1. Mood Disorders

2. Objectives Compare and contrast grief to depressive disorders
Identify stages of the grieving (mourning)process
Relate interventions appropriate to the grieving process
Identify symptoms and behaviors associated with mood disorders
Analyze predisposing factors and/or precipitating stressors to mood disorders
Apply the nursing process in the care of persons with mood disorders
Describe the treatment strategies for mood disorders and the implications for the nursing role

3. Grief Reactions Grief is universal
Grief is the subjective state that follows loss
A powerful emotional state that affects all aspects of a person’s life
Grief can continue for months, 1-2 years

4. Loss Types of loss Particularly the loss of a loved one
Other types of loss
Physiologic
Safety
Security
Self-esteem
Self-actualization

5. Types of Grief
Uncomplicated bereavement (normal grief) – this is not a disorder
Anticipatory grieving-grief associated with anticipation of predicted loss or death
Disenfranchised grief involves a loss not typically acknowledged by society (i.e., a pet, a home)
Chronic sorrow-grief associated with ongoing loss such as chronic mental or physical illness

6. Kubler-Ross Stages of Grieving
Normal mourning process:
Denial
Anger
Bargaining
Depression
Acceptance

7. Considerations for Interventions
Individuals grieve in different ways
Stage/phase of grief determines intervention
Developmental stage effects grief process
Nurses have role in helping persons who are grieving

8. Maladaptive Responses to Loss: Complicated Bereavement
Excessive hostility and bitterness
Prolonged emptiness and numbness
Inability to weep or express emotion
Failure to resume activities, work, go on with their lives

9. Nursing Understanding Promote expression and release of pain
Use of the therapeutic relationship/communication
Individualization of care, recognizing various beliefs and practices r/t loss such as death
Culture, religious practices, and spiritual beliefs

10. Nursing interventions for grief
Identification of loss
Expression of feelings
Discuss prior losses
Empathetic statements about grief
Explore fears about loss
Elicit coping strategies
Promote cultural, religious, social customs
Use the term “dead” rather than euphemisms
Clarify misconceptions
See Stuart 2013, p. 308, Box 18-9

11. Additional Interventions
Grief counseling
Traumatic grief psychotherapy

12. Grief vs. Major Depression
Grief can look very much like depression (overwhelming sadness, poor sleep, poor concentration, decreased appetite, somatic complaints)
Unlike depressed persons, the grieving person does not have poor self-attitude, worthlessness
Grief can progress to Major Depression

13. Distinguishing Grief & Depression
Feelings of emptiness and loss
Pangs (or waves) of grief
Positive emotions and humor
Preoccupation with the deceased (loss)
Depressed mood and/or inability to anticipate happiness or pleasure
Persistent
Pervasive unhappiness
Pessimism
GRIEF
DEPRESSION

14. Mood Disorders Depressive Disorders Bipolar Disorders I & II
Major Depressive Disorder
Postpartum Depression
Seasonal Affective Disorder
Dysthymic Disorder
Cyclothymic Disorder
Bipolar Disorders I & II

15. What is mood?
Mood - Pervasive and sustained emotion that colors one’s perspective of the world and how one functions in it

16. Mood Disorders:
20.9 million American adults (9.5% of the population) have a mood disorder in a given year
Median age of onset 30 years old
Depressive disorders often co-occur with anxiety and substance abuse
NIMH (n.d.). The numbers count: Mental disorders in American. Accessed on September 1, 2013 at

17. Major Depressive Disorder (MDD)
20% of people will experience depressive illness in their lifetime
Prevalence rates not affected by race
Leading cause of disability among ages y.o.
Effects 14.8 million (6.7 % of the U.S. population) in a given year
Median onset is 32 y.o.
More prevalent in women than men, 2:1
Incidence higher in young women, increasing in adolescents, increases with age among men

