Psychopharmacology:

Psychoses
Mental Health
1
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Introduction

• Main use of antipsychotic medications is treatment of schizophrenia.

• Schizophrenia is characterized by acute exacerbations along with
intervals of incomplete remission.
• Medications are used for the treatment of
– Positive symptoms
• Delusions.
• Hallucinations.
• Agitation.
– Negative symptoms
• Social withdrawal.
• Anergia.
• Lack of emotion.

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Goal of Medication Therapy for Schizophrenia

• Suppression of acute episodes.

• Prevention of recurrence of acute symptoms.
• Maintenance of the highest level of functioning possible.

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Medication Classifications: Conventional Antipsychotic Agents

• Mainly used for the treatment of positive psychotic

symptoms
– Especially helpful for clients who are
aggressive or violent.
• Low-potency agents
– Chlorpromazine.
– Thioridazine.
• Medium-potency agents
– Molindone.
• High-potency agents
– Haloperidol.
– Fluphenazine decanoate.

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Expected Pharmacological Action

• Conventional antipsychotic medications block dopamine (D2),

acetylcholine, histamine, and norepinephrine (NE) receptors in the brain
and peripheral nervous system.
• Inhibition of psychotic symptoms is believed to be a result of D2
blockade in the brain

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Therapeutic Uses of Chlorpromazine

• Schizophrenia.
• Bipolar disorder.
• Tourette’s syndrome.
• Delusional disorders.
• Schizoaffective disorder.
• Dementia.
• Huntington’s chorea.
• Prevention of nausea/vomiting.

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Chlorpromazine: Side/Adverse Effects

• Early extrapyramidal symptoms (EPSs)

– Acute dystonia with severe spasms of tongue and jaw that spreads
to the face, neck, and back.
– Parkinsonism.
– Akathisia with inability to sit or stand still.
• Late EPSs
– Tardive dyskinesia involving twisting/wormlike movement of tongue
and face, lip smacking, uncontrollable movements
• No treatment.
• Typically irreversible.

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Chlorpromazine Adverse Effect: Neuroleptic Malignant Syndrome

• Potentially fatal.
• Sudden onset of
– High fever.
– Blood pressure fluctuations.
– Dysrhythmias.
– Muscle rigidity.
– Change in level of consciousness that develops into a coma.
• Treatment
– Stop medication.
– Apply cooling blankets.
– Monitor vital signs.
– Increase fluids.
– Administer benzodiazepines for anxiety.
– Administer dantrolene (Dantrium) to induce muscle relaxation.
– Wait 2 weeks to resume therapy or change to atypical antipsychotic.

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Chlorpromazine: Side/Adverse Effects

• Anticholinergic effects
– Dry mouth.
– Visual disturbances.
– Acute urinary retention.
– Constipation.
– Tachycardia.
• Orthostatic hypotension, tachycardia, severe dysrhythmias.
• Sedation.
• Neuroendocrine effects
– Gynecomastia.
– Galactorrhea.
– Menstrual irregularities.
• Seizures.
• Skin effects, such as photosensitivity.
• Agranulocytosis.

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Chlorpromazine: Contraindications/Precautions

• Contraindicated for following

conditions:
– Coma.
– Severe depression.
– Parkinson’s disease.
– Prolactin-dependent breast
cancer.
– Severe hypotension.
• Use cautiously for the following
conditions:
– Glaucoma.
– Paralytic ileus.
– Prostate enlargement.
– Heart, liver, kidney, or seizure
disorders.

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Chlorpromazine: Medication/Food Interactions

• Concurrent use with anticholinergic agents will increase anticholinergic

effects.
• Increased central nervous system (CNS) depression will occur with
concurrent use with CNS depressants, such as alcohol, opioids, and
antihistamines.
• Concurrent use with levodopa decreases the antipsychotic effects.

