PHARMACOTHERAPY MODALITIES & THERAPIES.pptx

Psychopharmacology deals with medicine provided to patient during psychological ailments. Along with pharmacological management various therapies are included which helps in better prognosis of the patients.

1. Therapeutic modalities & Therapies used in psychiatry Amritanshu chanchal NURSING TUTOR SLMGNC

2. Physical therapies Physical therapy is treatment that helps you improve how your body performs physical movements. It can be part of a generalized pain management plan or a specific treatment for an injury or health condition. The most common form of physical therapies are: Psychopharmacology, Electroconvulsive therapy, repetitive transcranial magnetic stimulation.

3. Psychopharmacology Psychopharmacology is the use of medications to treat mental health conditions. Medications are most effective when combined with psychotherapy. Psychiatric medications should be monitored by a licensed physician or nurse practitioner.

4. Terminologies used in drug therapy Efficacy: The efficacy of a drug is its ability to produce the maximal response possible for a particular biological system and relates to the extent of functional change that can be imparted to the receptor by the drug, based on its affinity for the receptor and its ability to induce receptor signaling. Potency: Potency is the intensity of effect produced for a given drug dose. Two drugs can be equiefficacious (i.e., produce the same maximal response) but vary in potency (dose required to produce the response). Half life: The half-life of a drug is the time it takes for the amount of a drug's active substance in your body to reduce by half. This depends on how the body processes and gets rid of the drug. It can vary from a few hours to a few days, or sometimes weeks.

5. Agonist: An agonist is a substance that mimics the actions of a neurotransmitter or hormone to produce a response when it binds to a specific receptor in the brain. Antagonist: Antagonist: A chemical substance that binds to and blocks the activation of certain receptors on cells, preventing a biological response. Naloxone is an example of an opioid receptor antagonist. Neurotransmitters: Neurotransmitters are endogenous chemicals that allow neurons to communicate with each other throughout the body. They enable the brain to provide a variety of functions, through the process of chemical synaptic transmission. These endogenous chemicals are integral in shaping everyday life and functions. Receptors: Receptors are proteins, usually cell surface receptors, which bind to ligands and cause responses in the immune system, including cytokine receptors, growth factor receptors and Fc receptor. Receptors can be found in various immune cells like B cells, T cells, NK cells, monocytes and stem cells.

6. Neurotransmission & drug effects at synapse The transport processes of neurotransmitters are mediated by the membrane transport proteins. Those proteins play important roles in mediating the concentration of neurotransmitters in the synaptic cleft. In general, the proteins are classified into two groups: the intracellular vesicular transporters, which sequester neurotransmitters from the cytoplasm into synaptic vesicles; and the plasma membrane transporters, which sequester released neurotransmitters from the extracellular space (Gether et. al., 2006). There are three types of intracellular transporters and two major types of plasma membrane transporters (Kanai, 2003; Chen, et al, 2004). The studies from Sherman (2017) have shown that once neurotransmitters have interacted with 5 Impacts of Drugs on Neurotransmission the receptors on the postsynaptic neurons, the molecules detach from the receptors, and meet one of three fates: some of them attach to other receptors; some are dissolved by enzymes; and some re-enter the presynaptic neuron via plasma membrane transporters.

7. In the absence of drugs, neurons are capable of maintaining a low concentration of neurotransmitters in the synaptic cleft. Under most circumstances, addictive drugs can cause the brain to go out of control. The neurotransmission can increase or decrease beyond normal limits. Addictive drugs affect certain types or classes of neurotransmitters. The first type is called agonists. Opioids and heroin, for example, can stimulate more receptors than endogenous opioids by mimicking the action of endogenous opioids in the human brain (endorphin and enkephalin ) ( Hoskin and Hanks, 1991; NIDA, 2012).

8. The second class of drugs are known as antagonists. Research from NIDA (2012) showed some drugs like benzodiazepines, cannabinoids , and opiates promote dopamine spikes by interacting with inhibitory neurotransmitters (such as GABA) to reduce an inhibitory influence. The third and final class of drugs are the reuptake inhibitors. Cocaine can attach to the plasma membrane reuptake transporters for serotonin, norepinephrine, or dopamine on the presynaptic neurons. Once cocaine blocks the reuptake transporters, serotonin, norepinephrine, or dopamine can’t enter the presynaptic neurons and accumulate in the synapse (NIDA 2017).

