Antidepressant Drugs PDF

11/16/23, 10:30 AM Realizeit for Student Antidepressant Drugs Antidepressant drugs are primarily used in the treatment of major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression. Off-label uses of antidepressants include the treatment of chron...

11/16/23, 10:30 AM Realizeit for Student Antidepressant Drugs Antidepressant drugs are primarily used in the treatment of major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression. Off-label uses of antidepressants include the treatment of chronic pain, migraine headaches, peripheral and diabetic neuropathies, sleep apnea, dermatologic disorders, panic disorder, and eating disorders. Although the mechanism of action is not completely understood, antidepressants somehow interact with the two neurotransmitters, norepinephrine and serotonin, that regulate mood, arousal, attention, sensory processing, and appetite. Antidepressants are divided into four groups: Tricyclic and the related cyclic antidepressants 1. Selective serotonin reuptake inhibitors (SSRIs) 2. MAO inhibitors (MAOIs) 3. Other antidepressants such as desvenlafaxine (Pristiq), venlafaxine (Effexor), bupropion (Wellbutrin), duloxetine (Cymbalta), trazodone (Desyrel), and nefazodone (Serzone) The cyclic compounds became available in the 1950s and for years were the first choice of drugs to treat depression even though they cause varying degrees of sedation, orthostatic hypotension (drop in blood pressure on rising), and anticholinergic side effects. In addition, cyclic antidepressants are potentially lethal if taken in an overdose. During that same period, the MAOIs were discovered to have a positive effect on people with depression. Although the MAOIs have a low incidence of sedation and anticholinergic effects, they must be used with extreme caution for several reasons: A life-threatening side effect, hypertensive crisis, may occur if the client ingests foods containing tyramine (an amino acid) while taking MAOIs. Because of the risk of potentially fatal drug interactions, MAOIs cannot be given in combination with other MAOIs, tricyclic antidepressants, meperidine (Demerol), CNS depressants, many antihypertensives, or general anesthetics. MAOIs are potentially lethal in overdose and pose a potential risk in clients with depression who may be considering suicide. The selective serotonin reuptake inhibitors (SSRIs), first available in 1987 with the release of fluoxetine (Prozac), have replaced the cyclic drugs as the first choice in treating depression because they are equal in efficacy and produce fewer troublesome side effects. The SSRIs and clomipramine are effective in the treatment of obsessive-compulsive disorder (OCD) as well. Prozac Weekly is the first and only medication that can be given once a week as maintenance therapy for depression after the client has been stabilized on fluoxetine. It contains 90 mg of fluoxetine with an enteric coating that delays release into the bloodstream. Preferred Drugs for Clients at High Risk for Suicide Suicide is always a primary consideration when treating clients with depression. SSRIs, venlafaxine, nefazodone, and bupropion are often better choices for those who are potentially suicidal or highly impulsive because they carry no risk of lethal overdose in contrast to the cyclic compounds and the MAOIs. However, SSRIs are effective only for mild and moderate depression. Evaluation of the risk for suicide must continue even after treatment with antidepressants is initiated. The client may feel more energized but still have suicidal thoughts, which increases the likelihood of a suicide attempt. Also, because it often takes weeks before the medications have a full therapeutic effect, clients may become discouraged and tired of waiting to feel better, which can result in suicidal behavior. There is an FDA-required warning for SSRIs and increased suicidal risk in children and adolescents. Mechanism of Action The precise mechanism by which antidepressants produce their therapeutic effects is not known, but much is known about their action on the CNS. The major interaction is with the monoamine neurotransmitter systems in the brain, particularly norepinephrine and serotonin. Both of these neurotransmitters are released throughout the brain and help regulate arousal, vigilance, attention, mood, sensory processing, and appetite. Norepinephrine, serotonin, and dopamine are removed from the synapses after release by reuptake into presynaptic neurons. After reuptake, these three neurotransmitters are reloaded for subsequent release or metabolized by the enzyme MAO. The SSRIs block the reuptake of serotonin, the cyclic antidepressants and venlafaxine block the reuptake of norepinephrine primarily and block serotonin to some degree, and the MAOIs interfere with enzyme metabolism. This is not the complete explanation, however; the blockade of serotonin and norepinephrine reuptake and the inhibition of MAO occur in a matter of hours, while antidepressants are rarely effective until taken for several weeks. The cyclic compounds may take 4 to 6 weeks to be effective, MAOIs need 2 to 4 weeks for effectiveness, and SSRIs may be effective in 2 to 3 weeks. Researchers believe that the actions of these drugs are an “initiating event” and that eventual therapeutic effectiveness results when neurons respond more slowly, making serotonin available at the synapses (Burchum & Rosenthal, 2018). Side Effects of Selective Serotonin Reuptake Inhibitors SSRIs have fewer side effects compared to the cyclic compounds. Enhanced serotonin transmission can lead to several common side effects such as anxiety, agitation, akathisia (motor restlessness), nausea, insomnia, and sexual dysfunction, specifically diminished sexual https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwu… 1/23 11/16/23, 10:30 AM Realizeit for Student drive or difficulty achieving an erection or orgasm. In addition, weight gain is both an initial and ongoing problem during antidepressant therapy, although SSRIs cause less weight gain than other antidepressants. Taking medications with food usually can minimize nausea. Akathisia is usually treated with a beta-blocker, such as propranolol (Inderal) or a benzodiazepine. Insomnia may continue to be a problem even if the client takes the medication in the morning; a sedative–hypnotic or low-dosage trazodone may be needed. Less common side effects include sedation (particularly with paroxetine [Paxil]), sweating, diarrhea, hand tremor, and headaches. Diarrhea and headaches can usually be managed with symptomatic treatment. Sweating and continued sedation most likely indicate the need for a change to another antidepressant. Side Effects of Cyclic Antidepressants Cyclic