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ATI Pharmacology > CH 8: Depressive Disorders > Flashcards

CH 8: Depressive Disorders Flashcards

1
Q

Antidepressant medications are classified into five main groups:

A

1.selective serotonin reuptake inhibitors (SSRIs)
2. serotonin-norepinephrine reuptake inhibitors (SNRIs)
3. atypical antidepressants
4. tricyclic antidepressants (TCAs)
5. monoamine oxidase inhibitors (MAOIs).

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2
Q

How are atypical antispychotic meds used to treat depression?

A

They are used as monotherapy, and adjunct therapy for depression, and bipolar depressive disorders.

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3
Q

SSRI Meds include

A

Select Prototype Medication: Fluoxetine

Other Medications
Citalopram
Escitalopram
Paroxetine
Sertraline
Fluvoxamine

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4
Q

SNRIs meds include

A

Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran

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5
Q

SSRIs: Expected pharmacological action

A
  1. SSRIs selectively block reuptake of the monoamine neurotransmitter serotonin in the synaptic space, thereby intensifying the effects of serotonin.
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6
Q

Which meds are considered the first-line treatment for depression?

A

SSRIs. They can take 1 to 3 weeks or longer before pharmacological benefits take effect.

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7
Q

SSRIs: Therapeutic Uses

A
  1. Major depression
  2. Obsessive-compulsive disorders
  3. Bulimia nervosa
  4. Premenstrual dysphoric disorders
  5. Panic disorders
  6. Posttraumatic stress disorder
  7. Social anxiety disorder
  8. Generalized anxiety disorder
  9. Bipolar disorder
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8
Q

SSRIs Complications include

A
  1. Sexual dysfunction
  2. CNS stimulation
  3. Weight loss early in therapy
  4. Serotonin Syndrome
  5. Withdrawal syndrome
  6. Hyponatremia
  7. Rash
  8. Sleepiness, faintness, lightheadedness
  9. Gastrointestinal bleeding
  10. Bruxism
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9
Q

SSRI Complications– Sexual Dysfunction: Manifestations & Client Education

A

anorgasmia, impotence, increased libido

  1. remain aware of possible adverse effects and to notify the provider if intolerable
  2. Utilize ways to manage sexual dysfunction, which can include lowering dosage, discontinuing medication temporarily (med holiday), and using adjunct meds to improve sexual function (sildenafil, buspirone)
  3. An atypical antidepressant (bupropion) has fewer sexual dysfunction adverse effects
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10
Q

SSRI Complications– CNS Stimulation: Manifestations & Client Education

A

inability to sleep, agitation, anxiety

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11
Q

SSRI Complications– Weight loss in early therapy: Nursing Actions

A
  • can be follow by weight gain with long-term treatment
  1. monitor the client’s weight
  2. encourage clients to participate in regular exercise and to follow a healthy, well-balanced diet
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12
Q

SSRI Complications: Serotonin Syndrome- Manifestations

A

can begin 2-72 hr after starting tx and can be lethal

  1. Confusion, agitation, poor concentration, hostility
  2. Disorientation, hallucinations, delirium
  3. Seizures leading to status epilepticus
  4. Tachycardia leading to cardiovascular shock
  5. Labile blood pressure
  6. Diaphoresis
  7. Fever leading to hyperpyrexia
  8. Incoordination, hyperreflexia, tremors
  9. Nausea, Vomiting, Diarrhea, Abdominal Pain
  10. Coma leading to apnea (and death in severe cases)
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13
Q

SSRI Complications: Serotonin Syndrome- Nursing Actions & Client Education

A

Nursing Actions: start symptomatic tx (meds to create serotonin-receptor blockade and muscle rigidity, cooling blankets, anticonvulsants, artificial ventilation)

Client Education: Observe for manifestations. If any occur, notify provider and withhold med

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14
Q

SSRI Complications: Withdrawal Syndrome- Manifestations & Client Education

A

H/A, nausea, visual disturbances, anxiety, dizziness, tremors

Taper dose gradually

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15
Q

SSRI Complications: Hyponatremia- Nursing Actions

A

more likely to occur in older adult clients taking diuretics

obtain baseline blood Na, and monitor level periodically throughout tx

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16
Q

SSRI Complications: Rash- Client Education

A

a rash is treatable with an antihistamine or withdrawal of medication

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17
Q

SSRI Complications: Sleepiness, faintness, and light headedness- Client Education