9. General guidelines regarding drug administration in psychiatry A nurse should not administer any drug unless there is a written order. Do not hesitate to consult the doctor when in doubt about any medication. All mediation must be charted on the patient case record. Do not force medication in case of stuporous patient. Check drugs daily for change of color adour and number. Bottles must be tightly closed and labeled. Make sure that adequate supply of drug is on hand but do not overstock Make sure patient does not have access to the medication cupboard. Drug cupboard should always be kept locked when not in use.

10. Classification of psychotropic drugs Antipsychotics Chlorpromazine, Trifluperazine Antidepressant Imipramine, Amitryptaline Mood stabilizing Lithium, Carbamezipine Anxiolytics & Hypnosedatives Phenobarbital, ethanol, benzodiazepines Antiepileptic drugs Phenobarbitone, Dizazepam Antiparkinsonian drug Levodopa , Bromocriptine Miscellaneous drugs

11. Antipsychotics

12. Anti psychotics Anti psychotics are those psychotropic drugs which are used for the treatment of psychotic symptoms. These are also known as neuroleptics as they produce neurological a neuroleptics as they produce neurological side effect major tranquilizer, D2-receptor blocker and anti schizophrenic drug. Anti psychotic medication cannot cure the illness but treat can take away many of the symptoms or make the milder. In some cases they can shorten the course of an episodes of the illness as well.

13. Classification Organic psychiatric Disorder Functional Disorder Mood Disorder Childhood Disorder Neurotic Disorder Medical Disorder Delirium Schizophrenia Mania ADHD Anorexia nervosa Huntingtons Chorea Dementia Schizoaffective Disorder Major depression Autism OCD Hiccups Delirium Tremens Paranoid Disorder Enuresis Anxiety Nausea & Vomiting Drug Induced Psychosis Conduct Disorder Tic

14. 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 plasma concentration . They are metabolized in the liver and 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 it is result in toxicity or the drug is gain ineffective.

15. Mechanism of action Antipsychotic agents function by blocking the dopamine receptors or by both dopamine and serotonin receptors. Increased production of dopamine and serotonin produces psychotic thinking resulting in strange thoughts, hallucination and bizarre behaviour. Antiemetic is another property of antipsychotics and are also used in hiccoughs.

16. Indication Psychosis Organic brain disorders Drug induced psychosis Schizophrenia Mood affective disorders- mania and depression Neurosis Attention deficit hyperactivity disorder Autism Anorexia nervosa OCD Hiccup

17. 1. Pharmacological classification First generation 1.Low potency • Chlorpromazine • Prochlorperazine • Thioridazine 2.High potency • Haloperidol • Fluphenazine • Pimozide • Thiothixene • Loxapine • Trifulperzine

18. Second generation • Clozapine • Olanzapine • Quetiapine • Risperidone • Aripiprazole • Asenapine • Iloperidone • Lurasidone • Paliperidone • Ziprasidone

19. Chemical classification Typical antipsychotics Phenothiazines-chlorpromazines , triflupromazine , thioridazine,fluphenazine decanoate Butyrophenones-haloparidol , triperidol Thioxanthenes - flupenthixol , thiothixene , chlorprothixene Oxinodles - Molindone Dibenzoxazipines - loxapines Atypical antipsychotics - Clozapine , risperidone , olanzaines , quetiapine , ziprasidone

20. First generation Antipsychotics Competitive blockers of dopamine receptors Other names for FGA are conventional , Typical or traditional antipsychotics most commonly used for movement disorders

21. Second generation Antipsychotic drugs Also referred as atypical antipsychotics have unique activity to Blocks both dopamine and serotonin. Have fewer EPS than first generation drugs. Associated with higher risk of metabolic side effects, such as diabetes, hypercholesterolemia and weight gain.

22. Adverse drug reaction Hormonal effects • Decreased libido, gynecomastia • Amenorrhea • Infertility • Weight gain ECG changes • Q-T prolongation and T wave suppression Decreased threshold level Agranulocytosis Hypersalivation

23. Anticholinergic effects- Dry mouth Blurred vision Constipation Urinary retention Nausea GI upset Skin rashes Sedation Photosensitivity Orthostatic hypotension

24. Extrapyramidal symptoms Pseudo-parkinsonism (tremor, shuffling gait, drooling, rigidity) Akinesia (muscular weakness) Akathisia (continuous restlessness and fidgeting) Dystonia (involuntary muscular movements [spasms] of face, arms, legs, and neck) Oculogyric crisis (uncontrolled rolling back of the eyes) Tardive dyskinesia (bizarre facial and tongue movements, stiff neck, and difficulty swallowing)

25. Neuroleptic malignant syndrome (NMS) Symptoms include - Severe parkinsonian Muscle rigidity Hyperpyrexia Tachycardia Tachypnea Fluctuations in blood pressure Diaphoresis Rapid deterioration of mental status Stupor and coma.

