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Psychotherapeutic agents are a key component in the management of psychiatric disorders. Knowledge in this aspect of therapy goes a long way to help the health professional and the patient as well. However, care must be taken in administering these agents to pregnant women, and if possible stop, or consult your psychiatrist before taking these agents.

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  1. 1. PSYCHOPHARMOCOLOGY RICHARD OPOKUASARE M.Ed (Health Education) , B.Ed (Hons) Health Science, RN (Dip) RMN, Cert.Ed ©20111 PSYCHOTHERAPEUTIC DRUGS
  2. 2. ANTIANXIETY AND SEDATIVE-HYPNOTIC DRUGS ©20112 Two types 1.Benzodiazepines 2.Non-benzodiazepines
  3. 3. Indications for Benzodiazepines ©20113 Generalised Anxiety Disorder Insomnia or sleep disorders Posttraumatic stress disorders Alcohol and drug withdrawal Seizure disorders Phobic disorders Anxiety and apprehension experienced before surgery Skeletal muscle relaxation Anxiety associated with medical disease
  4. 4. Benzodiazepines Antianxiety drugs/Anxiolytics Sedative-Hypnotic Drugs ©20114 Alprazolam (Xanax) Chlordiazepoxide (Librium)* Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium)* Halazepam (Paxipam) Lorazepam (Ativan)* Oxazepam (Serax) Prazepam (Centrax) Estazolam (ProSom) Flurazepam (Dalmane) Temazepam (Restoril) Triazolam (Halcion)*
  5. 5. Side Effects/Withdrawal syndrome of Benzodiazepines ©20115  Insomnia  Agitation  Dizziness  Headache  Hyperventilation  Paraesthesias  Myalgia  Malaise  Paranoid delusions  Visual hallucinations  Tremor  Pruritus  Abdominal pain  Constipation  Nausea  Vomiting  Incontinence  Loss of libido  Urinary urgency and frequency  Chest pain  Flushing  Hypotension  Palpitations
  6. 6. Non-benzodiazepines ©20116 Disadvantages • Patients may develop tolerance to their effects • Drugs are more addictive • Drugs cause serious withdrawal symptoms • Drugs are dangerous when taking in overdose • They cause central nervous system depression • They cause a variety of dangerous drug interactions.
  7. 7. Non-benzodiazepines – cont’d Barbiturates Antihistamines ©20117 Amobarbital (Amytal) Butabarbital (Butisol) Pentobarbital (Nembutal) Phenobarbital (Phenobarb) Secobarbital (Seconal) Propanediols  Meprobamate (Equanil) Diphenhydramine (Benadryl) Hydroxyzine (Atarax) Beta-Adrenergic Blocker Propranolol (Inderal) Anxiolytic Buspirone (BuSpar)
  8. 8. Non-benzodiazepines – cont’d Acetylenic Alcohol Chloral Derivate ©20118 Ethchlorvynol (Placidyl) Imidazopyridine Zolpidem (Ambien) Choral hydrate (Noctec)
  9. 9. Common Side Effects (Benzos & non- benzos) ©20119 Drowsiness sedation Ataxia dizziness Feelings of detachment Increased irritability, hostility Anterograde amnesia Tolerance dependency Rebound insomnia, anxiety Nausea Headache Confusion Gross psychomotor impairment Depression Paradoxical rage reaction
  10. 10. ANTIDEPRESSANT DRUGS ©201110 Indications Major depressive illness Anxiety disorders Enuresis Attention deficit disorders Narcolepsy Bulimia
  11. 11. CLASSES OF ANTIDEPRESSANTS Tricyclic drugs ©201111 A. Tertiary (Parent)  Amitryptiline (Elavil)*  Doxepine (Adepin, Sinequan)  Imipramine (Tofranil)*  Trimipramine (Surmontil)  Clomipramine (Anafranil) B. Secondary (Metabolite)  Desipramine (Norpramin)*  Nortryptiline (Pamelor)  Protriptyline (Vivactil)
