Nathalie C.

Fat, RN, MAN

“Above all, do no harm.”
Hippocrates
Ideally, psychotropic drugs should be prescribed
based on accurate diagnosis, until acceptable
mental or emotional state can be maintained.
Then, patient will be withdrawn from the
medication and continue with his/ her own life,
but this does not always occur. Some individuals
recover and do not need medications, while
others become dependent and find it difficult to
quit, and still others need it for the rest of their
lives (Keltner, N. et al 2021).
 Psychotropic Drugs
• Antiparkinsonian
• Antipsychotic
• Antidepressants
• Antimanic
• Antianxiety
• Antidementia
 Neurotransmitters, which are
neurochemical substances in the brain, because
both neurotransmitter deficiency and excess are
related to mental disorders, psychotropic drugs
are effective, as they either increase or
decrease the brain’s ability to use specific
neurotransmitter.
 Antiparkinsonian Drugs
• Parkinson’s Disease (PD) is a progressive,
chronic, degenerative disease of unknown
cause that involves the area of the brain called
extrapyramidal system (EPS).

• A well-regulated EPS is needed for

coordination of involuntary movement, which
in turns supports voluntary movement.
PD is characterized by 4 cardinal symptoms:
• Tremors
• Bradykinesia
• Rigidity
• Postural instability
• A balance of neurotransmitters: dopamine
and Acetylcholine (ACh) is required for normal
functioning EPS.

• In PD there is a declining production of

dopamine. A deficiency in dopamine and a
subsequent decrease in dopamine
transmission to the basal ganglia will result in
an imbalance with Ach. An imbalance will also
cause Extrapyramidal Side Effects (EPSEs).
 EPSEs
• Akathisia – subjective feeling of restlessness
that elicits restless legs, jittery feelings and
nervous energy

• Dystonias – abnormal postures caused by

involuntary muscle spasm like muscle freezing

• Drug-induced parkinsonism
Dystonias
Tardive dyskinesia (TD) – late appearing symptoms
which include tongue writhing, tongue protrusion,
teeth grinding, lip smacking

TD stops with sleep;

It is irreversible but can be suppressed for a short

period but will reappear;

No pharmacologic treatment, prevention is the

most important approach.
Neuroleptic malignant Syndrome (NMS) – lethal side
effect of antipsychotic agents

Symptoms: Hyperthermia (38.3 – 39.4 °C to 42.2 °C)

Rigidity
Autonomic dysfunction (dizziness, fainting,
orthostatic hypotension, altered heart
rate, etc.)
Treatment: muscle relaxants (Dantrolene
(Dantrium); bromocriptine ( Parlodel)
Pisa syndrome – a condition marked by the
patient leaning to one side
Population at higher risk for EPSEs:
• Women
• Patients with first episode of schizophrenia
• Older adults
• Patients with affective symptoms
 PD is treated with antiparkisonian
agents that increase dopamine
(dopaminergic) levels with anticholinergic
agents. EPSEs are treated with
anticholinergics because psychosis is
thought to be related to an increase in
dopamine levels.
 Anticholinergic drugs are
used to treat EPSEs and work by
restoring the imbalance caused by
antipsychotic drugs.
Antipsychotic drugs block or antagonize
dopamine receptors. This dopamine-receptor
antagonism causes an artificial or iatrogenic
parkinsonian-like syndrome- EPSEs. However,
restoring the balance with a dopaminergic is
inappropriate with patients with schizophrenia
because it is hypothesized that schizophrenia is
cause by presence of excessive amounts of
dopamine. Hence, anticholinergic drugs are
used to restore the balance of dopamine and
ACh.
Helpful hints:
• Schizophrenia is linked to excessive dopamine.
• Antipsychotic drugs block dopamine.
• Blocked dopamine receptors can cause EPSEs.
• Antiparkinsonian drugs can fix the problem that
antipsychotics created.
• However, if dopaminergic antiparkinsonian drugs
are given, schizophrenia might worsen.
• Therefore, anticholinergic drugs are given to
restore Ach-dopamine balance.
 Side Effects
Dry mouth

• Offer sugarless hard candy and chewing

gum.
• Encourages frequent rinses
• Take medication before meals
Nasal congestion
• Recommend nasal decongestant, approved
by physician.
Urinary hesitation
• Introduce running water
• Privacy
• Warm water over perineum
Blurred vision, photophobia
• Provide reassurance (normal vision
typically returns in a few weeks)

