Mental Health Med Quiz 1
SSRI Drug interactions/Contraindications
Increased effects of SSRIs may occur with cimetidine, l-tryptophan, lithium, linezolid and St. Johns wort Serotonin Syndrome may occur with concomitant use of SSRIs and metoclopramide, sibutramine, tramadol, triptans Use of SSRIs may increase effects of: hydantoins, TCAs, cyclosporine, benzodiazepines, beta blockers, methadone, carbamazepine, clozapine, olanzapine, pimozide, haloperidol, mexiletine, phenothiazines, St. Johns wort, trazadone, sumatriptan, sympathomimetics, tacrine, theophylline, propafenone, risperidone, ropivacaine, zolpidem and warfarin. Concomitant use of SSRIs may decrease effects of buspirone and digoxin. Lithium levels may be increased or decreased with concomitant use of SSRIs
MAIO drug interactions
Serious and potentially fatal adverse reactions may occur with concurrent use of ALL other antidepressants, carbamazepine, cyclobenzaprine, buspirone, sympathomimetics, tryptophan, dextromethorphan, analgesic agents, CNS depressants and amphetamines. AVOID USING WITHING 2 WEEKS OF EACH OTHER AND 5 WEEKS AFTER FLUOXETINE. HYPERTENSIVE CRISIS may occur with amphetamines, methyldopa, levodopa, dopamine, epinephrine, norepinephrine, guanethdine, guanadrel or vasoconstrictors. Hyper or hypo tension, coma, convulsions and death may occur with opiods Avoid use of Valerian, St. John's Wort, SAMe, Ginko, Kava, caffeine, licorice if taking and MAOI Ingestion of the following substances while on MAOI therapy could result in a life threatening hypertensive crisis. A 14 day interval is recommended between use of these drugs and an MAOI. All other antidepressants (SSRI, SNRI, TCA, heterocyclics) Sympathomimetics (epinephrine, dopamine, norepinephrine, ephedrine, pseudoephedrine, phenylephrine, phenylpropanolamine, and over the counter cold remedies) Stimulants (amphetamines, cocaine, diet drugs) Antihypertensive (methyldopa, guanethidine, reserpine) Meperidine and other opioid narcotics (morphine and codeine) Antiparkinsonian agents (levodopa)
Nursing Interventions for serotonin syndrome
Treatment (Per provider orders): Discontinue all serotonergic drugs immediately, Anticonvulsants for seizures, serotonin antagonist like clozapine or quetiapine, lorazepam for restlessness/agitation, propranolol for HR and BP, cooling blanket and other symptomatic care as indicated. • If left untreated, may result in: seizures, coma, ventricular arrhythmias, DIC, metabolic acidosis and renal failure. Can Lead to death.
Lithium levels therapeutic range
0.6-1.2
Atypical antipsychotics
1. Abilify( aripiprazole), saphris(asenapine), Clozaril(clozapine), Geodon(ziprasidone), Invega(palperidone), Risperdal(risperidone), Seroquel(quetiapine), Olanzapine(zyprexa), Fluoxetine(prozac), Latuda(lurasidone)
Heterocyclics
1. Buropion (Wellbutrin/Zyban)-weight neutral, smoking cessation, sexual dysfunction, seizures 2. Mirtazapine (Remeron)- sedation 3. Trazodone (desyrel)- Sedation
List 5 patient education guidelines for pt on antidepressant
1. Continue taking the med even though you may still have symptoms or if your symptoms have gotten better 2. Drowsiness/dizziness can occur-use caution w/driving 3. Use sunscreen and protective clothing 4. Rise slowly from lying or sitting 5. For dry mouth-drink H2O/hard candy/chew gum 6. May take w/food to decrease nausea 7. avoid alcohol 8. Don't stop med abruptly 9. COnsult w/doc prior to taking other meds 10. For MAOI's avoic consuming tyramine containing foods-can cause hypertensive crisis
SNRI/Heterocyclics Drug Interactions
1. Do not use w/ MAOI's: can be fatal or cause symptoms resembling neuroleptic malignant syndrome 2. Increased risk of serotonin syndrome when any of the following are used together-St.Johns wort, sumartiptan, sibutramine, trazodone, nefazodone, venlafaxine, duloxetine, levomilnacipran, SSRI's triptans 3. Increased effects of haloperidol, clozapine, and desipramine w/ used concomitantly w/ venlafaxine 4. Increased risk of liver injury with concomitant use of duloxetine & alcohol 5. Altered anticoagulation effect of warfarin may occur w/ bupropion, venlafaxine, desvenlafaxine, duloxetine, levomilnacipran and trazodone 6. o Increased risk of seizures when bupropion is coadministered with drugs that lower the seizure threshold such as antidepressants, antipsychotics, systemic steroids, theophylline and tramadol.
