Antidepressants Flashcards
MAOi medications
** Phenelzine (Nardil)
**Tranylcypromine (Parnate)
Isocarboxazid (Marplan)
Selegiline (Eldepryl)
SSRIs
citlaopram (Celexa)
fluoxetine (Prozac)
fluvoxamine(Luvox)
paroxetine (Paxil)
sertraline (Zoloft)
Selective Antagonist Receptor Inhibitors (SARI)
trazadone (Desyrel)
Serotonin and Norepinephrine Reuptake Inhibitors
(SNRI)
venlafaxine (Effexor)
Norepinephrine Dopamine Reuptake Inhibitors (NDRI)
bupropion (Wellbutrin or Zyban)
Tricyclic Antidepressants (TCA)
Amitriptyline (Elavil)
Clomipramine (Anafranil)
Imipramine (Tofranil)
Current indications for the ‘antidepressant’ class of medications
- Major Depressive Disorder (+/- psychosis)
- Panic Disorder
- Depression with Psychotic Features
- Social Anxiety Disorder / Social Phobia
- Depression NOS
- Generalized Anxiety Disorder (GAD)
- Bipolar Disorder - Depressed Phase
- Post-Traumatic Stress Disorder (PTSD)
- Seasonal Affective Disorder
- Bulimia Nervosa
- Dysthymia
- Smoking Cessation
- Depression 2 ot general medical
- Insomnia condition
- Fibromyalgia
- Obsessive Compulsive Disorder (OCD)
- Ortho knee pain, Pain management
SSRI mode of action
- SSRI’s block the reuptake of serotonin at the serotonin reuptake pumps of the neuronal membrane.
- This means that there is more serotonin available at the extracellular level that is available for reabsorption and use.
- This drug has a weak affinity for norepinephrine and dopamine therefore decreases side effects.
side effects of SSRIs
dry mouth, nausea + GI complaints dizziness, drowsiness, sexual dysfunction and headache.
what is the first choice of antidepressants
why?
SSRI
- only really affects the serotonin
- less cardiac SE as it doesn’t affect norepinephrine
- non-lethal with overdose
SSRI known for weight gain
citalopram
off label use of trazodone
sleeping/insomnia
off label use for zyban
smoking cessation
what does SNRI stand for
serotonin and norepinephrine reupale inhibitors
what does NDRI stand for
norepinephrine and dopamine inhibitors
what does SARI stand for
Selective Antagonist Receptor Inhibitors
what is discontinuation syndrome
- it may occur in patients who are not taking medications regularly
(especially with venlafaxine or paroxetine) - to minimize risk of SE meds should be tapered down prior to discontinuation
- avoid drug holidays
- can occur 1-3 days after discontinuation (depending on 1/2 life of medication)
- flu like symptoms arise (malaise, headache, dizziness, GI upset
- mood disturbances
- aggression
- suicidal tendencies
- sleep disturbances
- electric shock like sensations in the head and upper extremities
- vivid dreams/nightmares
- impaired concentration
serotonin syndrome
- reaction to too much serotonin
- occurs when combinations of agents given at same time without sufficient wash out period
- MAO-I in combo with SSRI, TCAm antipsychotics (increases dopamine and serotonin)
- potentially fatal
Tricyclic Antidepressants (TCA) mode of action
- TCA’s are thought to exert their antidepressant effect by blocking the reuptake of norepinephrine (NE) and/or serotonin (SE) into the neuron that released the neurotransmitters (it works within the synapse between the cells).
- They work in a similar manner as SSRI’s but involve more neurotransmitters.
neurochemical explanation for depression
- depression implies that there is an imbalance or deficiency of certain neurotransmitters (serotonin, norepinephrine and dopamine are the main neurotransmitters associated with mood disorders however in reality it much more complex than this).
- Another neurochemical explanation for depression is: that there is a problem at the receptor site or the secondary messenger systems postsynaptically that regulates the activity of the receptor site.
Monoamine Oxidase Inhibitors (MOA-I) mode of action
- MOA-I’s appear to exert their antidepressant effect through the inhibition of the enzyme monoamie oxidase in the nerve endings.
- Normally MAO’s deactivate certain neurotransmitters (including serotonin, norepinephrine and dopamine).
- Therefore, if we inhibit MAO, we increased amounts of serotonin, norepinephrine and dopamine available to act on the neurons in the nervous system.
