Chapter 2 mental health nursing psychopharmacology

Mood stabilizing drugs dosages

Although lithium has many neurobiologic effects, its mechanism of action in bipolar illness is poorly understood. Lithium normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. It also reduces the release of norepinephrine through competition with calcium and produces its effects intracellularly rather than within neuronal synapses; it acts directly on G proteins and certain enzyme subsystems such as cyclic adenosine monophosphates and phosphatidylinositol. Lithium is considered a first-line agent in the treatment of bipolar disorder (Sadock et al., 2015). The mechanism of action for anticonvulsants is not clear because it relates to their off-label use as mood stabilizers. Valproic acid and topiramate are known to increase levels of the inhibitory neurotransmitter GABA. Both valproic acid and carbamazepine are thought to stabilize mood by inhibiting the kindling process. This can be described as the snowball-like effect seen when minor seizure activity seems to build up into more frequent and severe seizures. In seizure management, anticonvulsants raise the level of the threshold to prevent these minor seizures. It is suspected that this same kindling process also may occur in the development of full-blown mania with stimulation by more frequent, minor episodes. This may explain why anticonvulsants are effective in the treatment and prevention of mania as well. (Videbeck 31) Carbamazepine is available in liquid, tablet, and chewable tablet forms. Dosages usually range from 800 to 1200 mg/day; the extreme dosage range is 200 to 2000 mg/day. Valproic acid is available in liquid, tablet, and capsule forms and as sprinkles with dosages ranging from 1000 to 1500 mg/day; the extreme dosage range is 750 to 3000 mg/day. Serum drug levels, obtained 12 hours after the last dose of the medication, are monitored for therapeutic levels of both these anticonvulsants. (Videbeck 31) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Mood stabalizi drugs moa

Although lithium has many neurobiologic effects, its mechanism of action in bipolar illness is poorly understood. Lithium normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. It also reduces the release of norepinephrine through competition with calcium and produces its effects intracellularly rather than within neuronal synapses; it acts directly on G proteins and certain enzyme subsystems such as cyclic adenosine monophosphates and phosphatidylinositol. Lithium is considered a first-line agent in the treatment of bipolar disorder (Sadock et al., 2015). The mechanism of action for anticonvulsants is not clear because it relates to their off-label use as mood stabilizers. Valproic acid and topiramate are known to increase levels of the inhibitory neurotransmitter GABA. Both valproic acid and carbamazepine are thought to stabilize mood by inhibiting the kindling process. This can be described as the snowball-like effect seen when minor seizure activity seems to build up into more frequent and severe seizures. In seizure management, anticonvulsants raise the level of the threshold to prevent these minor seizures. It is suspected that this same kindling process also may occur in the development of full-blown mania with stimulation by more frequent, minor episodes. This may explain why anticonvulsants are effective in the treatment and prevention of mania as well. (Videbeck 31) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antianxiety Side Effects

Although not a side effect in the true sense, one chief problem encountered with the use of benzodiazepines is their tendency to cause physical dependence. Significant discontinuation symptoms occur when the drug is stopped; these symptoms often resemble the original symptoms for which the client sought treatment. This is especially a problem for clients with long-term benzodiazepine use, such as those with panic disorder or generalized anxiety disorder. Psychological dependence on benzodiazepines is common: Clients fear the return of anxiety symptoms or believe they are incapable of handling anxiety without the drugs. This can lead to overuse or abuse of these drugs. Buspirone does not cause this type of physical dependence. The side effects most commonly reported with benzodiazepines are those associated with CNS depression, such as drowsiness, sedation, poor coordination, and impaired memory or clouded sensorium. When used for sleep, clients may complain of next-day sedation or a hangover effect. Clients often develop a tolerance to these symptoms, and they generally decrease in intensity. Common side effects from buspirone include dizziness, sedation, nausea, and headache (Stahl, 2015). Elderly clients may have more difficulty managing the effects of CNS depression. They may be more prone to falls from the effects on coordination and sedation. They also may have more pronounced memory deficits and may have problems with urinary incontinence, particularly at night. (Videbeck 33) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Stimulants MOA

Amphetamines and methylphenidate are often termed indirectly acting amines because they act by causing release of the neurotransmitters (norepinephrine, dopamine, and serotonin) from presynaptic nerve terminals as opposed to having direct agonist effects on the postsynaptic receptors. They also block the reuptake of these neurotransmitters. Methylphenidate produces milder CNS stimulation than amphetamines; pemoline primarily affects dopamine and therefore has less effect on the sympathetic nervous system. It was originally thought that the use of methylphenidate and pemoline to treat ADHD in children produced the reverse effect of most stimulants—a calming or slowing of activity in the brain. However, this is not the case; the inhibitory centers in the brain are stimulated, so the child has greater abilities to filter out distractions and manage his or her own behavior. Atomoxetine helps to block the reuptake of norepinephrine into neurons, thereby leaving more of the neurotransmitter in the synapse to help convey electrical impulses in the brain. (Videbeck 34) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Drug interactions antidepressants

An uncommon but potentially serious drug interaction, called serotonin syndrome (or serotonergic syndrome), can result from taking an MAOI and an SSRI at the same time. It also can occur if the client takes one of these drugs too close to the end of therapy with the other. In other words, one drug must clear the person's system before initiation of therapy with the other. Symptoms include agitation, sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia, and, in extreme reactions, even coma and death (Sadock et al., 2015). These symptoms are similar to those seen with an SSRI overdose. (Videbeck 30) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

antianxiety drugs

Antianxiety drugs, or anxiolytic drugs, are used to treat anxiety and anxiety disorders, insomnia, OCD, depression, posttraumatic stress disorder, and alcohol withdrawal. Antianxiety drugs are among the most widely prescribed medications today. A wide variety of drugs from different classifications have been used in the treatment of anxiety and insomnia. Benzodiazepines have proved to be the most effective in relieving anxiety and are the drugs most frequently prescribed. Benzodiazepines also may be prescribed for their anticonvulsant and muscle relaxant effects. Buspirone is a nonbenzodiazepine often used for the relief of anxiety and therefore is included in this section. Other drugs such as propranolol, clonidine (Catapres), and hydroxyzine (Vistaril) that may be used to relieve anxiety are much less effective and are not included in this discussion. (Videbeck 32) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

