Appendix D. Psychiatric Medications

ANTIANXIETY MEDICATIONS

USES

• Anxiety disorders
• Relief of anxiety or tension associated with specific situations (prediagnostic or preoperative situations)
• Acute alcohol withdrawal syndrome
• Muscle spasm relief specifically skeletal muscles
• Decrease severe levels of anxiety to enable clients to utilize psychotherapy.

COMMON ADVERSE EFFECTS

• CNS: mental slowing, sedation, vertigo, confusion, tremors, fatigue, depression, headache, anxiety, insomnia, seizures, delirium, leg weakness ataxia, slurred speech
• CV: orthostatic hypotension, tachycardia, eletrocardiogram (ECG) changes
• EENT blurred vision, mydriasis, tinnitus
• Gl: anorexia, nausea, dry mouth, vomiting, diarrhea, constipation
• Skin: rash, dermatitis, pruritus

CONTRAINDICATIONS

• Liver disease
• Elderly clients
• Kidney disease
• Glaucoma
• Pregnancy or breast-feeding
• Psychoses
• Preexisting respiratory disease
• Hypersensitivity reactions

NURSING CARE IMPLICATIONS

• Antianxiety medications cause mental slowing and sedation; therefore, tell clients not to make important decisions, operate vehicles or equipment, or engage in activities involving risk of physical injury Sedation tends to diminish after 2 weeks of treatment.
• Taking antianxiety medications with cimetidine (Tagamet) causes increased sedation and may decrease hepatic metabolism of antianxiety drug.
• Buspirone is recommended for clients who need long-term antianxiety treatment and who are also prone to substance abuse.
• Benzodiazepines may cause erectile difficulties but have been shown to improve vaginismus and ejaculation difficulties.
• To discontinue medication, develop a tapering-down schedule of at least 2 weeks, depending on the drug.
• Monitor elderly clients or those with brain damage for agitation, aggressive behavior, and emotional instability or mood swings.
• Withdrawal from antianxiety drugs can be accompanied by anxiety, head-aches, irritability, choking sensations, depression, and perceptions of strange smells accompanied by a metallic taste.
• Substances such as alcohol, analgesics, tricyclic antidepressants, and anesthetic agents potentiate sedation effects.
• When clients ask for additional medications or stronger doses, investigate whether physiologic or psychological dependence is occurring.
• There is a potential for abuse of these drugs in vulnerable populations
• Inform the client that abrupt discontinuation of medication may cause withdrawal symptoms or an exacerbation of anxiety.
• Tell the client not to ingest antacids or caffeine because they decrease the effectiveness of the medications.

TRICYCLIC ANTIDEPRESSANTS (TCAs)

USES

• Relief of depression
• Relief of severe, chronic pain
• Management of enuresis for children over age 6
• Assisting clients with eating disorders to gain weight
• Obsessive-compulsive disorder

COMMON ADVERSE EFFECTS

• CNS: tremors, twitching, paresthesia, ataxia, seizures, dizziness, anxiety weakness, insomnia
• CV: tachycardia, arrhythmias, palpitations, orthostatic hypotension. hypertension
• EENT: blurred vision, tinnitus, mydriasis
• GI: dry mouth, epigastric pain, nausea, vomiting, abdominal cramps diarrhea, paralytic ileus, hepatitis, jaundice
• GU: urine retention, change in libido, erectile dysfunction, nonorgasmic response
• Hematologic: agranulocytosis, leukopenia, thrombocytopenia
• Skin: diaphoresis, photosensitivity, urticaria, rash

CONTRAINDICATIONS

• Glaucoma
• Liver disease
• Cardiovascular disease
• Hypertension
• Epilepsy
• Pregnancy or breast-feeding

NURSING CARE IMPLICATIONS

• Medication may cause mental slowing and sedation, creating difficulties or hazards with driving or other activities that require alertness.
• Advise the client to take the medication with food to decrease Gl upset.
• Inform the client that the effect of the medication may take up to 2 wee-s to occur.
• Clients who have cardiovascular disease must be carefully assessed before taking TCAs. Monitor these clients carefully by obtaining a baseline ECG and repeating the ECG periodically while the client is taking the drug.
• Explain to the client that quickly arising from a lying or sitting position may cause orthostatic hypotension.
• Tell the client not to drink alcohol or products that contain alcohol, such as over-the-counter cough medicines.
• When the drug is to be discontinued, use several weeks to wean the client off the medication to prevent TCA withdrawal syndrome. (Symptoms include headache, malaise, nausea, chills, dizziness, and nasal congestion and discharge.)
• Advise the client to avoid prolonged exposure to the sun and to use adequate sunscreen.
• Don't permit clients who are suicidal to have large amounts of drug available.
• Taking TCAs with anticonvulsants decreases the effectiveness of both drugs.
• Taking TCAs with antihypertensive agents decreases the effectiveness of the antihypertensive drug.
• Taking TCAs with oral contraceptives or estrogen therapy decreases the effectiveness of the antidepressant drug and may enhance the antidepressant's adverse effects.
• Have diabetic clients carefully monitor blood glucose levels because TCAs may alter insulin needs.
• Tell the client that taking a TCA and smoking decreases the blood level or the drug.