26. Nursing management Provide the client with sugarless candy or gum, ice, and frequent sips of water. Ensure that client practices strict oral hygiene. Explain that this symptom will most likely subside after a few weeks. Advise client not to drive a car until vision clears. Clear small items from pathway to prevent falls. Order foods high in fiber Instruct the client to report any difficulty urinating; monitor intake and output.

27. Tablets or capsules may be administered with food to minimize GI upset. Concentrates may be diluted and administered with fruit juice or other liquid. They should be mixed immediately before administration. Avoid spilling any of the liquid concentrate on skin since Contact dermatitis can occur with some medications.

28. Discuss with the physician the possibility of administering the drug at bedtime. Discuss with the physician a possible decrease in dosage or an order for a less sedating drug. Instruct client not to drive or operate dangerous equipment while experiencing sedation. Instruct the client to rise slowly from a lying or sitting position. Monitor blood pressure (lying and standing) each shift Document and report significant changes.

29. Ensure that the client wears a protective sunblock lotion, clothing, and sunglasses while spending time outdoors Instruct the client to continue use of contraception, because amenorrhea does not a cessation of ovulation. Caution is advised in prescribing this medication to individuals with history of arrhythmias. Conditions that produce hypokalemia and/or hypomagnesemia , such as diuretic therapy or diarrhea, should be taken into consideration when prescribing. Routine ECG should be taken before initiation of therapy and periodically during therapy. Monitor vital signs every shift. Observe for symptoms of dizziness, palpitations, syncope,or weakness.

30. Pseudoparkinsonism (tremor, shuffling gait, drooling, rigidity) may appear 1 to 5 days following initiation of antipsychotic medication; occurs most often in women, the elderly, and dehydrated clients. Akathisia (continuous restlessness and fidgeting) occurs most frequently in women, symptoms may occur 50 to 60 days following initiation of therapy. Dystonia (involuntary muscular movements [spasms] of face, arms, legs, and neck) and oculogyric crisis occurs most often in men and in people younger than 25 years of age.

31. Pseudoparkinsonism and akathisia can be treated with anticholinergics , antihistamine and dopaminergic agents. Dystonia and oculogyric crisis should be treated as an emergency situation. The physician should be contacted, and intravenous or intramuscular benztropine mesylate ( Cogentin ) is commonly administered. Stay with the client and offer reassurance and support during this frightening time.

32. For Tardive dyskinesia : All clients receiving long-term (months or years) antipsychotic therapy are at risk. The symptoms are potentially irreversible. The drug should be withdrawn at the first sign, which is usually vermiform movements of the tongue.Prompt action may prevent irreversibility for Hyper salivation (with clozapine ) : A significant number of clients receiving clozapine therapy experience extreme salivation. Offer support to the client because this may be an embarrassing situation. It may even be a safety issue (e.g., risk of aspiration) if the problem is very severe.

33. For Neuroleptic malignant syndrome (NMS) : This is a rare, but potentially fatal, complication of treatment with neuroleptic drugs. Routine assessments should include temperature and observation for parkinsonian symptoms. Onset can occur within hours or even years after drug initiation, and progression is rapid over the following 24 to 72 hours. Discontinue neuroleptic medication immediately. Monitor vital signs, degree of muscle rigidity, intake and output, level of consciousness. The physician may order bromocriptine ( Parlodel ) or dantrolene ( Dantrium ) to counteract the effects of neuroleptic malignant syndrome.

34. Anti depressant

35. Anti Depressant Antidepressant agents are used in affective disorders or disturbances mainly to treat depressive disorders caused by emotional or environmental stressors. Several groups of affective disturbances are treatable by antidepressants.

36. Action Antidepressant drugs are classified as Tricyclics,Tetracyclics & MAO inhibitors. Research studies have shown reduced levels of nor-epinephrine (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 & serotonin to the synaptic receptors in the central nervous system. Tricyclic inhibitors block the reuptake of NE & 5-HT & MAO inhibitors block the action of MONO amine oxidize in breaking down excess of NE.

37. Indications Dysthymic disorder Major depression with melancholia or psychotic symptoms Depression associated with organic disease, alcoholism, schizophrenia, or mental retardation Depressive phase of bipolar disorder Depression accompanied by anxiety.

