Psycho-pharmacotherapy

Psycho-pharmacotherapy refers to use of drugs for the treatment of mental illness.

The various drugs used on psychiatry are called as psychotropic (or psychoactive) drugs.

A. Antipsychotics
Antipsychotics are those psychotropic drugs, which are used for the treatment of psychotic
symptoms. These are also known as neuroleptics (as they produce neurological side-effects),
major tranquilizers, D2 –receptor blockers and anti - schizophrenic drugs.
Mechanism of Action
Exact mechanism of action of antipsychotic is unknown, but most probably anti-psychotic drugs
act by blocking dopamine receptors in the brain especially in limbic system. Most antipsychotic
drugs occupy or block dopamine receptors in brain tissue, thereby decreasing the effect of
dopamine. However, drug binding to the receptors does not completely explain antipsychotic
effects, as binding occurs within a few hours after a drug dose and antipsychotic effects may not
occur until the drugs have been given for a few weeks, that's why manifestations of hyper
arousal. (e.g. anxiety, agitation, hyperactivity, insomnia, aggressive or combative behavior) are
relived more quickly than hallucinations, delusions, and other thought disorders. Antipsychotic
also possess anti-cholinergic, anti-adrenergic, major tranquilizing and anti-histamine activities.
Indications for Use
1. Organic psychiatric disorder(used in low dose)
a. Delirium
b. Dementia
c. Delirium tremens
d. Drug-induced psychosis
2. Functional disorder
a. Schizophrenia
b. Schizoaffective disorders
c. Acute psychosis
d. Paranoid disorders
3. Mood disorders
a. Mania
b. Major depression with psychotic symptoms
4. Childhood disorders (used in low dose)
a. Attention – deficit hyperactivity disorder
b. Autism
c. Enuresis
d. Conduct disorder
5. Neurotic and other psychiatric disorders

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 a. Anorexia nervosa
b. Severe, intractable and disabling anxiety
6. Medical disorders(used in low dose)
a. Intractable hiccough
b. Nausea and vomiting
c. Tic disorder
d. Eclampsia
e. Tetanus
f. Severe pain in malignancy
Contraindications for Use
a. Liver damage
b. Coronary artery disease
c. Cerebro- vascular disease
d. Bone marrow depression
e. Severe hypotension or hypertension
f. Comatose state
g. Severely depressed states
h. Children under three years of age
Commonly used Antipsychotics
1. Conventional antipsychotic (old drugs)
S. Name of Medicine Dose Route Rema
N. rk
1 Chlorpromazine (300- Oral/ Inj. (50 -
(CPZ) 500)mg/day Injectio 100)mg
n
2 Trifluoprazine (15 - 60) Oral
mg/day
3 Fluphenazine (25 - 50) I/M
decanoate mg/day every 2
weeks
4 Haloperidol (5 - 20) mg/day Injectio
n/
Oral
5 Loxapine (50-225) Oral Oral
mg/day only
2. Atypical Antipsychotics (New drugs with fewer side effects)
S.No Name of Dose Route Remark
. Medicine
1 Clozapine (50 - 450 ) Oral

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 mg/day
2 Resperidone (2 - 10) Oral
mg/day
3 Olanzapine (5 -30)mg/day Oral
4 Oleanz Rapid (5-30)mg/day Oral/
sublingua
l
4 Quetiapine (300 - Oral
500)mg/day
5 Sulpiridine (400 - Oral
1800)mg/day
6 Ziprasidone (40 - Oral
160)mg/day
7 Aripiprazole (10- Oral
30)mg/day
Side effects: Side effects of antipsychotics according to the effect on various systems:
1. Central nervous system (May produce extra pyramidal side effects)
a. Parkinsonism - It occurs in 40% of the patients presenting extra pyramidal symptoms
(EPS). Parkinson’s symptoms are as follows;
– Rigidity of muscle
– Motor retardation
– Salivation
– Slurred speech
– Mask-like face
– Shuffling gait
b. Akathisia - It occurs in 50% of all the patients presenting EPS. Common characteristics
are;
– Restless (Walking in place)
– Difficulty in sitting still or strong urge to move about, referred to as "walkies and
talkies"
c. Dystonia - It occurs in 6% of total number of patients presenting EPS. The characteristics
features are;
– Rapidly developing contraction of muscles of the tongue, jaw, neck and extra ocular
muscles
– Dystonia is painful and gives a frightening experience to the patient.
– Dystonia occurs within a few minutes of giving medicine or after several hours.
d. Tardive Dyskinesia- It occurs due to abrupt termination or reduction of the antipsychotic
agents after long term high dose therapy. It is characterized by:
– Involuntary, rhythmic, stereotyped movements
– Protrusion of the tongue
– Puffing of the cheeks
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 – Chewing movements
– Involuntary movements of extremities and trunk
These symptoms occur in 3% of patients presenting EPS. After getting these symptoms
antipsychotics should be stopped immediately. There is no treatment, symptoms may
appear for years. It is irreversible.
e. Neuroleptic Malignant syndrome (NMS): This is rare complication of antipsychotic drugs
and is usually fatal. It may 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 may appear suddenly when medication is started or even after a long term use of
antipsychotic therapy and can persist for 10-14 days or longer. Symptomatic treatment is given to
the patients.
2. Autonomic Nervous system
– Dry mouth
– Blurred vision
– Constipation
– Urinary retention
– Under rare circumstances: paralytic ileus
3. Cardio- vascular system
– Tachycardia
– Orthostatic hypotension
– Reversible arrhythmias
4. Blood or hemopoietic system
– Agranulocytosis
– Leucopenia
– Leukocytosis
5. Endocrine system
– Menstrual irregularities, e.g. amenorrhoea, false positive pregnancy test
– Breast enlargement
– Lactation
– Weight gain
– Changes in libido
– Impotence
– Glycosuria
– Hyperglycemia

