Psychiatric Skills for Non-Psych Nurses

ANTIPSYCHOTIC AGENTS

Psychosis, per se, is not a psychiatric illness, rather it is a symptom associated with a wide range of disorders. The hallmark of psychosis is considered by many as loss of contact with reality. This may take various forms including delusions, severe confusion, hallucinations, or sever impairment in judgment or ability to reason. For many people, the disorder most often associated with psychosis is schizophrenia. However, psychosis sometimes compounds severe depression, and may be noted in various neurological conditions including acute metabolic and toxic states, head injury, M.S., delirium, dementia's, and CNS infections or neoplasm. Treating an individual with antipsychotic medications may relieve the psychotic symptoms but does not treat the underlying process.

Often the admission of a patient to the general hospital with an established diagnosis of schizophrenia can cause alarm or concern among the health care team. Many factors may influence an individuals’ reaction to this diagnostic label – education, previous professional or personal experience, input from our culture including the media and so on. The DSMIII-R discusses 5 subtypes of schizophrenia in detail. However, for a very brief overview, it may be helpful to think of 2 basic types of schizophrenia each with specific biological findings and clinical pictures. Type one schizophrenia is recognized by positive symptoms: hallucinations, delusions, and disturbed thought patterns. Positive symptom schizophrenia is currently believed to be associated with a hyperactive dopamine systems and it responds very well to antipsychotic medication. Type two or negative symptom schizophrenia is characterized by anhedonia (inability to experience pleasure), flat affect, diminished motivation, social isolation, and the absence of hallucinations or delusions. These symptoms are less responsive to antipsychotic medications. While schizophrenia is a chronic condition, it is characterized by periods of exacerbation and periods (often lengthy) or remission. Many individuals who are schizophrenic are maintained on anti-psychotic medication and may be admitted with a history of on-going antipsychotic use. This important information should be relayed to the primary care physician.

Some individuals become psychotic during a hospitalization and require intervention to decrease the alarming and unpleasant symptoms of psychosis. Antipsychotic agents are most effective in treating:

Hallucinations
Delusional thinking including paranoia
Severe confusion including impaired judgment
Psychomotor agitation
Bizarre behavior
Belligerence or aggression

The drug of choice in a given situation will be one which will effectively treat the psychotic symptoms while causing the least side effects. It is important to be aware of and consider side
effects when prescribing and administering these agents,. At times a certain antipsychotic may be chosen to use the expected side effects to benefit the patient in addition to the primary effect of the drug. An example of this might be to choose an agent with a sedative side effect when treating psychotic symptoms in a person who is agitated as well.

Table one lists the antipsychotic medications in current use. It illustrated the pharmacological principles of efficacy and potency. Efficacy of a drug refers to its maximal therapeutic effect while potency refers to the amount of medication required to achieve maximal effect.

TABLE I

From Handbook of Psychiatric Drug Therapy
S. Hyman & G. Arans, Little Brown, 1987

Antipsychotic drugs: potencies and side effect profiles

Drug	Approximate dose equivalent	Sedative Effect	Hypotensive Effect	Anticholinergic Effect	Extra pyramidal Effect
Phenothiazines Aliphatic Chlorpromazine (Thorazine)	100	High	High	Medium	Low
Triflupromazine (Vesprin)	30	High	High	Medium	Medium
Piperidines
Mesoridazine (Serentil)	50	Medium	Medium	Medium	Medium
Thioridazine (Mellaril)	95	High	High	High	Low
Piperazines
Acetopphenazine (Tindal)	15	Low	Low	Low	Medium
Fluphenazine (Prolixim, Perrmitil)	2	Medium	Low	Low	High
Perphenazine (Trilafon)	8	Low	Low	Low	High
Trifuoperazine (Stelazine)	5	Medium	Low	Low	High

Thiozanthenes
Aliphatic
Chlorprethizene (Taractan)	75	High	High	High	Low
Piperazine
Thiothizene (Navane)	5	Low	Low	Low	High

Dibenzoxazepine
Lozapine (Loxitane, Daxolin)	10	Medium	Medium	Medium	High

Butyrohenones
Droperidol (Inapsine-injection only)	1	Low	Low	Low	High
Haloperidol (Haldol)	2	Low	Low	Low	High

