PSYCHOPHARMACOLOGY

This module aligns with APNA’s “Pharmacotherapeutics and basic principles of Pharmacology” specific core nursing content (American Psychiatric Nurses Association Education Council, Undergraduate Branch, 2022).

Module Outline

• Psychiatric Drugs and Deinstitutionalization
• Neurotransmitters
• Psychotropic Medication Classes

Module Learning Outcomes

• Describe the role of neurotransmitters within the brain.
• Outline the classifications of psychotropic medications.
• Discuss each psychotropic class and associated side effects.

Psychopharmacology

Use of psychiatric drugs and deinstitutionalization.

Beginning in the 1950s, psychiatric or psychotropic drugs were used for the treatment of mental illness and made an immediate impact. Though drugs alone cannot cure mental illness, they can improve symptoms and increase the effectiveness of treatments such as psychotherapy.

Classes of psychiatric drugs include:

• Antidepressants-treat depression and anxiety
• Mood-Stabilizers– treat bipolar disorder
• Antipsychotics-treat schizophrenia
• Anxiolytics/Anti-Anxiety-treat generalized anxiety disorder and panic disorder
• Stimulants –treat attention-deficit/hyperactivity disorder (ADHD)
• Cholinesterase Inhibitors/N-methyl-D-aspartate (NMDA) Receptor Antagonists treat dementia

A result of the use of psychiatric drugs was deinstitutionalization or the release of patients from mental health facilities. This shifted resources from inpatient to outpatient care and placed the spotlight back on the biological or somatogenic perspective.  When people with severe mental illness do need inpatient care, it is typically in the form of short-term hospitalization.

Neurotransmitters

Neurotransmitters. What exactly are some of the neurotransmitters that are so critical for neural transmission, and why are they essential to our discussion of psychopathology? It is believed that neurotransmitter imbalances contribute to mental health imbalances. Sheffler et al. (2022) provide additional information on neurotransmitters here.

• Dopamine – controls voluntary movements and is associated with the reward mechanism in the brain
• Serotonin – regulates pain, sleep cycle, and digestion; leads to a stable mood, so low levels lead to depression
• Endorphins – involved in reducing pain and making the person calm and happy
• Norepinephrine – increases the heart rate and blood pressure and regulates mood
• Gamma-aminobutyric acid (GABA) – inhibitory; blocks the signals of excitatory neurotransmitters responsible for anxiety and panic
• Glutamate – excitatory; associated with learning and memory
• Histamine – mediates homeostasis functions, promotes wakefulness, modulates feeding, and motivational behavior

Checkout this YouTube video: Introduction and Neurotransmitters Mnemonics (Memorable Psychopharmacology Lectures 1 & 2)

Psychopharmacology Classes

Psychopharmacology and psychotropic drugs. One option to treat severe mental illness is psychotropic medications. These medications fall under six major categories.

Antidepressants

Antidepressants are used to treat depression, but also anxiety, insomnia, and pain. They typically require 4-8 weeks to reach full therapeutic benefit (National Institute of Mental Health, 2022). The most common types of antidepressants are selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and norepinephrine-dopamine reuptake inhibitors (NDRIs) (National Institute of Mental Health, 2022). Examples of SSRIs include Citalopram, Paroxetine, and Fluoxetine (Prozac). Tricyclic antidepressants and Monoamine Oxidase Inhibitors (MAOIs) are two other older types of antidepressants. Tricyclics and MAOIs are not typically first-line options as they have more side effects compared to SSRIs and SNRIs. The common side effects of antidepressants are upset stomach, headache, and sexual dysfunction, but generally improve with time (National Institute of Mental Health, 2022).

Individuals prescribed MAOIs need to avoid foods containing high amounts of tyramine (i.e., aged cheeses, aged/picked/smoked meats, beer, wine, yeast extracts, ginseng, sauerkraut, and avocado) to avoid MAOI toxicity (Garcia & Santos, 2022). MAOI toxicity can also occur with an overdose of an MAOI medication and a drug-drug interaction. Potential signs and symptoms related to MAOI toxicity can vary from mild to life-threatening. Monoamine oxidase breaks down epinephrine, norepinephrine, dopamine, serotonin, and tyramine in the body. Excess of these substances can result in tachycardia, hyperthermia, myoclonus, hypertension, and agitation (Garcia & Santos, 2022). See this reference to read more about MAOI toxicity.

Serotonin syndrome a potentially is a rare, but potentially life-threatening, condition associated with serotonergic drugs that can result from proper medication use, drug interactions, or overdose (Simon & Keenaghan, 2022).  Most cases are mild and will resolve within 24-72 hours after removing the precipitating medication (Simon & Keenaghan, 2022). The signs and symptoms include:

• Agitation
• Anxiety
• Restlessness
• Disorientation
• Diaphoresis
  Read more about Serotonin Syndrome here.
• Hyperthermia
• Tachycardia
• Nausea & Vomiting
• Tremor
• Muscle Rigidity
• Hyperreflexia
• Myoclonus
• Dilated Pupils
• Ocular Clonus
• Dry Mucous Membranes
• Flushed Skin
• Increased Bowel Sounds
• Bilateral Babinski Sign (Simon & Keenaghan, 2022).

Anxiolytics

Anxiolytics/Anti-anxiety medications help with the symptoms of anxiety and include benzodiazepines (a class of sedative-hypnotic drugs) such as Clonazepam, Alprazolam, and Lorazepam. Anti-anxiety medications such as benzodiazepines are effective in relieving anxiety and take effect more quickly than the antidepressant medications (or buspirone) often prescribed for anxiety. However, there is a potential for dependence and tolerance to benzodiazepines if they are taken over a long period and may need higher and higher doses to get the same effect. Side effects include drowsiness, dizziness, nausea, difficulty urinating, and irregular heartbeat, to name a few. It is important to note that some SSRIs and SNRIs as well as beta blockers are used to treat anxiety (National Institute of Mental Health, 2022). Buspirone is an anxiolytic medication prescribed to treat anxiety but requires 3-4 weeks to reach full therapeutic effect (National Institute of Mental Health, 2022).