compounds have more side effects than do SSRIs and the newer miscellaneous compounds. The individual medications in this category vary in terms of the intensity of side effects, but generally, side effects fall into the same categories. The cyclic antidepressants block cholinergic receptors, resulting in anticholinergic effects such as dry mouth, constipation, urinary hesitancy or retention, dry nasal passages, and blurred near vision. More severe anticholinergic effects such as agitation, delirium, and ileus may occur, particularly in older adults. Other common side effects include orthostatic hypotension, sedation, weight gain, and tachycardia. Clients may develop tolerance to anticholinergic effects, but these side effects are common reasons that clients discontinue drug therapy. Clients taking cyclic compounds frequently report sexual dysfunction similar to problems experienced with SSRIs. Both weight gain and sexual dysfunction are cited as common reasons for noncompliance (Stahl, 2017). Side Effects of Monoamine Oxidase Inhibitors The most common side effects of MAOIs include daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, and sexual dysfunction. The sedation and insomnia are difficult to treat and may necessitate a change in medication. Of particular concern with MAOIs is the potential for a life-threatening hypertensive crisis if the client ingests food that contains tyramine or takes sympathomimetic drugs. Because the enzyme MAO is necessary to break down the tyramine in certain foods, its inhibition results in increased serum tyramine levels, causing severe hypertension, hyperpyrexia, tachycardia, diaphoresis, tremulousness, and cardiac dysrhythmias. Drugs that may cause potentially fatal interactions with MAOIs include SSRIs, certain cyclic compounds, buspirone (BuSpar), dextromethorphan, and opiate derivatives such as meperidine. The client must be able to follow a tyramine-free diet; Box 2.1 lists the foods to avoid. Studies are currently underway to determine whether a selegiline transdermal patch would be effective in treating depression without the risks of dietary tyramine and orally ingested MAOIs. BOX 2.1 Foods (Containing Tyramine) to Avoid When Taking Monoamine Oxidase Inhibitors Mature or aged cheeses or dishes made with cheese, such as lasagna or pizza. All cheese is considered aged exce ricotta cheese, and processed cheese slices. Aged meats such as pepperoni, salami, mortadella, summer sausage, beef logs, meat extracts, and similar products. Make sure meat and chicke refrigerated. Italian broad beans (fava), bean curd (tofu), banana peel, overripe fruit, and avocado. All tap beers and microbrewery beer. Drink no more than two cans or bottles of beer (including nonalcoholic beer) or 4 oz of wine per day. Sauerkraut, soy sauce or soybean condiments, or marmite (concentrated yeast). Yogurt, sour cream, peanuts, brewer’s yeast, and monosodium glutamate (MSG). Adapted from Ohio State University Wexner Medical Center, Columbus, OH (2018) Side Effects of Other Antidepressants Of the other or novel antidepressant medications, nefazodone, trazodone, and mirtazapine commonly cause sedation. Both nefazodone and trazodone commonly cause headaches. Nefazodone can also cause dry mouth and nausea. Bupropion, venlafaxine, and desvenlafaxine may cause loss of appetite, nausea, agitation, and insomnia. Venlafaxine may also cause dizziness, sweating, or sedation. Sexual dysfunction is much less common with the novel antidepressants, with one notable exception: Trazodone can cause priapism (a sustained and painful erection that necessitates immediate treatment and discontinuation of the drug). Priapism may also result in impotence. WARNING - Nefazodone May cause rare but potentially life-threatening liver damage, which could lead to liver failure. WARNING - Bupropion https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwu… 2/23 11/16/23, 10:30 AM Realizeit for Student Can cause seizures at a rate four times that of other antidepressants. The risk for seizures increases when doses exceed 450 mg/day (400 mg SR); increments; the client has a history of seizures, cranial trauma, excessive use of or withdrawal from alcohol, or addiction to opiates, cocaine, or stim (OTC) stimulants or anorectics; or the client has diabetes being treated with oral hypoglycemics or insulin. Drug Interactions An uncommon but potentially serious drug interaction called serotonin syndrome (or serotonergic syndrome) can result from taking an MAOI and an SSRI at the same time. It can also occur if the client takes one of these drugs too close to the end of therapy with the other. In other words, one drug must clear the person’s system before initiation of therapy with the other. Symptoms include agitation, sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia, and, in extreme reactions, even coma and death (Burchum & Rosenthal, 2018). These symptoms are similar to those seen with an SSRI overdose. Client Teaching Clients should take SSRIs first thing in the morning unless sedation is a problem; generally, paroxetine most often causes sedation. If the client forgets a dose of an SSRI, he or she can take it up to 8 hours after the missed dose. To minimize side effects, clients generally should take cyclic compounds at night in a single daily dose when possible. If the client forgets a dose of a cyclic compound, he or she should take it within 3 hours of the missed dose or omit the dose for that day. Clients should exercise caution when driving or performing activities requiring sharp, alert reflexes until sedative effects can be determined. Clients taking MAOIs need to be aware that a life-threatening hyperadrenergic crisis can occur if they do not observe certain dietary restrictions. They should receive a written list of foods to avoid while taking MAOIs. The nurse should make clients aware of the risk for serious or even fatal drug interactions when taking MAOIs and instruct them not to take any additional medication, including OTC preparations, without checking with the physician or pharmacist. Mood-Stabilizing Drugs Mood-stabilizing drugs are used to treat bipolar disorder by stabilizing the client’s mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. Lithium is the most established mood stabilizer; some anticonvulsant drugs, particularly carbamazepine (Tegretol) and valproic acid (Depakote, Depakene), are effective mood stabilizers. Other anticonvulsants, such as gabapentin (Neurontin), topiramate (Topamax), oxcarbazepine (Trileptal), and lamotrigine (Lamictal), are also used for mood stabilization. Occasionally, clonazepam (Klonopin) is also used to treat acute mania. Clonazepam is included in the discussion of antianxiety agents. WARNING - Lamotrigine Can cause serious rashes requiring hospitalization, including Stevens-Johnson syndrome and, rarely, life-threatening toxic epidermal necrolysis. Th children younger than 16 years. Mechanism of Action Although lithium has many neurobiologic effects, its mechanism of action in bipolar illness is poorly understood. Lithium normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. It also reduces the release of norepinephrine through competition with calcium and produces its effects intracellularly rather than within neuronal synapses; it acts directly on G-proteins and certain enzyme subsystems such as cyclic adenosine monophosphates and phosphatidylinositol. Lithium is considered a first-line agent in the treatment of bipolar disorder (Stahl, 2017). The mechanism of action for anticonvulsants is not clear because it relates to their off-label use as mood stabilizers. Valproic acid and topiramate are known to increase the levels of the inhibitory neurotransmitter GABA. Both valproic acid and carbamazepine are thought to stabilize mood by inhibiting the kindling process. This can be described as the snowball-like effect seen when minor seizure activity seems to build up into more frequent and severe seizures. In seizure management, anticonvulsants raise the level of the threshold to prevent these minor seizures. It is suspected that this same kindling process may also occur in the development of full-blown mania with stimulation by more frequent minor episodes. This may explain why anticonvulsants are effective in the treatment and prevention of mania as well. Dosage Lithium is available in tablet, capsule, liquid, and sustained-release forms; no parenteral forms are available. The effective dosage of lithium is determined by monitoring serum lithium levels and assessing the client’s clinical response to the drug. Daily dosages generally range from 900 to 3,600 mg; more importantly, the serum lithium level should be about 1 mEq/L. Serum lithium levels of less than 0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L are usually considered toxic. The lithium level should be monitored every 2 to 3 days while https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwu… 3/23 11/16/23, 10:30 AM Realizeit for Student the therapeutic dosage is being determined; then, it should be monitored weekly. When the client’s condition is stable, the level may need to be checked once a month or less frequently. WARNING - Lithium Toxicity is closely related to serum lithium levels and can occur at therapeutic doses. Facilities for serum lithium determinations are required to monitor therapy. Carbamazepine is available in liquid, tablet, and chewable tablet forms. Dosages usually range from 800 to 1,200 mg/day; the extreme dosage range is 200 to 2,000 mg/day. Valproic acid is available in liquid, tablet, and capsule forms and as sprinkles with dosages ranging from 1,000 to 1,500 mg/day; the extreme dosage range is 750 to 3,000 mg/day. Serum drug levels, obtained 12 hours after the last dose of the medication, are monitored for therapeutic levels of both these anticonvulsants. Side Effects Common side effects of lithium therapy include mild nausea or diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, a metallic taste in the mouth, and fatigue or lethargy. Weight gain and acne are side effects that occur later in lithium therapy; both are distressing for clients. Taking the medication with food may help with nausea, and the use of propranolol often improves the fine tremor. Lethargy and weight gain are difficult to manage or minimize and frequently lead to noncompliance. Toxic effects of lithium are severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination. Untreated, these symptoms worsen and can lead to renal failure, coma, and death. When toxic signs occur, the drug should be discontinued immediately. If lithium levels exceed 3 mEq/L, dialysis may be indicated. Side effects of carbamazepine and valproic acid include drowsiness, sedation, dry mouth, and blurred vision. In addition, carbamazepine may cause rashes and orthostatic hypotension, and valproic acid may cause weight gain, alopecia, and hand tremor. Topiramate causes dizziness, sedation, weight loss (rather than gain), and increased incidence of renal calculi (Burchum & Rosenthal, 2018). WARNING - Valproic Acid and Its Derivatives Can cause hepatic failure, resulting in fatality. Liver function tests should be performed before therapy and at frequent intervals thereafter, especially teratogenic effects such as neural tube defects (e.g., spina bifida). Can cause life-threatening pancreatitis in both children and adults. Can occur sh therapy. WARNING - Carbamazepine Can cause aplastic anemia and agranulocytosis at a rate five to eight times greater than the general population. Pretreatment hematologic baseline periodically throughout therapy to discover lowered WBC or platelet counts. Client Teaching For clients taking lithium and the anticonvulsants, monitoring blood levels periodically is important. The time of the last dose must be accurate so that plasma levels can be checked 12 hours after the last dose has been taken. Taking these medications with meals minimizes nausea. The client should not attempt to drive until dizziness, lethargy, fatigue, or blurred vision has subsided. Treatment and Prognosis Psychopharmacology Major categories of antidepressants include cyclic antidepressants, monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and atypical antidepressants. The choice of which antidepressant to use is based on the client’s symptoms, age, and physical health needs; drugs that have or have not worked in the past or that have worked for a blood relative with depression; and other medications that the client is taking. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwu… 4/23 11/16/23, 10:30 AM Realizeit for Student Researchers believe that levels of neurotransmitters, especially norepinephrine and serotonin, are decreased in depression. Usually, presynaptic neurons release these neurotransmitters to allow them to enter synapses and link with postsynaptic receptors. Depression results if too few neurotransmitters are released, if they linger too briefly in synapses, if the releasing presynaptic neurons reabsorb them too quickly, if conditions in synapses do not support linkage with postsynaptic receptors, or if the number of postsynaptic receptors has decreased. The goal is to increase the efficacy of available neurotransmitters and the absorption by postsynaptic receptors. To do so, antidepressants establish a blockade for the reuptake of norepinephrine and serotonin into their specific nerve terminals. This permits them to linger longer in synapses and to be more available to postsynaptic receptors. Antidepressants also increase the sensitivity of the postsynaptic receptor sites (Burchum & Rosenthal, 2018). In clients who have acute depression with psychotic features, an antipsychotic is used in combination with an antidepressant. The antipsychotic treats the psychotic features; several weeks into treatment, the client is reassessed to determine whether the antipsychotic can be withdrawn and the antidepressant maintained. Evidence is increasing that antidepressant therapy should continue for longer than the 3 to 6 months originally believed necessary. Fewer relapses occur in people with depression who receive 18 to 24 months of antidepressant therapy. As a rule, the dosage of antidepressants should be tapered before being discontinued. Selective Serotonin Reuptake Inhibitors. SSRIs, the most frequently prescribed category of antidepressants (Table 17.1 ), are effective for most clients. Their action is specific to serotonin reuptake inhibition; these drugs produce few sedating, anticholinergic, and cardiovascular side effects, which make them safer for use in older adults. Because of their low side effects and relative safety, people using SSRIs are more apt to be compliant with the treatment regimen than clients using more troublesome medications. Insomnia decreases in 3 to 4 days; appetite returns to a more normal state in 5 to 7 days and energy returns in 4 to 7 days. In 7 to 10 days, mood, concentration, and interest in life improve. TABLE 17.1 SSRI Antidepressants Generic (Trade) Name Side Effects Nursing Implications Administer in AM (if nervous) or PM (if drowsy). Fluoxetine Headache, nervousness, anxiety, sedation, tremor, sexual dysfunction, (Prozac) anorexia, constipation, nausea, diarrhea, and weight loss Monitor for hyponatremia. Encourage adequate fluids. Report sexual difficulties to physician. Administer in PM if client is drowsy. Encourage use of sugar-free Sertraline (Zoloft) Dizziness, sedation, headache, insomnia, tremor, sexual dysfunction, diarrhea, dry mouth and throat, nausea, vomiting, and sweating beverages or hard candy. Drink adequate fluids. Monitor hyponatremia; report sexual difficulties to physician. Administer with food. Administer in PM if client is drowsy. Paroxetine (Paxil) Dizziness, sedation, headache, insomnia, weakness, fatigue, constipation, dry mouth and throat, nausea, vomiting, diarrhea, and sweating Encourage use of sugar-free hard candy or beverages. Encourage adequate fluids. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwu… 5/23 11/16/23, 10:30 AM Realizeit for Student Monitor for hyponatremia. Administer with food. Citalopram Drowsiness, sedation, insomnia, nausea, vomiting, weight gain, (Celexa) constipation, and diarrhea Administer dose at 6 PM or later. Promote balanced nutrition and exercise. Check orthostatic blood pressure. Assist client in rising slowly from Escitalopram Drowsiness, dizziness, weight gain, sexual dysfunction, restlessness, dry (Lexapro) mouth, headache, nausea, and diarrhea sitting position. Encourage use of sugar-free beverages or hard candy. Administer with food. Administer with food. Encourage use of sugar-free beverages or hard candy. Vortioxetine Nausea, vomiting, constipation, dry mouth, weight gain, sexual dysfunction, (Trintellix) and constipation Promote balanced nutrition and exercise. Report sexual difficulties to physician. SSRI: selective serotonin reuptake inhibitor. Fluoxetine (Prozac) produces a slightly higher rate of mild agitation and weight loss but less somnolence. It has a half-life of more than 7 days, which differs from the 25-hour half-life of other SSRIs. Cyclic Antidepressants. Tricyclics, introduced for the treatment of depression in the mid-1950s, are the oldest antidepressants. They relieve symptoms of hopelessness, helplessness, anhedonia, inappropriate guilt, suicidal ideation, and daily mood variations (cranky in the morning and better in the evening). Other indications include panic disorder, obsessive–compulsive disorder, and eating disorders. Each drug has a different degree of efficacy in blocking the activity of norepinephrine and serotonin or increasing the sensitivity of postsynaptic receptor sites. Tricyclic (and also heterocyclic) antidepressants have a lag period of 10 to 14 days before reaching a serum level that begins to alter symptoms; they take 6 weeks to reach full effect. Because they have a long serum half-life, there is a lag period of 1 to 4 weeks before steady plasma levels are reached and the client’s symptoms begin to decrease. They cost less, primarily because they have been around longer and generic forms are available. Tricyclic antidepressants are contraindicated in severe impairment of liver function and in myocardial infarction (acute recovery phase). They cannot be given concurrently with MAOIs. Because of their anticholinergic side effects, tricyclic antidepressants must be used cautiously in clients who have glaucoma, benign prostatic hypertrophy, urinary retention or obstruction, diabetes mellitus, hyperthyroidism, cardiovascular disease, renal impairment, or respiratory disorders (Table 17.2 ). TABLE 17.2 Tricyclic Antidepressant Medications Generic (Trade) Name Side Effects Nursing Implications https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwu… 6/23 11/16/23, 10:30 AM Realizeit for Student Assist client in rising slowly from sitting position. Administer at bedtime. Amitriptyline (Elavil) Dizziness, orthostatic hypotension, tachycardia, sedation, headache, tremor, blurred vision, constipation, dry mouth and throat, weight gain, urinary hesitancy, and sweating Encourage use of sugar-free beverages and hard candy. Ensure adequate fluids and balanced nutrition. Encourage exercise. Monitor cardiac function. Assist client in rising slowly from sitting position. Administer at bedtime if client is sedated. Amoxapine Dizziness, orthostatic hypotension, sedation, insomnia, constipation, dry mouth (Asendin) and throat, and rashes Ensure adequate fluids. Encourage use of sugar-free beverages and hard candy. Report rashes to physician. Assist client in rising slowly from sitting position. Administer at bedtime if client is sedated. Doxepin Dizziness, orthostatic hypotension, tachycardia, sedation, blurred vision, (Sinequan) constipation, dry mouth and throat, weight gain, and sweating Ensure adequate fluids and balanced nutrition. Encourage use of sugar-free beverages and hard candy. Encourage exercise. Assist client in rising slowly from sitting or supine position. Ensure adequate fluids and Imipramine Dizziness, orthostatic hypotension, weakness, fatigue, blurred vision, (Tofranil) constipation, dry mouth and throat, and weight gain balanced nutrition. Encourage use of sugar-free beverages and hard candy. Encourage exercise. Desipramine Cardiac dysrhythmias, dizziness, orthostatic hypotension, excitement, insomnia, (Norpramin) sexual dysfunction, dry mouth and throat, and rashes Monitor cardiac function. Assist client in rising slowly from sitting position. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwu… 7/23 11/16/23, 10:30 AM Realizeit for Student Administer in AM if client is having insomnia. Encourage sugar-free beverages and hard candy. Report rashes or sexual difficulties to physician. Monitor cardiac function. Administer in AM if stimulated. Nortriptyline Cardiac dysrhythmias, tachycardia, confusion, excitement, tremor, constipation, (Pamelor) and dry mouth and throat Ensure adequate fluids. Encourage use of sugar-free beverages and hard candy. Report confusion to physician. Overdosage of tricyclic antidepressants occurs over several days and results in confusion, agitation, hallucinations, hyperpyrexia, and increased reflexes. Seizures, coma, and cardiovascular toxicity can occur with ensuing tachycardia, decreased output, depressed contractility, and atrioventricular block. Because many older adults have concomitant health problems, cyclic antidepressants are used less often in the geriatric population than newer types of antidepressants that have fewer side effects and less drug interactions. Amoxapine (Asendin) may cause extrapyramidal symptoms, tardive dyskinesia, and neuroleptic malignant syndrome. It can create tolerance in 1 to 3 months. It increases appetite and causes weight gain and cravings for sweets. Maprotiline (Ludiomil) carries a risk for seizures (especially in heavy drinkers), severe constipation and urinary retention, stomatitis, and other side effects; this leads to poor compliance. The drug is started and withdrawn gradually. Central nervous system depressants can increase the effects of this drug. Atypical Antidepressants. Atypical antidepressants are used when the client has an inadequate response to or side effects from SSRIs. Atypical antidepressants include venlafaxine (Effexor), duloxetine (Cymbalta), bupropion (Wellbutrin), nefazodone (Serzone), mirtazapine (Remeron), and vilazodone (Viibryd) (Table 17.3 ). TABLE 17.3 Atypical Antidepressants Generic (Trade) Name Side Effects Nursing Implications Administer with food. Venlafaxine (Effexor) SNRI Increased blood pressure and pulse, nausea, vomiting, headache, dizziness, drowsiness, dry mouth, and sweating; can alter many lab tests, e.g., AST, ALT, alkaline phosphatase, creatinine, glucose, and electrolytes Ensure adequate fluids. Give in PM. Encourage use of sugar-free beverages or hard candy. Administer with food. Desvenlafaxine Headache, sedation or insomnia, agitation, dry mouth, constipation, sweating, (Pristiq) SNRI increased blood pressure, dizziness Encourage use of sugar-free beverages or candy. Rise slowly from sitting or lying position. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwu… 8/23 11/16/23, 10:30 AM Realizeit for Student Administer with food. Duloxetine (Cymbalta) SNRI Increased blood pressure and pulse, nausea, vomiting, drowsiness or insomnia, headache, dry mouth, constipation, lowered seizure threshold, and sexual dysfunction Ensure adequate fluids. Encourage use of sugar-free beverages or hard candy. Give with food. Administer dose in AM. Bupropion Nausea, vomiting, lowered seizure threshold, agitation, restlessness, insomnia, (Wellbutrin) may alter taste, blurred vision, weight gain, and headache Ensure balanced nutrition and exercise. Administer before meal (food Nefazodone Headache; dizziness; drowsiness; alters results of AST, ALT, LDH, cholesterol, (Serzone) glucose, and hematocrit inhibits absorption). Monitor liver and kidney functions. Administer in PM. Encourage use of sugar-free beverages and hard candy. Mirtazapine Sedation, dizziness, dry mouth and throat, weight gain, sexual dysfunction, (Remeron) and constipation Ensure adequate fluids and balanced nutrition. Report sexual difficulties to physician. Administer in AM. Administer with food. Encourage use of sugar-free beverages and Vilazodone Diarrhea, dizziness, dry mouth, nausea, insomnia, blurred vision, and sexual (Viibryd) dysfunction hard candy. Ensure adequate fluids and balanced nutrition. Report sexual difficulties to physician. ALT: alanine aminotransferase; AST: aspartate aminotransferase; LDH: lactate dehydrogenase; SNRI: serotonin and norepinephrine reuptake inhibitor. Venlafaxine blocks the reuptake of serotonin, norepinephrine, and dopamine (weakly). Duloxetine selectively blocks both serotonin and norepinephrine. Bupropion modestly inhibits the reuptake of norepinephrine, weakly inhibits the reuptake of dopamine, and has no effects on serotonin. Bupropion is marketed as Zyban for smoking cessation. Nefazodone inhibits the reuptake of serotonin and norepinephrine and has few side effects. Its half-life is 4 hours, and it can be used in clients with liver and kidney disease. It increases the action of certain benzodiazepines (alprazolam, estazolam, and triazolam) and the H2 blocker terfenadine. Remeron also inhibits the reuptake of serotonin and norepinephrine, and it has few sexual side effects; however, its use comes with a higher incidence of weight gain, sedation, and anticholinergic side effects. Vilazodone may also treat anxiety that often accompanies depression (Stuivenga et al., 2018). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdwu… 9/23 11/16/23, 10:30 AM Realizeit for Student Monoamine Oxidase Inhibitors. MAOIs have been used infrequently because of potentially fatal side effects and interactions with numerous drugs, both prescription and over-the-counter preparations (Table 17.4). However, they may be superior to typical medications for treatment of typical and treatment-resistant depression (Ricken, Ulrich, Schlattmann, & Adi, 2017). The most serious side effect is hypertensive crisis, a life-threatening condition that can result when a client taking MAOIs ingests tyramine-containing foods and fluids or other medications. Symptoms are occipital headache, hypertension, nausea, vomiting, chills, sweating, restlessness, nuchal rigidity, dilated pupils, fever, and motor agitation. These can lead to hyperpyrexia, cerebral hemorrhage, and death. The MAOI–tyramine interaction produces symptoms within 20 to 60 minutes after ingestion. For hypertensive crisis, transient antihypertensive agents, such as phentolamine mesylate, are given to dilate blood vessels and decrease vascular resistance (Burchum & Rosenthal, 2018). TABLE 17.4 MAOI Antidepressants Generic (Trade) Name Side Effects Nursing Implications Assist client in rising slowly from sitting position. Isocarboxazid (Marplan) Phenelzine (Nardil) Administer in AM. Drowsiness, dry mouth, overactivity, insomnia, nausea, anorexia, constipation, urinary retention, and orthostatic hypotension Tranylcypromine Administer with food. Ensure adequate fluids. (Parnate) Perform essential teaching on importance of low-tyramine diet. MAOI: monoamine oxidase inhibitor. There is a 2- to 4-week lag period before MAOIs reach therapeutic levels. Because of the lag period, adequate washout periods of 5 to 6 weeks are recommended between the times that the MAOI is discontinued and another class of antidepressant is started. DRUG ALERT Serotonin Syndrome Serotonin syndrome occurs when there is an inadequate washout period between taking MAOIs and SSRIs or when MAOIs are combined with mep include: Change in mental state: confusion and agitation Neuromuscular excitement: muscle rigidity, weakness, sluggish pupils, shivering, tremors, myoclonic jerks, collapse, and muscle paralysis Autonomic abnormalities: hyperthermia, tachycardia, tachypnea, hypersalivation, and diaphoresis DRUG ALERT Overdose of MAOI and Cyclic Antidepressants Both the cyclic compounds and MAOIs are potentially lethal when taken in overdose. To decrease this risk, depressed or impulsive clients who are categories may need to have prescriptions and refills in limited amounts. DRUG ALERT MAOI Drug Interactions There are numerous drugs that interact with MAOIs. The following drugs cause potentially fatal interactions: https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdw… 10/23 11/16/23, 10:30 AM Realizeit for Student Amphetamines Ephedrine Fenfluramine Isoproterenol Meperidine Phenylephrine Phenylpropanolamine Pseudoephedrine SSRI antidepressants Tricyclic antidepressants Tyramine Managing Medications The increased activity and improved mood that antidepressants produce can provide the energy for suicidal clients to carry out the act. Thus, the nurse must assess suicide risk even when clients are receiving antidepressants. It is also important to ensure that clients ingest the medication and are not saving it in an attempt to commit suicide. As clients become ready for discharge, careful assessment of suicide potential is important because they will have a supply of antidepressant medication at home. SSRIs are rarely fatal in overdose, but cyclic and MAOI antidepressants are potentially fatal. Prescriptions may need to be limited to only a 1-week supply at a time if concerns linger about overdose. An important component of client care is management of side effects. The nurse must make careful observations and ask clients pertinent questions to determine how they are tolerating medications. Tables 17.1 through 17.4 give specific interventions to manage side effects of antidepressant medications. Clients and their families must learn how to manage the medication regimen because clients may need to take these medications for months, years, or even a lifetime. Education promotes compliance. Clients must know how often they need to return for monitoring and diagnostic tests. Drug Therapy Antidepressant therapy may be indicated if depressive symptoms persist at least 2 weeks, impair social relationships or work performance, and occur independently of life events. Antidepressants are used to regulate mood specifically affecting serotonin, norepinephrine, and dopamine. Antidepressant effects are attributed to changes in receptors rather than changes in neurotransmitters. Although some of the drugs act more selectively on one neurotransmission system than another initially, this selectivity seems to be lost with chronic administration. Drugs used in the pharmacologic management of depressive disorders are derived from several chemical groups. Older antidepressants include the tricyclic antidepressants (TCAs) and the monoamine oxidase (MAO) inhibitors. Newer drugs include the selective serotonin reuptake inhibitors (SSRIs), the serotonin–norepinephrine reuptake inhibitors (SNRIs), and several adjuvant atypical antidepressant drugs that differ from TCAs and MAO inhibitors. As the name implies, reuptake inhibitors block the reuptake of certain neurotransmitters (serotonin with the SSRIs and serotonin and norepinephrine with the SNRIs). General characteristics of antidepressants include the following: All are effective in relieving depression, but they differ in their adverse effects. People must take them for 2 to 4 weeks before depressive symptoms improve. Administration is oral. Absorbed from the small bowel, they enter the portal circulation and circulate through the liver, where they undergo extensive first-pass metabolism before reaching the systemic circulation. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdw… 11/23 11/16/23, 10:30 AM Realizeit for Student Metabolism is by the cytochrome P450 (CYP) enzymes in the liver. Thus, antidepressants may interact with each other and with a wide variety of drugs that are normally metabolized by the same subgroups of enzymes. Additionally, there is a documented ethnic variation (ethnopharmacology) in response to antidepressants. Genetic and Ethnic Differences in Response to Antidepressant Drug Therapy Antidepressant therapy for nonwhite populations in the United States is based primarily on dosage recommendations, pharmacokinetic data, and a recipients. However, several studies document differences in drug effects in nonwhite populations mainly attributed to genetic or ethnic variations i enzyme activity of the cytochrome P450 enzyme system. People are poor, intermediate, extensive, or ultrafast metabolizers. Although all ethnic gro individual members may respond differently, health care providers must consider potential differences in responses to drug therapy. African Americans may be poor metabolizers and tend to have higher plasma drug levels for a given dose, respond more rapidly, experience a hi metabolize tricyclic antidepressants (TCAs) more slowly than whites. With lithium, African Americans report more adverse reactions than whites a Asians tend to metabolize antidepressant drugs slowly (poor metabolizers) and, therefore, have higher plasma drug levels for a given dose than w a limited number of Asian subgroups. Thus, it cannot be assumed that all antidepressants and all people of Asian heritage respond similarly. With between effects in Asians and whites. Information regarding the reaction of the Hispanic population to antidepressants is largely unknown. Few studies have been performed; some repo greater susceptibility to adverse effects, whereas others report no differences between Hispanics and whites. Because the available drugs have similar efficacy in treating depression, the choice of an antidepressant depends on the patient’s age; medical condition; previous history