Psychopharmacology Mood Disorders - Part 1 (Depressive Disorder) PDF

Psychopharmacology Mood disorders – Part 1 (Depressive Disorder) Presenter : Delmore Tyrell [email protected] May 2024 Learning Objectives Highlight DSM-5 criteria for diagnosing depression order Outline causes and symptoms of depression Discuss common drugs us...

Psychopharmacology Mood disorders – Part 1 (Depressive Disorder) Presenter : Delmore Tyrell [email protected] May 2024 Learning Objectives Highlight DSM-5 criteria for diagnosing depression order Outline causes and symptoms of depression Discuss common drugs used in the management of mood disorders - Depressive Identify factors which affect drug selection in the treatment of mood disorders –Depressive disorders To use an experimental case base approach Mood Disorder: Overview Mood Disorders: Also referred to as affective disorders - clinical pathology in which mood, the internal emotional state of a person is affected. DSM V-(Diagnostic and Statistical Manual of Mental Disorders-V ) classified mood disorders into two major types: ✓Depressive disorders ✓Bipolar Disorders  Mood Disorder : Definition Depressive Disorders According to DSM-V – depression is an illness characterized by feeling of hopelessness, sadness, worthlessness, changes in appetite, sleep patterns, delusion and hallucinations. Bipolar Disorders Previously known as manic-depression disorder , is a disorder with periods of emotional highs and lows encompassing the extremes of human experiences i.e. episodes of mania and depression Types of Depressive Disorders There are several types of depressive disorders, including: Bipolar disorder Major depressive disorder (MDD) or clinical depression Persistent depressive disorder (PDD) or dysthymia Postpartum depression Seasonal affective disorder (SAD)  Neurotransmitters that regulate mood Neurotransmitters Functions 1. Serotonin (5HT) Sensory perception and sleep pattern; feelings of well-being and happiness 2. Norepinephrine Arousal and dreaming ; flight or fight (NE) hormone 3. Dopamine (DA) Responsible for emotion, cognition and motor function 4. GABA Implicated in eating, sleeping, sexual behaviour and memory alteration Mood Disorders: Causes ?? ❑Causal basis unknown. Several factors appear to cause or precipitate. ❑Neurotransmitters and receptor theories ❑Biological markers - neuroendocrine abnormality ❑Psychological factors ❑Social influence ❑Other psychiatric disorders ❑Other medical problems ❑Drugs “Called the bio-psycho-social model of causation.” Neurotransmitter Imbalances 1. Serotonin (5HT) ❖Common contributor to mood problem. ❖Sad depressed mood, anxiety disorder, low energy levels ,sleeping problems associated with low levels. 2. Norepinephrine ❖ High levels are linked to anxiety, stress, high blood (NE) pressure, and hyperactivity. ❖Low levels are linked to lack of energy, focus, and motivation. Neurotransmitter Imbalances 3. Dopamine (DA) ❖High level has been observed in patients with poor GI function, autism, mood swings, psychosis, and children with attention disorders. ❖Low dopamine levels can drive us to use drugs (self medicate), alcohol, smoke cigarettes, gamble, and/or overeat 4. GABA ❖Major inhibitory neurotransmitter (Gamma Amino butyric ❖Significant mood modulator acid) ❖Implicated in eating, sleeping, sexual behaviour and memory alteration ❖Regulates norepinephrine, adrenaline, dopamine, and serotonin. ❖ Deficiency or down regulation  Theorized Biological Changes in Receptors Receptor upregulation Increase in receptor sensitivity Decreased receptor sensitivity  DEPRESSIVE DISORDERS “Case “ Meet MD She is a 30 Y/O female who has been well until 4 months ago when every things in her life drastically changed. She can’t put her finger on the exact situation that initiated the changes but she just doesn’t feel right. She reported being constantly tired. Ever since her parents were killed in a road accident some months ago she has increasingly felt low in mood. She sleeps poorly at night often waking at 3 am or even earlier. She has lost interest in cooking which she usually enjoys and has lost her appetite. Frequently she cries for no reason. “Perhaps I should end this life and join my parents in heaven” she says.  