Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

Types of psychotherapeutic drugs

1. Anxiolytic drugs (benzodiazepines)

2. Mood-stabilizing drugs

3. Antidepressant drugs

4. Antipsychotic drugs
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

Benzodiazepines

Mechanism of Action

 Reduce anxiety by reducing over activity in the CNS

 Depresses activity in the brainstem
 ^ action of GABA (inhibitory neurotransmitter)
 ANTIDOTE  benzodiazepine receptor blocker = flumazenil
Indications

 Anxiety
 Alcohol withdrawal
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

 Seizure control (status epilepticus)

 Adjunct therapy for
o Depression
o Insomnia and muscle spasms
o Anesthesia

Contraindications

 Allergy
 Narrow angle glaucoma
 Pregnancy

Interactions

 Alcohol & CNS depressants = ++ CNS depression

Adverse Effects

 Overexpression of their therapeutic effects

 CNS  amnesia, sedation, fatigue, confusion, dizziness, headache, visual changes
 CV  hypotension

Drug Mechanism of Indications Contraindications Interactions Adverse Effects

Action
Alprazolam  Produces Anxiety  Allergy  CNS  Restlessness
anxiolytic effect  Glaucoma depressants  Irritability
due to CNS  Grapefruit  Insomnia
depressant products ~ ^  Hand tremors
action level of effects  ANTIDOTE:
flumazenil

Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

Lorazepam  Produces Anxiety  Allergy  Alcohol  Restlessness

anxiolytic, Insomnia ~ anxiety  Glaucoma  CNS  Irritability
anticonvulsant, or stress  Sleep apnea depressants  Insomnia
sedative, muscle Status epilepticus  Severe resp.  Hand tremor
relaxant, depression  ANTIDOTE:
antiemetic flumazenil
effects
Flumazenil  Benzodiazepine
receptor blocker
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

Tricyclic Antidepressants (TCAs)

(1st gen. antidepressant)
Mechanism of Action

 Block reuptake of neurotransmitters (serotonin and NE), which makes them available for nerve transmission

Indications

 Depression
 Neuropathic pain
 Insomnia

Contraindications

 Allergy
 Pregnancy
 Use of MAOIs within the last 14 days  serotonin syndrome

Adverse Effects

 Anticholinergic effects ~ affecting muscarinic receptors in the PSNS

 CNS  sedation
 CV  constipation
 GU  urinary retention
 Other  sexual dysfunction

Drug Mechanism of Indications Contraindications Interactions Adverse Effects

Action
Amitriptyline  Antidepressant Depression  Allergy  CNS  Confusion
(Amish tripo effect  MI depressants  Seizures
tiling)  Use within 14  Anticonvulsants  Drowsiness
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

days of MAOIs  MOAIs  Fever

 Dyspnea
    
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

MonoAmine Oxidase Inhibitors (MAOIs)

(1st gen. antidepressant)
Mechanism of Action

 MAOIs inhibit the MAO enzyme in the CNS which stops the breakdown of dopamine, NE and serotonin = higher dope, NE
and serotonin concentrations

Indications

 Parkinson’s disease
 Depression

Interactions

 Adrenergic drugs
 Tyramine containing foods + beverages
 Selective serotonin reuptake inhibitors (SSRIs)  serotonin syndrome

Adverse Effects

 Orthostatic hypotension

Second Generation Antidepressants

SSRIs and SNRIs

Mechanism of Action

 Selective serotonin reuptake inhibitors (SSRIs)

 Selectively inhibit serotonin reuptake  ^ serotonin concentrations at nerve endings
 Serotonin norepinephrine reuptake inhibitors
 serotonin and norepinephrine reuptake  ^ concentration of neurotransmitters at nerve endings
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

