Pharmacology Week 3 (Mental Health)

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First pass happens in what?
Metabolism: It goes from the portal vein into the liver to become metabolized.

re-uptake
the axon Recycles chemicals to make neurotransmitters

synapse

neurotransmitter molecules

amygdale
(The Limbic System)

Hippocampus

The Limbic System
(Very high in)
Norepinephrine, epinephrine, and serotonin

forebrain
highest thought processes

midbrain

hindbrain

norepinephrine

epinephrine

serotonin

anxiety-anxiolytics
-panic disorders, OCD, PTSD, and phobias
-find and treat the cause of the anxiety before escorting to meds
-use meds only when it interferes with life
-antidepressants and benzodiazepines

benzodiazepines (Longterm Treatment)
-intensifies the inhibitory effect of GABA
-GABA decreases anxiety (Warm Blanket)
-specific meds differ in onset and duration
-long term treatment of anxiety; short time treatment of insomnia or alcohol withdrawal
-safer than barbiturates
-no respiratory depression IV can have rapid effects on the CNS and respirations
-adverse effects; drowsiness, sedation, lethargy, ataxia
-less addiction potential than barbiturates

GABA (Gamma amino buteric acid)
decreases anxiety (Charlie Brown’s blanket)

Benzodiazepines
-alprazoLAM (Xanax), clonazePAM (Klonopin)
-diazePAM (Valium), lorazePAM (Ativan)
temazePAM (restoril)

flumazenil (Romazicon)-
is used to reverse CNS depressants effects- Benzodiazepine receptor antagonist.

Hypnotics- Zolpidem (Ambien)
(Anxiolytic)
-affect serotonin levels
-schedule IV controlled substances
-caution with risk of suicide, respiratory impairment, or other CNS depressants
-rapid onset (7-27 minutes)
-adverse effects are minimal:Sedation (Fall risk) depression
-rebound insomnia an issue

Eszopiclone (Lunesta)

(Anxiolytic)

-similar to ambient
-longer half-life
-more daytime sedation

Buspirone (Buspar)
(Anxiolytic)
-probable affects D2 dopamine receptors in the brain
-less CNS depression or muscle relaxation
-adverse effects-dizziness, HA, and drowsiness
-dependence and withdrawal less of a concern
-may take several weeks to take effect

Nursing Considerations for Anxiolytics
-caution with older adults at risk for falls
-asess for increased depression, suicidal tendencies
-PT to avoid alcohol and other CNS depressants
-Avoid abrupt discontinuation- rebound anxiety/sleeplessness

Barbiturates-
-currently used primarily as anti-seizure meds
-used for treatment of acute manic reactions
-greater risk of addiction and dependance
-possible paradoxical excitement; Stevens-Johnson syndrome
-Amobarbital (amytal sodium); phenobarbital (luminal), secobarbital (seconal)

paradoxical excitement
pt goes from little crazy to very crazy. (Think LSD out of nowhere).

Steven-Johnson’s
-more common with psychiatric meds
-rash that becomes more and more involved can go from epidermis to dermis
-will end in result with almost third degree burns
-needs to be treated in a burn center

Depression
-affective disorder
-assessment of risk for suicide
-increased risk of depression improves
-also increased risk for homicide
(Could be very flat like Eeyore)
(could be BFF one minute and hating you the next)

Antidepressant- Therapeutic Class
-Pharmacologic Classifications
-tricyclic antidepressants (TCA)
– selective serotonin reuptake inhibitors (SSRI)
-Monoamine Oxidase Inhibitors (MAOI)
-delayed effect of antidepressant
-risk for falls
-avoid abrupt discontinuation of therapy; profound depression, seizures, or withdrawal

MAOI
(monoamine oxidase inhibitors)
breaks down inhibitors and results in more neurotransmitter

SSRI
(Selective Serotonin Reuptake Inhibitors)
Inhibits serotonin reuptake and leaves more serotonin in the synapse (Calming positive effect)

TCA
(Tricyclic antidepressants)
-inhibit reuptake of norepinephrine and serotonin leaving more available in the CNS
-USES:
-major depression
-obsessive-compulsive disorder (OCD)
-SIDE EFFECTS:
-orthostatic hypotension
-cardiac dysrhythmias
-suicidal ideation
-weight gain
-Anticholinergic effects-
-dry mouth
-constipation
-urinary retention
-tachycardia

TCA example
(Tricyclic Antidepressants)
(second resort for medication)
-amitriptyLINE (Elavil)
-ClomipraMINE (anafralil)
-DoxePINE (Sinequan)
-ImipraMINE (Tofranil)
-norty

