Drugs for Anxiety and Insomnia

Antidepressant /Anxiolytic

Antidepressant /Anxiolytic

escitalopram (Lexapro)Tri-Cyclic Antidepressant

Tri-Cyclic Antidepressant

MAOIsMAOIs

BenzodiazepinesBenzodiazepines lorazepam (Ativan)diazepam (Valium)

GABA AntagonistGABA AntagonistA zolpidem (Ambien)

Phenytoin-LikeDrugs

Phenytoin-LikeDrugs

SuccinimidesSuccinimides

BarbituratesBarbiturates phenobarbital (Luminal)

phenytoin (Dilantin)valproic acid (Depakote)

ethosuximide (Zarontin)

PhenothiazinesPhenothiazines chlorpromazine (Thorazine)

Non-PhenothiazinesNon-Phenothiazines halperidol (Haldol)

Atypical Antipsychotics

Atypical Antipsychotics risperidone (Risperdal)

OpioidsOpioids

Opioid AntagonistsOpioid Antagonists naloxone (Narcan)

morphine (Infumorph)

SalicylatesSalicylates aspirin (ASA)

NSAIDsNSAIDs ibuprofen (Motrin)

Non-OpioidNon-Opioid acetaminophen (Tylenol)

Central ActingCentral Acting tramadol (Ultram)

Anti-MigraineAnti-Migraine ergotamine (Cafergot)Sumatriptan (Imitrex)

OVERVIEW:Neuro System

Major Types of Anxiety Disorders

• Situational anxiety

• Generalized anxiety disorder (GAD)

• Panic disorder

• Phobias

• Social anxiety

• Obsessive-compulsive disorder

• Post-traumatic stress disorder

Pharmacotherapy Illustrated

Common Causes of Anxiety

• Phobias

• Post-traumatic stress

• Generalized anxiety

• Obsessive-compulsive feelings

• Panic

Nonpharmacologic Therapies to Cope with Anxiety

• Cognitive behavioral therapy

• Counseling

• Biofeedback techniques

• Meditation

Anxiolytics

• Drugs having the ability to relieve anxiety

• Quite effective

• Used when anxiety begins to significantly affect daily activities

Classes of Medications Used to Treat Anxiety and Sleep Disorders

• Antidepressants

• Benzodiazepines

• Barbiturates

• Nonbenzodiazepine/nonbarbiturate CNS depressants

Treating Anxiety and Insomniawith CNS Agents

• Antidepressants frequently used to treat anxiety

• Two major classes• Benzodiazepines• Barbiturates

• CNS depression - a continuum ranging from relaxation, to sedation, to the induction of sleep and anesthesia

Sedatives and Hypnotics

• CNS depressants called • sedatives due to ability to sedate or relax a patient, or• hypnotics because of their ability to induce sleep• sedative–hypnotic: calming effect at lower doses and sleep at

higher doses

• Most CNS depressants can cause physical and psychological dependence

Monitor Client’s Condition and Provide Education

• Obtain vital signs, medical and drug history

• Discuss lifestyle and dietary habits

• What precipitated the feelings of anxiety?

Assess Client’s Need for Antianxiety or Insomnia Drugs

• Assess intensity and duration of symptoms

• Identify precipitating factors

• Identify coping mechanisms

• Assess for sleep disorder

Obtain Drug History

• Hypersensitivity

• Use of alcohol and other CNS depressants

• Drug abuse and dependence

Use Cautiously for Certain Clients

• Those who are elderly

• Those with suicidal potential

• Those with impaired renal or liver function

Insomnia• Acts of sleeping and waking synchronized to many different bodily

functions• Insomnia sometimes associated with anxiety

• Short-term or behavioral insomnia sometimes attributed to stress

• Food or beverages with stimulants may disturb sleep

• Long-term insomnia often caused by depression, manic disorders, chronic pain

• Nonpharmacologic means should be attempted prior to drug therapy

• Rebound insomnia – caused by discontinuation of long-used sedative drug• Older patients more likely to experience medication-related sleep

problems

Antidepressants

• Treat major depression and a range of anxiety conditions

• Primary medications to reduce symptoms of panic and anxiety: TCAs, MAOIs, and SSRIs• Atypical antidepressants do not fall conveniently into the other

categories

• Adverse reactions make antidepressants unusable for some patients

Antidepressants (cont'd)

• Prototype drug: Escitalopram oxalate (Lexapro)• Mechanism of action: increases availability of

serotonin at specific postsynaptic receptor sites located within the CNS

• Primary use: generalized anxiety and depression• Adverse effects: dizziness, nausea, insomnia,

somnolennce, confusion, seizures

Prototype Drug: Escitalopram oxalate (Lexapro)

Escitalopram Oxalate Animation

Click here to view an animation on the topic of escitalopram oxalate.

