●​ Advances in Neurobiological Research: Over the past 30 years, there has been
significant progress in understanding how the brain works, with research into the causes
of mental illness expanding. Neurobiological theories, including genetics, stress, immune
system, and infections, are shaping psychiatric practice.
●​ Psychopharmacology: Medications used to treat mental illness target the central
nervous system (CNS) and influence behavior, perception, thinking, and emotions.
Although pharmacologic treatments are often effective, adjunct therapies like cognitive
and behavioral therapies can improve treatment outcomes.
●​ CNS Overview: The CNS consists of the brain, spinal cord, and associated nerves. The
brain is divided into the cerebrum, cerebellum, brainstem, and limbic system.
●​ Cerebrum:
○​ Divided into two hemispheres with different functions: the left hemisphere is
responsible for logical reasoning and tasks like reading and writing, while the
right hemisphere handles creativity and intuition.
○​ The frontal lobes regulate thought, movement, memories, emotions, and moral
behavior. Issues here are linked to disorders like schizophrenia and ADHD.
○​ Other lobes (parietal, temporal, occipital) manage sensory and emotional
functions.
●​ Cerebellum: Coordinates movements and posture, and problems with dopamine
transmission here are associated with Parkinson's disease and dementia.
●​ Brainstem: Includes the midbrain, pons, and medulla, which control vital functions like
respiration, motor pathways, sleep, consciousness, and movement coordination. The
reticular activating system and extrapyramidal system are part of this structure,
influencing motor control and awareness.
●​ Limbic System: Involved in regulating emotions, memory, and physiological functions
like temperature and appetite. Disturbances in this system are linked to disorders such
as dementia and psychosis.
Neurotransmission: Neurons communicate via electrochemical messages that travel from
dendrites through the soma, down the axon, and across synapses to other neurons.
Neurotransmitters are chemicals that aid in transmitting these messages across synapses and
can be excitatory (stimulate action) or inhibitory (stop action).
Neurotransmitter Action: Neurotransmitters fit into specific receptors in the dendrites, like a
key fitting a lock. After transmitting their message, neurotransmitters are either reuptaken for
reuse or metabolized by enzymes (e.g., monoamine oxidase, MAO).
Major Neurotransmitters:
1.​ Dopamine: Excitatory, controls complex movements, motivation, cognition, and
emotional responses. Imbalanced dopamine is associated with schizophrenia and
Parkinson's disease.
2.​ Norepinephrine: Excitatory, involved in attention, memory, sleep, and mood. Imbalance
can lead to anxiety, memory issues, depression.
3.​ Epinephrine: Excitatory, regulates the fight or flight response.
4.​ Serotonin: Inhibitory, regulates food intake, sleep, mood, pain, and emotions. Imbalance
is linked to anxiety, mood disorders, and schizophrenia.
5.​ Histamine: Neuromodulator, controls alertness, gastric secretion, and allergic
responses. Blocked by some psychotropic drugs, leading to side effects like weight gain
and sedation.
6.​ Acetylcholine: Excitatory or inhibitory, affects the sleep-wake cycle and muscle
activation. Decreased levels are seen in Alzheimer’s disease and myasthenia gravis.
7.​ Glutamate: Excitatory, plays a role in brain damage when levels are too high. Linked to
conditions like stroke, Alzheimer’s, and Huntington's disease.
8.​ Gamma-Aminobutyric Acid (GABA): Inhibitory, modulates other neurotransmitter
systems. Benzodiazepines enhance GABA function to treat anxiety and promote sleep.
Neurotransmitter Imbalances: Abnormal levels of neurotransmitters can contribute to various
mental disorders, such as schizophrenia, depression, anxiety, and neurodegenerative diseases.
●​ Brain Imaging Techniques: These techniques allow visualization of brain structure and
function without surgery or autopsy. They help diagnose disorders, correlate brain areas
with specific functions, and support mental disorder research.
●​ Types of Brain Imaging:
○​ Computed Tomography (CT): Uses serial x-rays to create cross-sectional brain
images. It is useful for diagnosing brain tumors, metastases, effusions, and
assessing ventricular size. Some people with schizophrenia show enlarged
ventricles. Duration: 20–40 minutes.