SSRI
(Selective Serotonin Reuptake Inhibitors)
-blocks the reuptake of serotonin leaving more in the CNS
USES:
-depression
-anxiety
-OCD
-panic
Adverse Effects:
-sexual dysfunction
-weight gain
-insomnia
-weight gain
SAFEST of the antidepressants
-less sympathomimetic and anticholinergic effects
-risk of serotonin syndrome if used with MAOIs

Serotonin Syndrom
FEVER M.A.N
-Mental status changes
-autonomic/GI lability
-Neuromotor disturbances

SSRI
(first medication resort)
-citalopram (celexa)
-escitalopram (Lexapro)
-Fluoxetine (Prozac)
-Paroxetine (Paxil)
-Sertraline (Zoloft)

MAOIs
-inhibits monoamine oxidose, an enzyme that breaks down norepinephrine, dopamine, and serotonin in the CNS leading to higher levels of these neurotransmitters
-SIDE EFFECTS: orthostatic hypotension, HA, weight gain, and insomnia
-interacting with other drugs and foods containing tyramine can cause hypertensive crisis
-low safety margin (Last Resort Drug)

Foods to avoid with MAOIs
-cheese
-wine
-chocolates
anything containing tyramine (Hypertensive crisis)

MAOIs examples
-isocarboazid (Marplan)
-phenelyzene (Nardil)
-tranylcpromine (Parnate)

Bipolar Disorder
(Manic Depressive)
think two bi-poles
-atypical antipsychotics- may be used for acute mania
-ClozAPINE (clozaril)-risk for agranulocytosis
-aripiprazole (Abilify)
-olanzAPINE (Zyprexa)
-quetiAPINE (Seroquel)
-risperidone (Risperdal)

agranulocytosis
-very low white blood cells
-lack of ability to fight off infection

anti-manic Lithium (eskalith)
-may be used for anti seizures or antidepressants
-narrow therapeutic index
-(1-3 days)
-0.6-1.5mEq/L is a therapeutic level
-lithium toxicity with sodium loss Pt teaching!
-evaluate renal, thyroid, heart function before therapy
-lithium toxicity
-vomiting
-diarrhea
-slurred speech
-drowsiness
-ataxia
-weakness
-tremor
-hypotension
-seizures
-lithim level low-S&S depression and/or mania

S&S
signs and symptoms

Psychoses (Plural)
-condition characterized by delusions, hallucinations, illusions, disorganized behavior, and paranoia.
-Acute or Chronic
-difficult to treat as pt does not recognize their illness
-many undesirable side effects with the medications
-goal is to reduce psychotic symptoms to a level that allows for social relationships, and ability to care for themselves
-relapse rate: 60-80%

Antipsychotic- (neuroleptics)
-phenothiazines (Typicals)
-chlorpromazine (Thorazine)
-fluphenozine (prolixin)
-halperidol (Haldol)
-prochlorperazine
Atypical Antipsychotics
-ariprazole (Abilify)
-clozapine (Clozaril)
-lurasidone (latuda)
-quetiapine (Seroquel)

Can elderly demented patients take antipsychotics?
NO! Will more than likely cause a heart attack

Typical Phenothiazines
(Anti-psychotics)
-dopamine receptor blockers
-anti-cholinergic side effects and alpha-adrenergic blocking effects
-extrapyramidal side effects
-hypotension, dysrhythmias (prolonged QT)
-CHF (congestive heart failure)
-pulmonary edema
-laryngospasm
-red urine
-weight gain
-risk of diabetes mellitus and bone marrow suppression
-risk of neuroleptic malignant syndrome
-(

Extrapyramidal side effects (EPS)
(permanent)
-dystonia
-akathisia
-akathisia
-parkinsonism
-tardive dyskinesia

-benztropine (Cogentin) to treat the dystonia
-Beta-adrenergic blockers and benzodiazepines are sometimes used to reduce akathisia.

