JOURNAL TRANSCRIPT

---

PHARMACOLOGIC AND PSYCHIATRIC MEDICINE 7 CONTACT HOURS By: Staff Writer

Learning objectives ●● Understand the responsibility of each health care professional caring for a patient with a psychiatric disorder. ●● Identify the most common psychiatric disorders in the United States. ●● Discuss the ways psychopharmacological medications work differently in individuals based upon their age, sex, genetic make-up and lifestyle.

●● Identify the medications prescribed for the most common psychiatric disorders. ●● Identify the typical uses, administration process, side effects and potential for abuse or dependence of various psychotherapeutic medications.

Introduction Psychiatric medicine is all around us. It may even be part of life for our families, our friends, colleagues or ourselves. In the past, the skewed stereotype of a psychiatric/mental patient was that of a person walking down the hall, delusional, disheveled and ready to hurt someone. Health care professionals should be attuned to the reality of psychiatric medicine, the illnesses and how we can work with our colleagues and patients to ensure that affected individuals are able to live safely and be in control of their disease process. According to the National Institute of Mental Health (NIMH) (2009), psychiatric disorders are common in the United States (U.S) and internationally. An estimated 26.2 percent of Americans ages 18 and older – about one in four adults – suffer from a diagnosable psychiatric disorder in any given year. When applied to the 2004 U.S. Census residential population estimate for people ages 18 and older, this figure translates to 57.7 million people. Even though psychiatric disorders are widespread in the population, the main burden of illness is concentrated in a much smaller proportion – about 6 percent, or 1 in 17 – who suffer from a serious psychiatric illness. In addition, psychiatric disorders are the leading cause of disability in the U.S. and Canada for people ages 15-44. The World Health Organization (WHO) lists depression, alcohol use, bipolar disorder, schizophrenia and obsessive-compulsive disorders among the 10 leading causes of disability [9]. Many people suffer from more than one psychiatric disorder at a given time. Nearly half (45 percent) of those with any psychiatric disorder meet criteria for two or more disorders, with severity strongly related to comorbidity [12]. Because of the declining economy in the past two years, more people are presenting to their primary care doctor, psychiatrists, psychologists or any health care professional who will listen with a new onset of stress, anxiety, depression, bipolar disorder or feelings of suicide. Health care professionals who listen to Nursing.EliteCME.com

the patient and recognize the symptoms can help ensure the patient is safe and receives the appropriate treatment modality. However, it can be very challenging because of an overlap of symptoms, disorders and coinciding substance abuse that may mimic or gear the novice health care professional to an inaccurate diagnosis and treatment plan. It can pose a detrimental challenge in treatment, especially if the patient is misdiagnosed. Psychiatric medicine has many elements to it and may be overwhelming at times. Nurses and others should always refer to guidelines, resources and professional colleagues to help direct the appropriate care for each patient. This course will focus on the most common psychiatric disorders and aims to ensure that health care professionals responsible for patient care understand the illnesses and pharmacological treatment modalities. There are many pharmacological agents available, and it is impossible to memorize every aspect of each medication prescribed. However, it is important to understand the basic principles of the pharmacological agents; doing so will help health care professionals to predict the use, side effects and possible drug interactions common in drug classifications. Psychiatric medications are called psychotropic or psychotherapeutic drugs and are necessary and beneficial because they can change the lives of people with psychiatric disorders for the better. But the majority of most psychiatric disorders cannot be cured, so it is important that patients be prescribed the appropriate medication that, if taken as prescribed, will help them function safely in their daily lives. Many people with mental disorders live fulfilling lives with the help of these medications. Without them, people with mental disorders might suffer serious and disabling symptoms.

Page 1

The central nervous system and psychiatric medicine Psychiatric disorders have been linked to specific neurochemical imbalances that are amenable to pharmacological interventions [18]. There are thousands of neuronal signals that race throughout our brains every minute, controlling our breathing, movement, thoughts and emotions. Neurotransmitters carry information from one neuron to another. If neurons are over-stimulated, they will fire in the absence of an appropriate stimuli, leading to seizures or bipolar-mania. In contrast, if there are too few neurotransmitters binding to the postsynaptic receptors, which occurs in depression, the treatment will be directed to help release neurotransmitters that are being stored [14]. Because numerous pathways in the brain use the same neurotransmitter, manipulating transmission in a diseased pathway simultaneously affects the synapses of normal neurons. That is why central nervous system medications are notorious for causing a variety of complications [14]. Although there are more than 100 confirmed or suspected neurotransmitters, they fall into four major categories, and only the first three will be explored because they affect psychiatric medicine [9, 14, 15]: ●● Acetylcholine is in a class by itself. It is formed by acetic acid (acetate) and choline. It mediates cognitive function by modulating another neurotransmitter indirectly. Acetylcholine contributes to the sleep-wake cycle. ●● Amino acids include glycine, glutamate, aspartate and y-aminobutyric acid (GABA). The main function of amino acids is to be the brain’s major “workforce.” Their presumed function is to slow down the body’s activity, which may affect seizures, dementia and anxiety. Antianxiety medications affect the GABA level. ●● Monoamines (biogenic amines) are synthesized from amino acids by removal of the -COOH group. The major monoamines are epinephrine, norepinephrine, dopamine and serotonin (5-hydroxytryptamine or 5-HT). It has been speculated that depression is caused by impaired monoamines (dopamine, epinephrine, norepinephrine and serotonin) neurotransmission.

○○ Dopamine 1 and 2 regulate complex motor activities or pleasurable sensations. ■■ The pathway along the substantia nigra to the basal ganglia controls movements. Deficiencies of dopamine in this area may result in movement disorders, such as Parkinson’s, and contributes to certain side effects found from antipsychotic medications. ■■ The pathway along the mesolimbic area is believed to be related to the pleasurable “high” sensations from substance abuse. If there is an overactivity of dopamine in this area, it may contribute to hallucinations and delusions. ■■ The pathway along the mesocarotical begins in the mid-brain and extends to the limbic cortex, which mediates both the negative and cognitive symptoms of psychoses. ■■ Epinephrine has limited presence in the brain and contributes to the “fight-flight” response. ■■ Norepinephrine regulates awareness of environment, attention, learning, memory and arousal. Deficient levels of norepinephrine may lead to mood disorders, poor concentration, depression, psychomotor retardation and fatigue. ■■ Serotonin contributes to the regulation of temperature. The pathways of serotonin originate in the brainstem. ■■ Deficiencies of serotonin may lead to depression, aggression, suicide and impulsive behavior. ■■ A high level may lead to anxiety disorders (fearful, avoidance). Although potential implications are addressed for each neurotransmitter, the latest research implies that an abnormality in one neurotransmitter alone does not definitely lead to mental illness. Rather it is the result of alterations in several neurotransmitters.

The psychiatric medical team The majority of psychiatric disorders are treated on an outpatient basis by a primary care provider. However, there are severe psychiatric disorders that require an inpatient setting with the expertise of a psychiatrist, psychologist, nurses, social workers and mental health technicians. Each institution may be set up slightly differently based upon the clientele, needs of the patients and funding. Regardless of the set-up, it is imperative that each patient be respected and provided due diligence care. According to the NIMH, approximately 90 percent of individuals with a psychiatric illness will improve or recover if they receive appropriate treatment. Psychiatrists and other physicians treating mental illnesses have a wide variety of treatments available today to help them help their patients. A psychiatrist has attended medical school, is a physician and therefore holds a medical doctoral (M.D.) license. In Page 2

residency, he or she received specialized training in the field of psychiatry. The medical psychiatrist is able to assess, diagnose and treat the patient with pharmacological agents. Most often, psychiatrists will work with their patients to construct a treatment plan that includes both psychotherapy and a psychiatric medication. The specific pharmacological regimen combined with other treatments such as individual psychotherapy, group therapy and behavioral therapy or selfhelp groups help millions of patients every year to return to normal, productive lives in their communities, living at home with loved ones and continuing to work. A psychologist usually holds a Doctor of Philosophy degree (PhD), Doctor of Psychology (PsyD) or a Doctor of Education (EdD). Generally, if he or she is in clinical practice, the degree will be in clinical psychology or psychology counseling. With Nursing.EliteCME.com

the exception of holding a PsyD (a purely clinical degree), all psychologists have had extensive training in research and have completed an original scientific study, a doctoral dissertation, as a major part of the training. The psychologist collaborates with a psychiatrist to provide new solutions for patients coping illness and stressors. Most nurses who work in mental health are a registered nurse (RN) and hold a minimum of an associate or bachelors degree. In an in-patient setting, the nurses will typically rotate in different capacities such as: ●● Admissions or the intake RN, who assesses each patient upon arrival to the inpatient facility. From the moment the patient walks in the door, the nurse is the initial person to greet the patient and to build a rapport during the assessment process. It is important to establish a therapeutic, trusting relationship – but that can be a challenge based upon the patient’s diagnosis, drug use or condition upon arrival. Therefore, it is crucial that psychiatric nurses be patient and reassuring, and that they remind patients that they are safe. In psychiatric care, safety is one of the main priorities. It is important to keep the patient and other patients and staff safe at all times. In psychiatric medicine, patient admission to a unit may be voluntary or involuntary [20]: ○○ Voluntary admission is a person’s autonomous decision to seek in-patient treatment by submitting a formal, written request. The majority of patients who seek voluntary treatment have typically tried outpatient therapy, but it was unsuccessful. Patients who are admitted voluntarily are free to request to leave. Once the patient requests to leave, the admitting physician and interdisciplinary team will decide whether leaving is appropriate and safe for the person. Based upon the protocols of the facility, there is typically a grace period from 24 hours to several days before the team has to finalize its decision. Although patients may have admitted themselves voluntarily, if they are a threat to themselves or others, the status may change to involuntary at any time based upon the decision of the interdisciplinary team. ○○ Involuntary admission requires verification that the patient is mentally ill, a danger to him- or herself or others and unable to care for him- or herself. There are different ways a patient may be brought to the facility as an involuntary admission. ■■ Police “parens patriae” allows the state to take responsibility for those who cannot care for and/ or are considered a danger to themselves. Every state designates guidelines and laws for defining involuntary admission. ●● Staff/floor RNs will be assigned a group of patients and will be responsible for assessing the patients’ neurological status, behavior and safety. It is important that staff/floor RNs be attuned to body language and non-verbal cues to ensure the safety of all. Most inpatient facilities utilize contracts to facilitate communication of expected behaviors. One of the most common nurse-patient contracts is known as a “no-self harm contract” in which patients agree not to harm themselves, but instead to seek help of the staff if Nursing.EliteCME.com

they should have that urge or desire to do so [9]. The staff is to help the patient seek other ways of dealing with stress, conflict or distress. ●● Medication RN will be responsible for administering medications, assessing side effects, potential health concerns and medication education for each of the patients on the unit for the day. The interdisciplinary team includes not only physicians and nurses, but a phenomenal team of professional social workers, occupational therapists, mental health technicians, speech therapists and dietitians, to name a few. All members of the team are vital to the success of each patient. In the majority of most mental health institutions, the team frequently meets to discuss the patient and plan of care. Health care professionals are accustomed to obtaining an informed consent on each patient before initiating any interventions and treatment modalities. However, in psychiatric medicine, it may be challenging because a patient’s frame of mind may be inappropriate or he/she may be unable to comprehend the true implications of the form that must be signed. Regardless, all patients seeking psychiatric care, whether voluntary or involuntary, have federal rights that should be upheld at all times. These include the [9]: ●● Right to appropriate treatment and related services. ●● Right to an individualized, written treatment or service plan. The plan should be developed after the admission process and reassessed as needed. ●● Right to ongoing participation in a manner that is appropriate to the patient’s capabilities. ●● Right to be provided with reasonable explanations, in terms and language appropriate to the patient’s condition (mental and physical) and his or her ability to comprehend. ●● Right not to receive a mode or course of treatment in the absence of informed, voluntary, written consent to treatment except during an emergency situation or as permitted by law when a person is being treated as a result of a court order. ●● Right not to participate in experimentation in the absence of informed, voluntary, written consent (including human subjection protection). ●● Right to freedom from restraints or seclusion, other than as a mode or course of treatment or in an emergency with a written order by a responsible mental health professional. ●● Right to humane treatment that provides protection from harm. ●● Right to access on request his or her own mental health care records. ●● Right to converse with others privately, to have convenient and reasonable access to the telephone, mail and scheduled visits. ●● Right to be informed promptly and in writing at the time of admission. ●● Right to assert grievances when these rights are infringed. ●● Right to referral to other providers upon discharge.

