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Mental Health ch 2

Mental Health Ch 2

by bookstudentnurse, Sep. 2022

Subjects: Chapter 2 vocab

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Psychopharmacology	The use of medications to treat mental illness. It is related to neurobiological theories. These medications directly affect the central nervous system (CNS) and subsequently behavior, perceptions, thinking, and emotions.
CNS (central nervous system)	Comprises the brain, the spinal cord, and associated nerves that control voluntary acts. Structurally, the brain consists of the cerebrum, cerebellum, brain stem, and lambic system, (figures 2.1/2.2)
Cerebrum	The cerebrum is divided into 2 hemispheres All lobes and structures are found in both halves except for the pineal body, or gland. Which os ;coated between the hemispheres.
Pineal body	Is an endocrine gland that influences the activities of the pursuit art gland, islets of Langerhans, parathyroids, adrenals, and gonads.
Corpus Callosum	Is a pathway connecting the two hemispheres and coordinating their functions.
Left Hemisphere (what does it control)	Controls the right side of the body and is the center for logical reasoning and analytic functions such as reading, writing, and mathematical tasks.
Right Hemisphere (what does it control)	Controls the left side of the body and is the center for creative thinking, intuition, and artistic abilities.
Cerebral hemispheres (divided into what 4 lobes)	1.frontal 2.parietal 3.temporal 4.occipital
Frontal lobe (does what)	Controls the organization of thought, body movement, memories, emotions, and moral behavior. The integration of all this information regulates arousal, focuses attention, and enables problem-solving and decision-making. Abnormalities in the frontal lobes are associated with schizophrenia, attention-deficit/hyperactivity disorder (ADHD), and dementia.
Partial lobes (what do they do)	Interpret sensations of taste and touch and assist in spatial orientation.
Temporal lobes (what do they do)	Centers for the senses of smell and hearing and for memory and emotional expression.
Occipital lobes (what do they do)	Assist in coordinating language generation and visual interpretation, such as depth perception.
Cerebellum	Located below the cerebrum and is the center for coordination of movements and postural adjustments. It receives and integrates information from all areas of the body, such as the muscles, joints, organs, and other components of the CNS. **Research has shown that inhibited transmission of dopamine, a neurotransmitter, in this area is associated with the lack of smooth coordinated movements in diseases such as Parkinson’s disease and dementia.
Brain Stem	Includes the midbrain, pons, and medulla oblongata and the nuclei for cranial nerves III through XII.
Medulla	Located at the top of the spinal cord It contains vital centers for respiration and cardiovascular functions.
Pons	Located above the medulla and in front of the cerebrum, it bridges the gap both structurally and functionally, serving as a primary motor pathway.
Midbrain	Connects the pons and cerebellum with the cerebrum. It measures only 0.8inches (2 cm) length and includes most of the reticular activating system and the extrapyramidal system.
Reticular activating systems	Influences motor activity, sleep, consciousness and awareness. It is part of the midbrain.
Extrapyramidal system	Relays information about movement and coordination from the brain to the spinal nerves. Part of the midbrain
Locus Coeruleus	Small group of norepinephrine-producing neurons in the brain stem Associated with stress, anxiety and impulsive behavior
Lambic System	An area of the brain located above the brain stem that includes the thalamus, hypothalamus, hippocampus, and amygdala (although some sources differs regarding the structures that this system include) **Disturbances in the Limbic system have been implicated in a variety of mental illnesses - ie: memory loss that accompanies dementia and the poorly controlled emotions and impulses seen with psychotic or manic behavior.
Thalamus	Regulates activity, sensation, and emotion. Part of the Limbic System
Hypothalamus	Involves in temperature regulation, appetite control, endocrine function, sexual drive, and impulsive behavior associated with feelings of anger, rage, or excitement. Part of the Limbic System
Hippocampus and Amygdala	Involves in emotional arousal and memory Part of the Limbic System
Neurotransmitters	Are the chemical substances manufactured in the neuron that aid in the transmission of information throughout the body. They either excite or stimulate an action in the cells (excitatory) or inhibit or stop an action (inhibitory) They fit into specific receptor cells embedded in the membrane of the dendrite. After they are released into the synapse and relay the message to the receptor cells, they are either transported back from the synapse to the axon to be sorted for later use (reputable) or metabolized and inactivated by enzymes, primarily monoamine oxidase (MAO) (fig 2.3) These neurotransmitters are necessary in just the right proportions to relay messages across the synapses. Major neurotransmitters have been found to play a role in psychiatric illnesses and in the actions and side effects of psychotropic drugs. **Dopamine and serotonin have gotten a lot of attention in terms of studies and treatment of psychiatric disorders.
Dopamine	A neurotransmitter located primarily in the brain stem, involved in the control of complex movements, motivation, cognition and regulation of emotional responses. Excitatory and os synthesized from tyrosine, a dietary amino acid. *schizophrenia and other psychoses as well as in movement disorders such as Parkinson’s disease. -Antipsychotic medications work by blocking dopamine receptors and reducing dopamine activity.
