are disorders of mood.
-Everyone has mood swings.
-Disorders are diagnosed when severe symptoms persist.
Two extremes of mood are
depression and mania or bipolar disorder, when the person can cycle between the two abnormal moods.
Affective disorders: Etiology
-A new leading theory attempting to explain the etiology of affective
disorders is the dysregulation hypothesis. -It views depression and affective
disorders as a result of the failure of the regulation of catecholamine activity.
The biogenic amine hypothesis and the permissive hypothesis postulate that depression
results from a deficiency of norepinephrine and serotonin
The biogenic amine hypothesis and the permissive hypothesis postulate that mania results
from increased norepinephrine but decreased serotonin levels.
-Primarily for the treatment of depression. Depression is primarily characterized by a profound sad mood and loss of interest in normal activities.
-These drugs elevate mood and alleviate other symptoms associated with
Depressed patients have symptoms of
fatigue, sadness, hopelessness,
helplessness, anxiety, changes in appetite and weight, loss of libido, changes in sleep pattern such as somnolence or insomnia and others.
-Antidepressants are chosen to relieve these symptoms and also to prevent
or minimize side effects.
Antidepressants: Action - General/Overall
-Depression represents too little norepinephrine or serotonin and or
dopamine on certain receptors in the brain.
-Drugs that act as antidepressants restore active norepinephrine and serotonin.
-The tricyclic antidepressants, atypical antidepressants, and selective serotonin reuptake inhibitors increase the sensitivity of the receptors to these
neurotransmitters and block the reuptake of these neurotransmitters.
-The MAO inhibitors prevent the degradation of norepinephrine and serotonin and also enhance receptor sensitivity to these neurotransmitters.
-Antidepressants take two or more weeks to produce improvement.
-Patient teaching needs to include this point.
(Serotonin is important in the sleep-wake cycle, appetite, and temperature
Antidepressants: Classification: Tricyclics
-Some of these are very sedating when first taken but the drowsiness should decrease after a few weeks.
Antidepressants: Classification: Tricyclics: Action
block the reuptake of norepinephrine or serotonin causing an accumulation at the nerve endings, up to 4-6 weeks to produce improvement. *
drugs affecting Adrenergic receptors
Therapeutic effects: Antihypertensive effects adverse effects: Orthostatic hypotension
drugs affecting Dopaminergic receptors
adverse effects: EPS and endocrine side effects
drugs affecting Histaminergic receptors
adverse effects: Sedation, weight gain
drugs affecting Muscarinic receptors
adverse effects: Dry mouth, constipation, blurred vision, tachycardia, urinary retention, confusion (Anticholinergic effects)
drugs affecting Norepinephrine reuptake
Therapeutic effects: Antidepressant adverse effects: Tremors, tachycardia, additive pressor effects with
drugs affecting Serotonergic receptors
Therapeutic effects: Alleviation of rhinitis adverse effects: Hypotension
drugs affecting Serotonin reuptake
Therapeutic effects: Antidepressant adverse effects: Nausea, headache, anxiety, sexual dysfunction
Tetracyclics: Toxicity and Overdose
-TCA overdoses are notoriously lethal. -The primary systems affected are the CNS and cardiovascular system and death
usually results from seizures or dysrhythmias.
-Very cardiac toxic.
-There is no specific antidote.
Monoamine Oxidase Inhibitors (MAOIs): Therapeutic Uses
Atypical depression characterized by increased sleep and increased appetite, marked panic, phobic or other anxiety
-Considered second-line agents and are never the first type of antidepressant prescribed because of the possibility of
severe side effects.
Monoamine Oxidase Inhibitors (MAOIs): Action
Inhibit the enzyme MAO-A and MAO-B which degrade or inactivate norepinephrine, dopamine, epinephrine and serotonin, therefore these levels of these neurotransmitters rise and help alleviate depression.
Monoamine Oxidase Inhibitors (MAOIs): Side-effects-
anticholinergic effects, orthostatic
hypotension, agitation, restlessness, insomnia
-A hypertensive crisis may be precipitated when a food containing tyramine or a sympathomimetic drug is ingested. -(Sympathomimetic drugs (OTC cough and cold remedies) and tyramine are normally degraded rapidly by MAO of the liver).
