PSYCHOTROPIC DRUGS

By: Rheajane Aguilar-Rosales

 PRINCIPLES THAT GUIDE THE USE OF MEDICATIONS
TO TREAT PSYCHIATRIC DISORDERS

• A medication is selected based on its effect on the client’s target symptoms such as
delusional thinking, pain attacks, or hallucinations. The medication’s effectiveness is
evaluated largely by its ability to diminish or eliminate the target symptoms.
• Many psychotropic drugs must be given in adequate dosages for some time before their full
effect is realized. For example, tricyclic antidepressants can require 4 to 6 weeks before the
client experiences optimal therapeutic benefit.
• The dosage of medication often is adjusted to the lowest effective dosage for the client.
Sometimes a client may need higher dosages to stabilize his or her target symptoms, whereas
lower dosages can be used to sustain those effects over time.
• As a rule, older adults require lower dosages of medications than do younger clients to
experience therapeutic effects. It also may take longer for a drug to achieve its full
therapeutic effect in older adults.
• Psychotropic medications often are decreased gradually (tapering) rather than abruptly. This
is because of potential problems with rebound (temporary return of symptoms), recurrence
of the original symptoms or withdrawal (new symptoms resulting from discontinuation of
the drug).
• Follow up care is essential to ensure compliance with the medication regimen, to make
needed adjustments in dosage, and to manage side effects.
• Compliance with the medication regimen is as simp0le as possible in terms of both the
number of medications prescribed and the number of daily doses.
1. MEDICATIONS FOR
MOOD DISORDERS

Antidepressants
Tricyclic antidepressants
Atypical antidepressants
Monoamine oxidase inhibitors
SSRI’s (Selective serotonin reuptake inhibitors)

Mood stabilizers
Lithium carbonate
Anticonvulsants
ANTIDEPRESSANTS
 Antidepressants

• Both unipolar and bipolar disorders respond to antidepressants medications, OCD, and other
anxiety disorders. Also used regularly to treat major depressive disorders and symptoms of
depression not associated with major depressive disorders. These symptoms are as follows:
*dysphoric mood
* change in appetite and energy level
*anhedonia (lack of interest in routine activities
* difficulty concentrating
* feelings of hopelessness
* suicidality
• It affect the actions of Norepinephrine, dopamine, serotonin in the brain
• decrease depressive symptoms, improve sleep, improve mood, and increase ability to
experience pleasure.
• should be used with caution in clients with history of cardiac or seizure disorders. Client
should not take MAOI with herbal remedies, particularly ginseng
 TRICYCLIC ANTIDEPRESSANTS
• It inhibit neural uptake of both serotonin • TCAs are used to relieve depression and, in
and norepinephrine. They are some cases panic disorder and OCD. They
anticholinergic at CNS and peripheral are thought to inhibit the reuptake of
receptors and act as sedatives. norepinephrine and serotonin in the
• currently, TCAs are used most often for synapse. They also block acytylcholine,
cases of severe melancholia. The typical which controls the cholinergic system.
symptom pattern in clinical depression
(early morning wakening, feeling worse in
the morning, anxiety, and weight loss) is
predictive of a good response to TCAs.
• . Blockage of acetylcholine leads to predominant side effects of TCAs:
 
1. Sedation and the anticholinergic effects of dry mouth, blurred vision, urinary retention,
delayed micturition, dizziness, and fainting.
2. Confusion, disturbed concentration, and constipation.
3. Nausea, headache, and vertigo can result if the medication is withdrawn abruptly.
4. Nurses should watch for orthostatic hypotension in clients beginning to take TCAs.
As a rule, the more sedating the TCA, the
more anticholinergic properties it will have
 TCA
• Doxepin (Siniquan)
• Amitriptyline (Elavil)
• Desipramine (Nopramin)
• Imipramine (Tofranil)
• Trimipramine(Surmontil)
• DADIT(SENTS)
• The tetracyclic antidepressant mirtazapine (Remeron) has been developed to reduce side
effects from TCAs include starting the client with low doses and raising doses slowly or
changing to another antidepressant with less problematic side effects.
• Because clients taking TCAs frequently do not experience clinical side effects for 2 to 6
weeks, they require support and encouragement to get through this time of adjustment.
• Administration is oral. Taken together, a 10 day supply of these medications may cause
cardiac and cerebral toxicity.
• Good rule of thumb “Is for practitioners to limit the amount of medication prescribed at any
one time”. Moreover, clients beginning these medications should be carefully monitored
because research indicates that risk for suicide increases when clients begin to “feel better”
or energized.
• When TCAs are given in conjunction with oral anticoagulants, the client may be at risk for
bleeding.
• Administration with clonidine may cause severe hypertension
 
