Psychiatric Medication Review

July 2015

Purpose

The purpose of this training module is to offer basic information on medications and their recommendations of use for specific psychiatric disorders.

This module in no way is intended to be used as treatment recommendations. It is recognized that a licensed practitioner is responsible for the ordering of medications, however a nurses responsibility is to understand classification of psychiatric medications, recommended dosing, side effects, and other information to provide a high quality of nursing care.

Medication Categories will include

• Antipsychotics

• Antidepressants

• Mood Stabilizers

• Anxiolytics

• CNS Stimulants

• Cholinesterase Inhibitors

• also referred to as neuroleptics and major tranquilizers

• used to treat schizophrenia, other psychotic disorders ( bipolar mania), and severe anxiety

Antipsychotics

2 groupings of antipsychoticsTypical Antipsychotics –

• is the older antipsychotic medications, now referred to as typical antipsychotics. These are primarily effective in reducing the positive symptoms of schizophrenia (refer to DU module on schizophrenia) .

• medications have an exhaustive side effect profile that complicates treatment and contributes to noncompliance.

Atypical Antipsychotics –

• is the newer generation. The atypical antipsychotic medications have an impact on the neurotransmitter serotonin as well as on dopamine. Therefore, they help produce a reduction in positive symptoms as well as an impact on the negative, or less obvious, psychotic symptoms.

• less severe side effect profile than the typicals.

Examples

Typical Antipsychotics Atypical AntipsychoticsChlorpromazine (Thorazine) Aripiprazole (Abilify

Thioridazine (Mellaril) Ziprasidone (Geodon)

Haloperidol (Haldol) Quetiapine (Seroquel)

Fluphenazine (Prolixin) Clozapine (Clozaril)

Thiothixene (Navane) Olanzapine (Zyprexa)

Trifluoperazine (Stelazine) Paliperidone

Perphenazine (Trilafon) Risperidone (Risperdal)

Lurasidone (Latuda)

Allergies

Allergies to antipsychotics are rare. Since the side effects can often be frightening and difficult to tolerate patients may report allergies to these medications rather than side effects. Reviewing the details of the patient’s allergic response may play a role in deciding the treatment regime.

Side Effects

• The side effect profile is extensive and some may be dangerous and potentially life-threatening. Some side effects are irreversible and some are treatable.

• Educating the patient of all the risks and benefits is an essential component of best practice.

The following slides high-lights some side effects and possible actions necessary

Antipsychotic Side Effects Possible Action

CNS – drowsiness, sedation Many patients adjust to over 5-10 days

Agranulocytosis ( especially with Clozaril) Periodic WBC

GI – Nausea Offer with meals

Cardiac – orthostatic hypotension Monitor vital signs, instruct to rise slowly

Skin - Photosensitivity , rash Use sunscreen and avoid direct sunlight

Anticholinergic – dry mouth, constipation, urinary retention, blurred vision, dilated pupils

Monitor and treat symptoms

Reduced seizure threshold ( especially with Clozaril)

Monitor as needed

Antipsychotic Side Effects Possible Actions

Endocrine – false positive pregnancy test, lactation, gynecomastia, weight gain, amenorrhea, decreased libido

Explain & reassure

Cardiac – prolonged QT intervals and irregularities

EKG & vital sign monitoring

Tardive Dyskinesia – often irreversible, bizarre facial and tongue movements, involuntary gross motor movements, incoordination, muscle rigidity.

Withdraw medication and report immediately. Evaluate using AIMS prior to initiation and during course of treatment.

Neuroleptic Malignant Syndrome (NMS) -rare and potentially fatal complication. Rigidity, elevated temp, increased pulse and respiratory rate, diaphoresis, elevated CPK, and deterioration in mental status

Discontinue medication immediately. Provide support systems as indicated.

