Psychoactive Drugs Professor Lana Chase Psychoactive Drug Categories

Psychoactive Drugs Professor Lana Chase

Psychoactive Drug Categories l Anti-psychotics: Schizophrenia, Agitation l Anti-depressants: Depression, OCD, Anxiety l Mood Stabilizers: Bipolar Disorder l Anti-Anxiety: Anxiety /Panic Disorders l Psycho-stimulants: ADHD, Narcolepsy

Purposes and Advantages l Used to affect the brain & behavior l To treat psychiatric disorders /symptoms l Used in conjunction with other treatments such as psychosocial rehabilitation, psychotherapy, crisis intervention l To control symptoms & allow consumer to participate in therapy & re-enter job market

Neurohormones Neurotransmitters l Dopamine l Serotonin l Norepinepherine

Antipsychotics l Mainly cause blockade of Dopamine & Serotonin in post synaptic membrane of CNS l Also act on other neurotransmitters which may cause increase in side effects (movement disorders)

Antipsychotics: Conditions Treated l Psychosis: Schizophrenia /Thought Disorders l Sedation l Hiccoughs l Dementia- Organic Psychosis / Agitation l Bipolar Disorder (acute mania)

Anti-psychotic Use l Treat Positive Symptoms of Schizophrenia – Delusions- false beliefs – Hallucinations- false sensory perceptions: – auditory, visual, tactile, olfactory, somatic, gustatory – Illusions- mistaken sensory perception

Phenothiazines l Developed in 1950’s 1 st. Tranquilizer l Thorazine (Chlorpromazine) sedation, anticholinergic side effects l Prolixin Decanoate (Fluphenazine) – – IM for Non-compliant patients Viscous liquid – use 21 gauge needle , Z track Q 2 -4 week admin. (absorbs slowly)

Non Phenothiazines Haldol (haloperidol): l used extensively in psychiatric emergencies to sedate patient frequently with Ativan and Benadryl l I M or PO l l Haldol Decanoate IM – For non-compliant pts. – Absorbed slowly over 2 -4 weeks – Large gauge needle, Z track

Non Traditional Antipsychotics l Less side effects l More effective with: l Negative Symptoms of Schizophrenia. – flat affect (mood), alogia(poverty of speech), avolition(apathy), anhedonia(no pleasure), asociality(loner), attentional impairment (poor concentration).

Non Traditional Antipsychotics l Clozaril(clozapine) – Biweekly WBC--risk agranulocytosis – Stop med for WBC below 2. 5 (do not restart) – Start low dose 25 mg (max dose 900 mg) – Benefits: low side effect profile, pts. like how they feel on it. – Effective antipsychotic especially for neg. s/s

Non Traditional Antipsychotics l Zyprexa (olanzapine) – Dopamine and serotonin blocking agent – Effective antipsychotic and for bipolar pts – Serious Side effects: weight gain , diabetes l Seroquel (quetiapine) – Little or no EPS(same as placebo) – Effective antipsychotic, sedative

Antipsychotic Side Effects Less side effects with newer medications l Older meds not very user friendly non compliance l – Sedation: drowsiness – Weight Gain – Photosensitivity – Dizziness (Orthostatic Hypotension) – Sexual Dysfunction – Elevation in Prolactin Levels

Antipsychotics (continued) l Side Effects – Tardive Dyskenesia: irreversible l Snake like tongue movements /thrusting, invol. movements – Anticholinergic: from acetylcholine blockade l blurred vision, dry mouth, constipation, GI distress, urinary ret. – Extrapyramidal (EPS): movement disorders l Dystonia, akathesia , tremors, shuffling gait, muscle stiffness (stiff neck, cogwheel rigidity), masked facies, oculogyric crisis (eyes roll back), diff. swallowing

Nursing Interventions for EPS l Notify MD & Obtain order for: l Cogentin or Artane (anticholinergics) – PO or IM l Symmetrel l Benadryl (dopamine agonist) (antihistamine)

Side Effects Antipsychotics (cont. ) l Tardive Dyskinesia (irreversible) – Wormlike tongue movements, ataxia, lip smacking, involuntary arm & leg movements, fever. Tx. Decrease dosage or D/C

Side Effects Antipsychotics cont. l Neuroleptic Malignant Syndrome (rare) – 14 -30 % mortality – Tachicardia, high fever, muscle rigidity – risk for cardiovascular collapse Nursing Measures: discontinue medication, Notify MD, treat symptomatically: cooling blanket, Bromocriptine, cardiac meds if necessary.

