Anxiety disorders are characterized by feelings of unease, dread, and abnormal responses that prevent normal functioning. Common types include panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, phobias, and social phobia. Antianxiety medications used to treat these disorders include antidepressants, benzodiazepines, MAOIs, buspirone, and SSRIs. Buspirone has no muscle relaxant or anticonvulsant effects and does not cause sedation, but its effects may take several weeks to be seen. Common side effects include dizziness, nausea, and headache.

3. Anxiety Disorders
A group of mental disorders characterized by a
vague uneasy feeling of discomfort or dread. The
symptoms of anxiety prevent the individual from
normal functioning . can be an exaggerated
response to an actual event or anxiety unrelated
to an identifiable event or condition.

4. Anxiety disorders
 Panic disorder
 Generalized anxiety disorder
 Obsessive-compulsive disorder
 Post-traumatic stress disorder
 Simple phobia
 Social phobia

5. Antianxiety Medications(Anxiolytics)
 Tricyclic antidepressants
 Benzodiazepines
 MAOIs
 Buspirone
 SSRIs

6. BUSPIRONE (BuSpar)
 Mechanism of action unknown
 Interacts with serotonin and dopamine in
the brain
 No muscle relaxant effects
 No anticonvulsant effects
 Does not cause sedation

7. BUSPIRONE (BuSpar)
Uses / indications
Short term management of anxiety
disorders
Not appropriate for immediate relief may
take
several weeks to see effects

8. BUSPIRONE (BuSpar)
Side effects
 Dizziness, nausea, headache, anxiety, fatigue,
 Insomnia
Contraindications
 Renal/hepatic failure
 Use of MAOIs

9. ANTIDEPRESSANTS AND
MOOD STABILIZERS DRUGS

10. ETIOLOGY OF DEPRESSION
Monoamine neurotransmitter dysfunction
Deficiency of norepinephrine and/or
serotonin.
Balance, integration and interactions
among
norepinephrine, serotonin, and other
neurotransmission systems is an
important
etiological factors.

11. ETIOLOGY OF DEPRESSION
 Neuroendocrine factors
 AN INCREASE IN CRF (corticotropin releasing
 factor/hormone) HAS BEEN NOTED IN
PATIENTS WITH DEPRESSION.

12. CLASSIFICATIONS OF ANTIDEPRESSANT
MEDICATIONS
Tricyclic antidepressants
Monoamine oxidase inhibitors
Selective serotonin reuptake inhibitors
Unclassified drugs

13. TRICYCLIC ANTIDEPRESSANTS
imipramine (Tofranil) prototype
nortriptyline (Pamelor)
amitryptyline (Elavil)
desipramine (Norpramin)

14. TRICYCLIC ANTIDEPRESSANTS(TCAs)
 First generation of antidepressant therapy
 Mechanism of action
 Corrects the imbalance in the neurotransmitter
concentrations of serotonin and norepinephrine at
the nerve endings in the CNS. This is done by
blocking the reuptake of the neurotransmitters and
thus causing these neurotransmitters to accumulate
at the nerve endings.
 Also have nonselective receptor antagonism
causing many side effects.

15. TRICYCLIC ANTIDEPRESSANTS
 Indications
 Depression
 Childhood enuresis(bed wetting)
 Imipramine
 Obsessive compulsive disorder
 Clomipramine
 Chronic pain syndromes
 Neuropathic pain (trigeminal neuralgia)

16. TRICYCLIC ANTIDEPRESSANTS
Adverse effects
 Sedation
 Impotence
 Orthostatic hypotension
 Disturbs cardiac conduction
 Delayed micturation
 Edema
 Muscle tremors

17. TRICYCLIC ANTIDEPRESSANTS
Interactions
 WHEN TAKEN WITH MAOIs MAY RESULT IN
INCREASED THERAPEUTIC LEADING TO
TOXIC EFFECTS (HYPERPYRETIC CRISIS)
 TCAs can inhibit the metabolism of
warfarin,resulting in an increase in
anticoagulation

18. TRICYCLIC ANTIDEPRESSANTS
 Toxicity and management of overdose
 TCA overdoses are fatal 70 - 80 of the time
 Death usually results from seizures or
dysrhythmias
 THERE IS NO SPECIFIC ANTIDOTE FOR TCAs

19. MONOAMINE OXIDASE INHIBITORS
(MAOIs)
 First generation of antidepressant drugs
 Highly effective
 Many side effects and drug/drug, drug/food
interactions
 Disadvantage potential to cause hypertensive crisis
when taken with tyramine

20. MAOIs
 phenelzine (Nardil)
 tranylcypromine (Parnate)

21. 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

22. MAOIs Indications
Depression, especially types characterized
by symptoms such as increased sleep and
appetite depression that does not respond to
other drugs such as tricyclics.

