NCM 117 LECTURE – PRELIMS

FOUNDATION OF PSYCHIATRIC – MENTAL HEALTH  Includes disorders that affect mood, behavior,
NURSING and thinking, such as depression, schizophrenia,
anxiety disorders, and addictive disorders.
The field of mental health often seems a little
unfamiliar or mysterious, making it hard to imagine what  Mental disorders often cause significant distress
the experience will be like or what nurses do in this area. or impaired functioning or both.
This chapter addresses these concerns and others by FACTORS CONTRIBUTING TO MENTAL ILLNESS
providing an overview of the history of mental illness,
advances in treatment, current issues in mental health, Individual factors include biologic makeup, intolerable
and the role of the psychiatric nurse. or unrealistic worries or fears, inability to distinguish
reality from fantasy, intolerance of life’s uncertainties,
HEALTH DEFINED ACCORDING TO THE WORLD
a sense of disharmony in life, and a loss of meaning in
HEALTH ORGANIZATION;
one’s life.
Health is a state of complete physical, mental, and
Interpersonal factors include ineffective communication,
social wellness, not merely the absence of disease or
excessive dependency on or withdrawal from
infirmity. This definition emphasizes health as a positive
relationships, no sense of belonging, inadequate social
state of well-being. People in a state of emotional,
support, and loss of emotional control.
physical, and social well-being fulfill life responsibilities,
function effectively in daily life, and are satisfied with Social/cultural factors include lack of resources, violence,
their interpersonal relationships and themselves. homelessness, poverty, an unwarranted negative view of
the world, and discrimination such as stigma, racism,
MENTAL HEALTH:
classism, ageism, and sexism. It can result in isolation,
NOTE: No single universal definition of mental health feelings of alienation, and maladaptive, violent, or
exists criminal behavior

In most cases, mental health is a state of emotional, Discrimination: The unjust or prejudicial (unfair)
psychological, and social wellness evidenced by treatment of different categories of people or things,
satisfying interpersonal relationships, effective behavior especially on the ground of race, age, or sex. (Oxford)
and coping, positive self-concept, and emotional stability.
CATEGORIES:
FACTORS INFLUENCING A PERSON”S MENTAL
HEALTH Stigma: A strong feeling of disapproval that most people
in a society have about something (Cambridge
Individual or personal: factors include a person’s Dictionary); mark of disgrace (Oxford)
biologic makeup, autonomy and independence, self-
esteem, capacity for growth, vitality, ability to find Ageism: Prejudice or discrimination on the grounds of a
meaning in life, emotional resilience or hardiness, sense of person’s age (Oxford)
belonging, reality orientation, and coping or stress Racism: Prejudice, discrimination, or antagonism directed
management abilities. against a person or people on the basis of their
Interpersonal or relationship: factors include effective membership in a particular racial or ethnic group,
communication, ability to help others, intimacy, and a typically one that is a minority or marginalized (Oxford)
balance of separateness and connectedness Sexism: Prejudice, stereotyping, or discrimination,
Social/cultural or environmental: factors include a sense typically against women, on the basis of sex
of community, access to adequate resources, intolerance Classism: Prejudice against or in favor of people
of violence, support of diversity among people, mastery belonging to a particular social class
of the environment, and a positive, yet realistic, view of
one’s world. DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS
MENTAL ILLNESS:
Mental Illness are both health conditions involving The Diagnostic and Statistical Manual of Mental
changes in emotion, thinking or behavior (or a Disorders, fifth edition (DSM-5), is a taxonomy
combination of these) according to American Psychiatric published by the American Psychiatric Association and
Association revised as needed.

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The current edition made some major revisions and In 1775, visitors at the institution were charges a fee for
was released in 2013. The DSM-5 describes all mental the privilege of viewing and ridiculing the inmates, who
disorders, outlining specific diagnostic criteria for each were seen as less than human animals (McMillan, 1997);
based on clinical experience and research. All mental colonies (USA) mentally ill were regarded as possessed
health clinicians who diagnose psychiatric disorders use or evil. Witch hunts were rampant; burning at the stake
this diagnostic taxonomy. as punishment.
