Psycho P Harm

PSYCHOPHARMACOLOGY
CHAPTER OUTLINE KEY TERMS

Objectives agranulocytosis hypertensive crisis
Historical Perspectives akathisia neuroleptic malignant
How Do Psychotropics Work? akinesia syndrome
Applying the Nursing Process amenorrhea oculogyric crisis
in Psychopharmacological Therapy dystonia priapism
Summary and Key Points extrapyramidal retrograde ejaculation
Review Questions symptoms serotonin syndrome
gynecomastia tardive dyskinesia
CORE CONCEPTS
neurotransmitter
psychotropic medication
receptor
OBJECTIVES
After reading this chapter, the student will be able to:
1. Discuss historical perspectives related to psychopharmacology.
2. Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classifications of drugs:
a. Antianxiety agents
b. Antidepressants
c. Mood-stabilizing agents
d. Antipsychotics
e. Antiparkinsonian agents
f. Sedative-hypnotics
g. Agents for attention deficit hyperactivity disorder
3. Apply the steps of the nursing process to the administration of psychotropic
medications.
The middle of the 20th century identifies a pivotal period in the treatment of individuals
with mental illness. It was during this time that the phenothiazine class of antipsychotics
was introduced into the United States. Before that time they had been used in France as
preoperative medications. As Dr. Henri Laborit of the Hospital Boucicaut in Paris stated,
It was our aim to decrease the anxiety of the patients to prepare them in advance for their
postoperative recovery. With these new drugs, the phenothiazines, we were seeing a profound
psychic and physical relaxation . . . a real indifference to the environment and to the upcoming
operation. It seemed to me these drugs must have an application in psychiatry. (Sage, 1984)
Indeed they have had a significant application in psychiatry. Not only have they helped
many individuals to function effectively, but they have also provided researchers and
clinicians with information to study the origins and etiologies of mental illness.
Knowledge gained from learning how these drugs work has promoted advancement in
understanding how behavioral disorders develop. Dr. Arnold Scheibel, Director of the
UCLA Brain Research Institute, stated,
[When these drugs came out] there was a sense of disbelief that we could actually do something
substantive for the patients . . . see them for the first time as sick individuals and not as something
bizarre that we could literally not talk to. (Sage, 1984)
This chapter explores historical perspectives in the use of psychotropic medications
in the treatment of mental illness. Seven classifications of medications are discussed, and
their implications for psychiatric nursing are presented in the context of the steps of the
nursing process.
Core
Concept
Psychotropic medication
Medication that affects psychic function, behavior, or experience.
HISTORICAL PERSPECTIVES
Historically, reaction to and treatment of individuals with mental illness ranged from
benign involvement to intervention some would consider inhumane. Individuals with
Copyright © 2014. F.A. Davis Company

mental illness were feared because of common beliefs associating them with demons or
the supernatural. They were looked upon as loathsome and often were mistreated.
Beginning in the late 18th century, a type of “moral reform” in the treatment of
persons with mental illness began to occur. Community and state hospitals concerned with
the needs of persons with mental illness were established. Considered a breakthrough in
the humanization of care, these institutions, however well intentioned, fostered the concept
of custodial care. Clients were ensured food and shelter but received little or no hope of
change for the future. As they became increasingly dependent on the institution to fulfill
their needs, the likelihood of their return to the family or community diminished.
The early part of the 20th century saw the advent of the somatic therapies in
psychiatry. Individuals with mental illness were treated with insulin shock therapy, wet
sheet packs, ice baths, electroconvulsive therapy, and psychosurgery. Before 1950,
sedatives and amphetamines were the only significant psychotropic medications available.
Even these had limited use because of their toxicity and addicting effects. Since the 1950s,
the development of psychopharmacology has expanded to include widespread use of
antipsychotic, antidepressant, and antianxiety medications. Research into how these drugs
work has provided an understanding of the etiology of many psychiatric disorders.
Psychotropic medications are not intended to “cure” the mental illness. Most
mental health practitioners who prescribe these medications for their clients use them as an
adjunct to individual or group psychotherapy. Although their contribution to psychiatric
care cannot be minimized, it must be emphasized that psychotropic medications relieve
physical and behavioral symptoms. They do not resolve emotional problems.
ROLE OF THE NURSE

Ethical and Legal Implications
Nurses must understand the ethical and legal implications associated with the
administration of psychotropic medications. Laws differ from state to state, but most
adhere to the client’s right to refuse treatment. Exceptions exist in emergency situations
when it has been determined that clients are likely to harm themselves or others.
Assessment
A thorough baseline assessment must be conducted before a client is placed on a regimen
of psychopharmacological therapy. A history and physical examination (see Chapter 9 of
the textbook), an ethnocultural assessment (see Chapter 6 of the textbook), and a
comprehensive medication assessment (see Box 1) are all essential components of this
database.
Medication Administration and Evaluation
For the client in an inpatient setting, as well as for many others in partial hospitalization
programs, day treatment centers, home health care, and other settings, the nurse is the key
health-care professional in direct contact with the individual receiving the chemotherapy.
Medication administration is followed by a careful evaluation, which includes continuous
monitoring for side effects and adverse reactions. The nurse also evaluates the therapeutic
effectiveness of the medication. It is essential for the nurse to have a thorough knowledge
of psychotropic medications to be able to anticipate potential problems and outcomes
associated with their administration.
Client Education

The information associated with psychotropic medications is copious and complex. An
important role of the nurse is to translate that complex information into terms that can be
easily understood by the client. Clients must understand why the medication has been
prescribed, when it should be taken, and what they may expect in terms of side effects and
possible adverse reactions. They must know whom to contact when they have a question
and when it is important to report to their physician. Medication education encourages
client cooperation and promotes accurate and effective management of the treatment
regimen.
Core
Concepts
Neurotransmitter
A chemical that is stored in the axon terminals of the presynaptic
neuron. An electrical impulse through the neuron stimulates the release
of the neurotransmitter into the synaptic cleft, which in turn determines
whether another electrical impulse is generated.
Receptor
Molecules situated on the cell membrane that are binding sites for
neurotransmitters.
HOW DO PSYCHOTROPICS WORK?

Most of the psychotropic medications have their effects at the neuronal synapse, producing
changes in neurotransmitter release and the receptors to which they bind (see Figure 1).
Researchers hypothesize that most antidepressants work by blocking the reuptake of
neurotransmitters, specifically, serotonin and norepinephrine. Reuptake is the process of
neurotransmitter inactivation by which the neurotransmitter is reabsorbed into the
presynaptic neuron from which it had been released. Blocking the reuptake process allows
more of the neurotransmitter to be available for neuronal transmission. This mechanism of

action may also result in undesirable side effects (see Table 1). Some antidepressants also
block receptor sites that are unrelated to their mechanisms of action. These include α-
adrenergic, histaminergic, and muscarinic cholinergic receptors. Blocking these receptors
is also associated with the development of certain side effects.
Figure 1: Area of synaptic transmission that is altered by drugs
Table 1. EFFECTS OF PSYCHOTROPIC INFLUENCE ON NEUROTRANSMITTERS

Action on
Example of Medication Neurotransmitter and/or Physiological Effects Side Effects
Receptor
Reduces depression Nausea, agitation, headache,
SSRIs Inhibit reuptake of Controls anxiety sexual dysfunction

serotonin (5-HT) Controls obsessions
Tricyclic Inhibit reuptake of Reduces depression Sexual dysfunction (NE &

antidepressants serotonin (5-HT) Relief of severe pain 5-HT)
Inhibit reuptake of Prevents panic attacks Sedation, weight gain (H1)
norepinephrine (NE) Dry mouth, constipation,
Block NE (α1) receptor blurred vision, urinary
Block ACh receptor retention (ACh)
Block Histamine (H1) Postural hypotension and
receptor tachycardia (α1)
MAO inhibitors Increase NE and 5-HT by Reduces depression Sedation, dizziness

inhibiting the enzyme Controls anxiety Sexual dysfunction
that degrades them Hypertensive crisis
(MAO-A) (interaction with
tyramine)
Trazodone and 5-HT reuptake block Reduces depression Nausea (5-HT)

nefazodone 5-HT2 receptor Reduces anxiety Sedation (5-HT2)
antagonism Orthostasis (α1)
Adrenergic receptor Priapism (α2)
blockade
SSNRIs: venlafaxine, Potent inhibitors of Reduces depression Nausea (5-HT)

desvenlafaxine, serotonin and Relieves pain of ↑ sweating (NE)
duloxetine, and norepinephrine reuptake neuropathy (duloxetine) Insomnia (NE)
levomilnacipran Weak inhibitors of Relieves anxiety Tremors (NE)
dopamine reuptake (venlafaxine) Sexual dysfunction (5-HT)
Bupropion Inhibits reuptake of NE Reduces depression Insomnia, dry mouth,

and dopamine (D) Aid in smoking cessation tremor, seizures
↓ symptoms of ADHD
Antipsychotics: Strong D2 receptor Relief of psychosis Blurred vision, dry mouth,

phenothiazines and blockade Relief of anxiety decreased sweating, cons-
haloperidol Weaker blockade of ACh, (Some) provide relief from tipation, urinary retention,
H1, α1-adrenergic, and nausea and vomiting and tachycardia (ACh)
5-HT2 receptors intractable hiccoughs EPS (D2)
↑ plasma prolactin (D2)
Sedation; weight gain (H1)
Ejaculatory difficulty
(5-HT2)
Postural hypotension (α; H1)
Antipsychotics (Novel):
aripiprazole, Receptor antagonism of Relief of psychosis (with Potential with some of the
asenapine 5-HT1 and 5-HT2 minimal or no EPS) drugs for mild EPS (D2)
clozapine, D1 – D5 (varies with Relief of anxiety Sedation, weight gain (H1)
iloperidone drug) Relief of acute mania Orthostasis and dizziness
lurasidone H1 (α-adrenergic)
olanzepine, α1-adrenergic Blurred vision, dry mouth,
paliperidone, muscarinic (ACh) decreased sweating, cons-
quetiapine, tipation, urinary retention,
risperdone, tachycardia (ACh)
ziprasidone
Table 1. Continued
Antianxiety: Bind to BZ receptor sites Relief of anxiety Dependence (with long-

benzodiazepines on the GABAA receptor Sedation term use)
complex; increase Confusion; memory
receptor affinity for impairment; motor
GABA incoordination
Antianxiety: 5-HT1A agonist Relief of anxiety Nausea, headache,

buspirone D2 agonist dizziness
D2 antagonist Restlessness
ACh, acetylcholine; ADHD, attention deficit-hyperactivity disorder; BZ, benzodiazepine; D, dopamine; EPS,
extrapyramidal symptoms; GABA, gamma-aminobutyric acid; H, histamine; 5-HT, 5-hydroxytryptamine (serotonin);
MAO, monoamine oxidase; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective
serotonin reuptake inhibitor.
Antipsychotic medications block dopamine receptors, and some affect
muscarinic cholinergic, histaminergic, and α-adrenergic receptors. The
“atypical” (or novel) antipsychotics block a specific serotonin receptor.
Benzodiazepines facilitate the transmission of the inhibitory neurotransmitter
gamma-aminobutyric acid (GABA). The psychostimulants work by
increasing norepinephrine, serotonin, and dopamine release.
Although each psychotropic medication affects neurotransmission, the specific
drugs within each class have varying neuronal effects. Their exact mechanisms of action
are unknown. Many of the neuronal effects occur acutely; however, the therapeutic effects
may take weeks for some medications such as antidepressants and antipsychotics. Acute
alterations in neuronal function do not fully explain how these medications work. Long-
term neuropharmacological reactions to increased norepinephrine and serotonin levels
relate more to their mechanisms of action. Recent research suggests that the therapeutic
effects are related to the nervous system’s adaptation to increased levels of
neurotransmitters. These adaptive changes result from a homeostatic mechanism, much
like a thermostat, that regulates the cell and maintains equilibrium.
APPLYING THE NURSING PROCESS IN

PSYCHOPHARMACOLOGICAL THERAPY
An assessment tool for obtaining a drug history is provided in Box 1. This tool may be
adapted for use by staff nurses admitting clients to the hospital or by nurse practitioners

who may wish to use it with prescriptive privileges. It may also be used when a client’s
signature of informed consent is required prior to pharmacological therapy.

Box 1. MEDICATION ASSESSMENT TOOL
Date_____________________
Client’s Name____________________________________________________________ ________Age________________________
Marital Status__________________________________ Children____________________________
Occupation____________________________________________
Presenting Symptoms (subjective &
objective)_______________________________________________________________________________________________
___________________________________________________________________________________________________________
________________________
Diagnosis (DSM-5) __________________________________________________________________________________________
Current Vital Signs: Blood Pressure: Sitting________/________; Standing________/________; Pulse__________ ;
Respirations____________
Height___________________ Weight_______________________
CURRENT/PAST USE OF PRESCRIPTION DRUGS (Indicate with “c” or “p” beside name of drug whether current or past use):
Name Dosage How Long Used Why Prescribed By Whom Side Effects/Results
______ ______ ______________ ____________ ________ _________________
______ _______ ______________ _____________ _________ _________________
______ ______ ______________ _____________ _________ _________________
CURRENT/PAST USE OF OVER-THE-COUNTER DRUGS (Indicate with “c” or “p” beside name of drug whether current or past
use):
Name Dosage How Long Used Why Prescribed By Whom Side Effects/Results
_____ ______ ____________ ____________ ________ ________________
_____ ______ ____________ ____________ ________ ________________
_____ ______ ____________ ____________ ________ ________________
CURRENT/PAST USE OF STREET DRUGS, ALCOHOL, NICOTINE, AND/OR CAFFEINE (Indicate with “c” or “p” beside name
of drug):
Name Amount Used How Often Used When Last Used Effects Produced
______ __________ ______________ ______________ ________________
______ __________ ______________ ______________ ________________
______ __________ _______________ ______________ ________________
Any allergies to food or

drugs?_________________________________________________________________ ____________________________________
Any special diet

considerations?______________________________________________________________________________________________
Do you have (or have you ever had) any of the following? If yes, provide explanation on the back of this sheet.
Yes No Yes No Yes No

1. Difficulty swallowing ___ ___ 12. Chest pain ___ ___ 24. Lumps in your breasts ___ ___
2. Delayed wound healing ___ ___ 13. Blood clots/pain in legs ___ ___ 25. Blurred or double vision ___ ___
3. Constipation problems ___ ___ 14. Fainting spells ___ ___ 26. Ringing in the ears ___ ___
4. Urination problems ___ ___ 15. Swollen ankles/legs/hands ___ ___ 27. Insomnia ___ ___
5. Recent change in elimination 16. Asthma ___ ___ 28. Skin Rashes ___ ___
6. patterns ___ ___ 17. Varicose veins ___ ___ 29. Diabetes ___ ___
6. Weakness or tremors ___ ___ 18. Numbness/tingling (location?) ___ ___ 30. Hepatitis (or other liver disease) ___ ___
7. Seizures ___ ___ 19. Ulcers ___ ___ 31. Kidney disease ___ ___
8. Headaches ___ ___ 20. Nausea/vomiting ___ ___ 32. Glaucoma ___ ___
9. Dizziness ___ ___ 21. Problems with diarrhea ___ ___
10. High blood pressure ___ ___ 22. Shortness of breath ___ ___
11. Palpitations ___ ___ 23. Sexual dysfunction ___ ___
Are you pregnant or breast feeding?_____________ Date of last menses____________________ Type of contraception
used________________________________
Describe any restrictions/limitations that might interfere with your use of medication for your current
problem._____________________________________________
___________________________________________________________________________________________________________
_________________________
Prescription orders: Patient teaching related to medications prescribed:

Lab work or referrals prescribed:
Nurse’s signature__________________________________________________
Client’s signature____________________________________

Antianxiety Agents
Background Assessment Data
Indications. Antianxiety drugs are also called anxiolytics and minor tranquilizers. They
are used in the treatment of anxiety disorders, anxiety symptoms, acute alcohol withdrawal,
skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation.
Their use and efficacy for periods greater than 4 months have not been evaluated.
Examples of commonly used antianxiety agents are presented in Table 2.
Table 2. ANTIANXIETY AGENTS