  12. 12. CLASSES OF ANTIDEPRESSANTS – cont’d ©201112 Monoamine Oxidase Inhibitors (MAOIs) Phenelzine (Nardil) Tranylcypromine (Parnate) Selective Serotonin Reuptake Inhibitors (SSRIs) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft)
  13. 13. CLASSES OF ANTIDEPRESSANTS – cont’d ©201113 Other Antidepressant Drugs (Atypical) Amoxapine (Asendin)* Bupropion (Wellbutrin)* Maproptiline (Ludodiomil) Mirtazepine (Remeron) Nefazedone (Serzone) Trazodone (Desyrel)* Venlafaxine (Effexor)
  14. 14. Contraindications to MAOIs ©201114 Asthma Congestive heart failure Hypertension Impaired kidney function Cardiac arrhythmias Liver disease Hypernatraemia Hyperthyroidism Pheochromocytoma Severe headaches Alcoholism Abnormal LFTs Glaucoma Paranoid schizophrenia Pregnancy Children < 16 years Patients > 60 years
  15. 15. Diets/foods to avoid when Patient is on MAOI Therapy ©201115  Cheese  Liver  Yeast  Snails  Soy sauce  Pickled herring  Distilled spirits  Broad bean pods  Chocolate  Dried fish  Tea  Beef  Smoked meat  Diary products  Avocado  Meat (preserved)  Sausages  Coffee  Smoked salmon  Over-ripe fruit  Cola drinks  Wines  Liquors  Banana  Maggi cubes  Beer  Yoghurt  Ice creams
  16. 16. Drugs to avoid when Patient is on MAOI Therapy ©201116 Nasal and sinus decongestants Narcotics, e.g., meperidine Asthmatic agents Epinephrine Stimulants Cocaine Amphetamines Weight reducing drugs Hay fever drugs Atypical/Newer antidepressants Antihypertensive drugs Aneasthetics (general)
  17. 17. Reasons to Avoid certain Foods and Drugs when on MAOI Therapy Tyramine which is an amino acid is released from the proteins in foods and meats when they are spoiled, fermented or smoked. It is deactivated by monoamine oxidase in the gut wall and liver. When monoamine oxidase is inhibited, tyramine may reach adrenergic nerve endings to cause the release of large amounts of norepinephrine to produce hypertensive reaction. Besides, sympathomimetic drugs act on the neurotransmitters to release norepinephrine from the presynaptic nerve ends. When an individual is on MAOI therapy, the actions of the drug are inhibited and for that matter large amount of norepinephrine are released and a severe hypertensive crisis occurs. ©201117
  18. 18. Common Side Effects of Antidepressants ©201118 Blurred vision Diarrhoea Dry mouth Hallucinations Constipation Delusions Tachycardia Hypertensive crisis Urination retention Hypotension Impaired cognition Insomnia Dizziness Impaired memory Lightheadedness Excessive sweating ECG changes Priapism Ejaculatory dysfunction Sedation drowsiness Nausea Tremors Weight gain
  19. 19. Nursing Care of Side Effects of Antidepressant Drugs ©201119 Advise patient to avoid hazardous tasks, if vision is blurred. Encourage fluids, frequent rinses, or use gums, if mouth is dry. Check for mouth sores. Stop the use of caffeine and give supportive therapy, if tachycardia is present. Encourage fluids and frequent voiding. Monitor voiding patterns, if there is urinary retention. Catheterize patient, if necessary. Increase fluids, dietary fibre and roughage, as well as exercises, if there is the presence of constipation. Monitor bowel habits and use stool softeners and laxatives, only if necessary.