MONOAMINE OXIDASE (MAO) INHIBITORS

USES

• Relief of depression refractory to TCAs
• Panic disorders, agoraphobia, hypochondrias

COMMON ADVERSE EFFECTS

• CNS: headache, stiff neck, confusion, dizziness, fatigue, sedation, tremors, insomnia
• CV: palpitations, hypertension, hypertensive crisis, orthostatic hypotension
• EENT blurred vision
• GI; decreased appetite, weight gain, nausea, vomiting, constipation, hepatic necrosis
• GU; urinary frequency
• Hematologic: anemia
• Skin: diaphoresis, rash, flushed feeling, jaundice

CONTRAINDICATIONS

• Hypertension
• Cardiovascular disease
• Liver disease
• Pregnancy or breast-feeding

NURSING CARE IMPLICATIONS

• Inform the client that the antidepressant effect of the drug may take 1 to 4 weeks to occur.
• Clients on MAO inhibitors must avoid foods that contain tyramine because ingestion of tyramine can cause a hypertensive crisis. (For further information, see Common Foods That Contain Tyramine).
• Medication may cause mental slowing and sedation, creating difficulties or hazards with driving or other activities that require alertness.
• Explain to the client that quickly arising from a lying or sitting position may cause orthostatic hypotension.
• Explain to the client that use of alcohol enhances CNS depression.
• Tell the client not to take the medication in the evening because it may, cause insomnia.
• Taking MAO inhibitors with thyroid medication may cause cardiac arrhythmias.
• Taking MAO inhibitors with products that contain caffeine may cause cardiac arrhythmias.
• Use of narcotics with MAO inhibitors may cause hypertension.
• Don't permit clients who are suicidal to have large amounts of drug available.
• Tell the client that even after MAO inhibitors are discontinued, the medication effects can continue for 2 weeks afterward: hence, drug and food restrictions must be maintained.

COMMON FOODS THAT CONTAIN TYRAMINE

Instant soup mixes that contain yeast Aged cheeses (cottage cheese, ricotta, and cream cheese are not aged) Aged or fermented meats, such as bologna, salami, pepperoni, and sausage, that do not require refrigeration Fermented beverages, such as ale, beer, red wine, and liqueurs Fermented foods, such as sauerkraut, sour cream, and yogurt Pickled or smoked fish, such as lox and herring Liver from either beef or poultry Caviar Fava beans, broad beans, and Italian green beans Snow pea pods Avocados

SEROTONIN REUPTAKE INHIBITORS (SRIs)

USES

• Relief of major depression
• Bulimia and anorexia nervosa
• Obsessive-compulsive disorder
• Premenstrual syndrome

COMMON ADVERSE EFFECTS

• CNS: nervousness, headache, insomnia, dizziness, tremors, impaired thinking, ataxia, impaired motor coordination
• Gl: nausea, anorexia, weight loss, diarrhea
• GU: change in libido
• Skin: rash, urticaria

CONTRAINDICATIONS

• Liver disease
• Kidney disease
• Pregnancy or breast-feeding

NURSING CARE IMPLICATIONS

• Tell the client that it may take 2 to 4 weeks before the effect of the drug is felt.
• Medication may cause mental slowing and sedation, creating difficulties or hazards with driving or other activities that require alertness.
• Explain to the client that use of alcohol enhances CNS depression
• SSRIs inhibit the liver isoenzyme cytochrome P-450, which is necessary for the metabolism of drugs, such as many benzodiazepines, narcotics. neuroleptics. TCAs, antimanic drugs, and barbiturates.
• Tell the client not to take SRI antidepressants within 14 days of taking an MAO inhibitor. Serotonin syndrome may occur when SSRIs or SNRIs are used with MAO inhibitors. The major symptoms are mental changes such as hypomania and confusion, twitching, tremors, lack of coordination seizures, muscle rigidity, tachycardia, hyperthermia, diaphoresis, and alterations in blood pressure.
• Each drug has its own particular adverse effects, so teaching must be individualized to each medication. For example, bupropion may cause seizures and would not be given to a client with a history of seizure disorders or head injury Trazodone may induce priapism (a persistent penile erection). Weight loss tends to occur with fluoxetine and sertraline.

