NEUROTRANSMITTERS

NEUROTRANSMITTERS
• Chemical messengers
• Inhibitory
• excitatory
NEUROTRANSMITTERS
DOPAMINE
• In the brainstem; excitatory

• Controls complex movements, motivation, cognition, and regulation

of emotional responses
• Implicated in Schiz and other psychoses as well as movement
disorders –Parkinson’s Disease
ACETYLCHOLINE
• Brain, spinal cord, and PNS; Excitatory and Inhibitory

• Affects sleep-wake cycles and signals muscle to become active

NOREPINEPHRINE
• Most prevalent in Nervous system located in the brain stem

• Changes in attention, learning, and memory, sleep and wakefulness,

and mood regulation
• NE and Epinephrine aka Noradrenaline and adrenaline

• Excess can cause memory loss, social withdrawal, and depression

• Limited in the brain, controls fight or flight response in PNS

SEROTONIN
• Found in the brainl inhibitory

• Control of food intake, sleep and wakefulness, temperature

regulation, pain control, sexual behavior, and regulation of
emotions
• Some antidepressants block serotonin reuptake thus lessening
available in the synapse for a longer period or time which results in
improved mood
• Plays role in delusion, hallucinations, withdrawn behavior
HISTAMINE
• Neuromodulator

• Peripheral allergic responses

• Control of gastric secretions, cardiac stimulations, alertness

NEUROPEPTIDES
• Neuromodulator

• Enhance prolong, inhibit or limit effects of principal

neurotransmitters.
GLUTAMATE
• Excitatory
• Can cause neurotoxic effects
• Brain damage can cause stroke, hypoglycemia, sustained hypoxia, or
ischemia, Huntington’s and Alzheimer’s
GABA (Gama Amino-Butyric Acid)
• Major inhibitory
• Modulates other neurotransmitters rather than provide direct
stimulis.
THERAPEUTIC
MODALITIES,
PSYCHOSOCIAL
STRATEGIES, AND
NURSING STRATEGIES
PSYCHOPHARMACOLOGY

9
 • Psychopharmacology is the study of drugs used to treat
psychiatric disorders.
• Medications that affect psychic function, behavior or
experience are called psychotropic medications.
• They have significant effect on higher mental
functions.
• Psychopharmacological agents are first line treatment
for almost all psychiatric ailments now a days.

4/24/2013 1
 • With the growing availability of a wide range of
drugs to treat mental illness, the nurse practicing in
modern psychiatric settings needs to have a sound
knowledge of the pharmacokinetics involved, the
benefits & potential risks of pharmacotherapy, as
well as her own role & responsibility.

4/24/2013 1
 DEFINITION OF PSYCHOTROPIC
DRUGS
Psychotropic drug is any drug that has
primary effects on behavior, experience, or other
psychological functions (Logman Dictionary of Psychology &
Psychiatry).
Psychotropic or psychoactive drugs can also
be defined as chemical that affects the brain & nervous
system, alter feelings & emotions. These drugs also affect
the consciousness in various ways. A broad range of these
drugs is used in emotional & mental illnesses.

4/24/2013 1
GENERAL GUIDELINES REGARDING DRUG ADMINISTRATION
IN PSYCHIATRY

• The nurse should not administer any drug unless there is a

written order. Do not hesitate to consult the doctor when in doubt
any medication.
• All medications given must be charted on the patient‘s case
record sheet.
• In giving medication:
– Always address the patient by name & make certain of his identification.
– Do not leave the patient until the drug is swallowed.
– Do not permit the patient to go to the bathroom to take medication.
– Do not allow one patient to carry medicine to another.
5
 • If it is necessary to leave the patient to get water, do not leave
the tray within the reach of the patient.
• Do not force oral medication because of the danger of
aspiration. This is especially important in stuporous patients.
• Check drugs daily for any change in color, odor & number.
• Bottle should be tightly closed & labeled. Labels should be
written legibly & in bold lettering. Poison drugs are to be legibly
labeled & to be kept in separate cupboard.

4/24/2013 1
 • Make sure that an adequate supply of drugs is on hand, but
do not overstock.
• Make sure no patient has access to the drug cupboard.
• Drug cupboard should always be kept locked when not in
use. Never allow a patient or worker to clean the drug
cupboard. The drug cupboard keys should not be given to
patients.

4/24/2013 JAYESH PATIDAR 1

 PATIENT EDUCATION RELATED TO
PSYCHOPHARMACOLOGY
• Nurses assess for drug side effects, evaluate desired effects,
& make decisions about prn (pro re neta) medication.
• Nurses must understand general principles of
psychopharmacology & have specific knowledge related to
psychotropic drugs.
• Teaching patients can decrease the incidence of side effects
while increasing compliance with the drug regimen.

4/24/2013
1
 Specific areas of education include the
following
1. Discussion of side effects: Side effects can directly
affect the patient‘s willingness to adhere to the drug
regimen. The nurse should always inquire about the
patient‘s response to a drug, both therapeutic responses
& adverse responses
2. Drug interactions: Patients & families must be taught to
discuss the effects of the addition of over-the-counter
drugs, alcohol & illegal drugs to currently prescribed
drugs.

4/24/2013 1
3. Discussion of safety issues: Because some drugs, such as
tricyclic antidepressants, have a narrow therapeutic index,
thoughts of self harm must be discussed.
• Discuss on abruptly discontinued effects.
• Many psychotropic drugs cause sedation or drowsiness,
discussions concerning use of hazardous machinery, driving
must be reviewed
4. Instructions for older adult patients: Because older
individuals have a different pharmacokinetic profile than
. younger adults, special instructions concerning side effects &
drug-drug interactions should be explained

10
 • 5. Instructions for pregnant or
breastfeeding patient:

• As pregnant or breastfeeding patients

have special risks associated with
psychotropic drug therapy, special
instructions should be tailored for
these individuals.

• Teaching patients about their

medications enables them to be
mature participants in their own care
& decreases undesirable side effects

4/24/2013
Overview on Psychopharmacology

Neurotransmitters are chemicals that are used to relay,

amplify and modulate signals between a neuron and
another cell.

According to the prevailing beliefs of the 1960s, a chemical can

be classified as a neurotransmitter if it meets the following
conditions:
Neurotransmitters
• synthesized from natural precursors (amino acid) in the body.
• These precursors are extracted from the bloodstream and are
synthesized in the cell into neurotransmitters, which are in turn
stored in the presynaptic terminals of the cell.
• Neurotransmitters are stimulated and released from the
synaptic terminal into the synaptic cleft and combine with the
postsynaptic receptors on the dendrites evoking neuronal
response.
• There are precursors and/or synthesis enzymes located in the
presynaptic side of the synapse;
• The chemical must be present in the presynaptic element
• It is available in sufficient quantity in the presynaptic neuron to affect
the postsynaptic neuron;
• There must be postsynaptic receptors and the ability for the chemical
to bind to said receptors
• A biochemical mechanism for inactivation must be present.
• Neurons expressing certain types of neurotransmitters sometimes
form distinct systems, where activation of the system causes effects
in large volumes of the brain, called volume transmission.
• The major neurotransmitter systems are the noradrenaline
(norepinephrine) system, the dopamine system, the serotonin system
and the cholinergic system.
• Drugs targeting the neurotransmitter of such systems affects the
whole system, and explains the mode of action of many drugs;
• Cocaine, for example, blocks the reuptake of dopamine, leaving these
neurotransmitters in the synaptic gap longer.
• Prozac is a selective serotonin reuptake inhibitor (SSRI), hence potentiating the
effect of naturally released serotonin.
• AMPT prevents the conversion of tyrosine to L-DOPA, the precursor to
dopamine; reserpine prevents dopamine storage within vesicles; and deprenyl
inhibits monoamine oxidase (MAO)-B and thus increases dopamine levels.
• Diseases may affect specific neurotransmitter systems.
• For example, Parkinson's disease is at least in part related to failure of
dopaminergic cells in deep-brain nuclei, for example the substantia nigra.
Treatments potentiating the effect of dopamine precursors have been proposed
and effected, with moderate success.
 System Origin Effects
locus coeruleus • arousal
Noradrenaline system
Lateral tegmental field • reward
• dopamine pathways:
mesocortical pathway motor system, reward,
Dopamine system • mesolimbic pathway cognition, endocrine,
• nigrostriatal pathway nausea
• tuberoinfundibular pathway
caudal dorsal raphe nucleus Increase (introversion),
mood, satiety, body
Serotonin system temperature and sleep,
rostral dorsal raphe nucleus while decreasing
nociception.
pontomesencephalotegment
al complex • learning
• short-term memory
Cholinergic system
basal optic nucleus of Meynert • arousal
 Neurotransmitter Inactivation
• They are metabolized by enzymes,
• They are taken back into the presynaptic storage
vesicles

AFFECTATION OF PSYCHOTROPIC DRUGS ON

NEUROTRANSMITTERS

• Some drugs cause the release of neurotransmitters

( amantadine causes the release of dopamine)
• Can combine with a receptor and prevent the natural
neurotransmitter from combining with it. (Thorazine blocks dopamine
receptors)

• Can affect the response of a receptor to a neurotransmitter. (TCAs

down-regulates postsynaptic receptors thus changing receptors
sensitivity to neurotransmitter)

• Can terminate the inactivation of neurotransmitters.