23. MAOIs Adverse Effects
✘ Tachycardia
✘ Dizziness
✘ Insomnia
✘ Anorexia
✘ Blurred vision
✘ Palpitations
✘ Drowsiness
✘ Headache
✘ Nausea
✘ Impotence

24. MAOIs Overdose
 Symptoms appear 12 hours after
ingestion
 Tachycardia, circulatory collapse,
seizures, coma
 Treatment protect brain and heart,
eliminate toxin

25. Hypertensive Crisis and Tyramine During
MAOI Therapy
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

26. Hypertensive Crisis and Tyramine (contd)
 Avoid foods that contain tyramine!
 Aged, mature cheeses (cheddar, blue, Swiss)
 Smoked/pickled or aged meats, fish, poultry
 (herring, sausage, corned beef, salami, pepperoni,
pâté)
 Yeast extracts
 Red wines (Chianti, burgundy, sherry, vermouth)
 Italian broad beans (fava beans)

27. Antidepressants MAOIs
 Concurrent use of MAOIs and SSRIs may lead to
serotonin syndrome
 If the decision is made to switch to an SSRI, there
must be a 2- to 5-week wash-out period between
MAOI therapy and SSRI therapy

28. Selective Serotonin Reuptake
Inhibitors(SSRIs)
 fluoxetine (Prozac)
 paroxetine (Paxil)
 sertraline (Zoloft)
 fluvoxamine (Luvox)
 citalopram (Celexa)
 escitalopram (Lexapro)

29. SSRIs Newer-Generation
Antidepressants
 Fewer adverse effects than tricyclics and
MAOIs
 Very few drug-drug or drug-food
interactions
 Still takes about 4 to 6 weeks to reach
maximum clinical effectiveness

30. SSRIs
Mechanism of action
✘ Selectively inhibits serotonin reuptake
✘ Little or no effect on norepinephrine or
dopamine reuptake
✘ Result in increased serotonin concentrations at
nerve endings
✘ Advantage over tricyclics and MAOIs little or no
effect on cardiovascular system

31. SSRIs
INDICATIONS
✘ Depression
✘ Bipolar disorder
✘ Obesity
✘ Eating disorders
✘ Obsessive-compulsive disorder

32. SSRI Antidepressants Adverse Effects
✘ Body System Effects
✘ CNS Headache, dizziness, tremor,
nervousness,
insomnia, fatigue
✘ GI Nausea, diarrhea, constipation, dry mouth
✘ Other Sexual dysfunction,
✘ weight gain, weight loss, sweating
✘ Most common and bothersome

33. Serotonin-Norepinephrine Reuptake
Inhibitors
 Duloxetine (Cymbalta)
 Venlafaxine (Effexor)

34. Serotonin-Norepinephrine Reuptake
Inhibitors
Indicated
For depression and general anxiety disorder
Also pain associated with diabetic peripheral
neuropathy
Contraindicated
CONCURRENT USE OF MAOIs
Angle closure glaucoma

35. SNRIs
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
 Inhibition of cytochrome P-450 system

36. OTHER ANTIDEPRESSANTS NOT CLASSIFIED
 bupropion
 Wellbutrin, zyban
 Commonly prescribed for smoking cessation
 maprotiline
 Similar to TCAs
 Mirtazapine
 Remeron
 Often prescribed to enhance appetite

37. NURSING CONSIDERATIONS WHEN PATIENTS
ARE TAKING ANTIDEPRESSANTS
 Comprehensive patient history
 Complete medication history
 Monitor patient for therapeutic effects
 Monitor patients for adverse effects
 Education of patient on drug expectations and adverse
effects
 Educate patient regarding drug-drug, drug-food and drug-
herbal interactions

38. MOOD STABILIZING AGENTS
 lithium carbonate
 Eskalith, lithobid
 MOA not completely understood
 Managed using serum levels
 Indications : mania, bipolar disorder
Adverse effects
 vomiting, diarrhea, drowsiness, difficult
 coordination, hand tremors, muscle twitching,
 mental confusion

39. NURSING CONSIDERATIONS
 Monitor serum lithium levels
 Therapeutic levels are 1.0 1.5 meq/L
 Lithium is eliminated intact by the kidneys.
 Encourage fluids to completely eliminate the drug
 Monitor for therapeutic and adverse effects

40. PSYCHOSIS
A severe mental disorder characterized by disordered thought
process and often bizarre thinking.
 Hypoactivity or hyperactivity
 Agitation
 Aggressiveness
 Hostility
 Social withdrawal

41. Antipsychotic Drugs
 Antipsychotic AKA Neuroleptic
 Any drug that modifies or treats psychotic behaviors
usually by blocking dopamine receptors in the brain