38. Pharmacokinetics Lipophillic and protein bound Half life long usually more than 1 day Metabolized in liver Excreted in urine

39. Adverse effects Autonomic side-effects: Dry mouth, constipation, cycloplegia , mydriasis , urinary retention, orthostatic hypotension, impotence, impaired ejaculation, delirium & aggravation of glaucoma. CNS effects:- Sedation, tremor & other extra pyramidal symptoms, withdrawal syndrome, seizures, jitteriness syndrome, precipitation of mania. Cardiac side-effects:- Tachycardia, ECG changes, arrhythmias, direct myocardial depression, quinidine -like action(decreased conduction time).

40. Allergic side-effects Agranulocytosis , cholestatic jaundice, skin rashes, systemic vasculitis . Metabolic & endocrine side-effects:- weight gain Special effects of MAOI drugs:- Hypertensive crises, severe hepatic necrosis, hyperpyrexia.

41. Nursing management Observation of the side-effects & monitoring the changes noted are very significant to prevent complications due to antidepressant agents. Encourage the patient to take medicine at bed time due to a sedative effect. Dryness of mouth to decrease, Give plenty of fluids orally. Lemonade or chewing gum should be given. A few sips of water also help the patient. Do not give medicine empty stomach as the patientcomplains of nausea & vomiting.

42. Accurate recording of intake & output of the patient should be maintained to check if he has retention of urine. If the patient complains of dizziness or light headedness he/she should be encouraged to get up slowly & sit in the bed before standing. These symptoms may due to orthostatic hypotension. The patient should be reassured that these symptoms are for a short period only. Some patients may present hypertension. Accurate recording of vital signs like B.P. & pulse. The nurse should be able to interpret the blood reports specially blood sugar level & W.B.C. count. If the patient complains of sore throat, fever, malaise, it should be reported to the physician on duty. These symptoms may be due to agranulocytosis or hyperglycemia.

43. To relieve constipation plenty of fluids & roughage should be encouraged in the diet. If the patient complains of sexual dysfunction inform the physician immediately & stop the drug. If the patient is presenting symptoms of pressure of speech, increased motor activity & elated mood, the physician should be informed & the drug should be stopped immediately. Antidepressant tricyclic drugs begin therapeutic effects within four to eight weeks. Accurate recording of the observation made.

44. Mood stabilisers Mood stabilizers are used for the treatment of bipolar affective disorders. Some commonly used mood stabilizers are:- Lithium Carbamazepine Sodium Valproate

45. 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.

46. 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.

47. Acute mania Prophylaxis for bipolar & unipolar mood disorder. schizoaffective disorder Cyclothymia Impulsivity & aggression Other disorders: Premenstrual dysphoric disorder Bulimia nervosa Borderline personality disorder Episodes of binge drinking Trichotillomania Cluster headaches

48. 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.

49. Dose 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.

50. 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

51. 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. 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.

52. Sign & symptoms of lithium toxicity (serum lithiumlevel >2.0 mEq /L): – Ataxia – Coarse tremor (hand) – Nausea & vomiting – Impaired memory – Impaired concentration – Nephrotoxicity – Muscle weakness – Convulsions – Muscle twitching – Dysarthria – Lethargy – Confusion – Coma – Hyperreflexia – Nystagmus

53. 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.

54. Contraindication Cardiac, renal, thyroid or neurological dysfunctions Presence of blood dyscrasias During first trimester of pregnancy & lactation Severe dehydration Hypothyroidism

55. Nurses 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 assessed, as the drug is known to depress the thyroid gland.

56. 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. 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.

57. Anti-anxiety & Hypnosedatives Anti Anxiety drug for different disorders

58. 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. Anti-anxiety drugs relieve moderate to- severe anxiety & tension

59. 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.

60. 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.

61. Contraindications Patients with renal or liver & respiratory impairment are given antianxiety drugs with caution.

62. Side effects Central nervous system: drowsiness, ataxia, confusion, depression, blurred vision. Cardiovascular system: hypotension, palpitation, syncope. Endocrine: change in libido. Allergic: skin rash. Physical / psychological dependence non- benzodiazepines & barbiturate group of drugs has a high risk of abuse & physical dependence. Acute toxicity of barbiturate that can be fatal when taken in excessive dosage usually for suicide attempts. Overdose can cause tachycardia, hypotension, shock, respiratory depression,coma & death.

63. Nurses 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.

64. 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.

65. Antiparkinsonian Agents

66. Description Antiparkinsonian agents are the specific drugs to treat the extra-pyramidal side effects of antipsychotic agents like parkinsonism, akathisia, acute dystonia & tardive dyskinesia.

