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Psychopharmacology

The middle of 20th century identifies a pivotal period in the treatment of persons with
mental illness. It was during this time that the phenothiazines were introduced into the
United States. Before that time they had been used in France as preoperative medications.
As Dr.Henry Laborit of the hospital Bouicaut in Paris stated “it was our aim to decrease
the anxiety of the patient’s to prepare them in advance for their postoperative recovery.
With these new drugs, Phenothiazines, we were seeing a profound psychic physical
relaxation. a real in difference to the environment and to the upcoming operation .It seem
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 given
many individuals a chance, without which they would have been unable to function, but
also they have 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 talk to (Sage 1984)

HISTORICAL PERSPECTIVES
Historically, reaction to and treatment of persons with mental illness ranged from benign
involvement to intervention some would consider in human. Individuals with mental
illness were feared because of common belief 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 reforms” in the treatment of persons
with mental illness considered a break through in the humanization of care, these
instutions, however, well intentioned, fostered the concept of custodial care. Clients were
ensured the provision of food and shelter but received little or no hope of exchange for
the future .As they became increasingly dependent on the institution to fill their need, 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 sheets packs,
ice baths, electroconvulsive therapy, and psycho-surgery. Prior to 1950, sedatives and
amphetamines were the only significant psychotropic medications available. Even these
had limited use because of there toxicity & addicting effects. Since the 1950s the
development of Psychopharmacology has expanded to include wide spread 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 physicians
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
minimizes, it must be emphasized that psychotropic medications relieve physical and
behavioral symptoms. They don’t resolve emotional problems.
Nurse must understand the legal implication associated with the administration of
psychotropic medications. Loss differ from state to state, but most adhere to the clients
rights to refuse treatment .Exceptions exist in emergency situation when it has been
determined that clients are likely to harm themselves or others.

Role of the nurse

Psychopharmacological treatment should be integrated with the principles of psychiatric


nursing practice .The psychiatric nurse has a wealth of knowledge and competencies that
make the nursing care provided to the people with psychiatric disorders unique in many
ways. Following are the role of nurse’s in psychopharmacological treatment of persons
with neurobiological illnesses.

1.Patient Assessment: Psychoactive drugs treat specific symptoms of neurobiological


brain disorders. However not all patient behavior are treated by drug therapy, not every
identified personality trait is a symptom of illness target for the treatment with the drugs.
It is essential that through patient baseline assessment, including history, physical and
laboratory examination, psychiatric evaluation, sociocultural assessment and a
medication history be completed for each patient before any treatment interventions are
initiated.
Medication Assessment Tool

For each of the following categories of drugs taken by the patient :


• Prescribed psychiatric medications ever taken.
• Prescribed nonpsychiatric medications taken in the past 6 months or taken for
major medical illnesses if more than 6 months ego.
• Over-the counter (OTC) medication taken in the past 6 months.
Obtain the following information from the patient and other sources:
• Name of the drug
• Reason taken
• Dates started and stopped
• Highest daily dose
• Who prescribed it?
• Was it effective?
• Side effects or adverse reactions
• Was it taken as directed?
• If not, how was it taken?
• History of drugs taken by first degree relative
For each of the following categories of drugs taken by the patient:
• Alcohol
• Tobacco
• Caffeine
• Street drugs
Obtain the following information from the patient & other sources:
• Name of the substance
• Dates & schedule of use
• Summarize effects
• Adverse reactions
• Attempts to stop

2. Coordinator of treatment modalities


The nurse has an important role in designing a comprehensive treatment program. The
most appropriate treatment choices should be individualized for each patient and
reflected in the treatment plan. The coordination of treatment modalities is often the
primary responsibility of the nurse who works the patient in an ongoing therapeutic
alliance as part of the health care team. The nurse is in position to integrate drug
treatment with wide range of non pharmacological treatments in a manner that is
knowledgeable, safe,effective and acceptable to the patient.

3.Drug administration:
No One on the health care team has a greater daily impact on the patient’s experiences
with psychopharmacological agents than the nurse. Nurse administers the medication
dose, works out a dosing schedule based on the drug requirements and the patient’s need
and preferences and is continually alert for and treats drug effects. This role defines the
nurse as a key professional in maximizing therapeutic effects of drug treatment and
minimizing side effects in such a way that the patient is a true collaborator in managing
the medication regimen.

