Psychopharmacology

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  • 1. MR. JAYESH PATIDAR www.drjayeshpatidar.blogspot.com
  • 2. INTRODUCTION… • Psychopharmacology is the study of drugs used to treat psychiatric disorders. • Medications that affect psychic function, behavior or experience are called psychotropic medications. • They have significant effect on higher mental functions. • Psychopharmacological agents are first line treatment for almost all psychiatric ailments now a days. 4/24/2013 2JAYESH PATIDAR
  • 3. Count… • With the growing availability of a wide range of drugs to treat mental illness, the nurse practicing in modern psychiatric settings needs to have a sound knowledge of the pharmacokinetics involved, the benefits & potential risks of pharmacotherapy, as well as her own role & responsibility. 4/24/2013 3JAYESH PATIDAR
  • 4. DEFINITION OF PSYCHOTROPIC DRUGS Psychotropic drug is any drug that has primary effects on behavior, experience, or other psychological functions (Logman Dictionary of Psychology & Psychiatry). Psychotropic or psychoactive drugs can also be defined as chemical that affects the brain & nervous system, alter feelings & emotions. These drugs also affect the consciousness in various ways. A broad range of these drugs is used in emotional & mental illnesses. 4/24/2013 4JAYESH PATIDAR
  • 5. GENERAL GUIDELINES REGARDING DRUG ADMINISTRATION IN PSYCHIATRY • The nurse should not administer any drug unless there is a written order. Do not hesitate to consult the doctor when in doubt any medication. • All medications given must be charted on the patient‘s case record sheet. • In giving medication: – Always address the patient by name & make certain of his identification. – Do not leave the patient until the drug is swallowed. – Do not permit the patient to go to the bathroom to take medication. – Do not allow one patient to carry medicine to another. 4/24/2013 5 JAYESHPATIDAR
  • 6. Count… • If it is necessary to leave the patient to get water, do not leave the tray within the reach of the patient. • Do not force oral medication because of the danger of aspiration. This is especially important in stuporous patients. • Check drugs daily for any change in color, odor & number. • Bottle should be tightly closed & labeled. Labels should be written legibly & in bold lettering. Poison drugs are to be legibly labeled & to be kept in separate cupboard. 4/24/2013 6JAYESH PATIDAR
  • 7. Count… • Make sure that an adequate supply of drugs is on hand, but do not overstock. • Make sure no patient has access to the drug cupboard. • Drug cupboard should always be kept locked when not in use. Never allow a patient or worker to clean the drug cupboard. The drug cupboard keys should not be given to patients. 4/24/2013 7JAYESH PATIDAR
  • 8. PATIENT EDUCATION RELATED TO PSYCHOPHARMACOLOGY… • Nurses assess for drug side effects, evaluate desired effects, & make decisions about prn (pro re neta) medication. • Nurses must understand general principles of psychopharmacology & have specific knowledge related to psychotropic drugs. • Teaching patients can decrease the incidence of side effects while increasing compliance with the drug regimen. 4/24/2013 8JAYESH PATIDAR
  • 9. Specific areas of education include the following… 1. Discussion of side effects: Side effects can directly affect the patient‘s willingness to adhere to the drug regimen. The nurse should always inquire about the patient‘s response to a drug, both therapeutic responses & adverse responses 2. Drug interactions: Patients & families must be taught to discuss the effects of the addition of over-the-counter drugs, alcohol & illegal drugs to currently prescribed drugs. 4/24/2013 9JAYESH PATIDAR
  • 10. Count… 3. Discussion of safety issues: Because some drugs, such as tricyclic antidepressants, have a narrow therapeutic index, thoughts of self harm must be discussed. • Discuss on abruptly discontinued effects. • Many psychotropic drugs cause sedation or drowsiness, discussions concerning use of hazardous machinery, driving must be reviewed 4. Instructions for older adult patients: Because older individuals have a different pharmacokinetic profile than younger adults, special instructions concerning side effects & drug-drug interactions should be explained. 4/24/2013 10 JAYESH PATIDAR
  • 11. Count… 5. Instructions for pregnant or breastfeeding patient: As pregnant or breastfeeding patients have special risks associated with psychotropic drug therapy, special instructions should be tailored for these individuals. Teaching patients about their medications enables them to be mature participants in their own care & decreases undesirable side effects 4/24/2013 11JAYESH PATIDAR
  • 12. CLASSIFICATIONS OF PSYCHOTROPIC DRUGS 1. Antipsychotic agents 2. Antidepressant agents 3. Mood stabilizing drug 4. Anxiolytics & hypnosedatives 5. Antiepileptic drug 6. Antiparkinsonian drugs 7. Miscellaneous drugs which include stimulants, drugs used in eating disorders, drugs used in deaddiction, drugs uses in child psychiatry, vitamins, calcium channel blockers etc. 4/24/2013 12JAYESH PATIDAR
  • 13. ANTIPSYCHOTIC AGENTS 4/24/2013 13JAYESH PATIDAR
  • 14. DESCRIPTION:- • Antipsychotic agents are also known as neuroleptic, major tranquillizers, or phenothaiazines. • This group of drugs has a major clinical use in the treatment of psychosis. • Psychosis is a state in which a person‘s ability to recognize reality to communicate & to relate to others is severely impaired. 4/24/2013 14JAYESH PATIDAR