• Encourage sunglasses

• Advice caution when driving

• Pilocarpine eye drops

Constipation
• Give laxatives, as ordered
• High-fiber diet
• 2.5 – 3L of water per day
Mydriasis
• Watch or monitor
Decreased sweating
• Monitor temperature
• Sponge bath for fever
Fever
• Limit strenuous activities
• Wear appropriate clothing
 Dopaminergics Anticholinergics

Levodopa (Dopar, Benztropine (Cogentin)

Larodopa) Biperiden (Akineton)
Amantadine Trihexyphenidyl (Artane)
(Symmetrel) Ethopropazine (Parsidol)
Bromocriptine (Parlodel) Procyclidine (Kemadrin)
Pergolide (Permax) Dipenhydramine
Selegiline (Eldepryl) (Benadryl)
DOPAMINERGICS
 Indications
• Depression – caused by decreased
norepinephrine

• Parkinson’s Disease
 Contraindication
• Schizophrenia – caused by too much
dopamine
 Side Effects
• Confusion – Amantadine

• Hallucinations – Bromocriptine

• Delusions – Levodopa

• Paranoid ideation – Pergolide

• Depression – Selegiline

• Agitation, anxiety, euphoria - Sinemet

• Decreased availability of Acetylcholine

• For Parkinson’s disease and Drug-induced

extrapyramidal side effects

• Contraindications: Alcohol and antacids

• Side effects: (previous or next slide)

 Other Treatment for EPSEs
Drugs:
Dopamine agonist: Amantadine
Antihistamine: Dipenhydramine
Beta blocker: Propanolol
Benzodiazepine: Diazepam, Lorazepam,
Clonazepam
• Vitamins:
– Vitamin E and B6
– Diminished symptoms of TD
Antipsychotic drugs are used to treat
schizophrenia, schizoaffective disorder, bipolar
disorder, psychotic depressions and other
psychoses.

Also called major tranquilizers or neuroleptics

• A tranquilizing effect occurs within an hour or
so after ingestion.

• So, it has an effect of emotional quieting and

sedation.

• With emotional quieting, it enables to patient

to participate in other therapeutic
interventions such as NPR and milieu.
• Antipsychotic effects are often observed
within a few weeks, with improvement
continuing for up to 6 to 8 weeks or longer.
2 Categories:
Traditional or typical antipsychotics or
first-generation drugs
Further classified according to its potency

Atypical antipsychotics or second-

generation drugs
Newer agents are referred to as atypical because
of the following characteristics:

1. Reduced or no risk for EPSEs

2. Increased effectiveness in treating negative
symptoms like alogia, bunted affect, passive,
social withdrawal, poor grooming and
hygiene, poor rapport, poverty of speech,
etc.
3. Minimal risk of TD

4. Reduced or no risk of elevated prolactin

With elevated prolactin:
Women Men
Amenorrhea Impotence
Loss of libido Loss of libido
Galactorrhea Gynecomastia
Long-term risk for Lowered sperm count
osteoporosis Feminization (development of
Changes in menstrual cycle female characteristics)
Traditional Antipsychotics
High-Potency
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Thiothixene (Navane)
Trifluperazine (Stelazine)
Moderate Potency
Perphenazine (Trilafon, Ertafon)
Molindone (Moban)
Loxapine (Loxitane)
Low Potency
Chlorpromazine (Thorazine)
Thioridazine (Mellaril)
Chlorprothixine (Taractan)
Atypical Antipsychotics
Clozapine (Clozaril)
Olanzapine ( Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Zeldox, Geodon) – effective
for both positive and negative
schizophrenia
Perperidone (Pisperdal)
Sertindole (Serlect)
Aripiprazole (Abilify) – new, 3rd generation
drug with unique action as a dopamine
system stabilizer (increasing dopamine in
deficient areas and decreases in areas
that are overactive
Asenapine (Saphris)
Palepiridone (Invega)
Risperidone(Risperdal) –most frequently
prescribed
Knowing this differences prepares the nurse for
the most likely set of side effects…

Generally, drugs with increased anticholinergic

effects produce fewer EPSEs.
• Low-potency drugs tend to cause more
intense anticholinergic effects such as dry
mouth, blurred vision, constipation,
tachycardia, etc.

