Psychopharmacology

MR. JAYESH PATIDAR
www.drjayeshpatidar.blogspot.com

INTRODUCTION…
• Psychopharmacology is the study of
drugs used to treat psychiatric disorders.
• Medications that affect psychic function,
behavior or experience are called
psychotropic medications.
• They have significant effect on higher
mental functions.
• Psychopharmacological agents are first
line treatment for almost all psychiatric
ailments now a days.
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• With the growing availability of a wide
range of drugs to treat mental illness, the
nurse practicing in modern psychiatric
settings needs to have a sound
knowledge of the pharmacokinetics
involved, the benefits & potential risks of
pharmacotherapy, as well as her own
role & responsibility.

DEFINITION OF PSYCHOTROPIC
DRUGS
Psychotropic drug is any drug
that has primary effects on behavior,
experience, or other psychological functions
(Logman Dictionary of Psychology &
Psychiatry). Psychotropic or psychoactive
drugs can also be defined as chemical that
affects the brain & nervous system, alter
feelings & emotions. These drugs also affect
the consciousness in various ways. A broad
range of these drugs is used in emotional &
mental illnesses.

GENERAL GUIDELINES REGARDING
DRUG ADMINISTRATION IN PSYCHIATRY
• The nurse should not administer any drug unless
there is a written order. Do not hesitate to consult
the doctor when in doubt any medication.
• All medications given must be charted on the
patient‘s case record sheet.
• In giving medication:
– Always address the patient by name & make certain of
his identification.
– Do not leave the patient until the drug is swallowed.
– Do not permit the patient to go to the bathroom to take
medication.
– Do not allow one patient to carry medicine to another.
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• If it is necessary to leave the patient to get
water, do not leave the tray within the reach of
the patient.
• Do not force oral medication because of the
danger of aspiration. This is especially
important in stuporous patients.
• Check drugs daily for any change in color, odor
& number.
• Bottle should be tightly closed & labeled. Labels
should be written legibly & in bold lettering.
Poison drugs are to be legibly labeled & to be
kept in separate cupboard.

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• Make sure that an adequate supply of drugs
is on hand, but do not overstock.
• Make sure no patient has access to the drug
cupboard.
• Drug cupboard should always be kept
locked when not in use. Never allow a
patient or worker to clean the drug
cupboard. The drug cupboard keys should
not be given to patients.

PATIENT EDUCATION RELATED TO
PSYCHOPHARMACOLOGY…
• Nurses assess for drug side effects, evaluate
desired effects, & make decisions about prn
(pro re neta) medication.
• Nurses must understand general principles of
psychopharmacology & have specific
knowledge related to psychotropic drugs.
• Teaching patients can decrease the incidence
of side effects while increasing compliance
with the drug regimen.

Specific areas of education include
the following…
1. Discussion of side effects: Side effects can
directly affect the patient‘s willingness to
adhere to the drug regimen. The nurse should
always inquire about the patient‘s response to
a drug, both therapeutic responses & adverse
responses
2. Drug interactions: Patients & families must
be taught to discuss the effects of the addition
of over-the-counter drugs, alcohol & illegal
drugs to currently prescribed drugs.

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3. Discussion of safety issues: Because some
drugs, such as tricyclic antidepressants, have a
narrow therapeutic index, thoughts of self harm
must be discussed.
• Discuss on abruptly discontinued effects.
• Many psychotropic drugs cause sedation or
drowsiness, discussions concerning use of
hazardous machinery, driving must be reviewed
4. Instructions for older adult patients: Because
older individuals have a different
pharmacokinetic profile than younger adults,
special instructions concerning side effects &
drug-drug interactions should be explained.
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5. Instructions for pregnant or breastfeeding
patient: As pregnant or breastfeeding patients
have special risks associated with
psychotropic drug therapy, special
instructions should be tailored for these
individuals. Teaching patients about their
medications enables them to be mature
participants in their own care & decreases
undesirable side effects

CLASSIFICATIONS OF PSYCHOTROPIC
DRUGS
1. Antipsychotic agents
2. Antidepressant agents
3. Mood stabilizing drug
4. Anxiolytics & hypnosedatives
5. Antiepileptic drug
6. Antiparkinsonian drugs
7. Miscellaneous drugs which include stimulants,
drugs used in eating disorders, drugs used in
deaddiction, drugs uses in child psychiatry,
vitamins, calcium channel blockers etc.

ANTIPSYCHOTIC
AGENTS

DESCRIPTION:-
• Antipsychotic agents are also known as
neuroleptic, major tranquillizers, or
phenothaiazines.
• This group of drugs has a major clinical
use in the treatment of psychosis.
• Psychosis is a state in which a person‘s
ability to recognize reality to
communicate & to relate to others is
severely impaired.

MODE OF ACTION:-
• Antipsychotic agents are thought to block the
dopamine receptors.
• Dopamine is a chemical which is released in
the brain & causes psychotic thinking.
• Increased production of dopamine transmits the
nerve impulses to the brainstem faster than
normal. This result in strange thoughts ,
hallucination & bizarre behavior.
• Antipsychotics helps in blocking or reducing the
activity of dopamine.
• Antiemetic is another property of antipsychotic
agents. They are also used in hiccoughs.