67. Mode of action Anticholinergic drugs block the secretion, thereby reducing the symptoms of akathesia & acute dystonia. It is not effective against tardive dyskinesia. Antihistamines have effects like anticholinergic drugs. Amantadines are dopamine-releasing agents from central neurons. Studies show that this drug may affect some clients with tardive dyskinesia.

68. Indication Antiparkinsonian drugs are used to treat the extrapyramidal symptoms.

69. Contraindication Patient with history of closed angle glaucoma, urinary or intestinal obstruction, hypersensitivity, prostatic hypertrophy, tachycardia are not given these drugs. The drugs are given with caution to patients with myasthenia gravis, artherosclerosis & chronic respiratory problems. Anticholinergic drugs and Amantadine is given with caution to patients with renal impairment as most of the medication is excreted through the kidney.

70. Side effects Anticholinergic:- Side-effects are dry mouth, flushed, dry skin, blurred vision, photophobia, increased heart rate, constipation, urinary retention, mental confusion & excitement. Antihistamines:- Side-effects are drowsiness, dizziness, anorexia, nausea, vomiting, euphoria, orthostatic hypotension, weight gain, weakness & tingling of hands. Amantadine:- Side-effects are mood changes, slurred speech, insomnia, inability to concentrate, dry mouth, livedo reticularis that is a red-blue netlike discolouration of the skin which becomes worse in winter.

71. Nurses responsibility Observation of the patient for side- effects of anti- parkinsonian drugs such as tachycardia, palpitation, sedation, drowsiness & blurred vision. Maintain an intake output chart in case the patient has urinary retention or constipation. Encourage adequate intake of fluids & roughage in the diet. Record vital sign such as B.P., pulse & respiration every four hours. Advise the patient not to get up quickly from a lying- down position to sitting because of orthostatic Educate the patient not to use hazardous machinery or driving when he is on anticholinergic drugs. Encourage the patient to get his routine eye check-up done for early detection of blurred vision or glaucoma. Record the medicine & side-effects accurately. Report & record any side-effects observed to the physician.

72. Antabuse drugs

73. Disulfiram is an important drug In this class and is used to ensure abstinence in the treatment of alcohol dependence. Its main effect is to produce a rapid and violently unpleasant reaction in a person who ingest even a small amount of alcohol while taking disulfiram.

74. Anticraving drugs

75. Through detoxification process the withdrawal symptoms of a particular type of drug or chemical are managed as the toxin from the drug are removed from the body. The removal of drug is accompanied by craving physical, psychological and emotional. A number of stimuli can put off a craving response within the brain . Anti craving drugs seems to work by blocking the receptor associated with cues that set relapse. Several different addiction are being treated with use of anti craving medication after detoxification. These drugs are used to help prevent relapse both during the detox phase and in early recovery phase. Commonly used anti craving drugs are Naltrexone, Naloxone. Subutex, Topiramate, Baclofen, Acomproste , Methadone, Neurontin etc

76. Drug used in child psychiatry

77. Clonidine-MOA Alpha2- adrenergic receptors agonist. The agonist effects of clonidine on presynaptic alpha 2-adrenergic receptors result in a decrease in the amount of neurotransmitters released from the presynaptic nerve terminals. This decrease serves generally to reset the sympathetic tone at a lower level & to decrease arousal.

78. Indication Control of withdrawal symptoms from opioids. Tourette‘s disorder Control of aggressive or hyperactive behaviour in children Autism Dosage Usual starting dosage is 0.1mg orally twice a day; the dosage can be raised by 0.3 mg a day to an appropriate level.

79. Side effects Dry mouth Dryness of eyes Fatigue Irritability Sedation Dizziness Nausea Vomiting Hypotension & constipation

80. Nurses responsibility Monitor BP, the drug should be withheld if the patient becomes hypotensive. Advise frequent mouth rinses & good oral hygiene for dry mouth.

81. Methylphenidate (Ritalin) Description Methylphenidate Dextroamphetamine & pemoline are sympathomimetics.

82. Mechanism of action Sympathomimetics cause the stimulation of alpha & beta-adrenergic receptors directly as agonists & indirectly by stimulating the release of dopamine & nor-epinephrine from presynaptic terminals. Dextroamphetamine & methylphenidate are also inhibitors of catecholamine reuptake, especially dopamine reuptake & inhibitors of monoamine oxidase. The net result of these activities is believed to be the stimulation of the several brain regions.

