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Home , Psychiatric medication

PSYCHIATRIC

TRAINING MODULE LEARNING OBJECTIVES

At the end of this module the learner will: • Be familiar with commonly prescribed psychiatric , intended benefits, and how they work • Be familiar with common side effects, risks, and contraindications for each medication • Recognize signs of or non- to medication prescriptions • Be familiar with potential reactions between prescription and nonprescription medications • Be familiar with alcohol and opioid addiction treatment medication THE BASICS

• All actions of the – sensory, motor, and intellectual – are carried out physiologically through the interactions of nerve cells (neurons) • Various areas of the brain are interconnected structurally and functionally by a network of neurons • Interaction of neurons involves: • Impulse conduction, • Neurotransmitter release, and • Receptor response • Alterations in these basic processes may lead to mental disturbance WHY IT IS IMPORTANT TO UNDERSTAND NEURONS, RECEPTORS, AND NEUROTRANSMITTERS

• Neurons (nerve cells) • Conduct electrical impulses • Release chemicals called neurotransmitters • Synapse (space between two neurons) • Neurotransmitters diffuse across a space, or synapse, to adjacent postsynaptic neuron, where it attaches to receptors on the neuron’s surface • Receptors (on the receiving neuron) • Neurotransmitters attach to receptors to stimulate or inhibit the receiving neuron • It is the interaction between neurotransmitter and receptor that is a major target of the drugs used to treat psychiatric disease TYPES OF NEUROTRANSMITTERS: MONOAMINES

MONOAMINES • (DA) • Is involved in integration of emotions and thoughts and decision making • Decrease in DA: Depression, Parkinson’s disease • Increase in DA: , • (NE) • Level in brain affects mood, attention & arousal • Stimulates for “fight or flight’ response to stress • Decrease in NE: Depression • Increase in NE: Mania, Anxiety states, Schizophrenia • (5-HT) • Plays role in sleep regulation, hunger, mood states, and pain perception, as well as aggression and sexual behavior • Decrease in 5-HT: Depression • Increase in 5-HT: Anxiety states

TYPES OF NEUROTRANSMITTERS: AMINO ACIDS

AMINO ACIDS • Gamma-aminobutyric acid (GABA) • plays a role in inhibition; reduces aggression, excitation, and anxiety; and muscle-relaxing properties; may play role in pain perception; may impair cognition and psychomotor functioning • Decrease in GABA: Anxiety disorders, Schizophrenia, Mania • Increase in GABA: Reduction of anxiety • Glutamate • is excitatory; plays a role in learning and memory • Decrease in glutamate: • Increase in glutamate: Neurodegeneration in Alzheimer’s disease PHARMACOLOGICAL TREATMENT

• Pharmacological treatment of mental disturbances is directed at the suspected neurotransmitter- receptor problem • For example: • Anti-psychotic drugs decrease dopamine • Anti- drugs increase synaptic levels of serotonin • Anti-anxiety drugs increase effectiveness of GABA or increase serotonin • Drugs used to treat the disturbance can affect more than one area of brain activity (side effects) • For example, basic drives, sleep patterns, or body movement ANTIANXIETY DRUGS

ANXIOLYTICS ANTIANXIETY DRUGS

• • Valium • Klonopin • Xanax • Ativan • Buspirone (BuSpar) • • Without strong - effect • to treat anxiety • SSRIs • SSNRIs • TCAs • MAOIs BENZODIAZEPINES

• Quick onset of action • Potential for dependence: • Use for short periods only until other medications take effect • Not recommended for patients with known substance abuse problem • Not for pregnant or women • May cause withdrawal symptoms after 3-4 months of daily use • Drug interactions: • delay absorption • Alcohol/ cause increased sedation BENZODIAZEPINES COMMONLY PRESCRIBED

Alprazolam (Xanax) (Ativan) (Klonopin) Panic disorder Panic disorder *Generalized Generalized anxiety *Generalized anxiety *Panic disorder disorder disorder *Social anxiety *Social anxiety *Social anxiety disorder disorder disorder

