Therapeutic modalities ( Psychopharmacology).pptx

This ppt contains psychopharmacology such as antipsychotics, antidepressants

1. THERAPEUTIC MODALITIES

2. PSYCHOPHARMACOLOGY 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. PSYCHOTROPIC DRUGS Psychotropic drug is any drug that has primary effects on behavior, experience, or other psychological functions. 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. 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.

5. 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. 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.

6. 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. 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.

7. 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.

8. 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.

9. 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

11. CLASSIFICATIONS OF PSYCHOTROPIC DRUGS 1. Antipsychotic agents 2. Antidepressant agents 3. Mood stabilizing drug 4. Anxiolytics & hypnosedatives 5. Antiepileptic drug 6. Antiparkinsonian drugs 7. Miscellaneous drugs which include stimulants, drugs used in eating disorders, drugs used in deaddiction, drugs uses in child psychiatry, vitamins, calcium channel blockers etc.

12. ANTIPSYCHOTIC AGENTS 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.

13. 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.

14. INDICATIONS Organic psychiatric disorders: Delirium Dementia Delirium tremens Drug-induced psychosis & other organic mental disorders Functional disorders: Schizophrenia Schizoaffective disorders Paranoid disorders

15. Mood disorders: Mania Major depression with psychotic symptoms Childhood disorders: Attention-deficit hyperactivity disorder Autism Enuresis Conduct disorder

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

17. CLASSIFICATION TYPICAL ANTIPSYCHOTICS ATYPICAL ANTIPSYCHOTICS Phenothiazines chlorpromazine 40-100 mg Perphenazine 12- 64 mg Fluphenazine 1- 40 mg Thioxanthenes thiothixene 6- 30 mg Butyrophenones Haloperidol 1- 100 mg Dibenzothiazepine Quietapine 150- 750 mg Clozapine 300- 900 mg Resperidone 4- 16 mg Olanzapine 5- 20 mg

18. FIRST GENERATION ANTIPSYCHOTIC ( Low potency ) Chlorpromazine Thioridazine FIRST GENERATION ANTIPSYCHOTIC ( High potency ) Fluphenazine Haloperidol Thiothixene SECOND GENERATION ANTIPSYCHOTIC Clozapine Resperidone Olanzapine Quietapine

19. 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.

20. SIDE-EFFECTS Extrapyramidal symptoms (EPS) Neuroleptic-induced parkinsonism Akathisia Acute Dystonia Tardive Dyskinesia Neuroleptic Malignant Syndrome 2. Autonomic Nervous System 3. Seizures 4. Sedation 5. Other effects

21. NURSE’S RESPONSIBILITY

22. ANTIDEPRESSANTS 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.

23. CLASSIFICATION Tricyclic antidepressants ( TCA’s ) Imipramine Clomipramine Selective serotonin reuptake inhibitors Flouxetine Sertraline Dopaminergic antidepressants Fluvoxamine Atypical antidepressants Amineptine Monoamine oxidase inhibitors Trazodone Isocarboxazid

24. MODE OF ACTION 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 & 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 monoamine oxidase in breaking down excess of NE & 5-HT at the presynaptic neuron.

25. INDICATIONS Depression Depressive episode Dysthymia Reactive depression Secondary depression Abnormal grief reaction  Childhood psychiatric disorders Enuresis Separation anxiety disorder Somnambulism School phobia Night terrors 

26. 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  Medical disorder Chronic pain Migraine Peptic ulcer disease

27. PHARMACOKINETICS Antidepressants are highly lipophilic & protein-bound. The half-life is long & usually more than 24 hours. It is predominantly metabolized in the liver

28. SIDE 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 extrapyramidal 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

29. 4. Allergic side-effects:- Agranulocytosis, cholestatic jaundice, skin rashes, systemic vasculitis. 5. Metabolic & endocrine side-effects:- weight gain 6. Special effects of MAOI drugs:- Hypertensive crises, severe hepatic necrosis, hyperpyrexia.

30. NURSE’S RESPONSIBILITY

31. MOOD STABILIZING DRUGS Mood stabilizers are used for the treatment of bipolar affective disorders. Some commonly used mood stabilizers are:- 1. Lithium 2. Carbamazepine 3. Sodium Valproate

32. Lithium 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.

33. 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.

34. INDICATION 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

35. 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.

36. DOSAGE 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.

37. 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

38. 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

39. 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.

40. Sign & symptoms of lithium toxicity (serum lithium level>2.0 mEq /L): – Ataxia Coarse tremor (hand) Nausea & vomiting Impaired memory Impaired concentration Nephrotoxicity Muscle weakness Convulsions

41. Muscle twitching Dysarthria Lethargy Confusion Coma Hyperreflexia Nystagmus

42. 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.

43. 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

44. 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.

45. 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.

46. 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.

47. 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.

48. CARBAMAZEPINE It is available in the market under different trade names like Tegretol, Mazetol , Zeptol & Zen Retard

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

50. 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.

51. 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.

52. 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.

53. 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.

54. SODIUM VALPROATE ENCORATE CHRONO VALPARIN EPILEX EPIVAL

55. MECHANISM OF ACTION The drugs acts on gamma- aminobutyric acid (GABA) an inhibitory amino acid neurotransmitters. GABA receptors activation serves to reduce neuronal excitability. DOSAGE The usual dose is 15 mg/kg/day with a maximum of 60mg/kg/day orally.

56. INDICATION 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

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

58. 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.

59. ANTIANXIETY AGENTS, INCLUDING SEDATIVES AND HYPNOTICS 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.

60. 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.

61. INDICATIONS Antianxiety agents are used to relieve mild, moderate & severe anxiety associated with: emotional disorders, physical disorders, excessive environmental stress and 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.

62. CONTRAINDICATIONS Patients with renal or liver & respiratory impairment are given antianxiety drugs with caution.

63. CLASSIFICATION BARBITURATES Phenobarbital Thiopentone NON-BARBITURATE Ethanol Diphenhydramine BENZODIAZEPINES VERY SHORT ACTING Midazolam Triazolam SHORT ACTING Lorazepam Alprazolam LONG ACTING Diazepam

64. 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. SIDE EFFECTS

65. 5) Physical/psychological dependence non- benzodiazepines & barbiturate group of drugs has a high risk of abuse & physical dependence. 6) 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.

66. 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.

67. 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.

68. ANTIPARKINSONIAN AGENTS 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.

69. 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. INDICATION :- Antiparkinsonian drugs are used to treat the extrapyramidal symptoms

70. CONTRAINDICATIONS 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.

71. CLASSIFICATION Anticholinergics Trihexyphenidyl Benztropine Dopaminergic agents Bromocriptine Carbidopa/Levodopa Monoamine Oxidase Type B Inhibitors Selegiline

72. NURSE’S RESPONSIBILITY 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.

73. 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.

74. DRUGS USED IN CHILD PSYCHIATRY 1. CLONIDINE 2. METHYLPHENIDATE

75. CLONIDINE MECHANISM OF ACTION 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.

76. INDICATION Control of withdrawal symptoms from opioids. Tourette‘s disorder Control of aggressive or hyperactive behavior in children Autism.

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

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