antipsychotic drugs often have ____________ side effects

Anticholinergic

antidepressant drugs

Antidepressant drugs are primarily used in the treatment of major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression. Off-label uses of antidepressants include the treatment of chronic pain, migraine headaches, peripheral and diabetic neuropathies, sleep apnea, dermatologic disorders, panic disorder, and eating disorders. Although the mechanism of action is not completely understood, antidepressants somehow interact with the two neurotransmitters, norepinephrine and serotonin, that regulate mood, arousal, attention, sensory processing, and appetite. (Videbeck 28) Antidepressants are divided into four groups: Tricyclic and the related cyclic antidepressants Selective serotonin reuptake inhibitors (SSRIs) MAO inhibitors (MAOIs) Other antidepressants such as desvenlafaxine (Pristiq), venlafaxine (Effexor), bupropion (Wellbutrin), duloxetine (Cymbalta), trazodone (Desyrel), and nefazodone (Serzone) Table 2.5 lists the dosage forms, usual daily dosages, and extreme dosage ranges. p. 28 p. 29 The cyclic compounds became available in the 1950s and for years were the first choice of drugs to treat depression even though they cause varying degrees of sedation, orthostatic hypotension (drop in blood pressure on rising), and anticholinergic side effects. In addition, cyclic antidepressants are potentially lethal if taken in an overdose. During that same period, the MAOIs were discovered to have a positive effect on people with depression. Although the MAOIs have a low incidence of sedation and anticholinergic effects, they must be used with extreme caution for several reasons: A life-threatening side effect, hypertensive crisis, may occur if the client ingests foods containing tyramine (an amino acid) while taking MAOIs. Because of the risk for potentially fatal drug interactions, MAOIs cannot be given in combination with other MAOIs, tricyclic antidepressants, meperidine (Demerol), CNS depressants, many antihypertensives, or general anesthetics. MAOIs are potentially lethal in overdose and pose a potential risk in clients with depression who may be considering suicide. The SSRIs, first available in 1987 with the release of fluoxetine (Prozac), have replaced the cyclic drugs as the first choice in treating depression because they are equal in efficacy and produce fewer troublesome side effects. The SSRIs and clomipramine are effective in the treatment of OCD as well. Prozac Weekly is the first and only medication that can be given once a week as maintenance therapy for depression after the client has been stabilized on fluoxetine. It contains 90 mg of fluoxetine with an enteric coating that delays release into the bloodstream. (Videbeck 28-29) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antipsychotic drugs

Antipsychotic drugs, formerly known as neuroleptics, are used to treat the symptoms of psychosis, such as the delusions and hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorder. Off-label uses of antipsychotics include treatment of anxiety and insomnia; aggressive behavior; and delusions, hallucinations, and other disruptive behaviors that sometimes accompany Alzheimer's disease. Antipsychotic drugs work by blocking receptors of the neurotransmitter dopamine. They have been in clinical use since the 1950s. They are the primary medical treatment for schizophrenia and also are used in psychotic episodes of acute mania, psychotic depression, and drug-induced psychosis. Clients with dementia who have psychotic symptoms sometimes respond to low dosages of conventional antipsychotics. Second-generation antipsychotics can increase mortality rates in elderly clients with dementia-related psychosis. Short-term therapy with antipsychotics may be useful for transient psychotic symptoms such as those seen in some clients with borderline personality disorder. Table 2.3 lists available dosage forms, usual daily oral dosages, and extreme dosage ranges for conventional and atypical antipsychotic drugs. The low end of the extreme range typically is used with older adults or children with psychoses, aggression, or extreme behavior management problems. (Videbeck 23) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antianxiety mechanism of action

Benzodiazepines mediate the actions of the amino acid GABA, the major inhibitory neurotransmitter in the brain. Because GABA receptor channels selectively admit the anion chloride into neurons, activation of GABA receptors hyperpolarizes neurons and thus is inhibitory. Benzodiazepines produce their effects by binding to a specific site on the GABA receptor. Buspirone is believed to exert its anxiolytic effect by acting as a partial agonist at serotonin receptors, which decreases serotonin turnover (Sadock et al., 2015). The benzodiazepines vary in terms of their half-lives, the means by which they are metabolized, and their effectiveness in treating anxiety and insomnia. Table 2.6 lists dosages, half-lives, and speed of onset after a single dose. Drugs with a longer half-life require less frequent dosing and produce fewer rebound effects between doses; however, they can accumulate in the body and produce "next-day sedation" effects. Conversely, drugs with a shorter half-life do not accumulate in the body or cause next-day sedation, but they do have rebound effects and require more frequent dosing. (Videbeck 32) Temazepam (Restoril), triazolam (Halcion), and flurazepam (Dalmane) are most often prescribed for sleep rather than for relief of anxiety. Diazepam (Valium), chlordiazepoxide (Librium), and clonazepam often are used to manage alcohol withdrawal as well as to relieve anxiety. (Videbeck 33) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Warning of carbamazepine

Can cause aplastic anemia and agranulocytosis at a rate five to eight times greater than the general population. Pretreatment hematologic baseline data should be obtained and monitored periodically throughout therapy to discover lowered WBC or platelet counts. (Videbeck 32) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Warning valporic acid and it's derivatives

Can cause hepatic failure, resulting in fatality. Liver function tests should be performed before therapy and at frequent intervals thereafter, especially for the first 6 months. Can produce teratogenic effects such as neural tube defects (e.g., spina bifida). Can cause life-threatening pancreatitis in both children and adults. Can occur shortly after initiation or after years of therapy. (Videbeck 32) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Warning pemoline

Can cause life-threatening liver failure, which can result in death or require liver transplantation in 4 weeks from the onset of symptoms. The physician should obtain written consent before the initiation of this drug. (Videbeck 34) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Warning brupoprion

Can cause seizures at a rate four times that of other antidepressants. The risk for seizures increases when doses exceed 450 mg/day (400 mg SR); dose increases are sudden or in large increments; the client has a history of seizures, cranial trauma, excessive use of or withdrawal from alcohol, or addiction to opiates, cocaine, or stimulants; the client uses over-the-counter (OTC) stimulants or anorectics; or the client has diabetes being treated with oral hypoglycemics or insulin. (Videbeck 30) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Warning lamotigrine