Neurotransmitters and Related Mental
Disorders
• Neurotransmitter Action Related Mental Disord

• Increase in Dopamine Schizophrenia

• Decrease in Norepinephrine Depression
• Decrease in Serotonin Depression
• Decrease in Acetylcholine Alzheimer’s
Dse
• Decrease in GABA Anxiety
BLOOD-BRAIN BARRIER
• Brain requires constant internal milieu, even small changes produce
serious problems.
• The blood-brain barrier protects brain from these fluctuations
• This regulates the amount and speed of substances in the blood
entering the brain. Water, carbon dioxide and oxygen readily cross it,
other substances excluded
Three dimensions
• Anatomical dimension – refers to the structures of the capillaries that
supply blood to the brain and prevent many molecules from slipping
through.

• Physiological dimension – refers to chemical and transport system

that recognizes and allows certain molecules into the brain. Eg. Lipid
solubility
• Metabolic Barrier – prevents molecules from entering the brain by
enzymatic action within the endothelial lining of the brain capillaries.
Eg. Levodopa can pass the blood-brain barrier, but much of it is
reduced to dopamine before it can pass completely through the
capillary wall into the brain.
CLASSIFICATIONS OF PSYCHOTROPIC DRUGS

• Antipsychotic agents
• Antidepressant agents
• Mood stabilizing drug
• Anxiolytics & hypnosedatives
• Antiepileptic drug
• Antiparkinsonian drugs
• Miscellaneous drugs which include stimulants, drugs used in eating
disorders, drugs used in deaddiction, drugs uses in child psychiatry,
vitamins, calcium channel blockers etc.

4/24/2013 34
 ANTIANXIETY AGENTS,
INCLUDING SEDATIVES AND
HYPNOTICS

4/24/2013 35
 36
DESCRIPTION
• Anxiety is a state which occurs in all human being at sometime or the
other.
• It is also a cardinal symptoms of many psychiatric conditions.
• The drugs used to relieve anxiety are called ANTIANXIETY OR
ANXIOLYTIC AGENTS.
• Antianxiety drugs relieve moderate-to-severe anxiety & tension.
JAYESH PATIDAR
4/24/2013
MODE OF ACTION

• These non-barbiturate benzodiazepines act as CNS depressants.

• It is believed that these drugs increase or help the inhibitory
neurotransmitter action of gama-aminobutyric inhibitor in all areas
of CNS. So, there is inhibition or control on the cortical & limbic
system of the brain, which is responsible for emotions such as rage &
anxiety.

37
 INDICATIONS
• Antianxiety agents are used to relieve mild, moderate & severe
anxiety associated with: emotional disorders physical disorders
excessive environmental stress neuroses & mild depressive
states without causing excessive sedation or drowsiness.
• For control of alcohol withdrawal symptoms.
• To control convulsions.
• To produce skeletal muscle relaxation.
• To provide short-term sleep preoperatively, prior to diagnosis
& insomnia.
• Antianxiety agents should always be used in time-limited
regimen.

4/24/2013 38
 CONTRAINDICATIONS
• Patients with renal or liver &
respiratory impairment are given
antianxiety drugs with caution.

4/24/2013 39
CLASSIFICATION OF ANTIANXIETY
AGENTS:-
CHEMICAL GROUP & TRADE NAME RANGE OF DAILY ACTION
GENERIC NAME DOSAGE IN mgm
I. Non-
Barbiturates Librium, 15-100 These are non-
A. Benzodiazepines Equibrome 6-50 barbiturate
Chlordiazepoxid Valium, 30-120
benzodiazepines
Calmpose 20-60
e Diazepam . They produce a
Serepax 11.25-60
Oxazepam Verstran tranquillizing
Prazepam Tranzene 15-60 effect without
Chlorazapate Azene 10-30 much sedation.
Flurazepam Dalmane, 2-6 These drugs are
Nitravet
Nitrazepam potential for
Mogadon
lorazepam ativan abuse.
 CHEMICAL GROUP & TRADE NAME RANGE OF DAILY ACTION
GENERIC NAME DOSAGE IN mgm

A. Non- Equanil 1.2-1.6 These drugs

Benzodiazepin Miltown 1.2-1.6 have sedative
e Propanediols Tybamat 1.2-1.6 action &
Meprobamate e present a high
risk of abuse &
physical
dependence.

II. Antihistamines Atarax 30-200

Hydroxyzine vistaril 30-200
83
CLASSIFICATION OF SEDATIVES AND HYPNOTICS:-
CHEMICAL GROUP TRDE NAME HYPNOTIC SEDATIVE DOSE ACTION
& GENERIC NAME DOSE RANGE- DAILY IN mgm.
DAILY IN
mgm
III. Barbiturates
Amobarbidtal SA Amytal 100-200 60-150 These drugs
Butabarbital SA Butisol 100-200 20-200 cause drowsiness
Pentobarbital LA Nembutal 100-200 60-150 lethargy,
Phenobarbital LA Luminal 100-200 30-90 decrased
Thiopental USA pentothal Used for alertness & sleep.
anasthesia Tolerance to drug
can occur within
7-14 days,
resulting in
physical
dependence.
IV. Nonbarbiturates
 CHEMICAL GROUP & TRDE NAME HYPNOTIC SEDATIVE DOSE ACTION
GENERIC NAME DOSE RANGE- DAILY IN mgm.
DAILY IN
mgm
V. Quinazolines 150-300 250-300
Methaquualone Quaalude
Parest
Optimal
mandrax

VI. Acetylinic Alcohols 0.5gm-1gms 200-600mgm

Ethchlorvynol placidyl
VII. Chloral
Derivatives Noctaec 0.5gm-2gms
Chloral Beta-chlor 870mg-1gm
hydrate
VIII.Chloral betaine
Monoureides
 SIDE – EFFECTS OF ANTIANXIETY,
SEDATIVES & HYPNOTICS

1)Central nervous system: drowsiness, ataxia,

confusion, depression, blurred vision.
2)Cardiovascular system: hypotension,
palpitation, syncope.

3)Endocrine: change in libido.

4)Allergic: skin rash.

4/24/2013 44
• Physical/psychological dependence non- benzodiazepines &
barbiturate group of drugs has a high risk of abuse & physical
dependence.
• Acute toxicity of barbiturate that can be fetal when taken in excessive
dosage usually for suicide attempts. Overdose can cause tachycardia,
hypotension, shock, respiratory depression, coma & death.

45
NURSE’S RESPONSIBILITY

• Assessment of the patient, prior to the use of antianxiety, sedative-

hypnotic agents. If the patient complains of sleep disturbance the
causative factor should be identified.
• Appropriate nursing measures to induce sleep should be taken such
as a calm & quite environment, a cup of hot milk, good back care,
allowing the patient to read magazines, sitting with the patient for
some time for reassurance purpose.
• While administering the drug daily dose should be given at bed time
to promote a normal sleep pattern, so that day-time activities are not
affected.

