– Define the term psychotherapeutic agent and list conditions that the psychotherapeutic agents are used to treat.
– Describe the therapeutic actions, indications, pharmacokinetics, contraindications, most common adverse reactions and important drug–drug interactions associated with each class of psychotherapeutic agent:
– typical antipsychotics,
– atypical antipsychotics,
– central nervous system stimulants.
– Outline the nursing considerations and teaching needs for patients receiving each class of psychotherapeutic agents.
Mental Disorders and Their Classification
– Mental disorders are now thought to be caused by some inherent dysfunction within the brain that leads to abnormal thought processes and responses.
– Diagnosis of a mental disorder is often based on distinguishing characteristics in the, patient assessment which must be carefully evaluated
– Schizophrenia, the most common type of psychosis, can be very debilitating and prevents affected individuals from functioning in society. Characteristics of schizophrenia include
– speech abnormalities, and
– affective problems.
– Mania, with its associated bipolar illness (i.e., manic-depressive illness), is characterized by periods of extreme overactivity and excitement. Bipolar illness involves extremes of depression followed by hyperactivity and excitement.
– Narcolepsy is characterized by daytime sleepiness and sudden periods of loss of wakefulness. This disorder may reflect problems with stimulation of the brain by the reticular activating system (RAS) .
– Attention-deficit disorders involve various conditions characterized by an inability to concentrate on one activity for longer than a few minutes and a state of hyperkinesis. These conditions are usually diagnosed in school-aged children but can occur in adults.
– The antipsychotic drugs, which are essentially dopamine receptor blockers, are used to treat disorders that involve thought processes. Because of their associated neurological adverse effects, these medications are also called neuroleptic agents.
– The classic, typical antipsychotics (which may be referred to as phenothiazines)
– are primarily dopamine receptor blockers ,preventing the stimulation of the postsynaptic neurons by dopamine.
– Cause several adverse effects associated with dopamine blockade, including
– anticholinergic effects, and
– extrapyramidal side effects (EPS).
– Therapeutic action; newer, atypical antipsychotics block both dopamine receptors and serotonin receptors.
– This dual action may help alleviate some of the unpleasant neurological effects and depression associated with the typical antipsychotics.
– The antipsychotics are indicated for
– schizophrenia and for
– manifestations of other psychotic disorders, including
– combative behavior,
– agitation in the elderly, and
– severe behavioral problems in children (short-term control).
– should not be used in the presence of medical conditions that could be exacerbated by the anticholinergic effects of the drugs, such as
– peptic ulcer, and
– urinary or intestinal obstruction.
– Care should be taken in patients with seizure disorders because the threshold for seizures could be lowered;
– The adverse effects associated with the antipsychotic drugs are related to their
– antihistamine, and
– alpha-adrenergic activities.
– CNS effects are
– weakness, tremor, drowsiness, and extrapyramidal effects
– tardive dyskinesia,
– Anticholinergic effects include
– dry mouth,
– urinary retention,
– sexual impotence,
– glaucoma, blurred vision, and photophobia.
– nasal congestion,
– Cardiovascular (CV) effects, which are probably related to the dopamine-blocking effects, include
– hypotension, orthostatic hypotension,
– cardiac arrhythmias,
– congestive heart failure, and pulmonary edema.
– Several of these agents are associated with prolongation of the QTc interval, which could lead to serious or even fatal cardiac arrhythmias.
Assessment: History and Examination
– Screen for a contraindications or cautions for the use of the drug:
– any known allergies to these drugs,
– coronary disease including prolonged QTc interval,
– urinary or intestinal obstruction,
– liver and renal function tests,
– thyroid function tests,
– ECG if appropriate, and
– complete blood count (CBC).
Implementation with Rationale
– Consider warning the patient or the patient’s guardians about the risk of development of tardive dyskinesias with continued use so they are prepared for that neurological change. Provide positioning of legs and arms to decrease the discomfort of dyskinesias.
– Provide sugarless candy and ice chips to increase secretions and frequent mouth care to prevent dry mouth from becoming a problem.
– Encourage the patient to void before taking a dose if urinary hesitancy or retention is a problem.
– Provide safety measures such as siderails and assistance with ambulation if CNS effects or orthostatic hypotension occurs to prevent patient injury.