Can cause serious rashes requiring hospitalization, including Stevens-Johnson syndrome and, rarely, life-threatening toxic epidermal necrolysis. The risk for serious rashes is greater in children younger than 16 years. (Videbeck 31) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Mood stabilizer client teaching

Carbamazepine is available in liquid, tablet, and chewable tablet forms. Dosages usually range from 800 to 1200 mg/day; the extreme dosage range is 200 to 2000 mg/day. Valproic acid is available in liquid, tablet, and capsule forms and as sprinkles with dosages ranging from 1000 to 1500 mg/day; the extreme dosage range is 750 to 3000 mg/day. Serum drug levels, obtained 12 hours after the last dose of the medication, are monitored for therapeutic levels of both these anticonvulsants. (Videbeck 31) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Mood stabilizers side effects

Carbamazepine is available in liquid, tablet, and chewable tablet forms. Dosages usually range from 800 to 1200 mg/day; the extreme dosage range is 200 to 2000 mg/day. Valproic acid is available in liquid, tablet, and capsule forms and as sprinkles with dosages ranging from 1000 to 1500 mg/day; the extreme dosage range is 750 to 3000 mg/day. Serum drug levels, obtained 12 hours after the last dose of the medication, are monitored for therapeutic levels of both these anticonvulsants. (Videbeck 31) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antianxiety client teaching

Clients need to know that antianxiety agents are aimed at relieving symptoms such as anxiety or insomnia but do not treat the underlying problems that cause the anxiety. Benzodiazepines strongly potentiate the effects of alcohol: One drink may have the effect of three drinks. Therefore, clients should not drink alcohol while taking benzodiazepines. Clients should be aware of decreased response time, slower reflexes, and possible sedative effects of these drugs when attempting activities such as driving or going to work. Benzodiazepine withdrawal can be fatal. After the client has started a course of therapy, he or she should never discontinue benzodiazepines abruptly or without the supervision of the physician (Burchum & Rosenthal, 2015). (Videbeck 33) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Client teaching antidepressants fa

Clients should take SSRIs first thing in the morning unless sedation is a problem; generally, paroxetine most often causes sedation. If the client forgets a dose of an SSRI, he or she can take it up to 8 hours after the missed dose. To minimize side effects, clients generally should take cyclic compounds at night in a single daily dose when possible. If the client forgets a dose of a cyclic compound, he or she should take it within 3 hours of the missed dose or omit the dose for that day. Clients should exercise caution when driving or performing activities requiring sharp, alert reflexes until sedative effects can be determined. p. 30 p. 31 Clients taking MAOIs need to be aware that a life-threatening hyperadrenergic crisis can occur if they do not observe certain dietary restrictions. They should receive a written list of foods to avoid while taking MAOIs. The nurse should make clients aware of the risk for serious or even fatal drug interactions when taking MAOIs and instruct them not to take any additional medication, including OTC preparations, without checking with the physician or pharmacist. (Videbeck 30-31) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antipsychotic drugs part 6

Clozapine produces fewer traditional side effects than do most antipsychotic drugs, but it has the potentially fatal side effect of agranulocytosis. This develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia. This side effect may not be manifested immediately and can occur up to 24 weeks after the initiation of therapy. Initially, clients needed to have a weekly white blood cell (WBC) count above 3500/mm3 to obtain the next week's supply of clozapine. Currently, all clients must have weekly WBCs drawn for the first 6 months. If the WBC is 3500/mm3 and the absolute neutrophil count (ANC) is 2000/mm3, the client may have these labs monitored every 2 weeks for 6 months, and then every 4 weeks. This decreased monitoring is dependent on continuous therapy with clozapine. Any interruption in therapy requires a return to more frequent monitoring for a specified period of time. After clozapine has been discontinued, weekly monitoring of the WBC and ANC is required for 4 weeks (Videbeck 27) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Side effects cyclic antidepressants

Cyclic compounds have more side effects than do SSRIs and the newer miscellaneous compounds. The individual medications in this category vary in terms of the intensity of side effects, but generally, side effects fall into the same categories. The cyclic antidepressants block cholinergic receptors, resulting in anticholinergic effects such as dry mouth, constipation, urinary hesitancy or retention, dry nasal passages, and blurred near vision. More severe anticholinergic effects such as agitation, delirium, and ileus may occur, particularly in older adults. Other common side effects include orthostatic hypotension, sedation, weight gain, and tachycardia. Clients may develop tolerance to anticholinergic effects, but these side effects are common reasons that clients discontinue drug therapy. Clients taking cyclic compounds frequently report sexual dysfunction similar to problems experienced with SSRIs. Both weight gain and sexual dysfunction are cited as common reasons for noncompliance (Stahl, 2013). (Videbeck 29) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Disulfuram (Antabuse)

Disulfiram is a sensitizing agent that causes an adverse reaction when mixed with alcohol in the body. This agent's only use is as a deterrent to drinking alcohol in persons receiving treatment for alcoholism. It is useful for persons who are motivated to abstain from drinking and who are not impulsive. Five to ten minutes after a person taking disulfiram ingests alcohol, symptoms begin to appear: facial and body flushing from vasodilation, a throbbing headache, sweating, dry mouth, nausea, vomiting, dizziness, and weakness. In severe cases, there may be chest pain, dyspnea, severe hypotension, confusion, and even death. Symptoms progress rapidly and last from 30 minutes to 2 hours. Because the liver metabolizes disulfiram, it is most effective in persons whose liver enzyme levels are within or close to normal range. Disulfiram inhibits the enzyme aldehyde dehydrogenase, which is involved in the metabolism of ethanol. Acetaldehyde levels are then increased from 5 to 10 times higher than normal, resulting in the disulfiram-alcohol reaction. This reaction is potentiated by decreased levels of epinephrine and norepinephrine in the sympathetic nervous system caused by inhibition of dopamine beta-hydroxylase (dopamine β-hydroxylase) (Virani et al., 2012). Education is extremely important for the client taking disulfiram. Many common products such as shaving cream, aftershave lotion, cologne, and deodorant and OTC medications such as cough preparations contain alcohol; when used by the client taking disulfiram, these products can produce the same reaction as drinking alcohol. The client must read product labels carefully and select items that are alcohol free. WARNING - Disulfiram Never give to a client in a state of alcohol intoxication or without the client's full knowledge. Instruct the client's relatives accordingly. Other side effects reported by persons taking disulfiram include fatigue, drowsiness, halitosis, tremor, and impotence. Disulfiram also can interfere with the metabolism of other drugs the client is taking, such as phenytoin (Dilantin), isoniazid, warfarin (Coumadin), barbiturates, and long-acting benzodiazepines such as diazepam and chlordiazepoxide. Acamprosate (Campral) is sometimes prescribed for persons in recovery from alcohol abuse or dependence. It helps reduce the physical and emotional discomfort encountered during the first weeks or months of sobriety, such as sweating, anxiety, and sleep disturbances. The dosage is two tablets (333 mg each) three times a day. Persons with renal impairments cannot take this drug. Side effects are reported as mild and include diarrhea, nausea, flatulence, and pruritus (Videbeck 35) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Efficiency potency and half life