THE DSM-5 HAS THREE PURPOSES: PERIOD OF ENLIGHTENMENT AND CREATION OF
MENTAL INSTITUTIONS
 To provide a standardized nomenclature and
language for all mental health professionals In the 1790s, a period of enlightenment concerning
 To present defining characteristics or symptoms persons with mental illness began. Philippe Pinel in France
that differentiate specific diagnoses and William Tuke in England formulated the concept of
 To assist in identifying the underlying causes of asylum as a safe refuge or haven offering protection at
disorders institutions where people had been whipped, beaten,
and starved because they were mentally ill (Gollaher,
THE CLASSIFICATION SYSTEM ALLOWS THE 1995). With this movement began the moral treatment of
PRACTITIONER TO IDENTIFY ALL THE FACTORS THAT the mentally ill. In the United States, Dorothea Dix
RELATE TO A PERSON’S CONDITION: (1802–1887) began a crusade to reform the treatment
of mental illness after a visit to Tuke’s institution in
 All major psychiatric disorders such as England
depression, schizophrenia, anxiety, and
substance-related disorders SIGMUND FREUD AND TREATMENT OF MENTAL
 Medical conditions that are potentially relevant DISORDERS
to understanding or managing the person’s The period of scientific study and treatment of mental
mental disorder as well as medical conditions disorders began with Sigmund Freud (1856–1939) and
that might contribute to understanding the person others, such as Emil Kraepelin (1856–1926) and Eugen
 Psychosocial and environmental problems that Bleuler (1857–1939). With these men, the study of
may affect the diagnosis, treatment, and psychiatry and the diagnosis and treatment of mental
prognosis of mental disorders. Included are illness started in earnest. Freud challenged society to
problems with the primary support group, the view human beings objectively. He studied the mind, its
social environment, education, occupation, disorders, and their treatment as no one had done
housing, economics, access to health care, and the before. Many other theorists built on Freud’s pioneering
legal system. work (see Chapter 3). Kraepelin began classifying
HISTORICAL PERSPECTIVES OF THE TREATMENT OF mental disorders according to their symptoms, and
MENTAL ILLNESS Bleuler coined the term schizophrenia.

ANCIENT TIMES: People of ancient times believed that DEVELOPMENT OF PSYCHOPHARMACOLOGY

any sickness indicated displeasure of the gods and, in A great leap in the treatment of mental illness began
fact, was a punishment for sins and wrongdoing. Those in about 1950 with the development of psychotropic
with mental disorders were viewed as either divine or drugs, or drugs used to treat mental illness.
demonic, depending on their behavior. Chlorpromazine (Thorazine), an antipsychotic drug, and
Aristotle: Imbalances in the amount 4 humors (water, lithium, an antimanic agent, were the first drugs to be
blood, yellow, and black bile) were believed to cause developed. Over the following 10 years, monoamine
mental disorders oxidase inhibitor antidepressants; haloperidol (Haldol),
an antipsychotic; tricyclic antidepressants; and
Early Christian Times: Possessed by Demons; priests antianxiety agents, called benzodiazepines, were
perform exorcisms or are incarcerated and punished introduced. For the first time, drugs actually reduced
agitation, psychotic thinking, and depression. Hospital
Renaissance: Mentally ill are distinguished from criminals stays were shortened, and many people became well
In 1547, The Hospital of St. Mary of Bethlehem was enough to go home. The level of noise, chaos, and
officially declared a hospital for the insane, the first of its violence greatly diminished in the hospital setting.
kind.

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MOVE TOWARD COMMUNITY MENTAL HEALTH The cerebrum is divided into two hemispheres; all
lobes and structures are found in both halves except for
Deinstitutionalization, a deliberate shift from the pineal body, or gland, which is located between the
institutional care in state hospitals to community facilities, hemispheres. The pineal body is an endocrine gland that
began. Community mental health centers served smaller influences the activities of the pituitary gland, islets of
geographic catchment, or service, areas that provided Langerhans, parathyroids, adrenals, and gonads. The
less restrictive treatment located closer to individuals’ corpus callosum is a pathway connecting the two
homes, families, and friends. hemispheres and coordinating their functions. The left
In addition to deinstitutionalization, federal legislation hemisphere controls the right side of the body and is the
was passed to provide an income for disabled persons: center for logical reasoning and analytic functions such as
supplemental security income (SSI) and Social Security reading, writing, and mathematical tasks. The right
disability income (SSDI). hemisphere controls the left side of the body and is the
center for creative thinking, intuition, and artistic abilities.