  20. 20. Nursing Care of Side Effects of Antidepressant Drugs – cont’d ©201120 Advise patient to adjust lifestyle and give supportive therapy, if there is cognitive dysfunctions and tremors. Protect patient from falls, in cases of dizziness/lightheadedness. Ask client to take drug as prescribed after sexual intercourse, not immediately before, in case there is ejaculatory dysfunction or sexual dysfunction. Use lubricant, if vaginal dryness is present. If there is priapism, change drug. If there is withdrawal syndrome in terms of malaise, muscle aches, chills, nausea, dizziness, and coryzia, taper off drug over a period of time.
  21. 21. Nursing Care of Side Effects of Antidepressant Drugs – cont’d ©201121 Increase exercise and reduce calorie diet, if there is weight gain. Change class of drug, if weight gain persists. In cases of excessive sweating (perspiration), ask patient to change clothes frequently, wear cotton or linen clothing, have good hygiene, and increase intake of fluids. In case of memory dysfunction, encourage client to concentrate on his normal activities, make a list of his/her daily routine, and provide social support.
  22. 22. Nursing Care of Side Effects of Antidepressant Drugs – cont’d ©201122 Ensure sleep hygiene by decreasing evening activities, eliminating the use of caffeine and ensuring relaxation technique, if s/he complaints of insomnia. Monitor blood pressure frequently. For postural hypotension, take lying and standing blood pressure. Ask client to change his/her position gradually, and protect client from falls. For hallucinations, delusions and other psychotic symptoms, initiate antipsychotic or mood stabilizers, if necessary or change prescribed drug to another antidepressant class of drug.
  23. 23. MOOD STABILIZING DRUGS ©201123 These are in two categories Antimanics Anticonvulsants /Antiepileptics
  24. 24. MOOD STABILIZING DRUGS – cont’d ©201124 Antimanic drug Lithium (Eskalith, Lithobid, Lithonate)
  25. 25. Antimanic drug ©201125 Indications Mania Hypomania Unipolar depression schizophrenia Schizoaffective disorder Catatonia (periodic) Alcoholism Aggressive-conduct disorder Self-abusive behaviour Borderline personality disorder Histrionic personality disorder Eating disorders
  26. 26. Antimanic drug – cont’d ©201126 What to do before Lithium Treatment Take complete history Regular medication checkups Kidney function test Conduct other physical examinations Thyroid function test ECG, FBS, Complete Blood Count
  27. 27. Side Effects of Antimanic/Lithium ©201127 Body Image  Weight gain Cardiac  ECG changes CNS  Tremor  Fatigue  Headache  Mental dullness  Lethargy Dermatological/Skin  Acne  Rash Endocrine  Hypothyroidism  Diabetes mellitus GIT  Gastric irritation  Anorexia  Abdominal cramps  Nausea  Vomiting  Diarrhoea Renal  Polydipsia  Polyuria  Oedema
  28. 28. Anticonvulsant/Antiepileptic drugs ©201128 Carbamazepine (Tegretol) Valproate (Depakene) Divalproex (Depakote)  Phenytoin (Epanutin) Phenobarbitone (Phenobarb)
  29. 29. Anticonvulsant drugs – cont’d ©201129 Indications Epilepsy Borderline personality Acute mania Schizophrenia Bipolar illness Schizoaffective disorder Panic attacks Substance abuse
  30. 30. Contraindications of Anticonvulsants Elderly people Decreased liver function High levels of urea in the blood (uraemia) Diabetes Hereditary blood disorders called porphyrias People who drink large amounts of alcohol People of Thai or Han Chinese ethnic origin* Pregnancy Breastfeeding Kidney disease ©201130
  31. 31. Common Side Effects of Anticonvulsants ©201131 Skin rash Sore throat Blurred vision Mucosal ulceration Drowsiness/sedation Low-grade fever Tremors  Vertigo Nausea Vomiting Ataxia Diplopia Weight gain Decreased in white blood cell count Diarrhoea Pancreatitis Increased appetite Hepatic dysfunction/hepatotoxicity
  32. 32. Neuroleptic drugs or neuroleptics Psychotropic drugs or psychotropics ©201132 ANTIPSYCHOTIC DRUGS
  33. 33. ANTIPSYCHOTIC DRUGS – cont’d ©201133 TWO classes dopamine receptor antagonists called “typical”; and serotonin-dopamine antagonists called “atypical.”