  • 15. MODE OF ACTION:- • Antipsychotic agents are thought to block the dopamine receptors. • Dopamine is a chemical which is released in the brain & causes psychotic thinking. • Increased production of dopamine transmits the nerve impulses to the brainstem faster than normal. This result in strange thoughts , hallucination & bizarre behavior. • Antipsychotics helps in blocking or reducing the activity of dopamine. • Antiemetic is another property of antipsychotic agents. They are also used in hiccoughs. 4/24/2013 15JAYESH PATIDAR
  • 16. Class Examples of drugs Trade name Oral dose mg/day Parenteral dose (mg) Phenothiazines Chlorpromazine Triflupromazine Thioridazine Trifluoperazine Fluphenazine decanoate Megatil Largactil Tranchlor Siquil Thioril, Melleril Ridazin Espazine prolinate 300-1500 100-400 300-800 15-60 - 50-100 IM only 30-60 IM only 1-5 IM 25-50 IM every 1-3 weeks. Thioxanthenes flupenthixol fluanxol 3-40 CLASSIFICATION:- 4/24/2013 16JAYESH PATIDAR
  • 17. Class Examples of drugs Trade name Oral dose mg/day Parenteral dose (mg) Diphenylbutyl Pimozide orap 4-20 piperidines penfluridol flumap 20-60 weekly - Indolic derivatives molindone mobam 50-225 - Dibenzoxazepines loxapine loxapac 25-100 - Atypical antipsychotics Clozapine Risperidone Olanzapine Quetiapine Ziprasidone Sizopine, Lozapin Sizodon, sizomax Oleanz Qutan Zisper 50-450 2-10 10-20 150-750 mg 20-80 mg Others reserpine serpasil 0.5-50 Count… 4/24/2013 17JAYESH PATIDAR
  • 18. INDICATIONS  Organic psychiatric disorders: • Delirium • Dementia • Delirium tremens • Drug-induced psychosis & other organic mental disorders  Functional disorders: • Schizophrenia • Schizoaffective disorders • Paranoid disorders  Mood disorders: • Mania • Major depression with psychotic symptoms  Childhood disorders: • Attention-deficit hyperactivity disorder • Autism • Enuresis • Conduct disorder 4/24/2013 JAYESH PATIDAR 18
  • 19. Count…  Neurotic & other psychiatric disorders: • Anorexia nervosa • Intractable obsessive- compulsive disorder • Severe, intractable & disabling anxiety  Medical disorders: • Huntington‘s chorea • Intractable hiccough • Nausea & vomiting • Tic disorder • Eclampsia • Heart stroke severe pain in malignancy tetanus 4/24/2013 JAYESH PATIDAR 19
  • 20. PHARMACOKINETICS • Antipsychotics when administered orally are absorbed variably from the gastrointestinal tract, with uneven blood levels. • They are highly bound to plasma as well as tissue proteins. Brain concentration is higher than the plasma concentration. • They are metabolized in the liver, & excreted mainly through the kidneys. The elimination half-life varies from 10 to 24 hours. • Most of the antipsychotics tend to have a therapeutic window. If the blood level is below this window, the drug is ineffective. If the blood level is higher than the upper limit of the window, there is toxicity or the drug is again ineffective. 4/24/2013 JAYESH PATIDAR 20
  • 21. SIDE-EFFECTS 1) Extrapyramidal symptoms (EPS) i. Neuroleptic-induced parkinsonism:- occur in 40% of the patients presenting extrapyramidal symptoms. There are two varieties of parkinsonia symptoms: a. Akinetic Form:- Appears in the first week of administration of antipsychotic drugs. The characteristics of akinetic form are: Difficulty in masticating movements, weakness & muscle fatigue. 4/24/2013 JAYESH PATIDAR 21
  • 22. Count… b. Agitating Form of parkinsonian Symptoms include:- Tremors at rest, rigidity & mask-like face. Most characteristic features of parkinsonism are:- Rigidity of muscles Motor retardation salivation slurred speech mask-like face shuffling gait Anticholinergi drugs are given as treatments. 4/24/2013 JAYESH PATIDAR 22
  • 23. Count… ii. Akathisia:- Akathisia occurs in 50% of all the patients presenting extrapyrimidal symptoms. The common characteristics: Restless ―walking in place‖. Difficulty in sitting still, or strong urge to move about- referred to as ―Walkies & Talkies‖ by haris . generally occurs after two weeks of treatment. Before administering anti-parkinsonian medication anxiety should be ruled out. 4/24/2013 JAYESH PATIDAR 23
  • 24. Count… iii. Dystonia:- Dystonia occurs in 6% of total number of patient‘s presenting EPS. The characteristic features are: rapidly developing contraction of muscles of the tongue, jaw, neck (producing torticollis) & etraocular muscles. Combined torticolis & extraocular spasm results in an oculogyric crisis in which eyes looked upward, head is turned to one side. Dystonia is painful & gives a frightening experience to the patient. Constant observation of the patient should be made. Dystonia occurs within a few minutes of giving medicine or after several hours. 4/24/2013 JAYESH PATIDAR 24
  • 25. Count… iv. Tardive Dyskinesia:- This occur due to abrupt termination or reduction of the antipsychotic drug after long-term-high-dose therapy. Tardive dyskinesia is characterized by involuntary rhythmic, stereotyped movements, protrusion of the tongue, puffing of cheeks, chewing movements, involuntary movements of extremities & trunk. These symptoms occur in 3% of patients. Antipsychotics should be stoped immediately. There is no treatment, symptoms may appear for years. It is irreversible. 4/24/2013 JAYESH PATIDAR 25