Nonrepinephrine	The most prevalent neurotransmitter in the nervous system, is located primarily in the brain stem and plays a role in changes in attention, learning and memory, sleep and wakefulness, and mood regulation. Also known as noradrenaline. Too much = anxiety disorders Too little = contribute to memory loss, social withdrawal and depression Antidepressants block the reputable of nonrepinephrine, while other inhibit MAO from metabolizing it.
Epinephrine	Also known as adrenaline Derivative of norepinephrine, the most prevalent neurotransmitter in the nervous system, located primarily in the brain stem, and plays a role in changes in attention, learning and memory, sleep and wakefulness, and mood regulation. **has limited distribution in the brain but controls the FIGHT-OR-FLIGHT response in the peripheral nervous system.
Serotonin	Derived from tryptophan, a dietary amino acid. Function = mostly inhibitory Involves in - the control of food intake, sleep and wakefulness, temperature regulation, pain control, sexual; behavior and regulation of emotions. Plays an important role in anxiety, mood disorders and schizophrenia. It contributes to delusions, hallucinations, and withdrawn behavior seen in schizophrenia. Some antidepressants block serotonin reputable, thus leaving it available longer in the synapse, which results in improved mood.
Histamine	Role = still under investigation for mental health. Involves in peripheral allergic responses, control of gastric secretions, cardiac stimulation, and alertness. Some psychotropic drugs block histamine, resulting in weight gain, sedation and hypotension
Acetylcholine	A neurotransmitter found in the brain, spinal cord, and peripheral nervous system, particularly at the neuromuscular junction of skeletal muscle. Can be excitatory or inhibitory. Synthesized from dietary choline found in red meat and vegetables and has been found to affect the sleep-wake cycle and to signal muscles to become active. Alzheimer’s disease people have decreased acetylcholine-secreting neurons, and people with myasthenia gravis (muscular disorder in which impulses fail to pass the mayo neural junction, which causes muscle weakness) have reduced acetylcholine receptors.
Glutamate	Excitatory amino acid that can have major neurotoxic effects at high levels. Implicates in brain damage caused by stroke, hypoglycemia, sustained hypoxia or ischemia, and some degenerative diseases such as Huntington’s and Alzheimer’s
Gamma-Aminobutyric Acid	GABA is an amino acid, is the major inhibitory neurotransmitter in the brain and has been found to modulate other neurotransmitter systems rather than provide a direct stimulus. Drugs that increase GABA function, such as benzodiazepines, are used to treat anxiety and to induce sleep.
Types of Brain Imaging Techniques	Computed tomography (CT) Magnetic resonance imaging (MRI) Position emission tomography (PET) Single-photon emission computed tomography (SPECT)
Computed Tomography (CT)	Also called computed axial tomography, is a procedure in which a precise x-ray beam takes cross-sectional images (slices) layer by layer. Computer reconstructs image on a monitor and stores images on magnetic tape or film. CT can visualize the brain’s soft tissues, so it is used to diagnose primary tumors, metastases, and effusions and to determine the size of the ventricles of the brain. Schizophrenia sho enlarged ventricles (usually a poorer prognosis and marked negative symptoms)( Person lies motionless for 20-40 minutes going through a tunnel-like ring while th serial x-rays are taken
Magnetic resonance imaging (MRI)	A type of body scan, an energy field is created with a huge magnet and radio waves. The energy field is converted to a visual image or scan. MRI produces more tissue detail and contrast than CT and can show blood flow patterns and tissue changes such as edema. Also used to measure the size ad thickness of brain structures; persons with schizophrenia can have as much as a 7% reduction in cortical thickness. Person must lie in a small, closed chamber and remain motionless during the procedure, which takes about 45 minutes. Some people require sedation before procedure. Client has pacemakers or metal implants such as heart valves or orthopedic devices, cannot undergo MRI.
Position emission tomography (PET)	A diagnostic test used to examine the function of the brain by monitoring the flow of radioactive substances that are injected into the bloodstream. PET uses 2 protons simultaneously. PET provides better resolution with sharper and clearer pictures and takes about 2-3 hours. These scans are used in oncology and brain disorders, such as tumors, and for cognitive problems. In psychiatry primarily for research not for diagnosis and treatment of clients with mental disorders.
Single-photon emission computed tomography (SPECT)	A diagnostic test used to examine the function of the brain by following the flow of an injected radioactive substance. SPECT uses a single photon Takes 1-2 hours Used in oncology and brain disorders, such as tumors, and for cognitive problems. More for research than for diagnosis or treatment
Limitations of Brain Imaging Techniques	1. Use of radioactive substances in PET and SPECT limits the number of times a person can undergo these tests. Allergic reaction risk to the substances. Imaging equipment is expensive to purchase and maintain so availability can be limited. Some persons cannot tolerate these procedures because of fear or claustrophobia Researchers are finding many disorders such as schizophrenia are at the molecular and chemical levels and cannot be detected with current imaging techniques.
