Psychotherapeutic Agents Antidepressants and Antipsychotics.

Psychotherapeutic AgentsPsychotherapeutic Agents

Antidepressants Antidepressants and Antipsychoticsand Antipsychotics

PsychotherapeuticsPsychotherapeutics

• The therapy of emotional and mental The therapy of emotional and mental disordersdisorders


• AnxietyAnxiety

• GriefGrief

• Depression Depression

are normal human emotionsare normal human emotions


• The ability to cope with these emotions can The ability to cope with these emotions can range from occasional depression or anxiety range from occasional depression or anxiety to constant emotional distress to the point to constant emotional distress to the point ofinterfering with the ability to carry on ofinterfering with the ability to carry on normal daily living.normal daily living.


• When these emotions significantly affect an When these emotions significantly affect an individual’s ability to carry out normal daily individual’s ability to carry out normal daily functions, treatment with a psychotherapeutic functions, treatment with a psychotherapeutic drug is a possible option. drug is a possible option.


Three main emotional and mental disorders:Three main emotional and mental disorders:

• PsychosesPsychoses

• Affective disordersAffective disorders

• AnxietyAnxiety


PsychosisPsychosis

• A major emotional disorder that impairs the mental A major emotional disorder that impairs the mental function of the affected individual to the point that function of the affected individual to the point that the individual cannot participate in everyday life.the individual cannot participate in everyday life.

• Hallmark: loss of contact with realityHallmark: loss of contact with reality


Affective DisordersAffective Disorders

• Major emotional disorders that impair the Major emotional disorders that impair the mental function of the affected individual to mental function of the affected individual to the point that the individual cannot the point that the individual cannot participate in everyday life.participate in everyday life.



• Mania: abnormally pronounced emotionsMania: abnormally pronounced emotions

• Depression: abnormally reduced emotionsDepression: abnormally reduced emotions

• Bipolar affective disorder: exhibits both mania Bipolar affective disorder: exhibits both mania and and depressiondepression

Psychotherapeutics Psychotherapeutics

Pathophysiology Pathophysiology

Biochemical ImbalanceBiochemical Imbalance

• Mental disorders are associated with abnormal Mental disorders are associated with abnormal levels of endogenous chemicals, such as levels of endogenous chemicals, such as neurotransmitters, in the brain.neurotransmitters, in the brain.




• Brain levels of certain catecholamines play an Brain levels of certain catecholamines play an important role in maintaining mental health.important role in maintaining mental health.

– DopamineDopamine

– SerotoninSerotonin

– HistamineHistamine




• Other biochemicals are necessary for normal Other biochemicals are necessary for normal mental function.mental function.

– GABAGABA

– acetylcholineacetylcholine

– lithiumlithium

Etiology of Depression Etiology of Depression

Biogenic Amine Hypothesis Biogenic Amine Hypothesis

• Depression and mania are due to an alteration in Depression and mania are due to an alteration in neuronal and synaptic catecholamine concentration neuronal and synaptic catecholamine concentration at adrenergic receptor sites in the brain.at adrenergic receptor sites in the brain.

– Depression: deficiency of catecholamine, Depression: deficiency of catecholamine, especially norepinephrineespecially norepinephrine

– Mania: excess aminesMania: excess amines


Drug CategoriesDrug Categories

• AntidepressantsAntidepressants

• tricyclics, tetracyclics, SSRIs, MAOIstricyclics, tetracyclics, SSRIs, MAOIs

• Antimanic AgentsAntimanic Agents

• lithiumlithium

AntidepressantsAntidepressants

Cyclic antidepressantsCyclic antidepressants

– tricyclicstricyclics

– tetracyclicstetracyclics

• Monoamine oxidase inhibitors (MAOIs)Monoamine oxidase inhibitors (MAOIs)

• Second-generation antidepressants Second-generation antidepressants and SSRIsand SSRIs

Cyclic AntidepressantsCyclic Antidepressants

• Tricyclic antidepressants—primary: Tricyclic antidepressants—primary: amitriptyline (Elavil), doxepin (Sinequan), amitriptyline (Elavil), doxepin (Sinequan), imipramine (Tofranil) imipramine (Tofranil)

