Psychopharmacology

Psychopharmacology
Aashish Parihar
Lecturer
College Of Nursing
AIIMS, Jodhpur

• Psychopharmacology is the study of the effects of drugs on affect,
cognition, and behavior
• Efficacy refers to the maximal therapeutic that a drug can achieve.
• Potency describe the amount of the drug needed to achieve the
maximum effect.
• Half life is the time taken for half of the drug to be removed from the
blood stream.
• Agonist a drug that binds to and activates a receptor
• Antagonist a drug that binds to but does not activate (block) a
receptor
Psychopharmacology

• Neurotransmitters are the chemical messengers that travel from one
brain cell to another and are synthesized by enzymes from certain
dietary amino acids or precursors
Receptors are molecules situated on the cell membrane that are
binding sites for neurotransmitters.
Psychopharmacology

Drug Action on Synaptic Transmission
Psychopharmacology
Agonist drugs are in red, Antagonists are in blue

Presynaptic Drug Actions
• Presynaptic autoreceptors regulate the amount of NT released from
the axon terminal
• Drugs that activate presynaptic autoreceptors reduce the amount of NT
released, an antagonistic action
• Drugs that inactivate presynaptic autoreceptors increase the amount of NT
released, an agonistic action
• Presynaptic heteroreceptors are sensitive to NT released by another
neuron, can be inhibitory or facilitatory
Psychopharmacology

Effect of drug in neurotransmission
• Release
• Blockade
• Changes in receptor sensitivity
• Blocked reuptake
• Interference with storage vesicles
• Precursor chain interference
Psychopharmacology

Classifications of psychotropic drugs
• Antipsychotics
• Antidepressants
• Mood stabilizing agents
• Anxiolytics
• Antiepileptic drugs
• Antiparkinsonian drugs
• Miscellaneous (stimulants, drugs used for de addiction,
drugs used in child psychiatry)
Psychopharmacology

Antiparkinsonian drugs
• Classification of antiparkinsonian Drugs:
• Drugs acting on dopaminergic system:
• Dopamine precursors – Levodopa (l-dopa)
• Peripheral decarboxylase inhibitors – carbidopa and benserazide
• Dopaminergic agonists: Bromocriptyne, Ropinirole and
Pramipexole
• MAO-B inhibitors – Selegiline, Rasagiline
• Dopamine facilitator - Amantadine
• Drugs acting on cholinergic system
• Central anticholinergics – Teihexyphenidyl (Benzhexol),
Procyclidine, Biperiden
• Antihistaminics – Orphenadrine, Promethazine

• Dopamine and Tyrosine Are Not Used for Parkinson Disease
Therapy, Why?
– Dopamine Doesn't Cross the Blood Brain Barrier
– Huge amount of tyrosine decreases activity of rate limiting
enzyme Tyrosine Hydroxylase

• Levodopa
• Single most effective agent in PD
• Inactive by itself but immediate precursor of Dopamine
• Peripherally - 95% is decarboxylated in peripheral tissues in gut
and liver to dopamine
– This dopamine acts on peripheral organs like heart, blood vessels
and CTZ etc. (NOT CNS)
• 1 - 2% crosses BBB, taken up by neurons and DA is formed
– Stored and released as neurotransmitter

• Levodopa
• Actions of Levodopa – CNS
• Effective in Eliminating Most of the Symptoms of Parkinson
Disease (initially motor)
– Bradykinesia and Rigidity Respond Quickly
– Reduction in Tremor Effect with Continued therapy
• Secondary symptoms - Handwriting , speech, facial expression and
interest in life improves gradually
• L -Dopa less Effective in Eliminating Postural Instability and
Shuffling Gait Meaning Other Neurotransmitters are Involved in
Parkinson Disease
• Behavioural Effects:
– Partially Changes Mood by elevating mood, and increases
Patient sense of well being - General alerting response
– Disproportionate increase in sexual activity
– No improvement in dementia – psychiatric symptoms