3 types of studies commonly conducted to investigate the genetic basis of mental illness	1. Twin studies used to compare the rates of certain mental illnesses or traits in monozygotic (identical) twins, who have an identical genetic makeup, and dizygotic (fraternal) twins, who have a different genetic makeup. Fraternal twins have the same genetic similarities and differences as non twin siblings. 2. Adoption studies used to determine a trait among biological versus adoptive family members. 3. Family studies used to compare whether a trait is more common among first-degree relatives (parents, siblings, and children) than among more distant relatives or the general population.	There are some genetic links that have been found in certain mental disorders, but studies have not shown that these illnesses are solely genetically linked. Influence of inherited traits versus the influence of the environment “nature versus nurture” debate.
Psychoimmunology	Relatively new field of study Examines the effect of psychosocial stressors on the body’s immune system. Compromised immune system could contribute to the development of a variety of illnesses, particularly in populations already genetically at risk Immune system and the brain can influence neurotransmitters. Current investigations = contribution of inflammation, such as mild encephalitis in the causality of severe mental disorders.
Infection as a possible cause	Theories that are being developed and tested include the existence of a virus that has an affinity for tissues of the CNS, the possibility that a virus may actually alter human genes, and maternal exposure to a virus during critical fetal development of the nervous system. Bacterial infections in pregnant women may impact the developing brain of the fetus and are associated with an elevated risk for psychosis in offspring.
Efficacy	The maximal therapeutic effect that a drug can achieve.
Potency	Describes the amount of the drug needed to achieve that maximum effect Low-potency drugs require higher dosages to achieve efficacy Higher-potency drugs achieve efficacy at lower dosages.
Half-life	The time it takes for half of the drug to be removed from the bloodstream. Drugs with a shorter half-life may need to be given 3-4 times a day Drugs with a longer half-life may be given once a day. The time that a drug needs to leave the body completely after it has been discontinued is about 5 times its half-life.
US Food and Drug Administration FDA	Responsible for supervising the testing and marketing of medications for public safety. These activities include clinical drug trials for new drugs and monitoring the effectiveness and side effects of medications. FDA approves each drug for use in a particular population and for specific diseases. Other FDA issues of approvals/side effect Off-label use Black box warning Risk evaluation and m,irrigation strategy (REMS)
Off-label use	A drug will prove effective for a disease that differs from the one involved in original testing and FDA approval., An anticonvulsant drug approved to prevent seizures are prescribed for their effects in stabilizing the moods of clients with bipolar disorder.
Black box warning	Medication package inserts must have a highlighted box, separate from the text, that contains a warning about the life threatening or otherwise serious side effect(s) of the medication.
Risk Evaluation and Mitigation Strategy (REMS)	Specific actions and/or safeguards instituted by the FDA that govern the use of drugs that are approved but have infrequent serious side effects that require close monitoring.
Principles that guide pharmacological treatment	Medication is selected based on its effect on the client’s target symptoms such as delusional thinking, panic attacks or hallucinations. Drug chided on its ability to diminish or eliminate the target symptoms. Many psychotropic drugs must be given in adequate dosages for some time before their full effects are realized. The dosage of medication is often adjusted to the lowest effective dosage for the client. As a rule, older adults require lower dosages of medications than do younger clients to experience therapeutic effects. It may also take longer for a drug to achieve its full therapeutic effect in older adults. Psychotropic meds are often decreased gradually (tapering) rather than abruptly. Because of potential problems with rebound or withdrawal. Follow-up care is essential to ensure compliance with the meds regimen, to make adjustments in dosage and manage side effects Compliance with the meds regimen is often enhanced when the regimen is as simple as possible in terms of both the number of medications prescribed and the number of daily doses.
Rebound	Temporary return of symptoms This is what you decrease gradually (tapering) than abruptly psychotropic meds
Withdrawl	New symptoms resulting from discontinuation of the drug
Antipsychotic drugs Formally known as neuroleptics	Used to treat the symptoms of psychosis such as delusions and hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorder. These drugs work by blocking receptors of the neurotransmitter dopamine. They have been in clinical use since the 1950s They are primary medical treatment for schizophrenia and are also used in psychotic episodes of acute mania, psychotic depression, and drug-induced psychosis. Client’s with dementia who have psychotic symptoms sometimes respond to low dosages of conventional antipsychotics.
Depot injection	A time release form of intramuscular medication for maintenance therapy.
Postinjection delirium/sedation syndrome (PDSS)	Cluster of symptoms, such as slurred speech, confusion, sedation, altered gait, or unconsciousness that result from accidental intravascular injection of a portion of plan spine (Zyprexa Relprevy)
Atypical Antipsychotics warning	Older clients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk for death. Causes of death are varied, but most appear to be either cardiovascular or infectious in nature.
Extrapyramidal symptoms (ESPs)	Neurological side effects of antipsychotic medications that are drug and dose related; treated with anticholinergic medications; includes dystopia, pseudoparkinsonism, and akathisia The major side effects of antipsychotic drugs Even though collectively referred to as EPSs, each of these reactions has distinct features.