* Off-label uses NON- FOR ANXIETY DISORDER

Buspirone (BuSpar) Generalized anxiety disorder *Social anxiety disorder *Obsessive-compulsive disorder • Does not cause dependence • 2-4 weeks required to reach full effects • May be used for long-term treatment

*Off-label uses ANTIDEPRESSANTS FOR ANXIETY DISORDERS

SSRIs SSNRIs MAOIs (Celexa) (Cymbalta) (Nardil)

Escitalopram (Lexapro) (Effexor) (Parnate)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Paroxetine (Paxil)

Sertraline (Zoloft)

First-line treatment for acute Panic disorders, GAD, SAD, Panic disorders, GAD, SAD, stress disorders and PTSD OCD, PTSD PTSD

Preferable to TCAs because Reserved for treatment- they have a more rapid onset resistant conditions of action & fewer problematic side effects Panic disorders, GAD, SAD, Risk of life-threatening OCD, PTSD pressure crisis if dietary restrictions are not followed OTHER CLASSES OF MEDICATIONS FOR ANXIETY DISORDERS

• Often added if the first course of treatment is ineffective • Beta-blockers • Atenolol (Tenormin) • Propranolol (Inderal) • Antihistamines – nonaddictive alternative to benzodiazepines to lower anxiety levels • Hydroxyzine hydrochloride (Atarax) • Hydroxyzine pamoate (Vistaril) • • (Tegretol) • Gabapentin (Neurontin) • Valproic acid (Depakote) DRUG TREATMENT FOR SLEEP DISORDERS SLEEP DISORDERS RELATED TO OTHER MENTAL DISORDERS

• Most psychiatric disorders are associated with sleep disturbance. Two classifications: • Insomnia – most frequent complaint • Hypersomnia • There is evidence that sleep disruption itself may be a precipitating factor in triggering mood and other psychiatric disorders and increases the risk to relapse • Insomnia is common with anxiety disorders and schizophrenia • Hypersomnia is associated with mood disorders, personality disorders, , and uncomplicated grief

MORE ON SLEEP DISORDERS RELATED TO OTHER MENTAL DISORDERS

• Patients tend to focus on their sleep and ignore the symptoms of the related • For example, patients who wake up frequently at night and awaken with a difficult mood report that if they could get a good nights sleep their mood symptoms would improve. • Poor health habits compound the problems: • Excessive caffeine use, smoking, inattention to regular sleep schedule

SUBSTANCE-INDUCED SLEEP DISORDER

• Can result from use or recent discontinuance of a substance or medication • Over-the-counter (OTC) medications • Alcohol • Decreases deep sleep and REM sleep • Middle-of-the-night awakenings, difficult returning to sleep • Nicotine • It is a , as levels decline overnight patients wake up in response to mild withdrawal • Caffeine • Difficulty falling asleep, reduces slow wave sleep • – awaken for urination DRUG TREATMENT FOR INSOMNIA

• Benzodiazepines used as sleep aids • Habit forming (Schedule IV) • Dalmane • Restoril • Halcion • Prosom • Doral • Short-Acting Sedative-Hypnotic Sleep Agents • “Z-” are habit forming (Schedule IV) • Ambien • Sonata • Lunesta Continued…

DRUG TREATMENT FOR INSOMNIA

Continued: • Melatonin Receptor Agonists • Not habit forming • Rozerem • Antidepressants for insomnia • Not habit forming • Trazadone (Desyrel) • Antihistamines for insomnia • Tolerance to hypnotic effects develops in 1-2 weeks • Diphenhydramine (in Benadryl) • Doxylamine (Unisom) MELATONIN FOR INSOMNIA

• Melatonin is a hormone naturally secreted in response to dark to produce sensation of sleepiness • Melatonin levels decline in the early morning and disappear during the day to reverse the effect • Synthetic melatonin is available OTC • Research actually does not indicate melatonin is useful in treatment of insomnia • It does show some effectiveness in managing jet lag and shift work disorder MELATONIN, CONTINUED