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6. Gastro intestinal system
– Anorexia
– Constipation
– Diarrhea
– Hyper salivation
– Nausea
– Vomiting
– Obstructive Jaundice
7. Allergic effects
– Dermatitis
– Photo-sensitization
– Pigment deposits
8. Ocular effects
– Blurring of vision
– Pigmentation of cornea and lens
– Retinopathy
9. Hepatic side effects
Liver toxicity – It occurs in approximately 0.5% of all cases with anti-psychotic therapy.
Symptoms of it occur usually within the one month of treatment. Symptoms are;
– Fever
– Chills
– Nausea
– Malaise
– Prurites
– Jaundice
Nursing considerations during administration of Antipsychotics
1. Administer accurately:
a. When feasible, give oral antipsychotic drugs once daily, before 1 to 2 hours of bedtime.
Peak sedation occurs about 2 hours after administration and aids sleep. Hypotension, dry
mouth, and other adverse reactions are less bothersome with this schedule.
b. When preparing oral concentrated solutions or parenteral solutions, try to avoid contact
with the solution. If contact is made, wash the area immediately. These solutions are
irritating to the skin and may cause contact dermatitis.
c. For intramuscular injections:
– Give only those preparations labeled for intramuscular use.
Do not mix any other drugs in the same syringe with antipsychotic drugs. These drugs
are physically incompatible with many other drugs, and a precipitate may occur.
– Change the needle after filling the syringe for injection. Parenteral solutions of these

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 drugs are highly irritating to body tissues. Changing needles helps in protecting the
tissues of the injection tract from unnecessary contact with the drug.
– Have the client lie down for 30 to 60 minutes after the injection to observe for adverse
reactions. Orthostatic hypotension is likely if the client tries to ambulate.
2. Observe for therapeutic effects:
a. When the drug is given for acute psychotic episodes, observe for decreased agitation,
combativeness, and psychomotor activity. The sedative effects of antipsychotic drugs are
started within 48 to 72 hours.
b. When the drug is given for acute or chronic psychosis, observe for decreased psychotic
behavior, such as:
– Decreased auditory and visual hallucinations
– Decreased delusions
– Continued decrease in or absence of agitation, hostility, hyperactivity, and other
behavior associated with acute psychosis
– Increased socialization
– Increased ability in self-care activities
– Increased ability to participate in other therapeutic modalities along with drug therapy
– When the drug is given for anti - emetic effects, observe for decreased or absent nausea
or vomiting.
Note: - These therapeutic effects may not be evident for 3 to 6 weeks after drug therapy is
begun. However, the initial effects are; sedation, improving sleep, decreasing agitation,
restlessness, visual hallucination etc.
3. Observe for side effects and manage accordingly:
a. Anti cholinergic effects
– Dry mouth: Frequent sips of water, sugarless candy.
– Blurred vision: Reassurance
– Constipation: Advise food high in fiber, physical exercise, increase fluid intake etc.
– Urinary retention: Strict intake - output monitoring, ensure laboratory investigation as
renal function test and routine urine are monitored as per need.
b. Sedation
– Administer drugs preferably at bed time.
– Ask the doctor to change to less sedating drugs, as far as, possible
– Instruct the patient not to drive or work in places involving dangerous equipment and
machineries.
c. Orthostatic hypotension:
– B.P. monitoring and recording at lying and standing position.
– Instruct the patient to rise slowly from a lying or sitting position.
d. Photosensitivity: Ask the patient to protect from sunlight

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 e. Endocrine effects
– Amenorrhea and lactation (women): reassurance
– Weight gain: calorie- controlled diet, exercise
– Decreased libido, gynaecomastia (men): reassurance
f. Reduction of seizure threshold:
- Close observation of patient with history of seizures.
g. Agranulocytosis:-
– Observe symptoms of sore throat, fever, malaise.
– Ensure complete blood count is monitored regularly.
h. Extrapyramidal side effects (EPS):-
– Observe for the symptoms of EPS and report immediately.
– Administer anti-parkinsonian drugs as prescribed.
i. Neuroleptic malignant syndrome (NMS):
– Immediate stopping of the anti-psychotics and supportive measures to imply.
4. Observe for drug interactions:
a. Drugs that increase effects of antipsychotic drugs:
– Anticholinergic drugs (e.g., atropine): potentiate anticholigergic effects
– Antidepressants, tricycles: potentiate sedative and anticholinergic effects.
– Antihistamines: acts as additive CNS depressants and sedatives
– CNS depressants (e.g. alcohol, narcotic analgesics, antianxiety agents, barbiturates and
other sedatives): potentiate sedative effects.
– Propranolol (e.g. Inderal): acts as additive hypotensive and may potentiate cardiac
arrhythmias
b. Drugs that decrease effects of antipsychotic drugs
– Antacids (e.g. oral antacids, especially Aluminum hydroxide and Magnesium
trisilicate): may inhibit gastrointestinal absorption of antipsychotic drugs.
– Barbiturates: may induce drug-metabolizing enzymes in the liver and decrease effects of
antipsychotic drugs.
– Norepinephrine (e.g.Levophed), Phenylephrine (e.g.Neo-synephrine): antagonize the
hypotensive effects of antipsychotic drugs.
5. Teach clients:
a. Do not take antacids with these drugs. If an antacid is needed, take it 1 hour before or 2
hours after the anti-psychotic drug. Antacids may decrease absorption of these drugs from
the intestine.
b. Lie down for about an hour after receiving medication when drug therapy is started or after
any injection to avoid low blood pressure, dizziness, and faintness, this may occur with
standing.
c. If dizziness and faintness occur on standing, they can be minimized by changing positions
slowly and sitting on the bedside a few minutes before standing. Do not try to stand or

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 walk when feeling dizzy as to avoid falls or other injuries.
d. Practice good oral hygiene measures, including dental checkups, and frequent tooth
brushing. Drink fluids, and practice frequent mouth rinsing as mouth dryness is a common
side effect of these drugs. Although more annoying than serious for the most part, it can
predispose to mouth infections, dental cavities, and ill-fitting dentures.
e. If skin reactions occur, stay out of sunlight or wear protective clothing and use sunscreen
lotions. Sensitivity to sunlight is an adverse reaction of these drugs.
f. Avoid exposure to excessive heat. Fever (hyperthermia) and heat prostration may occur
with high environmental temperatures.