Geodon warning	Contraindicated in clients with a known history of QT prolongation, recent myocardial infarction, or uncompensated heart failure, it should not be used with other QT-prolonging drugs.
Dystonia	Includes acute muscular rigidity and cramping, stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties. Most likely to occur in the first week of treatment in clients younger than 40 years, in males, and in those receiving high potency drugs such as haloperidol and thiothixene. Spasms or stiffness in muscle groups can produce TORTICOLLIS (twisted head and neck), OPISTHOTONUS (tightness in the entire body with the head back and an arched neck, or OCULOGYRIC CRISIS (eyes rolled back in a locked position.) Need immediate treatment with anticholinergic drugs, such as intramuscular benztropine mesylate (cogentin) or intramuscular or intravenous diphenhydramine (Benadryl) = rapid relief.
Pseudoparkinsonism	Drug-induced Parkinsonism, often referred to by the generic label of EPS. Symptoms resemble those of Parkinson’s disease and include a stiff, stooped posture; mask like Davies; decreased arm swing; a shuffling, festinating gait (with small steps); cogwheel rigidity (ratchet-like movements of joints); drooling; tremor; bradycardia; and coarse pill-rolling movements of the thumb and fingers while at rest. It is treated by changing to an antipsychotic medication that has a lower incidence of EPS or by adding an oral anticholinergic agent or amantadine, which is a dopamine agonist that increases the transmission of dopamine blocked by the antipsychotic drug.
Akathisia	Is reported by the client as having an intense need to move about. The client appears restless or anxious and agitated, often with a rigid posture or gait and a lack of spontaneous gestures. Inability to sit still or rest often leads clients to discontinue their antipsychotic medication. Can be treated by a change in antipsychotic medication or by the addition of an oral agent such as a beta-blocker, anticholinergic, or benzodiazepine.
Neuroleptic malignant syndrome (NMS)	A potentially fatal, idiosyncratic reaction to an antipsychotic (or neuroleptic) drug. The major symptoms of NMS are rigidity; high fever, autonomic instability such as unstable blood pressure, diaphoresis, and pallor, delirium; and elevated levels of enzymes, particularly creating phospholipids. Clients with NMS are usually confused and often mute; they may fluctuate from agitation to stupor **all antipsychotic seem to have the potential to cause NMS, but high dosages of high-potency drugs increase the risk. NMS occurs most often in the first 2 weeks of therapy or after an increase in dosage. But can occur at any time. Dehydration, poor nutrition and concurrent medical illness all increase the risk of NMS. Treatment: discontinue immediately all antipsychotic meds until physical condition stabilizes from dehydration or hyperthermia
Tardive dyskinesia (TD)	A syndrome of permanent involuntary movements Most commonly caused by the long-term use of conventional antipsychotic drugs. 20-30% clients develop TD Pathophysiology is unclear Symptoms: involuntary movements of the tongue, facial and neck muscles, upper and lower extremities, and truncated musculature. Once it develops, TD is irreversible, although decreasing or discontinuing antipsychotic meds can arrest its progression. Preventing TD is the primary goal when administering antipsychotics. Keep dosage low as possible.
Anticholinergic side effects	Dry mouth, constipation, urinary hesitancy or retention, dry nasal passages, and blurred near vision; commonly seen as side effects of medication. Often occur with the use of antipsychotics and include orthodontic hypotension, photophobia, nasal congestion and decreased memory. Side effects usually decrease within 3-4 weeks but not entirely.
Other side effects of antipsychotic drugs	Increase blood prolactin levels which may cause breast enlargement and tenderness in men and women Diminished libido Erectile and orgasmic dysfunction Menstrual irregularities Increased risk for breast cancer Contribute to weight gain
Metabolic syndrome	A cluster of conditions that increase the risk for heart disease, diabetes, and stroke. The syndrome is diagnosed when three or more of the following are present: 1.obesity 2.increased blood pressure 3.high blood sugar level 4.High cholesterol Obesity is common in clients with schizophrenia Causes shorter life expectancy because of increased risk of heart disease
Clozapine	Produces fewer tradition side effects than do most antipsychotic drugs, but it has the potentially fatal side effect of agranulocytosis. Develops suddenly and is characterized by fever, malaise, ulcerative sore throat and leukopenia. Side effects can occur up to 24 weeks after beginning therapy Clients must have a baseline WBC count and one done every week through treatment for 4 weeks after discontinuation of clozapine	Warning: may cause agranulocytosis, a potentially life-threatening event. Clients who are being treated with clozapine must have a baseline WBC count and differential before initiation of treatment and a WBC count every week throughout treatment and for 4 weeks after discontinuation of clozapine
Antidepressant drugs	Primarily used in the treatment of major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression. Off-label uses of antidepressants include the treatment of chronic pain, migraine headaches, peripheral and diabetic neuropathies, sleep apnea, dermatological disorders, panic disorder, and eating disorders. Antidepressants somehow interact with the two neurotransmitters, norepinephrine and serotonin, that regulate mood, arousal, attention, sensory processing, and appetite. **4 groups of antidepressants 1.Tricyclkic and the related cyclic antidepressants 2.selective serotonin reputable inhibitors (SSRIs) 3.MAO inhibitors (MAOIs) 4.Other antidepressants such as desvenlafaxine (Pristiq), venlafaxine (Effexor), bupropion (Wellbutrin), duloxetine (Cymbalta), trazodone (Desyrel), and nefazodone (Serzone) Look over Table 2.5 for dosages
Cyclic compounds	Became available in the 1950s and for years were the first choice of drugs to treat depression even though they cause varying degrees of sedation, orthodontic hypotension (drop in blood pressure on rising) and anticholinergic side effects. Cyclic antidepressants are potentially lethal if taken in an overdose. ***SSRIs first available in 1987 with the release of fluoxetine (Prozac) replace the cyclic drugs as the first choice in treatment for depression because they equal in efficacy and produce fewer troublesome side effects.
