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Psychoactive Drugs. Professor Lana Chase. Psychoactive Drug Categories . Anti-psychotics : Schizophrenia, Agitation Anti-depressants : Depression, OCD, Anxiety Mood Stabilizers : Bipolar Disorder Anti-Anxiety: Anxiety /Panic Disorders Psycho-stimulants : ADHD, Narcolepsy.

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Psychoactive Drugs

Professor Lana Chase

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Psychoactive Drug Categories

  • Anti-psychotics: Schizophrenia, Agitation

  • Anti-depressants: Depression, OCD, Anxiety

  • Mood Stabilizers: Bipolar Disorder

  • Anti-Anxiety: Anxiety /Panic Disorders

  • Psycho-stimulants: ADHD, Narcolepsy

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Purposes and Advantages

  • Used to affect the brain & behavior

  • To treat psychiatric disorders /symptoms

  • Used in conjunction with other treatments such as psychosocial rehabilitation, psychotherapy, crisis intervention

  • To control symptoms & allow consumer to participate in therapy & re-enter job market

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  • Dopamine

  • Serotonin

  • Norepinepherine

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  • Mainly cause blockade of Dopamine & Serotonin in post synaptic membrane of CNS

  • Also act on other neurotransmitters which may cause increase in side effects (movement disorders)

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Antipsychotics: Conditions Treated

  • Psychosis: Schizophrenia /Thought Disorders

  • Sedation

  • Hiccoughs

  • Dementia- Organic Psychosis / Agitation

  • Bipolar Disorder (acute mania)

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Anti-psychotic Use

  • Treat Positive Symptoms of Schizophrenia

    • Delusions- false beliefs

    • Hallucinations- false sensory perceptions:

    • auditory, visual, tactile, olfactory,somatic, gustatory

    • Illusions- mistaken sensory perception

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  • Developed in 1950’s 1st . Tranquilizer

  • Thorazine (Chlorpromazine)

    sedation, anticholinergic side effects

  • Prolixin Decanoate (Fluphenazine)

    • IM for Non-compliant patients

    • Viscous liquid – use 21 gauge needle ,

    • Z track

    • Q 2-4 week admin.(absorbs slowly)

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Non Phenothiazines

  • Haldol (haloperidol):

  • used extensively in psychiatric emergencies to sedate patient frequently with Ativan and Benadryl

  • I M or PO

  • Haldol Decanoate IM

    • For non-compliant pts.

    • Absorbed slowly over 2-4 weeks

    • Large gauge needle, Z track

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Non Traditional Antipsychotics

  • Less side effects

  • More effective with:

  • Negative Symptoms of Schizophrenia.

    • flat affect (mood), alogia(poverty of speech), avolition(apathy), anhedonia(no pleasure), asociality(loner), attentional impairment (poor concentration).

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Non Traditional Antipsychotics

  • Clozaril(clozapine)

    • Biweekly WBC--risk agranulocytosis

    • Stop med for WBC below 2.5 (do not restart)

    • Start low dose 25 mg (max dose 900 mg)

    • Benefits: low side effect profile, pts. like how they feel on it.

    • Effective antipsychotic especially for neg. s/s

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Non Traditional Antipsychotics

  • Zyprexa (olanzapine)

    • Dopamine and serotonin blocking agent

    • Effective antipsychotic and for bipolar pts

    • Serious Side effects: weight gain , diabetes

  • Seroquel (quetiapine)

    • Little or no EPS(same as placebo)

    • Effective antipsychotic, sedative

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Antipsychotic Side Effects

  • Less side effects with newer medications

  • Older meds not very user friendlynon compliance

    • Sedation: drowsiness

    • Weight Gain

    • Photosensitivity

    • Dizziness (Orthostatic Hypotension)

    • Sexual Dysfunction

    • Elevation in Prolactin Levels

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  • Side Effects

    • Tardive Dyskenesia: irreversible

      • Snake like tongue movements /thrusting, invol. movements

    • Anticholinergic: from acetylcholine blockade

      • blurred vision, dry mouth,constipation,GI distress, urinary ret.

    • Extrapyramidal (EPS): movement disorders

      • Dystonia,akathesia , tremors, shuffling gait, muscle stiffness (stiff neck, cogwheel rigidity), masked facies, oculogyric crisis (eyes roll back), diff. swallowing

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Nursing Interventions for EPS

  • Notify MD & Obtain order for:

  • Cogentin or Artane (anticholinergics)

    • PO or IM

  • Symmetrel (dopamine agonist)

  • Benadryl (antihistamine)

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Side Effects Antipsychotics (cont.)

  • Tardive Dyskinesia (irreversible)

    • Wormlike tongue movements, ataxia, lip smacking, involuntary arm & leg movements, fever. Tx. Decrease dosage or D/C

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Side Effects Antipsychoticscont.

  • Neuroleptic Malignant Syndrome (rare)

    • 14-30 % mortality

    • Tachicardia, high fever, muscle rigidity

    • risk for cardiovascular collapse

      Nursing Measures:

      discontinue medication, Notify MD,

      treat symptomatically: cooling blanket, Bromocriptine, cardiac meds if necessary.

