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Types of Antipsychotics

1. Typical Antipsychotics, or First Generation Antipsychotic Drugs. The typical, or conventional,

antipsychotics were first developed in the 1950s. Haldol (haloperidol) and Thorazine (chlorpromazine) are the
best known typical antipsychotics. They continue to be useful in the treatment of severe psychosis and
behavioral problems when newer medications are ineffective. However, these medications do have a high risk
of side effects, some of which are quite severe. In response to the serious side effects of many typical
antipsychotics, drug manufacturers developed another category referred to as atypical antipsychotics.

MOA: first-generation antipsychotics are D2 antagonists. As a result, they reduce dopaminergic

neurotransmission in the four dopamine pathways.

a. Mesocortical pathway.
Research on schizophrenia pathophysiology suggests that a dysfunction of this pathway is associated
with cognitive impairments and disturbances of emotions and affect (negative symptoms). Blockade of
the mesocortical pathway by high doses of first-generation antipsychotics can induce secondary negative
symptoms and cognitive effects.

b. Mesolimbic pathway: Antipsychotic effects

As explained earlier, overactivity of this pathway is thought to be involved in the pathophysiology of

positive symptoms of schizophrenia. Blockade of D2 receptors in the mesolimbic pathway has been
proposed as a possible mechanism of antipsychotic action of first-generation agents.

c. Nigrostriatal pathway: Extrapyramidal Symptoms

Antagonism of D2 receptors in the nigrostriatal pathway is associated with increased risk of
extrapyramidal symptoms.

d. Tuberoinfundibular pathway: Hyperprolactinemia

Dopamine acts as prolactin-inhibiting factor, D2 blockade increases prolactin levels by promoting its
release in the pituitary gland.

2. Atypical Antipsychotics, or Second Generation Antipsychotic Drugs. These new medications were
approved for use in the 1990s. Clozapine, asenapine, olanzapine, quetiapine, paliperidone, risperidone,
sertindole, ziprasidone, zotepine, and aripiprazole are atypical antipsychotic drugs. With the discovery of
clozapine in 1959, it became evident that this drug was less likely to produce extrapyramidal effects (physical
symptoms such as tremors, paranoia, anxiety, dystonia, etc. as a result of improper doses or adverse reactions
to this class of drug) in humans at clinically effective doses than some other types of antipsychotics. Clozapine
was categorized as the first atypical antipsychotic drug. This category of drugs has also been of great value in
studying the pathophysiology of schizophrenia and other psychoses.

MOA: Atypicals clinically help patients by transiently occupying D2 receptors and then rapidly dissociating to
allow normal dopamine neurotransmission. This keeps prolactin levels normal, spares cognition, and obviates EPS.
One theory of atypicality is that the newer drugs block 5-HT2A receptors at the same time as they block dopamine
receptors and that, somehow, this serotonin-dopamine balance confers atypicality.

3. Dopamine System Stabilizers, Dopamine system stabilizers are a potential new class of antipsychotic agents
without motor side effects. All known effective antipsychotics act at D2 receptors. A novel concept for an
antipsychotic without motor side effects is to stabilize these receptors rather than block them harshly.


Extrapyramidal Symptom:

What are extrapyramidal symptoms?

Extrapyramidal symptoms (EPS) are side effects of antipsychotic medicines. EPS can cause movement
and muscle control problems throughout your body.

What symptoms may I have?

