psychotherapeutics

PSYCHOPHARMOCOLOGY

RICHARD OPOKU ASAREM.Ed (Health Education)

, B.Ed (Hons) Health Science, RN (Dip) RMN, Cert.Ed [email protected] ©20111

PSYCHOTHERAPEUTIC DRUGS

ANTIANXIETY AND SEDATIVE-HYPNOTIC DRUGS

[email protected] ©20112

Two types

1.Benzodiazepines

2.Non-benzodiazepines

Indications for Benzodiazepines


Generalised Anxiety Disorder

Insomnia or sleep disorders

Posttraumatic stress disorders

Alcohol and drug withdrawal

Seizure disordersPhobic disorders

Anxiety and apprehension experienced before surgery

Skeletal muscle relaxation

Anxiety associated with medical disease

Benzodiazepines

Antianxiety drugs/Anxiolytics

Sedative-Hypnotic Drugs


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)*

Side Effects/Withdrawal syndrome of Benzodiazepines


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

Non-benzodiazepines


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.

Non-benzodiazepines – cont’d

Barbiturates Antihistamines


Amobarbital (Amytal)Butabarbital (Butisol)Pentobarbital

(Nembutal)Phenobarbital

(Phenobarb)Secobarbital (Seconal)

Propanediols Meprobamate (Equanil)

Diphenhydramine (Benadryl)

Hydroxyzine (Atarax)

Beta-Adrenergic Blocker

Propranolol (Inderal)

AnxiolyticBuspirone (BuSpar)

Non-benzodiazepines – cont’d

Acetylenic Alcohol Chloral Derivate


Ethchlorvynol (Placidyl)

ImidazopyridineZolpidem (Ambien)

Choral hydrate (Noctec)

Common Side Effects (Benzos & non-benzos)


DrowsinesssedationAtaxiadizziness Feelings of

detachmentIncreased irritability,

hostilityAnterograde amnesiaTolerance dependency

Rebound insomnia, anxiety

NauseaHeadacheConfusionGross

psychomotor impairment

DepressionParadoxical rage

reaction

ANTIDEPRESSANT DRUGS


IndicationsMajor depressive illnessAnxiety disordersEnuresisAttention deficit disordersNarcolepsyBulimia

CLASSES OF ANTIDEPRESSANTSTricyclic drugs


A. Tertiary (Parent) Amitryptiline (Elavil)* Doxepine (Adepin,

Sinequan) Imipramine (Tofranil)* Trimipramine

(Surmontil) Clomipramine

(Anafranil)

B. Secondary (Metabolite)

Desipramine (Norpramin)*

Nortryptiline (Pamelor)

Protriptyline (Vivactil)

CLASSES OF ANTIDEPRESSANTS – cont’d


Monoamine Oxidase Inhibitors (MAOIs)Phenelzine (Nardil)Tranylcypromine (Parnate)

Selective Serotonin Reuptake Inhibitors (SSRIs)

Fluoxetine (Prozac)Fluvoxamine (Luvox)Paroxetine (Paxil)Sertraline (Zoloft)

CLASSES OF ANTIDEPRESSANTS – cont’d


Other Antidepressant Drugs (Atypical) Amoxapine (Asendin)*Bupropion (Wellbutrin)*Maproptiline (Ludodiomil)Mirtazepine (Remeron)Nefazedone (Serzone)Trazodone (Desyrel)*Venlafaxine (Effexor)

Contraindications to MAOIs


AsthmaCongestive heart

failureHypertensionImpaired kidney

functionCardiac arrhythmiasLiver diseaseHypernatraemiaHyperthyroidismPheochromocytoma

Severe headachesAlcoholismAbnormal LFTsGlaucomaParanoid

schizophreniaPregnancyChildren < 16 yearsPatients > 60 years

Diets/foods to avoid when Patient is on MAOI Therapy


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

Drugs to avoid when Patient is on MAOI Therapy


Nasal and sinus decongestants

Narcotics, e.g., meperidine

Asthmatic agentsEpinephrineStimulantsCocaine

AmphetaminesWeight reducing drugsHay fever drugsAtypical/Newer

antidepressantsAntihypertensive

drugsAneasthetics (general)

Reasons to Avoid certain Foods and Drugs when on MAOI TherapyTyramine 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.


Common Side Effects of Antidepressants


Blurred visionDiarrhoeaDry mouthHallucinationsConstipationDelusionsTachycardiaHypertensive crisisUrination retentionHypotensionImpaired cognitionInsomnia

DizzinessImpaired memoryLightheadednessExcessive

sweating ECG changesPriapismEjaculatory

dysfunctionSedationdrowsiness NauseaTremorsWeight gain

Nursing Care of Side Effects of Antidepressant Drugs


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.

Nursing Care of Side Effects of Antidepressant Drugs – cont’d


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.



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.



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.

MOOD STABILIZING DRUGS


These are in two categories

Antimanics

Anticonvulsants /Antiepileptics

MOOD STABILIZING DRUGS – cont’d


Antimanic drug

Lithium (Eskalith, Lithobid, Lithonate)

Antimanic drug


Indications

ManiaHypomaniaUnipolar

depressionschizophreniaSchizoaffective

disorderCatatonia

(periodic)Alcoholism

Aggressive-conduct disorder

Self-abusive behaviour

Borderline personality disorder

Histrionic personality disorder

Eating disorders

Antimanic drug – cont’d


What to do before Lithium Treatment

Take complete historyRegular medication checkupsKidney function testConduct other physical examinationsThyroid function testECG, FBS, Complete Blood Count

Side Effects of Antimanic/Lithium


Body Image Weight gainCardiac ECG changesCNS Tremor Fatigue Headache Mental dullness LethargyDermatological/Skin Acne Rash

