Psychiatric Medications

Preparing for the NCLEX PN® requires a comprehensive understanding of psychiatric medications, a critical component of mental health nursing. Mastery of antidepressants, antipsychotics, mood stabilizers, and anxiolytics is essential. This knowledge enables nurses to safely administer medications, manage side effects, and educate patients, ensuring effective treatment and positive mental health outcomes.

Learning Objective

In studying “Psychiatric Medications” for the NCLEX PN® exam, you should learn to understand the classifications, mechanisms, and uses of antidepressants, antipsychotics, anxiolytics, and mood stabilizers. Analyze the role of these medications in managing conditions like depression, schizophrenia, anxiety, and bipolar disorder. Evaluate common side effects, contraindications, and the nurse’s responsibilities in monitoring adverse effects. Explore patient education strategies, emphasizing adherence, managing withdrawal symptoms, and recognizing early signs of toxicity. Additionally, focus on ethical considerations in mental health care, including informed consent and cultural sensitivity, and apply this knowledge to safely administer medications in NCLEX PN® practice scenarios.

Classifications and Mechanisms of Psychiatric Medications

Psychiatric medications are categorized based on their therapeutic use and mechanism of action. Each class targets specific neurotransmitters or brain functions to alleviate symptoms of mental health disorders. Understanding these classifications allows nurses to administer medications safely and monitor their effects effectively.

1. Antidepressants

• Selective Serotonin Reuptake Inhibitors (SSRIs): Includes fluoxetine, sertraline, and escitalopram. These medications block the reabsorption (reuptake) of serotonin in the brain, increasing its availability to improve mood and reduce anxiety.
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Medications like venlafaxine and duloxetine increase both serotonin and norepinephrine levels, providing dual action for mood improvement.
• Tricyclic Antidepressants (TCAs): Includes amitriptyline and nortriptyline. These medications work by blocking the reuptake of serotonin and norepinephrine but can have significant side effects, such as sedation and anticholinergic effects.
• Monoamine Oxidase Inhibitors (MAOIs): Medications like phenelzine and tranylcypromine inhibit the enzyme monoamine oxidase, which breaks down serotonin, norepinephrine, and dopamine. Due to dietary restrictions and potential interactions, they are often used as a last resort.

2. Antipsychotics

• Typical (First-Generation) Antipsychotics: Includes haloperidol and chlorpromazine. These medications block dopamine receptors in the brain, reducing symptoms like hallucinations, delusions, and agitation. However, they are associated with higher risks of extrapyramidal symptoms (EPS) such as tremors and rigidity.
• Atypical (Second-Generation) Antipsychotics: Includes risperidone, olanzapine, and quetiapine. These medications target both dopamine and serotonin receptors, making them effective for treating both positive (hallucinations, delusions) and negative (apathy, withdrawal) symptoms of schizophrenia. They have fewer EPS but pose a risk of metabolic syndrome.

3. Mood Stabilizers

• Lithium: A gold standard for treating bipolar disorder, lithium works by stabilizing mood and reducing the severity of manic and depressive episodes. It modulates neurotransmitter activity and improves neural connections. Regular monitoring is essential to prevent toxicity (e.g., tremors, confusion, vomiting).
• Anticonvulsants: Medications like valproate, lamotrigine, and carbamazepine are used to stabilize mood by regulating the firing of neurons and modulating neurotransmitter release. They are particularly effective in treating rapid-cycling bipolar disorder.

4. Anxiolytics

• Benzodiazepines: Includes lorazepam, alprazolam, and diazepam. These medications enhance the effect of gamma-aminobutyric acid (GABA), a calming neurotransmitter, to reduce anxiety and promote relaxation. They are effective for short-term use but have a high potential for dependency.
• Non-Benzodiazepine Anxiolytics: Buspirone is a long-term option for anxiety management. It acts on serotonin receptors without causing sedation or dependency, making it a safer alternative for chronic anxiety.

5. Stimulants (for ADHD)

• Amphetamine-Based Medications: Includes amphetamine-dextroamphetamine (Adderall) and methylphenidate (Ritalin). These medications increase the release of dopamine and norepinephrine in the brain, improving attention and focus. Nurses should monitor for side effects like insomnia, weight loss, and increased heart rate.

Key Nursing Responsibilities

• Understand the therapeutic effects and potential side effects of each class.
• Monitor for interactions, especially with other medications or substances like alcohol.
• Educate patients about adherence, expected outcomes, and managing common side effects.
• Conduct regular assessments, such as lithium levels or glucose monitoring, to prevent complications.

By mastering the classifications and mechanisms of psychiatric medications, nurses can provide safe and effective care for patients with mental health needs.

