Chapter 16 Psychotherapeutic Drugs Copyright 2014 by Mosby

Psychotherapeutic Drugs Used in the treatment of emotional and mental disorders Ability to cope with emotions can range from occasional depression or anxiety to constant emotional distress Ø When emotions significantly affect an individual’s ability to carry out normal daily functions, treatment with a psychotherapeutic drug is a possible option Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 2

Psychotherapeutic Drugs (cont’d) Three main emotional and mental disorders: Anxiety Ø Affective disorders Ø

Psychotherapeutic Drugs (cont’d) Types of psychotherapeutic drugs Anxiolytic drugs Ø Mood-stabilizing drugs Ø Antidepressant drugs Ø Antipsychotic drugs Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 4

Anxiety Unpleasant state of mind, characterized by a sense of dread and fear May be based on actual anticipated experiences or past experiences May be exaggerated responses to imaginary negative situations Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 5

Anxiety Disorders Six major anxiety disorders (persistent anxiety) Obsessive-compulsive disorder (OCD) Ø Posttraumatic stress disorder (PTSD) Ø Generalized anxiety disorder (GAD) Ø Panic disorder Ø Social phobia (social anxiety disorder) Ø Simple phobia Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 6

Affective Disorders (Mood Disorders) Changes in mood that range from mania (abnormally pronounced emotions) to depression (abnormally reduced emotions) Some patients may exhibit both mania and depression: bipolar disorder (BPD) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 7

Psychosis Severe emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in activities of daily living Hallmark: loss of contact with reality Examples Schizophrenia Ø Depressive and drug-induced psychoses Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 8

Anxiolytic Drugs Reduce anxiety by reducing overactivity in CNS Benzodiazepines • Depress activity in the brainstem and limbic system Ø Miscellaneous drug: buspirone (Bu. Spar) • Nonsedating and non–habit forming • May have drug interaction with SSRIs (serotonin syndrome) • Do not administer with MAOIs Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 9

Benzodiazepines alprazolam (Xanax) diazepam (Valium) lorazepam (Ativan) Copyright © 2014 by Mosby, an imprint

Benzodiazepines: Adverse Effects Benzodiazepine adverse effects are an overexpression of their therapeutic effects Decreased CNS activity, sedation Ø Hypotension Ø Drowsiness, loss of coordination, dizziness, headaches Ø Nausea, vomiting, dry mouth, constipation Ø Others Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 11

Benzodiazepines: Overdose Dangerous when taken with other sedatives or alcohol Treatment is generally symptomatic and supportive Flumazenil may be used to reverse benzodiazepine effects Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 12

Miscellaneous Anxiolytic buspirone (Bu. Spar) Unknown mechanism of action Ø Administered on a scheduled basis Ø Adverse effects • Paradoxical anxiety • Blurred vision • Headache • Nausea Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 13

Mood-Stabilizing Drugs Lithium carbonate and lithium citrate Other drugs may be used in combination with lithium Benzodiazepines Ø Antipsychotic drugs Ø Antiepileptic drugs Ø Dopamine receptor agonists Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 14

Mood-Stabilizing Drugs (cont’d) Lithium is the drug of choice for the treatment of mania It is thought to potentiate serotonergic neurotransmission Ø Narrow therapeutic range: maintenance serum levels should range between 0. 6 and 1. 2 m. Eq/L Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 15

Classroom Response Question Before administering lithium to a patient, it is most important for the nurse to assess which laboratory value? A. Blood sugar B. Sodium C. Urine osmolality D. Hematocrit Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 16

Antidepressants Tricyclic antidepressants Monoamine oxidase inhibitors (MAOIs) Second-generation antidepressants Selective serotonin reuptake inhibitors (SSRIs) Ø Serotonin-norepinephrine reuptake inhibitors (SNRIs) Ø Miscellaneous Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 17

Tricyclic Antidepressants Have largely been replaced by SSRIs as first-line antidepressant drugs Considered second line For patients who fail with SSRIs or other newergeneration antidepressants Ø As adjunct therapy with newer-generation antidepressants Ø amitriptyline (Elavil) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 18

Tricyclic Antidepressants: Mechanism of Action Block reuptake of neurotransmitters, causing accumulation at the nerve endings It is thought that increasing concentrations of neurotransmitters will correct the abnormally low levels that lead to depression Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 19

Tricyclic Antidepressants: Indications Depression Childhood enuresis (imipramine) Obsessive-compulsive disorders (clomipramine) Adjunctive analgesics for chronic pain conditions, such as trigeminal neuralgia Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 20

Tricyclic Antidepressants: Adverse Effects Sedation Impotence Orthostatic hypotension Others Older patients Ø Dizziness, postural hypotension, constipation, delayed micturation, edema, muscle tremors Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 21