Class Examples of
drugs
Trade name Oral dose
mg/day
Parenteral
dose (mg)
Phenothiazines Chlorpromazine
Triflupromazine
Thioridazine
Trifluoperazine
Fluphenazine
decanoate
Megatil
Largactil
Tranchlor
Siquil
Thioril, Melleril
Ridazin
Espazine
prolinate
300-1500
100-400
300-800
15-60
-
50-100 IM
only
30-60 IM only
1-5 IM
25-50 IM
every 1-3
weeks.
Thioxanthenes flupenthixol fluanxol 3-40
CLASSIFICATION:-

Class Examples of
drugs
Trade name Oral dose
mg/day
Parenteral
dose (mg)
Diphenylbutyl Pimozide orap 4-20
piperidines penfluridol flumap 20-60 weekly -
Indolic
derivatives
molindone mobam 50-225 -
Dibenzoxazepines loxapine loxapac 25-100 -
Atypical
antipsychotics
Clozapine
Risperidone
Olanzapine
Quetiapine
Ziprasidone
Sizopine, Lozapin
Sizodon, sizomax
Oleanz
Qutan
Zisper
50-450
2-10
10-20
150-750 mg
20-80 mg
Others reserpine serpasil 0.5-50
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INDICATIONS
 Organic psychiatric
disorders:
• Delirium
• Dementia
• Delirium tremens
• Drug-induced psychosis &
other organic mental
disorders
 Functional disorders:
• Schizophrenia
• Schizoaffective disorders
• Paranoid disorders
 Mood disorders:
• Mania
• Major depression with
psychotic symptoms
 Childhood disorders:
• Attention-deficit
hyperactivity disorder
• Autism
• Enuresis
• Conduct disorder
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 Neurotic & other
psychiatric disorders:
• Anorexia nervosa
• Intractable obsessive-
compulsive disorder
• Severe, intractable &
disabling anxiety
 Medical disorders:
• Huntington‘s chorea
• Intractable hiccough
• Nausea & vomiting
• Tic disorder
• Eclampsia
• Heart stroke severe
pain in malignancy
tetanus

PHARMACOKINETICS
• Antipsychotics when administered orally are absorbed
variably from the gastrointestinal tract, with uneven
blood levels.
• They are highly bound to plasma as well as tissue
proteins. Brain concentration is higher than the
plasma concentration.
• They are metabolized in the liver, & excreted mainly
through the kidneys. The elimination half-life varies
from 10 to 24 hours.
• Most of the antipsychotics tend to have a therapeutic
window. If the blood level is below this window, the
drug is ineffective. If the blood level is higher than the
upper limit of the window, there is toxicity or the drug
is again ineffective.

SIDE-EFFECTS
1) Extrapyramidal symptoms (EPS)
i. Neuroleptic-induced parkinsonism:- occur
in 40% of the patients presenting
extrapyramidal symptoms. There are two
varieties of parkinsonia symptoms:
a. Akinetic Form:- Appears in the first week
of administration of antipsychotic drugs.
The characteristics of akinetic form are:
Difficulty in masticating movements,
weakness & muscle fatigue.

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b. Agitating Form of parkinsonian Symptoms
include:- Tremors at rest, rigidity & mask-like
face. Most characteristic features of parkinsonism
are:-
Rigidity of muscles
Motor retardation
salivation
slurred speech
mask-like face
shuffling gait
Anticholinergi drugs are given as treatments.

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ii. Akathisia:-
Akathisia occurs in 50% of
all the patients presenting
extrapyrimidal symptoms. The common
characteristics: Restless ―walking in
place‖. Difficulty in sitting still, or strong
urge to move about- referred to as
―Walkies & Talkies‖ by haris . generally
occurs after two weeks of treatment.
Before administering anti-parkinsonian
medication anxiety should be ruled out.

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iii. Dystonia:-
Dystonia occurs in 6% of total number
of patient‘s presenting EPS. The characteristic
features are: rapidly developing contraction of
muscles of the tongue, jaw, neck (producing
torticollis) & etraocular muscles. Combined
torticolis & extraocular spasm results in an
oculogyric crisis in which eyes looked upward,
head is turned to one side. Dystonia is painful
& gives a frightening experience to the patient.
Constant observation of the patient should be
made. Dystonia occurs within a few minutes of
giving medicine or after several hours.

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iv. Tardive Dyskinesia:-
This occur due to abrupt
termination or reduction of the antipsychotic
drug after long-term-high-dose therapy.
Tardive dyskinesia is characterized by
involuntary rhythmic, stereotyped movements,
protrusion of the tongue, puffing of cheeks,
chewing movements, involuntary movements
of extremities & trunk. These symptoms occur
in 3% of patients. Antipsychotics should be
stoped immediately. There is no treatment,
symptoms may appear for years. It is
irreversible.

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V. Neuroleptic Malignant Syndrome (NMS):-
This is a rare
complication of antipsychotic agents & is
usually fetal. Many develop within hours or
after years of continued drug use. Symptoms
include hyperpyrexia, severe muscle rigidity,
altered consciousness, blood pressure
changes, increased count of W.B.C.
symptoms appear suddenly when medication
is started & can persist for 10-14 days or
longer. Symptomatic treatment is given to
patients.