• Levodopa
• Actions of Levodopa –
CVS:
–Cardiac Stimulation Due to Beta adrenergic effect on Heart
–Though stimulates peripheral adrenergic receptor – no rise
in BP
–Orthostatic Hypotension - some individuals – central DA
and NA action
–In elderly cardiovascular problems - transient tachycardia,
cardiac arrhythmias and hypertension
–Tolerance to CVS action develops within few weeks
• CTZ: DA receptors cause stimulation – nausea and vomiting –
tolerance
• Endocrine: Decrease in Prolactin level and increase in GH
release

• Levodopa
Pharmacokinetics
• Absorbed rapidly from small intestine
• High First Pass Effect
– Competition for amino acids present in food competes for the carrier
– Also depends on gastric emptying and pH
• Peak plasma conc. 1-2 hrs. and half life - 1 to 3 Hrs
• Metabolized in liver and peripherally - secreted in urine unchanged or conjugated
with glucoronyl sulfate
• Central entry into CNS (1%) - mediated by membrane transporter for aromatic
amino acids – competition with dietary protein
• In CNS – Decarboxylated and DA is formed – therapeutic effectiveness
• Transport back by presynaptic uptake or metabolized by MAO.

• Levodopa
Pharmacokinetics

• Levodopa
ADRs
• Initial Therapy:
Nausea and vomiting - 80% of patients
Postural hypotension , but asymptomatic : 30 % of patients tolerance
develops – disappear after prolonged treatment
Cardiac arrhythmias (due to beta adrenergic action and peripheral CA
synthesis) - tachycardia, ventricular extrasystoles and, rarely, atrial fibrillation
Exacerbation of angina

• Levodopa
ADRs
• Prolonged therapy:
1. Abnormal movements: Facial tics, grimacing, tongue thrusting,
choreoathetoid movements of limb after few months of treatment
2. Behavioural effects:
– 20 to 25% of Population
– Trouble in Thinking (Cognitive Effects)
– L- dopa can induce: Anxiety, psychosis, confusion, hallucination, delusion
– Hypomania - Inappropriate Sexual Behavior; "Dirty Old Man", "Flashers“
- Drug Holiday (1 - 3 weeks)

• Levodopa
ADRs
• Prolonged therapy – contd :
Fluctuation in Motor Performance:
 Initial therapy – each dose - good duration of action 9more than half-life)
Suggesting Nigrostriatum retains capacity to store and release
 Prolonged therapy – “buffering” capacity is lost – each dose causes fluctuation
of motor state - each dose has short duration of action– short therapeutic
effect (1 – 2 Hrs) – bradykinesia and rigidity comes back quickly - "On-off"
Phenomenon
Like a Light Switch: Without Warning
 DYSKINESIA – excessive abnormal involuntary movements even in on phase
(more troublesome)
 Dyskinesia often with high plasma conc. of levodopa
 Dyskinesia = Bradykinesia and Rigidity in terms of patient comfortness

Antianxiety drugs
• Anti-anxiety medications, as the name implies, are prescribed to
reduce anxiety.
• They are prescribed for a number of illnesses:
• Generalized Anxiety (GAD)
• Post-Traumatic Stress Disorder (PTSD)
• Phobias
• Obsessive Compulsive Disorder (OCD)
• Panic Disorder
• Insomnia related to Anxiety

Antianxiety drugs
• Classification
Barbiturates:
Benzodiazepines
Non barbiturates and non benzodiazepines

Antianxiety drugs
• Benzodiazepines are considered CNS depressants.
• How do they work? Enhance the actions of the neurotransmitter,
GABA, which slows down brain activity. This produces a drowsy or
calming affect.
• They are used to produce sedation, induce sleep, relieve anxiety and
muscle spasms, and to prevent seizures.

Antianxiety drugs
• Side Effects: drowsiness, dizziness, loss of coordination, fatigue,
mental slowing, confusion.
• Withdrawal reactions are possible. S/S: anxiety, shakiness, headache,
dizziness, seizures.
• Precautions: with elderly, lung disease, liver disease, kidney disease,
sleep apnea
• Contraindications: acute narrow angle glaucoma

Antianxiety drugs
• Safety Concerns:
• risk of addiction: should be only used short term.
• Patient should not drive or operate heavy machinery.
• Not to be mixed with ETOH, opiates, OTC cough/allergy medications, dental
anesthetics – can be life threatening (resp. depression)
• Discuss use of OTC medications and supplements and other prescribed drugs
with MD before taking them with this type of medication.
• MUST NOT be discontinued abruptly. Taper schedule is prescribed.