of drug response, if any; and the specific drug’s adverse effects. Also, prescribers often use the side effect profile to help determine the best choice for a specific patient. In addition, cost is a factor to consider. Although the newer drugs are much more expensive than the TCAs, they may be more cost-effective overall because TCAs are more likely to cause serious adverse effects, they require monitoring of plasma drug levels and electrocardiograms (ECGs), and patients are more likely to stop taking them. It is important to note that sudden termination of most antidepressants results in antidepressant discontinuation syndrome. In general, symptoms, which include flulike symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal, develop more rapidly and may be more intense with drugs that have a short half-life and/or that are given for long periods. As with other psychotropic drugs, to avoid this syndrome, it is essential to taper the dosage of the antidepressant and discontinue it gradually, over 6 to 8 weeks, unless severe drug toxicity, anaphylactic reaction, or another life-threatening condition is present. The occurrence of withdrawal symptoms may indicate skipped doses or abrupt discontinuation of the drug. 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. Self or Caregiver Administration With a tricyclic antidepressant (e.g., amitriptyline), take at bedtime to aid sleep and decrease adverse effects. Also, report urinary retention, fainting, irregular heartbeat, seizures, restlessness, and mental confusion. These are potentially serious adverse drug effects. With a selective serotonin reuptake inhibitor, take the drug in the morning because it may interfere with sleep if taken at bedtime. In addition, notify a health care provider if a skin rash or other allergic reaction occurs. Allergic reactions are uncommon but may require that the drug be discontinued. Recognize the importance of follow-up and seeking professional help for the signs of dizziness or insomnia or other symptoms that negatively affect your life. Realize that escitalopram (Lexapro) is a derivative of citalopram (Celexa). The two medications should not be taken concomitantly. With venlafaxine (Effexor), take as directed or ask for instructions. This drug is often taken twice daily. Notify a health care provider if a skin rash or other allergic reaction occurs. An allergic reaction may require that the drug be discontinued. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdw… 12/23 11/16/23, 10:30 AM Realizeit for Student With venlafaxine, use effective birth control methods while taking this drug. Pregnancy is a contraindication. With duloxetine and desvenlafaxine, swallow the medication whole; do not crush, chew, or sprinkle capsule contents on food. With phenelzine and other monoamine oxidase inhibitors, foods that contain tyramine or tyrosine may have to be avoided altogether to prevent the risk of hypertensive crisis. This includes aged cheeses, coffee, chocolate, wine, bananas, avocados, fava beans, and most fermented and pickled foods. Bupropion is a unique drug prescribed for depression (brand name, Wellbutrin) and for smoking cessation (brand name, Zyban). It is extremely important not to increase the dose or take the two brand names at the same time (as might happen with different physicians or filling prescriptions at different pharmacies). Overdoses may cause seizures as well as other adverse effects. When used for smoking cessation, Zyban is recommended for up to 12 weeks if progress is being made. If significant progress is not made by approximately 7 weeks, it is considered unlikely that longer drug use will be helpful. There are short-, intermediate-, and long-acting forms of bupropion that are taken three times, two times, or one time per day, respectively. Be sure to take your medication as prescribed by your physician. Make sure that you and the people you live with are familiar with the signs and symptoms of worsening depression and know how to seek help for signs of overdose. Tricyclic Antidepressants TCAs are the oldest antidepressants, although they are now second-line drugs for the treatment of depression. Imipramine is the prototype. A patient’s previous response or susceptibility to adverse effects may be the basis for initial selection of TCAs. For example, if a patient (or a close family member) once responded well to a particular drug, that drug is probably the drug of choice for repeated episodes of depression. The response of family members to individual drugs may be significant because there is a strong genetic component to depression and drug response. If therapeutic effects do not occur within 4 weeks, it is probably necessary to discontinue or change the TCA, because some patients tolerate or respond better to one TCA than to another. For patients with suicidal tendencies, beginning an SSRI or another newer drug is preferred over a TCA due to the safety profile. Pharmacokinetics Imipramine is well absorbed after oral administration, and the drug is widely distributed in body tissues. Peak levels occur in 2 to 6 hours, and the duration of action is unknown. Its half-life is 8 to 21 hours. Imipramine is metabolized in the liver by CYP2D6 enzymes to the active metabolite, desipramine, and inactive metabolites. It goes through significant first-pass metabolism. Imipramine is excreted primarily in the urine as metabolites. Action Imipramine blocks the reuptake of norepinephrine and serotonin at the presynaptic nerve endings, increasing the action of both neurotransmitters. The drug’s use in enuresis may be due to the fact that imipramine also blocks acetylcholine receptors. Use Imipramine may be useful in the treatment of depression. Prescribers may order it for children and adolescents in the management of enuresis (bed wetting or involuntary urination resulting from a physical or psychological disorder) after physical causes (e.g., urethral irritation, excessive intake of fluids) have been ruled out. Use in Children TCAs are more toxic in overdose than other antidepressants, and suicide is a leading cause of death in adolescents. The U.S. Food and Drug Administration (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 who are taking antidepressants, including imipramine. However, in clinical trials, imipramine and other TCAs have not been shown to be superior to placebo for the treatment of depression in children and adolescents. TCAs are not recommended as first-line agents, although they may be beneficial in patients with attention deficit hyperactivity disorder or enuresis. Use in Older Adults Imipramine may cause or aggravate conditions common in older adults (e.g., cardiac conduction abnormalities, urinary retention, narrowangle