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Use Antipsychotics Cautiously

  • Diabetics

  • Children under 6

  • Glaucoma

  • Ulcers

  • Elderly

    • Lower doses, hypotension

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Drug Interactions

Potentiates action of CNS Depressants:

e.g.. narcotics, alcohol

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Nursing Implications

  • Baseline assessment: EKG, liver function

  • Long term use: assess for adverse effects

  • Assess for movement disorder: EPS, T.D.

  • Observe for hording /”cheeking” meds

  • Administer liquid med in juice

  • Is it effective? monitor mental status

  • Safety : orthostatic hypotension, monitor for seizures

  • D/C or switch to new med gradually (cont)

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Antianxiety DrugsBenzodiazapines

  • Action

    • Increase action of GABA that inhibits nerve transmission in the CNS

    • Depresses activity in brainstem

      • Sedative

      • Hyponotic

      • Anticonvulsant

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Antianxiety Drugs

  • Therapeutic Uses:

    • sedative agent/conscious sedation

    • Treat psychiatric emergencies /agitation

    • Treat panic disorder, social phobia, anxiety

    • Treat alcohol withdrawal & seizures

    • Treat anxiety assoc with medical disorders

      • COPD

    • **use should be brief except with panic disorders due to risk of addiction

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Commonly Prescribed Antianxiey Drugs

  • Ativan PO or IM

    • Used for psych emergencies / severe agitation

  • Valium (diazepam) PO or IV

    • good IV anticonvulsant 2-40 mg qd

    • Muscle relaxant action used for neck & back pain

  • Xanax

  • Versed –conscious sedation, anesthesia induction

  • Tranxene, Librium

    • freq. Used for alcohol detoxification in tapering doses

  • Dalmane/Restoril

    • sedative sleeping medications

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Antianxiety Medicatons

  • Common Side Effects

    • Sedation, impaired consciousness,daytime sedation (hangover), ataxia, dizziness, feelings of detachment, rebound insomnia, amnesia, euphoric mood




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Antianxiety Drug Overdose

  • Overdose alone almost never fatal (safe)

  • Benzo + alcohol  respiratory depression

  • Treatment for Benzodiazapine Overdose:

    • Romazicon(flumazenil)

      (Antagonist) benzodiazapine receptor blocker

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    Teaching for Antianxiety Drugs

    • Drugs should be tapered to prevent withdrawal symptoms / DT’s

    • Drugs can store in fat cells and prolong withdrawal symptoms

    • Dosages ½ to 1/3rd. for elderly

    • Instruct about risk of addiction /safety from falls

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    Antianxiety Drugs

    • Buspar (buspirone)

      • Potent antianxiety drug

      • no muscle relaxant, anticonvulsant or sedative, or alcohol potentiating action

      • Takes several weeks for antianxiety effects

        ** works best with people who never took benzo’s because they are accustomed to immediate effect.

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    Antianxiety Drugs

    • Inderal (propranolol)

      • Beta Blocker

        • Used to decrease symptoms that lead to anxiety like tachicardia rather than centrally acting on anxiety

          • Treatment for “performance anxiety” found in social phobia.

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    • Uses:

      • Major Depressive Disorder

      • Premenstrual Dysphoric Disorder

      • Anorexia /Bulimia

      • Anxiety Disorders

        • GAD (Generalized Anxiety Disorder)

        • OCD (Obsessive Compulsive Disorder)

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    Target Patrticular Symptoms

    • Goal: to normalize transmission of impulses at the synapse

    • Amine Hypothesis: low norepinepherine (catacholamine) at synapse

    • Permissive Hypothesis: deficiency of serotonin at the synapse

    • Dysregulation Hypothesis: Failure to regulate catacholomine system

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    Tricyclic Antidepressants

    • Norpramine

    • Elavil

    • Tofranil

      Uses: panic disorder, depression, GAD, enuresis, sedation (for insomnia)

      ***2-4 weeks for antidepressant effect

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    • Trazadone

      • Drug of choice for sedation (sleep disturbances)

      • **Can cause priapism in males

        Antidepressant TX

        4-9 mos tx or may be lifetime if depression recurrent

        Anxiety Disorders: SSRI (Paxil) now treatment of choice

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    2nd Generation Antidepressants


    Selective Serotonin Reuptake Inhibitors

    increases serotonin reuptake at receptor site

    less SE than TCI’s

    less anticholinergic, no wt. Gain, safer for cardiac pts.

