Drugs Acting On the

Nervous System
Psychotherapeutic Drugs
Anxiety Disorders

A group of mental disorders characterized by a

vague uneasy feeling of discomfort or dread. The
symptoms of anxiety prevent the individual from
normal functioning . can be an exaggerated
response to an actual event or anxiety unrelated
to an identifiable event or condition.
Anxiety disorders

 Panic disorder
 Generalized anxiety disorder
 Obsessive-compulsive disorder
 Post-traumatic stress disorder
 Simple phobia
 Social phobia
Antianxiety Medications(Anxiolytics)
 Tricyclic antidepressants
 Benzodiazepines
 MAOIs
 Buspirone
 SSRIs
BUSPIRONE (BuSpar)
 Mechanism of action unknown
 Interacts with serotonin and dopamine in
the brain
 No muscle relaxant effects
 No anticonvulsant effects
 Does not cause sedation
BUSPIRONE (BuSpar)
 Uses / indications
 Short term management of anxiety
disorders
 Not appropriate for immediate relief may
take
 several weeks to see effects
BUSPIRONE (BuSpar)

Side effects
 Dizziness, nausea, headache, anxiety, fatigue,
 Insomnia

Contraindications
 Renal/hepatic failure
 Use of MAOIs
ANTIDEPRESSANTS AND
MOOD STABILIZERS
DRUGS
ETIOLOGY OF DEPRESSION

 Monoamine neurotransmitter dysfunction

 Deficiency of norepinephrine and/or
serotonin.
 Balance, integration and interactions
among
 norepinephrine, serotonin, and other
 neurotransmission systems is an
important
 etiological factors.
ETIOLOGY OF DEPRESSION

 Neuroendocrine factors
 AN INCREASE IN CRF (corticotropin releasing
 factor/hormone) HAS BEEN NOTED IN
PATIENTS WITH DEPRESSION.
CLASSIFICATIONS OF ANTIDEPRESSANT
MEDICATIONS

 Tricyclic antidepressants
 Monoamine oxidase inhibitors
 Selective serotonin reuptake inhibitors
 Unclassified drugs
TRICYCLIC ANTIDEPRESSANTS

 imipramine (Tofranil) prototype

 nortriptyline (Pamelor)
 amitryptyline (Elavil)
 desipramine (Norpramin)
TRICYCLIC ANTIDEPRESSANTS(TCAs)
 First generation of antidepressant therapy
 Mechanism of action
 Corrects the imbalance in the neurotransmitter
concentrations of serotonin and norepinephrine at
the nerve endings in the CNS. This is done by
blocking the reuptake of the neurotransmitters and
thus causing these neurotransmitters to accumulate
at the nerve endings.
 Also have nonselective receptor antagonism
causing many side effects.
TRICYCLIC ANTIDEPRESSANTS

 Indications
 Depression
 Childhood enuresis(bed wetting)
 Imipramine
 Obsessive compulsive disorder
 Clomipramine
 Chronic pain syndromes
 Neuropathic pain (trigeminal neuralgia)
TRICYCLIC ANTIDEPRESSANTS

Adverse effects
 Sedation
 Impotence
 Orthostatic hypotension
 Disturbs cardiac conduction
 Delayed micturation
 Edema
 Muscle tremors
TRICYCLIC ANTIDEPRESSANTS
Interactions
 WHEN TAKEN WITH MAOIs MAY RESULT IN
INCREASED THERAPEUTIC LEADING TO
TOXIC EFFECTS (HYPERPYRETIC CRISIS)

 TCAs can inhibit the metabolism of

warfarin,resulting in an increase in
anticoagulation
TRICYCLIC ANTIDEPRESSANTS
 Toxicity and management of overdose
 TCA overdoses are fatal 70 - 80 of the time
 Death usually results from seizures or
dysrhythmias
 THERE IS NO SPECIFIC ANTIDOTE FOR TCAs
MONOAMINE OXIDASE INHIBITORS
(MAOIs)

