Mood Stabilizing Drugs: Antidepressants & Psychotherapeutics PDF

Mood Stabilizing Drugs  Three main emotional and mental disorders: Anxiety Affective disorders Psychoses Psychotherapeutic Drugs Affective Disorders (Mood Disorders) Changes in mood that range from mania (abnormally pronounced emotions) to depression (abnormally reduced emotion...

Mood Stabilizing Drugs  Three main emotional and mental disorders: Anxiety Affective disorders Psychoses Psychotherapeutic Drugs Affective Disorders (Mood Disorders) Changes in mood that range from mania (abnormally pronounced emotions) to depression (abnormally reduced emotions) Some patients may exhibit both mania and depression: bipolar disorder 3 PRESENTATION TITLE Mood stablizers Indications: bipolar illness, altered moods, mania Prototypes: Lithium carbonate and Lithium citrate New agent: Cariprazine (Vraylar) Other drugs may be used in combination with lithium Benzodiazepines Antipsychotic drugs Antiepileptic drugs Dopamine receptor agonists 4  Lithium (salts) MOA: possibly potentiates serotonergic neurotransmission Adverse Effects: cardiac dysrhythmia.. Other effects: drowsiness, slurred speech, epilepsy-type seizures, choreoathetotic movements, ataxia and hypotension Long-term treatment may cause hypothyroidism Toxicity: symptoms include GI discomfort, N/V, tremor, confusion, somnolence, seizures, and possibly death. Keeping the NA level in the normal range(135 to 145 mEq/L)helps to maintain therapeutic lithium levels. 5  Antidepressants. Tricyclic antidepressants (TCAs) Selective serotonin reuptake inhibitors (SSRIs) Serotonin norepinephrine reuptake inhibitors (SNRIs) Atypical antidepressants Monoamine oxidase inhibitors (MAOIs) Higher risk of suicide among both adult and pediatric population  Tricyclic antidepressants (TCAs) MOA: Block reuptake of neurotransmitters, possibly by increasing concentrations of neurotransmitters to correct the abnormally low levels that lead to depression. Indications: Depression, Childhood enuresis (imipramine), Obsessive-. Compulsive Disorders (clomipramine), Adjunctive analgesics for chronic pain conditions, such as trigeminal neuralgia, anorexia nervosa Adverse Effects: Drowsiness, Impotence, Orthostatic hypotension Caution in Older patients Dizziness, postural hypotension, constipation, delayed micturition, edema, muscle tremors 7  Tricyclic antidepressants (TCAs) OVERDOSE Amitriptyline (Elavil) Lethal Indications: depression. commonly used for insomnia and neuropathic pain CNS and cardiovascular systems are Contraindications: pregnancy, and recent mainly affected. myocardial infarction No specific antidote Adverse effects: dry mouth, constipation, Activated charcoal if within 2 hours of blurred vision, urinary retention, and ingestion dysrhythmias, drowiness Speed elimination by alkalinizing urine. Manage seizures and dysrhythmias. Provide basic life support. Death results from seizures or dysrhythmias 8  SSRIs Selective Serotonin Reuptake Inhibitors Fluoxetine (Prozac) Prototypical SSRI Indications: depression, bulimia, OCD, panic disorder, and premenstrual dysphoric disorder Contraindications: concurrent MAOI therapy Several drug interactions Adverse effects of SSRIS: anxiety, dizziness, drowsiness, insomnia, sexual dysfunction-low libido, tremor Potential for Serotonin syndrome 9  Escitalopram (Lexapro) Indications: depression, anxiety disorder MOA: unknown Use with Caution: Side Effects: CNS effects, euphoria, While taking MAOIs, CNS depressants, Anticoagulation therapy, renal and hepatic amnesia, Anticholinergic effects, impairment Pregnancy and lactation, narrow angle glaucoma, Weakness, diarrhea, anorexia seizures, Hypokalemia, hyponatremia, hyperthyroidism, Adverse Effects: MI, heart failure Tachycardia, seizure, HTN, serotonin syndrome PRESENTATION TITLE 10 11  Escitalopram (Lexapro) Drug-Lab-Food-CAM Interactions: Alcohol and CNS depressants may: Increase effects of CNS, respiratory depression, and hypotension Anticoagulants and aspirin may: Increase bleeding Taking with other SNRIs, SSRIs may: Increase risk for NMS MAOIs: Hypertensive crisis and death St. John’s wort may: Serotonin syndrome PRESENTATION TITLE 12  SNRIs Serotonin Norepinephrine Reuptake Inhibitors Venlafaxene (Effexor), Duloxetine (Cymbalta and others) Indications: depression, GAD, diabetic peripheral neuropathy or