Tricyclic Antidepressants: Overdose Lethal— 70% to 80% die before reaching the hospital CNS and cardiovascular systems are mainly affected Death results from seizures or dysrhythmias Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 22

Tricyclic Antidepressants: Overdose (cont’d) No specific antidote Decrease drug absorption with activated charcoal Ø Speed elimination by alkalinizing urine Ø Manage seizures and dysrhythmias Ø Basic life support Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 23

Monoamine Oxidase Inhibitors (MAOIs) Highly effective Considered second-line treatment for depression, not responsive to cyclics Disadvantage: potential to cause hypertensive crisis when taken with tyramine Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 24

MAOIs (cont’d) isocarboxazid (Marplan) phenelzine (Nardil) tranylcypromine (Parnate) selegiline (Emsam) Copyright © 2014 by

MAOIs: Mechanism of Action Inhibit the MAO enzyme system in the CNS Amines (dopamine, serotonin, norepinephrine) are not broken down, resulting in higher levels in the brain Result: alleviation of symptoms of depression Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 26

MAOIs: Indications Depression, especially types characterized by reverse vegetative symptoms such as increased sleep and appetite Depression that does not respond to other drugs such as tricyclics Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 27

MAOIs: Adverse Effects Ø Ø Ø Ø Ø Few adverse effects—orthostatic hypotension most common Tachycardia Dizziness Insomnia Anorexia Blurred vision Palpitations Drowsiness Headache Nausea Impotence Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 28

MAOIs: Overdose Symptoms appear 12 hours after ingestion Tachycardia, circulatory collapse, seizures, coma Treatment: protect brain and heart, eliminate toxin Urine acidification Ø Hemodialysis Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 29

MAOIs and Tyramine Ingestion of foods or drinks with tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death Avoid foods that contain tyramine! Aged, mature cheeses (cheddar, blue, Swiss) Ø Smoked/pickled or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté) Ø Yeast extracts Ø Red wines (Chianti, burgundy, sherry, vermouth) Ø Italian broad beans (fava beans) Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 30

Second-Generation Antidepressants Fewer adverse effects than tricyclics and MAOIs Very few drug-drug or drug-food interactions Still take about 4 to 6 weeks to reach maximum clinical effectiveness Now considered first-line drugs for depression Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 31

Second-Generation Antidepressants (cont’d) SSRIs fluoxetine (Prozac) Ø paroxetine (Paxil) Ø sertraline (Zoloft) Ø fluvoxamine (Luvox) Ø citalopram (Celexa) Ø escitalopram (Lexapro) Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 32

Second-Generation Antidepressants (cont’d) SNRIs venlafaxine (Effexor) Ø duloxetine (Cymbalta) Ø desvenlafaxine (Pristiq) Ø Miscellaneous trazodone (Desyrel, Oleptro) Ø bupropion (Wellbutrin) Ø nefazodone (Serzone) Ø mirtazapine (Remeron) Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 33

Second-Generation Antidepressants: Mechanism of Action SSRIs Selectively inhibit serotonin reuptake Ø Little or no effect on norepinephrine or dopamine reuptake Ø Result in increased serotonin concentrations at nerve endings Ø SNRIs Ø Inhibit reuptake of both serotonin and norepinephrine Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 34

Second-Generation Antidepressants: Indications Depression Bipolar disorder Obesity Eating disorders Obsessive-compulsive disorder Copyright © 2014

Second-Generation Antidepressants: Indications (cont’d) Panic attacks or disorders Social anxiety disorders Posttraumatic stress disorders (PTSDs) Myoclonus Treatment of various substance abuse problems (bupropion [Zyban] is used for smoking cessation treatment) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 36

Second-Generation Antidepressants: Adverse Effects Body System CNS Effects Headache, dizziness, tremor, nervousness, insomnia*, fatigue Nausea, diarrhea, constipation, dry mouth Sexual dysfunction, weight gain*, weight loss*, sweating GI Other *Most common and bothersome Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 37

Classroom Response Question When patients are taking selective serotonin reuptake inhibitors (SSRIs) for the first time for depression, which is most important to monitor for during the first few weeks of therapy? A. Hypertensive crisis B. Suicidal thoughts C. Convulsions D. Orthostatic hypotension Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 38

Serotonin Syndrome Symptoms Ø Delirium, tachycardia, hyperreflexia, shivering, agitation, sweating, muscle spasms, coarse tremors Symptoms of severe cases Ø Hyperthermia, seizures, renal failure, rhabdomyolysis, dysrhythmias, disseminated intravascular coagulation (DIC) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 39

Classroom Response Question When providing teaching for a patient who is prescribed a selective serotonin reuptake inhibitor (SSRI), which statement will the nurse include? A. The SSRI will work faster than the older tricyclic antidepressants. B. The SSRI will have an immediate beneficial effect on the patient’s depression symptoms. C. The SSRI will not work well for severe cases of depression. D. The SSRI may take several weeks to have a beneficial effect. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 40