4.Monitoring Drug Effects:


The nurse has the important role of consistently monitoring the effects of psycho-
pharmacological drugs. This includes making standardized measurements of drug effects
on baseline target symptoms of illness, evaluating and minimizing side effects, treating
adverse reactions and noting the often subtle effects on the patient’s self concept and
sense of trust.
A drug should be given within the recommended dose range and for the appropriate
amount of time before it can be determined whether the drug has had an adequate
therapeutic trial for a particular patient. Therapeutic drug monitoring is important because
some drugs have a narrow therapeutic range (such as lithium) ,they can cause sudden
serious adverse reactions 9such as neuroleptic malignant syndrome) ,and drugs are often
co-administered ,thereby altering drug metabolism and clearance rates.
It is the responsibility of nurse to anticipate these possibilities and prescribe accordingly.
The nurse should be vigilant for signs of drug effects that seems inconsistent with what
doses prescribed or that are adverse reactions.

5.Medication education:
The nurse is a pivotal position to educate the patient and family about medications. This
includes teaching complex information to the patient so that it can be understood,
discussed and accepted. Patients should be informed about each drug prescribed for them.
They should be well educated about the expected benefits and potential risks, understand
Additional potential risks for their condition, and know what to do and whom to contact
if a question or problem arises.

6. Clinical Research drug Trials:


As a member of interdisciplinary research team, the nurse can contribute to the body of
scientific knowledge, often adding a nursing perspective to team research efforts. The
nurse can be included on many levels, from research data collectors and principal
investigator to funding agency monitor and consultant. The nurses’ roles in
interdisciplinary clinical research drug trials continue to evolve.

7. Prescriptive authority:
Legislation has been passed in almost every state in US authorizing Advanced Practice
Registered Nurses (APRN) to have atleast some degree of authority to prescribe
medications and in some states APRNs have full autonomy in this role. Psychiatric
mental health nurse practitioners and in some states includes clinical nurse specialists
,who are qualified under their state nurse practices acts are thus able to prescribe
pharmacological agents to treat the symptoms and improve the functional status of
patients with psychiatric disorders. Thus the role of nurses in Psychopharmacological
treatments has been expanded to encompass medication prescription authority in order to
capitalize on the expertise of APRNs and to increase patient access to quality and cost
effective health care.

Pharmacological Principles

Pharmacokinetics:
It is the study of how the body affects a drug. it answers the question. How does the body
get drugs to and from their intended target? Body functions such as absorption (how the
drug is moved into the blood stream from the site of administration), distribution (how
much the drug is moved into the various body tissues) and metabolism (how the drug is
altered, usually by liver enzymes into its active and inactive parts), and elimination (how
much of the drug is removed from the body in a specific amount of time are
pharmacokinetics properties.
Bioavailability (how much of the drug reaches systemic circulation unchanged) is an
estimate used to compare various drug preparations, particularly if the same generic drug
is made by several different manufacturers.
A half life is the name it takes for the dose amount of the drug in the body to decrease by
50%.e.g. Benzodiazipines alprazolam has a half life of approximately 11 hours ,it takes
about 2.5 days for nearly all traces of drugs to be eliminated from the body after taking a
single dose.
Half life determines how long it will take the body to achieve a steady state. Steady state
means that the plasma drug concentration remains relatively constant between the doses
because the amount of drug excreted equals the amount ingested and this equilibrium
occurs in approximately five half-lives of any given drug. Until steady state is reached
the drug level in the body continues to fluctuate accounting for some acute side effects
and preventing determination of the optimum dose for a particular patient.
Pharmacodynamics:
It is the study of the effects of the drugs on the body and in a particular, the interaction of
a drug on the receptor that is its targeted site of action.Pharmacodynamics answers the
questions: What does a drug do once it gets where it’s going? The time course and
intensity of the drug effects on the body can be determined, drug interactions can be
better understood and safety profiles can be developed that affect clinical decision
making by using pharmacologic models.

Receptor mechanisms:
Receptors are channels sitting on the cells that are gatekeepers of communication. They
recognize and respond to molecules (messengers) that affect their biological function thus
receptors are targets for drugs acting as messengers, which modify the biological activity
of receptors, bringing a dysfunctional system back towards normal.
A drug modifies a receptor by attaching (binding) to one (like a key in a single lock) or
many (like a master key for many locks) subtypes of receptors in several ways: a drug
can stimulate the receptor to fully(in which case the drug is an agonist) or partially(partial
agonist) open its channels :it can block(antagonist) another chemical agonist from
stimulating the receptor to open its channels :or can directly close the receptor
channels.e.g benzodiazepines are a agonists for the GABA system (they enhance the
activity of GABA ,an inhibitory neurotransmitter).