○​ Magnetic Resonance Imaging (MRI): Uses a magnetic field and radio waves to
create high-detail brain images. It can show blood flow, tissue changes, and
measure brain structure. Schizophrenia patients may show reduced cortical
thickness. Duration: 45 minutes.
○​ Positron Emission Tomography (PET): Involves injecting a radioactive tracer to
monitor brain function during cognitive tasks. It provides high-resolution images
of brain activity. Duration: 2–3 hours.
○​ Single-Photon Emission Computed Tomography (SPECT): Similar to PET but
with single photons. It is used for research but not for routine diagnosis. Duration:
1–2 hours.
●​ Limitations of Brain Imaging:
○​ PET and SPECT: Involve radioactive substances, limiting the number of tests a
person can undergo. There is also a risk of allergic reactions and discomfort from
the procedure.
○​ Cost: Imaging equipment is expensive (e.g., PET scanners cost around $2.5
million), limiting availability.
○​ Claustrophobia: Some individuals cannot tolerate MRI or PET/SPECT due to
fear or claustrophobia.
○​ Molecular Changes: Some brain disorders, like schizophrenia, involve molecular
and chemical changes that cannot be detected by current imaging techniques.
Genetics and Heredity
●​ Genetic Influence: Mental disorders are not solely hereditary. While some conditions
may have genetic components, environmental factors also play significant roles. Genetic
research continues to explore the relationship between genes and disorders such as
schizophrenia and mood disorders.
●​ SORL1 Gene: In 2007, variations in the SORL1 gene were linked to late-onset
Alzheimer disease.
●​ Research Efforts: The National Human Genome Research Institute has been
conducting extensive research on genetic links to mental illness, with a focus on genetic
encoding and the ethical implications of this research.
●​ Common Study Methods:
1.​ Twin Studies: Comparing the incidence of mental illnesses in identical vs.
fraternal twins.
2.​ Adoption Studies: Comparing traits in biological vs. adoptive families.
3.​ Family Studies: Examining if traits are more common among first-degree
relatives.
Stress and the Immune System (Psychoimmunology)
●​ Psychoimmunology: This field studies how psychosocial stressors affect the immune
system. A weakened immune system might contribute to illnesses, particularly in
genetically vulnerable populations.
●​ Mood Dysregulation: In diseases with inflammatory components (e.g., multiple
sclerosis, lupus), mood issues, including depression, are common.
Infection as a Possible Cause
●​ Viral Theories: Some researchers explore infections as causes of mental illness,
particularly schizophrenia. Theories include:
○​ Viruses targeting the central nervous system (CNS).
○​ Viral alteration of human genes.
○​ Maternal infection during fetal development affecting brain development,
potentially contributing to schizophrenia.
The Nurse's Role in Research and Education
●​ Nurse's Responsibility: Nurses must stay informed about research developments in
neurobiology, genetics, and mental illness. They should help clients and families
distinguish between facts and hypotheses, clarify how new research may influence
treatment, and provide resources to answer questions.
Medication Management:
●​ Medication is crucial for treating mental disorders, influencing treatment outcomes.
●​ Nurses need to understand drug mechanisms, side effects, contraindications, and
nursing interventions.
Key Terms:
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Efficacy: Maximal therapeutic effect.
Potency: Amount needed to achieve efficacy.
Half-life: Time for half of the drug to be cleared from the bloodstream.
Off-label use: Drugs used for purposes not originally approved by the FDA.
Principles of Psychopharmacology:
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Medications target specific symptoms (e.g., delusions, hallucinations).
Full therapeutic effects may take time (e.g., tricyclic antidepressants take 4-6 weeks).
Dosage is adjusted based on the individual's response, especially in older adults.
Medications may need to be tapered gradually to prevent withdrawal or rebound
symptoms.
Antipsychotics
Mechanism of Action:
●​ Antipsychotics primarily block dopamine receptors (D2, D3, D4).
●​ First-generation antipsychotics (e.g., Haloperidol, Fluphenazine) are potent D2 blockers,
leading to more extrapyramidal symptoms (EPS).