18. Major Depressive Disorder (MDD)
For at least 2 weeks a depressed, sad mood and/OR loss of interest & pleasure (anhedonia) with 4 of the following:
Appetite/weight change *
Sleep disturbance daily
Psychomotor agitation or retardation (observed by others)
Fatigue/low energy daily
Guilt or feelings of worthlessness daily
Poor concentration or indecisiveness daily
Recurrent thoughts of death, suicidal ideation
In children, failure to make expected weight gain

19. Affective features Anger/irritability Anxiety Apathy Withdrawal
Denial of feelings
Despondency
Loss of motivation
Guilt
Helplessness
Hopelessness
Loneliness
Low self-esteem
Pessimism
Bitterness
Self-destructive thoughts/behaviors

20. Physiological features of Depression
Sleep disturbances
Menstrual changes
Sexual problems
Weight change
Abdominal pain
Backache
Chest pain
Dizziness
Fatigue
Headache
GI disturbances

21. Cognitive features of Depression
Ambivalence
Confusion
Inability to concentrate- “can’t think, can’t focus”
Indecisiveness and uncertainty
Cognitive distortions
Impaired (short-term)memory
Negative thinking (self-blame, –deprecation, – destructive)
May include psychosis

22. Behaviors Associated with Depression
Aggressiveness/agitation
Alcohol/drug abuse
Altered activity level/psychomotor retardation
Over- dependency
Poor hygiene
Underachievement
Withdrawal

23. Risk Factors for Depression
Prior episodes of depression
Family history of depression
Prior suicide attempts
Female gender
Postpartum period
Medical comorbidity
Lack of social support
Life stressors
Personal history of sexual abuse
Current substance abuse

24. Models of Causation of Severe Mood Disturbances
Multifactorial:
Genetic/biological
Environmental- Life stressors, loss
Poor attachment in infancy/early childhood (object relations)
Learned helplessness/hopelessness
Most likely a combination of factors explain the cause of depression.

25. Neurobiology of Depression
Decrease in monoamine neurotransmitters (Norepinephrine, Serotonin) in the synapse between neurons
Over-Activation of the HPA axis
Stress hypothalamus secretes CRH  stimulates pituitary to release ACTH  stimulates adrenal cortex to release glucocorticoids  damages neurons  decrease in neurotransmitters  depression and anxiety
CRH = Corticotropin releasing factor
ACTH = adrenocorticotropic hormone
Glucocorticoids include cortisol

26. Association with mood d/o
Area of evidence for Dysregulation
Association with mood d/o
Behavior
5HT has a role in aggression, mood, anxiety, psychomotor activity, irritability, appetite, sexual activity, sleep/wake cycle, circadian and seasonal rhythms, neuroendocrine function, body temp., cognition, pain perception
Abnormalities found in persons with depression
Biochemistry
5HT is found in CSF, blood, brain tissue
Low levels found in persons with depression or who have completed suicide
Neuroendocrine
5HT has a role in secretion of growth hormone, prolactin, and cortisol
Treatment
5HT is enhanced with antidepressants and ECT
Clinically effective in the treatment of depression
Brain structure
MRI
In depression shows decreased size of the hippocampus suggesting damage via stress
In bipolar disorders shows increased size of brain structures associated with mood
Brain function
PET
In depression, decreased metabolism in the left frontal area, and on the right in mania
5HT = serotonin
Stuart (2013, p. 298)

27. PET scan
This PET shows glucose metabolism in depressed brain. The brain on the left is demonstrates hypometabolism in the frontal area (left side of the brain images shown). The brain on the right is a after treatment with antidepressants.