Atypicals
(Anti-psychotic drugs)
-block dopamine and serotonin receptors
-fewer EPS effects

ADVERSE EFFECTS:
-weight gain
-diabetes
-hypertriglycerides
-possible risk of CVS and mortality

Antipsychotics
-not a cure, only controls symptoms
-never stop taking medications without consulting physician
-need to be tapered off
-fall risk
-observe for anticholinergic effects (PT may not tell you)

CNS Stimulants
-treat ADHD
-narcolepsy
-sleep disorders
SIDE EFFECTS:
-anticholinergic side effects; excessive CNS stimulation
-controlled substances
EXAMPLES:
-Armodafinil (Nuvigil)
-atomoxetine (Stratteral)
-dextroamphetamine (dexedrine)
-lisedexamfetamine (Vyvanase
-Methylphenidate (Ritalin, Concerta)
-modafinil (Provigil)

(Uppers)

Seizure Disorders
CAUSES:
-head trauma
-infectious disease
-metabolic disorders (fluid and electrolyte imbalance)
-hypoxia
-vascular disease-stroke
-pediatric disorders-febrile
-neoplastic disease (Cancer)

Partial Seizure
simple or complex
(Maybe just an arm has a seizure)

Generalized Seizure
-absense (petit mal) (Staring off into space)
-tonic-clonic (Grand-mal)
-myoclonic
-atonic
-status epilepticus
-febrile

Anti-Seizure Medicines:
-GABA potentiate (primary inhibitory neurotransmitter in the brain)
-prevents abnormal or repetitive firing
-stabliizes neuronal membranes to control movement of electrolytes
-hydantoins
-barbiturates
-bensodiazepines
-succinimides

Seizure Pharmacotherapy
-may not eliminate seizures altogether
-risk of falls due to dizziness
-periodic drug levels and symptoms review
-alcohol might increase adverse effects of anti seizure drugs
-avoid abrupt discontinuation
-sedation common

Hydantoins
(Anti-seizure medications)
-phenytoin (Dilantin)- oldest and most common anti seizure
-fosphenytoin (cerebyx)
ALL SEIZURES EXCEPT ABSENCE
-low abuse potential and CNS depression
-narrow range of therapeutic and toxic dose-monitor blood levels
ADVERSE EFFECTS:
-dysarrhythmias (Bradycardia, ventricular fibrillation) hypotension, hyperglycemia, CNS-drowsiness, dizziness, agranulocytosis
-mix with saline only, only MaCI in IV line. irritating to vein
-use birth control

Hydantoins
(Adverse Effects)
-CNS depression (Sedation)
-dysarhythmias
-hypotension
-gingival hyperplasia
-nystagmus
-Stevens-Johnson syndrome
-Bone-Marrow suppression with agranulocytosis
-liver toxicity
-mix with saline only. Only give in IV line flushed with NaCI
-Irritating to Vein

Barbiturates
-intensify effect of GABA
-low margin of safety
-high potential for dependence and withdrawal
-cause profound CNS depression
-phenobarbital (solfoton, luminol)- inexpensive, long acting, and few adverse side effects
-used in all seizure types except absence
-drug of choice for neonates
-possible tissue necrosis at injection site

Benzodiazepine
(Anti-Seizure)
used in absence or myoclonic seizures
(Caffeine and nicotine may decrease the effectiveness of benzodiazepines)

Succinimides
-suppress the abnormal brain activity of absence seizures
-ethosuximide (Zarontin)
-methsuximide (Celontin)
-CNS and GI depression, bone marrow suppression with pancytopenia, Stevens-Johnson syndrome

pancytopenia
not enough of any blood cells

Patient Teaching
(antiseizure medicines)
-always take anti seizure meds
-do not switch brands
-take at the same time every day with food
-monitor blood tests as ordered
-do not drink alcohol
-do not stop taking abruptly

Drugs for Partial Seizures
-carbamazepine (Tegretol)
-Gabapentin (Neurontin)
-Lamotrigine (Lamictal)

Parkinson’s Disease
-degenerative disorder of the CNS caused by death of neurons that produce the neurotransmitter dopamine.
-lack of dopamine and overactivity of acetylcholine
-tremors
-muscle rigidity or weakness
-bradykinesia
-difficulty chewing, swallowing, and speaking
-postural instability, shuffling gait-easily lose balance, fall risk!

Dopaminergic Drugs
-carbidopa combined with levodopa (Sinemet) helps levodopa cross the blood brain barrier before transforming to dopamine
-may take up to 6 months for therapeutic effects
-adverse effects0 tachycardia, hypertension, loss of appetite, nausea and vomiting, constipation, urinary retention
-associated with development of melanoma
-avoid vitamin B6
-Abrupt withdrawal can produce acute parkinsonism

The CNS consists of
the spinal chord and the brain, it is protected by bone and meninges

Goal of Drug Therapy for Mental Health
-depress or decrease CNS
-regulate amounts of CNS Neurotransmitters
-stimulate or block autonomic receptors
-treat psychiatric disorders

Drugs for Sleep disorders
-benzodiazepines
-non-benzodiazepines

Benzodiazepines
(Hypnotic)
-relieve insomina
-relieve anxiety
-treat epilepsy in emergency situations
-relax muscle spasms
-help with moderate sedation
(Pams)
-they enhance GABA