46
• Give IM injection deep into muscles to prevent irritation.
• Look for side-effects, record & report immediately.
• If the patient complains of drowsiness tell him to avoid using knife or any
other dangerous equipment. He should be instructed not to drive.
• Instruct the patient not to take any stimulant like coffee, alcohol as
they alter the effect of drugs.
• Avoid excessive use of these drugs to prevent the onset of substance
abuse or addiction.
• Drug should be reduced gradually, sudden stoppage of the drug may cause
REM (Rapid Eye Movements), insomnia, dreams or nighmare,
hyperexcitability, agitation or convulsions.

47
SPECIFICS
Anti-Anxiety Agents

BENZODIAZEPINES – reduce anxiety by enhancing

the action of the Inhibitory neurotransmitter GABA on
its receptor. Also promotes anticonvulsant activity and
skeletal muscle relaxation.

Common drugs: Librium, Valium, Klonopin, Tranzene,

Versed
Nursing Implications
• Alters liver function test
• Assess for symptoms of leukopenia, such as sore throat, fever and
weakness.
• Encourage client to rise slowly from a supine position to dangle feet
before standing
• Librium: Do not inject or add IV Librium to an existing IV infusion;
inject directly into a large vein over a one-minute period
▪ Do not mix Librium or Valium with any other drug in
a syringe or add to existing IV fluids.

▪ Versed is commonly used for induction of

anesthesia and sedation prior to diagnostic tests and
endoscopic exams.

▪ Flumazenil (Rocmazicon) is approved for the

treatment of benzodiapine overdose; has an adverse
effect of precipitating convulsions, especially with
clients who have a history of epilepsy.
• Uses: anxiety and tension, muscle spasm,
preoperative medication, acute alcohol withdrawal,
and to induce sleep.

NONBENZODIAZEPINES – Interact with serotonin and

dopamine receptors in the brain to decrease anxiety.
Lack muscle relaxant and anticonvulsant effects, may
cause sedation or physical or psychological
dependence, does not increase CNS depression of
alcohol or other drugs.
Eg. Buspar
Side effects and Adverse Reactions
Benzodiazepines
• S/E: Central Nervous System depression, drowsiness(decreases with
usage), ataxia, dizziness, headaches, dry mouth.
• A/E: Leukopenia, tolerance commonly develops physical dependency
Nonbenzodiazepines
• Dizziness, drowsiness, headache, nausea, fatigue, insomnia
 Generic Name Use

Benzodiazepine Antianxiety
1. Alprazolam – Xanax Antianxiety
2. Chlordiazepoxide – Librium Antianxiety and anticonvulsant
3. Clonazepam – Klonopin Antianxiety
4. Diazepam – Valium Hypnotic
5. Flurazepam – Dalmane Antianxiety and hypnotic
6. Lorazepam – Ativan Antianxiety and hypnotic
7. Oxazepam – Serax Hypnotic
8. Temazepam – Restoril Hypnotic
9. Triazolam – Halcion

54
Nonbenzodiazepines
Hypnotic
1. Zolpidem - ambien Hypnotic
2. Zaleplon- sonata Antianxiety
Serotonin and dopamine agonist
Buspirone - Buspar

Barbiturates
Amobarbital- Amytal Hypnotic
Pentobarbital-Nembutal Hypnotic
Phenobarbital – Luminal Hypnotic
Secobarbital-Seconal Hypnotic
Beta blocker Antianxiety
Propanolol- Inderal

Antihistamine Hypnotic
Dipenhydramine-Benadryl
55
 ANTIPSYCHOTIC
AGENTS

4/24/2013
 DESCRIPTION:-
• Antipsychotic agents are also known as
neuroleptic, major tranquillizers, or
phenothiazines.
• This group of drugs has a major clinical
use in the treatment of psychosis.
• Psychosis is a state in which a person‘s
ability to recognize reality to
communicate & to relate to others is
severely impaired.

4/24/2013 57
 MODE OF ACTION:-
• Antipsychotic agents are thought to block the
dopamine receptors.
• Dopamine is a chemical which is released in the
brain & causes psychotic thinking.
• Increased production of dopamine transmits the nerve
impulses to the brainstem faster than normal. This
result in strange thoughts , hallucination & bizarre
behavior.
• Antipsychotics helps in blocking or reducing the
activity of dopamine.
• Antiemetic is another property of antipsychotic
agents. They are also used in hiccoughs.
58
 CLASSIFICATION:-
Class Examples of Trade name Oral dose Parenteral
drugs mg/day dose (mg)
Phenothiazines Chlorpromazine Megatil 300-1500 50-100 IM
Largactil only
Tranchlor
Triflupromazine Siquil 100-400
Thioridazine Thioril, Melleril 300-800 30-60 IM only
Ridazin
Trifluoperazine Espazine 15-60
Fluphenazine prolinate - 1-5 IM
decanoate 25-50 IM
every 1-3
weeks.
Thioxanthenes flupenthixol fluanxol 3-40

4/2
 Count
Class Examples of Trade name Oral dose…Parenteral
drugs mg/day dose (mg)
Diphenylbutyl Pimozide orap 4-20

piperidines penfluridol flumap 20-60 weekly -

Indolic molindone mobam 50-225 -

derivatives
Dibenzoxazepines loxapine loxapac 25-100 -

Atypical Clozapine Sizopine, Lozapin 50-450

antipsychotics Risperidone Sizodon, 2-10
Olanzapine sizomax Oleanz 10-20
Quetiapine Qutan 150-750 mg
Ziprasidone 20-80 mg
Zisper
Others reserpine serpasil 0.5-50
 INDICATIONS
Organic psychiatric Mood disorders:
disorders: • Mania
• Delirium • Major depression with
• Dementia psychotic symptoms
• Delirium tremens
• Drug-induced psychosis & Childhood disorders:
other organic mental • Attention-deficit
disorders hyperactivity disorder
Functional disorders: • Autism
• Schizophrenia • Enuresis
• Schizoaffective disorders • Conduct disorder
• Paranoid disorders
4/24/2013
Count…
Neurotic & other Medical disorders:
psychiatric disorders: • Huntington‘s chorea
• Anorexia nervosa • Intractable hiccough
• Intractable obsessive- • Nausea & vomiting
compulsive disorder
• Tic disorder
• Severe, intractable &
disabling anxiety • Eclampsia
• Heart stroke severe pain
in malignancy tetanus

4/24/2013
 PHARMACOKINETICS
• Antipsychotics when administered orally are absorbed
variably from the gastrointestinal tract, with uneven blood
levels.
• They are highly bound to plasma as well as tissue
proteins. Brain concentration is higher than the plasma
concentration.
• They are metabolized in the liver, & excreted mainly
through the kidneys. The elimination half-life varies from
10 to 24 hours.
• Most of the antipsychotics tend to have a therapeutic
window. If the blood level is below this window, the drug is
ineffective. If the blood level is higher than the upper limit of
the window, there is toxicity or the drug is again ineffective.

4/24/2013 63
Antipsychotic(Neuroleptic) Medications
• PHENOTHIAZINES – Block dopamine receptors and also thought to
depress various portions of the reticular activating system; have
peripherally exerting anticholinergic properties (atropine-like
symptoms, dryness of mouth, stuffy nose, constipation, blurring of
vision.
Eg. Thorazine, Sparine, Compazine, Prolixin, Stelazine, Mellaril, Serentil
Nursing Implications
• General considerations:
1. Use cautiously in elderly adults
2. Give daily dose 1-2 hours before bedtime
3. When mixing for parenteral use, do not mix with
other drugs
4. Inject deep IM- client should stay in reclined
position 30-60 minutes after dose
5. Caution against driving a car or operating
machinery
Phenothiazines
• Check BP prior to administration to avoid postural hypotension;
encourage client to rise slowly from sitting or lying position.
• Be aware if the antiemetic effect of phenothiazines; may mask other
pathology such as drug overdose, brain lesions, or intestinal
obstruction.
• Client teaching: protect skin from sunlight; wear long-sleeved shirts,
hats, and sunscreen lotion when out in the sunlight.
• Explain importance of reporting of sore throat, fever,
or symptoms of infection.
• Encourage periodic liver function studies to be done
• Teach that drug may turn urine pink or reddish brown
• Extrapyramidal symptoms treated with
anticholinergics.
• Uses: sever psychoses; schizophrenia; manic phase of
bipolar affective disorder, personality disorders, and
sever agitation and anxiety; also an adjunct to
preoperative anesthesia
Side Effects/ Adverse Effects Phenothiazine
• Extrapyramidal (movement disorder) occurs early in therapy and is usually
managed with other drugs.