28. Diagnosis of Depression
Psychiatric evaluation
Self-report of symptoms
Family report of symptoms
Signs of depression (decreased sleep, decreased appetite, etc)
Medical exam to rule out physical illness
Labs – TSH, T3, T4, CBC must rule out medical causes such as hypothyroidism
Screening tools

29. Screening Instruments
Hamilton Rating Scale for Depression (HAM-D) (1967)
Primary Care-Screener for Affective Disorders (PC- SAD)
(Rogers et al, 1998)
Primary Care Evaluation of Mental Disorders (PRIME- MD) (Spitzer, et al., 1994)
Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) (Broadhead et al., 1995)
Beck Depression Inventory (BDI) 1988
Child Depression Inventory
Zung Self-Rating Depression Scale (1965)

30. Impact of Depression Impaired relationships
Inability to perform usual activities
Loss of productivity
Alcohol and other substance abuse
Increased use of health care resources
Risk of suicide (about 15% of patients with severe depression commit suicide)

31. Differences by sex: Women
More common in women
Hormones directly effect the brain
Vulnerability to postpartum depression
Premenstrual dysphoric disorder
Increased risk during transition to menopause
Additional stresses at work, home, caring for children and aging parents, abuse, poverty, relationship strains
National Institute of Mental Health (n.d.). Depression. Accessed on September 1, 2013 at

32. Postpartum Depression
13% of all new mothers
Associated with drastic hormone changes
Higher risk with previous PPD, h/o mood disorder
Estradial for treatment

33. Differences by sex: Men
May experience differently
Feel tired, irritability, anhedonic, poor sleep, get frustrated, angry
More likely to use alcohol/drugs
Avoid talking about it
Excessive work
Behave recklessly
More likely to complete a suicide
NIMH

34. Depression in Older adults
More medical conditions that are associated with depression (i.e., cardiac, Parkinson’s, stroke, cancer)
Medications with SE of depression
Older white males age 85 + have the highest suicide rate in the U.S.
Psychotherapy and medications are effective treatments
NIMH

35. Depression in Children
Children may pretend sick, refuse school, cling to a parent, worry about a parent dying
Older children may sulk, get into trouble, be negative and irritable, feel misunderstood
Before puberty, no difference in incidence based on sex
By age 15 y.o., girls twice as likely as boys
NIMH

36. Depression in Children
In the teen years, often co-occurs with anxiety, eating d/o’s, or substance abuse
Childhood depression often persists into adulthood, esp. if not treated
NIMH

37. Other Types of Depression
Mood disorder due to medical condition
Endocrine dysfunction
Hypo- or hyperthyroidism
Cushing’s disease
Degenerative/structural change
Parkinson’s
Huntington’s Disease MS
TBI
Stroke
Substance-Induced Mood Disorder
Seasonal Affective Disorder (SAD)
Adjustment Disorder (situational)

38. Seasonal Affective Disorder (SAD)
Less daylight during the fall and winter causes depression in some people.
Overproduction of melatonin disrupts our internal body clock leading to depressive symptoms. If you have had episodes of depression that clearly have an onset in fall or winter followed by remission of symptoms in the spring or summer, you may have SAD.

39. SAD sx’s Depressed mood Irritability Hopelessness Anxiety
Loss of energy
Social withdrawal
Oversleeping (feeling like you want to hibernate)
Loss of interest in activities you normally enjoy
Appetite changes, especially a craving for foods high in carbohydrates such as pastas, rice, bread and cereal
Weight gain
Difficulty concentrating and processing information

40. Dysthymic Disorder
Characterized by chronic low-level depression experienced for at least 2 years
Not as severe as MDD, but can prevent normal functioning and feeling well
1.5 % of the adult population in the U.S.

41. Treatment of Depression
Safety - Environment free of harmful objects, safety plan
Pharmacology – antidepressants, sleep aids, short term anxiolytics
Psychotherapy – Cognitive Behavioral, Interpersonal, Solution Oriented, Supportive
Education- Coping skills, self esteem, illness, medications, resources
Phototherapy - Artificial bright light for SAD*
Electroconvulsive therapy (ECT)*
*see additional ppt on physical therapies (ECT, phototherapy, etc.)