-When MAO is inhibited, tyramine
remains un-degraded and triggers the release of accumulated norepinephrine, which in turn causes a hypertensive episode.
-First indication may be a severe
-Procardia (nifedipine) or Regitine may be given to lower blood pressure.
Monoamine Oxidase Inhibitors (MAOIs): Contraindications
other antidepressants concurrently,
including St. John's Wart.
-Patients should be off these for at least 2 weeks before or after another type of antidepressant has been tried.
-This is called a wash-out period.
-Decongestants, OTC cough and cold remedies.
**Tyramine - avocados, bananas, beet bologna, canned figs, hard cheese, chocolate, liver, papaya products, (meat
tenderizers), pickled fish, pepperoni, pods, fava beans, raisins, yeast, salami, sausage, sour cream, soy sauce, yogurt, red wine, and foreign wine. Hypertensive crisis can result with this combination.
-These drugs are only given when a patient has not
responded to other antidepressants.
Heterocyclics or Atypical: mechanism of Action
-chemically unrelated to other antidepressant agents, weak blocker of neuronal uptake of serotonin and
norepinephrine and affect dopamine.
Heterocyclics or Atypical: Side-effects
Lesser incidence of anticholinergic side effects, less cardiotoxicity
Selective Serotonin Reuptake Inhibitors: mechanism of Action
-block neuronal reuptake of serotonin and have little effect on the uptake of norepinephrine or dopamine.
Selective Serotonin Reuptake Inhibitors: indications
depression, obsessive-compulsive disorder and eating disorders, panic attacks
Selective Serotonin Reuptake Inhibitors: Side-effects
fewer or no anticholinergic effects or cardiac conduction disturbances
-Less severe side-effect include nausea, nervousness, and insomnia, headaches, tremor, anxiety, drowsiness, dry mouth, sweating and diarrhea, sexual dysfunction
The serotonin-enhancing property of these drugs can cause the hyperserotonergic state know as the serotonin syndrome (SS) or storm. Serotonin affects temperature* regulation in the hypothalamus-serotonin raises temperature. SS is caused following the use of SSRIs either alone or in combination with MAOIs.
Serotonin Syndrome is characterized by:
-Mental changes- agitation, restlessness, confusion, incoordination, hypomania, coma, seizures
-Altered muscle tone - tremor, rigidity, hyperreflexia
-Autonomic changes - hypertension, tachycardia, diaphoresis
-Similar to neuroleptic malignant syndrome (NMS)
Serotonin Syndrome is characterized by: Treatment
Stop the drug and symptom management (seizures, fever, hypertension)
Selective Serotonin Reuptake Inhibitors: Contraindications
The mnemonic FINISH can be used to remember six core symptoms associated with this discontinuation syndrome -
flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances and hyperarousal (anxiety or agitation). Therefore, these medications should be
-Can occur when doses are missed also.
These antidepressants are selective serotonin and norepinephrine
anxiety and neuropathic pain
Some of the antidepressants are useful in the treatment of _______________________ .
Antimanic Agents: Indications
-manic depressive/bipolar disorders
-stabilize mood, help prevent mood swings
Antimanic Agents: Classifications
Antimanic Agents: Lithium: Action -
lithium is a naturally occurring element (salt) related to sodium and potassium, it is not metabolized but is excreted through the kidneys. It affects sodium cellular transport mechanisms, inhibits the release of norepinephrine and serotonin and enhances their reuptake.
Antimanic Agents: Lithium: Contraindications
- pregnancy (fetus)
-thyroid disease, can lead to hypothyroidism: inhibits excretion of thyroxin.
***Use with Haldol can result in irreversible brain damage.
Antimanic Agents: Lithium: Therapeutic serum range
0.6 - 1.2 mEq/L
-Serum lithium levels must be monitored closely.
-The patient should hold (not take) the medicine prior to the blood test, usually 12h past the last dose.