 First generation of antidepressant drugs

 Highly effective
 Many side effects and drug/drug, drug/food
interactions
 Disadvantage potential to cause hypertensive crisis
when taken with tyramine
MAOIs
 phenelzine (Nardil)
 tranylcypromine (Parnate)
MAOIs Mechanism of Action

 Inhibit the MAO enzyme system in the CNS

 Amines (dopamine, serotonin, norepinephrine)
are not broken down, resulting in higher levels in
the brain
 Result alleviation of symptoms of depression
MAOIs Indications

Depression, especially types characterized

by symptoms such as increased sleep and
appetite depression that does not respond to
other drugs such as tricyclics.
 MAOIs Adverse Effects

✘ Palpitations ✘ Tachycardia
✘ Drowsiness ✘ Dizziness
✘ Headache ✘ Insomnia
✘ Nausea ✘ Anorexia
✘ Impotence ✘ Blurred vision
MAOIs Overdose

 Symptoms appear 12 hours after

ingestion
 Tachycardia, circulatory collapse,
seizures, coma
 Treatment protect brain and heart,
eliminate toxin
Hypertensive Crisis and Tyramine During
MAOI Therapy

Ingestion of foods and/or drinks with the

amino acid tyramine leads to hypertensive
crisis, which may lead to cerebral
hemorrhage, stroke, coma, or death
Hypertensive Crisis and Tyramine (contd)
 Avoid foods that contain tyramine!
 Aged, mature cheeses (cheddar, blue, Swiss)
 Smoked/pickled or aged meats, fish, poultry
 (herring, sausage, corned beef, salami, pepperoni,
pâté)
 Yeast extracts
 Red wines (Chianti, burgundy, sherry, vermouth)
 Italian broad beans (fava beans)
Antidepressants MAOIs
 Concurrent use of MAOIs and SSRIs may lead to
serotonin syndrome
 If the decision is made to switch to an SSRI, there
must be a 2- to 5-week wash-out period between
MAOI therapy and SSRI therapy
Selective Serotonin Reuptake
Inhibitors(SSRIs)
 fluoxetine (Prozac)
 paroxetine (Paxil)
 sertraline (Zoloft)
 fluvoxamine (Luvox)
 citalopram (Celexa)
 escitalopram (Lexapro)
SSRIs Newer-Generation
Antidepressants

 Fewer adverse effects than tricyclics and

MAOIs
 Very few drug-drug or drug-food
interactions
 Still takes about 4 to 6 weeks to reach
maximum clinical effectiveness
SSRIs
Mechanism of action
✘ Selectively inhibits serotonin reuptake
✘ Little or no effect on norepinephrine or
dopamine reuptake
✘ Result in increased serotonin concentrations
at nerve endings
✘ Advantage over tricyclics and MAOIs little
or no effect on cardiovascular system
SSRIs

INDICATIONS
✘ Depression
✘ Bipolar disorder
✘ Obesity
✘ Eating disorders
✘ Obsessive-compulsive disorder
SSRI Antidepressants Adverse Effects

✘ Body System Effects

✘ CNS Headache, dizziness, tremor,
nervousness,
insomnia, fatigue
✘ GI Nausea, diarrhea, constipation, dry
mouth
✘ Other Sexual dysfunction,
✘ weight gain, weight loss, sweating
✘ Most common and bothersome
Serotonin-Norepinephrine Reuptake
Inhibitors

 Duloxetine (Cymbalta)
 Venlafaxine (Effexor)
Serotonin-Norepinephrine Reuptake
Inhibitors

Indicated
 For depression and general anxiety disorder
 Also pain associated with diabetic peripheral
neuropathy
 Contraindicated
 CONCURRENT USE OF MAOIs
 Angle closure glaucoma
 SNRIs