Use Antipsychotics Cautiously l Diabetics l Children under 6 l Glaucoma l Ulcers l Elderly – Lower doses, hypotension

Drug Interactions Potentiates action of CNS Depressants: e. g. . narcotics, alcohol

Nursing Implications l l l l Baseline assessment: EKG, liver function Long term use: assess for adverse effects Assess for movement disorder: EPS, T. D. Observe for hording /”cheeking” meds Administer liquid med in juice Is it effective? monitor mental status Safety : orthostatic hypotension, monitor for seizures D/C or switch to new med gradually (cont)

Antianxiety Drugs Benzodiazapines l Action – Increase action of GABA that inhibits nerve transmission in the CNS – Depresses activity in brainstem Sedative l Hyponotic l Anticonvulsant l

Antianxiety Drugs l Therapeutic Uses: – sedative agent/conscious sedation – Treat psychiatric emergencies /agitation – Treat panic disorder, social phobia, anxiety – Treat alcohol withdrawal & seizures – Treat anxiety assoc with medical disorders l COPD – **use should be brief except with panic disorders due to risk of addiction

Commonly Prescribed Antianxiey Drugs l Ativan PO or IM – Used for psych emergencies / severe agitation l Valium (diazepam) PO or IV – good IV anticonvulsant 2 -40 mg qd – Muscle relaxant action used for neck & back pain Xanax l Versed –conscious sedation, anesthesia induction l Tranxene, Librium l – freq. Used for alcohol detoxification in tapering doses l Dalmane/Restoril – sedative sleeping medications

Antianxiety Medicatons l Common Side Effects – Sedation, impaired consciousness, daytime sedation (hangover), ataxia, dizziness, feelings of detachment, rebound insomnia, amnesia, euphoric mood – TOLERANCE l MUST INCREASE DOSE FOR SAME EFFECT – PHYSIOLOGICAL DEPENDENCY

Antianxiety Drug Overdose – Overdose alone almost never fatal (safe) – Benzo + alcohol respiratory depression l Treatment for Benzodiazapine Overdose: – Romazicon(flumazenil) (Antagonist) benzodiazapine receptor blocker

Teaching for Antianxiety Drugs l Drugs should be tapered to prevent withdrawal symptoms / DT’s l Drugs can store in fat cells and prolong withdrawal symptoms l Dosages ½ to 1/3 rd. for elderly l Instruct about risk of addiction /safety from falls

Antianxiety Drugs l Buspar (buspirone) – Potent antianxiety drug – no muscle relaxant, anticonvulsant or sedative, or alcohol potentiating action – Takes several weeks for antianxiety effects ** works best with people who never took benzo’s because they are accustomed to immediate effect.

Antianxiety Drugs l Inderal (propranolol) – Beta Blocker l Used to decrease symptoms that lead to anxiety like tachicardia rather than centrally acting on anxiety – Treatment for “performance anxiety” found in social phobia.

Antidepressants l Uses: – Major Depressive Disorder – Premenstrual Dysphoric Disorder – Anorexia /Bulimia – Anxiety Disorders GAD (Generalized Anxiety Disorder) l OCD (Obsessive Compulsive Disorder) l

Target Patrticular Symptoms Goal: to normalize transmission of impulses at the synapse l Amine Hypothesis: low norepinepherine (catacholamine) at synapse l l Permissive Hypothesis: deficiency of serotonin at the synapse l Dysregulation Hypothesis: Failure to regulate catacholomine system

Tricyclic Antidepressants l Norpramine l Elavil l Tofranil Uses: panic disorder, depression, GAD, enuresis, sedation (for insomnia) ***2 -4 weeks for antidepressant effect

Antidepressants l Trazadone – Drug of choice for sedation (sleep disturbances) – **Can cause priapism in males Antidepressant TX 4 -9 mos tx or may be lifetime if depression recurrent Anxiety Disorders: SSRI (Paxil) now treatment of choice

2 nd Generation Antidepressants SSRI’s Selective Serotonin Reuptake Inhibitors increases serotonin reuptake at receptor site less SE than TCI’s less anticholinergic, no wt. Gain, safer for cardiac pts. & pregnant women l Prozac l Zoloft l Paxil

Other Newer Antidepressants l Celexa & Lexapro l Serzone l Effexor l Vestra l Remeron l Wellbutrin /Zyban

Side Effects of Antidepressants **Overdose of TCA’s can be fatal due to Cardiac arrhythmias l Anticholinergic Side Effects l l SSRI’s Psychomotor excitement / insomnia (take in morning), tremor, headache, nervousness l TCA’s: Sedation, drowsiness especially 1 st week (instruct to start on weekend), often added as nighttime dose for insomnia l Sexual Side Effects – Ejaculatory disturbances & decreased libido, priapism (Deseryl)