Benzodiazepines end in lam/pam.
So, you might think “call pam” to help remember these medications.

Stimulants

Stimulants increase one’s alertness and attention and are frequently used to treat Attention Deficit Hyperactivity Disorder (ADHD). They include Lisdexamfetamine, the combination of dextroamphetamine and amphetamine, and Methylphenidate. Stimulants are generally effective and produce a calming effect. Possible side effects include loss of appetite, headache, motor or verbal tics, and personality changes such as appearing emotionless. There is a potential for abuse related to high feelings (Heldt, 2017). Additionally, stimulants may be associated with growth restriction and sleep disturbance; thus, both should be monitored (Heldt, 2017).

Antipsychotics

Antipsychotics (i.e., Neuroleptics) were developed in the 1950s and are used to treat psychosis and diagnoses of Schizophrenia. Schizophrenia is characterized by the core signs/symptoms: delusions (false, fixed beliefs), hallucinations (any alterations in the five senses, most commonly hearing voices or seeing things that are not present), disorganized speech, disorganized behavior, and negative symptoms (i.e., deficits in emotional, cognitive, or social experiences) (Heldt, 2017). Antipsychotics are commonly divided into Typical or 1st Generation antipsychotics (e.g., chlorpromazine and haloperidol) and Atypical or 2nd Generation (e.g., olanzapine and clozapine). There is also a 3rd Generation of antipsychotics, but we will limit this discussion to 1st Gen and 2nd Gen. Common antipsychotics include Chlorpromazine, Haloperidol, Olanzapine, Quetiapine, and Risperidone. Individual antipsychotics may have a particular side effect profile. However, extrapyramidal side effects (EPS) can occur with the use of any antipsychotic.

In general, there are two key differences between typical and atypical antipsychotics:

1. the tendency for more EPS side effects in the 1st Generation/Typical
2. 1st Generation/Typical treat the positive more than the negative signs/symptoms of Schizophrenia. See the Schizophrenia chapter for a continued discussion of the characteristics of Schizophrenia.

Extrapyramidal side effects

Extrapyramidal side effects (EPS) include acute dystonia, akathisia (i.e., restlessness), parkinsonism, and tardive dyskinesia (Heldt, 2017).

O’Dell, E. (2016). Recognizing extrapyramidal symptoms [Video]. YouTube. https://youtube.com/watch?v=2xfu-d_aYWs&si=EnSIkaIECMiOmarE

Tardive Dyskinesia

Tardive (i.e., meaning tardy or late) dyskinesia is associated with involuntary and rhythmic movements, typically of the perioral muscles (Heldt, 2017). Some of these movements may resemble grimacing, lip-smacking, or eye blinking (Heldt, 2017). If tardive dyskinesia is recognized, stop the antipsychotic and notify the provider.

Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS) is a rare, yet potentially fatal, event. Historically, antipsychotics were referred to as neuroleptics and the reason behind the naming of this syndrome (Heldt, 2017). Heldt (2017) uses the mnemonic FEVER to represent the signs and symptoms associated with NMS.

Hippo Education. (2019). Differences between serotonin syndrome and neuroleptic malignant syndrome [Video]. YouTube. https://youtube.com/watch?v=jil8KcAGG8Y&si=EnSIkaIECMiOmarE

Mood stabilizers

Mood stabilizers are used to treat bipolar disorder and, at times, depression, schizoaffective disorder, and disorders of impulse control. A common example is Lithium; side effects include loss of coordination, hallucinations, seizures, and frequent urination. Lithium has a narrow therapeutic range (0.8-1.2) and therefore a high risk of toxicity (>2.0) (Heldt, 2017). Lithium toxicity ranges from mild to severe (Heyda et al., 2022). Heyda et al. (2022) note symptoms of lithium toxicity can include:

• nausea, vomiting, tremors, and fatigue (mild toxicity)
• confusion, agitation, delirium, tachycardia (moderate toxicity
• coma, seizures, hyperthermia, hypotension (severe toxicity)

Cholinesterase Inhibitors/N-methyl D-aspartate (NMDA) Receptor Antagonists

Cholinesterase Inhibitors are used to treat mild to moderate Alzheimer’s (National Institute on Aging, 2021). These medications prevent the breakdown of acetylcholine, a neurotransmitter related to memory and thinking (National Institute on Aging, 2021). Examples of cholinesterase inhibitor medications include galantamine, rivastigmine, and donepezil. Common side effects of these medications include nausea, vomiting, diarrhea, and weight loss (National Institute on Aging, 2021). Memantine, an NMDA antagonist medication, helps treat moderate to severe Alzheimer’s disease by regulating glutamate (National Institute on Aging, 2021). Common side effects of memantine are dizziness, headache, diarrhea, constipation, and confusion (National Institute on Aging, 2021).

The use of these drugs has been generally beneficial to patients. Most report that their symptoms decline, leading them to feel better and improve their functioning. Also, long-term hospitalizations are less likely to occur as a result, though the medications do not benefit the individual in terms of improved living skills.

Adapted from Fundamentals of Psychological Disorders 2nd Edition- Module 3  by Alexis Bridley, Ph.D. and Lee W. Daffin Jr., Ph.D. licensed under a Creative Commons Attribution 4.0 International License. Modifications: revised for clarity and flow .