3.

1 Psychopharmacology
– Medication management is a crucial issue that greatly influences the outcomes of treatment for
many clients with mental disorders.
– Psychoactive/Psychotropic drugs exert effect on brain, altering emotions & affecting behavior
– Alleviate symptoms by regulating secretion of neurotransmitters thus normalizing transmission
of messages

Primary Mechanism of Action:

1. Alter amount of neurotransmitter in the synapse.

2. Bind to specific receptor sites at the pre-synaptic & post-synaptic neurons

Characteristics:

Used to modify behavior

Relieve symptoms of the illness
Does not cure mental illness

Principles that Guide Pharmacologic Treatment:

1. Medication is selected based on its effect on the client’s target symptoms.

2. The effectiveness of medication is evaluated in large part by its ability to diminish or eliminate the
target symptoms.
3. Psychotropic drugs must be given in adequate dosages for a period of time before their full effect is
realized.
4. Dosages of the medication are often adjusted to the lowest dosage effective for the client.
5. Sometimes, higher dosage may be needed to stabilize the client’s target symptoms, & this can be
used to sustain those effects overtime.
6. Elderly requires lower dosage to produce therapeutic effects, & it may take longer for a drug to
achieve its full therapeutic effect.
7. Psychotropic medications are often gradually tapered rather than abruptly D/C.
8. Follow up care is essential to ensure compliance w/ the medication regimen, to make needed
adjustments in dosage, & to manage S/E.
9. Compliance w/ the medication regimen is often enhanced when the regimen is as simple as possible
in terms of both the # of medications prescribed & the number of daily doses.

A. Antipsychotic/Neuroleptic

Action: Major action in the nervous system is to block receptors for the neurotransmitter dopamine;
thereby reducing the psychotic symptoms

Indication:
– schizophrenia
– psychotic episodes of acute mania,
– psychotic depression(d/t serotonin blocking effect)
– drug-induced psychosis use to tx symptoms of psychosis i.e. delusions, & hallucinations.
Contraindications:
– Hypersensitivity to the drug
– CNS depression
– Blood dyscrasias
– Liver & renal insufficiency
– Use w/ caution in diabetics, elderly & debilitated
– Causes respiratory depression if used w/ ROH
– Cigarette smoking reduces plasma conc.
– If used w/ beta blockers causes hypotension
– If used w/ antidepressants, increases antidepressant conc.
– If used w/ SSRI’s may cause sudden onset of EPS.

Classifications:

• Phenothiazines
- Aliphatic= strong sedative; may cause EPS (ex: Chlorpromazine HCl)
Content
- Piperazine= mod. sedative; cause more EPS; antiemetic (ex: Fluphenazine)
- Piperidine= strong sedative; few EPS; no antiemetic (ex: Thioridazine HCl)

• Butyrophenones (ex: Haloperidol )

• Dibenzoxazepines (ex: Loxapine )

• Thioxanthenes (ex: Thiothixene )

• Dihydroindolone (ex: Molindone )

Types of Antipshychotic:

a. Conventional/Typical

- block specific dopamine receptor sites (D2) - limbic areas of the brain, hypothalamus and cerebral
cortex, an action believed to reduce psychotic symptoms.
- blocks the dopamine receptor in the basal ganglia causing the EPS & other S/E.

Indications:

Relieves (+) symptoms

Clients w/ severe agitation, rage or combativeness & hyperactive states
Treatment of tics, intractable hiccups , vomiting & vertigo

Contraindications:

Any known allergic reaction to antipsychotics

Pts. w/ severe CNS depression d/t excessive ROH or narcotic use, brain damage or trauma,
elderly & debilitated pts.
Pts. w/ blood dyscrasias
Pts. w/ narrow angle glaucoma
 Pts. w/ BPH
Pts. w/ Parkinson’s dse.
Pts.w/ Narrow Angle Glaucoma – causes increase ICP
Pts. w/ BPH – risk for urinary hesitancy or retention

Side Effects:

Sedation / drowsiness
Orthostatic Hypotension
Depressed Hypothalamic function
– Increased appetite
– Weight gain
– Ammenorrhrea
– Gynecomastia ( in men)
– False (+) pregnancy test
– Sexual dysfunction – common
– Inc. risk of breast CA

Anticholinergic S/E
– Blurred vision
– Dry eyes (mydriasis – IOP – narrow angle glaucoma)
– Constipation
– Urinary retention or hesitancy
– Nasal congestion

GI S/E
– Nausea
– Diarrhea
– Increased appetite

Dermatologic Effect
– Systemic dermatoses may occur 2-8 wks after treatment
– Contact dermatitis may occur

CNS Effect:
– Extrapyramidal Syndrome ( EPS)
• Acute dystonia
Opisthotonus
Torticollis
Oculogyric crisis
• Pseudoparkinsonism/Parkinsonian Syndrome

• Akathisia

• Tardive Dyskinesia
– Neuroleptic Malignant Syndrome (NMS)

• Hyperthermia of 40 o C/ 102 o F
• Altered consciousness (mute/stupor)
• Diaphoresis, tachycardia
• EPS reactions
• Elevated CPK
• Elevated BP, arrythmmias
• Seizure
• Death

b. Atypical

- Block dopamine receptor in the limbic system and affect serotonin receptors in the cortical areas of
the brain.

Advantages over Typical:

1. reduce (+) and (-) symptoms

2. decreased (or no) EPS effects
3. does not cause Tardive Dyskinesia
Toxic Side Effect:

Seizures
Hematologic Effects
Agranulocytosis

Flu-like symptoms:

fever, malaise
sore throat
mouth sores
leukopenia.

Client Health Teachings:

Drink sugar free liquids & eat sugar free hard candy .
Avoid calorie laden beverages & candy.
Prevent constipation by increasing intake of water & bulk forming foods in the diet & by
exercising.
Stool softeners are permissible but laxative should be avoided.
Use sunscreen. Avoid long periods of time in the sun, wear protective clothing.
Rise slowly from lying or sitting position. Wait to walk until any dizziness has subside.
Inform pt. that the can cause sleepiness or drowsiness. Avoid activities that require alertness.
If a dose of antipsychotic medication is missed, take if the dose is only 3-4 hours late. If the
missed dosage > 4 hrs. late or the next dose is due, omit the forgotten dose.
If pts. have difficulty remembering medication, use a chart to record doses when taken, or use a
pill box labeled w/ dosage times &/or days of the week to help them remember when to take the
medication
Monitoring of V/S and CBC
 B. Antidepressant

Action:
- Reduce & ultimately remove all signs & symptoms of depression
- Restore occupational & psychosocial fxn
- Reduce the likelihood of relapse & recurrence

Indications:

major depressive illness

panic & anxiety disorders
bipolar depression
psychotic depression

Classifications:

1. Tricyclic Antidepressants

Indication:

used to treat depression, including symptoms of depressed mood, loss of interest in activities or
pleasure, altered sleep patterns and somatic complaints.
also used to treat anxiety disorders, like panic attacks, phobic disorders and OCD
Contraindications:
Patients with cardiovascular diseases -baseline ECG is recommended prior to treatment esp in
elderly
Patients with Glaucoma (can cause increased IOP)
Patient with BPH
Liver and Renal Diseases
Side Effects:
Sedation and fatigue, decreased libido
Confusion, disorientation, delusions, agitation, hallucinations & lowering of the seizure
threshold
Other potential CNS S/E:
– Anxiety
– Insomnia, nightmares
Toxic Effects:
Cause irregularities in heartbeat and cardiac toxicity
Overdose can be lethal : results to sedation, ataxia(loss of muscle coordination), agitation,
stupor, coma, convulsions and respiratory depression.
Agranulocytosis
Seizures
Serotonin Syndrome
- severe hypothermia, altered muscle tone or hyperflexia, altered consciousness, tachycardia and
diaphoresis.

