Psychiatric Nursing

Introduction

The middle of the 20 ^th centuries identifies a pivotal period in the treatment of mentally ill. Since the 1950's the development of psychopharmacology has expanded to include widespread use of antipsychotics, antidepressants and antianxiety medications. Psychotropic medications are not intended to cure the mental illness, but are used to relieve physical and behavioral symptoms. The psycho stimulants, also called sympathomimetics and analeptics, can improve the mood, apathy and anhedonia of depressed older persons and are effective in the treatment of various other mental illness.

History (Tyler 1986)

• The mild stimulant effect of cocaine found naturally in coca leaves when chewed by peasants in high altitude South American countries.  Freud supporting the psychotherapeutic use. Cocaine first isolated in 1860.
• Amphetamines widely used synthetic performance enhancing drugs used in wars and in peace.  First synthesised in 1880s.
• Amphetamine was first synthesized under the chemical name "phenylisopropylamine" in Berlin 1887 by the Romanian chemist Lazar Edeleanu. It was not widely marketed until 1932, when the pharmaceutical company Smith, Kline, and French (currently known as Glaxo smith cline) introduced it in the form of the Benzedrine.
• Three years later, in 1935, the medical community became aware of the stimulant properties of amphetamine, specifically dextroamphetamine, and in 1937 Smith, Kline, and French introduced tablets, under the trade name Dexedrine.

CNS stimulants or Sympathomimetics commonly used

Chemical group	Generic(trade name)	Daily dosage range
Amphetamines	1. amphetamine sulphate 2. Dextroamphetamine sulphate ( Dexedrine) 3. Methamphetamine(Desoxyn)	5-60 mg 5-60 mg 5-25 mg
Anorexigenics	1. Benzphetamine( Didrex) 2. Diethylpropion ( Tenuate) 3. Mazindol ( Mazanor) 4. Phendimetrazine ( Perlu-2) 5. Phentermine( Fastin)	25-150 mg 75-100 mg 1-3 mg 35- 105 mg 15-37.5 mg
Miscellaneous	1. Methylphenidate ( Ritalin) 2. Pemoline ( Cylert)	10-60 mg 37.5-112.5 mg

 

• Geriatric dosage of psycho stimulants

 

Generic name	Trade name	Dosage (mg/day)
Dextroamphetamine Pemoline Methylphenedate	Dexedrine Cylert Ritalin	2.5-10 18.75-37 2.5-20

Therapeutic indications:

• ADHD: It is the first line drug in the treatment of ADHD. Sympathomimetics improve the core ADHD symptoms of hyperactivity, impulsivity and inattentiveness and permit improved social interactions with teachers, family, older adults and peers. Methylphenidate and dextroamphetamine are equally effective and work within 15 to 30 mts.
• Narcolepsy: Narcolepsy consists of sudden sleep attacks, sudden loss of postural tone( cataplexy), loss of voluntary motor control going into( hypnagogic) or coming out of (hypnopompic) sleep (sleep paralysis) and hypnagogic and hypnopompic hallucinations.
  • - Sympathomimetics reduce narcoleptic sleep attacks and also improve wakefulness in other types of hyper somnolent states.
  • - Sympathomimetics are used to maintain wakefulness and accuracy of motor performance in persons subject to sleep deprivation, such as pilots and military personnel.
  • - Persons with narcolepsy, may develop tolerance for the therapeutic effects of the Sympathomimetics.
• Depressive disorders: Sympathomimetics may be used for treatment resistant depressive disorders, usually to augment standard antidepressant drug therapy.
  • - depression in elderly, who are at increased risk for adverse effects from standard antidepressant drugs.
  • - Depression in medically ill person especially persons with AIDS.
  • - Obtundation due to chronic use of opioids.
  • - Clinical situation in which rapid response is important but ECT is contraindicated.
  • - Depressed patients with abulia and anergia may also benefit.

Dextroamphetamine may be useful in differentiating pseudo dementia of depression from dementia. A depressed person generally responds to a 5 mg dose with increased alertness and improved cognition.