  • 26. Count… V. Neuroleptic Malignant Syndrome (NMS):- This is a rare complication of antipsychotic agents & is usually fetal. Many develop within hours or after years of continued drug use. Symptoms include hyperpyrexia, severe muscle rigidity, altered consciousness, blood pressure changes, increased count of W.B.C. symptoms appear suddenly when medication is started & can persist for 10-14 days or longer. Symptomatic treatment is given to patients. 4/24/2013 JAYESH PATIDAR 26
  • 27. Count… 2) Autonomic Nervous System:- Dry mouth, blurred vision, constipation, urinary hesitance or retention & under rare circumstances paralytic ileus. 3) Cardio-Vascular:- Tachycardia, orthostatic hypotension & reversible arrhythmias. 4) Blood or Hematopoietic:- Agrunulocytosis (marked decrease in leukocytes system especially with chlorpramozine) leucopenia, leukocytosis. 4/24/2013 JAYESH PATIDAR 27
  • 28. Count… 5) Endocrine Disruptions:- Menstrual irregularities, including amenorrhea & false positive pregnancy tests, breast enlargement, lactation, weight gain, changes in libido, impotence, glycosuria, hyperglycemia. 6) Gastro-Intestinal:- Anorexia, constipation, diarrhea, hypersalivation, nausea, vomiting, obstructive jaundice. 7) Allergic effects:- Dermatitis, photosensitization, pigment deposits. 4/24/2013 JAYESH PATIDAR 28
  • 29. Count… 8) Occular Effcts:- Blurring of vision, pigmentation of cornea & lens & retinopathy. 9) Hepatic Side-effects:- Liver toxicity occurs in 0.5% of cases presenting EPS. It is a hypersensitivity reaction & dose dependent. Onset of symptoms is within the first one month of treatment. Symptoms may be fever, chills, nausea, malaise, prurites & jaundice. 4/24/2013 JAYESH PATIDAR 29
  • 30. NURSE’S RESPONCIBILITY  Close observation, especially when the antipsychotic are just started. The expected results are reduction in aggressive hyperactive behavior & disorganized thoughts. Look for the possible side-effects.  Extrapyramidal reaction, i.e. Parkinsonism, akinesia, akathisia, dystonia, & tardive dyskinesia. These symptoms are reduced/treated with early observation, reporting & use of anti-parkinsonion or anticholinergic medication.  Observe drowsiness. Medicine should be administered at bed time. Report if the drowsiness persists for a very long time. The patient should be advised not to drive & handle hazardous machinery while taking antipsychotic drugs. Observe for sore throat, fever due to agranulocytosis. 4/24/2013 JAYESH PATIDAR 30
  • 31. Count…  Record blood pressure of the patient on antipsychotic drugs. If the BP is drops by 20 to30 mm of hg in the patient, immediate reporting & intervention should be done. The patient should be made aware of the possibility of dizziness & injuries after receiving medication & injection due to orthostatic hypotension.  Accurate rout of medication- antipsychotic drugs are not given subcutaneously unless specially prescribed as they cause tissue irritation. These drugs should be given deep IM.  Dry mouth may be may be reduced by encouraging the patient to rinse his or her mouth frequently. Give a piece of lemon or chewing gum. Good oral hygiene should also be maintained. 4/24/2013 JAYESH PATIDAR 31
  • 32. Count…  Blurred or impaired vision in the patient causes anxiety & annonyance to him. The patient should be encouraged to inform these symptoms immediately. Blurred vision or brown coloured vision, night blindness can be permanent due to pigmentary retinopathy.  The patient on antipsychotic drugs may have weight gain. Weight record should be maintained. The patient may be encouraged on a low salt & planned caloric diet.  The patient may complain of gastric irritation. He should be discouraged to take antacid as there will be decreased absorption of antipsychotic drugs.  An intake output chart should be maintained specially for male patients who are confined to bed & have an enlarged prostate gland. Encourage at least 2500 ml of liquid intake. 4/24/2013 JAYESH PATIDAR 32
  • 33. Count…  The patient should be advised to protect his skin, by not going in the sun & to wear protective clothing & sunglasses.  The patient should be explained not to increase or decrease or stop taking drugs without discussing with his doctor. The drugs should be withdrawn slowly to avoid nausea or seizures.  The nurse should find out menstrual changes from the female patient. Sometimes the patient may complain of fever, upper abdominal pain, nausea, jaundice & diarrhea. These symptoms can be due to cholestatic jaundice. The nurse should stop the medicine immediately & inform the doctor.  Reassurance to relatives- The patient & his relatives should be explained that desired effects will be achieved after weeks of medication, so the relatives need to wait for the effects of the drugs. 4/24/2013 JAYESH PATIDAR 33
  • 34. ANTIDEPRESSANTS AGENTS 4/24/2013 JAYESH PATIDAR 34
  • 35. DESCRIPTION • Antidepressant agents are used in affective disorders or disturbances mainly to treat depressive disorders caused by emotional or environmental stressors. • Several groups of affective disturbances are treatable by antidepressants. 4/24/2013 JAYESH PATIDAR 35
  • 36. MODE OF ACTION • Antidepressant drugs are classified as Tricyclics, Tetracyclics & MAO inhibitors. Research studies have shown reduced levels of norepinephrine (NE) & serotonin (5-HT) in the space between nerve ending carrying message from one nerve cell to another cause depression. • Tricyclic antidepressants & MAO inhibitors increase these neurotransmitters i.e. norepinephrine & sertinin to the synaptic receptors in the central nervous system. Tricyclic inhibitors block the reuptake of NE & 5-HT & MAO inhibitors block the action of MONOamine oxidize in breaking down excess of NE & 5-HT at the presynaptic neuron. 4/24/2013 JAYESH PATIDAR 36
