Psychotherapeutic Drugs PHAR1059 2024-2025 PDF

Psychotherapeutic Drugs PHAR1059 – 2024-2025 Psychotherapeutic Drugs  Terminology and General Concepts  Drug Classes 1. Antipsychotics (Neuroleptics) 2. Anxiolytics 3. Mood Stabilizers 4. Antidepressants 5. Other Mental Health Drug Principles  Often called psychotherapeutics...

Psychotherapeutic Drugs PHAR1059 – 2024-2025 Psychotherapeutic Drugs  Terminology and General Concepts  Drug Classes 1. Antipsychotics (Neuroleptics) 2. Anxiolytics 3. Mood Stabilizers 4. Antidepressants 5. Other Mental Health Drug Principles  Often called psychotherapeutics …Therefore, many drugs used to treat  Drugs that are “psychotropic” are mental health conditions attempt to capable of altering mental and correct this imbalance by blocking or emotional processes stimulating neurotransmitter release  Current theories in mental health  Need to be combined with suggest neurotransmitter nonpharmacological treatments (i.e. imbalances are a key factor in many counselling) disorders and are diagnosed according to DSM-V criteria  Goal- improve quality of life, ability to carry out ADLs, social and occupational functioning Mental Health Drug Principles  Some drugs may initially be approved to treat one condition but then be approved or expanded for treatment of other conditions  Response to medication varies considerably between patients  Children and elderly more sensitive to drug and greater risk of adverse effects  May require “trial and error” to find a drug that works for an individual  Stigma and fear of adverse effects is still a challenge in getting individuals to accept treatment and adhere to treatment Antipsychotic Drugs (Neuroleptics) Antipsychotic Drugs (Neuroleptics) 2 Generations Indication for Use  Psychoses associated with schizophrenia (Positive symptoms)  Does not cure psychoses but rather controls symptoms of illness  Also used for extreme mania, bipolar disorder, autism and other medical conditions Therapeutic Effects  Effect on stabilizing mood  Positive effect on reducing symptoms of schizophrenia  Visual hallucinations  Auditory hallucinations  Delusions  Disorganized behavior Antipsychotic Drugs (Neuroleptics) 2 Generations 1st Generation (Conventional Antipsychotics)  Phenothiazines  Thioxanthenes  Phenylbutylpiperidines 2nd Generation (Atypical Antipsychotics = newer)  Dibenzodiazepines  Benzisoxazoles Antipsychotic Drugs (Neuroleptics) 1st Generation 2nd Generation Phenothiazines Dibenzodiazepenes 1. Chlorpromazine 1. Clozapine (Clozaril®) 2. Prochlorperazine 2. Loxapine (Xylane, Loxapac®) 3. Fluphenazine 3. Olanzapine (Zyprexa®) 4. Quetiapine (Seroquel®) Thioxanthene Benzisoxazoles 1. Thiothixene (Navane®) Risperidone (Risperdal®) Phenylbutylpiperidines Quinolinone 1. Haloperidol (Haldol®) Aripiprazole (Abilify®) 2. Pimozide (Orap®) Antipsychotic Drugs – GEN 1 Mechanism of Action Few differences among conventional, or first-generation, antipsychotics in their mechanisms of action  Block dopamine receptors in the brain and decreases overall dopamine concentration in the limbic system and basal ganglia  Blocks dopamine receptors in chemoreceptors that are responsible for BP = hypotension  Inhibits vagus nerve in GIT – antiemetic effect  Depresses brainstem = anti-anxiety effect Antipsychotic Drugs – GEN 1 Phenothiazines  Largest group of psychotropic agents  Have the lowest potency  Look for “azine” in the Generic name 1. Chlorpromazine hydrochloride 2. Fluphenazine 3. Perphenazine 4. Prochlorperazine 5. Trifluoperazine hydrochloride Thioxanthenes Thiothixene (Navane®)  Same MEC as Phenothiazines but with less hypotension and sedative effects  Still has same degree of EPS Antipsychotic Drugs – GEN 1 Phenylbutylpiperidines 1. Haloperidol (Haldol®)  Structurally different than thioxanthenes and the phenothiazines but has similar