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Chlorpromazine: Nursing Interventions/Client Education

• Divide initial high doses throughout the

day.
• Keep maintenance doses low, and give
at bedtime.
• Monitor to distinguish between EPS and
increased psychosis.
• Treat EPS with anticholinergics, beta-
blockers, and benzodiazepines.
• Explain that antipsychotics do not lead
to addiction.
• Stress importance of taking medication
as prescribed and on a regular
schedule.
• Explain that effects occur in 1 to 2 days,
but can take 2 to 4 weeks to reach full
effect.

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Chlorpromazine:
Nursing Interventions/Client Education Continued
• Protect liquid preparations from sunlight.
• Avoid skin contact with liquid preparations.
• Administer in equal doses until effective
dose is determined
– Once determined, take at bedtime.
• Explain how to decrease anticholinergic
effects
– Sip liquids or suck on hard candy.
– Wear sunglasses to protect from
photophobia.
– Void just before dose to decrease
incidence of urinary retention.
– Increase fluids and fiber to prevent
constipation.

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Atypical Antipsychotic Agents
• Risperidone.
• Olanzapine.
• Quetiapine.
• Aripiprazole.
• Ziprasidone.
• Clozapine.

•Medication of choice for:

‒Initial therapy for psychoses.
‒Treating breakthrough episodes when
conventional antipsychotics are used.
•More effective and have fewer side effects
than conventional antipsychotics.

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Advantages of Atypical Antipsychotics

• Treat both positive and negative symptoms.

• Decrease depression, anxiety, and suicidal behaviors.
• Improvement of memory.
• Few/no EPSs.
• Fewer anticholinergic effects
– Clozapine is the exception and has high incidence of anticholinergic
effects.
• Lower incidence of relapse.

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Therapeutic Uses of Risperidone

• Relieves both positive and negative psychotic symptoms within 1 week

of starting therapy.
• Used to treat psychosis in other disorders, such as the mania in bipolar I
disorder.
• Treatment of autism in clients age 5 to 16 years.

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 Risperidone: Side/Adverse Effects

• Headache, sedation, anxiety.

• Weight gain in up to 18% of
clients.
• Prolonged QT interval.
• Agitation, dizziness, insomnia.
• Orthostatic hypotension possible
during first few weeks of
treatment.
• Mild EPSs.

Risperidone: Medication/Food Interactions

•Concurrent use with clozapine increases

effects of clozapine.

•Can increase effects of antihypertensive

medications, especially during first weeks of
treatment.

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Risperidone: Contraindications/Precautions

• Avoid concurrent use with alcohol.

• Use with caution in clients who have cardiovascular or cerebrovascular
disease, seizures, or diabetes mellitus
– Clients who have diabetes should have baseline fasting blood sugar
tested.
– Pregnancy Risk Category C medication.
• Do not use for dementia-related psychosis due to potential for
cerebrovascular accident.

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Risperidone: Nursing Interventions/Client Education

• Explain that medication doses will be lower at the start of treatment and
increase gradually.
• Explain that clozapine has a lower chance of causing EPSs and tardive
dyskinesia.
• Advise client to observe for the following and report them to the care
provider
– Signs of diabetes mellitus.
– Infection.
– Weight gain.

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Evaluating Effectiveness of Antipsychotic Medications

• Decrease in psychotic symptoms.

• Improved independence with completing Activities of Daily Living (ADL).
• Improved social interaction.
• Improved sleeping and eating habits.

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Learning Activity Review Questions

1. A nurse is caring for a client who has schizophrenia. The client is

scheduled to receive an antipsychotic medication, chlorpromazine. What
are three symptoms chlorpromazine can help relieve?

2. Name three other mental health disorders that can be treated by

chlorpromazine.

3. One adverse effect of chlorpromazine is EPSs. Explain an example of a

client with early EPS.

4. What are three anticholinergic effects of chlorpromazine?

5. When monitoring for the effectiveness of chlorpromazine, the nurse

should identify what examples of symptom resolution? Name three
examples.

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