• It is safe… maybe • No documented reports of toxicity or overdose • However: • There is no identified effective dosage range • Because it is available OTC and unregulated by the FDA, there is no standardization of ingredients • Side effects: • Nausea • Headache • Blood pressure changes DRUGS 3 HYPOTHESES OF ANTIDEPRESSANTS’ MECHANISM OF ACTION

1. There is a deficiency in one or more neurotransmitter - 5-HT, NE, or DA (dopamine) – and increasing these neurotransmitters alleviates depression. 2. Low levels of neurotransmitters cause receptors to be more sensitive. Increasing neurotransmitters results in desensitizing receptors. May answer why it takes so long for antidepressants to work. 3. Drugs increase production of neurotrophic factors (to enhance survival of neurons and new synaptic connections). TARGET SYMPTOMS

• Antidepressant drugs target symptoms that include: • Sleep disturbance • Appetite disturbance • (increase or decrease) • Fatigue • Decreased sex drive • Psychomotor retardation or agitation • Diurnal variations in mood • (usually worse in the morning) • Impaired concentration or forgetfulness • Anhedonia • (inability to experience joy or pleasure in living) TYPES OF ANTIDEPRESSANTS: TCA

• Tricyclic Antidepressants (TCAs) • Used widely before SSRIs were developed • Side effects are more prominent than SSRIs • Some examples: • (Elavil) • Clomipramine (Anafranil) • Imipramine (Tofranil) • Some side effects & warnings: • Dry mouth • Constipation • Blurred vision • Cardiac toxicity • Sedation • Lethal in overdose • Do not take with MAOIs

TYPES OF ANTIDEPRESSANTS: SSRI

• Selective Serotonin Reuptake Inhibitors (SSRIs) • Do not have side effects common w/TCAs, but have other side effects • Some examples: • Citalopram (Celexa), (Lexapro), (Prozac), Fluvoxamine (Luvox), (Paxil), (Zoloft) • Some side effects & warnings: • Agitation, insomnia • Headache, nausea, vomiting • Sexual dysfunction • Withdrawal effects may occur with discontinuation • Do not take with MAOIs

TYPES OF ANTIDEPRESSANTS: SNRI

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) • Some examples: • Venlafaxine (Effexor) – popular next-step after trying SSRIs • Duloxetine (Cymbalta) – also decreases neuropathic pain • Some side effects & warnings: • Hypertension (Effexor) • Nausea • Dry mouth • Insomnia, agitation • Sexual dysfunction • May cause withdrawal

TYPES OF ANTIDEPRESSANTS: SNDI

• Serotonin-Norepinephrine Disinhibitors (SNDIs) • Effects may be faster than SSRIs • May be used for sleep disorders • Only one: • (Remeron) • Some side effects & warnings: • Sleepiness • Exaggerated by alcohol, benzodiazepines • Do not take with MAOIs

TYPES OF ANTIDEPRESSANTS: MAOI

• Inhibitors (MAOIs) • Some examples: • Phenelzine (Nardil), Selegiline (EMSAM), Tranylcypromine (Parnate) • Some side effects & warnings: • Insomnia, agitation • Nausea • Confusion • Do not take with other antidepressants and check with physician before taking any other prescribed or OTC meds • Avoid -rich foods (for example, avacado, fig, aged meats, most cheese, yeast, beer/wine, protein dietary supplements)

TYPES OF ANTIDEPRESSANTS: NDRI

• Norepinephrine Dopamine Reuptake Inhibitor (NDRI) • Only one: • (Wellbutrin) • Some side effects & warnings: • Agitation, insomnia • Stimulant action may reduce appetite • Headache, nausea, vomiting • Very small risk of seizure (at high doses) • May increase • Used as an aid to quit smoking • Do not take with MAOIs

PREGNANCY AND ANTIDEPRESSANTS

• SSRI and TCAs • Risk of preterm birth • Higher risk for spontaneous abortion • TCAs • Congenital malformations of the heart and limbs • MAOIs • Severe hypertension and stroke with pregnancy • Breathing problems in infant • Withdrawal in infant