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2) Autonomic Nervous System:-
Dry mouth, blurred vision,
constipation, urinary hesitance or retention & under
rare circumstances paralytic ileus.
3) Cardio-Vascular:-
Tachycardia, orthostatic hypotension &
reversible arrhythmias.
4) Blood or Hematopoietic:-
Agrunulocytosis (marked decrease in
leukocytes system especially with chlorpramozine)
leucopenia, leukocytosis.

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5) Endocrine Disruptions:-
Menstrual irregularities, including
amenorrhea & false positive pregnancy tests, breast
enlargement, lactation, weight gain, changes in libido,
impotence, glycosuria, hyperglycemia.
6) Gastro-Intestinal:-
Anorexia, constipation, diarrhea, hypersalivation,
nausea, vomiting, obstructive jaundice.
7) Allergic effects:-
Dermatitis, photosensitization, pigment
deposits.

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8) Occular Effcts:-
Blurring of vision, pigmentation of
cornea & lens & retinopathy.
9) Hepatic Side-effects:-
Liver toxicity occurs in 0.5% of cases
presenting EPS. It is a hypersensitivity reaction &
dose dependent. Onset of symptoms is within the
first one month of treatment. Symptoms may be
fever, chills, nausea, malaise, prurites & jaundice.

NURSE’S RESPONCIBILITY
 Close observation, especially when the antipsychotic are
just started. The expected results are reduction in
aggressive hyperactive behavior & disorganized thoughts.
Look for the possible side-effects.
 Extrapyramidal reaction, i.e. Parkinsonism, akinesia,
akathisia, dystonia, & tardive dyskinesia. These symptoms
are reduced/treated with early observation, reporting &
use of anti-parkinsonion or anticholinergic medication.
 Observe drowsiness. Medicine should be administered at
bed time. Report if the drowsiness persists for a very long
time. The patient should be advised not to drive & handle
hazardous machinery while taking antipsychotic drugs.
Observe for sore throat, fever due to agranulocytosis.

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 Record blood pressure of the patient on
antipsychotic drugs. If the BP is drops by 20 to30
mm of hg in the patient, immediate reporting &
intervention should be done. The patient should be
made aware of the possibility of dizziness & injuries
after receiving medication & injection due to
orthostatic hypotension.
 Accurate rout of medication- antipsychotic drugs are
not given subcutaneously unless specially prescribed
as they cause tissue irritation. These drugs should
be given deep IM.
 Dry mouth may be may be reduced by encouraging
the patient to rinse his or her mouth frequently. Give
a piece of lemon or chewing gum. Good oral hygiene
should also be maintained.

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 Blurred or impaired vision in the patient causes anxiety
& annonyance to him. The patient should be
encouraged to inform these symptoms immediately.
Blurred vision or brown coloured vision, night blindness
can be permanent due to pigmentary retinopathy.
 The patient on antipsychotic drugs may have weight
gain. Weight record should be maintained. The patient
may be encouraged on a low salt & planned caloric diet.
 The patient may complain of gastric irritation. He should
be discouraged to take antacid as there will be
decreased absorption of antipsychotic drugs.
 An intake output chart should be maintained specially
for male patients who are confined to bed & have an
enlarged prostate gland. Encourage at least 2500 ml of
liquid intake.

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 The patient should be advised to protect his skin, by not going
in the sun & to wear protective clothing & sunglasses.
 The patient should be explained not to increase or decrease
or stop taking drugs without discussing with his doctor. The
drugs should be withdrawn slowly to avoid nausea or
seizures.
 The nurse should find out menstrual changes from the female
patient. Sometimes the patient may complain of fever, upper
abdominal pain, nausea, jaundice & diarrhea. These
symptoms can be due to cholestatic jaundice. The nurse
should stop the medicine immediately & inform the doctor.
 Reassurance to relatives- The patient & his relatives should
be explained that desired effects will be achieved after weeks
of medication, so the relatives need to wait for the effects of
the drugs.

ANTIDEPRESSANTS
AGENTS

DESCRIPTION
• Antidepressant agents are used in
affective disorders or disturbances
mainly to treat depressive disorders
caused by emotional or environmental
stressors.
• Several groups of affective
disturbances are treatable by
antidepressants.

MODE OF ACTION
• Antidepressant drugs are classified as Tricyclics,
Tetracyclics & MAO inhibitors. Research studies
have shown reduced levels of norepinephrine (NE) &
serotonin (5-HT) in the space between nerve ending
carrying message from one nerve cell to another
cause depression.
• Tricyclic antidepressants & MAO inhibitors increase
these neurotransmitters i.e. norepinephrine & sertinin
to the synaptic receptors in the central nervous
system. Tricyclic inhibitors block the reuptake of NE
& 5-HT & MAO inhibitors block the action of
MONOamine oxidize in breaking down excess of NE
& 5-HT at the presynaptic neuron.

