Psychotherapeutics

PSYCHOPHARMOCOLOGY
RICHARD OPOKUASARE
M.Ed (Health Education)
, B.Ed (Hons) Health Science, RN (Dip) RMN, Cert.Ed
asareor@yahoo.com ©20111
PSYCHOTHERAPEUTIC DRUGS

ANTIANXIETY AND SEDATIVE-HYPNOTIC
DRUGS
Two types
1.Benzodiazepines
2.Non-benzodiazepines

Indications for Benzodiazepines
Generalised Anxiety
Disorder
Insomnia or sleep
disorders
Posttraumatic stress
disorders
Alcohol and drug
withdrawal
Seizure disorders
Phobic disorders
Anxiety and
apprehension
experienced before
surgery
Skeletal muscle
relaxation
Anxiety associated
with medical disease

Benzodiazepines
Antianxiety
drugs/Anxiolytics
Sedative-Hypnotic
Drugs
Alprazolam (Xanax)
Chlordiazepoxide (Librium)*
Clonazepam (Klonopin)
Clorazepate (Tranxene)
Diazepam (Valium)*
Halazepam (Paxipam)
Lorazepam (Ativan)*
Oxazepam (Serax)
Prazepam (Centrax)
Estazolam (ProSom)
Flurazepam (Dalmane)
Temazepam (Restoril)
Triazolam (Halcion)*

Side Effects/Withdrawal syndrome of
Benzodiazepines
 Insomnia
 Agitation
 Dizziness
 Headache
 Hyperventilation
 Paraesthesias
 Myalgia
 Malaise
 Paranoid delusions
 Visual hallucinations
 Tremor
 Pruritus
 Abdominal pain
 Constipation
 Nausea
 Vomiting
 Incontinence
 Loss of libido
 Urinary urgency and
frequency
 Chest pain
 Flushing
 Hypotension
 Palpitations

Non-benzodiazepines
Disadvantages
• Patients may develop tolerance to their effects
• Drugs are more addictive
• Drugs cause serious withdrawal symptoms
• Drugs are dangerous when taking in overdose
• They cause central nervous system depression
• They cause a variety of dangerous drug interactions.

Non-benzodiazepines – cont’d
Barbiturates Antihistamines
Amobarbital (Amytal)
Butabarbital (Butisol)
Pentobarbital (Nembutal)
Phenobarbital (Phenobarb)
Secobarbital (Seconal)
Propanediols
 Meprobamate (Equanil)
Diphenhydramine
(Benadryl)
Hydroxyzine (Atarax)
Beta-Adrenergic Blocker
Propranolol (Inderal)
Anxiolytic
Buspirone (BuSpar)

Non-benzodiazepines – cont’d
Acetylenic Alcohol Chloral Derivate
Ethchlorvynol (Placidyl)
Imidazopyridine
Zolpidem (Ambien)
Choral hydrate (Noctec)

Common Side Effects (Benzos & non-
benzos)
Drowsiness
sedation
Ataxia
dizziness
Feelings of detachment
Increased irritability,
hostility
Anterograde amnesia
Tolerance
dependency
Rebound insomnia,
anxiety
Nausea
Headache
Confusion
Gross psychomotor
impairment
Depression
Paradoxical rage reaction

ANTIDEPRESSANT DRUGS
Indications
Major depressive illness
Anxiety disorders
Enuresis
Attention deficit disorders
Narcolepsy
Bulimia

CLASSES OF ANTIDEPRESSANTS
Tricyclic drugs
A. Tertiary (Parent)
 Amitryptiline (Elavil)*
 Doxepine (Adepin,
Sinequan)
 Imipramine (Tofranil)*
 Trimipramine (Surmontil)
 Clomipramine (Anafranil)
B. Secondary (Metabolite)
 Desipramine
(Norpramin)*
 Nortryptiline
(Pamelor)
 Protriptyline (Vivactil)