Antipsychotic Side Effects Possible Actions

Extrapyramidal Symptoms (EPS):

• Akathesia - restlessness and inability to sit still, which might be confused with agitation

• Pseudoparkinsonism

• Dystonia and muscle rigidity

• Oculogyric crisis

• Akinesia - muscle weakness

Treat EPS with monitoring, education, and antiparkinsonism drugs, as ordered.

These include benztropine (Cogentin), and diphenhydramine (Benadryl), which can be administered PO, IM, or IV.

Careful monitoring and early intervention for these side effects is essential in establishing patient confidence in the ability to take the medications long-term.

Hyperglycemia and diabetes, particularlywith the atypical antipsychotics.

Monitor weight. Monitor blood glucose as needed. Educate patient regarding signs and symptoms of diabetes

Long-acting Antipsychotics

These may be prescribed and administered weekly, or every two, three or four weeks. This tactic can be helpful when patients have difficulty remembering to take their medications or when they have a tendency to be non-compliant. The medications are administered IM and will slowly release over a relatively long period of time. These medications include:• Haldol Decanoate• Prolixin Decanoate

• Consta (Risperdal) Note: This medication requires refrigeration.

Long-acting Antipsychotics do not wear off in several hours. The medication is released into the system over a period of weeks.

Prior to the administration of the long-acting the short acting medication needs to be given to the patient to monitor their response and/or effectiveness.

• Primarily used in treatment of Depression & Generalized Anxiety Disorders.

Antidepressants

Categories of antidepressants

• Monoamine Oxidase Inhibitors (MAOI’s)

• Tricyclic Antidepressants (TCA’s)

• Selective Serotonin Reuptake Inhibitors (SSRI’s)

• Serotonin Norepinephrine reuptake inhibitors (SNRI’s)

• Other

Monoamine Oxidase Inhibitors

• Inhibits monoamine oxidase (which metabolizes an the enzyme that breaks down serotonin & norepinephrine –which is related to depressive symptoms

• Takes 4-6 weeks to reach therapeutic levels

• Must avoid some medications and high-tyramine food (details in next slide)

Examples of MAOI’s

• Phenelzine (Nardil)

• Tranylcypromine (Parnate)

• Isocarboxazid (Marplan)

MOAI’s and TyramineCertain medications and foods high in tyramine may react to MAOI’s potentially causing a hypertensive crisis, which could be very severe.

Foods high in tyramine to avoid include:bananas plums soy productsaged meats and cheeses prunes avocadoschianti wines oranges livereggplant grapes chocolatefigs raisins pineapples nuts

Patient education related to the tyramine free diet and possible side effects needs to be completed

Tricyclic Antidepressants (TCA’s)

• Inhibits the reuptake of Serotonin & Norepinephrine, causing an increase in availability

• Takes 4-6 weeks to reach therapeutic levels

• Caution in elderly due to being cardiotoxic and dangerous in overdose

Examples TCA’s

• Amitriptyline (Elavil)

• Clomipramine (Anafranil)

• Desipramine (Norpramin)

• Imipramine (Tofranil)

Side Effects of TCA’s

• Anticholinergic effects which can include dry mouth, constipation, blurred vision, & urinary retention

• Drowsiness

• Orthostatic hypotension (drop of 20/1omm of Hg may be considered significant)

Selective Serotonin Reuptake Inhibitors (SSRI’s)

• Inhibits reuptake of Serotonin

• Reaches therapeutic levels in 1-3 weeks

• Side effects include:

– Decrease in sexual libido

– Headache

– Insomnia

– Nervousness

– Nausea

Examples of SSRI’s

• Citalopram (Celexa)

• Fluoxetine (Prozac)

• Fluvoxamine (Luvox)

• Escitalopram ( Lexapro)

• Paroxetine (Paxil)

• Sertraline (Zoloft)

Serotonin Norepinephrine reuptake inhibitors (SNRI’s)

• SNRIs block the absorption (reuptake) of the neurotransmitters serotonin and norepinephrine in the brain

• Reaches therapeutic levels in 1-3 weeks

• The most common side effects of SNRIs include: (mild and go away after a few weeks)– Nausea