CLASSIFICATION
CLASS EXAMPLES OF
DRUGS
TRADE NAME ORAL DOSE
(mg/day)
Tricyclic
antidepressants (TCAs)
Imipramine
Amitriptyline
Clomipramine
Dothiepin
mianserin
Antidep
Tryptomer
Anafranil
Prothiaden
depnon
75-300
75-300
75-300
75-300
30-120
Selective serotonin
reuptake inhibitors
(SSRIs)
Fluoxetine
Sertraline
Fludac
Serenata
10-80
50-200
Dopaminergic
antidepressants
fluvoxamine faverin 50-300
Atypical
antidepressants
amineptine survector 100-400
Monoamine oxidase
inhibitors (MAOIs)
Trazodone
isocarboxazid
Trazalon
Marplan
150-600
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INDICATIONS
 Depression
• Depressive episode
• Dysthymia
• Reactive depression
• Secondary depression
• Abnormal grief reaction
 Childhood psychiatric
disorders
• Enuresis
• Separation anxiety disorder
• Somnambulism
• School phobia
• Night terrors
 Other psychiatric disorders
• Panic attack
• Generalized anxiety disorder
• Agrophobia, social phobia
• OCD with or without depression
• Eating disorder
• Borderline personality disorder
• Post-traumatic stress disorder
• Depersonalization syndrome
 Medical disorder
• Chronic pain
• Migraine
• Peptic ulcer disease

PHARMACOKINETICS
• Antidepressants are highly
lipophilic & protein-bound. The
half-life is long & usually more
than 24 hours.
• It is predominantly metabolized in
the liver.

CONTRAINDICATION
• Antidepressants are given with caution
to patients with cardiovascular disorder
because they cause arrhythmias.
• They increase symptoms of psychosis
& mania in cases of manic-depressive
psychosis.
• Drugs are given with caution to
prevents with liver disorders.

SIDE EFFECTS
1) Autonomic side-effects:
Dry mouth, constipation,
cycloplegia, mydriasis, urinary retention, orthostatic
hypotension, impotence, impaired ejaculation,
delirium & aggravation of glaucoma.
2) CNS effects:-
Sedation, tremor & other extrapyramidal
symptoms, withdrawal syndrome, seizures,
jitteriness syndrome, precipitation of mania.
3) Cardiac side-effects:-
Tachycardia, ECG changes, arrhythmias,
direct myocardial depression, quinidine-like
action(decreased conduction time).

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4) Allergic side-effects:-
Agranulocytosis, cholestatic
jaundice, skin rashes, systemic vasculitis.
5) Metabolic & endocrine side-effects:-
weight gain
6) Special effects of MAOI drugs:-
Hypertensive crises, severe
hepatic necrosis, hyperpyrexia.

NURSE’S RESPONSIBILITY
 Observation of the side-effects & monitoring the
changes noted are very significant to prevent
complications due to antidepressant agents.
 Encourage the patient to take medicine at bed
time due to a sedative effect. Dryness of mouth to
decrease.
 Give plenty of fluids orally. Lemonade or chewing
gum should be given. A few sips of water also
help the patient.
 Do not give medicine empty stomach as the
patient complains of nausea & vomiting.

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 Accurate recording of intake & output of the patient
should be maintained to check if he has retention of
urine.
 If the patient complains of dizziness or light headedness
he/she should be encouraged to get up slowly & sit in the
bed before standing. These symptoms may due to
orthostatic hypotension. The patient should be reassured
that these symptoms are for a short period only. Some
patients may present hypertension.
 Accurate recording of vital signs like B.P. & pulse.
 The nurse should be able to interpret the blood reports
specially blood sugar level & W.B.C. count. If the patient
complains of sore throat, fever, malaise, it should be
reported to the physician on duty. These symptoms may
be due to agranulocytosis or hyperglycemia.

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 To relieve constipation plenty of fluids &
roughage should be encouraged in the diet.
 If the patient complains of sexual dysfunction
inform the physician immediately & stop the
drug.
 If the patient is presenting symptoms of
pressure of speech, increased motor activity &
elated mood, the physician should be informed
& the drug should be stopped immediately.
 Antidepressant tricyclic drugs begin
therapeutic effects within four to eight weeks.
 Accurate recording of the observation made.

MOOD
STABILIZING
DRUGS

Mood stabilizers are
used for the treatment of bipolar
affective disorders. Some commonly
used mood stabilizers are:-
1. Lithium
2. Carbamazepine
3. Sodium Valproate

LITHIUM

DESCRIPTION
• Lithium is an element with atomic
number 3 & atomic weight 7.
• It was discovered by FJ Cade in
1949, & is a most effective &
commonly used drug in the
treatment of mania.

MODE OF ACTION
The probable mechanisms of action can be:
• It accelerates presynaptic re-uptake &
destruction of catecholamines, like
norepinephrine.
• It inhibits the release of catecholamines at the
synapse.
• It decreases postsynaptic serotonin receptor
sensitivity.
All these actions result in decreased
catecholamine activity, thus ameliorating
mania.

INDICATION
 Acute mania
 Prophylaxis for
bipolar & unipolar
mood disorder.
 Schizoaffective
disorder
 Cyclothymia
 Impulsivity &
aggression
Other disorders:
– Premenstrual
dysphoric disorder
– Bulimia nervosa
– Borderline
personality disorder
– Episodes of binge
drinking
– Trichotillomania
– Cluster headaches

PHARMACOKINETICS
• Lithium is readily absorbed with peak plasma
levels occurring 2-4 hours after a single oral
dose of lithium carbonate.
• Lithium is distributed rapidly in liver & kidney &
more slowly in muscle, brain & bone. Steady
state levels are achieved in about 7 days.
• Elimination is predominately via tubules & is
influenced by sodium balance. Depletion of
sodium can precipitate lithium toxicity.