• Tricyclic antidepressants—secondary: Tricyclic antidepressants—secondary: desipramine (Norpramin), nortriptyline desipramine (Norpramin), nortriptyline (Aventyl), protriptyline (Vivactil)(Aventyl), protriptyline (Vivactil)

• Tetracyclic antidepressants: Tetracyclic antidepressants: amoxapine (Asendin), maprotiline (Ludiomil)amoxapine (Asendin), maprotiline (Ludiomil)

Cyclic Antidepressants Cyclic Antidepressants Mechanism of ActionMechanism of Action

• Block reuptake of neurotransmitters, causing Block reuptake of neurotransmitters, causing accumulation at the nerve endings.accumulation at the nerve endings.

• It is thought that increasing concentrations of It is thought that increasing concentrations of neurotransmitters will correct the abnormally neurotransmitters will correct the abnormally low levels that lead to depression.low levels that lead to depression.

Cyclic Antidepressants Cyclic Antidepressants Mechanism of Action—Drug EffectsMechanism of Action—Drug Effects

Blockade of norepinephrine:Blockade of norepinephrine:

– antidepressant, tremors, tachycardia, additive antidepressant, tremors, tachycardia, additive pressor effects with sympathomimetic drugspressor effects with sympathomimetic drugs

Blockade of serotonin:Blockade of serotonin:

– antidepressant, nausea, headache, anxiety, antidepressant, nausea, headache, anxiety, sexual dysfunctionsexual dysfunction

Cyclic Antidepressants Cyclic Antidepressants Therapeutic UsesTherapeutic Uses

• DepressionDepression

• Childhood enuresis (imipramine)Childhood enuresis (imipramine)

• Obsessive-compulsive disorders Obsessive-compulsive disorders (clomipramine)(clomipramine)

• Adjunctive analgesicsAdjunctive analgesics

• Trigeminal neuralgiaTrigeminal neuralgia

Cyclic Antidepressants Cyclic Antidepressants Side EffectsSide Effects

• SedationSedation

• ImpotenceImpotence

• Orthostatic hypotensionOrthostatic hypotension

• Older patients:Older patients:

– dizziness, postural hypotension, constipation, dizziness, postural hypotension, constipation, delayed micturation, edema, muscle tremorsdelayed micturation, edema, muscle tremors

Tricyclic Antidepressants OverdoseTricyclic Antidepressants Overdose

• Lethal—70 to 80% die before reaching Lethal—70 to 80% die before reaching the hospitalthe hospital

• CNS and cardiovascular systems are CNS and cardiovascular systems are mainly affectedmainly affected

• Death results from seizures or dysrhythmiasDeath results from seizures or dysrhythmias• No specific antidoteNo specific antidote

– Decrease drug absorption with activated charcoalDecrease drug absorption with activated charcoal– Speed elimination by alkalinizing urineSpeed elimination by alkalinizing urine– Manage seizures and dysrhythmiasManage seizures and dysrhythmias– Basic life supportBasic life support

Antidepressants Antidepressants Monoamine Oxidase Inhibitors: MAOIsMonoamine Oxidase Inhibitors: MAOIs

• Highly effectiveHighly effective

• Considered second-line treatment for Considered second-line treatment for depression not responsive to cyclicsdepression not responsive to cyclics

• Disadvantage: potential to cause Disadvantage: potential to cause hypertensive crisis when taken with tyraminehypertensive crisis when taken with tyramine

Antidepressants: MAOIsAntidepressants: MAOIs

• phenelzine (Nardil)phenelzine (Nardil)

• tranylcypromine (Parnate)tranylcypromine (Parnate)

• isocarboxazid (Marplan)isocarboxazid (Marplan)

Antidepressants: MAOIs Antidepressants: MAOIs Mechanism of ActionMechanism of Action

• Inhibit the MAO enzyme system in the CNSInhibit the MAO enzyme system in the CNS

• Amines (dopamine, serotonin, Amines (dopamine, serotonin, norepinephrine) are not broken down, norepinephrine) are not broken down, resulting in higher levels in the brainresulting in higher levels in the brain

