Antidepressant Agents Flashcards
What are the signs and symptoms of depression?
- Low energy
- Sleep disturbances
- Altered appetite
- Altered libido
- Inability to perform activites of daily living
- Overwhelming feelings of sadness, despair, hopelessness, and disorganization
- Altered affect
What is the
Biogenic Theory of Depression?
- Depression results from a deficiency of norepinephrine (NE), dopamine, and serotonin (5HT)
- Monamine oxidase may break them down to be recycled or restored in the neuron
- Rapid fire of neurons may lead to their depletion
- The # or sensitivity of receptors may increase, depleting neurotransmitter levels.
Antidepressant Therapy
Mechanisms of Action
- Inhibit the effects of MAO => increased NE or 5HT in the synaptic cleft
- BLOCK reuptake by the releasing nerve => increased neurotransmitters in the synaptic cleft
- Regulate receptor sites and breakdown of neurotransmitters, leading to an accumulation of neurotransmitters in the synaptic cleft
Types of Antidepressants
- Triclycic antidepressants (TCAs)
- MAO inhibitors (MAOIs)
- Selective serotonin reuptake inhibitors (SSRIs)
- Serotonin neorepinephrine inhibitors (SNRIs)
- Others
Considerations for use of antidepressants
in Children
- Rule out medical reasons first
- First choice: SSRIs and SNRIs
- Response is unpredictable
- Possible long term effects
- Studies have not proven efficacy
- Many black box warnings r/t increased sucidal ideation/behavior
- Avoid MAOIs d/t drug-food interactions
Considerations for use of antidepressants
in Adults
- Rule out medical reasons first
- Effects may not be seen for 4 weeks or more
- Caution during pregnancy/lactation
Considerations for use of antidepressants
in Older Adults
- Rule out medical reasons first
- More susceptible to adv. effects (especially CNS effects)
- Renal and hepatic impairment: Start LOW and Go SLOW
- TCAs can worsen Benign Prostatic Hyperplasia (BPH) because they decrease bladder contractions
TCAs
Mechanism of Action
Reduces the reuptake of 5HT AND NE into the nerves => increase in the synaptic cleft
TCAs
Indications
- Depression
- Sleep disorders
- Enuresis (nightime bedwetting)
- Anxiety
- Chronic Pain
TCAs
Drug Names
“-triptyline”
* Amitriptyline
* Nortriptyline
“-pramine”
* Clomipramine
* Despramine
* Imipramine
* Trimipramine
Doxepin
TCAs
Contraindications
Absolute:
* Allergy
Relative:
* Recent MI (can cause it to worsen or reoccur)
Cautions:
* CV disease
* Anticholinergic conditions (BPH, glaucoma, urinary retention)
* Manic-depression/ bipolar (can shift into manic phase)
* Seizure disorders (can lower the threshold for seizures)
TCAs
Adverse Effects
- CNS: sedation, sleep disturbances, fatigue, hallucinations, ataxia (lack of voluntary muscle control)
- GI: Dry mouth, constipation, n&v, anorexia, decreased salivation
- CV: tachycardia, hypertension, arrhythmias
TCAs
Drug Interactions
- MAOIs
- Cimetidine (Histamine-2 antagonist)
- Fluoxetine (SSRI)
Risk of death
TCAs
Assessment
History:
* Cardiac dysfunction/disease
Labs:
* ECG
TCAs
Implementation/Patient Teaching
- Limit drug access if pt is suicidal (dec. risk of overdose)
- Parenteral form only if Oral is not feasible
- Reduce dose if minor adv. effects occur
- Discontinue slowly if major adv. effects occur
- Take at bedtime if drowsiness occurs
- Void before meds if urinary retention occurs
- sugarless lozenges for dry mouth
- small meals/take with meal for GI upset
- Takes 4 weeks to take effect
MAOIs
Mechanism of Action
Irreversibly inhibits monoamine oxidase
Allows NE, 5HT, and dopamine to accumulate in the synaptic cleft
NOT 1st line/1st choice
MAOIs
Indications
Depression
MAOIs
Drug Names
Isocarboxazid
Phenelzine
Tranylcypromine
Selegiline (transdermal)
MAOIs
Contraindications
Absolute:
* Allergy
* Pheochromocytoma (adrenal gland tumor)
Relative: (made worse)
* CV disease
* Headaches
* Renal or Hepatic impairment
Cautions:
* Bipolar disease (can lead to mania)
* Seizure disorder (lowers the threshold for seizures)
* Hyperthyroidism (made worse)
MAOIs
Adverse Effects
CNS: dizziness, diaphoresis, excitement, nervousness, mania, hyperreflexia, tremors, confusion, insomnia, agitation
CV: Hypertension, tachycardia, arrhythmia
Black Box warning: suicidal ideation and behavior (especially in children and young adults)
MAOIs
Drug Interactions
Drug:
* Other antidepressants: Hypertensive crisis, coma, convulsions, serotonin syndrome
* Sympathomimetics: CV effects increase
* Antidiabetic agents: Increased risk of HYPOglycemia