 ATYPICAL ANTIDEPRESSANTS
- effect both nonadrenergic and serotonergic neurotransmission.
- They include drugs such as
- Bupropion(Wellbutrion)
- mirtazapine(Remerol)
- trazodone (Desyrel)
- nefazodone (Serzone),
- BUMITRANE(WE’RE DESE)
• Administration and clinical management of clients taking these medications is the same as for clients taking
TCAs.
• Side effects are similar:
• headache,
• nervousness,
• nausea &vomiting,
• and postural hypotension
 MONOAMINE OXIDASE
INHIBITORS(MAOI)
Interfere with metabolism, increasing vesicular stores of Norepinephrine and serotonin.
• Characteristics:
• Not used as first line because of side effects
• Used if unresponsive to other antidepressant regimens or allergic
• Hypertensive Crisis:
• A life threatening side effect and may occur if the client ingest food containing TYRAMINE (an
amino acid).
• Always take BP.
• Mao breaks down tyramine; however, because MAOIs inhibit MAO, tyramine can build up in
the body when a person uses these drugs and eats tyramine containing foods at the same time.
• Tyramine releases also norepinephrine from nerve endings. These metabolic actions can
precipitate a hypertensive crisis.
• Tyramine rich foods:
• dairy products like cheese, chocolates, fermented foods, red wine, yeast extracts, yogurt, over
ripe fruit especially avocado, bananas
• Use in moderation: soy sauce, chocolates, caffeine drinks
• Drugs in this class, including;
• phenelzine sulfate (Nardil) (therapeutic dose 45-60 mg given initially in three doses of 15
mg/day daily with a maximum dose of 60-90 mg/day),
• tranylcropmine (parnate) and Isocarboxazid (Marplan)- inhibit monoamine oxidase (MAO), an
enzyme that breaks down amines (epinephrine, norepinephrine, and serotonin). Amines thus are
able to accumulate in neuronal storage sites, resulting in the clinical efficacy of MAOIs as
antidepressants.

• PheTrIso(NaPaMa)
 SSRI’S (SELECTIVE SEROTONIN REUPTAKE
INHIBITORS)

• Represents the newest class of antidepressants.

• Called the “designer drugs”- lesser side effects, pose no risk for lethal overdose and are
effective in 70% of the cases.
• The antidepressant response is 3-4 weeks like TCAs but may take as long as 2 to 3 months
• Providers should titrate medications; for example begin with a dose of 10mg of fluoxetine
and gradually increase the dose as tolerated up to 80 mg each day.
• Used in treating;
• Eating disorder
• OCD
• Tourette’s syndrome
• Most common side effects;
• Headache
• Nausea and vomiting
• Nervousness
• Sleep disturbance
• Sexual dysfunction
• Drugs:
• Citalopram (Celexa)
• Fluoxetine(Prozac)
• Paroxetine (Paxil)
• Sertraline(Zoloft)
• ALERT: Client should not take SSRIs with lithium and tryptophan( it potentiate the
effects of SSRIs)
• Cigarette smoking- decreases the effectiveness of SSRIs
• Risk of severe reaction is increased if the client takes SSRI medication with St. John’s wort
(hypericum perforatum)- An herbal plant most commonly used for "the blues" or depression
and symptoms that sometimes go along with mood such as nervousness, tiredness, poor
appetite, and trouble sleeping. There is some strong scientific evidence that it is effective for
mild to moderate depression.
• SEROTONIN SYNDROME
• A potentially fatal condition that develops when blood levels of serotonin are elevated
• Signs and symptoms:
• Tachycardia
• Hypertension
• Fever
• Sweating
• Shivering
• Confusion
• Anxiety
• Restlessness
• Disorientation,
• Tremors, muscular spasms, rigidity
• Risk Factors:
• Concomitant use of antidepressant from different classes (ie, TCAs and SSRIs)
• Inadequate time between discontinuing one antidepressant drug and initiating another
• Combined use of serotonergic agonist with SSRIs
• Use of SSRIs with St. John’s wort
• Management
• Temporary withdrawal of the SSRI is necessary.Prescription of an antianxiety drug, such as
diazepam (valium) or propranolol (inderol).
MOOD STABILIZERS
 MOOD STABILIZERS