St. Johns Wort
1. Increases serotonin, norepinephrine & dopamine 2. May be helpful for mild symptoms of depression
Anticonvulsants used as mood stabilizers
1. Lamictal(lamotrigine) 2. depakote(divalproex sodium) 3. Tegretol(carbamazepine) 4. Topamax(topiramate) 5. Neurontin(gabapentin) 6. Trileptal( oxycarbazepin)
Tricyclic antidepressants
1. Sinequen(doxepin) 2. Anafranil(clomipramine) 3. Elavil(amitriptyline) 4. Norpramin(desipramine) 5. Pamelor(anrtriptyline) 6. Tofranil(imipramine)
SSRI/SNRI why are they drug of choice for depression
1. They have very few SE and are relatively safe for the patient- have a decreased risk of death with overdose, least amt of interactions with meds
SNRI
1. Venlafaxine(Effexor)-Hot flashes, pain 2. Duloxetine(cymbalta)-pain 3. Desvenlafaxine(Pristiq)
Half-life
A drugs half-life is the time it takes for the dose amount of drugs in the body to decrease by 50%. Ex- alprazolam half life is 11 hours, so it takes about 2.5 days for nearly all traces of the drug to be eliminated from the body after taking a single dose
Role of the RN
Adhere to legal/ethical standards of care; Comprehensive med assessment; Med admin/evaluation; Client/family edcuation
Symptoms of serotonin syndrome
Agitation, diarrhea, restlessness, confusion, sweating, seizures, coma, increased HR, headache, rapid changes in BP, hyper-reflexia, hyperthermia, hallucinations, tremors
Which drugs are used as alternative to lithium in treating bipolar disorder
Anticonvulsants, atypical antipsychotics, benzos, and calcium channel blockers
Psychotropic Med classes
Antidepressants, anti-psychotics, anti-anxiety, mood stabilizers, & CNS stimulants
Critical assessments for client on antidepressants
As mood begins to lift pt may have increased energy to implement a suicie attempt; suicide potential increases as level of depression increases; RN must be alert for shifts in mood and suicide assessments
Benzodiazepines
Ativan(lorazepam), klonopin(clonazepam), Librium(chlordiasapoxide), Valium(diazepam), xnax(alprazolam)
Which antiolytic should not be used as a PRN
Buspirone(BuSpar)- it has a delayed onset- may take 2-4 weeks to become effective
Common SE of increased Lithium
Decreased sodium intake, diuretic therapy, decreased renal function, fluid & electrolyte loss(sweating, dehydration, fever, vomiting); medical illness(not eating/drinking); use of NSAID's
Four common reasons a pt may be taking antidepressant
Depression, anxiety, pain, smoking cessation
Use of antidepressants
Depression, dysthymia, depression assoc w/organic disease, alcoholism, schizophreni, intellectual disability, depressive phase of bipolar, anxiety & pain
St. Johns Wort SE
Dizziness, confusion, tiredness, & sedation
Lithium SE
Drowsiness/dizziness, headache, GI upset, N/V, abdominal cramping, muscle weakness/stiffness, fine hand tremors, hypotension/arrythmias, polyurea/dehydration, weight gain, metallic taste in mouth
Calcium Channel Blockers SE
Drowsiness/dizziness, hypotension, bradycardia, nausea, constipation
SSRI/SNRI SE
Dry mouth, blurred vision, urinary hesitancy, constipation, orthostatic BP, insomnia/agitation, headache, wt loss/gain, sexual dysfunction
Precautions w/antidepressants
Elderly/debilitated; clients with heptaic/cardiac/ or renal insufficiency; psychotic clients; client w/ benign prostatic hypertrophy; clients w/ Hx of seizure (tricyclics & MAOI's)
Role of nurse to improve adherence?