• High-potency drugs causes more EPSEs.

The neurochemical theory of schizophrenia
states that increased levels of dopamine in the
limbic area of the brain cause schizophrenia and
its psychotic symptoms such as hallucinations
and delusions.

Because antipsychotic drugs are dopamine

blockers, it follows that their effectiveness can
be attributed to this dopamine-blocking activity.
• Atypical types are dopamine agonists and
serotonin blockers.

• Antipsychotic drugs are most effective in

treating what we call the positive symptoms
of schizophrenia such as hallucinations,
delusions, suspiciousness, abnormal thoughts,
etc.
• Negative symptoms such as alogia, anergia
(abnormal lack of energy), avolition (lack of
motivation to do tasks), blunted affect (have
difficulty expressing emotions),
communication difficulties, passive social
withdrawal, etc. are less responsive to
antipsychotic drugs.
• The use of antipsychotic medications involves
a difficult trade-off between the benefit of
alleviating psychotic symptoms and the risk
of a wide variety of troubling adverse effects.
Antipsychotic drugs are not curative and do
not eliminate chronic thought disorders, but
they often decrease the intensity of
hallucinations and delusions and permit the
person with schizophrenia to function in a
supportive environment.
 Adverse Effects
1. NMS- fatal

2. EPS
Drug-induced parkinsonism ( tremors,
rigidity, and bradykinesia)
Akathisia – chief cause of noncompliance
Dystonias
TD
Contraindications
 Side Effects PNS
• Constipation
• Dry mouth
• Nasal congestion
• Blurred vision – thioridazine
• Mydriasis
• Photophobia
• Hypotension
• Tachycardia – with clozapine, hold the dose
with pulse rate >140 bpm
• Urinary retention/ hesitation
• Sedation
• Weight gain
• Agranulocytosis – associated with clozapine,
hold treatment if WBC is < 3500 cells/ mm³
 Side Effects CNS
• Seizures –caused by clozapine

• Excessive anxiety or depressive moods –

trifluoperazine
 Drug Interactions
• If with SSRIs – increased EPS
• Amphetamines – decreased antipsychotic
effect
• Anticholinergic – increased anticholinergic
effects
• Barbiturates – causes respiratory depression
• Benzodiazepines – increased sedation
• Insulin weakened control of diabetes
• Lithium – decreased antipsychotic effect,
neurotoxicity
• Narcotics – further hypotension and sedation
• Tricyclics – possible ventricular arrhythmias
Important Nursing Considerations
1. Monitor for compliance
2. Check for cheeking or hoarding
3. Daily therapy for 3 to 6 weeks or more is
needed before drug’s effectiveness
4. Give antiparkinsonian drugs or antihistamine
for dystonias
5. Routinely take temperature for NMS
6. Avoid immersion in hot water – may cause
further hypotension
7. Avoid abrupt withdrawal of medication
8. Monitor for blood dyscrasias; and report signs
of sore throat, malaise, fever, or bleeding
9. Use sunscreen; dress appropriately in hot
weather and drink plenty of water.
Antidepressants work by influencing these
neurotransmitters, which include:

• Dopamine, which plays a central role in decision-

making, motivation, arousal, and the signaling of
pleasure and reward
• Norepinephrine, which influences alertness and
motor function and helps regulate blood pressure
and heart rate in response to stress
• Serotonin, the neurotransmitter whose role it is
to regulate mood, appetite, sleep, memory, social
behavior, and sexual desire
In people with depression, the availability of
these neurotransmitters in the brain is
characteristically low.

Antidepressants work by increasing the

availability of one or several of these
neurotransmitters in different, distinctive ways.
 Goals of antidepressant medications
• Alleviate depressive symptoms

• Restore normal mood

• Prevent recurrence of depression

• Prevent a swing into mania for bipolar

patients
• Antidepressants are not always indicated when
individuals report being depressed; however,
when antidepressants are indicated, most
patients respond to treatment.

• These drugs do not cure depression, but long-

term use has been successful in reducing
symptoms.