• These are used primarily to treat bipolar disorders and impulse-control disorders. For several
decades, the predominant treatment of mania has been lithium carbonate (Eskalith). Other
major categories of mood stabilizers include anticonvulsants and medications of refractory
mania.
• Lithium produces its effects intracellularly rather than within neural synapses
• It acts directly in G proteins and certain enzymes
• Reduces the release of norepinephrine through competition with calcium
 LITHIUM CARBONATE
• Drug of choice for bipolar disorders and mania
• First line treatment for mania
• It alters transport of sodium in nerve and muscle cells and inhibits the release of
norepinephrine and dopamine. It does not however inhibit the release of serotonin.
• Takes 7-10 days to work
• 2-3 weeks of gradually increasing doses for a therapeutic level of lithium to develop
• Polydipsia, polyuria, a metallic taste in the mouth are common side effects
• In acute mania, lithium is generally prescribed as 600 to 900 mg 3 x day.
• The serum lithium level should be about 1.0 mEq/L
• In early weeks of lithium administration, blood should be drawn twice each week before the
client takes the morning dose of the drug.
• Maintenance therapy requires that the nurse assess the blood levels of lithium a least every 2
months.
• Lithium has similar structure to sodium
• ALERT FOR LITHIUM TOXICITY- can occur when the body’s sodium levels are lowered and absorption is
disrupted.
• Predisposing factors include:
• Excessive heat
• Diaphoresis
• Concurrent use of diuretics
• And decreased sodium intake
• Below 1.5 mEq/L symptoms include;
• Lethargy
• Slurred speech
• Muscle weakness
• Hand tremor- use propranolol to minimize fine tremor
• Nausea and vomiting-take drug with food to minimize these sx
• Diarrhea
• Mild to moderate toxicity (1.5 to 2.0 mEq/L) symptoms:
• Coarse hand tremor
• Mental confusion
• Drowsiness
• Lack of coordination
• GI upset
• Electrocardiographic changes
• 2.0-2.5 mEq/L symptoms:
• Ataxia
• Blurred vision
• Stupor
• Coma
• Respiratory failure
• Above 2.5 mEq/L- considered life threatening
• Needs dialysis
• Valporic acid (Depakote)
• Another 1st line treatment for bipolar disorder
• It is effective and is often used in combination with lithium
• Can cause hepatic failure, resulting in fatality
• Liver function test should be performed before the therapy and as frequent intervals thereafter, especially
for the 1st 6 months
• Can produce teratogenic effects such as neural tube defects (e.g. spina bifida). Can cause life threatening
pancreatitis in both children and adults
• Lamotrigine (lacmictal)
• May cause insomnia
• Can cause serious raches requiring hospitalization, including Stevens- Johnson syndrome, and rarely, life
threatening toxic epidermal necrolysis.
• The risk of serious rashes is greater in children younger than 16 years.
 Anticonvulsants

• Carbamazepine (Tegretol)-
• is used as mood stabilizers.
• 3rd most common drug used in mania following lithium and valporic acid
• Effective in moderating aggressive or hostile symptoms
• Peak concentrations in plasma occurring 4-8 hrs after ingestion
• Can cause aplastic anemia and agranulocytosis
• Pretreatment hematologic baseline data should be obtained and monitored periodically throughout
therapy to discover lowered WBC or platelet counts.
• Other Side effects;
• Uncoordinated and less mentally “sharp”
• Makes client feel bloated or uncomfortable
• Gabapentin (Neurontin)-
• May cause insomnia
• 900-1800 mg/day PO in 3 divided doses
• Maximum time between doses should not exceed 12 hr.
 Medications for Refractory Mania

• Refractory mania is defined as a bipolar disorder with mania that is completely or marginally
unresponsive to drug therapy with conventional mood stabilizing agents.
• Many drugs that have been used to successfully treat refractory mania originally were not
designed for this purpose.
• Clozapine (Clozaril)- used to treat resistant schizophrenia and has been used successfully to treat
refractory mania
• Olanzapine (Zyprexa)
• Risperidone (Risperdal)- for stabilization of bipolar disorder because these medications are proving to
be effective antimanic and antidepressant agents.
• Primidone (Myosoline)- used to treat epilepsy
• Pramipexole (Mirapex)- a direct dopamine agonist used to treat Parkinson’s disease
• Gabapentin (Neurontin)- an antiepileptic agent . Has decreased effectiveness if given with antacids.
• Lamotrigine (Lamictal)- an anticonvulsant but can cause rash in 15% of clients specially in co-
administration of valproic acid.

