Antidepressants and mood stabilizers

Herbal supplements for depression

St. John's Wort -can decrease reuptake of the neurotransmitters: serotonin, norepinephrine and dopamine -should NOTTTT be taken with other antidepressants -should be discontinued 1-2wks before surgery -pts should check with HCP regarding herbal treatments

Tricyclic antidepressants

-Amitriptyline, imipramine, trimipramine, doxepin, desipramine, nortriptyline, and protriptyline Action: blocks uptake of neurotransmitters norepinephrine and seratonin in the brain, blocks histamine receptors, elevates mood, interests in ADLs, decreases insomnia Use: MDD, and agitated depression

Depression Pathophysiology

-Insufficient amount of monamine neurotransmitters (norepinephrine, serotonin, dopamine) -other etiology: genetic predisposition, social and environmental factors

Serotonin Syndrome

-Too much serotonin can lead to excessive nerve cell activity, causing a potentially deadly collection of symptoms known as serotonin syndrome. - Confusion, agitation or restlessness, dilated pupils, headache, changes in BP and/or temperature, N/V, diarrhea, rapid HR, terror, loss of muscle coordination or twitching muscles, shivering/goosebumps, heavy sweating

Major antidepressant agents

-Tricyclic antidepressants (TCA's) -Selective serotonin reuptake inhibitors (SSRI's) -Atypical antidepressants -Monoamine oxidase inhibitors (MAOIs)

When teaching a patient about the use of tricyclic antidepressants, what will the nurse emphasize? 1. Common side effects can be relieved by increasing fluid and fiber intake and sucking hard candy. 2. The patient should notify the health care provider if therapeutic effects are not noted within 10 days. 3. The drugs are often given with monoamine oxidase inhibitors (MAOIs) for synergistic effect. 4. Dietary restrictions of beer and chocolate are needed to prevent a hypertensive crisis.

1. Common side effects can be relieved by increasing fluid and fiber intake and sucking hard candy. Tricyclic antidepressants (TCAs) cause anticholinergic side effects, including constipation and dry mouth. The time period required to produce therapeutic effects ranges from 2 to 4 weeks. Concurrent use of MAOIs with amitriptyline may lead to cardiovascular instability and toxic psychosis. The patient does not need to avoid beer and chocolate to prevent a hypertensive crisis as the patient would need to with MAOIs, but beer would potentiate central nervous system depression when taken with TCAs.

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) both function by which mechanism? 1. Blocking the reuptake of neurotransmitters at nerve endings 2. Increasing alertness levels in the brain 3. Decreasing levels of epinephrine and serotonin at nerve endings 4. Increasing the placebo effect

1. SSRIs block the reuptake of serotonin. TCAs block the reuptake of norepinephrine and serotonin.

A patient is being switched from amitriptyline to citalopram. Which statement made by the patient indicates understanding of medication instructions? 1. "I can stop taking my amitriptyline and start taking the citalopram as ordered." 2. "I can expect fewer cardiovascular side effects with the citalopram." 3. "The doctor is switching me to this medication because it is less expensive but just as effective." 4. "I will need to limit my intake of cheese when taking citalopram to prevent a rise in my blood pressure."

2. Citalopram, an SSRI, produces minimal anticholinergic and cardiovascular side effects. The patient will need to wait 14 days after stopping amitriptyline (Elavil) before starting the citalopram. The patient does not need to limit cheese intake with citalopram.

The nurse is reviewing a patient's medication history and notes that the patient recently began taking lithium. What intervention is a priority for this patient? 1. Monitoring for the recurrence of seizure activity 2. Assessing lithium levels every other week 3. Asking the patient if they have ringing in the ears 4. Monitoring the patient's intake and output

2. Lithium is the drug of choice to treat manic episodes associated with bipolar disorders. It has a narrow therapeutic range, and levels should be monitored biweekly until the therapeutic level has been obtained and then monitored monthly on the maintenance dose.

What information will the nurse include on the care plan for a patient taking fluvoxamine? 1. This medication must be given IV. 2. This medication will interact with caffeine. 3. This medication might not become therapeutic for 4 weeks. 4. This medication is safe in those with liver disease, unlike other SSRIs.

3 This medication takes between 1 and 4 weeks to be therapeutic. The patient must be encouraged to remain on the medication. This medication is given PO and does not interact with caffeine. Fluvoxamine should not be taken by those with hepatic disease.

Which food will the nurse teach the patient to avoid while taking a monoamine oxidase inhibitor (MAOI)? 1. Coffee 2. White bread 3. Aged cheese 4. White meat

3. Eating foods high in tyramine, including aged cheese, can cause a hypertensive crisis in patients taking MAOIs.

A 6-year-old child is taking imipramine. What will the nurse monitor as a therapeutic outcome of the administration of this medication? 1. The child has no tonic-clonic seizures. 2. The child is free of manic episodes. 3. The child has no more nocturnal enuresis. 4 The child is free of obsessive-compulsive disorder behaviors.