Establish therapeutic relationship, listen to concerns of patient, ask "what does taking this med mean to you", acknowledge S/E and ways to manage S/E, respect the client & their med concerns, develop trusting relationship, align taking med w/patient self identified goals of feeling better, provide follow-up care:can you client pay for med, use simplest med & routine, empower pt to use non-pharm interventions
Distribution
How much of the drug is moved into various body tissues
Elimination
How much of the drug is removed from the body in a specific amount of time
Pharmacokinetics
How the body gets the drug to and from the intended target: Absorption, Distribution, Metabolism, Elimination
Metabolism
How the drug is altered, usually by the liver enzymes into its active and inactive parts
Initial s/sx of lithium toxicity; 3.5 or higher
Impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrythmias, myocardial infarction, CV collapse
Medication admin and evaluation
Includes monitoring for S/E, adverse reactions and evaluating the effectiveness of the medication
Receptor Mechanism- Antagoist
Inhibits or blocks another chemical agonist from stimulating the receptor to open its channel (many anti-psychotic drugs are antagonists at dopamine receptors because they inhibit the activity of dopamine
Lithium- what are the reasons a atietn may be started on this med?
Lithium is a naturally occurring salt and is often a first line treatment for acute mania. Also is used for bipolar disorder, aggressive behavior, conduct disorder and schizoaffective disorder.
Contraindications of MAOI's
Liver & kidney disease; hx of stroke or CV disease; hypertension; seizure disorder; glaucoma
How long until signs of relief after starting antidepressants
May take up to 3-6 weeks to see therapeutic benefit-recommended to take atleast 1-year duration to prevent relapse-taper gradually
Psychotropic Medications refers to....
Meds that effect psychic function, behavior and experience
Action of antidepressants
Most act by increasing the concentration of serotonin, norepinephrine and/or dopamine in the body either by blocking their reuptake by the neurons (TCA, SSRI's, SNRI's) or by inhibiting the release of monoamine oxidase(MAOIs); Also block alpha-adrenergic, histamine and muscarinic cholinergic receptors which causes the development of SE
Psychotropic med teaching
NO ETOH
MAOI's
Nardil(phenelzine); Parnate(tranylcypromine
Anticonvulsants SE
Nausea/vomiting, drowsiness/dizziness; blood dyscrasias, prolonged bleeding time w/ valporic acid, risk of severe rash(report immediately), decrease efficacy of oral contraceptives, increased risk for suicide
Drug interactions with St. John's Wort
Oral contraceptives, benzos, anti-dysrhythmics, statins, digoxin, methadone, prilosec, warfarin, levadopa
Adhere to legal & ethical standards of care
Patients right to refuse medication except in emergency situations
Risk factors for developing drug interactions
Polypharmacology: use of multiple psychopharmacoloical & other meds, high doses, pediatric/pregnant/lactatig/geriatric pts, debilitated/dehydrated, concurrent illness(cardiac/ seizures/DM/glaucoma), compromised organ system function, inadequate pt/family education, Hx of non-adherence, failure to include patient/family in tx planning
Causes of medication non-adherence
Poor relationship with provider, inadequate teaching/understanding of med, poorly controlled side effects, social isolation, expense of drug, lack of follow-up care, increased restriction on pt lifestyle, remission of target symptoms, increased SI & paranoia, potential for stigmatism or idea of chronic illness, concurrent substance use
Important teaching considerations when pt is on lithium
REgular sodium intake; avoid excessive caffeine; 2500-3000ml fluid/day; replace fluids lost through exercise or GI illness;; serum lithium levels as determined by provider; monitor for lithium SE & toxicity; not recommended for use during pregnancy
Receptor mechanism
Receptors are channels on cells that act as gatekeepers of brain communication. A drug modifies a receptor by binding to one subtype of receptor (like a key in a single lock) or many subtypes of receptors (like a master key for many locks) a drug can act as an agoinst, partial agonist, antagonist, inverse antagonist
Tolerance
Requiring higher doses of the drug to be given over time to obtain the same initial therapeutic effect(ex-benzo and opioid)