Benzodiazepines
Adverse Effects
-drowsiness
-dizziness
-tolerance develops within weeks
-Withdrawal
-can cause paranoia, panic attacks, muscle twitching, and hallucinations

Benzo Signs of Toxicity
weakness
slurred speech
ataxia
respiratory depression
(Older Adults)-watch for paradoxical excitement

Non-Benzodiazepines
Zolpidem (Ambien)
Eczopiclone (Lunesta)

Non-Benzo
(Adverse Effects)
-daytime drowsiness
-headache
-anxiety
-dizziness
-diplopia
-amnesia
TAKE ON EMPTY STOMACH

CNS Depressants for muscle spasms
-centrally acting muscle relaxants
-peripherally acting muscle relaxants

Centrally acting Relaxants (Uses)
-Spinal Chord Injury
-multiple sclerosis
-cerebral palsy
-musculoskeletal injury

Centrally Acting Relaxants
(adverse effects)
-no physical dependance
-drowsiness/dizziness
-nausea
-constipation
-anxiety
-restlessness

Peripherally Acting muscle relaxants (Uses)
-relax muscle spasms r/t
-cerebrovascular accident
-spinal chord injury
-cerebral palsy
-multiple sclerosis
Prevent and treat hyperthermia (Side Effect of general Anesthesia

Peripherally Acting Muscle Relaxants
-prototype drug-dantrolene (Dantrium)
-inhibit release of calcium

Dantrolene
(Adverse Effects)
-liver toxicity
-diarrhea
-muscle weakness
-drowsiness/ dizziness

AED’s (Anti Epileptic Drugs)
CNS Depressant
-hydantoin
-iminostilbenes
-Valproic Acid

Hydantoin (AED)
treats:
-Grand-Mal (Tonic Clonic Seizure)
-partial seizure

phenytoin(Dilantin)

Hydantoin
-decrease neuronal activity of seizure producing cells in brain
-by inhibiting influx of sodium through sodium channels

A patient is beginning to take Mirapex for Parkinson’s Disease, which should be monitored?
creatine phosphokinase (CPK)

What should you monitor a patient for that is taking donepezil (Aricept) for Alzheimer’s
nausea

A patient is newly diagnosed with Parkinson’s Disease- what should they tell them about how levodopa/carbidopa (Sinermet) will help with her symptoms?
IT will increase the amount of dopamine that can get to the brain through the blood brain barrier

A newly diagnosed patient is taking Valproic Acid (Depakote) for seizures. What should the healthcare provider tall the pt to look out for
-rash
-drowsiness

An alert that pt is having adverse side effects to Beta-B1 Betaseron is?
fatigue

If a pt is taking a memantine (Namenda) for alzheimer’s they should notify the doctor before…
taking any over-the-counter antacid

When taking modafinil (Provigil) healthcare provider should include for patient to:
Take in the morning

A patient is taking baclofen (Lioresal) which should they understand?
They should not drive until the effects of the drug are known

A patient is beginning to take valproic acid (Depakote) which should they be advise to monitor for
jaundice

PT is taking temazepam (Restoril) What should the healthcare professional include?
-Avoid alcohol and other depressants
-take 30 minutes before bedtime
-taper the drug to decrease effects from withdrawal

PT is beginning to take zolpidem (Ambien) what should they know Ambien can cause?
memory impairment

patients taking adderall should be monitored for…
tachycardia

What’s the antidote for fentanyl (Sublimaze)
Naloxone

When taking Avonex pt should…
premedicate with tylenol

When taking Sumatriptan (Imitrex) advise patient to be cautious if having…
chest pains

A health care professional is talking to a patient and her family about how methylphenidate (Ritalin) will help manage attention-deficit hyperactivity disorder (ADHD). Which of the following therapeutic effects should they expect?
increased focus

Because of the potential for adverse effects, which of the following should a health care professional recommend for patients who begin taking carbamazepine (Tegretol)?
begin taking at a low dosage

An anesthetist is about to administer lidocaine (Xylocaine) as part of the protocol for spinal anesthesia for a patient who is undergoing a surgical procedure. The health care professional should be aware that the patient could develop which of the following potentially serious effect?
hypotension

A health care professional should include which of the following instructions when talking with a patient about taking levodopa/carbidopa (Sinemet) to treat Parkinson’s disease?
change positions to prevent orthostatic hypotension

When reviewing the adverse effects of drug therapy with a patient, a health care professional should explain orthostatic hypotension is a common adverse reaction of which of the following drugs?
Imipramine (Tofranil)