• Result: alleviation of symptoms of Result: alleviation of symptoms of depressiondepression

Antidepressants: MAOIs Antidepressants: MAOIs Therapeutic UsesTherapeutic Uses

• Depression, especially types characterized Depression, especially types characterized by reverse vegetative symptoms such as by reverse vegetative symptoms such as increased sleep and appetiteincreased sleep and appetite

• Depression that does not respond to other Depression that does not respond to other agents such as tricyclicsagents such as tricyclics

Antidepressants: MAOIs Antidepressants: MAOIs Side EffectsSide Effects

• Few side effects—orthostatic hypotension Few side effects—orthostatic hypotension most commonmost common

TachycardiaTachycardia PalpitationsPalpitations

DizzinessDizziness DrowsinessDrowsiness

InsomniaInsomnia HeadacheHeadache

AnorexiaAnorexia NauseaNausea

Blurred visionBlurred vision ImpotenceImpotence

Antidepressants: MAOIs Antidepressants: MAOIs OverdoseOverdose

• Symptoms appear 12 hours after ingestionSymptoms appear 12 hours after ingestion

• Tachycardia, circulatory collapse, Tachycardia, circulatory collapse, seizures, comaseizures, coma

• Treatment: protect brain and heart, Treatment: protect brain and heart, eliminate toxineliminate toxin

– Gastric lavageGastric lavage

– Urine acidificationUrine acidification

– HemodialysisHemodialysis

Antidepressants: MAOIs Antidepressants: MAOIs Hypertensive Crisis and TyramineHypertensive Crisis and Tyramine

• Ingestion of foods and/or drinks with Ingestion of foods and/or drinks with the amino acid TYRAMINE leads to the amino acid TYRAMINE leads to hypertensive crisis, which may lead hypertensive crisis, which may lead to cerebral hemorrhage, stroke, to cerebral hemorrhage, stroke, coma, or deathcoma, or death

Antidepressants: MAOIs Antidepressants: MAOIs Hypertensive Crisis and TyramineHypertensive Crisis and Tyramine

Avoid foods that contain tyramine!Avoid foods that contain tyramine!

• Aged, mature cheeses (cheddar, blue, Swiss)Aged, mature cheeses (cheddar, blue, Swiss)

• Smoked/pickled or aged meats, fish, poultry Smoked/pickled or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, (herring, sausage, corned beef, salami, pepperoni, paté)paté)

• Yeast extractsYeast extracts

• Red wines (Chianti, burgundy, sherry, vermouth)Red wines (Chianti, burgundy, sherry, vermouth)

• Italian broad beans (fava beans)Italian broad beans (fava beans)

Second-Generation AntidepressantsSecond-Generation Antidepressants

• NewerNewer

• Fewer side effects than tricyclics, but not Fewer side effects than tricyclics, but not superior in overall efficacy or onset of actionsuperior in overall efficacy or onset of action

– trazodone (Desyrel)trazodone (Desyrel)

– bupropion (Wellbutrin, Zyban)bupropion (Wellbutrin, Zyban)

– selective serotonin reuptake inhibitors (SSRIs)selective serotonin reuptake inhibitors (SSRIs)

Second-Generation Second-Generation Antidepressants and SSRIs Antidepressants and SSRIs Mechanism of ActionMechanism of Action

• Selectively inhibit serotonin reuptakeSelectively inhibit serotonin reuptake

• Little or no effect on norepinephrine or Little or no effect on norepinephrine or dopamine reuptakedopamine reuptake

• Results in increased serotonin Results in increased serotonin concentrations at nerve endingsconcentrations at nerve endings

Advantage over tricyclics and MAOIs:Advantage over tricyclics and MAOIs:Little or no effect on cardiovascular systemLittle or no effect on cardiovascular system

Second-Generation Antidepressants Second-Generation Antidepressants Therapeutic UsesTherapeutic Uses• Used for depression—very few serious side effectsUsed for depression—very few serious side effects

