PSYCHIATRIC

1. ANTIPSYCHOTIC AGENTS
a. Typical Antipsychotics
a.1 PHENOTHIAZINES
a.1.1 ALIPHATIC

Brand Name:

Generic Name: Chlorpromazine

Classification: Aliphatic phentothiazines

Recommended Dosage, Route, and Frequency:

- Dose for schizophrenia, other psychoses, anxiety and agitation:

 Adults: Start with 25mg three times a day or 75mg at bedtime. This may be increased by 25mg a day to an effective
dose. This is usually 75mg - 300mg daily, but some patients need up to 1000mg (1g) daily.
 Elderly weak or infirm patients: Start with 1/3–1/2 usual adult dose with a more gradual increase in dose.
 Children 6-12 years: 1/3-1/2 adult dose to a maximum daily dose of 75mg.
 Children 1-5 years: 0.5mg per kg body weight every 4-6 hours to a maximum daily dose of 40mg.
 Children under 1 year: Not to be used unless the need is life saving
-

Drug Action: ADME, Onset, Peak, Duration:

- A: Well absorbed following IM administration. PO – Onset:30–60 min. Peak: unknown. Duration: 4–6 hr
- D: Widely distributed; high CNS concentrations. Crosses the placenta; enters breast milk. Protein Binding: _90%.
- M & E: Highly metabolized by the liver and GI mucosa. Some metabolites are active. Half-life: 30 hr.
Drug-Drug and Drug-Food Interactions:

- Chlorpromazine and disopyramide both increase QTc interval.

- Abiraterone increases levels of chlorpromazine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
Avoid coadministration of abiraterone with substrates of CYP2D6. If alternative therapy cannot be used, exercise caution
and consider a dose reduction of the CYP2D6 substrate.
- Amiodarone will increase the level or effect of chlorpromazine by affecting hepatic enzyme CYP2D6 metabolism.
Minor/Significance Unknown.

Indications:

- Schizophrenia and other psychoses particularly paranoia (delusions and feelings of persecution), mania (overactive
behaviour and hypomania (elated moods and excitability), anxiety, agitation and violent or dangerously impulsive
behaviour.

Contraindications:

- Are allergic (hypersensitive) to Chlorpromazine, other phenothiazines or to any of the other ingredients in the tablets
- have a low number of blood cells (bone marrow depression)
- have urine retention due to a prostate disorder
- have an increased pressure in the eye (glaucoma)
- are taking a dopaminergic antiparkinsonism drug
- Breastfeeding

Side Effects:

- CNS: drowsiness, dizziness, headache, anxiety, sleep problems

- Reproductive: breast swelling and discharge, changes in menstrual period
 - Metabolic: weight gain
- Skin: edema

Adverse Reaction:

- Musculoskeletal: you have movements that you cannot control, mainly of the tongue, mouth, jaw, arms and legs trembling,
muscle stiffness or spasm, slow movement
- CNS: seizure
- Hypersensitivity: allergic reactions
- EENT: mouth ulcers, increased saliva secretions, stuffy nose
- GI: abdominal pain, constipation, upset stomach, cramping, indigestion
- Respiratory: shortness of breath,
- Skin: jaundice
- CV: palpitations, chest pain
- Hemato: thrombocytopenia

Nursing Responsibilities:

- A:
 Assess patient’s mental status (orientation, mood, behavior) before and periodically throughout therapy.
 Monitor blood pressure (sitting, standing, lying), pulse, and respiratory rate before and frequently during the period of
dosage adjustment.
 Observe patient carefully when administering medication to ensure medication is actually taken and not hoarded.
- D: Disturbed thought process
- P: Patient will have a decrease in excitable, paranoic, or withdrawn behavior.
- I:
 PO: Administer with food, milk, or a full glass of water to minimize gastric irritation.
 Dilute most concentrates in 120 mL of distilled or acidified tap water or fruit juice just before administration.
- E:
 Decrease in excitable, paranoic, or withdrawn behavior.
 Relief of nausea and vomiting.
 Relief of intractable hiccups.

a.1.2 PIPERIDINE
Brand Name: Mellaril

Generic Name: Thioridazine

Classification: Piperidine phenothiazines

Recommended Dosage, Route, and Frequency:

- Adults: The usual starting dose for adult schizophrenic patients is 50-100 mg three times a day, with a gradual increment to
a maximum of 800 mg daily if necessary. Once effective control of symptoms has been achieved, the dosage may be
reduced gradually to determine the minimum maintenance dose. The total daily dosage ranges from 200-800 mg, divided
into two to four doses.
- Pediatric Patients: For pediatric patients with schizophrenia who are unresponsive to other agents, the recommended initial
dose is 0.5 mg/kg/day given in divided doses. Dosage may be increased gradually until optimum therapeutic effect is
obtained or the maximum dose of 3 mg/kg/day has been reached.

Drug Action: ADME, Onset, Peak, Duration:

- A: Absorption varies with administration route. Oral tablet absorption is erratic and variable, with onset ranging from 1/2 to
1 hour. Oral concentrates and suspensions are much more predictable. Peak: 2-4hrs. Duration: 4-6hrs
 - D: Distributed widely throughout the body, including breast milk. Steady state serum level is achieved within 4 to 7 days.
Drug is 91% to 99% protein-bound.
- M & E: Metabolized extensively by the liver and forms the active metabolite mesoridazine. Mostly excreted as metabolites
in urine; some is excreted in feces by way of the biliary tract.

Drug-Drug and Drug-Food Interactions:

- Fluvoxamine: Concentrations of thioridazine and its two active metabolites, mesoridazine and sulforidazine, increased
three-fold following co-administration of fluvoxamine.
- Propranolol: Concurrent administration of propranolol (100-800 mg daily) has been reported to produce increases in
plasma levels of thioridazine (approximately 50%-400%) and its metabolites (approximately 80%-300%).
- Pindolol: Concurrent administration of pindolol and thioridazine have resulted in moderate, dose-related increases in the
serum levels of thioridazine and two of its metabolites, as well as higher than expected serum pindolol levels.
- Caffeine: Increased metabolism of drug

Indications:

- Management of schizophrenic patients who fail to respond adequately to treatment with other antipsychotic drugs

Contraindications:

- Mellaril® (thioridazine HCl) use should be avoided in combination with other drugs that are known to prolong the QTc
interval and in patients with congenital long QT syndrome or a history of cardiac arrhythmias
- Mellaril is contraindicated in severe central nervous system depression or comatose states from any cause including drug
induced central nervous system depression.

Side Effects:

- Hypersensitivity: Allergic reactions

- GI: nausea, vomiting, diarrhea, constipation
- CNS: headache

Adverse Reaction:

- CNS: Nocturnal confusion, hyperactivity, lethargy, psychotic reactions, restlessness

- EENT: dryness of mouth, blurred vision, nasal stiffness
- GI: nausea, constipation, vomiting, diarrhea
- Skin: Pallor, dermatitis, skin eruptions
- CV: prolongation of the QTc interval, which is associated with the ability to cause torsade de pointes-type arrhythmias, a
potentially fatal polymorphic ventricular tachycardia
- Endocrine: Menstrual irregularities, altered libido, gynecomastia, lactation

Nursing Responsibilities:

- A:
 Assess patient’s mental status (orientation, mood, behavior) before and periodically throughout therapy.
 Monitor blood pressure (sitting, standing, lying), pulse, and respiratory rate before and frequently during the period of
dosage adjustment.
 Observe patient carefully when administering medication to ensure medication is actually taken and not hoarded.
- D: Disturbed thought process
- P: Patient will have a decrease in excitable, paranoic, or withdrawn behavior.
- I:
 PO: Administer with food, milk, or a full glass of water to minimize gastric irritation.
 Dilute most concentrates in 120 mL of distilled or acidified tap water or fruit juice just before administration.
- E:
 Decrease in excitable, paranoic, or withdrawn behavior.
 Relief of nausea and vomiting.
 Relief of intractable hiccups.
a.1.3 PIPERAZINE

Brand Name: Modecate

Generic Name: Fluphenazine decanoate

Classification: piperazine phenothiazines

Recommended Dosage, Route, and Frequency:

- Psychotic disorders.
  Adults: Initially, 0.5 to 10 mg fluphenazine hydrochloride P.O. daily in divided doses q 6 to 8 hours; may increase
cautiously to 20 mg. Maintenance dosage is 1 to 5 mg P.O. daily. I.M. doses are one-third to one-half that of oral doses;
the usual starting dose is 1.25 mg I.M. The initial total daily dose is 2.5 to 10 mg divided and given every 6 to 8 hours.
For the enanthate and decanoate formulations, 12.5 to 25 mg I.M. q 3 to 6 weeks.

 Elderly patients: Use lower doses (1 to 2.5 mg P.O. daily).

Drug Action: ADME, Onset, Peak, Duration:

- A: Rate and extent of absorption vary with route of administration; oral tablet absorption is erratic and variable. IM: Onset:
less than 1hr. Peak: 1 ½-2hrs. Duration: 6-8hrs.
- D: Distributed widely into the body, including breast milk. CNS levels of drug are usually higher than those in plasma. Drug is
91% to 99% protein-bound.
- M & E: Metabolized extensively by the liver, but no active metabolites are formed; duration of action is about 6 to 8 hours
after oral administration; 1 to 6 weeks (average, 2 weeks) after I.M. depot administration. Mostly excreted in urine via the
kidneys; some is excreted in feces via the biliary tract.

