Tricyclic antidepressants (TCAs) medications
Imipramine (Tofranil)
Amitriptyline (Elavil)
Selective serotonin reuptake inhibitor (SSRI) medications
Fluoxetine (Prozac)
Citalopram (Celexa)
Lexapro (Escitalopram)
Paroxetine (Paxil)
Sertraline (Zoloft)
Serotonin-norepinephrine reuptake inhibitors (SNRI) medications
Venlafaxine (Effexor)
Duloxetine (Cymbalta)
Desvenlafaxine (Pristiq)
Norepinephrine and dopamine reuptake inhibitor (NDRI) medications
Bupropion (Wellbutrin)
Alkali metal ion salt medication
Lithium carbonate (Eskalith, Lithobid)
Nonphenothiazine, dopamine antagonist medications
Haloperidol (Haldol)
Dopamine antagonist medications
Risperidone (Risperdal)
Quetiapine (Seroquel)
Dopamine system stabilizer mediations
Aripiprazole (Abilify)
Major depressive disorder (depression)
Sad or despondent mood out of proportion to actual life events
Depressed mood lasting for a minimum of 2 weeks that is present for most of the day, every day, or almost every day.
Focus on the levels and functions of neurotransmitters in the limbic system
Dysthymic disorder
Mild chronic depression that persists for at least 2 years
Bipolar disorder
Alternates between intense excitement and major depressive disorder
The pathophysiology is not completely understood but is likely a result from abnormal functioning of neurotransmitters in the brain. (glutamate or norepinephrine)
Possible triggers includ
Mania is characterized by...
Inflated self-esteem or grandiosity
Decreased need for food or sleep
Distractibility
Increased psychomotor or goal-directed activity
Excessive pursuit of pleasurable activities without considering consequences
Increased talkativeness
Delusions, paranoia,
Drugs for Bipolar Disorder
Mood stabilizers are used to treat bipolar due to their ability to moderate extreme shifts in emotion and relieve symptoms of mania and depression during acute episodes
Mild symptoms: low dose mood stabilizer
Severe symptoms: mood stabilizer and atypical
Manic and hypomanic episodes
Mania symptoms that last for at least 1 week and significantly impact social functioning. Hypomania is less intense lasting only 4 days.
Cyclothymic disorder
Mild form of bipolar disorder in which patient alternates between hypomania and mild depression
Antidepressants
Drugs that are used to enhance, elevate, or stabilize mood.
Two MOAs are: blocking the enzymatic breakdown of norepinephrine; slowing the reuptake of serotonin
Black Box Warning: can increase the risk of suicidal thinking and behavior in children, adolesc
Antidepressant Classes of Medications
Monoamine oxidase inhibitors (MAOIs)
Tricyclic Antidepresants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
Norepniephrine and Dopamine reuptake inhibitors (NDRIs)
MAOIs
Antidepressants that block the action of MAO
Serious adverse effects and low safety margin limit the use of MAOIs
Rarely used unless other antidepressants are unsuccessful
The most serious adverse reaction is the ability to cause a hypertensive crisis whe
TCAs Adverse Effects
Anticholinergic Effects
Orthostatic hypotension
Life-threatening dysrhythmias*
Sedation, confusion, dizziness
Seizures
Sexual dysfunction
Weight gain
Imipramine (Tofranil) Adverse Effects
Jaundice
Photosensitivity Ventricular arrhythmias with overdose
Amitriptyline (Elavil) Adverse Effects
Sedation (take at bedtime)
TCAs Nursing Considerations
Takes 2-6 weeks for full effect
Increased risk of suicide at start of therapy
TCAs Off-label uses
Nocturnal enuresis/Overactive bladder
ADHD, Insomnia, Bulimia
Social anxiety disorder
Hiccups
Neuropathic pain/fibromyalgia
TCAs Contraindications
Seizure disorder
Pregnancy
Cardiac disease/MI - monitor closely
Caution with urinary retention, prostatic hyperplasia, cardiac or hepatic disease, increased intraocular pressure, hyperthyroidism
TCAs Drug Interactions
Increased sedation with other CNS depressants
Thyroid hormone may induce dysrhythmias
Antidysrhythmics that prolong QT interval
Do not give with MAOIs
SSRIs will increase Imipramine toxicity
St. John's Wort - risk of serotonin syndrome
Interacts with herb
TCAs Overdose Treatment
Supportive treatment for seizures, hypotension, and dysrhythmias
Serotonin Syndrome (SES)
A serious medical condition that can occur when a patient is taking multiple medications that affect the metabolism, synthesis, or reuptake of serotonin causing this neurotransmitter to accumulate in the neurons of the CNS.