antipsychotic properties  Secondary use in management of nausea in palliative patients  Strongly associated with EPS 2. Pimozide (Orap®)  Recall we have seen this drug as a contraindication in Sem 2 (cardiac meds) and in antibiotics  Contraindicated with antibiotics that effect QT interval (Clarithromycin and erythromycin) Antipsychotic Drugs – GEN 1 Administration Considerations  Physically Addictive  Withdraw of drug must be tapered and gradual  No cold turkey  Not Psychologically Addictive  Not controlled substances  Use has shifted now primarily for sedation and antiemetic  Risk of EPS is too high and potency too low to justify use in long term antipsychotic therapy Antipsychotic Drugs – GEN 2 2nd Generation Agents have essentially replaced all 1st Generation  More potent in treating the psychosis symptoms  Significantly less EPS Mechanism of Action  Block Serotonin as well as Dopamine receptors  Block dopamine 2 receptors (D2) and specific serotonin receptors called 2(5-HT2) receptors (greater effect on positive and negative symptoms)  This has a tranquilizing effect Antipsychotic Drugs – GEN 2 Dibenzodiazepines  Clozapine (Clozaril®)  Works on dopamine receptors in limbic system  Binds also to Serotonin and histamine receptors  Can cause Agranulocytosis during long term treatment  Primarily used as an adjunct with another drug to increase effects  Olanzapine (Zyprexa®) & Quetiapine (Seroquel®)  Blocks Dopamine and Serotonin receptors  Equal or more effective that other drugs  Least side effects of all drugs and more effective Antipsychotic Drugs – GEN 2 Benzisoxazoles & Quinolinone  Both Risperidone (Risperdal®) and Aripiprazole (Abilify®) work on the levels of Dopamine and Serotonin. Aripiprazole  Used to treat schizophrenia, manic-depressive illness (bipolar I disorder), and major depressive disorder. Risperidone  Used to treat of schizophrenia and irritability associated with autistic disorder  Has a higher risk of EPS than Aripiprazole (is still less than Haldol) Antipsychotic Drugs – CNS ADVERSE EVENTS Extrapyramidal Symptoms (EPS)  Involuntary motor symptoms similar to those associated with Parkinson’s disease.  Characterized by one or more of the following symptoms 1. Akathisia (distressing motor restlessness) 2. Tardive Dyskinesia (characterized by uncontrollable facial movements such as sucking, chewing, lip-smacking, sticking the tongue out, or blinking repeatedly) 3. Acute dystonia (painful muscle spasms)  Severe case is called an Acute Dystonic Reaction and is a MEDICAL EMERGENCY  Involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures  Contraction of larynx and bronchospasms can lead to asphyxiation Antipsychotic Drugs – CNS ADVERSE EVENTS Neuroleptic Malignant Syndrome  Relatively rare but potentially life-threatening adverse effect  May occur with medications that reduce Dopamine activity within the first 2 weeks of treatment  Key symptoms that present with NMS 1. Muscle rigidity 2. Altered thermoregulation (high fever) 3. Vital sign instability 4. Autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmias) Can also have the following additional symptoms  Elevated creatine phosphokinase  Myoglobinuria (rhabdomyolysis)  Acute kidney damage Antipsychotic Drugs – CNS ADVERSE EVENTS Treatment for EPS and NMS EPS  Discontinue medication  In emergency administer anticholinergic medication  Diphenhydramine (Benadryl®)  Benztropine (Cogentin®) NMS  Treatment involves prompt withdrawal of the causative medication  Supportive treatment for symptoms  Dopamine replacing agent (amantadine, bromocriptine) Antipsychotic Drugs – Adverse Effects CVS Skin  Low WBC (agranulocytosis)  Exfoliative dermatitis  Anemia (clozapine)  Hyperlipidemia GI/GU  Orthostatic hypotension  Constipation  ECG changes (QT)  Urinary retention  Sexual dysfunction  Endocrine  Gynecomastia  