Antipsychotic drugs
Synonymous
• Neuroleptic drugs
• Anti-schizophrenic drugs
• Major tranquilizers
• Dopamine receptor antagonists

Antipsychotic drugs
Classification:
TYPICAL ANTIPSYCHOTICS
a. Phenothiazine derivatives
• Aliphatic Derivative: CHLORPROMAZINE
• Piperidine Derivative: THIORIDAZINE
• Piperazine Derivative: FLUPENAZINE,
PERPHENAZINE, TRIFLUOPERAZINE
b. Thioxanthene Derivative: THIOTHIXENE
c. Butyrophenone: HALOPERIDOL

Antipsychotic drugs
Classification:
ATYPICAL ANTIPSYCHOTICS
• CLOZAPINE LOXAPINE
• OLANZAPINE QUETIAPINE
• RISPERIDONE MOLINDONE
• ZIPRASIDONE
• SERTINDOLE ARIPIPRAZOLE

Antipsychotic drugs
Difference between Typical Antipsychotics and
Atypical Antipsychotics
• 1. The side effects
• 2. The efficacy
• 3. Atypical anti psychotics are excreted faster.
• 4. Atypical anti psychotics are less likely to cause
extra pyramidal motor control and tardive
dyskinesia
• 5. Atypical anti psychotics are easier to
discontinue and are less addictive.

Antipsychotic drugs
Difference between Typical Antipsychotics and
Atypical Antipsychotics
• 6. Atypical anti psychotic drugs are recommended
over typical psychotic drugs.
• 7. Atypical anti psychotics fail to produce
prolactin in the serum.
• 8. Withdrawal symptoms are less likely with
atypical anti psychotic drugs
• 9. Akathesia to be less intense with these drugs
than the typical antipsychotic.

Antipsychotic drugs
Mechanism of action:
(Typical Antipsychotics)

Antipsychotic drugs
Pharmacological action of Anti psychotic drugs:
CNS-
• Reduction in irrational behavior, agitation,
aggressiveness.
• Disturbed thoughts and behavior gradually normalized
• Relives anxiety
• Hyperactivity , hallucination and delusions are
suppressed
• Sedation
• Lowers seizures threshold level
• Extrapyramidal motor disturbances

Antipsychotic drugs
ANS-
• Exerts  adrenergic blocking activity results in-
 postural hypotension
Palpitation
Inhibition of ejaculation
• Exerts anticholinergic activity results in-
 dry mouth
Blurring of vision
Constipation
Urinary hesitancy

Antipsychotic drugs
CVS-
• Hypotension due to  adrenergic blocking action
• Reflex tachycardia
• Q-T prolongation and T wave suppression
Endocrine-
• Increases secretion of prolactin hormone results in
gynecomastia and galactorrhea
• Reduction of gonadotropin hormone results in
amenorrhea, infertility.

Antipsychotic drugs
Pharmacokinetics:
• Most neuroleptic drugs are highly lipophilic, bind avidly to
proteins, and tend to accumulate in highly perfused tissues.
• Oral absorption is incomplete and erratic.
• IM injection is more reliable. With repeated administration,
variable accumulation occurs in body fat and possibly in
brain myelin.
• Half-lives are generally long, and so a single daily dose is
effective.
• After long-term treatment and drug administration is stopped,
therapeutic effects may outlast significant blood
concentrations by days or weeks. This may result from tight
binding of parent drug of active metabolites in the brain.
• Metabolites are excreted in urine and bile.