CLASSES OF ANTIDEPRESSANTS – cont’d
Monoamine Oxidase Inhibitors (MAOIs)
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)

CLASSES OF ANTIDEPRESSANTS – cont’d
Other Antidepressant Drugs (Atypical)
Amoxapine (Asendin)*
Bupropion (Wellbutrin)*
Maproptiline (Ludodiomil)
Mirtazepine (Remeron)
Nefazedone (Serzone)
Trazodone (Desyrel)*
Venlafaxine (Effexor)

Contraindications to MAOIs
Asthma
Congestive heart failure
Hypertension
Impaired kidney function
Cardiac arrhythmias
Liver disease
Hypernatraemia
Hyperthyroidism
Pheochromocytoma
Severe headaches
Alcoholism
Abnormal LFTs
Glaucoma
Paranoid schizophrenia
Pregnancy
Children < 16 years
Patients > 60 years

Diets/foods to avoid when Patient is on
MAOI Therapy
 Cheese
 Liver
 Yeast
 Snails
 Soy sauce
 Pickled herring
 Distilled spirits
 Broad bean pods
 Chocolate
 Dried fish
 Tea
 Beef
 Smoked meat
 Diary products
 Avocado
 Meat (preserved)
 Sausages
 Coffee
 Smoked salmon
 Over-ripe fruit
 Cola drinks
 Wines
 Liquors
 Banana
 Maggi cubes
 Beer
 Yoghurt
 Ice creams

Drugs to avoid when Patient is on MAOI
Therapy
Nasal and sinus decongestants
Narcotics, e.g., meperidine
Asthmatic agents
Epinephrine
Stimulants
Cocaine
Amphetamines
Weight reducing drugs
Hay fever drugs
Atypical/Newer
antidepressants
Antihypertensive drugs
Aneasthetics (general)

Reasons to Avoid certain Foods and Drugs when on
MAOI Therapy
Tyramine which is an amino acid is released from the proteins in
foods and meats when they are spoiled, fermented or smoked. It is
deactivated by monoamine oxidase in the gut wall and liver. When
monoamine oxidase is inhibited, tyramine may reach adrenergic nerve
endings to cause the release of large amounts of norepinephrine to
produce hypertensive reaction.
Besides, sympathomimetic drugs act on the neurotransmitters to
release norepinephrine from the presynaptic nerve ends. When an
individual is on MAOI therapy, the actions of the drug are inhibited
and for that matter large amount of norepinephrine are released and a
severe hypertensive crisis occurs.

Common Side Effects of Antidepressants
Blurred vision
Diarrhoea
Dry mouth
Hallucinations
Constipation
Delusions
Tachycardia
Hypertensive crisis
Urination retention
Hypotension
Impaired cognition
Insomnia
Dizziness
Impaired memory
Lightheadedness
Excessive sweating
ECG changes
Priapism
Ejaculatory dysfunction
Sedation
drowsiness
Nausea
Tremors
Weight gain

Nursing Care of Side Effects of Antidepressant
Drugs
Advise patient to avoid hazardous tasks, if vision is blurred.
Encourage fluids, frequent rinses, or use gums, if mouth is
dry.
Check for mouth sores.
Stop the use of caffeine and give supportive therapy, if
tachycardia is present.
Encourage fluids and frequent voiding.
Monitor voiding patterns, if there is urinary retention.
Catheterize patient, if necessary.
Increase fluids, dietary fibre and roughage, as well as
exercises, if there is the presence of constipation.
Monitor bowel habits and use stool softeners and laxatives,
only if necessary.

Nursing Care of Side Effects of Antidepressant Drugs
– cont’d
Advise patient to adjust lifestyle and give supportive therapy,
if there is cognitive dysfunctions and tremors.
Protect patient from falls, in cases of
dizziness/lightheadedness.
Ask client to take drug as prescribed after sexual intercourse,
not immediately before, in case there is ejaculatory
dysfunction or sexual dysfunction.
Use lubricant, if vaginal dryness is present.
If there is priapism, change drug.
If there is withdrawal syndrome in terms of malaise, muscle
aches, chills, nausea, dizziness, and coryzia, taper off drug
over a period of time.