MOOD STABILIZERS

TREATMENT OF BIPOLAR DISORDER BIPOLAR DISORDER

• Episodes of mania alternates with major depression • Rapid cycling – four or more mood episodes in a 12 month period • Depressive episodes: • Same symptoms as major depression, although more intense • & Lamictal are the first-line treatment for acute depressive episode; Antidepressants are not recommended (may result in mania) • Atypical may be added if psychotic features • Manic episodes: • Persistent elevated, expansive, or irritable mood • May necessitate hospitalization

LITHIUM

• Mechanism of action is not well understood • Low Therapeutic Index – this means the blood level that can cause death is not far above the blood level required for drug effectiveness • Blood level of lithium must be MONITORED on a regular basis • Adverse Effects: • Nervous/muscular - tremor, confusion, convulsions, uncoordinated movement • Digestive – nausea, vomiting, diarrhea • Cardiac – arrhythmias • Fluid/electrolyte – polyuria (large output of urine), polydipsia (excessive thirst), edema (swelling) • Goiter, hypothyroidism

ANTICONVULSANT DRUGS

USED IN TREATMENT OF BIPOLAR DISORDER (DEPAKOTE, DEPAKENE)

• Divalproex is recommended for mixed episodes and has been useful for rapid cycling bipolar disorder • Common Side Effects: • Tremor • Weight gain • Sedation • Therapeutic blood level monitoring required • Liver function tested before and throughout use CARBAMAZEPINE (TEGRETOL)

• Useful in preventing mania and during episodes of acute mania • Common Side Effects: • Dry mouth • Constipation • Urinary retention • Blurred vision • Sedation • Rash • Blood levels are monitored to avoid toxicity (LAMICTAL)

• Approved by FDA for maintenance therapy of bipolar disorder • Works well in treating the depression without switching the patient into mania, like other antidepressants • Not effective in acute mania • Promptly report rashes – could be a sign of life- threatening Stevens-Johnson syndrome • can be minimized by slow titration to therapeutic doses

OTHER ANTICONVULSANTS

• Other anticonvulsants used as mood stabilizers: • Gabapentin (Neurontin) • Topiramate (Topamax) • (Trileptal) • None of them have FDA approval as mood stabilizers • Studies have not provided strong evidence for their use as primary treatments for bipolar disorder • medications and clonazepam (Klonopin) are used for calming effect during mania ANTIPSYCHOTIC DRUGS POSITIVE VS. NEGATIVE SYMPTOMS OF SCHIZOPHRENIA

Positive Symptoms Negative Symptoms • Hallucinations • Uncommunicative/ • Delusions withdrawn • Loose association of • Talks about self as ideas “bad” or “no good” • Conversations • Extremely sensitive derailed by to real/perceived unnecessary/tediou slights s details • Lack of energy/motivation CONVENTIONAL ANTIPSYCHOTICS

• Also known as: • First-generation antipsychotic drugs • Typical • Standard • These drugs block dopamine to reduce symptoms • Overactivity of the dopamine system may be responsible for at least some of the symptoms of schizophrenia • Reduces POSITIVE SYMPTOMS • delusions (paranoid and grandiose ideas) • Hallucinations • These drugs are not first-line treatment anymore CONVENTIONAL ANTIPSYCHOTICS

• (Thorazine) • (Mellaril) • Loxapine (Moban) • (Trilafon) • (generic only) • Thiothixene (Navane) • Fluphenazine (Prolixin) • (Haldol) • Pimozide (Orap)

SIDE EFFECTS OF CONVENTIONAL ANTIPSYCHOTICS

• Dry mouth • Urinary retention/hesitancy and constipation • Blurred vision • Photosensitivity and dry eyes • Impotence in men • Pseudoparkinsonsim (Stiff/stooped posture, shuffling gait, tremor, “pill-rolling”) • Dystonias (acute contractions of tongue, face, neck, or back) • Akathisia (tapping foot incessantly, rocking, shifting weight side to side) • Tardive Dyskinesia (protruding/rolling tongue, smacking, spastic facial distortion) • Neuroleptic Malignant Syndrome (NMS) – rare, potentially fatal