Page 3

Psychopharmacology medications and psychiatric disorders Medications work differently for different people. Some people get great results from medications and only need them for a short time. For example, a person with depression may feel much better after taking a medication for a few months, and may never need it again. People with disorders such as schizophrenia or bipolar disorder or people who have long-term or severe depression or anxiety may need to take medication for the rest of their lives. Before a medication receives FDA approval, it has undergone extensive clinical trials in phases that on average last approximately eight to 10 years. If a medication is approved, the FDA provides the indicated label (the use) [9]. However, the FDA bases approval of psychotropic agents on descriptive diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). All psychiatric diagnoses for adults and children are published and characterized by the American Psychiatric Association, DSM-IV. The manual serves as a guide for all health care professionals caring for patients with psychiatric disorders because it lists the known causes of these disorders, statistics in terms of gender, age at onset and prognosis as well as some research concerning the optimal treatment approaches [5]. One of the major reasons patients stop complying with their medication regimen is the significant side effects that will be mentioned throughout this course. Unfortunately, because physicians cannot predict who will endure the potentially horrific side effects, it is important that patients and families are properly educated so a physician may make changes as needed in a patient’s medication regimen. Some people get side effects from medications, and others do not. Doses can be small or large, depending on the medication and the person. Factors that can affect how medications work in people include [9, 11]: ●● Type of mental disorder, such as depression, anxiety, bipolar disorder and schizophrenia. The use of two or more drugs in the same family or with similar pharmacologies for patients who have more than one mental disorder or require more than one drug is called polypharmacy. Polypharmacy increases the risk of adverse effects, drug interactions, patient non-compliance and medication errors [9]. Although polypharmacy may be necessary, it is imperative that health care professionals always ask about each medication that the patient is taking to prevent any unnecessary, lifethreatening effects. ●● Age, sex and body size of the patient. Psychiatric disorders affects patients of all backgrounds, but some groups have special needs, including children and adolescents, older adults and women who are pregnant or may become pregnant. ○○ Children and adolescents. Most medications used to treat young people with mental illness are safe and effective. However, many medications have not been studied or approved for use with children. Researchers are not sure how these medications affect a child’s growing body. Physicians often will prescribe an FDA-approved medication on an “off-label” basis for children even though the medicine is not approved Page 4

for the specific mental disorder or age. Therefore, it is important to watch young people who take these medications. Young people may have different reactions and side effects than adults. In addition to pharmacological agents, other treatments for children with mental disorders should be considered, such as psychotherapy, family therapy, educational courses and behavior management [11]. ○○ Older adults. Because older people often have more medical problems than other groups, they tend to take more medications than younger people, including prescribed, over-the-counter and herbal medications. As a result, older people have a higher risk for experiencing bad drug interactions, missing doses or overdosing. Older people also tend to be more sensitive to medications. Even healthy older people react to medications differently than younger people because their bodies process it more slowly. Therefore, lower or less frequent doses may be needed. Sometimes memory problems affect older people who take medications for mental disorders. An older adult may forget his or her regular dose and take too much or not enough. A good way to keep track of medicine is to use a sevenday pillbox, which can be bought at any pharmacy. At the beginning of each week, older adults and their caregivers fill the box so that it is easy to remember what medicine to take. Many pharmacies also have pillboxes with sections for medications that must be taken more than once a day. ○○ Women who are pregnant or may become pregnant. The research on the use of psychiatric medications during pregnancy is limited. The risks are different depending on the medication and at what point during the pregnancy the medication is taken. Research has shown that antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), are safe during pregnancy. The research on SSRIs and pregnancy varies; some studies indicate birth defects or other problems are possible, but they are very rare. Some research also suggests the use of SSRIs during pregnancy is associated with miscarriage or birth defects because antidepressant medications do cross the placental barrier and may reach the fetus. ■■ Studies have also found that fetuses exposed to SSRIs during the third trimester may be born with withdrawal symptoms, such as breathing problems, jitteriness, irritability, trouble feeding or hypoglycemia. Most studies have found that these symptoms in babies are generally mild and shortlived, and no deaths have been reported. On the flip side, women who stop taking their antidepressant medication during pregnancy may get depression again and may put both themselves and their infants at risk. In 2004, the FDA issued a warning against the use of certain antidepressants in the late third trimester. The warning said that doctors might want to gradually taper pregnant women off antidepressants in the third trimester so that the baby Nursing.EliteCME.com

will not be affected. After a woman delivers, she should consult with her doctor to decide whether to return to a full dose during the period when she is most vulnerable to postpartum depression. ■■ Some antipsychotic medications should not be taken during pregnancy, such as [11]: ■■ Benzodiazepines in the first trimester because of the potential for birth defects. The benzodiazepine Klonopin should never be taken during the entire pregnancy because it can cause teratogenic effects to the unborn baby. ■■ Mood stabilizers are known to cause birth defects. Benzodiazepines and lithium have been shown to cause “floppy baby syndrome,” which describes a baby who is drowsy and limp, and cannot breathe or feed well. Research suggests that taking antipsychotic medications during pregnancy can lead to birth defects, especially if they are taken during the first trimester. But results vary widely, depending on the type of antipsychotic. The conventional antipsychotic haloperidol has been studied more than others, and has been found not to cause birth defects. ■■ One of the biggest concerns for pregnant women comes after the delivery of the baby, when the mother should be assessed for post-partum depression. All women are at risk for post-partum depression after the delivery of their babies and for up to one year later. The risk is higher if the woman had a history of depression or stopped taking her medication during the pregnancy. ■■ In addition, women who nurse while taking psychiatric medications should know that a small amount of the medication passes into the breast milk. However, the medication may or may not affect the baby. It depends on the medication and when it is taken. Women taking psychiatric medications and who intend to breastfeed should discuss the potential risks and benefits with their doctors. Decisions on medication should be based on each woman’s needs and circumstances. Medications should be selected based on available scientific research, and they should be taken at the lowest possible dose. Pregnant women should be watched closely throughout their pregnancy and after delivery. ●● Co-morbidities and physical illnesses need to be considered because a patient’s psychological state may affect care

●●

●●

●● ●●

for other co-morbidities. In addition, if a patient is on other medications to treat other illnesses, psychological pharmacological agents may affect the absorption. Habits, such as drinking caffeine, smoking or drinking alcohol. It is estimated that 50 to 75 percent of individuals with severe mental illness have a substance abuse problem [9]. It is important to assess an accurate daily consumption of caffeine, packs of cigarettes and number of alcoholic drinks because each one plays a significant role in the efficacy of psychotropic medications. ○○ Caffeine changes the normal pH of gastric acid, thus altering drug absorption. A patient who ingests more than 225 milligrams (mg)/day will need a larger amount of medication to ensure adequate absorption and maintain a therapeutic response. Caffeine also stimulates the release of excitatory neurotransmitters (norepinephrine) and has a pharmacological makeup that is similar to amphetamines and cocaine in that it stimulates the frontal lobes of the brain, increasing energy and concentration. Research has demonstrated that caffeine is the most devastating, legally available stimulant that patients with mood disorders can ingest [9]. ○○ Smoking is one of the most closely scrutinized legal addictive drugs. Many patients taking psychotropic drugs are addicted to nicotine. Researchers have speculated the reason smokers with schizophrenia require a higher dose is nicotine’s effects on dopamine and serotonin. Smoking also causes the indirect ingestion of arial carbons (carbon monoxide). Liver and kidney function because most drugs are absorbed, metabolized or excreted in these major organs. Therefore, patients who are prescribed many of the medications listed here should be followed closely by the prescribing doctor so that the proper laboratory work may be completed. Genetics should be considered because the majority of psychiatric diagnoses have a familial/genetic link. Other medications and herbal/vitamin supplements that may increase or decrease the effectiveness of the prescribed pharmacological regimen to help control psychiatric symptoms. It is important that health care professionals ask patients about all prescribed, over-the-counter and herbal medications they take daily.

Alzheimer’s disease Alzheimer’s disease (AD) is a progressive form of dementia that affects both cognition and behavior with no apparent cause or cure. Eventually the patient affected by AD loses all cognitive, analytical and physical capabilities [11]. The most common initial symptom of AD is the patient complaining of vague “forgetfulness.” Over time, the symptoms intensify and the pharmacological treatment includes the following [11]: ●● Cognitive: Symptoms include memory loss (poor recall, losing items); aphasia (circumlocution and anomia); apraxia; agnosia; and disorientation (impaired perception of Nursing.EliteCME.com

time and unable to recognize familiar people). Medications prescribed are geared to improve symptoms, especially to improve or maintain cognition. The most common medications prescribed are cholinesterase inhibitors and vitamin E. ○○ Cholinesterase inhibitors delay cognitive decline in patients with Alzheimer’s disease. Cholinesterase inhibitors do not improve the ability to do things, but they do slow the loss of these skills and can make people with AD less apathetic. The benefits of Page 5

cholinesterase inhibitors are temporary; improvements are noticed within three months after initiating the drug followed by a slow return to the starting point nine to 12 months later [9]. ■■ Donepezil (Aricept) is a piperidine derivative with specificity for inhibiting acetylcholinesterase rather than butrylcholisterase. It is approved for treatment of impaired cognition in mild to moderate severe AD based upon the mini-mental state examination (MMSE) score 10 to 16. Patients taking Aricept typically have improvement in cognition for the first six to nine months, followed by a gradual decline. The initial dose is 5 mg once a night with a potential adjustment every four to six weeks. Maintenance dose is 5-10 mg/day. The most common side effects include nausea, vomiting, diarrhea, dizziness, headache, insomnia and hepatotoxicity. ■■ Rivastigmine (Exelon) has a central activity at acetylcholinesterase and butyrylcholinesterase sites, but low activity at the sites of the periphery. Exelon is designed to improve and/or stabilize cognition for approximately nine to 12 months. The initial dose is 1.5 mg twice a day as a capsule or oral solution (BID) with a potential adjustment every two weeks. The maintenance dose recommended is 3-6 mg BID; maximum dose is 6 to 12 mg/day. Exelon may be administered by mouth or as a patch. The most common side effects include insomnia, fatigue, rash, nausea, vomiting, dyspepsia, anorexia and abdominal pain. □□ If administered as an oral solution, it should be administered directly from a syringe provided or mixed with a glass of water, cold fruit juice or soda. The mixed oral solution is stable for four hours. □□ If applied as a transdermal patch, it should be placed on a clean, dry, hairless area that will not be rubbed by tight clothing. Recommended areas include the upper or lower back, upper arm or chest. The sites should be rotated every 24 hours to prevent irritation, and the same site should be avoided for 14 days. ■■ Galantamine (Reminyl) is a cholinesterase inhibitor that also has activity as a nicotinic receptor agonist. Reminyl has improved cognitive abilities for about nine months. The initial dose is 4 mg BID with food and a potential adjustment every four weeks. The pills are available in intermediate-release tablets (4mg/day) or extended release capsules (8mg/day) [18]. The maintenance dose recommended is 8-12 mg BID. Side effects are similar to those of Aricept and Exelon. ■■ Memantine (Namenda) is an antagonist of the N-methyl – D-aspartate (NMDA) receptor, which is indicated for the treatment of moderate to severe AD. It is typically tolerated well with limited side effects, which may include constipation, confusion, dizziness, headache, coughing and hypertension. Namenda is prescribed as a monotherapy and in combination with cholinesterase inhibitors. The initial dose is 5 mg once a day with a potential Page 6

adjustment weekly by 5mg/day to the effective maintenance dose of 10 to 20 mg/day. ■■ Vitamin E is an antioxidant that has been studied over the years in AD because of free radicals. The effectiveness of vitamin E in AD patients has not been determined at this time. ●● Noncognitive: Depression, psychotic symptoms (hallucinations, delusions), behavioral disturbances (physical and verbal aggression, motor hyperactivity, uncooperativeness, wandering, repetitive mannerisms and activities, and combativeness). ○○ Physicians and psychiatrists may prescribe secondary medications to lessen psychotic symptoms, inappropriate or disruptive behavior and depression. Psychotropic medications should be monitored closely, titrated frequently, documented appropriately and periodically reduced to prevent unwarranted side effects. In addition, nurses should be watchful for potential anticholinergic side effects that may worsen cognition and further exacerbate side effects, especially in the elderly patient. ■■ Antidepressants may be required in patients with AD; however, it may be a difficult diagnosis because many of the symptoms overlap. Therefore, before initiating an antidepressant, the patient’s symptoms should be discussed and examined over a few weeks by the caregiver. If the physician concurs with the assessment findings, serotonin reuptake inhibitors (SSRIs), such as Celexa and Zoloft, have been recommended as the first-line drugs. (See the section Depression and antidepressants for further information on SSRIs.) ■■ Antipsychotics are prescribed if a patient exhibits behaviors such as assault, extreme agitation, hyperexcitability, hallucinations, delusions, suspiciousness, hostility and uncooperativeness. Other symptoms may include withdrawal, apathy, cognitive deficits, wandering and incontinence. □□ Risperidone (Risperdal) is prescribed for patients with dementia who exhibit coinciding psychotic symptoms. The recommended initial dose is 0.25 mg daily, titrated in 0.25 to 0.5 mg increments up to 1 mg a day. (See the section Psychoses and antipsychotics for further information.) □□ Other antipsychotics that may be considered include [3,9]: Quetiapine (Seroquel), an alternative for patients who are unable to tolerate Risperdal. Aripiprazole (Abilify) and Ziprasidone (Geodon); these require further studies for AD patients. □□ Olanzapine (Zyprexa) is not beneficial for patients with AD because of anticholinergic side effects.

Nursing.EliteCME.com

Anxiety disorders and anti-anxiety medications Anxiety disorders are various disease processes in which anxiety and irrational symptoms impair daily functioning. Anxiety disorders affect 40 million adults in the United States and are the most common psychiatric disorder. Anxiety disorders typically present in the 20- to 45-year-old age group, with higher incidences amongst women. Pediatric prevalence rates vary, but approximately 20 percent of children under 18 years of age experience anxiety [9]. Anxiety is defined subjectively as an unpleasant state of physical and psychological arousal that interferes with effective psychosocial functioning [6]. For most people, mild anxiety is a normal fact of life that can be positive, linked to life events such as a marriage, moving, a new job or the birth of a baby. Throughout our lives, the causes of stress and our ability to adapt will be different. For example, in young adults, the sources of stress are found in marriage or parent-child relationships, employment and the struggle to achieve financial stability. In the middle years, the focus shifts to spousal relationships, problems with aging parents and problems with younger children encountering stressful situations. In old age, the primary stressors are adapting to retirement, loss of physical capabilities and the losses of a spouse, parents and friends [8]. Severe or chronic anxiety may become debilitating. Although stress and anxiety are inevitable, they can be overwhelming when other compounding, unexpected issues are encountered. As health care professionals, we should never judge others for the way they respond to stress. Individuals may react to a stressor by facing it head-on, by laughing it off, exercising, doing something therapeutic for themselves – or they may become anxious or depressed, have an influx of physical symptoms, run away, drink or start an affair [8]. Anxiety has two classifications: 1. The first is stress and adjustment disorders (situational disorders). Stress and anxiety may be manifested by restlessness, irritability, fatigue, feeling of tension, inability to concentrate, sleep disturbances (insomnia, bad dreams), and somatic preoccupations that can lead to alcohol or other central nervous system dependence [8]. Initially, an individual encountering stress and anxiety that is overwhelming can typically be treated on an out-patient basis by suggesting the following treatment plan [6, 8]: ○○ Behavioral-stress reduction techniques, such as rebreathing in a bag for hyperventilation for immediate symptom relief. Other techniques include, but are not limited to early recognition and removal from a stressful situation, keeping a log or journal, exercising and relaxation techniques. ○○ Therapists may be able to help the individual establish the framework of the problem because the patient’s own denial may prevent the person from seeing the true issue at hand. If the therapists are able to help the patient clarify the problem, the person may begin to view it appropriately and make the necessary healthy changes. 2. The second form is anxiety disorders and dissociative disorders. This form of anxiety is overt anxiety or an overt manifestation of coping mechanism, such as a phobia, Nursing.EliteCME.com