Antidepressants l MAOI’s – Monoamine Oxidase Inhibitors Action: Inhibit enzyme activity resulting in decreased amount of MAO in the body l Used for non responders to other antidepressant tx. l Effective for atypical depression, panic, and phobias l

Monoamine Oxidase Inhibitors l Role of Tyramine and Dietary Restrictions – MAO metabolizes neurotransmitters related to depression. Also linked to control of BP due to inhibition of norepinepherine. – Need to avoid norepinepherine agonists like dietary TYRAMINE. – HYPERTENSIVE CRISIS (life threatening) can occur from increased levels of norepinepherine ie risk of strokes (CVA)

MAOI’s Side Effects Life Threatening if taken with drugs or foods containing TYRAMINE l Hypertensive Crisis (Malignant Hypertesion) l – Sudden elevation of BP, palpitations, chest – – pain, sweating , fever, N&V HOLD MAOI : do not lie down (inc. BP in brain) Treatment: Thorazine 100 mg IM (blocks norepinepherine), Cooling blanket, Phentolamine IV in 5 mg doses (binds with norepinepherine) Cooling blanket

Seratonin Syndrome l Risk – May occur when SSRI’s are administered too close to the discontinuation of MAOI’s or other drugs affecting serotonin reuptake are taken together Signs and Symptoms confusion , disorientation, mania, restlessness, diaphoresis, shivering, diarrhea, nausea. Treatment: D/C all serotonergic drugs including SSRI’s, MAOI’s, anticonvulsants, Ativan, Klonapin ** do not reintroduce serotonin drugs

MAO Inhibitors l Only 3 Drugs in this Class – Nardil – Parnate – Marplan – Side effects: extreme hypotension – Toxic effect : malignant hypertension (if taken with sympathomimetic substance (Tyramine)

Nursing Interventions MAOI’s l l Careful teaching on diet and drug reactions Dietary Restrictions: aged cheese (blue, brick, brie), organ meats, pickled herring, bologna, pepperoni, salami, fava beans, avacado, red wine (Chianti), beer, tofu, miso soup – over ripe fruit (banana, raisons) l l In moderation: chocolate, soy sauce, yogurt Drug Restrictions l l l OTC drugs with epinepherine like effects: sudafed, sinus , allergy remedies Narcotics (Demerol especially), other antidepressant drugs, Cocaine, amphetamines

Mood Stabalizing Drugs l Lithium Carbonate – Classic Drug for Bipolar Disorder (Manic Depression) – Action: lithium replaces sodium in the cells – **Dosage adjusted by Serum Lithium Level (weekly then monthly levels), not by symptoms – Narrow Therapeutic Index: Risk of toxicity l Toxic and Theraputic serum levels are close . 5 -1. 5 meq. /l therapuetic above 2 meq. toxic l Usual dosage 900 mg. but depends on rate of excretion

Lithium Carbonate l Side Effects – : fine hand tremor, mental dullness, weight gain, polyuria, kidney impairment – Secondary hypothyroidism: give Synthroid l Lithium Toxicity (Flu like Symptoms) – ataxia(may look intoxicated), diarrhea, GI distrubance (N &V)

Lithium Carbonate Nursing Considerations Hold Lithium, Notify MD, get serum lithium level to confirm instruct patient in S/S of toxicity excessive sweating: will raise serum lithium levels (caution for people who have outdoor jobs in the heat (roofer) contraindicated/caution with diuretics such as Hydrodiuril (HCTZ)

Mood Stabalizers l Anticonvulsant Mood Stabalizers – Enhances effect of GABA – 2 nd. Line treatment for lithium intolerant pts. – Use is increasing –less Side Effects l Used to Treat: – Bipolar disorder (rapid cyclers), Schizoaffective Disorder, Borderline. Personality Disorder, Schizophrenia Given in combo with other meds l **Give Mood Stabalizer with SSRI to avoid Mania – Tegretal (carbamazapine) most studied – Depakote (valproic acid) most studied – Neurontin, Lamictal, Topramax (newer) l

Mood Stabilizers l Anticonvulsant Mood Stabilizers – Response in 1 -2 weeks – Side effects: l sedation, dizziness (subside over time), skin reaction may require D/C, Depakote-pancreatitis risk (liver func. Tests) – Nursing Implications Monitor serum levels, WBC, hepatic/renal function l Can be lethal in overdose l