Food:
* Tyramine: Increase in BP, possible hypertensive crisis
* Foods high in tyramine: aged cheeses and meats, red wine, soy sauce
MAOIs
Assessment
History:
* Cardiac dysfunction, seizure disorders, pheochromocytoma, headaches, hyperthryoidism
Labs:
* ECG
MAOIs
Implementation/Patient Teaching
- Limit drug access (potential overdose)
- Monitor BP and Ortho BP
- Discontinue drug at any complaint of severe headache (potential hypertensive crisis)
- Have phentolamine or adrenergic blocker on standby (antidote)
- Void before admin if at risk of urinary retention
- take with food for GI upset
- Patient Teaching - what to report to provider, follow up appts., emergency services for SI
Selective Serotonin Reuptake Inhibitors
SSRIs
Mechanism of Action
Specifically blocks the reuptake of 5HT, with little to no known effect on NE
Selective Serotonin Reuptake Inhibitors
SSRIs
Adverse Effects
- Not many because there is no effect on norepinephrine
Related to increase in 5HT:
* CNS: Headache, drowsiness, dizziness, insomnia, anxiety, tremor, agitation
* GU: Painful menstruation, sexual dysfunction, impotence, urgency
* Serotonin Syndrome
Selective Serotonin Reuptake Inhibitors
SSRIs
Indications
- Depression
- OCD
- Panic attacks
- bulimia
- PMDD
- post-traumatic stress disorders
- social phobias
- social anxiety disorders
Selective Serotonin Reuptake Inhibitors
SSRIs
Drug names
“-italopram”
* Citalopram
* Escitalopram
“-oxetine”
* Fluoxetine
* Paroxetine
Sertraline
Selective Serotonin Reuptake Inhibitors
SSRIs
Drug Interactions
Drug: (Increases risk of serotonin syndrome)
* MAOIs
* TCAs
* SNRIs
* St. John’s Wort
Selective Serotonin Reuptake Inhibitors
SSRIs
Contraindications
Absolute:
* Allergy
Cautions:
* impaired renal or hepatic function
* Pregnancy/lactation —> congenital abnormalities in animal studies
What is Serotonin Syndrome?
agitation, confusion, diaphoresis, increased BP, increased HR, diarrhea, headache, high fever, muscle rigidity, death
Serotonin Norepinephrine Reuptake Inhibitors
SNRIs
Mechanism of Action
Decreases neuronal reuptake of both serotonin and norepinephrine and more weakly inhibit dopamine reuptake
Serotonin Norepinephrine Reuptake Inhibitors
SNRIs
Indications
- Depression
- Neuropathic pain
- Fibromyalgia
- Anxiety (generalized and social)
Serotonin Norepinephrine Reuptake Inhibitors
SNRIs
Drug Names
- Desvenlafaxine
- Duloxetine
- Venlafaxine
Serotonin Norepinephrine Reuptake Inhibitors
SNRIs
Contraindications
Absolute:
* Allergy
* MAOIs use (increases risk of hypertenisve crisis and serotonin syndrome)
Cautions:
* Severe depression, suicidality (black box warning)
* Bipolar disorder (manic phase)
* Seizure disorder (lowers threshold)
Serotonin Norepinephrine Reuptake Inhibitors
SNRIs
Adverse effects
- Hyperhidrosis
- Erectile Dysfunction
- Cardiac: tachycardia, palpitations, hypertension
- abnormal bleeding
- anticholinergic: glaucoma, urinary retention, BHP
- Serotonin Syndrome
Serotonin Norepinephrine Reuptake Inhibitors
SNRIs
Drug Interactions
- MAOIs
- SSRIs, TCAs, serotonergic drugs (including St. John’s Wort)
- Anything that increases serotonin
SSRIs and SNRIs
Interventions/Patient Teaching
- Establish suicide precautions for severely depressed patients
- Limit the access to drugs (overdose risk)
- Administer the drug once a day, in the morning to achieve optimal Therapeutic effect (unless pt does better with the sedative effect at night)
- If severe GI effects, dose can be divided
- Can take 4 weeks to work
- Void before taking
- Risk of HT crisis, serotonin syndrome
Bupropion
Other antidepressant
Low doses: smoking cessation
Available in ER and SR formulas
Mirtazapine
Other Antidepressant
Atypical antidepressant
MANY anticholinergic effects
Trazadone
Other antidepressant
MANY CNS effects
Black Box warning for suicidality, hypotension, and priapism
Esketamine
Other Antidepressant
Nasal spray is approved for depression
CNS effects and increased BP
Antidepressants
General Nursing Assessment
History:
* Allergy, severe depression and suicidality, bipolar disorder, contraindications and cautions for specific drug class, impaired liver or kidney function, pregnancy/lactation
Physical:
* Vital signs and weight
* CNS, including vision
* Abdomen (GI issues)
Labs:
* Renal and hepatic
* EKG (for MAOIs and TCAs)
Antidepressants
General Nursing Conclusions
- Impaired comfort (r/t adverse effects)
- Altered thought process and sensory perception (r/t CNS effects)
- Malnutrition risk (r/t GI effects)
- Knowledge deficit