– Sexual libido

– Constipation

– Headache

– Insomnia

– Nervousness

Examples of SNRI’s

• Duloxetine (Cymbalta)

• Venlafaxine (Effexor XR)

• Desvenlafaxine (Pristiq)

Other Antidepressants

• Buproprion ( Wellbutrin, Zyban) – also associated with smoking cessation

• Trazadone ( Desyrel) – may be used as sedative

• Venlafaxine (Effexor)

• Duloxetine (Cymbalta)

General antidepressants

• Difficulty tolerating adverse effects is the most common reason for discontinuation

• Any medication involving serotonin regulation has potential to cause serotonin toxicity – also known as serotonin syndrome

Serotonin Syndrome

• Occurs with an excess of serotonin that may induce:

– Mania

– Restlessness

– Agitation

– Emotional lability

– Insomnia

– Confusion

Discontinuation Syndrome

Occurs if

• on antidepressant for at least 4 weeks

• Abruptly stopped taking medication or fast tapered off medication

Last for one to four weeks and usually resolve on own

Discontinuation SyndromeSymptoms

• Flu-like symptoms

• Sleep changes

• insomnia, nightmares, sleepiness

• Sensory disturbances –

• imbalance, tremors, vertigo

• Mood disturbances –

• dysphoria, anxiety, agitation

• Cognitive disturbances –

• confusion & hyperarousal

• Used to treat Bipolar Disorder, manic Phase, & Schizoaffective Disorder

• Takes 5-10 days to reach therapeutic levels – until reach therapeutic level may see antipsychotic medication for control of agitation and anxiety

Mood Stabilizers

Examples of Mood Stabilizers

• Lithium

• Anticonvulsants

– Clonazepam (Klonopin)

– Carbamazepine (Tegretol)

– Lamotrigine (Lamictal)

– Valproic acid (Depakote)

– Gabapentin (Neurontin)

– Topiramate (Topamax)

Anticonvulsants

• May be used in conjunction to Lithium

• Take 5-10 days to reach therapeutic level

• Some anticonvulsants monitored by blood levels

Lithium

• During the initial days of therapy, it is very important to ensure that patients are provided with adequate amounts of fluid and Na+.

• Narrow therapeutic window requiring frequent blood levels – daily when first start followed by monthly monitoring

• Therapeutic levels range 0.6-1.2

Lithium

• Side effects -

drowsiness dizziness headache

thirsty N/V fine tremor

bowel changes weight gain arrhythmias

Lithium Toxicity

• Occurs when serum Lithium level is above the therapeutic window.

• Signs of toxicity

blurred vision tinnitus sever diarrhea

severe N/V confusion seizures

muscular irritability

extreme lethargy

Could lead to cardiovascular collapse

Lithium toxicity treatment

• Hold the medication

• Treat the symptoms

• IV hydration if necessary

• Monitor for electrolyte imbalances

• Anti-anxiety

• Used to treat mild to moderate anxiety

• May be used in alcohol detoxification

• Acute anxiety may commonly see benzodiazepines used for a short period of time

• Physiologically addictive in large amounts over long periods of time may occur

Anxiolytics

Other Anxiolytics

• most SSRIs have anxiolytic properties.

• Barbituates exert an anxiolytic effect linked to the sedation they cause

• Azapirones approved for use are Buspironeb(Buspar) and tandospirone (Sediel).

• Most common group of anxiolytics are the benzodiazepines

Examples of Benzodiazepines (Benzos)

– Alprazolam (Xanax)

– Chlordiazepoxide (Librium)

– Clonazepam (Klonopin)

– Clorazepate (Tranxene)

– Diazepam (Valium)

– Lorazepam (Ativan)

– Oxazepam (Serax)

Side Effects of Benzos

• Sedation

• Ataxia

• Dependence

• Orthostatic hypotension

• Paradoxical excitement

• Nausea & vomiting

• Anticholinergic effects such as dry mouth

Benzos categorized by action time:

• The action time (or time it takes for the body to eliminate half the dose) will help decide on which category of benzos to be prescribed

Long-acting benzodiazepines such as diazepam & chlordiazepoxide are often prescribed for benzodiazepine or alcohol withdrawal as well as for anxiety if constant dose levels are required throughout the day.