• Bipolar affective disorderBipolar affective disorder

• ObesityObesity

• Eating disordersEating disorders

• Obsessive-compulsive disorderObsessive-compulsive disorder

• Panic attacksPanic attacks

• MyoclonusMyoclonus

• Treatment of various substance abuse problems Treatment of various substance abuse problems (bupropion [Zyban] is used for smoking cessation (bupropion [Zyban] is used for smoking cessation treatment)treatment)

Second-Generation Antidepressants Second-Generation Antidepressants Side EffectsSide Effects

Body SystemBody System EffectsEffects

CNSCNS Headache, dizziness, Headache, dizziness, tremor, nervousness, tremor, nervousness, insomnia, fatigueinsomnia, fatigue

GIGI Nausea, diarrhea,Nausea, diarrhea,constipation, dry mouthconstipation, dry mouth

OtherOther Sweating, sexual Sweating, sexual dysfunctiondysfunction

Second-Generation Antidepressants Second-Generation Antidepressants Drug InteractionsDrug Interactions

• Highly bound to plasma proteinsHighly bound to plasma proteins

• Compete with other protein-binding drugs, Compete with other protein-binding drugs, resulting in more free, unbound drug to resulting in more free, unbound drug to cause a more pronounced drug effectcause a more pronounced drug effect

AntipsychoticsAntipsychotics

• Drugs used to treat serious mental illnessDrugs used to treat serious mental illness

• Behavioral problems or psychotic disordersBehavioral problems or psychotic disorders

AntipsychoticsAntipsychotics

• Thioxanthenes: chlorprothixene, thiothixene Thioxanthenes: chlorprothixene, thiothixene (Navane)(Navane)

• Butyrophenones: haloperidol (Haldol)Butyrophenones: haloperidol (Haldol)

• Dihydroindolones: molindone (Moban)Dihydroindolones: molindone (Moban)

• Dibenzoxazepine: loxapine (Loxitane)Dibenzoxazepine: loxapine (Loxitane)

• Phenothiazines: three structural groups Phenothiazines: three structural groups

Antipsychotics Antipsychotics Phenothiazine Structural GroupsPhenothiazine Structural Groups

• Aliphatic: chlorpromazine (Thorazine), Aliphatic: chlorpromazine (Thorazine), triflupromazine (Vesprin)triflupromazine (Vesprin)

• Piperidine: mesoridazine (Serentil), Piperidine: mesoridazine (Serentil), thioridazine (Mellaril)thioridazine (Mellaril)

• Piperazine: fluphenazine (Prolixin), Piperazine: fluphenazine (Prolixin), perphenazine (Trilafon), prochlorperazine perphenazine (Trilafon), prochlorperazine (Compazine), trifluoperazine (Stelazine)(Compazine), trifluoperazine (Stelazine)

Largest group of psychotropic agentsLargest group of psychotropic agents

Antipsychotics Antipsychotics Atypical AntipsychoticsAtypical Antipsychotics

• clozapine (Clozaril)clozapine (Clozaril)

• risperidone (Risperdal)risperidone (Risperdal)

• olanzapine (Zyprexa)olanzapine (Zyprexa)

• quetiapine (Seroquel)quetiapine (Seroquel)

Antipsychotics: Mechanism of ActionAntipsychotics: Mechanism of Action

• Block dopamine receptors in the brain (limbic Block dopamine receptors in the brain (limbic system, basal ganglia)—areas associated system, basal ganglia)—areas associated with emotion, cognitive function, motor with emotion, cognitive function, motor functionfunction

• Dopamine levels in the CNS are decreasedDopamine levels in the CNS are decreased

• Result: tranquilizing effect in psychotic Result: tranquilizing effect in psychotic patientspatients

Antipsychotics: Mechanism of ActionAntipsychotics: Mechanism of Action

• The newer, atypical antipsychotics also block The newer, atypical antipsychotics also block specific serotonin receptors (serotonin-2 specific serotonin receptors (serotonin-2 [5HT2] receptors).[5HT2] receptors).

• This is responsible for their improved This is responsible for their improved efficacy and safety profiles.efficacy and safety profiles.