Insulin resistance  Weight gain https://www.semanticscholar.org/paper/Royal-Australian-and-New-Zealand-College-of-for-the-Galletly-Castle/c7c1871766b09f27b16b285cdb33925f26ea070d Antipsychotic Drugs – Contraindications Contraindications  Comatose state  Significant CNS depression  Brain damage  Uncontrolled epilepsy  Liver or kidney disease  Certain blood conditions Antipsychotic Drugs – Interactions & Caution Cautions  Atypical antipsychotics are used for severe agitation and psychosis in dementia that is unresponsive to non-pharmacological interventions  There is an association with increased risk of death and stroke when used to treat BPSD (Behavioral and Psychological Symptoms of Dementia)  Benefits typically outweigh risks Interactions  Additive CNS depressant effects and hypotension when taken with other CNS depressants or antihypertensive meds  Grapefruit juice increases levels - risk of toxicity https://www.camh.ca/en/professionals/treating-conditions-and-disorders/dementia/dementia---treatment/dementia---medications- for-treating-behavioural-and-psychological-symptoms Antipsychotic Drugs – Nursing  Develop trust  Takes several weeks for antipsychotic effects to work but has immediate effects on mood… monitor for effectiveness  Monitor blood levels  Awareness of potential adverse effects and support patient in management  Weight gain  Orthostatic hypotension etc.  Report abnormal movements to HCP  Mouth care, sugar-free candies, increased fluids  Avoid extreme heat  Use sunscreen (phenothiazines) Anxiolytic Drugs (Anti-Anxiety) Anxiolytic Drugs Only 2 types that are currently accepted for use 1. Benzodiazepines 2. Buspirone Hydrochloride Benzodiazepines Mechanism of Action  Increases the action of GABA to reduce overactivity in the CNS by depressing brainstem and limbic system activity 1. Diazepam (Valium®) 2. Lorazepam (Ativan®) 3. Clonazepam (Klonopin®) 4. Alprazolam (Xanax®) 5. Oxazepam (Serax®) Anxiolytic Drugs Benzodiazepines  Comes in various forms - Short, intermediate and long-acting  Onset is rapid quick action  Only indicated for short term use, not continuous long-term therapy (PRN)  Intermittent PRN use does not lead to tolerance or addiction  This medication is for symptom management, does not prevent anxiety from occurring  Not effective in pts with coexisting anxiety and depression  Does not affect REM sleep  Has very few drug interactions  High risk of dependence and misuse Anxiolytic Drugs Benzodiazepines Other Indications  Insomnia  Seizures  muscle spasm  Pre-op sedation Adverse effects  CNS depression  Hypotension  Paradoxical reactions  Dependence and addiction Anxiolytic Drugs Benzodiazepines Contraindications  Pregnancy  Narrow angle glaucoma Caution  Use cautiously in the elderly  Liver Disease  Renal Disease Anxiolytic Drugs – Benzo Overdose  Typically, not life-threatening unless combined with alcohol or other CNS depressants Manifestations  Excessive sedation  Hypotension  Seizures  Respiratory depression Treatment of overdose  Supportive care  No specific antidote  Cholinergic in extreme cases for adverse effects  Gastric lavage of 50-100 g activated charcoal  Flumazenil = benzodiazepine receptor blocker may be used Anxiolytic Drugs Buspirone Hydrochloride Mechanism of Action  Unknown mechanism  Thought to have agonist activity of serotonin and dopamine receptors Administration  Administered on a schedule or PRN  Not as sedating or dependence forming as Benzodiazepines Adverse effects  Paradoxical anxiety  Dizziness  blurred vision  Headache  Nausea Anxiolytic Drugs - Nursing Buspirone Hydrochloride…cont  MAOIs should be discontinued 2 weeks prior due to hypertension Nursing Considerations for Anxiolytic Drugs  Teach anxiety reduction strategies  Monitor for appropriate use, signs of dependence  Monitor for signs of overdose and intervene  