ANTIMANIC DRUGS

USES

• Mood stabilizer for clients with bipolar disorders
• Reduces anxiety, irritability, elation
• Impulse control disorder

COMMON ADVERSE EFFECTS

• CNS: headache, tremors, confusion, restlessness, memory loss, seizures slurred speech, muscle weakness, lack of coordination, lethargy, stupor
• CV: bradycardia, ECG changes, arrhythmias, hypotension, peripheral circulatory collapse
• EENT: blurred vision, tinnitus
• Gl: anorexia, nausea, vomiting, abdominal cramps or pain, diarrhea. dry mouth, extreme thirst, metallic taste, weight gain
• GU: polyuria, glycosuria, proteinuria, incontinence, edema, hyponatremia
• Hematologic: leukocytosis
• Skin: rash, pruritus, alopecia, sweating, dryness or thinning of hair

CONTRAINDICATIONS

• Hypersensitivity
• Kidney disease
• Cardiovascular disease
• Seizure disorder, myasthenia gravis
• Dehydration
• Hypothyroidism
• Pregnancy or breast-feeding

NURSING CARE IMPLICATIONS

• Inform the client that it may take up to 3 weeks to establish a consistent blood level for the drug to take effect.
• Explain the need to monitor lithium blood level because a higher-than-therapeutic level is extremely dangerous. Lithium levels are initially taken one to two times per week and then every 2 months once a therapeutic level is reached. Tell the client that the blood level is drawn 12 hours after the last dose of lithium. A therapeutic lithium level is 1.0 to 1.5 mEq/L.
• Explain to the client that before lithium therapy begins, kidney functions (creatinine level) and thyroid studies (T3 and T4 levels) are obtained.
• Inform the client about signs and symptoms of lithium toxicity, such as ataxia, impaired motor coordination, severe tremors, extreme thirst, blurred vision, slurred speech, lethargy, oliguria, severe confusion, and seizures. Toxic adverse effects occur when lithium level exceeds 1.5 mEq/L, although it is possible for the effects to occur at lower levels. Elderly clients are more prone to lithium toxicity.
• Have the client eat a normal diet and drink 6 to 12 glasses of fluid daily.
• Explain to the client that dehydration resulting from vomiting, diarrhea, excessive sweating, exposure to prolonged heat, use of saunas, and intense exercise can raise the lithium level in the blood.
• Have client take lithium with food because it can cause Gl discomfort. If Gl irritation occurs, instruct the client to eat small, frequent meals.
• Caution the client against ingesting large amounts of beverages and foods that have a strong diuretic effect, such as cantaloupe, watermelon, grape-fruit juice, and cranberry juice.
• Don't administer thiazide diuretics because they will cause retention of lithium and promote toxicity.
• Drugs that contain aminophylline, theophylline, sodium, calcium, antacids, and caffeine increase urinary excretion of lithium, thereby decreasing therapeutic effects.
• Use of haloperidol (Haldol) with lithium causes encephalopathy.
• Lithium and valproic acid may cause weight gain that persists throughout treatment.
• Use of marijuana with lithium increases the lithium level and may contribute to lithium toxicity.
• Maintain an adequate intake of sodium with a normal diet because a low-sodium diet causes lithium retention.
• Instruct the client not to abruptly stop taking the drug. Missed doses of lithium should be skipped and never doubled or otherwise made up.
• Carbamazepine and valproic acid are drugs that may cause bone marrow suppression during their use. Red cells, white cells, and platelets are monitored when a client is taking these medications.

ANTIPSYCHOTIC DRUGS

USES

• Schizophrenia
• Organic psychoses
• Acute psychotic symptoms
• Relieve hallucinations, delusions, disorganized thinking
• Severe anxiety
• Nausea and vomiting
• Seizures

COMMON ADVERSE EFFECTS

• CNS: extrapyramidal symptoms, such as muscle rigidity or spasm, shuffling gait, posture leaning forward, drooling, masklike facial appearance dysphagia, akathisia (motor restlessness), tardive dyskinesia. headache seizures
• CV: tachycardia, arrhythmias, hypertension, orthostatic hypotension.
• EENT: blurred vision, glaucoma
• Gl: dry mouth, anorexia, nausea, vomiting, constipation, diarrhea weight gain
• GU: urinary frequency, urine retention, impotence, enuresis, amenorrhea gynecomastia
• Hematologic: anemia, leukopenia, agranulocytosis
• Skin: rash, dermatitis, photosensitivity