CORPPGL(CZRMMNL)
 2. ANXIOLYTICS
BUSPIRONE BENZODIAZIPINES
 ANXIOLYTICS
Anxiolytics or antianxiety medications are used to
treat generalized anxiety disorder and may provide
relief for acute anxiety states, social phobia,
performance anxiety, and simple phobias, post-
traumatic stress, OCD
• They also are used for short-term relief of insomnia
• Anxiolytic medications include busipirone (BuSpar)
and the benzodiazipines.
 BUSPIRONE (BUSPAR)
• A nonbenzodiazipine is a novel anxiolytic that binds serotonin receptor which
decreases serotonin turnover. It has a HYPNOTIC EFFECT thus causing sleepiness
but not anti anxiety effect.
• Its mechanism of action is unknown. However, it lacks anticonvulsant, sedative, or muscle
relaxant properties.
• Buspirone generally is administered orally in tablet form. Adults usually begin with 15 mg daily in
three divided doses. Increase of 5 mg/day are made every 2 to 3 days, with the maximum dose not to
exceed 60 mg daily.
 • Contraindicated in clients with marked renal or liver failure and
lactating women.
• Adverse effects include dizziness, headache, nervousness, insomnia.
Light headedness, nausea, dry-mouth, and GI distress.

• must be use cautiously in clients who use alcohol or other CNS

depressant; fluoxetine decreases the drug’s effects. If taken with
erythromycin, itraconazole, or nefazodone, serum levels of buspirone
may increase and must be monitored.
 BENZODIAZIPINES
• are used to treat alcohol withdrawal ad control symptoms such
as anxiety and agitation. They also may prevent seizures and
progression to delirium tremens. They are also useful in
treating clients with mania or acute psychoses when safe and
rapid sedation with relatively few side effects is desired.
• Benzodiazipines have the pharmacologic effects of
anxiolysis, sedation n(hypnotic drugs), centrally
medicated muscle relaxation, and elevation of the
seizure threshold.
• Benzodiazipines act directly on GABA receptor (major
inhibitory neurotransmitter in the brain) and are thought to
increase the amount of GABA available to dampen neural
overstimulation.
• These medications generally are considered safe and
effective, and their adverse side effects are extension to their
central actions.
• Concurrent use with narcotics or alcohol can potentiate the
effects of of benzodiazipines
• In addition to these effects, and the side effects also found with
buspirone, benzodiazipines can stimulate a mild paradoxical
excitatory reaction (opposite to the effect which would
normally be expected e.g pain experienced after taking pain
reliever) at the beginning of treatment.
• Benzodiazipines have the potential to lose their efficacy. Clients may
begin increasing their doses to achieve the previous response and
discover that the medications are causing dependence. (Dependence
means that when the client stops taking the medications, he or she
experiences pathologic symptoms and signs).
• Physical withdrawal syndromes- Key indicator of
“addiction”. Moreover, stigma was attached to the idea of
being “physically dependent” or addicted to these drugs.

• Withdrawal syndrome is possible on discontinuation of

the medication and is most common with high doses of
medication used for more than 4 months.
• Symptoms include:
• Anxiety
• Irritability
• Tremulousness (trembling or tremors)
• Sweating
• Lethargy
• Diarrhea
• Insomnia
• Depression
• Abdominal and muscle cramps
• Vomiting
• Convulsions if most severe
• Withdrawal symptoms however have been known
to occur as late as 7-10 days after discontinuation.
Symptoms usually disappear slowly over 1 to 3
weeks. So client should be advised not to abruptly
discontinue taking these medications.
 Drug List
• Diazepam (Valium)-
• Lorazepam (Ativan)
• Alprazolam (Xanax)
• Chlordiazepoxide (Librium)
• Flurazelam (Dalmane)
• Diazepam (Valium)- is the commonly prescribed benzodiazipines. Also
used in alcohol withdrawal and to control seizures.
• In anxiety disorders- the usual oral dose is 15- 30 mg/day.
• In alcohol withdrawal- 10 mg 3xday
• Alcohol use, and concurrent administration of cimetidine, disulfiram,
and oral contraceptives increase the effects of diazepam
• Theophyllines and ranitidine- decreases the effects
• Contraindicated :
• narrow angle glaucoma,
• coma,
• shock,
• pregnancy and lactation.
• Barbiturates – can decrease the activity of excitatory neurotransmitter like acetylcholine and
glutamate