Antipsychotics Drugs used to treat serious mental illness Ø Behavioral problems or psychotic disorders Have been known as tranquilizers or neuroleptics Conventional drugs Atypical antipsychotics Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 41

Antipsychotics (cont’d) Thioxanthenes: thiothixene (Navane) Butyrophenones: haloperidol (Haldol) Dihydroindolones: molindone (Moban) Dibenzoxazepine: loxapine (Loxitane) Phenothiazines: three structural groups Atypical antipsychotics: new class Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 42

Antipsychotics: Mechanism of Action Block dopamine receptors in the brain (limbic system, basal ganglia)—areas associated with emotion, cognitive function, motor function Dopamine levels in the CNS are decreased Result: tranquilizing effect in psychotic patients Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 43

Atypical Antipsychotics clozapine (Clozaril) risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel) ziprasidone (Geodon) aripiprazole (Abilify) paliperidone (Invega) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 44

Atypical Antipsychotics: Mechanism of Action Block specific dopamine receptors: dopamine-2 (D 2) receptors Also block specific serotonin receptors: serotonin 2 (5 -HT 2) receptors Ø This is responsible for their improved efficacy and safety profiles Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 45

Antipsychotics: Adverse Effects Body System Adverse Effects CNS Cardiovascular Sedation, delirium Orthostatic hypotension, syncope, dizziness, ECG changes Photosensitivity, skin rash, hyperpigmentation, pruritus Dermatologic Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 46

Antipsychotics: Adverse Effects (cont’d) Body System GI GU Hematologic Adverse Effects Dry mouth, constipation Urinary hesitancy or retention, impaired erection Leukopenia and agranulocytosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 47

Antipsychotics: Adverse Effects (cont’d) Body System Metabolic/endocrine Adverse Effects Galactorrhea, irregular menses, increased appetite, polydipsia Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 48

Antipsychotics: Adverse Effects (cont’d) Neuroleptic malignant syndrome (NMS) Potentially life threatening Ø High fever, unstable BP, myoglobinemia Ø Extrapyramidal symptoms (EPS) Involuntary muscle symptoms similar to those of Parkinson’s disease Ø Akathisia (distressing muscle restlessness) Ø Acute dystonia (painful muscle spasms) Ø Treated with benztropine (Cogentin) and trihexyphenidyl (Artane) Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 49

Antipsychotics: Adverse Effects (cont’d) Tardive dyskinesia (TD) Involuntary contractions of oral and facial muscles Ø Choreoathetosis (wavelike movements of extremities) Ø Occurs with continuous long-term antipsychotic therapy Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 50

Herbal Products: St. John’s Wort Used for depression, anxiety, sleep disorders, nervousness May cause GI upset, fatigue, dizziness, confusion, dry mouth, photosensitivity Severe interactions if taken with MAOIs and SSRIs; many other drug interactions Food-drug interaction with tyramine-containing foods Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 51

Herbal Products: Ginseng Three varieties; has been used for over 5000 years Uses: stress reduction, improvement of physical endurance and concentration May cause elevated BP, chest pain, palpitations, anxiety, insomnia, headache, GI symptoms Interactions with anticoagulants, immunosuppressants, anticonvulsants, antidiabetic drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 52

Psychotherapeutic Drugs: Nursing Implications Before beginning therapy, assess physical and emotional status of patients Obtain baseline vital signs, including postural BP readings Obtain liver and renal function tests Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 53

Psychotherapeutic Drugs: Nursing Implications (cont’d) Assess for possible contraindications to therapy, cautious use, and potential drug interactions Assess for level of consciousness, mental alertness, potential for injury to self and others Check the patient’s mouth to make sure oral doses are swallowed Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 54

Psychotherapeutic Drugs: Nursing Implications (cont’d) Provide simple explanations about the drug, its effects, and the length of time before therapeutic effects can be expected Advise patients to avoid abrupt withdrawal Advise patients to change positions slowly to avoid postural hypotension and possible injury Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 55

Psychotherapeutic Drugs: Nursing Implications (cont’d) The combination of drug therapy and psychotherapy is emphasized because patients need to learn and acquire more effective coping skills Only small amounts of medications should be dispensed at a time to minimize the risk of suicide attempts Simultaneous use of these drugs with alcohol or other CNS depressants can be fatal Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 56

Psychotherapeutic Drugs: Nursing Implications (cont’d) Antianxiety drugs Ø In elderly patients, monitor closely for oversedation and profound CNS depression Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 57