• Encephalopathy due to brain injury: Sympathomimetics increase alertness, cognition, motivation and motor performance in persons with neurological deficits caused by strokes, trauma, tumors or chronic infections.
• Obesity: Sympathomimetics are used in the treatment of obesity because of their anorexia inducing effects. Because tolerance develops for the anorexic effects and because of the drugs high abuse potential their use for this indication is limited.

Careful limitation of caloric intake and judicious exercise are at the core of any successful weight loss program. Sympathomimetics facilitate loss of, at most, an additional fraction of a pound per week. Sympathomimetics are effective appetite suppressants only for the first few weeks of use; then the anorexigenic effects tend to decrease.

• Other disorders:
  • Chronic fatigue syndrome
  • Neurasthenia
  • Fibromyalgia
  • Dysthymia
  • Depressive personality disorder.

Pharmacology

• Pharmacokinetics
  • amphetamine and cocaine salts readily water soluble (injecting misuse), free base designed for smoking (but crack cocaine also commonly injected)
  • Widely distributed in the body, crossing the blood brain barrier
  • Metabolised by liver, metabolites in the urine
• Pharmacodynamic
  • Peripheral effects
  • Cocaine is a local anaesthetic (dentistry)
  • Cocaine and amphetamines produce smooth muscle contraction; vaso-constriction and bronchoconstriction
  • Central nervous system effects
  • Cocaine inhibits dopamine re-uptake (more dopamine), 5HT and noradrenaline uptake (antipsychotics drugs are dopamine antagonists)
  • Amphetamine affects range of neurotransmitters but main action is inhibiting dopamine re-uptake (more dopamine)

Pharmacological actions:

Sympathomimetic drugs cause the stimulation of a- and b adrenergic receptors directly as agonists and indirectly cause the release of dopamine and norepinephrine from presynaptic terminals. They are variously referred to as stimulants, produces CNS and respiratory stimulation, dilated pupils, increased motor activity and mental alertness, diminished sense of fatigue and brighter spirits.

Effects on specific organs and systems

• Central nervous system: Amphetamine stimulates the medullary respiratory center and has excitatory effects on cortical function. Depending on the personality and contextual factors, amphetamine in adults can increase wakefulness, energy, alertness, initiative, self confidence and physical mental performance, lessen fatigue and produce euphoria. These effects occur shortly after dosing.
• Cardiovascular system: Amphetamines can raise blood pressure and can lead to cardiac arrhythmias (especially in patients with cardiovascular disease).Amphetamine is more potent in producing cardiovascular effects than dextroamphetamine because of stronger effects on norepinephrine.
• Endocrine effects: Early reports suggested that both dextroamphetamine and methylphenidate might suppress growth in children. But certain studies revealed that the effects on growth are seemed to be related to the disorder, not its treatment.

Side effects:

1. Most common adverse effects:  stomach pain, anxiety, irritability, insomnia, tachycardia, cardiac arrhythmias and dysphoria
2. Less common adverse effects: induction of movement disorders such as tics, tourette's disorder like symptoms and dyskinesias
3. others:

• Exacerbation of glaucoma, hypertension, cardiovascular disorders, hyperthyroidism, anxiety disorders, psychotic disorders and seizure disorders.
• High doses of sympathomimetics can cause dry mouth, papillary dilation, bruxism, formication, excessive ebullience, restlessness and emotional liability.
• Long term use of high dosages can cause a delusional disorder that resembles paranoid schizophrenia.
• Overdoses of sympathomimetics results in hypertension, tachycardia, hyperthermia, toxic psychiosis, delirium and occasionally seizures.
• Physiological and psychological dependence.