ATYPICAL ANTIPSYCHOTICS

• These drugs target BOTH positive and negative symptoms • Produce fewer motor-related side effects • For example, tardive dyskinesia and pseudoparkinsonism • Often chosen as first-line treatment over conventional drugs • Increased risk of metabolic syndrome: • Increased weight, blood glucose, and triglycerides • Especially (Clozaril) and (Zyprexa)

CLOZAPINE (CLOZARIL)

• • Relatively free of motor side effects • Patients are more likely to adhere to medication regimen than other atypical antipsychotics • Increased risk of • Monitor blood work monthly • Side Effects: • Drowsiness/Sedation • Hypersalivation • Weight gain • Constipation • Dizziness • Dose-related risk of convulsions

RISPERIDONE (RISPERDAL)

• Atypical antipsychotic • Very low potential for infection risk or convulsions • High therapeutic doses may cause motor difficulties • Side Effects: • Bouts of low blood pressure (fall risk) • Weight gain • Sedations • Sexual dysfunction • Available as long-acting injection (every 2 weeks) (SEROQUEL)

• Atypical antipsychotic • High sedation • Side Effects: • Weight gain/ risk of metabolic syndrome • Low risk of motor difficulties

OTHER ATYPICAL ANTIPSYCHOTICS

• Olanzapine (Zyprexa) • Side effects: sedation, weight gain, high blood glucose w/type 2 diabetes onset, higher risk of metabolic syndrome • (Geodon) • Side effects: dizziness, moderate sedation • (Abilify) • Little sedation or weight gain • Side effects: insomnia, akathisia • (Invega) • Side effects: sedation, orthostasis DRUG TREATMENT FOR ATTENTION DEFICIT HYPERACTIVITY DISORDER

FOR CHILDREN & ADULTS WITH ADHD SYMPTOMS OF ADHD

• Short attention span • Difficulty listening, even with prompts or redirection • Easily distracted, loses things, forgetful • Impulsivity • Unable to sit still or play quietly • Acts as if “driven by a motor” • Talk excessively, blurts out answers before question is finished, interrupts, intrudes • Difficulty waiting for own turn STIMULANT DRUG THERAPY

• Paradoxically, the treatment for ADHD is stimulant drugs: • Methlphenidate (Ritalin, Concerta & Metadate - longer acting) • Dextroamphetamines () • (Vyvanse) • Side effects: • Insomnia • Agitation • Exacerbation of psychotic thought processes • Hypertension • Long-term growth suppression • Potential for abuse of the drugs

NONSTIMULANT DRUG THERAPY

• Atomoxetine (Strattera) • Approved for children and adults • Eliminates risk of abuse, but may not be as effective as • Response developed slowly (up to 3 weeks) • Common Side Effects: • Gastrointestinal disturbances • Reduced appetite, weight loss • Dizziness • Fatigue • Insomnia

INTEGRATIVE THERAPY EXERCISE

• Exercise • counteracts symptoms of depression, enhances mood • increases available serotonin • Has fewer side effects than antidepressants • Effects of exercise are: • Biological • Social • Psychological • A combination of exercise and meditation is helpful • Clients should consult with a medical professional before starting an exercise program

DIET

• Nutritional disturbances are common among people with a mental illness • Diabetes and obesity are prevalent in people with psychiatric disorders and require dietary management • Nutritional states may cause psychiatric disturbances • Lower rates of depression are reported in vegetarians • Anemia is often accompanied by depression NUTRITIONAL SUPPLEMENTS

• Omega 3 fatty acids may be recommended as adjunct therapy for persons with depression and bipolar disorder • Nutritional supplements, SAMe and B (B6 and folic acid), may improve depression • B vitamins and Folic acid may be useful for management of bipolar illness and schizophrenia • These vitamins augment, rather than replace, conventional medication therapy • Research results vary, and results should be carefully reviewed considering design of the study and populations examined

