1. Antidepressants and Mood Stabilizers
Chapter 28
Antidepressants and Mood Stabilizers
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2. Depression A mood disorder that involves Pathophysiology
Depressed mood, despair, insomnia
Loss of interest in normal activities
Fatigue, decreased ability to think
Suicidal thoughts
Pathophysiology
Insufficient amount of monamine neurotransmitters (norepinephrine, serotonin, dopamine)
Other etiology
Genetic predisposition
Social and environmental factors 2
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3. Depression (Cont.) Types Reactive Major Bipolar
Usually sudden onset resulting from precipitating event (e.g., death of a loved one)
Major
Characterized by loss of interest in work or home
Inability to complete tasks
Deep depression
Bipolar
Mood swings between manic (euphoric) and depressive (dysphoria) 3
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4. Herbal Supplements for Depression
St. John’s wort
Can decrease reuptake of the neurotransmitters serotonin, norepinephrine, and dopamine
Gingko biloba
The use of these and many herbal products should be discontinued 1 to 2 weeks before surgery.
The patient should check with the health care provider regarding herbal treatments. 4
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5. Major Antidepressants Agents
Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin norepinephrine reuptake inhibitors (SNRIs)
Atypical antidepressants
Monoamine oxidase inhibitors (MAOIs) 5
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6. Tricyclic Antidepressants
Amitriptyline, imipramine, trimipramine, doxepin, desipramine, nortriptyline, and protriptyline
Action
Blocks uptake of neurotransmitters norepinephrine and serotonin in brain
Blocks histamine receptors
Elevates mood, increases interest in ADLs, decreases insomnia
Use
Major depression and agitated depression 6
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7. Tricyclic Antidepressants (Cont.)
Amitriptyline (Elavil)
Interactions
Increased CNS effects with alcohol and other CNS depressants
Increased sedation and anticholinergic effects with phenothiazines, haloperidol
Side effects/adverse reactions
Sedation, dizziness, blurred vision, dry mouth and eyes, urinary retention, constipation, weight gain, GI distress, sexual dysfunction
Orthostatic hypotension, dysrhythmias, EPS, blood dyscrasias 7
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8. Selective Serotonin Reuptake Inhibitors
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
Popular because they do not cause sedation, hypotension, anticholinergic effects, or cardiotoxicity as do many of the TCAs. 8
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9. Selective Serotonin Reuptake Inhibitors (Cont.)
Interactions
Increased CNS effects with alcohol and other CNS depressants
Side effects/adverse reactions
Headache, nervousness, restlessness
Insomnia, tremors, seizures
GI distress
Sexual dysfunction
Suicidal ideation
Side effects often decrease over 2 to 4 weeks. 9
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10. Serotonin Norepinephrine Reuptake Inhibitors
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 10
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11. Serotonin Norepinephrine Reuptake Inhibitors (Cont.)
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. 11
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12. 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. 12
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13. Monoamine Oxidase Inhibitors
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 13
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14. Monoamine Oxidase Inhibitors (Cont.)
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. 14
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15. Monoamine Oxidase Inhibitors (Cont.)
Side effects/adverse effects
Agitation, restlessness, insomnia
Anticholinergic effects
Orthostatic hypotension
Hypertensive crisis from fatal tyramine interaction 15
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16. Nursing Process: Antidepressant Agents
Assessment
Nursing diagnosis
Planning
Nursing interventions
Patient teaching
Cultural considerations
Evaluation 16
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17. 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. 17
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18. Antidepressant Agents (Cont.)
Nursing interventions
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. 18
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19. Mood Stabilizers Bipolar disorders Lithium (Lithibid)
Carbamazepine (Tegretol)
Divalproex (Depakote, Valproate)
Lamotrigine (Lamictal)
Olanzapine (Zyprexa)
Ziprasidone (Geodon)
Aripiprazole (Abilify) 19
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20. Mood Stabilizer: Lithium
Lithium (Eskalith)
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 20
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21. Mood Stabilizer: Lithium (Cont.)
Interactions
Increased lithium level with thiazides, methyldopa, haloperidol, NSAIDs, antidepressants, theophylline, phenothiazines
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 21
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22. Nursing Process: Lithium
Assessment
Nursing diagnosis
Planning
Nursing interventions
Patient teaching
Cultural considerations
Evaluation 22
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23. Mood Stabilizer: Lithium (Cont.)