B. Anti-anxiety including Sedatives and Hypnotics

These drugs are mostly mild CNS depressants which are aimed to control the symptoms of
anxiety, produce a restful state of mind without interfering with normal mental or physical
functions.
Features of anti anxiety, sedative and hypnotic are as follows.
– Have no therapeutic effect to control thought disorder of schizophrenia.
– Do not produce extra pyramidal side effects.
– Have anticonvulsant property
– Produce physical dependence and carry abuse liability.
Commonly used Anti- anxiety agents:
A. Non barbiturate:
S. Name of Dose Rout Remark
N. Medicine e
Benzodiazepi
nes
1 Chlordiazepo (15 – 100) Oral
xide mg/day
2 Diazepam (5 – 50) Oral / Muscle Relaxant
mg/day Inject
ion
3 Nitraepam (5 – 30) Oral Hypnotics
mg/day
4 Clonazepam (0.5 – 10) Oral
mg/day
5 Lorazepam (2 – 6) Oral
mg/day
6 Alprazolam (0.25 – 6) Oral
mg/day
7 Midazolam (5 – 15) Inject Anaesthesia
mg/day ion
Non Particularly not

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 benzodiazepi sedating like
nes benzodiazepines
1 Buspirone (15 – 40) Oral Particularly
mg/day effective in
reducing
symptoms of
worry,
apprehension,
difficulties with
concentration and
congnition and
irritability
2 Propranolol (40 – 250) Oral Effectively
mg/day interrupts the
physiological
responses of
anxiety.

B. Barbiturate:
S.N Name of Dose Route Rema
. Medicine rk
1 Phenobarbit (100 – 200) Oral
al mg/day
Mechanism of Action
Barbiturates produce CNS depression by inhibiting functions of nerve cell, such as electrical
stimulation, depolarization, impulse transmission, and neurotransmitter release. Neurons in the
reticular formation which control cerebral cortex activity and level of arousal or wakefulness
are especially sensitive to the depressant effect of barbiturates.
Benzodiazepines bind with a receptor complex in the nerve cells of the brain; this receptor
complex also has binding sites for gamma- aminobutyric Acid (GABA). This
GABA/benzodiazepines receptor complex regulates the entry of chloride ions into the cell. When
GABA binds to the receptor complex, chloride ions enter the cell and stabilized (hyperpolarize)
the cell membrane so that it is less responsive to excitatory neurotransmitters such as
norepinephrine. Benzodiazepines bind at a different site on the receptor complex and enhance the
inhibitory effect of GABA to relieve anxiety, tension and nervousness and to produce sleep.
Indications for Use:
Benzodiazepines
– Before surgery
– Delirium tremens in acute alcohol with drawl
– Insomnia

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 – Sedation before invasive procedure, diagnostic test
– Convulsion
Barbiturates
– Before surgery
– Convulsion
Contraindication:
– Severe respiratory disorders
– Severe liver or kidney disease
– Hypersensitivity reaction
– History of alcohol or other drug abuse
Side effects of drug: Side effects of anti-anxiety, sedatives and hypnotics according to the effect
on various systems:
a. Central nervous system
– Drowsiness
– Ataxia
– Confusion
– Depression
– Blurred vision
b. Cardio vascular system
– Hypotension
– Palpitations
– Syncope
c. Allergic
– Allergic rashes
d. Endocrine system
- Changes in libido
e. Others
– Physical or psychological dependence (benzodiazepines and barbiturates group of drugs
have a high risk of abuse or physical dependence).
– Acute toxicity of barbiturates that can be fatal when taken in excessive dosage usually
for suicidal attempts. Overdose can cause tachycardia, hypotension, shock, respiratory
depression, coma and death.
Nursing considerations during administration of anti-anxiety, hypnotics and sedatives:
1. Administer accurately
a. Prepare the client for sleep before giving hypnotic doses of any drug. Most of the drugs
cause drowsiness within 15 to 30 minutes. The client should be in bed when he or she
becomes drowsy to increase the therapeutic effectiveness of the drug and to decrease the
likelihood of falls or other injuries.

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 b. Give medication with a glass of water or other fluid. The fluid enhances absorption of the
drug for a quicker onset of action.
c. Raise bedrails, and instruct the client to stay in bed or ask for help if necessary to get out of
bed to avoid falls and other injuries related to sedation and impaired mobility.
2. Observe for therapeutic effects:
Therapeutic effects depend largely on the reason for use. When a drug is given for anti
anxiety effects, observe for:
a. An appearance of being relaxed (perhaps drowsy, but easily aroused).
b. Verbal statements, such as "less worried" "more relaxed,” resting better"
c. Decrease or absence of manifestations of anxiety, such as rigid posture, facial grimaces, crying,
elevated blood pressure and heart rate.
(Note: With benzodiazepines, decreased anxiety and drowsiness may appear within a few
minutes. Antianxiety effects may occur within 7 to 10 days of regular use, with optimal
effects in 3 to 4 weeks.)
3. Observe for side effects and manage accordingly:
1. Drowsiness, confusion, lethargy: Instruct patient not to drive or operate dangerous
machinery while on medication.
2. Addiction: Instruct the patient not to increase the dose on their own or not to quit the drug
abruptly.
3. Potentiate the effect of other CNS depressants: Instruct the patient not to drink alcohol or
take other tranquilizers without prescription.
4. Aggravate symptoms in depressed persons: Take suicidal precautions.
5. Orthostatic Hypotension:
- B.P. monitoring and recording at lying and standing position.
- Instruct the patient to rise slowly from a lying or sitting position.
6. Paradoxical excitement: Withhold drug and inform the doctor.
7. Nausea: Instruct the patient to take drug with food.
4. Observe for drug interactions
a. Drugs that increase effects of anti-anxiety and sedative-hypnotic drugs:
– Alcohol, narcotic analgesics, tricyclic antidepressants, antihistamines, climetidine,
disulfiram, fluoxetine, isoniazid, ketoconazole, metoprolol, omeprazole, oral
contraceptives, propranolol, valproic acid.
b. Drugs that decrease effects of anti-anxiety and sedative hypnotic agents:
– CNS stimulants, appetite suppressants (e.g. phenyl propanolamine), bronchodilators, nasal
decongestants and social drugs (e.g., caffeine, nicotine).
– Enzyme inducers (e.g., barbiturates): With chronic use, these drugs antagonize their
own actions and the actions of other drugs metabolized in the liver. They increase the
rate of drug metabolism and elimination from the body.
c. Drugs that increase effects of barbiturates