Side Effects, Contraindications, and Monitoring

Understanding the side effects, contraindications, and monitoring requirements of psychiatric medications is essential to ensure patient safety and treatment efficacy. Nurses must be vigilant in recognizing adverse effects, educating patients, and identifying situations where medications may pose risks.

1. Side Effects of Psychiatric Medications

• Antidepressants:
  • SSRIs: Common side effects include nausea, headache, sexual dysfunction, insomnia, and weight gain. Monitor for serotonin syndrome, characterized by agitation, confusion, rapid heart rate, and muscle rigidity, especially when combined with other serotonergic drugs.
  • SNRIs: May cause hypertension, dry mouth, and dizziness. Monitor blood pressure regularly.
  • Tricyclic Antidepressants (TCAs): Side effects include drowsiness, dry mouth, constipation, and orthostatic hypotension. Overdose risk is high and can cause cardiac arrhythmias.
  • MAOIs: Can lead to hypertensive crisis when combined with tyramine-rich foods (e.g., aged cheese, cured meats). Monitor for headache, chest pain, or severe hypertension.
• Antipsychotics:
  • Typical Antipsychotics: Extrapyramidal symptoms (EPS) such as dystonia, akathisia, and tardive dyskinesia are common. Sedation and orthostatic hypotension are also frequent.
  • Atypical Antipsychotics: Increased risk of metabolic syndrome, including weight gain, hyperglycemia, and dyslipidemia. Clozapine can cause agranulocytosis, requiring regular white blood cell monitoring.
• Mood Stabilizers:
  • Lithium: Side effects include tremors, polyuria, and weight gain. Toxicity can cause confusion, ataxia, seizures, or cardiac arrhythmias.
  • Anticonvulsants: May cause drowsiness, dizziness, and gastrointestinal symptoms. Stevens-Johnson syndrome is a rare but serious reaction requiring immediate discontinuation.
• Anxiolytics:
  • Benzodiazepines: Common side effects include sedation, dizziness, and dependency with prolonged use. Overdose risk is higher when combined with alcohol or opioids.
  • Buspirone: Minimal side effects compared to benzodiazepines but may cause dizziness or nausea.

2. Contraindications

• Antidepressants:
  • SSRIs and SNRIs are contraindicated with MAOIs due to the risk of serotonin syndrome.
  • TCAs should be avoided in patients with cardiac conditions or a history of seizures.
  • MAOIs are contraindicated in patients who cannot adhere to dietary restrictions.
• Antipsychotics:
  • Avoid in patients with Parkinson’s disease (typical antipsychotics exacerbate symptoms) or severe liver impairment.
  • Use caution in elderly patients with dementia-related psychosis due to increased mortality risk.
• Mood Stabilizers:
  • Lithium is contraindicated in patients with renal impairment or significant dehydration due to its narrow therapeutic index.
  • Anticonvulsants like valproate are contraindicated during pregnancy due to teratogenic effects.
• Anxiolytics:
  • Benzodiazepines are contraindicated in patients with a history of substance abuse or respiratory disorders like COPD.

3. Monitoring Requirements

• Antidepressants: Monitor for mood changes, particularly during the first few weeks of treatment, as there is an increased risk of suicidal ideation.
• Antipsychotics: Regularly assess for EPS, tardive dyskinesia (using tools like the AIMS scale), and metabolic changes, including weight, glucose, and lipid levels.
• Mood Stabilizers:
  • For lithium, check serum levels (therapeutic range: 0.6–1.2 mEq/L) every 1–2 months. Monitor kidney function and thyroid levels to detect long-term complications.
  • Anticonvulsants require periodic liver function tests and monitoring for skin rashes.
• Anxiolytics: Monitor for signs of dependency, sedation, or respiratory depression, particularly in high-risk populations.

4. Patient Education

• Educate patients on recognizing side effects, such as serotonin syndrome or EPS, and emphasize the importance of reporting symptoms promptly.
• Teach the need for adherence to prescribed doses, avoiding abrupt discontinuation to prevent withdrawal or symptom relapse.
• Instruct patients on lifestyle adjustments, such as dietary restrictions with MAOIs or avoiding alcohol with benzodiazepines.

5. Role of the Nurse

• Conduct regular assessments to evaluate medication effectiveness and identify early signs of adverse effects.
• Advocate for patients by communicating concerns about side effects or contraindications to the healthcare provider.
• Provide emotional support to patients adjusting to new medications and their side effects, ensuring they feel informed and empowered.

By understanding and managing side effects, contraindications, and monitoring requirements, nurses ensure the safe and effective use of psychiatric medications while prioritizing patient safety and well-being.

Patient Education Strategies

Effective patient education on psychiatric medications is vital for ensuring adherence, managing side effects, and empowering patients to take an active role in their treatment. Nurses must provide clear, culturally sensitive, and practical information tailored to each patient’s needs and understanding.