42. Treatment of depression in children and adolescents
Unlike adults, children may not respond to tricyclics.
Children and adolescents do respond well to SSRIs and perhaps to other classes of antidepressants as well.
In 2003 a blackbox warning was implemented r/t increased suicide risk. More recent reports (June 2014) indicates an association between decrease rx and rise in child/teen suicide attempts
BMJ sited in NIH HealthDay.
Healthday (2014). As antidepressant warnings toughened, teen suicide attempts rose: Study. Accessed on September 16, 2014 at

43. Monoamine Oxidase Inhibitors (MAOIs)
Usual adult daily dosage ranges (not recommended for children):
Phenelzine (Nardil): 30-60mg
Tranylcypromine (Parnate): 20-60mg
Selegiline (Eldepryl, Atapryl) 10mg
Indications: may be useful in the treatment of depressed patients with marked anxiety or phobic symptoms. Selegiline is also used for the treatment of parkinsonism.
Because of the potential for serious adverse effects, MAOIs are not commonly used in clinical practice.

45. Monoamine Oxidase Inhibitors (MAOIs)
Pharmacokinetics: antidepressant effects may take 3-6 weeks
Most frequent adverse effects: orthostatic hypotension, insomnia, weight gain, edema, and sexual dysfunction.
Rare side effect: tyramine-induced hypertensive crisis. Avoid foods that are preserved, pickled or aged (e.g., aged cheese, cured meats or fish, alcoholic beverages)
Potential for severe drug-drug interactions

46. Tricyclic Antidepressants
Elavil (amitriptyline)
Norpramin (desipramine)
Pamelor (nortryptyline)
Pertofrane (desipramine)
Sinequan (doxepin)
Tofranil (imipramine)
Anafranil (clomipramine) - OCD

48. Tricyclic Antidepressants (TCAs): Indications
Depression
Anxiety disorders
Obsessive-compulsive disorder
Clomipramine (Anafranil)
Chronic pain:
Neurogenic pain, Trigeminal neuralgia, Diabetic neuropathy, Sciatica, Fibromyalgia
Sleep Disorders
Insomnia, Cataplexy

49. Tricyclic Antidepressants
Pharmacokinetics: therapeutic effects within 3-4 weeks; improved energy and sleep in 1-4 weeks
Adverse effects:
Anticholinergic: dry mouth, blurred vision, constipation, memory effects
Antiadrenergic: orthostatic hypotension
Antihistaminergic: sedation & weight gain
Cardiac: use in patients with conduction defects is contraindicated
Because of the potential for severe side effects and even death, TCAs are relatively contraindicated in the elderly, children, pregnant women and suicidal individuals.

50. Selective Serotonin Reuptake Inhibitors (SSRIs)
Adolescents often receive adult dose, but doses are slightly less for children.
Fluoxetine (Prozac): 20-80mg/day for depression and anxiety disorders; 60-80mg/ day for bulemia. Prozac weekly: 90mg.
Fluvoxamine (Luvox): mg/day for OCD; mg/day for depression
Paroxetine (Paxil): mg/day
Sertraline (Zoloft): mg/day
Citalopram (Celexa): 20-60mg/day
Escitalopram (Lexapro): 10-20mg/day

51. Selective Serotonin Reuptake Inhibitors (SSRIs)
Indications: depression, anxiety, traumatic stress, eating d/o, borderline personality d/o
Pharmacokinetics: therapeutic effects may take 3-6 weeks for depression and weeks for OCD.
Observe for activation of known or unknown bipolar disorder and/or suicidal ideation.
Inform parents or guardian of this risk so they can help observe child or adolescent patterns.