• Most relapses are associated with patient-

initiated tapering off or discontinuance.
 Treatment Strategies
First-line: SSRIs
New antidepressants (such as
Bupropion, Duloxetine, Mirtazapine,
Venlafaxine)

Second-line: TCAs

Third-line: MAOIs, ECT

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Citalopram
• Escitalopram
• Fluvoxamine – also approved for OCD
• Paroxetine –also approved for panic attacks
• Fluoxetine – associated with suicidal/ homicidal
behaviors
- also approved for bulimia, premenstrual
dysphoric disorder (Sarafem)
• Sertraline- cause sexual dysfunction
• Combination of Olanzapine/ Fluoxetine
Selective Serotonin Reuptake Inhibitors (SSRIs)

• Block the reuptake of serotonin

• First-line of treatment of depression

• Fewer side effects compared to TCAs and MAOIs

• Cause sexual dysfunction and GI symptoms

• Associated with antidepressant apathy syndrome (lack

of motivation, indifference, disinhibition, and poor
attention)
• Does not bind to histaminic, cholinergic,
dopaminergic or adrenergic receptors, thus
reducing many side effects

• Contraindication: Pregnancy
 Drug Interactions
MAOIs – fatal due to serotonin syndrome

Antipsychotics – Increased EPSEs

TCAs- Toxicity
• Lithium – increase lithium levels and
serotonergic effect

Too much serotonin can cause mild symptoms

such as shivering, heavy sweating, confusion,
restlessness, headaches, high blood pressure,
twitching muscles, and diarrhea. More severe
symptoms include high fever, unconsciousness,
seizures, or irregular heartbeat.
 Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs)

• Bupropion – should not be given in

combination with drugs that increase
dopamine level

• The only antidepressant that primarily inhibits

dopamine reuptake (absorption) and the only
one that does not affect serotonin systems.

• Also inhibits norepinephrine reuptake

 Selective Serotonin- Norepinephrine
Reuptake Inhibitors (SNRIs)

• Cymbalta (duloxetine)
• Effexor (venlafaxine)
• Fetzima (levomilnacipran)
• Pristiq (desvenlafaxine)
• Savella (milnacipran)
Inhibit the reuptake of both norepinephrine
and serotonin

Inhibition activity is dose dependent

At lower doses, they inhibit serotonin reuptake;

at moderate to high doses, norepinephrine
reuptake is inhibited; at higher doses, dopamine
reuptake is added.
Noradrenergic – Specific Serotonergic Agent (NaSSA)

• Mirtazapine – approved for major depression

• Increases availability of both serotonin and

norepinephrine
 Tricyclic Antidepressants (TCAs)
• Also called Nonselective Inhibition of
Norepinephrine and Serotonin

• More potent norepinephrine reuptake

inhibitors and some are more potent
serotonin reuptake inhibitors
• Because of its non-selectivity, TCAs cause more
side effects

– Anafranil (clomipramine)
– Asendin (amoxapine)
– Elavil (amitriptyline)
– Norpramin (desipramine)
– Pamelor, Aventyl (nortriptyline)
– Sinequan (doxepin)
– Surmontil (trimipramine)
– Tofranil (imipramine)
– Vivactil (protriptyline)
Other Therapeutic Effects of TCAs
• Sedation – therapeutic because patients
commonly experienced insomnia and agitation

• Improved appetite

• Anxiety reduction

• Used for childhood enuresis

Contraindications:
Benign prostatic hypertrophy – further problem
in bladder function

Pregnancy

Myocardial infarction
Interactions:
Sympathomimetic agents – interferes with
therapeutic actions

Warfarin – increased bleeding

Barbiturates, carbamazepine, phenytoin –

decreased TCA effect

Antipsychotics – Increased EPSEs

Procainamide – prolong cardiac conduction

Anticholinergics – increased cholinergic effect

Levodopa – increased agitation, tremor and

rigidity

Alcohol, anticonvulsants, benzodiazepines –

increased sedation
Adverse effects:
Arrhythmias – Desipramine
CVA
Cardiotoxicity – Amitriptyline
Suicide – Antidepressants can energize patients
who have been too depressed to act on their
suicidal thoughts
Priapism – Trazodone
 Important Nursing Consideration
1. When changing to MAOIs, discontinue first
TCAs for 14 days before new drug is given.

2. Three times the maximum dose is lethal

3. Monitor ECG – lengthening QRS complex >

0.12s is a danger sign
 Monoamine Oxidase Inhibitors (MAOIs)

• Inhibit neurotransmitter breakdown

• MAOIs are less commonly used due to

potentially severe reactions with foods high in
tyramine.