Acute Dystonia -spasm of muscles of the tongue, face neck, or back,

oculogyric crisis (upward deviation of the eyes), opisthotonus.

Parkinsonism – muscle tremors, rigidity, spasms, shuffling gait, stooped

posture, rigidity

Akathisia – motor restlessness, pacing

• Tardive Dyskinesia (occurs late in therapy- symptoms
are often irreversible ) slow worm-like movements of
the tongue is earliest symptoms; later – fine-twisting,
writhing movements of the tongue and face,
grimacing, lip-smacking, involuntary movements of
the limbs, toes, fingers, and trunk.

• Neuroleptic malignant syndrome – rare problem,

fever (>41C), “lead-pipe”, muscle rigidity, agitation,
confusion, delirium, respiratory and acute renal
failure.
• Endocrine : amenorrhea, increased libido in women,
decreased in men, delayed ejaculation, increased
appetite, weight gain, hypoglycemia, and edema.

• Dermatologic – photosensitivity

• Hypersensitivity reaction – jaundice, agranulocytosis

Butyrophenones

• Same as for phenothiazines

• Eg. Haloperidol
Nursing Implications
1. May reduce prothrombin time
2. Often used as the initial drug for treatment of
psychotic disorders.
Uses: tics, vocal disturbances, and psychotic
schizophrenia
Thioxanthenes – similar to phenothiazine
• Eg. Navane

Nursing Implications
1. Same as for phenothiazine

S/E: Frequent Parkinson-like symptoms; dystonia, atropine-like effects

 Typical antipsychotics
• Initially introduced in 1950s
• also referred to as neuroleptic medications
• effectively treat only the positive symptoms of schizophrenia and have
• no therapeutic effect on the negative symptoms.
• -depot therapy injections available in a few traditional antipsychotic drugs for
clients who have a poor adherence history.
• Most common sideeffects are EPS

73
Chlorpromazine (Thorazine)
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (Trilaton)
Thiorazidine (Mellaril)
Thiothixene (Navane)
Trifluoperazine (Stelazine

74
. Atypical antipsychotics

• developed and first marketed in 1990

• effective in treating the positive and negative symptoms of
Schizophrenia.
• Minimal to-no risk of developing EPS
• Decreased risk for development of tardive dyskinesia (TD)

75
• Clozapine (Clozaril)
• Olanzapine (Zyprexia)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Zeldox)

76
 SIDE-EFFECTS
1) Extrapyramidal symptoms (EPS)
i. Neuroleptic-induced parkinsonism:- occur
in 40% of the patients presenting
extrapyramidal symptoms. There are two
varieties of parkinsonia symptoms:
a. Akinetic Form:- Appears in the first week
of administration of antipsychotic drugs.
The characteristics of akinetic form are:
Difficulty in masticating movements,
weakness & muscle fatigue.
4/24/2013 JAYESH PATIDAR 77
 b. Agitating Form of parkinsonian Symptoms
include:-Tremors at rest, rigidity & mask-like
face. Most characteristic features of
parkinsonism are:-
Rigidity of muscles
Motor retardation
salivation
slurred speech
mask-like face
shuffling gait
Anticholinergic drugs are given as
treatments.
4/24/2013 78
 ii. Akathisia:-
Akathisia occurs in 50% of
all the patients presenting
extrapyramidal symptoms. The
common characteristics: Restless
―walking in place. Difficulty in sitting
still, or strong urge to move about-
referred to as
―Walkies & Talkies by haris
generally occurs after two weeks of
treatment.
4/24/2013 Before administering anti-parkinsonian
JAYESH PATIDAR 79
 iii. Dystonia:-
Dystonia occurs in 6% of total number of patient‘s
presenting EPS. The characteristic features are: rapidly developing
contraction of muscles of the tongue, jaw, neck (producing
torticollis) & etraocular muscles. Combined torticolis & extraocular
spasm results in an oculogyric crisis in which eyes looked upward,
head is turned to one side.
Dystonia is painful & gives a frightening experience to the
patient.
Constant observation of the patient should be made.
Dystonia occurs within a few minutes of giving medicine or after
several hours.

4/24/2013 24
 iv. Tardive Dyskinesia:-
This occur due to abrupt termination or
reduction of the antipsychotic drug after long-term-
high-dose therapy.

Tardive dyskinesia is characterized by involuntary

rhythmic, stereotyped movements, protrusion of the
tongue, puffing of cheeks, chewing movements,
involuntary movements of extremities & trunk.
These symptoms occur in 3% of patients.
Antipsychotics should be stoped immediately.
There is no treatment, symptoms may appear for
years. It is irreversible.
4/24/2013 81
4/24/2013

•V. Neuroleptic Malignant Syndrome (NMS):-

• This is a rare complication of antipsychotic agents & is
usually fetal.
• Many develop within hours or after years of continued
drug use.
• Symptoms include hyperpyrexia, severe muscle rigidity,
altered consciousness, blood pressure changes,
increased count of W.B.C. symptoms appear suddenly
when medication is started & can persist for 10-14 days
or longer. Symptomatic treatment is given to patients.

82
4/24/2013

• Autonomic Nervous System:-

• Dry mouth, blurred vision, constipation, urinary
hesitance or retention & under rare circumstances
paralytic ileus.

• Cardio-Vascular:-
• Tachycardia, orthostatic hypotension & reversible
arrhythmias.

• Blood or Hematopoietic:-
• Agrunulocytosis (marked decrease in leukocytes
system especially with chlorpramozine) leucopenia,
leukocytosis.

83
4/24/2013

• Endocrine Disruptions:-
• Menstrual irregularities, including amenorrhea & false
positive pregnancy tests, breast enlargement, lactation,
weight gain, changes in libido, impotence, glycosuria,
hyperglycemia.

• Gastro-Intestinal:-
• Anorexia, constipation, diarrhea, hypersalivation,
nausea, vomiting, obstructive jaundice.

• Allergic effects:-
• Dermatitis, photosensitization, pigment
• deposits.

84
4/24/2013

• Occular Effcts:-
• Blurring of vision, pigmentation of cornea & lens &
retinopathy.

• Hepatic Side-effects:-
• Liver toxicity occurs in 0.5% of cases presenting EPS. It is
a hypersensitivity reaction & dose dependent. Onset of
symptoms is within the first one month of treatment.
Symptoms may be fever, chills, nausea, malaise,
prurites & jaundice.

85
 Extrapyramidal Description
Symptoms

Akathisia Motor restlessness, inability to remain still, can also

occur as subjective feeling

Akinesia Absence of movement or difficulty with movement.

Dystonias Muscle spasms, spastic movement of the neck and back, can be
painful and frightening for the client.

Pseudo-parkinsonism Shuffling and slow gait, mask-like facial expression, tremors, pill-
rolling movements of hands, stooping posture, rigidity

Tardive Dyskinesia Involuntary and abnormal movements of the mouth, tongue, face,
and jaw, may progress to the limbs, irreversible condition, may
occur in months after antipsychotic medication use.

Neuroleptic Malignant syndrome A potentially lethal side effect of antipsychotic medication that
requires emergency treatment; manifest symptoms include;
hyperthermia,
Free Template muscle rigidity, tremors, altered consciousness,
from www.brainybetty.com 86
tachycardia, hypertension, and incontinence
 Anti-Parkinsonism (Anticholinergics)

• Increased dopamine levels

• Maybe helpful in the management of negative symptoms of schizophrenia
• Used to prevent or manage EPS of antipsychotic medications; common
anticholinergic side effects are: dry mouth, blurred vision, constipation,
decreased lacrimation, photophobia, urinary hesitance, tachycardia and nausea.

