Psychopharmacologic Therapy 2828 Valerie Levi, Pharm D Deborah Antai-Otong, MS, RN, CNS, PMHNP, CS, FAAN Duane F

Psychopharmacologic Therapy 2828 Valerie Levi, Pharm D Deborah Antai-Otong, MS, RN, CNS, PMHNP, CS, FAAN Duane F. Pennebaker, PhD, FNAP, FRCNA Joy Riley, DNSc, RN, CS CHAPTER OUTLINE The Human Genome and Pharmacology Protein Binding The Brain and Behavior Active Metabolites Neuroanatomical Structures Relevant Cultural Considerations to Behavior Psychopharmacologic Therapeutic Agents Cortical Structures Medication Administration The Cerebral Cortex Antidepressants The Four Lobes and Their Functions Mood Stabilizers The Association Cortices Anticonvulsants The Basal Ganglia Antipsychotics The Hippocampus and the Amygdala Sedatives and Hypnotic Agents Subcortical Structures Psychopharmacologic Therapy across The Brainstem the Life Span The Cerebellum Sedative and Antianxiety Agents The Diencephalon Antipsychotics Neurophysiology and Behavior Children and Adolescents Neurons Antipsychotics Synaptic Transmission Antidepressants Neurotransmitters Mood Stabilizers Biogenic Amines Sedative and Antianxiety Agents Acetylcholine Older Adults Amino Acids Antidepressants Peptides Mood Stabilizers Neurotransmitter Action Sedative and Antianxiety Agents Pharmacokinetic Concepts Antipsychotics Pharmacology The Role of the Nurse Factors That Include Drug Intensity and The Generalist Nurse Duration The Advanced-Practice Psychiatric Absorption Registered Nurse Distribution Treatment Adherence Metabolism Legal and Ethical Issues Elimination Client Advocacy Steady State, Half-Life, and Clearance Steady State Right to Refuse Half-Life Psychoeducation Clearance Medication Monitoring 767 768 UNIT THREE Therapeutic Interventions Competencies Upon completion of this chapter, the learner should be able to: 1. Describe current knowledge about the brain and 4. Explain the nurse’s role in the administration behavior as it relates to the clinical and pharmaco- and prescription of psychopharmacologic agents kinetics of the major psychopharmacologic agents. within the treatment regime. 2. Describe the clinical and pharmacologic proper- 5. Describe the importance of client and family ties of the major psychopharmacologic agents education in the use of psychopharmacologic and the use of these agents in the treatment of agents in the treatment of mental illness. mental illness. 6. Comprehend the nurse’s responsibilities and the 3. Apply knowledge about the pharmacokinetic ethical issues confronting the nurse in the use of properties of the major psychopharmacologic psychopharmacologic agents. agents to individualized client care. Key Terms Akathisia: Subjective feelings of restlessness and an Human Genome: The entire genetic information inability to sit still resulting from dopamine present in a human cell. blockade by certain neuroleptics; part of the extrapyramidal side effects. Linear Kinetics: A pharmacokinetic model in which a constant amount of drug is eliminated in a set unit Akinesia: A condition characterized by the inability of time. to make voluntary movements. Neuroleptic: Psychotropic medication; major Anxiolytic: Drug used to reduce anxiety, and is tranquilizers; synonymous with antipsychotic or synonymous to the term sedative. Examples include neuroleptic agent. benzodiazepines such as diazepam, lorazepam, and clonazepam. Neuroleptic Malignant Syndrome (NMS): A rare and potentially life-threatening syndrome primarily Cogwheeling: Refers to rigidity or rhythmic contrac- caused by antipsychotic medications and character- tions noted on passive stretching of muscles, as ized by marked muscle rigidity, high fever, altered occurs in Parkinson’s disease. consciousness or delirium, tachycardia, hypoxia, hypertension, and diaphoresis. Dopaminergic Pathway: Nerve fibers in the mesocortical area that project to the cortex and Neurotransmitters: Nervous system biochemicals hippocampus regions of the limbic system. involved in facilitating neurotransmission of impulses across synapses between neurons. Examples include Dystonia: Slow sustained muscle spasms of the serotonin, norepinephrine, and dopamine. trunk, neck, or limb; the result of dopamine blockade from neuroleptic (antipsychotic) medications. Paradoxical Reactions: A response to a drug that is opposite to what would be predicted by the drug’s Exponential Kinetics: A pharmacokinetic model in pharmacology. which a constant fraction of a drug is eliminated in a set unit of time. Pharmacodynamics: The study of biochemical and physiological actions and effects of drugs. Extrapyramidal Side Effects (EPS): Involuntary motor movements; and muscle tone side effects Pharmacokinetics: The study of a drug’s absorption, that result primarily from dopamine blockade by distribution, metabolism, and excretion or elimination. neuroleptic medications. Pharmacology: The