83. Indication Attention-deficit hyperactivity disorder Narcolepsy Depressive disorders Obesity

84. Side effects Anorexia or dyspepsia Weight loss Slowed growth Dizziness Insomnia or nightmares Dysphoric mood Psychosis Dosage Starting dose is 5-10 mg per day orally, maximum daily dose is 80mg/day

85. Assess mental status for change in mood, level of activity, degree of stimulation & aggressiveness. Ensure that the patient is protected from injury. Keep stimuli low & environment as quiet as possible to discourage over stimulation. To decrease anorexia, the medication may be administered immediately after meals. The patient should be weighed regularly during hospitalization & at home while on therapy with CNS stimulants, due to the potential for anorexia/ weight loss & temporary interruptions of growth & development.

86. To prevent insomnia administer last dose at least 6 hours before bedtime. In children with behavioural disorders a drug holiday should be attempted periodically under the direction of the physician to determine effectiveness of the medication & the need for continuation. Ensure that parents are aware of the delayed effects of Ritalin. Therapeutic response may not seen for 2-4 weeks; the drug should not be discontinued for lack of immediate results. Inform parents that OTC (over-the-counter) medications should be avoided while the child is on stimulant medication. Some OTC medications, particularly cold & hay fever preparation contain certain sympathomimetic agents that could compound the effects of the stimulants & create drug interactions that may be toxic to the child. Ensure that parents are aware that the drug should not be withdrawn abruptly. Withdrawal should be gradual & under the direction of the physician.

87. Electroconvulsive therapy

88. Electroconvulsive therapy, or ECT for short, is a treatment that involves sending an electric current through your brain, causing a brief surge of electrical activity within your brain (also known as a seizure). The aim of the treatment is to relieve the symptoms of some mental health problems. Electroconvulsive therapy is the artificial induction of a grandmal seizure through the application of electrical current to the brain . The stimulus is applied through electrodes that are placed either bilaterally in the fronto -temporal region or unilaterally on the non dominant side (right side of the head in a right handed individual).

89. Types of ECT Direct ECT: in this ECT is given in the absence of the anesthesia and muscular relaxation. This is not a commonly used method now. Modified: Here ECT is modified by drug induced muscular relaxation and general anesthesia.

90. Application of Electrodes Bilateral ECT : Each electrode is placed 2.5-4 cm above the midpoint, on a line joining on a line joining the tragus of the ear and the lateral canthus of the eye. Unilateral ECT: Electrodes are placed only on one side of the head usually non dominant side . Unilateral ECT is safer with much fewer side effects , particularly those of memory impairment.

91. Indication Major depression: With suicidal risk; Stupor; poor intake of foods and fluids; melancholia with psychotic features; unsatisfactory response to drugs or where drugs are contraindicated or have serious effects. Severe catatonia : With stupor; poor intake of food and fluids satisfactory response to drug therapy, or when drugs are contraindicated or have serious side effects. Severe psychosis : With risk of suicide, homicide or danger of physical assault; depressive features; unsatisfactory response to drugs therapy or when drugs contraindicated or have serious side effects. Organic mental disorder: Organic mood disorder, Organic psychosis

92. Contraindications Absolute : Raised ICP (Intracranial Pressure) Relative: Cerebral Aneurysm, Cerebral Hemorrhage, Brain Tumor, Acute Myocardial Infarction, Congestive heart failure, Pneumonia or aortic aneurysm, Retinal detachment

93. ECT Team Psychiatrist, anesthesiologist, trained nurses and aides should be involved in the administration of ECT.

94. Role of nurse during ECT Nursing Care in ECT Electroconvulsive therapy is treated like a minor surgical procedure that requires preoperative preparation and postoperative care. There are four components of nursing care in ECT Providing educational and emotional support Pre-treatment planning and assessment Preparing and monitoring the patient during the actual procedure Post-treatment care and evaluation

95. Providing Educational and emotional support Explain the procedure to the patient Obtain an informed consent from the patient and the caregiver Respond to patient’s concerns and feelings. Educate the patient concerning the procedure and explain to the patient the necessary tasks associated with ECT. Initiate education interventions based on knowledge deficits

96. Pre-treatment Nursing care Preparation of treatment suite for the ECT procedure An adjustable height stretcher trolley 2 Complete the pre-treatment check list. The patient’s identity is checked and the patient wears an identity bracelet. Ensure safekeeping of the patient’s valuables. NPO for minimum 4 hours before treatment to prevent possible aspiration during anaesthesia. The patient’s hair should be clean and dry to allow for electrode contact.

97. Hairpins, bracelets, body piercing should be removed to avoid burns. The patient should be encouraged to pass urine before the treatment to avoid incontinence during the procedure. Prostheses, dentures, glasses, hearing aids, contact lenses, should be removed. Minimise anxiety through anxiety management techniques, ensuring short waiting time and offering reassurance and support. Standard practices should be practiced regarding general anaesthesia care.

