1. Psychotherapeutic Agents
Sedative-Hypnotic Drugs
Antidepressants
Mood Stabilizers
1

2. Psychotherapeutic Agents
1. What does it mean when a drug has a sedative
effect?
2. What is the difference between sedation and
hypnosis?
3. What are the level of anxiety?
2

3. States Affected by Sedative-
Hypnotics
1. Anxiety
– Feeling of tension, nervousness or apprehension
– Manifested associated with SYMPATHETIC NS
• Sweating, fast heart rate, rapid breathing and elevated BP
– Mild
• Lowest level, source of positive motivation in certain situation
– Moderate
– High
• Overwhelming, can cause interference with activities of daily living
3

4. States Affected by Sedative-Hypnotics
2. Sedation
– loss of awareness and reaction to environmental stimuli
– Diminished physical & mental response
– Drugs can be administered to sedate client
• Irritable and restless
4

5. States Affected by Sedative-Hypnotics
3. Hypnosis
– Extreme state of sedation in which the person
no longer sense or reacts to incoming stimuli
– Effective hypnotics act on the RAS and block
the brain’s response to incoming stimuli
5

6. Sedative-Hypnotic Drugs
Benzodiazepines
Barbiturates
6

7. Benzodiazepines
• Alprazolam
• Clonazepam (Klonopin)
• Diazepam (Valium)
• Lorazepam (Ativan)
• Chlordiazepoxide (Librium)
7

8. Benzodiazepines
Action:
• Act on limbic system and RAS to enhance the action of gamma-
aminobutyric acid (GABA)
• GABA = inhibitory neurotransmitter
– depress neuronal function at multiple sites in the CNS
– Also promote sleep by affecting cortical areas and sleep-wakefulness cycle
– Muscle relaxation thru effects on supraspinal motor areas =cerebellum
8

9. Benzodiazepines
Indications:
• Drug of choice for anxiety and insomnia
• Anxiety disorders
• Alcohol withdrawal
• Hyperexcitability & agitation
• Short-acting are administered through IM
– Preop to sedate the client
– Before short diagnostic procedures
– For induction of general anesthesia
9

10. Benzodiazepines
Pharmacokinetics:
• GI peak of 30min-2h
• Readily cross blood-brain barrier to reach
intended sites
• Metabolized by liver
• Excreted in urine
10

11. Benzodiazepines
Contraindications:
• Psychosis = can exacerbate sedation,
• Acute narrow glaucoma
• Shock
• Coma
• Acute alcoholic intoxication
• Pregnancy cause
– cleft palate,
– inguinal hernia,
– cardiac defects,
– microcephaly,
– pyloric stenosis during 1st trim
11

12. Benzodiazepines
Caution:
• Elderly & debilitated clients
= renal/liver dysfunction
12

13. Benzodiazepines
Adverse Effects:
• CNS depression
– Drowsiness
– Lightheadedness
– Incoordination and difficulty concentrating
• Anterograde amnesia (impaired recall of recent
events)
• Paradoxical (opposite) responses:
– Insomnia
– Excitation
– Euphoria
– rage
13

14. Benzodiazepines
Adverse Effects
• Severe respiratory depression with IV use
Note:
Substantial respiratory depression can result from combining
oral benzodiazepine + other CNS depressants
Prolong use=physical dependence
Withdrawal symptoms:
panic, delirium, HPN, muscle twitches & convulsion
14

15. Barbiturates
• Amobarbital (Amytal)
• Butabarbital sodium (Butisol)
• Pentobarbital (Barbilixir, Luminal sodium)
• Secobarbital (Seconal)
15

16. Barbiturates
Actions:
• Bind with GABA receptors to enhance inhibitory functions
• Are general CNS depressants that inhibit neuronal
impulse conduction in ascending RAS
• Depress cerebral cortex
• Alter cerebellar function and depress motor output
16

17. Barbiturates
Indications:
• LONG ACTING (phenobarbital & mephobarbital)
– Control seizures in epilepsy
• INTERMEDIATE ACTING (amobarbital, aprobarbital)
– Use in maintaining long periods of sleep
• SHORT-ACTING (thiopental sodium)
– Used as general anesthetic
17

18. Barbiturates
Pharmacokinetics:
• Absorption : well in 20-60mins
• Metabolism: liver
• Distribution: lipid-soluble, readily cross placenta
& enter breastmilk
• Elimination: kidney
18

19. Barbiturates
Contraindications:
• +allergy to any barbiturate
• Previous hx of addiction to sedative-hypnotic
drugs
• Hepatic impairement
• Respiratory distress
• Pregnancy
19