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 – Acidifying agents (e.g., ascorbic acid). These agents increase absorption of barbiturates
in the gastrointestinal tract (GI) and increase drug reabsorption in renal tubules (except
for Phenobarbital).
– Benzodiazepines (e.g. diazepam): May potentiate sedative and respiratory depression
effects of barbiturates.
d. Drug that decrease effects of barbiturates:
– Alkalinizing agents (e.g. sodium bicarbonate) increase renal excretion of Phenobarbital;
have been used in treating Phenobarbital overdose.
5. Teach clients
a. Use no drug measures to promote relaxation and sleep when possible. Relaxation
techniques are safer than any drug.
b. Store drugs safely. Keep them out of reach of children and adults who are confused or less
than alert.
c. Do not drive a car or perform other tasks that require alertness if drowsy from medication. The
drugs often impair mental and physical functioning and thereby, make routine activities
potentially hazardous.
d. Avoid alcohol and other depressant drugs.
e. Omit one or more doses if excessive drowsiness occurs to avoid difficulty in breathing,
falls, and other adverse drug effects.
f. Use the drugs only when necessary. Do not increase dosage and frequency of
administration, and do not take for prolonged periods.
g. Caffeine- containing beverages and stimulant drugs can cancel or decrease the antianxiety
and sedative effects of these drugs.

C. Antidepressants
Antidepressant drugs are used in the pharmacologic management of depressive disorders.
Mechanism of action
The exact mechanism of action is not known. According to the clinical studies, it increases the
catecholamine levels in brain (amine hypothesis). Antidepressant drugs probably exert their
effect by regulating or normalizing abnormal neurotransmission systems in the brain. More
specifically, the drugs increase the amount of norepinephrine or serotonin in the CNS synapse
and alter the number or sensitivity of receptors.
Indication for Use
a. Depression (any type of depression)
– Manic-depressive psychosis - depressive phase
– Depressive episode with psychotic feature.
– Abnormal grief reaction.

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 b. Childhood psychiatric disorders
– Enuresis
- Attention deficit hyperactive disorder
– School phobia,
- Separation anxiety
– Somnambulism
- Night terrors
c. Other psychiatric disorders
– Panic attack
– Agoraphobia & social phobia
– Obsessive compulsive disorder
– Aggression in elderly (e.g. Trazodone)
– Eating disorder (e.g. Fluoxetine)
– Borderline personality disorder
– Post traumatic stress disorder (PTSD)
– Anxiety
– Nicotine dependence
– Alcohol dependence
d. Medical disorder
– Chronic pain
– Migraine
– Peptic ulcer disease (e.g. Doxepine)
Contraindications for Use
– Arrhythmias
– Mania
– Acute schizophrenia
– Mixed mania and depression
– Severe renal, hepatic or cardiovascular disease
– Narrow angle glaucoma
– Seizure disorders
Commonly used antidepressant drugs
1. Cyclic antiderpressant
S.N Name of Dose Route Remark
. Medicine
1 Imipramine (25 – Oral
300)mg/day
2 Amitriptyline (10 – Oral
300)mg/day

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 3 Doxepine (75 – Oral
300)mg/day
4 Tri-imipramine (75 – Oral
300)mg/day
5 Clomipramine (75 – Oral
250)mg/day
6 Nortriptyline (75 – Oral
200)mg/day
7 Mianserin (30 – Oral
120)mg/day
8 Amoxapine (150 – Oral
400)mg/day
2. Selective serotonin reuptake inhibitors (SSRIS):
S.N Name of Dose Rout Remar
. Medicine e k
1 Fluoxetine (10 – 60)mg/day Oral
2 Sertraline (25 – Oral
200)mg/day
Escitalopram/ (10 – 40)mg/day Oral
Citalopram
Paroxetine (10-50)mg/day Oral
Fluvoxamine (50-300)mg/day Oral
3. Serotorin norepinepharine reuptake inhibitors (SNRIS)
S.N. Name of Dose Route Remark
Medicine
1 Venlafaxine (37.5 – Oral
375)mg/day
4. Noradrenergic and specific serotonergic antidepressants (NASSA)
S.N. Name of Medicine Dose Route Remark
1 Mirtazapine (7.5 – Oral
45)mg/day
Side effects
– Dry mouth
– Tachycardia
– Palpitation
– Impotence
– Constipation
– Difficulty in accommodation
– Rarely hyperpyrexia and paralytic illeus

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 – Lethargy
– Headache
– Drowsiness
– Tremors
– Sweating
– Convulsion
– Urticaria
– Skin rash
– Cholestatic Jaundice
– Cardiac arrhythmias
– Orthostatic hypotension
– Agranulocytosis
– Gynaecomastia
– Gallactorrhoea
– Drug dependency
– Weight loss or gain
Nursing consideration during Administration of Antidepressant drug
1. Administer accurately
For e. g. give fluoxetine in the morning to prevent insomnia.
2. Observe for therapeutics effects
With antidepressants, observe for statements of "feeling better" or "being less depressed", "increased
appetite", "increased physical activity", and "interest in surroundings", "improved sleep pattern",
"improved appearance", "decreased anxiety", "decreased somatic effect". Therapeutic effects
usually do not occur for 2 to 3 weeks after drug therapy is started.
3. Observe for side effects and manage accordingly:
1. Anticholinergic effects:
a. Dry mouth
- Frequent sips of water, sugarless candy.
b. Blurred vision
- Reassurance
c. Constipation
- Advise food high in fiber, physical exercise, fluid intake etc.
d. Urinary retention
- Intake- output monitoring
- Instruct patient to report
2. Sedation:
– Administer drugs preferably at bed time.
– Ask the doctor to change to less sedating drugs
– Instruct the patient not to drive or work in places involving dangerous equipment and
machineries.

