Exam 15 - Drugs for Mental Health II

Tricyclic Antidepressants (TCAs)

• Older class of drugs used since the 1950s for depression.
• Mechanism of action unknown, but thought to interfere with norepinephrine and serotonin reuptake.
• Effective for mild to moderate depression, but more side effects than SSRIs or SNRIs.
• Primarily used in severe depression or unresponsive cases.
• Also used for migraine headaches, panic disorder, OCD, and peripheral neuropathy.

Side Effects and Adverse Reactions (TCAs)

• Common side effects: dry mouth, drowsiness, constipation, nausea, orthostatic hypotension.
• Weight gain or loss possible.
• Potential for mild to severe vision problems. Notify healthcare provider.
• Severe adverse reactions: cardiac dysrhythmias, heart failure, seizures, mania triggers in bipolar patients, delirium in older patients with cognitive impairment.
• Increased suicide risk in younger patients.
• Contraindicated in patients with glaucoma.

Drug Interactions (TCAs)

• Avoid with CNS depressants (opioids, sedatives, alcohol). These increase risk of respiratory depression, sedation, and hypotension.
• Interactions with antidysrhythmics can cause serious cardiac issues.
• Avoid with MAOIs, SSRIs, and SNRIs to prevent serotonin syndrome.
• St. John's wort (herbal) and marijuana are also dangerous to combine with TCAs.
• Tobacco reduces TCA effectiveness.

Nursing Implications and Patient Teaching (TCAs)

• Assess patient history, current drug use, and mental status, including suicide risk.
• Monitor vital signs and baseline weight.
• Note drug abuse history.
• Reassess symptoms to evaluate drug response (can take weeks).
• Educate patients on side effects (dry mouth, constipation, orthostatic hypotension), increased blood pressure reports.
• Taper TCAs when switching drugs to reduce withdrawal symptoms.
• Patient and family teaching: do not stop abruptly; avoid alcohol, sedatives, opioids; sugarless items for dry mouth; sun protection; slow position changes; bedtime dosing; report new/troublesome symptoms; wear medical alert bracelet.

Monoamine Oxidase Inhibitors (MAOIs)

• Block monoamine oxidase enzymes, increasing neurotransmitters (dopamine, norepinephrine, serotonin).
• Used as a last resort for severe depression that doesn't respond to other treatments.
• High-Risk Interaction: Hypertensive crisis triggered by foods containing tyramine (aged cheese, cured meats, wine, beer).

Side Effects and Adverse Reactions (MAOIs)

• Common side effects: constipation, headache, dizziness, drowsiness, dry mouth, orthostatic hypotension.
• Weight gain (in some).
• Severe adverse reactions: liver damage, blood disorders, suicidal thoughts, severe hyponatremia.
• Serotonin Syndrome Risk: Do not combine MAOIs with SSRIs within 2 weeks.

Drug Interactions (MAOIs)

• Hypertensive Crisis Risk: Avoid MAOIs with SSRIs, SNRIs, St. John's Wort, stimulants, drugs that lower blood pressure, CNS depressants (opioids, alcohol, benzodiazepines).
• Risk of hypoglycemia in patients taking insulin or oral hypoglycemics.
• Hypertensive crisis from high-tyramine foods.
• Caffeine and tyramine-rich foods should be avoided for 2 weeks after stopping MAOI.

Nursing Implications and Patient Teaching (MAOIs)

• Obtain detailed drug and diet history, including herbal drugs (St. John's wort).
• Monitor vital signs, weight, labs, and suicidal thoughts.
• Educate on dietary restrictions (avoid high-tyramine foods, caffeine, and alcohol).
• Educate on side effects (dry mouth). Monitor for hypotension.
• Teach about importance of monitoring blood sugar closely for patients on insulin or other antidiabetic drugs.
• Educate patients: take as prescribed, avoid alcohol and CNS depressants, avoid caffeine and high-tyramine food; slowly change positions; avoid driving, operating machinery; report symptoms (fever, severe headache, nausea, chest pain) immediately; wear medical ID

Mood Stabilizers (e.g., Lithium, Anticonvulsants)

• Primarily for bipolar disorder to manage mania and depression.
• Long-term treatment is common.