• Phenobarbital, phentobarbital, secobarbital

• Even small barbiturate overdose can cause coma or death due to respiratory depression
 DOPAMINE-4 Major Pathways

• Mesolimbic(thought)- Increased of hyperactive in schizo

• Mediates positive sx (hallucination, delusion)
• Mesocortical (emotion)-hypoactive in schizo
• Mediates (-) symptoms (social withdrawal)
• Nigostriatal( movements)- involve in motor function an movement (fine motor)
• Hig dopa- can lead to hyperkinetic movement (dyskinesia)
• Low dopa- dystonia and parkinsonian sx
• Tuberoinfundibular(endocrine function)-controls prolactin release
• Blocking may result to milk production
• Gynecomastia
• Low sexual desire/sexual dysfunction
 5 DOPAMINE RECEPTORS
• D1
• D2
• D3
• D4
• D5
 Low Potency Typical Antipsychotics:

• PHENOTHIAZINES (e.g chlorpromazine)

• 
• it is a phenothiazine used for psychotic disorders. The usual dose is 200 to 800 mg/day for the management
of psychosis. To treat intractable Hiccups (hiccups for more than 1 month)
 High potency antipsychotics

• Haloperidol(Haldol)- highest potency

• High EPS incidence
• Controls aggressive patients FAST (IM)
• initial dose is usually 2 mg/ 3xday or 5 mg 3xday with optimum dose being 20-30 mg/day
• Thioridazine(Mellaril) –can cause cataract or retinitis pigmentosa because of its deposits to retina
• Fluphenazine (prolixin)
• Trifluoperazine (stelazine)
• Thiothixene (Navane)
EXTRAPYRAMIDAL SIDE EFFECTS
 ATYPICAL ANTIPSYCHOTICS

• Atypical antipsychotic drugs differ from traditional antipsychotic agents in their ability to act as dopamine
receptor and serotonin receptor blockers.
• Used for pts. Resistant to traditional agents
• This simultaneous blocking may account for the increased efficacy of these drugs in improving the negative
symptoms of schizo with fewer EPS.
• CLOZAPINE-the only option for treating TD was discontinuing antipsychotic
medication. Clozapine produces little or no TD and may significantly decrease or
eliminate existing TD while the client takes the medication. The symptoms of TD
tend to return once clozapine is discontinued. Weekly monitor the WBC to assess for
agranulocytosis (bone marrow does not produce WBC)
RISPERIDONE- 1st line agent used for schizophrenia
• it blocks dopamine and serotonin receptors in the brain and has
anticholinergic, antihistaminic, and alpha adrenergic blocking
activity
• no cholinergic effect
• Diminished EPS
• OLANZIPINE- nurse must monitor for the side effect of orthostatic hypotension
• QUETIAPINE- it is also an antagonist at histamine and adrenergic receptor sites.
• Other effect of Neuroleptics:
• Chemoreceptor trigger zone (responsible for vomiting)- using neuroleptics can have anti-emetic effect
EXCEPT Thioridazine

• Histamine receptor- Antipyretic effect (Promethazine)

• Muscurinic recepors- Anticholinergic (diarhhea, urination, etc.)

• Alpha adrenergic receptor (if stimulated causes vasoconstriction and ejaculation)- causes orthostatic
hypotension and sexual dysfunction
 WHAT IS STIMULANT
MEDICATION?
• The key neurotransmitters deficient in ADHD brains are norepinephrine and dopamine. The
primary medications used to treat ADHD stimulate specific cells within the brain to produce
more of these deficient neurotransmitters — thus the descriptive label “stimulants.”
• STIMULANTS- are a class of drugs commonly used to treat ADHD.
• Dextroamphetamine sulphate (Dexedrine, dextrostat)
• METHYLPHENIDATE (Ritalin)- is a CNS stimulant with actions similar to those of
amphetamines.
• It is used to treat ADHD and narcolepsy.
• It is contraindicated in clients with glaucoma and motor tics, and in those with depressed states.
• If insomnia occurs, the last dose should be given before 6 pm.
• Tablets should be swallowed whole and not chewed
•  

•