●​ Second-generation antipsychotics (e.g., Clozapine, Risperidone, Ziprasidone,
Quetiapine) are weaker D2 blockers and inhibit serotonin reuptake, reducing EPS and
addressing depressive symptoms.
●​ Third-generation antipsychotics (e.g., Aripiprazole) stabilize dopamine transmission,
reducing side effects while treating psychosis and mood disorders.
Side Effects:
●​ First-Generation (e.g., Haloperidol, Fluphenazine): High EPS risk, including acute
dystonia, pseudoparkinsonism, and akathisia.
●​ Second-Generation (e.g., Clozapine, Risperidone, Quetiapine): Lower EPS but may
cause sedation, weight gain, and metabolic issues.
●​ Warnings: Ziprasidone (Geodon) contraindicated for QT prolongation or recent MI.
Clozapine requires monitoring for agranulocytosis.
EPS Treatment:
●​ Benztropine (Cogentin) and Diphenhydramine (Benadryl) are effective for acute
dystonia and pseudoparkinsonism.
●​ Other EPS therapies: Adjust antipsychotic dosage, switch to a lower-risk agent, or use
beta-blockers or benzodiazepines (e.g., Diazepam, Lorazepam) for akathisia.
Depot Injections:
●​ Long-acting formulations for maintenance:
○​ Haloperidol Decanoate (4-week duration).
○​ Risperidone (Risperdal Consta) (every 2 weeks).
○​ Aripiprazole (Abilify Maintena) (monthly).
Warnings for Specific Drugs:
1.​ Droperidol, Thioridazine, Mesoridazine:
○​ May cause QT prolongation, leading to cardiac dysrhythmias or cardiac arrest.
2.​ Clozapine:
○​ Agranulocytosis is a severe risk: sudden onset with symptoms like fever, sore
throat, malaise, and leukopenia.
○​ Monitoring schedule:
■​ Weekly WBC for the first 6 months.
■​ Every 2 weeks after consistent counts above 3,500/mm³ and ANC
>2,000/mm³.
■​ Monitoring returns to weekly if therapy is interrupted or upon
discontinuation for 4 weeks.
Client Teaching for Antipsychotics:
1.​ Managing Side Effects:
○​ Dry mouth: Use sugar-free fluids/candies, avoid high-calorie options.
○​ Constipation: Exercise, hydrate, and eat fiber-rich foods; avoid laxatives.
○​ Photosensitivity: Use sunscreen.
2.​ Missed Doses:
○​ Can take a missed dose if <4 hours late; otherwise, skip.
3.​ Avoid Dangerous Activities:
○​ Avoid driving until side effects like drowsiness subside.
Antidepressants Overview:
1.​ Classes:
○​ SSRIs (e.g., Fluoxetine, Sertraline): First-line treatment with fewer side effects.
○​ Cyclics (TCAs) (e.g., Amitriptyline, Nortriptyline): Effective but sedating and
lethal in overdose.
○​ MAOIs (e.g., Phenelzine): Risk of hypertensive crisis with tyramine-rich foods.
○​ Atypical Antidepressants (e.g., Bupropion, Venlafaxine): Fewer risks of
overdose and effective in anxiety and pain.
2.​ Mechanism of Action:
○​ SSRIs: Block serotonin reuptake.
○​ TCAs and Venlafaxine: Block norepinephrine (and partially serotonin) reuptake.
○​ MAOIs: Inhibit monoamine oxidase, affecting norepinephrine, serotonin, and
dopamine availability.
3.​ Therapeutic Onset:
○​ SSRIs: 2–3 weeks.
○​ TCAs: 4–6 weeks.
○​ MAOIs: 2–4 weeks.
4.​ Suicide Considerations:
○​ SSRIs, Venlafaxine, and Bupropion are safer for clients at risk of overdose.
○​ Increased energy from SSRIs may elevate the risk of suicidal behavior initially.
Monitoring for Efficacy and Safety:
●​ Regular lab tests for Clozapine users to prevent agranulocytosis.
●​ Careful assessment of side effects and adherence to avoid life-threatening interactions
or crises, especially with MAOIs.
