Psychotherapeutic Agents Antidepressants and Antipsychotics Copyright 2002 1998

Psychotherapeutics • The therapy of emotional and mental disorders Copyright © 2002, 1998, Elsevier

Psychotherapeutics • Anxiety • Grief • Depression are normal human emotions Copyright © 2002,

Psychotherapeutics • The ability to cope with these emotions can range from occasional depression

Psychotherapeutics • When these emotions significantly affect an individual’s ability to carry out normal

Psychotherapeutics Three main emotional and mental disorders: • Psychoses • Affective disorders • Anxiety

Psychotherapeutics Psychosis • A major emotional disorder that impairs the mental function of the

Psychotherapeutics Affective Disorders • Major emotional disorders that impair the mental function of the

Psychotherapeutics Affective Disorders • Mania: abnormally pronounced emotions • Depression: abnormally reduced emotions •

Psychotherapeutics Pathophysiology Biochemical Imbalance • Mental disorders are associated with abnormal levels of endogenous

Psychotherapeutics Pathophysiology Biochemical Imbalance • Brain levels of certain catecholamines play an important role

Psychotherapeutics Pathophysiology Biochemical Imbalance • Other biochemicals are necessary for normal mental function. –

Etiology of Depression Biogenic Amine Hypothesis • Depression and mania are due to an

Instructors may wish to insert EIC Image #45: Biogenic Amine Hypothesis Copyright © 2002,

Affective Disorders Drug Categories • Antidepressants • tricyclics, tetracyclics, SSRIs, MAOIs • Antimanic Agents

Antidepressants Cyclic antidepressants – tricyclics – tetracyclics • Monoamine oxidase inhibitors (MAOIs) • Second-generation

Cyclic Antidepressants • Tricyclic antidepressants—primary: amitriptyline (Elavil), doxepin (Sinequan), imipramine (Tofranil) • Tricyclic antidepressants—secondary:

Cyclic Antidepressants Mechanism of Action • Block reuptake of neurotransmitters, causing accumulation at the

Cyclic Antidepressants Mechanism of Action—Drug Effects Blockade of norepinephrine: – antidepressant, tremors, tachycardia, additive

Cyclic Antidepressants Therapeutic Uses • Depression • Childhood enuresis (imipramine) • Obsessive-compulsive disorders (clomipramine)

Cyclic Antidepressants Side Effects • Sedation • Impotence • Orthostatic hypotension • Older patients:

Tricyclic Antidepressants Overdose • Lethal— 70 to 80% die before reaching the hospital •

Antidepressants Monoamine Oxidase Inhibitors: MAOIs • Highly effective • Considered second-line treatment for depression

Antidepressants: MAOIs • phenelzine (Nardil) • tranylcypromine (Parnate) • isocarboxazid (Marplan) Copyright © 2002,

Antidepressants: MAOIs Mechanism of Action • Inhibit the MAO enzyme system in the CNS

Antidepressants: MAOIs Therapeutic Uses • Depression, especially types characterized by reverse vegetative symptoms such

Antidepressants: MAOIs Side Effects • Few side effects—orthostatic hypotension most common Tachycardia Palpitations Dizziness

Antidepressants: MAOIs Overdose • Symptoms appear 12 hours after ingestion • Tachycardia, circulatory collapse,

Antidepressants: MAOIs Hypertensive Crisis and Tyramine • Ingestion of foods and/or drinks with the

Antidepressants: MAOIs Hypertensive Crisis and Tyramine Avoid foods that contain tyramine! • Aged, mature

Second-Generation Antidepressants • Newer • Fewer side effects than tricyclics, but not superior in

Second-Generation Antidepressants and SSRIs Mechanism of Action • Selectively inhibit serotonin reuptake • Little

Second-Generation Antidepressants Therapeutic Uses • Used for depression—very few serious side effects • Bipolar

Second-Generation Antidepressants Side Effects Body System Effects CNS Headache, dizziness, tremor, nervousness, insomnia, fatigue

Second-Generation Antidepressants Drug Interactions • Highly bound to plasma proteins • Compete with other

Antipsychotics • Drugs used to treat serious mental illness • Behavioral problems or psychotic

Antipsychotics • Thioxanthenes: chlorprothixene, thiothixene (Navane) • Butyrophenones: haloperidol (Haldol) • Dihydroindolones: molindone (Moban)