Efficacy refers to the maximal therapeutic effect that a drug can achieve. Potency describes the amount of the drug needed to achieve that maximum effect; low-potency drugs require higher dosages to achieve efficacy, whereas high-potency drugs achieve efficacy at lower dosages. Half-life is the time it takes for half of the drug to be removed from the bloodstream. (Videbeck 22) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Warning for a typical antipsychotics

Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk for death. Causes of death were varied, but most of the deaths appeared to be either cardiovascular or infectious in nature. (Videbeck 24) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antipsychotic drugs side effects part 1

Extrapyramidal Side Effects. Extrapyramidal symptoms (EPSs), serious neurologic symptoms, are the major side effects of antipsychotic drugs. They include acute dystonia, pseudoparkinsonism, and akathisia. Although often collectively referred to as EPS, each of these reactions has distinct features. One client can experience all the reactions in the same course of therapy, which makes distinguishing among them difficult. Blockade of D2 receptors in the midbrain region of the brain stem is responsible for the development of EPS. First-generation antipsychotic drugs cause a greater incidence of EPS than do second-generation antipsychotic drugs, with ziprasidone (Geodon) rarely causing EPS (Virani et al., 2012). (Videbeck) Therapies for acute dystonia, pseudoparkinsonism, and akathisia are similar and include lowering the dosage of the antipsychotic, changing to a different antipsychotic, or administering anticholinergic medication (discussion to follow). Whereas anticholinergic drugs also produce side effects, atypical antipsychotic medications are often prescribed because the incidence of EPS side effects associated with them is decreased. Acute dystonia includes acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties. Dystonia is most likely to occur in the first week of treatment, in clients younger than 40 years, in males, and in those receiving high-potency drugs such as haloperidol and thiothixene. Spasms or stiffness in muscle groups can produce torticollis (twisted head and neck), opisthotonus (tightness in the entire body with the head back and an arched neck), or oculogyric crisis (eyes rolled back in a locked position). Acute dystonic reactions can be painful and frightening for the client. Immediate treatment with anticholinergic drugs, such as intramuscular benztropine mesylate (Cogentin) or intramuscular or intravenous diphenhydramine (Benadryl), usually brings rapid relief. (Videbeck 25) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Dosage of stimulants

For the treatment of narcolepsy in adults, both dextroamphetamine and methylphenidate are given in divided doses totaling 20 to 200 mg/day. The higher dosages may be needed because adults with narcolepsy develop tolerance to the stimulants and so require more medication to sustain improvement. Stimulant medications are also available in sustained-release preparations so that once-a-day dosing is possible. Tolerance is not seen in persons with ADHD. The dosages used to treat ADHD in children vary widely depending on the physician; the age, weight, and behavior of the child; and the tolerance of the family for the child's behavior. Table 2.7 lists the usual dosage ranges for these stimulants. Arrangements must be made for the school nurse or another authorized adult to administer the stimulants to the child at school. Sustained-released preparations eliminate the need for additional dosing at school. (Videbeck 34) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Foods to avoid when taking MAOIs

Mature or aged cheeses or dishes made with cheese, such as lasagna or pizza. All cheese is considered aged except cottage cheese, cream cheese, ricotta cheese, and processed cheese slices. Aged meats such as pepperoni, salami, mortadella, summer sausage, beef logs, meat extracts, and similar products. Make sure meat and chicken are fresh and have been properly refrigerated. Italian broad beans (fava), bean curd (tofu), banana peel, overripe fruit, and avocado. All tap beers and microbrewery beer. Drink no more than two cans or bottles of beer (including nonalcoholic beer) or 4 ounces of wine per day. Sauerkraut, soy sauce or soybean condiments, or marmite (concentrated yeast). Yogurt, sour cream, peanuts, brewer's yeast, and monosodium glutamate (MSG). (Videbeck 30) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Clozapine warning

May cause agranulocytosis, a potentially life-threatening event. Clients who are being treated with clozapine must have a baseline WBC count and differential before initiation of treatment and a WBC count every week throughout treatment and for 4 weeks after discontinuation of clozapine. (Videbeck 27) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

WARNING - Nefazodone

May cause rare but potentially life-threatening liver damage, which could lead to liver failure. (Videbeck 30) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Psychopharmacology

Medication management is a crucial issue that greatly influences the outcomes of treatment for many clients with mental disorders. The following sections discuss several categories of drugs used to treat mental disorders (psychotropic drugs): antipsychotics, antidepressants, mood stabilizers, anxiolytics, and stimulants. Nurses should understand how these drugs work; their side effects, contraindications, and interactions; and the nursing interventions required to help clients manage medication regimens. Several terms used in discussions of drugs and drug therapy are important for nurses to know. Efficacy refers to the maximal therapeutic effect that a drug can achieve. Potency describes the amount of the drug needed to achieve that maximum effect; low-potency drugs require higher dosages to achieve efficacy, whereas high-potency drugs achieve efficacy at lower dosages. Half-life is the time it takes for half of the drug to be removed from the bloodstream. Drugs with a shorter half-life may need to be given three or four times a day, but drugs with a longer half-life may be given once a day. The time that a drug needs to leave the body completely after it has been discontinued is about five times its half-life. The U.S. Food and Drug Administration (FDA) is responsible for supervising the testing and marketing of medications for public safety. These activities include clinical drug trials for new drugs and monitoring the effectiveness and side effects of medications. The FDA approves each drug for use in a particular population and for specific diseases. At times, a drug will prove effective for a disease that differs from the one involved in original testing and FDA approval. This is called off-label use. An example is some anticonvulsant drugs (approved to prevent seizures) that are prescribed for their effects in stabilizing the moods of clients with bipolar disorder (off-label use). The FDA also monitors the occurrence and severity of drug side effects. When a drug is found to have serious or life-threatening side effects, even if such side effects are rare, the FDA may issue a black box warning. This means that package inserts must have a highlighted box, separate from the text, which contains a warning about the serious or life-threatening side effects. Several psychotropic medications discussed later in this chapter carry black box warnings. (Videbeck 22) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antipsychotic drugs part 5