scientific study of chemical Genomics: The study of the human genome formulations (drugs), including their sources, sequencing and its contributions to disease and properties, uses, actions, and effects. treatment. (continues) CHAPTER 28 Psychopharmacologic Therapy 769 Key Terms (continued) Sedative: Drugs that are virtually synonymous to Synaptic Transmission: The process of nerve anxiolytics; used to calm nervousness, irritability, or impulse transmission through the generation of excitement; these agents depress the central nervous action potentials from one neuron to another. system and tend to cause lassitude and reduced Tardive Dyskinesia: A complex range of involuntary mental activity. movements associated with long-term and usually Serotonin Syndrome: A condition characterized by high-potency neuroleptic treatment. A chronic, serotonergic hyperstimulation that includes restless- progressive, and potentially fatal syndrome from ness, hyperthermia, myoclonus, hypertension, prolonged dopamine blockade by neuroleptic med- hyperreflexia, diaphoresis, lethargy, confusion, and ications. Major manifestations include choreiform tremor and which may cause death. movements of the face, tongue, upper and lower extremities, such as tongue movement or protru- Steady State: The state whereby the amount of sion, lip sucking, chewing, and smacking; other drug eliminated from the body equals the amount symptoms include puffing of cheeks and pelvic being absorbed. thrusting. he past three decades of research in the neurosciences is not intended to replace sound clinical judgment or individ- Thas dramatically increased our understanding of the ualized client care. Nurses are legally and ethically respon- neurobehavioral aspects of mental illness to the extent that sible for being familiar with information such as the action, the 1990s were referred to as the Decade of the Brain and dosage, adverse effects, and drug interactions of the med- more recent discoveries of the human genome and bioin- ications they administer. The reader is advised to check formatics in 2000. Scientists predict that the discovery of the product information before administering any drug, espe- human genome or human genetic blueprint offers incredi- cially new or infrequently ordered drugs. Unless otherwise ble promise for the treatment of diseases, including mental noted, all information concerning the pharmacokinetic and illness. Historically, the advent of the first psychotropic med- clinical properties of the psychopharmacologic agents dis- ications in the 1950s significantly changed the treatment of cussed in this chapter is based on adult oral dosages. It is the mentally ill. Part of the role of the psychiatric-mental assumed that the student has had a prerequisite to the mate- health nurse has evolved in tandem with the unfolding suc- rials in this chapter’s introduction to pharmacology and the cess of psychotropic medications. The psychiatric-mental anatomy and physiology of the brain and central nervous health nurse’s knowledge of psychopharmacology and its system (CNS). associated therapeutic agents is a significant factor in con- temporary practice. The psychiatric nurse has a critical role in assisting clients to incorporate the psychopharmacologic THE HUMAN GENOME AND agents into their efforts to recover and maintain mental health and prevent negative sequel and relapse. In addition, PHARMACOLOGY the psychiatric-mental health nurse is responsible for assess- Tremendous technological advances in bioinformatics and ing the therapeutic effects of the drugs. Monitoring adverse the human genome or genetic mapping discovery have pro- reactions, knowing therapeutic dosages, documenting pelled the study of pharmacology into a new era. Drugs are administration, and educating the client and family members believed to exert their curative effects by modifying the about the psychopharmacologic agents being used in the molecular structure of target proteins in the body. Today’s treatment regime. At the advanced-practice level in many researchers are bypassing lengthy animal studies and turn- states, psychiatric-mental health nurses also have prescrip- ing to a fast-growing new era of computer science known as tive authority. This chapter presents an overview of current bioinformatics. Bioinformatics are being used to fuel scien- major concepts that relate brain and behavioral response to tists’ quest for newer drugs and better targets. Bioinformatic the major psychopharmacologic agents used in the treat- algorithms are being used to help pharmaceutical compa- ment of mental illness. nies predict the future of proteins encoded by newly dis- Recommended treatments and drug therapies are changed covered genes. as clinical and scientific findings are made available. In this Scientists

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