87
Benztropine (Cogentin)
Biperiden(Akineton)
Dipenhydramine (Benadryl)
Ethoprazine(Parsidol*)
Procyclidine (Kemadrin)
Trihexphenidyl (Artane)

88
 NURSE’S RESPONCIBILITY
Close observation, especially when the antipsychotic are
just started. The expected results are reduction in
aggressive hyperactive behavior & disorganized thoughts.
Look for the possible side-effects.
Extrapyramidal reaction, i.e. Parkinsonism, akinesia,
akathisia, dystonia, & tardive dyskinesia. These symptoms
are reduced/treated with early observation, reporting &
use of anti-parkinsonion or anticholinergic medication.
Observe drowsiness. Medicine should be administered at
bed time. Report if the drowsiness persists for a very long
time. The patient should be advised not to drive & handle
hazardous machinery while taking antipsychotic drugs.
Observe for sore throat, fever due to agranulocytosis.

4/24/2013 JAYESH PATIDAR 89

 Record blood pressure of the patient on
antipsychotic drugs. If the BP is drops by 20 to30
mm of hg in the patient, immediate reporting &
intervention should be done. The patient should be
made aware of the possibility of dizziness & injuries
after receiving medication & injection due to
orthostatic hypotension.
Accurate rout of medication- antipsychotic drugs are
not given subcutaneously unless specially prescribed
as they cause tissue irritation. These drugs should
be given deep IM.
Dry mouth may be may be reduced by encouraging
the patient to rinse his or her mouth frequently. Give
a piece of lemon or chewing gum. Good oral hygiene
should also be maintained.
4/24/2013 90
 Blurred or impaired vision in the patient causes anxiety
& annonyance to him. The patient should be
encouraged to inform these symptoms immediately.
Blurred vision or brown coloured vision, night blindness
can be permanent due to pigmentary retinopathy.
The patient on antipsychotic drugs may have weight
gain. Weight record should be maintained. The patient
may be encouraged on a low salt & planned caloric diet.
The patient may complain of gastric irritation. He should
be discouraged to take antacid as there will be
decreased absorption of antipsychotic drugs.
An intake output chart should be maintained specially
for male patients who are confined to bed & have an
enlarged prostate gland. Encourage at least 2500 ml of
liquid intake.
4/24/2013 91
 The patient should be advised to protect his skin, by not going
in the sun & to wear protective clothing & sunglasses.
The patient should be explained not to increase or decrease
or stop taking drugs without discussing with his doctor. The
drugs should be withdrawn slowly to avoid nausea or
seizures.
The nurse should find out menstrual changes from the female
patient. Sometimes the patient may complain of fever, upper
abdominal pain, nausea, jaundice & diarrhea. These
symptoms can be due to cholestatic jaundice. The nurse
should stop the medicine immediately & inform the doctor.
Reassurance to relatives- The patient & his relatives should
be explained that desired effects will be achieved after weeks
of medication, so the relatives need to wait for the effects of
the drugs.
4/24/2013 JAYESH PATIDAR 92
 ANTIDEPRESSANTS
AGENTS

4/24/2013 JAYESH PATIDAR 93

 DESCRIPTION

• Antidepressant agents are used in affective disorders o

disturbances mainly to treat depressive disorders caused by
emotional or environmental stressors.
• Several groups of affective disturbances are treatable
by antidepressants.

4/24/2013 94
 MODE OF ACTION
• Antidepressant drugs are classified as Tricyclics,
Tetracyclics & MAO inhibitors. Research studies
have shown reduced levels of norepinephrine (NE) &
serotonin (5-HT) in the space between nerve ending
carrying message from one nerve cell to another
cause depression.
• Tricyclic antidepressants & MAO inhibitors increase
these neurotransmitters i.e. norepinephrine & sertinin
to the synaptic receptors in the central nervous
system. Tricyclic inhibitors block the reuptake of NE
& 5-HT & MAO inhibitors block the action of
MONOamine oxidize in breaking down excess of NE
& 5-HT at the presynaptic neuron.
4/24/2013 95
 CLASSIFICATION
CLASS EXAMPLES OF TRADE NAME ORAL DOSE
DRUGS (mg/day)
Tricyclic Imipramine Antidep 75-300
antidepressants (TCAs) Amitriptyline Tryptomer 75-300
Clomipramine Anafranil 75-300
Dothiepin Prothiaden 75-300
mianserin depnon 30-120
Selective serotonin Fluoxetine Fludac 10-80
reuptake Sertraline Serenata 50-200
inhibitors (SSRIs)
Dopaminergic fluvoxamine faverin 50-300
antidepressants
Atypical amineptine survector 100-400
antidepressants
Monoamine oxidase Trazodone Trazalon 150-600
inhibitors (MAOIs) isocarboxazid Marplan 10-30
 INDICATIONS
Depression Other psychiatric disorders
• Depressive episode • Panic attack
• Dysthymia • Generalized anxiety disorder
• Reactive depression • Agrophobia, social phobia
• Secondary depression • OCD with or without depression
• Abnormal grief reaction • Eating disorder
• Borderline personality disorder
Childhood psychiatric
• Post-traumatic stress disorder
disorders
• Enuresis • Depersonalization syndrome
• Separation anxiety disorder ✔ Medical
disorder • Chronic pain
• Somnambulism
• Migraine
• School phobia
• Peptic ulcer disease
4/24/2013 • Night terrors 97
 PHARMACOKINETICS
• Antidepressants are highly
lipophilic & protein-bound. The
half-life is long & usually more
than 24 hours.
• It is predominantly metabolized in
the liver.

4/24/2013 98
 CONTRAINDICATION
• Antidepressants are given with caution
to patients with cardiovascular disorder
because they cause arrhythmias.
• They increase symptoms of psychosis
& mania in cases of manic-depressive
psychosis.
• Drugs are given with caution
to prevents with liver
disorders.
4/24/2013 99
Antidepressant Medications
TRICYCLIC ANTIDEPRESSANTS (TCA) –
• prevents reuptake of norepinephrine and serotonin resulting to
increased concentration of these neurotransmitters.
E.g. Tofranil, Aventyl, Sinequan, Elavil

S/E: Drowsiness, dry mouth, blurred vision, constipation, and

hypotension
A/E: Cardiac dysrhythmias, nystagmus, tremor, hypotension,
restlessness
Nursing Implications
• Should not be given with MAOI; a time lag of 14 days is necessary
when changing from one drug group to another

• Because of marked sedation, client should avoid activities requiring

mental alertnes (driving or operating machines)

• Instruct client to move gradually from lying to sitting and standing

positions (postural hypotension).
Selective Serotonin Reuptake Inhibitors
(SSRI)
• Causes selective inhibition of serotonin uptake and produces CNS
excitation rather than sedation; has no effect on dopamine or
norepinephrine.
Eg. Prosac, Zoloft, Paxil

S/E: Nausea, headache, anxiety, nervousness, insomnia, weight loss,

skin rash
• Sinequan is tolerated better by elderlies, has less
cardiac effects; dilute concentrate with orange juice

• Contraindicated in clients with epilepsy, glaucoma,

and cardiovascular disease.

• Usually given once daily at bedtime

Uses: depression; Tofranil also used to treat enuresis in
children.
Nursing Implications
• Give medication in the morning
• Uses: depression, OCD, Bulimia, suppress appetite in obese clients
Monoamine Oxidase Inhibitors
• Inhibit the enzyme monoamine oxidase, which breaks down
norepinephrine and serotonin, increasing the concentration of these
neurotransmitters.
• Eg. Marplan, Nardil, Parnate
S/E: Drowsiness, insomnia, dryness of mouth, urinary retention,
hypotension
A/E: tachycardia, tachypnea, agitation, tremors, seizures, heart block,
hypotension.
Nursing Implications
• Potentiate many drug actions: narcotics, barbiturates,
sedatives, and atropine-like medications.
• Have a long duration of action: therefore, 2-3 weeks
must go by before taking another drug while on an
MAOI
• Interact with specific foods and drugs (ones
containing tyramine or sympathomimetic drugs). May
cause a severe hypertensive crisis characterized by
marked elevation of BP, increased temp. tremors and
tachycardia
• Eg. Coffee, tea, cola, aged cheese, beer and wine,
pickled foods, avocados, figs, and many OTC cold
preparations, hay fever medications, and nasal
decongestants.

• Monitor for bladder distention by checking urinary

output.