Pregnancy Daily Adult
Generic Controlled Categories/ Dosage Common Side Effects of
Chemical Class (Trade) Name Categories Half-life (hr) Range (mg) Antianxiety Agents
Antihistamines Hydroxyzine C (3) 100–400  Drowsiness, confusion, lethargy

(Vistaril)  Tolerance; physical and
psychological dependence (does
Benzodiazepines Alprazolam (Xanax) CIV D (6.3– 0.75–4 not apply to Buspirone). Client
26.9) should be tapered off long-term
Chlordiazepoxide CIV D (5–30) 15–100 use.
(Librium)  Potentiates the effects of other
Clonazepam CIV D(18–50) 1.5–20 CNS depressants. Client should
(Klonopin) not take alcohol or other CNS
Clorazepate CIV D (40– 15–60 depressants with the medication.
(Tranxene) 50)  May aggravate symptoms of
Diazepam (Valium) CIV D (20–80) 4–40 depression.
Lorazepam (Ativan) CIV D (10–20) 2–6  Orthostatic hypotension. Client
Oxazepam CIV D (5–20) 30–120 should rise slowly from lying or
sitting position.
 Paradoxical excitement. If
Carbamate Meprobamate CIV D (6–17) 400–1600 symptoms opposite of desired
derivative effect occur, notify physician
immediately.
Azaspirodecanedione Buspirone (BuSpar) B (2–3) 15–60  Dry mouth
 Nausea and vomiting. May be
taken with food or milk.
 Blood dyscrasias. Symptoms of
sore throat, fever, malaise, easy
bruising, or unusual bleeding
should be reported to the
physician immediately.
 Delayed onset (with Buspirone).
Lag time of 10 to 14 days for
anxiety symptoms to diminish
with buspirone. Buspirone is not
recommended for prn
administration.
Action. Antianxiety drugs depress subcortical levels of the CNS, particularly the
limbic system and reticular formation. They may potentiate the effects of the powerful
inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the brain, thereby
producing a calmative effect. All levels of CNS depression can be affected, from mild
sedation to hypnosis to coma. NOTE: Buspirone (BuSpar) does not depress the CNS.
Although its action is unknown, the drug is believed to produce the desired effects through
interactions with serotonin, dopamine, and other neurotransmitter receptors.
Contraindications/Precautions. Antianxiety drugs are contraindicated in
individuals with known hypersensitivity to any of the drugs within the classification (e.g.,
benzodiazepines). They should not be taken in combination with other CNS depressants
and are contraindicated in pregnancy and lactation, narrow-angle glaucoma, shock, and
coma.
Caution should be taken in administering these drugs to elderly or debilitated
clients and clients with hepatic or renal dysfunction. (The dosage usually has to be
decreased.) Caution is also required with individuals who have a history of drug abuse or
addiction and with those who are depressed or suicidal. In depressed clients, CNS
depressants can exacerbate symptoms.
Interactions. Increased effects of antianxiety agents can occur when taken
concomitantly with alcohol, barbiturates, narcotics, antipsychotics, antidepressants,
antihistamines, neuromuscular blocking agents, cimetidine, or disulfiram. Increased effects
can also occur with herbal depressants (e.g., kava, valerian). Decreased effects can be noted
with cigarette smoking and caffeine consumption.

Diagnosis
The following nursing diagnoses may be considered for clients receiving therapy with
antianxiety agents:
1. Risk for injury related to seizures; panic anxiety; acute agitation from alcohol
withdrawal (indications); abrupt withdrawal from the medication after long-term
use; effects of medication intoxication or overdose.
2. Anxiety (specify) related to threat to physical integrity or self concept.
3. Risk for activity intolerance related to side effects of sedation, confusion, and/or
lethargy.
4. Disturbed sleep pattern related to situational crises, physical condition, or severe
level of anxiety.
5. Deficient knowledge related to medication regimen.
6. Risk for acute confusion related to action of the medication on the CNS.
Planning/Implementation
The plan of care should include monitoring for the following side effects from antianxiety
agents. Nursing implications related to each side effect are designated by an asterisk (*).
1. Drowsiness, confusion, lethargy (most common side effects)
* Instruct the client not to drive or operate dangerous machinery while taking the
medication.
2. Tolerance; physical and psychological dependence (does not apply to
buspirone)

* Instruct the client on long-term therapy not to quit taking the drug abruptly.
Abrupt withdrawal can be life threatening. Symptoms include depression,
insomnia, increased anxiety, abdominal and muscle cramps, tremors, vomiting,
sweating, convulsions, and delirium.
3. Ability to potentiate the effects of other CNS depressants
* Instruct the client not to drink alcohol or take other medications that depress the
CNS while taking this medication.
4. Possibility of aggravating symptoms in depressed persons
* Assess the client’s mood daily.
* Take necessary precautions for potential suicide.
5. Orthostatic hypotension
* Monitor lying and standing blood pressure and pulse every shift.
* Instruct the client to arise slowly from a lying or sitting position.
6. Paradoxical excitement (client develops symptoms opposite of the medication’s
desired effect)
* Withhold drug and notify the physician.
7. Dry mouth
* Have the client take frequent sips of water, suck on ice chips or hard candy, or
chew sugarless gum.
8. Nausea and vomiting
* Have the client take the drug with food or milk.
9. Blood dyscrasias

* Symptoms of sore throat, fever, malaise, easy bruising, or unusual bleeding
should be reported to the physician immediately.
10. Delayed onset (buspirone only)
* Ensure that the client understands there is a lag time of 7 to 10 days between
onset of therapy with buspirone and subsiding of anxiety symptoms. Client should
continue to take the medication during this time. (Note: Buspirone is not
recommended for prn administration because of this delayed therapeutic onset.)
There is no evidence that buspirone creates tolerance or physical dependence as do
the CNS depressant anxiolytics.
Client/Family Education. Instruct the client that he or she should:
 Not drive or operate dangerous machinery. Drowsiness and dizziness can occur.
 Not stop taking the drug abruptly, as this can produce serious withdrawal
symptoms, such as depression, insomnia, anxiety, abdominal and muscle cramps,
tremors, vomiting, sweating, convulsions, delirium.
 (With buspirone only): Be aware of lag time between start of therapy and subsiding
of symptoms. Relief is usually evident within 7 to 10 days. The client must take the
medication regularly, as ordered, so that it has sufficient time to take effect.
 Not consume other CNS depressants (including alcohol).
 Not take nonprescription medication without approval from physician.
 Rise slowly from sitting or lying position to prevent sudden drop in blood pressure.
 Report symptoms of sore throat, fever, malaise, easy bruising, unusual bleeding, or
motor restlessness to physician immediately.

 Be aware of risks of taking this drug during pregnancy. (Congenital malformations
have been associated with use during the first trimester.) The client should notify
the physician of the desirability to discontinue the drug if pregnancy is suspected or
planned.
 Be aware of possible side effects. The client should refer to written materials
furnished by health-care providers regarding the correct method of self-
administration.
 Carry card or piece of paper at all times stating the names of medications being
taken.
Outcome Criteria/Evaluation
The following criteria may be used for evaluating the effectiveness of therapy with
antianxiety agents.
The Client:
 Demonstrates a reduction in anxiety, tension, and restless activity.
 Experiences no seizure activity.
 Experiences no physical injury.
 Is able to tolerate usual activities without excessive sedation.
 Exhibits no evidence of confusion.
 Tolerates the medication without gastrointestinal distress.
 Verbalizes understanding of the need for, side effects of, and regimen for self-
administration.
 Verbalizes possible consequences of abrupt withdrawal from the medication.

Antidepressants
Indications. Antidepressant medications are used in the treatment of major depressive
disorder; dysthymia; major depression with melancholia or psychotic symptoms;
depression associated with organic disease, alcoholism, schizophrenia, or intellectual
disability; depressive phase of bipolar disorder; and depression accompanied by anxiety.
These drugs elevate mood and alleviate other symptoms associated with moderate-to-
severe depression. Selected agents are also used to treat anxiety disorders, bulimia nervosa,
obsessive compulsive disorder, post traumatic stress disorder, and premenstrual dysphoric
disorder. Examples of commonly used antidepressant medications are presented in Table 3.
Table 3. Medications Used in the Treatment of Depression

Pregnancy Daily
Categories/ Adult Dosage Therapeutic
Chemical Class Generic (Trade) Name * Half-life (hr) Range (mg) † Plasma Ranges
Tricyclics Amitriptyline D/ 31–46 50–300 110–250 (including

metabolite)
Amoxapine C/ 8 50–300 200–500
Clomipramine (Anafranil) C/ 19–37 25–250 80–100
Desipramine (Norpramin) C/ 12–24 25–300 125–300
Doxepin C/ 8–24 25–300 100–200 (including
metabolite)
Imipramine (Tofranil) D/ 11–25 30–300 200–350 (including
metabolite)
Nortriptyline (Aventyl; D/ 18–44 30–100 50–150
Pamelor)
Protriptyline (Vivactil) C/ 67–89 15–60 100–200
Trimipramine (Surmontil) C/ 7–30 50–300 180 (including
metabolite)
Selective Serotonin Citalopram (Celexa) C/ ~35 20–40 Not well established
Reuptake Inhibitors Escitalopram (Lexapro) C/ 27–32 10–20 Not well established
(SSRIs) Fluoxetine (Prozac; Serafem; C/ 1–16 days 20–80 Not well established
Selfemra) (including metabolite)
Fluvoxamine (Luvox) C/ 13.6–15.6 50–300 Not well established
Paroxetine (Paxil) C/ 21 10–50 Not well established
(CR: 15–20) (CR: 12.5–75)
Sertraline (Zoloft) C/ 26–104 (including 25–200 Not well established
metabolite)
(SSRIs continued)
Vilazodone (Viibryd) (also acts C/ 25 40 Not well established

as a partial serotonergic
agonist)

Vortioxetine (Brintellix) C/ 66 5-20 Not well established
Monoamine Oxidase Isocarboxazid (Marplan) C/ Not established 20–60 Not well established
Inhibitors Phenelzine (Nardil) C/ 12 45–90 Not well established
Tranylcypromine (Parnate) C/ 2.4–2.8 30–60 Not well established
Selegiline Transdermal System C/ 18–25 (including 6/24 hr – 12/24 hr Not well established
(Emsam) metabolites) patch
Heterocyclics Bupropion (Wellbutrin) C/ 8-24 200–450 Not well established

Maprotiline B/ 21-25 25–225 200–300 (incl.
metabolite)
Mirtazapine (Remeron) C/ 20-40 15–45 Not well established
‡
Nefazodone C/ 2-4 200–600 Not well established
Trazodone C/ 4-9 150–600 800–1600
Serotonin-
Norepinephrine Levomilnacipran (Fetzima) C/ 12 40-120 Not well established
Reuptake Inhibitors Desvenlafaxine (Pristiq) C/ 11 50–400 Not well established
(SNRIs)
Duloxetine (Cymbalta) C/ 8-17 40–60 Not well established
Venlafaxine (Effexor) C/ 5-11 (incl. 75–375 Not well established
metabolite)
Psychotherapeutic Olanzapine and fluoxetine C/ (see individual 6/25–12/50 Not well established
Combinations (Symbyax) drugs)
Chlordiazepoxide and D/ (see individual 20/50–40/100 Not well established
fluoxetine (Limbitrol) drugs)
Perphenazine and amitriptyline C-D/ (see individual 6/30–16/200 Not well established
(Etrafon) drugs)
* Drugs without trade names are available in generic form only.
†
Dosage requires slow titration; onset of therapeutic response may be 1 to 4 weeks.
‡
Bristol Myers Squibb voluntarily removed their brand of nefazodone (Serzone) from the market in 2004. The generic equivalent is
currently available through various other manufacturers.
Action. These drugs ultimately work to increase the concentration of norepinephrine,
serotonin, and/or dopamine in the body. This is accomplished in the brain by blocking the
reuptake of these neurotransmitters by the neurons (tricyclics [TCAs], heterocyclics,
selective serotonin reuptake inhibitors [SSRIs], and serotonin norepinephrine reuptake
inhibitors [SNRIs]). It also occurs when an enzyme, monoamine oxidase (MAO), that is
known to inactivate norepinephrine, serotonin, and dopamine is inhibited at various sites in
the nervous system (MAO inhibitors [MAOIs]).
Contraindications/Precautions. Antidepressant medications are contraindicated in
individuals with hypersensitivity. TCAs are contraindicated in the acute recovery phase
following myocardial infarction and in individuals with angle-closure glaucoma. TCAs,
heterocyclics, SSRIs, and SNRIs are contraindicated with concomitant use of MAOIs.

CLINICAL PEARL
All antidepressants carry an FDA black-box warning for increased risk
of suicidality in children and adolescents.
Caution should be used in administering these medications to elderly or debilitated
clients and those with hepatic, renal, or cardiac insufficiency. (The dosage usually must be
decreased.) Caution is also required with psychotic clients, with clients who have benign
prostatic hypertrophy, and with individuals who have a history of seizures (may decrease
seizure threshold).
CLINICAL PEARL
As these drugs take effect, and mood begins to lift, the individual may
have increased energy with which to implement a suicide plan. Suicide
potential often increases as level of depression decreases. The nurse
should be particularly alert to sudden lifts in mood.
Interactions
Tricyclic Antidepressants
 Increased effects of tricyclic antidepressants with bupropion, cimetidine,

haloperidol, SSRIs, and valproic acid.
 Decreased effects of tricyclic antidepressants with carbamazepine, barbiturates, and
rifamycins.
 Hyperpyretic crisis, convulsions, and death can occur with MAO inhibitors.
 Coadministration with clonidine may produce hypertensive crisis.
 Decreased effects of levodopa and guanethidine with tricyclic antidepressants.
 Potentiation of pressor response with direct-acting sympathomimetics.
 Increased anticoagulation effects with dicumarol.
 Increased serum levels of carbamazepine occur with concomitant use of tricyclics.
 Increased risk of seizures with concomitant use of maprotiline and phenothiazines

MAO Inhibitors
 Serious, potentially fatal adverse reactions may occur with concurrent use of all
other antidepressants, carbamazepine, cyclobenzaprine, buspirone,
sympathomimetics, tryptophan, dextromethorphan, anesthetic agents, CNS
depressants, and amphetamines. Avoid using within 2 weeks of each other (5 weeks
after therapy with fluoxetine).
 Hypertensive crisis may occur with amphetamines, methyldopa, levodopa,
dopamine, epinephrine, norepinephrine, guanethidine, guanadrel, reserpine, or
vasoconstrictors.
 Hypertension or hypotension, coma, convulsions, and death may occur with opioids
(avoid use of meperidine within 14 to 21 days of MAOI therapy).
 Excess CNS stimulation and hypertension may occur with methylphenidate.
 Additive hypotension may occur with antihypertensives, thiazide diuretics, or spinal
anesthesia.
 Additive hypoglycemia may occur with insulins or oral hypoglycemic agents.
 Doxapram may increase pressor response.
 Serotonin syndrome may occur with concomitant use of St. John’s wort.
 Hypertensive crisis may occur with ingestion of foods or other products containing
high concentrations of tyramine (see Table 4).
TABLE 4. DIET AND DRUG RESTRICTIONS FOR CLIENTS ON MAOI THERAPY