– Provide thorough patient teaching, including drug name, prescribed dosage, measures for avoidance of adverse effects, warning signs that may indicate possible problems, and the need for monitoring and evaluation to enhance patient knowledge about drug therapy and to promote compliance.
– Mental disorders are thought process disorders possibly cased by brain dysfunction. A psychosis is a thought disorder, and schizophrenia is the most common psychosis in which delusions and hallucinations are hallmarks.
– Antipsychotic drugs are dopamine-receptor blockers that are effective in helping people to organize thought patterns and to respond appropriately to stimuli.
– Antipsychotics can cause
– anticholinergic effects,
– sedation, and
– extrapyramidal effects, including parkinsonism, ataxia, and tremors.
– Mania, the opposite of depression, occurs in individuals with bipolar disorder, who experience a period of depression followed by a period of mania. The cause of mania is not understood, but it is thought to be an overstimulation of certain neurons in the brain. The mainstay for treatment of mania is lithium
– Lithium salts (Lithane, Lithotabs) are taken orally for the management of manic episodes and prevention of future episodes. These very toxic drugs can cause severe CNS, renal, and pulmonary problems that may lead to death. Despite the potential for serious adverse effects, lithium is used with caution because it is consistently effective in the treatment of mania. The therapeutically effective serum level is 0.6 to 1.2 mEq/L.
Lithium; Therapeutic Actions
– Lithium functions in several ways.
– It alters sodium transport in nerve and muscle cells;
– inhibits the release of norepinephrine and dopamine, but not serotonin, from stimulated neurons;. This last mode of action may allow it to selectively modulate the responsiveness of hyperactive neurons that might contribute to the manic state.
– manic episodes of manic-depressive or bipolar illness and for maintenance therapy to prevent or diminish the frequency and intensity of future manic episodes.
– The adverse effects associated with lithium are directly related to serum levels of the drug.
– Serum levels of less than 1.5 mEq/L:
– CNS problems, including lethargy, slurred speech, muscle weakness, and fine tremor; polyuria, which relates to renal toxicity; and beginning of gastric toxicity, with nausea, vomiting, and diarrhea
– Serum levels of 1.5 to 2 mEq/L:
– Intensification of all of the above reactions, with ECG changes
– Serum levels of 2 to 2.5 mEq/L:
– Possible progression of CNS effects to ataxia, clonic movements, hyperreflexia, and seizures;
– possible CV effects such as severe ECG changes and hypotension;
– large output of dilute urine secondary to renal toxicity;
– fatalities secondary to pulmonary toxicity
– Serum levels greater than 2.5 mEq/L: Complex multiorgan toxicity, with a significant risk of death
– A lithium–haloperidol combination may result in an encephalopathic syndrome, consisting of weakness, lethargy, confusion, tremors, extrapyramidal symptoms, leukocytosis, and irreversible brain damage.
– If lithium is given with carbamazepine increased CNS toxicity may occur,
– In addition, a thiazide diuretic–lithium combination increases the risk of lithium toxicity because of the loss of sodium and increased retention of lithium.
– With the combination of lithium and antacids, the serum lithium level should be monitored closely and appropriate dosage adjustments made..
– If lithium is combined with indomethacin or with some nonsteroidal anti-inflammatory drugs, higher plasma levels of lithium occur.
Central Nervous System Stimulants
– CNS stimulants are used clinically to treat both attention-deficit disorders and narcolepsy.
– Site of action of the central nervous system (CNS) stimulants in the cortex and reticular activating system (RAS).
– Methylphenidate (Ritalin, Concerta) is commonly used for the treatment of attention-deficit disorders and other behavioral syndromes associated with hyperactivity, as well as narcolepsy.
Points to Remember
– Mental disorders are disorders of thought processes that may be caused by some inherent dysfunction within the brain.
– Psychoses are thought disorders.
– Schizophrenia, the most common psychosis, is characterized by
– hallucinations, and
– inappropriate responses to stimuli.
– is a state of hyperexcitability, one extreme of bipolar disorder.
– An attention-deficit disorder
– is a behavioral syndrome characterized by hyperactivity and a short attention span.