MAOIs	Were discovered during 1950s to have a positive effect on people with depression. Although the MAOIs have a low incidence of sedation and anticholinergic effects, they must be used with extreme caution because: Life threatening side effect, hypertensive crisis, may occur if the client ingests foods containing tyramine (an amino acid) while taking MAOIs. Because of the risk of potentially fatal drug interactions, MAOIs cannot be given in combination with other MAOIs, tricyclic antidepressants, meperidine (Demerol), CNS depressants, many anti hypertensives, or general anesthetic. MAOIs are potentially lethal in overdose and pose a potential risk in clients with depression who may be considering suicide.
SSRIs	1987 first availability with release of fluoxetine (Prozac), replacing Cyclic drugs as the first choice in treating depression because they are equal in efficacy and produce fewer side effects. SSRIs and clomipramine are effective in the treatment of OBSESSIVE-COMPULSIVE DISORDER (OCD) as well. Prozac Weekly is the first and only medication that can be given once a week as maintenance therapy for depression after the client has been stabilized on fluoxetine. (90mg of fluoxetine with an enteric coating that delays release into the bloodstream)
High risk for suicide	SSRIs, venlafaxine, nefazodone, and bupropion are often better choices for those who are potentially suicidal or highly impulsive because they carry no risk of lethal overdose in contrast to the cyclic compounds and the MAOIs. BUT SSRIs are effective only for mild and moderate depression. Must keep evaluating for suicide even after antidepressants are initiated. Client may feel more energized but still have suicidal thoughts. Also because it takes weeks before meds have full therapeutic effect, clients may become discouraged and tired of waiting to feel better. **FDA-required warning for SSRIs and increased suicidal risk in children and adolescents.
Mechanism of Action by which antidepressants produce therapeutic effects	Unknown precisely but… Action on the CNS, the major interaction is with the monoamine neurotransmitter systems in the brain, particularly norepinephrine and serotonin. Both these neurotransmitters are released throughout the brain and help regulate arousal, vigilance, attention, mood, sensory processing, and appetite. Norepinephrine, serotonin, and dopamine are removed from the synapses after release by reputable into presynaptic neurons. After reputable, these 3 neurotransmitters are reloaded for subsequent release or metabolized by the enzyme MAO. The SSRIs block the reputable of serotonin, the cyclic antidepressants and venlafaxine block the reputable of norepinephrine primarily and block serotonin to some degree and the MAOIs interfere with enzyme metabolism. These blockades occur in matter of hours, while antidepressants are rarely effective until taken for several weeks. cyclic compounds may take 4-6 weeks to be effective, MAOIs need 2-4 weeks and SSRIs may be effective in 2-3 weeks. Researchers believe the eventual therapeutic effectiveness results when neurons respond more slowly, making serotonin available at the synapses.
Side effects of selective serotonin reputable inhibitors	SSRIs have fewer side effects compared to the cyclic compounds. Enhanced serotonin transmission can lead to several common side effects such as anxiety, agitation, akathisia (motor restlessness), nausea, insomnia, and sexual dysfunction, specifically diminished sexual drive or difficulty achieving an erection or orgasm. Weight gain is both an initial and ongoing problem SSRIs cause less weight gain Akathisia is usually treated with a beta-blocker such as propranolol (Inderal) or a benzodiazepine. Insomnia = teat with low dosage trazodone Less common side effects: Sedation (particularly with paroxetine (Paxil), sweating, diarrhea, hand tremor, and headaches. (Sweating and continued sedation indicates need for a change to another antidepressant.)
