Psychopharmacology

this content is for bsc nursing 3rd year

1. PSYCHOPHARMACOLOGY UNIT-V Treatment modalities & Therapies used in Mental disorders Presented by, Mr. Vipin Chandran

2. INTRODUCTION … 2 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.

3. Co u nt… 3 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. DEFINITION OF PSYCHOTROPIC DRUGS 4 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.

5. 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

6. Co u nt… 6 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.

7. Co u nt … … 7 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.

8. PATIENT EDUCATION RELATED TO PSYCHOPHARMACOLOGY… 8 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.

9. Specific areas of education include the following… 9 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.

10. Co u nt… 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

11. Co u nt… 11 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.

12. CLASSIFICATIONS OF PSYCHOTROPIC DRUGS 12 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.

13. ANTIPSYCHOTIC AGENTS 13

14. DESCRIPTION:- 14 Antipsychotic agents are also known as neuroleptic, major tranquillizers, or phenothaiazines . 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.

15. MODE OF ACTION:- 15 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.

16. Class Examples of drugs Trade name Oral dose mg/day Parenteral 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 CLASSIFICATION:- 16

17. C l ass Count… 17 Examples of drugs Trade name Oral dose mg/day Parenteral dose (mg) Dip he n ylb u t y l P i m o zide o r ap 4 - 20 piperidines penfluridol flu m ap 20 - 60 w e e k l y - Indolic der i v a ti v es mo l indon e mobam 50-225 - Dibenzoxazepines l o x apine loxapac 25-100 - Atypical a n ti p s y c h otics Clozapine Rispe r idone Olanzapine Quetiapine Ziprasidone Sizopine, Lozapin Sizodon, sizomax Oleanz Qu t an Zisper 50-450 2-10 10-20 150-750 mg 20-80 mg Ot he r s reserpine serpasil 0. 5 - 50

18. INDICATIONS 18 Organic psychiatric disorders: Delirium Dementia Delirium tremens Drug-induced psychosis & other organic mental disorders Functional disorders: Schizophrenia Schizoaffective disorders Paranoid disorders Mood disorders: Mania Major depression with psychotic symptoms Childhood disorders : Attention-deficit hyperactivity disorder Autism Enuresis Conduct disorder

19. Co u nt… Medical disorders: Huntington‘s chorea Intractable hiccough Nausea & vomiting Tic disorder Eclampsia Heart stroke severe pain in malignancy tetanus 19 Neurotic & other psychiatric disorders: Anorexia nervosa Intractable obsessive- compulsive disorder Severe, intractable & disabling anxiety

20. PHARMA C OKINETICS 20 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.

21. SIDE-EFFECTS 21 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.

22. Co u nt… 22 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 S alivation S lurred S peech M ask like face S huffling gait

23. Co u nt… 23 ii. Akathisia:- Akathisia occurs in 50% of all the patients presenting extrapyrimidal 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. Before administering anti-parkinsonian medication anxiety should be ruled out.

24. Co u nt… 24 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.

25. Co u nt… 25 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.

26. Co u nt… 26 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.

27. Co u nt… 27 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.

28. NURSE’S Responsibility 28 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.

29. Co u nt… 29 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. Accurate rout e 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.

30. Co u nt… 30 Blurred or impaired vision in the patient causes anxiety & annonyance to him. The patient should be encouraged to inform these symptoms immediately. 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.

31. ANTIDEPRESSANTS AGENTS 31

32. DESC R IPTION 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. 32

33. MODE OF ACTION 33 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 & ser o t o nin 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.