EPIDEMIOLOGY Depression is a common mental illness which is pervasive and often persistent A common illness worldwide that affects up to 3% of the population each year There is a wide range of symptoms and the extent of the incapacity caused by depression can vary from person to person Can lead to suicide - Over 700 000 people die due to suicide every year The lifetime risk is between 8% - 12% for men and 20% - 26% for women Many people who suffer depression will at some future stage of their lives suffer a further episode 20 % of patients with major depressive disorder develop psychotic symptoms  Depression: Diagnosis ❑ Screening tools ✓Hamilton Rating Scale Test (HAM-D) ✓ PHQ-9 ( the patient health questionnaire) – self reporting tool ❑ Dexamethasone suppression test (biomarker for psychiatry) - failure of suppression useful for identifying endogenous depression ( i.e., greater than 1.7mcg/dl after a single or multiple dosing protocol of dexamethasone) ❑ DSM-V (Diagnostic & Statistical Manual of Mental Disorder) criteria or ICD - 10 (international classification of Diseases) assessment tools (ICD-11 Jan 2022)  Diagnostic criteria- SIGECAPS (DSM-V) 1. Depressed Mood ( sad, hopeless, irritable - daily ) 2. Change in Sleep habits 3. Loss of pleasure/ Interest in usual activities (anhedonia) 4. Feelings of worthlessness or Guilt 5. Loss of Energy 6. Difficulties in thinking / Concentration 7. Appetite – weight loss or gain , thus ↑or ↓ appetite nearly daily 8. Psychomotor retardation or agitation 9. Recurrent thoughts of death and Suicide ❖Must include # 1 and 5 of the others symptoms occurring almost every day for 2 weeks  DEPRESSIVE DISORDERS “Case “ Meet MD She is a 30 Y/O female who has been well until 4 months ago when every things in her life drastically changed. She can’t put her finger on the exact situation that initiated the changes but she just doesn’t feel right. She reported being constantly tired. Ever since her parents were killed in a road accident some months ago she has increasingly felt low in mood. She sleeps poorly at night often waking at 3 am or even earlier. She has lost interest in cooking which she usually enjoys and has lost her appetite. Frequently she cries for no reason. “Perhaps I should end this life and join my parents in heaven” she says. What are the symptoms of depression Identified suffered by Ms. MD?  DEPRESSIVE DISORDERS “Case “ Meet MD She is a 30 Y/O female who has been well until 4 months ago when every things in her life drastically changed. She can’t put her finger on the exact situation that initiated the changes but she just doesn’t feel right. She reported being constantly tired. Ever since her parents were killed in a road accident some months ago she has increasingly felt low in mood. She sleeps poorly at night often waking at 3 am or even earlier. She has lost interest in cooking which she usually enjoys and has lost her appetite. Frequently she cries for no reason. “Perhaps I should end this life and join my parents in heaven” she says. What are the symptoms of depression Identified suffered by Ms. MD?  