Editing Mental Health and Psychosocial Nursing (section)

== Psychopharmacology Essentials ==

=== Antidepressants ===
* '''SSRIs''' (fluoxetine, sertraline, escitalopram, paroxetine, citalopram): first-line. Nausea, headache, insomnia or sedation, and sexual dysfunction are common. Full effect takes '''4 to 6 weeks'''; teach the client not to stop early. Abrupt discontinuation causes a discontinuation syndrome (dizziness, flu-like symptoms, paresthesias), so taper. Risk of hyponatremia in older adults and increased bleeding risk with NSAIDs or anticoagulants.
* '''SNRIs''' (venlafaxine, duloxetine): monitor blood pressure with venlafaxine.
* '''Bupropion''': no sexual side effects, aids smoking cessation, but '''lowers the seizure threshold'''; contraindicated in seizure disorder, bulimia, and anorexia.
* '''Mirtazapine''': sedation and appetite gain, sometimes used deliberately in older adults with weight loss and insomnia.
* '''Tricyclics''' (amitriptyline, nortriptyline, imipramine): anticholinergic effects, orthostatic hypotension, and '''lethal in overdose from cardiac conduction block'''; dispense limited quantities to at-risk clients.
* '''MAOIs''' (phenelzine, tranylcypromine, isocarboxazid): require a '''tyramine-restricted diet'''. Avoid aged cheese, cured and smoked meats, fermented foods, soy sauce, sauerkraut, tap and draft beer, red wine, fava beans, and overripe fruit. Tyramine causes '''hypertensive crisis''' with severe occipital headache, stiff neck, palpitations, and marked hypertension. Allow a '''2-week washout''' between MAOIs and most serotonergic agents (5 weeks after fluoxetine). Avoid combining with SSRIs, meperidine, or sympathomimetics.

'''Serotonin syndrome''': onset within hours of a serotonergic increase or combination. Mental status change, autonomic instability, hyperthermia, diaphoresis, diarrhea, and the distinguishing '''neuromuscular hyperactivity: hyperreflexia, clonus, and tremor, greater in the lower extremities'''. Stop the agent, provide supportive cooling and benzodiazepines, and consider cyproheptadine.

=== Mood Stabilizers ===
* '''Lithium''': therapeutic serum level 0.6 to 1.2 mEq/L for maintenance; acute mania is often managed at 1.0 to 1.5 mEq/L. '''Toxicity begins above 1.5 mEq/L and is severe above 2.0 mEq/L.''' Narrow therapeutic index.
** Early toxicity: nausea, vomiting, diarrhea, coarse hand tremor, drowsiness, muscle weakness.
** Moderate to severe: ataxia, confusion, blurred vision, giddiness, slurred speech, nystagmus, seizures, arrhythmias, coma.
** Teaching: maintain '''consistent sodium intake and 2 to 3 liters of fluid daily'''. '''Sodium loss raises lithium levels''' because lithium is reabsorbed in place of sodium. Caution with vomiting, diarrhea, sweating, fever, exercise in heat, and low-sodium diets. Avoid '''NSAIDs, thiazide diuretics, and ACE inhibitors''', which raise lithium levels. Baseline and periodic renal and thyroid studies. Draw levels 12 hours after the last dose. Contraindicated in pregnancy in most cases because of cardiac malformation risk (Ebstein anomaly).
* '''Valproate/divalproex''': monitor liver function, ammonia, platelets, and pancreatitis symptoms. '''Highly teratogenic''' (neural tube defects); confirm contraception.
* '''Carbamazepine''': monitor for agranulocytosis and aplastic anemia, hyponatremia, and Stevens-Johnson syndrome (screen for HLA-B*1502 in clients of Asian ancestry). Strong enzyme inducer that lowers oral contraceptive efficacy.
* '''Lamotrigine''': effective for bipolar depression. '''Titrate slowly''' to reduce the risk of serious rash including Stevens-Johnson syndrome. Any rash requires immediate provider notification and usually discontinuation.

=== Antipsychotics ===
'''First generation''' (haloperidol, fluphenazine, chlorpromazine): strong dopamine blockade, more extrapyramidal symptoms. '''Second generation''' (risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, paliperidone, lurasidone, clozapine): fewer extrapyramidal symptoms, more '''metabolic syndrome''' (weight gain, dyslipidemia, hyperglycemia). Monitor weight, waist circumference, fasting glucose or A1C, and lipids.

'''Extrapyramidal symptoms''':
{| class="wikitable"
! Type !! Typical onset !! Features !! Management
|-
| Acute dystonia || Hours to days || Torticollis, oculogyric crisis, opisthotonos, '''laryngospasm''' || Emergency; IM/IV diphenhydramine or benztropine
|-
| Akathisia || Days to weeks || Inner restlessness, inability to sit still; often mistaken for agitation and linked to suicide risk || Reduce dose, propranolol, benzodiazepine
|-
| Pseudoparkinsonism || Weeks || Shuffling gait, mask facies, pill-rolling tremor, cogwheel rigidity, bradykinesia || Anticholinergic agent, dose reduction
|-
| Tardive dyskinesia || Months to years || Involuntary lip smacking, tongue protrusion, choreoathetoid movements; may be irreversible || Screen with AIMS, switch agent, valbenazine or deutetrabenazine
|}

'''Neuroleptic malignant syndrome''': a life-threatening reaction developing over days. '''Hyperthermia, "lead-pipe" muscular rigidity, autonomic instability, altered consciousness, and markedly elevated creatine kinase with myoglobinuria and risk of acute kidney injury.''' Stop the antipsychotic immediately, cool aggressively, hydrate, and expect dantrolene or bromocriptine. Contrast with serotonin syndrome, which is faster in onset and features hyperreflexia and clonus rather than lead-pipe rigidity.

'''Clozapine''' is reserved for treatment-resistant schizophrenia and reduces suicidality, but requires '''absolute neutrophil count monitoring for agranulocytosis'''; report fever, sore throat, or flu-like symptoms immediately. Also causes myocarditis, seizures at higher doses, orthostatic hypotension, sialorrhea, and '''severe constipation and ileus''' that can be fatal. Assess bowel function routinely.

=== Anxiolytics, Hypnotics, and Stimulants ===
* '''Benzodiazepines''' (lorazepam, alprazolam, diazepam, clonazepam): rapid relief, but sedation, fall risk in older adults, tolerance, dependence, and dangerous respiratory depression when combined with opioids or alcohol. Use short-term. '''Taper; do not stop abruptly.'''
* '''Buspirone''': nonaddicting anxiolytic with '''no immediate effect'''; takes 2 to 4 weeks. Not useful PRN. Avoid grapefruit juice.
* '''Hydroxyzine''': nonaddicting, sedating, useful PRN.
* '''Stimulants''' for ADHD (methylphenidate, amphetamine salts): monitor growth, appetite, sleep, blood pressure, and heart rate; give in the morning; controlled substances with diversion risk. '''Atomoxetine''' and '''guanfacine''' are nonstimulant options.

=== Electroconvulsive Therapy ===
Indicated for severe or treatment-resistant depression, depression with psychotic features, acute suicidality where speed matters, and catatonia. Care: informed consent, NPO after midnight, remove dentures and jewelry, void before, an anticholinergic (atropine or glycopyrrolate) to reduce secretions, a short-acting anesthetic (methohexital), and a muscle relaxant (succinylcholine). Afterward, monitor airway and vital signs, position on the side until responsive, reorient frequently, and expect transient confusion and '''short-term memory loss''', most commonly retrograde around the treatment period.