapse or intracranial bleeding.circulatory collapse or intracranial bleeding.


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Side effects (contSide effects (contd)d) FOOD TO AVOID WITH MAOIsFOOD TO AVOID WITH MAOIs

Absolutely restricted:Absolutely restricted:

-- Aged cheeses; aged and cured meats; improperly storedAged cheeses; aged and cured meats; improperly stored

or spoiled meat, fish or poultry; banana peel; broador spoiled meat, fish or poultry; banana peel; broadbean pods; sauerkraut; soy sauce and other dosybean pods; sauerkraut; soy sauce and other dosycondiments; draft beer.condiments; draft beer.

Consume in moderation:Consume in moderation:

-- Red or white wine (no more than two 4Red or white wine (no more than two 4--oz glasses peroz glasses perday); bottled or canned beer, including nonday); bottled or canned beer, including non--alcoholic (noalcoholic (nomore than two 12more than two 12--oz servings per day).oz servings per day).

(Gardner, 1996)(Gardner, 1996)


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Side effects (contSide effects (contd)d) The SSRIs and SNRIs increase the availability ofThe SSRIs and SNRIs increase the availability of

55--HT, which relieves depression but can alsoHT, which relieves depression but can alsocause the hyperserotonergic state known as thecause the hyperserotonergic state known as the

serotonin syndrome (SS).serotonin syndrome (SS). This syndrome is more likely to occur whenThis syndrome is more likely to occur when

these agents are used in combination withthese agents are used in combination withMAOIs.MAOIs.

SS develops very quickly and must be attendedSS develops very quickly and must be attendedto immediately. Characteristic symptoms are:to immediately. Characteristic symptoms are:high fever, confusion, hypomania, tachycardia,high fever, confusion, hypomania, tachycardia,diaphoresis, discodiaphoresis, disco--ordination and seizures.ordination and seizures.


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Toxicity and overdoseToxicity and overdose Symptoms of toxicity are varied and mustSymptoms of toxicity are varied and must

be noticed immediately.be noticed immediately.

If MAOIs and other antidepressants areIf MAOIs and other antidepressants areadministered together, serious reactionsadministered together, serious reactionsmay occur.may occur.

CAUTION! Seven to 14 days should elapseCAUTION! Seven to 14 days should elapsebetween the use of MAOIs and otherbetween the use of MAOIs and otherantidepressants.antidepressants.


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AdministrationAdministration OralOral

Usually takes 2Usually takes 2--4 weeks to reach4 weeks to reach

therapeutic levelstherapeutic levels

Changes may be observed by othersChanges may be observed by othersbefore client recognizes thembefore client recognizes them


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Antianxiety medicationAntianxiety medication

Physiological effectsPhysiological effects Benzodiazepine antianxiety medications act onBenzodiazepine antianxiety medications act on

the limbic system and the reticular activatingthe limbic system and the reticular activatingsystem (RAS).system (RAS).

They produce a calming effect by potentiatingThey produce a calming effect by potentiatingthe effects of gamma aminobutyric acid (GABA),the effects of gamma aminobutyric acid (GABA),on of the inhibitory neurotransmitters.on of the inhibitory neurotransmitters.

CNS depression can range from mild sedation toCNS depression can range from mild sedation to

coma.coma. Other physiological effects include skeletalOther physiological effects include skeletal

muscle relaxation and anticonvulsant properties.muscle relaxation and anticonvulsant properties.


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Therapeutic effectsTherapeutic effects Different medications are effective in variousDifferent medications are effective in various

anxiety disorders.anxiety disorders. Individual benzodiazepines differ in potency,Individual benzodiazepines differ in potency,

speed in crossing the bloodspeed in crossing the blood--brain barrier, andbrain barrier, anddegree of receptor binding.degree of receptor binding. HighHigh--potency and shortpotency and short--acting benzodiazepinesacting benzodiazepines

include Xanax (alprazolam), Ativan (lorazepam),include Xanax (alprazolam), Ativan (lorazepam),Paxipam (halazepam) and Serax (oxazepam).Paxipam (halazepam) and Serax (oxazepam).

LowLow--potency and longpotency and long--acting benzodiazepinesacting benzodiazepinesinclude Tranxene (clorazepate), Valiuminclude Tranxene (clorazepate), Valium(diazepam) and Librium (chlordiazepoxide).(diazepam) and Librium (chlordiazepoxide).