Antipsychotic drugs
Uses: :
• Schizophrenia
• Schizoaffective disorder
• Mania
• Organic brain syndrome
• Anxiety
• Preanaesthtic medication
• Intractable hiccough
• Tetanus
• Alcoholic hallucination
• Huntington’s disease
• Tourette’s syndrome

Antipsychotic drugs
Contraindications:
These drugs are contraindicated in
• Hypersensitivity
• CNS depression
• Blood dyscrasias
• Parkinson’s disease
• Liver, renal, or cardiac insufficiency

Antipsychotic drugs
Precautions:
• Elderly, severely ill, or debilitated, and to diabetic
clients or clients with respiratory insufficiency,
prostatic hypertrophy, or intestinal obstruction.
• Individuals should avoid exposure to extremes in
temperature while taking antipsychotic
medication.
• Safety in pregnancy and lactation has not been
established.

Antipsychotic drugs
Adverse drug reactions:
Anticholinergic effects-
• Dry mouth
• Blurred vision
• Constipation
• Urinary retention
Nausea, GI upset
Skin rashes
Sedation
Photosensitivity
Orthostatic hypotension

Antipsychotic drugs
Hormonal effects
• Decreased libido, gynecomastia
• Amenorrhea
• Infertility
• Weight gain
ECG changes
• Q-T prolongation and T wave suppression
Decreased threshold level
 Agranulocytosis
 Hypersalivation

Antipsychotic drugs
 Extrapyramidal symptoms
• Pseudo-parkinsonism (tremor, shuffling gait, drooling,
rigidity)
• Akinesia (muscular weakness)
• Akathisia (continuous restlessness and fidgeting)
• Dystonia (involuntary muscular movements [spasms] of
face, arms, legs, and neck)
• Oculogyric crisis (uncontrolled rolling back of the eyes)

Antipsychotic drugs
Extrapyramidal
symptoms
• Pseudo-parkinsonism
(tremor, shuffling
gait, drooling, rigidity)
Akinesia Akathisia

Antipsychotic drugs
Extrapyramidal
symptoms
• Dystonia Oculogyric crisis

Antipsychotic drugs
 Tardive dyskinesia (bizarre facial and tongue
movements, stiff neck, and difficulty swallowing)

Antipsychotic drugs
 Neuroleptic malignant syndrome (NMS)
Symptoms include -
Severe parkinsonian muscle rigidity,
Hyperpyrexia up to 107 f,
Tachycardia,
Tachypnea,
Fluctuations in blood pressure,
Diaphoresis,
Rapid deterioration of mental status
Stupor and coma.

Antipsychotic drugs
Nursing management of ADR:
For Anticholinergic effects :
• Provide the client with sugarless candy or gum, ice, and frequent sips of
water.
• Ensure that client practices strict oral hygiene.
• Explain that this symptom will most likely subside after a few weeks.
• Advise client not to drive a car until vision clears.
• Clear small items from pathway to prevent falls.
• Order foods high in fiber
• Encourage increase in physical activity and fluid intake if not
contraindicated.
• Instruct the client to report any difficulty urinating; monitor intake and
output.

Antipsychotic drugs
For Nausea and GI upset:
• Tablets or capsules may be administered with food to
minimize GI upset.
• Concentrates may be diluted and administered with fruit
juice or other liquid.
• They should be mixed immediately before administration.

Antipsychotic drugs
For Skin Rash:
• Report appearance of any rash on skin to physician.
• Avoid spilling any of the liquid concentrate on skin
• Contact dermatitis can occur with some medications.

Antipsychotic drugs
For Sedation:
• Discuss with the physician the possibility of
administering the drug at bedtime.
• Discuss with the physician a possible decrease in dosage
or an order for a less sedating drug.
• Instruct client not to drive or operate dangerous
equipment while experiencing sedation.

Antipsychotic drugs
For Orthostatic hypotension :
• Instruct the client to rise slowly from a lying or sitting
position
• Monitor blood pressure (lying and standing) each shift
• Document and report significant changes.

Antipsychotic drugs
For Photosensitivity:
• Ensure that the client wears a protective sunblock lotion,
clothing, and sunglasses while spending time outdoors.

Antipsychotic drugs
For Hormonal effects:
• Provide an explanation of the effects and reassurance of
reversibility.
• If necessary, discuss with the physician the possibility of
ordering alternate medication.
• Offer reassurance of reversibility
• Instruct the client to continue use of contraception, because
amenorrhea does not indicate cessation of ovulation.
• Weigh client every other day
• Order a calorie controlled diet
• Provide an opportunity for physical exercise
• Provide diet and exercise instruction.