•  If taken inappropriately, MAOIs can cause

tyramine levels to rise, triggering critical
increases in blood pressure.
• Usually administered to hospitalized patients
or closely supervised

• Because of the serious adverse reactions to

these drugs, especially life-threatening HPN,
the older irreversible MAOIs are almost always
prescribed after other antidepressants failed.
• Emsam (selegiline)
• Marplan (isocarboxazid)
• Nardil (phenelzine)
• Parnate (tranylcypromine)
• Moclobemide (Manerix)
Contraindications:
Meperidine
Pregnancy
History of stroke or CVA
Undergoing elective surgery
Elderly - tranylcypromine
Pheochromycytoma
Drug Interactions:
Those that cause hypertension

Those that cause severe anticholinergic

responses

Those that cause profound CNS depression

Side effects:
CNS hyperstimulation
Reassure patient.
Assess developing psychosis, hypomania, or
seizures.
Notify physician.

Hypotension
Monitor BP
Keep patient safe and free from injury
Have patient lie down (might help return BP
to normal)
Anticholinergic effect (dry mouth, blurred
vision, constipation, etc.)

Hepatic and hematologic dysfunction

Monitor blood counts and liver function
test result
Important Nursing Considerations
• Takes 10 to 14 days for the antidepressant
effect of MAOI to occur
• Moclobemide should not be combined with
irreversible MAOIs (Nardil, Parnate) or
narcotics.
• Should not be given in combination with TCAs
and SSRIs
• Avoid tyramine-rich foods
• External cooling for high fever
• Driving should be avoided
• Headache, palpitations, and stiff neck should
be reported
• Take after meals especially Moclobemide
• Lithium

• Carbamazepine

• Vaproic acid (Valproate)

Other antimanic drug used to treat bipolar
disorder:
Lamotrigine – used as adjunctive agent,
effective if patient has anxiety
- cause skin rashes like Stevens-
Johnson syndrome
Oxcarbazepine – does not cause serious adverse
reaction associated in carbamazepine
Gabapentin
Topiramate – cause weight loss and cognitive
dulling
Antimanic drug, any drug that stabilizes mood
by controlling symptoms of mania, the
abnormal psychological state of excitement.
• Lithium and several anticonvulsants

• Antipsychotics are also used to treat bipolar

disorder.

• No single drug or combination of drugs is

always effective.
• Antipsychotics:
All antipsychotics except clozapine have been
approved for treatment of mania.

Olanzapine
Risperidone
Quetiapine
Ziprasidone
Clozapine
Aripiprazole
• A person is progressively and inappropriately euphoric and
simultaneously hyperactive in speech and locomotor
behaviour.

• Often accompanied by significant insomnia, excessive

talking, extreme confidence, and increased appetite.

• As the episode builds, the person experiences racing

thoughts, extreme agitation, and incoherence, frequently
replaced with delusions, hallucinations, and paranoia, and
ultimately may become hostile and violent and may finally
collapse.

• In some persons, periods of depression and mania

alternate, giving rise to bipolar disorder.
 Goal of treatment
• Control symptoms of mania
• Maintenance treatment
Prevent relapse
Reduce suicides
Improve functioning
Reduce subthreshold symptoms
(nonspecific depressive symptoms)
 Lithium
• Gold standard

• For treatment and prophylaxis of manic phase

of manic-depressive illness

• Absorbed from GI tract, given orally

• Takes 7 – 10 days to take effect

↑ 1.5 mEq/L – toxic
Side effects:
Common:
nausea
dry mouth
diarrhea
thirst/ polydipsia –most common
drowsiness
mild hand tremor
polyuria – most common
weight gain
bloated feeling
sleeplessness
lightheadedness
Hypotheses of effectiveness of lithium:
• Substitutes sodium and regulates calcium
• Inhibits the release and facilitates the
reuptake of norepinephrine, serotonin and
dopamine
• Stabilizes the second messenger system,
thus regulating intracellular signaling
• Lithium can affect thyroid gland function
(hypothyroidism)

• Contraindications:
CVD
Renal disease
Pregnancy
Interactions:
Diuretics, except acetazolamide (Diamox) – decrease lithium
excretion

Indomethacin and other NSAIDs – reduce renal elimination

Low salt diet – elevates serum lithium levels

Acetazolamide, caffeine, alcohol – increase lithium excretion

Antipsychotics – antiemetic properties mask the early signs of

lithium toxicity – nausea and vomiting
Important Nursing Considerations
No antidote for lithium poisoning

-Gastric lavage as ordered

-Administer normal saline as ordered

- Forced diuresis or hemodialysis might be

needed
• Prepare patient for expected side effects
without instilling anxiety.