• Parnate: most likely to cause hypertensive crisis and

onset of action is more rapid.

• Uses: primarily psychotic depression and depressive

episodes of bipolar affective disorder.
Misc Antidepressants
• Trazodone (Desyrel)
S/E: sedation, orthostatic hypotension, nausea, vomiting, can cause
priapism (prolonged painful erection of the penis)

• Bupropion (Wellbutrin)
S/E: weight loss, dry mouth
 Name Dosage mg/day

Tricyclic Antidepressants 75-300

1. Amitrypline (elavil) 75-300
2. Clomipramine (Anafranil) 75-300
3. Desipramine (Norpramine) 75-300
4. Doxepin (Senequin) 50-150
5. Imipramine (tofranil) 50-100
6. Maprotiline (Ludiomil) 25-100
7. Nortriptyline(Pamelor) 10-60
8. Protriptyline(Vivactil) 50-100
9. Trimipramine (Surmontil)

109
Monoamine oxidase
inhibitors (MAOs) 45-75
1. Phenelzine (Nardil) 20-30
2. Tranylcypromine (Parnate)

Selective Serotonin Reuptake 20-80

Inhibitors (SSRI) 50-100
1. Fluoxetine (Prozac) 20-50
2. Fluvoxamine (Luvox) 50-200
3. Paroxetine(Paxil)
4. Sertraline(Zoloft)
Atypical Antidepressants
Bupropion (Wellbutrin) 200
110
Trazodone (Desyrel) 150
OVER-THE-COUNTER DRUGS

N
 MOOD
STABILIZING
DRUGS
4/24/2013 11
 Mood stabilizers are
used for the treatment of bipolar
affective disorders. Some commonly
used mood stabilizers are:-
1. Lithium
2. Carbamazepine
3. Sodium Valproate

4/24/2013 JAYESH PATIDAR 11

 LITHIUM

4/24/2013 11
 DESCRIPTION

• Lithium is an element with atomic

number 3 & atomic weight 7.
• It was discovered by FJ Cade in
1949, & is a most effective &
commonly used drug in the
treatment of mania.

4/24/2013 JAYESH PATIDAR 11

Antimanic Medications
• Lithium Carbonate – acts to lower concentrations of norepinephrine
and serotonin by inhibiting their release; believed to alter sodium
transport in both nerve and muscle cells.
• Uses: bipolar affective disorder- manic episode
• Eg. Lithane, Lithobid
 MODE OF ACTION
The probable mechanisms of action can be:
• It accelerates presynaptic re-uptake &
destruction of catecholamines, like
norepinephrine.
• It inhibits the release of catecholamines at the
synapse.
• It decreases postsynaptic serotonin receptor
sensitivity.
All these actions result in decreased
catecholamine activity, thus ameliorating
mania.
4/24/2013 11
 INDICATION

Acute mania
Other disorders:
Prophylaxis for bipolar
– Premenstrual
& unipolar mood
dysphoric disorder
disorder.
– Bulimia nervosa
Schizoaffective
disorder – Borderline
personality disorder
Cyclothymia
– Episodes of binge
Impulsivity &
drinking
aggression
– Trichotillomania
– Cluster headaches
4/24/2013
 PHARMACOKINETICS
• Lithium is readily absorbed with peak
plasma levels occurring 2-4 hours after a
single oral dose of lithium carbonate.
• Lithium is distributed rapidly in liver & kidney &
more slowly in muscle, brain & bone. Steady
state levels are achieved in about 7 days.
• Elimination is predominately via tubules & is
influenced by sodium balance. Depletion of
sodium can precipitate lithium toxicity.

4/24/2013 11
 DOSAGES
Lithium is available in the market in the form of
the following preparation:
– Lithium carbonate: 300mg tablet (eg. Licab);
400mg sustained release tablets (eg.
Lithosun-SR).
– Lithium citrate: 300mg/5ml liquid.
The usual range of dose
per day in acute mania is 900-2100mg given in
2-3 divided doses. The treatment is started after
serial lithium estimation is done after a loading
dose of 600mg or 900mg of lithium to
determine the pharmacokinetics.
4/24/2013 12
 BLOOD LITHIUM LEVEL

• Therapeutic levels = 0.8-1.2 mEq/L

(for treatment of acute mania)
• Prophylactic levels = 0.6-1.2 mEq/L
(for prevention of relapse in bipolar
disorder)
• Toxic lithium levels>2.0 mEq/L

4/24/2013 12
 SIDE EFFECTS
• Neurological: Tremors, motor hyperactivity,
muscular weakness cogwheel rigidity,
seizures, neurotoxicity (delirium, abnormal
involuntary movements, seizures, coma).
• Renal: Polydipsia, polyuria, tubular enlargement,
nephritic syndrome.
• Cardiovascular: T-wave depression.
• Gastrointestinal: Nausea, vomiting, diarrhea,
abdominal pain & metallic taste.
• Endocrine: Abnormal thyroid function, goiter &
weight gain.
•
4/24/2013 12
 Count
• …
Dermatological: Acneiform eruptions,
popular eruptions & exacerbation of
psoriasis.
• Side-effect during pregnancy &
lactation: Teratogenic possibility,
increase incidence of Ebstein‘s anomaly
(distortion & downward displacement of
tricuspid value in right ventricle) when
taken in first trimester. Secreted in milk
& can cause toxicity in infant.

4/24/2013 12
 Count…
• Sign & symptoms of
lithium toxicity (serum – Muscle twitching
lithium level>2.0 – Dysarthria
mEq/L): – Lethargy
– Ataxia – Confusion
– Coarse tremor (hand) – Coma
– Nausea & vomiting – Hyperreflexia
– Impaired memory – Nystagmus
– Impaired concentration
– Nephrotoxicity
– Muscle weakness
– Convulsions
4/24/2013
57
 MANAGEMENT OF LITHIUM TOXICITY:-
• Discontinue the drug immediately.
• For significant short-term ingestions, residual
gastric content should be removed by induction of
emesis, gastric lavage adsorption with activated
charcoal.
• If possible instruct the patient to ingest fluids.
• Assess serum lithium levels, serum electrolytes,
renal functions, ECG as soon as possible.
• Maintenance of fluid & electrolyte balance.
• In a patient with serious manifestations of
lithium toxicity, hemodialysis should be initiated.
4/24/2013 12
 CONTRAINDICATION OF
LITHIUM:-
• Cardiac, renal, thyroid or neurological
dysfunctions
• Presence of blood dyscrasias
• During first trimester of pregnancy &
lactation
• Severe dehydration
• Hypothyroidism
• History of seizures

4/24/2013 12
 NURSE’S RESPONSIBILITY
• The pre—lithium work up: A complete physical history, ECG,
blood studies (TC, DC, FBS, BUN, Creatinine, electrolytes)
urine examination (routine & microscopic) must be carried
out.

• It is important to assess renal function as renal side-effects

are common & the drug can be dangerous in an individual
with compromised kidney function.

• Thyroid functions should also be assesses, as the drug is

known to depress the thyroid gland.

4/24/2013 12
 To achieve therapeutic effect & prevent lithium toxicity,
the following precaution should be taken:
• Lithium must be taken on a regular basis, preferably at the
same time daily (for example, a client taking lithium on TID
schedule, who forget a dose should wait until the next
scheduled time to take lithium & not take twice the amount at
one time, because toxicity can occur).
• When lithium therapy is initiated, mild side-effects such as fine
hand tremors, increased thirst & urination, nausea, anorexia
etc may develop,
• Most of them are transient & do not represent lithium toxicity.

4/24/2013 12
 • Serious side-effects of lithium that necessitate its discontinuance
include vomiting, extreme hand tremor, sedation, muscle
weakness & vertigo.
• The psychiatrist should be notified immediately if any of these
effects occur.
• Since polyuria can lead to dehydration with risk of lithium
intoxication, patients should be advised to drink enough water to
compensate for the fluid loss.
• Various situations may require an adjustment in the amount of
lithium administered to a client, such as the addition of the new
medicine to the client drug regimen, a new diet or an illness with
fever or excessive sweating.
• They must be advised to consume large quantities of water with
salts, to prevent lithium toxicity due to decreased sodium levels.