Treatment Options For Depression ❑Psychotherapy Interpersonal psychotherapy, cognitive behavioural therapy (CBT) Combination with pharmacotherapy Mindfulness-based cognitive therapy (MBCT) - Formal meditation practices (S.T.O.P) a mindful practice: S- Stop, or pause. T -Take a breath. O-Observe the body, thoughts, feelings, emotions, and physical sensations. P - Proceed with more awareness ❑Pharmacotherapy Quicker onset ❑Electroconvulsive therapy (ECT) - an electrical stimulation delivered to the brain to cause a seizure – use to manage refractory mental disorders Treatment Challenge (Psychiatrist) Approximately: 50% of cases are undiagnosed 50% diagnosed and not being treated 50% of those being treated not being treated optimally  Classes /Types of Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI’s) Serotonin and Norepinephrine Reuptake Inhibitors SNRI’s) Tricyclic/ Tetracyclic (TCA’s) MonoAmine Oxidase Inhibitors (MOAI’s) OTHERS  Drug selection criteria Patients history of response Family history Age Patients medical status Side effects profile Patients clinical presentation Cost Treatment Algorithm GOALs OF THERAPY Reducing symptoms Improving functioning Coping with triggers Preventing relapse Improving quality of life (Response: Remission: Recovery)  Treatment Guidelines ( Algorithm Affective Illnesses ) ❑ Texas Medication Algorithm Project (TMAP) start patient on one drug, allow adequate trial dose and duration – adjust according to response ❑ Sequenced Treatment behavioural Alternatives to Relieve Depression (STAR*D) study Uses various levels of treatment - starts SSRI and includes combination of behavioural therapy among levels Texas medication algorithm Project STAR*D Algorithm  SSRI’s Drug Trade Dosing Range Half life Names ® Citalapram Cipramil 10-60mg/day 35 hrs Escitalapram Lexapro 10-30mg/day 27-32hrs fluoxetine Prozac 20-80mg/day 24-96hrs Sertraline Zoloft 50-200mg/day 13-45 hrs Fluvoxamine Luvox 150-400mg/day ~17- 25hrs Paroxetine Paxil 20-50mg/day 24 Hrs  SSRI’s Mechanism of Action (MOA) Selectively inhibit the re-uptake of 5HT at the synapses, hence potentiating its action on the post-synaptic membrane. NB. Therapeutic action 2-4 weeks delay before therapeutic effects. SSRI’s-Pharmacokinetics Drug AB Metabolis Protein S m Binding Citalapram Not affected by food Liver 80 % Escitalapram Not affected Liver 56% by food Fluoxetine Not affected Liver to active 94.5% by food and less active metabolite Paroxetine Not affected Extensively liver 95% by food Sertraline Peak Abs Liver 98% delayed with food  Citalapram Versus Escitalapram Citalopram is a mixture of two stereo-isomers: R- citalopram and S- citalopram. Stereo-isomers are compounds that have the same chemical formula but differ only in their arrangement of atoms. Escitalopram contains only one isomer, S-citalopram. The equivalent dose of escitaapram is approximately half of that of citalapram This means the dosing range of escitalapram is 10-20 mg/day and the dosing range for citapram is 20-40 mg/day  Common Side Effects of SSRI’s Insomnia Loss of libido/ failure to orgasm Increased aggression and occasional violence reported Dry mouth Head ache and abnormal dream EPS - extrapyramidal symptoms (akathsia, dyskinesia,dystonia) Hyponatremia May precipitate mania and hypomania Memory Helper from online !  DRUG INTERACTIONS - SSRIs ❑Many SSRI’S are ✓Enzyme Inhibitors Inhibit hepatic cytochrome p450 isoenzymes which can lead to increase activity of other drugs. E.g. TCA’s (Increased anticholinergic actions) and warfarin (hemorrhagic complications) ✓Effect of other enzyme inhibitors E.g. Erythromycin, Ciprofloxacin ,Isoniazid– inhibit metabolism and ↑SSRI conc  SSRI’s Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) FDA approval date July 17, 1998 August 14, 2002 December 29, 1987 December 29, 1992 December 30, 1991 Pharmaceutical Forms 10mg, 20mg, 40mg 5mg, 10mg, 20mg tablets, 10mg tablets, 10mg, 20mg, 30mg, 40mg 25mg, 50mg, 100mg tablets, oral solution 5 mg/5 mL 10mg, 20mg, 40mg tablets, tablets, oral solution 10 mg/5 mL pulvules, oral suspension 10 mg/5 oral concentrate 20 oral solution 20mg/5mL, mL mg/mL weekly capsules 90 mg Recommended dose (for Major Depressive 20-40 mg/day 10–20 mg/day 5-20 mg/day 20 mg/day 50 mg/day Disorder) Drug