  • 37. CLASSIFICATION CLASS EXAMPLES OF DRUGS TRADE NAME ORAL DOSE (mg/day) Tricyclic antidepressants (TCAs) Imipramine Amitriptyline Clomipramine Dothiepin mianserin Antidep Tryptomer Anafranil Prothiaden depnon 75-300 75-300 75-300 75-300 30-120 Selective serotonin reuptake inhibitors (SSRIs) Fluoxetine Sertraline Fludac Serenata 10-80 50-200 Dopaminergic antidepressants fluvoxamine faverin 50-300 Atypical antidepressants amineptine survector 100-400 Monoamine oxidase inhibitors (MAOIs) Trazodone isocarboxazid Trazalon Marplan 150-600 10-304/24/2013 JAYESH PATIDAR 37
  • 38. INDICATIONS  Depression • Depressive episode • Dysthymia • Reactive depression • Secondary depression • Abnormal grief reaction  Childhood psychiatric disorders • Enuresis • Separation anxiety disorder • Somnambulism • School phobia • Night terrors  Other psychiatric disorders • Panic attack • Generalized anxiety disorder • Agrophobia, social phobia • OCD with or without depression • Eating disorder • Borderline personality disorder • Post-traumatic stress disorder • Depersonalization syndrome  Medical disorder • Chronic pain • Migraine • Peptic ulcer disease 4/24/2013 JAYESH PATIDAR 38
  • 39. PHARMACOKINETICS • Antidepressants are highly lipophilic & protein-bound. The half-life is long & usually more than 24 hours. • It is predominantly metabolized in the liver. 4/24/2013 JAYESH PATIDAR 39
  • 40. CONTRAINDICATION • Antidepressants are given with caution to patients with cardiovascular disorder because they cause arrhythmias. • They increase symptoms of psychosis & mania in cases of manic-depressive psychosis. • Drugs are given with caution to prevents with liver disorders. 4/24/2013 JAYESH PATIDAR 40
  • 41. SIDE EFFECTS 1) Autonomic side-effects: Dry mouth, constipation, cycloplegia, mydriasis, urinary retention, orthostatic hypotension, impotence, impaired ejaculation, delirium & aggravation of glaucoma. 2) CNS effects:- Sedation, tremor & other extrapyramidal symptoms, withdrawal syndrome, seizures, jitteriness syndrome, precipitation of mania. 3) Cardiac side-effects:- Tachycardia, ECG changes, arrhythmias, direct myocardial depression, quinidine-like action(decreased conduction time). 4/24/2013 JAYESH PATIDAR 41
  • 42. Count… 4) Allergic side-effects:- Agranulocytosis, cholestatic jaundice, skin rashes, systemic vasculitis. 5) Metabolic & endocrine side-effects:- weight gain 6) Special effects of MAOI drugs:- Hypertensive crises, severe hepatic necrosis, hyperpyrexia. 4/24/2013 JAYESH PATIDAR 42
  • 43. NURSE’S RESPONSIBILITY  Observation of the side-effects & monitoring the changes noted are very significant to prevent complications due to antidepressant agents.  Encourage the patient to take medicine at bed time due to a sedative effect. Dryness of mouth to decrease.  Give plenty of fluids orally. Lemonade or chewing gum should be given. A few sips of water also help the patient.  Do not give medicine empty stomach as the patient complains of nausea & vomiting. 4/24/2013 JAYESH PATIDAR 43
  • 44. Count…  Accurate recording of intake & output of the patient should be maintained to check if he has retention of urine.  If the patient complains of dizziness or light headedness he/she should be encouraged to get up slowly & sit in the bed before standing. These symptoms may due to orthostatic hypotension. The patient should be reassured that these symptoms are for a short period only. Some patients may present hypertension.  Accurate recording of vital signs like B.P. & pulse.  The nurse should be able to interpret the blood reports specially blood sugar level & W.B.C. count. If the patient complains of sore throat, fever, malaise, it should be reported to the physician on duty. These symptoms may be due to agranulocytosis or hyperglycemia. 4/24/2013 JAYESH PATIDAR 44
  • 45. Count…  To relieve constipation plenty of fluids & roughage should be encouraged in the diet.  If the patient complains of sexual dysfunction inform the physician immediately & stop the drug.  If the patient is presenting symptoms of pressure of speech, increased motor activity & elated mood, the physician should be informed & the drug should be stopped immediately.  Antidepressant tricyclic drugs begin therapeutic effects within four to eight weeks.  Accurate recording of the observation made. 4/24/2013 JAYESH PATIDAR 45
  • 46. MOOD STABILIZING DRUGS 4/24/2013 JAYESH PATIDAR 46
  • 47. Mood stabilizers are used for the treatment of bipolar affective disorders. Some commonly used mood stabilizers are:- 1. Lithium 2. Carbamazepine 3. Sodium Valproate 4/24/2013 JAYESH PATIDAR 47
  • 48. LITHIUM 4/24/2013 JAYESH PATIDAR 48
  • 49. DESCRIPTION • Lithium is an element with atomic number 3 & atomic weight 7. • It was discovered by FJ Cade in 1949, & is a most effective & commonly used drug in the treatment of mania. 4/24/2013 JAYESH PATIDAR 49
  • 50. MODE OF ACTION The probable mechanisms of action can be: • It accelerates presynaptic re-uptake & destruction of catecholamines, like norepinephrine. • It inhibits the release of catecholamines at the synapse. • It decreases postsynaptic serotonin receptor sensitivity. All these actions result in decreased catecholamine activity, thus ameliorating mania. 4/24/2013 JAYESH PATIDAR 50
