TREATMENT

MODALITIES:
PHARMACOLOGY

Dr Angie Lam
DHS, MSc, PgD(MHN), Dip(CCN), BN(Hons), RN, RMN
What do you think of the
treatments for psychiatric
disorders?
Treatable? Untreatable?

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• In contemporary [psychiatric] treatment, psychological
psychological and
psychopharmacologic approach are highly compatible. When used in a
psychopharmacologic models
clinical outcomes
combination or matric model, the clinical outcomes are
are positive
positive and
and
powerful in enhancing quality of life for both the client and family and
improving functional status.
• ------ KRUPNICK, 1996

• The use of drugs to treat psychiatric disorders is often the foundation for a
successful treatment approach that can also include other types of
interventions such as psychotherapy or behavioural therapies.
• ------ SADOCK & SADOCK, 2008

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Learning Objectives
• Differentiate primary effects of psychotropic drugs.
• Understand the rationale for the administration of main psychotropic
drugs, and recognize the contraindications for and possible adverse
effects of them.
• Explain the nursing implications when administering drugs.

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PSYCHOPHARMACOLOGY
• is the scientific study of the effects drugs have on mood,
sensation, thinking, and behavior.

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SCIENCE OF
PSYCHOPHARMACOLOGY

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When neurotransmitters
cross the synapse, they
undergo 6 steps:
1. synthesis,
2. vesicular uptake,
3. transmitter release,
4. receptor binding,
5. cellular uptake,
6. transmitter
metabolism.

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Physiology of the Brain: Neuro-transmitters

Dopamine Serotonin Norepinephrine

GABA (gamma-
Acetylcholine Neuro-peptides
Aminobutyric)

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 Dopamine Serotonin Norepinephrine GABA Glutamate Acetylcholine
Function Movement Mood a “stress An inhibitory An excitatory Memory
Coordinatio (happiness) hormone” neuro- neuro- Movement
n, Emotions, Appetite (from the transmitter transmitter Sleep and
Motivation Sleep and adrenal gland) Calming arousal
arousal Memory
Attention effect,
Slowdown Learning
Mood
the body Motor
Cognition
activity Sensory
Sleep and
information
arousal
Decrease Parkinson’s Depression Depression Anxiety Alzheimer’s
d level disease, disorder disease
Depression Parkinson’s
disease
Increased Schizophren Anxiety states Schizophrenia Alzheimer’s Depression
level ia Mania disease,
Mania Anxiety states schizophrenia

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Dopamine
• Function: movement coordination, emotions, motivation

• Decreased level: Parkinson’s disease, depression

• Increased level: Mania and schizophrenia

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Norepinephrine
• As a hormone (released from the adrenal gland into the
blood); a “stress hormone”
• Function: arousal, Attention, mood , cognition, sleep

• Decreased level: depression

• Increased level: mania, anxiety states, schizophrenia

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Serotonin
• Function: Mood, appetite, sleep and arousal

• Decreased level: depression

• Increased level: anxiety states

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GABA (Gamma-aminobutyric acid)
• An inhibitory neuro-transmitter
• Function: calming effect, slowdown the body activity

• Decreased level: Anxiety disorder, schizophrenia

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Glutamate
• An excitatory neuro-transmitter
• Function: Memory, Learning , Motor, Sensory
information

• Increased level: Alzheimer’s disease (late stage, AD

leads to excessive release  further damaged brain
cell)

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Acetylcholine
• Function: memory consolidation, sleep and arousal

• Decreased level: Alzheimer’s disease (Early stage),

Parkinson’s disease
• Increased level: depression

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Types of psychotropic medication

Antipsychotic agents Antianxiety agents &

hypnotics
1 3
Antidepressants Mood stabilizer and
Anticonvulsant drugs
2 4
ANTIPSYCHOTIC
AGENTS

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Indication
• Primarily treat psychosis / psychotic symptoms
• Typical antipsychotics (first generation antipsy/old drug):
• Dopamine 2 receptor (D2) blocker
• block dopamine activity  ↓ dopamine  ↓ delusions and hallucinations
(positive symptoms).
• Atypical antipsychotics (second generation antipsy/new drug):
• block both serotonin and dopamine activities  treat both positive and
negative symptoms (i.e. Apathy. Absent emotional responses, reductions
in speech, reduced social drive, loss of motivation…)

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Classification of Antipsychotics
First-generation Antipsychotics/
Typical
• Haloperidol (Haldol)
• Chlorpromazine (Largactil)
Second-generation
Antipsychotics/ Atypical
• Clozapine (Clozaril)
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Aripiprazole (Abilify)
• Quetiapine (Seroquel)
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General Side Effects
Typical antipsychotic (old drug) Atypical antipsychotic (new drug)
Higher Neuromuscular side effects Higher metabolic side effects