MENTAL ILLNESS IN THE 21ST CENTURY
The cerebral hemispheres are divided into four lobes:
According to the National Institutes of Health frontal, parietal, temporal, and occipital. Some functions
(2018), 44.7 million people in the United States have a of the lobes are distinct; others are integrated. The
mental illness, though only 19.2 million received frontal lobes control the organization of thought, body
treatment with in the past year. The 18 to 25 age group movement, memories, emotions, and moral behavior. The
had the highest prevalence of mental illness as well as integration of all this information regulates arousal,
the lowest percent of people receiving treatment. focuses attention, and enables problem-solving and
Furthermore, mental illness or serious emotional decision-making. Abnormalities in the frontal lobes are
disturbances impair daily activities for an estimated 15 associated with schizophrenia, attention-
million adults and 4 million children and adolescents. deficit/hyperactivity disorder (ADHD), and dementia. The
parietal lobes interpret sensations of taste and touch and
The WHO estimated that 154 million Filipinos suffer
assist in spatial orientation. The temporal lobes are
from depression, 1 million from schizophrenia, and 15.3
centers for the senses of smell and hearing and for
million from substance use disorders, while 877,000 die
memory and emotional expression. The occipital lobes
due to suicide every year (DOH, 2018)
assist in coordinating language generation and visual
MENTAL HEALTH PROGRAM: DOH interpretation, such as depth perception.
NOTE: Mental Health and well-being is a concern of all CEREBULLUM

Through a comprehensive mental health program that The cerebellum is located below the cerebrum and is
includes a wide range of promotive, preventive, the center for coordination of movements and postural
treatment and rehabilitative services; that is for all adjustments. It receives and integrates information from
individuals across the life course especially those at risk all areas of the body, such as the muscles, joints, organs,
of and suffering from MNS disorders; integrated in and other components of the CNS. Research has shown
various treatment settings from community to facility that that inhibited transmission of dopamine, a
is implemented from the national to the barangay level; neurotransmitter, in this area is associated with the lack of
and backed with institutional support mechanisms from smooth coordinated movements in diseases such as
different government agencies and CSOs, we hope to Parkinson disease and dementia.
attain the highest possible level of health for the nation
BRAIN STEM
because there is no Universal Health Care without mental
health The brain stem includes the midbrain, pons, and
medulla oblongata and the nuclei for cranial nerves III
NEUROBIOLOGIC THEORIES AND
through XII. The medulla, located at the top of the spinal
PSYCHOPHARMACOLOGY
cord, contains vital centers for respiration and
The CNS comprises the brain, the spinal cord, and cardiovascular functions.
associated nerves that control voluntary acts. Structurally,
Above the medulla and in front of the cerebrum, the
the brain consists of the cerebrum, cerebellum, brain stem,
pons bridges the gap both structurally and functionally,
and limbic system.
serving as a primary motor pathway. The midbrain
CEREBRUM connects the pons and cerebellum with the cerebrum. It
measures only 0.8 in (2 cm) length and includes most of
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the reticular activating system and the extrapyramidal be stored for later use (reuptake) or metabolized and
system. The reticular activating system influences motor inactivated by enzymes, primarily monoamine oxidase
activity, sleep, consciousness, and awareness. The
extrapyramidal system relays information about Schematic illustration of (1) neurotransmitter (T)
movement and coordination from the brain to the spinal release; (2) binding of transmitter to postsynaptic
nerves. The locus coeruleus, a small group of receptor; termination of transmitter action by (3a)
norepinephrineproducing neurons in the brain stem, is reuptake of transmitter into the presynaptic terminal, (3b)
associated with stress, anxiety, and impulsive behavior. enzymatic degradation, or (3c) diffusion away from the
synapse; and (4) binding of transmitter to presynaptic
LIMBIC SYSTEM receptors for feedback regulation of transmitter release.
