Treatment of Somatic Symptom Illnesses PDF

11/16/23, 11:06 AM Realizeit for Student reatment For many clients, depression and anxiety may accompany or result from somatic symptom illnesses. Thus, antidepressants help in some cases (Strohle, Gensichen, & Domschke, 2018). Selective serotonin reuptake inhibitors such as fluoxetine (Prozac), s...

11/16/23, 11:06 AM Realizeit for Student reatment For many clients, depression and anxiety may accompany or result from somatic symptom illnesses. Thus, antidepressants help in some cases (Strohle, Gensichen, & Domschke, 2018). Selective serotonin reuptake inhibitors such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are most commonly used. Antidepressants Used to Treat Somatic Symptom Illnesses Drug Usual Dose (mg/day) Nursing Considerations Fluoxetine (Prozac) 20–60 Monitor for rash, hives, insomnia, headache, anxiety, drowsiness, nausea, loss of appetite; avoid Paroxetine (Paxil) 20–60 Monitor for nausea, loss of appetite, dizziness, dry mouth, somnolence or insomnia, sweating, se Sertraline (Zoloft) 50–200 Monitor for nausea, loss of appetite, diarrhea, headache, insomnia, sexual dysfunction; avoid alc For clients with pain disorder, referral to a chronic pain clinic may be useful. Clients learn methods of pain management, such as visual imaging and relaxation. Services such as physical therapy to maintain and build muscle tone help improve functional abilities. Providers should avoid prescribing and administering narcotic analgesics to these clients because of the risk for dependence or abuse. Clients can use nonsteroidal antiinflammatory agents to help reduce pain. Involvement in therapy groups is beneficial for some people with somatic symptom illnesses. Clients with somatic symptom disorder and anxiety illness disorder who participated in a structured cognitive–behavioral group showed evidence of improved physical and emotional health. The overall goals of the group were offering peer support, sharing methods of coping, and perceiving and expressing emotions. Clients with hypochondriasis who were willing to participate in cognitive–behavioral therapy and take medications were able to alter their erroneous perceptions of threat (of illness) and improve. Cognitive–behavioral therapy also produced significant improvement in clients with somatic symptom disorder (Hedman, Axelsson, Anderson, Lekander, & Ljotsson, 2016). Education or providing information has also been effective for clients with somatic illness or symptoms. Reading both internet-based educational material and books were other effective therapies (Hedman et al., 2016). In terms of prognosis, somatic symptom illnesses tend to be chronic or recurrent. With treatment, conversion disorder often remits in a few weeks but recurs in 25% of clients. Somatic symptom disorder, illness anxiety disorder, and pain disorder often last for many years, and clients report being in poor health. Selective Serotonin Reuptake Inhibitors SSRIs, of which fluoxetine (Prozac, Sarafem) is the prototype, produce fewer serious adverse effects than the TCAs. (SSRIs are called “selective” because they seem to primarily affect serotonin and not other neurotransmitters.) The drugs of first choice in the treatment of depression, SSRIs are effective and usually produce fewer and milder adverse effects than other antidepressants. There are no guidelines for choosing one SSRI over another. Pharmacokinetics Fluoxetine is well absorbed with oral administration, with a peak of action of 6 to 8 hours. The half-life of elimination for the parent drug is 2 to 3 days; this may lead to accumulation with chronic administration. (An active metabolite has a half-life of 7 to 9 days.) Thus, steady-state blood levels are achieved slowly, over several weeks, and drug effects decrease slowly (over 2 to 3 months) when fluoxetine is discontinued. The drug is present in breast milk. Metabolism takes place in the liver, and excretion predominately occurs in the kidneys. Action https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IfXgL26npJPT22aAWsq08u6Npe56xgiyh8MpUasnCQGXnd… 1/4 11/16/23, 11:06 AM Realizeit for Student Fluoxetine blocks the reabsorption of the neurotransmitter serotonin in the brain. This helps elevate the patient's mood. Fluoxetine has no effect on the norepinephrine or dopamine. Use Uses for fluoxetine include the treatment of depression and its associated anxiety, obsessive–compulsive disorder, bulimia nervosa, and premenstrual dysphoric disorder. Use in Children The FDA has issued a BLACK BOX WARNING ♦ alerting health care providers to the increased risk of suicidal ideation in children, adolescents, and young adults 18 to 24 years of age when taking antidepressant