DOSAGES
Lithium is available in the market in the form of the
following preparation:
– Lithium carbonate: 300mg tablet (eg. Licab);
400mg sustained release tablets (eg.
Lithosun-SR).
– Lithium citrate: 300mg/5ml liquid.
The usual range of dose
per day in acute mania is 900-2100mg given in
2-3 divided doses. The treatment is started after
serial lithium estimation is done after a loading
dose of 600mg or 900mg of lithium to determine
the pharmacokinetics.

BLOOD LITHIUM LEVEL
• Therapeutic levels = 0.8-1.2 mEq/L
(for treatment of acute mania)
• Prophylactic levels = 0.6-1.2 mEq/L
(for prevention of relapse in bipolar
disorder)
• Toxic lithium levels>2.0 mEq/L

SIDE EFFECTS
• Neurological: Tremors, motor hyperactivity,
muscular weakness cogwheel rigidity, seizures,
neurotoxicity (delirium, abnormal involuntary
movements, seizures, coma).
• Renal: Polydipsia, polyuria, tubular enlargement,
nephritic syndrome.
• Cardiovascular: T-wave depression.
• Gastrointestinal: Nausea, vomiting, diarrhea,
abdominal pain & metallic taste.
• Endocrine: Abnormal thyroid function, goiter &
weight gain.
•

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• Dermatological: Acneiform eruptions,
popular eruptions & exacerbation of
psoriasis.
• Side-effect during pregnancy &
lactation: Teratogenic possibility,
increase incidence of Ebstein‘s anomaly
(distortion & downward displacement of
tricuspid value in right ventricle) when
taken in first trimester. Secreted in milk
& can cause toxicity in infant.

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• Sign & symptoms of
lithium toxicity (serum
lithium level>2.0
mEq/L):
– Ataxia
– Coarse tremor (hand)
– Nausea & vomiting
– Impaired memory
– Impaired concentration
– Nephrotoxicity
– Muscle weakness
– Convulsions
– Muscle twitching
– Dysarthria
– Lethargy
– Confusion
– Coma
– Hyperreflexia
– Nystagmus

MANAGEMENT OF LITHIUM TOXICITY:-
• Discontinue the drug immediately.
• For significant short-term ingestions, residual
gastric content should be removed by induction of
emesis, gastric lavage adsorption with activated
charcoal.
• If possible instruct the patient to ingest fluids.
• Assess serum lithium levels, serum electrolytes,
renal functions, ECG as soon as possible.
• Maintenance of fluid & electrolyte balance.
• In a patient with serious manifestations of lithium
toxicity, hemodialysis should be initiated.

CONTRAINDICATION OF LITHIUM:-
• Cardiac, renal, thyroid or neurological
dysfunctions
• Presence of blood dyscrasias
• During first trimester of pregnancy &
lactation
• Severe dehydration
• Hypothyroidism
• History of seizures

NURSE’S RESPONSIBILITY:-
• The pre—lithium work up: A complete
physical history, ECG, blood studies (TC, DC,
FBS, BUN, Creatinine, electrolytes) urine
examination (routine & microscopic) must be
carried out. It is important to assess renal
function as renal side-effects are common &
the drug can be dangerous in an individual
with compromised kidney function. Thyroid
functions should also be assesses, as the
drug is known to depress the thyroid gland.

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To achieve therapeutic effect & prevent lithium toxicity,
the following precaution should be taken:
• Lithium must be taken on a regular basis,
preferably at the same time daily (for example, a
client taking lithium on TID schedule, who forget
a dose should wait until the next scheduled time
to take lithium & not take twice the amount at one
time, because toxicity can occur).
• When lithium therapy is initiated, mild side-effects
such as fine hand tremors, increased thirst &
urination, nausea, anorexia etc may develop,
Most of them are transient & do not represent
lithium toxicity.

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• Serious side-effects of lithium that necessitate its
discontinuance include vomiting, extreme hand tremor,
sedation, muscle weakness & vertigo. The psychiatrist
should be notified immediately if any of these effects
occur.
• Since polyuria can lead to dehydration with risk of lithium
intoxication, patients should be advised to drink enough
water to compensate for the fluid loss.
• Various situations may require an adjustment in the
amount of lithium administered to a client, such as the
addition of the new medicine to the client drug regimen, a
new diet or an illness with fever or excessive sweating.
They must be advised to consume large quantities of
water with salts, to prevent lithium toxicity due to
decreased sodium levels.

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• Frequent serum lithium level evaluation is
important. Blood for determination of lithium
levels should be drawn in the morning
approximately 12-14 hours after the last dose
was taken.
• The patient should be told about the importance
of regular follow up. In every six months, blood
sample should be taken for estimation of
electrolytes, urea, creatinine, a full blood count
& thyroid function test.

CARBAMAZEPINE

DESCRIPTION
• It is available in the market under
different trade names like Tegretol,
Mazetol, Zeptol & Zen Retard.