Antipsychotic drugs
For ECG Changes:
• Caution is advised in prescribing this medication to
individuals with history of arrhythmias.
• Conditions that produce hypokalemia and/or
hypomagnesemia, such as diuretic therapy or diarrhea,
should be taken into consideration when prescribing.
• Routine ECG should be taken before initiation of therapy and
periodically during therapy.
• Monitor vital signs every shift.
• Observe for symptoms of dizziness, palpitations, syncope, or
weakness.

Antipsychotic drugs
For Reduction of seizure threshold:
• Closely observe clients with history of seizures.

Antipsychotic drugs
For Agranulocytosis:
• There is a significant risk of agranulocytosis with clozapine.
• A baseline white blood cell (WBC) count and absolute neutrophil
count (ANC) must be taken before initiation of treatment with
clozapine and weekly for the first 6 months of treatment.
• Only a 1-week supply of medication is dispensed at a time.
• If the counts remain within the acceptable levels (i.e., WBC at least
3,500/mm3 and the ANC at least 2,000/mm3) during the 6-month
period, blood counts may be monitored biweekly, and a 2-week
supply of medication may then be dispensed
• If the counts remain within the acceptable level for the biweekly
period, counts may then be monitored every 4 weeks thereafter.
• When the medication is discontinued, weekly WBC counts are
continued for an additional 4 weeks.

Antipsychotic drugs
For Hyper salivation (with clozapine) :
• A significant number of clients receiving clozapine therapy
experience extreme salivation.
• Offer support to the client because this may be an embarrassing
situation.
• It may even be a safety issue (e.g., risk of aspiration) if the problem
is very severe.

Antipsychotic drugs
For Extrapyramidal symptoms (EPS) :
• Pseudoparkinsonism (tremor, shuffling gait, drooling, rigidity) may appear 1 to 5
days following initiation of antipsychotic medication; occurs most often in
women, the elderly, and dehydrated clients.
• Akathisia (continuous restlessness and fidgeting) occurs most frequently in
women, symptoms may occur 50 to 60 days following initiation of therapy.
• Dystonia (involuntary muscular movements [spasms] of face, arms, legs, and
neck) and oculogyric crisis occurs most often in men and in people younger than
25 years of age.
• Pseudoparkinsonism and akathisia can be treated with anticholinergics,
antihistamine and dopaminergic agents.
• Dystonia and oculogyric crisis should be treated as an emergency situation.
• The physician should be contacted, and intravenous or intramuscular
benztropine mesylate (Cogentin) is commonly administered.
• Stay with the client and offer reassurance and support during this frightening
time.

Antipsychotic drugs
For Tardive dyskinesia :
• All clients receiving long-term (months or years) antipsychotic
therapy are at risk.
• The symptoms are potentially irreversible.
• The drug should be withdrawn at the first sign, which is usually
vermiform movements of the tongue
• Prompt action may prevent irreversibility.

Antipsychotic drugs
For Neuroleptic malignant syndrome (NMS) :
• This is a rare, but potentially fatal, complication of treatment with
neuroleptic drugs.
• Routine assessments should include temperature and observation
for parkinsonian symptoms.
• Onset can occur within hours or even years after drug initiation,
and progression is rapid over the following 24 to 72 hours.
• Discontinue neuroleptic medication immediately.
• Monitor vital signs, degree of muscle rigidity, intake and output,
level of consciousness.
• The physician may order bromocriptine (Parlodel) or dantrolene
(Dantrium) to counteract the effects of neuroleptic malignant
syndrome

Antidepressants
Indications
• Dysthymic disorder
• Major depression with melancholia or psychotic
symptoms
• Depression associated with organic disease, alcoholism,
schizophrenia, or mental retardation
• Depressive phase of bipolar disorder
• Depression accompanied by anxiety.