20. Barbiturates
Adverse Effects:
• With increasing dosage, responses range from sedation – sleep –
general anesthesia
• Can ↓BP & HR; toxic dose lead to shock
• They stimulate hepatic enzymes that can accelerate their own
metabolism and that of other drugs
• Prolonged used=physical dependence
20

21. Sedative-Hypnotic Drugs
General Nursing Considerations:
• Do not administer intra-arterially
– Serious arteriospasm and gangrene can occur
• Do not mix IV drugs in solution with other drugs
– To avoid drug-drug interxn
• Parenteral forms should be the last resort, only if oral forms are
not available
– Oral less likely cause AE
• Give IV medications slowly
– Rapid administration can cause cardiac problems
21

22. Sedative-Hypnotic Drugs
General Nursing Considerations:
• Maintain client who receive parenteral benzodiazepines in bed
for a period of 3 hrs
• Monitor hepatic & renal functions, CBC during long therapy
• Taper dosage gradually after long-term therapy, esp in epileptic
client
– Abrupt withdrawal could trigger seizures
22

23. Sedative-Hypnotic Drugs
General Nursing Considerations:
• Prepare emergency life support facilities in case of
severe respiratory depression
• Provide comfort measures to help client tolerate drug
effects
– Small, frequent meal
– Consume drug with food
23

24. Anti-Depressant Agents
24

25. Major Depression Disorder
• Characterized by:
– Low mood
– Low self-esteem
– Loss of interest or pleasure in normally
enjoyable activities
• Commit suicide
25

26. Biogenic Amine Theory of Depression
• Depression results from a deficiency in biogenic amines:
– norepinephrine, dopamine and serotonin
• Norepinephrine
– Alertness & energy, anxiety, attention and interest in life
• Serotonin
– Anxiety, obsession and compulsion
• Dopamine
– Attention, motivation, pleasure and reward and interest in life
26

27. Biogenic Amine Theory of Depression
• Deficiency of these neurotransmitter may be caused by:
– Breakdown by monoamine oxidase to be recycled or restored in
neuron
– Rapid or sudden abnormal electrical discharges from the brain
– Increase in # or sensitivity of postsynaptic receptors
27

28. Anti-Depressant Drugs
• Given with major depression
• Works: balance the neurotransmitters
• Purpose:
– Improve sleeping pattern
• Onset/effective:
– 2-3wks after
– Given with anti-psychotic to minimize bizarre behavior
– On 3rd week:
• Very watchful and vigilant
• Pt can commit suicide
– Have enough energy
28

29. Classification of
Anti-Depressants
TCA
MAOI
SSRI
Atypical
29

30. 1. Tricyclic Anti-Depressants (TCA)
• TCAs inhibit uptake at presynaptic junction of the norepinephrine
and serotonin
• results in the accumulation of these neurotransmitter in the
synaptic cleft and increased stimulation of postsynaptic receptors.
• asserts that depression stems from a deficiency in monoamine-
mediated transmission.
• Elevate mood, increase alertness, improve appetite and normalize
sleep patterns.
30

31. 1. Tricyclic Anti-Depressants (TCA)
• Preferred drug for major depression.
• Therapeutic effect: 1-3 wks
• Full relief of symptoms: 1-2mos
• Tx of enuresis in children >6yo due to its anticholinergic
effects
31

32. 1. Tricyclic Anti-Depressants (TCA)
• Amitriptyline HCl
• Desipramine HCl
• Imipramine HCl (Tofranil)
32

33. 1. Tricyclic Anti-Depressants (TCA)
Contraindications:
• Recent MI
– Reinfarction can occur
• Undergone myelography within prev 24h or in the next
24h
• Should not be taken with MAOI
– Severe HYPERPYRETIC CRISIS with severe convulsion
– Elevated BP and death
33

34. 1. Tricyclic Anti-Depressants (TCA)
Caution:
• With cardiovascular disorders
• Hx of seizures
– Seizure threshold may decreased
• Renal and liver disease
34

35. Adverse Effects:
• ORTHOSTATIC HYPOTENSION = most serious
• Anticholinergic effects
– Dry mouth
– blurred vision
– Photophobia
– constipation
– urinary hesitancy
– Tachycardia
• Sedation
• Dysrhythmias = slows heart conduction
• Lowers seizure threshold
35

36. 1. Tricyclic Anti-Depressants (TCA)
Note:
NO MILK/MILK PRODUCTS
Contain tryptophan = precursor of serotonin
36

37. Examples of TCAs
(3 SISTERS):
PAM ELLOR
ELA VIL
T OFRA NIL
37

38. 2. Monoamine Oxidase Inhibitors
• MAO is an enzyme found in liver, intestinal wall and
terminals of monoamine-containing neurons
• Function:
– convert norepinephrine, serotonin and dopamine into inactive
products
– In intestine, MAO serves to inactivate tyramine and other biogenic
amines in food
38