Metabolic syndrome is a cluster of conditions that increase the risk for heart disease, diabetes, and stroke. The syndrome is diagnosed when three or more of the following are present: Obesity—excess weight, increased body mass index (BMI), and increased abdominal girth due to fat deposits Increased blood pressure High blood sugar level High cholesterol—with at least 150 mg/dL of triglyceride; less than 40 mg/dL of HDL for women and 50 mg/dL for men Obesity is common in clients with schizophrenia, further increasing the risk for type 2 diabetes mellitus and cardiovascular disease. In addition, clients with severe, persistent mental illness are less likely to exercise or eat low-fat nutritionally balanced diets; this pattern decreases the likelihood that they can minimize potential weight gain or lose excess weight. The increased risk of heart disease results in shorter life expectancy (Flynn et al., 2015). It is recommended that clients taking antipsychotics be involved in an educational program to control weight and decrease BMI. However, it can be a difficult task. Bergqvist et al. (2013) found that clients had greater success when staff provided information and practical support when it was needed. Information about healthy eating and the need for physical activity was modified to account for the client's cognitive difficulties where they existed. Community-based social support was provided to help clients make needed changes over time in their home environment. Most antipsychotic drugs cause relatively minor cardiovascular adverse effects such as postural hypotension, palpitations, and tachycardia. Certain antipsychotic drugs, such as thioridazine (Mellaril), droperidol (Inapsine), and mesoridazine (Serentil), also can cause a lengthening of the QT interval. A QT interval longer than 500 ms is considered dangerous and is associated with life-threatening dysrhythmias and sudden death. Though rare, the lengthened QT interval can cause torsade de pointes, a rapid heart rhythm of 150 to 250 beats/minute, resulting in a "twisted" appearance on the electrocardiogram; hence the name torsade de pointes. Thioridazine and mesoridazine are used to treat psychosis; droperidol is most often used as an adjunct to anesthesia or to produce sedation. Sertindole (Serlect) was never approved in the United States to treat psychosis, but was used in Europe and was subsequently withdrawn from the market because of the number of cardiac dysrhythmias and deaths that it caused (Stahl, 2013). (Videbeck 27) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

mood-stabalizing drugs

Mood-stabilizing drugs are used to treat bipolar disorder by stabilizing the client's mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. Lithium is the most established mood stabilizer; some anticonvulsant drugs, particularly carbamazepine (Tegretol) and valproic acid (Depakote, Depakene), are effective mood stabilizers. Other anticonvulsants, such as gabapentin (Neurontin), topiramate (Topamax), oxcarbazepine (Trileptal), and lamotrigine (Lamictal), are also used for mood stabilization. Occasionally, clonazepam (Klonopin) also is used to treat acute mania. Clonazepam is included in the discussion of antianxiety agents. (Videbeck 31) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Side effects of other antidepressants

Of the other or novel antidepressant medications, nefazodone, trazodone, and mirtazapine commonly cause sedation. Both nefazodone and trazodone commonly cause headaches. Nefazodone also can cause dry mouth and nausea. Bupropion, venlafaxine, and desvenlafaxine may cause loss of appetite, nausea, agitation, and insomnia. Venlafaxine also may cause dizziness, sweating, or sedation. Sexual dysfunction is much less common with the novel antidepressants, with one notable exception: Trazodone can cause priapism (a sustained and painful erection that necessitates immediate treatment and discontinuation of the drug). Priapism also may result in impotence. (Videbeck 30) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antipsychotic drugs side effects part 4

Other Side Effects. Antipsychotic drugs also increase blood prolactin levels. Elevated prolactin may cause breast enlargement and tenderness in men and women; diminished libido, erectile and orgasmic dysfunction, and menstrual irregularities; and increased risk for breast cancer; and may contribute to weight gain. Weight gain can accompany most antipsychotic medications, but it is most likely with the second-generation antipsychotic drugs, with ziprasidone (Geodon) being the exception. Weight increases are most significant with clozapine (Clozaril) and olanzapine (Zyprexa). Since 2004, the FDA has made it mandatory for drug manufacturers that atypical antipsychotics carry a warning of the increased risk for hyperglycemia and diabetes. Though the exact mechanism of this weight gain is unknown, it is associated with increased appetite, binge eating, carbohydrate craving, food preference changes, and decreased satiety in some clients. Prolactin elevation may stimulate feeding centers, histamine antagonism stimulates appetite, and there may be an as yet undetermined interplay of multiple neurotransmitter and receptor interactions with resultant changes in appetite, energy intake, and feeding behavior. Mutsatsa and Currid (2013) found that genetics can also make clients more prone to weight gain and metabolic syndrome. (Videbeck 26) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

first generation antipsychotics

Phenothiazines Chlorpromazine (Thorazine) T, L, INJ 200-1600 25-2000 Perphenazine (Trilafon) T, L, INJ 16-32 4-64 Fluphenazine (Prolixin) T, L, INJ 2.5-20 1-60 Thioridazine (Mellaril) T, L 200-600 40-800 Mesoridazine (Serentil) T, L, INJ 75-300 30-400 Trifluoperazine (Stelazine) T, L, INJ 6-50 2-80 Thioxanthene Thiothixene (Navane) C, L, INJ 6-30 6-60 Butyrophenones Haloperidol (Haldol) T, L, INJ 2-20 1-100 Droperidol (Inapsine) INJ 2.5 Dibenzazepine Loxapine (Loxitane) C, L, INJ 60-100 30-250 Dihydroindolone Molindone (Moban) T, L 50-100 15-250