MECHANISM OF ACTION
• Its mood stabilizing mechanism is
not clearly established. Its
anticonvulsant action may
however be by decreasing
synaptic transmission in the CNS.

INDICATIONS
• Seizures-complex partial seizures, GTCS,
seizures due to alcohol withdrawal.
• Psychiatric disorders- rapid cycling bipolar
disorder, acute depression, impulse control
disorder, aggression, psychosis with
epilepsy, schizoaffective disorders,
borderline personality disorder, cocaine
withdrawal syndrome.
• Paroxysmal pain syndromes- trigeminal
neuralgia & phantom limb pain.

DOSAGE
• The average daily dose is 600-1800
mg orally, in divided doses. The
therapeutic blood levels are 6-12
µg/ml. toxic blood levels are attained at
more than µg/ml.

SIDE EFFECTS
• Drowsiness, confusion, headache,
ataxia, hypertension, arrhythmias, skin
rashes, steven-Johnson syndrome,
nausea, vomiting, diarrhea, dry mouth,
abdominal pain, jaundice, hepatitis,
oliguria, leucopenia, thrombocytopenia,
bone marrow depression leading to
aplastic anemia.

NURSE’S RESPONCIBILITY
• Since the drug may cause dizziness &
drowsiness advise him to avoid driving &
other activities requiring alertness?
• Advise patient not to consume alcohol
when he is on the drug.
• Emphasize the importance of regular
follow-up visits & periodic examination of
blood count & monitoring of cardiac,
renal, hepatic & bone marrow functions.

SODIUM
VALPROATE
(ENCORATE CHRONO,
VALPARIN, EPILEX,
EPIVAL)

MECHANISM OF ACTION
• The drugs acts on gamma-
aminobutyric acid (GABA) an
inhibitory amino acid
neurotransmitters. GABA
receptors activation serves to
reduce neuronal excitability.

INDICATION
• Acute mania, prophylactic treatment of
bipolar-I disorder, rapid cycling bipolar
disorder.
• Schizoaffective disorder.
• Seizures.
• Other disorders like bulimia nervosa,
obsessive-compulsive disorder, agitation
& PTSD.

DOSAGE
• The usual dose is 15
mg/kg/day with a maximum of
60mg/kg/day orally.

SIDE EFFECTS
• Nausea, vomiting, diarrhea,
sedation, ataxia, dysarthria,
tremor, weight gain, loss of hair,
thrombocytopenia, platelet
dysfunction.

• Explain to the patient to take the drug
immediately after food to reduce GI
irritation.
• Advise to come for regular follow-up &
periodic examination of blood count,
hepatic function & thyroid function.
Therapeutic serum level of valproic
acid is 50-100 micrograms/ml.

ANTIANXIETY
AGENTS,
INCLUDING
SEDATIVES AND
HYPNOTICS

DESCRIPTION
• Anxiety is a state which occurs in all
human being at sometime or the other.
• It is also a cardinal symptoms of many
psychiatric conditions.
• The drugs used to relieve anxiety are
called ANTIANXIETY OR ANXIOLYTIC
AGENTS. Antianxiety drugs relieve
moderate-to-severe anxiety & tension.

MODE OF ACTION
• These non-barbiturate benzodiazepines
act as CNS depressants.
• It is believed that these drugs increase
or help the inhibitory neurotransmitter
action of gama-aminobutyric inhibitor in
all areas of CNS. So, there is inhibition
or control on the cortical & limbic system
of the brain, which is responsible for
emotions such as rage & anxiety.

INDICATIONS
• Antianxiety agents are used to relieve mild, moderate &
severe anxiety associated with: emotional disorders
physical disorders excessive environmental stress
neuroses & mild depressive states without causing
excessive sedation or drowsiness.
• For control of alcohol withdrawal symptoms.
• To control convulsions.
• To produce skeletal muscle relaxation.
• To provide short-term sleep preoperatively, prior to
diagnosis & insomnia.
• Antianxiety agents should always be used in time-limited
regimen.

CONTRAINDICATIONS
• Patients with renal or liver &
respiratory impairment are
given antianxiety drugs with
caution.

CLASSIFICATION OF ANTIANXIETY
AGENTS:-
CHEMICAL GROUP &
GENERIC NAME
TRADE NAME RANGE OF DAILY
DOSAGE IN mgm
ACTION
I. Non-Barbiturates
A. Benzodiazepines
Chlordiazepoxide
Diazepam
Oxazepam
Prazepam
Chlorazapate
Flurazepam
Nitrazepam
lorazepam
Librium,
Equibrome
Valium,
Calmpose
Serepax
Verstran
Tranzene
Azene
Dalmane,
Nitravet
Mogadon
ativan
15-100
6-50
30-120
20-60
11.25-60
15-60
10-30
2-6
These are non-
barbiturate
benzodiazepines.
They produce a
tranquillizing
effect without
much sedation.
These drugs are
potential for
abuse.