Lithium - Action and Uses

• Used primarily for bipolar illness (acute mania, maintenance).
• Thought to inhibit neurotransmitter synthesis, storage, release, and reuptake.
• Non-sedative effects.
• Onset of action is roughly 1 week, full benefit in 2-3 weeks.

Lithium - Therapeutic Range

• Very narrow therapeutic range.
• Careful monitoring of lithium blood levels (initial level ~3 days into therapy).
• Regular serum measurements are essential to avoid toxicity.
• Therapeutic level 0.8-1.2 mEq/L initially, then 0.8-1mEq/L for maintenance.
• Toxicity risks: older age, kidney disease, low sodium levels, dehydration, heart disease, or taking certain drugs (ACE inhibitors, diuretics, NSAIDs).

Lithium - Side Effects and Adverse Reactions

• Mild weight gain, thirst, urine output increase, dry skin, mild drowsiness.
• Hand tremors (often decrease with continued use).
• Initial nausea, vomiting, or diarrhea.
• Toxicity symptoms worsen with elevated lithium levels.

Lithium - Drug Interactions

• Interactions with diuretics, NSAIDs, antidepressants, and antipsychotics.

Nursing Implications and Patient Teaching (Lithium)

• Baseline labs (CBC, BUN/creatinine, electrolytes, thyroid function).
• Assess mental status (acute symptoms, hyperactivity, irritability), dietary history and sodium, fluid intake.
• Monitor for signs of toxicity (nausea, vomiting, drowsiness, tremors, incoordination).
• Report symptoms needing immediate intervention by RN or physician.
• Frequent lithium level monitoring. Desired level for acute mania is 0.8-1.2 mEq/L, while maintenance level is ~0.8 -1 mEq/L. Levels over 1.5 are toxic.
• Teach about avoiding significant changes in salt/fluid intake; reporting thirst / urination changes; avoiding alcohol/sedatives; seeking help for suicidal thoughts; wearing a medical alert bracelet/card; frequent blood level checks.

Antipsychotics (Typical & Atypical)

• Treat psychosis (loss of reality contact) in schizophrenia and other conditions.
• Atypical antipsychotics often better for long-term use due to lower risk of EPS.
• Typical antipsychotics primarily treat positive symptoms (hallucinations, delusions)

Typical Antipsychotics

• Block dopamine receptors, impacting positive symptoms.
• Cause extrapyramidal side effects (EPSs) - movement disorders.
• Includes phenothiazines and nonphenothiazines.
• Potential for neuroleptic malignant syndrome (NMS): High fever, confusion, blood pressure changes, severe EPSs

Atypical Antipsychotics

• Work via various mechanisms, often blocking both dopamine and serotonin receptors.
• Reduced risk of EPSs compared to typical.
• Often used alone for long-term.
• Risk of weight gain, hypertriglyceridemia, insulin resistance, and diabetes.
• Increased risk of cardiac dysrhythmias (prolonged QT interval), more frequent in clozapine (agranulocytosis - lower white blood cells)
• Drug interactions with other psych meds and alcohol.

Nursing Implications and Patient Teaching (Antipsychotics)

• Assess level of consciousness, agitation, hallucinations, and delusions (mental status exam, if applicable).
• Monitor vital signs closely (especially temperature).
• Recognize and report EPSs.
• Monitor for NMS (high fever, confusion, blood pressure change, EPSs).
• Closely monitor vital signs in patients with other health issues.
• Teach patients about side effects, medication adherence, avoiding alcohol/sedatives, and reporting symptoms.
• Encourage good oral hygiene.
• Teach about temperature changes ( avoid extremes, recognize dehydration as a concern).