-Levels higher than 1.5 to 2mEq/L are toxic.
Antimanic Agents: Lithium: Patient education
should include teaching the patient the
*importance of having the serum blood level checked regularly.
Patients should be monitored closely for electrolyte imbalances that could result from vomiting, diarrhea, excessive sweating, water intoxication (Li tends to deplete sodium)
Antimanic Agents: Lithium: Side effects: toxic effects: related to dose/serum level*
Fine tremor of hands
Peripheral vascular collapse
Other meds used to treat Bipolar disorder:
a. Klonopin (Antianxiety agent)
b. Tegretol (Anticonvulsant)
c. Valproic acid (Depakote) (Anticonvulsant)
d. Topamax (Anticonvulsant)
e. Seroquel (Antipsychotic)
Action in the treatment of bipolar disorder is unclear.
Treatment of psychosis, schizophrenia, mania, paranoia, rage, agitation and poor
Antipsychotics: mechanism of Action
-Psychotic symptoms result from too much of the neurotransmitter dopamine in the brain so sometimes antipsychotics are called dopamine antagonists.
-They block dopamine receptors in the brain, thereby reducing the psychotic symptoms.
-Many of the antipsychotic meds also block the dopamine receptors in the
chemoreceptor trigger zone and vomiting center in the brain, producing an
-The more immediate results after receiving an antipsychotic medication (minutes if I.M. within an hour if p.o.) include a reduction in agitation, rage and sexual impulses. Reactivity to sensory stimuli is also reduced.
Antipsychotics: The long term effects begin
within 2 to 21 days after therapy begins. -The antipsychotics suppress hallucinations, delusions, and paranoia. -Thinking processes are slowed to a normal speed.
Antipsychotic drugs are eliminated
very slowly from the body, therefore, after the patient has been stabilized on a dosage the entire dosage can be given at bedtime.
-This minimizes sedation in the daytime and helps patients with insomnia sleep
through the night.
Antipsychotics are divided into two major categories:
1. Typical or traditional
The major differences in the typical/traditional and the atypical antipsychotics are
the specific neurotransmitters that are blocked which is evidenced by different
side effects and the individual's reaction and responses to the medication.
-The dosage must be individualized for the patient according to the patient's clinical responses and side effects.
-The nurse helps in this by observing the patient's reactions carefully.
Differences between Typical and Atypical Antipsychotics: Typical
more helpful in managing the positive symptoms of schizophrenia.
-These positive symptoms are hallucinations, delusions, paranoia and conceptual disorganization.
-Less effective for negative symptoms. -Cause more side effects.
Differences between Typical and Atypical Antipsychotics: Atypical
help alleviate the positive symptoms and are more effective in managing the negative symptoms.
-Negative symptoms include apathy, social withdrawal, blunted affect, poverty of speech, abulia and poor self-care.
-Cause less incidence of side-effects of EPS.
Examples of Typical/Traditional Antipsychotics
-Thorazine p.o. 100-1500 mg (Low potency)
-Mellaril 100-800 mg
-Stelazine 10-50 mg
-Prolixin 0.5-20 mg
-Haldol 2-30 mg (High potency)
-Navane 10-60 mg
-Mobane 50-200 mg
-IM meds - Haldol 2-5 mg q4h PRN IM
-Haldol decanoate 50-100 mg q4 weeks (deep, Z-track)
Side effects associated more often with Typical/Traditional Antipsychotics
-These drugs often produce anticholinergic side effects due to cholinergic blockade (ACH in CNS).
-These include dry mouth, blurred vision, urinary retention, constipation, and nasal congestion.
-Chewing sugarless gum may help combat dry mouth.
-If blurred vision develops the client may wish to see an ophthalmologist for specific treatment.
-A high fiber diet may help counteract constipation along with an increase of fluid intake.
-Observe the client for a distended bladder.
Side effects associated more often with Typical/Traditional Antipsychotics: Orthostatic hypotension
is caused by these drugs due to adrenergic blocking activity (alpha 1).
-Tell the client to dangle his feet before he gets out of bed and to rise slowly to allow time for cardiac compensation.