Indications

 Depression
 Bipolar disorder
 Obesity
 Eating disorders
 OCD
 PTSD

Contraindications

 Allergy
 Use of MAOIs in the last 14 days  serotonin syndrome

Interactions

 Protein bound drugs

 MAOIs = serotonin syndrome

Adverse Effects

 insomnia
 weight gain
 sexual dysfunction
 serotonin syndrome

Drug Mechanism of Action Indications Contraindications Interactions Adverse Effects

Citalopram  relieves symptoms of depression  allergy  MAOIs  Dizziness
depression  use of MAOIs  Drowsiness
 blocks reuptake of within 14 days  Tachycardia
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

serotonin  Confusion
 Seizures
Fluoxetine  Relieves depression Depression  Allergy  MAOIs  ^ risk of suicide
 Reduces OCD OCD  Use of MAOIs  NSAIDs ~ ^  Agitation
behavior Binge-eating + within 5 wks or bleeding  Coma
 Inhibits serotonin vomiting 14 days  Antiplatelet  Diarrhea
reuptake  Anticoagulant  Hallucinations
 Alcohol
 CNS
depressants
Venlafaxine  Relieves depression Depression  Allergy  NSAIDs,  Serotonin
(vanilla fax  Inhibits reuptake of Anxiety  MAOIs within 14 aspirin, warfarin syndrome
machine) serotonin days ~ ^ bleeding
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

Fluoxetine

Serotonin syndrome (SS) is a group of symptoms that may occur following use of certain serotonergicmedications or
drugs. The degree of symptoms can range from mild to severe. Symptoms include high body temperature, agitation,
increased reflexes, tremor, sweating, dilated pupils, and diarrhea.
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

Venlafaxine
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

Assessment
Both the physical and emotional status of patients taking psychotherapeutic drugs should be thoroughly
assessed before, during, and after initiation of therapy. The poten- tial for drug interactions, drug toxicity, drug
overdose, and other adverse effects associated with these drugs is great, thus the need for an ongoing
assessment. Constant assessment for any suicidal ideations or tendencies is important because patients may
have covert, as well as overt, related cues or thoughts. The potential for sui- cide with psychotherapeutic drugs
with or without the combination or other drugs or alcohol should always be considered a risk. Many of the
patients needing these medications are so mentally distressed that their physical needs may be neglected,
resulting in a complexity of other problems such as insomnia, poor health status, and weight loss or gain.
Baseline blood pressure (BP), pulse rate, body temperature, and weight should be assessed and documented
before, during, and after drug therapy. Postural (supine, then standing) BP readings are par- ticularly important
because of the postural hypotension associated with psychotherapeutics. The more potent, first-generation
drugs, such as the MAOIs and TCAs, may lead to a significant drop in BP and warrant even more astute
assessment.

The patient’s neurological functioning should be assessed, including level of consciousness, mental alert- ness,
and level of motor and cognitive functioning. The Mini-Mental Status Examination (MMSE) is one tool that may
be used to assess the cognitive impairment found with mental health disorders. It is simple, cost efficient, and
can be completed in about 20 minutes by the nurse or clinician. The procedure for conducting an MMSE is
usually found in nursing assessment textbooks as well as psychiatric–mental health nursing textbooks. It
includes an assessment with scoring of points in four major areas: level of orientation, attention and calculation
ability, recall test- ing, and language skills. Other assessment tools include the six-item Blessed Orientation-
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

Memory-Concentration Test; Clock Drawing Tasks; Functional Activities Ques- tionnaire (for those with
dementia), Alzheimer’s Disease Assessment Scale; Mattis Dementia Rating Scale; Severe Impairment Battery;
and Hamilton Rating Scale (HAM-D) previously discussed in this chapter. To complete assess- ment of the
neurological system, baseline levels of motor responses and reflexes, presence of any tremors, agita- tion, as well
as cold, clammy hands, sweating, and pallor (indicative of autonomic responses) should be assessed for and
documented. It is also important to assess laboratory studies performed, which are usually ordered before, dur-
ing, and after psychotropic drug therapy. It is particularly important in those who are in long-term therapy to
prevent or identify early any possible complications and toxicity. Laboratory tests may include, but are not
limited to, serum