4/24/2013 12
 • Frequent serum lithium level evaluation is important.
Blood for determination of lithium levels should be
drawn in the morning approximately 12-14 hours
after the last dose was taken.

• The patient should be told about the importance of

regular follow up. In every six months, blood sample
should be taken for estimation of electrolytes, urea,
creatinine, a full blood count & thyroid function test.

4/24/2013 13
Side Effects
• High Incidence : Increased thirst, increased urination

• Frequent: 1.5mEq/L levels or less; Dry mouth, lethargy, fatigue,

muscle weakness, headache, GI disturbance, fine hand tremors

• A/E: 1.5-2.0 mEq/L may produce vomiting, diarrhea, drowsiness,

incoordination, coarse hand tremors, muscle twitching.
• 2.0-2.5 mEq/L may result in ataxia, slurred speech,
confusion, clonic movements, high output of dilute
urine, blurred vision, hypotension.

• Acute toxicity: Seizures, oliguria, coma, peripheral

vascular collapse, death.
Nursing Implications
• Monitor lithium blood levels: to be taken 12 hours after dosage.
• Teach the following:
Symptoms of lithium toxicity
The importance of frequent blood tests (2-3 days) to check
lithium levels
• Encourage a diet containing normal amounts of salt and a fluid intake
of 3L/day; avoid caffeine, due to its diuretic effect.
• Report polyuria, prolonged vomiting, diarrhea, or
fever to physician (may need to temporarily reduce or
discontinue dosage)

• Do not crush, chew, or break the extended-release or

film-coated tablets

• Assess clients at high risk of developing toxicity;

postoperative, dehydrated, hyperthyroid, those with
renal disease, or those taking diuretics.
• Blood levels:
*extremely narrow therapeutic range – 0.5-
1.5 mEq/L
* toxic serum lithium level is greater than 2
mEq/L
• Management of lithium toxicity; administration of
osmotic diuretics (e.g. urea or mannitol);
aminophylline and Diamox
• Long-term use may cause goiter, may be associated
with hypothyroidism
• Hyponatremia can lead to marked lithium retention
and possible toxicity. Avoid conditions that decrease
sodium level: perspiration, vomiting, diarrhea,
dehydration, etc. which may require temporary
reduction, discontinuance of dosage
Plasma Level of Lithium and common side effects

Plasma Level Side effects

<1.5 Fine hand tremors, mild thirst,

mild nausea, muscle
weakness, restlessness
1.5-2.0 Coarse hand tremors, diarrhea,
vomiting, drowsiness, lack of
coordination (early signs of
toxicity)
2.0-3.0 Blurred vision, vertigo,tinnitus,
slurred speech, twitching, and
fasciculation, hyperreflexia,
confusion
>3.0 Seizures, arrythmias,
peripheral vascular collapse,
Coma
Both drugs below were originally developed and used for seizure disorders. Both
have mood stabilizing abilities

• Carbamazepine (Tegretol)
S/E: Drowsiness, dizziness, visual problems (spots before eyes,
difficulty focusing, blurred vision), dry mouth
• Valproic acid (Depakene)
S/E: GI upsets, drowsiness, may cause heptatotoxicity.
Nursing Implications
• Used primarily for clients who have failed to respond to lithium or
who cannot tolerate the side effects.
• Avoid tasks that require alertness, motor skills until response to drug
is established.
• Tegretol – monitor CBC frequently during initiation of therapy and at
monthly intervals thereafter.
• Depakene – monitor liver function studies
 CARBAMAZEPINE

4/24/2013 14
 DESCRIPTION
• It is available in the market under
different trade names like Tegretol,
Mazetol, Zeptol & Zen Retard.

4/24/2013 JAYESH PATIDAR 14

 MECHANISM OF ACTION
• Its mood stabilizing mechanism
is not clearly established. Its
anticonvulsant action may
however be by decreasing
synaptic transmission in the CNS.

4/24/2013 14
 INDICATIONS
• Seizures-complex partial seizures, GTCS,
seizures due to alcohol withdrawal.
• Psychiatric disorders- rapid cycling bipolar
disorder, acute depression, impulse
control disorder, aggression, psychosis
with epilepsy, schizoaffective disorders,
borderline personality disorder, cocaine
withdrawal syndrome.
• Paroxysmal pain syndromes- trigeminal
neuralgia & phantom limb pain.

4/24/2013 14
 DOSAGE
• The average daily dose is 600-1800
mg orally, in divided doses. The
therapeutic blood levels are 6-12
µg/ml. toxic blood levels are attained at
more than µg/ml.

4/24/2013 14
 SIDE EFFECTS
• Drowsiness, confusion, headache,
ataxia, hypertension, arrhythmias, skin
rashes, steven-Johnson syndrome,
nausea, vomiting, diarrhea, dry mouth,
abdominal pain, jaundice, hepatitis,
oliguria, leucopenia, thrombocytopenia,
bone marrow depression leading to
aplastic anemia.

4/24/2013 14
 NURSE’S RESPONSIBILITY
• Since the drug may cause dizziness &
drowsiness advise him to avoid driving &
other activities requiring alertness?
• Advise patient not to consume alcohol
when he is on the drug.
• Emphasize the importance of regular
follow-up visits & periodic examination of
blood count & monitoring of cardiac,
renal, hepatic & bone marrow functions.

4/24/2013 70
 SODIUM
VALPROATE
(ENCORATE CHRONO,
VALPARIN, EPILEX,
EPIVAL)
4/24/2013
 MECHANISM OF
ACTION
• The drugs acts on gamma-
aminobutyric acid (GABA) an
inhibitory amino acid
neurotransmitters. GABA
receptors activation serves to
reduce neuronal excitability.

4/24/2013 14
 INDICATI
ON
• Acute mania, prophylactic treatment of
bipolar-I disorder, rapid cycling bipolar
disorder.
• Schizoaffective disorder.
• Seizures.
• Other disorders like bulimia nervosa,
obsessive-compulsive disorder, agitation
& PTSD.

4/24/2013 14
 DOSAGE
• The usual dose is 15
mg/kg/day with a maximum of
60mg/kg/day orally.

4/24/2013 15
 SIDE EFFECTS
• Nausea, vomiting, diarrhea,
sedation, ataxia, dysarthria,
tremor, weight gain, loss of hair,
thrombocytopenia, platelet
dysfunction.

4/24/2013 15
 NURSE’S
RESPONSIBILITY
• Explain to the patient to take the drug immediately after foo
to reduce GI irritation.
• Advise to come for regular follow-up & periodic examination
blood count, hepatic function & thyroid function. Therapeut
serum level of valproic acid is 50-100 micrograms/ml.

4/24/2013 15
Remotivation Technique
Therapeutic Activities and
Intervention Modalities
• REMOTIVATION TECHNIQUES

-Of simple group interactions between group of

psychiatric nurses and group of patients

- usually done once a week for 12 weeks

• Remotivation- the urge to get moving again.
• a small group therapeutic modality objective in nature, designed to
help clients by promoting self-esteem, awareness, and socialization
History
• 1971- National Remotivation Therapy was formed
• When remotivation was first developed, it was not considered a
"formal therapy“.
• Dorothy Hoskins Smith – developed remotivation
Purpose:
• to help mentally ill persons recognize the realities
• to see themselves for the persons they really are
• to see other people as they really are
• to see relationships as they actually exist
• To restore that value, to arouse interest in the real
world, to get patients moving again, mentally, in
the direction of reality
• WAYS TO REMOTIVATE CLIENTS;

establishing communication
inspire confidence
deal with the patients’ weaknesses
deal with their strengths
Why Remotivation works?
• it helps set in motion two processes that are vital to the patients
• it builds on the patients’ strengths, reinforcing them as objective
people in our eyes and, in respect to their healthy roles, as subjective
people in their own eyes
• remotivation works because the psychiatrist tries to challenge the
distortions of reality that plague the patients
Types of Remotivation Techniques
• Individual Remotivation
• conducted individually with one person
• ex. homebound and receive home health care

• Group Remotivation
• size of the group is limited
• 6-8 persons and up to 15 persons
What distinguishes remotivation therapy from teaching
methods and other therapies?