34. CLASSIFICATION CLASS EXAMPLES OF DRUGS TRADE NAME ORAL DOSE (mg/day) Tricyclic antidepressants (TCAs) Imipramine Amitriptyline Clo m ip r am i ne Dothiepin mianserin Antidep Tryptomer Anafranil P r othiaden depnon 75-300 75-300 75-300 75-300 30-120 Selective serotonin reuptake inhibitors (SSRIs) Fluoxetine Sertraline Fludac Serenata 10-80 50-200 Dopaminergic antidepressants fluvoxamine faverin 50-300 Atypical antidepressants amineptine survector 100-400 Monoamine oxidase inhibitors (MAOIs) 4/24/2013 Trazodone isocarboxazid Trazalon Marplan 150-600 10-30 37

35. INDICATIONS 35 Depression Depressive episode Dysthymia Reactive depression Secondary depression Abnormal grief reaction Childhood psychiatric disorders Other psychiatric disorders Panic attack Generalized anxiety disorder Agrophobia, social phobia OCD with or without depression Eating disorder Borderline personality disorder Post-traumatic stress disorder Depersonalization syndrome Enuresis Separation anxiety disorder  Medical disorder Somnambulism School phobia Night terrors Chronic pain Migraine Peptic ulcer disease

36. PHA R MAC O KINETICS 36 Antidepressants are highly lipophilic & protein-bound. The half-life is long & usually more than 24 hours. It is predominantly metabolized in the liver.

37. CO N TR A INDI C ATION 37 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.

38. SIDE EFFECTS 38 Autonomic side-effects: Dry mouth, constipation, cycloplegia, mydriasis, urinary retention, orthostatic hypotension, impotence, impaired ejaculation, delirium & aggravation of glaucoma. CNS effects:- Sedation, tremor & other extrapyramidal symptoms, withdrawal syndrome, seizures, precipitation of mania. Cardiac side-effects:- Tachycardia, ECG changes, arrhythmias, direct myocardial depression.

39. C o u n t… 39 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.

40. NURSE’S RESPONSIBILITY 40 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 patient complains of nausea & vomiting.

41. Co u nt… 41 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. 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 .

42. MOOD STABILIZING DRUGS 42

43. Mood stabilizers are used for the treatment of bipolar affective disorders. Some commonly used mood stabilizers are:- Lithium Carbamazepine Sodium Valproate 43

44. LITHIUM 44

45. DESCRIPTION 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. MODE OF ACTION 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. INDICATION Acute mania Prophylaxis for bipolar & unipolar mood disorder. Sch i z o af f e c ti v e disorder Cyclothymia Impulsivity & aggression 47 Other disorders: Premenstrual dysphoric disorder Bulimia nervosa Borderline personality disorder Episodes of binge drinking Trichotillomania Cluster headaches

48. PHARMA C OKINETICS 48 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. DOSAGES 49 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 50 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. SIDE EFFECTS 51 Neurological: Tremors, motor hyperactivity, 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. •

52. MANAGEMENT OF LITHIUM TOXICITY:- 52 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.

53. CONTRAINDICATION OF LITHIUM:- 53 Cardiac, renal, thyroid or neurological dysfunctions Presence of blood dyscrasias During first trimester of pregnancy & lactation Severe dehydration Hypothyroidism History of seizures

54. NURSE’S RESPONSIBILITY:- 54 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.

55. Co u nt… 55 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.

56. Co u nt… 56 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.

57. C o u n t… 57 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.

58. CARBAMAZEPINE 58

59. DESC R IPTION 59 It is available in the market under different trade names like Tegretol, Mazetol, Zeptol & Zen Retard.

60. MECHANISM OF ACTION 60 Its mood stabilizing mechanism is not clearly established. Its anticonvulsant action may however be by decreasing synaptic transmission in the CNS.

61. INDI C ATIO N S 61 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.

62. DOS A GE 62 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 13 µg/ml .

63. SIDE EFFECTS 63 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.

64. NURSE’S Responsibility 64 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.

65. SODIUM VALPROATE 65 ( ENCORATE CHRONO, VALPARIN, EPILEX, EPIVAL )

66. MECHANISM OF ACTION 66 The drugs acts on gamma- aminobutyric acid (GABA) an inhibitory amino acid neurotransmitters. GABA receptors activation serves to reduce neuronal excitability.