Drug-Drug and Drug-Food Interactions:

-  Aluminum- and magnesium-containing antacids and antidiarrheals: Decreases absorption. Monitor patient.

- Antiarrhythmics, disopyramide, procainamide, quinidine: Increases risk of arrhythmias and conduction defects. Avoid use
together.
- Anticholinergics, including antidepressants, antihistamines, antiparkinsonians, atropine, MAO inhibitors, meperidine,
phenothiazines: Causes oversedation, paralytic ileus, visual changes, and severe constipation. Avoid use together.
- Beta blockers: Increases plasma levels and toxicity. Monitor patient closely.
- Bromocriptine: Antagonizes therapeutic effect of bromocriptine on prolactin secretion. Monitor patient for drug effect.
- Centrally acting antihypertensives, such as clonidine, guanabenz, guanadrel, guanethidine, methyldopa, and
reserpine: Inhibits blood pressure response. Monitor patient closely.
- CNS depressants, including analgesics, barbiturates, narcotics, parenteral magnesium sulfate, tranquilizers, and general,
spinal, or epidural anesthetics: May cause additive effects of oversedation, respiratory depression, and hypotension. Avoid
use together.
- Dopamine: Decreases vasoconstricting effects. Monitor patient carefully.
- Levodopa: Decreases effectiveness and increases toxicity of levodopa. Monitor patient carefully.
- Lithium: May cause severe neurologic toxicity with an encephalitis-like syndrome and a decreased therapeutic response to
fluphenazine. Monitor patient closely.
- Metrizamide: Increases risk of seizures. Observe patient closely.
- Nitrates: May result in hypotension. Check blood pressure frequently.
- Phenobarbital: Enhances renal excretion. Monitor patient closely.
- Phenytoin, tricyclic antidepressants: Inhibits metabolism and increases toxicity of these drugs. Monitor patient closely.
- Propylthiouracil: Increases risk of agranulocytosis. Monitor patient carefully.
- Sympathomimetics including ephedrine, epinephrine, and phenylephrine (common in nasal sprays) and appetite
suppressants: Decreases stimulatory and pressor effects of these drugs. Use together cautiously.
- Caffeine: Increases fluphenazine metabolism.

Indications:

- Psychotic disorders
Contraindications:

- Contraindicated in patients hypersensitive to drug and patients experiencing coma, CNS depression, bone marrow
suppression, other blood dyscrasia, subcortical damage, or liver damage.

Side Effects:

- CNS: dizziness, drowsiness

- CV: ECG changes
- GI: nausea, vomiting
- GU: dark urine, menstrual irregularities

Adverse Reaction:

- CNS: neuroleptic malignant syndrome, extrapyramidal reactions, tardive dyskinesia, sedation, pseudoparkinsonism, EEG

changes ,seizures, 
- CV: orthostatic hypotension, tachycardia,
- EENT: ocular changes, blurred vision, nasal congestion.
- GI: dry mouth, constipation.
- GU: urine retention,  inhibited ejaculation.
- Hematologic: leukopenia, agranulocytosis, eosinophilia, hemolytic anemia, aplastic anemia, thrombocytopenia.
- Hepatic: cholestatic jaundice.
- Metabolic: elevated protein-bound iodine level, weight gain, increased appetite.
- Skin: mild photosensitivity, allergic reactions.
- Other: gynecomastia.

Nursing Responsibilities:

- A:
 Assess patient’s mental status (orientation, mood, behavior) before and periodically throughout therapy.
 Monitor blood pressure (sitting, standing, lying), pulse, and respiratory rate before and frequently during the period of
dosage adjustment.
 Observe patient carefully when administering medication to ensure medication is actually taken and not hoarded.
- D: Disturbed thought process
- P: Patient will have a decrease in excitable, paranoic, or withdrawn behavior.
- I:
 PO: Administer with food, milk, or a full glass of water to minimize gastric irritation.
 Dilute most concentrates in 120 mL of distilled or acidified tap water or fruit juice just before administration.
 Stop giving drug and notify prescriber immediately if patient shows signs or symptoms of blood dyscrasias (fever,
infection, sore throat, cellulitis, or weakness).
- E:
 Decrease in excitable, paranoic, or withdrawn behavior.

a.2 NONPHENOTHIAZINES

1. BUTYROPHENONES
Brand Name:

Generic Name: Haloperidol

Classification: Butyprophenones - nonphenothiazines

Recommended Dosage, Route, and Frequency:

- Psychotic disorders; alcohol dependence (adults only). 

 Adults:  Dosage varies for each patient and for different symptoms. Initial dosage range is 0.5 to 5 mg P.O. b.i.d. or t.i.d.;
or, 2 to 5 mg I.M. q 4 to 8 hours, increased rapidly if needed for prompt control. Maximum dose is 100 mg P.O. daily.
Doses of more than 100 mg have been used to treat patients who have severely resistant conditions.
  Children ages 3 to 12: Usual initial dose is 0.5 mg P.O. daily given in two or three divided doses. Subsequent dosing may
be increased by 0.5 mg daily at 5- to 7-day intervals. Usual maintenance dosage range is 0.05 to 0.15 mg/kg daily
divided in two or three doses.
- Psychotic patients who require prolonged therapy. 
 Adults:  100 mg I.M. of haloperidol decanoate q 4 weeks. Experience with doses of more than 450 mg monthly is
limited.
- Control of tics, vocal utterances in Tourette syndrome.
  Adults: 0.5 to 2 mg P.O. b.i.d. or t.i.d., increased, p.r.n,
 Children ages 3 to 12: 0.05 to 0.075 mg/kg daily given b.i.d. or t.i.d
- Delirium. 
 Adults:  1 to 2 mg I.V. every 2 to 4 hours.

Drug Action: ADME, Onset, Peak, Duration:

- A: Rate and extent of absorption vary with route of administration. Oral administration yields 60% bioavailability. PO –
Peak: 3-6hrs.
- D: Distributed widely into body, with high levels in adipose tissue. Drug is 90% to 92% protein-bound.
- M & E: Metabolized extensively by the liver; there may be only one active metabolite that’s less active than parent
drug. About 40% of a given dose is excreted in urine within 5 days; about 15% is excreted in feces via the biliary tract.

Drug-Drug and Drug-Food Interactions:

- Aluminum- and magnesium-containing antacids and antidiarrheals:  Decreases drug absorption. Separate administration
times by 2 hours.
- Antiarrhythmics, disopyramide, procainamide, quinidine:  Increases risk of arrhythmias and conduction defects. Avoid use
together.
- Anticholinergics, including antidepressants, antihistamines, antiparkinsonians, atropine, MAO inhibitors, meperidine,
phenothiazines:  Causes oversedation, paralytic ileus, visual changes, and severe constipation. Use cautiously.
- Beta blockers:  May inhibit haloperidol metabolism, increasing plasma levels and toxicity. Use cautiously.
- Bromocriptine: Antagonizes therapeutic effect of bromocriptine on prolactin secretion. Avoid use together.
- Centrally acting antihypertensives (such as clonidine, guanabenz, guanadrel, guanethidine, methyldopa, reserpine): Inhibits
blood pressure response. Monitor blood pressure carefully.
- CNS depressants, including analgesics, barbiturates, narcotics, tranquilizers, and general, spinal, or epidural anesthetics;
parenteral magnesium sulfate:  Increases CNS depression. Avoid use together.
- Dopamine: Decreases vasoconstricting effects. Monitor patient for lack of therapeutic effect.
- Levodopa:  Decreases effectiveness and increases toxicity of levodopa. Avoid use together.
- Lithium:  May result in severe neurologic toxicity with an encephalitis-like syndrome and a decreased therapeutic response
to haloperidol. Use cautiously; monitor patient.
- Metrizamide:  Increases risk of seizures. Avoid use together.
- Nitrates: Causes hypotension. Monitor blood pressure frequently.
- Phenobarbital: Enhances renal excretion. Monitor patient closely.
- Phenytoin:  Inhibits metabolism and increases toxicity of phenytoin. Avoid use together.
- Propylthiouracil:  Increases risk of agranulocytosis. Avoid use together.
- Rifampin:  Decreases haloperidol levels and efficacy. Monitor patient carefully.
- Sympathomimetics, including ephedrine, epinephrine, and phenylephrine (often found in nasal sprays):  May decrease
stimulatory and pressor effects of these drugs. Monitor patient carefully.

Indications:

- Psychotic patients who require prolonged therapy

- Control of tics, vocal utterances in Tourette syndrome
- Control of tics, vocal utterances in Tourette syndrome

Contraindications:

- Contraindicated in patients hypersensitive to drug and in those experiencing parkinsonism, coma, or CNS depression.

Side Effects:
 - GI: constipation, dry mouth, nausea, vomiting, diarrhea
- CNS: lethargy, headache, insomnia, confusion, vertigo
- Skin: rash, other skin reactions, diaphoresis

Adverse Reaction:

- CNS: severe extrapyramidal reactions, tardive dyskinesia, sedation, drowsiness, seizures, neuroleptic malignant syndrome.
- CV: tachycardia, hypotension, hypertension, ECG changes.
- EENT: blurred vision.
- GU: urine retention, menstrual irregularities, priapism.
- Hematologic: leukopenia, leukocytosis.
- Hepatic: jaundice.
- Skin: rash, other skin reactions, diaphoresis.
- Other: gynecomastia.