Antipsychotics Phenothiazine Structural Groups • Aliphatic: chlorpromazine (Thorazine), triflupromazine (Vesprin) • Piperidine: mesoridazine (Serentil),

Antipsychotics Atypical Antipsychotics • clozapine (Clozaril) • risperidone (Risperdal) • olanzapine (Zyprexa) • quetiapine

Antipsychotics: Mechanism of Action • Block dopamine receptors in the brain (limbic system, basal

Antipsychotics: Mechanism of Action • The newer, atypical antipsychotics also block specific serotonin receptors

Antipsychotics: Drug Effects • Block dopamine receptors in CNS • Block alpha receptors (causing

Antipsychotics: Therapeutic Uses • Treatment of serious mental illnesses: – – Bipolar affective disorder

Antipsychotics: Side Effects Body System Effects CNS Sedation, delirium Cardiovascular Orthostatic hypotension, syncope, dizziness,

Antipsychotics: Side Effects Body System Effects GI Dry mouth, constipation GU Urinary hesitancy or

Psychotherapeutic Agents: Nursing Implications • Before beginning therapy, assess both the physical and emotional

Psychotherapeutic Agents: Nursing Implications • Assess for possible contraindications to therapy, cautious use, and

Psychotherapeutic Agents: Nursing Implications • Provide simple explanations about the drug, its effects, and

Psychotherapeutic Agents: Nursing Implications • The combination of drug therapy and psychotherapy is emphasized

Psychotherapeutic Agents: Nursing Implications Antidepressants • Many cautions, contraindications, and interactions exist pertaining to

Psychotherapeutic Agents: Nursing Implications Antidepressants • Sedation often occurs with tricyclic therapy; notify physician

Psychotherapeutic Agents: Nursing Implications Antidepressants • Tricyclics may need to be weaned and discontinued

Psychotherapeutic Agents: Nursing Implications Antidepressants • Caffeine and cigarette smoking may decrease effectiveness of

Psychotherapeutic Agents: Nursing Implications Antipsychotics—Phenothiazines • Instruct patients to wear sunscreen due to photosensitivity

Psychotherapeutic Agents: Nursing Implications Antipsychotics—Phenothiazines • Long-term haloperidol therapy may result in tremors, nausea,

Psychotherapeutic Agents: Nursing Implications Monitor for therapeutic effects: • Monitor mental alertness, cognition, affect,

Psychotherapeutic Agents: Nursing Implications Monitor for therapeutic effects • For antidepressants: – Improved sleep

Psychotherapeutic Agents: Nursing Implications Monitor for therapeutic effects • For antipsychotics: – Improved mood

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Psychotherapeutics • The ability to cope with these emotions can range from occasional depression or anxiety to constant emotional distress to the point ofinterfering with the ability to carry on normal daily living. Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutics • When these emotions significantly affect an individual’s ability to carry out normal daily functions, treatment with a psychotherapeutic drug is a possible option. Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutics Psychosis • A major emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in everyday life. • Hallmark: loss of contact with reality Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutics Affective Disorders • Major emotional disorders that impair the mental function of the affected individual to the point that the individual cannot participate in everyday life. Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutics Affective Disorders • Mania: abnormally pronounced emotions • Depression: abnormally reduced emotions • Bipolar affective disorder: exhibits both mania and depression Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutics Pathophysiology Biochemical Imbalance • Mental disorders are associated with abnormal levels of endogenous chemicals, such as neurotransmitters, in the brain. Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutics Pathophysiology Biochemical Imbalance • Brain levels of certain catecholamines play an important role in maintaining mental health. – Dopamine – Serotonin – Histamine Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutics Pathophysiology Biochemical Imbalance • Other biochemicals are necessary for normal mental function. – GABA – acetylcholine – lithium Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Etiology of Depression Biogenic Amine Hypothesis • Depression and mania are due to an alteration in neuronal and synaptic catecholamine concentration at adrenergic receptor sites in the brain. – Depression: deficiency of catecholamine, especially norepinephrine – Mania: excess amines Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants Cyclic antidepressants – tricyclics – tetracyclics • Monoamine oxidase inhibitors (MAOIs) • Second-generation antidepressants and SSRIs Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Cyclic Antidepressants • Tricyclic antidepressants—primary: amitriptyline (Elavil), doxepin (Sinequan), imipramine (Tofranil) • Tricyclic antidepressants—secondary: desipramine (Norpramin), nortriptyline (Aventyl), protriptyline (Vivactil) • Tetracyclic antidepressants: amoxapine (Asendin), maprotiline (Ludiomil) Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Cyclic 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 © 2002, 1998, Elsevier Science (USA). All rights reserved.