It can occur within 2 hours of
Treatment of Serotonin Syndrome
discontinuing the medication. Usually resolves in 24 hours. May require mechanical ventilation and muscle relaxants. Death may occur if left untreated
Symptoms of Serotonin Syndrome
mental status changes, HTN, tremors, sweating, hyperpyrexia, and ataxia
Drugs that cause Serotonin Syndrome
SSRIs, MAOIs, TCAs, Lithium, St. John's Wort, Opioids, Triptans
SSRIs Adverse Effects
Sexual dysfunction (70% of both men and women)
Weight gain
Nausea, headache, nervousness, and insomnia
Pediatric patients may experience personality disorder
SSRIs Nursing Considerations
Optimal effects 2-4 weeks; more quickly than TCAs
Most widely prescribed drug class in the United States
Drug of choice for depression - used for pediatrics and geriatrics
Taper off slowly: dizziness, HA, tremor, anxiety, dysphoria
SSRIs Off-label Uses
Anxiety disorders/OCD
Schizophrenia
Anorexia nervosa, obesity
Alcohol dependence
Fibromyalgia, autism
Refractory hypotension
Premature ejaculation/premenstrual dysphoric disorder
SSRIs Drug Interactions
TCAs, phenothiazine, MAOIs, St. John's Wort
Caution with antidysrhythmics and benzos
Excessive sedation may occur with other CNS depressants
Warfarin, ASA, NSAIS may increase bleeding risk
Grapefruit juice
SSRIs Contraindications
Concerns with bipolar disorder
Newborn may have withdrawal symptoms
Caution with cardiac dysfunction, diabetes, or seizure disorders
SSRIs Overdose Treatment
Gastric lavage or activated charcoal
Supportive treatment as necessary
Atypical Antidepressants
miscellaneous" class of medications. They are newer and act by mechanisms that do not fit in the category of SSRIs, TCAs, or MAOIs
They have little in common with each other
They act by preventing the reuptake of specific neurotransmitter in the CNS or b
Venlafaxine (Effexor) Indications
Major depression, panic disorder, general anxiety disorder, and social anxiety disorder
Off-label: neuropathy pain, OCD, fibromyalgia, menopausal hot flashes, migraines, premenstrual disorder
Venlafaxine (Effexor) Nursing Considerations
Do not stop abruptly: nervousness, HA, agitation, fatigue, drowsiness, sweating, tremor
Venlafaxine (Effexor) Adverse Effects
CNS stimulation, nervousness, and insomnia, but it can have a sedative effect on some patients
May cause a decrease of overall weight and height in pediatric patients
May cause a sustained increase in BP by 10-15 mmHg
Sexual dysfunction
Rare: rectal, vagi
Venlafaxine (Effexor) Contraindications
Patients taking SSRI or MAOI
Safety not established in children under 18
Duloxetine (Cymbalta) Indications
Used to treat major depression, neuropathic pain, fibromyalgia, and generalized anxiety disorder
Off-label indication:
Stress urinary incontinence
Duloxetine (Cymbalta) Adverse Effects
Abnormal vision (most common)
Photosensitivity
Bruising, thrombophlebitis
Thrombophlebitis
Insomnia, anorexia, anxiety
Duloxetine (Cymbalta) Contraindications
Use caution in patients with mania, seizures, HTN, hepatic disease, elderly, children, and lactating women
Duloxetine (Cymbalta) Nursing Considerations
Discontinuation of therapy should be tapered slowly
Patients generally feel effects in 2 weeks
Desvenlafaxine (Pristiq) Indications
Used to treat major depressive disorder
Desvenlafaxine (Pristiq) Adverse Effects
Nausea, dizziness, excessive sweating, somnolence, anxiety, male function disorders, and decreased appetite
Hypertension
Desvenlafaxine (Pristiq) Nursing Considerations
Discontinuation should be tapered slowly
HTN should be corrected before starting therapy
Bupropion (Wellbutrin) Indications
Used to treat major depression, seasonal affective disorder, management of nicotine withdrawal (Zyban)
Off-label indications: Neuropathic pain and ADHD
Bupropion (Wellbutrin) Adverse Effects
CNS stimulation
Weight loss
HA, dry mouth, constipation, GI upset
Seizures have been reported in infants receiving breastmilk from mothers taking bupropion
Does not cause weight gain or sexual dysfunction
Bupropion (Wellbutrin) Nursing Considerations
High risk of medication error due to the medication dosing in immediate release, extended release (XL), and sustained release (SR).