39. 2. Monoamine Oxidase Inhibitors
• Isocarboxazid (Marplan)
• Phenelzine (Nardil)
• Tranylcypromine (Pamate)
39

40. 2. Monoamine Oxidase Inhibitors
Action:
• Irreversibly inhibit MAO
• Preventing the inactivation of neurotransmitters.
• Allows accumulation of such chemicals in
postsynaptic receptors
40

41. 2. Monoamine Oxidase Inhibitors
Indications:
• Depression
• Bulimia
• Obsessive-Compulsive disorders
41

42. 2. Monoamine Oxidase Inhibitors
Contraindications:
• + allergy to MAOI
• Pheochromocytoma
– Tumor of adrenal gland
– Sudden ↑norepinephrine = HYPERTENSIVE CRISIS
• 1st sign: pounding occipital headache
• Give REGITINE (antidote)
• Cardiovascular dse
• Scheduled for myelography w/in past 24h to next 48h =
reaction to dye
42

43. 2. Monoamine Oxidase Inhibitors
Caution:
• Psyche pt = lead to overstimulation/manic
phase
• Seizure disorders & hyperthyroidism =
exacerbate stimulation of drug
43

44. 2. Monoamine Oxidase Inhibitors
Adverse Effect
• In contrast to TCA, MAOI cause direct CNS
stimulation
– Excessive stimulation produce:
• anxiety
• Agitation
• Hypo/hypermania
• Orthostatic hypotension
44

45. MAOI + TYRAMINE
not compatible
Cause HYPERTENSIVE CRISIS
Special Nursing Consideration:
• NO TYRAMINE RICH FOOD
– Processed foods
– Fermented foods
– Preserved foods
– Ex. Use of yeast, cheese, f.sausage, aged fish and meat
– Give WHITE wine & cheese (cottage)
45

46. Examples of MAOI:
PA RNATE
MA RPLAN
NA RDIL
46

47. 3. Selective Serotonin Reuptake Inhibitors
(SSRI)
• Block the reuptake of serotonin into the
nerve terminal of the CNS
• Enhancing its transmission at the
serotonergic synapse
47

48. 3. Selective Serotonin Reuptake Inhibitors
(SSRI)
Indications:
• Major depression
• Anxiety disorders:
– Obsessive-compulsive
– Panic
– Phobias
– Posttraumatic stress disorders
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49. 3. Selective Serotonin Reuptake Inhibitors
(SSRI)
• Fluoxetin (Prozac, Sarafem)
• Paroxetine (Paxil)
• Sertraline (Zoloft)
49

50. 3. Selective Serotonin Reuptake Inhibitors
(SSRI)
Contraindications:
• + allergy to drugs
• Pregnancy and lactation
Caution:
• Impaired renal/liver functions
50

51. Adverse Effects:
• ↑ Serotonin levels
– Headache
– Drowsiness
– Insomnia
– Tremors
– Agitation
– Seizures
• GU
– Painful menstruation
– Cystitis
– SEXUAL DYSFUNCTION
– IMPOTENCE
51

52. If pt wants to get pregnant
To change drug:
Gradual ↓dosage of SSRI to MAOI
Examples of SSRI:
Z
OLOFT
PA IL
PRO AC
52

53. 4. Atypical Antidepressants
• Also called second-generation antidepressants
• Affect 1 or 2 of the 3 neurotransmitters (serotonin, dopamine&
norepinephrine)
• Used in treating depression who do not respond to other
antidepressants
• Examples:
– bupropion (Wellbutrin)
– amoxapine (Asendin)
– nefazodone (Serzone)
53

54. Anti-Depressants
General Nursing Considerations:
• Maintain initial dosage for 4-8wks to achieve full
therapeutic effect.
• Maintain suicide precaution for severely depressed
clients
• Monitor BP and PR on regular schedule; q4
• Instruct to avoid sudden change in position
– to prevent orthostatic hypotension
• Advise to avoid hazardous activities if sedation is
prominent
54

55. Anti-Depressants
General Nursing Considerations:
• Encourage to undergo ECG prior and during tx
• Instruct not to abruptly stop taking the drug. Dosage
should be gradually decreased
• Encourage client who wants to get pregnant to consult
HCP about possible teratogenic effects of the drug on
fetus.
55

56. Anti-Depressants
General Nursing Considerations:
• Take drug with food if GI upset occurs.
• Advise that antidepressants may be taken at bedtime to
decrease the dangers from the sedative effect
56

57. Mood Stabilizers
(ANTI-MANIA)
Tx for Bipolar disorder
(Manic-Depressive Disorders)
Lithium
Valproic acid
Carbamazepine
57