3. Imipramine causes urinary retention and delayed micturition, side effects that make it useful to treat nocturnal enuresis (bedwetting) in children. This is most likely the reason a young child is on this medication. For adults, the drug can treat major depressive disorders.

The patient is receiving a selective serotonin reuptake inhibitor (SSRI). Which item on the patient's breakfast tray should the nurse remove? 1. A carbonated soda 2. Grapefruit juice 3. Coffee 4. Milk

3. Many SSRIs have an interaction with grapefruit juice that can lead to possible toxicity. It is recommended that daily intake be limited to 8 ounces of grapefruit juice or one half of a grapefruit.

The nurse notes that the health care provider is considering starting the patient on a selective serotonin reuptake inhibitor (SRRI) drug. The nurse recognizes that the health care provider will select which drug? 1. Amitriptyline 2. Doxepin 3. Fluvoxamine 4. Imipramine

3. Of the drugs listed, only the SRRI drug is fluvoxamine.

A patient currently prescribed duloxetine (Cymbalta) comes to the health clinic complaining of restlessness, agitation, diaphoresis, and tremors. The nurse suspects serotonin syndrome and questions the patient regarding concurrent use of which substance? 1. Ibuprofen 2. Ginkgo 3. St. John's wort 4. Glucosamine chondroitin

3. Serotonin syndrome may occur with selective serotonin reuptake inhibitors (SSRIs) when they are combined with herbal products such as ginseng and St. John's wort.

The patient has been started on a treatment regimen that includes imipramine. The patient tells the nurse that he also is being treated with diazepam for a separate condition. What is the nurse's highest priority action? 1. Notify the pharmacy because the dosage of the imipramine will need to be increased. 2. Notify the health care provider because the patient may experience an anaphylactic reaction. 3. Notify the pharmacy because the dosage of the imipramine will need to be decreased. 4. Notify the health care provider because central nervous system (CNS) depression may result.

4 the combination of the imipramine and the diazepam (Valium) will potentiate CNS depression.

A patient who has taken fluoxetine (Prozac) for 2 weeks to treat an anxiety disorder complains of dissatisfaction with the therapy. What is the best information for the nurse to include in patient education to promote adherence to the therapeutic regimen? 1. The adverse effects can be managed well. 2. This medication usually requires titration. 3. Relaxation exercises can offer some relief. 4. A therapeutic effect can be expected in another 2 to 4 weeks.

4. The full therapeutic effects of selective serotonin reuptake inhibitor (SSRI) therapy may take 4 to 6 weeks to occur, so this patient can anticipate experiencing a therapeutic effect in 2 to 4 more weeks. Knowing the time frame offers the patient realistic hope and provides a justification for adherence to therapy. Adverse effects can usually be managed, and relaxation exercises may provide some relief from anxiety. The patient must fulfill these tasks to get the full therapeutic effect of the medication, but it can be difficult for a patient with depression to do so. SSRIs can require considerable titration, but, because of the nature of the patient's illness, this information is unlikely to promote adherence to therapy.

The nurse notes in the patient's chart that the health care provider is considering adding a tricyclic antidepressant to the patient's treatment regimen. The nurse recognizes that the health care provider will select which drug? 1. Amoxapine 2. Maprotiline 3. Trazodone 4. Doxepin

4. Of the drugs listed, the only drug that is a tricyclic antidepressant is doxepin.

MAOI side effects/adverse effects

Agitation, restlessness, insomnia Anticholinergic effects Orthostatic hypotension Hypertensive crisis from fatal tyramine interaction

Atypical antidepressants

Amoxapine (Asendin), maprotiline (Ludiomil), nefazodone, trazodone (Desyrel) Action: affect one or two of the three neurotransmitters: serotonin, norepinephrine, and dopamine. Interaction: Do not take with MAOIs and do not use within 14 days after discontinuing MAOIs. Trazodone may have a potential drug interaction with ketoconazole, ritonavir, and indinavir that may lead to increased trazodone levels and adverse effects.

Mood stabilizers

Bipolar disorders: Lithium (Lithibid) Carbamazepine (Tegretol) Divalproex (Depakote, Valproate) Lamotrigine (Lamictal) Olanzapine (Zyprexa) Ziprasidone (Geodon) Aripiprazole (Abilify)

MAOI interactions

Drug interactions: Vasoconstrictors and cold medications containing phenylephrine and pseudoephedrine can cause a hypertensive crisis when taken with an MAOI. Food interactions: Foods that contain tyramine Some cheeses, cream, yogurt, coffee, chocolate, bananas, raisins, Italian green beans, liver, pickled foods, sausage, soy sauce, yeast, beer, and red wines, can cause a hypertensive crisis.