• Neuromuscular effects: Extrapyramidal symptoms (EPS)

• Metabolic syndrome : Weight gain, hyperglycaemia, HT, DM, hyperlipdemia
• Anticholinergic effects: drowsiness, dry mouth, nasal congestion, blurred
vision, constipation, urinary retention.
• Photosensitivity
• Agranulocytosis
• Alteration in sexual functioning
• Laboratory alteration
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Extrapyramidal Symptoms (EPS) & Tardive Dyskinesia (TD)
- very common side effects caused by typical antipsychotic drugs

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 Precaution
First-generation Antipsychotics/ Second-generation Antipsychotics/
Typical Atypical
• Haloperidol (Haldol) • Clozapine (Clozaril)  agranulocytosis,
• Chlorpromazine (Largactil) leukopenia+++, weight gain+++
• Risperidone (Risperdal)  Prolactin elevation+++
/ EPS++
• Olanzapine (Zyprexa)  weight gain+++
EPS & TD+++ • Aripiprazole (Abilify)
• Quetiapine (Seroquel)  weight gain++

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Old drug (New drug)

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Depot Injection
• Long acting antipsychotic injection, slow released medication in a
consistent way over several weeks.
• IM route
• Usually oil-based, sometimes aqueous based
• the maintenance treatment in the treatment of Schizophrenia, Mania and
other psychoses
• Both typical and atypical antipsychotic are available.

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Depot injection example

Trade name Proper name Dose/amount How often

1 injection every 2 to 4
Haldol Decanoas Haloperidol decanoate 50-300mg
weeks

Zuclopenthixol 1 injection every1 to 4

Clopixol 200-400mg
Decanoate weeks

1 injection every 2
Risperdal Consta Risperidone 25-50mg
weeks

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ANTIDEPRESSANTS

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Indication
• Depression
• Dysthymic disorder

• Anxiety and Obsessive Compulsive related disorders (first-

line treatment):
• Obsessive Compulsive Disorder
• Generalized anxiety disorder.
• posttraumatic stress disorder
• Social anxiety disorder
• Panic disorder
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Antidepressant Drugs Mechanism of action Cautions Example
Selective Serotonin Blockage 5-HT Receptors,  First line therapy Citalopram (Celexa))
Reuptake Inhibitors inhibit the reuptake of serotonin Escitalopram (Lexapro)
(SSRIs) Fluoxetine (Prozac)
Serotonin and Inhibit the reuptake of both Second-line therapy Venlafaxine (Effexor)
norepinephrine norepinephrine and serotonin Desvenlafaxine (Pristiq)
reuptake inhibitors
(SNRIs)
Atypical Inhibit the reuptake of Second-line therapy Trazodone (Oleptro)
antidepressants Serotonin/Norepinephrine/Do Vortioxetine (Brintellix)
pamine, or Mirtazapine (Remeron)
Antagonist of monoamine
neurotransmitters
Tricyclic Blockage Serotonin and Can have dangerous Amitriptyline (Elavil)
Antidepressants Norepinephrine Receptors cardiac side effects.
(TCAs) Safety and adverse
effects
Monoamine Blocking the effects of Less effective, more Phenelzine (Nardil)
Oxidase Inhibitors monoamine oxidase enzymes, toxic, long duration
(MAOIs) which breaks down of action. Less
monoamine neurotransmitters frequently used. 28
Action of SSRI/SNRI and TCA
• SSRI: Increase concentration of serotonin
• SNRI: Increase concentration of serotonin and norepinephrin
• TCA: Increase concentration of norepinephrine, serotonin, dopamine (non-selective)

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Side effects of antidepressants
Hypotension
Dizziness Dry mouth
Insomnia Sweating
Headache

Cognitive &
Memory Tachycardia
dysfunction ECG change

Fatigue GI upset:
Weight gain Constipation
Nausea
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Diarrhea
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Client Education
• Takes several week to affect mood
• Side effect occurs after two to three days
• Initial course a continuation phase of at least 6 to 9 months.
• If symptom free, tapered off the medication and monitored for
potential relapse.
• If relapse : maintenance phase medication of 1 or more years’
duration to prevent recurring depression.
• Clients require Long-term maintenance : recurrent severe depression,
concurrent anxiety disorders, suicide attempts, and first-relatives with
an anxiety disorder.
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Serotonin syndrome (serotonin overdose)
• Too much serotonin to be released or remain
• a potentially life-threatening drug reaction, Deadly
• Most often occurs when two SSRI drugs takes together
• present within 6 to 8 hours of initiating or increasing serotonergic
medications

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Serotonin Syndrome

(dilation of the pupil)

(sweating)