58. 1. Lithium
Actions:
• Alters sodium transmission in nerve and muscle cells
• Inhibit release of norepinephrine and dopamine but not serotonin
• In manic client, lithium reduces euphoria & hyperactivity
• Antimanic effect begins at 5-7days after onset of tx
• Full benefit: 2-3 wks
58

59. 1. Lithium
• Lithium
– Carbolith
– Duralith
– Eskalith
– Lithonate
59

60. 1. Lithium
Indications:
• Controlling acute manic episodes in Bipolar
disorder
• Long-term prophylaxis against recurrence of
mania and depression
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61. 1. Lithium
Pharmacokinetics
• Absorption: oral
• Distribution: all tissues & body fluids
• Elimination: kidney
• Short half-life due to rapid renal excretion.
61

62. 1. Lithium
• Renal excretion is affected by blood levels of sodium.
• Lithium excretion is reduced when blood levels of sodium
are low.
• Thus, toxicity happens when there is not enough sodium
in the blood
• Dehydration will cause lithium to remain in
kidneys, accumulation can lead to toxicity
62

63. 1. Lithium
• Therapeutic level:
– 0.8-1.4 mEq/L
• >1.4mEq/L = toxic
63

64. 1. Lithium
Contraindications:
• + hypersensitivity
• Pregnancy and lactation
• Renal/cardiac disease
• Hx of leukemia
• Metabolic disorders (Na++ depletion, dehydration
and diuretic use)
64

65. 1. Lithium
Cautions:
• Any condition that could alter Na++ level
– Diarrhea
– Excessive sweating
– Infection with fever
65

66. 1. Lithium
Adverse Effects:
<1.5mEq/L:
• Lethargy
• Slurred speech
• Muscle weakness
• Fine tremor
• Polyuria – renal toxicity
1.5-2.0mEq/L
• Increased intensity s/sx
• ECG changes 66

67. 1. Lithium
Adverse Effects:
2.0-2.5 mEq/L
• Ataxia
• Clonic movements
• Hyperreflexia
• Seizure
• Cardio effects: severe ECG changes & hypotension
• Large output of diluted urine secondary to renal toxicity
• Fatalities = pulmo toxicity
67

68. 1. Lithium
Adverse Effect:
>2.5 mEq/L
• Complex multi-organ toxicity = death
68

69. 1. Lithium
Special Nursing Considerations:
1. Draw samples immediately before the next dose (8-12hrs after
previous dose)
2. Advise to maintain adequate fluid intake
– 2-3L/day initially
– 1-2L/day maintenance
3. advise to maintain adequate Na++ intake and to avoid
crash diets that affect physical and mental health
69

70. 1. Lithium
Special Nursing Considerations:
4. Can be taken with meals
– to decrease gastric irritation
5. Therapeutic effect will be observed after 1-2 weeks
6. Advice client who are planning to conceive to consult with HCP about
possible teratogenic effects on fetus
70

71. 2. Valproic Acid
Action:
• Control symptoms in acute manic episodes
• Can provide prophylaxis against recurrent episodes of mania
and depression
• Has higher therapeutic index than lithium and more desirable
side effects
71

72. 2. Valproic Acid
Action:
• Increases levels of GABA in brain, resulting to decreased
seizure activity
• Starting dosage in adult:
– 250mg, tid
• Maintenance 1000-2500mg/day
72

73. 2. Valproic Acid
• Depakene-syrup
• Depacon-injection
73

74. 2. Valproic Acid
Adverse Effects:
• GI
– N&V
– Diarrhea
– Dyspepsia
– Indigestion
– Depakote = to minimize these effects
• Blood dyscrasia:
– Thrombocytopenia
– Leucopenia
• Hepatotoxicity
74

75. 2. Valproic Acid
Special Nursing Consideration:
• Monitor for dev’t:
– Sore throat
– Fever
– Purpura
– Jaundice
– Excessive and progressive weakness
75

76. 3. Carbamazepine
• Like lithium, reduces symptoms of manic and depressive
episodes
• Preferred for
– with mixed mania/rapid-cycling bipolar disorder
• For tx of acute manic episodes, dosage increases
• Maximum dosage: 1600-2000mg/day
76

77. 3. Carbamazepine
• Carbatrol
• Tegretol
• Epitol
77

78. • Hematologic effects:
– Leucopenia
– Anemia
– Thrombocytopenia
– Aplastic anemia
78

79. Case Analysis
M.H, 38 years old, was started on oral lorazepam for her anxiety attacks.
Four days after, she calls the clinic complaining that the dose must
not be high enough because she reports that her symptoms of anxiety
have been increased. She feels euphoric and excited for no reason and
she has difficulty falling asleep.
a. What is the therapeutic action of lorazepam?
b. What is your assessment of the client’s problem?
c. What will be your nursing interventions at this time?
79