The limbic system is an area of the brain located These neurotransmitters are necessary in just the right
above the brain stem that includes the thalamus, proportions to relay messages across the synapses.
hypothalamus, hippocampus, and amygdala (although Studies are beginning to show differences in the amount
some sources differ regarding the structures this system of some neurotransmitters available in the brains of
includes). The thalamus regulates activity, sensation, and people with certain mental disorders compared with
emotion. The hypothalamus is involved in temperature
regulation, appetite control, endocrine function, sexual
drive, and impulsive behavior associated with feelings of
anger, rage, or excitement. The hippocampus and
amygdala are involved in emotional arousal and
memory. Disturbances in the limbic system have been
implicated in a variety of mental illnesses, such as the
memory loss that accompanies dementia and the poorly
controlled emotions and impulses seen with psychotic or
manic behavior. those who have no signs of mental illness
NEUROTRANSMITTERS Abnormal neurotransmission causing some mental
Neurotransmitters are the chemical substances disorders because of excess transmission or excess
manufactured in the neuron that aid in the transmission of responsiveness of receptors
information throughout the body. They either excite or MAJOR NEUROTRANSMITTERS
stimulate an action in the cells (excitatory) or inhibit or
stop an action (inhibitory). These neurotransmitters fit into TYPE MECHANISM PHYSIOLOGIC
specific receptor cells embedded in the membrane of the OF ACTION EFFECTS
dendrite, just like a certain key shape fits into a lock. Dopamine Excitatory Controls
After neurotransmitters are released into the synapse complex
and relay the message to the receptor cells, they are movements,
either transported back from the synapse to the axon to motivation,
cognition;
regulates
emotional
response
Norepinephrine Excitatory Causes changes
in attention,
learning and
memory, sleep
and
wakefulness,
mood
Epinephrine Excitatory Controls fight or
flight response
Serotonin Inhibitor Controls food
intake, sleep
and

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wakefulness, ethical, legal, and social implications of human genetics
temperature research. This program (known as Ethical, Legal, and
regulation, pain Social Implications, or ELSI) focuses on privacy and
control, sexual fairness in the use and interpretation of genetic
behaviors, information, clinical integration of new genetic
regulation of technologies, issues surrounding genetics research, and
emotions professional and public education.
Histamine Neuromodulator Controls
alertness, gastric THREE TYPES OF STUDIES ARE COMMONLY
secretions, CONDUCTED TO INVESTIGATE THE GENETIC BASIS OF
cardiac MENTAL ILLNESS:
stimulation,
peripheral 1. Twin studies are used to compare the rates of certain
allergic mental illnesses or traits in monozygotic (identical) twins,
responses who have an identical genetic makeup, and dizygotic
Acetycholine Excitatory or Controls sleep (fraternal) twins, who have a different genetic makeup.
Inhibitory and wakefulness Fraternal twins have the same genetic similarities and
cycle; signals differences as nontwin siblings.
muscles to
become 2. Adoption studies are used to determine a trait among
alert biologic versus adoptive family members.
Neuropeptides Neuromodulator Enhance,
prolong, inhibit, 3. Family studies are used to compare whether a trait is
or limit the more common among first-degree relatives (parents,
effects of siblings, and children) than among more distant relatives
principal or the general population.
neurotransmitters
Glutamate Excitatory Results in Although some genetic links have been found in
neurotoxicity if certain mental disorders, studies have not shown that
levels are too these illnesses are solely genetically linked. Investigation
high continues about the influence of inherited traits versus the
y-Aminobutyric Excitatory Modulates other influence of the environment—the “nature versus nurture”
Acid neurotransmitters debate.
STRESS AND THE IMMUNE SYSTEM
NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS (PSYCHOIMMUNOLOGY)
GENETICS AND HEREDITY Psychoimmunology, a relatively new field of study,
Current theories and studies indicate that several examines the effect of psychosocial stressors on the
mental disorders may be linked to a specific gene or body’s immune system. A compromised immune system
combination of genes but that the source is not solely could contribute to the development of a variety of
genetic; nongenetic factors also play important roles. illnesses, particularly in populations already genetically
at risk. So far, efforts to link a specific stressor with a
To date, one of the most promising discoveries is the specific disease have been unsuccessful. However, the
identification in 2007 of variations in the gene SORL1 immune system and the brain can influence
that may be a factor in late-onset Alzheimer disease. neurotransmitters. When the inflammatory response is
Research is continuing in an attempt to find genetic links critically involved in illnesses such as multiple sclerosis or
to other diseases such as schizophrenia and mood lupus erythematosus, mood dysregulation and even
disorders. This is the focus of the ongoing research of the depression are common (Raison & Miller, 2017).