– is a disorder characterized by daytime sleepiness and sudden loss of wakefulness.
– Antipsychotics are dopamine-receptor blockers.
– Side effects include
– anticholinergic effects,
– sedation, and
– extrapyramidal effects, including parkinsonism, ataxia, and tremors.
– Lithium, a membrane stabilizer, is the only effective antimanic drug. Because it is a very toxic salt, serum levels must be carefully monitored to prevent severe toxicity.
– CNS stimulants, which stimulate cortical levels and the RAS to increase RAS activity, are used to treat attention-deficit disorders and narcolepsy. These drugs improve concentration and the ability to filter and focus incoming stimuli.
– Multiple Choice
– Select the best answer to the following.
– 1. Mental disorders are now thought to be caused by some inherent dysfunction within the brain that leads to abnormal thought processes and responses. They include
– a. depression.
– b. anxiety.
– c. seizures.
– d. schizophrenia.
– 2. Antipsychotic drugs are basically
– a. serotonin reuptake inhibitors.
– b. norepinephrine blockers.
– c. dopamine receptor blockers.
– d. acetylcholine stimulators.
– 3. Adverse effects associated with antipsychotic drugs are related to the drugs’ effects on receptor sites and can include
– a. insomnia and hypertension.
– b. dry mouth, hypotension, and glaucoma.
– c. diarrhea and excessive urination.
– d. increased sexual drive and improved concentration.
– 4. Lithium toxicity can be dangerous. Patient assessment to evaluate for appropriate lithium levels would look for
– a. serum lithium levels greater than 3 mEq/L.
– b. serum lithium levels greater than 4 mEq/L.
– c. serum lithium levels less than 1.5 mEq/L.
– d. undetectable serum lithium levels.
– 5. Your patient, a 6-year-old boy, is starting a regimen of Ritalin (methylphenidate) to control an attention-deficit disorder. Family teaching should include which of the following?
– a. This drug can be shared with other family members who might seem to need it.
– b. This drug may cause insomnia, weight loss, and GI upset.
– c. Do not alert the school nurse to the fact that this drug is being taken because the child could have problems later on.
– d. This drug should not be stopped for any reason for several years.
– 6. Antipsychotic drugs are also known as neuroleptic drugs because
– a. they cause numerous neurological effects.
– b. they frequently cause epilepsy.
– c. they are also minor tranquilizers.
– d. they are the only drugs known to directly affect nerves.
– 7. Attention-deficit disorders (the inability to concentrate or focus on an activity) and narcolepsy (sudden episodes of sleep) are both most effectively treated with the use of
– a. neuroinhibitors.
– b. dopamine receptor blockers.
– c. major tranquilizers.
– d. CNS stimulants.
– Select all that apply.
– 1. Before administering lithium to a client, the nurse should check for the concomitant use of which of the following drugs, which could cause serious adverse effects?
– a. Ibuprofen
– c. Thiazide diuretics
– d. Antacids
– b. Haloperidol
– e. Ketoconazole
– f. Theophylline
– 2. Dyskinesias are a common side effect of antipsychotic drugs. Nursing interventions for the patient receiving antipsychotic drugs should include which of the following?
– a. Positioning to decrease discomfort of dyskinesias
– b. Implementing safety measures to prevent injury
– c. Encouraging the patient to chew tablets to prevent choking
– d. Careful teaching to alert the patient and family about this adverse effect
– e. Applying ice to the joints to prevent damage
– f. Pureeing all food to decrease the risk of aspiration
– Match the following words with the appropriate definition.
– 1. schizophrenia
– 2. narcolepsy
– 3. attention-deficit disorder
– 4. neuroleptic
– 5. major tranquilizer
– 6. mania
– 7. antipsychotic
– A. A state of hyperexcitability
– B. A behavioral syndrome characterized by an inability to concentrate
– C. A mental disorder characterized by daytime sleepiness and sudden periods of loss of wakefulness
– D. A name once used to describe antipsychotic drugs
– E. A drug used to treat a disorder of the thought processes; a dopamine receptor blocker
– F. A psychotic disorder characterized by delusions, hallucinations, and thought and speech disturbances
– G. An antipsychotic drug, so named because of the numerous neurological adverse effects caused by these drugs