or both. Researchers and medical professionals believe that the various manifestations of anxiety are not a result of unconscious conflicts, but habits (persistent patterns of nonadaptive behavior acquired by learning) [5]. The patient with this severe form of anxiety may be able to function in a job because it is structured. However, on the weekends when life is “free-flowing” and often with no structure, the individual can feel lost, spiraling with psychological forms of anxiety (tension, fear, difficulty concentrating, apprehension), somatic issues (tachycardia, hyperventilation, palpitations, tremor, sweating), problems with other organ systems (gastrointestinal), and fatigue or decreased sleep. The anxiety may be exacerbated by stimulants such as caffeine, alcohol, cocaine and smoking. The most common anxiety/dissociative disorders include generalized anxiety disorder (GAD), panic attacks, phobias and post-traumatic stress disorder (PTSD). The symptoms of anxiety are typically manifested in multiple dimensions: affective, cognitive, behavioral and somatic. ○○ Generalized anxiety disorder is the most common of the anxiety/dissociative disorders and is characterized by chronic and excessive worry and anxiety more days than not for at least six months [9]. GAD initially manifests between the ages of 20 and 35, with a higher incidence in women. The most common symptoms include apprehension, worry and irritability; difficulty concentrating; insomnia; and somatic complaints (tachycardia, high blood pressure, nausea, epigastric pain, headache, near syncope) for more days than not for at least six months. ○○ Panic attacks are characterized by a discrete period of intense apprehension or terror without a “real” danger, coinciding with at least four of 13 somatic or cognitive symptoms. Patients who experience a panic attack perceive the situation as a real event and will have physiologic reactions such as chest pain, choking or feeling smothered, dizziness, dyspnea, faintness, palpitations, paresthesias, sweating and vertigo. The panic attacks usually last approximately five to 20 minutes, but may continue for one hour [9]. ○○ Phobia is a persistent, irrational fear attached to an object or situation that objectively does not pose a significant danger. The affected patient experiences anticipatory anxiety followed by compelling desires to avoid the dreaded object or situation [9]. Phobias are always anticipated and never unexpected. Patients who experience panic disorders and phobias are diagnosed with panic disorder. ○○ Panic disorders are characterized by short-lived, recurrent, unpredictable episodes of intense anxiety that coincide with physiological manifestations, such as agoraphobia (fear of being in places where escape is difficult, or open spaces and public places), resulting in the person feeling the need to be confined to his/ her home to avoid these fears). Somatic complaints may be distressing at times, such as dyspnea (trouble breathing), tachycardia, palpitations, dizziness, paresthesias, choking, feeling smothered, bloating Page 7

and a sense of doom. Approximately 30 percent of these individuals will experience recurrent sleep panic attacks that will further exacerbate their symptoms and confinement. Panic disorders are familial, with a typical onset before age 25. They affect 3 to 5 percent of the population and occur more in women. Interestingly, many patients frequently undergo emergency medical interventions, such as a contemplated “heart attack” or “hypoglycemia” event before the correct diagnosis is made. Approximately 25 percent of patients with panic disorders also have obsessive-compulsive disorder (OCD). Panic disorders respond most effectively to benzodiazepines, such as lorazepam (Ativan) or clonazepam (Klonopin). ○○ Post-traumatic stress disorder is a syndrome among the anxiety disorders characterized by “re-experiencing” a traumatic event, (such as a rape, severe burn, military combat) and decreased responsiveness and avoidance of current events associated with trauma. With PTSD, a patient’s physiological response includes a vast array of hyperarousal symptoms that include being easily startled, intrusive thoughts, illusions, overgeneralized associations, sleep problems, impulsivity, difficulties in concentration and hyperalertness. If PTSD persists longer than three months, the disorder is referred to as chronic PTSD. The most common medications for the treatment of anxiety include anti-anxiety/anxiolytics, barbiturates, benzodiazepines and antidepressants. Each pharmacological agent is prescribed to treat various forms of anxiety to enhance the actions of the inhibitory neurotransmitter GABA. ●● Anti-anxiety/anxiolytics are reserved for the treatment of generalized anxiety disorder, acute anxiety, social phobia, performance anxiety, simple phobias and short-term relief of insomnia. Anti-anxiety response requires two to four weeks before alleviating anxiety. ○○ Buspirone (BuSpar) is approved for the treatment and management of anxiety. Although the mechanism of action is unknown, it binds serotonin receptors and lacks anticonvulsants, sedative and muscle relaxant properties [9]. BuSpar does not have the anticonvulsant, muscle relaxant or hypnotic properties. The typical dose is 7.5 mg BID, increasing by 5 mg/day every two to four days as needed [3]. Typical dose is 20-30 mg/day in two divided doses. BuSpar requires one to two weeks before it alleviates the anxiety symptoms, and maximal effects take six weeks. The most common side effects of BuSpar are dizziness, headaches, nausea, nervousness, lightheadedness, excitement and trouble sleeping. BuSpar should be avoided in a patient with renal or liver impairment. It is important to avoid confusing buspirone with bupropion (Wellbutrin), an antidepressant. ■■ Effects of BuSpar will be decreased in patients who drink alcohol (ETOH) or take other central nervous system (CNS) depressants, such as fluoxetine (Prozac). ■■ Effects of BuSpar will be increased in patients concurrently drinking grapefruit juice or taking erythromycin, itraconazole or nefazodone.

Page 8

●● Barbiturates bind to the receptor adjacent to the GABA receptor on the chloride channels that result in an increase in chloride through the channel. Barbiturates induce sedation, euphoria, other mood alterations, hypnosis, “barbiturate fast waves” on an electroencephalogram (EEG) and respiratory depression. At higher doses, it may result in cardiovascular depression or death. Barbiturates are not used as frequently as benzodiazepines because of their significant, serious complications and are typically prescribed more for epileptic seizures or as a component of anesthesia. The most common barbiturate is phenobarbital (Ancalixir, Luminal, Solfoton), but it is not typically prescribed for anti-anxiety treatment. ●● Benzodiazepines have always been the mainstay drugs of choice for the treatment of anxiety disorders, although research has not demonstrated more effectiveness than antidepressants [9]. Benzodiazepines bind to the benzodiazepine site on neuronal GABA receptors as it enhances the GABA-mediated chloride influx (neuronal inhibition). Benzodiazepines enhance or diminish the inhibitory effects of y-aminobutyric acid (GABA) receptor. Benzodiazepines are the most effective and safest medications for the treatment of acute anxiety symptoms. Acute anxiety symptoms typically improve within two weeks of initiating therapy. ○○ Benzodiazepines induce sedation, skeletal muscle relaxation and “barbiturate fast waves” on the EEG and may have anticonvulsant effects. The sedating effects of benzodiazepines are enhanced with concurrent use of narcotics or alcohol. Benzodiazepines are generally prescribed for the treatment of anxiety and neurotic states, nervousness, psychosomatic illness, delerium tremors, skeletal muscle relaxer and as an anticonvulsant. ○○ The most common side effects of benzodiazepines are patient and dose dependency. The longer the patient uses a benzodiazepine, the more it has the potential to lose its efficacy. Therefore as the dose increases, so do the levels of sedation, disinhibition (impulsivity, disregard for proper social behavior), ataxia (lack of muscle coordination), dysarthria (motor speech disorder resulting from neurological injury that results in poor articulation aphasia) and nystagmus (involuntary eye movement). Health care workers may recognize signs of dependence by recognizing withdrawal symptoms (especially if the patient has used benzodiazepines longer than four months) based upon the half-life of the specific drug. The half-life for short-acting benzodiazepines is one to two days, and for long acting benzodiazepines, it is two to five days. However, they may be seen up to seven to 10 days after discontinuation, and symptoms may last for one to three weeks [9]. Symptoms of withdrawal from benzodiazepines include anxiety, irritability, tremulousness, sweating, lethargy, diarrhea, insomnia, depression, abdominal and muscle cramps, vomiting and convulsions. Before initiating a benzodiazepine to a patient, there is some important education that should be addressed [3,9]: Nursing.EliteCME.com

■■ The patient should avoid any alcohol, grapefruit juice, over-the-counter medications with antihistamines, or drinking alcohol or driving while taking any benzodiazepine. ■■ Avoid abrupt withdrawal of the medication. If benzodiazepines are abruptly discontinued, the patient may have immediate rebound symptoms within 24 to 48 hours. The most typical withdrawal symptoms include anxiety, insomnia, agitation, muscle tension, irritability, delusions, hallucinations or seizures). ■■ Always assess each medication that the patient is taking to avoid polypharmacy and educate the patient about the importance of not taking another benzodiazepine from anyone but their prescribing physician. Over the years, there has been a lot of media attention to the accidental tragic deaths of many individuals who have died from taking benzodiazepines with other medications, overdosing or mixing it with alcohol. Overdosage results in respiratory depression, hypotension, shock syndrome, coma and death. If available, the antidote is flumazenil (Anexate), a benzodiazepine antagonist that can be administered for complete or partial reversal. But as noted, benzodiazepines should be prescribed with diligent care to avoid over-prescribing or high doses that pose a risk of dependence. ■■ Use benzodiazepines with caution with the elderly because of potential central nervous system effects. In older patients, it is important to assess for CNS effects and the risk of falls and to make sure fall prevention strategies are implemented [3]. ■■ Short-acting benzodiazepines are short acting, water soluble and used frequently in anesthesia. ●● Alprazolam (Xanax) has antidepressant and anti-anxiety actions. It is frequently used for generalized anxiety disorder, panic attacks and anxiety associated with depression [3]. Unlike most benzodiazepines, it does not cause daytime drowsiness. The usual daily dose is 0.25 mg to 1 mg three times a day (TID); maximum dose of 4 mg. Half-life is 6 to 20 hours. The most common side effects include depression, lethargy, apathy, fatigue, lightheadedness, disorientation, constipation and dry mouth. ●● Lorazepam (Ativan) is another anti-anxiety agent that does not cause daytime sedation. The usual daily dose is 2 to 4 mg/day with a maximum dose of 4 mg. If the patient is enduring a panic attack, Xanax or Ativan may be administered sublingual to increase the onset of action. Ativan may help with short-term anxiety; however, the patient may experience withdrawal symptoms if discontinued abruptly. Ativan should be tapered by 0.05 mg every three days to decrease potential withdrawal symptoms [3]. If an individual continues to take it longer than four months, there is a chance the patient may develop dependency on the medication. The most common side effects of Ativan include dizziness, memory problems, sedation, transient amnesia, unsteadiness and weakness. ●● Midazolam (Versed) is the most common used benzodiazepine in anesthesia, but not typically prescribed for anxiety because of its significant sedative effects. Nursing.EliteCME.com

●● Oxazepam (Serax) is an ideal short-term agent reserved for patients with hepatic disease and the elderly because it does not rely on the liver for metabolism. Serax is typically prescribed for anxiety associated with depression. The typical dose is 10 to 30 mg/day with a maximum of 60 mg. Similar to Ativan, Serax should be tapered at the completion of therapy (0.5 mg every three days) to avoid withdrawal symptoms (insomnia, irritability, nervousness and tremors) [3]. ●● Temazepam (Restoril) is not typically prescribed for anxiety because it causes significant drowsiness; therefore, it is ideal for insomnia. The typical daily dose is 15 mg every night as needed for sleep with a maximum of 30 mg/per night. ●● Triazolam (Halcion) is ideal for insomnia. The typical dose is 0.125 mg/day, with a maximum of 0.25 mg. ●● Long-acting benzodiazepines are the most rapidly absorbed. They are metabolized in the liver to activate metabolites that prolong the duration of the actions. However, they are metabolized slowly in infants, the elderly and individuals with hepatic disease. Long-acting benzodiazepines are ideal for the treatment of alcohol withdrawal and anxiety symptoms. ○○ Clonazepam (Klonopin) is indicated for anxiety disorders and panic disorders. Avoid confusing it with Clonodine. The typical dose is 1 to 2 mg/day with a maximum of 10 mg/day. If the dose needs to be increased, slowly increase by 0.5 to 1 mg every three days [3]. The most common side effects include behavioral changes, drowsiness and ataxia. Klonopin may be overdosed if serum concentrations are greater than 80 mg/ml. Overdose symptoms of Klonopin include extreme drowsiness, confusion and lightheadedness. ○○ Clorazepate (Tranxene) is used for anxiety disorders and alcohol withdrawal. The typical dose is 7.5-15 mg/ (two to four times a day). In geriatric patients, the dose should be lower, 3.75 to 15 mg/day [3]. The most common side effects include dizziness, drowsiness and lethargy. Tranxene has the potential for dependence if used for a prolonged time or in high doses. It should be used with caution, and the patient should be assessed frequently for continued use. ○○ Chlordiazepoxide (Librium) has the longest duration of action and is used for anxiety disorders. It may also be used for the treatment of alcohol withdrawal. Librium may be administered by mouth (po), intramuscular (IM) or intravenous (IV), with the typical daily dose being 10 to 20 mg/day; a maximum dose can be up to 100 mg/day. ○○ Diazepam (Valium) is indicated for anxiety disorders. Typical dose is 2 to 10mg/day with a maximum of 30 mg/day. Half-life is 20 to 50 hours. The most common side effects include mild drowsiness initially, sedation, depression, lethargy, apathy, fatigue, lightheadedness, disorientation, restless, confusion, urinary retention, changes in libido and drug dependence with a withdrawal syndrome. If administered intravenously (IV), the nurse should assess the site frequently for phlebitis and venous thrombosis [3].

Page 9

There is never a magic pill and/or an ideal regimen for each patient. Therefore, every patient should be assessed individually to ensure the appropriate pharmacological treatment is provided. Other medications that may be prescribed for anxiety disorders include, but are not limited to [8]: ●● Anticonvulsants, such as gabapentin (Neurontin), 900 to 1,800 mg/day in three divided doses; maximum time between doses should not exceed 12 hours because the half-life is about five to seven hours. Never exceed 2,400 to 3,600 mg/day. The most common side effects are dizziness, insomnia, somnolence and ataxia. Neurontin should not be taken within two hours of an antacid. ●● Antidepressants are the first-line alternative drugs of choice for long-term treatment of chronic anxiety, especially generalized anxiety and panic attacks. (See Depression and antidepressants for further elaboration on antidepressants.) ○○ Generalized anxiety disorder: Because of the potential anxiogenic effects of antidepressants and anti-anxiety agents, venlafaxine (Effexor) is usually started low, 37.5 to 75 mg/day, with a usual dose of 75 to 225 mg. Other antidepressants that may be given include Paxil (paroxetine).