Indoine
Molindone (Moban)	10	Medium	Low	Medium	High

Diphenylbutyipiperidines
Pimozide (Orap)	1	Low	Low	Low	High

Antipsychotic medications have the potential to cause a wide range of side effects including sedation, hypotension, anticholinergic effects and extra pyramidal symptoms. Sedation and hypotension (usually postural) require no elaboration as they are common drug side effects which can be easily monitored and/or self reported b the patient. Precautions and patient teaching are the same for these side effects when caused by any other drug. The typical anticholinergic effects noted include dry mouthm blurred vision, constipation and urinary hesitancy or retention. These effects often diminish as the individual becomes accustomed to the medication. Anticholinergic side effects are best treated symptomatically with fluids, diet, etc.

Extrapyramidal side effects include several different types of CNS reactions which can be both severe and frightening in nature. The Parkinson-lie side effects include a mask-like facial expression, muscular rigidity, tremor, slower motor responses or shuffling gait. Such side effects typically become evident about one week or so after the initiation of antipsychotic therapy. Another extra pyramidal side effect (EPS) is an acute dystonia. Acute dystonia can occur even after one dose of medication and usually occur early in the course of antipsychotic therapy. Patients often complain of a stiff neck or jaw when experiencing a dystonic reaction. However, these bizarre and painful muscle contractions can affect the tongue, face, neck and back.

Both of these EPS respond well to IM or PO anticholinergic agents. Typically, Cogentin, Benadryl, or Artane are used to counteract these EPS.

Another EPS is akathesia. The nurse may observe this as restlessness or an inability to be still. The patient’s motor restlessness is visable and is subjectively experienced as anxiety, or agitation. Akathesia may develop weeks or months after the onset of drug therapy. Unfortunately, this side effect can present as an increase in symptoms and may be addressed by increasing the antipsychotic dose which intensifies the akathesia. While akathesia may partially respond to anticholinergic medications the most effective remedy may be low dose benzodiazepines in conjunction with lowering the dose of antipsychotic medication to the minimum effective dose. Low potency antipsychotic agents usually cause less akathesia.

A final EPS is Tardive Dyskinesia. This serious and often irreversible side effect usually begins late in the course of antipsychotic drug therapy. Clinically, the presentation of TD includes involuntary sucking and smacking movements of the mouth, involuntary tongue thrusting, and other facial grimacing. Chorea of the trunk and extremities is typical as well. There is no cure for TD and the only treatment is to discontinue the antipsychotic medication. When discontinuation occurs, there is usually an increase in the face and body movements because the medication had been masking as well as causing this side effect. Over time the TD symptoms may diminish.

In addition to these major and fairly frequent side effects, antipsychotic can cause agranulocytosis, photosensivity, eye problems, hormonal problems, and cardiac side effects in rare instances.

Aside from these side effects, antipsychotic drugs can cause a rare idiosyncratic reaction known as Neuroleptic Malignant Syndrome (NMS). This extremely serious condition has a mortality rate of about 20% and even acutely psychotic patients who develop NMS may require transfer for treatment in an ICU.

NMS usually begins with muscle rigidity and fever. These symptoms precede autonomic instability and encephalopathy. A full blown NMS takes from 24 to 72 hours to develop. Fevers as high as 41 C or more are usual. Muscle tone can be so rigid as to lead to myonecrosis with secondary renal failure from myoglobinuria. Autonomic instability including unstable blood pressure, tachycardia, diaphoresis and pallor is common. Levels of consciousness may vary; however, stupor and even coma are not uncommon. Lab values reveal C
PK 3 up to 15,000; leucocytosis of 15,000 to 30,000’ creatine phosphokinase up to 5.1 mg/dl; increased liver enzymes and generalized slowing of EEF.

