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Medication Basics for Equine Facilitated Mental Health Workers

Reprinted from NARHA Strides magazine, October 1998 (Vol. 4, No. 4)

By Mandy Branton, R.N., NARHA Advanced Instructor

Many of today's equine facilitated mental health professionals and others will work with clients receiving pharmacotherapy, which is treatment with medication. Today's mental health clients receive medication as an integral part of their treatment regime. In the current health care environment, many mental health clients are briefly stabilized on psychotropic medications on an inpatient basis, then released to a lesser level of care within their community's health system. When a client enters your equine facilitated mental health program, you should document and review the medications the client receives. The client may or may not be aware, however, of the potential side effects of his medication. Will you, as a responsible equine facilitated mental health professional, be able to provide this client safe sessions by having an understanding of the ways in which his medication regimen may affect his functioning within the therapeutic riding environment?

The wise equine facilitated mental health instructor will know which client may need to be reminded to apply sunscreen on a bright summer day...which client may need to drink extra water during a strenuous session...which client may be at risk for dizziness or a decrease in co-ordination for a period of time as result of a medication adjustment. As an equine professional, you face a significant responsibility for your client's safety and well being during the potentially high-risk activity of riding. When planning therapeutic riding sessions for the mental health client, you will assess the needs of your client may have as a result of the medication he takes.

Many psychotropic drugs influence central nervous system functioning. Central nervous system symptoms such as headache, dizziness, drowsiness, depression, confusion, fatigue anxiety, tremors or even psychotropic medications. Any physical complaints the client voices should be considered, and the therapeutic riding session adapted to respond to the client's status or terminated. Additionally, as the key observer of your client during the session, you may notice symptoms, unnoticed by the client himself that are a result of the medication's effects. The instructor who works as a part of a mental health team may be particularly helpful in alerting others on the team to changes in the client's functioning.

A basic familiarity with the categories of psychotropic medication will help the instructor be aware of the additional safety needs the client has as a result of his medication regimen. A reference book, "The Physician's Desk Reference," is published annually and is a valuable reference tool available at any library or bookstore, or consult your local pharmacist for information. Psychotropic medications are grouped into categories that share common effects on the body's systems, making it easier for the equine facilitated mental health worker without a mental health background to remember basic side effects. Medications utilized by the mental health client typically belong to one of the following categories: antipsychotic medications, antianxiety agents, antidepressants, mood stabilizers, anticonvulsants and stimulants.

Antipsychotics (Major Tranquilizers)

Thorazine, Mellaril, Prolixin, Trilofon, Haldol, Risperdal, Zyprexa, and Clozaril

These medications are used to treat psychotic symptoms such as hallucinations, delusional thinking, paranoia or mania. They can decrease agitation or aggression and can improve the ability to think clearly in people with schizophrenia. They are thought to block the serotonin activity in the brain. These medications are usually sedating at first, but this usually lessens with time. As a decrease in mental alertness is often experienced during the first few weeks a client takes these medications; the instructor will need to assess the client's alertness, balance and coordination when a client reports he is taking antipsychotic medications. The client may experience dizziness or faintness, especially when rising to stand. If he feels faint, he can sit with his head level to his knees, or lay down and elevate his feet. The prevent faintness, the client can exercise his legs or arms briefly before standing.

Some antipsychotic medications are capable of producing central nervous system effects that are similar to the effects of Parkinson's Disease. These effects can include an inability to sit still, or conversely, loss of motivation and decreased movements. For example, one client's movement may appear restless and jumpy; another may appear stiff and shaky. Tremors, a mask-like facial expression, a shuffling way of walking or writhing movements may be obvious. Instructors working with older clients may notice signs of "tardive dyskinesia" - involuntary, purposeless muscle movements. The instructor may notice that these clients have tremors, making it more difficult to thread the billet straps of the saddle into the girth buckles, or to hold the reins steady; or that they may move slowly and appear expressionless, or even "zombie-like." These behaviors are not a sign of the mental illness itself, but rather a result of the antipsychotic medications that the client must take in order to function. Educating volunteers and barn workers to this fact may help them feel more comfortable around your mental health clients.