Nursing Responsibilities:

- A:
 Assess mental status (orientation, mood, behavior) prior to and periodically during therapy.
 Assess positive (hallucination, delusions) and negative (social isolation) symptoms of schizophrenia.
 Monitor BP (sitting, standing, lying) and pulse prior to and frequently during the period of dose adjustment. May cause
QT interval changes on ECG.
- D: Disturbed thought process
- P: Patient will have a decrease in hallucinations, insomnia, agitation, hostility, and delusions
- I:
 Direct IV: Diluent: May be administered undiluted for rapid control of acute psychosis or delirium. Concentration: 5
mg/mL. Rate: Administer at a rate of 5 mg/min.
- E:
 Decrease in hallucinations, insomnia, agitation, hostility, and delusions.
 Decreased tics and vocalization in Tourette’s syndrome.
 Improved behavior in children with severe behavioral problems. If no therapeutic effects are seen in 2–4 wk, dosage
may be increased.

2. DIBENZOXAPINES
Brand Name: Loxitane

Generic Name: Loxapine HCl

Classification: Dibenzoxapines

Recommended Dosage, Route, and Frequency:

- Psychotic disorders.
 Adults: Initially, 10 mg P.O. b.i.d. (in severe schizophrenia, 50 mg P.O. daily); usual therapeutic and maintenance
dosage is 60 to 100 mg P.O. daily b.i.d. to q.i.d. (dose varies from patient to patient) or 12.5 to 50 mg I.M. q 4 to 6 hours
or longer. Maximum daily dose is 250 mg. After desired symptom control, change to oral therapy. Don’t administer
drug I.V.

Drug Action: ADME, Onset, Peak, Duration:

- A: Absorbed rapidly and completely from the GI tract. First-pass metabolism results in lower systemic availability. P.O., I.M.
– Onset:1/2 hr. Peak: 1 1/2-3 hr. Duration. 12 hr
- D: Distributed widely throughout the body, including breast milk. Steady state serum level is achieved within 3 to 4 days.
Drug is 91% to 99% protein-bound.
- M & E: Metabolized extensively by the liver, forming a few active metabolites; duration of action is 12 hours. Mostly
excreted as metabolites in urine; some is excreted in feces by way of the biliary tract. About 50% is excreted in urine and
feces within 24 hours.
Drug-Drug and Drug-Food Interactions:

- Aluminum- and magnesium-containing antacids and antidiarrheals: Decreases loxapine absorption and therapeutic
effects. Separate administration times.
- Antiarrhythmics, disopyramide, quinidine, procainamide: Increases risk of arrhythmias and conduction defects. Use
together cautiously.
- Anticholinergics, including antidepressants, antihistamines, antiparkinsonians, atropine, MAO inhibitors, meperidine,
phenothiazines: Causes oversedation, paralytic ileus, visual changes, and severe constipation. Avoid use together.
- Beta blockers: May inhibit loxapine metabolism, increasing plasma levels and toxicity. Use together cautiously.
- Bromocriptine: May antagonize therapeutic effect of bromocriptine on prolactin secretion. Monitor patient for effect.
- Centrally acting antihypertensives, such as clonidine, guanabenz, guanadrel, guanethidine, methyldopa, and reserpine: May
inhibit blood pressure response. Use together cautiously.
- CNS depressants, including analgesics, anesthetics (general, spinal, and epidural), barbiturates, narcotics, tranquilizers, and
parenteral magnesium sulfate: May cause additive effects.

Indications:

- LOXITANE is indicated for the treatment of schizophrenia.

Contraindications:

- Contraindicated in patients hypersensitive to dibenzoxazepines and in patients experiencing coma, severe CNS depression,
or drug-induced depressed states.

Side Effects:

- CNS: numbness, confusion, syncope

- CV: ECG changes
- EENT: nasal congestion
- GI: nausea, vomiting, diarrhea
- GU: menstrual irregularities
- Hypersensitivity: allergic reactions
- Metabolic: weight gain
- Hepatic: jaundice
- Reproductive: Gynecomastia

Adverse Reaction:

- CNS: extrapyramidal reactions, sedation, drowsiness, seizures, tardive dyskinesia, neuroleptic malignant

syndrome, pseudoparkinsonism,.
- CV: orthostatic hypotension, tachycardia, hypertension
- EENT: blurred vision
- GI: dry mouth, constipation, paralytic ileus.
- GU: urine retention
- Hematologic: leukopenia, agranulocytosis, thrombocytopenia.
- Skin: mild photosensitivity

Nursing Responsibilities:

- A:
 Assess mental status (orientation, mood, behavior) prior to and periodically during therapy.
 Assess positive (hallucination, delusions) and negative (social isolation) symptoms of schizophrenia.
 Monitor BP (sitting, standing, lying) and pulse prior to and frequently during the period of dose adjustment. May cause
QT interval changes on ECG.
- D: Disturbed thought process
- P: Patient will have a decrease in hallucinations, insomnia, agitation, hostility, and delusions
- I:
  Direct IV: Diluent: May be administered undiluted for rapid control of acute psychosis or delirium. Concentration: 5
mg/mL. Rate: Administer at a rate of 5 mg/min.
- E:
 Decrease in hallucinations, insomnia, agitation, hostility, and delusions.
 Decreased tics and vocalization in Tourette’s syndrome.
 Improved behavior in children with severe behavioral problems. If no therapeutic effects are seen in 2–4 wk, dosage
may be increased.
3. DIHYDROINDOLONES
Brand Name: Moban

Generic Name: Molindone

Classification: Dihydroindolones

Recommended Dosage, Route, and Frequency:

- Psychotic disorders. Adults:  50 to 75 mg P.O. daily in 3 to 4 divided doses, increased 100 mg daily in 3 to 4 days to a
maximum of 225 mg daily. Maintenance dosage for mild disease is 5 to 15 mg t.i.d. or q.i.d., moderate disease is 10 to 25
mg t.i.d. or q.i.d., and severe disease is up to 225 mg daily.
-  Behavioral complications related to mental retardation, mentally retarded schizophrenic child: Children ages 3 to 5: 1 to 2.5
mg P.O. daily as a single dose.

Drug Action: ADME, Onset, Peak, Duration:

- A: Data are limited, but absorption seems to be rapid. PO – Peak: 1 ½ hr. Duration: 24-36hrs.
- D: Distributed widely into the body. Drug is 90% to 95% protein-bound.
- M & E: Metabolized extensively in the liver. Most of drug is excreted as metabolites in urine; some is excreted in feces by
way of the biliary tract. Overall, 90% of a given dose is excreted within 24 hours.

Drug-Drug and Drug-Food Interactions:

- Antacids: May inhibit absorption of molindone. Separate administration times by 2 hours.

- Antiarrhythmics, disopyramide, procainamide, quinidine: Increases risk of arrhythmias and conduction defects. Avoid use
together.
- Anticholinergics, including antidepressants, antihistamines, antiparkinsonians, atropine, MAO inhibitors, meperidine, and
phenothiazines: Causes oversedation, paralytic ileus, visual changes, and severe constipation. Use together cautiously.
- Beta blockers: May inhibit molindone metabolism, increasing plasma levels and toxicity. Monitor patient for toxicity.
- Bromocriptine: May antagonize therapeutic effect of bromocriptine on prolactin secretion. Use together cautiously.
- Centrally acting antihypertensives, such as clonidine, guanabenz, guanadrel, guanethidine, methyldopa, and reserpine: May
inhibit blood pressure response to these drugs. Monitor blood pressure carefully.
- CNS depressants, including analgesics, anesthetics (general, spinal, or epidural), barbiturates, opioids, parenteral
magnesium sulfate, tranquilizers: Causes oversedation, respiratory depression, and hypotension. Avoid use together.
- High-dose dopamine: Decreases vasoconstricting effects. Monitor patient for effects.
- Levodopa: Decreases effectiveness and increases levodopa toxicity. Use together cautiously.
- Lithium: May cause confusion, delirium, seizures, abnormal EEG changes, and extrapyramidal symptoms. 

Indications:

- MOBAN is indicated for the management of schizophrenia.

Contraindications:

- MOBAN is contraindicated in severe central nervous system depression (alcohol, barbiturates, narcotics, etc.) or comatose
states, and in patients with known hypersensitivity to the drug.

Side Effects:

- Hepatic: jaundice
- Hemato: leukocytosis
- Hypersensitivity: allergic reactions
Adverse Reaction:

- CNS: extrapyramidal reactions, tardive dyskinesia, sedation, drowsiness, depression, euphoria, pseudoparkinsonism, EEG
changes, dizziness.
- CV: orthostatic hypotension, tachycardia, ECG changes.
- EENT: blurred vision.
- GI: dry mouth, constipation, nausea.
- GU: urine retention, menstrual irregularities, inhibited ejaculation.
- Hematologic: leukopenia
- Skin: mild photosensitivity
- Other: gynecomastia.