National Human Genome Research Institute, funded by
the National Institutes of Health and the U.S. Department INFECTION AS A POSSIBLE CAUSE
of Energy. This international research project, started in Theories that are being developed and tested include
1988, is the largest of its kind. It has identified all human the existence of a virus that has an affinity for tissues of
DNA and continues with research to discover the human the CNS, the possibility that a virus may actually alter
characteristics and diseases to which each gene is related human genes, and maternal exposure to a virus during
(encoding). In addition, the project also addresses the critical fetal development of the nervous system.
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Prenatal infections may impact the developing brain  Antidepressant
of the fetus, giving rise to a proposed theory that  Anti-Anxiety Medications
inflammation may causally contribute to the pathology of  Stimulants
schizophrenia (DeBost et al., 2017).
 Antipsychotics
 Mood stabilizer
PSYCHOPHARMACOLOGY Psychotropic medications are often decreased
gradually (tapering) rather than abruptly. This is because
Psychopharmacology is the scientific study of the of potential problems with rebound (temporary return of
effects drugs have on mood, sensation, thinking, and symptoms), recurrence (of the original symptoms), or
behavior. withdrawal (new symptoms resulting from discontinuation
It is distinguished from neuropsychopharmacology, of the drug)
which emphasizes the correlation between drug-induced Follow-up care is essential to ensure compliance with
changes in the functioning of cells in the Nervous system the medication regimen, to make needed adjustments in
and changes in consciousness and behavior. dosage, and to manage side effect.
Efficacy refers to the maximal therapeutic effect that a The term Extrapyramidal effects describes
drug can achieve. involuntary movements that you cannot control. These side
Potency describes the amount of the drug needed to effects are most common when taking antipsychotic
achieve that maximum effect; low-potency drugs require medication? When you experience extrapyramidal
higher dosages to achieve efficacy, while high-potency effects, movements that were once voluntary happen
drugs achieve efficacy at lower dosages. without your control.

Halflife is the time it takes for half of the drug to be First-generation ‘typical’ or conventional
removed from the bloodstream. Drugs with a shorter half- antipsychotics are an older class of antipsychotic than
life may need to be given three or four times a day, but second-generation ‘atypical’ antipsychotic. First-
drugs with a longer half-life may be given once a day. generation antipsychotics are used primarily to treat
The time that a drug needs to leave the body completely positive symptoms such as hallucinations and delusions
after it has been discontinued is about five times its half- The third generation of antipsychotics, called
life. dopamine system stabilizers.
Off-label use when a drug will prove effective for a ANTIPSYCHOTIC DRUGS
disease that differs from the one involved in original
testing and FDA approval. Antipsychotic drugs, formerly known as neuroleptics,
are used to treat the symptoms of psychosis, such as the
Delusion: an idiosyncratic belief or impression that is delusions and hallucinations seen in schizophrenia,
firmly maintained despite being contraindicated by what schizoaffective disorder, and the manic phase of bipolar
is generally accepted as reality or rational argument, disorder.
typically a symptom of mental disorder
Off-label uses of antipsychotics include treatment of
Hallucination: defined as the “perception of a anxiety and insomnia; aggressive behavior; and
nonexistent object or event” and “sensory experiences delusions, hallucinations, and other disruptive behaviors
that are not caused by stimulation of the relevant sensory that sometimes accompany Alzheimer disease.
organ”
Antipsychotic drugs work by blocking receptors of the
PSYCHOTROPIC DRUGS neurotransmitter dopamine.
Psychotropic medication is a broad term referring to
medications that affect mental function, behavior, and
experience (NSW Department of Health, 1997).
Psychotropic medications are typically administered to
older adults to manage symptoms of anxiety, depression,
psychological distress, and/or insomnia.
TYPES OF PSYCHOTROPIC MEDICATIONS:
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They have been in clinical use since the 1950s. They In addition, second-generation antipsychotics inhibit
are the primary medical treatment for schizophrenia and the reuptake of serotonin, as do some of the
are also used in psychotic episodes of acute mania antidepressants, increasing their effectiveness in treating
(malakas humalakhak, very active), psychotic depression, the depressive aspects of schizophrenia.
and drug-induced psychosis.
The third generation of antipsychotics, called
dopamine system stabilizers, is being developed. These
drugs are thought to stabilize dopamine output; that is,
they preserve or enhance dopaminergic transmission
when it is too low and reduce it when it is too high. This
results in control of symptoms without some of the side
effects of other antipsychotic medications. Aripiprazole
(Abilify), the first drug of this type, was approved for use
in 2002. Cariprazine (Vraylar) and brexpiprazole
(Rexulti) are newer third-generation antipsychotics. These
drugs are used for schizophrenia, manic episodes, and as
adjunct medication in both bipolar disorder and
depression. The most common side effects are sedation,
weight gain, akathisia, headache, anxiety, and nausea
(Stahl, 2017).