Common side effects of these medications include a dry mouth, nasal congestion and constipation. The client may experience relief of constipation from the exercise of horseback riding, but his dry mouth may be exacerbated, either from the effort of riding, or from nervousness. Having all your clients bring bottles of water to sessions as a standard protocol may increase not only their comfort, but also their safety, as clients on these medications can also be at risk for heat stroke because these drugs can alter body temperature and perspiration regulatory systems. The riding instructor needs to be particularly aware of encouraging fluid intake and decreasing strenuousness of the session's activity during the hot weather months for these clients. Good fluid intake has the added benefit of decreasing the risk of dizziness that patients may feel on these medications. On sunny days, the instructor may need to remind new clients to apply a good sunscreen to exposed areas, as people on antipsychotics have a greatly increased vulnerability to the sun and are at risk for a potentially dangerous sunburn, even under ordinary conditions.

Two adverse reactions to these drugs will require prompt attention from medical professionals. A client may experience a sudden, frightening stiffness and tightening of the muscles in his jaw, neck, back or legs termed a dystonic reaction. The first symptom may be a slurring of speech and difficulty controlling the tongue's movement. A dystonic reaction can be easily treated with medication, but the instructor will want to observe the client for adequate airway exchange and summon emergency services if the client has difficulty breathing as a result of the muscle spasms. Dystonic reactions are most common in younger males in the first five days of medication therapy, or after a dosage increase. Newer medications are less likely to produce dystonic reactions.

A rare, but much more serious reaction occurs when the client experiences symptoms such as severe muscle rigidity, fever, labored breathing, sweating, mental confusion, eye pain or rapid, irregular pulse. Termed neuroleptic malignant syndrome, this adverse reaction to antipsychotic therapy requires immediate emergency room evaluation. Fortunately, increasing numbers of newer antipsychotic medications having fewer side effects are being used and developed, improving the lives of people who must use these medications to manage their psychiatric symptoms.

Antianxiety Agents

Benzodiozepines/Minor Tranquilizers: Valium, Librium, Xanax, Ativan ·

Antihistamines: Benadryl, Vistaril, Atarax

Beta-Blockers: Inderal, Corgard, Tenormin

Other: BuSpar, Equanil, Klonopin

Antianxiety medications are typically prescribed on a short-term basis. Small or moderate doses rarely cause side effects. Those who do exercise central nervous system effects may complain of dizziness, drowsiness, mental confusion, clumsiness, and headache, tremors or fatigue. Gastrointestinal effects can include nausea or vomiting, diarrhea and dry mouth. Blurred vision or ringing in the ears can also occur. If a client tells you he is taking antianxiety medications, you will want to assess his coordination and balance on the ground prior to performing mounted activities. Incoordination, slurred speech and poor balance may indicate that the client is taking more than the recommended dose, or that the client is experiencing untoward efforts of combining this medication with alcohol and other mediation.

Some clients may report taking cardiac drugs called beta-blockers as antianxiety medications. These block the physical symptoms of anxiety, such as palpitations, sweating and tremors. They may also be used to reduce aggression, particularly with mental retardation, autism and brain injury. They can be used to treat migraines and tremors. They may decrease the client's blood pressure, increasing the risk of dizziness or faintness upon rising to stand, and may make the client feel weak or fatigued. A client reporting a history of asthma may be at higher risk for airway spasms when taking these medications, and will need to have an asthma inhaler available to use if needed.

Antidepressants

Tricyclics: Norpramin, Tofranil

Selective Serotonin Reuptake Inhibitors: Prozac, Zoloft, Paxil

Monoamine Oxidase Inhibitors: Nardil, Parnate, Marplan

Antidepressant medications do not make people feel "high" or intoxicated. Many people take them for several weeks before noticing an increased feeling of well being. These medications act by increasing the activity of brain chemicals such a norepinephrine and serotonin. They may be used to treat a variety of disorders in addition to depression, obsessive-compulsive disorders, generalized anxiety, eating disorders and childhood bedwetting. A person may take an antidepressant medication for a period of six to 12 months or longer.