WARNING AMPHETAMINES

Potential for abuse is high. Administration for prolonged periods may lead to drug dependence. (Videbeck 33) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Side effects of SSRIs antidepressants

Selective serotonin reuptake inhibitors have fewer side effects compared with the cyclic compounds. Enhanced serotonin transmission can lead to several common side effects such as anxiety, agitation, akathisia (motor restlessness), nausea, insomnia, and sexual dysfunction, specifically diminished sexual drive or difficulty achieving an erection or orgasm. In addition, weight gain is both an initial and ongoing problem during antidepressant therapy, although SSRIs cause less weight gain than other antidepressants. Taking medications with food usually can minimize nausea. Akathisia usually is treated with a β-blocker such as propranolol (Inderal) or a benzodiazepine. Insomnia may continue to be a problem even if the client takes the medication in the morning; a sedative-hypnotic or low-dosage trazodone may be needed. Less common side effects include sedation (particularly with paroxetine [Paxil]), sweating, diarrhea, hand tremor, and headaches. Diarrhea and headaches usually can be managed with symptomatic treatment. Sweating and continued sedation most likely indicate the need for a change to another antidepressant. (Videbeck 29) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Stimulant drugs

Stimulant drugs, specifically amphetamines, were first used to treat psychiatric disorders in the 1930s for their pronounced effects on CNS stimulation. In the past, they were used to treat depression and obesity, but those uses are uncommon in current practice. Dextroamphetamine (Dexedrine) has been widely abused to produce a high or to remain awake for long periods. Today, the primary use of stimulants is for ADHD in children and adolescents, residual attention deficit disorder in adults, and narcolepsy (attacks of unwanted but irresistible daytime sleepiness that disrupt the person's life). (Videbeck 33) The primary stimulant drugs used to treat ADHD are methylphenidate (Ritalin), amphetamine (Adderall), and dextroamphetamine (Dexedrine). Pemoline (Cylert) is infrequently used for ADHD because of the potential for liver problems. Of these drugs, methylphenidate accounts for 90% of the stimulant medication given to children for ADHD (Stahl, 2015). About 10% to 30% of clients with ADHD who do not respond adequately to the stimulant medications have been treated with antidepressants. In 2003, atomoxetine (Strattera), a selective norepinephrine reuptake inhibitor, was approved for the treatment of ADHD, becoming the first nonstimulant medication specifically designed and tested for ADHD. WARNI (Videbeck 34) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Preferred antidepressant for clients at high risk for suicide

Suicide is always a primary consideration when treating clients with depression. SSRIs, venlafaxine, nefazodone, and bupropion are often better choices for those who are potentially suicidal or highly impulsive because they carry no risk of lethal overdose, in contrast to the cyclic compounds and the MAOIs. However, SSRIs are effective only for mild and moderate depression. Evaluation of the risk for suicide must continue even after treatment with antidepressants is initiated. The client may feel more energized but still have suicidal thoughts, which increases the likelihood of a suicide attempt. Also, because it often takes weeks before the medications have a full therapeutic effect, clients may become discouraged and tired of waiting to feel better, which can result in suicidal behavior. There is an FDA-required warning for SSRIs and increased suicidal risk in children and adolescents. (Videbeck 29) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antipsychotic drugs side effects part 2

Table 2.4 lists the drugs, and their routes and dosages, used to treat EPS. The addition of a regularly scheduled oral anticholinergic such as benztropine may allow the client to continue taking the antipsychotic drug with no further dystonia. Recurrent dystonic reactions would necessitate a lower dosage or a change in the antipsychotic drug. Assessment of EPS using the Simpson-Angus rating scale is discussed further in Chapter 16. Drug-induced parkinsonism, or pseudoparkinsonism, is often referred to by the generic label of EPS. Symptoms resemble those of Parkinson's disease and include a stiff, stooped posture; masklike facies; decreased arm swing; a shuffling, festinating gait (with small steps); cogwheel rigidity (ratchet-like movements of joints); drooling; tremor; bradycardia; and coarse pill-rolling movements of the thumb and fingers while at rest. Parkinsonism is treated by changing to an antipsychotic medication that has a lower incidence of EPS or by adding an oral anticholinergic agent or amantadine, which is a dopamine agonist that increases transmission of dopamine blocked by the antipsychotic drug. Akathisia is reported by the client as an intense need to move about. The client appears restless or anxious and agitated, often with a rigid posture or gait and a lack of spontaneous gestures. This feeling of internal restlessness and the inability to sit still or rest often leads clients to discontinue their antipsychotic medication. Akathisia can be treated by a change in antipsychotic medication or by the addition of an oral agent such as a β-blocker, anticholinergic, or benzodiazepine. Neuroleptic Malignant Syndrome. Neuroleptic malignant syndrome (NMS) is a potentially fatal idiosyncratic reaction to an antipsychotic (or neuroleptic) drug. The major symptoms of NMS are rigidity; high fever; autonomic instability such as unstable blood pressure, diaphoresis, and pallor; delirium; and elevated levels of enzymes, particularly creatine phosphokinase. Clients with NMS usually are confused and often mute; they may fluctuate from agitation to stupor. All antipsychotics seem to have the potential to cause NMS, but high dosages of high-potency drugs increase the risk. Neuroleptic malignant syndrome most often occurs in the first 2 weeks of therapy or after an increase in dosage, but it can occur at any time. Dehydration, poor nutrition, and concurrent medical illness all increase the risk for NMS. Treatment includes immediate discontinuance of all antipsychotic medications and the institution of supportive medical care to treat dehydration and hyperthermia until the client's physical condition stabilizes. After NMS, the decision to treat the client with other antipsychotic drugs requires full discussion between the client and the physician to weigh the relative risks against the potential benefits of therapy. (Videbeck 26) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antipsychotic drugs side effects part 3