  • 51. INDICATION  Acute mania  Prophylaxis for bipolar & unipolar mood disorder.  Schizoaffective disorder  Cyclothymia  Impulsivity & aggression Other disorders: – Premenstrual dysphoric disorder – Bulimia nervosa – Borderline personality disorder – Episodes of binge drinking – Trichotillomania – Cluster headaches 4/24/2013 JAYESH PATIDAR 51
  • 52. PHARMACOKINETICS • Lithium is readily absorbed with peak plasma levels occurring 2-4 hours after a single oral dose of lithium carbonate. • Lithium is distributed rapidly in liver & kidney & more slowly in muscle, brain & bone. Steady state levels are achieved in about 7 days. • Elimination is predominately via tubules & is influenced by sodium balance. Depletion of sodium can precipitate lithium toxicity. 4/24/2013 JAYESH PATIDAR 52
  • 53. DOSAGES Lithium is available in the market in the form of the following preparation: – Lithium carbonate: 300mg tablet (eg. Licab); 400mg sustained release tablets (eg. Lithosun-SR). – Lithium citrate: 300mg/5ml liquid. The usual range of dose per day in acute mania is 900-2100mg given in 2-3 divided doses. The treatment is started after serial lithium estimation is done after a loading dose of 600mg or 900mg of lithium to determine the pharmacokinetics. 4/24/2013 JAYESH PATIDAR 53
  • 54. BLOOD LITHIUM LEVEL • Therapeutic levels = 0.8-1.2 mEq/L (for treatment of acute mania) • Prophylactic levels = 0.6-1.2 mEq/L (for prevention of relapse in bipolar disorder) • Toxic lithium levels>2.0 mEq/L 4/24/2013 JAYESH PATIDAR 54
  • 55. SIDE EFFECTS • Neurological: Tremors, motor hyperactivity, muscular weakness cogwheel rigidity, seizures, neurotoxicity (delirium, abnormal involuntary movements, seizures, coma). • Renal: Polydipsia, polyuria, tubular enlargement, nephritic syndrome. • Cardiovascular: T-wave depression. • Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain & metallic taste. • Endocrine: Abnormal thyroid function, goiter & weight gain. • 4/24/2013 JAYESH PATIDAR 55
  • 56. Count… • Dermatological: Acneiform eruptions, popular eruptions & exacerbation of psoriasis. • Side-effect during pregnancy & lactation: Teratogenic possibility, increase incidence of Ebstein‘s anomaly (distortion & downward displacement of tricuspid value in right ventricle) when taken in first trimester. Secreted in milk & can cause toxicity in infant. 4/24/2013 JAYESH PATIDAR 56
  • 57. Count… • Sign & symptoms of lithium toxicity (serum lithium level>2.0 mEq/L): – Ataxia – Coarse tremor (hand) – Nausea & vomiting – Impaired memory – Impaired concentration – Nephrotoxicity – Muscle weakness – Convulsions – Muscle twitching – Dysarthria – Lethargy – Confusion – Coma – Hyperreflexia – Nystagmus 4/24/2013 JAYESH PATIDAR 57
  • 58. MANAGEMENT OF LITHIUM TOXICITY:- • Discontinue the drug immediately. • For significant short-term ingestions, residual gastric content should be removed by induction of emesis, gastric lavage adsorption with activated charcoal. • If possible instruct the patient to ingest fluids. • Assess serum lithium levels, serum electrolytes, renal functions, ECG as soon as possible. • Maintenance of fluid & electrolyte balance. • In a patient with serious manifestations of lithium toxicity, hemodialysis should be initiated. 4/24/2013 JAYESH PATIDAR 58
  • 59. CONTRAINDICATION OF LITHIUM:- • Cardiac, renal, thyroid or neurological dysfunctions • Presence of blood dyscrasias • During first trimester of pregnancy & lactation • Severe dehydration • Hypothyroidism • History of seizures 4/24/2013 JAYESH PATIDAR 59
  • 60. NURSE’S RESPONSIBILITY:- • The pre—lithium work up: A complete physical history, ECG, blood studies (TC, DC, FBS, BUN, Creatinine, electrolytes) urine examination (routine & microscopic) must be carried out. It is important to assess renal function as renal side-effects are common & the drug can be dangerous in an individual with compromised kidney function. Thyroid functions should also be assesses, as the drug is known to depress the thyroid gland. 4/24/2013 JAYESH PATIDAR 60
  • 61. Count… To achieve therapeutic effect & prevent lithium toxicity, the following precaution should be taken: • Lithium must be taken on a regular basis, preferably at the same time daily (for example, a client taking lithium on TID schedule, who forget a dose should wait until the next scheduled time to take lithium & not take twice the amount at one time, because toxicity can occur). • When lithium therapy is initiated, mild side-effects such as fine hand tremors, increased thirst & urination, nausea, anorexia etc may develop, Most of them are transient & do not represent lithium toxicity. 4/24/2013 JAYESH PATIDAR 61
  • 62. Count… • Serious side-effects of lithium that necessitate its discontinuance include vomiting, extreme hand tremor, sedation, muscle weakness & vertigo. The psychiatrist should be notified immediately if any of these effects occur. • Since polyuria can lead to dehydration with risk of lithium intoxication, patients should be advised to drink enough water to compensate for the fluid loss. • Various situations may require an adjustment in the amount of lithium administered to a client, such as the addition of the new medicine to the client drug regimen, a new diet or an illness with fever or excessive sweating. They must be advised to consume large quantities of water with salts, to prevent lithium toxicity due to decreased sodium levels. 4/24/2013 JAYESH PATIDAR 62