therapeutic levels and ranges of the specific drug, and, if appropriate, a complete blood cell count (CBC),
erythro- cyte sedimentation rate (ESR), serum electrolytes, glucose levels, blood urea nitrogen (BUN), liver
function studies, serum vitamin B12, and thyroid studies. If the patient is experiencing forms of dementia, other
types of testing may be needed, such as genetic studies, computed tomography (CT) scan, or magnetic
resonance imaging (MRI).

With psychotherapeutic drugs, the nurse should always assess the patient’s mouth to make sure the patient has
swallowed the entire oral dosage. This helps prevent “hoarding” or “cheeking” of medications, a form of
nonadherence that may lead to drug toxicity or over- dose. If the assessment shows that this is a potential risk,
use of liquid dosage forms, when available, may mini- mize such problems. Appetite, sleeping patterns, addict-
ive behaviours, elimination difficulties, hypersensitivity, and other complaints also need to be watched for and
documented. Assessment of motor responses, such as trembling and agitation, and of autonomic responses
(cold, clammy hands, sweating and pallor) is also import- ant to establishing baseline information.

Antianxiety Drugs
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

Antianxiety drugs are associated with many contraindi- cations, cautions, and drug interactions; specific
concerns related to children and older adults are presented in Special Populations: Children and Special
Populations: the Older Adult on p. 315. The older adult needs to be closely assessed and observed for
oversedation and profound CNS depression for the duration of therapy. Older adults are often more sensitive to
drugs, so there is constant concern for their safety. It is also critical for nurses to document these assessment
findings and make safety a top priority in all phases of the nursing process. Specific serum studies that may be
ordered include com- plete blood count (CBC), lactate dehydrogenase (LDH), creatinine, alkaline phosphatase,
and BUN. In addition, blood pressure (BP) readings are important because of drug-related postural hypotension
as an adverse effect. Pulse rate and temperature should also be assessed.

Ocular symptoms may occur with benzodiazepines; therefore, baseline visual testing should be determined with
a basic Snellen chart examination or by the appro- priate health care provider, for example, an ophthalmolo-
gist, optometrist, or nurse practitioner. Allergic reactions to some of these medications, such as clonazepam, are
characterized by a red, raised rash. A significant reduc- tion in bone marrow functioning may occur with
possible blood dyscrasias, fever, sore throat, bruising, and jaun- dice. These “at-risk” patients for complications
would require closer assessment. In addition, patients who are obese may become toxic within a shorter period
of time than those who are not obese. This toxicity occurs because several antianxiety drugs are lipid soluble and
most obese patients have a higher percentage of lipids; the lipid-soluble drug would have greater affinity for
these tissues and stay in the body longer than anticipated, with a resultant prolonged half-life (and increased
toxicity).

Some benzodiazepines, as well as most drug groups, are associated with medication errors that are “sound
alike/look alike” in nature. Assessing the drug order for the right drug is important in order to prevent this
potential error and the negative consequences to the patient. Sound-alike benzodiazepine drugs that could be
confused with other medications include the following:
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