Drug Interactions

 Highly bound to plasma proteins

 Compete with other protein-binding drugs, resulting in
more free, unbound drug to cause a more pronounced
drug effect
 Inhibition of cytochrome P-450 system
OTHER ANTIDEPRESSANTS NOT CLASSIFIED

 bupropion
 Wellbutrin, zyban
 Commonly prescribed for smoking cessation
 maprotiline
 Similar to TCAs
 Mirtazapine
 Remeron
 Often prescribed to enhance appetite
NURSING CONSIDERATIONS WHEN PATIENTS
ARE TAKING ANTIDEPRESSANTS

 Comprehensive patient history

 Complete medication history
 Monitor patient for therapeutic effects
 Monitor patients for adverse effects
 Education of patient on drug expectations and adverse
effects
 Educate patient regarding drug-drug, drug-food and drug-
herbal interactions
MOOD STABILIZING AGENTS

 lithium carbonate
 Eskalith, lithobid
 MOA not completely understood
 Managed using serum levels
 Indications : mania, bipolar disorder

Adverse effects
 vomiting, diarrhea, drowsiness, difficult
 coordination, hand tremors, muscle twitching,
 mental confusion
NURSING CONSIDERATIONS

 Monitor serum lithium levels

 Therapeutic levels are 1.0 1.5 meq/L
 Lithium is eliminated intact by the kidneys.
 Encourage fluids to completely eliminate the drug
 Monitor for therapeutic and adverse effects
PSYCHOSIS
 A severe mental disorder characterized by disordered
thought process and often bizarre thinking.
 Hypoactivity or hyperactivity
 Agitation
 Aggressiveness
 Hostility
 Social withdrawal
 Antipsychotic Drugs

 Antipsychotic AKA Neuroleptic

 Any drug that modifies or treats psychotic behaviors
usually by blocking dopamine receptors in the brain
Antipsychotic Drugs

✘ Thioxanthenes ✘ loxapine (Loxitane)

✘ thiothixene (Navane) ✘ Benisoxazoles
✘ Phenylbutylpiperidines ✘ Risperidone
✘ haloperidol (Haldol) ✘ Quinolinine
✘ Dihydroindolones ✘ Aripiprazole (Abilify)
✘ molindone (Moban) ✘ Phenothiazines
✘ Dibenzodiazepines ✘ Chlorpromazine
(Thorazine)
 HALDOL- FIRST GENERATION
ANTIPSYCHOTIC
 Schizophrenia
 Long half-life facilitates better
compliance by patients
 Long-term treatment of psychosis
 Can be given either IV or po
ADVERSE REACTIONS TO ANTIPSYCHOTIC MEDICATION

✘ Seizures
✘ Extrapyramidal reactions
✘ Blurred vision, dry eyes
✘ Neuroleptic malignant syndrome
✘ Tartive dyskinesia
 ATYPICAL ANTIPSYCHOTICS
NEWER-GENERATION ANTIPSYCHOTICS

✘ clozapine (Clozaril)
✘ risperidone (Risperdal)
✘ olanzapine (Zyprexa)
✘ quetiapine (Seroquel)
✘ ziprasidone (Geodon)
✘ aripiprazole (Abilify)
Mechanism of Action

▫ Block dopamine receptors in the

brain (limbic
system, basal ganglia)areas
associated with
emotion, cognitive function,
motor function
▫ Dopamine levels in the CNS are
decreased
▫ Result tranquilizing effect in
psychotic patients
ADVANTAGES OF NEWER GENERATION
ANTIPSYCHOTICS

 Reduced effect on Prolactin levels

 Stimulates mammary glands to produce milk

Lower risk of
o Neuroleptic malignant syndrome
o Extrapyramidal adverse effects
o Tartive dyskinesia
Indications

 Treatment of serious mental illnesses

 Bipolar affective disorder
 Depressive and drug-induced psychoses
 Schizophrenia
 Autism
 Movement disorders (such as Tourettes
syndrome)
 Some medical conditions
 Nausea, intractable hiccups
Adverse Effects