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 3. Orthostatic hypotension:
– B.P. monitoring and recording at lying and standing position.
– Instruct the patient to rise slowly from a lying or sitting position.
4. Tachycardia, arrhythmias:
- Monitor E.C.G. as well as B.P and report to the doctor and follow the instruction
accordingly if needed.
5. Allergic side effects:
a. Agranulocytosis
b. Cholestatic jaundice
c. Skin rashes
– Inform to the doctor
– Monitor the sign of infection
– Isolation
– Supportive care
4. Teach clients
a. Avoid activities that require high degrees of alertness and physical coordination (e.g.
operating a motor vehicle or other machinery) until reasonably sure the medication does
not impair abilities.
b. For safety, avoid alcohol and other CNS depressants. Additive CNS depression may occur.
c. Do not take other prescription or over the counter drugs without consulting a health care
provider. Potentially serious drug interactions may occur.
D. Mood stabilizing drugs/Antimanic agents

Lithium carbonate
Lithium carbonate is effective in treating causes of mania. It is a potential antimanic agent.
Mechanism of action
Exact mechanism of action is not clear. Antimanic agents produce many neurochemical changes
in the area of brain. These changes may affect norepinehrine and serotonin in the part of CNS
involved in emotions. It may decrease the nerve impulse, resulting in depression or mania.
Lithium is thought to enhance the uptake of the biogenic amines in the brain, thus lowering their
level in the body.
Indication
– Mania and recurrent manic episodes
– Bipolar disorder
– Seizures
Contra-indication
– Renal impairment
– Sodium depletion or receiving diuretics
– Cardiovascular problem
– Pregnancy

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Commonly used drug for treatment of Mania:
S.N. Name of Dose Route Rema
Medicine rk
1 Lithium (900 – 1200) Oral “Dru
carbonate mg/day g of
choic
e”
2 Sodium (1000 – 3000) Oral
valporate mg/day
3 Valporate (1000 – 3000) Oral
chorono mg/day
4 Carbamazepine\ (600 – 1600) Oral
Zeptal CR mg/day
Side effects
1. Lithium:
– Dry mouth
– Pulse irregularities
– Headache
– Tremors
– Twitching, muscles spasm
– Seizures
– Anorexia (Loss of Appetite)
– Nousea / Vomiting / Diarrhoea
– Polyurea
– Alopecia
– Dryness of Hair
2. Sodium Valporate:
– Nausea
– Vomiting
– Sedation
– Tremor
– Flushing
– Weight gain
– Menstrual disturbances
– Loss of hair
3. Carbamazepine:
– Drowsiness
– Dizziness
– Nausea

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 – Vomiting
– Diplopia
– Ataxia
– Skin rashes
– Photo sensitivity
– Jaundice
– Hypertension
– Leucopenia etc.
Nursing considerations during administration of Lithium therapy:
a. Give medicine during or after meal to decrease gastric irritability.
b. Make observation of side effects of medicine and record and report immediately.
c. Monitor serum Lithium level – monitor serum lithium level at least after one week of
starting drugs and then monitor at each three month interval. Normal level is (0.8-1.2)
meq / liter. Toxicity occurs if > 2meq/ liter.
d. Maintain intake and out put .Focus on balanced fluid intake.
e. Observe for signs of "Lithium toxicity". Monitor for persistent nausea, vomiting, tremors,
dehydration, restless, polyuria etc.
f. Avoid machinery work before the Lithium level is maintained.
g. Weight should be recorded before lithium therapy. And Weight record weekly. Observe
for swelling of ankles and wrists.

E. Anti-parkinsonian drugs
These drugs are effective against all forms of “parkinsonism” and anti- psychotic induced extra-
pyramidal side effects. But is not effective against tradive dyskinesia. The main mechanism of
action is that it blocks action of acetylcholine, thereby reducing excitement of basal ganglia.
Use:
– To treat and prevent EPS and other side effects.
Contraindication:
– History of closed angle glaucoma
– Urinary retention
– Intestinal obstruction
– Prostatic hypertrophy
– Tachycardia
– Hypersensitivity
Commonly used Anti-parkinsonians:
S. Name of Dose Route Remark
N. Medicine
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 Anticholinergics
1 Trihexyphenidy (1- Oral
l (Pacitane) 6)mg/day
2 Benzexasol (1-6) Oral
(Benzex) mg/day
Antihistamine
1 Diphenydramine (75-100) Oral
(Benadryl) mg/day
2 Phenergan 10mg/day Oral (25 -50) mg
IM/IV (in
allergic
condition)
Phenergan: Anti - emetic medicine. It also works as sedative.
Indication
– Allergic condition (prevention, treatment)
– Vomiting.
Contra-indication
– Hypersentivity (Allergic)
– Lactation
– Obstruction
– Paralytic illus
Side effect
– Dryness of mouth
– Blurring vision
– Retention of urine
– Constipation
– Glaucoma
Dose
– 25 -50 mg IM/IV (in Allergic condition), (10mg -Tab BD / TDS)
– Sever condition - 100mg (im or iv in Sever condition)
Nursing implication
– Give deep I /M Injection
– Give slowly.
– Observe for action.
Pacitane (Trihexyphenidyl)
Indication

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It is used to reduce the Side effect (EPS) of Antipsychotic medicine.
Side Effects
– Dryness of mouth
– Blurring of vision
– Constipation
Dose: 2 mg Oral TDS
Nursing implication: nursing management according to side effects.