Side effects of cyclic antidepressants	Cyclic compounds have more side effects than do SSRIs and the newer miscellaneous compounds The Cyclic antidepressants block cholinergic receptors, resulting in anticholinergic effects such as dry mouth, constipation, urinary hesitancy or retention, dry nasal passages, and blurred near vision. More severe anticholinergic effects such as agitation, delirium, and ileum may occur in older adults. Other side effects: Orthostatic hypotension Sedation, weight gain, and tachycardia. Even tolerance to anticholinergic effects. Sexual dysfunction similar to problems experienced with SSRIs. Common reason for noncompliance = weight gain and sexual dysfunction
Side effects of Monoamine Oxidase Inhibitors	Most common = daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, and sexual dysfunction. Sedation and insomnia are difficult to treat and may mean a change of meds. most concerning with MAOIs is the potential for a life-threatening hypertensive crisis if the client ingests found that contains tyramine or takes sympathomimetic drugs. (Because the enzyme MAO is necessary to break down the tyramine in certain foods, its inhibition results in increased serum tyramine levels, causing severe hypertension, hyperpyrexia, tachycardia, diaphoresis, tremulous meds, and cardiac dysrhythmias. Drugs that may cause potentially fatal interactions with MAOIs include SSRIs, certain cyclic compounds, buspirone (BuSpar), dextromethorphan, and opiate derivatives such as meperidine. *client must follow a tyramine-free diet (box 2.1 lists foods to avoid) -no mature or aged cheeses -no aged meats No Italian broad beans (fava), bean curd (tofu) banana peel, overripe fruit and avocado -no tap beers and microbrewery beer -sauerkraut, soy sauce or soybean, marmite (concentrated yeast) -yogurt, sour cream, peanuts, brewer’s yeast, and MSG
Side effects of other Antidepressants	Nefazodone, trazodone and mirtazapine = sedation Nefazodone and trazodone = headaches Nefazodone can also cause dry mouth and nausea Bupropion, venlafaxine, and desvenlafaxine may cause loss of appetite, nausea, agitation and insomnia Venlafaxine = dizziness, sweating or sedation. Sexual dysfunction less common with the novel antidepressants except for Trazodone (can cause Priapism - a sustained and painful erection that necessitates immediate treatment and discontinuation of the drug) this can also cause impotence.
Nefazodone warning	May cause rare but potentially life-threatening liver damage, which could lead to liver failure.
Bupropion warning	Can cause seizures at a rate four times that of other antidepressants. Risk increases when doses exceeds 460mg/day (400mg SR); dose increase are sudden or large increments; client has history of seizures, cranial trauma, excessive use of or withdrawal from alcohol or addiction to opiates, cocaine, or stimulants; the client uses over-the-counter (OTC) stimulants or anorectics; or the client has diabetes being treated with oral hypoglycemic or insulin.
Serotonin syndrome (or serotonergic syndrome)	Uncommon but potentially life-threatening disorder called serotonin or serotonergic syndrome; characterized by agitation,m sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia, confusion and in extreme cases coma and death; most commonly results from a combination of two or more medications with serotonin-enhancing properties, such as taking MAOI and SSRI antidepressants at the same time or too close together. **Symptoms are similar to those seen with an SSRI overdose.**
Client teaching when to take meds	SSRIs first thing in the morning unless sedation is a problem (paroxetine) - if client forgets they can take up to 8 hours after the missed dose. Cyclic compounds at night in a single daily dose when possible to minimize side effects. If client missed dose must take within 3 hours or omit dose for that day. MAOIs need to be made aware of life-threatening hyperadrenergic crisis that can occur if they do not observe certain dietary restriction.
Mood-stabilizing drugs	Are used to treat bipolar disorder by stabilizing the client’s mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. Lithium is the most established mood stabilizer; some anticonvulsant drugs, particularly carbamazepine (Tegretol) and calorific acid (Depakote, Depakene), are effective mood stabilizers. Other anticonvulsants used for mood stabilization: Gabapentin (Neurontin), topiramate (Topamax), oxcarbazepine (Trileptal), and lamotrigine (Lamictal) Treat acute mania = climax episode (Klonopin)
Lamotrigine warning	Can cause serious rashes requiring hospitalization, including Steven-Johnson syndrome and rarely life-threatening toxic epidermal necrolysis. The risk for serious rashes is greater in children younger than 16 years.
mechanism of action for Lithium	Has many neurobiological effects, its mechanism of action in bipolar illness is poorly understood. Lithium normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine and dopamine. It also reduces the release of norepinephrine through competition with calcium and produces its effects intracellularly rather than within neuronal synapses Acts directly on G-proteins and certain enzyme subsystems such as cyclic adenosine monophosphates and phosphatidylinositol. Lithium is considered a first-line agent in the treatment of bipolar disorder.
Mechanism of action for anticonvulsants	Not clear because it relates to their off-label use as mood stabilizers. Calorific acid and topiramate are known to increase the levels of inhibitory neurotransmitter GABA. Both calorific acid and carbamazepine are thought to stabilize mood by inhibiting the kindling process.
Kindling process	The snowball-like effect seen when a minor seizure activity seems to build up into more frequent and severe seizures.
Lithium warning	Toxicity is closely related to serum lithium and can occur at therapeutic doses. Facilities for serum lithium determinations are required to monitor therapy.