Cyclic Antidepressants Mechanism of Action—Drug Effects Blockade of norepinephrine: – antidepressant, tremors, tachycardia, additive pressor effects with sympathomimetic drugs Blockade of serotonin: – antidepressant, nausea, headache, anxiety, sexual dysfunction Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Cyclic Antidepressants Therapeutic Uses • Depression • Childhood enuresis (imipramine) • Obsessive-compulsive disorders (clomipramine) • Adjunctive analgesics • Trigeminal neuralgia Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Cyclic Antidepressants Side Effects • Sedation • Impotence • Orthostatic hypotension • Older patients: – dizziness, postural hypotension, constipation, delayed micturation, edema, muscle tremors Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

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 • No specific antidote – – Decrease drug absorption with activated charcoal Speed elimination by alkalinizing urine Manage seizures and dysrhythmias Basic life support Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants 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 © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants: 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 © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants: MAOIs Therapeutic Uses • Depression, especially types characterized by reverse vegetative symptoms such as increased sleep and appetite • Depression that does not respond to other agents such as tricyclics Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants: MAOIs Side Effects • Few side effects—orthostatic hypotension most common Tachycardia Palpitations Dizziness Drowsiness Insomnia Headache Anorexia Nausea Blurred vision Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved. Impotence

Antidepressants: MAOIs Overdose • Symptoms appear 12 hours after ingestion • Tachycardia, circulatory collapse, seizures, coma • Treatment: protect brain and heart, eliminate toxin – Gastric lavage – Urine acidification – Hemodialysis Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants: MAOIs Hypertensive Crisis and Tyramine • Ingestion of foods and/or drinks with the amino acid TYRAMINE leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidepressants: MAOIs Hypertensive Crisis and Tyramine Avoid foods that contain tyramine! • Aged, mature cheeses (cheddar, blue, Swiss) • Smoked/pickled or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté) • Yeast extracts • Red wines (Chianti, burgundy, sherry, vermouth) • Italian broad beans (fava beans) Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Second-Generation Antidepressants • Newer • Fewer side effects than tricyclics, but not superior in overall efficacy or onset of action – trazodone (Desyrel) – bupropion (Wellbutrin, Zyban) – selective serotonin reuptake inhibitors (SSRIs) Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Second-Generation Antidepressants and SSRIs Mechanism of Action • Selectively inhibit serotonin reuptake • Little or no effect on norepinephrine or dopamine reuptake • Results in increased serotonin concentrations at nerve endings Advantage over tricyclics and MAOIs: Little or no effect on cardiovascular system Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Second-Generation Antidepressants Therapeutic Uses • Used for depression—very few serious side effects • Bipolar affective disorder • Obesity • Eating disorders • Obsessive-compulsive disorder • Panic attacks • Myoclonus • Treatment of various substance abuse problems (bupropion [Zyban] is used for smoking cessation treatment) Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Second-Generation Antidepressants Side Effects Body System Effects CNS Headache, dizziness, tremor, nervousness, insomnia, fatigue GI Nausea, diarrhea, constipation, dry mouth Other Sweating, sexual dysfunction Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Second-Generation Antidepressants Drug Interactions • Highly bound to plasma proteins • Compete with other protein-binding drugs, resulting in more free, unbound drug to cause a more pronounced drug effect Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics • Thioxanthenes: chlorprothixene, thiothixene (Navane) • Butyrophenones: haloperidol (Haldol) • Dihydroindolones: molindone (Moban) • Dibenzoxazepine: loxapine (Loxitane) • Phenothiazines: three structural groups Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics Phenothiazine Structural Groups • Aliphatic: chlorpromazine (Thorazine), triflupromazine (Vesprin) • Piperidine: mesoridazine (Serentil), thioridazine (Mellaril) • Piperazine: fluphenazine (Prolixin), perphenazine (Trilafon), prochlorperazine (Compazine), trifluoperazine (Stelazine) Largest group of psychotropic agents Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics Atypical Antipsychotics • clozapine (Clozaril) • risperidone (Risperdal) • olanzapine (Zyprexa) • quetiapine (Seroquel) Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