Antidepressant Class Information

• TCAs (partial list information/conditions):• Not for use for patients with heart attack, heart block, or

arrhythmia• Potential side effects: dry mouth, blurred vision, urine retention,

and hypertension• concurrent use with alcohol or other CNS depressants should be

avoided

Antidepressant Class Information (cont'd)

• SSRIs (partial list information/conditions):• Safer than other classes• Less common sympathomimetic effects (increased heart rate and

hypertension)• Fewer anticholinergic effects• can cause weight gain and sexual dysfunction

Antidepressant Class Information (cont'd)

• SNRIs (partial list information/conditions):• Many possible side effects:• abnormal dreams, sweating,• constipation, dry mouth, loss of appetite, weight loss,• tremor, abnormal vision, headaches, nausea and• vomiting, dizziness, and loss of sexual desire

Antidepressant Class Information (cont'd)

• MAOIs (partial list information/conditions):• avoid foods containing tyramine• potentiate the effects of insulin and other diabetic drugs• common adverse effects include orthostatic hypotension,

headache, and diarrhea

Benzodiazepines

• Prototype drug: lorazepam (Ativan)• Mechanism of action: binds to GABA receptor-

chloride channel molecule, which intensifies GABA effects

• Primary use: for anxiety disorders and insomnia• Adverse effects: drowsiness, dizziness, respiratory

depression

Prototype Drug: Lorazepam (Ativan)

Benzodiazepines

• Some treat short-term insomnia

• Others treat various anxiety disorders

• Most benzodiazepines given orally

• Drugs of choice for short-term treatment of insomnia caused by anxiety – greater margin of safety

Benzodiazepines Bind To GABA Receptor-Chloride Channel Molecule

• Intensify effects of GABA

• Examples: Xanax, Librium, Tranxene

Benzodiazepines

• Have a number of other important indications• Seizure disorders• Alcohol withdrawal• Central muscle relaxation• Induction agents in anesthesia

Benzo’s

• Prototype drug: diazepam (Valium)• Mechanism of action:

• Binds with GABA receptor-chloride channel molecules, intensifying effects of GABA

• Inhibits brain impulses from passing through limbic and reticular activating systems

• Primary use: as sedative and hypnotic• Adverse effects: tolerance, respiratory depression,

psychological and physical dependence

Nonbenzodiazepines, Nonbarbiturate CNS depressants

• Chemically unrelated to either benzodiazepines or barbiturates

• Used mainly for treatment of social anxiety symptoms

• Prototype: zolpidem (Ambien)• Mechanism of action: binds to GABA receptors• Primary use: as hypnotic• Adverse effects: mild nausea, dizziness, diarrhea,

daytime drowsiness, amnesia, sleepwalking, ingesting carbohydrates while sleepwalking

Nonbenzodiazepines, Nonbarbiturate CNS depressants (cont'd)

• Mechanism of action: binds to GABA receptor • Preserves sleep stages III and IV• Offers minor effects of REM sleep

• Other Nonbarbiturate CNS Depressants:• Buspar, Noctec, Placidyl

Prototype Drug: Zolpidem (Ambien)

Zolpidem Animation

Click here to view an animation on the topic of zolpidem.

Nonbenzodiazepine, NonbarbiturateCNS Depressants (cont'd)

• Assess for common side effects of CNS depression

• Assess neurological status, level of consciousness

• Monitor vital signs, observe respiratory patterns particularly during sleep

• Monitor patient’s intake of stimulants, such as caffeine and nicotine

• Monitor affect and emotional status

NCLEX-RN ReviewQuestion 1

The nurse should assess a patient who is taking lorazepam (Ativan) for the development of which of these adverse effects?

1. Tachypnea 2. Astigmatism 3. Ataxia 4. Euphoria

NCLEX-RN ReviewQuestion 1 – Answer

1. Tachypnea

2. Astigmatism

3. Ataxia

4. Euphoria

NCLEX-RN ReviewQuestion 1 – RationaleRationale: CNS side effects for lorazepam (Ativan) include amnesia, weakness, disorientation, ataxia, blurred vision, diplopia, nausea, and vomiting.

NCLEX-RN ReviewQuestion 2

A patient is receiving temazepam (Restoril). Which of these responses should a nurse expect the patient to have if the medication is achieving the desired affect?

1. The patient sleeps in 3-hour intervals, awakes for a short time, and then falls back to sleep.

2. The patient reports feeling less anxiety during activities of daily living.

3. The patient reports having fewer episodes of panic attacks when stressed.

4. The patient reports sleeping 7 hours without awakening.

NCLEX-RN ReviewQuestion 2 – Answer

1. The patient sleeps in 3-hour intervals, awakes for a short time, and then falls back to sleep.

2. The patient reports feeling less anxiety during activities of daily living.

3. The patient reports having fewer episodes of panic attacks when stressed.

4. The patient reports sleeping 7 hours without awakening.

NCLEX-RN ReviewQuestion 2 – RationaleRationale: The nurse should recognize that this medication is ordered for insomnia. Therefore, the patient should be experiencing relief from insomnia and reporting feeling rested when awakening.