Nursing Responsibilities:

- A:
 Assess mental status (orientation, mood, behavior) prior to and periodically during therapy.
 Assess positive (hallucination, delusions) and negative (social isolation) symptoms of schizophrenia.
 Monitor BP (sitting, standing, lying) and pulse prior to and frequently during the period of dose adjustment. May cause
QT interval changes on ECG.
- D: Disturbed thought process
- P: Patient will have a decrease in hallucinations, insomnia, agitation, hostility, and delusions
- I:
 Monitor patient for CNS adverse effects, especially drowsiness and extrapyramidal symptoms.
 Monitor CBC and liver function tests in long-term therapy.
- E:
 Decrease in hallucinations, insomnia, agitation, hostility, and delusions.
 Decreased tics and vocalization in Tourette’s syndrome.
 Improved behavior in children with severe behavioral problems. If no therapeutic effects are seen in 2–4 wk, dosage
may be increased.

4. THIOXANTHENES

Brand Name: Navane

Generic Name: Thiothixene HCl

Classification: Thioxanthenes

Recommended Dosage, Route, and Frequency:

- Acute agitation. Adults: 4 mg I.M. b.i.d. to q.i.d. Maximum dosage is 30 mg I.M. daily. Change to P.O. form as soon as
possible.
- Mild to moderate psychosis. Adults: Initially, 2 mg P.O. t.i.d. May increase gradually to 15 mg daily. Maximum dose is 60
mg daily.
- Severe psychosis. Adults: Initially, 5 mg P.O. b.i.d. May increase gradually to 20 to 30 mg daily. Maximum recommended
dose is 60 mg daily.

Drug Action: ADME, Onset, Peak, Duration:

- Absorption: Rapidly absorbed. PO – Onset: 10-30min. Peak: 1-6hrs.

- Distribution: Widely distributed throughout the body. Drug is 91% to 99% protein-bound.
- M & E: Metabolized in the liver.Mostly excreted as parent drug in feces by way of the biliary tract.

Drug-Drug and Drug-Food Interactions:

- CNS depressants: Increases CNS depression.

- Caffeine: Increases metabolism of drug. Discourage caffeine use.

Indications:
 - Navane is effective in the management of schizophrenia. Navane has not been evaluated in the management of behavioral
complications in patients with mental retardation.

Contraindications:

- Contraindicated in patients hypersensitive to drug and in those experiencing circulatory collapse, coma, CNS depression, or
blood dyscrasia.

Side Effects:

- CNS: Pseudoparkinsonism, dizziness

- CV: tachycardia, ECG changes.
- EENT: nasal congestion
- GU: menstrual irregularities, inhibited ejaculation
- Hypersensitivity: allergic reactions

Adverse Reaction:

- CNS: neuroleptic malignant syndrome, extrapyramidal reactions, drowsiness, restlessness, agitation, insomnia, tardive

dyskinesia, sedation, EEG changes
- CV: hypotension, tachycardia,
- EENT: ocular changes, blurred vision
- GI: dry mouth, constipation.
- GU: urine retention
- Hematologic: transient leukopenia, leukocytosis, agranulocytosis.
- Skin: mild photosensitivity
- Other: gynecomastia

Nursing Responsibilities:

- A:
 Assess patient’s mental status (orientation, mood, behavior) before and periodically throughout therapy.
 Monitor blood pressure (sitting, standing, lying), pulse, and respiratory rate before and frequently during the period of
dosage adjustment.
 Observe patient carefully when administering medication to ensure medication is actually taken and not hoarded.
- D: Disturbed thought process
- P: Patient will have a decrease in excitable, paranoic, or withdrawn behavior.
- I:
 PO: Administer with food, milk, or a full glass of water to minimize gastric irritation.
 Dilute the concentrate in 2 to 4 oz (60 to 120 ml) of liquid, preferably water, carbonated drinks, fruit juice, tomato
juice, milk, or pudding.
- E:
 Decrease in excitable, paranoic, or withdrawn behavior.

b. Atypical Antipsychotics

Brand Name: Clozaril

Generic Name: Clozapine

Classification: Atypical Antipsychotics

Recommended Dosage, Route, and Frequency:

- Treatment of schizophrenia in severely ill patients unresponsive to other therapies. Adults:  Initially, 12.5 mg P.O. once or
twice daily, adjusted upward at 25 to 50 mg daily (if tolerated) to a daily dose of 300 to 450 mg by end of 2 weeks.
Individual dosage is based on clinical response, patient tolerance, and adverse reactions. Subsequent dosage increases
 should occur no more than once or twice weekly and shouldn’t exceed 100 mg. Many patients respond to doses of 300 to
600 mg daily, but some patients require as much as 900 mg daily. Don’t exceed 900 mg daily.

Drug Action: ADME, Onset, Peak, Duration:

- A: Food doesn’t appear to interfere with bioavailability. Only 27% to 50% of the dose reaches systemic circulation. PO –
Peak: 2 ½ hrs. Duration: 4-12hrs.
- Distribution: About 97% bound to serum proteins.
- M & E: Metabolism is nearly complete; very little unchanged drug appears in the urine. About 50% appears in the urine and
30% in the feces, mostly as metabolites. Elimination half-life appears to be proportional to dose and may range from 4 to 66
hours.

Drug-Drug and Drug-Food Interactions:

- Anticholinergics:  May potentiate anticholinergic effects of clozapine. Avoid use together.

- Antihypertensives:  May potentiate hypotensive effects. Check blood pressure frequently.
- Benzodiazepines: Causes risk of respiratory arrest and severe hypotension. Avoid use together.
- Bone marrow suppressants:  Increases bone marrow toxicity. Use together cautiously.
- CNS-active drugs: May cause additive effects. Use together cautiously.
- Digoxin, highly protein-bound drugs, warfarin:  Increases levels of these drugs. Monitor patient closely for adverse reactions.
- Phenytoin:  Decreases phenytoin levels and may lower seizure threshold.
- Food: Beverages containing caffeine:  May inhibit antipsychotic effects of clozapine.

Indications:

- Clozaril is used to treat people with schizophrenia in whom other medicines have not worked.

Contraindications:

- Contraindicated in patients with uncontrolled epilepsy or history of clozapine-induced agranulocytosis; in patients with a
WBC count below 3,500/mm3
- In patients with severe CNS depression or coma
- In patients taking other drugs that suppress bone marrow function
- In those with myelosuppressive disorders.

Side Effects:

- CNS: sedation, dizziness

- CV: hypotension, tachycardia
- GI: nausea, vomiting, constipation

Adverse Reaction:

- CNS: drowsiness, sedation,seizures, dizziness, syncope, vertigo, headache, tremor, disturbed sleep or nightmares,

restlessness, hypokinesia or akinesia, agitation, rigidity, akathisia, confusion, fatigue, insomnia, hyperkinesia, weakness,
lethargy, ataxia, slurred speech, depression, myoclonus, anxiety, neuroleptic malignant syndrome, fever.
- CV: tachycardia, hypotension, hypertension, chest pain, cardiomyopathy, ECG changes, orthostatic hypotension.
- EENT: visual disturbances.
- GI: dry mouth,  nausea, vomiting, excessive salivation, heartburn, constipation, diarrhea.
- GU: urinary abnormalities (urinary frequency or urgency, urine retention), incontinence, abnormal ejaculation.
- Hematologic: leukopenia, agranulocytosis, eosinophilia, neutropenia, thrombocytopenia.
- Metabolic: weight gain.
- Musculoskeletal: muscle pain or spasm, muscle weakness.
- Skin: rash, diaphoresis.
- After abrupt withdrawal of long-term therapy: Possible abrupt recurrence of psychotic symptoms. Monitor patient closely.

Nursing Responsibilities:

- A:
 Monitor patient’s mental status (orientation, mood, behavior) before and periodically during therapy.
  Assess weight and BMI initially and throughout therapy. Refer as appropriate for nutritional/weight management and
medical management
- D:
 Risk for other-directed violence (Indications)
 Disturbed thought process (Indications)
 Risk for injury (Side Effects)
- P: Patient will have a decrease in excitable, paranoic, or withdrawn behavior
- I:
 PO: Administer capsules with food or milk to decrease gastric irritation.
 Leave oral disintegrating tablet in blister until time of use. Do not push tablet through foil. Just before use, peel foil and
gently remove disintegrating tablet. Immediately place tablet in mouth and allow to disintegrate and swallow with
saliva. If 1/2 tablet dose used, destroy other half of tablet.
- E:
 Decreased positive symptoms (delusions, hallucinations) of schizophrenia.
 Decrease in negative symptoms (social withdrawal, flat, blunt affect) of schizophrenia.

2. ANXIOLYTICS
1. BENZODIAZEPINES
Brand Name:

Generic Name: Lorazepam

Classification: Benzodiazepines/Minor tranquilizer/Anxiolytic

Recommended Dosage, Route, and Frequency:

- Adults (and children over 13 years of age) :

 Anxiety: 1 to 4mg daily in divided doses. Your doctor will tell you how often to take your tablets.
 Sleeping Problems: 1 to 2mg before going to sleep. You should make sure that you will be able to sleep for 7 to 8 hours
before taking your tablets.
 Before Surgery: 2 to 3mg the night before your operation and 2 to 4mg 1 or 2 hours before your operation.
- Children (between 5 and 13 years of age):
 Before Surgery: The dose is usually between 0.5 and 2.5mg (depending on your child’s weight) at least 1 hour before
your child’s operation.
 Lorazepam is not recommended for the treatment of anxiety or sleeping problems in children. Nor is it recommended
for children below 5 years of age.
- Elderly or patients with liver or kidney problems :
 Older patients may be given lower doses. They may respond to half the usual adult dose or less.