• clonazepam and clonidine

• diazepam and ditropan

• lorazepam and alprazolam

• Antidepressants
• There are many cautions, contraindications, and drug interactions to assess prior to giving
antidepressants. The potential for suicide with psychotherapeutic drugs, with or without the combination
of other drugs or alcohol, should always be considered a risk, whether with an antidepressant or other
drug group. Many of the patients needing these medications are so mentally distressed that their physical
needs go unmet, resulting in a complexity of other problems, including insomnia, poor health status, and
weight loss or gain. Baseline BP, pulse rate, body tem- perature, and body weight should be assessed and
docu- mented before, during, and after drug therapy. Postural (supine, then standing) BP readings are
important because of postural hypotension. The more potent, older drugs, such as MAOIs and TCAs, may
lead to a significant drop in BP and warrant even more astute assessment.
• Serotonin syndrome may occur with the use of SSRIs, especially when combining two or more such drugs.
Any of the following drugs may also result in hazardous adverse effects, such as MAOIs, tryptophan, and
natural health products such as ephedra, ginseng (see Natural Health Products: Ginseng), and St. John’s
wort. See Box 16-3 for common symptoms of serotonin syndrome.
• Because the newer antidepressants are associated with fewer and less potent adverse effects, only a few
MAOIs are used today in psychiatric mental health settings. Patients receiving MAOIs who have a history
of suicide
• attempts or suicidal ideations or have seizure disorders, hyperactivity, diabetes, or psychosis need to be
closely monitored. Suicidal thoughts and attempts are important to consider because “hoarding” these
drugs may then be used by the patient to carry out suicide. These patients should be under the care of a
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

health care professional (such as a psychiatrist, physician, or nurse practitioner) so that they may be
closely monitored for destructive behaviours. MAOIs are known for their potentiation of hypertensive
crisis when used with SSRIs, meperidine, or TCAs; thus it is imperative to monitor for the risk of
complications to the patient that are associated with this hypertensive event. Assess for dietary intake of
tyramine if the patient is taking an MAOI (see the foods high in tyramine in Table 16-9).
• Other parameters to assess with the MAO inhibitors include BP readings and postural BP. These are
important for the nurse to obtain because of postural hypotension, an MAOI adverse effect, and
subsequent risk of dizzi- ness and fainting. If the patient is hospitalized, the nurse should assess supine
and standing or sitting BP levels at least with each shift or more frequently, if needed. The nurse needs to
wait 1 to 2 minutes after taking supine BP before taking standing or sitting BP and pulse rate. Laboratory
values such as those indicative of liver func- tioning (alanine aminotransferase [ALT], aspartate amino-
transferase [AST], bilirubin) as well as CBCs are needed to rule out any further contraindications or
cautions.
• Contraindications to the use of TCAs are numer- ous and have been previously discussed in this chap- ter.
In addition, the older adult should be given these drugs only if absolutely necessary and only with careful
monitoring. The older adult’s BP, pulse, CBCs, weight, and liver and kidney studies should also be
assessed.
• The extrapyramidal adverse effects are often worse in the older adult (e.g., worsening of tremors, inability
to carry out ADLs). This syndrome may lead to progres- sive deterioration of motor activities, so baseline
motor abilities are important to assess and document. The drug interaction between TCAs and MAOIs can
produce ser- ious effects: a hyperpyretic crisis may occur if TCAs are used with MAOIs and clonidine or
with patients exhib- iting high fever, convulsions, or a hypertensive crisis.
• With second-generation antidepressants, cautious use in the older adult and the heart patient is
important. Bupro- pion may be preferred over other antidepressants because it has fewer anticholinergic,
antiadrenergic, and cardio- toxic effects. However, the therapeutic effect of bupropion may not be reached
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