– cont’d
Increase exercise and reduce calorie diet, if there is weight
gain.
Change class of drug, if weight gain persists.
In cases of excessive sweating (perspiration), ask patient to
change clothes frequently, wear cotton or linen clothing,
have good hygiene, and increase intake of fluids.
In case of memory dysfunction, encourage client to
concentrate on his normal activities, make a list of his/her
daily routine, and provide social support.

– cont’d
Ensure sleep hygiene by decreasing evening activities,
eliminating the use of caffeine and ensuring relaxation
technique, if s/he complaints of insomnia.
Monitor blood pressure frequently.
For postural hypotension, take lying and standing blood
pressure. Ask client to change his/her position gradually, and
protect client from falls.
For hallucinations, delusions and other psychotic symptoms,
initiate antipsychotic or mood stabilizers, if necessary or
change prescribed drug to another antidepressant class of
drug.

MOOD STABILIZING
DRUGS
These are in two categories
Antimanics
Anticonvulsants /Antiepileptics

MOOD STABILIZING DRUGS – cont’d
Antimanic drug
Lithium (Eskalith, Lithobid, Lithonate)

Antimanic drug
Indications
Mania
Hypomania
Unipolar depression
schizophrenia
Schizoaffective
disorder
Catatonia (periodic)
Alcoholism
Aggressive-conduct
disorder
Self-abusive behaviour
Borderline personality
disorder
Histrionic personality
disorder
Eating disorders

Antimanic drug – cont’d
What to do before Lithium Treatment
Take complete history
Regular medication checkups
Kidney function test
Conduct other physical examinations
Thyroid function test
ECG, FBS, Complete Blood Count

Side Effects of Antimanic/Lithium
Body Image
 Weight gain
Cardiac
 ECG changes
CNS
 Tremor
 Fatigue
 Headache
 Mental dullness
 Lethargy
Dermatological/Skin
 Acne
 Rash
Endocrine
 Hypothyroidism
 Diabetes mellitus
GIT
 Gastric irritation
 Anorexia
 Abdominal cramps
 Nausea
 Vomiting
 Diarrhoea
Renal
 Polydipsia
 Polyuria
 Oedema

Anticonvulsant/Antiepileptic
drugs
Carbamazepine (Tegretol)
Valproate (Depakene)
Divalproex (Depakote)
 Phenytoin (Epanutin)
Phenobarbitone (Phenobarb)

Anticonvulsant drugs – cont’d
Indications
Epilepsy
Borderline personality
Acute mania
Schizophrenia
Bipolar illness
Schizoaffective disorder
Panic attacks
Substance abuse

Contraindications of Anticonvulsants
Elderly people
Decreased liver function
High levels of urea in the blood (uraemia)
Diabetes
Hereditary blood disorders called porphyrias
People who drink large amounts of alcohol
People of Thai or Han Chinese ethnic origin*
Pregnancy
Breastfeeding
Kidney disease

Common Side Effects of
Anticonvulsants
Skin rash
Sore throat
Blurred vision
Mucosal ulceration
Drowsiness/sedation
Low-grade fever
Tremors
 Vertigo
Nausea
Vomiting
Ataxia
Diplopia
Weight gain
Decreased in white blood
cell count
Diarrhoea
Pancreatitis
Increased appetite
Hepatic
dysfunction/hepatotoxicity

Neuroleptic drugs or neuroleptics
Psychotropic drugs or psychotropics
ANTIPSYCHOTIC DRUGS

ANTIPSYCHOTIC DRUGS – cont’d
TWO classes
dopamine receptor antagonists called “typical”;
and
serotonin-dopamine antagonists called “atypical.”