Drug Action: ADME, Onset, Peak, Duration:

- A: Well absorbed following oral administration. Rapidly and completely absorbed following IM administration. Sublingual
absorption is more rapid than oral and is similar to IM. PO Peak: 1-6hrs, PO Duration: 8-12hr.
- D: Widely distributed. Crosses the blood-brain barrier. Crosses the placenta; enters breast milk.
- M & E: Highly metabolized by the liver. Half-life: Full-term neonates: 18–73 hr; Older children: 6–17 hr; Adults: 10–16 hr.
Drug-Drug and Drug-Food Interactions:

- Valproic acid may increase concentration/effects.

- Alcohol, other CNS depressants (e.g., morphine, PHENobarbital, zolpidem) may increase CNS depression.

Indications:

- Anxiety disorder (oral).

- Preoperative sedation (injection).
- Decreases preoperative anxiety and provides amnesia.
Contraindications:

- Hypersensitivity to LORazepam, other benzodiazepines.

 - Acute narrow-angle glaucoma, IV administration in patients with sleep apnea, severe respiratory depression (except during
mechanical ventilation).

Side Effects:

- CNS: headache, drowsiness, dizziness, confusion

- GI: nausea, vomiting
- CV: Hypotension

Adverse Reaction:

- CNS: amnesia, agitation, ataxia, depression, disorientation, dizziness, drowsiness, headache, incoordination, asthenia
- CV (with too rapid I.V. administration): hypotension, bradycardia, tachycardia, apnea, cardiac arrest, cardiovascular –
collapse
- EENT: blurred vision, diplopia, nystagmus
- GI: nausea, abdominal discomfort
- Other: increased or decreased appetite

Nursing Responsibilities:

- A:
 Monitor blood pressure, pulse, and respiratory status frequently throughout IV administration. Prolonged high-dose
therapy may lead to psychological or physical dependence.
 Restrict the amount of drug available to patient, especially if patient is depressed, suicidal, or has a history of addiction.
- D: Anxiety
- P: Patient will have an improvement in sleep patterns.
- I:
 PO: Tablet may also be given sublingually (unlabeled) for more rapid onset.
 Take concentrated liquid solution with water, soda, pudding, or applesauce.
 IM: Administer IM doses deep into muscle mass at least 2 hr before surgery for optimum effect.
- E:
 Increase in sense of well-being.
 Decrease in subjective feelings of anxiety without excessive sedation.
 Reduction of preoperative anxiety.
 Postoperative amnesia.
 Improvement in sleep patterns

2. AZAPIRONES
Brand Name:

Generic Name: Buspirone HCl

Classification: Azapirones

Recommended Dosage, Route, and Frequency:

- Adults (including the elderly): The recommended starting dose is 5mg two to three times a day, which may be increased
every two to three days. The usual dose you will be maintained on is 15mg to 30mg a day in divided doses. The maximum
daily dosage should not exceed 60mg per day.
- Children: Not recommended.

Drug Action: ADME, Onset, Peak, Duration:

- Absorption: Absorbed rapidly and completely after oral administration, but extensive first-pass metabolism limits absolute
bioavailability to 1% to 13% of the oral dose. Food slows absorption but increases the amount of unchanged drug in
systemic circulation.
- Distribution: 95% protein-bound; it doesn’t displace other highly protein-bound drugs such as warfarin.
- M & E: Metabolized in the liver by hydroxylation and oxidation, resulting in at least one pharmacologically active
metabolite, 1, pyrimidinylpiperazine (1-PP). 29% to 63% is excreted in urine in 24 hours, primarily as metabolites; 18% to
38% is excreted in feces.
Drug-Drug and Drug-Food Interactions:

- CNS depressants:  Increase sedation. Avoid use together.

- Digoxin: Buspirone may displace digoxin from serum-binding sites. Monitor digoxin levels.
- Haloperidol:  Increases serum haloperidol levels. Decrease haloperidol dosage.
- MAO inhibitors:  Elevate blood pressure.
- Food: Grapefruit juice:  Elevates buspirone levels and increases pharmacologic and adverse effects. Tell patient to take drug
with liquid other than grapefruit juice.

Indications:

- Short term management of anxiety disorders

- Relief of symptoms of anxiety with or without symptoms of depression.

Contraindications:

- Contraindicated in patients hypersensitive to drug or within 14 days of taking an MAO inhibitor.

Side Effects:

- GI: nausea, vomiting, diarrhea, constipation

Adverse Reaction:

- CNS: dizziness, drowsiness,  nervousness, insomnia, headache, light-headedness, fatigue, numbness.

- EENT: blurred vision.
- GI:  abdominal distress.

Nursing Responsibilities:

- A:
 Assess degree and manifestations of anxiety before and periodically during therapy.
 Buspirone does not appear to cause physical or psychological dependence or tolerance. However, patients with a
history of drug abuse should be assessed for tolerance or dependence. Restrict amount of drug available to these
patients.
- D;
 Anxiety (Indications)
 Risk for injury (Side Effects)
- P: Patient will have an increase in sense of well-being.
- I:
 PO: May be administered with food to minimize gastric irritation. Food slows but does not alter extent of absorption.
- E:
 Decrease in subjective feelings of anxiety. Some improvement may be seen in 7–10 days. Optimal results take 3–4 wk
of therapy. Buspirone is usually used for short-term therapy (3–4 wk). If prescribed for long-term therapy, efficacy
should be periodically assessed.

3. BENZODIAZEPINE ANTAGONIST
Brand Name:

Generic Name: flumazenil

Classification: Benzodiazepine Antagonist

Recommended Dosage, Route, and Frequency:

- Anaesthesia:
 The recommended starting dose for adults is 0.2 mg administered intravenously over 15 seconds. If the required level
of consciousness is not obtained within 60 seconds, a further dose of 0.1 mg can be injected and repeated at 60-second
intervals, up to a maximum dose of 1.0 mg. The usual dose required lies between 0.3 and 0.6 mg, but may deviate
depending on the patient’s characteristics and the benzodiazepine used.
 - Intensive Care:
 The recommended initial dose of Flumazenil for adults is 0.3 mg i.v. If the required level of consciousness is not
obtained within 60 seconds, a further dose of 0.1 mg can be injected and repeated at 60-second intervals, up to a total
dose of 2 mg or until the patient awakes. If drowsiness recurs, an intravenous infusion of 0.1 – 0.4 mg/h may be useful.

Drug Action: ADME, Onset, Peak, Duration:

- A: IV administration results in complete bioavailability. Peak: 6-10min. Duration: 1-2hrs.

- D: Unknown. Protein Binding: 50% primarily to albumin.
- M & E: Metabolism of flumazenil occurs primarily in the liver. Half-life: Children: 20–75 min; Adults: 41–79min.
Drug-Drug and Drug-Food Interactions:

- None significant.

Indications:

- Complete/partial reversal of effects of benzodiazepines used as general anesthetics, or during diagnostic or therapeutic
procedures.
- Management of intentional or accidental overdose of benzodiazepines.

Contraindications:

- Hypersensitivity to flumazenil or benzodiazepines

- Patients receiving benzodiazepines for life-threatening medical problems, including status epilepticus or increased
intracranial pressure
- Serious cyclic antidepressant overdosage

Side Effects:

- CNS: Dizziness
- GI: Nausea, vomiting

Adverse Reaction:

- CNS: SEIZURES, dizziness, agitation, confusion, drowsiness, emotional lability, fatigue, headache, sleep disorders. EENT:
abnormal hearing, abnormal vision, blurred vision.
- CV: arrhythmias, chest pain, hypertension.
- GI: nausea, vomiting, hiccups.
- Skin: flushing, sweating.
- Local: pain/injectionsite reactions, phlebitis.
- Neuro: paresthesia.
Nursing Responsibilities:

- A:
 Assess level of consciousness and respiratory status before and during therapy. Observe patient for at least 2 hr after
administration for the appearance of resedation. Hypoventilation may occur.
 Overdose: Attempt to determine time of ingestion and amount and type of benzodiazepine taken. Knowledge of agent
ingested allows an estimate of duration of CNS depression.
- D:
 Risk for injury
 Risk for poisoning
- P: Patient will have an improved level of consciousness.
- I:
 Ensure that patient has a patent airway before administration of flumazenil.
 Observe IV site frequently for redness or irritation. Administer through a free-flowing IV infusion into a large vein to
minimize pain at the injection site.
 Institute seizure precautions. Seizures are more likely to occur in patients who are experiencing sedative/hypnotic
withdrawal, patients who have recently received repeated doses of benzodiazepines, or those who have a previous
history of seizure activity. Seizures may be treated with benzodiazepines, barbiturates, or phenytoin. Larger than
normal doses of benzodiazepines may be required.
 - E:
 Improved level of consciousness.
 Decrease in respiratory depression caused by benzodiazepines.

3. ANTIDEPRESSANTS
1. TRICYCLIC ANTIDEPRESSANTS (TCAs)
Brand Name:

Generic Name: Imipramine

Classification: Tricyclic Antidepressants

Recommended Dosage, Route, and Frequency:

- Depression.
  Adults: Initially, 75 to 100 mg P.O. daily in divided doses, with 25- to 50-mg increments, up to 200 mg. Or, some
patients can start with lower doses (25 mg P.O.) and dosage is adjusted slowly in 25-mg increments every other day.
Maximum dose is 300 mg daily. Or, entire dosage may be given h.s. Maximum daily dose is 200 mg for outpatients, 300
mg for inpatients, 100 mg for elderly patients.
 Elderly patients: Give 30 to 40 mg P.O. daily, not to exceed 100 mg daily. Start therapy at low doses (10 mg) and adjust
slowly.
- Childhood enuresis. Children age 6 and older: 25 to 75 mg P.O. daily, 1 hour before bedtime. Usual dose is 1.5 mg/kg daily
in three divided doses. Maximum dose is 2.5 mg/kg daily.