○○ Panic attacks. Antidepressants, such as serotonin reuptake inhibitors (SSRIs), are the drug of choice for panic attacks. The dose should always be started low and then gradually increased to avoid possible initial agitation with the initiation of an SSRI. High-potency benzodiazepines may be used for symptomatic treatment as the antidepressant is being titrated up. ○○ Antihistamines. First-generation sedation antihistamines such as diphenhydramine (Benadryl). ○○ Beta-blockers, propranolol (Inderal) 80 to 160 milligrams (mg) daily may also be prescribed for severe anxiety, GAD or PTSD to decrease the peripheral symptoms of anxiety, such as tremors and palpitations. Although the beta-blocker may help alleviate the physical signs related to anxiety, it does not control or treat the anxiety [9]. The most common side effects of beta-blockers include fatigue, nightmares, cold hands, dizziness and weakness. In addition, beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms. Like benzodiazepines, beta-blockers should never be abruptly discontinued to avoid rebound anxiety symptoms.

Attention deficit/hyperactivity disorder (ADHD) Attention deficit/hyperactivity disorder (ADHD) occurs in both children and adults. ADHD is commonly treated with stimulants, such as: ●● Methylphenidate (Ritalin, Metadate, Concerta and Daytrana) has actions similar to those of amphetamines as they block the dopamine transporter and release dopamine from the terminals [9]. ○○ The NIMH funded a research study on ADHD, the Preschoolers with Attention Deficit Hyperactivity Disorder Treatment Study, which involved 300 preschoolers (3 to 5 years old) diagnosed with ADHD. The study found that low doses of the stimulant Ritalin are safe and effective for preschoolers. However, children of this age are more sensitive to the side effects of the medication, including slower growth rates, so children taking Ritalin should be watched closely. Parents should check children’s weight two to three times a week and report any loss to a health care professional [3]. ○○ Ritalin is contraindicated in patients with glaucoma, motor tics and severe depression because of the pharmacological actions of blocking dopamine [9]. It is usually administered in oral tablets 5 to 20 mg and in sustained release (18 and 36 mg), 30 minutes before eating. The most common side effects of Ritalin include nervousness, insomnia, anorexia, bradycardia and hypotension [20]. Ritalin may be administered to children 6 years and older. ●● Amphetamine (Adderall) is a mixed amphetamine and d-amphetamine that is administered in a capsule formula 5 to 30 mg BID, with a maximum 60 mg. The half-life is two to four hours. The most common side effects include hyperactivity, dry mouth, insomnia, restlessness, tremor, palpitations, tachycardia and anorexia. It may be

administered to children 6 years and older. Parents should be encouraged to administer it to their children at least six hours before bedtime to avoid sleep disturbances. ●● Dextroamphetamine (Dexedrine, Dextrostat) is administered in 5-10 mg tablets (normal range 5 to 60 mg/ day by mouth). The most common side effects include overstimulation, restlessness, dizziness, insomnia, unpleasant taste, tachycardia and hypertension. It may be administered in children 6 years and older. It also affects the growth of children, whose weight should be checked frequently. ●● Atomoxetine (Strattera). In 2002, the FDA approved the nonstimulant medication atomoxetine (Strattera) for use as a treatment for ADHD. In February 2007, the FDA approved the use of the stimulant lisdexamfetamine dimesylate (Vyvanse) for the treatment of ADHD in children ages 6 to 12 years. ○○ The typical dose of Strattera is 40mg/day by mouth with a goal of 80 mg and a maximum 100 mg/day if weighing over 70 kilograms (kg). If the patient weighs less than 70 kg, the dose is 0.5 mg/kg per day by mouth with a goal of 1.2 mg/kg per day as a single dose in the morning, not to exceed 1.4 mg/kg or 100 mg/day (whichever is less) [9]. One of the most significant side effects of Strattera is injury to the liver, so parents should be encouraged to assess for pruritus, dark urine, jaundice, right upper quadrant pain/tenderness and flulike symptoms) [3]. ○○ The most common side effects of the two pharmacological agents Vyvanse and Strattera include [11]: ■■ Decreased appetite. Children seem to be less hungry during the middle of the day, but are often hungry by dinnertime as the medication wears off. ■■ Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower dose. The doctor might also suggest that parents give the medication to

Page 10 Nursing.EliteCME.com

their child earlier in the day, or stop the afternoon or evening dose. To help ease sleeping problems, a doctor may add a prescription for a low dose of an antidepressant or a medication called Clonodine. ■■ Stomachaches and headaches. ■■ Less common side effects include repetitive movements (tics). The tics may be so subtle that they may not be noticeable. Another potential but rare side effect is a change in a child’s personality, such as appearing “flat” or without emotion. It is important that the parents discuss the side effects with the prescribing physician to help eliminate the tics. ○○ Strattera carries another potentially life-threatening warning. Studies show that children and teenagers with ADHD who take Strattera are more likely to have suicidal thoughts than children and teenagers with ADHD who do not take it. Therefore, the parents should be educated to monitor their child’s behavior daily while taking Strattera because the symptoms may develop suddenly. The most significant side effects of Strattera that require a follow-up appointment with the physician include [11]: ■■ Acting more subdued or withdrawn than usual. ■■ Feeling helpless, hopeless or worthless. ■■ New or worsening depression.

■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

Thinking or talking about hurting himself or herself. Extreme worry. Agitation. Panic attacks. Trouble sleeping. Irritability. Aggressive or violent behavior. Acting without thinking. Extreme increase in activity or talking. Frenzied, abnormal excitement. Any sudden or unusual changes in behavior.

In 2007, the FDA required that all makers of ADHD medications develop patient medication guides. The guides must alert patients to possible heart and psychiatric problems related to ADHD medicine. The FDA required the guides because a review of data found that ADHD patients with heart conditions had a slightly higher risk of strokes, heart attacks and sudden death when taking the medications. The review also found a slightly higher risk (about 1 in 1,000) for medicationrelated psychiatric problems, such as hearing voices, having hallucinations, becoming suspicious for no reason or becoming manic. Ironically, the new psychotic symptoms occurred in patients without a past medical history of psychiatric problems. Therefore, the FDA recommends that any treatment plan for ADHD include an initial health and family history examination.

Depression and antidepressant medications Depression is another prevalent condition seen in primary care and is associated with a higher morbidity, mortality, lost productivity, diminished quality of life and increased health care costs. Depression is not related to the normal reaction to various tragedies and/or sad events, but a constellation of signs and symptoms. Health care professionals should not assume that when an individual feels “down” that the person is depressed, because substance abuse and/or chronic health conditions (such as rheumatoid arthritis, multiple sclerosis and chronic heart disease) can play a role [8]. Other depressive disorders involve disturbances in emotional, cognitive, behavioral and somatic regulation [17]. Depression is classified as one of the following [11]: ●● Major depressive disorder (MDD), also called major depression, is characterized by a combination of symptoms that interfere with a person’s ability to work, sleep, study, eat and enjoy once-pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person’s lifetime, but more often, it recurs throughout a person’s life. MDD is a primary disorder not associated with non-mood psychiatric disorders (eating disorders, panic attacks and obsessive-compulsive disorder), substance abuse or medical conditions. Instead, it is an intense sadness or loss of interest in usual activities, accompanied by poor appetite, insomnia, psychomotor agitation or retardation, decrease in sexual drive, fatigue, feelings of worthlessness, decreased concentration or thoughts of death or suicide [14]. MDD episodes last several weeks to several months, followed by periods of normal mood and behavior. The average major Nursing.EliteCME.com

episode lasts four months, but may last up to 12 months without remitting [9]. ○○ The elderly are often misdiagnosed as being depressed, or their symptoms are confused with “normal aging.” ●● Dysthymic disorder, also called dysthymia, is characterized by long-term chronic depression (two years or longer) but with less severe symptoms that may not disable a person but can prevent him or her from functioning normally or feeling well. Dysthymia affects 1.5 percent of people over 18 years [20]. People with dysthymia may also experience one or more episodes of major depression during their lifetimes. ●● Some forms of depressive disorder exhibit slightly different characteristics than those described above, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression, which include [11]: ○○ Childhood depression, which often is not taken seriously but is real. Approximately 1-2 percent of pre-pubertal children and 3-8 percent of adolescents are depressed [9]. ○○ Psychotic depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations and delusions. ○○ Postpartum depression, which is diagnosed if a new mother develops a major depressive episode within one month after delivery. Post-partum depression is a serious form of depression that has a higher incidence among women with a history of psychiatric disorders, interpersonal difficulties, post-partum blues or Page 11

significant life-events [9]. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth. ○○ Post-partum blues is a normal phenomenon that occurs shortly after birth by many women, with the new mom being happy yet tearful at times. Ironically, she does not feel sad, just emotional at these times. It is normal and fades within the first weeks of delivery. ○○ Post-partum depression is an abnormal depression that may occur up to 12 months after delivering a baby. With post-partum depression, the woman has intense sadness, anxiety, hopelessness and may exhibit signs of not caring for her new baby or herself. It is important that health care professionals routinely screen for postpartum depression because it can lead to a neglect or harm to the baby, especially if the mom experiences psychoses. All pregnant women as well as their spouses or caretakers should be educated about post-partum blues and depression in a non-threatening manner so that symptoms may be recognized and help sought before any harm occurs. ●● Seasonal affective disorder (SAD), which is characterized by the onset of a depressive illness during the winter months when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy. Antidepressants are commonly prescribed for patients with depression. However there are numerous risks involved, and it is imperative that a patient be accurately diagnosed and not undertreated before an antidepressant is prescribed [18]. It is thought that antidepressants work by playing a neuroprotective role in how they relieve anxiety and depression. It is thought that antidepressants may increase the effects of brain receptors that help nerve cells keep their sensitivity to glutamate, an organic compound of a nonessential amino acid. Therapeutic effects of antidepressants vary from individual to individual because of many factors, such as genetics, severity of depression, age, compliance and resources, to name a few. A non-modifiable factor, genetics, varies based upon how the individual’s serotonin reuptake receptor works and inherited chromosomes [7]. It is important that the patient be properly diagnosed and monitored to assess for suicidal ideations. The most serious consequence of depression is suicide, which occurs among the depressed at a rate of 30 times that of nondepressed people [17, 18]. Antidepressant medications are often the first treatment choice for adults with moderate or severe depression, sometimes along with psychotherapy. Psychotherapy often is tried as an initial treatment for mild depression and in combination with antidepressants for moderate to severe depression. Psychotherapy may help to determine the severity and persistence of the depression and whether antidepressant medications may be warranted. Types of psychotherapies include cognitive behavioral therapy, which helps people learn new ways of thinking and behaving, and interpersonal therapy,

which helps people understand and work through troubled personal relationships [13]. Although antidepressants may not cure depression, they can help control the symptoms. Once an antidepressant is initiated, it takes approximately two to six weeks for relief of symptoms [9]. There a few different classes of antidepressants, with the most commonly prescribed being the selective serotonin reuptake inhibitors (SSRIs), followed by serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs) and other antidepressants. Sometimes finding the right antidepressant is a matter of trial and error. It is important to assess the patient for mania symptoms after starting an antidepressant, especially SSRIs. In an undiagnosed bipolar patient, antidepressants may precipitate a mania phase that can be dangerous [9]. The most common antidepressants are as follows [11, 14]: ●● SSRIs and SNRIs are the most popular because they do not cause as many side effects as older classes of antidepressants, pose no risk of lethal overdose and are effective in 70 percent of the cases for chronic depression [20]. The most common side effects associated with SSRIs and SNRIs are headache, nausea, sleeplessness or drowsiness, agitation or sexual problems. Most patients taking antidepressants say they feel either energized or drowsy, so health care professionals must take the time to listen to what might seem like bothersome complaints. Most side effects are short-term and will resolve or diminish. But if they are affecting the patient’s life, other pharmacological agents should be considered. The most serious potential complication with SSRIs is the risk of serotonin syndrome, a potentially fatal condition that includes elevated serotonin levels, tachycardia, hypertension, fever, sweating, shivering, confusion, anxiety, restless, disorientation, tremors, muscular spasms and rigidity. The risk factors for serotonin syndrome include any of the following [8, 9]: ○○ Concomitant use of another class of antidepressant, especially MAOIs. It is usually more troublesome in the elderly. ○○ Inadequate time between discontinuing the use of one antidepressant and initiating the use of another. ○○ Combined use of serotonergic agonists with SSRIs. ○○ Combined use of SSRIs with St John’s wort. Tell patients to avoid taking most antidepressants, including SSRIs, with grapefruit juice. If serotonin syndrome should occur, the SSRI should temporarily be withdrawn safely and the patient should be started on antianxiety meds, such as Valium or a calcium channel blocker (Inderal) to control the cardiac symptoms. In addition, a patient should never abruptly withdraw an SSRI and the SNRI venlafaxine (Effexor) because it can produce a significant drop in serotonin levels. Unfortunately, health care professionals are unable to predict which patient may experience symptoms related to abruptly withdrawing the drug, such as electrical surges in the head (brain shivers), body sensation of pins and needles, blackouts, memory loss, agitation or flu-like symptoms [20]. It is recommended that SSRIs and SNRIs be discontinued gradually over a period of weeks or months.

Page 12 Nursing.EliteCME.com

SSRIs target the reuptake of serotonin only, and they are the most popular and considered the first-line drug for depression. SSRIs immediately block neuronal transport of serotonin, thus stimulating many post-synaptic receptors sites. The SSRIs are listed from most to least energizing, Prozac, Zoloft, Celexa, Lexapro and Paxil. SSRIs are usually the drug of choice for children and adolescents because of their minimal side effects and lower risk of overdosing [9]. SSRIs are used to treat depression, OCD and bulimia nervosa. ●● Fluoxetine (Prozac) is one of the most common SSRIs prescribed although it should be noted that 15 percent of patients discontinue the drug because of nausea, headaches, nervousness, anxiety, altered platelet function or a rash. The usual dosage is 5 to 40 mg, with a maximum of 80 mg, and the half-life is one of the longest of all the SSRIs, lasting up to 84 hours. Therefore, it is not ideal for the elderly. Because of the long half-life, it takes weeks to reach therapeutic levels. Prozac has an increased suicide rate compared to other antidepressants. Relief of symptoms typically occurs in the first four weeks. ●● Sertraline (Zoloft) treats depression, OCD and panic disorders. The most common side effects are nausea, headaches, diarrhea, dry mouth, dizziness, insomnia, fatigue, impotence and altered platelet function. The usual dosage is 50 to 150 mg, with a maximum of 200 mg, and the half-life is 26 hours. The relief of symptoms usually begins within the first two to four weeks. ○○ Both Prozac and Zoloft should be avoided with a patient taking a MAOI because of the risk for stroke. Therefore, if a patient has been taking a MAOI and it is discontinued because of a physician’s recommendation to initiate Prozac or Zoloft, the patient should be off the MAOI for two weeks beginning the new medication. ●● Paroxetine (Paxil) is used to treat depression, OCD and panic disorders. The most common side effects are nausea, vomiting, somnolence (drowsiness), insomnia, dizziness, agitation, anxiety, weakness, headache, abnormal ejaculation and altered platelet function. Research in the past few years has demonstrated that a patient is two times at risk of cardiac abnormalities with Paxil. Paxil is prescribed once a day, and the dose should be reduced with any renal/hepatic insufficiency. Cimetidine (Tagamet) increases Paxil, whereas Paxil increases phenytoin (Dilantin) and digoxin (Lanoxin). The usual dosage of Paxil is 20 to 30 mg, with a maximum of 50 mg. Paxil has one of the shortest half-lives (1 hour) of all the SSRIs except Luvox, so the patient must be told to always make sure to take it every day to ensure that it will work. Relief of symptoms usually begins within one to four weeks. ●● Citalopram (Celexa) is used to treat depression. The usual dose of Celexa is 20 mg, with a maximum of 40 mg a day, and the half-life is 33 hours. Relief of symptoms usually occurs within four to six weeks. ●● Trazodone (Desyrel) is used to treat depression. The usual initial dose is 150 mg/day, with an increase of 50 mg/day every three to four hour days; maximum dose should not exceed 600 mg/day in divided doses. Relief of symptoms may occur in 10 days to one month.