A
  1. these adverse effects are not common, but can occur
    2.. Avoid driving if these adverse effect occur
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18
Q

SSRI Complications: GI bleeding- Nursing Actions

A

Use caution in clients who have hx of GI bleed and ulcers, and those taking other meds that affect blood coagulation

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19
Q

SSRI Complications: Bruxism- Nursing Actions & Client Education

A

NA: Changing to a different classification of antidepressant or adding a low dose of buspirone

CE: Report to the provider, use a mouth guard

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20
Q

SSRIs Contraindications/Precautions

A
  1. Pregnancy Risk Category C (except for paroxetine, which is Category D)
  2. contraindicated in clients taking MAOIs or TCAs. SSRIs need to be discontinued at least 2 weeks before initiating a MAOI
  3. Use cautiously in clients who have liver and kidney dysfunction, cardiac disease, seizure disorders, diabetes, ulcers, and a hx of GI bleeding
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21
Q

SSRIS and pregnancy

A

Paroxetine increases the risk of birth defects so other SSRIs are recommended.

Late in pregnancy, use of SSRIs increases the risk of withdrawal manifestations or pulmonary HTN in the newborn

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22
Q

SSRIS Interactions

A
  1. TCAs, MAOIs, St. Johns Wort
  2. Warfarin
  3. Tricyclic antidepressants and Lithium
  4. NSAIDs and anticoagulants
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23
Q

SSRIs interactions: TCAs, MAOIs, St. Johns Wort- Nursing Actions

A

these increase the risk of serotonin syndrome

  1. should be discontinued for 14 days prior to starting an SSRI. If already taking fluoxetine, an SSRI, client should wait 5 weeks before starting an MAOI
  2. Avoid concurrent use of TCAs and St. John’s wort due to suppression of platelet aggregations that can increase the risk of GI bleeding
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24
Q

SSRIs Interactions: Warfarin- Nursing Actions

A

fluoxetine can displace warfarin from bound protein and result in increased warfarin levels

  1. Monitor PT and INR levels
  2. Assess for indications of bleeding and the need for dosage adjustment
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25
Q

SSRIs Interactions: Tricyclic antidepressants and Lithium- Nursing Actions

A

Fluoxetine can increase the levels of tricyclic antidepressants and lithium

  1. avoid concurrent use
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26
Q

SSRIs Interactions: NSAIDs and anticoagulants- Client Education

A

Fluoxetine suppresses platelet aggregation and this increases the risk of bleeding when used concurrently with NSAIDs and anticoagulants

  1. Monitor for indicaitons of bleeding (bruising, hematuria) and notify provider if they occur
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27
Q

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) medicaitons include:

A

Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran

28
Q

SNRIs Expected Pharmacological Action

A

SNRIs block reuptake of norepinephrine as well as serotonin w/ effects similar to the SSRIs

29
Q

SNRIs Therapeutic Uses

A
  1. Major depression
  2. GAD (duloxetine, venlafaxine, desvenlafaxine, lecomilnacipran unlabeled use)
  3. Social Anxiety disorder (venlafaxine, desvenlafaxine unlabeled use)
  4. Panic Disorder (Venlafaxine, Desvenlafaxine unlabeled use)
  5. Pain due to fibromyalgia, osteoarthritis, low-back pain, diabetic neuropathy
30
Q

SNRIs Complications and Nursing actions

A
  1. Nausea, anorexia, weight loss ( NA: Monitor weight and food intake)
  2. H/a, insomnia, anxiety (NA: monitor for these actions)
  3. HTN, tachycardia: (NA: monitor vital signs and report changes)
  4. Dizziness, blurred vision (CE: avoid driving and use of machinery; Venlafaxine can cause mydriasis and can increase ocular damage if take when the client has glaucoma)
  5. Withdrawal syndrome (see CE above)
  6. Risk for suicide in children and adolescents (NA: assess for suicidal ideation, thought disorders)
  7. Sexual dysfunction (see manifestations and CE above)
  8. Serotonin Syndrome (see manifestations and CE above)
31
Q