Side effects may be more pronounced in the first weeks that a person takes these medications. The client may experience dizziness upon standing, as the blood supply to the brain temporarily decreases. A brief period of stretching or exercising prior to mounting the horse for riding may help to pump blood back to the brain. The client on tricyclic antidepressants, like the client receiving antipsychotic medication, may experience dry mouth and photosensitivity. He may also complain of drowsiness, headache, anxiety, tremors, increased heart rate, blurred vision or ringing in the ears. The client would want to report these symptoms to his physician, but these symptoms would not necessarily need to result in a termination of the riding session. For example, a client complaining of a decrease in mental alertness or coordination may benefit from an unmounted session with the horse, and may feel better able to ride safely as his body adjusts to the effects of his medication over the coming weeks.

Persons receiving Prozac and Zoloft may complain of nervousness, tremors and anxiety. You may note restlessness, an increase in activity level, or rapid speech in your client. For this client, the riding session may be patterned to accentuate the slow, steady movement of the horse, and may prove soothing and calming to the client. Many times these symptoms may be relived by a simple lowering of the client's medication dosage, so sharing your perceptions with your client and encouraging him to share this with his physician may be helpful. These symptoms may also decrease with time.

Some persons may take a special type of antidepressant, called a Monoamine Oxidase Inhibitor (MAOI). The use of these antidepressants requires strict dietary restrictions to avoid an adverse reaction termed a "hypertensive crisis." These clients must avoid food containing tyramine, a substance found in aged foods such as sauerkraut, pickles, raisins, ripe bananas, aged cheese, soy sauce, sour cream, yeast, yogurt and alcohol. Excessive caffeine consumption may produce cardiac arrhythmias, as can the use of decongestants or cold, hay fever or sinus medications. Even if a client's MAOI is discontinued, he must maintain the dietary restrictions for a few weeks to avoid this reaction. The person experiencing a hypertensive crisis will experience a sudden and severe increase in blood pressure, placing him at risk for stroke due to a rupture of a blood vessel in the brain. If your client experiences symptoms suggesting an increase in blood pressure (nausea, sweating, neck stiffness or a sudden headache), terminate the session to allow the client to have his blood pressure checked immediately.

Mood Stabilizers

Lithium Carbonate, Lithium Citrate

Lithium is a medication used to stabilize abnormal highs and lows of mood swings. Some people may take Lithium indefinitely to manage their psychiatric symptoms. The person on Lithium must have regular blood testing performed to ensure that the Lithium in his bloodstream is in a therapeutic range, as too low is ineffective, and too high a level can result in the serious problem of Lithium toxicity.

An instructor working with a client taking Lithium will need to pay special attention to his client's fluid intake, particularly when sessions are scheduled during periods of hot weather, or the client experiences increased exertion during the session. If excessive fluid loss from sweating occurs without replacement by adequate water intake, the Lithium in the client's bloodstream may be concentrated, causing Lithium toxicity in your client. A large intake of coffee, tea or cola can also have this effect on your client due to diuretic action of these liquids. The high concentration of Lithium in the bloodstream may cause signs such as dizziness, drowsiness, slurred speech, confusion, headache, eye pain, lack of coordination, irregular heartbeat, ringing in the ears, shortness of breath, seizures or stupor. The instructor noticing these symptoms would need to obtain medical help for the client. Common side effects of Lithium that are less serious are gastrointestinal complaints such as nausea, diarrhea, or decreased appetite, a dry mouth and tremors of the hands. There is also significant drug interaction with Lithium and common over-the-counter pain relievers like Ibuprofen (Motrin, Advil), Naproxen (Aleve) and Ketoprofen (Arudis KT). These medications are NSAIDS (non-steroidal anti-inflammatory medications) and can increase Lithium blood levels to a toxic dose, so they should be avoided.