  • 63. Count… • Frequent serum lithium level evaluation is important. Blood for determination of lithium levels should be drawn in the morning approximately 12-14 hours after the last dose was taken. • The patient should be told about the importance of regular follow up. In every six months, blood sample should be taken for estimation of electrolytes, urea, creatinine, a full blood count & thyroid function test. 4/24/2013 JAYESH PATIDAR 63
  • 64. CARBAMAZEPINE 4/24/2013 JAYESH PATIDAR 64
  • 65. DESCRIPTION • It is available in the market under different trade names like Tegretol, Mazetol, Zeptol & Zen Retard. 4/24/2013 JAYESH PATIDAR 65
  • 66. MECHANISM OF ACTION • Its mood stabilizing mechanism is not clearly established. Its anticonvulsant action may however be by decreasing synaptic transmission in the CNS. 4/24/2013 JAYESH PATIDAR 66
  • 67. INDICATIONS • Seizures-complex partial seizures, GTCS, seizures due to alcohol withdrawal. • Psychiatric disorders- rapid cycling bipolar disorder, acute depression, impulse control disorder, aggression, psychosis with epilepsy, schizoaffective disorders, borderline personality disorder, cocaine withdrawal syndrome. • Paroxysmal pain syndromes- trigeminal neuralgia & phantom limb pain. 4/24/2013 JAYESH PATIDAR 67
  • 68. DOSAGE • The average daily dose is 600-1800 mg orally, in divided doses. The therapeutic blood levels are 6-12 µg/ml. toxic blood levels are attained at more than µg/ml. 4/24/2013 JAYESH PATIDAR 68
  • 69. SIDE EFFECTS • Drowsiness, confusion, headache, ataxia, hypertension, arrhythmias, skin rashes, steven-Johnson syndrome, nausea, vomiting, diarrhea, dry mouth, abdominal pain, jaundice, hepatitis, oliguria, leucopenia, thrombocytopenia, bone marrow depression leading to aplastic anemia. 4/24/2013 JAYESH PATIDAR 69
  • 70. NURSE’S RESPONCIBILITY • Since the drug may cause dizziness & drowsiness advise him to avoid driving & other activities requiring alertness? • Advise patient not to consume alcohol when he is on the drug. • Emphasize the importance of regular follow-up visits & periodic examination of blood count & monitoring of cardiac, renal, hepatic & bone marrow functions. 4/24/2013 JAYESH PATIDAR 70
  • 71. SODIUM VALPROATE (ENCORATE CHRONO, VALPARIN, EPILEX, EPIVAL) 4/24/2013 JAYESH PATIDAR 71
  • 72. MECHANISM OF ACTION • The drugs acts on gamma- aminobutyric acid (GABA) an inhibitory amino acid neurotransmitters. GABA receptors activation serves to reduce neuronal excitability. 4/24/2013 JAYESH PATIDAR 72
  • 73. INDICATION • Acute mania, prophylactic treatment of bipolar-I disorder, rapid cycling bipolar disorder. • Schizoaffective disorder. • Seizures. • Other disorders like bulimia nervosa, obsessive-compulsive disorder, agitation & PTSD. 4/24/2013 JAYESH PATIDAR 73
  • 74. DOSAGE • The usual dose is 15 mg/kg/day with a maximum of 60mg/kg/day orally. 4/24/2013 JAYESH PATIDAR 74
  • 75. SIDE EFFECTS • Nausea, vomiting, diarrhea, sedation, ataxia, dysarthria, tremor, weight gain, loss of hair, thrombocytopenia, platelet dysfunction. 4/24/2013 JAYESH PATIDAR 75
  • 76. NURSE’S RESPONSIBILITY • Explain to the patient to take the drug immediately after food to reduce GI irritation. • Advise to come for regular follow-up & periodic examination of blood count, hepatic function & thyroid function. Therapeutic serum level of valproic acid is 50-100 micrograms/ml. 4/24/2013 JAYESH PATIDAR 76
  • 77. ANTIANXIETY AGENTS, INCLUDING SEDATIVES AND HYPNOTICS 4/24/2013 JAYESH PATIDAR 77
  • 78. DESCRIPTION • Anxiety is a state which occurs in all human being at sometime or the other. • It is also a cardinal symptoms of many psychiatric conditions. • The drugs used to relieve anxiety are called ANTIANXIETY OR ANXIOLYTIC AGENTS. Antianxiety drugs relieve moderate-to-severe anxiety & tension. 4/24/2013 JAYESH PATIDAR 78
  • 79. MODE OF ACTION • These non-barbiturate benzodiazepines act as CNS depressants. • It is believed that these drugs increase or help the inhibitory neurotransmitter action of gama-aminobutyric inhibitor in all areas of CNS. So, there is inhibition or control on the cortical & limbic system of the brain, which is responsible for emotions such as rage & anxiety. 4/24/2013 JAYESH PATIDAR 79
  • 80. INDICATIONS • Antianxiety agents are used to relieve mild, moderate & severe anxiety associated with: emotional disorders physical disorders excessive environmental stress neuroses & mild depressive states without causing excessive sedation or drowsiness. • For control of alcohol withdrawal symptoms. • To control convulsions. • To produce skeletal muscle relaxation. • To provide short-term sleep preoperatively, prior to diagnosis & insomnia. • Antianxiety agents should always be used in time-limited regimen. 4/24/2013 JAYESH PATIDAR 80
  • 81. CONTRAINDICATIONS • Patients with renal or liver & respiratory impairment are given antianxiety drugs with caution. 4/24/2013 JAYESH PATIDAR 81
  • 82. CLASSIFICATION OF ANTIANXIETY AGENTS:- CHEMICAL GROUP & GENERIC NAME TRADE NAME RANGE OF DAILY DOSAGE IN mgm ACTION I. Non-Barbiturates A. Benzodiazepines Chlordiazepoxide Diazepam Oxazepam Prazepam Chlorazapate Flurazepam Nitrazepam lorazepam Librium, Equibrome Valium, Calmpose Serepax Verstran Tranzene Azene Dalmane, Nitravet Mogadon ativan 15-100 6-50 30-120 20-60 11.25-60 15-60 10-30 2-6 These are non- barbiturate benzodiazepines. They produce a tranquillizing effect without much sedation. These drugs are potential for abuse. 4/24/2013 JAYESH PATIDAR 82
