Antidepressants: SSRIs, SNRIs, and Atypical

• Antidepressants are a class of medications used to treat depression.

SSRIs: Serotonin Selective Reuptake Inhibitors

• The medications are the first line of treatment for depression
• They inhibit the reuptake of serotonin in the brain
• The effects of the medication take 1-3 weeks to appear
• There is a black box warning for increased suicidal ideation and behaviors in children, teens, and young adults
• Serotonin syndrome can occur 2-72 hours after starting treatment
• Monitor for changes in weight, dry mouth, GI upset, flu-like symptoms, dizziness, and headache

SNRIs: Serotonin (5HT) & Norepinephrine (NE) Reuptake Inhibitors

• These medications decrease the reuptake of norepinephrine and serotonin
• Side effects are similar to SSRIs, including elevated blood pressure, nausea and vomiting, dry mouth, constipation, dizziness, and suicidal ideation

Atypical Antidepressants

• They do not fit into other antidepressant categories and are considered second-generation antidepressants
• Used to treat depression, psychotic disorders, and anxiety disorders
• Medications affect serotonin and dopamine levels
• Side effects include weight gain, increased cholesterol, and diabetes (metabolic syndrome)

Tricyclics (TCAs)

• Block the presynaptic reuptake of 5HT and NE, increasing effects at the receptors
• Avoid use in patients with urinary retention or closed-angle glaucoma
• It takes 2-4 weeks for effects to appear
• Monitor for anticholinergic effects like dryness and constipation

MAOIs: Monoamine Oxidase Inhibitors

• Block MAOI enzymes, increasing norepinephrine, dopamine, 5HT, and tyramine levels
• These medications are not the first line of treatment and are very restrictive
• It takes 2-4 weeks for effect (can take up to 12 weeks)
• Nardil (phenelzine) and Parnate (tranylcypromine) are examples of MAOI medications

Foods Containing Tyramine (MAOIs)

• Foods containing tyramine MUST be avoided
• Fermented or pickled foods
• Cured meats (smoked and processed)
• Alcohol beverages (red wines and liqueurs)
• Aged cheeses (Swiss, parmesan, provolone, brie)
• Tofu, beans, pineapples, plums, raspberries, nuts, and raisins
• Sauerkraut
• Soy sauce
• MSG
• Moderate tyramine consumption should only be occasional
• Chocolate
• Yogurt and sour cream
• Avocados and bananas
• Gouda, processed American, and mozzarella cheeses
• White wine, coffee, colas, and hot chocolate
• Low tyramine consumption is permissible through
• Figs, pasteurized cheeses (cream cheese, cottage cheese, and ricotta)
• Distilled spirits

Pharm Cont. Anti-anxiety & Benzos

• Used to treat anxiety and anxiety-related depression
• These medications can come from various drug classes: benzos and barbiturates
• Monitor for CNS effects
• Side effects include hangover-type effects
• Used to treat anxiety, insomnia, delirium, seizures, tension, tremors, muscle spasms, and used to sedate
• Acts on the limbic, thalamic, and hypothalamic systems, causing relaxation effects
• It can cause drowsiness and sedation
• Avoid these medications during pregnancy
• HRF suicidal ideation is possible, particularly with a history of substance abuse

Anticonvulsants (AED) & Mood Stabilizer

• AEDs are used to treat withdrawal syndromes, anxiety disorders, dementia, bipolar disorder, and schizophrenia
• Medications affect mood
• Has CNS effects
• Medications affect GABA
• Valproic acid (Depakote) and carbamazepine (Tegretol) are examples of these medications

Lithium

• Lithium is a mood stabilizer, used to treat mania, bipolar disorder, major depression, schizoaffective disorder, schizophrenia, eating disorders, phobias, ADHD, and PTSD
• Exact action is unknown; is a salt, alters NA transport to muscle and nerve cells
• Narrow therapeutic window
• Maintain steady fluid and electrolyte balance (sodium and water)
• Medication is contraindicated in pregnancy

Antipsychotics/Neuroleptic Agents

• Block dopamine receptors
• Treat disorders of impaired thought processes
• Helps to organize thoughts
• Therapeutic effects appear after several weeks
• Crosses placenta and breast milk
• Divided into two categories: typical and atypical

Serotonin Syndrome

• A toxic state caused by an increase in brain serotonin activity

Symptoms of Serotonin Syndrome

• Neuromuscular symptoms include: restlessness, myoclonus (uncontrollable jerking movements), tremor and rigidity, hyperreflexia
• Other symptoms include: shivering/elevated temperature, arrhythmias, etc.
• Serotonin Syndrome can be fatal due to cardiac collapse
• Causes can include combined or consecutive treatment with SSRIs, tricyclics, MAOIs, tryptophan, etc.
• Stop drugs - usually resolves in no more than 24 hours, symptomatic measures (i.e., cooling, BDZs)
• Prevention can come from taking care when combining or switching serotonergic antidepressants

Neuroleptic Malignant Syndrome

• A potentially life-threatening reaction to antipsychotic drugs
• Cause: after taking drug for first time or abrupt discontinuation of antipsychotic medications

Presentation of Neuroleptic Malignant Syndrome

• Muscle rigidity, hyperthermia, vital sign instability (increased/decreased BP and tachycardia), diaphoresis, elevated creatine kinase
• Nursing interventions: immediately stop taking medication, monitor fluid and electrolytes, cooling methods (ice packs, cool blankets), administer fever reducer, place on cardiac monitoring, provider may order muscle relaxer