medications, including fluoxetine. Use in Older Adults Fluoxetine and other SSRIs are the drugs of choice in older adults because they produce fewer sedative, anticholinergic, cardiotoxic, and psychomotor adverse effects than the TCAs and related antidepressants. Elimination may be slower, and smaller or less frequent doses may be prudent in older adults. Weight loss is often associated with SSRIs and may be undesirable in older adults. Use of maintenance antidepressant therapy is beneficial to prevent recurrence of depression in older adults. Use in Patients With Hepatic Impairment Hepatic impairment leads to reduced first-pass metabolism of fluoxetine and most antidepressant drugs, resulting in higher plasma levels. Thus, caution is warranted in severe liver impairment. Use in Patients With Critical Illness Patients who are critically ill may need a drug to combat the depression that often develops with major illness. The decision to start fluoxetine should involve a thorough assessment of the patient’s condition, other drugs being given, and potential adverse drug effects. Antidepressants, including imipramine, warrant caution perioperatively because of the risk of serious adverse effects and adverse interactions with anesthetics and other commonly used drugs. Adverse Effects Adverse effects of fluoxetine include a high incidence of GI symptoms (e.g., nausea, diarrhea, and weight loss) and sexual dysfunction (e.g., delayed ejaculation in men, impaired orgasmic ability in women). Most SSRIs also cause some degree of CNS stimulation (e.g., anxiety, nervousness, insomnia), which is most prominent with fluoxetine. These drugs are also associated with increased risk of GI bleeding. For patients with diabetes mellitus, SSRIs may have a hypoglycemic effect. Serotonin syndrome, a serious and sometimes fatal reaction characterized by hypertensive crisis, hyperpyrexia, extreme agitation progressing to delirium and coma, muscle rigidity, and seizures, may occur due to combined therapy with an SSRI and an MAO inhibitor or another drug that potentiates serotonin neurotransmission. It is important not to take an SSRI or SNRI and an MAO inhibitor concurrently or within 2 weeks of each other. In most cases, if a patient taking an SSRI is transferred to an MAO inhibitor, it is necessary to discontinue the SSRI at least 14 days before starting the MAO inhibitor. However, the patient should discontinue fluoxetine at least 5 weeks before starting an MAO inhibitor due to the prolonged half-life. As previously discussed, antidepressant discontinuation syndrome can occur with sudden termination of the SSRIs. Withdrawal symptoms include dizziness, GI upset, lethargy or anxiety/hyperarousal, dysphoria, sleep problems, and headache, which can last from several days to several weeks. More serious symptoms may include aggression, hypomania, mood disturbances, and suicidal tendencies. Fluoxetine, with its long half-life, has not been associated with withdrawal symptoms. Contraindications Contraindications to fluoxetine include known sensitivity to the drug as well as the use of MAO inhibitors or thioridazine. QSEN Alert: Safety People of any age who have attempted suicide should not receive fluoxetine. Nursing Implications Preventing Interactions https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IfXgL26npJPT22aAWsq08u6Npe56xgiyh8MpUasnCQGXnd… 2/4 11/16/23, 11:06 AM Realizeit for Student Because fluoxetine and other SSRIs are highly bound to plasma proteins, they compete with endogenous compounds and other medications for binding sites, resulting in drug interactions. Several drugs increase the effects of fluoxetine. Also, CYP2D6 enzymes metabolize fluoxetine; therefore, the drug may cause accumulation of other drugs using this enzyme system (e.g., amitriptyline, imipramine, desipramine, thioridazine). QSEN Alert: Safety In addition, fluoxetine can prevent the conversion of codeine to its active form, resulting in lack of pain relief when the drugs are used concurrently. Administering the Medication People typically take SSRIs, including fluoxetine, once daily in the morning to prevent interference with sleep. They may take the drug with food to avoid GI upset. The nurse advises the patient to use sugar-free gum or hard candies to counteract dry mouth. Assessing for Therapeutic Effects The nurse assesses for statements of improved depression. He or she assesses improvement in appetite, physical activity, and interest in surroundings; improved sleep patterns; improved appearance; decreased anxiety; and reduced somatic complaints. The patient response to fluoxetine can significantly vary from patient to patient. The full response of the medication may not be seen for 8 to 12 