2. Selective Serotonin Reuptake Inhibitors (SSRIs)

Action:
- Serotonin is normally removed from the synapse by the reuptake sites on the presynaptic neurons.
SSRI blocks the serotonin reuptake sites, allowing serotonin to remain active in the synapse.

Side Effects:

- Insomnia
- Headache
- Weight loss
- Sexual Dysfunction
Anorgasmia in women and ejaculatory dysfunction in men.

Management:

Take the dose early in the day, eliminate caffeine, use relaxation measures before going to bed.
May use analgesics as prescribed for headache. If headache becomes severe, then may require
discontinuance of the medication.
Encourage adequate caloric intake.
Use with caution in patients with eating disorder.
Teach client to report any sexual function problem with the health care provider. If problem
persists, another antidepressant may be recommended.
Effects of the drug usually take place 3 weeks to 1 month after initial dose
Do not D/C the prematurely
May alleviate depression, but suicidal thoughts & ideation will still persist
Maintain suicide precaution.

3. Monoamine Oxidase Inhibitors (MAOI)

Action:

- MOA: blocks reuptake of norepinephrine, serotonin, acetylcholine and dopamine thus increasing their
concentration in the synapse.

- MAOIs are fast to react and have lesser side effects, but one might need to observe a slight alteration
in diet.

Indication:

Most effective in treatment of ATYPICAL DEPRESSION

s/sx: overeating and oversleeping
weight gain
highly reactive emotions
marked anxiety
at times sleeplessness
Toxic Effect:

– Agranulocytosis
– Hepatic Toxicity
– Hypertensive Crisis
Contraindications:

– Cardiovascular disease or history of stroke

– Hyperthyroidism
– Patient’s for surgical procedure – MAOIs
– should be discontinued 2wks prior to surgery
– Pheochromocytoma – a tumor that secretes pressor substances

Management:

Therapeutic effect achieved w/in 10 days – 4 weeks

Avoid driving if drowsy.
Certain over-the-counter drugs should be avoided (e.g.Ritalin, ephedrine)
All of the pt’s Hx care providers should be aware that pt is taking MAOI
Avoid high tyramine foods
Headache, palpitations & stiff neck should be reported immediately.

C. Anxiolytics/Anti anxiety/Benzodiazepines

Indication:

- Benzodiazepines - most widely use, effective in relieving anxiety & are drugs most
frequently prescribed.
- May also be prescribed for their anticonvulsant & muscle relaxant effects

Management:

Not for minor stresses in life

Over the counter drugs may potentiate axn
Avoid driving until tolerance develops
ROH & other CNS depressants potentiate
effect of benzodiaepine
Hypersensitivity to the drug
Should not be stopped abruptly

D. Mood Stabilizer

Action:

- Lithium- normalizes the reuptake of certain neurotransmitters i.e. serotonin

norepinephrine, acetylcholine & clopamine
Indications:

– Effective in controlling manic behavior that arises from underlying depression

– Controls evidences of flight of ideas & hyperactivity without impairing intellectual activity
– Has calming effect
 Side Effect:

– nausea
– dry mouth
– diarrhea
– thirst
– mild hand tremor
– wt. gain
– insomnia
– light-headedness

Management

Suggest taking lithium w/ meals

Suggest drinking 240 ml of water/day
Advise to elevate feet
Advise pt. to maintain a consistent sodium intake(causes Na depletion)
Increase sodium intake if there is a major increase in perspiration
Watch out for lithium toxicity

E. Antiparkinsonism

Classification:

a. Dopaminergic agent
– agents that increase dopamine
– used to restore the balance one dimensionally (that is working only on the dopamine aspect of
the imbalance)
b. Anti cholinergic agent
– DOC for drug induced parkinsonism
– useful in early stages of Parkinson’s dse. but more effective when combined w/ other
dopaminergic agents

Health Teachings:

Advise to avoid alcohol, cigarette smoking, caffeine & aspirin to decrease gastric acidity
Encourage to ingest foods that are high in fiber & to increase fluid intake
Hard candy, ice chips or sugarless chewing gum for dry mouth
Sunglasses in direct sun because of possible photosensitivity