52. Adverse Effects Associated with SSRIs
Common: anxiety, agitation, akathisia, insomnia, nausea, diarrhea, sexual dysfunction
Most side effects will pass. May need to add buproprion for sexual dysfunction or switch to another agent.
Serotonin syndrome (excess serotonin): diarrhea, restlessness, extreme agitation, hyperreeflexia and autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, and possible death.
Serotonin discontinuation syndrome: agitation, nausea, disequilibrium, and dysphoria. Tapering is advised.
A symptom chart for serotonin discontinuation syndrome can be found in:
Warner, C.H., et al. (2006). Serotonin discontinuation syndrome. American Family Physician. Accessed October 15, 2012 at

53. Medication Management of Depression: Novel Agents
Serotonin-2 antagonist/ reuptake inhibitors
Nephazodone (Serzone): mg/day
Risk of hepatotoxicity so not a first-line med.
Trazodone (Desyrel): mg/day
Generally used for insomnia due to sedative properties
Risk for priapism in males
Should not be used in children/adolescents and used cautiously with elderly.
Serotonin/norepinephrine reuptake inhibitors (SNRIs)
Venlafaxine (Effexor): mg/day
Higher incidence of activation with children and adolescents. Effective with anxiety control. Can cause hypertension.
Duloxatine (Cymbalta): 40-60mg/day Significant potential for liver toxicity so alcohol prohibited.
Taper down on both of these medications should be slow due to significant serotonin discontinuation syndrome.
A symptom chart for serotonin discontinuation syndrome can be found in:
Warner, C.H., et al. (2006). Serotonin discontinuation syndrome. American Family Physician. Accessed October 15, 2012 at

54. Medication Management of Depression: Novel Agents
Norepinephrine dopamine reuptake inhibitor (NDRI)
Bupropion (Wellbutrin; Zyban): mg/day
Also available in SR and XL forms
May increase seizure risk: avoid if hx of seizures or bulemia
Commonly used as an augmenting agent with other antidepressants, no sexual side effects, useful for smoking cessation
Has been used to treat ADHD in children at mg/day
Alpha 2 antagonist / noradrenaline and specific serotonergic agent (NaSSA)
Mirtazepine (Remeron): 15-45mg at bedtime
Antihistamine effects: Highly sedating at lower doses but also causes weight gain.

55. Comparison of Antidepressant Side Effects
Tricyclic
SSRI
MAOI
Anticholinergic
++++ +
Sedation
Hypotension ++
0/+
Seizures
+++
Cardiac
Weight gain
Sexual dysfunction
Other
bleeding
Hypertensive Crisis

56. Safety
Patients with depression are at particular risk when they appear to be coming out of their depression because they may then have the energy and opportunity to kill themselves

57. Bipolar Disorder Bipolar I: 1 or more manic episodes
Bipolar II: Recurrent major depressive episodes with hypomanic episodes

58. Bipolar Disorder
Prevalence of BD I & II is 2.6% in the U.S. adult population (based on interview-based survey)
Average age of onset is 25 years old
Having a parent or sibling who has Bipolar Disorder increases a child’s chance, but most who have family hx, will not get it
NIMH (n.d.) Biplolar disorder among adults. Accessed on February 11, 2014 at

59. Predisposing Factors for Bipolar Disorder
Male: female = 1:1
No difference based on race/ethnicity
Onset = adolescence, middle aged women
Etiology = Genetics
Prognosis = Variable

60. Bipolar Disorder Imaging studies
Brain development pattern is different
Brain’s prefrontal cortex in adults tends to be smaller and function less well than adults without
NIMH

61. Bipolar I Disorder
Characterized by recurrent episodes of mania (at least one manic episode to meet criteria)
Theoretical mechanisms
Sensitization: Recurrent stressors and episodes can both predispose an individual to increased vulnerability to future episodes in a long-lasting fashion.
Kindling: repeated intermittent subthreshold stimulation of a given region of the brain eventually leads to full-blown amygdala seizures (affective episodes).
Support: Anticonvulsants and lithium have anti-kindling effects. Post (2003). Pediatric bipolar disorder.