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Side effects (contSide effects (contd)d) There is a potential for abuse inThere is a potential for abuse in

vulnerable client populations.vulnerable client populations.

BuSpar (buspirone) has no potential forBuSpar (buspirone) has no potential fordependence and does not potentiate thedependence and does not potentiate theeffects of alcohol on the CNS.effects of alcohol on the CNS.

It is the drug of choice for clients who areIt is the drug of choice for clients who are

prone to substance abuse or for thoseprone to substance abuse or for thosewho require longwho require long--term treatment withterm treatment withantianxiety medications.antianxiety medications.


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Toxicity and overdoseToxicity and overdose Symptoms of toxicity include euphoria,Symptoms of toxicity include euphoria,

slurred speech, disorientation, unsteadyslurred speech, disorientation, unsteady

gait and impaired judgment.gait and impaired judgment. Symptoms of overdose include respiratorySymptoms of overdose include respiratory

depression, cold and clammy skin,depression, cold and clammy skin,

hypotension, weak and rapid pulse, dilatedhypotension, weak and rapid pulse, dilatedpupils and coma.pupils and coma.

These must be reported immediately!These must be reported immediately!


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AdministrationAdministration All antianxiety medications may be taken orally.All antianxiety medications may be taken orally.

Antacids interfere with the absorption of theseAntacids interfere with the absorption of thesemedications and should not be taken untilmedications and should not be taken untilseveral hours later.several hours later.

Some medications may be administered IM orSome medications may be administered IM orIV.IV.

Benzodiazepines should not be discontinuedBenzodiazepines should not be discontinuedabruptly because of the risk of withdrawalabruptly because of the risk of withdrawalsymptoms. They shoudl be gradually reducedsymptoms. They shoudl be gradually reducedvery carefully.very carefully.


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MoodMood--stabilizing medicationstabilizing medication

Physiological effectsPhysiological effects Mood stabilizers include a small group of diverseMood stabilizers include a small group of diverse

medicationsmedications Lithium is the best known and most often prescribedLithium is the best known and most often prescribed

mood stabilizer.mood stabilizer. In recent years, several anticonvulsant medications haveIn recent years, several anticonvulsant medications have

been added to this category: Tegretol (carbamazepine),been added to this category: Tegretol (carbamazepine),Depakene and Depakote (valproate) and KlonopinDepakene and Depakote (valproate) and Klonopin(clonazepam).(clonazepam).

Calcium channel blockers (Calan and Isoptin) areCalcium channel blockers (Calan and Isoptin) are

increasingly being used with success in manic disordersincreasingly being used with success in manic disorderseither alone or in combination with other moodeither alone or in combination with other moodstabilizers. They have been found to be effective in thestabilizers. They have been found to be effective in thetreatment of bipolar disorder and seem to work best intreatment of bipolar disorder and seem to work best inpeople who also respond to lithium.people who also respond to lithium.


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Physiological effects (contPhysiological effects (contd)d) The specific action of these medications isThe specific action of these medications is

unclear.unclear. In the body, lithium substitutes for sodium,In the body, lithium substitutes for sodium,

calcium, potassium and magnesium. It alsocalcium, potassium and magnesium. It alsointeracts with neurotransmitters.interacts with neurotransmitters.

Like antidepressants, lithium normalizes REMLike antidepressants, lithium normalizes REMsleep abnormalities which are present in moodsleep abnormalities which are present in mooddisorders.disorders.

Mood stabilizers which increase GABA activityMood stabilizers which increase GABA activityseem to have an antimanic, antipanic andseem to have an antimanic, antipanic andantianxiety effect.antianxiety effect.


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Physiological effects (contPhysiological effects (contd)d) Manic episodes may be triggered byManic episodes may be triggered by

persistent lowpersistent low--level stimulation of thelevel stimulation of the

brain referred to as kindling.brain referred to as kindling. The anticonvulsants may be effective inThe anticonvulsants may be effective in

that they block this persistent stimulation.that they block this persistent stimulation.

Clients with acute manic episode haveClients with acute manic episode have

been found to have increased levels ofbeen found to have increased levels ofintracellular calcium, which decrease whenintracellular calcium, which decrease whenlithium is administered.lithium is administered.