Nursing.EliteCME.com

●● Escitalopram (Lexapro). The usual dosage is 10 mg, with a maximum of 20 mg; the half-life is 27 to 32 hours. Relief of symptoms usually occurs within four to six weeks. ●● Nefazodone (Serzone) inhibits the uptake of serotonin and norepinephrine. The typical dose is 200 mg/day in two divided doses. It may be increased 100 to 200 mg/day every week, with a maximum of 300 to 600 mg/day. Relief of symptoms may occur in two to four weeks. ○○ Serzone is contraindicated with cisapride (Propulsid) or pimozide (Orap). Propulsid was removed from the U.S drug market in 2004 because of an association with serious cardiac arrhythmias, such as QT prolongation, ventricular tachycardia (VT) or death. Serzone increases the effects of Halcion and Xanax ●● Fluvoxamine (Luvox) is also used to treat OCD, and the most common side effects are nausea, dry mouth and weakness. It is contraindicated with a patient taking cisapride. Luvox is is started at 50 mg nightly and can be increased in 50 mg increments at four- to seven-day intervals to a maximum of 300 mg, which typically will be split into two doses. Relief of symptoms usually begins within two to four weeks. SNRIs target the reuptake of norepinephrine, are similar to SSRIs and include: ●● Venlafaxine (Effexor), which inhibits the serotonin and norepinephrine uptake and is used to treat depression and anxiety. Effexor is usually well tolerated without significant anticholinergic or cardiovascular side effects. The most serious side effects are hypertension, photosensitivity, nervousness and profuse sweating [5]. The usual dose is 150 to 225 mg, maximum of 225 mg administered by mouth two to three times a day. ●● Duloxetine (Cymbalta), with the usual dosage of 20 to 30 mg BID, maximum of 60 mg. The most common side effects include fatigue, drowsiness, insomnia, decreased appetite, decreased sweating and decreased libido [3]. Similar to Strattera, liver damage may occur, so educate the patient and families about the signs to monitor. ○○ Both SNRIs (Effexor and Cymbalta) are ideal pharmacological agents for the patient experiencing both depression and anxiety. ●● TCAs: At one time, TCAs were the first-line pharmacologic treatment for depression, but now are reserved for major depression or when an SSRI or SNRI is ineffective. TCAs may also be prescribed in the treatment of agoraphobia, panic attacks, OCD, chronic pain, neuralgia and migraine headaches. TCAs’ mechanism is still not understood by many, but it is speculated that they work by blocking the reuptake of monoamine and serotonin, therefore increasing the synaptic levels of the transmitters. Over time, because there are higher concentrations of the monoamine neurotransmitter circulating, fewer receptors are needed on the post-synaptic membrane [14]. The most significant side effects with all TCAs are the undesirable anticholinergic effects (blurred vision, dry mouth, urinary retention), cardiotoxicity, sedation, orthostatic hypotension, weight gain, constipation, bladder problems, sexual disorders (impotence, lack of interests) and obstructive jaundice. The anticholinergic effects vary Page 13

based upon the drug, and the history of the patient should be considered. TCAs are well absorbed and widely distributed. TCAs are usually given as a single dose at bedtime, starting at a lower dose [8]. TCAs also come with dangerous warnings, similar to SSRIs, such as the consequences of abruptly withdrawing from the medication, which can lead to malaise, chills, coryza (common head cold symptoms) and muscle aches. TCAs also should never be administered with MAOIs because it can be a lethal combination. Other medications that should be taken with caution or avoided with TCAs include but are not limited to anticoagulants (increased risk of bleeding), and clonodine (severe hypotension).

●●

●●

●●

●●

●●

●●

The most drastic potential consequence of TCAs is suicide. Once the symptoms have improved (typically two to four weeks), the patient should be monitored closely because the risk of suicide increases when the patient starts to feel better [9]. Amitriptyline (Elavil) is the most prescribed TCA by non-psychiatrists and has the most severe anticholinergic and sedating effects. The initial dose is 75 to 100 mg/day in divided doses (maximum of 300 mg) administered po/IM, with a half-life of 30 to 45 hours. The relief of symptoms usually occurs in two to four weeks. Doxepin (Sinequan) is very sedating and has substantial anticholinergic effects. The dosage is 25 to 50 mg by mouth three times a day (maximum of 300 mg/day), administered po with a half-life of 10 to 25 hours. Relief of symptoms usually occurs in two to four weeks. Desipramine (Norpramin, Pertofrane) is prescribed frequently because it has fewer anticholinergic and sedating side effects. The dosage is 100 to 250 mg, with a maximum of 300 mg, administered po with a half-life of 10 to 25 hours. Norpramin appears to be most effective when plasma levels are between 100 and 250 ng/ml [8]. Imipramine (Tofranil) is the original TCA and is prescribed less often today because of its potential quinidine-like side effects that may induce arrhythmias. The dosage is 150 to 200 mg, with a maximum of 300 mg, administered po/IM, and a half-life of 10 to 25 hours. Tofranil appears to be most effective when plasma levels are between 200 and 250 ng/ml [8]. Relief of depression symptoms usually occurs gradually over two to four weeks, but anxiety may be decreased immediately. Nortriptyline (Pamelor) is one of the most effective TCAs because of its clinical efficacy, although it has both anticholinergic and sedating side effects. However, it may not be the ideal medication for the elderly because of an increased risk of confusion. The usual dosage is 100 to 150 mg, with a maximum of 150 mg, administered po with a half-life of 18 to 45 hours. Pamelor appears to be most effective when plasma levels are between 50 and 150 mg/ day [8]. Relief of symptoms may occur in three to seven days or up to three weeks. Amoxapine (Asendin) is prescribed only for depression, and it has anticholinergic, sedative and neuroleptic malignant syndrome side effects. The usual dosage is 150 to 200 mg, with a maximum of 400 mg. The onset of action

●●

●●

●●

●●

can be within hours, but on average, it is 4-14 days after initiation of therapy. Asendin has the shortest half-life of the TCAs at 18 to 45 hours. ○○ Neuroleptic malignant syndrome (NMS) is a rare, but potentially life-threatening event characterized by fever, muscular rigidity, altered mental status and autonomic dysfunction. It may occur with other potent neuroleptics, such as Haldol. All antipsychotic agents, typical or atypical, may precipitate the syndrome, including other agents such as prochlorperazine (Compazine), promethazine (Phenergan), clozapine (Clozaril), and risperidone (Risperdal). It has also been associated with other non-neuroleptic agents that block central dopamine pathways such as metoclopramide (Reglan) and lithium. It is thought to occur because blockage of dopamine neurotransmission in the nigrostriatum and hypothalamus results in muscular rigidity and altered thermoregulation, respectively. However, NMS can occur at any time during neuroleptic use, even years after initiating therapy [2]. (See Psychoses and antipsychotics for further elaboration) Protriptyline (Vivactil) has the least sedative and anticholinergic effects, but it has the longest half-life of 75 to 90 hours. The usual dosage is 15 to 40 mg in four divided doses, with a maximum of 60 mg. Similar to Pamelor, it also increases the risk of confusion in the elderly. Relief of symptoms can occur is as little as 24 hours. Clomipramine (Anafranil) is typically prescribed for OCD and unfortunately has very sedative effects. The usual dosage is 100 mg, with a maximum of 250 mg, administered po/IM, and a half-life of 20 to 35 hours. Anafranil can be lethal in a suicide attempt. Trimipramine (Surmontil) has very sedating effects and a half-life of 7 to 30 hours. The usual dosage is 75 to 200 mg, with a maximum of 200 mg a day. In addition to typical sedating and anticholinergic side effects, confusion (in the elderly), disturbed concentration, orthostatic hypotension, stroke, myocardial infarction and congestive heart failure can occur. Because of the significant side effects of TCAs, they are rarely given to a pediatric patient. The only exceptions are Tofranil and Elavil; both are useful in the treatment of enuresis (bedwetting) and ADHD in children with depression [9]. MAOIs work by blocking the metabolism of biogenic amines (norepinephrine, serotonin and dopamine), thus increasing the synaptic concentrations of these transmitters because all three levels will remain high in the brain, boosting the overall mood. MAOIs are typically prescribed to treat depression if SSRIs and TCAs are ineffective, when electroconvulsive therapy (ECT) fails or for “atypical” depression. ECT is a controversial form of electro-shock administered to severely depressed, catatonic or manic patients. MAOIs may also be prescribed for the treatment of narcolepsy, phobia, anxiety or Parkinson’s disease. The most common side effects of MAOIs are hepatotoxicity, headaches, vertigo, dizziness, orthostatic hypotension, and increased central nervous stimulation. Although abuse is unlikely, overdose may occur and result in agitation, hallucinations, hyperreflexia (exaggeration of reflexes),

Page 14 Nursing.EliteCME.com

hyperpyrexia (abnormal high fever), convulsions and altered blood pressure. Before a patient is prescribed a MAOI, it is imperative to assess their medications and diet history because of the potential effects of sympathomimetics that can lead to life-threatening events, such as hypertension crisis. The patient should avoid taking any ginseng herbals, diet pills, decongestants (phenylephrine, dextromethorphan and pseudoephedrine) and SSRIs (such as Prozac and Zoloft). In addition, the patient should avoid any tyramine foods (which increase norepinephrine) leading to a hypertension crisis, such as dairy (cheeses), meat, yeast products, fermented or aged meats (bologna, salami), broad bean pod (Chinese bean pods), liver, wines, soy sauce, shrimp paste, sauerkraut and pickles [8]. Foods and medicines that contain high levels of a chemical called tyramine are dangerous for people taking MAOIs. Normally, MAO breaks down tyramine, but because MAOIs inhibit MAO, tyramine may accumulate in the bodies of patients who take certain medications or eat tyramine foods [20]. Mixing MAOIs and tyramine can cause a sharp increase in blood pressure, which can lead to a stroke. If the blood pressure increases while taking a MAOI, the patient may be prescribed nifedipine (Procardia) 10 mg chewed and placed under the tongue to normalize the pressure within one to five minutes [8]. It is imperative that the nurse and patient consistently review the diet and pharmacological agents that can induce a hypertensive crisis. ○○ Tranylcypromine (Parnate), usual dosage is 20 to 30 mg in two divided doses. If there is no improvement within two weeks, the dosage should be increased 10mg/ day to a maximum of 60 mg/day. Symptoms may be relieved within 48 hours to three weeks. ○○ Phenelzine (Nardil) usual initial dosage is 15 mg three times a day, with a maximum of 90 mg/day. It may take up to four weeks to reach a maximum response. ○○ Isocarboxazid (Marplan) has a typical dose of 30 to 60 mg/day. Symptoms may be improved within three to six weeks. Over the past few years, transdermal MAOI patches were developed to help reduce the potentially significant complications as described above. However, the same dietary and OTC precautions still need to be implemented. The transdermal patch, Selegiline transdermal (EmSam) is a 6 mg patch that must be changed every 24 hours. The dose can be increased every two weeks to a maximum of 9 mg. Possible side effects includes headache and HTN. Relief of symptoms typically occurs within seven days [9].

●● Other atypical antidepressants is a classification for antidepressants that do not fit into a specific classification and whose mechanisms are unknown. It is believed that they affect both noradrenergic and serotonergic neurotransmitters. ○○ Maprotiline (Ludiomil) is similar to a TCA, but has fewer anticholinergic effects. Ludiomil may induce blood dyscrasias (pathological blood disorders). ○○ Mirtazapine (Remeron) is also similar to a TCA with few anticholinergic effects. Remeron is thought to work by enhancing central and serotonin activity [8]. Remeron has a unique ability to block two specific serotonin receptors, leading to minimal serotonergic side effects. Remeron treats depression and anxiety associated with depression. The most common side effects are low anticholinergic effects, orthostatic hypotension, sedation and agranulocytosis (severe, dangerous leukopenia – a low white blood cell count). The typical dose initially starts at 15 mg/day every night; it may be increased to 45 mg/day. ○○ Bupropion (Wellbutrin). Wellbutrin, which works on the neurotransmitter dopamine, is unique in that it does not fit into any specific drug type and it helps treat depression and cessation of smoking. The most common side effects include seizures, change in libido or sexual dysfunction, hepatotoxicity, tremor, nausea, vomiting, headaches and anticholinergic effects. Wellbutrin lowers the seizure threshold. Wellbutrin should be avoided by any individual with a history of seizures and/or eating disorders. Research has demonstrated that individuals with eating disorders who take Wellbutrin have a higher incidence of seizures caused by hyponatremia. The typical dose is 300 to 450mg/day. Relief of symptoms may occur within 10 to 14 days. Sometimes the pharmacological regimen may need to be altered in the best interest of the patient. Any time a medication is changed from one group to another, there should be an adequate “washout time.” If the medication is within the same group, such as an SSRI to an SSRI, no washout time is required. The Current Medical Diagnosis and Treatment guidelines (2010) recommend the following washout times [8]: ●● Switching from a MAOI to a TCA, allow two to three weeks between stopping one drug and starting another. ●● Switching from an SSRI to a MAOI, allow four to five weeks. Once the patient attains relief of symptoms, the medication should be for continued for 12 months in an effective maintenance dose. The full dosage should be continued indefinitely if the individual was diagnosed before the age of 20 or after the age of 50 [8].