The dose-response curve:


If the concentration of the drug is plotted against the effects of the drug on a graph, the
curve plotted is a measure of drug potency. Potency is the amount of dose required to
achieve certain effects. This concept is helpful when comparing the actions of one drug to
another.
Drug Co-Administration
Once generally discouraged the use of more than one psychopharmacological drug in the
same patient at the same time is rapidly becoming standard clinical practice under
specific circumstances.
Patients who are prescribed multiple medications or are taking over the counter
medications addition to their prescribed medication can potentially receive benefits from
these combinations, but also may be at increased risk for side effects, drug interactions;
lack of clarity concerning which drug is causing which effects, complex dosing schedule
and higher cost of treatment.
• Primary medication: The medication used to treat the target symptoms of the
patients primary diagnosis is the primary medication in drug treatment regimen
• Combination drug therapy: Combination drug therapy refers to simultaneous use
of two or more psychopharmacological drugs in the same class for the long term
treatment.
• Augmentation or Adjunctive Therapy: Augmentation is the addition of another
class of medications to supplement the effectiveness of the primary
medication.e.g an antidepressant is added to the primary antipsychotic drug for
persistent symptom of depression in a patient with schizophrenia.
Anxiety

Anxiety is a psychological and physiological state characterized by cognitive, somatic, emotional,


and behavioral components.[1] These components combine to create an unpleasant feeling that is
typically associated with uneasiness, fear, or worry.

Anxiety is a generalized mood condition that occurs without an identifiable triggering stimulus. As
such, it is distinguished from fear, which occurs in the presence of an observed threat.
Additionally, fear is related to the specific behaviors of escape and avoidance, whereas anxiety is
the result of threats that are perceived to be uncontrollable or unavoidable.[2]

Another view is that anxiety is "a future-oriented mood state in which one is ready or prepared to
attempt to cope with upcoming negative events"[3] suggesting that it is a distinction between future
vs. present dangers that divides anxiety and fear.

Anxiety is considered to be a normal reaction to stress. It may help a person to deal with a difficult
situation, for example at work or at school, by prompting one to cope with it. When anxiety
becomes excessive, it may fall under the classification of an anxiety disorder.[4]

Anxiety can be accompanied by physical effects such as heart palpitations, fatigue, nausea, chest
pain, shortness of breath, stomach aches, orheadaches. Physically, the body prepares the
organism to deal with a threat. Blood pressure and heart rate are increased, sweating is
increased, bloodflow to the major muscle groups is increased, and immune and digestive system
functions are inhibited (the fight or flight response). External signs of anxiety may include pale
skin, sweating, trembling, and pupillary dilation. Someone suffering from anxiety might also
experience it as a sense of dread or panic. Although panic attacks are not experienced by every
anxiety sufferer, they are a common symptom. Panic attacks usually come without warning, and
although the fear is generally irrational, the perception of danger is very real. A person
experiencing a panic attack will often feel as if he or she is about to die or pass out. Panic attacks
may be confused with heart attacks.

Anxiety does not only consist of physical symptoms. There are many emotional symptoms
involved as well. Some of them include: "Feelings of apprehension or dread, trouble
concentrating, feeling tense or jumpy, anticipating the worst, irritability, restlessness, watching
(and waiting) for signs (and occurrences) or danger, and, feeling like your mind's gone
blank." [5] There's also, "nightmares/bad dreams, obsessions about sensations, deja vu, a trapped
in your mind feeling, and feeling like everything is scary." [6]
One of the most common symptoms of anxiety is fear, which includes the fear of dying. "You
may...fear that the chest pains [a physical symptom of anxiety] are a deadly heart attack or that
the shooting pains in your head [another physical symptom of anxiety] are the result of a tumor or
aneurysm. You feel an intense fear when you think of dying, or you may think of it more often
than normal, or can’t get it out of your mind." [7]

ANTIANXIETY DRUGS

Antianxiety drugs are medicines that calm and relax people with excessive anxiety,
nervousness, or tension, or for short-term control of social phobia disorder or specific
phobia disorder. Antianxiety drugs are among the most widely prescribed today. A wide
variety of drugs from different classification has been used in the treatment of anxiety.