ANTIPSYCHOTIC DRUGS –
cont’d
1. Typical/Traditional/Conventional Antipsychotics
These help to decrease positive symptoms of
schizophrenia.
They produce extrapyramidal side effects and many
other neurological disturbances, e.g., muscular
rigidity, tremors, drooling, shuffling gait
(Parkinsonism), restlessness (akathisia), involuntary
postures (dystonia), akinesia (motor inertia), etc.
They serve as dopamine (DA) antigonists, blocking
postsynaptic D2receptors in several DA tracts in the
brain.asareor@yahoo.com ©201134

ANTIPSYCHOTIC DRUGS –
cont’d
2. Atypical/Newer Antipsychotics
They improve positive symptoms of schizophrenia.
They exert therapeutic action in treating the
negative symptoms of schizophrenia
They neither do not have nor produce
extrapyramidal side effects associated with
traditional antipsychotics.
They serve as dopamine and serotonin antagonists,
by inhibiting or stopping the reception of these two
neurotransmitters at specific postsynaptic sites.

Indications or Clinical Use of Antipsychotics
Non-psychiatric/General
uses Psychiatric uses
Vomiting
Vertigo
Pain relief
Hiccups
Porphyria
Relief of itching
Facilitate sleep in insomnic
clients
Migraine headache
 Schizophrenia
 Organic brain syndrome with
psychosis
 Manic-depressive illness
 Severe depression with
psychotic features
 Mania
 Delusional disorder
 Agitated aggressive behaviour in
dementia
 Gilles de la Tourette’s syndrome
 Impulsivity
 Huntington’s disease

TYPICAL ANTIPSYCHOTICS
37
Phenothiazines
Aliphatics
Chlorpromazine (Largactil, Thorazine)*
Trifluopromazine (Vesprin)
Piperidines
Mesoridazine (Serentil)
Thioridazine (Mellaril)
Piperazines
Acetophenazine (Tindal)
Fluphenazine (Modecate, Prolixin, Permitil)*
Perphenazine (Trilafon)
Trifluoperazine (Stelazine)*

TYPICAL ANTIPSYCHOTICS – cont’d
38
Thioxanthenes
Aliphatic
Chlorprothixene (Taractan)
Piperazine
Thiothixene (Navene)
Butyrophenones
Haloperidol (Haldol, Serenace)*
Dibenzoxazepine
Loxapine (Loxitane)
Dihydroindolone
Molindone (Moban)

ATYPICAL ANTIPSYCHOTICS
39
Clozapine (Clozaril)
Olazapine (Zyprexa)
Risperidone (Risperdal)*
Quetiapine (Seroquel)
Ziprasidone (Zeldox)
Other neuroleptic medications include:
Pimozide (Orap)
Reserpine (Serpasil)

POTENCY OF ANTIPSYCHOTICS
Low Potency High Potency
Chlorpromazine
Thioridazine
Clozapine
Mesoridazine
Quetiapine (Seroquel)
Ziprasidone (Zeldox)
Trifluoperazine
Thiothixene
Loxapine
Molindone
Perphenazine
Fluphenazine
Haloperidol
Pimozide
Risperidone
Olanzapine

Common Side Effects of Antipsychotic Drugs
Anticholinergic Symptoms Other Side Effects
41
Constipation
Dry mouth
Blurred vision
Memory impairment
Confusion
Dizziness
Urinary retention/slowing
of urination
Nasal congestion
Excessive salivation
Sedation/drowsiness
Weight gain
Impaired concentration
Seizures
Sexual dysfunction
Photosensitivity
Oculogyric crisis (rotation
of the eye balls in a fixed
position, usually upward)
Agranulocytosis (Ulcerative
sore throat, Fever, Malaise,
Leukopenia)