Antidepressants
Classification
• Tricyclics
• SSRIs (Selective serotonin reuptake inhibitor)
• MAOIs (Mono amine oxidase inhibitors)
• Others

Antidepressants
Classification
• Tricyclics
Amitriptyline, Nortriptyline Protriptyline
Amoxapine, Doxepin
Clomipramine, Desipramine, Imipramine,
Trimipramine

Antidepressants
Classification
• SSRIs (Selective serotonin reuptake inhibitor)
Citalopram, Escitalopram
Flu , Par
Fluvoxamine
Sertraline

Antidepressants
Classification
• MAOIs (Mono amine oxidase inhibitors)
Isocarboxazid
Phenelzine
Tranylcypromine

Antidepressants
Classification
• Others
Bupropion
Maprotiline
Mirtazapine
Trazodone
Nefazodone
Venlafaxine
Duloxetine

Antidepressants
Mechanism of action

Antidepressants
Pharmacokinetics
Lipophiloic and protein bound
Half life long usually more than 1 day
Metabolized in liver
Excreted in urine

Antidepressants
Contraindications/Precautions
• Hypersensitivity.
• Myocardial infarction and angle-closure glaucoma.
• Caution-
Elderly or debilitated clients
Hepatic, renal, or cardiac insufficiency. (The
dosage usually must be decreased.)
Psychotic clients,
prostatic hypertrophy
History of seizures

Antidepressants
Interactions
• Tricyclic antidepressants
Hyperpyretic crisis, hypertensive crisis, severe seizures,
and tachycardia may occur when used with MAOIs.
Additive CNS depression occurs with concurrent use of
CNS depressants.
Additive sympathomimetic and anticholinergic effects
occur with use of other drugs possessing these same
properties.
Increased effects of tricyclic antidepressants may occur
with bupropion, cimetidine, haloperidol, selective
serotonin reuptake inhibitors (SSRIs), and valproic acid.

Antidepressants
Interactions
• SSRIs
Use of SSRIs with cimetidine may result in increased
concentrations of SSRIs.
Hypertensive crisis can occur if SSRIs are used within 14
days of MAOIs.
Impairment of mental and motor skills may be
potentiated with use of alcohol.
Serotonin syndrome may occur with concurrent use of
MAOIs, and other drugs that increase serotonin, such as
tryptophan, amphetamines or other psychostimulants

Antidepressants
Interactions
• MAOIs
Hypertensive crisis may occur with concurrent use of amphetamines,
methyldopa, levodopa, dopamine, epinephrine, norepinephrine, reserpine,
vasoconstrictors, or ingestion of tyramine containing foods
Hypertension or hypotension, coma, convulsions, and death may occur with
meperidine or other narcotic analgesics when used with MAOIs.
Additive hypotension may result with concurrent use of antihypertensives or
spinal anesthesia and MAOIs.
Additive hypoglycemia may result with concurrent use of insulin or oral
hypoglycemic agents and MAOIs.
Serious, potentially fatal adverse reactions may occur with concurrent use of
other antidepressants, carbamazepine, cyclobenzaprine, maprotiline,
furazolidone, procarbazine, or selegiline.

Antidepressants
Adverse effects
List of adverse effects with all classes of
antidepressants
• Dry mouth
• Sedation
• Nausea and GI upsets
• Discontinuation syndrome

Antidepressants
Adverse effects
List of adverse effects with Tricyclics
• Blurred vision
• Constipation
• Urinary retention
• Orthostatic hypotension
• Reduction of seizure threshold
• Tachycardia; arrhythmias
• Photosensitivity
• Weight gain

Antidepressants
Adverse effects
List of adverse effects with SSRIs
• Insomnia; agitation
• Headache
• Weight loss
• Sexual dysfunction
• Serotonin syndrome
Symptoms include changes in mental status,
restlessness, myoclonus, hyperreflexia,
tachycardia, labile blood pressure, diaphoresis,
shivering, and tremors.