for up to 4 weeks (as with many anti- depressants); therefore, it is critical for the nurse to assess the patient
for suicidal tendencies and support systems to ensure patient safety. Many of the antidepressants take
weeks to have full therapeutic effect, thus close monitoring and observation of the patient are important
until the drug begins to work. Because of the risk for seizures associated with second-generation
antidepressants, an assessment should help to identify those patients with a history of seizures so that
another medication may be used.
• Third-generation antidepressants have several advan- tages over the older classes of antidepressants but
still have contraindications, cautions, and drug interactions. The older adult with decreased kidney
functioning should not take these drugs if at all possible. Concurrent use of third-generation
antidepressants with any of the serotonergic (SSRIs) drugs carries the risk for serotonin syndrome and
should be avoided.
• Antipsychotics
• The antipsychotics require careful assessment of all body systems. Different antipsychotics are associated
with dif- ferent adverse effects. For example, olanzapine may cause an increase in total cholesterol, and
the phenothiazines are associated with extrapyramidal symptoms and a high incidence of anticholinergic
effects. Therefore, assessment of cardiovascular, cerebrovascular, neurological, gastro- intestinal,
genitourinary, kidney, liver, and hematological functioning is important to safe and efficacious drug
therapy. If there are significant diseases of one or sev- eral organ systems, the response to a drug may be
more adverse and even dose limiting, thus the need for close and astute assessment of the patient prior to
and during drug therapy. Weight gain may occur, and if the patient is experiencing adverse health
conditions because of gaining weight, another drug may need to be ordered. Changes in sex drive,
oversedation, suicidal ideations, orthostatic changes in BP, and insomnia related to some of these drugs
need to be assessed thoroughly and reported as appropriate for the option of another drug. The common
“anticholinergic” adverse effects of the phenothiazines (e.g., dry mouth, urinary hesitancy, constipation)
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

and the extrapyramidal symptoms may be bothersome for some patients and lead to the use of other
drugs (as ordered by the physician) for long-term treatment. It is essential
• that the nurse use careful and astute assessment skills to enable the most effective and high-quality
therapeutic regimen for each patient in need of psychotherapeutic drug therapy and for each drug
therapeutic regimen.
• Haloperidol is similar to other high-potency anti- psychotics because its sedating effects are low but the
incidence of extrapyramidal symptoms is high. Assess- ment of baseline motor, sensory, and neurological
func- tioning is, therefore, important to patient safety. With some of the antipsychotic drugs, patients may
experience adverse effects of tremors and muscle twitching from the drug’s blockade of dopamine
receptors (dopamine gener- ally has an inhibitory effect on specific motor movements in the
musculoskeletal system). These extrapyramidal movements are manifested as parkinsonism-like and are
irritating and uncomfortable for the person experiencing them. Therefore, it is important to know if there
are underlying motor movement disturbances so that the best drug for the situation may be ordered.
• Movement assessments are recommended for patients who are started on antipsychotic medications
symptoms to assess for any movement disorders. A general recom- mendation is to do an assessment
before a patient is started on a new medication and then every 6 months for patients who receive a first-
generation antipsychotic and every 12 months for those receiving a second-generation antipsychotic. More
frequent monitoring is advocated for individuals at high risk, such as older adult patients. In doing this
assessment, patients can be better managed with changes or a reduction in dosage of medications and
reducing the need for antiparkinsonian medications that can increase adverse effects. It is important with
patients who have significant CNS disorders or symp- toms or are taking medications that impact the
CNS that antipsychotic drugs, such as haloperidol, be used with extreme caution and close monitoring.
• Atypical antipsychotics (AAPs), such as quetiapine or clozapine, have many contraindications, cautions,
and drug interactions with newer drugs in this group showing great promise, as previously discussed. A
thor- ough mental status examination should be performed and documented appropriately before
Week 11 – Medications Summary – Psychotherapeutic Drugs, Antianxiety and Antidepressants

initiation of these and other antipsychotic drugs. An assessment of mus- culoskeletal functioning and
monitoring for any extra- pyramidal symptoms reactions is also important, as is assessment of the
following laboratory studies: bili- rubin and other liver function studies, CBC, and urin- alysis. BP
readings, with postural BP readings, should be assessed and documented; a drop of 20 mmHg or more
should be reported to the physician immediately. In addition, the health care provider may order reduced
doses to avoid toxicity in the older adult. These drugs are also associated with a high degree of sedation
and should be used cautiously in the older adult and other patients who are at risk for personal injury or
harm or have limited motor and sensory capabilities. With risperidone use in the older adult, it is
important to assess for any unusual adverse effects, such as excessive sedation and sleepiness, that may
lead to significant