Increased risk of respiratory depression if given IV  Maintain safety- increased risk of falls in elderly, avoid driving, no alcohol  Use lower doses in elderly Mood Stabilizer Drugs (Lithium) Lithium (lithium carbonate, lithium citrate) Indications for use  Used to treat bipolar disorder (mania, hypomanic, depressive episodes)  Used for acute episodes or maintenance treatment Mechanism of Action  Not well understood  Causes a shift in sodium ion (cation) transport in nerve cells  May enhance GABA action  Inhibits excitatory neurotransmitters (serotonin, dopamine & norepinephrine) by increasing destruction, inhibiting release, and decreasing receptor sensitivity Lithium (lithium carbonate, lithium citrate) Administration Considerations  Taken PO  May be used in combination with other drugs such as benzodiazepines, antiepileptics, antipsychotics, dopamine receptor agonists  Clinical response seen in 1-3 weeks  Quickly absorbed in GI tract- action peaks in 30min-3hrs  Slowly crosses blood brain barrier  Narrow therapeutic range - Highly toxic  Does not metabolize in liver or kidneys; excreted unchanged by kidneys  Keeping serum sodium levels normal helps maintain therapeutic effects  Requires blood monitoring Lithium (lithium carbonate, lithium citrate) Drug interactions  Toxicity increased by 1. Thiazide diuretics 2. ACE inhibitors 3. NSAIDS Contraindications  Dehydration  Sodium imbalances  Kidney disease  Cardiac disease  Pregnancy  Under age 6 Lithium (lithium carbonate, lithium citrate) Serum Level Treatment & Adverse Effects/Events (mEq/L) 0.6-1.2 Maintenance range Acceptable adverse 1.0-1.5 Treatment of acute manic episode effects 1.5-2.5 Nausea, vomiting, lethargy, tremor, and fatigue Mild Intoxication Confusion, agitation, delirium, tachycardia, and 2.5-3.5 Moderate Intoxication hypertonia >3.5 Coma, seizures, hyperthermia, and hypotension Severe Intoxication https://www.ncbi.nlm.nih.gov/books/NBK499992/ Lithium (lithium carbonate, lithium citrate) Adverse Effects  Hypothyroidism is associated with long-term use  Decreased bone density has been observed in children Adjunct Therapy  Lithium may be used in combination with the following drugs/classes for acute and long-term management  These drugs can be used alone for mild cases of mania or in combination with Lithium 1. Valproic acid 2. Lamotrigine 3. Topiramate 4. Oxcarbazepine Lithium (lithium carbonate, lithium citrate) Nursing Considerations  Drug must be administered on time  Monitor electrolyte levels (sodium), drug levels, thyroid  Frequency of drug levels is client dependent  What action if drug levels are >1.5 mEq/L?  Ensure adequate fluid intake and maintain diet  Educate client about S&S of toxicity  Poor coordination  Tremors  Weakness Antidepressant Drugs Antidepressant Drugs GENERAL CONCEPTS FOR ALL ANTIDEPRESSANT DRUGS  There are 2 Generations of Antidepressant Drugs  These drugs are generally used for major depression that accompany several mental health disorders  Anxiety  Dysthymia  Schizophrenia (as an adjunct)  Eating disorders  Personality disorders  Also used for non-mental health medical conditions  Migraine  chronic pain  sleep disorders etc. https://www.camh.ca/en/professionals/treating-conditions-and-disorders/depression/depression---treatment/depression---psychopharmacology Antidepressant Drugs BLACK BOX WARNING FOR ALL ANTIDEPRESSANT DRUGS  Antidepressants have been associated with a small increased risk of suicidal thoughts, particularly in adolescents and young adults  Risk decreases in older age groups  The risk of suicide is highest at the onset of treatment, when neurovegetative symptoms subside without the accompanying improvement in mood.  Close monitoring is essential during the first few weeks of treatment.  