Foods Containing Tyramine
High Tyramine Content Moderate Tyramine Content Low Tyramine Content
(Avoid while on MAOI (May eat occasionally while on (Limited quantities permissible
Therapy) MAOI Therapy) while on MAOI Therapy )
Aged cheeses (cheddar, Swiss, Gouda cheese, processed Pasteurized cheeses (cream
Camembert, blue cheese, American cheese, mozzarella cheese, cottage cheese, ricotta)
Parmesan, provolone, Yogurt, sour cream Figs
Romano, brie) Avocados, bananas Distilled spirits (in moderation)
Raisins, fava beans, flat Beer, white wine, coffee, colas,
Italian beans, Chinese pea pods tea, hot chocolate
Red wines (Chianti, burgundy, Meat extracts, such as bouillon
cabernet sauvignon) Chocolate
Smoked and processed meats
(salami, bologna, pepperoni,
summer sausage)
Caviar, pickled herring, corned
beef, chicken or beef liver
Soy sauce, brewer’s yeast, meat
tenderizer (MSG)
Drug Restrictions
Ingestion of the following substances while on MAOI therapy could result in life-threatening hypertensive crisis. A
14-day interval is recommended between use of these drugs and an MAOI.
 All other antidepressants (e.g., SSRIs, TCAs, SNRIs, heterocyclics)
 Sympathomimetics: (epinephrine, dopamine, norepinephrine, ephedrine, pseudoephedrine,

phenylephrine, phenylpropanolamine, over-the-counter cough and cold preparations)
 Stimulants (amphetamines, cocaine, diet drugs)
 Antihypertensives (methyldopa, guanethidine, reserpine)
 Meperidine and (possibly) other opioid narcotics (morphine, codeine)
 Antiparkinsonian agents (levodopa)

SOURCES: Black & Andreasen (2011); Martinez, Marangell, & Martinez (2008); and Sadock &
Sadock (2007).
 Consumption of foods or beverages with high caffeine content increases the risk of
hypertension and arrhythmias.
 Bradycardia may occur with concurrent use of MAOIs and beta blockers.
 Risk of toxicity from the 5-HT-receptor agonists with concurrent use of MAOIs.
Selective Serotonin Reuptake Inhibitors (SSRIs)

 Toxic, sometimes fatal, reactions have occurred with concomitant use of MAOIs.
 Increased effects of SSRIs may occur with cimetidine, L-tryptophan, lithium,
linezolid, and St. John’s wort.
 Serotonin syndrome may occur with concomitant use of SSRIs and
metoclopramide, sibutramine, tramadol, 5-HT-receptor agonists (triptans), or any
drug that increases levels of serotonin.
 Concomitant use of SSRIs may increase effects of hydantoins, tricyclic
antidepressants, cyclosporine, benzodiazepines, beta blockers, methadone,
carbamazepine, clozapine, olanzapine, pimozide, haloperidol, mexiletine,
phenothiazines, St. John’s wort, trazodone, sumatriptan, sympathomimetics,
tacrine, theophylline, procyclidine, propafenone, risperidone, ropivacaine,
zolpidem, and warfarin.
 Concomitant use of SSRIs may decrease effects of buspirone and digoxin.
 Lithium levels may be increased or decreased by concomitant use of SSRIs.
 Decreased effects of SSRIs with concomitant use of carbamazepine and
cyproheptadine.
Others (Heterocyclics and SNRIs)

 Concomitant use with MAOIs results in serious, sometimes fatal, effects
resembling neuroleptic malignant syndrome. Coadministration is contraindicated.
 Serotonin syndrome may occur when any of the following are used together:
St. John’s wort, sumatriptan, sibutramine, trazodone, nefazodone, venlafaxine,
duloxetine, levomilnacipran, SSRIs, 5-HT-receptor agonists (triptans).
 Increased effects of haloperidol, clozapine, and desipramine when used
concomitantly with venlafaxine.
 Increased effects of levomilnacipran with concomitant use of CYP3A4 inhibitors.
 Increased effects of venlafaxine with cimetidine.

 Increased effects of duloxetine with CYP1A2 inhibitors (e.g., fluvoxamine,
quinolone antibiotics) and CYP2D6 inhibitors (e.g., fluoxetine, quinidine,
paroxetine).
 Increased risk of liver injury with concomitant use of alcohol and duloxteine.
 Increased risk of toxicity or adverse effects from drugs extensively metabolized by
CYP2D6 (e.g., flecainide, phenothiazines, propafenone, tricyclic antidepressants,
thioridazine) when used concomitantly with duloxetine or bupropion.
 Decreased effects of bupropion and trazodone with carbamazepine.
 Altered anticoagulant effect of warfarin may occur with bupropion, venlafaxine,
desvenlafaxine, duloxetine, levomilnacipran, or trazodone.
 Increased risk of seizures when bupropion is coadministered with drugs that lower
the seizure threshold (e.g., antidepressants, antipsychotics, systemic steroids,
theophylline, tramadol).
 Decreased effects of midazolam with desvenlafaxine
 Increased effects of desvenlaafaxine and levomilnacipran with concomitant use of
potent CYP3A4 inhibitors (e.g., ketoconazole).
Diagnosis
antidepressant medications:
1. Risk for suicide related to depressed mood.
2. Risk for injury related to side effects of sedation, lowered seizure threshold,
orthostatic hypotension, priapism, photosensitivity, arrhythmias, hypertensive crisis,
or serotonin syndrome.
3. Social isolation related to depressed mood.
4. Risk for constipation related to side effects of the medication.
5. Insomnia related to depressed mood and elevated level of anxiety.
The plan of care should include monitoring for the following side effects from
antidepressant medications. Nursing implications are designated by an asterisk (*).

May Occur with All Chemical Classes
 Dry mouth
* Offer the client sugarless candy, ice, frequent sips of water.
* Strict oral hygiene is very important.
 Sedation
* Request an order from the physician for the drug to be given at bedtime.
* Request that the physician decrease the dosage or perhaps order a less sedating
drug.
* Instruct the client not to drive or use dangerous equipment while experiencing
sedation.
 Nausea
* Medication may be taken with food to minimize GI distress.
 Discontinuation syndrome
* All classes of antidepressants have varying potentials to cause discontinuation
syndromes. Abrupt withdrawal following long-term therapy with SSRIs and SNRIs
may result in dizziness, lethargy, headache, and nausea. Fluoxetine is less likely to
result in withdrawal symptoms because of its long half-life. Abrupt withdrawal from
tricyclics may produce hypomania, akathisia, cardiac arrhythmias, gastrointestinal
upset, and panic attacks. The discontinuation syndrome associated with MAOIs
includes flulike symptoms, confusion, hypomania, and worsening of depressive
symptoms. All antidepressant medication should be tapered gradually to prevent
withdrawal symptoms (Schatzberg, Cole, & DeBattista, 2010).

Most Commonly Occur with Tricyclics and Heterocyclics
 Blurred vision
* Offer reassurance that this symptom should subside after a few weeks.
* Instruct the client not to drive until vision is clear.
* Clear small items from routine pathway to prevent falls.
 Constipation
* Order foods high in fiber; increase fluid intake if not contraindicated; and
encourage the client to increase physical exercise, if possible.
 Urinary retention
* Instruct the client to report hesitancy or inability to urinate.
* Monitor intake and output.
* Try various methods to stimulate urination, such as running water in the bathroom
or pouring water over the perineal area.
 Orthostatic hypotension
* Instruct the client to rise slowly from a lying or sitting position.
* Monitor blood pressure (lying and standing) frequently, and document and report
significant changes.
* Avoid long hot showers or tub baths.
 Reduction of seizure threshold
* Observe clients with history of seizures closely.
* Institute seizure precautions as specified in hospital procedure manual.

* Bupropion (Wellbutrin) should be administered in doses of no more than 150 mg
and should be given at least 4 hours apart. Bupropion has been associated with a
relatively high incidence of seizure activity in anorexic and cachectic clients.
 Tachycardia; arrhythmias
* Carefully monitor blood pressure and pulse rate and rhythm, and report any
significant change to the physician.
 Photosensitivity
* Ensure that client wears sunblock lotion, protective clothing, and sunglasses
while outdoors.
 Weight gain
* Provide instructions for reduced-calorie diet.
* Encourage increased level of activity, if appropriate.
Most Commonly Occur with SSRIs and SNRIs
 Insomnia; agitation
* Administer or instruct client to take dose early in the day.
* Instruct client to avoid caffeinated food and drinks.
* Teach relaxation techniques to use before bedtime.
 Headache
* Administer analgesics, as prescribed.
* If relief is not achieved, physician may order another antidepressant.
 Weight loss (may occur early in therapy)

* Ensure that client is provided with caloric intake sufficient to maintain desired
weight.
* Caution should be taken in prescribing these drugs for anorectic clients.
* Weigh client daily or every other day, at the same time, and on the same scale, if
possible.
* After prolonged use, some clients may gain weight on these drugs.
 Sexual dysfunction
* Men may report abnormal ejaculation or impotence.
* Women may experience delay or loss of orgasm.
* If side effect becomes intolerable, a switch to another antidepressant may be
necessary.
 Serotonin syndrome (may occur when two drugs that potentiate serotonergic
neurotransmission are used concurrently [see “Interactions”])
* Most frequent symptoms include changes in mental status, restlessness,
myoclonus, hyperreflexia, tachycardia, labile blood pressure, diaphoresis,
shivering, and tremors.
* Discontinue the offending agent immediately.
* The physician may prescribe medications to block serotonin receptors, relieve
hyperthermia and muscle rigidity, and prevent seizures. In severe cases, artificial
ventilation may be required. The histamine-1 receptor antagonist, cyproheptadine,
is commonly used to treat the symptoms of serotonin syndrome.
* Supportive nursing measures include monitoring vital signs, providing safety

measures to prevent injury when muscle rigidity and changes in mental status
are present, cooling blankets and tepid baths to assist with temperature
regulation, and monitoring intake and output (Cooper & Sejnowski, 2013).
* The condition will usually resolve on its own once the offending medication has
been discontinued. However, if left untreated, the condition may progress to
life- threatening complications such as seizures, coma, hypotension, ventricular
arrhythmias, disseminated intravascular coagulation, rhabdomyolysis, metabolic
acidosis, and renal failure (Cooper & Sejnowski, 2013).
Most Commonly Occur with MAOIs
 Hypertensive crisis
* Hypertensive crisis occurs if the individual consumes foods containing tyramine
while receiving MAOI therapy (see Table 4). (NOTE: Hypertensive crisis has not
shown to be a problem with selegiline transdermal system at the 6 mg/24 hr
dosage, and dietary restrictions at this dose are not recommended. Dietary
modifications are recommended, however, at the 9 mg/24 hr and 12 mg/24 hr
dosages.)
* Symptoms of hypertensive crisis include severe occipital headache, palpitations,
nausea/vomiting, nuchal rigidity, fever, sweating, marked increase in blood
pressure, chest pain, and coma.
* Treatment of hypertensive crisis includes discontinuing the drug immediately;
monitoring vital signs; administering short-acting antihypertensive medication, as

ordered by the physician; and using external cooling measures to control
hyperpyrexia.
 Application site reactions (with selegiline transdermal system [Emsam])
* The most common reactions include rash, itching, erythema, redness, irritation,
swelling, or urticarial lesions. Most reactions resolve spontaneously, requiring no
treatment. However, if reaction becomes problematic, it should be reported to the
physician. Topical corticosteroids have been used in treatment.
Miscellaneous Side Effects
 Priapism (with trazodone)
* Priapism is a rare side effect, but it has occurred in some men taking trazodone.
* If prolonged or inappropriate penile erection occurs, the medication should be
withheld and the physician notified immediately.
* Priapism can become very problematic, requiring surgical intervention, and, if
not treated successfully, can result in impotence.
 Hepatic failure (with nafazodone)
* Cases of life-threatening hepatic failure have been reported in clients treated with
nafazodone.
* Advise clients to be alert for signs or symptoms suggestive of liver dysfunction
(e.g., jaundice, anorexia, GI complaints, or malaise) and to report them to the

 Continue to take the medication even though the symptoms have not subsided. The
therapeutic effect may not be seen for as long as 4 weeks. If after this length of time
no improvement is noted, the physician may prescribe a different medication.
 Use caution when driving or operating dangerous machinery. Drowsiness and
dizziness can occur. If these side effects become persistent or interfere with
activities of daily living, the client should report them to the physician. Dosage
adjustment may be necessary.
 Not stop taking the drug abruptly. To do so might produce withdrawal symptoms,
such as nausea, vertigo, insomnia, headache, malaise, nightmares, and return of
symptoms for which the medication was prescribed.
 Use sunblock lotion and wear protective clothing when spending time outdoors. The
skin may be sensitive to sunburn.
 Report occurrence of any of the following symptoms to the physician immediately:
sore throat, fever, malaise, yellowish skin, unusual bleeding, easy bruising,
persistent nausea/vomiting, severe headache, rapid heart rate, difficulty urinating,
anorexia/weight loss, seizure activity, stiff or sore neck, and chest pain.
 Rise slowly from a sitting or lying position to prevent a sudden drop in blood
pressure.
 Take frequent sips of water, chew sugarless gum, or suck on hard candy if dry mouth
is a problem. Good oral care (frequent brushing, flossing) is very important.
 Not consume the following foods or medications while taking MAOIs: aged cheese,
wine (especially Chianti), beer, chocolate, colas, coffee, tea, sour cream, smoked

and processed meats, beef or chicken liver, canned figs, soy sauce, overripe and
fermented foods, pickled herring, raisins, caviar, yogurt, yeast products, broad
beans, cold remedies, diet pills. To do so could cause a life-threatening
hypertensive crisis.
 Avoid smoking while receiving tricyclic therapy. Smoking increases the metabolism
of tricyclics, requiring an adjustment in dosage to achieve the therapeutic effect.
 Avoid drinking alcohol while taking antidepressant therapy. These drugs potentiate
the effects of each other.
 Avoid use of other medications (including over-the-counter medications) without
the physician’s approval while receiving antidepressant therapy. Many medications
contain substances that, in combination with antidepressant medication, could
precipitate a life-threatening hypertensive crisis.
 Notify the physician immediately if inappropriate or prolonged penile erections
occur while taking trazodone. If the erection persists longer than 1 hour, seek
emergency department treatment. This condition is rare but has occurred in some
men who have taken trazodone. If measures are not instituted immediately,
impotence can result.
 Not “double up” on medication if a dose of bupropion (Wellbutrin) is missed, unless
advised to do so by the physician. Taking bupropion in divided doses will decrease
the risk of seizures and other adverse effects.
 Follow the correct procedure for applying the selegiline transdermal patch:
 Apply to dry, intact skin on upper torso, upper thigh, or outer surface of
upper arm.

 Apply approximately same time each day to new spot on skin, after
removing and discarding old patch.
 Wash hands thoroughly after applying the patch.
 Avoid exposing application site to direct heat (e.g., heating pads, electric
blankets, heat lamps, hot tub, or prolonged direct sunlight).
 If patch falls off, apply new patch to a new site and resume previous
schedule.
 Be aware of possible risks of taking antidepressants during pregnancy. Safe use
during pregnancy and lactation has not been fully established. These drugs are
believed to readily cross the placental barrier; if so, the fetus could experience
adverse effects of the drug. Inform the physician immediately if pregnancy occurs,
is suspected, or is planned.
 Be aware of the side effects of antidepressants. Refer to written materials furnished
by health-care providers for safe self-administration.
 Carry a card or other identification at all times describing the medications being
taken.
antidepressant medications:
The client:
1. Has not harmed self.