42. Antipsychotic Drugs
✘ Thioxanthenes
✘ thiothixene (Navane)
✘ Phenylbutylpiperidines
✘ haloperidol (Haldol)
✘ Dihydroindolones
✘ molindone (Moban)
✘ Dibenzodiazepines
✘ loxapine (Loxitane)
✘ Benisoxazoles
✘ Risperidone
✘ Quinolinine
✘ Aripiprazole (Abilify)
✘ Phenothiazines
✘ Chlorpromazine
(Thorazine)

43. HALDOL- FIRST GENERATION ANTIPSYCHOTIC
 Schizophrenia
 Long half-life facilitates better compliance
by patients
 Long-term treatment of psychosis
 Can be given either IV or po

44. ADVERSE REACTIONS TO ANTIPSYCHOTIC MEDICATION
✘ Seizures
✘ Extrapyramidal reactions
✘ Blurred vision, dry eyes
✘ Neuroleptic malignant syndrome
✘ Tartive dyskinesia

45. ATYPICAL ANTIPSYCHOTICS
NEWER-GENERATION ANTIPSYCHOTICS
✘ clozapine (Clozaril)
✘ risperidone (Risperdal)
✘ olanzapine (Zyprexa)
✘ quetiapine (Seroquel)
✘ ziprasidone (Geodon)
✘ aripiprazole (Abilify)

46. 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

47. ADVANTAGES OF NEWER GENERATION
ANTIPSYCHOTICS
 Reduced effect on Prolactin levels
 Stimulates mammary glands to produce milk
Lower risk of
o Neuroleptic malignant syndrome
o Extrapyramidal adverse effects
o Tartive dyskinesia

48. Indications
 Treatment of serious mental illnesses
 Bipolar affective disorder
 Depressive and drug-induced psychoses
 Schizophrenia
 Autism
 Movement disorders (such as Tourettes
syndrome)
 Some medical conditions
 Nausea, intractable hiccups

49. Adverse Effects
 Body System Adverse Effects
 CNS Sedation, delirium
 Cardiovascular Orthostatic hypotension,
syncope, dizziness, EKG changes
 Dermatologic Photosensitivity, skin rash,
 hyper-pigmentation, pruritus

50. Adverse Effects (contd)
 Body System Adverse Effects
 GI Dry mouth, constipation
 GU Urinary hesitancy or retention,
impaired erection
 Hematologic Leukopenia and
agranulocytosis

51. Adverse Effects (contd)
 Body System Adverse Effects
 Metabolic/endocrine Galactorrhea,
irregular menses, increased appetite,
polydipsia

52. Nursing Implications
 Before beginning therapy, assess both
the physical and emotional status of
patients
 Obtain baseline vital signs, including
postural BP readings
 Obtain liver and renal function tests

53. Nursing Implications (contd)
 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 patients mouth to make sure oral
doses are swallowed

54. Nursing Implications (contd)
 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

55. Nursing Implications (contd)
 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 drugs with alcohol or
other CNS depressants can be fatal

56. ANTI PARKINSON DRUGS

57. Parkinson’s Disease
✘ Parkinson’s Disease is a chronic, progressive
neurological disorder with rhythmic tremors
as its initial manifestation. These tremors lead
to rigidity and weakness which interfere with
the ability to maintain posture.

58. ✘ Antiparkinsonism agents are drugs used for
management of signs and symptoms of
Parkinson’s disease, a progressive, chronic
neurological disorder primarily characterized
by lack of coordination.
✘ There is no known treatment for Parkinson’s
as of present and drug therapy remains to be
the primary treatment.

59. Antiparkinsonism Agents:
Generic and Brand Names
Classification Generic Name Brand Name
Dopaminergic Agents
amantadine Symmetrel
apomorphine Apokyn
bromocriptine Parlodel
carbidopa-levodopa Sinemet
levodopa Dopar
ropinirole Requip
Anticholinergic agents
benztropine Cogentin
diphenhydramine Benadryl
trihexyphenidyl Artane
Others
entacapone Comtan
tolcapone Tasmar
selegiline Carbex

60. Dopaminergic Agents
✘ Dopamine does not cross the blood-brain
barrier so other drugs with actions similar to
dopamine and those that increase its
concentration in the substantia nigra (area
responsible for muscle tone) must be used.
This is one way of restoring the balance
between stimulatory and inhibitory
neurotransmitters.

61. ✘ Levodopa, the precursor of dopamine is the
mainstay of treatment for Parkinson’s. It
crosses the blood-brain barrier and is
converted into dopamine. When combined
with carbidopa, the enzyme dopa
decarboxylase is inhibited from metabolizing
levodopa, leading to higher levels that can
cross the barrier.