Herbals For centuries, people have been using the herbal St. John’s wort to treat depression. The National Institute of Health (NIH) conducted a clinical research to determine the effectiveness of treating adults who have major depression with St. Johns wort. The study included 340 people diagnosed with major depression. One-third of the people took the herbal medicine, one-third took an SSRI and one-third took a placebo, or “sugar Nursing.EliteCME.com

pill.” The subjects participating in the study did not know what they were taking. The study found that St. John’s wort was no more effective than the placebo in treating major depression. A study currently in progress is looking at the effectiveness of St. John’s wort for treating mild or minor depression. Other research has shown that St. John’s wort can dangerously interact with other medications, including those used to control Page 15

human immunodeficiency virus (HIV). On February 10, 2000, the Food Drug Administration (FDA) issued a Public Health Advisory letter stating that the herb appears to interfere with

certain medications used to treat heart disease, depression, seizures, certain cancers and organ transplant rejection.

FDA warning on antidepressants Since 2005, the FDA has mandated a “black box” warning label for all antidepressant medication noting the drug may increase the risk of suicidal thinking or attempts in children and adolescents. To help clarify any misconceptions, it is important to convey that antidepressants are safe and popular, but that some studies have suggested that they may have unintentional effects, especially in young people. In 2004, the FDA looked at published and unpublished data on trials of antidepressants that involved nearly 4,400 children and adolescents. They found that 4 percent of those taking antidepressants thought about or tried suicide (although no suicides occurred), compared to 2 percent of those receiving placebos (sugar pill). In 2007, the FDA and National Institute of Mental Health (NIMH) proposed that makers of all antidepressant medications extend the warning to include young adults up through age 25 [13]. The warning also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders. At this time, Prozac is the only medication approved by the FDA for use in treating depression in children ages 8 and older. The other SSRI medications and the SSRIrelated antidepressants have not been approved for treatment of depression in children or adolescents, but doctors still sometimes prescribe them to children on an “off-label” basis. In June 2003, however, the FDA recommended that Paxil not be used in children and adolescents for treating major depression.

Prozac can be helpful in treating childhood depression, and can lead to significant improvement of depression overall. However, it may increase the risk for suicidal behaviors in a small subset of adolescents. As with all medical decisions, doctors and families should weigh the risks and benefits of treatment for each individual patient. Finally, the FDA has warned that combining the newer SSRI or SNRI antidepressants with one of the commonly used “triptan” medications used to treat migraine headaches could cause a life-threatening illness called serotonin syndrome. A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well if they are mixed with the wrong medications. Those who are prescribed an SSRI medication should receive ongoing medical monitoring. Children already taking an SSRI medication should remain on the medication if it has been helpful, but should be carefully monitored by a doctor for side effects. Parents should promptly seek medical advice and evaluation if their child or adolescent experiences suicidal thinking or behavior, nervousness, agitation, irritability, mood instability or sleeplessness that either emerges or worsens during treatment with SSRI medications. Once started, treatment with these medications should not be abruptly stopped. Although they are not habit-forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Families should not discontinue treatment without consulting their doctor. All treatments can be associated with side effects. Families and doctors should carefully weigh the risks and benefits, and maintain appropriate follow-up and monitoring to help control for the risks.

Bipolar disorder and mood stabilizers Bipolar disorders consist of episodic mood shifts that include mania, major depression, hypomania (persistent elevated, irritable mood) and mixed mood states. Bipolar is probably one of the most challenging disorders and often is initially misdiagnosed because its symptoms mimic other disorders, and the patient also may abuse other, illegal substances. Bipolar disorder is classified as either bipolar I, bipolar II or cyclothymic disorder. ●● Bipolar I is characterized by one or more manic episodes, alternating with major depression. Manic episodes are periods of abnormal and persistently elevated moods. Mania is a mood characterized by elation with hyperactivity, overinvolvement in life activities, increased irritability, flight of ideas, distraction and little need for sleep. Initially,

the behavior may appear intriguing to others because the individual is overexcited and “the life of the party.” However, the patient will also exhibit irritability, mood swings into depression, aggression and grandiosity of ideas and spending. During the patient’s manic state, the individual will typically exhibit lavish spending, resignation from a job or marriage, acting out sexually and alterations of friends. The episodes usually begin abruptly after a life stressor, and the patient has more depressed days than manic [8]. ●● Bipolar II is characterized by major depression and at least one hypomanic episode. Hypomania is a less severe form of mania without any psychosis and does not impair the individual’s function. Bipolar II is usually more difficult

Page 16 Nursing.EliteCME.com

to diagnose because the patient typically appears more depressed than manic, plus there are no psychoses involved. ●● Cyclothymic disorder is similar to bipolar I, but the symptoms are less severe. Patients experience repeated episodes of nonpsychotic depression and hypomania for at least two years (one year for children and adolescents). Cyclothymic disorder is usually diagnosed when the patient does not meet the DSM-IV criteria for bipolar. Bipolar disorder may be challenging to treat. Often the patient is initially misdiagnosed as being depressed started on an SSRI and the patient switches into a dangerous form of mania. The World Health Organization (WHO) lists bipolar as the sixth leading cause of global disability [20]. Therefore, to prevent this from occurring, the patient should be properly screened to ensure the appropriate regimen is initiated. The mainstay, firstline pharmacological treatment for bipolar is a mood stabilizer, which helps stabilize the depressive and manic cycles. In general, people continue treatment with mood stabilizers for years. Lithium has been the predominant treatment of mania for years, but other mood stabilizers include anticonvulsants. ●● Lithium is a very effective mood stabilizer. It was the first mood stabilizer approved by the FDA in the 1970s for treating both manic and depressive episodes. Lithium significantly decreases the frequency and severity of manic and depressive attacks in approximately 70 percent of patients [8]. Most patients will do well on lithium if they have no more than two manic episodes a year [8]. The usual doses of lithium are 600 mg po three times a day (TID) or 900 mg in slow-release form twice a day (BID) to produce serum levels between 1 and 1.5 mEq/liters in acute mania; and 300 mg po TID or four times a day (QID) for serum levels between 0.6 and 1.2 mEq/l [9]. Lithium usually takes several weeks of administration before reaching its full effect. Lithium can cause several side effects, and some of them may become serious, so the patient should be monitored closely to assess for the following symptoms [9, 11]: ○○ Lithium levels less than 1.5 mEq/L: ■■ Initially after starting lithium, the patient is lethargic because the blood level in the body is still low and not therapeutic. ■■ Slurred speech. ■■ Loss of coordination. ■■ Muscle weakness. ■■ Hand tremor. ■■ Nausea, vomiting and diarrhea. ○○ Lithium levels 1.5 to 2 mEq/L (mild to moderate toxicity levels): ■■ Coarse hand tremor. ■■ Mental confusion. ■■ Drowsiness. ■■ Lack of coordination. ■■ Gastrointestinal upset. ■■ Electrocardiographic changes. ○○ Lithium levels 2 to 2.5 mEq/l: ■■ Ataxia. ■■ Blurred vision. ■■ Stupor. ■■ Coma. ■■ Respiratory failure. Nursing.EliteCME.com

○○ Lithium levels above 2.5 mEq/l are considered lifethreatening: ■■ Respiratory depression. ■■ Death. Because of the potential adverse effects, it is imperative to ensure serum levels are drawn frequently because the two are significantly correlated. Life-threatening respiratory symptoms may occur if the lithium levels are greater than 2.5 mEq/L. Blood specimens should be drawn twice a week, eight to 12 hours after the previous dose was swallowed. Once the patient’s levels are therapeutic, blood should be drawn every two months. Relief of mania and/or severe depression symptoms takes several weeks to improve. Research has also demonstrated that more than 50 percents of patients with bipolar are refractory to lithium (the drug does not work or the patient cannot tolerate the side effects). Because of the potential serious complications with taking lithium, nurses should educate their patients on the need to [9]: ○○ Consume a steady diet of sodium in the diet while taking lithium because the kidneys cannot differentiate the excretion of sodium or salt. However, any increase or decrease in foods with salt will affect the effectiveness of lithium. For instance, an increase in salt in the diet will cause lithium to decrease. The same concept should be addressed in relation to hot weather or exercise because heavy sweating causes the body to lose water and salt from the body, thus increasing lithium levels and the potential risk of side effects. ○○ Avoid taking with any alcohol, sleeping pills or pain medications because lithium itself causes drowsiness. ○○ Avoid caffeine, which affects the effectiveness of lithium. Anticonvulsant medications also are used as mood stabilizers. They were originally developed to treat seizures, but they were found to help control mood and impulse-control in people with bipolar disorder. Some of the most common anticonvulsants used successfully as mood stabilizers include carbamazepine (Tegretol), divalproex sodium (Depakote), lamotrigine (Lamictal) and oxcarbazepine (Trileptal). ●● Tegretol is closely related to the chemical structure of a TCA. Tegretol is the third-most commonly prescribed pharmacological agent for mania. Tegretol has an ability to control aggressive and hostile symptoms and is ideal in the treatment of acute mania and long-term maintenance therapy. Tegretol is initially started at 200 mg po TID with a gradual increase up to 200 mg in divided doses (not to exceed 1200 mg/day). Potential side effects include dizziness, drowsiness, unsteadiness, vertigo, diplopia, blurred vision, aplastic anemia, fatal massive hepatic necrosis with total loss of intact liver tissue, and fatal cardiovascular complications. If the patient takes more than is prescribed, toxicity may result in stupor, coma, hyperirritability, convulsions and respiratory depression. ●● Depakote has been found to be effective for patients with mixed mania, multiple episodes and those with co-morbid substance abuse [20]. Depakote is the only drug that helps significantly reduce alcohol consumption in patients with dual-diagnosis. Depakote can cause damage to the liver or pancreas, so people taking it should see their doctors Page 17

regularly. Depakote may affect young girls and women in unique ways. Sometimes, Depakote may increase testosterone (a male hormone) levels in teenage girls and lead to a condition called polycystic ovarian syndrome (PCOS), a disease that can affect fertility and make the menstrual cycle become irregular. Symptoms tend to go away after Depakote is discontinued. It also may cause birth defects in women who are pregnant. The typical dose for Depakote is 750 mg by mouth QID, never to exceed 60 mg/ kg/day. For some people, it may work better than lithium. The most common side effects of Depakote include changes in weight, nausea or vomiting, and stomach pain. Potential life-threatening side effects include pancreatitis and hepatic failure [11]. ●● Lamictal is approved by the FDA for treatment of depression for monotherapy and adjunctive therapy for bipolar depression. Lamictal has decreased manic symptoms in 74 percent of patients, but a severe, rare, life-threatening rash may occur (Steven’s Johnsons syndrome) in 15 percent of the patients studied [20]. Therefore, nurses should always make sure that patients understand that if they develop a rash while taking anticonvulsants, they should immediately go to the emergency room (ER). In some cases, Steven’s Johnsons syndrome rash can cause permanent disability or be life-threatening. Lamictal is initially started at 50 mg/ day for two weeks then 10 mg/day in two divided doses for two weeks (maintenance dose is 300 to 500 mg/day B ID). Other potential dangerous side effects include toxic epidermal necrolysis with multiorgan failure. ●● Trileptal is an analogue of Tegretol, but is different in the composition. This slight difference reduces the risk of Trileptal causing aplastic anemia. It is initially started at 300 mg po BID with increases up to 1,200 mg. The most common side effects include dizziness, drowsiness, unsteadiness, hypo- or hypertension and hyponatremia. Relief of symptoms may occur within four to five hours. The FDA has issued warnings for Depakote, Lamictal, Tegretol and Trileptal that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional. There is a small percentage of patients with refractory mania (unresponsive to the mood-stabilizing agents). Unfortunately, it is debilitating to patients because they experience rapid cycling with dangerous, impulsive behaviors and severe depression [9]. The patient has a higher risk of morbidity and mortality

during the depressed, mixed phases. In 2007, the FDA approved Lamictal as the first-line treatment for refractory bipolar or alternative antipsychotic agents that are usually a first line for schizophrenia [9, 11]: ●● Clozapine (Clozaril), which is often used for people who do not respond to lithium or anticonvulsants. ●● Olanzapine (Zyprexa) helps people with severe or psychotic depression, which often is accompanied by a break with reality, hallucinations or delusions [11]. ○○ One of the biggest complications of Clozaril or Zyprexa is the development of diabetes and/or dyslipidemia because of weight gain. Other pharmacological agents that may be prescribed are further elaborated under Psychoses and antipsychotics, such as: ■■ Aripiprazole (Abilify), which can be taken as a pill or as a shot. ■■ Risperidone (Risperdal). ■■ Ziprasidone (Geodon). ○○ Symbyax, the first FDA-approved drug for the treatment of bipolar depression, is a combination of Zyprexa and Prozac. Symbyax is administered once a night 6/25 mg capsule. The most common side effects include but are not limited to the risk of suicide, stroke, hyperlipidemia, serotonin syndrome, neuroleptic malignant syndrome, hyponatremia and hyperglycemia. Bipolar patients who require a temporary antidepressant should always be on an antidepressant with a mood stabilizer or an antipsychotic. For patients who find that a mood stabilizer alone does not control severe depression, adding an antidepressant to the treatment modality may be beneficial. Once the depression has improved, the antidepressant should be discontinued to prevent the patient from going into a manic phase. It is important to closely monitor the patient and provide education to the patient and family. Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder. Fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft) are a few that are used. However, people with bipolar disorder should not take an antidepressant only. In addition to pharmacological agents, patients with bipolar disorder also benefit with coinciding psychotherapy. The most common psychotherapies include psychoeducation, cognitive-behavioral therapy (CBT), family therapy and interpersonal and social rhythm therapy (IPSRT) [9]. Research has demonstrated that the most beneficial options are intense family-focused therapies (input of the family to help with coping, communication and problem solving), CBT (focuses on helping the patients understanding of distortions and learn new ways of coping) and IPSRT (focuses on stabilizing daily activities).