Given the consistent link between depression and suicidality, clinicians should screen for and treat depression attentively. https://www.camh.ca/en/professionals/treating-conditions-and-disorders/depression/depression---treatment/depression---psychopharmacology Antidepressant Drugs First Generation Second Generation 1. Tricyclic antidepressants 1. Serotonin Reuptake Inhibitors 2. MAOI (Monoamine oxidase (SSRIs) inhibitors) 2. Serotonin-norepinephrine reuptake inhibitors (SNRIs) 3. Tetracyclic antidepressants 3. Miscellaneous antidepressants Antidepressant Drugs First Generation 1. Tricyclic antidepressants 2. MAOI (Monoamine oxidase inhibitors) 3. Tetracyclic antidepressants PHAR1059 2023 Antidepressant Drugs - Tricyclic Tricyclic Antidepressants  Named for the three rings found in their chemical structure  Amitriptyline (Elavil®)  Nortriptyline (Aventyl®)  Clomipramine (Anafranil®) Mechanism of Action  Monoamine oxidases (MAO) metabolizes NE and serotonin  Correct imbalance of serotonin and norepinephrine by blocking reuptake, making more available for neurotransmission  Also thought to regulate malfunctioning neurons 45 PHAR1059 2023 Antidepressant Drugs - Tricyclic Tricyclic Antidepressants Indications for Use  Less common for depression - replaced by SSRIs and SNRIs  Neuropathic pain  Insomnia  OCD (clomipramine)  Sometimes for anorexia nervosa Administration Considerations  Rapidly absorbed in GI tract and evenly distributed bound to plasma albumin  Onset is 3-6weeks, usually begin with a low dose and work as tolerated and effective 46 PHAR1059 2023 Antidepressant Drugs - Tricyclic Tricyclic Antidepressants Contraindications  MAOI use in past 2 weeks  Cardiac disease  Seizures  Pregnancy Drug Interactions (Many)  Other antidepressants  Sympathomimetics (additive effects- dysrhythmias)  Anticholinergic (additive effects) 47 PHAR1059 2023 Antidepressant Drugs - Tricyclic Adverse Effects GI/GU CNS  Constipation  Blurred vision  Urinary retention  Sedation  Dry mouth  Dizziness  Weight gain  Confusion  Impotence  Headache CVS  Orthostatic hypotension  Cardiac dysrhythmias 48 Antidepressant Drugs - Tricyclic Tricyclic Overdose  Tend to be lethal  Primarily affects CV and CNS systems  Death due to cardiac dysrhythmias and seizures Treatment  No antidote  Activated charcoal to reduce absorption  Speed up elimination by alkylating urine using sodium bicarbonate  Treat seizures (diazepam)  Treat dysrhythmias (antidysrhythmic)  May require life support until drug is eliminated Antidepressant Drugs - MOAIs Monoamine oxidase inhibitors (MAOIs)  Second or third-line antidepressant for treatment of depression that does not respond to other safer drugs.  Used in Parkinson’s disease (Selegiline)  Rarely used because they require a specific diet to prevent toxicity Diet must be free of tyramine.  Phenelzine Sulfate (Nardil®)  Tranylcypromine sulfate (Parnate®)  Selegiline (Anipryl®, Eldepryl®, l-deprenyl, Selgian®, Zelapar®) Antidepressant Drugs - MOAIs Mechanism of Action  Irreversibly inhibit the activity of MAO to carry out metabolism  Stops the metabolism of the following  Epinephrine  Dopamine  Norepinephrine  Serotonin  Tyramine  Accumulation of serotonin, norepinephrine and dopamine occurs in synaptic clefts and neuronal stage vesicles  Causes increased stimulation of the postsynaptic receptors and relief of depression Antidepressant Drugs - MOAIs Adverse Effects CVS  Severe hypertension (can escalate to adverse event = fatal)  Orthostatic Hypotension (Syncope) CNS  Dizziness  Mania  Blurred vision  Sleep Disturbance  Dyskinesias GI  Liver toxicity  Nausea Antidepressant Drugs - MOAIs ADVERSE EVENTS Hypertensive Crisis  Occurs from consuming tyramine containing foods with MAOIs  Tyramine is an amino acid that helps regulate BP  MAOIs block the metabolism of tyramine and excess accumulates  Excess tyramine triggers catecholamine release  Increases risk