  • 83. COUNT… CHEMICAL GROUP & GENERIC NAME TRADE NAME RANGE OF DAILY DOSAGE IN mgm ACTION A.Non- Benzodiazepine Propanediols Meprobamate Equanil Miltown Tybamate 1.2-1.6 1.2-1.6 1.2-1.6 These drugs have sedative action & present a high risk of abuse & physical dependence. II. Antihistamines Hydroxyzine Atarax vistaril 30-200 30-200 4/24/2013 JAYESH PATIDAR 83
  • 84. CLASSIFICATION OF SEDATIVES AND HYPNOTICS:- CHEMICAL GROUP & GENERIC NAME TRDE NAME HYPNOTIC DOSE RANGE- DAILY IN mgm SEDATIVE DOSE DAILY IN mgm. ACTION III. Barbiturates Amobarbidtal SA Butabarbital SA Pentobarbital LA Phenobarbital LA Thiopental USA Amytal Butisol Nembutal Luminal pentothal 100-200 100-200 100-200 100-200 Used for anasthesia 60-150 20-200 60-150 30-90 These drugs cause drowsiness lethargy, decrased alertness & sleep. Tolerance to drug can occur within 7-14 days, resulting in physical dependence. IV. Nonbarbiturates 4/24/2013 JAYESH PATIDAR 84
  • 85. COUNT… CHEMICAL GROUP & GENERIC NAME TRDE NAME HYPNOTIC DOSE RANGE- DAILY IN mgm SEDATIVE DOSE DAILY IN mgm. ACTION V. Quinazolines Methaquualone Quaalude Parest Optimal mandrax 150-300 250-300 VI. Acetylinic Alcohols Ethchlorvynol placidyl 0.5gm-1gms 200-600mgm VII. Chloral Derivatives Chloral hydrate Chloral betaine Noctaec Beta-chlor 0.5gm-2gms 870mg-1gm VIII. Monoureides 4/24/2013 JAYESH PATIDAR 85
  • 86. SIDE – EFFECTS OF ANTIANXIETY, SEDATIVES & HYPNOTICS 1)Central nervous system: drowsiness, ataxia, confusion, depression, blurred vision. 2)Cardiovascular system: hypotension, palpitation, syncope. 3)Endocrine: change in libido. 4)Allergic: skin rash. 4/24/2013 JAYESH PATIDAR 86
  • 87. COUNT… 5) Physical/psychological dependence non- benzodiazepines & barbiturate group of drugs has a high risk of abuse & physical dependence. 6) Acute toxicity of barbiturate that can be fetal when taken in excessive dosage usually for suicide attempts. Overdose can cause tachycardia, hypotension, shock, respiratory depression, coma & death. 4/24/2013 JAYESH PATIDAR 87
  • 88. NURSE’S RESPONSIBILITY  Assessment of the patient, prior to the use of antianxiety, sedative-hypnotic agents. If the patient complains of sleep disturbance the causative factor should be identified.  Appropriate nursing measures to induce sleep should be taken such as a calm & quite environment, a cup of hot milk, good back care, allowing the patient to read magazines, sitting with the patient for some time for reassurance purpose.  While administering the drug daily dose should be given at bed time to promote a normal sleep pattern, so that day-time activities are not affected. 4/24/2013 JAYESH PATIDAR 88
  • 89. COUNT…  Give IM injection deep into muscles to prevent irritation.  Look for side-effects, record & report immediately.  If the patient complains of drowsiness tell him to avoid using knife or any other dangerous equipment. He should be instructed not to drive.  Instruct the patient not to take any stimulant like coffee, alcohol as they alter the effect of drugs.  Avoid excessive use of these drugs to prevent the onset of substance abuse or addiction.  Drug should be reduced gradually, sudden stoppage of the drug may cause REM (Rapid Eye Movements), insomnia, dreams or nighmare, hyperexcitability, agitation or convulsions. 4/24/2013 JAYESH PATIDAR 89
  • 90. ANTIPARKINSONIAN AGENTS 4/24/2013 JAYESH PATIDAR 90
  • 91. DESCRIPTION • Antiparkinsonian agents are the specific drugs to treat the extrapyramidal side- effects of antipsychotic agents. • Side-effects are parkinsonism, akathisia, acute dystonia & tardive dyskinesia. • Anticholinergics, antihistamines & amantidne are used to treat these side- effects. 4/24/2013 JAYESH PATIDAR 91
  • 92. MODE OF ACTION • Anticholinergic drugs block the secretion, thereby reducing the symptoms of akathesia & acute dystonia. It is not effective against tardive dyskinesia. • Antihistamines have effects like anticholinergic drugs. Amantadines are dopamine-releasing agents from central neurons. Studies show that this drug may affect some clients with tardive dyskinesia. 4/24/2013 JAYESH PATIDAR 92
  • 93. INDICATION • Antiparkinsonian drugs are used to treat the extrapyramidal symptoms. 4/24/2013 JAYESH PATIDAR 93
  • 94. CONTRINDICATION • Patient with history of closed angle glaucoma, urinary or intestinal obstruction, hypersensitivity, prostatic hypertrophy, tachycardia are not given these drugs. • The drugs are given with caution to patients with mysthesia gravis, arthesclerosis & chronic respiratory problems. • Anticholinergic drugs: Amantadine is given with caution to patients with renal impairment as most of the medication is excreted through the kidney. 4/24/2013 JAYESH PATIDAR 94
  • 95. CLASSIFICATION CHEMICAL & GENERIC NAME TRADE NAME DOSE RANGE PER DAY mgm/Day FROM OF AVAILABILITY I. Anticholinergic Benztropine Biperiden HCL Hydrochiride Trihexyphenidyl Hydrochiride Procyclidine hydrochiride Cogentin Akinetone Dyskinon Pacitane Parbenz kemadrin 0.5-6.0 2.0-8.0 2.0-12.0 5.0-20mg Tab, injection -do- -do- Tab. Tab. II. Antihistamine Diphenhydramine Benadryl 75-100 Capsule & syrup III. Dopamine Drugs L. Dopa Amantadine Hydrochiride Selegline Carbidopa & L.Dopa. Larodopa Symmetrel Deprenyl Sinemet 2 gms-3gms 100-200gms 5-10mg 10-100mg Tab. Tab . Tab. Tab. 4/24/2013 JAYESH PATIDAR 95