Antipsychotics: Drug EffectsAntipsychotics: Drug Effects

• Block dopamine receptors in CNSBlock dopamine receptors in CNS

• Block alpha receptors (causing Block alpha receptors (causing hypertension, other cardiovascular effects)hypertension, other cardiovascular effects)

• Block histamine receptors (causing Block histamine receptors (causing anticholinergic effects)anticholinergic effects)

• Block serotoninBlock serotonin

• Also function as antiemeticsAlso function as antiemetics

• Antianxiety effectsAntianxiety effects

Antipsychotics: Therapeutic UsesAntipsychotics: Therapeutic Uses

• Treatment of serious mental illnesses:Treatment of serious mental illnesses:– Bipolar affective disorderBipolar affective disorder

– Depressive and drug-induced psychosesDepressive and drug-induced psychoses

– SchizophreniaSchizophrenia

– AutismAutism

• Movement disorders (such as Tourette’s Movement disorders (such as Tourette’s syndrome)syndrome)

• Some medical conditionsSome medical conditions– Nausea, intractable hiccups Nausea, intractable hiccups

Antipsychotics: Side EffectsAntipsychotics: Side Effects


CNSCNS Sedation, deliriumSedation, delirium

CardiovascularCardiovascular Orthostatic hypotension, Orthostatic hypotension, syncope, dizziness, syncope, dizziness, ECG changesECG changes

DermatologicDermatologic Photosensitivity, skin Photosensitivity, skin rash,rash, hyperpigmentation, hyperpigmentation, prurituspruritus

Antipsychotics: Side EffectsAntipsychotics: Side Effects


GIGI Dry mouth, constipationDry mouth, constipation

GUGU Urinary hesitancy or Urinary hesitancy or retention, impaired erectionretention, impaired erection

HematologicHematologic Leukopenia andLeukopenia andagranulocytosisagranulocytosis

Metabolic/endocrineMetabolic/endocrine Galactorrhea, irregularGalactorrhea, irregularmensesmensesincreased appetite, increased appetite, polydipsiapolydipsia

Psychotherapeutic Agents: Psychotherapeutic Agents: Nursing ImplicationsNursing Implications

• Before beginning therapy, assess both the Before beginning therapy, assess both the physical and emotional status of patientsphysical and emotional status of patients

• Obtain baseline VS, including postural BP Obtain baseline VS, including postural BP readingsreadings

• Obtain liver and renal function tests (and Obtain liver and renal function tests (and baseline platelet levels for MAOIs)baseline platelet levels for MAOIs)


• Assess for possible contraindications to Assess for possible contraindications to therapy, cautious use, and potential drug therapy, cautious use, and potential drug interactionsinteractions

• Assess LOC, mental alertness, potential Assess LOC, mental alertness, potential for injury to self and othersfor injury to self and others

• Check the patient’s mouth to make sure Check the patient’s mouth to make sure oral doses are swallowedoral doses are swallowed


• Provide simple explanations about the drug, Provide simple explanations about the drug, its effects, and the length of time before its effects, and the length of time before therapeutic effects can be expectedtherapeutic effects can be expected

• Abrupt withdrawal should be avoidedAbrupt withdrawal should be avoided

• Advise patients to change positions slowly Advise patients to change positions slowly to avoid postural hypotension and possible to avoid postural hypotension and possible injuryinjury


• The combination of drug therapy and The combination of drug therapy and psychotherapy is emphasized because psychotherapy is emphasized because patients need to learn and acquire more patients need to learn and acquire more effective coping skillseffective coping skills

• Only small amounts of medications should Only small amounts of medications should be dispensed at a time to minimize the risk be dispensed at a time to minimize the risk of suicide attemptsof suicide attempts

• Simultaneous use of these agents with Simultaneous use of these agents with alcohol or other CNS depressants can alcohol or other CNS depressants can be fatalbe fatal



• Many cautions, contraindications, and interactions Many cautions, contraindications, and interactions exist pertaining to the use of antidepressants.exist pertaining to the use of antidepressants.

• Inform patients that it may take 1 to 3, even 4, Inform patients that it may take 1 to 3, even 4, weeks to see therapeutic effects.weeks to see therapeutic effects.