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 23
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24. Mood Stabilizer: Lithium (Cont.)
Nursing interventions
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. 24
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25. Practice Question #1
A patient with major depression has been prescribed fluoxetine (Prozac). What appropriate dosing regimen would the nurse expect?
20 mg every morning
40 mg 3 times per day
50 mg at bedtime
100 mg 4 times per day
Answer: A
Rationale: Fluoxetine (Prozac) is usually initially ordered at 20 mg every morning and may be increased every 2 weeks with a maximum dose of 80 mg/day. The other answers do not fit these guidelines. 25
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26. Practice Question #2 A patient with major depression has been
prescribed fluoxetine (Prozac). What nursing diagnosis would be most appropriate?
A. Social isolation
B. Impaired physical mobility
C. Impaired urinary elimination
D. Disturbed sensory perception
Answer: A
Rationale: The most appropriate nursing diagnosis for the patient taking fluoxetine is social isolation. Impaired physical mobility, impaired urinary elimination, and disturbed sensory perception are not associated with fluoxetine. 26
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27. Practice Question #3
A patient with reactive depression is ordered to receive fluoxetine (Prozac). Which information will the nurse include when teaching this patient?
The medication takes effect in 1 week.
The medication increases libido.
The medication should be taken with grapefruit juice.
The medication may cause headaches and insomnia.
Answer: D
Rationale: Side effects include headache, nervousness, restlessness, insomnia, blurred vision, tremors, GI distress, and sexual dysfunction. The drug takes about 2 to 4 weeks for onset, decreases libido, and has no interaction with grapefruit juice. 27
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28. Practice Question #4
Before administering an MAO inhibitor, it is most important for the nurse to assess the patient’s
sexual history.
socioeconomic status.
dietary intake.
hydration status.
Answer: C
Rationale: Certain drug and food interactions with MAO inhibitors can be fatal. Foods that contain tyramine have sympathomimetic-like effects and can cause a hypertensive crisis. These types of food must be avoided by MAOI users. 28
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29. Practice Question #5
Which laboratory test is most important for the nurse to monitor when a patient is receiving lithium (Lithobid)?
A. Urinalysis
B. Serum glucose
C. Serum electrolytes
D. Complete blood count
Answer: C
Rationale: Serum sodium levels need to be monitored in patients taking lithium. Lithium tends to deplete sodium. Lithium must be used with caution, if at all, by patients taking diuretics. 29
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30. Practice Question #6
When providing dietary teaching for a patient taking monamine oxidase inhibitors (MAOIs), the nurse should teach the patient to avoid which food?
Yogurt
Avocado
Grapefruit
Potato chips
Answer: A
Rationale: When taking monamine oxidase inhibitors (MAOIs), patients should avoid cheese, red wine, beer, liver, bananas, yogurt, and sausage. 30
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31. Practice Question #7
Which advice will the nurse include when teaching the patient about lithium therapy?
Take the drug on an empty stomach.
Eliminate all sodium from your diet.
Stop taking the lithium when you feel better.
It may take 1 to 2 weeks before you have any benefits from taking the medication.
Answer: D
Rationale: The effectiveness of lithium may not be evident until 1 to 2 weeks after the start of therapy. The patient should be taught to maintain adequate sodium intake and to avoid crash diets that affect physical and mental health. Lithium levels are maintained by taking the drug on a daily basis. The patient should be taught to take lithium with meals to decrease gastric irritation. 31
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32. Practice Question #8
Which statement about amitriptyline (Elavil) does the nurse identify as being true?
A. The drug is administered first thing in the morning.
B. The drug should be discontinued slowly.
C. The onset of antidepressant effect is 48 hours.
D. Hypertension is a frequent side effect of this drug.
Answer: B
Rationale: When discontinuing TCAs such as amitriptyline (Elavil), the drug should be gradually decreased to avoid withdrawal symptoms such as nausea, vomiting, anxiety, and akathisia. TCAs are given at night to minimize problems caused by their sedative action. The onset of the antidepressant effect of amitriptyline is 1 to 4 weeks. Orthostatic hypotension is a common side effect of amitriptyline (Elavil). 32
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