Lithium therapy side effects	Mild nausea or diarrhea, anorexia, fine hand tremor, poly dips is, polyuria, a metallic taste in the mouth and fatigue or lethargy. Weight gain and acne occur later in therapy Taking med with food may help with nausea and the use of propranolol often improves the fine tremor. Noncompliance usually because of weight gain and lethargy
Toxic effects of Litium	Severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination. Untreated these symptoms worsen and can lead to renal failure, coma, and death. When toxic signs occur, the drug should be discontinued immediately. If lithium levels exceed 3mEq/L, dialysis my be indicated
Side effects of carbamazepine and calorific acid	Drowsiness, sedation, dry mouth, and blurred vision. Carbamazepine Also may cause rashes and orthostatic hypotension, and calorific acid may cause weight gain, slope is, and hand tremor. Topiramate causes dizziness, sedation, weight loss and increased incidence of renal calculi.
WARNING Valproic Acid and its Derivatives	Can cause hepatic failure, resulting in fatality. Liver function tests should be performed before therapy and at frequent intervals thereafter, especially for the first 6 months. Can produce teratogenic effects such as neural tube defects (spina bodies). Can cause life-threatening pancreatitis in both children and adults. Can occur shortly after initiation or after years of therapy
WARNING Carbamazepine	Can cause aplastic anemia and agranulocytosis at a rate 5 - 8 times greater than the general population. Pretreatment hematologist baseline data should be obtained and monitored periodically throughout the therapy to discover lowered WBC or platelet counts.
Client teaching for lithium and the anticonvulsants	Monitor blood levels periodically The time of the last dose must be accurate so that plasma levels can be checked 12 hours after last dose has been taken. Taking meds with meals minimizes nausea Client should not attempt to drive until dizziness, lethargy, fatigue, or blurred vision has subsided.
Anxiolytic drugs	Used to treat anxiety and anxiety disorders, insomnia, obsessive-compulsive disorder (OCD), depression, PTSD and alcohol withdrawal Anxiety drugs are among the most prescribed meds today. Classifications: Benzodiazepines - prescribed for anticonvulsant and muscle relaxant effects Buspirone - nonbenzodiazepine often used for the relief of anxiety Propranolol Cloned one (scrapers) Hydroxyzine (Vistaril) __those three used to relieve anxiety and are much less effective
Benzodiazepines mechanism of action	Mediate the actions of the amino acid GABA, the major inhibitory neurotransmitter in the brain. Produce their effects by binding to a specific site on the GABA receptor. Is beloved to exert its anxiolytic effect by acting as a partial agonist at serotonin receptors, which decreases serotonin turnover. Vary in terms of Hal-lives, the means by which they are metabolized, and their effectiveness in treating anxiety and insomnia.	Temazepam (Restoril), triazolam (Halcion) and flurazepam (Dalmane) are most often prescribed for sleep rather than for relief of anxiety. Diazepam (Valium), chlordiazepoxide (Librium), and clonazepam are often used to manage alcohol withdrawal as well as to relieve anxiety.
Benzodiazepines side effects	Cause physical dependence Significant discontinuation symptoms occur when the drug is stopped; Problematic for patients with long-term a benzodiazepine use, such as those with panic disorders or generalized anxiety disorder Psychological dependence is common Clients fear return of anxiety symptoms which leads to overuse or abuse of these drugs Buspirone does not cause this type of physical dependence Most common side effect: mostly associated with CNS depression, such as drowsiness, sedation, poor coordination, and impaired memory or clouded sensorium. Clients develop a tolerance to these symptoms and gradually decrease in intensity.
Buspirone side effect	Dizziness, sedation, nausea, and headache Older clients may have more difficulty managing the effects of CNS depression. - prone to falls from effects on coordination and sedation, more pronounced memory deficits and have urinary incontinence at night
Client teaching regarding anti anxiety agents	Client’s need to know that antianxiety agents are aimed at relieving symptoms such as anxiety or insomnia but do not treat the underlying problems that cause the anxiety. Benzodiazepines strongly potentiate the effects of alcohol; one drink while on a benzodiazepine may have the effect of three drinks. Benzodiazepine withdrawal can be fatal. Client should never abruptly or without supervision of the physician discontinue benzodiazepine.
Stimulant drugs	Drugs that stimulate or excite the central nervous system. Specifically amphetamines, were first used to treat psychiatric disorders in the 1930s for their pronounced effects on CNS stimulation. Used to treat depression and obesity, but those uses are uncommon in current practice Dextroamphetamine (Dexedrine) has been widely abused to produce a high or to remain awake for long periods. Today used for ADHD in children and adolescents and narcolepsy.
WARNING Amphetamines	Potential for abuse is high. Administration for prolonged periods may lead to drug dependence
ADHD drugs used	Methylphenidate (Ritalin) Amphetamine (adder all) Dextroamphetamine (Dexedrine) These stimulants are considered first-line treatment for ADHD. Pemoline (Cylert) is infrequently used for ADHD because of the potential for liver problems. 10-30% of ADHD clients who do not respond adequately to the stimulant medications have been treated with antidepressants. Atomxetine (Strattera), a selective norepinephrine reuptake inhibitor was approved for the treatment of ADHD, becoming the first nonstimulant medication specifically designed and tested for ADHD.