TABLE II

Medications commonly used to treat Neuroleptic Malignant Syndrome (NMS)
From Nurseweek – Northern California edition – March 9, 1952
Article Authors L. Pellitier, D. Daily & D,. Bennett

NAME
GENERIC/TRADE

ACTION

USUAL DOSAGE

Bromocriptine mesylate
(Pariodel)

Direct dopamine agonist; relieves akathesia and rigidity

2.5-5mg/TID

Amantadine (Symmetrel)

Anti-cholinergic agent; reversed
Extrapyramidal symptoms and
Catatonia

200-300 mg/day

Lorazepam (Ativan)

Restoration of dopamine-y-
Aminobutyric acid balance,
Relieving catatonia

3mg/day

Diphenhydramine
Hydrochloride

Antihistamine; also provides
Local anesthesia by preventing
Initiation and transmission of
Nerve impulses

50mg/IM

Benztropine mesylate
(Cogentin)

(Same as amantadine)

2-4mg/day

Dantrolene sodium
(Dantrium)

Direct acting skeletal muscle
Relaxant; drug of choice for
Treating malignant hyperthermia

1-10mg/kg/day (IV,po)

Lavodopa (Dopar, Larodopa, Levopa, Parda, Rio-Dopa)

Counters the presumed central dopamine blockade of NM: reduces profound parkinsonism (not first choice treatment)

100 mg/BID for suspected NM; up to 1mg/day for NM

Table II suggests the appropriate pharmacologic interventions to reverse NMS. However, excellent supportive care is essential including hydration, management of high fever, preventive skin care, cardiac monitoring and careful monitoring of output and renal function. When respiratory functions have been impaired due to muscle rigidity, pneumonias can complicate recovery.

Risk factors for NMS are:

Physical agitation
Physical exhaustion
High doses of antipsychotics
Dehydration
A diagnosis of schizophrenia
Hypernatremi
Concomitant lithium therapy

Males develop NMS twice as frequently as women and 80% of those affected are under 40 years of age.

In the past two years, a new antipsychotic medication has been approved for use in the United States. Clozapine (brand name Clozaril) is targeted toward negative symptom of type 2 schizophrenia which has traditionally been more difficult to treat effectively with medications. While Clozaril has a very low side effect profile and does not appear to cause EPS, it has been associated with life threatening blood dycrasias which develops very rapidly. At present all patients who use Clozaril must have weekly blood tests.

ANTIDEPRESSANTS

Antidepressants are another major class of psychopharmalogical agents. Major depression, bipolar depression and depression with psychotic features are the disorders which are treated with antidepressants. These drugs have been found to be effective in panic disorders, neuropathic pain, and bulimia, as well, and to a lesser extent may be helpful in adjustment disorder with depressed mood, obsessive compulsive disorder, and PTSD (post traumatic stress disorder).

There are three types of antidepressants to review:

Tricyclic related cyclic antidepressants
Mono-anime oxidase inhibitors (MAOIS)
Atypical antidepressants

The action of all these agents occurs at the level of receptor sites in the brain where the drugs alter the regulation of the neurotransmitter receptor systems.

Major depression is one of the more common psychiatric diagnosis in the U.S. Therefore, health care providers can expect to care for patients who have an established diagnosis of major depression. Symptoms include:

Pervasive and continuous depressed mood which may be experienced as sadness, emptiness, hopelessness and helplessness.
Increasing impairment in normal functioning in all areas of ones life.
Ahedonia
Disturbed sleep pattern – insomnia or hypersomnia
Psychomotor retardation or agitation (speech, gait, movements)
Exaggerated diminution of self esteem which may be experienced as worthlessness or guilt.
Suicidal ideas, plans or recurrent thoughts of death.
Indecisiveness and/or impaired concentration

In addition to psychiatric origins for depression, there are many physical disorders that can cause depression. Some of these are:

AIDS	Hyperthyroidism
Addison’s Disease	Malignancies
Cushing Disease	MS
CHF	Rheumatoid Arthritis
Diabetes	Lupus

And depression is often associated with the use of certain drugs listed on Table 3

TABLE III

J. Preston and J. Johnson
Clinical Psychopharmacology Made Ridiculously Simple
1990 Med Master

TYPE	GENERIC NAME	BRAND NAME

Antihypertensives (for high blood pressure)	Reserpine Propranolo hydrochloride Methyldopa Guanethidine sulfate Clonidine hydrochloride Hydralazine hydrochloride	Serpasil, Ser-Ap-Es, Sandri Inderall