67. INDI C ATION 67 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.

68. DOS A GE 68 The usual dose is 15 mg/kg/day with a maximum of 60mg/kg/day orally.

69. SIDE EFFECTS 69 Nausea, vomiting, diarrhea, sedation, ataxia, dysarthria, tremor, weight gain, loss of hair, thrombocytopenia, platelet dysfunction.

70. NURSE’S RESPONSIBILITY Explain to the patient to take the drug immediately after food to reduce GI irritation. Advise to come for regular follow-up & periodic examination of blood count, hepatic function & thyroid function. Therapeutic serum level of valproic acid is 50-100 micrograms/ml. 70

71. ANTIANXIETY AGENTS, INCLUDING SEDATIVES AND HYPNOTICS 71

72. DESC R IPTION 72 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.

73. MODE OF ACTION 73 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.

74. INDICATIONS 74 Antianxiety agents are used to relieve mild, moderate & severe anxiety associated with: emotional disorders For control of alcohol withdrawal symptoms. To control convulsions. To produce skeletal muscle relaxation. To provide short-term sleep preoperatively, prior to diagnosis & insomnia.

75. CO N TR A INDI C ATIO N S 75 Patients with renal or liver & respiratory impairment are given antianxiety drugs with caution.

76. CLASSIFICATION OF ANTIANXIETY AGENTS:- CHEMICAL GROUP & GENERIC NAME TRADE NAME RANGE OF DAILY DOSAGE IN mgm ACTION I. Non-Barbiturates A. Benzodiazepines Chlordiazepoxide Diazepam Oxazepam Prazepam Chlorazapate Flurazepam Nitrazepam lorazepam Librium, E q u ib r ome Valium, Calmpose Serepax Verstran Tranzene Azene Dalmane, Nitravet Mogadon ativan 15-100 6-50 30-120 20-60 11.25-60 15-60 10-30 2-6 These are non- barbiturate be n z odia z epi n es. They produce a tranquillizing effect without much sedation. These drugs are potential for abuse. 82

77. COU N T… CHEMICAL GROUP & GENERIC NAME TRADE NAME RANGE OF DAILY DOSAGE IN mgm ACTION A. Non- Ben z od i a z epi n e Propanediols Meprobamate Equanil Miltown T ybam a t e 1.2-1.6 1.2-1.6 1.2-1.6 These drugs have sedative action & present a high risk of abuse & physical dependence. 83 II. Antihistamines Hydroxyzine Atarax vistaril 30-200 30-200

78. CLASSIFICATION OF SEDATIVES AND HYPNOTICS:- CHEMICAL GROUP & GENERIC NAME TRDE NAME HYPNOTIC DOSE RANGE- DAILY IN mgm SEDATIVE DOSE DAILY IN mgm. ACTION III. Barbiturates These drugs cause drowsiness lethargy, decrased alertness & sleep. Tolerance to drug can occur within 7-14 days, resulting in physical dependence. 84 Amobarbidtal SA Amytal 100-200 60-150 Butabarbital SA Butisol 100-200 20-200 Pentobarbital LA Nembutal 100-200 60-150 Phenobarbital LA Luminal 100-200 30-90 Thiopental USA pentothal Used for anasthesia IV. Nonbarbiturates

79. COU N T… CHEMICAL GROUP & GENERIC NAME TRDE NAME HYPNOTIC DOSE RANGE- DAILY IN mgm SEDATIVE DOSE DAILY IN mgm. ACTION 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 hydrate Beta-chlor 870mg-1gm Chloral betaine VIII. Monoureides 85

80. SIDE – EFFECTS OF ANTIANXIETY, SEDATIVES & HYPNOTICS Central nervous system : drowsiness, ataxia, confusion, depression, blurred vision. Cardiovascular system : hypotension, palpitation, syncope. 80 Endocrine : change in libido. Allergic : skin rash.