DEPOT INJECTION
A Depot injection is a slow-release form of
medication. The injection uses a liquid that releases the
medication…
Six antipsychotics are available in depot injection, a
MECHANISM OF ACTION time-release form of intramuscular medication for
maintenance therapy.
Two first-generation antipsychotics use sesame oil as
the vehicle for these injections, so the medication is
absorbed slowly over time; thus, less frequent
administration is needed to maintain the desired
therapeutic effects. Decanoate fluphenazine (Prolixin)
has a duration of 7 to 28 days, and decanoate
haloperidol (Haldol) has a duration of 4 weeks
SIDE EFFECTS

Dopamine receptors are classified into subcategories Extrapyramidal Side Effects. Extrapyramidal symptoms
(D1, D2, D3, D4, and D5), and D2, D3, and D4 have (EPSs), serious neurologic symptoms, are the major side
been associated with mental illness effects of antipsychotic drugs. First-generation
antipsychotic drugs cause a greater incidence of EPSs
The conventional, or first-generation, antipsychotic than do second-generation antipsychotic drugs, with
drugs are potent antagonists (blockers) of D2, D3, and ziprasidone (Geodon) rarely causing EPSs (Virani,
D4. This not only makes them effective in treating target Bezchlibnyk-Butler, & Jeffries, 2017).
symptoms but also produces many extrapyramidal side
effects (discussion to follow) because of the blocking of GENERIC ORAL IM/IV Drug Class
the D2 receptors. NAME DOSAGE Dose
S (mg) s
Newer, atypical or second-generation antipsychotic (mg)
drugs, such as clozapine (Clozaril), are relatively weak Amantadine 100 bid Dopaminergic
blockers of D2, which may account for the lower (Symmetrel) or tid agnonist
incidence of extrapyramidal side effects. Benztropine 1-3 bid 1-2 Anticholinergic
(Cogentin)
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Biperiden 2 tid-qid 2 Anticholinergic Pseudoparkinsonism is a reaction to medications that
(Akineton) imitates the symptoms and appearance of Parkinson’s
Diazepam 5 tid 5-10 Benzodiapine disease.
(Valium)
Diphenhydramin 25-50 tiq 25- Antihistamine Symptoms resemble those of Parkinson disease and
e (Benadryl) or qid 50 include a stiff, stooped posture; masklike facies;
Lorazepam 1-2 tid Benzodiazepin decreased arm swing; a shuffling, festinating gait (with
(Ativan) e small steps); cogwheel rigidity (ratchet-like movements of
Procyclidine 2.5 – 5 Anticholinergic joints); drooling; tremor; bradycardia; and coarse pill-
(Kemadrin) tid rolling movements of the thumb and fingers while at rest.
Propranolol 10-20 Beta-Blocker
(Inderal) tid; up to Parkinsonism is treated by changing to an
40 qid antipsychotic medication that has a lower incidence of
Trihexyphenidyl 2-5 tid Anticholinergic EPS or by adding an oral anticholinergic agent or
(Artane) amantadine, which is a dopamine agonist that increases
transmission of dopamine blocked by the antipsychotic
drug. This condition is generally reversible and can be
ACUTE DYSTONIA treated by stopping the medication causing the reaction.
S/S: acute muscular rigidity and cramping, a stiff or AKATHISIA
thick tongue with difficulty swallowing, and, in severe
cases, laryngospasm and respiratory difficulties. is reported by the client as an intense need to move
about. The client appears restless or anxious and
Dystonia is most likely to occur in the first week of agitated, often with a rigid posture or gait and a lack of
treatment, in clients younger than 40 years, in males, and spontaneous gestures. This feeling of internal restlessness
in those receiving high-potency drugs such as haloperidol and the inability to sit still or rest often leads clients to
and thiothixene. discontinue their antipsychotic medication. Akathisia can
Spasms or stiffness in muscle groups can produce be treated by a change in antipsychotic medication or by
torticollis (twisted head and neck), opisthotonus (tightness the addition of an oral agent such as a betablocker,
in the entire body with the head back and an arched anticholinergic, or benzodiazepine.
neck), or oculogyric crisis (eyes rolled back in a locked NEUROLEPTIC MALIGNANT SYNDROME
position).