Selective Serotonin Reuptake Inhibitors (SSRIs):
●​ Common Side Effects: Anxiety, agitation, nausea, insomnia, akathisia, sexual
dysfunction, weight gain (less than cyclic antidepressants).
○​ Management: Nausea can be reduced by taking the medication with food;
akathisia managed with propranolol or benzodiazepines.
●​ Less Common Side Effects: Sedation (e.g., paroxetine), sweating, diarrhea,
headaches, hand tremor.
○​ Persistent sedation or sweating may require switching medications.
●​ Important Note: Insomnia may persist even with morning dosing; sedatives like
trazodone may help.
Cyclic Antidepressants (TCA):
●​ Common Side Effects: Anticholinergic effects (dry mouth, constipation, blurred vision),
orthostatic hypotension, sedation, weight gain, tachycardia.
○​ Severe Anticholinergic Effects: Agitation, delirium, ileus (more common in older
adults).
●​ Sexual Dysfunction: Often reported and a reason for discontinuation, along with weight
gain.
●​ Tolerance to side effects may develop over time.
Monoamine Oxidase Inhibitors (MAOIs):
●​ Common Side Effects: Sedation, insomnia, weight gain, dry mouth, orthostatic
hypotension, sexual dysfunction.
●​ Serious Concern: Hypertensive crisis from consuming foods with tyramine (e.g., aged
cheeses, processed meats, certain beers, soy products). Symptoms: Severe
hypertension, fever, tachycardia, diaphoresis.
●​ Drug Interactions: Risk with SSRIs, TCAs, buspirone, opiate derivatives. MAOIs
require a clear washout period to avoid serotonin syndrome.
Other Antidepressants:
●​ Sedation: Common with nefazodone, trazodone, mirtazapine.
●​ Sexual Dysfunction: Less frequent but notable exception—trazodone may cause
priapism (emergency condition).
●​ Warnings:
○​ Nefazodone: Potentially life-threatening liver damage.
○​ Bupropion: Higher risk of seizures, especially with predisposing conditions.
Critical Syndromes:
●​ Serotonin Syndrome: Overlapping SSRIs and MAOIs or overdose can cause agitation,
fever, tachycardia, and in severe cases, coma or death.
Client Teaching:
●​ SSRI Dosing: Morning unless sedation occurs; missed doses can be taken within 8
hours.
●​ TCA Dosing: Preferably at night; missed doses within 3 hours or skip for the day.
●​ MAOIs: Adhere to dietary restrictions and avoid OTC medications without consultation.
Provide clients with written dietary instructions.
Mood Stabilizers Overview:
●​ Used primarily for bipolar disorder to stabilize mood, treat mania, and minimize mood
swings.
●​ Lithium is the most established mood stabilizer; anticonvulsants like carbamazepine,
valproic acid, and others are also effective.
Mechanism of Action:
●​ Lithium: Normalizes neurotransmitter reuptake (e.g., serotonin, norepinephrine) and
intracellular processes (e.g., G-proteins, enzyme systems). First-line agent for bipolar
disorder.
●​ Anticonvulsants:
○​ Valproic acid and topiramate increase GABA levels.
○​ Carbamazepine and valproic acid inhibit the kindling process, potentially
preventing mania progression.
Dosage and Monitoring:
●​ Lithium:
○​ Therapeutic serum level: ~1 mEq/L.
○​ Toxicity at >1.5 mEq/L; severe toxicity at >3 mEq/L.
○​ Frequent monitoring during initiation (every 2–3 days), then less frequent as
stable.
●​ Carbamazepine: 800–1,200 mg/day (extreme range: 200–2,000 mg/day).
●​ Valproic Acid: 1,000–1,500 mg/day (extreme range: 750–3,000 mg/day).
●​ Drug levels for carbamazepine and valproic acid are checked 12 hours after the last
dose.
Common Side Effects:
●​ Lithium:
○​ Early effects: Nausea, diarrhea, anorexia, fine hand tremor, polydipsia, polyuria,
metallic taste, fatigue.
○​ Late effects: Weight gain, acne.
○​ Management: Take with food for nausea; propranolol for tremor.