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Therapeutic effectsTherapeutic effects For clients with problems such as bipolarFor clients with problems such as bipolar

disorder, major depression, schizoaffectivedisorder, major depression, schizoaffectivedisorder, treatmentdisorder, treatment--resistant schizophrenia,resistant schizophrenia,

alcoholalcohol--withdrawal, and other moodwithdrawal, and other mood--regulationregulationproblems, moodproblems, mood--stabilizing medication has beenstabilizing medication has beenfound to be helpful.found to be helpful.

The antimanic effectiveness of lithium is 60The antimanic effectiveness of lithium is 60--70%; some people seem to be resistant to it70%; some people seem to be resistant to it

and others cannot tolerate the side effects.and others cannot tolerate the side effects. Because it takes 1Because it takes 1--3 weeks to control symptoms,3 weeks to control symptoms,

antipsychotic medication or benzodiazepines areantipsychotic medication or benzodiazepines aregiven initially for more immediate relief.given initially for more immediate relief.


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Side effectsSide effects The early side effects of lithium often disappear after 4The early side effects of lithium often disappear after 4

weeks.weeks. These side effects include lack of spontaneity, memoryThese side effects include lack of spontaneity, memory

problems, difficulty concentrating, nausea, vomiting,problems, difficulty concentrating, nausea, vomiting,

diarrhoea and hand tremorsdiarrhoea and hand tremors Weight gain and a worsening of acne often persistWeight gain and a worsening of acne often persist

throughout treatmentthroughout treatment Women taking Tegretol (carbamazepine) may haveWomen taking Tegretol (carbamazepine) may have

menstrual cycle irregularities and experience falsemenstrual cycle irregularities and experience false

positive pregnancy tests.positive pregnancy tests. Weight gain is the side effect which causes mostWeight gain is the side effect which causes most

complaints and is the major cause of discontinuing moodcomplaints and is the major cause of discontinuing moodstabilizers.stabilizers.


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AdministrationAdministration The administration of lithium is oral, in capsuleThe administration of lithium is oral, in capsule

or liquid form.or liquid form.

Both carbamazepine and valproate are availableBoth carbamazepine and valproate are available

in tablet and liquid forms. Initially low doses arein tablet and liquid forms. Initially low doses areincreased gradually.increased gradually.

The ultimate dosages are determined byThe ultimate dosages are determined byreduction of symptoms, blood levels and sidereduction of symptoms, blood levels and side

effects.effects. Patients must continuously be monitored forPatients must continuously be monitored for

hypotension and bradycardia.hypotension and bradycardia.


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PSYCHOPHARMACOLOGYPSYCHOPHARMACOLOGY

Client educationClient education

One of the aims of client education is to reduceOne of the aims of client education is to reduceRECIDIVISM: the tendency to relapse into aRECIDIVISM: the tendency to relapse into aprevious mode of behaviour requiringprevious mode of behaviour requiring

readmission to a treatment programmereadmission to a treatment programme Assess learning capacityAssess learning capacity especially withespecially with

chronically ill patientschronically ill patients and use most relevantand use most relevantand appropriate teaching methodand appropriate teaching method

Explore cognitive, psychological, cultural,Explore cognitive, psychological, cultural,personal and social factors affecting attitudespersonal and social factors affecting attitudesand beliefs concerning medicationand beliefs concerning medication


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What nurses need to know forWhat nurses need to know for

Medication TeachingMedication Teaching

PSYCHOSESPSYCHOSES

-- Cognitive difficulties secondary to thoughtCognitive difficulties secondary to thought

disorderdisorder-- Motivational problems secondary toMotivational problems secondary to

negative symptomsnegative symptoms

--

Unpleasant side effects from medicationUnpleasant side effects from medication-- Persistence of positive symptomsPersistence of positive symptoms

(delusions) mitigating against adherence(delusions) mitigating against adherence


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What nurses need to know (contWhat nurses need to know (contd)d)

MOOD DISORDERSMOOD DISORDERS

-- Persistent dysphoria leads to amotivationPersistent dysphoria leads to amotivation

-- SelfSelf--destructivenessdestructiveness lethalitylethality-- Manic irresponsibilityManic irresponsibility

-- Loss of manic or hypomanic egosyntonicLoss of manic or hypomanic egosyntonic

(identity(identity--related) excitementrelated) excitement-- Unpleasant side effects from medicationsUnpleasant side effects from medications


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What nurses need to know (contWhat nurses need to know (contd)d)

ANXIETY DISORDERSANXIETY DISORDERS

-- Addiction to antianxiety medicationAddiction to antianxiety medication

-- Quick action of many antianxiety agentsQuick action of many antianxiety agentsleads to positive reinforcement ofleads to positive reinforcement ofincreasing dosagesincreasing dosages