    & pregnant women

    • Prozac

    • Zoloft

    • Paxil

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    Other Newer Antidepressants

    • Celexa & Lexapro

    • Serzone

    • Effexor

    • Vestra

    • Remeron

    • Wellbutrin /Zyban

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    Side Effects of Antidepressants

    • **Overdose of TCA’s can be fatal due to Cardiac arrhythmias

    • Anticholinergic Side Effects

    • SSRI’s Psychomotor excitement / insomnia (take in morning), tremor,headache, nervousness

    • TCA’s: Sedation, drowsiness especially 1st week (instruct to start on weekend), often added as nighttime dose for insomnia

    • Sexual Side Effects

      • Ejaculatory disturbances & decreased libido, priapism (Deseryl)

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    • MAOI’s

      • Monoamine Oxidase Inhibitors

        • Action: Inhibit enzyme activity resulting in decreased amount of MAO in the body

        • Used for non responders to other antidepressant tx.

        • Effective for atypical depression, panic, and phobias

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    Monoamine Oxidase Inhibitors

    • Role of Tyramine and Dietary Restrictions

      • MAO metabolizes neurotransmitters related to depression. Also linked to control of BP due to inhibition of norepinepherine.

      • Need to avoid norepinepherine agonists like dietary TYRAMINE.

      • HYPERTENSIVE CRISIS (life threatening) can occur from increased levels of norepinepherine ie risk of strokes (CVA)

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    MAOI’s Side Effects

    • Life Threatening if taken with drugs or foods containing TYRAMINE

    • Hypertensive Crisis (Malignant Hypertesion)

      • Sudden elevation of BP, palpitations,chest pain,sweating , fever, N&V

      • HOLD MAOI : do not lie down (inc. BP in brain)

      • Treatment: Thorazine 100 mg IM (blocks norepinepherine), Cooling blanket,

      • Phentolamine IV in 5 mg doses (binds with norepinepherine)

      • Cooling blanket

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    Seratonin Syndrome

    • Risk

      • May occur when SSRI’s are administered too close to the discontinuation of MAOI’s or other drugs affecting serotonin reuptake are taken together

        Signs and Symptoms

        confusion , disorientation, mania, restlessness, diaphoresis, shivering, diarrhea, nausea.


        D/C all serotonergic drugs including

        SSRI’s, MAOI’s, anticonvulsants, Ativan, Klonapin

        ** do not reintroduce serotonin drugs

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    MAO Inhibitors

    • Only 3 Drugs in this Class

      • Nardil

      • Parnate

      • Marplan

      • Side effects: extreme hypotension

      • Toxic effect : malignant hypertension (if taken with sympathomimetic substance (Tyramine)

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    Nursing Interventions MAOI’s

    • Careful teaching on diet and drug reactions

    • Dietary Restrictions: aged cheese (blue, brick, brie), organ meats, pickled herring, bologna, pepperoni, salami, fava beans,avacado,red wine (Chianti), beer, tofu, miso soup

      • over ripe fruit (banana, raisons)

        • In moderation: chocolate, soy sauce, yogurt

    • Drug Restrictions

      • OTC drugs with epinepherine like effects: sudafed, sinus , allergy remedies

      • Narcotics (Demerol especially), other antidepressant drugs,

      • Cocaine, amphetamines

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    Mood Stabalizing Drugs

    • Lithium Carbonate

      • Classic Drug for Bipolar Disorder (Manic Depression)

      • Action: lithium replaces sodium in the cells

      • **Dosage adjusted by Serum Lithium Level (weekly then monthly levels), not by symptoms

      • Narrow Therapeutic Index: Risk of toxicity

        • Toxic and Theraputic serum levels are close

          .5-1.5 meq./l therapuetic above 2 meq. toxic

        • Usual dosage 900 mg. but depends on rate of excretion

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    Lithium Carbonate

    • Side Effects

      • : fine hand tremor,mental dullness,weight gain, polyuria, kidney impairment

      • Secondary hypothyroidism: give Synthroid

    • Lithium Toxicity (Flu like Symptoms)

      • ataxia(may look intoxicated),diarrhea,GI distrubance (N &V)

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    Lithium Carbonate

    Nursing Considerations

    Hold Lithium, Notify MD, get serum lithium level to confirm

    instruct patient in S/S of toxicity

    excessive sweating: will raise serum lithium levels (caution for people who have outdoor jobs in the heat (roofer)

    contraindicated/caution with diuretics such as Hydrodiuril (HCTZ)

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    Mood Stabalizers

    • Anticonvulsant Mood Stabalizers

      • Enhances effect of GABA

      • 2nd. Line treatment for lithium intolerant pts.

      • Use is increasing –less Side Effects

    • Used to Treat:

      • Bipolar disorder (rapid cyclers),Schizoaffective Disorder, BorderlinePersonality Disorder, Schizophrenia

    • Given in combo with other meds

    • **Give Mood Stabalizer with SSRI to avoid Mania

      • Tegretal (carbamazapine) most studied

      • Depakote (valproic acid) most studied

      • Neurontin,Lamictal, Topramax (newer)

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    Mood Stabilizers

    • Anticonvulsant Mood Stabilizers

      • Response in 1-2 weeks

      • Side effects:

        • sedation, dizziness (subside over time), skin reaction may require D/C, Depakote-pancreatitis risk (liver func. Tests)

      • Nursing Implications

        • Monitor serum levels, WBC,hepatic/renal function

        • Can be lethal in overdose