Symptoms may be noticed after you take one dose of medicine or after long-term use. You may not be
aware of these symptoms, but others close to you may notice any of the following:

Restlessness and nervous energy shown by pacing, marching, shuffling, or foot-tapping

Severe, uncontrolled muscle contractions of your head, neck, trunk, and limbs that cause stiff tongue,
twisted neck, or back arching
Tremors, stiff posture, or no arm movement when you walk
Uncontrolled movements of your tongue, jaw, lips, or face, such as pursing, chewing, or frequent eye
Uncontrolled movements of your fingers or toes, head nodding, or pelvic thrusting
Fast, irregular breathing with grunts, gasping, or sighing
Weak voice, drooling, or little or no facial expression
Side Effects and Adverse Drug Reactions

People who take antipsychotic medications may experience negative side effects, such as:

Extrapyramidal Effects: Dystonias, akathisia, tardive dyskinesia, Parkinsons-like symptoms, unwanted

movements, ataxia, muscle breakdown, rigidity, tremors, and seizures are some major effects of this
category of drugs. Neuroleptic malignant syndrome may occur as well.
Effects on the Central Nervous System: Drowsiness, sedation, and hypnosis occur. Confusion, vertigo,
syncope, disturbed sleep, nightmares, and agitation are also reported by various
studies. Dementia, amnesia, and loss of memory are some adverse effects. Suicidal ideation in old and
young with increased mania, anxiety, agitation, violent behavior, and depression can also be seen in
people taking these drugs.
Effects on the Cardiovascular System: Cardiomyopathy is noted in nine out of every 100,000 people using
clozapine. Alteration in electrocardiogram (ECG) readings, chest pain, angina, myocarditis, palpitation,
tachycardia, edema, phlebitis, and arrhythmias are serious adverse effects. Myocardial infarction (heart
attack) occurs in only 1% of people using this category of drug. Orthostatic hypotensionthe medical
name for the fuzzy feeling you get when standing up to quicklyis very common.
Hepatic (Liver) Effects: These agents increase the serum concentration of alkaline aminotransferase.
Reversible liver cell hyperplasia, increase in bilirubin, jaundice, drug induced hepatitis, and necrosis have
been recorded in studies.
Gastrointestinal Effects: Constipation, dry mouth, anorexia, weight gain, increases in pancreatic enzymes,
epigastric distress, abdominal cramps, dyspepsia, heartburn, and nausea are some common adverse
Genitourinary (Urinary and Reproductive) Effects: Impotence, delayed and premature ejaculation, testicular
swelling, priapism, increased or decreased libido, virginal itching, enuresis, polyuria, breast
engorgement, galactorrhea, and anorgasmia have been reported.
Other Effects: Cases of blurred vision, hot flashes, dry throat, nasal congestion, severe hyperglycemia,
numbness, chills, glaucoma, leukopenia, neutropenia, hyperlipidemia, agranulocytosis, and respiratory
depression have been reported.
Pregnancy and Lactation: Antipsychotic drugs can be used in pregnant females since they have shown no
teratogenic (development of the fetus or embryo) effects in animal studies. Drugs like clozapine and
olanzapine have shown no harm to the fetus. However, during lactation, the metabolites may be disturbed
in the milk and could harm the newborn.

NSG Responsibilities:

Assess for the mentioned cautions and contraindications (e.g. drug allergies, CNS depression, CV
disorders, glaucoma, respiratory depression, etc.) to prevent any untoward complications.
Perform a thorough physical assessment (other medications taken, CNS, skin, respirations, and
laboratory tests like thyroid, liver, and renal functions tests and complete blood count or CBC) to
establish baseline data before drug therapy begins, to determine effectiveness of therapy, and to
evaluate for occurrence of any adverse effects associated with drug therapy.


Valproic Acid:

Valproic acid is used alone or with other medications to treat certain types of seizures. Valproic acid is
also used to treat mania (episodes of frenzied, abnormally excited mood) in people with bipolar
disorder (manic-depressive disorder; a disease that causes episodes of depression, episodes of mania,
and other abnormal moods). It is also used to prevent migraine headaches, but not to relieve
headaches that have already begun. Valproic acid is in a class of medications called anticonvulsants. It
works by increasing the amount of a certain natural substance in the brain.