1. Importance of Medication Adherence

• Consistent Use: Educate patients about the importance of taking medications as prescribed, even when symptoms improve, to prevent relapse or withdrawal. For example, stopping antidepressants abruptly can lead to discontinuation syndrome, causing dizziness, nausea, or irritability.
• Timing and Routine: Encourage patients to take medications at the same time daily to maintain consistent blood levels. Suggest using tools like pill organizers, alarms, or smartphone apps to support adherence.
• Therapeutic Timeframes: Explain that many psychiatric medications, such as SSRIs or antipsychotics, take several weeks to reach full effect, so patience is essential.

2. Managing Side Effects

• Recognizing Common Side Effects: Provide information about typical side effects for each medication, such as drowsiness with benzodiazepines or weight gain with antipsychotics. Reassure patients that many side effects subside with time.
• When to Seek Help: Teach patients to recognize signs of serious adverse effects, such as serotonin syndrome (e.g., agitation, rapid heart rate) or lithium toxicity (e.g., tremors, confusion), and advise immediate medical attention if these occur.
• Coping Strategies: Offer practical tips, such as taking medications with food to reduce nausea or adjusting schedules to manage sedation by taking medications at bedtime.

3. Educating on Drug Interactions

• Alcohol and Substance Use: Warn patients about the risks of combining medications, such as benzodiazepines, with alcohol or other CNS depressants, which can exacerbate sedation or respiratory depression.
• Herbal Remedies and OTC Medications: Encourage patients to inform their healthcare provider about any supplements or over-the-counter medications they use to avoid harmful interactions, such as serotonin syndrome when combining SSRIs with St. John’s Wort.

4. Addressing Patient Concerns and Misconceptions

• Fear of Dependency: Reassure patients that many medications, such as SSRIs or antipsychotics, are not addictive. For anxiolytics like benzodiazepines, emphasize short-term use and monitoring to prevent dependency.
• Cultural Beliefs: Be sensitive to cultural or personal beliefs about mental health and medication use. Address misconceptions with evidence-based information while respecting the patient’s values and preferences.

5. Encouraging Communication and Follow-Up

• Open Communication: Encourage patients to share concerns about their medications, such as side effects or financial barriers. Addressing these concerns fosters trust and improves adherence.
• Follow-Up Appointments: Stress the importance of attending follow-up visits to monitor medication effectiveness and make necessary adjustments. Patients should understand that psychiatric care is a collaborative and ongoing process.

6. Promoting a Holistic Approach

• Lifestyle Modifications: Educate patients on the role of exercise, nutrition, sleep hygiene, and stress management in improving mental health. These practices complement medication effectiveness.
• Support Networks: Encourage participation in support groups or counseling sessions to address emotional and social needs. Family education may also enhance understanding and create a supportive environment for the patient.

7. Using Patient-Friendly Communication

• Simplify Information: Avoid medical jargon and use simple language to ensure understanding. For instance, explain “serotonin reuptake inhibition” as “helping your brain use serotonin to improve your mood.”
• Visual Aids: Use handouts, diagrams, or videos to explain medication mechanisms, side effects, and dosages visually. These tools can reinforce verbal instructions.
• Teach-Back Method: Ask patients to repeat back key information to confirm their understanding, such as “Can you tell me how you will take this medication each day?”

Role of the Nurse
Nurses act as educators, advocates, and support systems for patients. Providing individualized education, addressing barriers to adherence, and promoting ongoing communication ensures patients feel confident managing their medications and mental health. Empowered patients are more likely to adhere to their treatment plans and achieve positive outcomes.

Ethical Considerations and Cultural Sensitivity

Ethical and culturally sensitive care in mental health nursing is essential to ensure patient rights, autonomy, and dignity. Nurses must balance ethical obligations with the diverse cultural needs of patients, fostering trust and delivering equitable, individualized care.

1. Respect for Patient Autonomy

• Informed Consent: Ensure patients fully understand their treatment options, including medication benefits, potential side effects, and alternatives. Obtain voluntary consent before initiating or changing treatment plans.
• Right to Refuse Treatment: Respect patients’ decisions to refuse medications or therapy, even if it conflicts with the nurse’s judgment. Educate patients about the risks and potential consequences of refusal, while supporting their autonomy.
• Advance Directives: For patients with chronic mental health conditions, encourage the creation of psychiatric advance directives, which outline their treatment preferences during a crisis.

2. Balancing Confidentiality with Mandatory Reporting

• Confidentiality: Protect patient information by sharing it only with authorized parties involved in care. Avoid disclosing sensitive details to family members or others without patient consent.
• Mandatory Reporting: Recognize situations where confidentiality must be breached for safety, such as when a patient poses an immediate risk to themselves or others. In these cases, inform the patient about the reporting requirement while maintaining professionalism.