Management of common stimulant induced adverse effects

Adverse effect	Management
Anorexia, nausea, weight loss	Administer stimulant with meals. Use caloric enhanced supplements, discourage forcing meals. If using pemoline, check liver function tests.
Insomnia,night mares.	Administer stimulants earlier in the day. Change to short acting preparations. Discontinue afternoon or evening dosing. Consider adjunctive treatment. (antihistamine, antidepressant)
Dizziness	Monitor blood pressure. Encourage fluid intake Change to long acting form
Rebound phenomena	Overlap stimulant dosing. Change to long acting preparation or combine long and short acting preparations. Consider adjunctive and alternative treatment
Irritability	Assess timing of the phenomena( during peak or withdrawal phase) Evaluate co morbid symptoms. Reduce dose. Consider adjunctive or alternative treatment
Dysphoria, moodiness, agitation	Consider co morbid diagnosis( mood disorder) Reduce dose or change to long acting preparation. Consider adjunctive or alternative treatment( lithium, anticonvulsant, antidepressant)

Contraindications:

• Hypersensitivity to Sympathomimetics.
• Advanced arteriosclerosis, symptomatic cardiovascular disease, hypertension, hyperthyroidism, glaucoma, agitated or hyper excitability states, in clients with history of drug abuse, during or within 14 days of receiving therapy with MAOIs, in children under 3 years of age and in pregnancy.

Precautions:

• Lactation
• Psychotic children
• Tourette's disorder
• Anorexia
• Insomnia
• Elderly, debilitated or asthenia clients
• Clients with suicidal or homicidal tendencies.

Drug-drug interactions:

• Co administration of Sympathomimetics and tricyclic or tetra cyclic antidepressants , warfarin, primidone, Phenobarbital,phenytoin or phenylbutazone decreases the metabolism of these compounds, resulting in increased plasma levels.
• Sympathomimetics decrease the therapeutic efficacy of many antihypertensive drugs, guanethidine.
• Use of CNS stimulants within 14 days following administration of MAOIs may result in hypertensive crisis, headache, hyperpyrexia, intracranial hemorrhage and bradycardia.
• Insulin requirements may be altered with CNS stimulants.
• Urine alkalinizers decrease excretion, enhancing the effects of amphetamines.
• Urine acidifiers increase excretion, decreasing the effects.
• Decreased effects of both the drugs can occur when administered concurrently with phenothiazines.

MODAFINIL:

• It is a unique compound among the currently approved psycho stimulant drugs.

Pharmacological action

• Modafinil is rapidly absorbed from the gastro intestinal tract and reaches peak plasma concentration in 2 to 4 hrs, has a half life of about 15 hrs, and reaches steady state after two to four days of daily dosing.
• The mechanism of action for the wakefulness- inducing properties of modafinil is not known. One possibility is that dopamine acts as a weak inhibitor of dopamine reuptake. This is supported by the observation of an extracellular dopamine levels without an increase in dopamine release.

Effects on specific organs:

• Central nervous system: Euphoric effects, alterations in mood, perception and thinking.
• Cardiovascular system: There were small numbers of cardiovascular related side effects in the narcolepsy clinical studies; there fore it is currently not recommended to be used in patients with cardiovascular disorders.

Therapeutic indications:

• Treatment of day time sedation in neurological and psychiatric disorders.
• Parkinson's disease and multiple sclerosis with day time sedation.

Dosage and administrations:

• Starting dosage is 200 mg a day given once in the morning. Some patients may require 300-400 mg a day, also given once in the morning.

Adverse effects:

• Headache, nausea.
• Abuse potential
• Precautions:
• Pregnancy, because it is excreted in human milk.
• Drug to drug interaction:
• Plasma concentration of low dose of steroidal contraceptive may be reduced to levels below therapeutic effectiveness.
• Co administration of modafinil may result in increased plasma concentrations of diazepam, phenytoin and propranolol.

NURSING MANAGEMENT

Diagnosis: The following nursing diagnosis can be considered for clients receiving therapy with CNS stimulants.