interaction potential Relatively low Relatively low High Moderate to high Relatively low Most common side effects Nausea Nausea Nausea Nausea Nausea Dry mouth Insomnia Headache Drowsiness Headache Drowsiness Diarrhea Insomnia Headache Insomnia Insomnia Headache Nervousness Dry mouth Diarrhea Increased sweating Anxiety Dizziness Dry mouth Diarrhea Drowsiness Weakness Sexual dysfunction Anorexia Fatigue (ejaculation failure, Diarrhea Sexual dysfunction decreased libido) Increased sweating Drowsiness Diarrhea Dizziness Insomnia Fatigue  Citalopram (Celexa/ Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) cipramil) Less common side effects Tremor Sexual dysfunction Dizziness Tremor Tremor Sexual dysfunction (abnormal ejaculation, Weakness Constipation Increased sweating (abnormal ejaculation, decreased libido, Dry mouth Decreased appetite Agitation decreased libido, impotence) Anxiety Anxiety Anorexia impotence) Dry mouth Agitation Nervousness Nervousness Fatigue Drowsiness Tremor Anxiety Anxiety Fatigue Increased sweating Agitation Increased sweating Sexual dysfunction Anorexia Dizziness Anxiety Anorexia Half-life 35 hours 27–32 hours 2-4 days 20 hours (highly 26 hours variable) Time to steady-state 7 days 7 days 30 to 60 days 10-14 days 7-14 days Active Metabolite? Yes Yes, but not significant  SAFETY CONCERNS OF SSRI’s SSRIs are relatively safe. However, some examples of safety issues to be considered: ✓Pregnancy Some antidepressants may harm your child if you take them during pregnancy or while you're breast-feeding. Paroxetine in particular appears to increase the risk of birth defects, including heart and lung problems. ✓Abnormal bleeding: NSAIDs and anticoagulant increase risk of Bleeding ✓Serotonin Syndrome: seen with 2 drugs or some herbals ( St John wort) ✓Suicidal risk: teenagers, young adults < 25 Y/O Incr. risk ✓Abrupt discontinuation: Abrupt D/C or missing several doses can cause with-drawal like syndrome ( discontinuation syndrome ) ✓Withdrawal-like symptoms can include: Nausea, Dizziness, Lethargy, Flu-like symptoms  SNRI’s Drug Trade names DosingRange Half Life ® Duloxetine Cymbolta 40-60mg/d 12hrs Bupropion(NDRI) Wellbutrin/Zyban 100-450mg/d 21-37hrs Venlafaxine EffexorPristiq 37.5-375mg/d50- 5hrs Desvenlafaxine 100mg /d ˜11hrs  MOA – SNRI’s Serotonin (5HT) and Noradrenaline (NA) re-uptake inhibitors ( also slight dopamine inhibition – AKA NDRI’s {Noradrenaline and Dopamine re-uptake inhibitors}) Effects of these drugs, most times are considered similar to SSRI’s ▪ Other uses Bupropion- smoking cessation Use in other mental disorders- Anxiety disorder and other affective component in psychosis Serontonin and Noradrenaline Reuptake Inhitors (SNRI’S) ❑MOA: 5HT and NA re-uptake inhibitors (also slight dopamine inhibition) P/kinetics: Onset, peak, and duration of action are highly variable and depend on the formulation (immediate versus extended-release) ✓Primarily metabolized by the liver by the cytochrome P450 CYP2D6 enzyme. ✓Large volume of distribution. Side Effects - most time similar to SSRI’s ✓Most common - nausea and dry mouth ✓Increased BP, Nausea/Vomiting /Diarrhea -with venlafaxine  Venlafaxine versus Desvenlafaxine ❑Venlafaxine relies on CYP2D6 for conversion to desvenlafaxine while desvenlafaxine has no significant metabolism by CYP2D6 at recommended doses. ✓significant metabolism by CYP2D6 at recommended doses. ✓Both venlafaxine and desvenlafaxine have limited clinically significant drug interactions. The most ✓striking difference between the two products is cost ✓Hypertension is an important side effect to bear in mind when prescribing venlafaxine. Higher dose therapy is associated ✓with an increased risk of sustained elevations of blood pressure, hypertension is a dose related side effect  PRECAUTION Concurrent use with other antidepressants e.g. MAOI’s can result in