62. Manic Episode Psychotic symptoms may also be present
Period of abnormally and persistently elevated, expansive, or irritable mood and abnormally goal- directed activity or energy, which persists for at least 1 week with presence of 3 or more of the following symptoms:
Inflated self esteem or grandiosity
Decreased need for sleep (and feels rested)
More talkative, rapid or pressured speech
Flight of ideas, racing thoughts
Distractibility
Increased goal directed activity or psychomotor hyperactivity
Excessive involvement in activities that have high potential for painful consequences (buying sprees, sexual indiscretions, foolish investments, etc.)
Any duration if hospitalization is necessary
Psychotic symptoms may also be present

63. Behaviors Associated with Mania
Resistance to treatment efforts
Disorganized thinking and bizarre behavior
Psychotic features, primarily delusions
Alteration in mode of dress and appearance
Impulsive, high risk behavior such as gambling, spending, sex, driving fast, drugs
Pacing and hyperactive
Behaviors & mood cause marked impairment in function

64. Comparing BD I & II Bipolar I Bipolar II
Manic episode, which causes marked impairment in function or includes psychosis
Duration 7 days or less if need of hospitalization
May or may not include h/o depression, but likely
Hypomanic episode, same symptoms as mania, but duration is shorter (4 days), episode does not impair function, nor include psychotic symptoms
Requires lifetime episode(s) of depression

65. Treatment of Bipolar Disorder
Pharmacology
Psychotherapy (CBT, Family-focused therapy, Interpersonal)
Psychoeducation
ECT

66. Treatment--Pharmacology
Lithium Carbonate: Eskalith, Lithobid- gold standard
Anticonvulsants: Lamotrigine,
Valproic acid (Depakote),
Carbamazepine (Tegretol)
Antipsychotics: risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel), olanzapine (Zyprexa), ziprasidone (Geodon)

67. Nursing Care Safety Sleep hygiene Low stress level
Maintain medication regimen
Exercise and nutrition
Mood chart
Avoid alcohol and drugs

68. Bipolar Disorder: Acute / Initiation Phase
Goals: Control symptoms of agitation, aggression, and impulsivity. Return to usual levels of psychosocial functioning. If depressed, avoid precipitation of manic episode.
Treatment:
Severe mania or mixed episodes: initate lithium or valproate in combination with an antipsychotic.
For less severely ill: monotherapy with lithium, valproate, or an atypical antipsychotic.
If symptoms are inadequately controlled after days, add another first-line medication.
Baseline:
Lithium: BUN, creatinine, thyroid, ECG, pregnancy.
Valproate: Assess for hepatic, hematological and bleeding abnormalities and pregnancy.

69. Bipolar Disorder: Stabilization and Maintenance
Goals: Prevent relapse and recurrence, reduce subthreshold symptoms, reduce suicide risk, reduce cycling frequency or milder degrees of mood instability, and improve overall function.
Treatment: Maintenance medication is recommended following a manic or depressive episode. Monitor lithium or valproic acid levels, hemotologic, and hepatic functioning at least every 6 months.

70. Medication Management of Bipolar Disorders in Children and Adolescents
Current approach is to treat acute mania with lithium or divalproex sodium (Depakote, valproic acid), and Risperidone or Abilify.
Have more weight gain than adults on all mood stabilizing agents: lithium, anticonvulsants, atypical antipsychotics
Polypharmacy is often necessary for stability: atypical antipsychotics are useful due to more rapid onset of action than lithium and the mood stabilizers.