F. Anti-convulsant/anti epileptic agent

Apart from their main role as anti-epileptic agents, anti-convulsants are widely used in the
management of psychiatric disorders.
Commonly used drugs are:
1. Sodium valporate
2. Carbamazepine
3. Phenytoin
4. Phenobarbital
5. Diazepam (Anticonvulsant)

II. Electroconvulsive Therapy (ECT)

Electroconvulsive therapy is a type of Physical treatment first introduced in April, 1938 by
Italian psychiatrists Lucio Bini and Ugo Cerletti in Rome. From 1980 onwards ECT is being
considered as a unique psychiatric treatment.
In Electroconvulsive therapy, there is the artificial induction of a grandmal type of seizure
through the application of electrical current to the brain. The stimulus is applied through
electrodes that are placed either bilaterally in the fronto-temporal region, or unilaterally on the
non-dominant side (right side of head in a right-handed individual).
Parameters of electrical current applied
Standard dose according to American Psychiatric Association (APA), 1978:
– Voltage – 70 -120 volts (may be varies device to device)
– Duration – 0.7 - 1.5 seconds
Types of Seizure produced
– Grandmal seizure – tonic phase lasting for 10 – 15 seconds
– Clonic phase lasting for 30 – 60 seconds
Mechanism of action
The exact mechanism of action is not known. A number of researchers have demonstrated that
electric stimulation results in significant increases in the circulating levels of several
neurotransmitters. These neurotransmitters include serotonin, norepinephrine, and dopamine, the

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same biogenic amines that are affected by antidepressant drugs.
Types of ECT
– Direct ECT: In this, ECT is given in the absence of anesthesia and muscular relaxation.
This is not a commonly used method now in developed context.
– Modified ECT: Here, ECT is modified by drug induced muscular relaxation and general
anesthesia.
Frequency and total number of ECT
– Frequency: Three times per week or as indicated.
– Total number: 9 to 10; up to 25 may be preferred as indicated.
Application of electrodes
– Bilateral ECT: Each electrode is placed 2.5 – 4 cm (1-1 ½ inch) above the midpoint, on a
line joining the tragus of the ear and the lateral canthus of the eye.
– Unilateral ECT: Electrodes are placed only on one side of head, usually on non-dominant
side (right side of head in a right-handed individual).
Note: Unilateral ECT is safer, with much fewer side-effects particularly those of memory
impairment.
Indications
a. Major depression: With suicidal risk; with stupor; with poor intake of food and fluids;
melancholia with psychotic features with unsatisfactory response to drugs or where drugs
are contraindicated or have serious side-effects.
b. Severe catatonia (functional): With stupor; with poor intake of food and fluids; with
unsatisfactory response to drug therapy, or when drugs are contraindicated or have serious
side effects.
c. Severe psychosis (schizophrenia or mania): With risk of suicide, homicide or danger or
physical assault; with depressive features; with unsatisfactory response to drug therapy, or
when drugs are contraindicated or have serious side effects.
d. Not improved by medication
e. Postnatal Psychosis
Contraindications
a. Absolute: Raised intracranial pressure (ICP)
b. Relative
– Cerebral aneurysm
– Cerebral hemorrhage
– Brain tumor
– Acute myocardial infarction
– Congestive heart failure
– Pneumonia or aortic aneurysm

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 – Retinal detachment
– Old fracture long bone and Osteoporosis
– Cardiac respiratory failure
– Permanent pacemaker insertion
Complications of ECT
a. Life threatening complications of ECT are rare. ECT does not cause any brain damage.
b. Fractures can sometimes occur in elderly patients with osteoporosis. In patients with a history
of heart disease, cardio and respiratory arrest may occur.
Side effects of ECT
– Memory impairment
– Drowsiness, confusion and restlessness
– Poor concentration, anxiety
– Headache, weakness/fatigue, backache, muscle aches
– Dryness of mouth, palpitations, nausea, vomiting
– Unsteady gait
– Tongue bite and incontinence of bowel and bladder
ECT Team
Psychiatrist, anesthesiologist, trained nurses and aides should be involved in the administration
of ECT.
Treatment facilities/equipments
There should be a suite of three rooms:
a. A pleasant, comfortable waiting room (pre-ECT room)
b. ECT room, which should be equipped with ECT machine accessories, anesthetic
appliances, suction apparatus, face masks, oxygen cylinders with adjustable flow valves,
curved tongue depressors, mouth gags, resuscitation apparatus and emergency drugs. There
should be immediate access to a defibrillator.
c. A well – equipped recovery room.
Role of the Nurse
Pre-ECT Care
a. Detailed medical and psychiatric history, including history of allergies.
b. Assessment of patient’s and family’s knowledge of indications, side-effects, therapeutic
effects and risks associated with ECT.
c. An informed consent should be taken. Allay any unfounded fears and anxieties regarding
the procedure.
d. Check through physical examination, including ECG, X-ray, and biochemistry of blood.
Assess baseline vital signs.
e. Patient should be on empty stomach for 6-8 hours prior to ECT.
f. Withhold night doses of drugs, like diazepam, barbiturates and anticonvulsants.

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 g. Withhold oral medications in the morning.
h. Head shampooing in the morning since oil causes impedance of passage of electricity to
brain.
i. Any jewellery, prosthesis, dentures, contact lens metallic objects and tight clothing should
be removed from the patient’s body.
j. Empty bladder and bowel just before ECT.
k. Remove lipstick, nail polish, and other make up.
l. Prepare all necessary equipment, emergency drugs, ECT machine, suction machine,
oxygen cylinder, mask etc.
Intra-procedure care
a. Place the patient comfortably on the ECT table in supine position.
b. Stay with the patient to allay anxiety and fear.
c. Give Inj Midazolam or Diazepam as prescribed
d. Give few breathe of O2.
e. In case of modified ECT:
– Assist in administering the anesthetic agent (Thiopental sodium 3 – 5 mg/kg body
weight) and muscle relaxant (1 mg/kg weight of Succynylcholine).
– Since the muscle relaxant paralyzes all muscles including respiratory muscles, patient’s
airway should be ensured and ventilatory supports should be started.
f. Mouth gag should be inserted to prevent possible tongue bite.
g. The places of electrode should be cleaned with normal saline or 25 percent bicarbonate
solution, or a conducting gel.
h. Support the shoulder and arms tightly, restraint the thighs with the help of sheet.
i. Hyperextension of the head with support to the chin.
j. Monitor voltage, intensity and duration of electrical stimulus given.
k. Give ECT with adjusting voltage.
l. Make an observation of grand mal seizures .The presence of initial tonic stage which last
for (10-15) seconds, followed by convulsion lasting for (25 to 30) seconds. Then there is a
phase of muscular relaxation with sterious respiration.
m. Do suction immediately.
n. Restore respiration by giving full oxygen with mask.
o. Check vitals- pulse, respiration, blood pressure and cyanosis.
p. Record the findings and medicines given in the patient’s chart.
Post procedure care
a. Monitor vital signs
b. Continue oxygenation till spontaneous respiration starts.
c. Assess for post-ictal confusion and restlessness.
d. Take safety precautions to prevent injury (side-laying position and suctioning to prevent
aspiration, use of side rails to prevent falls).
e. If there is severe post-ictal confusion and restlessness, IV diazepam may be administered.
Romina Shrestha, IDEAL[Type text] Page 23
 f. Close observation of the patient till 2 hours time.
g. Allow the patient to sleep for two hours if he or she wants to sleep.
h. Reorient the patient after recovery and stay with him/her until fully oriented.
i. Make observation of any changes.