• It focuses discussion on concrete things and ideas

rather than subjective feelings and emotions.
• It accepts client/patient behavior, ideas and/or
feelings as expressions of personal opinion. A
person's opinion is never corrected or commented
upon in a critical manner.
• It focuses on what is healthy and right about the
client/patient. It does not discuss personal problems
or make feelings the subject of discussion.
• The questions that facilitate discussion are geared to
the vocabulary, literacy, IQ and/or cognitive ability of
the client/patient making it an effective approach
with all types of persons.
Steps or Stages
I. Creating Atmosphere of Acceptance
- Establishment of Rapport to put participants at
ease
- call patient by name

II. Create a Bridge to Reality

- know topics the group would like to discuss. Can
be presented through play, poetry, visual aids
- objects must be real. Use sensory organs
III. Sharing The World We Live In
- The use of pictures and visual aids to get acquainted
with the reality of the topic through the senses. Think
of what they can do
IV. Appreciation of the Work of the World
- Asking benefits out of the occupation, who makes
use of which.
V. Climate of Appreciation
- contribution appreciation and highight importance
- moderator summarizes highlights of the interaction/
meeting
Reminders
• Ideal number: 10-12 members
• Know proper time to give to the patients
• Must have enough time to attend to all group
members
• Sitting arrangement: Circular/ comfortable
• Diameter of 10 ft
• Select venue- consider the place free from
distractions
Results of Remotivation:
• they are encouraged to describe themselves concretely and
accurately as individuals with specific social functions, jobs, a place in
the world
• they are encouraged to speak concretely and accurately of what they
did in these jobs
 Crisis/ Crisis Intervention
• Crisis Intervention - Self-limiting situation in which
usual problem-solving or decision-making methods are
not adequate.
• A crisis offers opportunities for growth and renewal
• Crisis interventions strategy views people as capable of
personal growth and able to control their own lives.
• Types of crisis interventions strategies;
- Individual crisis counseling
- crisis groups
- telephone counseling

• Crisis intervention requires support, protection and

enhancement of the client’s self-image.
Group Therapy
• A structured or semi-structured process in which
individuals (7-12 memebers ideal size) are
interrelated and interdependent and who may share
common purposes and norms.
• Emphasis on clear communication to promote
effective interaction
• Disturbed perception can be corrected through
consensual validation
• Socially ineffective behaviors can be modified
through peer pressure.
Family Therapy
• Treatment modality designed to bring about a
change in communication and interactive patterns
and among family members.

1. A family can be viewed as a system that is dynamic.

A change or movement in any part of the family
system affects all other parts of the system.
2. Family seeks to maintain a balance or “homeostasis”
among various forces that operate within and upon
it.
• Emotional symptoms or problems of an individual are
an expression of the emotional symptoms or
problems in the family.
• Therapeutic approaches involve helping the family
members look at themselves in the here-and-now
and recognize the influence of past models on their
behavior and expectations.
Milieu
• A scientifically, planned, purposeful manipulation in the
environment aimed at causing changes in the behavior and
personality of the client.

1. Nurse is viewed as a facilitator and a helper to clients

rather than a therapist.
2. The therapeutic community is a very special kind of
milieu therapy in which the total social structure of the
treatment unit is involved as part of the helping
process.
3. Emphasis is placed on open communication, both
within and between staff and client group.
Somatic Therapies
• Restraints
a. Must consider client’s civil liberties
b. Mechanical restraints include camisoles, wrist and
ankle restraints, sheet restraints, and cold wet sheet
packs.
• Seclusion
a. Confinement to a room that may be locked. Often,
the room is without a mattress or linens and the
client is in a hospital nightgown.
b. There is limited opportunity for communication.
Psychosurgery
• Surgical interruption of selected neutral pathways
that govern transmission of emotion between the
frontal lobes of the cerebral cortex and the
thalamus.
1. Recent resurgence of interest in psychosurgery as
knowledge of neuroanatomy and “mapping” the
cerebral cortex has become more sophisticated.
2. Area of moral and ethical debate, especially since
nerve once damaged cannot regenerate.
Electroconvulsive Therapy
• Used primarily for clients with depression
a. Short-acting anesthesia is used to induce
unconsciousness. The client’s vital signs, oxygenation,
and cardiac functioning are carefully monitored
before, during, and following ECT.
b. An electric current (70-150 volts) is applied through
the brain for 0.5 to 2 seconds, producing a seizure
that lasts 30 to 60 seconds.
c. Following ECT, the client is monitored according to
routine postoperative protocols.
Other therapies
Psychodrama
• the use of structured and directed dramatization of
client’s emotional problems and experiences
• A form of group therapy developed by Jacob Moreno.
• Patients are encouraged to act out their inner
conflicts and problems before an audience in an
unrehearsed manner
Purposes
• Catharsis
• Support
• Self-awareness
• Problem Identification
• Insight
Stages
I. Group Warm-up- Pt. acts as director and asks a
particular pt to act as protagonist.
II. Action Phase – Participants ready to act on stage.
The director must not dictate
III. Final – Discuss problem on the drama director/
nurse gives advices
DRILL
QUESTION 1

1. Flumazenil (Romazicon) has been ordered for a client who has

overdosed on oxazepam (Serax). Before administering the
medication, the nurse should be prepared for which common adverse
effect?
• Seizures

• Shivering

• Anxiety

• Chest pain
A. Seizures . Seizures are the most common serious adverse effect of
using flumazenil to reverse benzodiazepine overdose.

The effect is magnified if the client has a combined tricyclic

antidepressant and benzodiazepine overdose.

Less common adverse effects include shivering, anxiety, and chest

pain.
QUESTION 2
2. A dystonic reaction can be caused by which of the following
medications?
• diazepam (Valium)

• haloperidol (Haldol)

• amitriptyline (Elavil)

• clonazepam (Klonopin)
• B. haloperidol (Haldol) . Haloperidol is a phenothiazine and is
capable of causing dystonic reactions. Diazepam and clonazepam
are benzodiazepines, and amitriptyline is a tricyclic antidepressant.
Benzodiazepines don’t cause dystonic reactions; however, they can
cause drowsiness, lethargy, and hypotension. Tricyclic
antidepressants rarely cause severe dystonic reactions; however,
they can cause a decreased level of consciousness, tachycardia, dry
mouth, and dilated pupils.
QUESTION 3
3. Which of the following drugs may be abused because of tolerance
and physiologic dependence.
• lithium (Lithobid) and divalproex (Depakote).

• verapamil (Calan) and chlorpromazine (Thorazine)

• alprazolam (Xanax) and phenobarbital (Luminal)

• clozapine (Clozaril) and amitriptyline (Elavil)

• C. alprazolam (Xanax) and phenobarbital (Luminal) . Both
benzodiazepines, such as alprazolam, and barbiturates, such as
phenobarbital, are addictive, controlled substances. All the other
drugs listed aren’t addictive substances.
QUESTION 4
4. An attorney who throws books and furniture around the office after
losing a case is referred to the psychiatric nurse in the law firm’s
employee assistance program. The nurse knows that the client’s
behavior most likely represents the use of which defense mechanism?
• Regression

• Projection

• Reaction-formation

• Intellectualization
• A. Regression . An adult who throws temper tantrums, such as this
one, is displaying regressive behavior, or behavior that is
appropriate at a younger age. In projection, the client blames
someone or something other than the source. In reaction
formation, the client acts in opposition to his feelings. In
intellectualization, the client overuses rational explanations or
abstract thinking to decrease the significance of a feeling or event.
QUESTION 5

Clonidine (Catapres) can be used to treat conditions other than

hypertension. For which of the following conditions might the drug be
administered?
• Phencyclidine (PCP) intoxication

• Alcohol withdrawal

• Opiate withdrawal

• Cocaine withdrawal
C. Opiate withdrawal.
Clonidine is used as adjunctive therapy in opiate withdrawal.
Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic
agents, such as haloperidol, are used to treat alcohol withdrawal.
Benzodiazepines and neuropleptic agents are typically used to treat
PCP intoxication.
Antidepressants and medications with dopaminergic activity in the
brain, such as fluoxotine (Prozac), are used to treat cocaine
withdrawal.