Drug Action: ADME, Onset, Peak, Duration:

- Absorption: Absorbed rapidly from GI tract. PO – Peak: ½ - 2hrs.

- Distribution: Distributed widely throughout the body, including the CNS and breast milk. Drug is 90% protein-bound. Steady
state is achieved within 2 to 5 days. Therapeutic plasma levels (parent drug and metabolite) range from 150 to 300 ng/ml.
- M & E: Metabolized by the liver to the active metabolite desipramine. A significant first-pass effect may explain variability
of serum levels in different patients taking the same dosage. Mostly excreted in urine.

Drug-Drug and Drug-Food Interactions:

- Antiarrhythmics (disopyramide, procainamide, quinidine), pimozide, thyroid medication:  May increase risk of arrhythmias
and conduction defects. Avoid use together.
- Atropine or other anticholinergic drugs, including antihistamines, antiparkinsonian agents, meperidine, and phenothiazines;
CNS depressants, including analgesics, anesthetics, barbiturates, narcotics, and tranquilizers: Causes oversedation, paralytic
ileus, visual changes, and severe constipation. Avoid use together.
- Barbiturates:  Induces imipramine metabolism and decreases therapeutic efficacy. Avoid use together.
- Beta blockers, cimetidine, methylphenidate, hormonal contraceptives, propoxyphene: Inhibits imipramine metabolism,
increasing plasma levels and toxicity. Use together cautiously.
- Centrally acting antihypertensives, such as clonidine, guanabenz, guanadrel, guanethidine, methyldopa, and
reserpine:  Decreases hypotensive effects of antihypertensives. Use cautiously.
- Disulfiram or ethchlorvynol:  May cause delirium and tachycardia. Observe patient closely.
- Haloperidol and phenothiazines: Decreases metabolism of imipramine, decreasing therapeutic efficacy. Monitor patient
closely.
- Metrizamide:  Increases risk of seizures. Monitor patient closely.
- Sympathomimetics, including ephedrine, epinephrine, and phenylephrine (often found in nasal sprays):  May increase blood
pressure. Patient needs frequent blood pressure checks.
- Warfarin:  May prolong PT and cause bleeding. Monitor PT and INR.

Indications:

- Treatment for depression

Contraindications:
 - Contraindicated during acute recovery phase of MI, in patients hypersensitive to drug, and in those receiving MAO
inhibitors.

Side Effects:

- CNS: drowsiness, dizziness

- CV: orthostatic hypotension
- GI: dry mouth, constipation, nausea, vomiting
- GU: urine retention
- Skin: diaphoresis

Adverse Reaction:

- CNS: excitation, tremor, confusion, hallucinations, anxiety, ataxia, paresthesia, nervousness, EEG
changes, seizures, extrapyramidal reactions, CVA.
- CV: tachycardia, ECG changes, hypertension, MI, arrhythmias, heart block, precipitation of heart failure.
- EENT: blurred vision, tinnitus, mydriasis.
- GI: anorexia, paralytic ileus, abdominal cramps.
- GU: testicular swelling, impotence.
- Skin: rash, urticaria, photosensitivity, pruritus.
- Other: gynecomastia, galactorrhea and breast enlargement, altered libido, SIADH, hypersensitivity reaction.

Nursing Responsibilities:

- A:
 Monitor BP and pulse rate prior to and during initial therapy.
 Monitor plasma levels in treatment-resisant patients.
 For overweight/obese individuals, obtain FBS and cholesterol levels. Refer as appropriate for nutrition/weight
management and medical management.
- D:
 Ineffective coping (Indications)
 Chronic pain (Indications)
 Impaired urinary elimination (Indications, Side Effects)
 Sexual dysfunction (Side Effects)
- P: Patient will have an ncreased sense of well-being.
- I:
 Dose increases should be made at bedtime because of sedation. Dose titration is a slow process; may take weeks to
months. May be given as a single dose at bedtime to minimize sedation during the day.
 PO: Administer medication with or immediately following a meal to minimize gastric irritation.
- E:
 Increased sense of well-being.
 Renewed interest in surroundings.
 Increased appetite.
 Improved energy level.
 Pain relief.
 Diminished incidence of enuresis.
 Improved sleep in patients treated for depression.
 Patient may require 2–6 wk of therapy before full therapeutic effects of medication are noticeable.
 Control of bedwetting in children less than 6 yrs.
 Decrease in chronic neurogenic pain.

2. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

Brand Name:

Generic Name: Citalopram

Classification: Selective Serotonin Reuptake inhibitors (SSRIs)

Recommended Dosage, Route, and Frequency:

- Depression:
 The recommended dose is 20 mg per day. This may be increased by your doctor to a maximum of 40 mg per day.
 The exact dose will depend on how your condition responds to treatment
 You will normally be asked to keep taking this medicine for at least 6 months
- Panic disorder (panic attacks):
 The starting dose is 10 mg per day for the first week before increasing the dose to 20-30 mg per day. The dose may be
increased by your doctor to a maximum of 40 mg per day.
 The exact dose will depend on how your condition responds to treatment.
- Older people (above 65 years of age):
 The starting dose should be decreased to half of the recommended dose, e.g. 10-20 mg per day. Older people should
not usually receive more than 20 mg per day.

Drug Action: ADME, Onset, Peak, Duration:

- Absorption: Absolute bioavailability is 80% following oral administration. PO – Peak:2-4hrs.

- Distribution: Highly bound to plasma proteins (80%).
- M & E: Extensively metabolized primarily by cytochrome P-450 3A4 and cytochrome P-450 2C19 to inactive metabolites.
About 20% of drug is excreted in urine. Elimination half-life is about 35 hours. In patients older than age 60, the half-life is
increased up to 30%.

Drug-Drug and Drug-Food Interactions:

- Carbamazepine:  May increase citalopram clearance. Monitor patient.

- CNS drugs: Causes additive effects. Use together cautiously.
- Drugs that inhibit cytochrome P-450 isoenzymes 3A4 and 2C19:  Decreases citalopram clearance. Monitor patient closely.
- Imipramine, other tricyclic antidepressants: Level of imipramine metabolite desipramine increases by about 50%. Use
together cautiously.
- Lithium:  May enhance serotonergic effect of citalopram. Use cautiously, and monitor lithium level.
- MAO inhibitors:  Serious, sometimes fatal, reactions may occur. Don’t use drug within 14 days of MAO inhibitor therapy.
- Warfarin:  PT is increased by 5%.

Indications:

- Depression
- Panic disorders including fear of wide open spaces (agoraphobia) or crowds

Contraindications:

- Contraindicated in patients hypersensitive to drug or its components, in those taking MAO inhibitors, and within 14 days of
MAO inhibitor therapy.

Side Effects:

- CNS: somnolence, insomnia

- GI: dry mouth, nausea
- Skin: increased sweating

Adverse Reaction:

- CNS: tremor,  anxiety, agitation, dizziness, paresthesia, migraine, impaired concentration, amnesia, depression,
apathy, suicide attempt, confusion, fatigue, fever.
- CV: tachycardia, orthostatic hypotension, hypotension.
- EENT: rhinitis, sinusitis, abnormal accommodation.
- GI:  diarrhea, anorexia, dyspepsia, vomiting, abdominal pain, taste perversion, increased saliva, flatulence, increased
appetite.
- GU: dysmenorrhea, amenorrhea, ejaculation disorder, impotence, polyuria.
- Metabolic: hyponatremia, weight changes.
 - Musculoskeletal: arthralgia, myalgia.
- Respiratory: upper respiratory tract infection, cough.
- Skin: rash, pruritus.
- Other: yawning, decreased libido, SIADH.

Nursing Responsibilities:

- A:
 Assess for suicidal tendencies, especially during early therapy and dose changes. Restrict amount of drug available to
patient. Risk may be increased in children, adolescents, and adult.. After starting therapy, children, adolescents, and
young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for the next 4 wk, and on
advice of health care professional thereafter.
- D:
 Ineffective coping (Indications)
 Chronic pain (Indications)
 Impaired urinary elimination (Indications, Side Effects)
 Sexual dysfunction (Side Effects)
- P: Patient will have an increased sense of well-being.
- I:
 Dose increases should be made at bedtime because of sedation. Dose titration is a slow process; may take weeks to
months. May be given as a single dose at bedtime to minimize sedation during the day.
 PO: Administer medication with or immediately following a meal to minimize gastric irritation.
- E:
 Increased sense of well-being.
 Renewed interest in surroundings

3. SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)

Brand Name:

Generic Name: Venlafaxine

Classification: Serotonin Norephinephrine

Recommended Dosage, Route, and Frequency:

- Depression. Adults:  Initially, 75 mg P.O. daily, in two or three divided doses with food. Increase dosage as tolerated and
needed in increments of 75 mg daily at intervals of no less than 4 days. For moderately depressed outpatients, usual
maximum dose is 225 mg daily. In certain severely depressed patients, dosage may be as high as 375 mg daily divided into
three doses. For extended-release capsules, 75 mg P.O. daily, in a single dose. For some patients, it may be desirable to
start at 37.5 mg P.O. daily for 4 to 7 days before increasing to 75 mg daily. Dosage may be increased at increments of 75 mg
daily q 4 days to a maximum of 225 mg daily.
- Generalized anxiety disorder. Adults: Initially, 75 mg daily (extended-release) in a single dose. Increase dosage as needed in
75-mg daily increments at intervals of at least 4 days. Maximum, 225 mg daily.
- Prevention of major depressive disorder relapse : Adults:  100 to 200 mg (Effexor) P.O. daily or 75 to 225 mg (Effexor XR)
P.O. daily.

