NurseReview.Org - Psychotherapeutic Agents Updates (lesson 1 pharmacology)

Psychotherapeutic Agents Antidepressants and Antipsychotics

Psychotherapeutics
The therapy of emotional and mental disorders

Psychotherapeutics
Anxiety
Grief
Depression
are normal human emotions

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.

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.

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

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

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.

Psychotherapeutics
Affective Disorders
Mania: abnormally pronounced emotions
Depression: abnormally reduced emotions
Bipolar affective disorder: exhibits both mania and depression

Psychotherapeutics
Pathophysiology
Biochemical Imbalance
Mental disorders are associated with abnormal levels of endogenous chemicals, such as neurotransmitters, in the brain.

Psychotherapeutics
Pathophysiology
Brain levels of certain catecholamines play an important role in maintaining mental health.
Dopamine
Serotonin
Histamine

Psychotherapeutics
Pathophysiology
Other biochemicals are necessary for normal mental function.
GABA
acetylcholine
lithium

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

Instructors may wish to insert EIC Image #45: Biogenic Amine Hypothesis

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

Antidepressants
Cyclic antidepressants
tricyclics
tetracyclics
Monoamine oxidase inhibitors (MAOIs)
Second-generation antidepressants and SSRIs

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)

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.

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

Cyclic Antidepressants Therapeutic Uses
Depression
Childhood enuresis (imipramine)
Obsessive-compulsive disorders (clomipramine)
Adjunctive analgesics
Trigeminal neuralgia

Cyclic Antidepressants Side Effects
Sedation
Impotence
Orthostatic hypotension
Older patients:
dizziness, postural hypotension, constipation, delayed micturation, edema, muscle tremors

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

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

Antidepressants: MAOIs
phenelzine (Nardil)
tranylcypromine (Parnate)
isocarboxazid (Marplan)

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

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

Antidepressants: MAOIs Side Effects
Few side effects—orthostatic hypotension most common
Tachycardia Palpitations
Dizziness Drowsiness
Insomnia Headache
Anorexia Nausea
Blurred vision 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

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

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)

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)

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

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)

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

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

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

Antipsychotics
Thioxanthenes: chlorprothixene, thiothixene (Navane)
Butyrophenones: haloperidol (Haldol)
Dihydroindolones: molindone (Moban)
Dibenzoxazepine: loxapine (Loxitane)
Phenothiazines: three structural groups

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

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

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

Antipsychotics: Mechanism of Action
The newer, atypical antipsychotics also block specific serotonin receptors (serotonin-2 [5HT2] receptors).
This is responsible for their improved efficacy and safety profiles.

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

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

Antipsychotics: Side Effects
Body System Effects
CNS Sedation, delirium
Cardiovascular Orthostatic hypotension, syncope, dizziness, ECG changes
Dermatologic Photosensitivity, skin rash, hyperpigmentation, pruritus

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

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)

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

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

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

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.

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.

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.

Antidepressants
Caffeine and cigarette smoking may decrease effectiveness of medication therapy
Instruct patients and family regarding tyramine-containing foods and signs and symptoms of hypertensive crisis

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

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

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

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

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

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NurseReview.Org - Psychotherapeutic Agents Updates (lesson 1 pharmacology)

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