NCLEX-RN ReviewQuestion 3

A 32-year-old female patient has been taking lorazepam (Ativan) for her anxiety and is brought into the emergency department after taking 30 days’ worth at one time. The antagonist used in some cases of benzodiazepine overdosage is:

1. Epinephrine2. Atropine 3. Flumazenil 4. Naloxone

NCLEX-RN ReviewQuestion 3 – Answer

1. Epinephrine

2. Atropine

3. Flumazenil

4. Naloxone

NCLEX-RN ReviewQuestion 3 – RationaleRationale: Flumazenil (Romazicon) is a benzodiazepine-receptor blocker which may be used to reverse CNS depressant effects. Naloxone (Narcan) is an opioid antagonist.

NCLEX-RN ReviewQuestion 4A patient has been given instructions about the newly prescribed medication alprazolam (Xanax). Which of these statements, if made by the patient, would indicate that the patient needs further instruction?

1. “I will stop smoking by undergoing hypnosis.” 2. “I will not drive immediately after I take this

medication.”3. “I will stop the medication when I feel less

anxious.”4. “I will take my medication with food if my

stomach feels upset.”

NCLEX-RN ReviewQuestion 4 – Answer

1. “I will stop smoking by undergoing hypnosis.”

2. “I will not drive immediately after I take this medication.”

3. “I will stop the medication when I feel less anxious.”

4. “I will take my medication with food if my stomach feels upset.”

NCLEX-RN ReviewQuestion 4 – Rationale

Rationale: Benzodiazepines should not be stopped abruptly. The health care provider should decide when and how to discontinue the medication.

NCLEX-RN ReviewQuestion 5A patient has been taking diazepam (Valium) for 3 months. Which of these statements by the patient would indicate that the outcome of medication therapy has been successful?

1. “I will need to take this medication for the rest of my life.”

2. “I feel like I am able to cope with routine stress at my job.”

3. “I like this medication. I know that I needed it to treat my anxiety, which is now better, but I think it just makes me feel good, so I am planning to stay on it for quite a while.”

4. “I thought this medication would make me think clearly, but I don’t feel any change in my feelings.”

NCLEX-RN ReviewQuestion 5 – Answer

1. “I will need to take this medication for the rest of my life.”

2. “I feel like I am able to cope with routine stress at my job.”

3. “I like this medication. I know that I needed it to treat my anxiety, which is now better, but I think it just makes me feel good, so I am planning to stay on it for quite a while.”

4. “I thought this medication would make me think clearly, but I don’t feel any change in my feelings.”

NCLEX-RN ReviewQuestion 5 – RationaleRationale: The statement by the patient needs to show clearly that the expected benefit of the medication therapy has been experienced by the patient.

NCLEX-RN ReviewQuestion 6

Education given to patients about the use of benzodiazepines should include an emphasis on what important issue?

1. They will be required lifelong to achieve lasting effects.

2. They require frequent blood counts to avoid adverse effects.

3. If the drug is not effective within the first 2 months, it will be stopped immediately.

4. The use of counseling or behavioral techniques in addition to the drug will assist in addressing the underlying disorder.

NCLEX-RN ReviewQuestion 6 – Answer

1. They will be required lifelong to achieve lasting effects.

2. They require frequent blood counts to avoid adverse effects.

3. If the drug is not effective within the first 2 months, it will be stopped immediately.

4. The use of counseling or behavioral techniques in addition to the drug will assist in addressing the underlying disorder.

NCLEX-RN ReviewQuestion 6 – RationaleRationale: Counseling or behavioral techniques such as stress reduction will assist in addressing the underlying problem and help ensure the drug is not taken longer than necessary. Benzodizepines are not stopped abruptly or rebound anxiety or cardiovascular effects may occur.

Drugs for Anxiety and Insomnia

• Assessment

• Potential nursing diagnoses

• Reason for drug

• Monitoring vital signs

• Cautions and contraindications

• Possible drug interactions• Completing health history• Drug history• Evaluation of lab reports

Drugs for Anxiety and Insomnia(cont'd)

• Nursing Diagnosis• Risk for injury• Knowledge deficient, related to drug therapy• Ineffective individual coping

Drugs for Anxiety and Insomnia (cont'd)

• Planning: client will • Experience therapeutic effects depending on drug• Be free of adverse effects• Demonstrate an understanding of the drug’s activity• Accurately describe drug side effects and precautions• Demonstrate proper self-administration technique

Drugs for Anxiety and Insomnia (cont'd)

• Implementation• Interventions and rationales• Administration of drug• Observing for adverse effects• Client education and discharge planning

Drugs for Anxiety and Insomnia (cont'd)

• Evaluation • Effectiveness of drug therapy

• Evaluate the achievement of goals and expected outcomes

Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders

Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders

Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders

Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders

Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders

“Receptors” & The Autonomic Nervous System

Beta 1 Receptors