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Treatment
• Discontinue all serotonergic drugs immediately
• BP/P, SaO2, temp, RR, GCS
• Protect airway, O2 supply
• Blood X CBC, electrolyze, RFT/LFT, clotting
• ECG / cardiac monitoring
• NPO (confused) , foley (renal function monitoring)
• IVF (hydration and NPO)
• Antipyretic / cold pads if fever (eliminate excessive muscle activity
• Anticonvulsants for seizures
• • Serotonin antagonist drugs may help
• • Clonazepam / Lorazepam for restlessness/agitation
• Do not reintroduce serotonin drugs. 35
TCA overdose

TCAs can have dangerous cardiac side effects

• Monitor electrocardiograms (ECGs) in adults older than 40 years, all children and
young adolescents
• Contraindication on cardiac conduction problem
TCAs also are lethal in overdose
• careful ongoing suicide assessment.
TCAs have: clinically relevant blood levels
• monitoring therapeutic doses more precise if necessary. 36
ANTIANXIETY
AGENTS &
HYPNOTICS

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Indication Sedative

muscle
hypnotic
relaxant
Antianxiety
and
sedative

Anti-
anxiolytic
convulsant

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Indication – short term usage
• Anxiety disorders – panic, GAD, Panic disorder, Social phobia
• Insomnia
• Alcohol withdrawal
• Skeletal muscle relaxation
• Substance-induced and psychotic agitation

• Long-term use of benzodiazepine is not recommended because of

dependency. !!!

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Benzodiazepine Nonbenzodiazepines
Antianxiety drugs Antianxiety drugs:
• Alprazolam (Xanax), • pregabalin (Lyrica)
• Chlordiazepoxide (Librium),
DDA
• Diazepam (Valium),
• Lorazepam (Ativan),

Sedative-hypnotic drugs Sedative-hypnotic agents:

• temazepam (Restoril), • Zolpidem (Stilnox),
• triazolam (Halcion), • Zopiclone (Imovane)
• quazepam (Doral)

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Sedation Tolerance
Dependence
Irritability
Hostility / Violence

Cognitive impairment

Nausea
Mood stabilizer
and
Anticonvulsant
drugs
Mood stabilizers

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Indication
• Bipolar affective disorder
• Major depressive disorder
• Schizoaffective disorder

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Mood stabilizer
Lithium
• First-line treatment : acute mania,
aggressive behaviour, and dyscontrol
syndrome.
• Takes weeks to months to be effective
• Therapeutic range (0.6-1.4 Eq/L for
adults).
Anticonvulsant drugs
Valproate (Epilim)
Carbamazepine (Tegretol)
Lamotrifine (Lamictal)
• Also call "anticonvulsant
mood stabilizers"

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Nursing
Implications

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 Assessment

Maintenance Administration
program

Nursing Role

Pharmaco- Monitor effect

education and side effect

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Assessment
• s/s
• Drug compliance
• s/e
• Drug knowledge
• Any myths / difficulties 4:40 – 8:57
• Take drug practice and rituals
• Family support

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Psychoeducation
• Teach the name of med, purpose , desire effect, time frame
for effect, side effect + management of s/e, dose, frequent,
correct mthys
• do not cause addiction
• decrease symptoms of disease, facilitate normal function
• effect occur after 4-6 wks, need to be patience
• Side effect occurs few days, such as….
• can be easily managed by other interventions, such as ….
• Please integrate the drug knowledge in the drug education !!!!
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Psychoeducation
• The importance of drug compliance:
• Maintenance medication from months to years
• fully recovered from MI by strictly following the treatment
• Poor compliance or stop medication may leads to relapse
• Relapse: more difficult to cure, poor prognosis, increase
treatment regimen

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Strategies to improve drug compliance
• Simplest regimen
• Use simple written information to support teaching
• match drug administration with daily schedule, e.g. take drug
after the breakfast
• Establish methods of following medication regimen : Drug
box, checklist
• Encourage self-monitoring e.g. by diary: date and time, the
medication record and symptoms experienced.
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Family education
• Importance, indication, effect, s/e, overdose s/s
• Give support to patient
• Involve patient’s family to monitor drug compliance. eg drug
counting, month checking, hoarding

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References:
• Townsend, M. C., & Morgan, K. I. (2017). Psychiatric mental health nursing:
concepts of care in evidence-based practice. (9th ed.). F.A. Davis.
• UpToDate@https://www-uptodate-com.eproxy.lib.hku.hk/contents/search
• Stuart, G.W. (2013). Principles & practice of psychiatric nursing (10th ed.). St.
Louis: Elsvier Mosby.
• Lippincott Williams & Wilkins (2012). Basic concepts of Psychiatric-mental
health nursing (8th ed.). Wolters Kluwer

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