71. Lithium
Indicated for acute mania and mood stabilization
Routine lab and physical exams required
Usual adult dosage: mg/day in divided doses
Long half-life yet narrow therapeutic index
Response in acute mania may take 7-14 days
Narrow therapeutic index requires frequent physical exams and labs. Serum blood levels should be:
Acute episode: mEq per L.
Maintenance: mEq per L.
Teratogenic in the first trimester of pregnancy.
Can cause hypothyroidism,renal damage
Armstrong, C. (2008). ACOG Guidelines on psychiatric medication use during pregnancy and lactation. American Family Physician, 15, Accessed 11/05/2012 at

72. Lithium Side Effects Potential Side Effects ***Toxicity***
Polyuria/polydipsia
Weight gain
Hair loss
Acne
Cognitive dullness
Hypothyroidism
Indigestion
Renal insufficiency (LT)
Serum levels > 1.5 mEq/L
Early: coarse hand tremor, severe GI upset (N,V,D) blurred vision, vertigo, ataxia
Late: seizures, coma, dysrhythmias, permanent neurological impairment—may need hemodialysis
Death

73. Management of Lithium Toxicity
Obtain history of incident
Check VS, LOC-stabilize as needed
Li level, electrolytes, EKG-monitor if needed
Hydrate: 5-6 L
Adequate NaCL intake
Dialysis in severe cases with decreased UO & increased CNS depression

74. Health Teaching
Health conditions may increase Li+ resorption toxicity
Diet: caffeinediuresis
Side effects may nonadherence
Take with meals to decrease GI irritation
PREVENT DEHYDRATION glasses water/day (2.5L),
Do not change Na+ intake
Do not change brands
No OTC’s without provider OK
NO NSAIDS due to renal toxicity

75. Management with Anticonvulsant Mood stabilizers
Therapeutic effects on mania begin after days but mood stabilization may take weeks to months.
Common transient adverse effects of the anticonvulsants
Nausea, diarrhea, sedation
Common maintained adverse effects:
Weight gain: monitor weight and BMI; diet and exercise (lamotrigene and topiramate have lowest risk)
Tremor: consider low dose beta-blocker
Increased risk for thrombocytopenia: monitor prothrombin time
Risk for agranulocytosis (especially carbemazepine): monitor WBC

76. Anticonvulsants
Valproic acid (Valproate, Depakote): mg/day (adult); up to 20mg/kg/day (child/adol)
Useful for acute mania. Less effective for maintenance and bipolar depression.
MOA: Increases GABA availability
Pregnancy: D
Need blood levels (therapeutic= )
Side Effects:
Inhibits platelet aggregation
Overdose (OD) lethal
Adverse hormone changes in teenage girls
Polycystic ovary syndrome in women who began taking the medication before age 20
Black Box Warnings for Hepatic Failure, Pancreatic Failure

77. Anticonvulsant Mood Stabilizers
Carbamazepine (Tegretol): mg/day; up to mg/kg/day (child/adol)
Many drug-drug interactions- induces P450 enzyme breakdown
Need blood levels
Risk for agranulocytosis: monitor WBC q 2 wks X 2 mo then q 3 mo
Lamotrigene (Lamictal): mg /day
Risk of rare toxic necrolysis skin condition (Steven Johnsons Syndrome). Start very low and go slow. Start at 25mg q o day X 2 wk then increase by 50 mg every two weeks. Takes 6 weeks to get to a therapeutic dose.
Children and adolescents have higher incidence of life threatening rash than in adults.
Do not need blood levels
Topiramate (Topomax): mg/day
May be a useful adjunct in bipolar disorder. Not effective as first-line.
Significant sedation

78. Management of Bipolar Disorder: Antipsychotics
Atypical antipsychotics: Olanzepine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon), Risperidone and Abilify are FDA approved for bipolar maintenance.

79. Adverse Effects of Antipsychotics
Liver toxicity and blood dyscrasias
Sedation
Hypotension (mild)
EPS
Seizures
Anticholinergic effects (moderate-marked)
Risperidone: increased Prolactin which can lead to gynecomastia, galactorhea, mentrual changes and osteoporosis.
Weight gain
Neuroleptic malignant syndrome

80. Antipsychotic side effects
Metabolic syndrome
Weight gain, especially abdominal
Hyperlipidemia
Hyperglycemia
Collectively increase the risk for diabetes and cardiovascular disease
Monitor: weight, BMI, glucose and lipids, blood pressure