 Body System Adverse Effects

 CNS Sedation, delirium
 Cardiovascular Orthostatic hypotension,
syncope, dizziness, EKG changes
 Dermatologic Photosensitivity, skin rash,
 hyper-pigmentation, pruritus
Adverse Effects (contd)

 Body System Adverse Effects

 GI Dry mouth, constipation
 GU Urinary hesitancy or retention,
impaired erection
 Hematologic Leukopenia and
agranulocytosis
Adverse Effects (contd)

 Body System Adverse Effects

 Metabolic/endocrine Galactorrhea,
irregular menses, increased appetite,
polydipsia
Nursing Implications

 Before beginning therapy, assess both

the physical and emotional status of
patients
 Obtain baseline vital signs, including
postural BP readings
 Obtain liver and renal function tests
Nursing Implications (contd)

 Assess for possible contraindications to

therapy, cautious use, and potential drug
interactions
 Assess LOC, mental alertness, potential for
injury to self and others
 Check the patients mouth to make sure oral
doses are swallowed
Nursing Implications (contd)

 Provide simple explanations about the

drug, its effects, and the length of time
before therapeutic effects can be
expected
 Abrupt withdrawal should be avoided
 Advise patients to change positions
slowly to avoid postural hypotension and
possible injury
Nursing Implications (contd)

 The combination of drug therapy and psychotherapy

is emphasized because patients need to learn and
acquire more effective coping skills
 Only small amounts of medications should be
dispensed at a time to minimize the risk of suicide
attempts
 Simultaneous use of these drugs with alcohol or
other CNS depressants can be fatal
ANTI PARKINSON
DRUGS
Parkinson’s Disease
✘ Parkinson’s Disease is a chronic,
progressive neurological disorder with
rhythmic tremors as its initial
manifestation. These tremors lead to
rigidity and weakness which interfere with
the ability to maintain posture.
✘ Antiparkinsonism agents are drugs used
for management of signs and symptoms of
Parkinson’s disease, a progressive, chronic
neurological disorder primarily
characterized by lack of coordination.
✘ There is no known treatment for
Parkinson’s as of present and drug therapy
remains to be the primary treatment.
Antiparkinsonism Agents: Generic and
Brand Names

Classification Generic Name Brand Name

amantadine Symmetrel
apomorphine Apokyn
bromocriptine Parlodel
Dopaminergic Agents
carbidopa-levodopa Sinemet
levodopa Dopar
ropinirole Requip
benztropine Cogentin
Anticholinergic agents diphenhydramine Benadryl
trihexyphenidyl Artane
entacapone Comtan
Others tolcapone Tasmar
Dopaminergic Agents

✘ Dopamine does not cross the blood-brain

barrier so other drugs with actions similar
to dopamine and those that increase its
concentration in the substantia nigra (area
responsible for muscle tone) must be used.
This is one way of restoring the balance
between stimulatory and inhibitory
neurotransmitters.
✘ Levodopa, the precursor of dopamine is
the mainstay of treatment for Parkinson’s.
It crosses the blood-brain barrier and is
converted into dopamine. When combined
with carbidopa, the enzyme dopa
decarboxylase is inhibited from
metabolizing levodopa, leading to higher
levels that can cross the barrier.
Indications
✘ Dopaminergics are indicated for the following medical
conditions:

✘ Dopaminergics are indicated for the relief of the signs and

symptopms of idiopathic Parkinson’s disease.
✘ Levodopa is the drug of choice and acts as a replacement
therapy.
✘ Amantadine is an antiviral drug that increases release of
dopamine.
✘ Apomorphine directly binds with postsynaptic dopamine
receptors.
 Nursing Considerations
✘ Decrease dose of drug as ordered if therapy has
been interrupted to prevent systemic dopaminergic
effects.
✘ Evaluate disease progress and signs and symptoms
periodically for reference of disease progress and
drug response.
✘ Give drug with meals to alleviate GI irritation if
present.
✘ Monitor bowel function and institute bowel
 Nursing Considerations
✘ Have patient void before taking the drugs to decrease
risk of urinary retention.
✘ Monitor laboratory test results (renal and liver
function, CBC) to detect early signs of dysfunction.
✘ Provide comfort measures to help patient tolerate
drug effects.
✘ Provide safety measures (e.g. adequate lighting,
raised side rails, etc.) to prevent injuries.
✘ Educate client on drug therapy to promote
understanding and compliance.
Anticholinergic Agents
✘ Anticholinergic agents are synthetic drugs
which have been developed to achieve a
greater affinity for cholinergic receptor
sites in the CNS.
✘ Drugs that inhibit the effects of
acetylcholine at receptor sites of substantia
nigra and corpus striatum.
Therapeutic Action

✘ The desired and beneficial actions of

anticholinergic agents are as follows:
✗ Returns the balance to the basal
ganglia and reduces the severity of
rigidity, akinesia, and tremors.
✗ Peripheral anticholinergics reduce
drooling and other secondary effects
of parkinsonism.
 Nursing Considerations
✘ Administer drug with caution for patients
exposed in hot weather or environments
because patients are at increased risk for heat
prostration due to decreased ability to sweat.
✘ Give drug with meals to alleviate GI irritation if
present.
✘ Monitor bowel function and institute bowel
program if constipation is severe.
✘ Have patient void before taking the drugs to
decrease risk of urinary retention.
✘ Monitor laboratory test results (renal and liver
function) to detect early signs of dysfunction.
✘ Provide comfort measures to help patient tolerate
drug effects.
✘ Provide safety measures (e.g. adequate lighting,
raised side rails, etc.) to prevent injuries.
✘ Educate client on drug therapy to promote
understanding and compliance.
✘ Evaluate disease progress and signs and symptoms
periodically for reference of disease progress and
drug response.
Substance Use Disorders
Substance use disorders
✘ develop when a person’s use of alcohol or
another substance such as drugs leads to
health issues, disability, and or not
adhering to responsibilities at home, work,
or school.
✘ common chronic relapsing illness that are
characterized by drug-seeking and drug-
taking behaviors that persist despite
negative consequences.
 Comprehensive Dangerous Drugs Act of
2002
✘ The Comprehensive Dangerous Drugs Act
of 2002, or (Republic Act of the Philippines
) R.A. No. 9165, is a consolidation of Senate
Bill No. 1858 and House Bill No. 4433. It was
enacted and passed by the 
Senate of the Philippines and 
House of Representatives of the Philippines on
May 30, 2002 and May 29, 2002, respectively.
It was signed into law by President Gloria
Macapagal-Arroyo on June 7, 2002. 
Pharmacologic Management

TWO MAIN PURPOSES:

 to permit safe withdrawal from
alcohol, sedative-hypnotics, and
benzodiazepines
 to prevent relapse.
 Pharmacologic treatment
✘ Benzodiazepines. Alcohol withdrawal is usually managed
with a benzodiazepine-anxiolytic agent, which is used to
suppress the symptoms of abstinence.
✘ Disulfiram. Disulfiram (Antabuse) may be prescribed to help
deter clients from drinking.
✘ Acamprosate. Acamprosate (Campral), may be prescribed
for clients recovering from alcohol abuse or dependence to
help reduce cravings for alcohol and decrease the physical
and emotional discomfort that occurs especially in the first
few months of recovery.
 Pharmacologic treatment
✘ Methadone. Methadone, a potent synthetic
opiate, is used as a substitute for heroin in some
maintenance programs.
✘ Levomethadyl. Levomethadyl is a narcotic
analgesic whose only purpose is the treatment of
opiate dependence.
✘ Naltrexone. Naltrexone (ReVia) is an opioid
antagonist often used to treat an overdose. It can
also be used to treat alcohol abuse.
Nursing Management

✘ Providing health teaching for client

and family.
✘ Addressing family issues.
✘ Promoting coping skills.
END OF PART 1