• Notify physician immediately when side

effects are noted such as vomiting, severe
tremor, sedation, muscle weakness, vertigo.
• Take lithium with meals, on regular basis, same
time daily.

• Drink 10 -12 glasses per day

• Elevate feet to relieve edema

• Maintain consistent dietary sodium intake,

increase sodium with major perspiration.
Normal Carbamazepine levels: 4 – 12 µ/ ml

For determination of lithium levels blood should

be drawn in the morning at 8 – 12 hours after
the last dose was taken.
Nonbenzodiazepine: Buspirone (Buspar)
 Actions
• Inhibit function of GABA
• Serotonin agonist
• Readily absorbed after oral administration
• Lipid-soluble and cross the blood brain barrier
• Active metabolites can exert an effect up to 1
days
• No therapeutic value for psychoses
 Drug Interactions
• Alcohol and other CNS depressants

• Antacids – impaired absorption

• Disulfiram (Antabuse) and Cimetidine

(Tagamet) – increased plasma level of
benzodiazepines
• TCAs – increased sedation, confusion,
impaired muscle function

• MAOIs – CNS depression

• Succinylcholine – decreased neuromuscular

blockage
Important Nursing Considerations
• If toxicity happens, gastric lavage with activated
charcoal as indicated

• Monitor blood pressure

• Driving should be avoided

• Benzodiazepines should be tapered while

initiating Buspirone
 Nursing Care related to Side Effects
Drowsiness, confusion, lethargy Instruct client not to drive or operate
machinery while taking medication.
Orthostatic hypotension Monitor V/S.
Instruct client to change position slowly.
Nausea and vomiting Advise that this medication may be taken
with meals.
Dry mouth Frequent sips of water , sugarless gum
and candy.
Potentiates the effects of CNS depressants Avoid alcohol and check with healthcare
provider before taking other medications.
Blood dyscrasias Symptoms of sore throat, fever, malaise,
easy bruising, or unusual bleeding should
be reported.
Paradoxical excitement Report to physician immediately.
Tolerance Not to discontinue drug abruptly .
Liver dysfunction Monitor liver functions test. Watch for
nausea, upper abdominal pain, jaundice,
fever, rash.
• Donepezil (Aricept), which is approved to.
treat all stages of Alzheimer's disease.

• Galantamine (Razadyne), approved for mild-

to-moderate stages.

• Rivastigmine (Exelon), approved for mild-to-

moderate Alzheimer's as well.
• Memantine (Namenda) and a combination of
Memantine and donepezil (Namzaric®) are
approved by the FDA for treatment of
moderate to severe Alzheimer’s.
Acts as inhibitor of acetylcholinesterase
Side Effects:
Nausea and Vomiting
Diarrhea
Ataxia
Los of appetite

Adverse effects: Hepatotoxicity

Vagotonic effect – slows heart rate
References Psychopharmacology

https://www.parkinson.org/Understanding-Parkinsons/Treatment/Prescription-
Medications/COMT-Inhibitors

https://www.healthline.com/health/what-is-a-psychotropic-drug#drug-table

https://www.webmd.com/parkinsons-disease/default.htm

https://healthjade.net/tardive-dyskinesia/

https://www.verywellmind.com/what-are-the-major-classes-of-antidepressants-1065086

https://www.britannica.com/science/antimanic-drug

https://www.verywellmind.com/symptoms-of-mania-380311

https://www.alz.org/alzheimers-dementia/treatments/medications-for-memory

Psychiatric Nursing Made Incredibly Easy! 2010 Wolters Kluwer Health, Inc.

Keltner, N. et al (2021) Psychiatric Nursing, 8th edition Mosby Elsevier Inc.

Flores, C. (2009) Mastering Psychiatric Nursing, 1st edition. Educational Publishing House