Corticosteroidsand Other Hormones	Cortisone acetate Estrogen Progesterone	Cortone Evex, Menrium, femest, lipo-Lutin, Progestasert, Proputon

Antiparkinson Drugs	Levodopa and carbidopa Levodopa Amantadine hydrochloride	Sinemet Dopar, Larodopa Symmetrel

Antianxiety Drugs	Diazepam Chlordiazepoxide	Valium Librium

Birth Control Pills	Progesterone estrogen	Various Brands

Alcohol	Wine, beer, spirits	Various Brands

Sedation or anticholinergic side effects are the two major types of side effects associated with antidepressant drugs. Just as with the antipsychotic drugs, in some cases side effects can be utilized to benefit the patient in addition to the primary action of the drug. For example, an agitated, restless patient with disturbed sleep ay benefit from an antidepressant with greater sedation as a side effect while a fatigued individual with psychomotor retardation may benefit from an antidepressant with enervating side effects.

Table IV lists the antidepressants in current use and compares their side effect profiles.

TABLE IV

J. Preston and J. Johnson
Clinical Psychopharmacology Made Ridiculously Simple
1990 Med Master

NAMES		USUAL DAILY DOSAGE		ACH
GENERIC	BRAND	RANGE	SEDATION	EFFECTS

TRYCYCLIC and LIKE COMPOUNDS

Imipramine	Tofanil	150-300 mg	Mid	Mid
Desipramine	Norpramin	150-300 mg	Low	Low
Amitriptyline	Elavil	150-300 mg	High	High
Nortriptyline	Aventyl, Pamelor	75-125 mg	Mid	Mid
Protriptyline	Vivactil	15-40 mg	Low	Mid
Trimipramine	Surmontil	100-300 mg	High	Mid
Doxepin	Sinequan, Adapin	150-300	High	Mid
Maprotiline	Ludiomil	150-225mg	Mid	Low
Amoxapine	Asendin	150-400 mg	Mid	low
Trazodone	Desyrel	150-400 mg	Mid	None
Fluoxetine	Prozac	20-80mg	Low	None
Bupropion	Wellbutrin	200-450 mg	Low	None

MAO INHIBITORS

Phenelzine	Nardil	30-90mg	Low	None
Tranycypromine	Parnate	20-60 mg	Low	None

The anticholinergic side effects of antidepressant medications can provoke non-compliance with medication regimens, Thorough patient education including what side effects are possible and suggestions for dealing with them is essential. Mild anticholinergic effects are more serious; examine all the drugs the patient is receiving to determine if other therapeutic agents could be causing anticholinergic effects as well.

Postural hypotension can occur with any of the antidepressans.

Cardiac toxicity is another concern with antidepressant medications because they exert a guanidine like effect and cause intra-cardiac conduction to slow. Patients at greater risk, therefore, are those with pre-existing cardiac conduction system disease. Benign EKG changes are sometimes noted in patients with normal cardiac status.

The MAOI groups of antidepressants are often reserved for use in individuals who have not responded to tricyclic or related cyclic anti-depressants. Successful use of MAOI’s does require inactivate mono amine oxidase in both the liver and the intestine. When foods containing tyramine or vasoactive amines or medications which are sympathomimetic are ingested, life threatening side effects which require emergency medical attention can result. Symptoms of a hyperdrenergic crisis include severe headache, diaphoresis, mydriasis, neuromuscular irritability, hypertension, cardiac arrhythmias and CVAs.

When a patient is admitted for inpatient care who is on MAOI’s it is essential to notify the dietary department. Typically a dietician will wish to consult with the patient and provide a copy of patient instruction re: MAOI’s for staff. Table 4 is a sample of patient instructions for safe use of MAOI’s.

In addition to hyperdrenergic crisis precipitated by non-compliance with dietary restrictions, the noted drugs can cause serious reactions when ingested with MAOI’s.

TABLE V

Dr. Hyman and G, Arana
Handbook of Psychiatric Drug Therapy
1987 Little, Brown & Co.