3.2 Somatic therapy

a. ECT (Electroconvulsive Therapy)

– Treatment of clients who have severe depression; acute suicidal; unwilling to eat & cannot
tolerate medications
– May also be indicated for manic clients whose conditions are resistant to lithium & antipsychotic
drugs.
Content
Mechanism of Action:
– Exact mechanism w/c ECT effects a therapeutic response is unknown
– Several experts have demonstrated that electrical stimulation results in significant increases in
circulating levels of several neurotransmitters.
Contraindication:
– Absolute C/I is increase ICP
– High risk cases: CV disorders, aortic & cerebral aneurism, severe hpn & acute or chronic
pulmonary disorder.
Management:
Before ECT;
NPO
Check consent
V/S monitoring
Empty bladder
Remove denture, lenses, hair pins etc.
Meds are prescribed
After ECT:
V/S q 15 mins.
Position at the side to prevent aspiration
Orient the time
Reassure that memory loss is transient
Offer fluid & flood when gag & swallow reflexes resume.
Special Interventions
Client’s VS, oxygenation, cardiac functioning are carefully monitored before, during & following
ECT (postop protocols)
Assess client’s medical status (CV & pulmo)
Be sure that consent was signed
Address the families concern regarding effects/side effects of the procedure

4. Complementary / Alternative Therapies

4.1 Music

– Music helps people regain inner peace and is the voice that binds people together. It has been
used to treat the sick since ancient times and frequently is used to cure depression

Types of Music Therapy:

1. Creative Music – ranges from simple clapping to using simple instruments establishing a band,
orchestra, or choir.

2. Music Appreciation – consist of playing carefully selected pieces of music followed by a

discussion of memories & assocs. evoked.

3. Music Discussion – focuses on communication of emotion stimulated by particular passages of

music carefully chooses for their mood content.
 4.2 Dance/movement

– expression of feelings through rhythmic body movements, which enhances emotional & physical
integration of the individual

4.3 Art

– Tool for stimulating self-expression in client

– As a diagnostic tool from w/c modifications in tx can be made

– Provide opportunities for increased self-esteem & for promoting sublimation & personal
growth.

– Facilitate group process

– As a cathartic experience.

Criteria Used in Art Therapy

1. Content – reflects what concerns the pt

Ex. Haggard-looking figure -Body image distortion

Man falling from a bridge – supports suicidal ideation

2. Color- represent’s pt’s emotions

Ex. Red & Orange – anger & frustration

Blue & Green – coldness; probable alienation

Content

Dark brown & black- depression

3. Size – indicates pts’ feelings to others & his environemnt

Ex. Minute figure in w/c the pt identifies suggest small & unimportant.

4. Organization – reflects degree of cohesiveness of the individual or the group.

4.4 Occupational

– It’s a rehabilitative procedure that diverts pt attention & this develops their creative abilities for
a purposeful living & lead to the mastery of self & envt.

– A method of tx in w/c pts are given some kind of light work, not only to save hospital expense
but also for psychological benefit the pt will get.

Goals of Occupational Therapy:

• Gives sense of achievement

• Restores elf-confidence
• Diverts patient’s attention

• Helps build up & maintain contact w/ reality

• Develop his creative abilities

• Orients patient’s toward future self-support by practical means

Examples:

Rug-making, hog raising, housekeeping, gardening, embroidery, Crochet, Weaving, Poultry

raising

4.5 Meditation

– A type of mind-body intervention that includes meditation, prayer, mental healing & creative
therapies that uses art, music or dance.

4.6 Therapeutic touch/massage

– A type of body based therapy that involves manipulation or movement of one or more parts of
the body

5. Observation / Interviewing Skills

– The first step of the nursing process & involves the collection, organization, & analysis of info. –
Serves as the basis for developing a plan of care to meet the needs of the client.

Purposes:

– to construct a picture of the client’s current emotional state, mental capacity, & behavioral
functioning.