SNRIs Contraindications/Precautions

A
  1. Pregnancy category risk C. Avoid during 3rd trimester due to infant having withdrawal syndrome and avoid breastfeeding while taking SNRI
  2. SNRIs are contraindicated in clients taking SSRIs, MAOIs, or TCAs. SNRIs need to be discontinued at least 2 weeks before initiating an MAOI
  3. Precautions are needed for older adults, and clients who have BPD, mania, seizure disorder, recent MI, or interstitial lung disease
  4. Taper slowly when discontinuing antidepressant med, esp venlafaxine, which can cause severe withdrawal syndrome if stopped abruptly
32
Q

SNRIS interactions

A
  1. MAOIs can cause serotonin syndrome (NA: stop MAOI at least 14 days before beginning a SNRI)
  2. NSAIDs, anticoagulants increase risk for bleeding w/ Venlafaxine (NA: Review client’;s meds with provider, including OTC meds)
  3. Alcohol and other meds affecting the CNS increase risk for CNS effects (CE: avoid alcohol and other CNS depressants; use caution when driving or using machinery)
  4. Kava, Valerian increases risk for CNS depression (NA: avoid these supplements)
  5. St. John’s wort can cause serotonin syndrome (NA: avoid these supplements)
33
Q

Atypical antidepressants include

A

Buproprion
Vilazodone
Mirtazapine
Nefazodone
Trazodone ER

34
Q

Atypical antidepressants Expected Pharmacological Action

A

Buproprion acts by inhibiting norepinephrine and dopamine uptake, and is referred to as a norepinephrine-dopamine reuptake inhibitor

35
Q

Atypical Antidepressants Therapeutic Uses

A
  1. Tx of depression
  2. Alternative to SSRIs and SNRIs for clients unable to tolerate sexual dysfunction adverse effects of these antidepressants
  3. Aid for smoking cessarion
  4. Prevention of seasonal pattern depression
  5. Alternative tx choice for attention-deficit disorder
36
Q

Atypical Antidepressant Complications w/ Nursing Action and/or Client Education

A
  1. H/A, dry mouth, GI distress, constipation, increased HR, HTN, restlessness, and insomnia
    -NA: treat h/a with mild analgesic
    -CE: observe for effects and notify the provider if intolerable
    - sip on fluids to treat dry mouth and increase dietary fiber to prevent constipation
  2. Nausea, vomiting, anorexia, weight loss
    -NA: monitor weight and food intake
  3. Seizures
    -NA: avoid administering to clients at risk for seizures (ex. client who has had head injuries)
    -Monitor for seizures and treat accordingly
37
Q

Atypical Antidepressants Contraindications/Precautions

A
  1. Buproprion is a Pregnancy Risk Category B
  2. Notify the provider if pregnant or breastfeeding.
  3. Contraindicated in clients taking MAOIs
  4. Contraindicated for clients who have seizure of eating disorders
38
Q

Atypical Antidepressants Interactions

A

MAOIs (phenlzine) increase the risk of toxicity
NA: MAOIs should be discontinued 2 weeks prior to beginning tx with buproprion

39
Q

Vilazodone: Pharmacological Action

A

both blocks serotonin and works as a serotonin agonist at receptor sites (first medication to work in this way)

40
Q

Vilazodone: Nursing Actions

A
  1. Contraindicated with SSRIs and SNRIs (serotonin syndrome), and other serotonin receptor agonists (buspirone and phenothiazines). Stop MAOI at least 14 days before starting this med
  2. Teach manifestations of serotonin syndrome to client and instruct when to notify provider
  3. Monitor for suicidal ideation
  4. Many adverse effects are similar to those of SSRIs and SNRIs
  5. Take with food to help increase absorption
41
Q

Vilazodone: Client Education

A

avoid grapefruit juice while taking this med bc it inhibits CYP3A4 metabolism resulting in an increase in the medication blood level

42
Q

Mirtazapine: Pharmacological Actions

A

Referred to as a SNRI. It increases the release of serotonin and norepinephrine by blocking presynaptic receptors, and thereby increases the amount of neurotransmitters available for impulse transmission