SEROTONIN SYNDROME ✓Excess of NA & 5HT ✓Causing tremors, hyperthermia, M/rigidity CV collapse and CNS stimulation inducing seizures TREATMENT: anti-seizures, M/relaxant, 5HT blockers ( E.g. cyproheptadine -an antagonist at the 5-HT2, histamine H1, and muscarinic cholinergic receptors) New serotonergic Agents Levomilnacipran (Fetzima )- SNRI Vortioxetine (Trintellix ) - called serotonin modulators - SSRI Vilazodone (Viibryd) –SSRI – not associated with weight gain and sexual dysfunction Tricyclic Anti- depressants (TCA’S) Secondary Amines ✓Despramine ✓Nortriptyline ✓Protriptyline Tertiary Amines ✓Imipramine (150-300mg/day) ✓Amitriptyline(150-300mg/d) ✓Trimipramine ✓Doxepin ❑Effect drugs : SE profile reduce use. Must titrate upward slowly TCA’s ▪ Mechanism of action (MOA) TCA’s blocks the uptake of NE, 5HT and dopamine into the nerve pre-synaptic nerve ending. The net result is the potentiating of the neurotransmitters action at the post-synaptic receptor. Pharmcokinetics (TCA) TCA’s are all rapidly and well absorbed after oral dosing. May undergo first pass metabolism Lipophilic Strongly protein bound (90-95%) Metabolized in the liver Peak plasma levels ~ 2-6 hrs. t ½ are generally long ( 12-44hrs, average 24hrs) Therapeutic effect seen in 2-4 weeks TCA’s Side Effects T – toxic in overdose C – cardiovascular problems A – anticholinergic problems S – sleep problem SIDE EFFECTS- TCA’s Anti-muscarinic/ anti cholinergic Dry mouth Blurred vision and disturbance of accommodation Increased intraocular pressure Constipation Urinary retention These effects are worst with amitriptylline and weaker with desipramine SIDE EFFECTS TCA’s (contd) Others Postural hypotension Tachycardia Confusion Fatigue, sedation, drowsiness &lassitude Agitation, sweating and weight gain DRUG INTERACTIONS-TCA’s Enzyme Inhibitors –↑TCA’s level fluoxetine, cimetidine, erythromycin, verapamil Enzyme Inducers - ↓TCA’s level CZB, phenytoin , barbiturates Mgt – ↓ dose of TCA’S until enzyme inhibitor is removed while larger dose of TCA’s may be required in the presence of enzyme inducers. DRUG INTERACTIONS-TCA’s (cont’d) Others Alcohol- potentiates TCA’s drowsy effect. Clonidine – ↑antihypertensive effects IV NE/EP – 2-4 fold ↑in pressor pressure response MOAI’s – may cause hypertensive crisis, avoid large doses, monitor patient with combination therapy. When TCA’s to replace MOAI’s a washout period of 1-2 weeks is recommended.  CONTRAINIDICATION /PRECAUTION (TCA’s) Suicide ideation Concurrent use of MAOI’s BPH (Benign prostatic hyperplasia) and glaucoma (narrow angle) Pts with seizure (TCA’s lower the seizure threshold) MAOI’s DRUG TRADE DOSING RANGE NAMES ® Phenelzine Nardil 45-90mg/d Isocarboxazid Marplan 10-50mg/d Tranylcypromine Parnate 10-60mg/d SELEGILINE Emsam 20-40mg/d Transdermal FDA approved 2006 Patch* Moclobemide Aurorix 300-600/d (reversible MOAI’s)* MAOI’s First type of antidepressants developed ✓first discovered in the 1950s, inhibits the action of an enzyme called monoamine oxidase, whose role it is to break down monoamines Indication : atypical depression MOA: Inhibit monoamine oxidase (subtype A), preventing the breaking down of NA,5HT and dopamine. Pharmacokinetics - all are well absorbed orally - clinically active up to 2 weeks after discontinuation Common S/Es : MOAI’s- Major concerns Hypertensive crisis Cause: MAO inhibition prevents the metabolism of tyramine in the GI and liver, causing release of NA/NE. Clinical effects : sudden onset of painful occipital throbbing HA, severe HTN, profuse sweating, pallor, palpitation, and occasionally death. MAOI’s- Dietary restrictions Some tyramine containing food High content- not permitted - Aged, matured cheeses (unpasteurized) - Aged/fermented meats, fish, or poultry - Yeast extract e.g. brew’s yeast - Red wines e.g. sherry, vermouth Low content permissible - Chocolate and caffeine beverages - Fruits e.g. raisins, grapes, pineapple, oranges - Soy sauce - Yogurt, sour cream  OTHER ANTIDEPRESSANTS Roboxetine : 1st selective NARI (norepinephrine reuptake inhibitor) or NERi Trazodone: inhibits serotonin – Tricyclic related antidepressant aka serotonin modulator ( acts by altering post synaptic serotonin receptors) ; serotonin receptor antagonists and reuptake inhibitors (SARIs) : not a true SSRI but share many properties ✓Sedating without anticholinergic effects Nefazodone is a new antidepressant that is a structural analogue of trazodone but is less sedating Maprotine : similar to TCA’s Amoxapine : similar to TCA’s Mitrazapine : Remeron® - Tetracyclic Antidepressant ; Similar TCA’s (also blocks the effect of histamine) : sedating  OTHER ANTIDEPRESSANTS - (cont’d) Agomelatine ❑ Agomelatine (Valdoxan ®) , 2010 JA. – 1st melanotonergic antidepressant : a relatively new class, indicated in the treatment of major depressive episodes in adult no less 18 Y/O ❑ Relatively favorable side effect profile ❑Dose: 25mg initially, up to 50mg after 2 wks with no response (bedtime) ❑MOA: Resynchronises or causes restoration of circadian rhythms by stimulating melatonin receptor in the brain and blocking serotonin ( believed to be disrupted in depressed patients) ❑Test : LFT day 1 , 6wks then 3 months interval OTHER ANTIDEPRESSANTS - Agometaline (cont’d) C/I: Hypersensitivity to the active substance or to any of the excipients - Hepatic impairment (ie, cirrhosis or active liver disease) - Concomitant use of potent CYP1A2 inhibitors (eg, fluvoxamine, ciprofloxacin) -Valdoxan had a neutral effect on body weight, heart rate, and blood pressure in clinical studies. OTHER ANTIDEPRESSANTS (cont’d) ▪ Viladoxone : US FDA approved January 2011 ▪ Vilazodone is the first approved (2011)drug that is both a combination selective serotonin reuptake inhibitor (SSRI) and a partial agonist of serotonergic (5HT1A) receptors ▪ Not associated with wt gain or sexual dysfunction ▪ Its mechanism of action "is not fully understood but is thought to be related to its enhancement of serotonergic activity in the central nervous system through selective inhibition of serotonin reuptake. ▪ Dose : 10- 40mg daily ▪ SE: most common – D, N, V  Other drugs Anti – psychotics ; typical, atypical ( review listing BPD & Schiz PPT) Mirtazapine -an atypical antidepressant with noradrenergic and specific serotonergic activity ✓Mirtazapine (Remeron): Mixed antidepressant - acts distinctly as an alpha- 2 antagonist, consequently increasing synaptic norepinephrine and serotonin, while also blocking some postsynaptic serotonergic receptors that conceptually mediate excessive anxiety when stimulated with serotonin Benzodiazepines– very addictive, use controversial ( read more)  New Antidepressants ▪ Brintellix (Vortioxetine) -serotonin modulator and stimulator (SMS). ▪ Drug in development – SNDRI triple re-uptake inhibitors ✓Serotonin-norepinephrine-dopamine reuptake inhibitor (SNDRI) antidepressants are medications that are being developed to treat depression. Ansofaxine, a novel SNDRI, is in clinical trials for safety and efficacy for the treatment of the major depressive disorder ▪ Ketamine ( use in anesthesia) Currently seeking approval from the FDA to use in the MGT of depression. There is some research proving the effectiveness of ketamine improving the neurotransmitter/receptor activity. Therapeutic Option & Response Options - SSRI’s and TCAs ( suitable 1st choice) - SNRI’s – newer or third generations Time course of response - Weeks 1 &2: physical symptoms (sleep, appetite) - Weeks 3 & 4: energy level↑ (caution, suicide risk ) - Weeks 5 & 6 : emotional response - > 80 % of depressed pts will respond to at least one Antidepressants4. TREATMENT ASSESSMENT Review and optimize current therapy with response rate If no response, change to different agent If