2. Has not experienced injury caused by side effects such as priapism, hypertensive
crisis, or photosensitivity.
3. Exhibits vital signs within normal limits.
4. Manifests symptoms of improvement in mood (brighter affect, interaction with
others, improvement in hygiene, clear thought and communication patterns).
5. Willingly participates in activities and interacts appropriately with others.
Mood-Stabilizing Agents
For many years, the drug of choice for treatment and management of bipolar mania was
lithium carbonate. However, in recent years, a number of investigators and clinicians in
practice have achieved satisfactory results with several other medications, either alone or in
combination with lithium. Table 5 provides information about the indication, action, and
contraindications and precautions of various medications being used as mood stabilizers.
Drug interactions associated with mood stabilizers are presented in Table 6.
TABLE 5. MOOD-STABILIZING AGENTS

Daily Adult
Pregnancy Category/ Dosage Range/
Classification: Half-life/ Mechanism Contraindications/ Therapeutic
Generic (Trade) Indications of Action Precautions Plasma Range
ANTIMANIC
Lithium carbonate D/ 24 hr Not fully Hypersensitivity. Acute mania:
(Eskalith, Lithobid)  Prevention and understood, Cardiac or renal 1800–2400 mg
treatment of manic but may modulate disease, dehydra- Maintenance:
episodes of bipolar the effects of tion; sodium 900–1200 mg /
disorder. various depletion; brain
Unlabeled uses: neurotransmitters damage; Acute mania:
 Neutropenia such as pregnancy 1.0–1.5 mEq/L
 Cluster headaches norepinephrine, and lactation. Maintenance:
(prophylaxis) serotonin, Caution with 0.6–1.2 mEq/L
 Alcohol dopamine, thyroid disorders,
dependence glutamate, and diabetes, urinary
 Bulimia GABA, that are retention, history
 Postpartum thought to play a of seizures, and
affective role in the with the elderly.
psychosis symptomatology

 Corticosteroid- of bipolar disorder
induced psychosis (may take 1–3
weeks for
symptoms to
subside).
ANTICONVULSANTS
Carbamazepine D/ 25–65 hr Action in the Hypersensitivity. 200–1600 mg/
(Tegretol) (initial); treatment of With MAOIs, 4–12 mcg/mL
12–17 hr (repeated bipolar disorder lactation.
doses)/ is unclear. Caution with
 Epilepsy elderly,
 Trigeminal liver/renal/cardiac
neuralgia disease,
Unlabeled uses: pregnancy.
 Bipolar disorder
 Resistant
schizophrenia
 Management of
alcohol
withdrawal
 Restless legs
syndrome
 Postherpetic
neuralgia
Clonazepam D/ 18–60 hr/ Action in the Hypersensitivity, 0.5–20 mg /

(Klonopin)  Petit mal, akinetic, treatment of glaucoma, liver 20–80 ng/mL
and myoclonic bipolar disorder disease, lactation.
seizures is unclear. Caution in elderly,
 Panic disorder liver/renal disease,
Unlabeled uses: pregnancy.
 Acute manic
episodes
 Uncontolled leg
movements during
sleep
 Neuralgias
Valproic acid D/ 5–20 hr/ Action in the Hypersensitivity; 5 mg/kg to

(Depakene; Depakote)  Epilepsy treatment of liver disease. 60 mg/kg /
 Manic episodes bipolar disorder Caution in elderly, 50–150 mcg/mL
 Migraine is unclear. renal/cardiac
prophylaxis diseases,
 Adjunct therapy in pregnancy
schizophrenia and lactation.
Lamotrigine
(Lamictal) C/ ~33 hr /
 Epilepsy Action in the Hypersensitivity. 100–200 mg /
treatment of Caution in renal Not established
Unlabeled use:
bipolar and hepatic
 Bipolar disorder disorder is insufficiency,
unclear. pregnancy,
lactation, and
children < 16
years old.
Topiramate C/ 21 hr / Action in the Hypersensitivity. 50–400 mg /

(Topamax)  Epilepsy treatment of Caution in renal Not established
 Migraine bipolar and hepatic
prophylaxis disorder is impairment,
Unlabeled uses: unclear. pregnancy,
 Bipolar disorder lactation, children,
 Cluster headaches and the elderly.
 Bulimia
 Binge eating

disorder
 Weight loss in
Obesity
Oxcarbazepine C/ 2–9/ Action in the Hypersensitivity. 600–2400 mg
(Trileptal)  Epilepsy treatment of Caution in renal Not established
Unlabeled uses: bipolar disorder is and hepatic
unclear. impairment,
 Bipolar disorder pregnancy,
 Diabetic lactation,
neuropathy children, and the
 Neuralgia elderly.
CALCIUM CHANNEL
BLOCKER
Verapamil (Calan; C/ 3–7 hr (initially); Action in the treat- Hypersensitivity; 80–320 mg /
Isoptin) 4.5–12 hr ment of bipolar severe left Not established
(repeated dosing) disorder is unclear. ventricular
 Angina dysfunction, heart
 Arrhythmias block, hypo-
 Hypertension tension, cardio-
Unlabeled uses: genic shock,
 Bipolar mania congestive heart
 Migraine failure.
headache Caution in
prophylaxis liver or renal
disease,
cardiomyopathy,
intracranial
pressure, elderly
patients,
pregnancy
and lactation.
Table 5. Cont’d
ANTIPSYCHOTICS
Olanzapine (Zyprexa) C/ 21–54 hr/ All antipsychotics: All antipsychotics: 10–20 mg /
 Schizophrenia Efficacy in Hypersensitivity, Not established
 Acute manic schizophrenia is children, lactation.
episodes achieved through Caution with
 Management of a combination of hepatic or
bipolar disorder dopamine and cardiovascular
 Agitation serotonin type 2 disease, history of
associated with (5HT2) seizures, comatose
schizophrenia or antagonism. or other CNS-
mania Mechanism of depression,
Unlabeled uses: action in the prostatic
 Obsessive- treatment of hypertrophy,
compulsive mania is narrow-angle
disorder unknown. glaucoma,
diabetes or risk
factors for
diabetes,
pregnancy, elderly
and debilitated
patients.
Olanzapine and C/ (see individual 6/25–12/50 mg /
fluoxetine (Symbyax) drugs) / Not established
 For the treatment
of depressive
episodes
associated with
bipolar disorder
Aripiprazole (Abilify) C/ 75-94 hr / 10–30 mg /

 Bipolar mania Not established
 Schizophrenia

Chlorpromazine C/ 24 hr / 75–400 mg/
 Schizophrenia
 Emesis/
hiccoughs
 Acute
intermittent
porphyria
 Preoperative
apprehension
Unlabeled uses:
 Migraine
headaches
Quetiapine (Seroquel) C/ 6 hr / 100–800 mg/

 Schizophrenia Not established
 Acute manic
episodes
Table 5. Cont’d
Risperidone (Risperdal) C/ 3–20 hr/ 1–6 mg /
 Schizophrenia
Unlabeled uses:
 Severe behavioral
problems in
children
 Behavioral
problems
associated with
autism
 Obsessive-
compulsive
disorder
Ziprasidone (Geodon) C/ 7 hr (oral)/ 40–160 mg /

 Schizophrenia
 Acute agitation in
schizophrenia
10–20 mg/
Asenapine (Saphris) C/ 24 hr/ Not established
 Schizophrenia
 Bipolar mania
Table 6. Interactions of Mood-Stabilizing Agents
The effects of: Are increased by: Are decreased by: Concurrent use may
result in:
ANTIMANIC:
Lithium Carbamazepine, fluoxetine, Acetazolamide, osmotic Increased effects of
haloperidol, loop diuretics, theophylline, neuromuscular blocking
diuretics, methyldopa, and urinary alkalinizers agents and tricyclic
NSAIDs, and thiazide antidepressants;
diuretics decreased pressor

sensitivity of
sympathomimetics;
neurotoxicity may occur
with phenothiazines or
calcium channel blockers
ANTICONVULSANTS:
Clonazepam CNS depressants, Rifampin, theophylline (↓ Increased phenytoin levels;
cimetidine, hormonal sedative effects), decreased efficacy of
contraceptives, phenytoin levodopa
disulfiram, fluoxetine,
isoniazid, ketoconazole,
metoprolol,
propranolol, valproic
acid,
probenecid
Carbamazepine Verapamil, diltiazem, Cisplatin, doxorubicin, Decreased levels of

propoxyphene, felbamate, rifampin, corticosteroids,
erythromycin, barbiturates, hydantoins, doxycycline,
clarithromycin, SSRIs, primidone, theophylline quinidine, warfarin,
tricyclic estrogen-containing
antidepressants, contraceptives,
cimetidine, isoniazid, cyclosporine,
danazol, lamotrigine, benzodiazepines,
niacin, acetazolamide, theophylline,
dalfopristin, valproate, lamotrigine, valproic
nefazodone acid, bupropion,
haloperidol, olanzapine,
tiagabine, topiramate,
voriconazole,
ziprasidone, felbamate,
levothyroxine, or
antidepressants;
increased levels of
lithium;
life-threatening
hypertensive reaction
with MAOIs
Valproic Acid Chlorpromazine, Rifampin, carbamazepine, Increased effects of
cimetidine, erythromycin, cholestyramine, tricyclic antidepressants,
felbamate, salicylates lamotrigine, carbamazepine, CNS
phenobarbital, depressants,
ethosuximide, hydantoins ethosuximide,
lamotrigine,
phenobarbital, warfarin,
zidovudine, hydantoins
Lamotrigine Valproic acid Primidone, phenobarbital, Decreased levels of
phenytoin, rifamycin, valproic acid;
succinimides, oral increased levels of
contraceptives, carbamazepine and
oxcarbazepine, topiramate
carbamazepine,
acetaminophen
Topiramate Metformin, Phenytoin, carbamazepine, Increased risk of CNS
hydrochlorothiazide valproic acid, lamotrigine depression with alcohol
or other CNS
depressants; increased
risk of kidney stones with
carbonic anhydrase
inhibitors; increased

effects of phenytoin,
metformin, amitriptyline;
decreased effects of oral
contraceptives, digoxin,
lithium, riseridone, and
valproic acid.
Oxcarbazepine Carbamazepine, Increased concentrations of
phenobarbital, phenytoin, phenobarbital and
valproic acid, verapamil phenytoin; decreased
effects of oral
contraceptives,
felodipine, and
lamotrigine
CALCIUM CHANNEL
BLOCKER:
Verapamil Amiodarone, beta blockers, Barbiturates, calcium salts, Increased effects of beta
cimetidine, ranitidine, hydantoins, rifampin, and blockers, disopyramide,
and grapefruit juice antineoplastics flecainide, doxorubicin,
benzodiazepines,
buspirone,
carbamazepine, digoxin,
dofetilide, ethanol,
imipramine,
nondepolarizing muscle
relaxants, prazosin,
quinidine, sirolimus,
tacrolimus, and
theophylline; altered
serum lithium levels
ANTIPSYCHOTICS:
Olanzapine Fluvoxamine and other Carbamazepine and other Decreased effects of
CYP1A2 inhibitors, CYP1A2 inducers, levodopa and dopamine
fluoxetine omeprazole, rifampin agonists; increased
hypotension with
antihypertensives;
increased CNS
depression with alcohol
or other CNS depressants
Aripiprazole Ketoconazole and other Carbamazepine, Increased CNS depression
CYP3A4 inhibitors; famotidine, valproate with alcohol or other
quinidine, fluoxetine, CNS depressants;
paroxetine, or other increased hypotension
potential CYP2D6 with antihypertensives
inhibitors
Chlorpromazine Beta-blockers, paroxetine Centrally acting Increased effects of beta
anticholinergics blockers; excessive
sedation and hypotension
with meperidine;
decreased hypotensive
effect of guanethidine;
decreased effect of oral
anticoagulants; decreased
or increased phenytoin
levels; increased
orthostatic hypotension
with thiazide diuretics;
increased CNS
or other CNS
hypotension with

antihypertensives;
increased anticholinergic
effects with
anticholinergic agents
Quetiapine Cimetidine; ketoconazole, Phenytoin, thioridazine Decreased effects of
itraconazole, fluconazole, levodopa and dopamine
erythromycin, or other agonists; increased CNS
CYP3A4 inhibitors depression with alcohol
or other CNS
hypotension with
antihypertensives
Risperidone Clozapine, fluoxetine, Carbamazepine Decreased effects of
paroxetine, or ritonavir levodopa and dopamine
agonists; increased
effects of clozapine and
valproate; increased CNS
or other CNS
hypotension with
antihypertensives
Ziprasidone Ketoconazole and other Carbamazepine Life-threatening prolong-
CYP3A4 inhibitors ation of QT interval with
quinidine, dofetilide,
other class Ia and III
antiarrhythmics,
pimozide, sotalol,
thioridazine, chlor-
promazine,
pentamadine, arsenic
trioxide, mefloquine,
dolasetron, tacrolimus,
droperidol, gatifloxacin,
or moxifloxacin;
decreased effects of
levodopa and dopamine
agonists; increased CNS
or other CNS
hypotension with
antihypertensives
(Continued)
Asenapine Fluvoxamine, imipramine, Carbamazepine, Increased effects of
valproate cimetidine, paroxetine paroxetine and
dextromethorphan;
increased CNS depression
with alcohol or other CNS
hypotention with
antihypertensives; additive
effects of QT interval
prolongation with
quinidine, dofetilide, other
class Ia and III
antiarrhythmics, pimozide,
sotalol, thioridazine,
chlorpromazine,
pentamadine, arsenic
trioxide, mefloquine,

dolasetron, tacrolimus,
droperidol, gatifloxacin, or
moxifloxacin
Diagnosis
mood-stabilizing agents:
1. Risk for injury related to manic hyperactivity.
2. Risk for self-directed or other-directed violence related to unresolved anger turned
inward on the self or outward on the environment.
3. Risk for injury related to lithium toxicity.
4. Risk for injury related to adverse effects of mood-stabilizing drugs.
5. Risk for activity intolerance related to side effects of drowsiness and dizziness.
The plan of care should include monitoring for side effects of therapy with mood-
stabilizing agents and intervening when required to prevent the occurrence of adverse
events related to medication administration. Side effects and nursing implications for
mood-stabilizing agents are presented in Table 7.
TABLE 7. SIDE EFFECTS AND NURSING IMPLICATIONS OF MOOD-STABILIZING AGENTS

Medication Side Effects Nursing Implications
Antimanic
Lithium carbonate 1. Drowsiness, dizziness, headache 1. Ensure that client does not participate in
(Eskalith, Lithane, activities that require alertness or operate
Lithobid) dangerous machinery.
2. Dry mouth; thirst 2. Provide sugarless candy, ice, frequent sips of
water. Ensure that strict oral hygiene is
maintained.
3. GI upset; nausea/vomiting 3. Administer medications with meals to
minimize GI upset.
4. Fine hand tremors 4. Report to physician, who may decrease
dosage. Some physicians prescribe a small
dose of beta-blocker propranolol to

counteract this effect.
5. Hypotension; arrhythmias; pulse 5. Monitor vital signs two or three times a day.
irregularities Physician may decrease dose of medication.
6. Polyuria; dehydration 6. May subside after initial week or two.
Monitor daily intake and output and weight.
Monitor skin turgor daily.
7. Weight gain 7. Provide instructions for reduced-calorie diet.
Emphasize importance of maintaining
adequate intake of sodium
Anticonvulsants
Clonazepam (Klonopin) 1. Nausea/vomiting 1. May give with food or milk to minimize GI
Carbamazepine (Tegretol) upset.
Valproic acid (Depakene; 2. Drowsiness; dizziness 2. Ensure that client does not operate dangerous
Depakote) machinery or participate in activities that
require alertness.
Lamotrigine (Lamictal) 3. Blood dyscrasias 3. Ensure that client understands the importance
Topiramate (Topamax) of regular blood tests while receiving anti-
Oxcarbazepine (Trileptal) convulsant therapy.
4. Prolonged bleeding time (with 4. Ensure that platelet counts and bleeding time
valproic acid) are determined before initiation of therapy
with valproic acid. Monitor for spontaneous
bleeding or bruising.
5. Risk of severe rash (with 5. Ensure that client is informed that he or she
lamotrigine) must report evidence of skin rash to
6. Decreased efficacy with oral 6. Ensure that client is aware of decreased
contraceptives (with topiramate) efficacy of oral contraceptives with
concomitant use.
7. Risk of suicide with all 7. Monitor for worsening of depression,
antiepileptic drugs (warning by suicidal thoughts or behavior, or any
FDA, December 2008) unusual changes in mood or behavior.
Calcium Channel Blocker

Verapamil (Calan; 1. Drowsiness; dizziness 1. Ensure that client does not operate dangerous
Isoptin) machinery or participate in activities that
require alertness.
2. Hypotension; bradycardia 2. Take vital signs just before initiation of
therapy and before daily administration
of the medication. Physician will provide
acceptable parameters for administration.
Report marked changes immediately.
3. Nausea 3. May give with food to minimize GI upset.
4. Constipation 4. Encourage increased fluid (if not
contraindicated) and fiber in the diet.
Antipsychotics
Olanzapine (Zyprexa) 1. Drowsiness; dizziness 1. Ensure that client does not operate dangerous
Aripiprazole (Abilify) machinery or participate in activities that
require alertness.
Chlorpromazine
2. Dry mouth; constipation 2. Provide sugarless candy or gum, ice, and
frequent sips of water. Provide foods high
Quetiapine (Seroquel) in fiber; encourage physical activity and
Risperidone (Risperdal) fluid if not contraindicated.
Ziprasidone (Geodon)
Asenapine (Saphris) 3. Increased appetite; weight gain 3. Provide calorie-controlled diet; provide
opportunity for physical exercise; provide
diet and exercise instruction.