3. Cultural Sensitivity in Mental Health Care

• Understanding Cultural Beliefs: Recognize that cultural backgrounds influence patients’ perceptions of mental health, treatment preferences, and medication adherence. For example, some cultures may view mental illness as a stigma or prefer traditional remedies over pharmacological treatments.
• Adapting Care: Tailor interventions to align with cultural practices when safe and appropriate. For instance, incorporate prayer or spiritual practices if requested, alongside evidence-based treatment.
• Effective Communication: Use interpreters for patients with language barriers to ensure clear communication. Avoid assumptions and ask open-ended questions to understand the patient’s perspective.

4. Ethical Advocacy in Vulnerable Populations

• Involuntary Treatment: Advocate for patients when involuntary treatment is considered. Ensure it is only used as a last resort, when the patient poses a risk to themselves or others, and aligns with legal and ethical standards.
• Addressing Disparities: Be aware of systemic inequities in mental health care access and work to address barriers such as cost, transportation, or language. Collaborate with social workers or community resources to provide holistic support.
• Supporting Marginalized Groups: Provide nonjudgmental care for patients from marginalized communities, such as LGBTQ+ individuals, who may face unique stressors and discrimination affecting their mental health.

By integrating ethical principles and cultural sensitivity into care, nurses promote trust, respect, and collaboration, ensuring patients receive equitable and effective mental health treatment.

Examples

Example 1: Administering Antidepressants Safely

A patient with major depressive disorder starts fluoxetine therapy. The nurse educates the patient about common side effects like nausea and insomnia and advises taking the medication in the morning to reduce sleep disturbances. The nurse monitors for increased suicidal ideation during the initial weeks of treatment, ensuring early intervention if necessary.

Example 2: Managing Antipsychotic Side Effects

A patient on haloperidol develops symptoms of tardive dyskinesia, such as involuntary facial movements. The nurse notifies the healthcare provider, who adjusts the medication. The patient is transitioned to an atypical antipsychotic like risperidone, which has a lower risk of extrapyramidal side effects, while the nurse monitors metabolic health.

Example 3: Preventing Lithium Toxicity

A patient with bipolar disorder is prescribed lithium. The nurse teaches the patient to maintain consistent fluid intake and avoid dehydration, as it increases the risk of toxicity. Regular lab tests are scheduled to monitor serum lithium levels, kidney function, and thyroid health, ensuring safe and effective treatment.

Example 4: Educating on Benzodiazepine Use

A patient with generalized anxiety disorder is prescribed lorazepam for short-term use. The nurse explains the risk of dependency and advises the patient to use the medication only as needed. The patient is also introduced to long-term management strategies, including cognitive-behavioral therapy and non-benzodiazepine anxiolytics like buspirone.

Example 5: Addressing Cultural Concerns About Psychotropic Medications

A patient hesitant to start antidepressants due to cultural beliefs about natural healing shares concerns about medication. The nurse respects the patient’s viewpoint and provides evidence-based information on how SSRIs work. The nurse collaborates with the patient to integrate safe complementary therapies alongside prescribed treatment.

Practice Questions

Question 1

A patient taking lithium reports nausea, tremors, and confusion. What is the nurse’s priority action?
A) Encourage increased fluid intake
B) Administer anti-nausea medication
C) Notify the healthcare provider immediately
D) Reassess the patient in one hour

Answer: C) Notify the healthcare provider immediately

Explanation:
Nausea, tremors, and confusion are signs of lithium toxicity, which can be life-threatening. The nurse must notify the provider immediately for further evaluation and intervention. Increasing fluid intake or administering anti-nausea medication is inappropriate without addressing the toxicity.

Question 2

Which of the following should the nurse include when educating a patient prescribed an MAOI like phenelzine?
A) Avoid foods high in protein
B) Limit fluid intake to prevent toxicity
C) Avoid tyramine-rich foods like aged cheese
D) Take the medication at bedtime to reduce nausea

Answer: C) Avoid tyramine-rich foods like aged cheese

Explanation:
MAOIs like phenelzine can cause a hypertensive crisis when combined with tyramine-rich foods, such as aged cheese or cured meats. Patients should be educated to avoid these foods. Protein or fluid intake is unrelated, and timing for nausea management is less critical.

Question 3

A patient on haloperidol develops rigidity and fever. What condition should the nurse suspect?
A) Serotonin syndrome
B) Neuroleptic malignant syndrome
C) Tardive dyskinesia
D) Extrapyramidal symptoms

Answer: B) Neuroleptic malignant syndrome

Explanation:
Neuroleptic malignant syndrome is a rare but severe reaction to antipsychotics like haloperidol. It is characterized by rigidity, fever, and altered mental status. Immediate medical intervention is required. Serotonin syndrome, tardive dyskinesia, and extrapyramidal symptoms have different presentations and are not associated with high fever.