Common Side Effects of Antipsychotic Drugs – cont’d
Tardive Dyskinesia
Extrapyramidal
Symptoms
Tongue protrusion
Writhing of Tongue
Lip smacking
Chewing
Blinking
Facial grimacing
Movements of neck, trunk,
and pelvis
Leg jiggling/jerky
movements
Muscle rigidity
Tremors
Drooling
Restlessness
Allergic Reactions
Jaundice
Skin rash

Positive Side Effects of Antipsychotics
1. They are not addictive.
2. It is extremely difficult to use them to
commit suicide.
(Ray & Ksir, 2004)

ANTIPARKINSONIAN MEDICATIONS
44
Antiparkinsonian drugs are used to treat the
side effects that result from the use of
antipsychotic agents.
They are drugs used to counter the effects of
extrapyramidal symptoms.

Anticholinergics Antihistamine
Benztropine*
(Cogentin)
Trihexyphenidyl
(Artane, Pipanol)*
Biperiden
(Akineton)
Procyclidine
(Kemadrin)
Diphenhydramine
(Benadryl)
Ethopropazine
(Parsidol)
Orphenadrine
(Disipal, Norlex)
45
Groups of Antiparkinsonian drugs

Dopamine Agonist Benzodiazepines
Amantadine
(Symmetrel)
Bromocriptine
(Parlodel)
Diazepam (Valium)*
Lorazepam (Ativan)*
Clonazepam
(Klonopin)*
46
Groups of Antiparkinsonian drugs – cont’d

Common Side Effects of
Antiparkinsonian/Anticholinergic medications
47
Dry mouth
Nasal congestion
Blurred vision
Constipation
Urinary hesitancy
Urinary retention
(potentially serious in
the elderly)
Delirium (marked by
disorientation, agitation,
tachycardia, and
tachypnoea)
Dry, hot, flushed skin
Enlarged pupils
(mydriasis)
Problem with recent
memory

Specific Nursing Interventions for Anticholinergic
Agents
48
Reassure client that problem will go away, if there is
blurred vision.
Discontinue medication, if problem persists.
Administer anticholinergic drugs in minimal doses, and
only when necessary.
Give antiparkinsonics with or immediately following food
intake to prevent or reduce gastro-intestinal distress.

Specific Nursing Interventions for Anticholinergic Agents – cont’d
49
Observe for therapeutic effects such as decreased
salivation, tremor, and drooling.
Observe for improvement in gait, balance, posture,
speech, and self-care ability.
Monitor for adverse effects due to anticholinergic
drugs such as dry mouth, drowsiness and constipation.
Monitor for adverse reaction to antiparkinson agents.

SOME REASONS FOR NOT TAKING ALCOHOLIC BEVERAGES
WITH PSYCHOTROPIC MEDICATIONS
The medication can increase the depressant effect of
alcohol.
The stimulant in alcohol can decrease the effect of
the medication or the efficacy of the medication.
The efficacy of the drug may be totally destroyed.
Instead of the medication relaxing and making the
patient sleep, s/he is going to have sleepless nights.
50

WITH PSYCHOTROPIC MEDICATIONS – Cont’d
Because the medicine may not be effective, patient
may take more of the prescribed dosage causing over
dose.
Alcohol may cause contra-reaction.
Alcohol react with the medication causing severe
adverse effect.
Taking alcohol with medication may cause death.
51

WITH PSYCHOTROPIC MEDICATIONS – Cont’d
Alcohol can influence the effectiveness of a drug by
altering its availability.
Alcohol may inhibit a drug’s metabolism by
competing with the drug for the same set of
metabolizing enzymes.
 Alcohol will potentially increase the patient’s risk of
experiencing harmful side effects from the drug.
Some drugs affect the metabolism of alcohol, thus
altering its potential for intoxication and the adverse
effects associated with alcohol consumption.
52

THANKYOU
53
END OF LECTURE ON PSYCHOTROPIC DRUGS

Psychotherapeutics

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Psychotherapeutics

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