History of anti anxiety drugs

The family of drugs labeled as barbiturates were the primary biological treatment for
anxiety disorders before the 1950’s. These anti anxiety medications were used in low
doses to calm people and help them to sleep and were referred to as sedative-
hypnoticdrugs. However, barbiturates were found to cause relatively serious problems
with people making them drowsy, were found to be deadly in high doses, and eventually
would lead to a physical dependence upon them.

In the late 1940’s, a pharmacologist by the name of Frank Berger who was trying to make
a more effective antibiotic medicine developed a compound called meprobamate that
relaxed muscles and reduced anxiety. It was later released in the 1950’s as a new
sedative- hypnotic medication under the brand name of Milltown. While this new anti
anxiety medication still continued to cause great drowsiness, it was much less dangerous
and less addictive than barbiturates.

Then in the late 1950’s, a researcher by the name of Lowell Randall found that
chlordiazepoxide, a member of the drug family calledbenzodiazepines, was able to
tranquilize animals without making them extremely tired. This drug was actually
discovered in the 1930’s but was set aside because it was believed to be relatively
useless. After Randall’s discovery however, this anti anxiety medication was then
marketed as a sedative- hypnotic drug under the brand name Librium. Several years later
another benzodiazepine medication was developed and marketed under the name of
diazepam or Valium. Most doctors and patients considered these medications to be very
safe for use as sedative hypnotics and soon became the most widely prescribed
medications in the United States.

However, it was actually many years later that investigators came to understand the
reasons for the effectiveness of these anti anxiety medications. Researchers began to
recognize that there were specific neurons (nerve cells) in the brain that were affected by
benzodiazepines and that these same receptor sites also were able to receive and be
affected by the neurotransmitter GABA. Apparently, when benzodiazepines were
received by certain neurons in the brain (GABA-A receptors), they actually increased the
ability of GABA to bind to them which would then improve GABA’s ability to stop the
firing of neurons which would then slow bodily arousal and reduce anxiety.

ASSESSMENT
Indications:
Anti anxiety drugs are also called anxiolytics and minor tranquillers.They are used in the
treatment of:
• Generalized anxiety disorders
• Panic disorders
• Phobias
• Obsessive Compulsive disorder
• Acute alcohol withdrawal syndrome
• Skeletal muscle spasms
• Convulsive disorders
• Status epileptics
• Preoperative sedation
Their use and efficacy for periods greater than 4 months have not been evaluated.

Antianxiety Drugs
Chemical class Generic (trade)name Half Daily Available
life adult forms(mg)
dosage
Antihistamines Hydsroxyzine 3 hrs 100- Tab:10,25,50,100
(Atarax) 400mg Syrups:10/5ml

(Visatril) 3 hrs 100- Cap:25,50,100


400mg Oral susp:25/5ml
Inj:25,50,100

Benzodiazipenes Alprazolam(xanax) 6-26 hrs 0.7-4mg Tab:0.25,0.5,1.0,2.0


Oral susp:0.5/5ml

Chlorodiazepoxide 5-30 hrs 1-100mg Cap:5,10,25


(Librium) Inj:100

Clonazepam(klonopin) 18-50 hrs 1.5-20mg Tab:0.5.1.0,2.0

Chlorazepate(tranxene 40-50 hrs 15-60mg Tab & cap:0.5,1.0,2


) Single
dose:11.25,22.5
20-80 hrs 4-40mg Tab:2,5,10
Diazepam(valium) Oral sol:5/5ml
Inj:5ml
10-20hrs 2-6mg Tabs:0.5,1.0,2.0
Lorazepam(Ativan) Oral sol:2ml
Inj:2ml,4ml
5-20 hrs 30-120mg Tabs:15
Oxazepam(serax) Cap:10,15,30

Propanediols 6-17hrs 400- Tabs:200,400


Meprobamate 2400mg
(equanil) 6-17hrs 400- Tabs:200,400
(Milton) 2400mg

Azaspirodecane- 2-11 hrs 15-60mg Tabs:5,10,15,30


diones Buspirone
(buspar)

Mechanism of action:

Antianxiety drugs depress the sub- cortical levels of the CNS, particularly the limbic
system and reticular formation. Benzodiazepines mediate the actions of amino acid
GABA, the major inhibitory neurotransmitter in the brain. Because GABA receptor
channels selectively admit the anions chloride into the neurons, the activation of GABA
receptors hyperpolarizes neurons, thus is inhibitory benzodiazepines produce their effects
by binding to a specific site on the GABA receptor.Buspirone is believed to expert its
effect by acting as a partial agonist at serotonin receptors, which decreases serotonin
turnover.

