PSYCHOPHARMACOLOGY
Presented by:
Akhlaque Ahmed Qadri
Acknowledgement:
Sobia Rasheed
Objectives
Define Psychopharmacology
Explain characteristics of antidepressants,
antipsychotics and mood stabilizers in terms of
mechanism of action, indications for use,
different categories and adverse effect
Discuss the implications for nursing actions for
various categories of psychotropic drugs
Discuss the importance of client and family
education regarding psychotropic drugs.
Psychopharmacology is the
study of the effects of drugs on
affect, cognition, and behavior
Antidepressants
Types of Antidepressants
Monoamine oxidaxe inhibitors
(MAOIs)
Tricyclic antidepressants (TCAs)
Serotonin Specific Reuptake
Inhibitors (SSRIs)
Mono Amine Oxidase Inhibitors
(MAOIs)
MAO Inhibitors are the second or third choice
antidepressants for many patients
Effective as an antidepressant/antipanic/antiphobic
drugs
Risk for hypertensive crises in response to food
rich in tyramine
With the advent of SSRI’s & TCA’s, use of MAOI’S
continue to decline
Mechanism of Action
MAO: Mono amine oxidase : metabolize nor
epinephrine and serotinin
These drugs inhibits MAO-A and MAO-B in the nerve
terminals
Enables the previous deficient amine to accumulate in
neuronal sites
By inhibiting the intraneuronal MAO, these drugs
increase the amount of norepinephrine and serotonin
available for release
Thereby intensify transmission at noradrenergic and
serotonergic junctions
(Cont.…)
Indications:
Depression
Obsessive Compulsive Disorder
Panic attacks
Bulimia
Adverse effects
CNS Stimulation (Anxiety, agitation,
hypomania)
Orthostatic Hypotension
Hypertensive crisis from dietary tyramine
(Symptoms include severe occipital
headache, palpitations, nausea/vomiting,
fever, sweating, marked increase in BP,
chest pain and coma)
Diet and Drug Restriction for
Client on MAOI Therapy
Aged Cheeses
Chicken and beef liver
Yeast preparations
Alcoholic beverages
Protein extracts such as those contained in soup cubes and
commercial gravies
Red wines
Smoked and processed meat
Drug Restrictions
Other antidepressants
Sympethomimetics
Stimulants
Antihypertensive
Antiparkinsonian agents (Levodopa)
Tricyclic antidepressants
(TCAs)
First tricyclic agent was introduced in
psychiatry in 1950’s –Imipramine
Mechanism of Action
Under Drug free condition , the actions of
norepinephrine and serotonin are terminated by
active uptake of these transmitters back into the
nerve terminals from which they were released
TCAs block Norepinephrine and serotonin reuptake
Causes accumulation of these neurotransmitters in the
synaptic space
Thus intensifying their effects
Cont.…
Therapeutic Uses:
Depression
Bipolar Disorder
Attention Deficit Hyperactive Disorder
Panic Disorder
Drug Examples
Amitriptyline(Elavil)
Imipramine (Tofranil)
Trimipramine (Surmontil)
Clomipramine (Anafranil)
Cont.…
Adverse effects:
Orthostatic Hypotension
Anticholinergic effects
◦ Dry mouth, blurred vision, photophobia, constipation,
Urinary hesitancy, and tachycardia)
Diaphoresis Sedation & weight gain
Cardiac Toxicity
Seizures
Hypomania
Lethal if overdose therefore baseline and ongoing
suicide assessment is important.
Serotonin Specific Reuptake
Inhibitors (SSRIs)
Drugs that produce selective blockade of serotonin reuptake
SSRIs are as effective as TCAs , but do not cause
hypotension, sedation, or anticholinergic effects
Over dosage do not result in cardiac toxicity
Fluoxetine is the most popular SSRI
Indication:
Major depression
Panic disorder
OCD
Menstrual syndrome
Investigational uses include Bulimia, ADHD, Bipolar
disorder, migraine
Mechanism of Action
Inhibit the re uptake of serotonin at pre synaptic
membrane
An increase of available serotonin in the synapse and
Causes accumulation of these neurotransmitters in the
synaptic space
promote serotonin neurotransmission
SSRI Antidepressants
Generic Name Brand
Name
Citalopram Celexa
Escitalopram Lexapro
Fluoxetine Prozac
Fluvoxamine Luvox
Paroxetine Paxil
Sertraline Zoloft
Adverse effects of SSRIs
Headache
Nausea
Nervousness
Anxiety
Diarrhea
Insomnia
Weight gain
Dizziness and fatigue
Sexual dysfunction
Serotonin syndrome
Nursing Care and
Teaching
Encourage fluids, frequent rinses
and check mouth for sores
Monitor voiding patterns and
encourage frequent voiding
Avoid hazardous tasks
Supportive therapy
Protect from fall
Careful cardiac history
Nursing Care and
Teaching
Check ECG if patient is >40 years
Frequent BP monitoring (both lying and
standing BP)
Increase exercise and reduce calorie
intake
Discontinue serotonergic drug if serotonin
syndrome occur (igh body temperature,
agitation, increased reflexes, tremor,
sweating, dilated pupils, and diarrhea)
Eliminate caffeine
Encourage concentration
ANTIPSYCHOTICS
Classification of Antipsychotics
Typical Neuroleptics
Atypical Neuroleptics
Dopaminergic Pathways and Innervation
Typical Antipsychotics
Also called as traditional antipsychotics
Traditional antipsychotic agents can be
classified as high potency (Haloperidol), medium
and low potency (Thorazine)
Potency refers only to the size of dose needed
to elicit a given response. Potency implies