NMS is a potentially fatal idiosyncratic reaction to an
Acute dystonic reactions can be painful and antipsychotic (or neuroleptic) drug. The major symptoms
frightening for the client. of NMS are rigidity; high fever; autonomic instability such
Immediate treatment with anticholinergic drugs, such as unstable blood pressure, diaphoresis, and pallor;
as intramuscular benztropine mesylate (Cogentin) or delirium; and elevated levels of enzymes, particularly
creatine phosphokinase. Clients with NMS are usually
confused and often mute; they may fluctuate from
agitation to stupor. All antipsychotics seem to have the
potential to cause NMS, but high dosages of high-
potency drugs increase the risk. NMS most often occurs in
the first 2 weeks of therapy or after an increase in
dosage, but it can occur at any time.
Dehydration, poor nutrition, and concurrent medical
illness all increase the risk for NMS. Treatment includes
immediate discontinuance of all antipsychotic medications
and the institution of supportive medical care to treat
intramuscular or intravenous diphenhydramine (Benadryl), dehydration and hyperthermia until the client’s physical
usually brings rapid relief. condition stabilizes. After NMS, the decision to treat the
client with other antipsychotic drugs requires full
PSEUDOPARKINSONISM
discussion between the client and the physician to weigh
the relative risks against the potential benefits of therapy
TARDIVE DYSKINESIA (TD)
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a syndrome of permanent involuntary movements, is congestion, and decreased memory. These side effects
most commonly caused by the long-term use of usually decrease within 3 to 4 weeks but do not entirely
conventional antipsychotic drugs. About 20% to 30% of remit. The client taking anticholinergic agents for EPSs
patients on long-term treatment develop symptoms of TD, may have increased problems with anticholinergic side
and the pathophysiology is still unclear. The symptoms of effects. Using calorie-free beverages or hard candy may
TD include involuntary movements of the tongue, facial alleviate dry mouth, and stool softeners, adequate fluid
and neck muscles, upper and lower extremities, and intake, and the inclusion of grains and fruit in the diet
truncal musculature. Tongue thrusting and protruding, lip may prevent constipation.
smacking, blinking, grimacing, and other excessive
unnecessary facial movements are characteristic. After it CLIENT TEACHING
has developed, TD is irreversible, although decreasing or The nurse informs clients taking antipsychotic
discontinuing antipsychotic medications can arrest its medication about the types of side effects that may occur
progression. Unfortunately, antipsychotic medications can and encourages clients to report such problems to the
mask the beginning symptoms of TD; that is, increased physician instead of discontinuing the medication. The
dosages of the antipsychotic medication cause the initial nurse teaches the client methods of managing or avoiding
symptoms to disappear temporarily. As the symptoms of unpleasant side effects and maintaining the medication
TD worsen, however, they “break through” the effect of regimen. Drinking sugar-free fluids and eating sugar-free
the antipsychotic drug. hard candy ease dry mouth.
Preventing TD is the primary goal when administering Methods to prevent or relieve constipation include
antipsychotics. This can be done by keeping maintenance exercising and increasing water and bulk-forming foods
dosages as low as possible, changing medications, and in the diet. Stool softeners are permissible, but the client
monitoring the client periodically for initial signs of TD. should avoid laxatives. The use of sunscreen is
recommended because photosensitivity can cause the
client to sunburn easily.
Clients should monitor the amount of sleepiness or
drowsiness they feel. They should avoid driving and
performing other potentially dangerous activities until
their response times and reflexes seem normal.
If the client forgets a dose of antipsychotic
medication, he or she can take the missed dose if it is
only 3 or 4 hours late. If the dose is more than 4 hours
overdue or the next dose is due, the client can omit the
forgotten dose. The nurse encourages clients who have
difficulty remembering to take their medication to use a
chart and to record doses when taken or to use a pillbox
that can be prefilled with accurate doses for the day or
week.