Precautions

Precautions and warnings apply to the use of antianxiety agents for use over long periods
of time. They are unlikely to occur in patients who have only received a single dose prior
to surgery. Benzodiazepines should not be used in patients with psychosis, acute narrow-
angle glaucoma, or liver disease. The drugs can act as respiratory depressants and should
be avoided in patients with respiratory conditions. Benzodiazepines are potentially
addictive and should not be administered to patients with substance abuse disorders.
Because benzodiazepines are sedatives, they should be avoided in patients who must
remain alert. Their use for periods over four months has not been documented. These
drugs should not be used during the second and third trimester of pregnancy, although
use during the first trimester appears to be safe. They should not be taken while
breastfeeding. Specialized references for use in children should be consulted.

Buspirone is metabolized by the liver and excreted by the kidney, and should be used
with care in patients with hepatic or renal disease. The drug is classified as schedule B
during pregnancy, but should not be taken during breastfeeding. Its use in children under
the age of 18 years has not been studied.

Interactions

The metabolism of alprazolam may be increased by cimetidine, oral contraceptives,


disulfiram, fluoxetine, isoniazid, ketoconazole, metoprolol, propoxyphene,
propranolol, and valproic acid. The absorption of all benzodiazepines is inhibited
by concomitant use of antacids. Benzodiazepines may increase blood levels of
digoxin, and reduce the efficacy of levodopa.

Buspirone levels will be increased by concomitant use of erythromycin, itraconazole, and


nefazadone. Doses should be adjusted based on clinical response. Use of buspirone
at the same time as monoamine oxidase inhibitors (MAOIs, including phenelzine
and tranycypromine) may cause severe blood pressure elevations. Use of buspirone
with MAOIs should be avoided.

DIAGNOSIS

The following nursing diagnosis may be considered for the clients receiving therapy with
antianxiety agents:

1.Risk for injury related to seizures ,panic anxiety abrupt withdrawal after long term
use,effects of intoxication or overdose.
2.Risk for activity intolerance related to side effects of sedation and lethargy.

3.Risk for acute condition 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 at risk:

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: Instruct the client on long term
therapy 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 take other medications the CNS while taking this medications.

4. Possibility of aggravating symptoms in depressed persons: Assess the clients mood


daily. Take necessary precautions for potential suicide.

5. Orthostatic hypotension: Monitor lying, & standing blood pressure & 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 desired


effects): Withhold drug & 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: Symptom of sore throat, fever,malaise,easy bruising ,unusual
bleeding should be reported to the physician immediately.

10.Delayed onset(Buspirone): ensure that the client understands there is a long time of 10
days to 2 weeks between onset of therapy with buspirone and subsiding of anxiety
symptoms. Client should continue to take the medication during this time.

Client /family Education: The client should:

Not drive or operate dangerous machinery.drowsinsess and dizziness can occur.


Not stop taking the drug abruptly because this can produce serious withdrawal symptoms,
such as depression,insomnia,anxiety ,abdominal and muscle cramps, tremors,
convulsions and delirium.
With Buspirone only: be aware of lag time between start of therapy and subsiding of
symptoms. relief is usually evident with 10-14 days. The client must take
medication regularly, so that it has sufficient time to take effect.
Not consume CNS depressants.
Not take nonprescription medications without approval from physician.
Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure.
Report symptoms of sore throat, fever, malaise, easy bruising, unusual bleeding or motor
restlessness to physician 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 derialibility 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.

OUTCOME CRITERIA/EVALUATION

The folleoing critera may be used for evaluating the effectiveness of therapy with
antianxiety agents .The Client:

Demonstrate 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

Bibliography:

Townsend Mary C, Psychiatric Mental health nursing,4th edition,F.A Davis company,Pp


291-294
Stuart and Laraia ,Principles and Practice of Psychiatric Nursing,8th edition,Elsevier
publishers,Pp565-576
En.wikipedia.org/wiki
www.springerlink.com
ANTIANXIETY DRUGS

Submitted to:
Miss Amarjit Kaur Submitted by:
Professor(Vice-Principal) Manu
Dr.SLT CON,Moga M.Sc(N) 1st year