Sample instructions for patients taking monoamine oxidase inhibitors

Certain foods and beverages must be avoided:

All cheese except for fresh cottage cheese or cream cheese

Meat
Beef liver
Chicken liver
Fermented sausages

Pepperoni
Salami
Bologna
Other fermented sausages

Other cured, unrefrigerated meats

Fish
Caviar
Cured unrefrigerated fish
Herring (dried or pickled)
Dried fish

Vegetables
Overripe avocados
Fava beans

Fruit
Overripe fruits, canned figs

Other foods
Yeast extracts (e.g., Marmite, Bovril)

Beverages
Chianti wine
Some imported beers

Some foods and beverages should be used only in moderation
Chocolate
Coffee

If you visit other physicians or dentists, inform them that you are taking an MAOI. This precaution is especially important if other medications are to be prescribed of if you are to have dental work or surgery.
Take no medications without a doctor’s approval.

Avoid all over-the-counter pain medications except:

Plain aspirin, acetaminophen (Tylenol) or ibuprofen

Avoid all cold or allergy medication except:

Plain chlorpheniramine (Chlortrimeton) or brompheniramine (Dimetane)

Avoid all nasal decongestants and inhalers

Avoid all cough medications except:

Lain quaifenisin elixir, (Robitussin)

Avoid all stimulants and diet pills.
Please report promptly any severe headache, nausea, vomiting, chest pain, or other unusual symptoms; if I am not available go directly to an emergency room.

Any symptoms occurring after ingesting these drugs concurrently with MAOI’s require immediate assessment in an emergency room.

Other side effects which may occur with MAOI therapy include: hypotension which is dose related and may interfere with increasing the MAOI dosage; insomnia and agitation; weight gain; anticholinergic effects such as dry mouth, constipation or urinary retention; and impotence or anorgasmia.

Despite the effectiveness of the tricyclic antidepressants and mono-amine oxidase inhibitors in treating depression, both groups have several drawbacks which encourage research for additional antidepressant agents. This overall efficacy rate seems to be 75-80%. While this is significant, it still leaves a considerable percentage of depressed individuals unassisted, Secondly, both these groups of antidepressants take 2-4 weeks before maximum therapeutic effect is experienced. This can lead to frustration with subsequent non-compliance and create very complicated clinical situations when more than one therapeutic trial is required. Finally, both these groups of drugs can be highly lethal when used in overdose attempts.

The third group of drugs in the antidepressant category is the atypical antidepressants’. These newer antidepressants are noteworthy for having more specific neurochemical action than the tricyclics. While researchers are hopeful of developing an antidepressant with rapid onset of therapeutic effectiveness, the atypical antidepressants have not realized this goal. Although some may affect improvement more quickly than many of the original antidepressants, none seem to have a lag time shorter than 10 days.

The atypical antidepressants in current usage are:

Trazadone (Desyrel) This drug features no anticholinergic side effects, however, its sedating properties often cause it to be prescribed at bedtime. Usual dose is 500 – 600 mg/day. Trazadone is less toxic when used for overdose purposes

Buproprion (Wellbutrim) While without anticholinergic or cardiac side effects, Buproprion is associated with higher than expected incidence of seizures. It is slow in onset of therapeutic action and has a narrow therapeutic window. Usual dose is 200-400 mg/day.

Fluoxetine (Prozac) Probably the most well known of the *new antidepressants, Prozac has a more rapid onset of therapeutic effects and has relatively low lethality if used in a suicide attempt. Prozac is often given in one AM dose due to side effects of anxiety and insomnia. Other effects include GI distress, headache or increased perspiration. Usual dose is 20mg each am.

*Which are also referred to as second generation antidepressants.

Sertraline (Zoloft) The newest atypical antidepressant, Zoloft has less severe side effects and is associated with GI disturbances, headache agitation and insomnia or fatigue, Usual dose is 50-200 mg given in one AM dose. Therapeutic effect occurs in about two weeks.

In concluding a discussion of antidepressant drugs, there are a few common points relevant to all. Clinical action is slow. Antidepressant response includes improved sleep, less emotional liability, decreased fatigue and decreased psychomotor retardation. These are objective symptoms and patients using antidepressants must be made aware that these medications do not raise self esteem or eradicate the sadness, loneliness, or emptiness that often characterizes depression. (Concurrent psychotherapy is most useful for these subjective aspects of depression.) Antidepressant medications are not addictive. Depressions are recurrent illnesses and the discontinuation of antidepressants should be supervised by a psychiatrist. Finally, alcohol use is strongly discouraged while using antidepressants.