  34. 34. ANTIPSYCHOTIC DRUGS – cont’d 1. Typical/Traditional/Conventional Antipsychotics These help to decrease positive symptoms of schizophrenia. They produce extrapyramidal side effects and many other neurological disturbances, e.g., muscular rigidity, tremors, drooling, shuffling gait (Parkinsonism), restlessness (akathisia), involuntary postures (dystonia), akinesia (motor inertia), etc. They serve as dopamine (DA) antigonists, blocking postsynaptic D2receptors in several DA tracts in the ©201134
  35. 35. ANTIPSYCHOTIC DRUGS – cont’d 2. Atypical/Newer Antipsychotics They improve positive symptoms of schizophrenia. They exert therapeutic action in treating the negative symptoms of schizophrenia They neither do not have nor produce extrapyramidal side effects associated with traditional antipsychotics. They serve as dopamine and serotonin antagonists, by inhibiting or stopping the reception of these two neurotransmitters at specific postsynaptic sites. ©201135
  36. 36. Indications or Clinical Use of Antipsychotics Non-psychiatric/General uses Psychiatric uses ©201136 Vomiting Vertigo Pain relief Hiccups Porphyria Relief of itching Facilitate sleep in insomnic clients Migraine headache  Schizophrenia  Organic brain syndrome with psychosis  Manic-depressive illness  Severe depression with psychotic features  Mania  Delusional disorder  Agitated aggressive behaviour in dementia  Gilles de la Tourette’s syndrome  Impulsivity  Huntington’s disease
  37. 37. TYPICAL ANTIPSYCHOTICS ©2011 37 Phenothiazines Aliphatics Chlorpromazine (Largactil, Thorazine)* Trifluopromazine (Vesprin) Piperidines Mesoridazine (Serentil) Thioridazine (Mellaril) Piperazines Acetophenazine (Tindal) Fluphenazine (Modecate, Prolixin, Permitil)* Perphenazine (Trilafon) Trifluoperazine (Stelazine)*
  38. 38. TYPICAL ANTIPSYCHOTICS – cont’d ©2011 38 Thioxanthenes Aliphatic Chlorprothixene (Taractan) Piperazine Thiothixene (Navene) Butyrophenones Haloperidol (Haldol, Serenace)* Dibenzoxazepine Loxapine (Loxitane) Dihydroindolone Molindone (Moban)
  39. 39. ATYPICAL ANTIPSYCHOTICS ©2011 39 Clozapine (Clozaril) Olazapine (Zyprexa) Risperidone (Risperdal)* Quetiapine (Seroquel) Ziprasidone (Zeldox) Other neuroleptic medications include: Pimozide (Orap) Reserpine (Serpasil)
  40. 40. POTENCY OF ANTIPSYCHOTICS Low Potency High Potency ©201140 Chlorpromazine Thioridazine Clozapine Mesoridazine Quetiapine (Seroquel) Ziprasidone (Zeldox) Trifluoperazine Thiothixene Loxapine Molindone Perphenazine Fluphenazine Haloperidol Pimozide Risperidone Olanzapine
  41. 41. Common Side Effects of Antipsychotic Drugs Anticholinergic Symptoms Other Side Effects ©2011 41 Constipation Dry mouth Blurred vision Memory impairment Confusion Dizziness Urinary retention/slowing of urination Nasal congestion Excessive salivation Sedation/drowsiness Weight gain Impaired concentration Seizures Sexual dysfunction Photosensitivity Oculogyric crisis (rotation of the eye balls in a fixed position, usually upward) Agranulocytosis (Ulcerative sore throat, Fever, Malaise, Leukopenia)
  42. 42. Common Side Effects of Antipsychotic Drugs – cont’d Tardive Dyskinesia Extrapyramidal Symptoms ©201142 Tongue protrusion Writhing of Tongue Lip smacking Chewing Blinking Facial grimacing Movements of neck, trunk, and pelvis Leg jiggling/jerky movements Muscle rigidity Tremors Drooling Restlessness Allergic Reactions Jaundice Skin rash
  43. 43. Positive Side Effects of Antipsychotics ©201143 1. They are not addictive. 2. It is extremely difficult to use them to commit suicide. (Ray & Ksir, 2004)
  44. 44. ANTIPARKINSONIAN MEDICATIONS ©2011 44 Antiparkinsonian drugs are used to treat the side effects that result from the use of antipsychotic agents. They are drugs used to counter the effects of extrapyramidal symptoms.