43
Q

Mirtazapine: Nursing Actions

A
  1. Therapeutic effects can occur sooner with less sexual dysfunction than with SSRIs
  2. Generally well tolerated. Clients can experience sleepiness that can be exacerbated by other CNS depressants (alcohol, benzos), weight gain, and elevated cholesterol
44
Q

Mirtazapine: Client Education

A

take at bedtime; can be used as a sleep aid

45
Q

Nefazodone: Pharmacological Action

A

Selectively inhibits the reuptake of serotonin and norepinephrine

46
Q

Nefazodone: Nursing Actions

A
  1. Rapidly absorbed within 1 hr when taken w/o food
  2. Adverse effects are sleepiness, h/a, dizziness, blurred vision, dry mouth, nausea, constipation, weight gain, and sexual dysfunction
  3. Stop MAOI at least 14 days before starting this med
47
Q

Trazodone ER: Pharmacological Action

A

Moderate selective blockade of serotonin receptors, which allows more serotonin to be available for impulse transmission

48
Q

Trazodone ER: Nursing Actions

A
  1. Usually used with another antidepressant agent
  2. Sedation is a potential problem; can be indicated for a client who has insomnia
  3. Priapism is a potential adverse effect. Instruct clients to seek medical attention immediately if this occurs
  4. Grapefruit juice inhibits CYP3A4 metabolism resulting in an increase in the medication blood level resulting in toxicity.
49
Q

Tricyclic Antidepressants include

A

Amitriptyline
Imipramine
Doxepin
Nortriptyline
Amoxapine
Trimipramine
Desiparmine
Clomipramine

50
Q

Tricyclic Antidepressants: Expected Pharmacological Action

A
  1. these medications block reuptake of norepinephrine and serotonin in the synaptic space, thereby intensifying the effects of these neurotransmitters.
  2. it can take 10 to 14 days or longer before TCAs begin to work, and maximum effects might not be seen until 4-8 weeks
51
Q

Tricyclic Antidepressants: Complications

A
  1. Orthostatic Hypotension
  2. Anticholinergic Effects
  3. Sedation
  4. Toxicity
  5. Decreased seizure threshold
  6. Excessive sweating
52
Q

Tricyclic Antidepressants: Uses

A

Therapeutic Uses: Depression, Depressive episodes of BPDs
Other uses:
1. neuropathic pain
2. Fibromyalgia
3. Anxiety disorders
4. Obsessive-Compulsive Disorder
5. Insomnia
6. ADHD
7. BPD

53
Q

Tricyclic Antidepressants Complications: Orthostatic Hypotension- Nursing Actions & Client Education

A

Nursing Actions
- Monitor BP and HR before administration and 1 hr after. If a significant decrease in BP or increase in HR is noted, do not administer the medication, and notify the provider

Client Education
-Be aware of the effects of postural hypotension (lightheadedness, dizziness). If these occur, advise the client to sit or lie down. Orthostatic hypotension is minimized by changing positions slowly
-avoid dehydration, which increases the risk of hypotension

54
Q

Tricyclic Antidepressants Complications: Anticholinergic Effects- Manifestations and Client Education

A

manifestations: dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia

Client Education
minimize anticholinergic effects by:
- chewing sugarless gum, sipping on water, wearing sunglasses when outdoors, eating food high in fiber, regular exercise, increasing fluid intake to at least 2-3L a day from beverages and food sources, voiding just before taking medications
-notify provider if effects persist

55
Q

Tricyclic Antidepressants Complications: Sedation

A

usually diminishes over time

Client Education
-avoid hazardous activities (driving) if sedation is excessive
-take med at bedtime to minimize daytime sleepiness and to promote sleep

56
Q

Tricyclic Antidepressants Complications: Toxicity- Manifestations and Nursing Actions

A

-results in cholinergic blockade and cardiac toxicity evidenced by dysrhythmias, mental confusion, and agitation, followed by seizures, coma, and possible death

Nursing Actions
-obtain baseline ECG
-monitor vital signs frequently
-monitor manifestations of toxicity
-notify provider if manifestations of toxicity occur

