Antidepressants and Mood Stabilizers

Antidepressants and Mood Stabilizers

• Antidepressants help with symptoms of depression
• Antidepressants may precipitate a manic or psychotic episode in people with bipolar illness or schizophrenia
• Ketamine, a dissociative drug in anesthesia, treats resistant depression
• Abilify, an antipsychotic, may enhance antidepressant activity for resistant depression

Classifications of Antidepressants

• New generation antidepressants include: Selective Serotonin Reuptake Inhibitors (SSRIs), Selective Norepinephrine Serotonin Inhibitors (SNRIs), Serotonin Antagonist and Reuptake Inhibitors (SARIs), Norepinephrine Dopamine Reuptake Inhibitor (NDRI), and Noradrenergic and Specific Serotonergic (NASSA)
• Old generation antidepressants include Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs)

New Generation Antidepressants

• Common adverse side effects of newer generation antidepressants impact the CV, CNS, GI, and other systems
• Newer generation medications are safer from OD, have fewer adverse effects, are less sedating, and have no dietary restrictions compared to tricyclics and MAOIs
• SSRIs take 2-4 weeks to take effect, while tricyclics and MAOIs take 4-6 weeks
• Newer generation antidepressants are not addictive (craving)
• Take SSRIs in the morning if anxiety is a side effect
• Initial side effects may include headache, sweating, jitters, and nausea

Serotonin Syndrome

• Serotonin Syndrome symptoms include stiffness, diaphoresis, achiness, and emotional changes

SSRI Interactions and Discontinuation

• SSRIs interact with MAOIs, TCAs, St. John's Wort, Warfarin, Lithium, and NSAIDs
• Discontinuation syndrome is observed with SSRIs

New Generation Antidepressant Drugs

• Trazadone (desyrel) helps with sleep and is given only at night
• Duloxetine (cymbalta) helps treat physical pain

Tricyclic Antidepressants (TCAs)

• Adverse side effects of TCAs impact CV and CNS
• TCAs may cause anticholinergic effects: Cant pee, see, constipation
• Monitor for symptoms of TCA toxicity/overdose
• Amitriptyline (elavil) treats depression, chronic pain, and ulcerative colitis
• Imipramine (tofranil) treats depression and enuresis
• Doxepine (sinequan) causes sedation
• Amoxapine (ascendin) and Desipramine (norpramin) treat depression

MAOIs

• Identify the major action of the monoamine oxidase inhibitors (MAOI’s)
• Identify the indications for MAOis.
• Identify adverse side effects, food and drug interactions
• Identify foods to avoid while taking MAOI’s
• Identify drugs that interact with MAOIs
• Identify important patient teaching with use of MAOI’s.
• MAOI’s include: Phenelzine (nardil), Tranylcypromine (parnate), and EMSAM (selegiline transdermal system)

Mood Stabilizers: Lithium Carbonate

• Lithium's mechanism of action is believed to involve breaking down dopamine
• Lithium helps stabilize mood and slow people down in a manic phase, but it is not an antipsychotic
• Expected side effects are fine hand tremor, thirst, and increased urinary output
• Mild side effects are GI upset, coarse tremor, and ataxia
• The therapeutic range is 0.6-1.2
• Thiazide and loop diuretics should be avoided because they cause an abnormal level of Lithium
• Dehydration is a contraindication
• Weight gain is an expected side effect
• Maintain normal salt and fluid intake
• Take with food because it can cause nausea/vomiting
• This drug is not addictive

Anticonvulsants as Mood Stabilizers

• Anticonvulsants slow down electrical impulses in the brain and interact with sodium and calcium to control manic behavior
• Anticonvulsants are better than lithium because they do not have as narrow of a therapeutic range for toxicity
• Identify side effects of anticonvulsants
• Anticonvulsant drugs include: Carbamazepine (Tegretol), Valproic Acid (Depakote), Clonazepam (Klonopin), Gabitril (Tiagabine), Gabapentin (Neurontin), Lamotrigine (Lamictal), and Oxcarbazepine (Trileptal)

Multiple Choice Study Points

• Continue taking tricyclic antidepressants (TCAs) even when feeling better, without altering the dose or frequency
• It may take 4-6 weeks for TCAs to achieve therapeutic effects
• The most serious side effects of TCAs are dysrhythmias and tachycardia
• TCAs should be administered at bedtime to a depressed elderly client
• MAOIs exert their effect by inhibiting neurotransmitter breakdown
• Caution clients receiving MAOIs against ingesting wines and aged cheese
• The drug of choice for a client in the manic phase of bipolar disorder is Lithium (Eskalith)
• Common side effects of SSRIs include diarrhea, constipation, anxiety/agitation, insomnia, headache, sweating, and sexual dysfunction
• Withhold Lithium (Li) and promptly call the physician if a client on Lithium for 6 days feels drowsy, weak, shaky, and has diarrhea, with a Li level of 1.5 mEq/L
• A client may have a problem with their Lithium therapy if they "can't even walk a straight line today."
• Imipramine (Tofranil) may also be used to control bed wetting
• Ingesting foods with tyramine when taking MAOIs will cause a severe rise in BP
• The major controversy involving the safe use of SSRI's with adolescents and children is related to the increased potential for suicide
• MAOIs interact negatively with foods containing tyramine
• A patient on fluoxetine (Prozac), a SSRI, for 3 weeks may experience sleep disturbances and weight changes
• Abruptly stopping SSRIs has been associated with “discontinuation syndrome," causing weakness, nausea, headache, and anxiety
• Question continued use of bupropion (Wellbutrin) if a client is at risk for seizure due to a potential closed head injury
• A priority teaching point for a client newly prescribed lithium carbonate (lithium) is to ensure consistent salt intake
• Pressured speech four days after starting citalopram (Celexa) suggests it could be a manic episode caused by the citalopram
• Someone with undiagnosed bipolar disorder starting citalopram (Celexa) can trigger a manic episode
• A rare life-threatening event associated with SSRI's is serotonin syndrome