81. NURSE’S RESPONSIBILITY 81 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.

82. COU N T… 82 Give IM injection 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.

83. ANTIPARKINSONIAN AGENTS 83

84. DESCRIPTION 84 Antiparkinsonian agents are the specific drugs to treat the extrapyramidal side- effects of antipsychotic agents. Side-effects are parkinsonism, akathisia, acute dystonia & tardive dyskinesia. Anticholinergics, antihistamines & amantidne are used to treat these side- effects.

85. MODE OF ACTION 85 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.

86. INDI C ATION 86 Antiparkinsonian drugs are used to treat the extrapyramidal symptoms.

87. CONT R INDICATION 87 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 mysthesia gravis, arthesclerosis & chronic respiratory problems. Anticholinergic drugs: Amantadine is given with caution to patients with renal impairment as most of the medication is excreted through the kidney.

88. CLASSIFICATION CHEMICAL & GENERIC NAME TRADE NAME DOSE RANGE PER DAY mgm/Day FROM OF AVAILABILITY I. Anticholinergic Benztropine Biperiden HCL Hydrochiride T r i h e xyp h enidyl Hydrochiride Procyclidine hydrochiride Cogentin Akin e t one Dyskinon Pacitane Parbenz kemadrin 0.5-6.0 2.0-8.0 2.0-12.0 5.0-20mg Tab, injection -do- - d o - T ab. Tab. II. Antihistamine Diphenhydramine Benadryl 75-100 Capsule & syrup III. Dopamine Drugs L. Dopa Amantadine Hydrochiride Selegline Carbidopa & L.Dopa. Larodopa S ymme t r el Deprenyl Sinemet 2 gms-3gms 100 -200gms 5-10mg 10-100mg Tab. Tab . Tab. Tab. 95

89. SIDE-EFFECTS 89 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.

90. NURSE’S RESPONSIBILITY 90 Observation- 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 hypotension.

91. COU N T… 91 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.

92. DRUGS USED IN CHILD PSYCHIATRY 92

93. CLONIDINE METHYLPHENIDATE (RITALIN):- 93

94. CLONIDINE 94

95. MECHANISM OF ACTION 95 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.

96. INDI C ATION 96 Control of withdrawal symptoms from opioids. Tourette‘s disorder Control of aggressive or hyperactive behavior in children Autism.

97. DOS A GE 97 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.

98. SIDE-EFFECTS 98 Dry mouth, dryness of eyes, fatigue, irritability, sedation, dizziness, nausea, vomiting, hypotension & constipation.

99. NURSE’S RESPONSIBILITY Monitor BP, the drug should be withheld if the patient becomes hypotensive. Advise frequent mouth rinses & good oral hygiene for dry mouth. 99

100. METH Y LPH E NIDATE (RITALIN) 100

101. DESC R IPTION 101 Methylphenidate , dextroamphetamine & pemoline are sympathominetics.

102. MECHANISM OF ACTION 102 Sympathomimetics cause the stimulation of alpha & beta-adrenergic receptors directly as agonists & indirectly by stimulating the release of dopamine & norepinephrine from presynaptic terminals. Dextroamphetamine & methylphenidate are also inhibitors of catecholamine reuptake, especially dopamine reuptake & inhibitors of monoamino oxidase. The net result of these activities is believed to be the stimulation of the several brain regions.

103. INDI C ATION 110 Attention-deficit hyperactivity disorder Narcolepsy Depressive disorders Obesity

104. DOS A GE 104 Starting dose is 5-10 mg per day orally, maximum daily dose is 80mg/day.

105. SIDE-EFFECTS 105 Anorexia or dyspepsia, weight loss, slowed growth, dizziness, insomnia or nightmares, dysphoric mood, tics & psychosis.

106. NURSE’S RESPONSIBILITY 106 Assess mental status for chang 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.

107. CO U NT… 107 To prevent insomnia administer last dose at least 6 hours before bedtime. In children with behavioral 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.

108. CO U NT… 108 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 withdraw abruptly. Withdrawal should be gradual & under the direction of the physician.