COUNT…
CHEMICAL GROUP &
GENERIC NAME
TRADE NAME RANGE OF DAILY
DOSAGE IN mgm
ACTION
A.Non-
Benzodiazepine
Propanediols
Meprobamate
Equanil
Miltown
Tybamate
1.2-1.6
1.2-1.6
1.2-1.6
These drugs
have sedative
action &
present a high
risk of abuse &
physical
dependence.
II. Antihistamines
Hydroxyzine
Atarax
vistaril
30-200
30-200

CLASSIFICATION OF SEDATIVES AND
HYPNOTICS:-
CHEMICAL GROUP
& GENERIC NAME
TRDE NAME HYPNOTIC
DOSE RANGE-
DAILY IN mgm
SEDATIVE DOSE
DAILY IN mgm.
ACTION
III. Barbiturates
Amobarbidtal SA
Butabarbital SA
Pentobarbital LA
Phenobarbital LA
Thiopental USA
Amytal
Butisol
Nembutal
Luminal
pentothal
100-200
100-200
100-200
100-200
Used for
anasthesia
60-150
20-200
60-150
30-90
These drugs
cause drowsiness
lethargy,
decrased
alertness & sleep.
Tolerance to drug
can occur within
7-14 days,
resulting in
physical
dependence.
IV. Nonbarbiturates

COUNT…
CHEMICAL GROUP &
GENERIC NAME
TRDE NAME HYPNOTIC
DOSE RANGE-
DAILY IN mgm
SEDATIVE DOSE
DAILY IN mgm.
ACTION
V. Quinazolines
Methaquualone Quaalude
Parest
Optimal
mandrax
150-300 250-300
VI. Acetylinic Alcohols
Ethchlorvynol placidyl
0.5gm-1gms 200-600mgm
VII. Chloral
Derivatives
Chloral hydrate
Chloral betaine
Noctaec
Beta-chlor
0.5gm-2gms
870mg-1gm
VIII. Monoureides

SIDE – EFFECTS OF ANTIANXIETY,
SEDATIVES & HYPNOTICS
1)Central nervous system: drowsiness,
ataxia, confusion, depression, blurred
vision.
2)Cardiovascular system: hypotension,
palpitation, syncope.
3)Endocrine: change in libido.
4)Allergic: skin rash.

COUNT…
5) Physical/psychological dependence non-
benzodiazepines & barbiturate group of
drugs has a high risk of abuse & physical
dependence.
6) Acute toxicity of barbiturate that can be
fetal when taken in excessive dosage
usually for suicide attempts. Overdose can
cause tachycardia, hypotension, shock,
respiratory depression, coma & death.

 Assessment of the patient, prior to the use of
antianxiety, sedative-hypnotic agents. If the patient
complains of sleep disturbance the causative factor
should be identified.
 Appropriate nursing measures to induce sleep
should be taken such as a calm & quite
environment, a cup of hot milk, good back care,
allowing the patient to read magazines, sitting with
the patient for some time for reassurance purpose.
 While administering the drug daily dose should be
given at bed time to promote a normal sleep
pattern, so that day-time activities are not affected.

COUNT…
 Give IM injection deep into muscles to prevent
irritation.
 Look for side-effects, record & report immediately.
 If the patient complains of drowsiness tell him to
avoid using knife or any other dangerous equipment.
He should be instructed not to drive.
 Instruct the patient not to take any stimulant like
coffee, alcohol as they alter the effect of drugs.
 Avoid excessive use of these drugs to prevent the
onset of substance abuse or addiction.
 Drug should be reduced gradually, sudden stoppage of the
drug may cause REM (Rapid Eye Movements), insomnia,
dreams or nighmare, hyperexcitability, agitation or convulsions.

ANTIPARKINSONIAN
AGENTS

DESCRIPTION
• Antiparkinsonian agents are the specific
drugs to treat the extrapyramidal side-
effects of antipsychotic agents.
• Side-effects are parkinsonism,
akathisia, acute dystonia & tardive
dyskinesia.
• Anticholinergics, antihistamines &
amantidne are used to treat these side-
effects.

MODE OF ACTION
• Anticholinergic drugs block the
secretion, thereby reducing the symptoms
of akathesia & acute dystonia. It is not
effective against tardive dyskinesia.
• Antihistamines have effects like
anticholinergic drugs. Amantadines are
dopamine-releasing agents from central
neurons. Studies show that this drug may
affect some clients with tardive
dyskinesia.

INDICATION
• Antiparkinsonian drugs are
used to treat the
extrapyramidal symptoms.

CONTRINDICATION
• Patient with history of closed angle glaucoma,
urinary or intestinal obstruction, hypersensitivity,
prostatic hypertrophy, tachycardia are not given
these drugs.
• The drugs are given with caution to patients with
mysthesia gravis, arthesclerosis & chronic
respiratory problems.
• Anticholinergic drugs: Amantadine is given with
caution to patients with renal impairment as
most of the medication is excreted through the
kidney.

CLASSIFICATION
CHEMICAL & GENERIC
NAME
TRADE NAME DOSE RANGE PER
DAY mgm/Day
FROM OF
AVAILABILITY
I. Anticholinergic
Benztropine
Biperiden HCL
Hydrochiride
Trihexyphenidyl
Hydrochiride
Procyclidine
hydrochiride
Cogentin
Akinetone
Dyskinon
Pacitane
Parbenz
kemadrin
0.5-6.0
2.0-8.0
2.0-12.0
5.0-20mg
Tab, injection
-do-
-do-
Tab.
Tab.
II. Antihistamine
Diphenhydramine Benadryl 75-100
Capsule & syrup
III. Dopamine Drugs
L. Dopa
Amantadine Hydrochiride
Selegline
Carbidopa & L.Dopa.
Larodopa
Symmetrel
Deprenyl
Sinemet
2 gms-3gms
100-200gms
5-10mg
10-100mg
Tab.
Tab .
Tab.
Tab.