Types of antidepressants
SSRI, SNRI, & heterocyclics, TCA, MAOIs
Target symptoms w/antidepressants
Sleep disturbance, appetite disturbance, anxiety, fatigue, decreased sex drive, psychomotor retardation/agitation, diurnal variation in mood, impaired concentration/ forgetfulness, anhedonia, suicidal thoughts, pain
Receptor mechanism- Agonist
Stimulates the receptor to fully open its channel (benzos are agonists for the GABA system because the enhance the activity of GABA)
Receptor mechanism- Partial agonist
Stimulates the receptor to partially open its channel
Potency
The amount of drug required to achieve certain effects-how much of this drug is needed to get desired results
Steady state
The point at which the plasma drug concentration remains relatively constant between doses becuse the amount of drug excreted equals the amount ingested
Discontinuation syndrome
The symptoms that result after abruptly stopping many psychotropic medications including anti-depressants, benzos, and atypical anti-psychotics- patients can get pretty severe SE
Client/family education
These are very powerful drugs with the potential for significant S/E-education is very important
Comprehensive medication assessments
Use of MOSES, DISCUS, AIMS scale-very important to establish baseline because all psychotropic medications have the potential for significant S/E. Must include: non-psychiatric dx & tx, over the counter meds * substances, and complimentary treatments
Calcium channel blockers
Verapamil (calan;Isoptin)
SE with tricyclic antidepressants
Weight gain/loss; tremor, blurred vision, constipation, confusion, urinary retention; sleep problems(insomnia/sedation); orthostatic hypotension; arrythmias/tachycardia; photosensitivity; reduction in seizure threshold; ataxia, unsteadiness & tremulousness
Drug interaction
When one drug interferes with the absorption, metabolism, distribution, and/or elimiation of another drug-thus raising or lowering the levels of the second drug in the blood stream/tissues (the mood stabalizer carbamazepine, St. Johns Wort & smoking cigs can reduce many psychotropic drug levels making them ineffective
SNRI
block the reuptake of norepinephrine & serotonin
SSRI
block the reuptake of serotonin
Initial s/sx of lithium toxicity- 1.5-2.0
blurred vision; ataxia; tinnitus; nausea, vomiting, diarrhea
SSRI meds
celexa(citalopram); Lexapro(escitalopram); Luvox(fluvoxamine); Paxil(paroxetine); prozac(fluozetine); Zoloft(sertraline)
Receptor Mechanism- Inverse antagonist
directly closes the receptor channel
SE of MAOI's
dry mouth; constipation; blurred vision; orthostatic hypotension; urinary problems; edema; confusion
Initial s/sx of lithium toxicity; 2.0-3.5
excessive o/p of dilute urine, tremors, muscular irritability, psychomotor retardation, mental confusion
Absorption
how the drug is moved into the blood stream from the site of administration
Antiolytics SE
hypotension, slowed breathing, memory issues, can be habit forming, drowsiness, dizziness, confusion, orthostatic hypotension
Contraindications w/antidepressants
known hypersensitivity; acute phase of recovery from MI; angle-closure glaucoma (TCA)
Toxic lithium level
levels greater than 1.5
Dietary restrictions of MAOI's
o Hypertensive crisis may occur with the ingestion of foods or other products containing high concentrations of tyramine. o Tyramine is found in many foods including: aged cheese, smoked and processed meats, sauerkraut, soy sauce, draft beer, avocado, raisins, red wines, caviar, pickled herring, brewers yeast etc.
Tricyclic drug interactions
o Increased effects of TCAs with bupropion, cimetidine, haloperidol, SSRIs and valproic acid o Carbamazepine, barbiturates and rifamycins decrease effects of TCAs o If TCA are given with MAOIs, hyperpyretic crisis, convulsions and death can occur o Use of TCAs can decrease effects of levodopa and guanethidine o Increased anticoagulation effects with dicumarol o Increased serum levels of carbamazepine o Increased risk of seizures with concomitant use of maprotiline and phenothiazines
Reason for monthly lithium levels to be drawn
o Is a medical emergency requiring rapid treatment o There is no antidote for Lithium toxicity o Client education and compliance is mandatory o Nurse's working with clients who are taking lithium need to be aware of the potentially fatal consequences of lithium toxicity