weeks. Therapeutic serum levels of fluoxetine range from 100 to 800 ng/mL. Assessing for Adverse Effects The nurse assesses for dizziness, headache, nervousness, insomnia, nausea, diarrhea, dry mouth, sedation, skin rash, and sexual dysfunction. QSEN Alert: Safety It is essential to assess for suicidal thoughts or plans, especially at the beginning of therapy or when dosages are increased or decreased. Patient Teaching Patient Teaching Guidelines for Antidepressants General Considerations Take antidepressants as directed to maximize therapeutic benefits and minimize adverse effects. Do not alter doses when symptoms subside. Antidepressants are usually given for several months, perhaps years. Therapeutic effects (relief of symptoms) may not occur for 2 to 4 weeks after drug therapy is started. As a result, it is very important not to think the drug is ineffective and stop taking it prematurely. Continue to take the drug even if you feel better to prevent the return of depression. Do not take other prescription or over-the-counter drugs, including cold remedies, without consulting a health care provider. Potentially serious drug interactions may occur. Do not take the herbal supplement St. John’s wort while taking a prescription antidepressant. Serious interactions may occur. Inform any physician, surgeon, dentist, or nurse practitioner about the antidepressants being taken. Potentially serious adverse effects or drug interactions may occur if certain other drugs are prescribed. Avoid activities that require alertness and physical coordination (e.g., driving a car, operating other machinery) until reasonably sure the medication does not make you drowsy or impair your ability to perform the activities safely. Avoid alcohol and other CNS depressants (e.g., any drugs that cause drowsiness). Excessive drowsiness, dizziness, difficulty breathing, and low blood pressure may occur, with potentially serious consequences. Learn the name and type of the prescribed antidepressant to help avoid undesirable interactions with other drugs or a physician prescribing other drugs with similar effects. There are several different types of antidepressants, with different characteristics and precautions for safe and effective usage. Do not stop taking any antidepressant without discussing it with a health care provider. If a problem occurs, the type of drug, the dose, or other aspects may be changed to solve the problem and allow continued use of the medication. Counseling, support groups, relaxation techniques, and other nonpharmacologic treatments are recommended along with drug therapy. Notify your physician if you become pregnant or intend to become pregnant during therapy with antidepressants. Other Drugs in the Class Other SSRIs include citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), sertraline (Zoloft), and vilazodone (Viibryd, Viibryd Starter Pack). Sertraline and citalopram also have active metabolites, but paroxetine, like fluoxetine, is more likely to accumulate. Escitalopram, paroxetine, and sertraline reach steady-state concentrations in 1 to 2 weeks. People may take the drugs in the morning or evening (but at the same time each day). An evening dose may interfere with sleep. The SSRIs are strong inhibitors of the CYP enzyme system, which metabolizes many drugs. As a result, serum drug levels and risks of adverse effects are greatly increased. Most significantly, fluoxetine, paroxetine, and sertraline slow metabolism of bupropion, codeine, desipramine, dextromethorphan, flecainide, metoprolol, nortriptyline, phenothiazines, propranolol, risperidone, and timolol. Vilazodone can produce discontinuation syndrome; its abrupt discontinuation or https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IfXgL26npJPT22aAWsq08u6Npe56xgiyh8MpUasnCQGXnd… 3/4 11/16/23, 11:06 AM Realizeit for Student interruption will produce symptoms including nausea, vomiting, diarrhea, headache, lightheadedness, sweating, chills, tremors, paresthesias, somnolence, and sleep disturbances. Discontinuation of antidepressant treatment should last for >3 weeks. QSEN Alert: Safety With citalopram and escitalopram, poor metabolizers of CYP2C19 or concurrent use of moderate-to-strong CYP2C19 inhibitors (e.g., cimetidine, c receive half the maximum dose (20 mg) daily. Paroxetine, which has a half-life of approximately 24 hours and does not produce active metabolites, may be associated with antidepressant discontinuation syndrome even when discontinued gradually, over 7 to 10 days. Symptoms may include a flulike syndrome with nausea, vomiting, fatigue, muscle aches, dizziness, headache, and insomnia. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IfXgL26npJPT22aAWsq08u6Npe56xgiyh8MpUasnCQGXnd… 4/4