CONTRAINDICATIONS

• Seizure disorder
• Glaucoma
• Elderly clients
• Pregnancy or breast-feeding

NURSING CARE IMPLICATIONS

• Inform the client about common adverse effects, such as anticholinergic adverse effects, extrapyramidal symptoms, parkinsonian symptoms, dry-tonic reactions, and neuroleptic malignant syndrome.
• Discuss the need to take antiparkinson medication to handle the drug-induced extrapyramidal effects.
• Teach the client how to cope with anticholinergic adverse effects such as dry mouth (sip water, suck on hard candy), constipation (drink fluids, eat high-fiber foods), decreased lacrimation (use artificial tears), and urine retention or hesitancy (void every 2 to 3 hours, use methods to induce voiding). Reassure the client that the symptoms of dry mouth, blurred vision, and nasal congestion usually resolve within 2 weeks after treatment is initiated.
• Explain that a condition called agranulocytosis is an emergency. Symptoms are fever, severe sore throat, malaise, and leukopenia. This condition is associated with the use of clozapine: clients taking this drug are required to have complete blood counts drawn weekly to monitor for decreases white cell count.
• Instruct clients taking antipsychotic medications to wear sunglasses use sunscreen, and cover body parts that are frequently exposed to the sun in order to decrease photosensitivity reactions.
• Explore if the client is experiencing sexual difficulties, such as decreased sexual drive, decreased frequency of orgasm, erectile difficulty, and ejaculation difficulty. Sometimes a different antipsychotic medication may be used.
• Teach the client how to deal with the common adverse effect of weight gain by decreasing daily caloric intake, eating low-calorie snacks, and maintaining an exercise program.
• Explain to the client that sedation is a common effect of antipsychotic drugs and that it subsides as treatment progresses.
• Explain to the client that drinking alcohol while taking antipsychotic medication can cause the client to become sedated. It is best to abstain from alcohol or limit alcohol intake to one or two drinks on occasion.
• Inform the client that orthostatic hypotension may occur and that it is handled by rising slowly and holding on to a stationary object until the sensations of dizziness and nausea pass.
• Encourage clients who have preexisting heart disease to be monitored by their primary care provider because some antipsychotic drugs can cause ECG changes.
• Make the client aware that atropine psychosis can occur with anyone taking antipsychotic medication. The symptoms are disorientation, agitation, flushing of the skin, and tachycardia, which are treated without residual problems occurring.
• Inform the client that taking antacids hinders the absorption of the medication.
• Explain to the client that combining an antipsychotic medication with an anticholinergic medication increases the risk of atropine psychosis.
• When smoking and taking an antipsychotic drug, the client may need to take a larger dose of the antipsychotic drug to obtain the same effect.
• Advise the client that antipsychotic drugs lower the seizure threshold and larger doses may be needed for clients with seizure disorders.
• Inform the client that antipsychotic drugs may potentiate the affects of anesthetics agents.

ANTIPARKINSONIAN DRUGS

USES

• Parkinsonism or drug-induced extrapyramidal effects

COMMON ADVERSE EFFECTS

• CNS: headache, fatigue, anxiety, tremors, vertigo, confusion, depression seizures, hallucinations
• CV: tachycardia, palpitations, orthostatic hypotension, heart failure
• EENT: blurred vision
• GI: dry mouth, nausea, vomiting, constipation, flatulence
• GU: urinary hesitancy or frequency, urine retention
• Hematologic: leukopenia
• Skin: photosensitivity dermatitis

CONTRAINDICATIONS

• Cardiac disease or hypertension
• Glaucoma
• Asthma
• Gastric or duodenal ulcers
• Pregnancy or breast-feeding

NURSING CARE IMPLICATIONS

• Caution the client that the medication may cause drowsiness, creating difficulties or hazards with driving or other activities that require alertness
• Tell the client to take the medication with food to decrease Gl upset
• Explain to the client that arising quickly from a lying or sitting position may cause orthostatic hypotension.
• When taking these medications, the client needs to have blood cell counts, renal function, hepatic function, and blood pressure monitored.
• Adverse effects of these drugs occur more commonly in elderly clients.
• Explain to the client that use of these drugs in warm weather mav increase the likelihood of heatstroke.

CENTRAL NERVOUS SYTEM STIMULANTS

USES

• Attention deficit hyperactivity disorder (not recommended for children under age 6)

COMMON ADVERSE EFFECTS

• CNS: anxiety, insomnia, depression, temporary growth delay
• CV: arrhythmias, blood pressure changes
• GI: anorexia, stomachache, weight loss, nausea

CONTRAINDICATIONS

• Cardiovascular or kidney disease
• Diabetes mellitus
• Tourette syndrome

NURSING CARE IMPLICATIONS

• Decrease anorexia by giving drug with meals.
• Administer medication at least 6 hours before bedtime.
• Have the client avoid caffeine because it enhances the stimulant action of the drug.
• Continuously monitor the client's growth and development.
• Don't give the client foods or drugs that turn the urine alkaline because they increase the drug's effect.