Tardive Dyskinesia. Tardive dyskinesia (TD), a syndrome of permanent involuntary movements, is most commonly caused by the long-term use of conventional antipsychotic drugs. About 20% to 30% of patients on long-term treatment develop symptoms of TD (Sadock et al., 2015). The pathophysiology is still unclear, and no effective treatment has been approved for general use. However, there is some reported success in treating TD with levetiracetam in clinical trials. The symptoms of TD include involuntary movements of the tongue, facial and neck muscles, upper and lower extremities, and truncal musculature. Tongue thrusting and protruding, lip smacking, blinking, grimacing, and other excessive unnecessary facial movements are characteristic. After it has developed, TD is irreversible, although decreasing or discontinuing antipsychotic medications can arrest its progression. Unfortunately, antipsychotic medications can mask the beginning symptoms of TD; that is, increased dosages of the antipsychotic medication cause the initial symptoms to disappear temporarily. As the symptoms of TD worsen, however, they "break through" the effect of the antipsychotic drug (Aquino & Lang, 2014). Preventing TD is one goal when administering antipsychotics. This can be done by keeping maintenance dosages as low as possible, changing medications, and monitoring the client periodically for initial signs of TD using a standardized assessment tool such as the Abnormal Involuntary Movement Scale (see Chapter 16). Clients who have already developed signs of TD but still need to take an antipsychotic medication often are given one of the atypical antipsychotic drugs that have not yet been found to cause or, therefore, worsen TD. Anticholinergic Side Effects. Anticholinergic side effects often occur with the use of antipsychotics and include orthostatic hypotension, dry mouth, constipation, urinary hesitance or retention, blurred near vision, dry eyes, photophobia, nasal congestion, and decreased memory. These side effects usually decrease within 3 to 4 weeks but do not entirely remit. The client taking anticholinergic agents for EPS may have increased problems with anticholinergic side effects. Using calorie-free beverages or hard candy may alleviate dry mouth; stool softeners, adequate fluid intake, and the inclusion of grains and fruit in the diet may prevent constipation. (Videbeck 26) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Principles that guide pharmacologic treatment

The following are several principles that guide the use of medications to treat psychiatric disorders: A medication is selected based on its effect on the client's target symptoms such as delusional thinking, panic attacks, or hallucinations. The medication's effectiveness is evaluated largely by its ability to diminish or eliminate the target symptoms. Many psychotropic drugs must be given in adequate dosages for some time before their full effect is realized. For example, tricyclic antidepressants can require 4 to 6 weeks before the client experiences optimal therapeutic benefit. The dosage of medication often is adjusted to the lowest effective dosage for the client. Sometimes, a client may need higher dosages to stabilize his or her target symptoms, whereas lower dosages can be used to sustain those effects over time. As a rule, older adults require lower dosages of medications than do younger clients to experience therapeutic effects. It also may take longer for a drug to achieve its full therapeutic effect in older adults. Psychotropic medications often are decreased gradually (tapering) rather than abruptly. This is because of potential problems with rebound (temporary return of symptoms), recurrence (of the original symptoms), or withdrawal (new symptoms resulting from discontinuation of the drug). Follow-up care is essential to ensure compliance with the medication regimen, to make needed adjustments in dosage, and to manage side effects. Compliance with the medication regimen often is enhanced when the regimen is as simple as possible in terms of both the number of medications prescribed and the number of daily doses. (Videbeck 23) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antipsychotic drugs moa

The major action of all antipsychotics in the nervous system is to block receptors for the neurotransmitter dopamine; however, the therapeutic mechanism of action is only partially understood. Dopamine receptors are classified into subcategories (D1, D2, D3, D4, and D5), and D2, D3, and D4 have been associated with mental illness. The conventional, or first-generation antipsychotic drugs are potent antagonists (blockers) of D2, D3, and D4. This makes them effective in treating target symptoms but also produces many extrapyramidal side effects (discussion to follow) because of the blocking of the D2 receptors. Newer, atypical or second-generation antipsychotic drugs, such as clozapine (Clozaril), are relatively weak blockers of D2, which may account for the lower incidence of extrapyramidal side effects. In addition, second-generation antipsychotics inhibit the reuptake of serotonin, as do some of the antidepressants, increasing their effectiveness in treating the depressive aspects of schizophrenia. Paliperidone (Invega), iloperidone (Fanapt), asenapine (Saphris), and lurasidone (Latuda) are the newest second-generation agents. Paliperidone (Invega) is chemically similar to risperidone (Risperdal); however, it is an extended-release preparation. This means the client can take one daily dose in most cases, which may be a factor in increased compliance. Asenapine (Saphris) is a sublingual tablet, so clients must avoid food or drink for 10 to 15 minutes after the medication dissolves. The third generation of antipsychotics, called dopamine system stabilizers, is being developed. These drugs are thought to stabilize dopamine output; that is, they preserve or enhance dopaminergic transmission when it is too low and reduce it when it is too high. This results in control of symptoms without some of the side effects of other antipsychotic medications. Aripiprazole (Abilify), the first drug of this type, was approved for use in 2002. In clinical trials, the most common side effects were headache, anxiety, and nausea. It has been successfully prescribed as an adjunct medication in both bipolar disorder and depression, and has received approval for that use. Six antipsychotics are available in depot injection, a time-release form of intramuscular medication for maintenance therapy. Two first-generation antipsychotics use sesame oil as the vehicle for these injections, so the medication is absorbed slowly over time; thus, less frequent administration is needed to maintain the desired therapeutic effects. Prolixin (decanoate fluphenazine) has a duration of 7 to 28 days, and Haldol (decanoate haloperidol) has a duration of 4 weeks. After the client's condition is stabilized with oral doses of these medications, administration by depot injection is required every 2 to 4 weeks to maintain the therapeutic effect. Risperidone (Risperdal Consta), paliperidone (Invega Sustenna), and olanzapine pamoate (Zyprexa Relprevv), second-generation antipsychotics, encapsulate active medication into polymer-based microspheres that degrade slowly in the body, gradually releasing the drug at a controlled rate. Risperdal Consta, 25 mg, is given every 2 weeks. Paliperidone (Invega Sustenna), 117 mg, is given every 4 weeks. Zyprexa Relprevv can be given 210 mg every 2 weeks or 405 mg every 4 weeks. Zyprexa Relprevv has the potential to cause postinjection delirium/sedation syndrome, including sedation, confusion, disorientation, agitation, and cognitive impairment that can progress to ataxia, convulsions, weakness, and hypertension, which can lead to arrest. For that reason, the client must be directly observed by a health-care professional for 3 hours after the injection, and must be alert, oriented, and symptom-free before he or she can be released. Aripiprazole (Abilify Maintena), a third-generation antipsychotic, is slowly absorbed into the bloodstream because of insolubility of aripiprazole particles (Otsuka America Pharmaceuticals, 2015). After initiation with oral medication, Aripiprazole 400 mg is given monthly. (Videbeck 23) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Side effects of MAOIs