98. Nursing Care during ECT Procedure Transfer the patient on a trolley from the waiting room to the ECT room on a well padded bed and placed in a comfortable dorsal position or supine position. A small pillow is placed under the lumber curve. Apply ECG electrodes, BP cuff, and pulse oximetry sensor (not on same extremity as BP cuff). Give a short acting anaesthetic agent. Thiopental .25mg to .5 mg, IV and secoline (succynyl choline) 30-50 mg. The dose of drug may vary from patient to patient. Prepare EEG electrodes, per treatment specifications. Prepare scalp and stimulus ECT electrodes (unilateral vs. bilateral) and apply paste to electrodes. Support the shoulder and arms of the patient. Restraint the thigh with the help of a sheet.

99. Hyperextension of the head with support to the chin. Administer oxygen Apply jelly to the electrodes Make the observations of the convulsions. The presence of initial tonic stage which lasts for 10-15 seconds followed by clonic stage which lasts for 25-30 sec then there is a phase of muscular relaxation with stertorus respiration i.e flaccid stage. Do suction immediately Restore respiration by giving O2 if necessary

100. Post-ECT Care Observe and record the vital parameters Place the patient on side lying position, clean the secretions Transfer the patient from recovery room. Record vital signs every 15 min for 30 min and once in every 30 min till the patient recover to the normal stage. Allow the patient to sleep for 30 min to one hour Reassure the client and reorient to the ward Allow the patient to have tea or any drinks Record the procedure

101. Light therapy

102. Light therapy sometimes called phototherapy, involves exposing the patient to an artificial light source during winter months to relieve seasonal depression. The light source must be very bright, full spectrum. Indication: Bulimia, Sleep Maintaince insomnia, Seasonal Depression, Adverse Effect: Nausea, Eye Irritation, Headache Nurse Role: The patient is instructed to sit in front of the light at a distance of about 3 feet, engaging in a variety of others activities, but glancing directly into every few minutes. The directly into light. The duration of administration 1-2 hours daily.

103. Psychotherapy

104. Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.

105. Principles Psychological problems are based, in part, on faulty or unhelpful ways of thinking. Psychological problems are based, in part, on learned patterns of unhelpful behavior. People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.

106. CBT treatment usually involves efforts to change thinking patterns. These strategies might include: Learning to recognize one’s distortions in thinking that are creating problems, and then to reevaluate them in light of reality. Gaining a better understanding of the behavior and motivation of others. Using problem-solving skills to cope with difficult situations. Learning to develop a greater sense of confidence in one’s own abilities. Facing one’s fears instead of avoiding them. Using role playing to prepare for potentially problematic interactions with others. Learning to calm one’s mind and relax one’s body It is important to emphasize that advances in CBT have been made on the basis of both research and clinical practice. Indeed, CBT is an approach for which there is ample scientific evidence that the methods that have been developed actually produce change. In this manner, CBT differs from many other forms of psychological treatment.

107. Music Therapy

108. Music therapy is a therapeutic approach that uses the naturally mood-lifting properties of music to help people improve their mental health and overall well-being. It’s a goal-oriented intervention that may involve: Making music Writing songs Singing Dancing Listening to music Discussing music   This form of treatment may be helpful for people with depression and anxiety, and it may help improve the quality of life for people with physical health problems. Anyone can engage in music therapy; you don’t need a background in music to experience its beneficial effects.

109. Cognitive behavioral music therapy (CBMT) : This approach combines cognitive behavioral therapy (CBT) with music. In CBMT, music is used to reinforce some behaviors and modify others. This approach is structured, not improvisational, and may include listening to music, dancing, singing, or playing an instrument. Community music therapy : This format is focused on using music as a way to facilitate change on the community level. It’s done in a group setting and requires a high level of engagement from each member . Vocal psychotherapy : In this format, you use various vocal exercises, natural sounds, and breathing techniques to connect with your emotions and impulses. This practice is meant to create a deeper sense of connection with yourself.

110. Marital Therapy

111. Marital therapy is a type of counseling specifically for couples, focusing on improving their relationship. It helps partners address and resolve conflicts, enhance communication, and strengthen their emotional connection. Emotionally Focused Therapy: EFT focuses on improving the attachment and bonding between you and your partner. The therapist helps you understand and change patterns that lead to feelings of disconnection. Gottman method:  This method involves addressing areas of conflict and equipping you and your partner with problem-solving skills. It aims to improve the quality of friendship and the level of intimacy between you and your partner. 