  45. 45. Anticholinergics Antihistamine ©2011 Benztropine* (Cogentin) Trihexyphenidyl (Artane, Pipanol)* Biperiden (Akineton) Procyclidine (Kemadrin) Diphenhydramine (Benadryl) Ethopropazine (Parsidol) Orphenadrine (Disipal, Norlex) 45 Groups of Antiparkinsonian drugs
  46. 46. Dopamine Agonist Benzodiazepines ©2011 Amantadine (Symmetrel) Bromocriptine (Parlodel) Diazepam (Valium)* Lorazepam (Ativan)* Clonazepam (Klonopin)* 46 Groups of Antiparkinsonian drugs – cont’d
  47. 47. Common Side Effects of Antiparkinsonian/Anticholinergic medications ©2011 47 Dry mouth Nasal congestion Blurred vision Constipation Urinary hesitancy Urinary retention (potentially serious in the elderly) Delirium (marked by disorientation, agitation, tachycardia, and tachypnoea) Dry, hot, flushed skin Enlarged pupils (mydriasis) Problem with recent memory
  48. 48. Specific Nursing Interventions for Anticholinergic Agents ©2011 48 Reassure client that problem will go away, if there is blurred vision. Discontinue medication, if problem persists. Administer anticholinergic drugs in minimal doses, and only when necessary. Give antiparkinsonics with or immediately following food intake to prevent or reduce gastro-intestinal distress.
  49. 49. Specific Nursing Interventions for Anticholinergic Agents – cont’d ©2011 49 Observe for therapeutic effects such as decreased salivation, tremor, and drooling. Observe for improvement in gait, balance, posture, speech, and self-care ability. Monitor for adverse effects due to anticholinergic drugs such as dry mouth, drowsiness and constipation. Monitor for adverse reaction to antiparkinson agents.
  50. 50. SOME REASONS FOR NOT TAKING ALCOHOLIC BEVERAGES WITH PSYCHOTROPIC MEDICATIONS The medication can increase the depressant effect of alcohol. The stimulant in alcohol can decrease the effect of the medication or the efficacy of the medication. The efficacy of the drug may be totally destroyed. Instead of the medication relaxing and making the patient sleep, s/he is going to have sleepless nights. ©2011 50
  51. 51. SOME REASONS FOR NOT TAKING ALCOHOLIC BEVERAGES WITH PSYCHOTROPIC MEDICATIONS – Cont’d Because the medicine may not be effective, patient may take more of the prescribed dosage causing over dose. Alcohol may cause contra-reaction. Alcohol react with the medication causing severe adverse effect. Taking alcohol with medication may cause death. ©2011 51
  52. 52. SOME REASONS FOR NOT TAKING ALCOHOLIC BEVERAGES WITH PSYCHOTROPIC MEDICATIONS – Cont’d Alcohol can influence the effectiveness of a drug by altering its availability. Alcohol may inhibit a drug’s metabolism by competing with the drug for the same set of metabolizing enzymes.  Alcohol will potentially increase the patient’s risk of experiencing harmful side effects from the drug. Some drugs affect the metabolism of alcohol, thus altering its potential for intoxication and the adverse effects associated with alcohol consumption. ©2011 52