A health care professional is caring for a patient who is about to begin amitriptyline therapy to treat major depression. The health care professional should include which of the following instructions when talking with the patient about taking the drug?
-change position slowly
-do not quit taking abruptly
-take at bedtime to prevent daytime drowsiness
-Increase fiber and fluid intake

A healthcare professional is caring for a patient who is taking lithium carbonate (Lithobid) to treat bipolar disorder. Which of the following diagnostic test should the health care professional recommend periodically for the patient?
Thyroid function test

A health care professional should question the use of alprazolam (Xanax) for a patient who
drinks two or more glasses of wine each night

A health care professional is obtaining a patient drug history when he finds that the patient is taking lithium carbonate (Lithobid) for bipolar disorder. Which of the following findings in the patients drug history should alert the health care professional to monitor him for lithium toxicity?
Furosemide (Lasix) for hypertension

A health care professional should monitor and older adult patient who is taking alprazolam (Xanax) for which of the following adverse effects?
-tolerance
-anxiety
-sedation
-respiratory depression

A health care professional is talking to a patient who is taking lithium carbonate (Lithobid). Which of the following instructions should be included to reduce the risk of lithium toxicity?
Avoid taking NSAIDS

Which of the following instructions should a health care professional include when advising a patient about instilling pilocarpine (Isopto Carpine) for managing open-angle glaucoma?
-do not touch the tip of the dropper
-apply pressure nasolacrimal duct for 1 minute after
-Remove contact lenses prior to inserting drops

A patient is admitted to the emergency department with spasms of his face and back. He has recently begun taking chlorpromazine to treat schizophrenia. Which of the following adverse reactions should the health care professional suspect?
acute dystonia

A health care professional is caring for a patient who is taking venlafaxine to treat major depression. The health care professional should recognize that which of the following drugs can cause serotonin syndrome when patient take it concurrently with venlafaxine
Phenelzine (Nardil)

A health care professional is caring for a patient who has been taking alprazolam (Xanax) for an extended period of time to treat anxiety. The health care professional should recognize that stopping alprazolam therapy suddenly can resulting which of the following?
withdrawal symptoms

Soon after beginning fluxetine (Prozac), a patient is admitted to the emergency department with agitation and confusion. The health care professional should suspect which of the following?
Seratonin Syndrome

A health care professional is caring for a young adult patient who is taking fluuxetine (Prozac) to treat depression. The health care professional should tell the patient and the patients family to report which of the following?
Suicidal Thoughts

While taking with a patient about taking chlorpromazine, which of the following instructions should the health care professional include?
wear sunscreen when exposed to light

When talking to a patient about buspirone, the health care professional should include which of the following instructions?
allow 2 to 4 weeks to notice effects

A health care professional should advise a patient who is taking phenelzine (Nardil) to avoid tyamine-enriched foods because of an increased risk for which of the following adverse reactions?
hypertensive crisis

When reviewing the indications for various antidepressants, a health care professional should understand that bupropion hydrochloride (Wellbutrin) is an appropriate choice for patients who have which of the following?
-depression
-seasonal affective disorder
-nicotine addiction

A health care professional is caring for a patient who is about to begin using betaxolol (Betoptic) eye drops to treat open-angle glaucoma. The health care professional should advise the patient to expect which of the following reactions?
Ocular Stinging

During and immediately following IV administration of chlorpromazine to a patient who has schizoaffective disorder, the health care professional should monitor which of the following?
blood pressure

A health care professional is caring for a patient who is about to begin taking echothiophate (Phospholine Iodid) to treat glaucoma. The health care professional should monitor the patient for the development of which of the following adverse effects?
cataracts

A health care professional is caring for a patient who is about to begin taking lithium carbonate (Lithobid) to treat bipolar disorder. The health care professional should caution the patient to watch for which of the following indications of litium toxicity?
-tremors
-confusion
-nausea
-muscle weakness

When caring for a patient who is taking risperidone (Risperdal) for schizophrenia, the health care professional should monitor for which of the following adverse effects of the drug?
polyuria

A health care professional should question the use of timolol (Timoptic) for a patient who has which of the following disorders?
asthma

A health care professional should expect which of the following adverse effects for a patient who is taking betaxolol (Betoptic) eye drops to treat glaucoma?
bradycardia

A health care professional is collecting data from a patient who is taking bupropion hydroooride (Wellbutrin) to treat depression. The health care professional notes that the patient has a recent history of a head injury. She should recognize that the drug is inappropriate for the patient because of the increase risk for which of the following?
seizure activity

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