112. Ellen Wachtel’s approach:  This is a strength-based approach that involves focusing on the positive aspects of the relationship. It focuses on self-reflection rather than blame. Psychodynamic couple’s therapy:  Psychodynamic therapy explores the underlying hopes and fears that motivate you and your partner, to help you understand each other better. Behavioral therapy:  Also known as behavioral couples therapy (BCT), this form of therapy involves shaping behavior by reinforcing positive behaviors that promote stability and satisfaction, while discouraging behaviors that foster negativity

113. Supportive therapy

114. Supportive therapy is a form of psychotherapy that relies on the therapeutic alliance to alleviate symptoms, improve self-esteem, restore relation to reality, regulate impulses and negative thinking, and reinforce the ability to cope with life stressors and challenges . The specific techniques used in supportive psychotherapy may vary depending on the needs of the client, but some common techniques include: Active listening:  The therapist listens carefully to your concerns and validates your feelings. Empathy:  The therapist shows empathy and understanding towards your situation, helping you feel supported.

115. Encouragement:  The therapist provides encouragement and positive feedback, helping you build self-confidence and a sense of accomplishment. Psycho-education:  The therapist provides information about mental health issues and coping strategies, helping you develop greater insight and understanding. Problem-solving:  The therapist helps you identify and address specific problems or challenges. Reframing:  The therapist helps you view your situation from a different perspective, reframing negative thoughts and emotions in a more positive light.

116. Family Therapy

117. Family therapy is a form of talk therapy that focuses on the improvement of relationships among family members. It can also help treat specific mental health or behavioral conditions, such as substance use disorder or oppositional defiant disorder. Family therapy can involve any combination of family members .

118. Family therapy is a form of group psychotherapy (talk therapy) that focuses on the improvement of interfamilial relationships and behaviors. A family unit is a group of people who care about each other. In family therapy, a group can consist of many different combinations of loved ones, such as parents/guardians and their children, siblings, grandparents, aunts and uncles, friends, kinship caregivers, etc. Therapy can help with situations such as: Adjusting to a new life change (like moving) or a medical condition. Changes and challenges that come with aging. Death and grief. Relationship conflicts, such as parent-child conflict or sibling conflict.

119. Mental health professionals also use family therapy to help treat certain mental health or behavioral conditions for one person within the family unit. For example, family therapy involving all or multiple members of the family can help treat anorexia for one person in the family. Family therapy takes place with a trained, licensed mental health professional, such as a psychologist, therapist or counselor, who has specialized knowledge in working with families. Oftentimes, they’re Licensed Marriage and Family Therapists (LMFTs). Therapy can provide support, education and guidance to you and your loved ones to help you function better and increase your well-being. There are several different types of family therapy that vary widely in terms of therapy length, techniques and treatment goals.

120. Dance Therapy

121. Dance/movement therapy, or DMT, is the psychotherapeutic use of movement to promote emotional, social, cognitive, and physical integration. DMT can help people with physical health by increasing strength, improving flexibility, decreasing muscle tension, and boosting coordination. It can also offer important mental health benefits including stress reduction and even symptom relief from conditions such as anxiety and depression.

122. In a dance therapy session, a therapist may: Help you explore and make meaning on the connection between movement and your emotions Encourage tracking of bodily sensations and breath Help guide you through self-expressive and improvisational movements Offer specific movement or verbal therapeutic interventions to promote healing Help you process the feelings evoked by the movement

123. Recreational Therapy/Play Therapy

124. Recreational therapy, also known as therapeutic recreation, is a systematic process that utilizes recreation and other activity-based interventions to address the assessed needs of individuals with illnesses and/or disabling conditions, as a means to psychological and physical health, recovery and well-being.

125. Recreational therapy can take place in a variety of settings, including: hospitals schools Inpatient and outpatient mental health facilities and programs skilled nursing facilities assisted living facilities sports programs substance use programs correctional facilities community center

126. Relaxation Therapy

127. Relaxation therapy refers to a number of techniques designed to teach someone to be able to relax voluntarily. These techniques can include special breathing practices and progressive muscle relaxation exercises, which are designed to reduce physical and mental tension. There are a number of other activities that can promote relaxation, including massage, listening to music, yoga and meditation.

128. Techniques Practicing relaxation techniques can have many benefits, including: Slowing heart rate Lowering blood pressure Slowing your breathing rate Improving digestion Maintaining normal blood sugar levels Reducing activity of stress hormones Increasing blood flow to major muscles Reducing muscle tension and chronic pain Improving concentration and mood Improving sleep quality Lowering fatigue Reducing anger and frustration Boosting confidence to handle problems