WARNING Methylphenidate	Use with causation in emotionally unstable clients such as those with alcohol or drug dependence because they may increase the dosage on their own. Chronic abuse can lead to marked tolerance and psychic dependence.
WARNING Pemoline	Can cause life-threatening liver failure, which can result in death or require liver transplantation in 4 weeks from the onset of symptoms. The physician should obtain written consent before the initiation of this drug.
Mechanism of action - Amphetamines and Methylphenidate	Indirectly acting amines because they act by causing the release of the neurotransmitters (norepinephrine, dopamine, and serotonin) from presynaptic nerve terminals as opposed to having direct agonist effects on the postsynaptic receptors. Also block the reuptake of these neurotransmitters. Methylphenidate produces milder CNS stimulation than amphetamines; permoline primarily affects dopamine and therefore has less effect on the sympathetic nervous system. The inhibitory centers in the brain are stimulated, so the child has greater abilities to filter out distractions and manage their own behavior Atomoxetine helps block the reuptake of norepinephrine into neurons, thereby leaving more of the neurotransmitter in the synapse to help convey electrical impulses in the brain.
Narcolepsy in adults dosage	Dextroamphetamine and methylphenidate given in divided doses totaling 20-200 mg/day. The higher dosages may be needed because adults with narcolepsy develop tolerance to the stimulants and so require more medication to sustain improvement. Stimulant meds can also come in sustained-release preparations so once a day dosing. Pistol is any (Wakix) and solriamfetol (Sunosi) are two non-stimulant drugs that are FDA approved to treat narcolepsy
Side effects of stimulants	Anorexia, weight loss, nausea, irritability. Client should avoid caffeine, sugar and chocolate which worsen these symptoms. Less common side effects - dry mouth, dizziness, blurred vision and palpitations. Most common long-term problem is growth and weight suppression that occurs in some children. Atomoxetine can cause decreased appetite, nausea, vomiting, fatigue, or upset stomach.
Client teaching of stimulants	Take after meal Caffeine-free beverages Avoid chocolate and excessive sugar Potential for abuse exists except in children on stimulants
Disulfiram (Antabuse)	A sensitizing agent that causes an adverse reaction when mixed with alcohol in the body. This agent’s only use is as a deterrent to drinking alcohol in persons receiving treatment for alcoholism. Takes 5-10 minutes after client ingests alcohol for symptoms to appear; facial and body flushing from vasodilation, a throbbing headache, sweating, dry mouth, nausea, vomiting, dizziness, and weakness. Severe cases, chest pain, suspension, severe hypotension, confusion and even death. Symptoms last 20min to 2 hours. Because liver metabolizes disulfiram, it is most effective in persons whose liver enzyme levels are within or close to the normal range. -it inhibits the enzyme aldehyde dehydrogenase which is involved in the metabolism of ethanol. -acetaldehyde levels are then increased from 5-10 times higher than normal, resulting in disulfiram-alcohol reaction. Reaction caused by decreased levels of epinephrine and norepinephrine in the sympathetic nervous system caused by inhibition of dopamine beta-hydroxylase. Clients stay away from shaving cream, aftershave lotion, cologne, deodorant and OTC medications such as cough meds that contain alcohol;
WARNING Disulfiram	Never give to a client in a state of alcohol intoxication or without the client’s full knowledge. Instruct client’s relatives accordingly.
Side effects Disulfiram	Fatigue, drowsiness, halitosis, tremor, and impotence. Can interfere with the metabolism of other drugs the client is taking such as Phenytonin (Dilantin), isoniazid, warfarin (Coumadin), babiturates, and long-acting benzodiazepines such as diazepam and chlordiazepoxide.
Acamprosate (Campari)	Given to persons in recovery from alcohol abuse or dependence. Helps reduce the physical and emotional discomfort encountered during the first weeks or months of sobriety, ie sweating, anxiety and sleep disturbances. Dose=2 tablets 3times a day ***person with renal impairments cannot take this drug Mild side effects: diarrhea, nausea, flatulence, and pruritus.
Cultural considerations	Giger and haddad write about reactions to drugs differing based on rates of metabolism Slower drug metabolism is likely caused by genetic differences Population becoming more blended can’t rely on past data regarding groups and the nurse needs to ask clients about past experiences, being open to the possibility of different responses so they will avoid stereotyping expectations of clients. Herbal medicines used with increasing frequency ie: St. John’s Wort used to treat depression, Kava is used to treat anxiety and can potentiate the effects of alcohol, benzodiazepines, and other sedative-hypnotic agents. Valerian helps produce sleep and relieve stress and anxiety. Ginkgo biloba improves memory and also for fatigue, anxiety and depression. Combining these herbal preparations can have an unwanted interaction on other meds. Essential to assess all clients use of these products.