  • 96. SIDE-EFFECTS • Anticholinergic:- Side-effects are dry mouth, flushed, dry skin, blurred vision, photophobia, increased heart rate, constipation, urinary retention, mental confusion & excitement. • Antihistamines:- Side-effects are drowsiness, dizziness, anorexia, nausea, vomiting, euphoria, orthostatic hypotension, weight gain, weakness & tingling of hands. • Amantadine:- Side-effects are mood changes, slurred speech, insomnia, inability to concentrate, dry mouth, livedo reticularis that is a red-blue netlike discolouration of the skin which becomes worse in winter. 4/24/2013 JAYESH PATIDAR 96
  • 97. NURSE’S RESPONSIBILITY  Observation- observation of the patient for side- effects of anti-parkinsonian drugs such as tachycardia, palpitation, sedation, drowsiness & blurred vision.  Maintain an intake output chart in case the patient has urinary retention or constipation.  Encourage adequate intake of fluids & roughage in the diet.  Record vital sign such as B.P., pulse & respiration every four hours.  Advise the patient not to get up quickly from a lying- down position to sitting because of orthostatic hypotension.4/24/2013 JAYESH PATIDAR 97
  • 98. COUNT… Educate the patient not to use hazardous machinery or driving when he is on anticholinergic drugs. Encourage the patient to get his routine eye check-up done for early detection of blurred vision or glaucoma. Record the medicine & side-effects accurately. Report & record any side-effects observed to the physician. 4/24/2013 JAYESH PATIDAR 98
  • 99. DRUGS USED IN CHILD PSYCHIATRY 4/24/2013 JAYESH PATIDAR 99
  • 100. 1. CLONIDINE 2. METHYLPHENIDATE (RITALIN):- 4/24/2013 JAYESH PATIDAR 100
  • 101. CLONIDINE 4/24/2013 JAYESH PATIDAR 101
  • 102. MECHANISM OF ACTION • Alpha2- adrenergic receptors agonist. • The agonist effects of clonidine on presynaptic alpha 2-adrenergic receptors result in a decrease in the amount of neurotransmitters released from the presynaptic nerve terminals. This decrease serves generally to reset the sympathetic tone at a lower level & to decrease arousal. 4/24/2013 JAYESH PATIDAR 102
  • 103. INDICATION • Control of withdrawal symptoms from opioids. • Tourette‘s disorder • Control of aggressive or hyperactive behavior in children • Autism. 4/24/2013 JAYESH PATIDAR 103
  • 104. DOSAGE • Usual starting dosage is 0.1mg orally twice a day; the dosage can be raised by 0.3 mg a day to an appropriate level. 4/24/2013 JAYESH PATIDAR 104
  • 105. SIDE-EFFECTS • Dry mouth, dryness of eyes, fatigue, irritability, sedation, dizziness, nausea, vomiting, hypotension & constipation. 4/24/2013 JAYESH PATIDAR 105
  • 106. NURSE’S RESPONSIBILITY • Monitor BP, the drug should be withheld if the patient becomes hypotensive. • Advise frequent mouth rinses & good oral hygiene for dry mouth. 4/24/2013 JAYESH PATIDAR 106
  • 107. METHYLPHENIDATE (RITALIN) 4/24/2013 JAYESH PATIDAR 107
  • 108. DESCRIPTION • Methylphenidate , dextroamphetamine & pemoline are sympathominetics. 4/24/2013 JAYESH PATIDAR 108
  • 109. MECHANISM OF ACTION • Sympathomimetics cause the stimulation of alpha & beta-adrenergic receptors directly as agonists & indirectly by stimulating the release of dopamine & norepinephrine from presynaptic terminals. • Dextroamphetamine & methylphenidate are also inhibitors of catecholamine reuptake, especially dopamine reuptake & inhibitors of monoamino oxidase. • The net result of these activities is believed to be the stimulation of the several brain regions. 4/24/2013 JAYESH PATIDAR 109
  • 110. INDICATION • Attention-deficit hyperactivity disorder • Narcolepsy • Depressive disorders • Obesity 4/24/2013 JAYESH PATIDAR 110
  • 111. DOSAGE • Starting dose is 5-10 mg per day orally, maximum daily dose is 80mg/day. 4/24/2013 JAYESH PATIDAR 111
  • 112. SIDE-EFFECTS • Anorexia or dyspepsia, weight loss, slowed growth, dizziness, insomnia or nightmares, dysphoric mood, tics & psychosis. 4/24/2013 JAYESH PATIDAR 112
  • 113. NURSE’S RESPONSIBILITY • Assess mental status for chang in mood, level of activity, degree of stimulation & aggressiveness. • Ensure that the patient is protected from injury. • Keep stimuli low & environment as quiet as possible to discourage over stimulation. • To decrease anorexia, the medication may be administered immediately after meals. The patient should be weighed regularly during hospitalization & at home while on therapy with CNS stimulants, due to the potential for anorexia/ weight loss & temporary interruptions of growth & development. 4/24/2013 JAYESH PATIDAR 113
  • 114. COUNT… • To prevent insomnia administer last dose at least 6 hours before bedtime. • In children with behavioral disorders a drug ‗holiday‘ should be attempted periodically under the direction of the physician to determine effectiveness of the medication & the need for continuation. • Ensure that parents are aware of the delayed effects of Ritalin. Therapeutic response may not seen for 2-4 weeks; the drug should not be discontinued for lack of immediate results. 4/24/2013 JAYESH PATIDAR 114
  • 115. COUNT… • Inform parents that OTC (over-the-counter) medications should be avoided while the child is on stimulant medication. Some OTC medications, particularly cold & hay fever preparation contain certain sympathomimetic agents that could compound the effects of the stimulants & create drug interactions that may be toxic to the child. • Ensure that parents are aware that the drug should not be withdraw abruptly. Withdrawal should be gradual & under the direction of the physician. 4/24/2013 JAYESH PATIDAR 115
  • 116. 4/24/2013 JAYESH PATIDAR 116