Side effects associated more often with Typical/Traditional Antipsychotics: Sometimes ejaculation
is inhibited or sexual impulses are inhibited with use of these drugs.
-These symptoms can often be eliminated by changing drugs or lowering the dose (due to serotonin blockade).
hypothalamic function which can cause weight gain, edema, and amenorrhea.
-These problems can be alleviated by
changing medications or by diet and exercise.
the seizure threshold, therefore, you should ascertain if your client has epilepsy.
-Even if the client has never experienced a seizure they are more common in clients who take antipsychotic
-Observe your clients and prevent injury if a seizure occurs by knowing appropriate nursing interventions.
Antipsychotics: side effects
Skin pigmentation, allergic dermatitis, and photosensitivity are side effects
of these drugs.
-Long-term use of high doses of phenothiazines may cause deposits of blue-gray pigments in the skin or retinas which should be reported to the physician immediately.
-Protect your client from photosensitivity with sun block lotion, sunglasses, and protective clothing.
-Obstructive Jaundice (fever, nausea, abdominal pain, itching).
-Agranulocytosis (fever, sore throat, infection, leucopenia) (" WBC less
Antipsychotics: EKG changes
(arrhythmias, tachycardia), elongation of the QT interval.
-This can lead to ventricular tachycardia or ventricular fibrillation.
-It can also lead to a specific type of ventricular tachycardia called Torsade de
Pointe (turning of the points).
-S/S: decrease LOC, shock -like symptoms
-Tx: treat S/S of shock, Lidocaine.
Antipsychotic agents generally produce
sedation (Histamine - 1 blockade).
-Advise your clients to be cautious and avoid driving, operating heavy machinery and other potentially dangerous situations.
Extrapyramidal Symptoms (EPS)
-more likely to be caused by traditional
-The extrapyramidal motor system is a network of nerves in the brain which helps regulate movement.
-The system is important in maintenance
of equilibrium, muscle tone, and posture.
-Extrapyramidal symptoms occur in about a third of the clients using antipsychotics. -These symptoms include tremors, akathisia, akinesia, dystonias, and rigidity.
-These effects are thought to be caused by an increase in cholinergic effects in the extrapyramidal system brought on by
-These reactions are particularly prominent with low dose phenothiazines, Prolixin and Haldol. They are seen less with Mellaril and Loxitane.
Some EPS are also called ________________ resemble symptoms of Parkinson's.
-These are stooped posture, shuffling gait, rigidity, brady- kinesia, and a pill-rolling motion of the hand.
Types of EPS: Acute dystonia or dystonia
- unusual jerking movements of neck,
face, eyes, tongue, body, limbs, and rolling eyes, drooling or twisting head to one side.
-These symptoms are very frightening for
Types of EPS: Akathisia
compelling need to be in constant motion with a marked inability to sit still.
-This may be confused with increased
Types of EPS: Cogwheel rigidity
stop-release, stop-release movement
noticeable in the ante-cubital area, back of neck and knuckles of fingers
Treatment of EPS
-The symptoms above are treated with anticholinergic or antiparkinson
-These medications include: Cogentin (benztropine, mesylate) 0.5-6mg*
Benadryl (diphenhydramine) 50-200mg
-These medications possess anticholinergic and antihistamine effects. -The drugs are quickly absorbed and improvement is sometimes noticeable
within a few minutes after injection.
-May be given po or Im.
-May be ordered routinely or prn.
-Side effects may be anticholinergic or antihistaminic.
Tardive dyskinesia (Serious EPS)
is usually seen after several years of therapy with antipsychotics but occasionally is seen after only a few weeks or months of drug therapy.
-It is characterized by stereotyped involuntary movements such as lateral jaw movements, darting tongue movements, pill-rolling actions of the hands, smacking and sucking of the mouth or purposeless movements of the extremities.
-These movements disappear when the
client is asleep.
-Symptoms are usually irreversible in many cases.