of hemorrhage, stroke, coma, death  Treat with antihypertensive medications Serotonin Syndrome  Rare but potentially life-threatening drug reaction  Triad of autonomic dysfunction, neuromuscular excitation, and altered mental status  Excess amount of Serotonin building up ADVERSE EVENT - Serotonin Syndrome  Due to effects of excessive serotonin on the CNS associated with drugs that increase serotonin(i.e. Gen 2s & MOAI) or overdose Body System Manifestations Cognitive changes Delirium, agitation Autonomic changes Tachycardia, sweating, hyperthermia, mydriasis, shivering Neuromuscular changes Muscle spasm (myoclonus), hyperreflexia, tremors Other Rhabdomyolysis, kidney damage, cardiac dysrhythmias, DIC Treatment  Discontinue causative drug  Effects are usually self-limiting but can be fatal Antidepressant Drugs - MOAIs ADVERSE EVENTS MAOI Overdose  Manifestations appear 12 hrs after ingestion  Primarily affects CV and neurological systems  CVS = tachycardia, circulatory collapse  CNS = seizures, coma  Hyperthermia  Treatment  Eliminate ingested toxin through hemodialysis, acidify urine pH to 5  Protect brain and heart with supportive measures Antidepressant Drugs - MOAIs Contraindications  Tyramine containing foods that MUST be avoided when taking MAOIs  Meats & Fish  pickled, aged, smoked, fermented, or marinated (some fish, poultry, and beef); most pork (except cured ham)  shrimp paste  Chocolate  Alcoholic beverages (Red Wine)  Nuts  Brazil nuts, coconuts, peanuts Antidepressant Drugs - MOAIs  Soy & Beans  soy sauce, soybean condiments, broad (fava) beans, green bean pods, Italian flat (Romano) beans, snow peas,  Fruits & Veg  sauerkraut, kimchi, avocados, bananas, pineapple, eggplants, figs, red plums, raspberries, and an array of cacti.  Fermented foods  cheeses (except ricotta, cottage, cream and Neufchâtel cheeses)  sour cream, yogurt  Other  teriyaki sauce, tempeh, miso soup, yeast Antidepressant Drugs - MOAIs Drug Interactions (Many)  Pain medications (Serotonin Syndrome)  Tramadol  Meperidine  Methadone  Antidepressants (Serotonin Syndrome)  SSRIs  SNRIs  TCAs  Bupropion  Mirtazapine Antidepressant Drugs - MOAIs Drug Interactions (Many)  Seizure Medications  Carbamazepine  Oxcarbazepine  OTC cold meds (Hypertensive crisis)  Pseudoephedrine  Phenylephrine  Ephedrine  Phenylpropanolamine  St. John's wort (Serotonin Syndrome)  Dextromethorphan (Serotonin Syndrome) Antidepressant Drugs Second Generation 1. Serotonin Reuptake Inhibitors (SSRIs) 2. Serotonin-norepinephrine reuptake inhibitors (SNRIs) 3. Miscellaneous antidepressants Antidepressant Drugs – GEN 2 Overview of General Concepts  Includes SSRIs, SNRIs, Miscellaneous  Fewer adverse effects than TCAs and MAOIs, therefore now preferred drugs Indication for Use  Depression  Bipolar disorder  Obesity  Eating disorders  OCD  Panic disorder  Social anxiety disorder  PTSD  Premenstrual symptoms  Alcoholism Antidepressant Drugs – GEN 2 Overview of General Concepts Pharmacokinetics  Highly bound to albumin  many drug interactions due to competition for binding sites resulting in higher amounts of free drug available and greater drug effects (i.e. warfarin)  Metabolized by liver, excreted by kidneys General Contraindications for Gen 2s  Gen 2 and Gen 1 MOAIs do not mix!  