fibromyalgia MOA: increase serotonin and norepinephrine levels by inhibiting the reuptake by nerves Adverse effects: dizziness, drowsiness, headache, GI upset, anorexia, and hepatotoxicity Interactions: SSRIs and triptans (increased risk of serotonin syndrome), alcohol (increased risk of liver injury) Can worsen uncontrolled angle-closure glaucoma 13 Second-Generation Antidepressants: Serotonin Syndrome Common symptoms Delirium Agitation Tachycardia Sweating Myoclonus (muscle spasms) Hyperreflexia Shivering Course tremors Extensor plantar muscles (sole of foot) response More severe cases Hyperthermia Seizures Rhabdomyolysis Renal failure Cardiac dysrhythmias Disseminated intravascular coagulation DIC 14 MAOIs Monoamine Oxidase Inhibitor Phenelzine (Nardil) isocarboxazid, tranylcypromine, selegiline (transdermal patch) Parkinson’s Indications: depression, social phobia, panic disorder, disease Adverse reaction: potential to cause hypertensive crisis when taken with tyramine Interactions: other antidepressants and anticonvulsants 15 PRESENTATION TITLE MAOIs and Tyramine Ingestion of foods or drinks with tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death Avoid foods that contain tyramine! Aged, mature cheeses (cheddar, bleu, Swiss) Smoked, pickled, or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté) Yeast extracts Red wines (Chianti, burgundy, sherry, vermouth) Italian broad beans (fava beans) 16  Atypical Antidepressant Bupronion (Wellbutrin and others ) Indications: depression, smoking cessation, seasonal affective disorder Adverse effects: seizures, suicidal ideation Contraindications: seizure disorder Interactions: CNS depressants, azole antifungals Zyban: approved for smoking cessation treatment and was the first nicotine-free prescription medicine used to treat nicotine dependence 17  Nursing Implications Antidepressants AVOID Herb commonly used for anxiety or depression: St. John’s Wort Takes about 4 to 6 weeks to reach maximum clinical effectiveness Second generation: Used for other than depression Very few drug–drug or drug–food interactions. Adverse effects: insomnia /reduced rapid eye movement, weight gain, and sexual dysfunction. Highly protein bound 18  Nursing Implications Tricyclics may interact with anesthetic drugs. Monitor for adverse effects and discuss with patients. Encourage patients to wear medication ID badges naming the drugs being taken. Caffeine and cigarette smoking may decrease effectiveness of medication therapy. With MAOIs, instruct patients and family regarding tyramine-containing foods and signs and symptoms of hypertensive crisis Monitor for therapeutic effects—For antidepressants Improved sleep patterns and nutrition Increased feelings of self-esteem Decreased feelings of hopelessness Increased interest in self and appearance t Increased interest in daily activities h Fewer depressive manifestations or suicidal thoughts MONITOR o u 19 g  Complementary and Alternative Therapy for Depression Ginkgo biloba and St. John’s wort Discontinue use of herbal products 1 to 2 weeks before surgery. Check with the health care provider before taking herbal treatments. Do not take with prescription antidepressants 20 Psychoses Psychotherapeutic Drugs Types of psychotherapeutic drugs Anxiolytic drugs Mood-stabilizing drugs Antidepressant drugs Antipsychotic drugs Non-pharmacologic therapies Psychotherapy Support groups PRESENTATION TITLE 22  Psychotherapeutic Drugs Indications: serious mental illness, Psychotic illness, most commonly schizophrenia, anxiety, mood disorders, BPD MOA: Block dopamine receptors in the brain in areas associated with emotion, cognitive function, motor function, decreases Dopamine levels in CNS, tranquilizing effect in psychotic patients Adverse effects: Agranulocytosis, hemolytic anemia, CNS effects, Insulin resistance, Weight gain, Change in serum lipid levels, Metabolic syndrome Conventional, or first-generation: phenothiazines 23  Haloperidol (Haldol) Indications: long-term treatment of psychosis with schizophrenia or BPD to reduce hallucinations and delusions. Contraindications: hypersensitivity, Parkinson’s disease, and in patients taking large amounts of CNS depressants Side effects: extrapyramidal Useful in treating patients with schizophrenia who were nonadherent with their drug regimen 24  Atypical Antipsychotics ) Clozapine (Clozaril) Risperidone (Risperdal) ) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invega) Iloperidone (Fanapt) Asenapine (Saphris) Lurasidone (Latuda) Brexpiprazole (Rexulti) 25  Atypical Antipsychotics Aripiprazole (Abilify) Clozapine (Clozaril) Risperidone Brexipiprazole (Rexulti) (Risperdal) Quinolinone atypical antipsychotic Selectively blocks the Indication: schizophrenia, Used for schizophrenia, bipolar dopaminergic receptors in including negative disorder, major depressive the mesolimbic region of symptoms disorder, agitation associated the brain Adverse effects: minimal with autistic disorder Associated with minor or EPS at therapeutic no EPS dosages of 1 to 6 mg/day Adverse effects: similar to other atypical antipsychotics Adverse effects: blood Risperdal Consta: long- Abilify: Oral and extended release dyscrasias acting injectable form; IM injection Monitor WBC counts lasts 2 weeks frequently throughout Invega Sustenna: long- beginning of therapy. acting injection; lasts 1 month 26  Nursing Implications Antipsychotics Before beginning therapy, assess the physical and emotional status Obtain baseline VS, including postural BP, liver and renal function tests. Complete Suicide Assessment Scale Assess for possible contraindications to therapy and potential drug interactions. Assess for level of consciousness, and potential for injury to self and others. Check the patient’s mouth to see oral doses are swallowed, dispense few at a time Advise patients to avoid abrupt withdrawal. Advise patients to change positions slowly Simultaneous use of these drugs with alcohol or other CNS depressants can be fatal. 27  More Nursing Implications Typical Antipsychotics—phenothiazines Instruct patients to wear sunscreen because of photosensitivity. Long-term haloperidol therapy may result in tremors, nausea, vomiting, or uncontrollable shaking of small muscle groups; report these symptoms to the physician. Oral forms may be taken with meals to decrease GI upset. These drugs may cause drowsiness, dizziness, or fainting; change positions slowly Monitor for therapeutic effects-antipsychotics Improved mood and affect Alleviation of psychotic symptoms and episodes Decreased hallucinations, paranoia, delusions, garbled speech, and inability to cope 28  Six major anxiety disorders Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder (PTSD) Anxiety Generalized anxiety disorder (GAD) Panic disorder Anxiolytic Drugs Social phobia (social anxiety disorder) Simple phobia  Anxiolytic Drugs Reduce anxiety by reducing overactivity in central nervous system (CNS).  Benzodiazepines Depress activity in the brainstem and limbic system Alprazolam (Xanax) Diazepam (Valium) Lorazepam (Ativan) Miscellaneous drug: Buspirone (Buspar) Nonsedating and nonhabit forming May have drug interaction with selective serotonin reuptake inhibitors (SSRIs) (serotonin syndrome) Do not administer with MAOIs 30  Anxiolytic Drugs-Benzodiazepines Alprazolam (Xanax) Diazepam (Valium) Lorazepam (Ativan) Indications: anxiety, Can be given by IV push; Indications: GAD, short-term alcohol withdrawal, relief of anxiety symptoms, useful for acutely agitated reverses status epilepticus, patients panic disorder, and anxiety preop sedation, adjunct for associated with depression skeletal muscle spasms Continuous infusion for Adverse effects: confusion, agitated patients who are Avoid in patients with ataxia, headache, and others on mechanical ventilation hepatic dysfunction Interactions: alcohol, oral Used to treat or prevent Adverse effects: headache, alcohol withdrawal contraceptives, and others confusion, slurred speech, Interactions: alcohol, oral contraceptives, and others I T 31 L Miscellaneous Anxiolytic Buspirone (Buspar) MOA: Unknown Administered on a scheduled basis (not prn) Lacks sedative properties and dependency potential as other benzodiazepines Adverse effects: Paradoxical anxiety Blurred vision Headache Nausea 32 Nursing Implications-Anxiolytics In elderly patients, monitor closely for oversedation and profound CNS depression. Monitor for therapeutic effects—Improved mental alertness, cognition, and mood Fewer anxiety and panic attacks Improved sleep patterns and appetite Less tension and irritability; fewer feelings of fear, impending doom, and stress More interest in self and others 33 PRESENTATION TITLE 34