RISKS VS. BENEFITS: HERBALS & SUPPLEMENTS

• Many people believe herbal treatments are safer because they are “natural” or may have fewer side effects • Research has yet to determine their mechanisms of action • Some herbal treatments, supplements, herbal preparations, and protein supplements are not safe: • Interactions with conventional drugs • Detrimental long-term effects to nerves, kidneys, and liver • May reduce effectiveness of conventional drugs • No regulation by FDA • Inconsistent quality or dosing • We should be discussing herbal supplements with persons served: • Do they help? How much are you taking? How long have you been taking them? ST. JOHN’S WORT

• May have serious interactions with a number of conventional medications • Taking St. John’s Wort with SSRIs or triptans can cause serotonin syndrome: • Abdominal pain, diarrhea • Sweating, fever • High heart rate, high blood pressure • Delirium • Muscle spasm • Mood changes (hostility, irritability) • Death • It may reduce effectiveness of other medications by reducing blood levels of the drugs ADDICTION

ALCOHOL & OPIOID ADDICTION TREATMENT ADDICTION PHARMACOLOGY

• Alcohol and drug use affects neurotransmitters and areas of the brain. • Medication Assisted Treatment/Pharmacology Interventions used: • To manage withdrawal • To alter drug use

ALCOHOL WITHDRAWAL TREATMENT

• Not all persons who stop drinking require management of withdrawal • Depends on: • Overall health • Prior history of withdrawal complications • Amount person has been drinking • Length of time drinking • Naltrexone • Manage level of craving and somatic symptoms • Disulfiran (Antabuse) • Works on inhibiting drinking because the patient tries to avoid the unpleasant physical effects caused by antabuse- alcohol reaction

TREATMENT OF OPIOID ADDICTION

• Methadone • Blocks the cravings for and effects of heroin • Taken every day and is highly addicting • Levo-alpha-acetylmethadol (LAAM) • Alternative to Methadone effective for 72-96 hours • Side effects: dizziness, light headedness, constipation, sedation • Naltrexone • Blocks euphoric effects of opioid for up to 72 hours • Low toxicity and few side effects • Buprenorphine (Subutex) • Partial opioid agonist blocks signs and symptoms of opioid withdrawal • Suboxone (buprenorphine + naloxone/Narcan) • Supresses withdrawal symptoms and cravings THE CLINICIAN’S ROLE WHEN YOUR CLIENT IS ON MEDICATION

• Know the current medication list • Medication type • Dose • Administration times/when it is supposed to be taken • Common side effects • Discuss side effects with the agency nurse • Monitor medication compliance • Communicate with agency nurse with any concerns • Watch for abuse or addiction • Refer the client to the agency nurse if • he/she has any questions about their medication • Becomes pregnant/thinking of becoming pregnant

ADHERENCE

• The clinician should emphasize the importance of taking medications as prescribed • Help the client identify and resolve obstacles to adherence • Potential obstacles to adherence: • Cost of medication • Negative attitudes of self or family towards taking medications • Frequent dosing/many pills • Side effects • Consider or extended release patches, when it is an option • Involve the doctor in discussion of any fears or problems in the use of medication and management of side effects

OTHER CONSIDERATIONS RELATED TO ADHERENCE

• Patient family education is significantly related to adherence with medication regimen • Medications may be needed over long periods of time • Therapeutic interventions should be made to assist the persons served maintain occupation and social relationships

RECOGNIZING SIGNS OF RELAPSE OR NONADHERENCE

• Be aware that the medication may take 2 or more weeks to become effective • The key to adherence is: • Shared decision making between the person served and • The person served perspective of their diagnosis is critical in their acceptance and ability to manage symptoms • Research demonstrates people want more than watered-down, simplistic information • Persons served need current, evidence-based information • Nurses and physicians are in a position to help to recognize side effects and interactions among drugs that are prescribed for physical and mental illness HANDLING THE COSTS OF MEDICATION

• The doctor should be alerted to restrictions in inability to pay • They may prescribe an equally effective medication that costs less money • Coordinate with the pharmacist to enroll the client in drug company assistance programs