on a SSRI, switch to SNRI or mirtazapine. Assess at 6 and 12 weeks Partial response (20-50%), Response (≥50%), remission (75-80%) QOL : improved with treatment. TREATMENT ASSESSMENT (cont’d) Consider antidepressant combinations or augmentation with lithium, atypical antipsychotics, thyroid hormone, folic acid etc Consider ECT- gold standard in resistant depression Consider referral (if in primary care) Antidepressants may ↑ the risk of suicidal thoughts or action in children and young adults Newer agents : started with post marketing reports of ↑ed suicidal thought and self-injury in England 2003 FDA: 2004 suggest monitoring of all new drugs for child and adults  Patient Education/ S/E Mgt - Anticholinergic: dietary fibre, sugarless gum/candy - Orthostatic HTN: rise slowly, dangle feet at edge of bed - Sedation: dose medication at bedtime - For MAOI’s avoid foods containing tyramine - Expected response time - Duration of TX - Educate care givers PRECAUTIONS FOR ANTIDEPRESSANTS Drugs Precautions/ considerations TCA’s Heart dz, NA glaucoma, BPH, constipation, epilepsy, renal liver dz, syncope , sedation SSRI’s Liver dz, insomnia, agitation Bupropion Seizures, drug that lower seizure threshold Venlafaxine/ HTN, recent MI, renal/liver dz, anorexia Duloxetine Nefazodone Postural hypotension, liver dz, sedation Mirtazapine Renal/liver dz, CV disease, sedation  Discussion: questions & answers List symptoms associated with Ms. MD’s diagnosis. What is the stipulated time required for a diagnosis of depression to be made for Janet – contrast with anxiety T/F. The lifetime risk of depressive disorder is at highest % in men compared to female Discuss the use of BZD’s in the management of depression What management approach would you recommend for this patient-include in answer drug option/s, side effects and monitoring parameters. As the nurse for this patient, what monitoring would you carry out in a patient placed on warfarin and imipramine. What recommendation would you make to a Dr who orders the D/Cn of phenelzine and the addition of amitriptylline What time course response expected in Ms. MD’s with use of serotonergic agents  SUMMARY ❑Effective therapy of mood disorder often requires a multimodal approach and the achievement of remission may require more than one intervention ❑Knowledge of how to select and monitor both efficacy and safety of drugs used in mood disorders is critical to safe and effective pharmacotherapy ❑GOAL To eliminate mood episodes with complete remission of symptoms and to prevent further episodes Maintain adherence with therapy while minimizing medication adverse effects To eliminate factors contributing to illness The for clinicians (nurses etc.) in this field of practice to be familiar with the clinical presentation of mood disorders and its treatment in order to minimize the climbing challenges – especially in this era of pandemics  NURSES ROLE IN ADMINISTERING PSYCHOTROPIC AGENTS Actions – check and monitor vitals, administer meds. Assess patient’s status - mental and physical Observations – therapeutic effects, side effects, drug interaction, signs of adverse effects Information – provide to patient, psychiatrist, care givers and other members of health care team 68 References 1. Katzung, BG. (2001). Basic & Clinical Pharmacology(8th Ed.0 New york: Mcgraw Hill 2. Rang, H.P., Dale, M.M & Ritter, J.M(2000). Pharmacology (4th ed.) Edinburgh: Churchill Livingstone 3. Dipiro, Joseph T. Pharmacotherapy : A pathophysiological Approach (6th ed.) Mcgraw Hill 4. NHS ( MeReC Briefing) Specific issues in depression: Issue No. 17; pages 1-3 April 2002 5.http://www.medicinenet.com/mirtazapine/article.htm accessed May 2010 6. Antidepressant Use During Pregnancy May Increase Miscarriage Risk Accessed @ http://cme.medscape.com/viewarticle/723297?src=cmenews&uac=88115DY June 2010 7. Online search 2021- 22