III. Psychotherapy
Definition
Psychotherapy is planned and systematic application of psychological facts and theories to
alleviate a large variety of human ailments and disturbances, particularly those of psychogenic
origin.
There are several kinds of psychotherapies:
A. Psychoanalysis
In psychoanalysis, the therapist helps the patient to discover and cope with thoughts and feelings
that directed his behavior but of which he is unaware. It is time consuming, expensive and not be
suitable for everyone. Psychoanalysis is more commonly preferred in hysteria, other neurotic
disorders and mild personality disorders.
There are several key features in psychoanalysis:
A comfortable physical environment
Freud felt that it was very important to make the patient comfortable. He had them lay down on a
soft couch, and provided pillows and comforters to wrap themselves in, if they should feel the
need, giving him a chance to relax and get in touch with their deeper unconscious mind.
An accepting social environment
Even more important was to make the patient feel at ease socially. They should be permitted to
express freely and try to behave in a socially acceptable fashion.
Free association
Free association is the central “technique” of psychoanalysis. It is just a matter of the patient
talking about whatever comes to mind. It’s another way of getting a person to relax: just talking
about whatever they want makes comfortable.
Slips of tongue
A slip of tongue is technically called a parapraxis, and is commonly called a Freudian slip.
Sometimes, we say things we didn’t intend to say, and a little bit of what we are thinking about
comes out by accidents. Freud considered these clues very significant.
Dream interpretation
Freud is, of course, famous for his views on dream interpretation. Basically, he believed that
when we dream, our defenses are down, and things that we are deeply concerned about rise to
the surface.
Transference

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Transference is when the patient begins to feel feelings towards the therapist. It can be anger; it
can be affection; it can even be sexual desires. Freud believed that these feelings were actually
being transferred from their true object- some important person in the patient’s life- onto the
therapist. Transference is therefore an important clue. Freud also believed that transference was
necessary to progress in therapy, in that it takes what is going on in the patient’s unconsciousness
and brings it out into the real world. It is only a matter of time until the patient comes to realize
what those feelings truly represent.
Catharsis
Catharsis is an outpouring of “pent-up” emotions. When the client makes a breakthrough, they
may become very emotional- whether it be ranting and raving and storming around the office, or
the much more common outburst of crying. Freud considered this a very good sign indeed.
Insight
Ultimately, a patient will achieve insight into their problems. They will as Freud put it, “make
the unconscious conscious”. This is the goal of therapy. Once a person can see the original
trauma face-to- face, recognize if for what it is, come to understand it as an adult, and lay it back
to rest, their symptoms should disappear, and they are on the road to recovery.

B. Behavioral therapy
Behavioral therapy focuses upon the application of certain principles of learning theory in order
to create favorable changes.
The assumption of behavioral approach is that problematic behavior occurs when there has been
inadequate learning and therefore it can be corrected through the provision of appropriate
learning experiences.
It is used for the treatment of phobia, obsessional thoughts, compulsive behaviors, schizophrenic
mannerisms, eating disorders and others undesirable habits like smoking, drinking and sexual
perversion.
It is specialized form of treatment and only some principles are described.
For the treatment of phobia
1. Systematic desensitization: The phobic patient is exposed slowly to a gradual hierarchy of
phobic objects or situations.
2. Flooding: The phobic patient is forced to remain in the phobic situation until his anxiety
is exhausted.
3. Implosion: The phobic patient is instructed to imagine the phobic situation and remain in
it until his anxiety is exhausted. Imagination is used when any other way is not feasible.
For the treatment of compulsive acts
1. Modeling: Where the therapist carries out the act which the patient is afraid of and
requires the patient to imitate.
2. Response Prevention: Where the therapist prevents the patient from avoiding unpleasant

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 acts or situations.
3. Thought Stopping: Where the therapist prevents the patient from continuing to ruminate
his obsessive thoughts by shouting "stop" or inflicting mild pain on his arm with a rubber
band.
For the treatment of schizophrenia or mental retardation
1. Operant Conditioning: The patient is rewarded for desired behavior and punished for
undesirable behavior.
2. Social Skill Training: This is to improve social manners like encouraging eye contact,
speaking appropriately, observing simple etiquette, and relating to people.
For the treatment of alcoholism and sexual deviation
1. Aversion Therapy: The undesirable behavior is paired with an unpleasant stimulus e.g.;
drinking alcohol is followed with a mild electric shock, Disulfiram therapy etc.

C. Cognitive therapy
Cognitive therapy is designed to help a client to identify and change distorted thought (cognitive)
patterns that can lead to feelings and behaviors that are troublesome, self-defeating or self-
destructive. It's based on the premise that how a person interprets his experiences in life
determines the way he feels and behaves. If a person has depression, for instance, he might see
himself and his experiences in negative ways, which worsens the symptoms of depression. Like
behavior therapy, cognitive therapy focuses on one’s current problem, rather than addressing
underlying or past issues or conflicts. Unlike behavior therapy, however, one’s experiences are
an important part of the cognitive therapy process.
Cognitive behavioral therapy
Cognitive-behavior therapy combines features of both cognitive and behavior therapies to
identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones.
It's based on the idea that one’s own thoughts — not other people or situations — determine how
one behaves. Even if an unwanted situation doesn't change, one can change the way he thinks
and behave in a positive way. Cognitive Behavioral therapy is considered effective in the
treatment of depression and adjustment difficulties.
D. Individual psychotherapy
Individual psychotherapy is conducted on a one to one basis.
E. Group therapy
Group therapy is a form of psychosocial treatment, in which a number of clients meet together
with a therapist for the purposes of sharing, gaining personal insight, and improving
interpersonal coping strategies. The patients, usually between eight and twelve in number, learn
from each other as well as therapist.