4. ECG Changes 4. Monitor vital signs. Observe for symptoms of
dizziness, palpitations, syncope, or weakness.
5. Extrapyramidal Symptoms 5. Monitor for symptoms. Administer prn
medication at first sign.
6. Hyperglycemia and diabetes. 6. Monitor blood glucose regularly. Observe for the
appearance of symptoms of polydipsia, polyuria,
polyhagia, and weakness at any time during
therapy.
Lithium Toxicity
The margin between the therapeutic and toxic levels of lithium carbonate is very narrow.
The usual ranges of therapeutic serum concentrations are as follows (Drug Facts and
Comparisons, 2014; Schatzberg, Cole, & DeBattista, 2010):
 For acute mania: 1.0 to 1.5 mEq/L
 For maintenance: 0.6 to 1.2 mEq/L
Serum lithium levels should be monitored once or twice a week after initial treatment until
dosage and serum levels are stable, then monthly during maintenance therapy. Blood
samples should be drawn 12 hours after the last dose.
Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L
and are dosage determinate. Symptoms include:
 At serum levels of 1.5 to 2.0 mEq/L: blurred vision, ataxia, tinnitus, persistent
nausea and vomiting, severe diarrhea.
 At serum levels of 2.0 to 3.5 mEq/L: excessive output of dilute urine, increasing
tremors, muscular irritability, psychomotor retardation, mental confusion,
giddiness.
 At serum levels above 3.5 mEq/L: impaired consciousness, nystagmus, seizures,
coma, oliguria/anuria, arrhythmias, myocardial infarction, cardiovascular collapse.

Lithium levels should be monitored prior to medication administration. The dosage should
be withheld and the physician notified if the level reaches 1.5 mEq/L or at the earliest
observation or report by the client of even the mildest symptom. If left untreated, lithium
toxicity can be life threatening.
Lithium is similar in chemical structure to sodium, behaving in the body in much the
same manner and competing at various sites in the body with sodium. If sodium intake is
reduced or the body is depleted of its normal sodium (e.g., due to excessive sweating,
fever, or diuresis), lithium is reabsorbed by the kidneys, increasing the possibility of
toxicity. Therefore, the client must consume a diet adequate in sodium as well as 2,500 to
3,000 mL of fluid per day. Accurate records of intake, output, and client’s weight should be
kept on a daily basis.
Client/Family Education (for Lithium). Instruct the client that he or she should:
 Take medication on a regular basis, even when feeling well. Discontinuation can
result in return of symptoms.
 Not drive or operate dangerous machinery until lithium levels are stabilized.
Drowsiness and dizziness can occur.
 Not skimp on dietary sodium intake. He or she should eat a variety of healthy foods
and avoid “junk” foods. The client should drink 6 to 8 large glasses of water each
day and avoid excessive use of beverages containing caffeine (coffee, tea, colas),
which promote increased urine output.
 Notify the physician if vomiting or diarrhea occurs. These symptoms can result in
sodium loss and an increased risk of toxicity.

 Carry card or other identification noting that he or she is taking lithium.
 Be aware of appropriate diet should weight gain become a problem. Include
adequate sodium and other nutrients while decreasing number of calories.
 Be aware of risks of becoming pregnant while receiving lithium therapy. Use
information furnished by health-care providers regarding methods of contraception.
Notify the physician as soon as possible if pregnancy is suspected or planned.
 Be aware of side effects and symptoms associated with toxicity. Notify the physician
if any of the following symptoms occur: persistent nausea and vomiting, severe
diarrhea, ataxia, blurred vision, tinnitus, excessive output of urine, increasing
tremors, or mental confusion.
 Refer to written materials furnished by health-care providers while receiving self-
administered maintenance therapy. Keep appointments for outpatient follow-up;
have serum lithium level checked every 1 to 2 months, or as advised by physician.
Client/Family Education (for Anticonvulsants). Instruct the client that he or she should:
 Refrain from discontinuing the drug abruptly. Physician will administer orders for
tapering the drug when therapy is to be discontinued.
 Report the following symptoms to the physician immediately: skin rash, unusual
bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow
skin or eyes.
 Not drive or operate dangerous machinery until reaction to the medication has been
established.

 Avoid consuming alcoholic beverages and nonprescription medications without
approval from physician.
 Carry card at all times identifying the name of medications being taken.
CLINICAL PEARL
The U.S. Food and Drug Administration requires that all antiepileptic
(anticonvulsant) drugs carry a warning label indicating that use of the
drugs increases risk for suicidal thoughts and behaviors. Patients being
treated with these medications should be monitored for the emergence
or worsening of depression, suicidal thoughts or behavior, or any
unusual changes in mood or behavior.
Client/Family Education (for Calcium Channel Blocker). Instruct the client that he or
she should:
 Take medication with meals if gastrointestinal (GI) upset occurs.
 Use caution when driving or when operating dangerous machinery. Dizziness,
drowsiness, and blurred vision can occur.
 Refrain from discontinuing the drug abruptly. To do so may precipitate
cardiovascular problems. Physician will administer orders for tapering the drug
when therapy is to be discontinued.
 Report occurrence of any of the following symptoms to physician immediately:
irregular heart beat, shortness of breath, swelling of the hands and feet, pronounced
dizziness, chest pain, profound mood swings, severe and persistent headache.
pressure.

 Avoid taking other medications (including over-the-counter medications) without
physician’s approval.
 Carry card at all times describing medications being taken.
Client/Family Education (for Antipsychotics)
This information is included in the next section on “Antipsychotic Agents.”
The following criteria may be used for evaluating the effectiveness of therapy with mood-
stabilizing agents:
The client:
1. Is maintaining stability of mood.
2. Has not harmed self or others.
3. Has experienced no injury from hyperactivity.
4. Is able to participate in activities without excessive sedation or dizziness.
5. Is maintaining appropriate weight.
6. Exhibits no signs of lithium toxicity.
7. Verbalizes importance of taking medication regularly and reporting for regular
laboratory blood tests.
Antipsychotic Agents
Antipsychotic medications are also called major tranquilizers and neuroleptics. They were
introduced into the United States in the 1950s with the phenothiazines. Other drugs in this

classification soon followed. Since that time a second generation of medications has been
developed. The first-generation antipsychotics are called “typical” and include the
phenothiazines, haloperidol, loxapine, pimozide, and thiothixene. The second-generation
antipsychotics are called “atypical” or “novel” antipsychotics and include aripiprazole,
asenapine, clozapine, olanzapine, quetiapine, risperidone, paliperidone, iloperidone,
lurasidone, and ziprasidone.
Indications. Antipsychotics are used in the treatment of schizophrenia and other
psychotic disorders. Selected agents are used in the treatment of bipolar mania (see
previous section on “Mood-Stabilizing Agents”). Others are used as antiemetics
(chlorpromazine, perphenazine, prochlorperazine), in the treatment of intractable
hiccoughs (chlorpromazine), and for the control of tics and vocal utterances in Tourette’s
disorder (haloperidol, pimozide). Examples of commonly used antipsychotic agents are
presented in Table 8.
TABLE 8. ANTIPSYCHOTIC AGENTS
Pregnancy Categories/ Daily Dosage

Category Generic (Trade Name) Half-life (hr) Range (mg)
Typical Antipsychotic
Agents (first generation;
conventional) Chlorpromazine (Thorazine) C/ 24 40–400
Fluphenazine C/ 2.5–10
HCl: 18 hr
Decanoate: 6.8–9.6 days
Haloperidol (Haldol) C/ ~18 (oral); 1–100
~3 wk (IM decanoate)
Loxapine (Loxitane) C/ 8 20–250
Perphenazine C/ 9–12 12–64

Pimozide (Orap) C/ ~55 1–10
Prochlorperazine C/ 15–150
3–5 (oral)
6.9 (IV)
Thioridazine C/ 24 150–800
Thiothixene (Navane) C/ 34 6–30
Trifluoperazine C/ 18 4–40
Atypical Antipsychotic

Agents (second
generation; novel) Aripiprazole (Abilify) C/ 75–146 10–30
Asenapine (Saphris) C/ 24 10–20
Clozapine (Clozaril) B/ 8 (single dose); 300–900
12 (at steady state)
Iloperidone (Fanapt) C/ 18–33 12–24
Lurasidone (Latuda) B/ 18 40–80
Olanzapine (Zyprexa) C/ 21–54 5–20
Paliperidone (Invega) C/ 23 6–12
Quetiapine (Seroquel) C/ ~6 300–400
Risperidone (Risperdal) C/ 3–20 4–8
Ziprasidone (Geodon) C/ ~7 (oral); 2–5 (IM) 40–160
Action
Typical antipsychotics work by blocking postsynaptic dopamine receptors in the basal
ganglia, hypothalamus, limbic system, brainstem, and medulla. They also demonstrate
varying affinity for cholinergic, alpha1-adrenergic, and histaminic receptors. Antipsychotic
effects may also be related to inhibition of dopamine-mediated transmission of neural
impulses at the synapses.
Atypical antipsychotics are weaker dopamine receptor antagonists than the
conventional antipsychotics, but are more potent antagonists of the serotonin type 2A
(5HT2A) receptors. They also exhibit antagonism for cholinergic, histaminic, and
adrenergic receptors.
Contraindications/Precautions
Typical antipsychotics are contraindicated in clients with known hypersensitivity (cross
sensitivity may exist among phenothiazines). They should not be used in comatose states or
when CNS depression is evident; when blood dyscrasias exist; in clients with Parkinson’s
disease or narrow-angle glaucoma; those with liver, renal, or cardiac insufficiency; in
individuals with poorly controlled seizure disorders; or in elderly clients with dementia-

related psychosis. Thioridazine, pimozide, and haloperidol have been shown to prolong the
QT interval and are contraindicated if the client is taking other drugs that also produce this
side effect.
Caution should be taken in administering these drugs to clients who are elderly,
severely ill, or debilitated, and to diabetic clients or clients with respiratory insufficiency,
prostatic hypertrophy, or intestinal obstruction. Antipsychotics may lower the seizure
threshold. Individuals should avoid exposure to extremes in temperature while taking
antipsychotic medication. Safety in pregnancy and lactation has not been established.
Atypical antipsychotics are contraindicated in hypersensitivity, comatose or severely
depressed patients, elderly patients with dementia-related psychosis, and lactation.
Ziprasidone, resperidone, paliperidone, asenapine, and iloperidone are contraindicated in
patients with a history of QT prolongation or cardiac arrhythmias, recent myocardial
infarction (MI), uncompensated heart failure, and concurrent use with other drugs that
prolong the QT interval. Clozapine is contraindicated in patients with myeloproliferative
disorders, with a history of clozapine-induced agranulocytosis or severe granulocytopenia,
and in uncontrolled epilepsy. Lurasidone is contraindicated in concomitant use with strong
inhibitors of cytochrome P450 isozyme 3A4 (CYP3A4) (e.g., ketoconazole) and strong
CYP3A4 inducers (e.g., rifampin).
Caution should be taken in administering these drugs to elderly or debilitated patients;
patients with cardiac, hepatic, or renal insufficiency; to those with a history of seizures; to
patients with diabetes or risk factors for diabetes; to clients exposed to temperature
extremes; under conditions that cause hypotension (dehydration, hypovolemia, treatment

with antihypertensive medication); and to pregnant clients or children (safety not
established).
Interactions
Typical antipsychotics have additive hypotensive effects when taken with antihypertensive
agents, additive CNS effects when taken with CNS depressants, and additive
anticholinergic effects when taken with drugs that have anticholinergic properties.
Phenothiazines may reduce effectiveness of oral anticoagulants. Concurrent use of
phenothiazines or haloperidol with epinephrine or dopamine may result in severe
hypotension. Additive effects of QT prolongation occur when haloperidol, thioridazine, or
pimozide are taken concurrently with other drugs that prolong QT interval. Pimozide is
contraindicated with CYP3A inhibitors, and thioridazine is contraindicated with CYP2D6
inhibitors. Concurrent use of haloperidol and carbamazepine results in decreased
therapeutic effects of haloperidol and increased effects of carbamazepine.
Atypical antipsychotics have additive hypotensive effects when taken with
antihypertensive agents and additive CNS effects with CNS depressants. There are additive
anticholinergic effects when resperidone or paliperidone are taken with other drugs that
have anticholinergic properties. Additive effects of QT prolongation occur with
ziprasidone, risperidone, paliperidone, asenapine, and iloperidone and other drugs that
prolong QT interval. Decreased effects of levodopa and dopamine agonists occur with
concurrent use of ziprasidone, olanzapine, quetiapine, resperidone, or paliperidone.
Increased effects of ziprasidone, clozapine, quetiapine, aripiprazole, lurasidone, and
iloperidone occur with CYP3A4 inhibitors. Decreased effects of lurasidone occur with

CYP3A4 inducers. Increased effects of iloperidone occur with CYP2D6 inhibitors.
Decreased effects of ziprasidone, clozapine, olanzapine, risperidone, paliperidone,
asenapine, and aripiprazole occur with CYP1A2 inducers and increased effects occur with
CYP1A2 inhibitors. Concurrent use of asenapine and paroxetine results in decreased
therapeutic effects of asenapine and increased effects of paroxetine. Additive orthostatic
hypotension occurs with resperidone, paliperidone, or iloperidone and other drugs that also
cause this adverse reaction.
Diagnosis
The following nursing diagnoses may be considered for clients receiving antipsychotic
therapy:
1. Risk for other-directed violence related to panic anxiety and mistrust of others.
2. Risk for injury related to medication side effects of sedation, photosensitivity,
reduction of seizure threshold, agranulocytosis, extrapyramidal symptoms, tardive
dyskinesia, neuroleptic malignant syndrome, and/or QT prolongation.
3. Risk for activity intolerance related to medication side effects of sedation, blurred
vision, and/or weakness.
4. Noncompliance with medication regimen related to suspiciousness and mistrust of
others.
The plan of care should include monitoring for the following side effects from
antipsychotic medications. Nursing implications related to each side effect are designated

by an asterisk (*). A profile of side effects comparing various antipsychotic medications is
presented in Table 9.
Table 9. Comparison of Side Effects Among Antipsychotic Agents

Anti- Orthostatic Weight
Class Generic (Trade) Name EPS† Sedation cholinergic Hypotension Gain
Typical
Antipsychotic
Agents Chlorpromazine 3 4 3 4 *
Fluphenazine 5 2 2 2
Haloperidol (Haldol) 5 2 2 2
Loxapine 3 2 2 2 *
Perphenazine 4 2 2 2 *
Pimozide (Orap) 4 2 3 2 *
Prochlorperazine 3 2 2 2 *
Thioridazine 2 4 4 4 *
Thiothixene (Navane) 4 2 2 2 *
Trifluoperazine 4 2 2 2 *
Atypical
Antipsychotic
Agents Aripiprazole (Abilify) 1 2 1 3 2
Asenapine (Saphris) 1 3 1 3 4
Clozapine (Clozaril) 1 5 5 4 5
Iloperidone (Fanapt) 1 3 2 3 3
Lurasidone (Latuda) 1 3 1 3 3
Olanzapine (Zyprexa) 1 3 2 2 5
Paliperidone (Invega) 1 2 1 3 2
Quetiapine (Seroquel) 1 3 1 3 4
Risperidone (Risperdal) 1 2 1 3 4
Ziprasidone (Geodon) 1 3 1 2 2
Key: 1 = Very low; 2 = Low; 3 = Moderate; 4 = High; 5 = Very high