SIDE-EFFECTS
• Anticholinergic:- Side-effects are dry mouth,
flushed, dry skin, blurred vision, photophobia,
increased heart rate, constipation, urinary
retention, mental confusion & excitement.
• Antihistamines:- Side-effects are drowsiness,
dizziness, anorexia, nausea, vomiting, euphoria,
orthostatic hypotension, weight gain, weakness &
tingling of hands.
• Amantadine:- Side-effects are mood changes,
slurred speech, insomnia, inability to concentrate,
dry mouth, livedo reticularis that is a red-blue
netlike discolouration of the skin which becomes
worse in winter.

 Observation- observation of the patient for side-
effects of anti-parkinsonian drugs such as
tachycardia, palpitation, sedation, drowsiness &
blurred vision.
 Maintain an intake output chart in case the patient
has urinary retention or constipation.
 Encourage adequate intake of fluids & roughage in
the diet.
 Record vital sign such as B.P., pulse & respiration
every four hours.
 Advise the patient not to get up quickly from a lying-
down position to sitting because of orthostatic
hypotension.4/24/2013 JAYESH PATIDAR 97

COUNT…
Educate the patient not to use hazardous
machinery or driving when he is on
anticholinergic drugs.
Encourage the patient to get his routine
eye check-up done for early detection of
blurred vision or glaucoma.
Record the medicine & side-effects
accurately.
Report & record any side-effects
observed to the physician.

DRUGS USED IN
CHILD
PSYCHIATRY

1. CLONIDINE
2. METHYLPHENIDATE (RITALIN):-

CLONIDINE

MECHANISM OF ACTION
• Alpha2- adrenergic receptors agonist.
• The agonist effects of clonidine on
presynaptic alpha 2-adrenergic
receptors result in a decrease in the
amount of neurotransmitters released
from the presynaptic nerve terminals.
This decrease serves generally to reset
the sympathetic tone at a lower level &
to decrease arousal.

INDICATION
• Control of withdrawal symptoms from
opioids.
• Tourette‘s disorder
• Control of aggressive or hyperactive
behavior in children
• Autism.

DOSAGE
• Usual starting dosage is 0.1mg
orally twice a day; the dosage can
be raised by 0.3 mg a day to an
appropriate level.

SIDE-EFFECTS
• Dry mouth, dryness of eyes,
fatigue, irritability, sedation,
dizziness, nausea, vomiting,
hypotension & constipation.

• Monitor BP, the drug should be
withheld if the patient becomes
hypotensive.
• Advise frequent mouth rinses &
good oral hygiene for dry mouth.

METHYLPHENIDATE
(RITALIN)

DESCRIPTION
• Methylphenidate ,
dextroamphetamine &
pemoline are
sympathominetics.

MECHANISM OF ACTION
• Sympathomimetics cause the stimulation of
alpha & beta-adrenergic receptors directly as
agonists & indirectly by stimulating the release
of dopamine & norepinephrine from
presynaptic terminals.
• Dextroamphetamine & methylphenidate are
also inhibitors of catecholamine reuptake,
especially dopamine reuptake & inhibitors of
monoamino oxidase.
• The net result of these activities is believed to
be the stimulation of the several brain regions.

INDICATION
• Attention-deficit hyperactivity disorder
• Narcolepsy
• Depressive disorders
• Obesity

DOSAGE
• Starting dose is 5-10 mg per
day orally, maximum daily
dose is 80mg/day.

SIDE-EFFECTS
• Anorexia or dyspepsia, weight
loss, slowed growth, dizziness,
insomnia or nightmares,
dysphoric mood, tics &
psychosis.

• Assess mental status for chang in mood, level of
activity, degree of stimulation & aggressiveness.
• Ensure that the patient is protected from injury.
• Keep stimuli low & environment as quiet as
possible to discourage over stimulation.
• To decrease anorexia, the medication may be
administered immediately after meals. The
patient should be weighed regularly during
hospitalization & at home while on therapy with
CNS stimulants, due to the potential for anorexia/
weight loss & temporary interruptions of growth &
development.

COUNT…
• To prevent insomnia administer last dose at
least 6 hours before bedtime.
• In children with behavioral disorders a drug
‗holiday‘ should be attempted periodically
under the direction of the physician to
determine effectiveness of the medication &
the need for continuation.
• Ensure that parents are aware of the delayed
effects of Ritalin. Therapeutic response may
not seen for 2-4 weeks; the drug should not be
discontinued for lack of immediate results.

COUNT…
• Inform parents that OTC (over-the-counter)
medications should be avoided while the child
is on stimulant medication. Some OTC
medications, particularly cold & hay fever
preparation contain certain sympathomimetic
agents that could compound the effects of the
stimulants & create drug interactions that may
be toxic to the child.
• Ensure that parents are aware that the drug
should not be withdraw abruptly. Withdrawal
should be gradual & under the direction of the
physician.

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