nothing about the maximum effect that a drug
can produce
Knowing the potency is important because these
agents differ in their side effects
Mechanism of Action
Dopamine is produced in the substantia
nigra and ventral tegmental regions of
the brain, and dopamine alterations are
related to schizophrenia
Potent dopamine antagonists
Block post synaptic D2 receptors in in the
mesolimbic and mesocortical areas of the brain
(Region thought to be involved in psychosis)
Decrease in positive symptoms of
schizophrenia
Typical Antipsychotics
High Potency Typical Antipsychotics
Serenace (Haloperidol)
Prolixin (Fluphenazine)
Navane (Thiothixine)
Stelazine (Trifluoperazine)
Orap (Pimozide)
Low Potency Typical Antipsychotics
Mellaril (Thioridazine)
Thorazine (Chlorpromazine)
Serentil (Mesoridazine)
Mid Potency Typical Antipsychotics
Trilafon (Perphenazine)
Moban (Molindone )
Loxitane (Loxapine)
Compazine (Prochlorperazine)
Cont.…
Therapeutic Uses:
Schizophrenia
Bipolar Disorder (Manic depressive illness)
Tourette’s syndrome
Prevention of emesis
High Potency Antipsychotics
Benefits & Risks (Typical)
Higher binding to D2 receptors:
◦ Higher Efficacy
◦ More EPS (Extra Pyramidal Symptoms)
◦ Higher incidence of TD (Tardive Dyskinesia)
Less Cognitive Problems
◦ Less Sedation
◦ Less Anti-cholinergic SE (Side Effects)
Less Cardiovascular SE
Low Potency Antipsychotics
Benefits & Risks (Typical)
Lower binding to D2 receptors:
◦ Lower Efficacy
◦ Less EPS (Extra Pyramidal Symptoms)
◦ Lower incidence of TD (Tardive
Dyskinesia)
More Cognitive Problems
◦ More Sedation
◦ More Anti-cholinergic SE
More Cardiovascular SE and Other SE
Atypical Antipsychotics
Atypical antipsychotic differs from traditional
agents in the following important ways
These agents cause fewer or no EPS (Extra
Pyramidal Symptoms)
These agents can relieve both positive and
negative symptoms of schizophrenia whereas
traditional agents are limited largely to positive
symptoms
Atypical Agents
Clozapine
Olazipine
Resperidone
Quetiapine
Ziprasidone
Adverse effects of Antipsychotics
Risperidone: Extrapyramidal side effects (EPS)
Olanzapine and clozapine: Weight gain and
metabolic disturbances
Quetiapine, Olanzapine and clozapine:
Sedation
Ziprasidone: Mild to moderate Q-T interval
prolongation
Clozapine:Seizure,Myocarditis,
agranulocytosis
Extra Pyramidal
Symptoms
Physical symptoms, including
tremor, slurred speech,
akathesia, dystonia, anxiety,
distress, paranoia, that are
primarily associated with
improper dosing of or unusual
reactions to neuroleptic
(antipsychotic) medications.
Cont.…
Four types of EPS
Parkinsonism (akinesia (loss of voluntary
movement), rigidity, tremor)
Akathisia (uncontrollable restlessness)
Dystonia (involuntary movements, spasm of
muscles of face, tongue, neck and back)
Tardive dyskinesia (TD) (involuntary
movements of the face, tongue and also of the
trunk and limbs).
Neuroleptic Malignant Syndrome
Marked muscle rigidity
Rapid rise in body temperature (dangerous levels)
Mental confusion
Autonomic symptoms: tachycardia, blood pressure
fluctuations, excess sweating
Extrapyramidal symptoms
Treatment:
◦ Stop neuroleptic medications
◦ Muscle relaxant administration (diazepam)
◦ Cooling
◦ Fluid administration
Nursing Care and
Teaching
Use sunscreen and sun glasses
Patient education on healthy lifestyle i.e., eating,
exercise and smoking cessation.
If symptoms of EPS persists:
◦ decrease dose of drug
◦ Add drug to treat EPS
◦ Taper after 3 months on antipsychotic
• If neurologic malignant Syndrome occur:
• then discontinue all drug
• Supportive symptomatic care
• Hydration
• Renal dialysis
• ventilation
Mood Stabilizers (Lithium)
Lithium is a naturally occurring salt.
First line treatment of patients with mania.
Sodium depletion and dehydration can decrease renal
excretion of lithium thus leading to lithium toxicity
Therapeutic level of lithium is 0.6-1.4meq/L, when
exceed that 1.5, seriously toxicity begins to start.
Maintenance drug level 0.4-1meq/l
Mechanism of Action
Exact mechanism of action is not known
Lithiumcorrect the ion exchange abnormality in
neurons distribution (calcium, sodium and
magnesium)
Resultin normalize synaptic neurotranmition of
epinephrine, serotinin, dopamine and acetacholine
Used in bipolar disorder (Mania)
Cont.…
Adverse effects:
Weight gain
ECG changes
Fatigue, headache,
Thyroid dysfunction
Polyuria, nephrogenic Diabetic Insipidus Fetal
abnormality if used in pregnancy
Harmful for nursing infant
Cont.…
Lithium Toxicity
Nausea/ vomiting
Fine hand tremor
GI disturbances
polyuria
Confusion
ECG changes
Sedation
Seizures
Oliguria
Severe hypotension
Coma, death
Nursing Care and Teaching
Ensure adequate sodium intake
Ensure adequate fluid intake
Replace fluid and electrolytes lost during exercise
Monitor signs for toxicity
Monitor electrolytes
Monitor ECG
Monitor thyroid function
Lithium level should be done every week for first month
then every 3 to 6 months for 6 months, every 6months,
then 12 months
Cont.…
Carbamazepine and valproic acid are
also used as mood stabilizer agents
Reference
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