†
EPS = extrapyramidal symptoms
* Weight gain occurs, but incidence is unknown.
SOURCE: Adapted from Black & Andreasen (2011); Drug facts and comparisons (2014); and Schatzberg, Cole, &
DeBattista (2010).
 Anticholinergic effects (see Table 9 for differences between typical and atypical
antipsychotics)
 Dry mouth
* Provide the client with sugarless candy or gum, ice, and frequent sips of water.
* Ensure that client practices strict oral hygiene.
 Blurred vision
* Explain that this symptom will most likely subside after a few weeks.
* Advise client not to drive a car until vision clears.
* Clear small items from pathway to prevent falls.
 Constipation
* Order foods high in fiber; encourage increase in physical activity and fluid
intake if not contraindicated.
 Urinary retention
* Instruct client to report any difficulty urinating; monitor intake and output.
 Nausea; GI upset (may occur with all classifications)
* Tablets or capsules may be administered with food to minimize GI upset.
* Concentrates may be diluted and administered with fruit juice or other liquid;
they should be mixed immediately before administration.
 Skin rash (may occur with all classifications)
* Report appearance of any rash on skin to physician.
* Avoid spilling any of the liquid concentrate on skin; contact dermatitis can
occur with some medications.
 Sedation (see Table 9 for differences between typical and atypical antipsychotics)
* Discuss with physician the possibility of administering the drug at bedtime.
* Discuss with physician a possible decrease in dosage or an order for a less
sedating drug.
* Instruct client not to drive or operate dangerous equipment while experiencing
sedation.
 Orthostatic hypotension (see Table 9 for differences between typical and atypical
antipsychotics)

* Instruct client to rise slowly from a lying or sitting position.
* Monitor blood pressure (lying and standing) each shift; document and report
significant changes.
 Photosensitivity (may occur with all classifications)
* Ensure that the client wears a sunblock lotion, protective clothing, and
sunglasses while spending time outdoors.
 Hormonal effects (may occur with all classifications, but are more common with
typical antipsychotics)
 Decreased libido, retrograde ejaculation (the discharge of seminal fluid into the
bladder rather than through the urethra), gynecomastia (men)
* Provide explanation of the effects and reassurance of reversibility. If necessary,
discuss with physician possibility of ordering alternate medication.
 Amenorrhea (women)
* Offer reassurance of reversibility; instruct client to continue use of
contraception, because amenorrhea does not indicate cessation of ovulation.
 Weight gain (may occur with all classifications; has been problematic with the
atypical antipsychotics)
* Weigh client every other day; order calorie-controlled diet; provide opportunity
for physical exercise; provide diet and exercise instruction.
 Electrocardiogram (ECG) changes
ECG changes, including prolongation of the QT interval, are possible with most of the
antipsychotics. This is particularly true with ziprasidone, thioridazine, pimozide,
haloperidol, paliperidone, iloperidone, asenapine, and clozapine. Caution is advised in

prescribing these medications to individuals with history of arrhythmias. Conditions that
produce hypokalemia and/or hypomagnesemia, such as diuretic therapy or diarrhea,
should be taken into consideration when prescribing. Routine ECG should be performed
before initiation of therapy and periodically during therapy. Clozapine has also been
associated with other cardiac events, such as ischemic changes, arrhythmias, congestive
heart failure, myocarditis, and cardiomyopathy.
* Monitor vital signs every shift.
* Observe for symptoms of dizziness, palpitations, syncope, or weakness.
 Reduction of seizure threshold (more common with the typical than the atypical
antipsychotics, with the exception of clozapine)
* Closely observe clients with history of seizures.
* NOTE: This is particularly important with clients taking clozapine (Clozaril),
with which seizures have been frequently associated. Dose appears to be an
important predictor, with a greater likelihood of seizures occurring at higher
doses. Extreme caution is advised in prescribing clozapine for clients with
history of seizures.
 Agranulocytosis (more common with the typical than the atypical antipsychotics,
with the exception of clozapine)
* Agranulocytosis usually occurs within the first 3 months of treatment. Observe
for symptoms of sore throat, fever, malaise. A complete blood count should be
monitored if these symptoms appear.
* EXCEPTION: There is a significant risk of agranulocytosis with clozapine
(Clozaril). Agranulocytosis is a potentially fatal blood disorder in which the

client’s white blood cell (WBC) count can drop to extremely low levels. A
baseline WBC count and absolute neutrophil count (ANC) must be taken before
initiation of treatment with clozapine and weekly for the first 6 months of
treatment. Only a 1-week supply of medication is dispensed at a time. If the
counts remain within the acceptable levels (i.e., WBC at least 3,500/mm3 and the
ANC at least 2,000/mm3) during the 6-month period, blood counts may be
monitored biweekly and a 2-week supply of medication may then be dispensed. If
the counts remain within the acceptable level for the biweekly period (6 months),
counts may then be monitored every 4 weeks thereafter. When the medication is
discontinued, weekly WBC counts are continued for an additional 4 weeks.
 Hypersalivation (most common with clozapine)
* A significant number of clients receiving clozapine (Clozaril) therapy
experience extreme salivation. Offer support to the client because this may be an
embarrassing situation. It may even be a safety issue (e.g., risk of aspiration) if the
problem is very severe. Management has included the use of sugar-free gum to
increase the swallowing rate, as well as the prescription of medications such as an
anticholinergic (e.g., scopolamine patch) or alpha2-adrenoceptor agonist (e.g.,
clonodine).
 Extrapyramidal symptoms (EPS) (see Table 9 for differences between typical and
* Observe for symptoms and report; administer antiparkinsonian drugs, as
ordered (Table 10).

Table 10. Antiparkinsonian Agents Used to Treat Extrapyramidal Side Effects of
Antipsychotic Drugs
Indication Used to treat parkinsonism of various causes and drug-induced extrapyramidal reactions.
Action Restores the natural balance of acetylcholine and dopamine in the CNS. The imbalance is a
deficiency in dopamine that results in excessive cholinergic activity.
Contraindications/ Antiparkinsonian agents are contraindicated in individuals with hypersensitivity. Anti-
Precautions cholinergics should be avoided by individuals with angle-closure glaucoma; pyloric,
duodenal, or bladder neck obstructions; prostatic hypertrophy; or myasthenia gravis.
Caution should be used in administering these drugs to clients with hepatic, renal or
cardiac insufficiency; elderly and debilitated clients; those with a tendency toward
urinary retention; or those exposed to high environmental temperatures.
Common side effects Anticholinergic effects (dry mouth, blurred vision, constipation, paralytic ileus, urinary
retention, tachycardia, elevated temperature, decreased sweating), nausea/GI upset,
sedation, dizziness, orthostatic hypotension, exacerbation of psychoses.
Pregnancy
Categories/
Chemical Class Generic (Trade) Name Half-life (hr) Daily Dosage Range (mg)
Anticholinergics Benztropine (Cogentin) C/ UK 1–8
Biperiden (Akineton) C/ 18.4-24.3 2–6
Trihexyphenidyl C/ 5.6-10.2 1–15
Antihistamines Diphenhydramine (Benadryl) C/ 4-15 25–200
Dopaminergic Agonists Amantadine C/ 10-25 200–300
 Pseudoparkinsonism (tremor, shuffling gait, drooling, rigidity)
* Symptoms may appear 1 to 5 days following initiation of antipsychotic
medication; occurs most often in women, the elderly, and dehydrated clients.
 Akinesia (muscular weakness)
* Same as for pseudoparkinsonism.
 Akathisia (continuous restlessness and fidgeting)
* This occurs most frequently in women; symptoms may occur 50 to 60 days
following initiation of therapy.
 Dystonia (involuntary muscular movements [spasms] of face, arms, legs, and
neck)
* This occurs most often in men and in people younger than 25 years of age.
 Oculogyric crisis (uncontrolled rolling back of the eyes)

* This may appear as part of the syndrome described as dystonia. It may be
mistaken for seizure activity. Dystonia and oculogyric crisis should be treated as
an emergency situation. The physician should be contacted, and intravenous
benztropine mesylate (Cogentin) is commonly administered. Stay with the client
and offer reassurance and support during this frightening time.
 Tardive dyskinesia (bizarre facial and tongue movements, stiff neck, and difficulty
swallowing; may occur with all classifications, but more common with typical
antipsychotics)
* All clients receiving long-term (months or years) antipsychotic therapy are at
risk.
* The symptoms are potentially irreversible.
* The drug should be withdrawn at the first sign, which is usually vermiform
movements of the tongue; prompt action may prevent irreversibility.
* The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was
developed in the 1970s by the National Institute of Mental Health to measure
involuntary movements associated with tardive dyskinesia. The AIMS aids in
early detection of movement disorders and provides a means for ongoing
surveillance.
 Neuroleptic malignant syndrome (NMS) (more common with the typical than the

* This is a relatively rare, but potentially fatal, complication of treatment with
antipsychotic drugs. Routine assessments should include temperature and
observation for parkinsonian symptoms.
* Onset can occur within hours or even years after drug initiation, and progression
is rapid over the following 24 to 72 hours.
* Symptoms include severe parkinsonian muscle rigidity, very high fever,
tachycardia, tachypnea, fluctuations in blood pressure, diaphoresis, and rapid
deterioration of mental status to stupor and coma.
* Discontinue antipsychotic medication immediately.
* Monitor vital signs, degree of muscle rigidity, intake and output, level of
consciousness.
* The physician may order bromocriptine (Parlodel) or dantrolene (Dantrium) to
counteract the effects of NMS.
 Hyperglycemia and diabetes (more common with atypical antipsychotics)
Studies have suggested an increased risk of treatment-emergent, hyperglycemia-
related adverse events in clients using atypical antipsychotics (e.g., risperidone,
clozepine, olanzapine, quetiapine, ziprasidone, paliperidone, iloperidone, asenapine,
lurasidone, and aripiprazole). The U.S. Food and Drug Administration (FDA)
recommends that clients with diabetes starting on atypical antipsychotic drugs be
monitored regularly for worsening of glucose control. Clients with risk factors for
diabetes should undergo fasting blood glucose testing at the beginning of treatment
and periodically thereafter. All clients taking these medications should be monitored
for symptoms of hyperglycemia (polydipsia, polyuria, polyphagia, and weakness). If

these symptoms appear during treatment, the client should undergo fasting blood
glucose testing.
 Increased risk of mortality in elderly patients with psychosis related to
neurocognitive disorder (NCD).
Studies have indicated that elderly patients with NCD-related psychosis who are
treated with antipsychotic drugs are at increased risk of death, compared with those
taking a placebo. Causes of death are most commonly related to infections or
cardiovascular problems. All antipsychotic drugs now carry black-box warnings to this
effect. They are not approved for treatment of elderly patients with NCD-related
psychosis.
 Use caution when driving or operating dangerous machinery. Drowsiness and
dizziness can occur.
 Not discontinue the drug abruptly after long-term use. To do so might produce
withdrawal symptoms, such as nausea, vomiting, dizziness, gastritis, headache,
tachycardia, insomnia, tremulousness.
 Use sunblock lotion and wear protective clothing when spending time outdoors.
Skin is more susceptible to sunburn, which can occur in as little as 30 minutes.
 Report weekly (if receiving clozapine therapy) to have blood levels drawn and to
obtain a weekly supply of the drug.
 Report the occurrence of any of the following symptoms to the physician
immediately: sore throat, fever, malaise, unusual bleeding, easy bruising, persistent

nausea and vomiting, severe headache, rapid heart rate, fainting, difficulty
urinating, muscle twitching, tremors, darkly colored urine, excessive urination,
excessive thirst, excessive hunger, weakness, pale stools, yellow skin or eyes,
muscular incoordination, or skin rash.
pressure.
 Take frequent sips of water, chew sugarless gum, or suck on hard candy if dry mouth
is a problem. Good oral care (frequent brushing, flossing) is very important.
 Consult the physician regarding smoking while on antipsychotic therapy. Smoking
increases the metabolism of antipsychotics, requiring an adjustment in dosage to
achieve a therapeutic effect.
 Dress warmly in cold weather and avoid extended exposure to very high or low
temperatures. Body temperature is harder to maintain with this medication.
 Avoid drinking alcohol while on antipsychotic therapy. These drugs potentiate each
other’s effects.
 Avoid taking other medications (including over-the-counter products) without the
physician’s approval. Many medications contain substances that interact with
antipsychotics in a way that may be harmful.
 Be aware of possible risks of taking antipsychotics during pregnancy. Safe use
during pregnancy has not been established. Antipsychotics are thought to readily
cross the placental barrier; if so, a fetus could experience adverse effects of the
drug. Inform the physician immediately if pregnancy occurs, is suspected, or is
planned.

 Be aware of side effects of antipsychotic drugs. Refer to written materials furnished
by health-care providers for safe self-administration.
 Continue to take the medication, even if feeling well and as though it is not needed.
Symptoms may return if medication is discontinued.
 Carry a card or other identification at all times describing medications being taken.
antipsychotic medications.
The client:
1. Has not harmed self or others.
2. Has not experienced injury caused by side effects of lowered seizure threshold or
photosensitivity.
3. Maintains a WBC within normal limits.
4. Exhibits no symptoms of extrapyramidal side effects, tardive dyskinesia,
neuroleptic malignant syndrome, or hyperglycemia.
5. Maintains weight within normal limits.
6. Tolerates activity unaltered by the effects of sedation or weakness.
7. Takes medication willingly.
8. Verbalizes understanding of medication regimen and the importance of regular
administration.