Antipsychotic Medications

• See page 4 for extrapyramidal side effects (EPS)

Classifications of Antipsychotics

• First-generation antipsychotics are typical, conventional, or traditional
• Second-generation antipsychotics are atypical
• Third-generation antipsychotics are atypical
• Second generation treat both negative and positive affects
• Third generation costs $$$ and can cause weight gain

Side Effects

• Common side effects include: hypotension, tachycardia, EKG changes (CV system), sedation, delirium in older adults, neuroleptic malignant syndrome (CNS), dry mouth, constipation, urinary retention, weight gain (GI), sexual dysfunction, urinary retention (GU)
• Hematologic/integumentary side effects may include leukopenia and photosensitivity
• Endocrine side effects include: Women stop getting periods, men develop breast tissue, diabetes

Matching - EPS

• Parkinsonism: Muscle rigidity, drooling, pill rolling, and tremors
• Akathisia: Uncontrolled restlessness, pacing
• Dystonia: Facial grimacing, torticollis
• Tardive dyskinesia: Rhythmic stereotyped motions of sucking, smacking lips, rocking, repetitive protrusion of tongue

Medications Used To Treat EPS

• Trihexyphenidyl (Artane)
• Diphenhydramine hydrochloride (Benadryl)
• Benztropine mesylate (Cogentin)

Medications Used To Treat Tardive Dyskinesia

• Deutetrabenazine (Austedo)
• Valbenazine (Ingrezza)
• These drugs reduce dopamine, serotonin, and norepinephrine in the brain to reduce abnormal movements

Serious Side Effects of Antipsychotics

• Anticholinergic toxicity
• Neuroleptic Syndrome
• Cardiovascular side effects: Hypotension, EKG changes
• Agranulocytosis: Increased risk for infection
• Metabolic syndrome: Gaining weight, more heart risks

Compare and Contrast

• First-generation antipsychotics target positive symptoms of schizophrenia
• Second- and third-generation antipsychotics target negative symptoms
• Advantages of the 2nd and 3rd antipsychotics include: Treat both positive and negative symptoms, help thinking, memory, decrease depression, and have fewer EPS and anticholinergic effects (but still some)
• Disadvantages of the 2nd and 3rd antipsychotics include: Expensive, weight gain, and metabolic syndrome
• Major patient teaching points: How to control side effects (dry mouth), ways to maintain weight, laying down and gradually getting up after taking it, and to promote compliance by teaching schizophrenia is a disease

First generation/TYPICAL Antipsychotics include:

• Haloperidol (Haldol)
• Trifluoperazine (Stelazine)
• Fluphenazine (Prolixin)
• Thiothixene (Navane)
• Perphenazine (Trilafon)
• Chlorpromazine (Thorazine)
• Thioridazine (Mellaril)
• Mesoridazine (Serentil)
• Second Generation and Third/ATYPICAL Antipsychotics:
• Clozapine (Clozaril)
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Paliperidone (Invega)

Multiple Choice Study Points

• Encourage clients to lie down for an hour after giving antipsychotic medications due to orthostatic hypotension
• Anticipate muscle stiffness and difficulty swallowing before administering Cogentin 2 mg IM to a client
• Antipsychotic medications control symptoms of psychosis
• Administer benztropine (Cogentin) PRN due to increased extrapyramidal symptoms for a client on fluphenazine (prolixin) who reports severe muscle spasms, with a P of 110, BP of 160.92, and temp of 101.5 F
• Antipsychotic drugs lower the seizure threshold
• Clients should stop taking pills and stand up because they are getting dizzy as this indicates a need for further teaching
• Major autonomic side effects of the antipsychotics include: dry mouth, postural hypotension, urinary retention
• Blockage of dopamine transmission can lead to increased pituitary secretion of prolactin, resulting in amenorrhea in women
• Agranulocytosis is the major side effect reported thus far from clozapine (Clozaril)
• Atypical antipsychotics are used more frequently today because: they have fewer extrapyramidal symptoms, and they target both the negative and the positive symptoms of schizophrenia
• A major disadvantage of the new atypical antipsychotics is that they cause weight gain, development of diabetes, development of tardive dyskinesia, hypercholesterolemia, and they are more expensive than the older antipsychotics
• Symptoms of neuroleptic malignant syndrome (NMS) include hyperthermia, Parkinsonian signs, and elevated CPK
• Haldol (haloperidol), Prolixin (Fluphenazine), Risperdal Consta, Paliperidone (Invega), Aripiprazole (abilify) are available in a long-acting injectable form, which increases medication compliance since the medication does not have to be taken every day
• Antipsychotic medications are used for sedation, sleep disturbances, control manic behavior, rapid calming, kids behavior control, organizing thoughts, and control severe nausea