ANTIDEPRESSANT DRUGS
Antidepressant drugs are primarily used in the treatment
of major depressive illness, anxiety disorders, the
depressed phase of bipolar disorder, and psychotic
depression. Off-label uses of antidepressants include the
treatment of chronic pain, migraine headaches,
peripheral and diabetic neuropathies, sleep apnea,
dermatologic disorders, panic disorder, and eating
ANTICHOLINERGIC SIDE EFFECTS disorders. Although the mechanism of action is not
completely understood, antidepressants somehow interact
Anticholinergic side effects often occur with the use with the two neurotransmitters, norepinephrine and
of antipsychotics and include orthostatic hypotension, dry serotonin, that regulate mood, arousal, attention, sensory
mouth, constipation, urinary hesitance or retention, processing, and appetite.
blurred near vision, dry eyes, photophobia, nasal
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NCM 117 LECTURE – PRELIMS
ANTIDEPRESSANTS ARE DIVIDED INTO FOUR OTHER
GROUPS: COMPOUNDS
Bupropion T 200-300 100-450
Tricyclic and the related cyclic antidepressants (Wellbutrin)
1. Selective serotonin reuptake inhibitors (SSRIs) Venlafaxine T, C 75-225 75-375
(Effexor)
2. MAO inhibitors (MAOIs) Desvenlafaxine T 50-100 50 every
(Pristiq) other day
3. Other antidepressants such as desvenlafaxine (Pristiq), Trazodone T 200-300 100-600
venlafaxine (Effexor), bupropion (Wellbutrin), duloxetine (Desyrel)
(Cymbalta), trazodone (Desyrel), and nefazodone Nefazodone T 300-600 100-600
(Serzone) (Serzone)
Duloxetine C 60 30-90
GENERIC FORMS USUAL EXTREME (Cymbalta)
NAME DAILY DOSAGE Vilazodone T 20-4 10-40
DOSAGES RANGES (Viibryd)
SELECTIVE MONOAMINE
SEROTONIN OXIDASE
REUPTAKE INHIBITORS
INHIBITORS Phenelzine T 45-60 15-90
Fluoxetine C, L 20-60 10-80 (Nardil)
(Prozac) Tranylcypromine T 30-50 10-90
Fluvoxamine T 150-200 50-300 (Parnate)
(Luvox) Isocarboxazid T 20-40 10-60
Paroxetine T 20-40 10-50 (Marplan)
(Paxil)
Sertraline T 100-150 50-200
(Zoloft) The SSRIs and clomipramine are effective in the
Citalopram T, L 20-40 20-60 treatment of obsessive-compulsive disorder (OCD) as
(Celexa) well.
Escitalopram T 10-20 5-30
(Lexapro) Prozac Weekly is the first and only medication that
CYCLIC can be given once a week as maintenance therapy for
COMPOUNDS depression after the client has been stabilized on
Imipramine T, C , INJ 150-200 50-300 fluoxetine. It contains 90 mg of fluoxetine with an enteric
(Tofranil) coating that delays release into the bloodstream.
Desipramine T, C 150-200 50-300
(Norpramin) The cyclic compounds became available in the 1950s
Amitriptyline T, INJ 150-200 50-300 and for years were the first choice of drugs to treat
(Elavil) depression even though they cause varying degrees of
Nortriptyline C, L 75-100 25-150 sedation, orthostatic hypotension (drop in blood pressure
(Pamelor) on rising), and anticholinergic side effects. In addition,
Doxepin C, L 150-200 25-300 cyclic antidepressants are potentially lethal if taken in an
(Sinequan) overdose.
Trimipramine C 150-200 50-300
(Surmontil) During that same period, the MAOIs were discovered
Protriptyline T 15-40 10-60 to have a positive effect on people with depression.
(Vivactil) Although the MAOIs have a low incidence of sedation
Maprotiline T 100-150 50-200 and anticholinergic effects, they must be used with
(Ludiomil) extreme caution for several reasons:
Mirtazapine T 15-45 15-60
(Remeron)  A life-threatening side effect, hypertensive crisis,
Amoxapine T 150-200 50-250 may occur if the client ingests foods containing
(Asendin) tyramine (an amino acid) while taking MAOIs.
Clomipramine C, INJ 150-200 50-250  Because of the risk of potentially fatal drug
(Anafranil) interactions, MAOIs cannot be given in
combination with other MAOIs, tricyclic
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NCM 117 LECTURE – PRELIMS
antidepressants, meperidine (Demerol), CNS
depressants, many antihypertensives, or general
anesthetics.
 MAOIs are potentially lethal in overdose and
pose a potential risk in clients with depression
who may be considering suicide.

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