Lithium carbonate (Eskalith) Indications
Management of bipolar disorder
Off-label indications:
Alcoholism, bulimia, neutropenia, schizophrenia, prevention of vascular headaches, and hyperthyroidism
Lithium carbonate (Eskalith) Nursing Considerations
Onset of action may take 1-3 weeks
Short half-life and must be taken several times per day
Lithium carbonate (Eskalith) Adverse Effects
Initial: muscle weakness, n/v, lethargy, polyuria, nocturia, headache, dizziness, drowsiness, tremors and confusion
Long term: Can produce toxicity including kidney impairment, dysrhythmias, circulatory collapse, and leukocytosis. Can cause hypothyroidism
Lithium carbonate (Eskalith) Contraindications
Serious cardiovascular or renal impairment
Severe dehydrations or sodium depletion
Should not be used in pregnancy
Lithium carbonate (Eskalith) Black Box Warning
Toxicity from lithium is closely related to serum concentrations and may occur at doses close to therapeutic levels. Serum levels should be monitored regularly during therapy and maintained within the narrow range
Lithium carbonate (Eskalith) Drug Interactions
Diuretics increase the risk of lithium toxicity
NSAIDS and thiazides increase lithium reabsorption
Concurrent use with haloperidol may increase neurotoxicity
SSRIs, MAOIs and dextromethorphan may cause SES
Lithium carbonate (Eskalith) Overdose Treatment
Supportive treatment
Maintaining airway
Possible dialysis
Pyschoses
are severe mental disorders characterized by the inability to recognize reality
Can be caused by: brain tumors, overdose on certain medications, extreme depression, electrolyte disorders, chronic alcoholism, or psychoactive drugs. The majority have no ide
Delusions
are firm ideas and beliefs that are false and not founded in reality
Hallucinations
involve seeing, hearing, or feeling something that is not really there
Lack of insight and judgement
Patients are unaware of their bizarre behavior and truly believe that the voice they hear and delusions are real
Mood and affect
During psychotic episodes, the patient's mood and affect may vary widely and be inappropriate
Schizophrenia
The etiology of schizophrenia is unknown but it is known that there is a genetic component to developing schizophrenia
Currently it is suggested the schizophrenia is caused by overactive dopaminergic pathways in the basal nuclei of the brain
Antipsychotic
Positive Symptoms
Associated with an excess or distortion of normal function
Easily recognized and respond more favorably to pharmacotherapy with antipsychotic drugs
Hallucinations
Delusions
Paranoia
Agitation, anxiety
Disorganized thoughts and speech
Aggressiveness, comba
Negative Symptoms
Associated with a loss of normal functioning
Characteristic of the indifferent personality exhibited by many patients with schizophrenia. May be mistaken for depression or even laziness
Apathy
Withdrawal from other persons and the social environment
Lack
Cognitive Symptoms
A new category of symptoms: Retrospective evidence shows that cognitive symptoms are often the first signs of schizophrenia
Deficits in long-term memory
Inability to focus attention
Diminished "working memory": an inability to remember recently learned in
Classification of Antipsychotics
First generation (conventional)- older drugs (originated in the 1950's) with severe adverse effects
Phenothiazine
Non Phenothiazine
Second generation (atypical)-newer drugs (1970's and 80's) with fewer side effects, better patient adherence, more effectiv
Antipsychotic Drug Adverse Effects