Tardive dyskinesia (Serious EPS): "Treatment"
-Stop the drug
-Some meds can help decrease the condition - benzodiazepines, beta
blockers, calcium channel blockers
Clozaril has been helpful
Neuroleptic Malignant Syndrome
-A rare condition that develops in up to 3% of patients who take neuroleptic drugs.
-an emergency situation.
-Men are twice as likely to be affected as women.
-The condition can be fatal: More than 10% of NMS patients die from complications of the syndrome
-Onset typically begins four to five days after the start of neuroleptic therapy, with symptoms generally peaking over a 24-hour period.
-It's not unusual, though, for a patient to be on neuroleptics for months or even years before developing the syndrome.
-In rare cases, non-neuroleptic medications have triggered the syndrome.
Clinicians believe specific drugs cause the syndrome by blocking the dopamine receptors in the basal ganglia and in the hypothalamus.
While you are more likely to see NMS on a ________________, it can be encountered in
any unit of the hospital. That is because neuroleptics are commonly given in single doses as an antiemetic or sedative, for example, and some patients have developed NMS within hours of just one dose.
-How do you know you are seeing NMS?
-There are no lab tests to diagnose NMS, but lab values are useful for ruling out
Diagnostic criteria for NMS:
-Neuroleptic treatment within seven days of onset-two to four weeks if the patient was given IM depot neuroleptics, which are formulated to absorb slowly.
-Exclusion of any other drug-induced, systemic, or neuropsychiatric illnesses
-Fever of 100.4 F or higher
-Muscle rigidity, sometimes called "lead pipe"
-At least five of the following: tremors, altered mental status, drooling, dysphagia, fluctuating B/P, increased respirations or HR, diaphoresis,
incontinence, elevated creatine phosphokinase, metabolic acidosis, and
Diagnostic criteria for NMS: Other symptoms
may include slurred speech, arching of the back, and oculogyric crisis-a fixation of the eyeballs in one position, and rarely
-NMS is difficult to recognize because it mimics other disorders of the CNS such as CNS infection, dystonia with fever, malignant hyperthermia, catatonia, and encephalopathy.
-Provide supportive and vigilant care.
-Stop the drug.
-Symptoms usually subside in 5 to 10 days, maybe 2-3 days longer than this if depot neuroleptics were given.
-The MD will probably order IV or PO Dantrium 1 to 2 mg/kg q6h to help decrease muscle rigidity.
-The patient should begin to improve within a day or two.
may place the patient at risk for liver toxicity so remain alert for possible side-effects of the treatment ordered. -This drug can also cause phlebitis and tissue damage when given IV.
-Your patient will need antipyretics, fluids and possibly IV fluids.
-Because NMS complications can be fatal, assess regularly for thromboembolism, aspiration pneumonia, and renal failure. -Monitor BUN, creatinine, and urine closely.
-Many times the patient must be put back on a neuroleptic, this time a different one.
-It is essential that you teach the patient and the family how to detect a recurrence.
Examples of Atypical Antipsychotics
(they can all cause weight gain)
-Zyprexa (can cause diabetes daily weights and BS)
Atypical Antipsychotics: Properties/Actions: Advantages
-Treat both positive and negative symptoms of schizophrenia
-Not as likely to cause EPS or TD
Atypical Antipsychotics: Properties/Actions:
-block serotonin and
-block dopamine 4 receptors (also block dopamine 2 but not primary)
Side-effects of Clozaril
Clozapine/Clozaril - causes agranulocytosis* "WBC, CBC must be
routinely done if WBC (Leukocytes) fall less than 30003 , drug should be stopped.
-RN must assess for S/S of infection.
-Risperdal, Zyprexa, Serlect and the other atypicals do not cause agranulocytosis
Many drugs (legal and illegal) can stimulate the CNS.
-Medically approved use of these drugs is limited to certain diagnoses and conditions.
-These drugs have been greatly abused and long term use can produce dependence and tolerance, a condition in which larger and larger doses of a drug are needed to reproduce the initial response.
-Once dependence has developed abruptly stopping the drug will cause withdrawal symptoms.