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 © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics: Mechanism of Action • The newer, atypical antipsychotics also block specific serotonin receptors (serotonin-2 [5 HT 2] receptors). • This is responsible for their improved efficacy and safety profiles. Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics: Drug Effects • Block dopamine receptors in CNS • Block alpha receptors (causing hypertension, other cardiovascular effects) • Block histamine receptors (causing anticholinergic effects) • Block serotonin • Also function as antiemetics • Antianxiety effects Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics: Therapeutic Uses • Treatment of serious mental illnesses: – – Bipolar affective disorder Depressive and drug-induced psychoses Schizophrenia Autism • Movement disorders (such as Tourette’s syndrome) • Some medical conditions – Nausea, intractable hiccups Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics: Side Effects Body System Effects CNS Sedation, delirium Cardiovascular Orthostatic hypotension, syncope, dizziness, ECG changes Dermatologic Photosensitivity, skin rash, hyperpigmentation, pruritus Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antipsychotics: Side Effects Body System Effects GI Dry mouth, constipation GU Urinary hesitancy or retention, impaired erection Hematologic Leukopenia and agranulocytosis Metabolic/endocrine Galactorrhea, irregular menses increased appetite, polydipsia Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications • Before beginning therapy, assess both the physical and emotional status of patients • Obtain baseline VS, including postural BP readings • Obtain liver and renal function tests (and baseline platelet levels for MAOIs) Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications • Assess for possible contraindications to therapy, cautious use, and potential drug interactions • Assess LOC, mental alertness, potential for injury to self and others • Check the patient’s mouth to make sure oral doses are swallowed Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications • Provide simple explanations about the drug, its effects, and the length of time before therapeutic effects can be expected • Abrupt withdrawal should be avoided • Advise patients to change positions slowly to avoid postural hypotension and possible injury Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications • 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 agents with alcohol or other CNS depressants can be fatal Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications Antidepressants • Many cautions, contraindications, and interactions exist pertaining to the use of antidepressants. • Inform patients that it may take 1 to 3, even 4, weeks to see therapeutic effects. • Monitor patients closely during this time and provide support. Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications Antidepressants • Sedation often occurs with tricyclic therapy; notify physician if this lasts more than 2 weeks. • Assist elderly or weakened patients with ambulation and other activities as falls may occur due to drowsiness or postural hypotension. Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications Antidepressants • Tricyclics may need to be weaned and discontinued before undergoing surgery to avoid interactions with anesthetic agents. • Monitor for side effects and discuss with patients. • Encourage patients to wear medication ID badges naming the agent being taken. Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications Antidepressants • Caffeine and cigarette smoking may decrease effectiveness of medication therapy • Instruct patients and family regarding tyraminecontaining foods and signs and symptoms of hypertensive crisis Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications Antipsychotics—Phenothiazines • Instruct patients to wear sunscreen due to photosensitivity • Avoid taking antacids or antidiarrheal preparations within 1 hour of a dose • Do not take alcohol or other CNS depressants with these medications Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications Antipsychotics—Phenothiazines • Long-term haloperidol therapy may result in tremors, nausea, vomiting, or uncontrollable shaking of small muscle groups; these symptoms should be reported to the physician • Oral forms may be taken with meals to decrease GI upset • These agents may cause drowsiness, dizziness, or fainting; instruct patients to change positions slowly Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications Monitor for therapeutic effects: • Monitor mental alertness, cognition, affect, mood, ability to carry out activities of daily living, appetite, and sleep patterns • Monitor the patient’s potential for self-injury during the delay between the start of therapy and symptomatic improvement Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications Monitor for therapeutic effects • For antidepressants: – Improved sleep patterns and nutrition, increased feelings of self-esteem, decreased feeling of hopelessness, increased interest in self and appearance, increased interest in daily activities, fewer depressive manifestations or suicidal thoughts or ideations Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Psychotherapeutic Agents: Nursing Implications Monitor for therapeutic effects • For antipsychotics: – Improved mood and affect, alleviation of psychotic symptoms and episodes – Decrease in hallucinations, paranoia, delusions, garbled speech, inability to cope Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.