Neuroleptic malignant syndrome (NMS): High fever, diaphoresis, muscle rigidity, tachycardia, and blood pressure fluctuations. Potentially fatal if medication not discontinued
Extrapyramidal symptoms (EPS): serious adverse effects to antipsychotic drugs
Ac
Haloperidol (Haldol) Indications
Treats acute and chronic psychotic disorders
Off-label indications:
Tourette's syndromes, persistent hiccups, autism, children with severe behavioral problems and for emergency sedations of agitated or delirious (given IV) patients, nausea for chemotherap
Haloperidol (Haldol) Adverse Effects
Anticholinergic
Weight gain
Anemia
Blurred vision, glaucoma
EPS, NMS, drowsiness
Can increase the QT interval causing possible dysrhythmia
Haloperidol (Haldol) Contraindications
Parkinson's disease, seizure disorders, coma, alcoholism, severe mental depressions, CNS depression, lactation
Haloperidol (Haldol) Black Box Warning
Not indicated for the treatment of dementia-related psychosis
Haloperidol (Haldol) Drug Interactions
CNS depression can occur with other CNS depressants
Do not give with lithium - potential for irreversible brain damage
Haloperidol (Haldol) Overdose Treatment
Supportive treatment for sedation, respiratory depression, coma, hypotension, and severe EPS
Risperidone (Risperdal) Indications
Approved to treat negative psychotic symptoms in a person with schizophrenia
Acute mania associated with bipolar
Irritability in pediatric autism patients
Off-label indications:
Tourette's syndrome, attention deficit/hyperactivity disorder, severely disru
Risperidone (Risperdal) Adverse Effects
Similar side effects to other atypical antipsychotics
(n/v, drowsiness, constipation)
Elevated prolactin levels resulting in galactorrhea, impotence, gynecomastia (check prolactin levels), and menstrual irregularities
Hyperglycemia
Orthostatic hypotension
Risperidone (Risperdal) Contraindications
Caution should be used with CNS depression, seizures, dysrhythmias, hypotension, DKA, and suicidal ideation
Lactation
Risperidone (Risperdal) Drug Interactions
SSRIs may increase the levels of risperidone
CNS depression may occur with other CNS depressants
Antihypertensive may potentiate hypotension
Risperidone (Risperdal) Overdose Treatment
Supportive treatment, gastric lavage, and cardiovascular function maintenance
Quetiapine (Seroquel) Indications
Used to treat positive and negative symptoms of schizophrenia Short-term therapy of acute mania with bipolar disorder
Depression associated with bipolar disorder
Quetiapine (Seroquel) Adverse Effects
Low incidence of EPS
Baseline and 6 month eye check ups must be completed due to possible lens changes
Aripiprazole (Abilify) Indications
Controls the positive and negative symptoms of schizophrenia Mania associated with bipolar
Add-on drug for major depressive disorder
Irritability with autism spectrum disorder
Aripiprazole (Abilify) Adverse Effects
Little or no weight gain, hypotension, dysrhythmias, anticholinergic effects, or prolactin release, drowsiness, EPS, NMS, Akathisia, Seizures, Tachycardia
Aripiprazole (Abilify) Contraindications
Lactation
Seizure disorders
Aripiprazole (Abilify) Drug Interactions
Drugs that are metabolized by the liver
SSRIs
Antipsychotics and lithium increase risk for EPS
No grapefruit juice
Aripiprazole (Abilify) Black Box Warning
Not indicated for the treatment of dementia-related psychosis. Older adults treated with atypical antipsychotics are at increased risk for death. Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adult