Endocrine Hypothyroidism Diabetes mellitusGIT Gastric irritation Anorexia Abdominal cramps Nausea Vomiting DiarrhoeaRenal Polydipsia Polyuria Oedema

Anticonvulsant/Antiepileptic drugs


Carbamazepine (Tegretol)Valproate (Depakene)Divalproex (Depakote) Phenytoin (Epanutin)Phenobarbitone (Phenobarb)

Anticonvulsant drugs – cont’d


IndicationsEpilepsyBorderline personality Acute maniaSchizophreniaBipolar illnessSchizoaffective disorderPanic attacksSubstance abuse

Contraindications of Anticonvulsants

Elderly peopleDecreased liver functionHigh levels of urea in the blood (uraemia)DiabetesHereditary blood disorders called porphyriasPeople who drink large amounts of alcoholPeople of Thai or Han Chinese ethnic origin*PregnancyBreastfeedingKidney [email protected] ©201130

Common Side Effects of Anticonvulsants


Skin rashSore throatBlurred visionMucosal ulcerationDrowsiness/

sedationLow-grade feverTremors VertigoNauseaVomiting

AtaxiaDiplopiaWeight gainDecreased in white

blood cell countDiarrhoeaPancreatitisIncreased appetiteHepatic

dysfunction/hepatotoxicity

Neuroleptic drugs or neuroleptics

Psychotropic drugs or psychotropics


ANTIPSYCHOTIC DRUGS

ANTIPSYCHOTIC DRUGS – cont’d


TWO classes

dopamine receptor antagonists called “typical”;

and

serotonin-dopamine antagonists called “atypical.”


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 D2 receptors in several DA tracts in the brain.



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.


Indications or Clinical Use of Antipsychotics

Non-psychiatric/General uses Psychiatric uses


Vomiting Vertigo Pain reliefHiccupsPorphyriaRelief of itchingFacilitate sleep in

insomnic clientsMigraine 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

TYPICAL ANTIPSYCHOTICS


PhenothiazinesAliphaticsChlorpromazine (Largactil, Thorazine)*Trifluopromazine (Vesprin)PiperidinesMesoridazine (Serentil)Thioridazine (Mellaril)PiperazinesAcetophenazine (Tindal)Fluphenazine (Modecate, Prolixin, Permitil)*Perphenazine (Trilafon)Trifluoperazine (Stelazine)*

TYPICAL ANTIPSYCHOTICS – cont’d


ThioxanthenesAliphatic Chlorprothixene (Taractan)PiperazineThiothixene (Navene)ButyrophenonesHaloperidol (Haldol, Serenace)*DibenzoxazepineLoxapine (Loxitane)DihydroindoloneMolindone (Moban)

ATYPICAL ANTIPSYCHOTICS


Clozapine (Clozaril)Olazapine (Zyprexa)Risperidone (Risperdal)*Quetiapine (Seroquel)Ziprasidone (Zeldox)Other neuroleptic medications include:Pimozide (Orap)Reserpine (Serpasil)

POTENCY OF ANTIPSYCHOTICS

Low Potency High Potency


ChlorpromazineThioridazineClozapineMesoridazineQuetiapine (Seroquel)Ziprasidone (Zeldox)

TrifluoperazineThiothixeneLoxapineMolindonePerphenazineFluphenazineHaloperidolPimozide RisperidoneOlanzapine

Common Side Effects of Antipsychotic Drugs

Anticholinergic Symptoms

Other Side Effects


ConstipationDry mouthBlurred visionMemory impairmentConfusionDizziness Urinary

retention/slowing of urination

Nasal congestionExcessive salivation

Sedation/drowsinessWeight gainImpaired

concentrationSeizuresSexual dysfunctionPhotosensitivityOculogyric crisis

(rotation of the eye balls in a fixed position, usually upward)

Agranulocytosis (Ulcerative sore throat, Fever, Malaise, Leukopenia)

Common Side Effects of Antipsychotic Drugs – cont’d

Tardive Dyskinesia

Extrapyramidal Symptoms


Tongue protrusion Writhing of TongueLip smackingChewing BlinkingFacial grimacingMovements of neck,

trunk, and pelvisLeg jiggling/jerky

movements

Muscle rigidityTremorsDroolingRestlessness

Allergic ReactionsJaundiceSkin rash

Positive Side Effects of Antipsychotics


1. They are not addictive.

2. It is extremely difficult to use them to commit suicide.

(Ray & Ksir, 2004)

ANTIPARKINSONIAN MEDICATIONS


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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.

Anticholinergics Antihistamine


Benztropine* (Cogentin)

Trihexyphenidyl (Artane, Pipanol)*

Biperiden (Akineton)

Procyclidine (Kemadrin)

Diphenhydramine (Benadryl)

Ethopropazine (Parsidol)

Orphenadrine (Disipal, Norlex)

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Groups of Antiparkinsonian drugs

Dopamine Agonist Benzodiazepines


Amantadine (Symmetrel)

Bromocriptine (Parlodel)

Diazepam (Valium)*

Lorazepam (Ativan)*

Clonazepam (Klonopin)*

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Groups of Antiparkinsonian drugs – cont’d

Common Side Effects of Antiparkinsonian/Anticholinergic medications


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Dry mouthNasal congestionBlurred visionConstipationUrinary hesitancyUrinary 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

Specific Nursing Interventions for Anticholinergic Agents


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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.

Specific Nursing Interventions for Anticholinergic Agents – cont’d


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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.

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.


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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.


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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.


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THANK YOU


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END OF LECTURE ON PSYCHOTROPIC DRUGS

psychotherapeutics

Health & Medicine