Antidepressants
Adverse effects
List of adverse effects with MAOIs
• Hypertensive crisis
Symptoms of hypertensive crisis include severe
occipital headache, palpitations, nausea/vomiting,
nuchal rigidity, fever, sweating, marked increase in
blood pressure, chest pain, and coma.
• Priapism (With trazodone )
• Hepatic failure (with nefazodone)

Antidepressants
Health education/ nursing management
• Treatment adherence
• Use caution when driving or operating dangerous machinery
• Not stop taking the drug abruptly
• If taking a tricyclic, use sunblock lotion and wear protective
clothing
• Report occurrence of any of the following symptoms to the
physician immediately:
sore throat, fever, malaise, yellowish skin, unusual bleeding,
easy bruising, persistent nausea/vomiting, severe headache,
rapid heart rate, difficulty urinating, anorexia/weight loss,
seizure activity, stiff or sore neck, and chest pain.

Antidepressants
• Rise slowly from a sitting or lying position to prevent a sudden
drop in blood pressure
• Take frequent sips of water, chew sugarless gum, or suck on
hard candy
• Good oral care
• Not consume the following foods or medications while taking
MAOIs:
Aged cheese, wine (especially Chianti), beer, chocolate, colas,
coffee, tea, sour cream, beef/chicken livers, canned figs, soy
sauce, overripe and fermented foods, pickled herring, preserved
sausages, yogurt, yeast products, broad beans, cold remedies,
diet pills. (TYRAMINE CONTAINING FOOD)

Antidepressants
• Avoid smoking while receiving tricyclic therapy.
• Not drink alcohol while taking antidepressant therapy
• Not consume other medications (including overthe-counter
medications) without the physician’s approval
• Notify the physician immediately if inappropriate or
prolonged penile erections occur while taking trazodone
• Establish seizure precaution especially with Bupripion

Antidepressants
Serotonin syndrome
• May occur when two drugs that potentiate serotonergic neurotransmission such
as tryptophan, amphetamines or other psychostimulants are used concurrently
• Most frequent symptoms include changes in mental status, restlessness,
myoclonus, hyperreflexia, tachycardia, labile blood pressure, diaphoresis,
shivering, and tremors.
• Discontinue offending agent immediately.
• The physician will prescribe medications to block serotonin receptors, relieve
hyperthermia and muscle rigidity, and prevent seizures.
• Artificial ventilation may be required.
• The condition will usually resolve on its own once the offending medication has
been discontinued.
• However, if the medication is not discontinued, the condition can progress to a
more serious state and become fatal

Mood stabilizing agents
• Any medication that is able to decrease vulnerability to subsequent
episodes of mania or depression; and not exacerbate the current
episode or maintenance phase of treatment.

Classification of mood stabilizing drugs
• Antimanic- Lithium carbonate
• Anticonvulsants- Carbamazepine, Clonazepam, Valproic acid,
Lamotrigine, Gabapentin & Topiramate
• Calcium channel blocker- Verapamil
• Antipsychotics

Antimanic(Lithium carbonate)
• Lithium as an antimanic drug was first discovered by FJ Cade in
1949.
• Indications –
Acute mania
Prophylaxis for bipolar and unipolar mood disorder
Schizoaffective disorder
Cyclothymia
Impulsivity and aggression
Others like bulimia nervosa, trichotillomania, cluster headache,
borderline personality disorder.

Mechanism of action-
• Exact mechanism is unknown, however it probably works by-
 accelerating presynaptic reuptake and destruction of
catecholamine.
Inhibiting the release of catecholamine
Decreasing postsynaptic serotonin receptor sensitivity.

Interaction-
• Increased renal excretion of lithium with acetazolamide, osmotic diuretics,
and theophylline.
• Decreased renal excretion of lithium with NSAIDsand thiazide diuretics.
• There is an increased risk of neurotoxicity with carbamazepine, haloperidol,
or methyldopa.
• Fluoxetine or loop diuretics may result in increased serum lithium levels.
• Increased effects of neuromuscular blocking agents or tricyclic
antidepressants,
• Use of lithium with phenothiazines may result in neurotoxicity,

Dosage-
• 900-2100 mg in 2-3 divided dose.
Blood lithium level-
• Therapeutic level- 0.8-1.2 mEq/litre
• Prophylactic level- 0.6-1.2 mEq/litre
• Toxic lithium level - >2.0 mEq/litre

Pharmacokinetics-
• Well absorbed orally
• Neither protein bound nor metabolized
• Kidney handles lithium in much same way as sodium.
• Plasma half life is 16-30 hrs.