●​ Anticonvulsants:
○​ General: Drowsiness, sedation, dry mouth, blurred vision.
○​ Carbamazepine: Rashes, orthostatic hypotension.
○​ Valproic acid: Weight gain, alopecia, hand tremor.
○​ Topiramate: Dizziness, sedation, weight loss, risk of renal calculi.
Warnings:
●​ Lithium:
○​ Toxic effects: Severe diarrhea, vomiting, drowsiness, muscle weakness, lack of
coordination. Can lead to renal failure or death if untreated.
○​ Immediate discontinuation is required for toxic signs; dialysis for levels >3 mEq/L.
●​ Valproic Acid:
○​ Hepatic failure, teratogenic effects (e.g., spina bifida), pancreatitis.
○​ Monitor liver function tests regularly.
●​ Carbamazepine:
○​ Risk of aplastic anemia and agranulocytosis. Periodic blood count monitoring
required.
●​ Lamotrigine:
○​ Risk of serious rashes (e.g., Stevens-Johnson syndrome), especially in children
under 16.
Client Teaching:
●​ Importance of periodic blood level monitoring:
○​ Ensure accuracy by measuring 12 hours after the last dose.
●​ Take medication with meals to reduce nausea.
●​ Avoid driving until dizziness or sedation subsides.
●​ Report side effects such as rashes, persistent tremors, or gastrointestinal symptoms
immediately.
Antianxiety Drugs (Anxiolytics)
Overview:
●​ Used to treat anxiety, insomnia, OCD, depression, PTSD, and alcohol withdrawal.
●​ Benzodiazepines are the most commonly prescribed for their efficacy in anxiety relief,
as well as anticonvulsant and muscle relaxant properties.
●​ Buspirone is a nonbenzodiazepine alternative for anxiety, without risk of physical
dependence.
Mechanism of Action:
●​ Benzodiazepines: Enhance GABA action (major inhibitory neurotransmitter) by binding
to GABA receptors, leading to neuronal hyperpolarization and inhibitory effects.
●​ Buspirone: Acts as a partial agonist at serotonin receptors, reducing serotonin turnover.
Dosage and Pharmacokinetics:
●​ Benzodiazepines vary by half-life, onset, and use:
○​ Longer half-life: Fewer rebound effects, risk of accumulation (e.g., diazepam).
○​ Shorter half-life: No accumulation but more frequent rebound effects (e.g.,
triazolam).
●​ Common benzodiazepines for anxiety: Alprazolam, lorazepam, clonazepam.
●​ Sleep-inducing benzodiazepines: Temazepam, flurazepam, triazolam.
●​ Buspirone: Onset is very slow and requires consistent use.
Side Effects:
1.​ Benzodiazepines:
○​ CNS depression: Drowsiness, sedation, poor coordination, impaired memory.
○​ Physical and psychological dependence with prolonged use.
○​ Discontinuation symptoms may mimic original anxiety.
○​ Elderly risks: Falls, pronounced memory deficits, urinary incontinence.
2.​ Buspirone:
○​ Dizziness, sedation, nausea, headache.
○​ No risk of physical dependence or severe withdrawal.
Warnings:
●​ Benzodiazepines:
○​ Withdrawal can be fatal; tapering is essential under medical supervision.
○​ Potentiate alcohol effects (e.g., 1 drink feels like 3).
●​ Clients may experience next-day sedation or a hangover effect.
●​ Avoid abrupt discontinuation.
Client Teaching:
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These drugs relieve symptoms, not underlying causes of anxiety.
Avoid alcohol due to amplified sedative effects.
Be cautious with activities requiring alertness (e.g., driving).
Do not stop benzodiazepines suddenly; seek medical supervision for discontinuation.
Stimulants
Overview:
●​ Primary uses: ADHD in children and adults, narcolepsy.
●​ Historically used for depression and obesity but not common now.
●​ Drugs: Methylphenidate (Ritalin), Amphetamine (Adderall), Dextroamphetamine
(Dexedrine).
●​ Non-stimulant option: Atomoxetine (Strattera), a selective norepinephrine reuptake
inhibitor.