-CNS Stimulants elevate mood, produce a sense of increased energy and alertness,
decrease appetite and enhance the performance of tasks impaired by fatigue or boredom.
Two of the oldest know stimulants
are cocaine and amphetamine.
-Caffeine is another CNS stimulant.
-Caffeine should be avoided while on these drugs.
CNS Stimulants: Analeptics: Action
stimulate respiration, because of action on the brainstem and spinal cord
CNS Stimulants: Analeptics: Examples
Dopram: used to treat O.D. of CNS depressants and acute respiratory insufficiency associated with COPD
CNS Stimulants: Anorexiants: Action
suppress appetite control centers in the brain by elevating levels of neurotransmitters like norepinephrine, serotonin, and dopamine.
-Orlistat works by altering fat metabolism. (Alli)
-Meridia - structurally related to amphetamine. Works by inhibiting
reuptake of norepinephrine and serotonin, resulting in decreased appetite.
-Fenfen and Redux have been removed from the market
CNS Stimulants: Anorexiants: Side effects
Side effects (do not include Orlistat, Alli)
CNS Stimulants: Anorexiants: Indications
-Short term treatment (4-12 weeks) for obesity
CNS Stimulants: Amphetamine and amphetamine: Action
-Amphetamine and amphetamine-like stimulants
-Amphetamines stimulate the release of the neurotransmitters norepinephrine and dopamine from the brain and the sympathetic nervous system.
-The overall response is global CNS excitement and stimulation with improved mental alertness and attentiveness.
-Cause euphoria, alertness, but can also cause sleeplessness, restlessness,
tremors and irritability.
-Have a high abuse potential and cause withdrawal symptoms when abruptly stopped.
CNS Stimulants: Amphetamine and amphetamine: Side effects and adverse reactions.
-Heart palpitations - (long term use can result in cardiac dysrythmias)
-Diarrhea or constipation
CNS Stimulants: Amphetamine and amphetamine: Indications
-Narcolepsy - falling asleep during normal waking activity (driving a car)
-ADD (attention deficit d.o.) or ADHD (attention deficit hyperactivity d.o.) - the inability to learn due to hyperactivity and
a decrease in attention span.
-Stimulants are given to increase the child's attention span and improve daytime sleepiness.
-Depression in the elderly, occasionally
CNS Stimulants: Amphetamine and amphetamine: Examples
-Ritalin - drug of choice for treating ADHD, Concerta
-Provigil - used to treat narcolepsy, improves wakefulness
-Strattera - not a controlled drug, lacks addictive properties
CNS Stimulants: Amphetamine and amphetamine: Nursing Considerations/Patient Education:
-Should not be taken in the evening or before bedtime because insomnia
may result, usually given once a day before breakfast, Ritalin can be given
twice a day - before breakfast and lunch. Give 6-8 hours before sleep.*
-Cylert is given once a day because of the long half-life.
-Give after meals so the med does not interfere with appetite.
Serotonin Agonists: Action
used to treat migraine headaches.
-They work by stimulating 5- HT1 receptors in the brain and are referred to as selective serotonin receptor agonists (SSRAs) or triptans.
-This stimulation results in constriction of dilated blood vessels in the brain and decreased release from inflammatory neuropeptides.
-Available as sub q self-injections, oral
form and nasal sprays.
Serotonin Agonists: Examples:
Serotonin Agonists: Nursing Considerations and patient education:
Other SSRIs and tyramine - containing foods should be avoided
Serotonin Agonists: Drug Effects
-Many of the effects of CNS stimulants are dose related.
-Their pharmacologic actions are similar to the actions of the SNS neurotransmitters and these drugs are sometimes referred to as sympathomimetic agents.
-The CNS effects most frequently noted are increased motor activity and mental alertness, diminished sense of fatigue, mood elevation and euphoria.
-The respiratory effects are due to the inhibition of the enzyme phosphodiesterase which breakdown cyclic adenosine monophosphate or cAMP.
-When the breakdown of cAMP is
blocked, it accumulates and results in relaxation of the respiratory tract, increased respiration, dilation of pulmonary arterioles and stimulation of CNS.