Contraindication and precaution-
• Hypersensitivity
• Cardiac or renal disease
• Dehydration
• Sodium depletion
• Brain damage
• Pregnancy and lactation.
• Caution with thyroid disorders, diabetes, urinary retention, history of
seizures, and with the elderly

Adverse drug reaction-
• Neurological
Tremors,
Motor hyperactivity
Muscular weakness
• Renal
Polydipsia
Polyuria
Nephrotic syndrome
• CVS
T-wave depression
• Dermatological
Acne eruption
Exacerbation of psoriasis
• Gastrointestinal
Nausea, vomiting
Diarrhea
Abdominal pain
Metallic taste
• Endocrine
Abnormal thyroid function
Goiter
Weight gain
• Others
Teratogenicity
Ebstein’s anomaly
Toxicity in infant

Lithium toxicity-
• The margin between the therapeutic and toxic levels of lithium carbonate is very
narrow.
• Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L
• Symptoms include:
At serum levels of 1.5 to 2.0 mEq/L: Blurred vision, ataxia, tinnitus, persistent
nausea and vomiting, severe diarrhea.
At serum levels of 2.0 to 3.5 mEq/L: Excessive output of dilute urine, increasing
tremors, muscular irritability, psychomotor retardation, mental confusion,
giddiness.
At serum levels above 3.5 mEq/L: Impaired consciousness, nystagmus, seizures,
coma, oliguria/ anuria, arrhythmias, myocardial infarction, cardiovascular collapse.

Lithium toxicity-
• Lithium levels should be monitored prior to medication administration.
• The dosage should be withheld and the physician notified if the level reaches 1.5
mEq/L or at the earliest observation or report by the client of even the mildest
symptom.
• If left untreated, lithium toxicity can be life threatening.
• The client must consume a diet adequate in sodium as well as 2500 to 3000 ml of
fluid per day.
• Accurate records of intake, output, and client’s weight should be kept on a daily
basis.

Nursing management-
• Take medication on a regular basis
• Not drive or operate dangerous machinery
• Not skimp on dietary sodium intake.
• Avoid “junk” foods.
• The client should drink six to eight large glasses of water each day
• Avoid excessive use of beverages containing caffeine (coffee, tea, colas), which
promote increased urine output.
• Notify the physician if vomiting or diarrhea occurs.
• Carry a card or other identification noting that he or she is taking lithium.
• Notify the physician as soon as possible if pregnancy is suspected or planned.

Nursing management-
• Be aware of side effects and symptoms associated with toxicity.
• Notify the physician if any of the following symptoms occur: persistent nausea and
vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive output of urine,
increasing tremors, or mental confusion.
• Refer to written materials furnished by health care providers while receiving self-
administered maintenance therapy.
• Keep appointments for outpatient follow-up; have serum lithium level checked
every 1 to 2 months, or as advised by physician.

Drugs usedin child psychiatry
Clonidine
• Used to control withdrawal symptoms from opioids, Tourette’s disorder, aggression
and autism
• It is an alpha 2 adrenergic receptor agonist
• Dose is 0.1 mg BD
• Side effects are dry mouth, dryness of eye, fatigue, irritability, sedation, dizziness,
nausea, vomiting, hypotension and constipation.

Methylphenidate (Retalin)
• Used in attention deficit and hyperkinetic disorder, narcolepsy, depressive disorder
and obesity.
• It is sympathomimetic drug
• Dosage is 5-10 mg/day orally
• Side effects are dyspepsia, weight loss, slowed growth, dizziness insomnia,
nightmares, tics and psychosis

Antabuse drugs (Disulfiram)
• It is used in the de-addiction from alcohol.
• Its main effect is to produce a rapid and violently unpleasant reaction in a person
who ingests even a small amount of alcohol while taking disulfiram.
• It cause flushing, headache, nausea and vomiting if a person drinks alcohol while
taking drug
• One dose of disulfiram usually effective for 1-2 weeks.
• Overdose can be dangerous, causing low blood pressure, chest pain, shortness of
breath and even death.

Psychopharmacology

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