In recent years, various antidepressant drugs have been noted to be helpful in clinical situations other than major depression. Antidepressants are frequently used to treat phobias, panic attacks and obsessive-compulsive disorders. They may be used alone or in conjunction with other psychopharmacologic agents. Childhood enuresis and hyperactivity also may respond positively to antidepressant therapy. Chronic pain is often improved through use of antidepressant drugs, as well.

LITHIUM AND ANTICONVULSIVE AGENTS

Lithium is the drug of choice for bipolar disorder. This psychiatric disorder is characterized by episodes of manic behavior alternating with periods of serious depression. Between these acute episodes are periods of stable behavior and normal mood.

Symptoms of mania include:

Euphoria or irritability which is persistent
Grandiosity
Racing thoughts
Rapid and pressured speech
Decreased sleep
Distractibility
Increased activity or agitation
Poor judgment
Excessive emotionality

Lithium is a naturally occurring salt which is highly effective in stabilizing the mood in manic-depressive illness. On-going use of lithium may prevent relapse or diminish the intensity of future manic episodes. Lithium is immediately available in the body, however, 10-14 days are usually required before a therapeutic level is reached in the blood and manic behavior subsides. Initially, a blood level in the range of 1.0 to 1.5 may be needed o effect symptomatic relief. Once mood stabilization is achieved, therapeutic levels are typically in the 0.8 to 1.2 range. In the initial stages of lithium therapy blood levels will be drawn frequently;; as progress occurs and is maintained blood samples are decreased to weekly, then monthly and ultimately, every few months.

One of the drawbacks to effective treatment with lithium is that the therapeutic level and the toxic level are quite close. Toxicity is quite unpleasant and experience with lithium toxicity can provoke non-compliance. This is one reason why blood level are monitored so closely. Sings of toxicity include lethargy, ataxia, slurred speech, severe nausea and vomiting, tremor, tinnitus, arrhythmia's and hypotension. This can proceed if unrecognized to seizures, shock, delirium, coma and death.

While 70-80% of manic patients improve with lithium, the remainder cannot tolerate the drug or do not respond therapeutically. In recent years considerable attention has been paid to other drugs which may be effective in treating bi-polar disorder. The most promising drugs for this use are anticonvulsants including carbamazepine and valporic acid. Both of these drugs have been effective in some individuals who did not respond to lithium. These two drugs have also been used with lithium and in some cases augment the effectiveness of lithium. This augmentation may be useful for someone who experiences lithium side effects at doses below the therapeutic level, for example. In such a situation, the anticonvulsant drug essentially boosts the action of the lithium without requiring and increase in the dose of lithium.

Side effects of lithium include G.I. distress, polyuria, lethargy, fatigue, mild tremor, memory disturbances and benign EKG changes. Many of these side effects are transient. Common side effects of carbamazepine include dizziness, ataxia, sedation, dysarthis, diplopia and G.I. distress. Even these are infrequent and generally mild. Side effects ay be further minimized by increasing dosage in small increments. Valporic acid has few side effects: notably nausea and sedation.

ANTI-ANXIETY AGENTS

The final class of psychoactive drugs is the anti-anxiety agents also knows as tranquilizers.

Anxiety is a familiar phenomena which is part of the human experience. Minor anxiety has positive value and increases alertness, awareness and concentration. Severe anxiety, however, can interfere with day-to-day functioning.

Anxiety may be a component of a major psychiatric disorder such as schizophrenia or depression or anxiety may be a reaction to stressful event or life situation. Additionally there are several discreet anxiety disorders seen in psychiatric practice. Anti-anxiety medications may be effective treatment for anxiety arising from any of these origins.