-- Lack of consistent provider knowledge ofLack of consistent provider knowledge of

and expertise in application of effectiveand expertise in application of effectivenonmedication treatment strategies fornonmedication treatment strategies foranxiety problemsanxiety problems


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TeachingTeaching

The nurse needs to be able to discuss theThe nurse needs to be able to discuss thefollowing questions with clients:following questions with clients:

1.1. What does this medication do?What does this medication do?2.2.

How should I take this medication?How should I take this medication?3.3. What if I miss a dose?What if I miss a dose?4.4. What other medicine does not mix with thisWhat other medicine does not mix with this

one?one?5.5. What side effects can I expect?What side effects can I expect?6.6. Where can I keep my medication?Where can I keep my medication?7.7. What do I do if I have a problem?What do I do if I have a problem?


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P t ti l idP t ti l id ff t fff t f


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Potential sidePotential side--effects ofeffects of

antipsychotic medicationsantipsychotic medications

REVISIONREVISION Autonomic nervous system or anticholinergic side effects:Autonomic nervous system or anticholinergic side effects:

orthostatic hypotension (measure lying and standing blood pressureorthostatic hypotension (measure lying and standing blood pressurefrequently), dry mouth, blurred vision, constipation, urinaryfrequently), dry mouth, blurred vision, constipation, urinaryhesitance or retention, rarely also paralytic ileushesitance or retention, rarely also paralytic ileus

Extrapyramidal (EPSEs): acute dystonic reactions (bizarre andExtrapyramidal (EPSEs): acute dystonic reactions (bizarre andsevere muscular contractions), Parkinsonian syndrome or pseudosevere muscular contractions), Parkinsonian syndrome or pseudo--parkinsonism, akathisia (lit: not sitting motor reslessness).parkinsonism, akathisia (lit: not sitting motor reslessness).

Tardive Dyskinesia (TD): rapid, jerky, slowTardive Dyskinesia (TD): rapid, jerky, slow--writing involuntary of lip,writing involuntary of lip,tongue, eyeballs, facial musclestongue, eyeballs, facial muscles

Most symptoms may be reversible if detected early enough.Most symptoms may be reversible if detected early enough. Must be CORRECTLY INTERPRETED AS STEMMING FROMMust be CORRECTLY INTERPRETED AS STEMMING FROM

MEDICATION!MEDICATION!


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ANTIDEPRESSANT MEDICATIONANTIDEPRESSANT MEDICATION

Tricyclic antidepressants (TCIs)Tricyclic antidepressants (TCIs)

Monoamine oxidase inhibitors (MAOIs)Monoamine oxidase inhibitors (MAOIs)

Selective Serotonin Reuptake InhibitorsSelective Serotonin Reuptake Inhibitors(SSRIs)(SSRIs)

Phenethylamine antidepressantsPhenethylamine antidepressants

MORE ON THIS AND FOLLOWING TOPICSMORE ON THIS AND FOLLOWING TOPICSIN HANDOUT.IN HANDOUT.


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SECTIONS OF HANDOUT TOSECTIONS OF HANDOUT TO

FOCUS ON:FOCUS ON:

LowLow--Tyramine dietTyramine diet

Mood stabilizersMood stabilizers

LithiumLithium

AnxiolyticsAnxiolytics

Treatment of InsomniaTreatment of Insomnia

HANDOUT REFERENCE: ContemporaryHANDOUT REFERENCE: Contemporary

PsychiatricPsychiatric--Mental Health Nursing, KneislMental Health Nursing, Kneislet al, Pearson Education Inc. 2004, Ch.et al, Pearson Education Inc. 2004, Ch.13, pp. 74513, pp. 745--761761


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PSYCHOPHARMACOLOGYPSYCHOPHARMACOLOGY

Names and actions of drugsNames and actions of drugs

Familiarize yourself with the 35 medicationFamiliarize yourself with the 35 medicationcards handed out in class.cards handed out in class.

ALWAYS LOOK UP INFORMATION ONALWAYS LOOK UP INFORMATION ONDRUGS YOU ARE ADMINISTERING TODRUGS YOU ARE ADMINISTERING TOPATIENTS IN PHARMACA FENNICA!!!PATIENTS IN PHARMACA FENNICA!!!

psychiatric nursing - psycho pharmacology

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