62. Indications
✘ Dopaminergics are indicated for the following medical
conditions:
✘ Dopaminergics are indicated for the relief of the signs and
symptopms of idiopathic Parkinson’s disease.
✘ Levodopa is the drug of choice and acts as a replacement
therapy.
✘ Amantadine is an antiviral drug that increases release of
dopamine.
✘ Apomorphine directly binds with postsynaptic dopamine
receptors.

63. Nursing Considerations
✘ Decrease dose of drug as ordered if therapy has been
interrupted to prevent systemic dopaminergic effects.
✘ Evaluate disease progress and signs and symptoms
periodically for reference of disease progress and drug
response.
✘ Give drug with meals to alleviate GI irritation if present.
✘ Monitor bowel function and institute bowel program if
constipation is severe.

64. ✘ Have patient void before taking the drugs to decrease risk
of urinary retention.
✘ Monitor laboratory test results (renal and liver function,
CBC) to detect early signs of dysfunction.
✘ Provide comfort measures to help patient tolerate drug
effects.
✘ Provide safety measures (e.g. adequate lighting, raised
side rails, etc.) to prevent injuries.
✘ Educate client on drug therapy to promote understanding
and compliance.
Nursing Considerations

65. Anticholinergic Agents
✘ Anticholinergic agents are synthetic drugs
which have been developed to achieve a
greater affinity for cholinergic receptor sites in
the CNS.
✘ Drugs that inhibit the effects of acetylcholine
at receptor sites of substantia nigra and corpus
striatum.

66. Therapeutic Action
✘ The desired and beneficial actions of
anticholinergic agents are as follows:
✗ Returns the balance to the basal ganglia
and reduces the severity of rigidity,
akinesia, and tremors.
✗ Peripheral anticholinergics reduce
drooling and other secondary effects of
parkinsonism.

67. Nursing Considerations
✘ Administer drug with caution for patients
exposed in hot weather or environments
because patients are at increased risk for heat
prostration due to decreased ability to sweat.
✘ Give drug with meals to alleviate GI irritation if
present.
✘ Monitor bowel function and institute bowel
program if constipation is severe.
✘ Have patient void before taking the drugs to
decrease risk of urinary retention.

68. ✘ Monitor laboratory test results (renal and liver function)
to detect early signs of dysfunction.
✘ Provide comfort measures to help patient tolerate drug
effects.
✘ Provide safety measures (e.g. adequate lighting, raised
side rails, etc.) to prevent injuries.
✘ Educate client on drug therapy to promote
understanding and compliance.
✘ Evaluate disease progress and signs and symptoms
periodically for reference of disease progress and drug
response.

69. Substance Use
Disorders

70. Substance use disorders
✘ develop when a person’s use of alcohol or
another substance such as drugs leads to
health issues, disability, and or not adhering to
responsibilities at home, work, or school.
✘ common chronic relapsing illness that are
characterized by drug-seeking and drug-
taking behaviors that persist despite negative
consequences.

71. Comprehensive Dangerous Drugs Act
of 2002
✘ The Comprehensive Dangerous Drugs Act of
2002, or (Republic Act of the Philippines) R.A. No.
9165, is a consolidation of Senate Bill No. 1858 and
House Bill No. 4433. It was enacted and passed by
the Senate of the Philippines and House of
Representatives of the Philippines on May 30,
2002 and May 29, 2002, respectively. It was signed
into law by President Gloria Macapagal-Arroyo on
June 7, 2002.

72. Pharmacologic Management
TWO MAIN PURPOSES:
 to permit safe withdrawal from alcohol,
sedative-hypnotics, and
benzodiazepines
 to prevent relapse.

73. Pharmacologic treatment
✘ Benzodiazepines. Alcohol withdrawal is usually managed
with a benzodiazepine-anxiolytic agent, which is used to
suppress the symptoms of abstinence.
✘ Disulfiram. Disulfiram (Antabuse) may be prescribed to help
deter clients from drinking.
✘ Acamprosate. Acamprosate (Campral), may be prescribed
for clients recovering from alcohol abuse or dependence to
help reduce cravings for alcohol and decrease the physical
and emotional discomfort that occurs especially in the first
few months of recovery.

74. Pharmacologic treatment
✘ Methadone. Methadone, a potent synthetic opiate, is
used as a substitute for heroin in some maintenance
programs.
✘ Levomethadyl. Levomethadyl is a narcotic analgesic
whose only purpose is the treatment of opiate
dependence.
✘ Naltrexone. Naltrexone (ReVia) is an opioid antagonist
often used to treat an overdose. It can also be used to
treat alcohol abuse.

75. Nursing Management
✘ Providing health teaching for client
and family.
✘ Addressing family issues.
✘ Promoting coping skills.

76. END OF PART 1