1. Risk for injury related to over stimulation and hyperactivity.

2. Risk for self- directed violence related to abrupt withdrawal after extended release.

3. Imbalanced nutrition less than body requirement related to side effects of anorexia and weight loss.

4. Imbalanced nutrition more than body requirements related to excess intake in relation to metabolic needs.

5. Insomnia related to over stimulation resulting from use of the medication.

Planning/ implementation:

• The plan of care should include monitoring for the following side effects from stimulants. Nursing implications related to each side effect are:

1. Over stimulation, restlessness, insomnia.

• Assess the mental status for changes in mood, level of activity, degree of stimulation and aggressiveness.
• Ensure that the client is protected from injury.
• Keep stimuli low and environment as quiet as possible to discourage overstimulation.
• To prevent insomnia, administer last dose at least 6 hours before bedtime. Administer sustained release forms in the morning.

2. Palpitations, tachycardia.

• Monitor and record vital signs at regular intervals throughout the therapy.
• Report significant changes to the physician immediately.

3. Anorexia and weight loss:

To reduce anorexia, the medication may be administered immediately after the meals.

• The client should be weighed regularly during hospitalization and at home while receiving the therapy with CNS stimulants because of the potential for anorexia/ weight loss and temporary interruption of growth and development.

4. Tolerance:

• Tolerance develops rapidly. If anorexigenic effects begin to diminish, the client should notify the physician immediately. Client should be on reduced- calorie diet and program of regular exercise in addition to the medication.
• In children with behavior disorders, a drug " holiday" should be attempted periodically under direction of the physician to determine the effectiveness of the medication and the need for continuation.
• The drug should not be withdrawn abruptly. To do so could initiate the following syndrome of symptoms: nausea, vomiting, abdominal pain, headache, fatigue, weakness, mental depression, suicidal ideation, increased dreaming and psychotic behavior.
• Client and family education:
• Use caution in driving or operating dangerous machinery. Drowsiness, dizziness and blurred vision can occur.
• Not stop taking the drug abruptly. To do so could produce serious withdrawal symptoms.
• Avoid taking the drug late in the day to prevent insomnia. Take no later than 6 hours before bed time.
• Not to take other medications without physicians approval. Many drugs contain substances that in combination with stimulants can be harmful.
• Diabetic clients should monitor blood sugar twor three times a day or as instructed by the physician. Be aware of need for  possible alteration in insulin requirements owing tchanges in food intake, weight and activity.
• Avoid consumption of large amounts of caffeinated products (coffee, tea, colas, and chocolate) as they may enhance the stimulant effect of these medications.
• Follow a reduced calorie diet provided by the dietitian, as well as program of regular exercise. Dnot exceed the recommended dose if the appetite suppressant effect is diminished. Contact the physician.
• Notify the physician if restlessness, insomnia, anorexia or dry mouth become more severe or if rapid , pounding heartbeat becomes evident.
• Be aware of potential side effects of CNS stimulants. Refer tthe written material furnished by health care providers for safe self administration.
• Be aware of possible risks of taking CNS stimulants during pregnancy. Safe use during pregnancy and lactation has not been established. Inform the physician immediately if pregnancy is suspected or planned.
• Carry a card or other identification at  all times describing the medications being taken.
• Outcome criteria/ evaluation: The following may be used for evaluating the effectiveness of therapy with CNS stimulants.

The client:

• Does not exhibit excessive hyperactivity.
• The overweight client is losing a safe 2 lb per week.
• Has not experienced injury.
• The behavior disorder client is maintaining expected parameters of growth and development.
• Verbalizes understanding of safe self administration and the importance of not withdrawing medication abruptly.

References:

1. Kaplan and Sadock. Synopsis of psychiatry-behavioral science, clinical approach. (6 th edition) Williams and Wilkins publishers. Baltimore: (1998).
2. Townsend M C. Psychiatric mental health nursing-concepts of care. (3 rd edition) F.H Davis publishers; Philadelphia :( 2005)
3. Anderson I, Reid I .Fundamentals of clinical psychopharmacology. Martin Dunitz publishers. London: (2002).
4. Charach A et.al. Stimulant treatment over 5 years: effects on growth. J AM ACAD. Child adollesc psychiatry. 2006. April 45(4).
5. Gorman, E B. et.al. Effects of methylphenidate on subtypes of attention deficit hyperactivity disorder. J AM ACAD. Child adollesc psychiatry. 2006. April 45(7).