Sedative-Hypnotics
Indications. Sedative-hypnotics are used in the short-term management of various anxiety
states and to treat insomnia. Selected agents are used as anticonvulsants (pentobarbital,
phenobarbital) and preoperative sedatives (pentobarbital, secobarbital) and to reduce
anxiety associated with alcohol withdrawal (chloral hydrate). Examples of commonly used
sedative-hypnotics are presented in Table 11.
TABLE 11. SEDATIVE-HYPNOTIC AGENTS

Pregnancy
Generic (Trade) Controlled Categories/ Daily Dosage
Chemical Class Name Categories Half-life (hr) Range (mg)
Barbiturates Amobarbital CII D/ 16–40 60–200

Butabarbital CIII D/ 66–140 45–120
(Butisol)
Pentobarbital CII D/ 15–50 150–200

(Nembutal)
Phenobarbital CIV D/ 53–118 30–200
(Luminal; Solfoton)
Secobarbital CII D/ 15–40 100 (hypnotic)
(Seconal) 200–300 (pre-op
sedation)
Benzodiazepines Estazolam CIV X/ 8–28 1–2

Flurazepam CIV X/ 2–3 (active 15–30
metabolite-
47–100)
Quazepam (Doral) CIV X/39 (active 7.5–15 mg
metabolite-
73)
Temazepam CIV X/ 9–15 15–30 mg
(Restoril)
Triazolam (Halcion) CIV X/ 1.5–5.5 0.125–0.5
Miscellaneous Chloral hydrate CIV C/ 7–10 500–1000

Eszopiclone CIV C/ 6 1–3
(Lunesta)
Ramelteon C/ 1–2.6 8
(Rozerem)
Zaleplon (Sonata) CIV C/ 1 5–20
Zolpidem (Ambien) CIV C/ 2–3 5–10 (immediate
release),

12.5 (extended
release)
Action. Sedative-hypnotics cause generalized CNS depression. They may produce
tolerance with chronic use and have the potential for psychological or physical dependence.
EXCEPTION: Ramelteon (Rozerem) is not a controlled substance. It does not produce
tolerance or physical dependence. Sleep-promoting properties are the result of ramelteon’s
agonist activity on selective melatonin receptors.
Contraindications/Precautions. Sedative-hypnotics are contraindicated in individuals
with hypersensitivity to the drug or to any drug within the chemical class; in pregnancy
(exceptions may be made in certain cases based on benefit-to-risk ratio); lactation; in
severe hepatic, cardiac, respiratory, or renal disease; children younger than age 15
(flurazepam) and children younger than age 18 (estazolam, quazepam, temazepam,
triazolam). Triazolam is contraindicated in concurrent use with ketoconazole, itraconazole,
or nefazodone, medications that impair the metabolism of triazolam by cytochrome
P4503A (CYP3A). Ramelteon is contraindicated in concurrent use with fluvoxamine.
Zolpidem, zaleplon, eszopiclone, and ramelteon are contraindicated in children. Chloral
hydrate is contraindicated in persons with esophagitis, gastritis, or peptic ulcer disease, and
those with hepatic, renal, or cardiac impairment.
Caution should be used in administering these drugs to clients with cardiac, hepatic,
renal, or respiratory insufficiency. They should be used with caution in clients who may be
suicidal or who may have been addicted to drugs previously. Hypnotic use should be short
term. Elderly clients may be more sensitive to CNS depressant effects, and dosage

reduction may be required. Chloral hydrate should be used with caution in clients
susceptible to acute intermittent porphyria.
Interactions
Barbiturates. The effects of barbiturates are increased with concomitant use of alcohol,
other CNS depressants, MAO inhibitors, or valproic acid. The effects of barbiturates may
be decreased with rifampin. Possible decreased effects of the following drugs may occur
when used concomitantly with barbiturates: anticoagulants, beta blockers, carbamazepine,
clonazepam, oral contraceptives, corticosteroids, digitoxin, doxorubicin, doxycycline,
felodipine, fenoprofen, griseofulvin, metronidazole, phenylbutazone, quinidine,
theophylline, or verapamil. Concomitant use with methoxyflurane may enhance renal
toxicity.
Benzodiazepines. The effects of the benzodiazepine hypnotics are increased with
concomitant use of alcohol or other CNS depressants, cimetidine, oral contraceptives,
disulfiram, isoniazid, or probenecid. The effects of the benzodiazepine hypnotics are
decreased with concomitant use of rifampin, theophylline, carbamazepine, St. John’s wort,
or with cigarette smoking. The effects of digoxin or phenytoin are increased when used
concomitantly with benzodiazepines. There is increased bioavailability of triazolam with
concurrent use of macrolides.
Chloral Hydrate. The effects of choral hydrate are increased with concomitant use of
alcohol or other CNS depressants. Possible decreased effects of hydantoins occur when
used concomitantly with chloral hydrate. Possible increased effects of oral anticoagulants
occur when used concomitantly with chloral hydrate. Symptoms of sweating, hot flashes,

tachycardia, hypertension, weakness, and nausea may occur if used concurrently with IV
furosemide.
Eszopiclone. There are additive effects of eszopiclone with alcohol or other CNS
depressants. Decreased effects of eszopiclone occur with CYP3A4 inducers (e.g., rifampin,
phenytoin, carbamazepine, phenobarbital), with lorazepam, or following a high-fat or
heavy meal. Increased effects of eszopiclone occur with CYP3A4 inhibitors (e.g.,
ketoconazole, clarithromycin, nefazodone, ritonavir). There are decreased effects of
lorazepam with concomitant use.
Zaleplon. Additive effects of zaleplon occur with alcohol or other CNS depressants.
Decreased effects of zaleplon occur with CYP3A4 inducers (e.g., rifampin, phenytoin,
carbamazepine, phenobarbital) or following a high-fat or heavy meal. There are increased
effects of zaleplon with cimetidine.
Zolpidem. Increased effects of zolpidem occur with alcohol or other CNS depressants,
azole antifungals, ritonavir, or SSRIs. Decreased effects of zolpidem occur with
flumazenil, rifampin, and with food. There is a risk of life-threatening cardiac arrhythmias
with concomitant use of amiodarone.
Ramelteon. Increased effects of ramelteon occur with alcohol, ketoconazole (and other
CYP3A4 inhibitors), or fluvoxamine (and other CYP1A2 inhibitors). Decreased effects of
ramelteon occur with rifampin (and other CYP3A4 inducers) and following a heavy or
high-fat meal.

Diagnosis
sedative hypnotics:
1. Risk for injury related to abrupt withdrawal from long-term use or decreased mental
alertness caused by residual sedation.
2. Disturbed sleep pattern/insomnia related to situational crises, physical condition, or
severe level of anxiety.
3. Risk for activity intolerance related to side effects of lethargy, drowsiness, and
dizziness.
4. Risk for acute confusion related to action of the medication on the central nervous
system.
Refer to this section in the discussion of antianxiety medications. In addition to the side
effects listed in the anxiety medication section, the following have also been noted in some
individuals taking sedative/hypnotics:
* Abnormal thinking and behavioral changes
Unusual changes in behavior, including aggressiveness, hallucinations, and suicidal
ideation, have been reported. Certain complex behaviors, such as sleep-driving,
preparing and eating food, and making phone calls, with amnesia for the behavior, have
occurred. Although a direct correlation to the behavior with the use of
sedative/hypnotics cannot be made, the emergence of any new behavioral sign or
symptom of concern requires careful and immediate evaluation.

sedative-hypnotic medications:
The client:
1. Demonstrates a reduction in anxiety, tension, and restless activity.
2. Falls asleep within 30 minutes of taking the medication and remains asleep for 6 to
8 hours without interruption.
3. Is able to participate in usual activities without residual sedation.
4. Experiences no physical injury.
5. Exhibits no evidence of confusion.
6. Verbalizes understanding of taking the medication on a short-term basis.
7. Verbalizes understanding of potential for development of tolerance and dependence
with long-term use.
Agents for Attention Deficit Hyperactivity Disorder (ADHD)
Indications. The medications in this section are used for ADHD in children and adults.
Amphetamines are also used in the treatment of narcolepsy and exogenous obesity.
Bupropion is used in the treatment of major depression and for smoking cessation (Zyban
only). Clonidine and guanfacine are used to treat hypertension. Examples of commonly
used agents for ADHD are presented in Table 12.

TABLE 12. AGENTS FOR ATTENTION DEFICIT HYPERACTIVITY DISORDER
Pregnancy
Daily Dosage Controlled Categories/
Chemical Class Generic (Trade) Name Range (mg) Categories Half-life (hr)
CNS STIMULANTS
Amphetamines Dextroamphetamine 2.5-40 CII C/ ~12

sulfate (Dexedrine;
Dextrostat)
Methamphetamine 5-25 CII C/ 4-5

(Desoxyn)
Lisdexamfetamine 20-70 CII C/< 1

(Vyvanse)
Amphetamine Dextroamphetamine/ 2.5-40 CII C/ 9-13

Mixtures amphetamine
(Adderall; Adderall
XR)
Miscellaneous Methylphenidate 10-60 CII C/ 2-4

(Ritalin; Ritalin-SR;
Ritalin LA; Methylin;
Methylin ER;
Metadate ER;
Metadate CD;
Concerta; Daytrana)
Dexmethylphenidate 5-20 CII C/ 2.2

(Focalin)
ALPHA AGONISTS Clonidine (Catapres) 0.05-0.3 ----- C/ 12-16
Guanfacine (Tenex; 1-4 ----- B/ 10-30

Intuniv)
MISCELLANEOUS >70 kg: 40-100; ----- C/ 5.2

Atomoxetine (Strattera) < 70 kg: 0.5-1.4 (metabolites
mg/kg (or 100 6-8)
mg—whichever
is less)
3 mg/kg ----- C/ 8-24

Bupropion (Wellbutrin; (ADHD);
Wellbutrin SR; 100-300
Wellbutrin XL) (depression)

Action. CNS stimulants increase levels of neurotransmitters (probably norepinephrine,
dopamine, and serotonin) in the CNS. They produce CNS and respiratory stimulation,
dilated pupils, increased motor activity and mental alertness, diminished sense of fatigue,
and brighter spirits. The CNS stimulants discussed in this section include
dextroamphetamine sulfate, methamphetamine, lisdexamphetamine, amphetamine
mixtures, methylphenidate, and dexmethylphenidate. Action in the treatment of ADHD is
unclear. However, recent research indicates that their effectiveness in the treatment of
hyperactivity disorders is based on the activation of dopamine D4 receptors in the basal
ganglia and thalamus, which depress, rather than enhance, motor activity (Erlij et al.,
2012).
Atomoxetine inhibits the reuptake of norepinephrine, and bupropion blocks the
neuronal uptake of serotonin, norepinephrine, and dopamine. Clonidine and guanfacine
stimulate central alpha-adrenergic receptors in the brain, resulting in reduced sympathetic
outflow from the CNS. The exact mechanism by which these nonstimulant drugs produce
the therapeutic effect in ADHD is unclear.
Contraindications/Precautions. CNS stimulants are contraindicated in individuals
with hypersensitivity to sympathomimetic amines. They should not be used in advanced
arteriosclerosis, cardiovascular disease, hypertension, hyperthyroidism, glaucoma, agitated
or hyperexcitability states, in clients with a history of drug abuse, during or within 14 days
of receiving therapy with MAOIs, in children younger than 3 years of age, and in
pregnancy and lactation. Atomoxetine and bupropion are contraindicated in clients with
hypersensitivity to the drugs or their components, in lactation, and in concomitant use with

or within 2 weeks of using MAOIs. Atomoxetine is contraindicted in clients with narrow-
angle glaucoma. Bupropion is contraindicated in individuals with known or suspected
seizure disorder, in the acute phase of myocardial infarction, and in clients with bulimia or
anorexia nervosa. Alpha agonists are contraindicated in clients with known hypersensitivity
to the drugs.
Caution is advised in using CNS stimulants in children with psychosis; in Tourette’s
disorder; in clients with anorexia or insomnia; in elderly, debilitated, or asthenic clients;
and in clients with a history of suicidal or homicidal tendencies. Prolonged use may result
in tolerance and physical or psychological dependence. Use atomoxetine and bupropion
cautiously in clients with urinary retention; hypertension; hepatic, renal, or cardiovascular
disease; suicidal clients; pregnancy; and elderly and debilitated clients. Alpha agonists
should be used with caution in clients with coronary insufficiency, recent myocardial
infarction, or cerebrovascular disease; in chronic renal or hepatic failure; the elderly; and in
pregnancy and lactation.
Interactions
CNS stimulants (amphetamines). Effects of amphetamines are increased with
furazolidone or urinary alkalinizers. Hypertensive crisis may occur with concomitant use of
(and up to several weeks after discontinuing) MAOIs. Increased risk of serotonin syndrome
occurs with coadministration of selective serotonin reuptake inhibitors (SSRIs). Decreased
effects of amphetamines occur with urinary acidifiers, and decreased hypotensive effects of
guanethidine occur with amphetamines.
Dexmethylphenidate and methylphenidate. Effects of antihypertensive agents and
pressor agents (e.g., dopamine, epinephrine, phenylephrine) are decreased with

concomitant use of the methylphenidates. Effects of coumarin anticoagulants,
anticonvulsants (e.g., phenobarbital, phenytoin, primidone), tricyclic antidepressants, and
SSRIs are increased with the methylphenidates. Hypertensive crisis may occur with
coadministration of MAOIs.
Atomoxatine. Effects of atomoxetine are increased with concomitant use of CYP2D6
inhibitors (e.g., paroxetine, fluoxetine, quinidine). Potentially fatal reactions may occur
with concurrent use of (or within 2 weeks of discontinuation of) MAOIs. Risk of
cardiovascular effects is increased with concomitant use of albuterol or vasopressors.
Bupropion. Effects of bupropion are increased with amantadine, levodopa, or
ritonavir. Effects of bupropion are decreased with carbamazepine. There is increased risk
of acute toxicity with MAOIs. Increased risk of hypertension may occur with nicotine
replacement agents, and adverse neuropsychiatric events may occur with alcohol. Increased
anticoagulant effects of warfarin, as well as increased effects of drugs metabolized by
CYP2D6 (e.g., nortriptyline, imipramine, desipramine, paroxetine, fluoxetine, sertraline,
haloperidol, risperidone, thioridazine, metoprolol, propafenone, and flecainide), occur with
concomitant use.
Alpha agonists. Synergistic pharmacologic and toxic effects, possibly causing
atrioventricular (AV) block, bradycardia, and severe hypotension, may occur with
concomitant use of calcium channel blockers or beta-blockers. Additive sedation occurs
with CNS depressants, including alcohol, antihistamines, opioid analgesics, and
sedative/hypnotics. Effects of clonidine may be decreased with concomitant use of tricyclic
antidepressants and prozosin. Decreased effects of levodopa may occur with clonidine, and
effects of guanfacine are decreased with barbiturates or phenytoin.

Diagnosis
agents for ADHD:
1. Risk for injury related to overstimulation and hyperactivity (CNS stimulants) or
seizures (possible side effect of bupropion).
2. Risk for suicide secondary to major depression related to abrupt withdrawal after
extended use (CNS stimulants).
3. Risk for suicide (children and adolescents) as a side effect of atomoxetine and
bupropion (black-box warning).
4. Imbalanced nutrition, less than body requirements, related to side effects of
anorexia and weight loss (CNS stimulants).
5. Insomnia related to side effects of overstimulation.
6. Nausea related to side effects of atomoxetine or bupropion.
7. Pain related to side effect of abdominal pain (atomoxetine, bupropion) or headache
(all agents).
8. Risk for activity intolerance related to side effects of sedation and dizziness with
atomoxetine or bupropion.
The plan of care should include monitoring for the following side effects from agents for
ADHD. Nursing implications related to each side effect are designated by an asterisk (*).
 Overstimulation, restlessness, insomnia (CNS stimulants)

 Assess mental status for changes in mood, level of activity, degree of
stimulation, and aggressiveness.
 Ensure that the client is protected from injury.
 Keep stimuli low and environment as quiet as possible to discourage
overstimulation.
 To prevent insomnia, administer the last dose at least 6 hours before bedtime.
Administer sustained-release forms in the morning.
 Palpitations, tachycardia (CNS stimulants, atomoxetine, bupropion, clonidine), or
bradycardia (clonidine, guanfacine)
 Monitor and record vital signs at regular intervals (two or three times a day)
throughout therapy. Report significant changes to the physician immediately.
NOTE: The FDA has issued warnings associated with CNS stimulants and
atomoxetine of the risk for sudden death in patients who have cardiovascular
disease. A careful personal and family history of heart disease, heart defects, or
hypertension should be obtained before these medications are prescribed.
Careful monitoring of cardiovascular function during administration must be
ongoing.
 Anorexia, weight loss (CNS stimulants, atomoxetine, bupropion)
 To reduce anorexia, the medication may be administered immediately after
meals. The client should be weighed regularly (at least weekly) when receiving
therapy with CNS stimulants, atomoxetine, or bupropion because of the potential
for anorexia and weight loss and temporary interruption of growth and
development.

 Tolerance, physical and psychological dependence (CNS stimulants)
 Tolerance develops rapidly.
 In children with ADHD, a drug “holiday” should be attempted periodically under
direction of the physician to determine the effectiveness of the medication and
the need for continuation.
 The drug should not be withdrawn abruptly. To do so could initiate the
following syndrome of symptoms: nausea, vomiting, abdominal cramping,
headache, fatigue, weakness, mental depression, suicidal ideation, increased
dreaming, and psychotic behavior.
 Nausea and vomiting (atomoxetine and bupropion)
* May be taken with food to minimize GI upset.
 Constipation (atomoxetine, bupropion, clonidine, guanfacine)
* Increase fiber and fluid in diet, if not contraindicated.
 Dry mouth (clonidine and guanfacine)
* Offer the client sugarless candy, ice, frequent sips of water.
* Strict oral hygiene is very important.
 Sedation (clonidine and guanfacine)
* Warn client that this effect is increased by concomitant use of alcohol and other
CNS drugs.
* Warn clients to refrain from driving or performing hazardous tasks until response
has been established.
 Potential for seizures (bupropion)

* Protect client from injury if seizure should occur. Instruct family and significant
others of clients on bupropion therapy how to protect client during a seizure if one
should occur. Ensure that doses of the immediate-release medication are
administered at least 4 to 6 hours apart and doses of the sustained-release
medication at least 8 hours apart.
 Severe liver damage (with atomoxetine)
* Monitor for the following side effects and report to physician immediately:
itching, dark urine, right upper quadrant pain, yellow skin or eyes, sore throat,
fever, malaise.
 New or worsened psychiatric symptoms (with CNS stimulants and atomoxetine)
* Monitor for psychotic symptoms (e.g., hearing voices, paranoid behaviors,
delusions).
* Monitor for manic symptoms, including aggressive and hostile behaviors.
 Rebound syndrome (with clonidine and guanfacine)
* Client should be instructed not to discontinue therapy abruptly. To do so may
result in symptoms of nervousness, agitation, headache, and tremor, and a rapid rise
in blood pressure. Dosage should be tapered gradually under the supervision of the
physician.
 Use caution in driving or operating dangerous machinery. Drowsiness, dizziness,
and blurred vision can occur.