Psychopharmacologic treatment of depression is based on ?
the restoration on normal neurotransmitter functioning
S&S of serotonin syndrome
- Sudden onset
- Fever (moderate)
- Diaphoresis
- Muscle Rigidity
- Hyperreflexia
- Increase HR
- Increase BP
- Delirium
- Hyperarousal and agitation
- shivering / tremors
Neuroleptic Malignant
Syndrome (NMS)
- Reaction to Dopamine
- More gradual onset
- Extreme Stiffness/Muscle rigidity
- Hyporreflexia
- Pupils normal
- Elevated CPK
- Fever
- Increase HR
- Increase BP
- Diaphoresis
- Changes to LOC
- Confusion/coma/death
alternative/conjunctive tx for depression with antidepressants
- CBT
- Psychotherapy
- ECT
- Transcranial Magnetic Stimulation
- Sleep Hygiene
- Exercise
- Diet: Omega 3 fatty acids + folic acid
** Adjunctive Therapy with meds
- Anticonvulsants (Gabapentin)
- Lithium to augment antidepressants
- Cytonel (Thyroid med)
- Atypical Antipsychotics (Olanzapine,
Risperidone, Quetiapine, Aripiprazole)
- Amphetamines (Ritalin)
- More than 1 antidepressant (SSRI/SNRI)
Maintenance Therapy
- Steady state comes with longer period (4-6 weeks)
- Initial treatment is 6-12 months
- Long term therapy considered for
Multiple episodes of depression
Hx of suicide
Elderly
Nursing Process/Patient
teaching
- Lag time of min. 2 weeks before therapeutic effects
- 4-6 weeks maximum therapeutic effect
(steady state) - Do not abruptly stop taking meds
- Report headache/palpitations and stiff neck immediately.
- Careful with hypotension or >BP venlafaxine
- Report eye pain to Dr. immediately (antidepressants put pts at risk for glaucoma)
- Managing anticholinergic SE
- Avoid driving if sedated from meds
- Stay out of the sun
- Sexual Dysfunction –esp. SSRI
- Some side effects are temporary and
should go away (anxiety, agitation,
blurred vision, nausea) - If taking MAO-I, need wash out period
before and after - If taking MAO -I avoid certain foods
- Monitor for SE of medications
- Suicidal/homicidal ideation
- OTC and prescription meds
- Substance use/abuse
- See Information Sheets: MAOI
- Assess for TD
which antidepressants are LEAST likely to be given to a pt at high risk for suicide
- MAOI
- TCA
- highly lethal with overdose
MAOIs useful in treating
Useful to treat depression with mixed anxiety,
panic disorder, phobic, social anxiety
disorder.
why are MAOI not first choice of antidepressants
- many SE
- highly lethal with overdose
- cannot be taken with other antidepressants
- certain foods must be avoided when taking
MAOI side effects
- Orthostatic hypotension (10-30%)
- Anticholinergic effects
- Anxiety, agitation, restlessness (CNS stimulation) (10-30%)
- Insomnia (10-30%)
- Hypomania/mania
- Psychosis
- Seizures
foods that must be avoided when taking MAOI -
why?
- Avoid foods tyramine
- Foods that have been aged, fermented,
pickled or smoked - Preserved meats (sausage, salami, liver)
- Aged cheeses (cheddar, blue, brie,
mozzarella) - Can eat cottage, cream, processed cheese
- Fermented (beer, ale, sherry wine, soy sauce)
- Pickled herring
- Caffeinated coffee/tea
- Can result in Hypertensive Crisis
S&S of Hypertensive Crisis
Palpitations
Increase HR
Tight Chest
Stiff neck
Throbbing/radiating headache
High BP
- CAN BE FATAL
TCAs useful to treat
depression, anxiety, OCD,
insomnia, pain management (chronic)
TCA Side Effects
- Tachycardia/dysrhythmias/orthostatic
hypotension (10-30%) - CNS Effects (10-30%)
- Sedation, nightmares, agitation, anxiety
- Anticholinergic Effects
Dry mouth, blurred vision, photosensitive, glaucoma, constipation, urinary retention - Weight gain (10-30%)
- Highly lethal with overdose (Use with caution in suicidal patients)
SSRIs useful to treat
MDD, GAD, Social Anxiety
Disorders, OCD, PTSD, Panic Disorders
SSRI Side Effects
GI complains (10-19%)
Headache
Dizziness
Anxiety/agitation/ akathisia
Insomnia/ sedation
Sexual dysfunction (10-30%)
First choice of treatment
Low SE profile
“wash out period” for MAOI
- Wash out period: when switching from MAOI you need to wait 14 days after frinishing it before starting a new medication.
- Before starting an MAOI you have to have a one week wash out period from other antidepressant
- Only exception is fluoxetine/Prozac 5-8 week wash out period before starting MAOI
- May result in serotonin syndrome from too much serotonin
why are tyramine foods contraindicated in MAOIs
o Liver can no longer metabolize tyramine
o Causes a release of norepinephrine – risk for hypertensive crisis – risk for stroke/fatal