glaucoma). In addition, impaired compensatory mechanisms make older adults more likely to experience anticholinergic effects, confusion, orthostatic hypotension, and sedation. It is important to monitor vital signs, serum drug levels, and ECGs regularly. Use in Patients With Hepatic Impairment Hepatic impairment leads to higher plasma levels of imipramine. Thus, caution is necessary in patients with severe liver impairment. Use in Patients With Critical Illness https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdw… 13/23 11/16/23, 10:30 AM Realizeit for Student Adverse effects common with imipramine use (e.g., confusion, dysrhythmias, tachycardia, orthostatic hypotension, urinary retention) are a concern and may further compromise patients who are critically ill. Antidepressants, including imipramine, warrant very cautious use perioperatively because of the risk of serious adverse effects and interactions with anesthetics and other commonly used drugs. It is necessary to discontinue imipramine several days before elective surgery and resume it several days after surgery. Use in Patients Receiving Home Care The nurse who sees a patient taking imipramine in the home setting should assess him or her for improvement of symptoms, appropriate administration of the drug, and management of adverse effects, particularly safety factors. A nurse visiting the home for other reasons should observe for signs of depression; health concerns may precipitate symptoms. Adverse Effects Adverse effects of imipramine include sedation, orthostatic hypotension, cardiac dysrhythmias, anticholinergic symptoms (e.g., blurred vision, dry mouth, constipation, urinary retention), and weight gain. Symptoms of TCA overdose occur 1 to 4 hours after drug ingestion. They consist primarily of CNS depression and cardiovascular effects (e.g., nystagmus, tremor, restlessness, seizures, hypotension, dysrhythmias, myocardial depression). Death usually results from cardiac, respiratory, and circulatory failure. TCAs are associated with clearly defined withdrawal syndromes, and these drugs also have strong anticholinergic effects. When they are abruptly discontinued, cholinergic rebound may occur. Symptoms include hypersalivation, diarrhea, urinary urgency, abdominal cramping, and sweating. Contraindications Contraindications to imipramine include known sensitivity to the drug and immediately post–acute myocardial infarction. Nursing Implications Preventing Interactions Several drugs interact with imipramine. The drug may inhibit the metabolism of other drugs, including antidepressants, phenothiazines, carbamazepine, flecainide, and propafenone. The use of imipramine and MAO inhibitors concurrently may have serious effects, including severe seizures and death. Alcohol may increase the sedative effects of imipramine. The herb St. John’s wort may reduce the blood levels of imipramine and other TCAs. Grapefruit juice can inhibit the metabolism of imipramine and other TCAs. Administering the Medication People should take imipramine at bedtime to aid sleep and decrease daytime sedation. Overall, with TCAs, it is best to begin with small doses, which are increased to the desired dose over 1 to 2 weeks. Administration once or twice daily is possible because the drug has a long elimination half-life. Measurement of plasma levels is helpful in adjusting drug dosages. Imipramine, like other TCAs, should not be administered with grapefruit juice. Assessing for Therapeutic Effects The nurse is aware of patient statements about feeling better or less depressed. He or she observes for increased appetite, physical activity, and interest in surroundings; improved sleep patterns; improved appearance; decreased anxiety; and decreased somatic complaints. Mood elevation may take 2 to 3 weeks or longer. Note that it may even take 4 to 8 weeks of treatment before a patient may experience a response, partial response, or no response to imipramine. Assessing for Adverse Effects The nurse observes for CNS effects, gastrointestinal (GI) effects, cardiovascular effects, and other effects. Because imipramine may have adverse effects on the heart, especially in overdose, experts recommend baseline and follow-up ECGs for all patients. In addition, it is important to assess for suicidal thoughts or plans, especially at the beginning of therapy or when dosages are increased or decreased. Patient Teaching 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. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUZWdjLO5UHpukqIHual8pZRZOPKGxj61nPC0Rzizzdw… 14/23 11/16/23, 10:30 AM Realizeit for Student 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. Self or Caregiver Administration With a tricyclic antidepressant (e.g., amitriptyline), take at bedtime to aid sleep and decrease adverse effects. Also, report urinary retention, fainting, irregular heartbeat, seizures, restlessness, and mental confusion. These are potentially serious adverse drug effects. With a selective serotonin reuptake inhibitor, take the drug in the morning because it may interfere with sleep if taken at bedtime. In addition, notify a health care provider if a skin rash or other allergic reaction occurs. Allergic reactions are uncommon but may require that the drug be discontinued. Recognize the importance of follow-up and seeking professional help for the signs of dizziness or insomnia or other symptoms that negatively affect your life. Realize that escitalopram (Lexapro) is a derivative of citalopram (Celexa). The two medications should not be taken concomitantly. With venlafaxine (Effexor), take as directed or ask for instructions. This drug is often taken twice daily. Notify a health care provider if a skin rash or other allergic reaction occurs. An allergic reaction may require that the drug be discontinued. With venlafaxine, use effective birth control methods while taking this drug. Pregnancy is a contraindication. With duloxetine and desvenlafaxine, swallow the medication whole; do not crush, chew, or sprinkle capsule contents on food. With phenelzine and other monoamine oxidase inhibitors, foods that contain tyramine or tyrosine may have to be avoided altogether to prevent the risk of hypertensive crisis. This includes aged cheeses, coffee, chocolate, wine, bananas, avocados, fava beans, and most fermented and pickled foods. Bupropion is a unique drug prescribed for depression (brand name, Wellbutrin) and for smoking cessation (brand name, Zyban). It is extremely important not to increase the dose or take the two brand names at the same time (as might happen with different physicians or filling prescriptions at different pharmacies). Overdoses may cause seizures as well as other adverse effects. When used for smoking cessa