•  Neuroleptics
• Dopamine receptor antagonists (DRA's) 

• Serotonin-dopamine antagonists (SDAs)

• Monoaimine oxidase inhibitor
   
• It prevents the destruction of monoamines by inhibiting the action of MAO, an enzyme that destroys monoamines 

Block reuptake of norepinephrine & serotonin

[By blocking, it prevents norepinephrine from coming into contact w/ MAO therefore increasing norepinephrine level]

• Cyclic antidepressants (TCA's)
• SSRIs
• Atypical antidepressants 

Tricyclic Antidepressants have Anticholinergic Effects, Normally Sedate And Lethal oVerdose

Tofranil, Aventyl, Asendin, Elavil, Norpramin, Surmontil, Adapin, Ludiomil, Vivactil

Serotonin syndrome

Caused by too high or too low a dose

• Med-induced seizures (more than 300mg)
• Nausea
  
  Atypical antidepressant 

• Postural hypotension
• Weight gain
• Memory dysfunction
  
  Atypical antidepressant 

• Hypertension
• Dizziness
  
  Atypical antidepressant 

• Sedation
• Increasd appetite
• Weight gain
• Cholesterol elevation
  
  Atypical antidepressant  

• Hypotension
• Sedation, weakness
• Insomnia
• Cardiac rhythm change
• Muscle cramps
• Anorgasmia
• Weight gain

• OTC meds for cold, allergies, congestion
• TCAs
• Narcotics
• Antihypertensives
• Sedatives
• General anesthetics
• Stimulants
• Amine precursors (levodopa, 1-tryptophan)

• Mixed mania (elation and depression
• Rapic cycling
• Atypical features

• Elation, grandiosity
• Flight of ideas
• Irritability
• Anxiety
  
  Also: Insomnia, Psychomotor agitation, Paranoia, Hypersexuality

0.4 - 1.3 mEq/L

Should NOT exceed 1.5mEq/L

When should the nurse check Lithium levels in blood?

a. 2-3 hours before bedtime

b. 8-12 hours after last dose
c. 1-2 hours before lunch time
d. 3-4 hours after last dose 

1. Hypothyroidism

2. Impairment of the kidneys' ability to concentrate urine

1. Cardiovascular diseases

2. Brain damage

3. Renal disease
4. Thyroid disease
5. Myasthenia (neuromuscular disorder causing muscle weakness)
6. Pregnant or breastfeeding women

7. Children under 12

• Persist through therapy: Fine hand tremors, polyuria, mild thirst
• Subside during therapy: Mild nausea, general discomfort
• Weight gain

What are early signs of Lithium toxicity?

< 1.5 mEq/L

• Nausea, vomiting, diarrhea, thirst, polyuria, slurred speech, muscle weakness

Med should be withheld, blood lithium levels measured, and dosage reevaluated.

What are advanced signs of Lithium toxicity?

1.5 - 2 mEq/L

• Coarse hand tremor, persistent GI upset, menal confusion, muscle hyperirritability, ECG changes, incoordination
  
   

What are severe signs of Lithium toxicity?

> 2.5 mEq/L

• Ataxia, serious ECG changes, blurred vision, large output of dilute urine, tinnitus (ringing in the ears), blurred vision, seizures, stupor, severe hypotension, coma, death
  
  There is no known antidote for Lithium poisoning 

• Dysphoric mania (depressive thoughts/feelings)
• Rapid cycling
• ECG abnormalities
• Substance abuse not associated with mood disorders
• Progression in the frequency and severity of symptoms
• No family history of bipolar disorder among first degree relations

1. carbamazepine (Tegretol)

2. divalproex (Depakote)

3. lamotrigine (Lamictal)

When teaching the patient about Lithium and salt intake, the nurse should explain that:

a. Low sodium intake leads to increased lithium retention

b. High salt intake leads to increased lithium retention

c. Low sodium intake leads to decreased lithium retention

d. High salt intake leads to decreased lithium retention

A: Low sodium intake leads to increased lithium retention which could cause toxicity.

Lithium should be taken with/without meals?

a. With

b. Without

• Agranulocytosis
• Aplastic anema
• Diplopia (double vision), incoordination, sedation signal excessive levels

• Baseline liver function test should be performed 
• Fever, chills, RUQ pain, dark urine, malaise, jaundice
• Tremors, GI upset, weight gain, alopecia

• Life-threatening rash (Steven-Johnson syndrome)
• Dizziness, diplopia, headache, ataxia, somnolence (drowsiness)

• Most serious: difficulty breathing, lips swelling, rash, slurred speech, drowsiness, diarrhea
• Frequent: fatigue, somnolence, dizziness, ataxia, diplopia, hypertension

• Weight loss, cognitive side effects, fatigue, dizziness, paresthesia

Weight gain

Hypertension

Low self-esteem (due to weight)

Glucose dysregulation (increases diabetes risk)
Hypercholesterolemia (increases risk for CVD) 

First-generation antipsychotics are used more/less than AAPs.

a. More

b. Less 

In first-generation antipsychotics, what receptor is responsible for the troubling side effects (EPS, akathisia)? 

• Appears after prolonged treatment
• Very serious side effect
• Not always reversible
• Involuntary tonic muscle spasms involving the tongue, fingers, toes, neck, trunk, pelvis

Women

(And older patients)

False, there is no known cure.