Mechanism of Action:
●​ Amphetamines and methylphenidate: Increase norepinephrine, dopamine, and
serotonin by promoting release and inhibiting reuptake.
●​ Pemoline: Primarily affects dopamine, less impact on the sympathetic nervous system.
●​ Atomoxetine: Blocks norepinephrine reuptake, enhancing synaptic availability.
Dosages:
●​ Dosages vary by age, condition (ADHD or narcolepsy), and formulation (regular vs.
sustained-release).
●​ Methylphenidate: 20–200 mg/day in adults; 10–60 mg/day in children (divided or
sustained-release).
●​ Dextroamphetamine: 20–200 mg/day for adults; 5–40 mg/day for children.
●​ Sustained-release formulations reduce the need for school-hour dosing.
Side Effects:
1.​ Common:
○​ Anorexia, weight loss, nausea, irritability.
○​ Dizziness, dry mouth, blurred vision, palpitations (less common).
2.​ Long-term issue:
○​ Growth and weight suppression in children, mitigated by “drug holidays.”
3.​ Atomoxetine-specific:
○​ Decreased appetite, nausea, vomiting, fatigue.
Warnings:
●​ Amphetamines and methylphenidate: High abuse potential; prolonged use may lead
to dependence.
●​ Pemoline: Risk of life-threatening liver failure; requires informed consent.
●​ Store all stimulants securely to prevent accidental ingestion or abuse; a 10-day supply
can be fatal in children.
Client Teaching:
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Take stimulants after meals to reduce anorexia and nausea.
Avoid caffeine, sugar, and chocolate to prevent symptom exacerbation.
Monitor growth in children and plan "drug holidays" during non-school periods.
Educate clients and caregivers on the potential for abuse and safe storage practices.
Disulfiram Overview:
●​ Primary Use: Deterrent for alcohol consumption in motivated individuals undergoing
treatment for alcoholism.
●​ Mechanism of Action: Inhibits aldehyde dehydrogenase, leading to elevated
acetaldehyde levels when alcohol is consumed, causing severe adverse reactions.
●​ Reaction Symptoms:
○​ Mild: Flushing, headache, nausea, vomiting, dizziness.
○​ Severe: Chest pain, dyspnea, hypotension, confusion, or even death.
●​ Contraindications:
○​ Never administer during alcohol intoxication.
○​ Requires client consent and knowledge before use.
Client Education:
●​ Avoid products containing alcohol (e.g., shaving cream, aftershave, cologne, deodorant,
OTC cough medications).
●​ Read labels carefully to prevent inadvertent reactions.
●​ Monitor for side effects: fatigue, drowsiness, halitosis, tremor, impotence.
Drug Interactions:
●​ Can interfere with metabolism of:
○​ Phenytoin, warfarin, isoniazid, barbiturates, benzodiazepines.
Alternative Medication: Acamprosate (Campral):
●​ Purpose: Reduces physical and emotional discomfort during early sobriety (e.g.,
sweating, anxiety, sleep issues).
●​ Dosage: 333 mg tablets, two tablets three times daily.
●​ Contraindication: Not suitable for individuals with renal impairment.
●​ Side Effects: Mild (diarrhea, nausea, flatulence, pruritus).
Cultural Considerations in Psychotropic Medications:
●​ Drug Responses by Ethnicity:
○​ African Americans: Faster response but higher side effect risk with
antipsychotics and TCAs.
○​ Asians: Slower metabolism of antipsychotics and TCAs, requiring lower
dosages.
○​ Variations likely linked to genetic differences rather than race alone.
●​ Clinical Approach: Avoid stereotypes; tailor treatments based on individual responses
and history.
Herbal Medicine Use:
●​ Common examples:
○​ St. John’s Wort: Depression.
○​ Kava: Anxiety; potentiates alcohol and sedatives.
○​ Valerian: Sleep aid and stress relief.
○​ Ginkgo Biloba: Memory enhancement; also used for fatigue, anxiety,
depression.
●​ Precautions:
○​ Ask clients about herbal use explicitly.
○​ Be aware of potential interactions with medications.
○​ Recognize that herbal products are not standardized or regulated for medical
treatment.