Drug Action: ADME, Onset, Peak, Duration:

- A: About 92% of drug absorbed after oral administration.

- D: About 25% to 29% protein-bound in plasma.
- M & E: Extensively metabolized in liver, with ODV the only major active metabolite. About 87% of dose recovered in urine
within 48 hours (5% as unchanged venlafaxine, 29% as unconjugated ODV, 26% as conjugated ODV, 27% as minor inactive
metabolites). Elimination half-life is about 5 hours for venlafaxine and 11 hours for ODV.

Drug-Drug and Drug-Food Interactions:

- Cimetidine, CNS-active drugs:  Significantly increases venlafaxine level in elderly patients and those with hepatic dysfunction
or hypertension. 
 - MAO inhibitors:  May precipitate a syndrome similar to neuroleptic malignant syndrome when used with venlafaxine. Don’t
start venlafaxine within 14 days of stopping an MAO inhibitor; don’t start MAO inhibitor within 7 days of stopping
venlafaxine.

Indications:

- Treatment of depression.
- Treatment of generalized anxiety disorder (GAD), social anxiety disorder (SAD).
- Treatment of panic disorder, with or without agoraphobia.

Contraindications:

- Contraindicated in patients hypersensitive to drug and within 14 days of MAO inhibitor therapy. 

Side Effects:

- GI: nausea, dry mouth, constipation, diarrhea

- Genitourinary: impotence, ejaculatory disturbance
- CNS: headache, drowsiness, insomnia, abnormal dreams

Adverse Reaction: By system

- CNS: anxiety, tremor, abnormal dreams, paresthesia, agitation, asthenia.

- CV: hypertension, vasodilation.
- EENT: blurred vision.
- GI:  vomiting, anorexia,  dyspepsia, flatulence.
- GU:  impotence, urinary frequency, impaired urination.
- Metabolic: weight loss.
- Skin: diaphoresis,  rash.
- Other: yawning, chills, infection, decreased libido (extended-release).

Nursing Responsibilities:

- A: Obtain initial weight, B/P. Assess appearance, behavior, speech pattern, level of interest, mood. Assess risk of suicide
- D:
 Ineffective coping (Indications)
 Risk for injury (Side Effects)
- P: Patient will have a decreased anxiety.
- I:
 Monitor signs/symptoms of depression, B/P, weight.
 Assess sleep pattern for evidence of insomnia. Check during waking hours for drowsiness, dizziness, anxiety; provide
assistance as necessary.
 Assess appearance, behavior, speech pattern, level of interest, mood for therapeutic response.
 Monitor for suicidal ideation (esp. at initiation of therapy or changes in dosage).
- E:
 Increased sense of well-being.
 Renewed interest in surroundings. Need for therapy should be periodically reassessed. Therapy is usually continued for
several months.
 Decreased anxiety.

4. MONOAMINE OXIDASE INHIBITORS (MAOIs)

Brand Name:

Generic Name: Isocarboxazid

Classification: Monoamine oxidase inhibitor

Recommended Dosage, Route, and Frequency:

 - The recommended dose is between one and three tablets daily, taken at different times or all together.

Drug Action: ADME, Onset, Peak, Duration:

- A: Absorbed rapidly and completely from GI tract. PO – Peak: 1-2hrs.

- Distribution: No information available.
- M & E: Metabolized in liver. Excreted primarily in urine within 24 hours; some drug excreted in feces via biliary tract.
Relatively short half-life, but enzyme inhibition is prolonged and unrelated to half-life.

Drug-Drug and Drug-Food Interactions:

- Amphetamines, ephedrine, phenylephrine, other related drugs: Enhances pressor effects. Avoid use together.
- Barbiturates, dextromethorphan, narcotics, tricyclic antidepressants, other sedatives:  Increases adverse reactions. 
- Disulfiram:  May cause tachycardia, flushing, or palpitations. Monitor patient closely.
General, spinal anesthetics:  Causes severe hypotension and excessive CNS depression. Avoid use together.
- Local anesthetics (lidocaine, procaine): Decreases effectiveness of these drugs; causes poor nerve block. Stop phenelzine for
at least 1 week before giving these drugs.
- OTC cold, hay fever, weight-reduction products: Causes serious CV toxicity. Avoid use together.
- Serotonergic drugs (fluoxetine, fluvoxamine, paroxetine, sertraline), tricyclic antidepressants:  Causes serious adverse
effects. At least a 2-week waiting period between drug use is recommended.

Indications:

- Depression in patients who have failed other modes of therapy.

Contraindications:

- Contraindicated in patients hypersensitive to drug and in those with heart failure, pheochromocytoma, hypertension, liver
disease, or CV disease.
- Also contraindicated during therapy with other MAO inhibitors

Side Effects:

- CNS: dizziness
- GI: anorexia

Adverse Reaction:

- CNS: vertigo, headache, hyperreflexia, tremor, muscle twitching, insomnia,  drowsiness, weakness, fatigue.
- CV: orthostatic hypotension, edema.
- GI: dry mouth, nausea, constipation.
- GU: elevated urinary catecholamine levels, sexual disturbances.
- Metabolic: weight gain.
- Skin: diaphoresis.

Nursing Responsibilities:

- A:
 Assess mental status (orientation, mood, behavior) and anxiety level frequently. Assess for suicidal tendencies,
especially during early therapy. Restrict amount of drug available to patient.
 Monitor BP and pulse before and frequently during therapy. Report significant changes promptly. Headache is often
first symptom of a hypertensive crisis.
 Monitor intake and output ratios and daily weight. Assess patient for urinary retention.
- D:
 Ineffective coping (Indications)
 Ineffective therapeutic regimen management (Patient/Family Teaching)
 Risk for falls (Side Effects)
 Imbalanced nutrition: more than body requirements (Side Effects)
 Sexual dysfunction (Side Effects)
 Impaired oral mucous membrane (Side Effects)
- P: The patient will have an increased sense of well-being.
 - I:
 Do not administer these medications in the evening because the psychomotor stimulating effects may cause insomnia
or other sleep disturbances.
 PO: Tablets may be crushed and mixed with food or fluids for patients with difficulty swallowing.
- E:
 Improved mood in depressed patients.
 Increased sense of well-being.
 Decreased anxiety.
 Increased appetite.
 Improved energy level.
 Improved sleep.
5. ATYPICAL ANTIDEPRESSANTS
Brand Name:

Generic Name: Amoxapine

Classification: Atypical antidepressants

Recommended Dosage, Route, and Frequency:

- Depression. Adults:  Initially, 150 mg daily in divided doses, which can be increased by 50 mg daily q 3 to 4 days. Average
dose ranges from 150 mg to 400 mg daily. Maximum dose is 400 mg daily in outpatients; 600 mg daily in hospitalized
patients.
-  Aggressive behavior: Adults: 50 mg P.O. b.i.d.
- Panic disorder:  Adults: 300 mg P.O. daily.

Drug Action: ADME, Onset, Peak, Duration

- A: Well absorbed from GI tract. Taking drug with food delays absorption and increases amount absorbed by 20%. PO –
Peak: 1-2hrs
- D: Widely distributed throughout the body. Drug isn’t concentrated in any particular tissue, but small amounts may appear
in breast milk. About 90% is protein-bound. Proposed therapeutic drug levels haven’t been established. Steady state plasma
levels are reached in 3 to 7 days, and onset of therapeutic activity occurs in 7 days.
- M&E: Metabolized by the liver; more than 75% of metabolites are excreted within 3 days. Mostly excreted in urine; the rest
is excreted in feces via the biliary tract.

Drug-Drug and Drug-Food Interactions:

-  Antihypertensives, CNS depressants: Causes additive effects of antihypertensives and CNS depressants. Monitor patient
closely. Dosage adjustment may be needed.
- Digoxin, phenytoin:  Increases serum levels of digoxin and phenytoin. Monitor patient closely.
- Selective serotonin reuptake inhibitors: Increases risk of serotonin syndrome.

Indications:

- Treatment of various types of depression

Contraindications:

- Contraindicated during initial recovery phase of MI or in patients hypersensitive to drug. 

Side Effects:

- CNS: fatigue, sedation

- EENT: blurred vision
- GI: constipation

Adverse Reaction:

- CNS: drowsiness, dizziness, nervousness, fatigue, confusion, tremor, weakness, hostility, anger, nightmares, vivid dreams,
headache, insomnia, generalized tonic-clonic seizures.
 - CV: orthostatic hypotension, tachycardia, hypertension, prolonged conduction time on ECG, syncope.
- EENT: blurred vision, tinnitus, nasal congestion.
- GI: dry mouth, dysgeusia, constipation, nausea, vomiting, anorexia.
- GU: urine retention; priapism, possibly leading to impotence; hematuria.
- Hematologic: anemia.
- Metabolic: altered serum glucose levels.
- Respiratory: shortness of breath.
- Skin: rash, urticaria, diaphoresis.
- Other: decreased libido.