F. Interpersonal Psychotherapy

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Family therapy 
In family therapy the aim is either to use the family as the social context in which an individual
is treated, or to regard the 'family' itself as the patient. Family therapy involves treatment of two
or more related members, who may represent one or two generations of a family. In family
therapy the main aims of the therapeutic regimen may be supportive, restoration or
reconstructive. It represents a form of intervention in which members of a family are assisted to
identify and change problematic, maladaptive, self-defeating, repetitive relationship patterns.
Family therapy, recently has received a great deal of attention.
Marital therapy
In couple, or marital therapy, the principles of family therapy are applied to a marital couple, or
those in an equivalent relationship.
G. Occupational therapy
Occupational Therapy
Any activity included in the process of rehabilitation can be called occupational therapy.
Occupational therapy works with the patients and their care givers always seeking to encourage
the patient to gain their maximum possible functional ability in all the skills. Functional ability
refers to the person's all possible necessary life skills; this includes washing themselves,
dressing, going to the toilet, sitting and standing from their usual seat getting in and out of bed
and also work skills such as building up stamina to stand for long periods, arm strength for
cutting grass- whatever is needed for their particular work.
Recreational Therapy
Recreation is a form of activity therapy used in most psychiatric settings. It is a planned
therapeutic activity that enables people with limitations to engage in recreational experiences.
Relaxation Therapy
The relaxation therapy aims at producing relaxation to those with anxiety and stress related
problems. Such people are tense and agitated and what they require is a relaxed mind. By
relaxing the body one can achieve relaxation of mind. This forms the basis for all the relaxation
techniques. These include:
– Progressive muscle relaxation technique
– Meditation
– Yoga etc.

V. Psychosocial Rehabilitation
It is the process designed to help the handicapped individuals to make maximum use of their
residual capacities and to enable them to lead a beneficial and meaningful life in the community.
Psychosocial rehabilitation is defined as, "A therapeutic approach to the care of mentally ill
individuals that encourages capacities through learning procedures and environmental supports"
by Banchrach (1992).
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Psychiatric Rehabilitation is the range of social, educational, occupatinal, behavioural and
cognitive interventions for increasing the role performance of persons with serious and persistant
mental illness and enhancing their recovery ( Barton, 1999).
Rehabilitation of mentally ill is an essential component of any therapeutic programme that
purpose to tackle effectively the maladies of mental illness. The main tasks of rehabilitation are
to assist in integrating psychiatrically disabled person into the community and maintain their
ability to function independently.
Rehabilitation is much beneficial to the long term mentally ill people the following disorder are
indicated commonly for rehabilitation:
 Chronic Schizophrenia
 Chronic organic mental disorder
 Mental retardation
 Alcohol and drug dependence
Principles of psychosocial rehabilitation
1. Goal should be focused on improving quality of life as identified by the patient and
family.
2. Rehabilitation takes place in the partnership with a disabled person.
3. Individual difference must be recognized and respected.
4. Rehabilitation must adjust to the changes that people experience over the time.
5. Rehabilitation should not be focused on symptoms and should be focused on improving
capabilities and competencies.
Psychiatric rehabilitation approaches
1. Psycho-education: It includes diagnosing the problem, telling the person what to
expect regarding illness and discussing treatment alternatives.
2. Working with family: Encouraging family members to get involved in treatment and
rehabilitation program.
3. Group therapy: Positive aspect of group therapy includes an opportunity for on going
contact with others, validation for perceptions, sharing their views about problems and
problem solving abilities.
4. Social skill training: It involves teaching specific living skills that the patient is
expected to have in order to survive in the community.
Steps in psychiatric rehabilitation
Psychiatric rehabilitation begins with comprehensive medical psychiatric diagnosis and
functional assessment. The steps of rehabilitation include:
1. Reduction of impairment: It involves reduction or elimination of the symptoms and
cognitive impairments that interfere with social and vocational performance. These
impairments are reduced and eliminated for the greater part by various psychotropic
agents.

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 2. Remediation of disabilities through skill training: Skill training is used to remediate
disabilities in social, family and vocational functioning. Patients generally require training
in self-care skills, interpersonal skills, vocational and employment pursuits, recreational
and leisure skills.
3. Remediation of disabilities through supportive intervention: When restoration of
social and vocational functioning through skill training is limited by continuing deficits,
rehabilitation strategies aim at helping the individuals compensate for handicap by learning
skills in living and working environments, adjusting the individual and family expectations
to a level of functioning that is realistically attainable.
4. Remediation of handicaps: In addition to clinical rehabilitation interventions, the
disabled person can be helped to overcome their handicaps through social rehabilitations
e.g. community support programs.
Interventions in psychosocial rehabilitation
1. Social skill training: include modeling, shaping, positive reinforcement, goal setting,
home work etc.
2. Vocational rehabilitation: include job training, job club, and job coach for certain
particular job
3. Cognitive training
4. Environmental restructuring
5. Occupational therapy
Role of a nurse in rehabilitation
Rehabilitative psychiatric nursing must be studied in the contexts of patient’s and social system.
This requires the nurse to focus on three elements; the individual, family and community.
 Assess the patient’s ability, interest and need related to occupational therapy.
 Plan activities with the help of the patient.
 Encourage the patient to participate and achieve the goal.
 Set a realistic goal.
 Include the family members in this process; explain that it is dangerous to isolate him/her and
to discourage him/her from working. Ask them to involve the patient in household work after
discharge.
 Make sure that activities are interesting and stimulating but not too difficult.
 Be available and provide support when necessary.
 Make observation of the patient’s behavior.



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