Should not mix these Gen 2 and MOAIs within 2 weeks of each other  All Gen 2s have the following contraindications  Heart disease  Seizure disorders Antidepressant Drugs – GEN 2 Overview of General Concepts Common Adverse Effects  Insomnia (reduced REM)  Weight gain  Sexual dysfunction  Dizziness, drowsiness headache  GI upset Common Adverse Event  Serotonin syndrome Antidepressant Drugs - SSRIs SSRIs (Selective Serotonin Reuptake Inhibitors)  Are safer than and as effective as the other anti-depressants  Some can also be used to treat OCD Mechanism of Action  Reduce the amount of serotonin that is reabsorbed by the presynaptic neuron  Leaves more serotonin in the synaptic gap creating the antidepressant effect  Weak effects on dopamine and norepinephrine reuptake 1. Fluoxetine (Prozac®) 2. Sertraline (Zoloft®) 3. Paroxetine (Paxil®) 4. Fluvoxamine (Luvox®) 5. Citalopram (Celexa®)  Antidepressant Drugs - SSRIs SSRIs (Selective Serotonin Reuptake Inhibitors) Adverse Effects  Nausea, vomiting, diarrhea,  Dry mouth  Headaches  Anxiety  Sedation  Decrease in sexual desire and response  Disturbed Sleep  Problems falling asleep  Waking in the night  Vivid dreams or nightmares. https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/antidepressant-medications  Antidepressant Drugs - SSRIs SSRIs (Selective Serotonin Reuptake Inhibitors) Contraindicated  Concurrent use of MAOIs  Phenytoin (Dilantin®), Clozapine (Clozaril®), Theophylline (Theo-Dur®), Cisapride (Propulsid®)  Bipolar disorder (manic phases)  QT interval prolongation  Bleeding disorders  Liver impairment Caution  Kidney impairment  Pregnancy  Epilepsy https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/antidepressant-medications  Antidepressant Drugs - SNRIs SNRIs (Serotonin and Norepinephrine Reuptake Inhibitor) Mechanism of Action  Increases the levels of both serotonin and norepinephrine by inhibiting their reabsorption (reuptake) into cells in the brain  Enhance neurotransmission (the sending of nerve impulses) and so improve and elevate mood  Sometimes called dual reuptake inhibitors 1. Venlafaxine (Effexor®) 2. Duloxetine (Cymbalta®) 3. Levomilnacipran (Fetzima®) 4. Desvenlafaxine (Pristiq®)  Antidepressant Drugs - SNRIs Contraindicated  Pregnancy and breastfeeding  MAOIs  Liver impairment  Severe renal impairment Caution  History of bleeding disorders  History of epilepsy  History or family history of mania or bipolar disorder  Cardiac disease  Conditions associated with high risk of cardiac arrhythmia  Hypertension  Diabetes mellitus  Antidepressant Drugs - Miscellaneous Antidepressants (Heterocyclic) Bupropion (Wellbutrin®, Zyban®)  Norepinephrine & dopamine reuptake inhibition, weak effects on serotonin  Weak antidepressant action but has been shown to effective for smoking cessation Mirtazapine (Remeron®)  Unlike all Antidepressants as it promotes the release of both serotonin and norepinephrine in the brain  It does not inhibit the reuptake of either of these neurotransmitters  Indicated for the treatment of depression, including that associated with bipolar disorder  Causes sedation and optimal dosing is still being studied GENERAL NURSING CONSIDERATIONS  Develop trust  Ensure other supports are in place  MAOIs must be stopped for at least 2 weeks before starting a new antidepressant or eating tyramine containing foods (3 wks)  Monitor for worsening of depressive symptoms, nonadherence  use of alcohol and other CNS depressants  Monitor for suicidal ideation  Monitor for signs of serotonin syndrome  Monitor for efficacy and adverse effects  Neurological, mental status, mood, sleep patterns, weight, general health status, BP  Labs- CBC, electrolytes, renal and liver function, lipids, thyroid  Monitor drug levels if applicable  May need to do mouth checks after administration in inpatient situation GENERAL PATIENT EDUCATION Educate  It takes several weeks to see effects  Take medication as prescribed- do not abruptly discontinue  Caffeine and cigarette smoking may decrease effectiveness  Do not combine antidepressants with St John’s Wort or other antidepressants  It works like a natural antidepressant  Avoid alcohol and other CNS depressants  Awareness of potential adverse effects- weight gain, orthostatic hypotension, constipation etc.  GI upset- take with food or full glass water  Pharmacotherapy should be done in concert with mental health counselling