Psychotherapeutic Drugs: Nursing Implications (cont’d) Antidepressants Many cautions, contraindications, and interactions exist pertaining to the use of antidepressants Ø Inform patients that it may take several weeks to see therapeutic effects Ø Monitor patients closely during this time, assess for suicidal tendencies, and provide support Ø Assist elderly or weakened patients with ambulation and other activities because falls may occur because of drowsiness or postural hypotension Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 58

Psychotherapeutic Drugs: Nursing Implications (cont’d) Antidepressants (cont’d) Tricyclics may need to be weaned and discontinued before undergoing surgery to avoid interactions with anesthetic drugs Ø Monitor for adverse effects, and discuss with patients Ø Encourage patients to wear medication ID badges naming the drugs being taken Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 59

Psychotherapeutic Drugs: Nursing Implications (cont’d) Antidepressants (cont’d) Caffeine and cigarette smoking may decrease effectiveness of medication therapy Ø With MAOIs, instruct patients and family regarding tyramine-containing foods, and signs and symptoms of hypertensive crisis Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 60

Psychotherapeutic Drugs: Nursing Implications (cont’d) Antipsychotics—phenothiazines Instruct patients to wear sunscreen because of photosensitivity Ø Tell patients to avoid taking antacids or antidiarrheal preparations within 1 hour of a dose Ø Inform patients to avoid alcohol or other CNS depressants with these medications Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 61

Psychotherapeutic Drugs: Nursing Implications (cont’d) Antipsychotics—phenothiazines (cont’d) Ø Long-term haloperidol therapy may result in tremors, nausea, vomiting, or uncontrollable shaking of small muscle groups; report these symptoms to the physician Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 62

Psychotherapeutic Drugs: Nursing Implications (cont’d) Antipsychotics—phenothiazines (cont’d) Oral forms may be taken with meals to decrease GI upset Ø These drugs may cause drowsiness, dizziness, or fainting; instruct patients to change positions slowly Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 63

Psychotherapeutic Drugs: Nursing Implications (cont’d) Monitor for therapeutic effects Monitor mental alertness, cognition, affect, mood, ability to carry out activities of daily living, appetite, and sleep patterns Ø Monitor potential for self-injury during the delay between the start of therapy and symptomatic improvement Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 64

Psychotherapeutic Drugs: Nursing Implications (cont’d) Monitor for therapeutic effects (cont’d) Ø For anxiolytics • Improved mental alertness, cognition, and mood • Fewer anxiety and panic attacks • Improved sleep patterns and appetite • Less tension and irritability; fewer feelings of fear, impending doom, and stress • More interest in self and others Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 65

Psychotherapeutic Drugs: Nursing Implications (cont’d) Monitor for therapeutic effects (cont’d) Ø For antidepressants • Improved sleep patterns and nutrition • Increased feelings of self-esteem • Decreased feelings of hopelessness • Increased interest in self and appearance • Increased interest in daily activities • Fewer depressive manifestations or suicidal thoughts/ideations Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 66

Psychotherapeutic Drugs: Nursing Implications (cont’d) Monitor for therapeutic effects (cont’d) Ø For antipsychotics • Improved mood and affect • Alleviation of psychotic symptoms and episodes • Decreased hallucinations, paranoia, delusions, garbled speech, and inability to cope Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 67

Psychotherapeutic Drugs: Nursing Implications (cont’d) Monitor for therapeutic effects (cont’d) Ø For lithium • Less mania • Therapeutic lithium levels of 0. 6 to 1. 2 m. Eq/L Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 68

Case Study A patient is admitted to the emergency department. The patient’s heart rate is 112 beats/min; he is sweating, has muscle tremors, and is agitated. The patient says, “I was depressed and took more of the pills the doctor gave me so I would feel better. ” 1. What does the nurse suspect is happening with this patient? 2. What treatment does the nurse expect to implement? Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 69

Case Study (cont’d) The patient was admitted to the hospital for observation and has now recovered. Which information will the nurse include in patient teaching about SSRIs? A. It usually takes 4 to 6 weeks until you will experience benefits from the medication. B. The patient must avoid foods that contain tyramine. C. If the patient develops an upset stomach when taking this medication, he should discontinue use. D. The patient should take the medication at bedtime to enhance sleep. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 70

Case Study Several months later the patient returns to the health care provider’s office for follow-up regarding use of the SSRI. The patient tells the nurse that he is feeling better and stopped taking the SSRI yesterday. He doesn’t plan on taking the medication again. When talking with the patient, which knowledge should guide the nurse’s response? A. B. C. D. Drug dependency will develop, so it is appropriate to stop therapy after a few months. Drug therapy must be stopped as soon as the patient feels better to avoid serotonin syndrome. The patient is the best person to determine when the drug therapy should end. A 1 - to 2 -month taper period is indicated to prevent adverse effects of abrupt drug discontinuation. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 71