Anticonvulsants

(Tegretol, Depakote)

Anticonvulsants are used to control seizures, as well as reduce aggression, anger or severe mood swings in psychiatric clients. The client taking an anticonvulsant may experience dizziness, clumsiness, decreased coordination or blurred vision, especially early in treatment. Dry mouth, constipation and trembling of the hands or arms are also common. If the client experiences excessive sleepiness, adapt the riding sessions to maintain a safe level of activity for the client. Persons on Tegretol should use a sunscreen on bright days.

 A seizure occurs when the brain's normal electrical activity is disrupted by injury, disease or infection. Persons experiencing seizure activity can exhibit a wide variety of motor or sensory abnormalities, depending on the area of the brain affected. For example, one person may exhibit the muscular contractions of a grand mal seizure, while another may exhibit nonconvulsive seizures (petit mal or absence seizures), in which some alteration in the level of consciousness may be noted for a brief period of time, such as stopping an activity and appearing to stare blankly for a few seconds. Since such wide variations in the manifestations of seizure activity exist, an instructor working with a client with a known history of seizures should insist his client have medical clearance to participate in the therapeutic riding program, and an understanding of the physical manifestation of his client's seizure activity. For example, some people have a feeling that a seizure is imminent, and may have time to tell the instructor and sit down before the seizure occurs. If a convulsive seizure occurs, don't try to stop the seizure by holding or restraining any nearby objects that might cause injury. IF there are any fluids in his mouth, roll him onto one side so that the fluid drains from his mouth. Call 911 if the seizure lasts for more than a few minutes, the client doesn't regain consciousness, or has repeated seizures. The client may be confused and sleepy after the episode. Simply consult with the client's medical provider if the client is known to have a history of seizures and recovers from the seizure within a few minutes.

Stimulants

Ritalin, Cylert, Dexedrine

Stimulants are prescribed to treat Attention Deficit Hyperactivity Disorder (ADHD). Their effects usually last three to four hours, unless given in a "sustained release" form, which will last six to eight hours. The instructor may notice that his client feels tired or "slowed down" during the first few weeks of medication use. Occasionally, the instructor may notice the appearance of nervous tics or stuttering. Side effects may include headache, stomachache, and loss of appetite, nervousness, or emotional irritability. The therapeutic riding instructor can provide valuable feedback regarding the effectiveness of these medications by sharing observations from the riding session with the client's family or medical team. If effective, the instructor may see an increase in attention span and ability to finish tasks or follow directions during the riding session. The client may also be less distractible and less apt to act before thinking. If medication therapy with stimulants works effectively, the client will be calmer and more efficient in his participation in the therapeutic riding program.

In summary, the equine facilitated mental health provider does the things that promote the safety, comfort and health of any person who rides, regardless of physical or mental impairment. He assesses his client's balance and coordination, using sidewalkers as needed, in order to provide a challenging yet appropriate activity for the riding session. Just as the instructor encourages his client to wear comfortable clothing for riding, he encourages the client to avoid sunburn to maintain the enjoyment of the riding experience. He helps the client avoid physical exhaustion or heat stress by ensuring the client has an adequate water intake and a safe level of physical exertion during the therapeutic activity with the horse. He considers the emotional state of his client, and his client's strengths and weaknesses in interacting with others, just as an instructor working with the physically disabled does. Just as he is aware of an appropriate response to a physical crisis such as a fall, the equine facilitated mental health instructor will know the appropriate response to a crisis such a seizure or dystonic reaction. With the knowledge of the unique needs of the mental health client receiving pharmacotherapy, the equine facilitated mental health provider will safely assist his client in making adaptive changes in his life through participation in the physically and mentally challenging riding activity offered through the therapeutic riding program. Mandy Branton, R.N., has a Bachelor of Science degree in nursing, and is a NARHA Advanced Instructor. She has 12 years experience in psychiatric nursing and five years experience in therapeutic riding. Thanks to Ronda Williams, RPH, Clinical Pharmacist, for her review and input in this article.

Mandy Branton, R.N., has a bachelor of science degree in nursing and is a NARHA Advanced Instructor. She has 12 years of experience in psychiatric nursing and five years experience in therapeutic riding.

Thanks to Ronda Williams, RPH, Clinical Pharmacist, for her review and input on this article.