Antianxiety Agents: Benzodiazepines

• Discussion includes the action of benzodiazepines, side effects of benzos, interaction of alcohol and benzos, and treatment and management of toxicity and overdose of benzos
• Examples of benzos: Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam (Valium), Lorazepam (Ativan), Oxazepam (serax), and Chlordiazepoxide (librium)

Antianxiety Agents: Antihistamines

• Antihistamines might be used to treat anxiety instead of the benzos
• Examples of antihistamines: Hydroxyzine hydrochloride (Atarax) and hydroxyzine pamoate (Vistaril)

Nonbenzodiazepine Antianxiety Agents

• Buspirone hydrochloride (BuSpar) is a nonbenzodiazepine antianxiety agent
• Buspirone hydrochloride (BuSpar) action and unique properties must be known
• Eszopiclone (Lunesta) is an effective nonbenzodiazepine hypnotic for short- and long-term insomnia

Other Agents Used To Treat Anxiety

• SSRI’s and SNRI’s
• Beta Blockers
• Tricyclic antidepressants

Antianxiety: Multiple Choice

• Long-term use of antianxiety agents results in tolerance
• Benzodiazepines are the most widely prescribed antianxiety drugs
• A drug that induces sleep is referred to as a hypnotic
• The correct nursing response to a client claiming clonazepam 3 mg qid stopped working is: "Do not quit taking this drug without the doctor's knowledge as you may experience withdrawal symptoms."
• Caution is necessary in prescribing a benzodiazepine if the client has a history of alcohol dependence
• In an overdose with a benzodiazepine, the patient is at most risk of respiratory depression
• Possesses an antipsychotic effect is not true of Diazepam (Valium)
• Recommend you call doctor to change drug order after first does of Lorazepam (Ativan)
• The use of benzodiazepines is associated with increases in depression, falls, and sedation with elderly clients
• Medications to treat panic symptoms can include SELECT ALL THAT APPLY: SSRI’s, Anticonvulsants, and tricyclic antidepressants

Antianxiety: Which statement indicates that teaching has been effective?

• Answer: The client states the clonazepam is to be used short-term until the buspirone takes full effect
• Benzodiazepines are appropriately prescribed for short-term treatment of generalized anxiety disorder, alcohol withdrawal, and preoperative sedation
• Symptoms seen when a client abruptly stops taking diazepam (Valium) include: Insomnia, tremor, and delirium

Miscellaneous Medications: ADHD

• CNS Stimulants to treat: Methylphenidate (Ritalin), Adderall, Pemoline (Cylert), Lisdexamfetamine dinesylate (Vyvanse)- ADHD control for up to 12 hours
• Nonstimulant medication for ADHD: Atomoxetine (Strattera) increases attention span in ADHD

Behavior Management

• Medication to manage anger in Children/Adolescents with Oppositional Defiant Disorder, Intermittent Explosive Disorder and Conduct Disorder with: Anticonvulsants, Lithium, SSRI’s, Antipsychotics, Adrenergic, Beta Blockers, and Stimulants

Alcohol and Drug Addictions

• Alcohol Withdrawal/Detoxification: Use Benzodiazepines and Barbiturates
• Diazepam (Valium), Lorazepam (Ativan), Chlordiazepoxide (Librium), and Phenobarbital Sodium
• Benzo Action must be known
• Barbiturate Action must be known
• Intended effects must be known
• Drug tapering process must be known
• Nursing considerations for Benzos and Barbiturates must be known
• Acamprosate (Campral)

Addiction meds Intended Effects:

• Acamprosate: Action unknown decreases hyperexcitability of GABA and glutamate that occurs during early abstinence from alcohol, Used for maintenance of abstinence in alcohol dependence, Decreases anxiety, dysphoria, restlessness, insomnia
• Naltrexone: Blocks opiate receptors, Decreases craving and pleasant effects of opioids and alcohol, Does not produce dependence, and is Used to maintain alcohol and opioid abstinence.
• Disulfiram: Inhibits impulsive drinking by using classical conditioning, Avoid unpleasant effects from the alcohol-Antabuse reaction.
• Opioids- Clonidine Intended Effects: Initially used as an antihypertensive agent, Suppesser of opioid withdrawal symptoms (ie autonomic hyperactivity).
• Clonidine is non-addicting
• Methadone: Synthetic opiate that blocks craving for Heroin, Highly addictive
• Buprenorphine: partial opioid agonist

Nicotine Addiction

• Name a medication that is used for Nicotine addiction
• Intended Effects of drug: must be known