However, with early intervention, symptoms may dissapear after the medication is stopped.

Clozaril

EPS: Yes/No?

Risperdal has mild/severe EPS

a. Mild

b. Severe

Zyprexa has low/high EPS

a. Low

b. High

Geodon has low/high EPS

a. Low

b. High

Abilify has low/high EPS

a. Low

b. High

• Agranulocytosis
   
• Also: high seizure rate, weight gain, excessive salivation

• Hypotension
• Insomnia
• Sedation
• Rarely NMS, TD
• Sexual dysfunction
• Weight gain

• Weight gain
• Drowsiness
• Agitation
• Insomnia
• Akathisia or parkinsonism

• Weight gain
• Headache
• Drowsiness
• Orthostasis

• ECG changes
• Low risk for weight gain

• New class of AAP
• Little/no weight gain

• Haldol
• Stelazine
• Prolixin
• Navane

• Loxitane
• Moban
• Trilafon

• Thorazine
• Taractan
• Mellaril

• Lower the dosage
   
• Prescribe antiparkinsonian meds (can intensify anticholinergic effects)
   
• Commonly used: Artane, Cogentin, Akineton, Benadryl, Parodel

1. Pseudoparkinsonism

2. Acute dystonic reactions

      a. Opisthotonos - tightening of entire body

      b. Oculogyric crisis: eyes locked upward

3. Akathisia

4. TD (facial, limbs, trunk)

Masklike facies, stiff and stooped posture, shuffling gait, drooling, tremor, "pill-rolling"

Onset: 5 hours to 30 days
 

RN should give anticholinergic agent (ex. Artane, Cogentin)

Onset: 1-5 days

RN: Benadryl (first choice) then Cogentin to prevent further dystonia

The experience is very frightening. Take patient to quiet area and stay with himher until medicated.

Motor inner-driven reslessness (constant tapping foot, rocking in chair)

Onset: 2 hours to 60 days

RN should change antipsychotic med or give antiparkinson agent. Inderal, Ativan and Valium may be used. Akathisia disappears when med is D/C

Facial: protruding/rolling tongue, blowing, smacking, licking

Limbs:

      a. Choreic: rapid, purposeless, irregular movements

      b. Athetoid: slow, complex, serpentine movements

Trunk: neck and shoulder movements, hip jerks, pelvic thrusts

Onset: months to years

No known treatment. D/C the drug doesn't always relieve symptoms. Patient should be screened for TD every 3 months. 

Rare, potentially fatal

Severe EPS: muscle rigidity, oculogyric crisis, dysphagia
Hyperpyrexia: > 103F

Autonomic dysfunction: hypertension, tachycardia, diaphoresis, incontinence

• Concomitant use of psychotropics
• Older age
• Female gender
• Prescence of a mood disorder
• Rapid dose titration

• Stop neuroleptic
• Parlodel: reduces fever, reieves muscle rigidity
• Dantrium: reduce muscle spasm
• Cool body to reduce fever
• Maintain hydration (oral/IV fluids)
  
  Early detection is key!

1. Razadyne

2. Exelon

3. Aricept

SSRI because they have less side-effects and are better tolerated. Wellbutrin, Effexor, Remeron

** Meds with anticholinergic side effects should be avoided

Atypical antipsychotics: Risperdal, Zyprexa, Seroquel

**Non-drug interventions should be used first. Antipsychotic use should be limited.

Sedatives: Librium, Valium, Serax, Ativan
 

Seizure control: Tegretol, Depacote, Mag sulfate, Thiamine (vitamin B1)
 

Alleviation of Autonomic NS: Beta blockers (propranolol), folic acid, multivitamin

Antabuse causes patient to become nauseous and vomit if alcohol is ingested.

Risks: metallic aftertase, dermatitis, severe reaction or death from alcohol ingestion

Indications: Helps with alcohol/opiate cravings

Risks: Nausea, abdominal pain, constipation, dizziness, headache, anxiety, fatigue

**Patient must be opiod free for 7-10 days 

Indications: Used for alcohol abuse only

Risks: Should not be used by patients who also use opioids (heroin)

Indications: Helps with alcohol cravings by reducing intensity of prolonged withdrawal syndrome

Risks: Diarrhea, increasted libido

Indications: Helps treat patients addicted to opiates, substitute for methadone

Risks: Dizziness, nausea, respiratory depression

Antidepressants, especially SSRIs

Short-term antianxiety medication (must be monitored due to high dependence risk)

Meds with low toxicity (huge risk for suicide/overdose)

There is no specific med to treat

Commonly used: antidepressants (SSRI), antipsychotics, Lithium, anticonvulsants

clomipramine (Anafranil) a tricyclic

SSRIs for obsessional thinking and depression

Antipsychotics can help treat psychosis

**These patients are distrustful of taking meds 

Atypical antipsychotic: psychotic under stress

SSRI: depression, panic attacks

Carbamazepine (anticonvulsant): impulsivity, dyscontrol

SSRI (Prozac): reduce occurrence of relapse once maintenance weight is reached
 

Atypical antipsychotics (Zyprexa): improve mood, decrease obsessional behaviors & resistance to weight gain

Z CLLaPP

Zoloft, Celexa, Luvox, Lexapro, Paxil, Prozac

Antianxiety

Less sedating than benzos

Doesn't produce dependence

Treat anxiety

Inderal, Tenormin