SSRIs

Fluvoxamine (Luvox) Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) Action Block uptake of neurotransmitter serotonin Uses Major depression Anxiety disorders Obsessive-compulsiveness Panic Phobias Prevention of migraine headaches

Lithium side effects/adverse reactions

Headache, drowsiness, dizziness Hypotension, dysrhythmias Restlessness, slurred speech Dry mouth, metallic taste, GI distress Tremors, muscle weakness Edema of hands and ankles Increased urination, blood dyscrasias, nephrotoxicity

Lithium interactions

Increased lithium level with thiazides, methyldopa, haloperidol, NSAIDs, antidepressants, theophylline, phenothiazines

SSRI interactions and side effects

Interactions: -Increased CNS effects with alcohol and other CNS depressants Side effects/adverse reactions -Headache, nervousness, restlessness, Insomnia, tremors, seizures, GI distres, Sexual dysfunction, Suicidal ideation, serotonin syndrome ***Side effects often decrease over 2 to 4 weeks.***

Amitriptyline (elavil)

Interactions: -increased CNS effects w alcohol and other CNS depressants -increased sedation and anticholinergic effects w phenothiazines, haloperidol -Asians & hispanics may need lower doses Side effects -sedation, dizziness, blurred vision, dry mouth/eyes, urinary retention, constipation, wt gain GI distress, sexual dysfunction -orthostatic hypotension, dysrhythmias, EPS, blood dycrasias

Lithium nursing interventions

Monitor vital signs, sodium levels. Monitor for drug effectiveness, suicidal tendencies. Monitor urine output, renal function tests. Encourage adequate fluid intake (1 to 2 L daily). Take with food to decrease GI irritation. Monitor lithium levels every 1 to 2 months (0.5 to 1.5 mEq/L); toxic range is greater than 2 mEq/L. Toxic side effects: persistent nausea, vomiting, severe diarrhea, blurred vision, tinnitus, ataxia, increasing tremors, confusion, dysrhythmias, seizures

Antidepressant agents nursing interventions

Monitor vital signs. Monitor mood for drug effectiveness. Monitor for suicidal tendencies, seizures. Warn that foods that contain tyramine can cause a hypertensive crisis with MAOIs. Encourage taking drug as prescribed. Encourage avoiding alcohol, CNS depressants, and cold medicines. Teach to take drug with food if GI distress occurs.

SNRI's side effects/adverse effects

Side effects of venlafaxine (Effexor) include drowsiness, dizziness, insomnia, headache, euphoria, amnesia, blurred vision, photosensitivity, and ejaculation dysfunction. Adverse effects of venlafaxine (Effexor) include hyponatremia, bleeding, hypertension, angioedema, blood dyscrasias, suicidal ideation, and Stevens-Johnson syndrome.

Lithium nursing interventions cont

Teach patient to wear medical alert identification. Teach patient to take drug as prescribed and keep medical appointments. Warn against driving motor vehicles or operating dangerous equipment until drug effect is known. Advise patient that drug effect may take 1 to 2 weeks. Encourage patient to avoid caffeine, crash diets, NSAIDs, diuretics. Advise patient against getting pregnant because of teratogenic effects.

Lithium

Therapeutic serum range: 0.5 to 1.5 mEq/L Serum lithium levels greater than 1.5 to 2 mEq/L are toxic. Action Alteration of ion transport in muscle and nerve cells Increased receptor sensitivity to serotonin Use Treat manic episodes in bipolar psychosis

MAOIs

Tranylcypromine sulfate (Parnate), isocarboxazid (Marplan), selegiline (Emsam), phenelzine sulfate (Nardil) Action Monamine oxidase enzyme inactivates norepinephrine, dopamine, epinephrine, and serotonin. Use: depression not controlled by TCAs and second-generation antidepressants

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq) Action: Inhibit the reuptake of serotonin and norepinephrine, increasing these substances in nerve fibers Use: Major depression as well as generalized anxiety disorder and social anxiety disorder Interactions: concurrent interaction of venlafaxine and St. John's wort may increase the risk of serotonin syndrome and neuroleptic malignant syndrome

Antidepressant agents nursing interventions cont

Warn patient against driving or using dangerous mechanical equipment until drug effect is known. Warn patient against abruptly stopping drug. Instruct patient to take drug at bedtime. Advise patient that a therapeutic response usually occurs in 2 to 4 weeks. Inform patient that herbs (e.g., St. John's wort, ginseng) may interact with antidepressants.

A patient has been prescribed an MAOI for depression. Which of the following foods should the patient be taught to avoid? 1. pickles 2. raisins 3. chicken breast 4. red wine

pickles, raisins, red wine