The most common side effects of MAOIs include daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, and sexual dysfunction. The sedation and insomnia are difficult to treat and may necessitate a change in medication. Of particular concern with MAOIs is the potential for a life-threatening hypertensive crisis if the client ingests food that contains tyramine or takes sympathomimetic drugs. Because the enzyme MAO is necessary to break down the tyramine in certain foods, its inhibition results in increased serum tyramine levels, causing severe hypertension, hyperpyrexia, tachycardia, diaphoresis, tremulousness, and cardiac dysrhythmias. Drugs that may cause potentially fatal interactions with MAOIs include SSRIs, certain cyclic compounds, buspirone (BuSpar), dextromethorphan, and opiate derivatives such as meperidine. The client must be able to follow a tyramine-free diet; Box 2.1 lists the foods to avoid. Studies are currently under way to determine whether a selegiline transdermal patch would be effective in treating depression without the risks of dietary tyramine and orally ingested MAOIs. (Videbeck 30) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Side effects of stimulants

The most common side effects of stimulants are anorexia, weight loss, nausea, and irritability. The client should avoid caffeine, sugar, and chocolate, which may worsen these symptoms. Less common side effects include dizziness, dry mouth, blurred vision, and palpitations. The most common long-term problem with stimulants is the growth and weight suppression that occurs in some children. This can usually be prevented by taking "drug holidays" on weekends and holidays or during summer vacation, which helps to restore normal eating and growth patterns. Atomoxetine can cause decreased appetite, nausea, vomiting, fatigue, or upset stomach. (Videbeck 34) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antipsychotic client teaching

The nurse informs clients taking antipsychotic medication about the types of side effects that may occur and encourages clients to report such problems to the physician instead of discontinuing the medication. The nurse teaches the client methods of managing or avoiding unpleasant side effects and maintaining the medication regimen. Drinking sugar-free fluids and eating sugar-free hard candy ease dry mouth. The client should avoid calorie-laden beverages and candy because they promote dental caries, contribute to weight gain, and do little to relieve dry mouth. Methods to prevent or relieve constipation include exercising and increasing water and bulk-forming foods in the diet. Stool softeners are permissible, but the client should avoid laxatives. The use of sunscreen is recommended because photosensitivity can cause the client to sunburn easily. Clients should monitor the amount of sleepiness or drowsiness they feel. They should avoid driving and performing other potentially dangerous activities until their response times and reflexes seem normal. p. 27 p. 28 If the client forgets a dose of antipsychotic medication, he or she can take the missed dose if it is only 3 or 4 hours late. If the dose is more than 4 hours overdue or the next dose is due, the client can omit the forgotten dose. The nurse encourages clients who have difficulty remembering to take their medication to use a chart and to record doses when taken or to use a pillbox that can be prefilled with accurate doses for the day or week. (Videbeck 27-28) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Stimulants client teaching

The potential for abuse exists with stimulants, but this is seldom a problem in children. Taking doses of stimulants after meals may minimize anorexia and nausea. Caffeine-free beverages are suggested; clients should avoid chocolate and excessive sugar. Most important is to keep the medication out of the child's reach because as little as a 10-day supply can be fatal. (Videbeck 35) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Antidepressants moa

The precise mechanism by which antidepressants produce their therapeutic effects is not known, but much is known about their action on the CNS. The major interaction is with the monoamine neurotransmitter systems in the brain, particularly norepinephrine and serotonin. Both of these neurotransmitters are released throughout the brain and help to regulate arousal, vigilance, attention, mood, sensory processing, and appetite. Norepinephrine, serotonin, and dopamine are removed from the synapses after release by reuptake into presynaptic neurons. After reuptake, these three neurotransmitters are reloaded for subsequent release or metabolized by the enzyme MAO. The SSRIs block the reuptake of serotonin, the cyclic antidepressants and venlafaxine block the reuptake of norepinephrine primarily and block serotonin to some degree, and the MAOIs interfere with enzyme metabolism. This is not the complete explanation, however; the blockade of serotonin and norepinephrine reuptake and the inhibition of MAO occur in a matter of hours, whereas antidepressants are rarely effective until taken for several weeks. The cyclic compounds may take 4 to 6 weeks to be effective, MAOIs need 2 to 4 weeks for effectiveness, and SSRIs may be effective in 2 to 3 weeks. Researchers believe that the actions of these drugs are an "initiating event" and that eventual therapeutic effectiveness results when neurons respond more slowly, making serotonin available at the synapses (Burchum & Rosenthal, 2015). (Videbeck 29) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

WARNING - Lithium

Toxicity is closely related to serum lithium levels and can occur at therapeutic doses. Facilities for serum lithium determinations are required to monitor therapy. (Videbeck 31) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

Warning methylphenidate

Use with caution in emotionally unstable clients such as those with alcohol or drug dependence because they may increase the dosage on their own. Chronic abuse can lead to marked tolerance and psychic dependence (Videbeck 34) Videbeck, Sheila L. Lippincott CoursePoint for Videbeck: Psychiatric-Mental Health Nursing, 7th Edition. CoursePoint, 10/3/2016. VitalBook file.

cyclic antidepressants side effects

have anticholinergic side effects

client teaching antipsychotic

• Adherence to regimen • Side effects, management - Thirst/dry mouth (sugar-free candy, liquids) - Constipation (dietary fiber, stool softeners) - Sedation (safety measures) • Actions for missed dose (dose if within 4 hours of usual time) • CBC, ANC with clozapine

groups of antidepressants

• Four groups (see Table 2.5): - Tricyclic and related cycle antidepressants (TCAs) - Selective serotonin reuptake inhibitors (SSRIs) - MAO inhibitors (MAOIs) - Others (venlafaxine, bupropion, duloxetine, trazodone, nefazodone)

antidepressants

• Lithium, some anticonvulsants (carbamazepine, valproic acid; gabapentin, topiramate, oxcarbazepine, and lamotrigine) • Use: treatment of bipolar disorders

anitdpressent uses

• Use: major depressive illness, anxiety disorders, depressed phase of bipolar disorder, psychotic depression