57
Q

Tricyclic Antidepressants Complications: Decreased seizure threshold- Nursing Actions

A

monitor clients who have seizure disorders

58
Q

Tricyclic Antidepressants Complications: Excessive sweating- Client Education

A

Be aware of adverse effects. Perform frequent linen changes

59
Q

Tricyclic Antidepressants: Contraindications/Precautions

A
  1. TCAs are Pregnancy Risk Category C. These meds are not generally recommended for use during pregnancy or breastfeeding
  2. Contraindicated in clients who have seizure disorders or who have recently experienced a MI
  3. Use cautiously in clients who are elderly or who have CAD; diabetes, liver, kidney, or respiratory disorders; urinary retention or obstruction; angle-closure glaucoma; BPH; and hyperthyroidism
  4. Clients at an increased risk for suicide should receive a 1 week supply of medication at a time due to the lethality of a toxic dose
60
Q

Medications used to treat depression, but not classified as antidepressants

A

Atypical antipsychotics
-Aripiprazole
-Quetiapine
-Brexpiprazole
-Cariprazine
-Lurasidone
-Vortioxetine

61
Q

TCAs Interactions and Nursing Actions

A
  1. use w/ MAOIs or St. Johns’s wort can lead to serotonin syndrome (NA: avoid concurrent use)
  2. MAOIs can cause severe HTN (NA: avoid concurrent use)
  3. Antihistamines and other anticholinergic agents have additive anticholinergic effects (NA: avoid concurrent use)
  4. Increased effect of epinephrine, dopamine (direct-acting sympathomimetics) occur bc uptake into the nerve terminals is blocked by TCAs & they remain for a longer amount of time in the synaptic space (NA: avoid concurrent use)
  5. TCAs decrease the effect of ephedrine, amphetamine (indirect-acting sympathomimetics) bc uptake into the nerve terminals is blocked, and they are unable to reach their site of action (NA: avoid concurrent use)
  6. Alcohol, benzodiazepines, opioids, and antihistamines cause additive CNS depression when used concurrently (CE: avoid other CNS depressants)
62
Q

Monoamine Oxidase Inhibitors include which medications?

A
  1. Phenelzine
  2. Isocarboxazid
  3. Tranylcypromine
  4. Selegiline (transdermal MAOI)
63
Q

MAOI: Expected Pharmacological Action

A

-These meds block MAOI enzymes in the brain, increasing the amount of norepinephrine, dopamine, serotonin, and tyramine available for transmission of impulses. An increased amount of these neurotransmitters at nerve endings intensifies responses and relieves depression. However, the increase in tyramine can cause heightened BP or hypertensive crisis if dietary and medication restrictions are not implemented

-onset of therapeutic action usually takes 2-4 weeks
-less used in comparison to other antidepressants due to food/drug interactions and adverse effects

64
Q

MAOI: Therapeutic Uses

A

Depression
Bulimia Nervosa
Panic Disorder
Social Anxiety Disorder
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
PTSD

65
Q

MAOI Complications and Nursing actions and/or Client Education

A
  1. CNS Stimulation (anxiety, agitation, mania, or hypomania)
    Client Education: Observe for effects and notify provider if occurs
  2. Orthostatic hypotension
    Nursing Actions: Monitor BP and HR. Hold med and notify provider if significant changes occur. Instruct client to change positions slowly
  3. Local rash with transdermal preparation
    Nursing Actions: choose a clean, dry area for each application; apply a topical glucocorticoid on the affected area
  4. Hypertensive crisis, severe HTN, HA, Nausea, Increased HR, and increased BP
66
Q

MAOI Complications continued: Hypertensive crisis, severe HTN, etc.

A

-Hypertensive crisis results from intake of dietary tyramine, which could lead to a cerebral vascular accident
-Severe HTN as a result of intensive vasoconstriction and stimulation of the heart
-HA, Nausea, Increased HR, and increased BP

Nursing Actions
-Administer phentolamine IV (a rapid-acting alpha-adrenergic blocker) or nifedipine SL.
-Provide continuous cardiac monitoring and respiratory support as indicated

67
Q
A

ATI Pharmacology (5 decks)

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