 Not stop taking CNS stimulants abruptly. To do so could produce serious
withdrawal symptoms.
 Avoid taking CNS stimulants late in the day to prevent insomnia. Take no later than
6 hours before bedtime.
 Not take other medications (including over-the-counter drugs) without physician’s
approval. Many medications contain substances that, in combination with agents for
ADHD, can be harmful.
 (Diabetic clients): Monitor blood sugar two or three times a day or as instructed by
the physician. Be aware of need for possible alteration in insulin requirements
because of changes in food intake, weight, and activity.
 Avoid consumption of large amounts of caffeinated products (coffee, tea, colas,
chocolate), as they may enhance the CNS stimulant effect.
 Notify physician if restlessness, insomnia, anorexia, or dry mouth becomes severe
or if rapid, pounding heartbeat becomes evident.
 Report any of the following side effects to the physician immediately: shortness of
breath, chest pain, jaw/left arm pain, fainting, seizures, sudden vision changes,
weakness on one side of the body, slurred speech, confusion, itching, dark urine,
right upper quadrant pain, yellow skin or eyes, sore throat, fever, malaise, increased
hyperactivity, believing things that are not true, or hearing voices.
 Be aware of possible risks of taking agents for ADHD during pregnancy. Safe use
during pregnancy and lactation has not been established. Inform the physician
immediately if pregnancy is suspected or planned.

 Be aware of potential side effects of agents for ADHD. Refer to written materials
furnished by health-care providers for safe self-administration.
 Carry a card or other identification at all times describing medications being taken.
The following criteria may be used for evaluating the effectiveness of therapy with agents
for ADHD.
The client:
1. Does not exhibit excessive hyperactivity.
2. Has not experienced injury.
3. Is maintaining expected parameters of growth and development.
4. Verbalizes understanding of safe self-administration and the importance of not
withdrawing medication abruptly.
SUMMARY AND KEY POINTS
 Psychotropic medications are intended to be used as adjunctive therapy to individual
or group psychotherapy.
 Antianxiety agents are used in the treatment of anxiety disorders and to alleviate
acute anxiety symptoms. The benzodiazepines are the most commonly used group.
They are CNS depressants and have a potential for physical and psychological
dependence. They should not be discontinued abruptly following long-term use
because they can produce a life-threatening withdrawal syndrome. The most
common side effects are drowsiness, confusion, and lethargy.

 Antidepressants elevate mood and alleviate other symptoms associated with
moderate-to-severe depression. These drugs work to increase the concentration of
norepinephrine and serotonin in the body. The tricyclics and related drugs
accomplish this by blocking the reuptake of these chemicals by the neurons.
Another group of antidepressants inhibits MAO, an enzyme that is known to
inactivate norepinephrine and serotonin. They are called MAO inhibitors (MAOIs).
A third category of drugs blocks neuronal reuptake of serotonin and has minimal or
no effect on reuptake of norepinephrine or dopamine. They are called selective
serotonin reuptake inhibitors (SSRIs). Antidepressant medications may take up to 4
weeks to produce the desired effect. The most common side effects are
anticholinergic effects, sedation, and orthostatic hypotension. They can also reduce
the seizure threshold. MAOIs can cause hypertensive crisis if products containing
tyramine are consumed while taking these medications.
 Lithium carbonate is widely used as a mood-stabilizing agent. Its mechanism of
action is not fully understood, but it is thought to enhance the reuptake of
norepinephrine and serotonin in the brain, thereby lowering the levels in the body,
resulting in decreased hyperactivity. The most common side effects are dry mouth,
GI upset, polyuria, and weight gain. There is a very narrow margin between the
therapeutic and toxic levels of lithium. Serum levels must be drawn regularly to
monitor for toxicity. Symptoms of lithium toxicity begin to appear at serum levels
of approximately 1.5 mEq/L. If left untreated, lithium toxicity can be life
threatening.

 Several other medications are used as mood-stabilizing agents. Two groups,
anticonvulsants (carbamazepine, clonazepam, valproic acid, lamotrigine,
oxcarbazepine, and topiramate) and the calcium channel blocker verapamil have
been used with some effectiveness. Their action in the treatment of bipolar mania is
unknown. Most recently, a number of atypical antipsychotic medications have been
used with success in the treatment of bipolar mania. These include olanzapine,
aripiprazole, quetiapine, risperidone, asenapine, and ziprasidone. The phenothiazine
chlorpromazine has also been used effectively. The action of antipsychotics in the
treatment of bipolar mania is not understood.
 Antipsychotic drugs are used in the treatment of acute and chronic psychoses. The
action of phenothiazines is caused by blocking postsynaptic dopamine receptors in
the basal ganglia. Their most common side effects include anticholinergic effects,
sedation, weight gain, reduction in seizure threshold, photosensitivity, and
extrapyramidal symptoms. A newer generation of antipsychotic medications, which
includes clozapine, risperidone, paliperidone, olanzapine, quetiapine, aripiprazoole,
asenapine, iloperidone, lurasidone, and ziprasidone, may have an effect on
dopamine, serotonin, and other neurotransmitters. They show promise of greater
efficacy with fewer side effects.
 Antiparkinsonian agents are used to counteract the extrapyramidal symptoms
associated with antipsychotic medications. Antiparkinsonian drugs work to restore
the natural balance of acetylcholine and dopamine in the brain. The most common
side effects of these drugs are the anticholinergic effects. They may also cause
sedation and orthostatic hypotension.

 Sedative-hypnotics are used in the management of anxiety states and to treat
insomnia. These CNS depressants have the potential for physical and psychological
dependence (with the exception of ramelteon). They are indicated for short-term use
only. Side effects and nursing implications are similar to those described for
antianxiety medications.
 Several medications have been designated as agents for treatment of ADHD. These
include CNS stimulants, which have the potential for physical and psychological
dependence. Tolerance develops quickly with CNS stimulants, and they should not
be withdrawn abruptly because they can produce serious withdrawal symptoms.
The most common side effects are restlessness, anorexia, and insomnia. Other
medications that have shown to be effective with ADHD include atomoxetine,
bupropion, and the alpha-adrenergic agonists clonidine and guanfacine. Their
mechanism of action in the treatment of ADHD is not clear.
REVIEW QUESTIONS
Self-Examination/Learning Exercise
Select the answer that is most appropriate for each of the following questions.
1. Antianxiety medications, such as benzodiazepines, produce a calming effect by:

a. Depressing the CNS.
b. Decreasing levels of norepinephrine and serotonin in the brain.
c. Decreasing levels of dopamine in the brain.
d. Inhibiting production of the enzyme MAO.
2. Nancy has a new diagnosis of panic disorder. Dr. S has written a prn order for
alprazolam (Xanax) for when Nancy is feeling anxious. She says to the nurse, “Dr. S
prescribed Buspirone for my friend’s anxiety. Why did he order something different for
me?” The nurse’s answer is based on which of the following?
a. Buspirone is not an antianxiety medication.
b. Alprazolam and buspirone are essentially the same medication, so either one is
appropriate.

c. Buspirone has delayed onset of action and cannot be used on a prn basis.
d. Alprazolam is the only medication that really works for panic disorder.
3. Education for the client who is taking MAOIs should include which of the following?
a. Fluid and sodium replacement when appropriate, frequent drug blood levels, signs
and symptoms of toxicity.
b. Lifetime of continuous use, possible tardive dyskinesia, advantages of an injection
every 2 to 4 weeks.
c. Short-term use, possible tolerance to beneficial effects, careful tapering of the drug
at end of treatment.
d. Tyramine-restricted diet, prohibitive concurrent use of over-the-counter medications
without physician notification.
4. There is a very narrow margin between the therapeutic and toxic levels of lithium
carbonate. Symptoms of toxicity are most likely to appear if the serum levels exceed:
a. 0.15 mEq/L.
b. 1.5 mEq/L.
c. 15.0 mEq/L.
d. 150 mEq/L.
5. Initial symptoms of lithium toxicity include:

a. Constipation, dry mouth, drowsiness, oliguria.
b. Dizziness, thirst, dysuria, arrhythmias.
c. Ataxia, tinnitus, blurred vision, diarrhea.
d. Fatigue, vertigo, anuria, weakness.
6. Antipsychotic medications are thought to decrease psychotic symptoms by:

a. Blocking reuptake of norepinephrine and serotonin.
b. Blocking the action of dopamine in the brain.
c. Inhibiting production of the enzyme MAO.
d. Depressing the CNS.
7. Part of the nurse’s continual assessment of the client taking antipsychotic medications
is to observe for extrapyramidal symptoms. Examples include:
a. Muscular weakness, rigidity, tremors, facial spasms.
b. Dry mouth, blurred vision, urinary retention, orthostatic hypotension.
c. Amenorrhea, gynecomastia, retrograde ejaculation.
d. Elevated blood pressure, severe occipital headache, stiff neck.
8. If the foregoing extrapyramidal symptoms should occur, which of the following would
be a priority nursing intervention?
a. Notify the physician immediately.
b. Administer prn trihexyphenidyl (Artane).
c. Withhold the next dose of antipsychotic medication.

d. Explain to the client that these symptoms are only temporary and will disappear
shortly.
9. A concern with children on long-term therapy with CNS stimulants for ADHD is:
a. Addiction.
b. Weight gain.
c. Substance abuse.
d. Growth suppression.
10. Doses of bupropion should be administered at least 4 to 6 hours apart and never
doubled when a dose is missed. The reason for this is:
a. To prevent orthostatic hypotension.
b. To prevent seizures.
c. To prevent hypertensive crisis.
d. To prevent extrapyramidal symptoms.
REFERENCES
Black, D.W., & Andreasen, N.C. (2011). Introductory textbook of psychiatry (5th ed.).
Washington, DC: American Psychiatric Publishing.
Cooper, B.E., & Sejnowski, C.A. (2013). Serotonin syndrome: Recognition and
treatment. AACN Advanced Critical Care, 24(1), 15-20.
Drug facts and comparison. (2014). St. Louis: Wolters Kluwer.
Erlij, D., Acosta-Garcia, J., Rojas-Marquez, M., Gonzalez-Hernandez, B., Escartin-Perez,
E., Aceves, J., & Floran, B. (2012). Dopamine D4 receptor stimulation in
GABAergic projections of the globus pallidus to the reticular thalamic nucleus
and the substantia nigra reticulate of the rat decreases locomotor activity.
Neuropharmacology, 62(2), 1111-1118.
Karasu, T.B., Gelenberg, A., Merriam, A., & Wang, P. (2006). Treatment of patients with
major depressive disorder. In the American Psychiatric Association practice

guidelines for the treatment of psychiatric disorders, Compendium 2006.
Martinez, M., Marangell, L.B., & Martinez, J.M. (2008). Psychopharmacology. In R.E.
Hales, S.C. Yudofsky, & G.O. Gabbard (Eds.), Textbook of psychiatry (5th ed.).
Sadock, B.J., & Sadock, V.A. (2007). Synopsis of psychiatry: Behavioral sciences/
clinical psychiatry (10th ed.). Philadelphia: Lippincott Williams & Wilkins.
Sage, D.L. (Producer) (1984). The Brain: Madness. Washington, DC: Public
Broadcasting Company.
Schatzberg, A.F., Cole, J.O., & DeBattista, C. (2010). Manual of clinical
psychopharmacology (7th ed.). Washington, DC: American Psychiatric Publishing.

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PSYCHOPHARMACOLOGY

CHAPTER OUTLINE KEY TERMS

UCLA Brain Research Institute, stated,

bizarre that we could literally not talk to. (Sage, 1984)

This chapter explores historical perspectives in the use of psychotropic medications

benign involvement to intervention some would consider inhumane. Individuals with

Copyright © 2014. F.A. Davis Company

the development of psychopharmacology has expanded to include widespread use of

work has provided an understanding of the etiology of many psychiatric disorders.

adjunct to individual or group psychotherapy. Although their contribution to psychiatric

care cannot be minimized, it must be emphasized that psychotropic medications relieve

physical and behavioral symptoms. They do not resolve emotional problems.

ROLE OF THE NURSE

Copyright © 2014. F.A. Davis Company

A thorough baseline assessment must be conducted before a client is placed on a regimen

of psychopharmacological therapy. A history and physical examination (see Chapter 9 of

the textbook), an ethnocultural assessment (see Chapter 6 of the textbook), and a

Medication Administration and Evaluation

Medication administration is followed by a careful evaluation, which includes continuous

of psychotropic medications to be able to anticipate potential problems and outcomes

associated with their administration.

Copyright © 2014. F.A. Davis Company

and when it is important to report to their physician. Medication education encourages

HOW DO PSYCHOTROPICS WORK?

Researchers hypothesize that most antidepressants work by blocking the reuptake of

neurotransmitters, specifically, serotonin and norepinephrine. Reuptake is the process of

neurotransmitter inactivation by which the neurotransmitter is reabsorbed into the

more of the neurotransmitter to be available for neuronal transmission. This mechanism of

adrenergic, histaminergic, and muscarinic cholinergic receptors. Blocking these receptors

is also associated with the development of certain side effects.

Figure 1: Area of synaptic transmission that is altered by drugs

Table 1. EFFECTS OF PSYCHOTROPIC INFLUENCE ON NEUROTRANSMITTERS

Copyright © 2014. F.A. Davis Company

Tricyclic Inhibit reuptake of Reduces depression Sexual dysfunction (NE &

MAO inhibitors Increase NE and 5-HT by Reduces depression Sedation, dizziness

Trazodone and 5-HT reuptake block Reduces depression Nausea (5-HT)

SSNRIs: venlafaxine, Potent inhibitors of Reduces depression Nausea (5-HT)

Bupropion Inhibits reuptake of NE Reduces depression Insomnia, dry mouth,

Antipsychotics: Strong D2 receptor Relief of psychosis Blurred vision, dry mouth,

Antianxiety: Bind to BZ receptor sites Relief of anxiety Dependence (with long-

Antianxiety: 5-HT1A agonist Relief of anxiety Nausea, headache,

Copyright © 2014. F.A. Davis Company

Antipsychotic medications block dopamine receptors, and some affect

muscarinic cholinergic, histaminergic, and α-adrenergic receptors. The

“atypical” (or novel) antipsychotics block a specific serotonin receptor.

Benzodiazepines facilitate the transmission of the inhibitory neurotransmitter

gamma-aminobutyric acid (GABA). The psychostimulants work by

increasing norepinephrine, serotonin, and dopamine release.

Although each psychotropic medication affects neurotransmission, the specific

term neuropharmacological reactions to increased norepinephrine and serotonin levels

effects are related to the nervous system’s adaptation to increased levels of

neurotransmitters. These adaptive changes result from a homeostatic mechanism, much

like a thermostat, that regulates the cell and maintains equilibrium.

APPLYING THE NURSING PROCESS IN

Copyright © 2014. F.A. Davis Company

signature of informed consent is required prior to pharmacological therapy.

Copyright © 2014. F.A. Davis Company

Any allergies to food or

Any special diet