Psychoses and antipsychotics Psychotic disorders are a constellation of clinical schizophrenic disorders that are characterized by an impaired sense of reality, disturbances of thought and emotions, hallucinations (often auditory, “the voices tell me”), delusions (“I am the president of the U.S.”) and confusion that often require hospitalization. Some of the most psychotic disorders are as follows [8]:

●● Schizophrenia is a psychotic disorder in which the patient exhibits all of the above symptoms for a minimum of six months, leading to an impaired ability to maintain interpersonal relationships, a job or daily living skills. If a patient has schizophrenic symptoms that are prodromal, acute, or longer than a week but less than six months, it is

Page 18 Nursing.EliteCME.com

documented as schizophreniform disorder. Active psychosis occurs during a small portion of the patient’s life; between the psychotic episodes, the patient is often withdrawn and probably antisocial [14]. It is currently believed that schizophrenic symptoms are due to genetics, environmental and neurotransmitter pathophysiological components. ●● Delusional disorders are psychoses in which the predominant symptoms are persistent, nonbizarre delusions with minimal impairment of daily functioning. Common delusional themes include paranoid delusions of persecution, delusions of being related to or loved by a well-known person, and delusions that one’s partner is unfaithful. Hallucinations are not common. ●● Schizoaffective disorders are a group of symptoms that do not fit in the schizophrenic or the affective categories. Typically they have affective symptoms that precede or develop concurrently with psychotic manifestations. Other common symptoms vary, but can include any of the following [8]: ●● Appearance may be bizarre to unkempt blandness. ●● Affect is usually flat with occasional inappropriateness. ●● Depression is present the majority of times, but may be less apparent during the acute psychotic phase and more obvious during recovery. ●● Motor activity varies from catatonic to frenzied excitement. ●● Social behavior is usually withdrawn with disturbed interpersonal relationships and a reduced ability to experience pleasure. ●● Thought content varies from a paucity of ideas to a rich complex of delusional fantasy with archaic thinking. Delusions involve disturbances in thought content rather than perception. Delusions are false beliefs that vary in their degree from believing someone is trying to hurt them to believing they are a famous, historical individual [20]. Hallucinations are sensory perceptions with a compelling sense of reality, but no objective basis, including auditory (hearing voices) or visual (monsters, bugs) and rarer forms, such as tactile (touch), olfactory (smell) and gustatory (taste). ●● Verbal utterances vary from mute to rambling statements, neologisms (made-up words or phrases), echolalia (repetition of words spoken by others) or verbigeration (repetition of senseless of words). The gold standard of treatment is to administer antipsychotic medications. These medications are complex pharmacological agents that work by blocking the dopamine 2 receptors (thus altering the release and turnover of dopamine) [9]. Antipsychotic medications have demonstrated clinical efficacy and have reduced relapse by approximately 50 percent if the patient takes them as directed. The “positive” symptoms of schizophrenia, such as feeling agitated and having hallucinations, usually go away within days; delusions usually dissipate within a few weeks. After about six weeks of treatment, many people will see a lot of improvement and feel much better. The “negative” schizophrenic symptoms, such as being withdrawn, and having psychomotor retardation and poor interpersonal relationships, may improve within six weeks of treatment. Although antipsychotic agents work well at reducing the schizophrenia symptoms, there are many problems with Nursing.EliteCME.com

compliance because of the significant side effects. The most common side effects are [8, 11]: ●● Anticholinergic (dry mouth, blurred vision, urinary retention). ●● Cardiovascular issues (tachycardia, orthostatic hypotension, electrocardiogram changes prolong QT). ●● Eye problems (precipitation of glaucoma). ●● Gastrointestinal issues (delayed gastric emptying, esophageal reflux). ●● Drowsiness. ●● Dizziness when changing positions. ●● Photosensitivity to the sun. ●● Skin rashes. ●● Sexual dysfunction (retrograde ejaculation, delay in orgasm). ●● Menstrual problems for women. Other significant changes includes weight gain and changes in a person’s metabolism. Unfortunately, this may lead to other co-morbidities, such as diabetes and high cholesterol. Therefore, health care professionals should monitor the patient’s weight, glucose levels and lipid levels while the patient is taking an atypical antipsychotic medication. There is no way to predict how a patient will respond to an antipsychotic regimen; however, it is important to diligently monitor for undesirable side effects so that the prescribing psychiatrists may make adjustments as needed. The patient should never stop taking the medication without the knowledge and guidance of the psychiatrist. Most of the side effects will diminish as time goes on. However, there are long-term side effects that are the direct result of long-acting injectable neuroleptics available for the noncompliant patient or an individual who does not respond to oral medications. The most common undesirable side effects of antipsychotic drugs are [14]: ●● Acute dystonias, which occur early or late in the treatment. Symptoms include face, neck, tongue and back spasms within a week of therapy initiation or after years of therapy. The patient typically develops [9]: ○○ Torticollis (severe twisting of the neck and back). ○○ Opisthotonus (severe arching of the back). ○○ Oculogyric cries (severe rolling back of the eyes into the head). ○○ Laryngospasms (spasms of the throat in which breathing and swallowing become severely impaired, leading to an emergency situation requiring a tracheotomy). ○○ Oral-facial-maxillary spasms (spasms of the face, lips and tongue that makes it very difficult to eat, drink and chew). Treatment includes Benadryl 50 mg IM for the acute crisis, then Benztropine (Cogentin) 0.5 to 1mg (up to 2 mg) BID for several weeks, then discontinued gradually. ●● Akathisia is one of the most common undesirable side effects, occurring in approximately 20 percent of patients. Also known as extrapyramidal symptoms (EPS), it includes constant, uncontrolled motor restlessness occurring within two months of initiating therapy, when patients appear to be pacing [9]. The risk is exacerbated in women who smoke and by the use of older, high-potency agents such as Haldol. It is recommended that the medication be decreased, discontinued or the patient be treated with anti-Parkinsonism meds (trihexyphenidyl 2 to 5 mg orally three times a day or Page 19

benztropine mesylate 1 to 2 mg twice daily), benzodiazepines or low dose Inderal (propranolol). Propranolol, a beta-blocker that is typically prescribed for the treatment of hypertension (HTN), however, does have unlabeled uses for antipsychotic akathisia and situational anxiety. The typical dosing for antipsychotic akathisia is 40 mg BID that may be increased up to 120 mg daily. Avoid abrupt withdraw of the medication, which can induce life-threatening arrhythmias, HTN or myocardial infarction (MI), and instead taper the drug off over a two-week period and never less than nine days. Toxic/overdose signs include bradycardia, severe dizziness, severe drowsiness, cyanotic (bluish) fingernails or palms and seizures. Notify the doctor immediately [3]. ●● Drug-induced Parkinsonism symptoms include “pill rolling” with fingers, limb rigidity, shuffling gait, bradykinesia (slow movements) and mask facies (no expression) caused by dopamine receptor antagonism that is reversible. The Parkinsonism symptoms usually develop within one month of initiating therapy. The patient requires anti-Parkinsonism drugs (such as Cogentin) for about four to six weeks, and which then can be discontinued with no recurrent symptoms. ●● Neuroleptic malignant syndrome (NMS) is a rare, but possibly fatal syndrome marked by catatonia, rigidity, stupor, fluctuating blood pressure, fever and dysarthria (poor articulation, aphasia). If any of these symptoms occur, the antipsychotic medications must be discontinued promptly. The risk is increased if the patient is taking lithium in combination with an antipsychotic neuroleptic agent. NMS is treated with bromocriptine (dopamine agonist) 2.5 to 10 mg orally three times a day or Dantrolene 50 mg IM as needed. ●● Tardive dyskinesia (TD) is the most serious and often irreversible side effect of long-term use that causes an involuntary movement of the face (facial tics), increased blinking, worm-like movements of the tongue, trunk and extremities movements that occurs in approximately 20 to 35 percent of all patients being treated with antipsychotic agents for months to years. The movements commonly happen around the mouth. TD can range from mild to severe, and in some people, the problem cannot be cured. Sometimes people with TD recover partially or fully after they stop taking the medication. Patients who are most vulnerable include the elderly and those with years of antipsychotic use, cigarette smoking or diabetes. Although antipsychotic agents are required for the treatment of psychoses and schizophrenia, the potential pharmacological side effects may be frightening to the patient and/or family. Therefore, it is imperative that health care professionals focus on prevention of the side effects and education. In order to prevent the side effects, the smallest dose of a drug should be prescribed to diminish the psychotic symptoms, and the atypical agents appear to offer less risk. If any dyskinesia (facial tics and twitches, chewing movements, lip smacking) occur, all anticholinergic drugs should be stopped and antipsychotic agents should be weaned. The patient should remain off the drugs until the psychotic symptoms re-emerge, then start slowly and gradually increase. Typically, Clozaril and Zyprexa are the drugs of choice because of their lower risk of recurrence [8].

Antipsychotic agents were initially implemented in the 1950s to treat schizophrenia and schizophrenia-related disorders. Today, most of the original “typical” antipsychotic neuroleptic agents that are still used today include [3, 11, 14]: ●● Chlorpromazine (Thorazine) is sometimes referred to as a neuroleptic agent because of the way it reduces the patient’s initiative and interest in the environment, alleviates aggressive and impulsive behavior. The typical dose is 100 to 400 mg, with the maximum of 1,000 mg administered po/ IM/pr (rectal) that distributes well and is metabolized in the liver. Half-life is 20 to 40 hours. It is non-addicting. ●● Haloperidol (Haldol) is structured differently than Thorazine, but side effects are very similar. The usual dose is 2 to 5 mg a day, with a maximum of 60 mg a day. Haldol may be given orally or intramuscular. It should never be administered greater than 1 mg per minute (1 mg/ min) to reduce cardiovascular side effects, such as torsades de pointes. ●● Perphenazine (generic only) with a usual dose of 16 to 32 mg a day and a maximum of 64 mg/day. ●● Fluphenazine (generic only) is another great alternative for patients who are unable to swallow pills or non-compliant with their regimen. A patient can take a fluphenazine longacting shot every two weeks at the doctor’s office. The usual dose is 2 to 10 mg, with a maximum of 60 mg/day. In the 1990s, new antipsychotic medications were developed and well tolerated because there were fewer undesirable side effects associated with them. The newer antipsychotic agents are referred to as second generation, or “atypical” antipsychotics and include [3, 11, 14]: ●● Clozapine (Clozaril) is a very effective medication that treats psychotic symptoms, hallucinations and breaks with reality, such as when a person believes he or she is the president. It is effective in the treatment of approximately 30 percent of psychosis that are resistant to other neuroleptic drugs. In addition, research has demonstrated that Clozaril decreases suicidal ideations in patients with schizophrenia. One of the biggest complications with Clozaril is agranulocytosis, a loss of the white blood cells that help a person fight infection, especially in those of Ashkenazi Jewish ancestry. Therefore, people who take clozapine must get their white blood cell counts checked weekly for the first six months, then every other week after. Even if Clozaril is discontinued, the white blood cell level should be checked weekly for a month [3,8]. There is a contraindication in patients with severe heart disease because of the risk of myocarditis. The usual dose is 300 to 450 mg, with a maximum of 900 mg a day. ○○ Other atypical antipsychotics were developed. All of them are effective and none of the following atypicals (except Abilify) cause agranulocytosis [3, 13, 14]: ■■ Risperidone (Risperdal). The exact mechanism is unknown, but it binds as an antagonist at the serotonin, dopamine, alpha adrenergic and H1 histamine receptors. Risperdal causes fewer EPS side effects than the typical antipsychotics at doses of less than 6 mg (usual dose 2 to 6 mg a day). Risperdal is available in oral or injectable (IM)

Page 20 Nursing.EliteCME.com

shots every two weeks. Risperdal is as effective as Haldol and Clozaril without the need for weekly laboratory tests. One of the major side effects of Risperdal is Risperdal-induced hyperprolactinemia. To date, researchers have noted a potential increase of prolactin while taking antipsychotics, but not to the significant degree as seen while taking Risperdal. Patients with a history of breast cancer should not receive Risperdal because of the potential activation of prolactin and growth in the breast. □□ Dopamine, a neurotransmitter that is blocked to a certain degree by all antipsychotic medications, acts in the brain to decrease prolactin. When dopamine gets blocked by medication, its ability to regulate the prolactin level is also disturbed. Since it can no longer keep the level down to a normal amount, the level of prolactin is able to increase without regulation, and that can cause the abnormal levels in some people. It is possible that the newer antipsychotics, which can be less potent against dopamine, may have a lesser impact on prolactin. Prolactin is a normal hormone stimulated by the pituitary gland to stimulate the production of gynecomastia (abnormal breast development in men or earlier in women), galactorrhea (abnormal milk production in men or women) and amenorrhea (absence of a menstrual period in women). When prolactin is administered, it should be monitored closely, especially with children because their growth may be affected. ■■ Olanzapine (Zyprexa) is a potent pharmacological agent and is more effective than Haldol in the treatment of negative symptoms. The usual dose of Zyprexa is 5 to 10 mg, with a maximum of 10 mg a day, and available in both a disintegrating oral and an injectable form for patients unable to swallow tablets or who may be agitated. There are fewer undesirable side effects than with Haldol. The most common side effects include somnolence, agitation, nervousness, headaches, insomnia, dizziness and significant weight gain. In 2004, Eli Lilly announced there was an increased risk of developing type-2 diabetes in patients taking Zyprexa. Although the exact mechanism is still unknown to date, in January 2010, the FDA and Eli Lilly placed warning labels on Zyprexa warning health care professionals and patients of the potential risk. Therefore, a patient with diabetes who is started on atypical antipsychotics should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (i.e., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia and weakness. Patients who develop symptoms of hyperglycemia Nursing.EliteCME.com

■■

■■

■■

■■

during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of Zyprexa [4]. Quetiapine (Seroquel) is a neuroleptic that is as effective as Haldol in treating positive and negative symptoms of schizophrenia with fewer extra pyramidal side effects even at high dosages. The usual dose is 200 to 400 mg a day, with a maximum of 800 mg. The most common side effects include somnolence, dizziness and postural hypotension. One of the unique side effects is the effect on the eye lens with long-term usage. Patients should be encouraged to have routine eye examinations to assess for cataract formation upon initiation of Seroquel and at six-week intervals. Ziprasidone (Geodon) works on the dopamine and serotonin receptors, with good efficacy for both positive and negative symptoms of schizophrenia. Geodon is not associated with significant weight gain, hyperlipidemia or new-onset diabetes. The most common side effect is QT interval delays, so all patients should be screened for cardiac disease and have routine electrocardiograms (ECGs) performed to assess the QT interval. The usual dose is 40 to 160 mg, with a maximum of 160 mg a day. Aripiprazole (Abilify) is the first neuroleptic agent that is a dopamine stabilizer and is effective against positive and negative schizophrenic symptoms. Abilify has also been used as an add-on in major depressive disorders. Abilify’s most common side effects include risk of suicide, low white blood cells (may occur, but the risk is low), risk of stroke, hyperglycemia, neuroleptic malignant syndrome and Tardive dyskinesia. The usual dose is 10 to 15 mg, with a maximum of 30 mg a day. Paliperidone (Invega) was approved by the FDA for the treatment of schizophrenia; however in October 2009, the 6 mg extended-release tablet was recalled. The most common side effects are similar to the other agents, and the usual dose is 3 to 12 mg daily.