Shorter-acting benzodiazepines are often preferred for insomnia due to their lesser hangover effect.

Benzodiazepine Onset of Action* Peak Onset (hrs)Half-lifeparent (hrs)

Chlordiazepoxide (Librium®) Int. (po) 2-4(po) 5-30

Diazepam1

(Valium®)Rapid (po, IV) 1(po) 20-50

Flurazepam(Dalmane®)

Rapid 0.5-2 inactive

Alprazolam1

(Xanax®)Int. 0.7-1.6 6-20

Clonazepam1

(Rivotril®)Int. 1-4 18-39

Lorazepam1

(Ativan®)Int. (po),Rapid (sl, IV)

1-1.5 (po) 10-20

Oxazepam1

(Serax®)Slow 2-3 3-21

Temazepam1

(Restoril®)Slow 0.75-1.5 10-20

Midazolam1

(Versed®)Most Rapid IV 0.5-1 (IV ) 1-4

Triazolam(Halcion®)

Int. 0.75-2 1.6-5.5

• Rapid onset =

within 15

minutes,

• Intermediate =

15-30 minutes,

• Slow = 30-60

minutes

special notes about benzos

• Generally viewed as safe for short-term duration

• Paradoxical reaction may worsen agitation or panic

• Elderly are at increased risk of adverse effects

• Long term use may cause physical dependence and/or decrease in effectiveness

• Used in the treatment of Attention-Deficit Hyperactivity Disorder (ADHD) by reducing hyperactivity and Impulsivity and improve focus.

CNS Stimulants

CNS Stimulants

• Methylphenidate (Concerta, Ritalin) • Dextroamphetamine (Dexedrene)• Dexmethylphenidate (Focalin)• Adderall

• The FDA has issued a warning about the risk of drug abuse with amphetamine stimulants. FDA safety advisors are also concerned about the possibility that all amphetamine and methylphenidate stimulants used for ADHD may increase the risk of heart and psychiatric problems.

Non Stimulant used to treat ADHD

• Intuniva

• Atomoxetine (Strattera)

Both of the above are long-acting extended release lasting 24 hours

• Enhances cholinergic transmission in the brain by stopping acetylcholine from breaking down

• Used to treat dementia in patients with Alzheimer's

• they don't stop or reverse the destruction of brain cells and loss of acetylcholine that occur in Alzheimer’s Disease. They don't prevent the disease from getting worse, but they may slow it down

Cholinesterase Inhibitors

Examples and common side effectsGeneric Brand Side Effects

• Donepezil • Aricept Nausea, vomiting, loss of appetite and increased frequency of bowel

movements.

• Galantamine • Razadyne Nausea, vomiting, loss of appetite and increased frequency of bowel

movements.

• Rivastigimine • Exelon Nausea, vomiting, loss of appetite and increased frequency of bowel

movements.

• Tacrine • Cognex Possible liver damage, nausea, and vomiting.

References

Boyd, M.A. Atypical antipsychotics: Impact on overall health and quality of life, Journal of the American Psychiatric Nurses Association, August 2002.

deLange, E. Pharmacometrics in psychiatric diseases, chapter 10.Applied Pharmacometrics, V14, 2014. Schmidt & Derendorf.

Jarboe, K.S. Considering the impact on overall patient health when choosing antipsychotic therapy. The American Psychiatric Nurses Association, 13(5).

Littrell, K.H. & Litrell, S.H. Emerging applications of newer antipsychotic agents in specific patient populations. Journal of the American Psychiatric Nurses Association, 4(4).

National Institute of Mental Health. Mental health medications overview. Available On-line @ www.nimh.nih.gov/health/topics/mental-health-medications.