Nursing Responsibilities:

- A:
 Assess mental status (orientation, mood, behavior) and anxiety level frequently. Assess for suicidal tendencies,
especially during early therapy. Restrict amount of drug available to patient.
 Monitor BP and pulse before and frequently during therapy. Report significant changes promptly. Headache is often
first symptom of a hypertensive crisis.
 Monitor intake and output ratios and daily weight. Assess patient for urinary retention.
- D:
 Ineffective coping (Indications)
 Ineffective therapeutic regimen management (Patient/Family Teaching)
 Risk for falls (Side Effects)
 Imbalanced nutrition: more than body requirements (Side Effects)
 Sexual dysfunction (Side Effects)
 Impaired oral mucous membrane (Side Effects)
- P: The patient will have an increased sense of well-being.
- I:
 Do not administer these medications in the evening because the psychomotor stimulating effects may cause insomnia
or other sleep disturbances.
 PO: Tablets may be crushed and mixed with food or fluids for patients with difficulty swallowing.
- E:
 Improved mood in depressed patients.
 Increased sense of well-being.
 Decreased anxiety.
 Increased appetite.
 Improved energy level.
 Improved sleep.
-

6. NOREPINEPHRINE & DOPAMINE REUPTAKE INHIBITOR (NDRI)

Brand Name:

Generic Name: Bupropion

Classification: Norepinephrine & dopamine reuptake inhibitor

Recommended Dosage, Route, and Frequency:

-  Depression. Adults: Initially, 100 mg P.O. b.i.d. or 75 mg P.O. t.i.d. If needed, increase after 3 days to usual dosage of 100
mg P.O. t.i.d. If no response occurs after several weeks of therapy, consider increasing dosage to 150 mg t.i.d. Maximum,
450 mg daily. For sustained-release tablets, start with 150 mg P.O. q morning; increase to target dosage of 150 mg P.O.
b.i.d. as tolerated as early as day 4 of dosing. If no response after several weeks of therapy, increase to 200 mg b.i.d.
Maximum, 400 mg daily.

Drug Action: ADME, Onset, Peak, Duration

- Absorption: Only 5% to 20% is bioavailable in animal studies. PO – Peak: 2hrs

- Distribution: At plasma levels up to 200 mcg/ml, drug appears to be about 80% bound to plasma proteins.
 - M & E: Metabolism is probably hepatic; several active metabolites have been identified. With prolonged use, the active
metabolites probably accumulate in plasma, and their level may exceed that of the parent compound. Appears to induce its
own metabolism. Excretion is primarily renal; elimination half-life of parent compound in single-dose studies ranges from 8
to 24 hours.

Drug-Drug and Drug-Food Interactions:

- Levodopa, MAO inhibitors, phenothiazines, recent and rapid withdrawal of benzodiazepines, tricyclic
antidepressants:  Increase risk of adverse effects, including seizures. 

Indications:

- Treatment of depression (with psychotherapy).

- Depression in patients with seasonal affective disorder

Contraindications:

- Hypersensitivity to the drug

- History of bulimia, and anorexia nervosa
- Concurrent MAO inhibitor or ritonavir therapy
- Lactation

Side Effects:

- CNS: headache, confusion

- CV: arrhythmias
- EENT: auditory disturbances
- GI: nausea, vomiting, diarrhea, dry mouth
- Metabolic: weight changes

Adverse Reaction:

- CNS: seizures, anxiety, delusions, euphoria, hostility, impaired sleep quality, insomnia, sedation, tremor, akinesia, akathisia,
agitation, dizziness, syncope, fatigue, fever.
- CV:  hypertension, hypotension, palpitations, tachycardia.
- EENT: blurred vision.
- GI:  taste disturbance, increased appetite, constipation, dyspepsia, diarrhea.
- GU: impotence, menstrual complaints, urinary frequency, urine retention.
- Metabolic:  hyperglycemia.
- Musculoskeletal: arthritis.
- Skin: pruritus, rash, cutaneous temperature disturbance, excessive diaphoresis.
- Other: chills, decreased libido.

Nursing Responsibilities:

- A: Monitor mood changes. Inform health care professional if patient demonstrates significant increase in anxiety,
nervousness, or insomnia.
- D: Ineffective coping (Indications)
- P: Patient will have an increased sense of well-being.
- I:
 Administer doses in equally spaced time increments during the day to minimize the risk of seizures.
 Risk of seizures increases four fold in doses greater than 450 mg per day.
 PO: Swallow sustained-release or extended-release tablets whole; do not break, crush, or chew.
 May be administered with food to lessen GI irritation.
- E:
 Increased sense of well-being.
 Renewed interest in surroundings. Acute episodes of depression may require several months of treatment.
 5. MOOD STABILIZERS
Brand Name: Negretol

Generic Name: Carbamazepine

Classification: Iminostilbenes

Recommended Dosage, Route, and Frequency:

- To treat epilepsy the usual doses are:

 Adults: 800-1,200 mg a day, although higher doses may be necessary. If you are elderly you might require a lower
dose.
 Children: Aged 5-10 years: 400-600 mg a day Aged 10-15 years: 600-1,000 mg a day.
- Tegretol Tablets are not recommended for children under 5.
- To treat trigeminal neuralgia the usual dose is: 600-800 mg a day. The maximum dose is 1200mg a day. If you are elderly
you might require a lower dose.
- To treat mood swings the usual dose is: 400-600 mg a day

Drug Action: ADME, Onset, Peak, Duration:

- A: Absorption is slow but complete. Suspension produces earlier, higher peak, and lower trough levels. Peak: 4-5hr.
Duration: 6-12hrs.
- D: Widely distributed. Crosses the blood-brain barrier. Crosses the placenta rapidly and enters breast milk in high
concentrations. Protein Binding: Carbamazepine—75–90%; epoxide—50%.
- M & E: Extensively metabolized in the liver by cytochrome P450 3A4 to active epoxide metabolite; epoxide metabolite has
anticonvulsant and antineuralgic activity. Half-life: Carbamazapine—single dose—25– 65 hr, chronic dosing—Children—8–
14 hr; Adults—12–17 hr; epoxide—34_9 hr.
Drug-Drug and Drug-Food Interactions:

- CYP3A4 inhibitors (e.g., cimetidine, clarithromycin, azole antifungals, protease inhibitors) may increase concentration.
- CYP3A4 inducers (e.g., rifampin, phenytoin) may decrease concentration/effects.
- May decrease concentration/effects of hormonal contraceptives, warfarin, trazodone.

Indications:

- Treatment of tonic-clonic, mixed, and complex-partial seizures.

- Management of pain in trigeminal neuralgia or diabetic neuropathy.

Contraindications:

- Concomitant use or within 14 days of use of MAOIs, myelosuppression.

- Concomitant use of delavirdine or other NNRT inhibitors, hypersensitivity to carBAMazepine, tricyclic antidepressants.

Side Effects:

- CNS: Vertigo, somnolence, ataxia

- GI: nausea, vomiting, dry mouth
- Neuro: Tremors
- Metabolic: edema, fluid retention, increased weight
- Hematologic: thrombocytopenia

Adverse Reaction:

- CNS: ataxia, drowsiness, fatigue, psychosis, syncope, vertigo, headache, worsening of seizures
- CV: hypertension, hypotension, arrhythmias, atrioventricular block, aggravation of coronary artery disease, heart failure
- EENT: blurred vision, diplopia, nystagmus, corneal opacities, conjunctivitis, pharyngeal dryness
- GI: nausea, vomiting, diarrhea, abdominal pain, stomatitis, glossitis, dry mouth, anorexia
- GU: urinary hesitancy, retention, or frequency; albuminuria; glycosuria; erectile dysfunction
- Hematologic: eosinophilia, lymphadenopathy, agranulocytosis, aplastic anemia, thrombocytopenia, leukopenia
- Hepatic: hepatitis
 - Metabolic: syndrome of inappropriate antidiuretic hormone secretion
- Respiratory: pneumonitis
- Skin: photosensitivity, rash, urticaria, diaphoresis, erythema multiforme, Stevens-Johnson syndrome
- Other: weight gain, chills, fever
Nursing Responsibilities:

- A:
 CBC, serum iron determination, urinalysis, BUN should be performed before therapy begins and periodically during
therapy.
 Seizures: Review history of seizure disorder (intensity, frequency, duration, level of consciousness [LOC]).
 Initiate seizure precautions.
 Neuralgia: Assess facial pain, stimuli that may cause facial pain.
 Bipolar: Assess mental status, cognitive abilities
- D:
 Disturbed thought process
 Risk for injury
 Chronic pain
- P: Patient will have an absence or reduction of seizure activity
- I:
 Administer medication with food to minimize gastric irritation.
 May take at bedtime to reduce daytime sedation.
 Tablets may be crushed if patient has difficulty swallowing.
 Do not crush or chew extended-release tablets.
- E:
 Absence or reduction of seizure activity.
 Decrease in trigeminal neuralgia pain. Patients with trigeminal neuralgia who are pain-free should be re-evaluated
every 3 mo to determine minimum effective dose.
 Decreased mania and depressive symptoms in Bipolar I disorder.