Valproic Acid dissociates to the valproate ion in the gastrointestinal tract and then binds to and
inhibits GABA transaminase. The drug's anticonvulsant activity may be related to increased brain
concentrations of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the CNS, by
inhibiting enzymes that catabolize GABA or block the reuptake of GABA into glia and nerve endings.
Valproic Acid may also work by suppressing repetitive neuronal firing through inhibition of voltage-
sensitive sodium channels. It is also a histone deacetylase inhibitor.


Carbamazepine is an anticonvulsant. It works by decreasing nerve impulses that cause seizures and
pain. Carbamazepine is used to treat seizures and nerve pain such as trigeminal neuralgia and diabetic
neuropathy. Carbamazepine is also used to treat bipolar disorder.


The specific mechanism of action of carbamazepine in stabilizing mood is unknown. It exerts effects by
decreasing dopamine turn over, enhancement of brain ?-aminobutyric acid (GABA) levels via multiple actions
of synthesis and degradation, and modulation of other neurotransmitters, voltage sensitive Na+ channels, extra
hypothalamic neuropeptides, secondary messenger systems, and neuro protection.

Carbamazepine is a use-dependant blocker of voltage-gated sodium channels. It is ionised within intracellular

fluid, and is then able to bind to activated voltage-gated sodium channels, preventing repetitive and sustained
firing of an action potential.This leaves the affected cells less excitable until the drug dissociates.
Carbamazepine is also a GABA receptor agonist, as it has also been shown to potentiate GABA receptors made
up of alpha1, beta2, and gamma2 subunits.[26] This mechanism may contribute to its efficacy in neuropathic pain
and bipolar disorder.

Side effects
respiratory depression
aplastic anemia
gingival hypertrophy
ataxia (aka uncoordinated movements)
Nursing considerations
do not discontinue anticonvulsants abruptly
monitor I&Os
careful when using medications that lower seizure threshold (ex: MAOIs, antipsychotics)
take with food
provide oral care - be gently
avoid alcohol (may cause severe respiratory depression)

Why is Lithium Carbonate not the choice?

Because its side effects are worse than NA Divalproex.


Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants. They
can ease symptoms of moderate to severe depression, are relatively safe and typically cause fewer side
effects than other types of antidepressants do.


SSRIs ease depression by increasing levels of serotonin in the brain. Serotonin is one of the chemical
messengers (neurotransmitters) that carry signals between brain cells. SSRIs block the reabsorption
(reuptake) of serotonin in the brain, making more serotonin available. SSRIs are called selective because
they seem to primarily affect serotonin, not other neurotransmitters.

SSRIs also may be used to treat conditions other than depression, such as anxiety disorders.

SSRIs work by enhancing the function of nerve cells in the brain that regulate emotion. Information is
communicated between your brain cells with signals. The chemical messengers that deliver these signals are
called neurotransmitters. Serotonin is one type of neurotransmitter.

When these brain cells (called neurons) send signals to one another, they release a little bit of a neurotransmitter
so that the message can be delivered. They then have to take back the neurotransmitter they released so they can
send the next message. This process of replacing the neurotransmitter is called reuptake.

If youre struggling with depression, the areas of your brain that regulate mood and send messages using
serotonin might not function properly. SSRIs help make more serotonin available by blocking the reuptake
process. This allows serotonin to build up between neurons so messages can be sent correctly. Theyre called
selective serotonin reuptake inhibitors because they specifically target serotonin.

Nursing Responsibilities:

Monitor patient response to therapy (e.g. alleviation of signs and symptoms of depression).
Monitor for adverse effects (e.g. hypotension, suicidal thoughts, cardiac arrhythmias, etc).
Evaluate patient understanding on drug therapy by asking the patient to name the drug, its
indication, and adverse effects to watch for.
Monitor patient compliance to drug therapy.



It increases neuronal membranepermeability to chloride ions by binding to

stereospecificbenzodiazepine receptors on thepostsynaptic GABA neuron within theCNS and
enhancing the GABAinhibitory effects resulting inhyperpolarisation and stabilization