Symptoms of anxiety include:

Tachycardia
Shortness of breath
Dizziness/light-headaches
Diarrhea or urinary frequency
Initial insomnia
Parethesias
Muscle tension or trembling
Restlessness/agitation
Impaired concentration or attention
Tension, nervousness
Feelings of unreality

Some medications can cause a feeling of anxiety such as caffeine, nasal decongestant sprays asthma medications, steroids, allergy preparations, amphetamines and cocaine. Such drugs should be discontinued if possible rather than using anti-anxiety agents in addition.

Anti-anxiety agents can be quite effective in treating stress related anxiety. In such situations, drug treatment for a week to a month is optimal as dependence on anti-anxiety agents is well known.

In generalized anxiety disorder, Buspar is the drug of choice. Unlike traditional anti-anxiety agents, Buspar requires 2 – 6 weeks usage before optimal therapeutic effects is experienced,. This medication is used on a routine not a PRN basis. Buspar is not a benzodiazepine.

Panic disorder is serious and debilitating anxiety disorder. Effective treatment of this biochemical illness is usually an antidepressant agent often in combination with an anti-anxiety agent. Treatment of panic disorders requires careful monitoring and can be a lengthy process.

Concurrent psychotherapy is suggested for optimal outcomes in stress related anxiety, generalized anxiety disorder and panic disorders.

Other than Buspar, all the anti-anxiety agents in concurrent use are benzodiazepines. All the members of this drug family are associated with risk for drug dependency, addiction and withdrawal.

Sudden discontinuation or too rapid decrease in dosage can result in withdrawal symptoms that mimic the symptoms for which the drug was originally prescribed. Convulsions are seen in benzodiazepine withdrawal and may occur up to a few weeks after the last dose. Benzodiazepine withdrawal requires competent medical oversight to be brought to a safe conclusion.

TABLE VI

Dr. Hyman and G. Arana
Handbook of Psychiatric Drug Therapy
1987 Little, Brown & Co.

			Elimination
Compound	Active substances in Blood	Distribution	Half-life (hr)*


Alprazolam	Alprazolam	Intermediate	6 - 20
Chlordiazepoxide	Chlordiazepoxide	Slow	5 – 100
	Desmethychlordiazepoxide
	Demoxepam, desmethyldiazepa
Clonazepam	Clonazepam		34
Clorazepate	Desmethyldiazepam	Rapid	30 – 100
Diazepam	Diazepam, desmethyldiazepam	Rapid	30 – 100
Flurazepam	Hydroxyethyl flurazepam	Rapid	50 – 100
	Desalkyldiazepam
Halazepam	Desmethyldiazzepam		30 – 100
Lorazepam	Lorazepam	Intermediate	10 – 20
Oxazepam	Oxazepam		5 – 21
Prazepam	Desmethyldiazepam		30 – 100
Tamazepam	Tamazepam		10 – 12
Triazolam	Triazolam		1.7 – 3

The half-life represents the total for all active metabolites; the elderly tend to have the longer half-lives in the ranges reported.
*The parent compound is a product for desmethyldiazepam, which is the active compound in the blood. These drugs differ in the rates at which they are metabolized to the active substance (e.g., clorazepate has a very rapid onset, prazepam a very slow one).

Benzodiazepines are the drug of choice for alcohol withdrawal which will be discussed in depth a bit later.

Side effects of benzodiazepines include fatigue, drowsiness, sedation, impaired memory and diminished motor coordination. When alcohol is co-ingested with benzodiazepines, CNS depression is intensified. Alcohol and benzodiazepines can be lethal when used together in an overdose attempt.

As psychiatric disorders become more recognized and psychopharmacological interventions become more specific and effective, care providers will see more patients utilizing psychiatric medications, A few simple guidelines to enhance patient care are:

Obtain a thorough history of prescription drug use.
When a person is using a psychopharmacologic agent inquire: “Why is (name of drug) prescribed for you?” “Who prescribes __________for you?” and “How long have you been on _______?” All this information should be recorded and relayed to the primary M.D.
Suggest that the patient’s psychiatrist be notified of the patient’s admission.
Suggest the patient’s psychiatrist be consulted re: alterations in psychopharmacology.
Psychopharmacologic agents should not be discontinued abruptly.

Next: PSYCHOPHARMACOLOGIC MANAGEMENT OF THE PATIENT IN ACUTE ALCOHOL WITHDRAWAL