In a public health advisory for all atypical antipsychotic medications, the FDA said it has determined that death rates are higher for elderly people with dementia when taking these medications. A review of data has found a risk with conventional antipsychotics as well. At this time, antipsychotic pharmacological agents are not FDA approved for the treatment of behavioral disorders in patients with dementia psychosis. There is a “black box” warning located on each of the atypical agents with this FDA advisory. Other pharmacological agents typically prescribed with antipsychotic agents, include but are not limited to: ●● Antidepressants (if significant depression). ●● Lithium, Tegretol or Depakote (if resistance is present). ●● Benzodiazepine may improve agitation or catatonic psychoses, especially if the patient has had no response Page 21

to antipsychotics alone. Some psychiatrists will prescribe an atypical antipsychotic cocktail in conjunction with a benzodiazepine for a quick response of symptoms: ○○ Risperdal oral solution 2 mg , Zyprexa 10 mg orally or Haldol 10 mg IM and ○○ Ativan 2 mg every two to four hours as needed. ●● ECT has been effective in treating catatonia.

The long-term prognosis of patients with psychosis varies based upon the patient’s compliance, diligent care of health care professionals, support system and the patient’s congruent drug history. Substance abuse and psychosis do not go well together. Illegal drugs diminish the function of the central nervous system, and it is compounded with psychiatric illnesses.

Substance abuse Substance abuse typically coincides with many psychiatric disorders. It is estimated that approximately 22 percent of the U.S population have substance abuse disorders [9]. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) (2006) [16]: ●● More than 50 percent of Americans 12 years or older drink alcohol. ●● An estimated 19.7 million Americans 12 years or older are current illicit drug users. ●● Abuse of marijuana, cocaine, prescription opiates, methamphetamine and ecstasy are the most common, with marijuana being the most preferred by the younger population. The DSM-IV classifies substance abuse in 12 different categories; all share common subdiagnostic categories, such as dependence, abuse, intoxication and withdrawal that impair their physical, social and psychological abilities at some time [9]. It is important for health care professionals to understand the most common substance abuse symptoms and treatment modalities. After prolonged abuse of any substance, an individual builds up physical and behavioral tolerance. In physical tolerance, the tissues in the body change in the cells so the body requires more to achieve the desired option [9]. ●● Alcohol intoxication may increase the risk of inappropriate behavior, such as fighting and impaired judgment. Physiological signs involve slurred speech, lack of coordination, unsteady gait, nystagmus and flushed face, impaired attention and mood changes. Alcohol abuse may cause sedation, impaired mental and motor functioning, stupor, coma and death. Alcohol is absorbed in the mouth, stomach and small intestine and delivered unchanged in the blood where it circulates through the body, including the brain. ○○ Alcohol withdrawal (abstinence syndrome) occurs after a reduction or cessation of heavy drinking. The most common signs include irritability; impatient behavior; coarse tremor of the hands, tongue and eyelids; nausea and vomiting; hyperactivity; increased blood pressure and pulse; headache; and sleep disturbances. The most serious form of alcohol withdrawal is delirium tremens, which occurs within 48 hours with increased agitation, confusion, anxiety, delusions, coarse tremors, fever, diaphoresis, increased heart rate and precordial pain. ○○ Long-term, the most serious complications are liver damage (alcoholic hepatitis, cirrhosis), alcoholic amnestic disorder (impaired ability to learn new information, recall long-term, neuropathy, unsteady gait and myopathy), thiamine deficiency (Wernicke’s encephalopathy) and alcoholic dementia.

○○ Detoxification can occur within three to five days. The most commonly used, first-line pharmacological agent is a benzodiazepine with other pharmacological agents as follows [9]: ■■ Benzodiazepines decreases the number of withdrawal seizures. ■■ Anticonvulsants (Tegretol) prevents alcohol withdrawal seizures. ■■ Phenobarbital for patients who are dependent upon sedative hypnotics and alcohol. ■■ Beta-blockers (Inderal) to reduce hyperactivity symptoms. ■■ Antipsychotics (Haldol) to decrease auditory, visual or tactile hallucinations. ■■ Magnesium sulfate to reduce the risk of seizures. ■■ Vitamins to treat nutritional deficiencies, especially thiamine. ●● Marijuana (cannabinoids) leads to euphoria, slowed thinking and reaction time, and confusion. Withdrawal symptoms occur within the first 24 hours, most pronounced on the 10th day and may last up to 28 days. The most common withdrawal symptoms include irritability, anxiety, physical tension, decreased appetite and mood. Detoxification includes Restoril to alleviate sleep difficulties. ●● Stimulants: ○○ Amphetamines are used to treat ADHD, sleep disorders and depression. Amphetamines use initially increases energy, alertness and concentration; elevates mood; or suppress the appetite. Intoxication causes rapid breathing. ○○ Methamphetamine (“chalk, crank, crystal, fire, glass, go fast, ice, meth, speed”) is ingested, smoked, snorted or injected and causes high release of dopamine. Over time, the effects of intoxication can include aggressive behavior, paranoia, hallucinations, depression, tooth decay, motor disturbances, cerebrovascular accident (CVA) and weight loss. During withdrawal symptoms, the patient becomes depressed, has cravings, is exhausted and exhibits mental confusion, restlessness, insomnia, psychotic reactions and anxiety up to 48 hours afterwards. ○○ Ecstasy (MDMA referred to as a “club drug, Adam, Eve, lover’s speed, peace, STP, X, XTC”) can lead to malignant hyperthermia with muscle breakdown, kidney and cardiovascular failure and death. Effects of intoxication cause mild hallucinogenic effects, increased tactile sensitivity, empathetic feelings. Withdrawal symptoms include depression, anxiety, panic attacks, sleeplessness and paranoid delusions. ○○ Cocaine (“blow, bump, C, candy, Charlie, coke, crack, flake, rock, snow and toot”) is smoked, snorted

Page 22 Nursing.EliteCME.com

or injected. Over time, increased amounts result in agitation, restlessness and tremors that may lead to psychosis, fatal convulsions and respiratory distress. Withdrawal symptoms are characterized by disturbed sleep, fatigue, lack of concentration, myopathy (muscle pain), angry outbursts, decreased sex drive and depressed mood. ○○ There is no specific detoxification for stimulants, but Amantadine and Modafinil are currently being studied for reduction of withdrawal symptoms. ●● Opioids: The effects of opiate intoxication are similar in each opioid, including analgesia, sedation and respiratory depression. ○○ Codeine (“Tylenol with Codeine, schoolboy, pancakes and syrup”). The withdrawal symptoms pass within a few days, but it may take months for a patient to feel normal again (runny nose, sweating, muscle twitching, muscle pain, headaches, irregular heartbeat, high blood pressure, fever, insomnia, dehydration). ○○ Fentanyl (“China girl, china white, jackpot, murder 8, TNT, Tango and cash”) has similar effects to those of codeine. ○○ Heroin (“brown, sugar, H, horse, junk, skag, skunk, smag, white horse”) is the most commonly abused opiate and the most dangerous form of addiction. The intoxication effects are similar to codeine, but withdrawal symptoms also include dilated pupils, piloerection (goose bumps), watery eyes, runny nose, yawning, tremors, profuse sweating, irritability and jitteriness. ○○ Morphine (“Roxanol, duramorph, emma, monkey, white stuff”) is similar to codeine, except withdrawal symptoms reach intensity in 36 to 72 hours and cease in five to seven days with the added symptoms listed under heroin.

○○ Opium (“Big O, block, gum, hop”). ○○ Oxycodone (“Oxycontin, Oxy, O.C, killer) includes additional withdrawal symptoms such as perpetual fatigue, hot/cold sweats, joint and muscle aches. ○○ Hydrocodone (“Vicodin, vike, Watson-387”) is similar to other opiates except the withdrawal symptoms may grow stronger for 24 to 72 hours and gradually decline over seven to 14 days with the added symptoms mentioned under heroin. ○○ The detoxification of opiates includes [9]: ■■ Clonidine to treat some of the symptoms, but it does not alleviate muscle aches, insomnia or drug cravings. ■■ Methadone (long-acting narcotic) that is legally administered to relieve withdrawal, especially from heroin and fentanyl, and prevents severe withdrawal symptoms. ■■ Buprenorphine, a semisynthetic narcotic in oral form of Subutex and in combination as oral. ■■ Buprenorphine/naloxone (Suboxone), which produces mild opioid effects but not much euphoria. Health care professionals continuously battle to eradicate substance abuse, but it has been a long war because of the addiction cycle. The most important things health care professionals can do is to keep the patient safe, and provide detoxification and rehabilitation to the patient and family. Recovery is a life-long process and many require more than one type of rehabilitation in order to stay clean. Research has demonstrated that the chance of recovery improves when certain medications are used for the first six months in conjunction with behavioral therapies [9].

Closing Psychiatric medicine is complex, and there is no specific regimen for everyone; rather, each individual must be thoroughly assessed and treated appropriately. Health care professionals should not be apprehensive about caring for a patient diagnosed with a psychiatric disorder; we need to realize that psychiatric/mental health issues are all around us. People do not choose to be affected by a psychiatric disorder, the disorder chooses them. In the medical field, we have patient charts with their diagnoses in front of us, and unfortunately, the mental illness becomes a stereotypical label of the patient. We cannot forget that these individuals are affected by a disease

process. With the appropriate regimen and treatment modalities, many patients can go on living their lives well controlled. It is important that all health care professionals work together to ensure that holistic aspects of a patient and family are considered. All patients, families and caregivers should be educated on each diagnosis, the course of the illness, prognosis, symptoms, treatment modalities and potential complications. The more we collaborate with our patients and empower them with knowledge, they more likely it is that they will adhere to a required, prescribed regimen.

References ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ

American Psychiatry Association. (2010). DSM-IV-TR: The Current Manual. Retrieved online March 17, 2010 at http://www.psych.org/mainmenu/research/dsmiv/ dsmivtr.aspx Benzer, T. (1999). Neuroleptic Malignant Syndrome. Retrieved online March 17, 2010 at http://emedicine.medscape.com/article/816018-overview Deglin, J. & Vallerand, A. (2009). Davis’s Drug Guide for Nurses (11th ed). F.A. Davis: Philadelphia. Diabetes Monitor. (2010). Diabetes Monitor - Atypical Antipsychotics And Diabetes. Retrieved online April 6, 2010 at http://www.diabetesmonitor.com/b84.htm Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). (2003). Retrieved online February 7, 2010 at http://allpsych.com/disorders/dsm.html Dunphy, L., Winland-Brown, J., Porter, B. & Thomas, D. (2007). Primary Care: Art and Science of Advanced Practice. (2nd ed) FA. Davis. Mayo Clinic (2008). Depression: Monoamine oxidase inhibitors. Retrieved online March 17, 2010 at http://www.mayoclinic.com/health/maois/MH00072

Nursing.EliteCME.com

ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ

McPhee, S & Papadakis, M. (2010). Current Medical Diagnosis and Treatment. McGraw-Hill Lange: New York. Mohr, W. (2009). Psychiatric-Mental Health Nursing. (7th edition). Wolters:Lippincott & Wilkins: Philadelphia. Munoz, R. (2007). PDR: Drug Guide for Mental Health Professionals. Thomson: New Jersey. National Institute of Health. (2009). Health Medications. Retrieved online February 18, 2010 at http://www.nimh.nih.gov/health/publications/mental-health-medications/ complete-index.html National Institute of Mental Health. (2009). Statistics. Retrieved online March 18, 2010 at http://www.nimh.nih.gov/health/topics/statistics/index.shtml National Institute of Mental Health. (2010). Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers. Retrieved online March 8, 2010 at http://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/

Page 23

ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ

antidepressant-medications-for-children-and-adolescents-information-for-parents-andcaregivers.shtml Olson, J. (2003). Clinical Pharmacology Made Ridiculously Simple. MedMaster:Miami Saladin, K. (2007). Anatomy and Physiology: The unity of form and function. (4th ed). McGraw-Hill: New York. Substance Abuse and Mental Health Services Administration. (2006). Results from the 200 5 National Survey on Drug Use and Health: National Findings. Retrieved online March 28, 2010 at http://www.oas.samhsa.gov/nsduh/2k5nsduh/2k5Results.htm#TOC Wells, B, DiPir, J., Schwinghammer, T. & Hamilton, C. (2006). Pharmacotherapy Handbook. (6th ed). McGraw-Hill: New York. Youngkin, E., Sawin, K., Kissinger, J. & Israel, D. (2005). Pharmacotherapeutics: A Self Evaluation primary care guide. (2nd ed). Pearson: New Jersey.

PHARMACOLOGIC AND PSYCHIATRIC MEDICINE

Exercises Select the best answer for each question and check your answers at the bottom of the page. You do not need to submit this self-evaluation exercise with your participant sheet..

6. The most serious complication with SSRIs is serotonin syndrome.

¨¨ True

¨¨ True

¨¨ False

¨¨ False

2. Cholinesterase inhibitors delay cognitive decline in patients with Alzheimer’s disease. ¨¨ True ¨¨ False 3. Researchers and medical professionals believe that the various manifestations of anxiety are the result of unconscious conflicts.

7. The most significant side effects of TCAs are anticholinergic effects (dry mouth, blurred vision and urinary retention). ¨¨ True ¨¨ False 8. Mixing MAOIs and tyramine can cause neuroleptic malignant syndrome.

¨¨ True

¨¨ True

¨¨ False

¨¨ False

4. Children who are prescribed Ritalin and similar drugs should be weighed monthly.

9. The patient taking lithium should have a steady intake of salt and avoid the use of alcohol.

¨¨ True

¨¨ True

¨¨ False

¨¨ False

5. The most common side effect of benzodiazepines is a low white blood cell count. ¨¨ True ¨¨ False

10. Antipsychotic medications have demonstrated clinical efficacy and have reduced relapse by approximately 50 percent if the patient takes them as directed. ¨¨ True ¨¨ False

Answers:

1.T 2.T 3.F..4.F 5.F 6.T 7.T 8.F 9.T..10.T

1. Benzodiazepines should be avoided in the first trimester because of potential birth defects.

Page 24 Nursing.EliteCME.com