• Monitor patients closely during this time and Monitor patients closely during this time and provide support.provide support.

Psychotherapeutic Agents:Psychotherapeutic Agents:Nursing ImplicationsNursing Implications


• Sedation often occurs with tricyclic therapy; notify Sedation often occurs with tricyclic therapy; notify physician if this lasts more than 2 weeks.physician if this lasts more than 2 weeks.

• Assist elderly or weakened patients with ambulation Assist elderly or weakened patients with ambulation and other activities as falls may occur due to and other activities as falls may occur due to drowsiness or postural hypotension.drowsiness or postural hypotension.



• Tricyclics may need to be weaned and discontinued Tricyclics may need to be weaned and discontinued before undergoing surgery to avoid interactions with before undergoing surgery to avoid interactions with anesthetic agents.anesthetic agents.

• Monitor for side effects and discuss with patients.Monitor for side effects and discuss with patients.

• Encourage patients to wear medication ID badges Encourage patients to wear medication ID badges naming the agent being taken.naming the agent being taken.



• Caffeine and cigarette smoking may decrease Caffeine and cigarette smoking may decrease effectiveness of medication therapyeffectiveness of medication therapy

• Instruct patients and family regarding tyramine-Instruct patients and family regarding tyramine-containing foods and signs and symptoms of containing foods and signs and symptoms of hypertensive crisishypertensive crisis


Antipsychotics—PhenothiazinesAntipsychotics—Phenothiazines

• Instruct patients to wear sunscreen due to Instruct patients to wear sunscreen due to photosensitivityphotosensitivity

• Avoid taking antacids or antidiarrheal preparations Avoid taking antacids or antidiarrheal preparations within 1 hour of a dosewithin 1 hour of a dose

• Do not take alcohol or other CNS depressants Do not take alcohol or other CNS depressants with these medicationswith these medications


Antipsychotics—PhenothiazinesAntipsychotics—Phenothiazines

• Long-term haloperidol therapy may result in tremors, Long-term haloperidol therapy may result in tremors, nausea, vomiting, or uncontrollable shaking of small nausea, vomiting, or uncontrollable shaking of small muscle groups; these symptoms should be reported muscle groups; these symptoms should be reported to the physicianto the physician

• Oral forms may be taken with meals to decrease Oral forms may be taken with meals to decrease GI upsetGI upset

• These agents may cause drowsiness, dizziness, or These agents may cause drowsiness, dizziness, or fainting; instruct patients to change positions slowlyfainting; instruct patients to change positions slowly


Monitor for therapeutic effects:Monitor for therapeutic effects:

• Monitor mental alertness, cognition, affect, Monitor mental alertness, cognition, affect, mood,ability to carry out activities of daily mood,ability to carry out activities of daily living, appetite, and sleep patternsliving, appetite, and sleep patterns

• Monitor the patient’s potential for self-injury Monitor the patient’s potential for self-injury during the delay between the start of therapy during the delay between the start of therapy and symptomatic improvementand symptomatic improvement


Monitor for therapeutic effectsMonitor for therapeutic effects

• For antidepressants: For antidepressants:

– Improved sleep patterns and nutrition, increased Improved sleep patterns and nutrition, increased feelings of self-esteem, decreased feeling of feelings of self-esteem, decreased feeling of hopelessness, increased interest in self and hopelessness, increased interest in self and appearance, increased interest in daily activities, appearance, increased interest in daily activities, fewer depressive manifestations or suicidal fewer depressive manifestations or suicidal thoughts or ideationsthoughts or ideations


Monitor for therapeutic effectsMonitor for therapeutic effects

• For antipsychotics: For antipsychotics:

– Improved mood and affect, alleviation of Improved mood and affect, alleviation of psychotic symptoms and episodespsychotic symptoms and episodes

– Decrease in hallucinations, paranoia, delusions, Decrease in hallucinations, paranoia, delusions, garbled speech, inability to copegarbled speech, inability to cope

Psychotherapeutic Agents Antidepressants and Antipsychotics.

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Transcript of Psychotherapeutic Agents Antidepressants and Antipsychotics.