Medications for depressive disorders

Question 1

What is the black-box warning for all of the antidepressant drugs we discuss? What age groups are more effected by this? Due to this, what are some nursing considerations?

Answer 1

Higher risk for suicide

Especially in children/adolescents

Make sure to assess for suicide risk/isolation and educate parents and loved ones of this risk and teach signs of risk.

Question 2

What is the therapeutic action/outcome for SSRIs?

Answer 2

selectively inhibits the reuptake of serotonin making more of it available; reduces depression/anxiety symptoms

Question 3

What drugs are the most common used for depression (first line)? why?

Answer 3

SSRIs

much safer than other drug classes discussed

Question 4

How long does it take for SSRIs to reach their full effect?

Answer 4

4-6 weeks (make sure that this is emphasized to patient, adherence is HUGE)

Question 5

When would we prescribe other antidepressants other than SSRIs?

Answer 5

When we know that SSRIs are not effective.

Question 6

What is a risk of having to much serotonin available?

Answer 6

serotonin syndrome!!

Question 7

What are some adverse effects of SSRIs?

Answer 7

Sexual dysfunction (common)

CNS stimulation

n/v

weight gain/loss

Serotonin syndrom (fever, confusion, agitation/anxiety, hallucinations, hyperreflexia, diaphoresis, tremors)

Withdrawals (HA, nausea, anxiety, dizziness, tremor) - elevated serotonin levels suddenly fall and produce symptoms

Bruxism (teeth grinding)

hyponatremia

Question 8

What are some nursing considerations for SSRIs?

Answer 8

sexual dysfunction is a big cause of compliance issues, educate patient and tell them to call physician if they think they are going to stop taking medication (other SSRIs may have less sexual dysfunction side effects and may be prescribed)

weight gain/loss can also lead to compliance issues, educate the patient! same as sexual dysfunction

n/v usually subsides with time (few weeks)

CNS stimulation - patient may have difficultly sleeping, may need to lower dose or have patient take in the morning

Serotonin syndrome - monitor for signs and notify physician if they present, educate patient on symptoms

For withdrawals - taper the dose gradually (usually over a week)

Bruxism - might need to wear a mouth guard

hyponatremia is especially a problem in elderly patients that are also taking diuretics

Question 9

When can serotonin syndrome begin to manifest?

Answer 9

2-72 hours

Question 10

What are some drug-drug interactions for SSRIs?

Answer 10

MAOIs - increase serotonin levels as well

TCAs - increase serotonin as well

St. Johns Wort - increase serotonin levels as well

ALL OF THESE INCREASE THE RISK FOR SEROTONIN SYNDROME

warfarin (coumadin) - SSRIs are highly protein bound, so is warfarin, this may result in an incresed serum drug level of warfarin which increases the risk for bleeding. THESE TWO MEDICATIONS COMPETE FOR PROTEIN BINDING

Question 11

If taking an SSRI, how long should the patient wait after the last dose to start taking an MAOI?

Answer 11

5 weeks

Question 12

If taking an MAOI, how long should the patient wait after the last dose to start taking an SSRI?

Answer 12

14 days

Question 13

What are some patient teaching points for SSRIs?

Answer 13

Take as directed - taper off slowly (over a week… withdrawals)

report symptoms of serotonin syndrome (educate symptoms)

report side effects if intolerable

can take 4-6 weeks to reach full effect

Suicide watch (young adults, adolescents, children) tell providers and parents about risk!!!!

dont take with st. johns wort (OTC) - serotonin syndrome

Make sure they know possible interactions for MAOI (and time lapse between switces) and TCAS…… MAOIs ESPECIALLY

keep lab appointments for sodium levels if elderly on diuretics

Question 14

What is the therapeutic action/outcome for Tricyclic antidepressants (TCAs)?

Answer 14

inhibit reabsorption and reuptake of serotonin and norepinephrine (NE) making both more readily available;

this will reduce symptoms of depression, anxiety, insomnia, and neuropathic pain

Question 15

How long does it take for TCAs to take full effect?

Answer 15

2-6 weeks

Question 16

What does the increase of available norepinephrine with TCAs increase the risk for?

Answer 16

Increases the risk for HTN crisis.

Question 17

What are some adverse effects of TCAs?

Answer 17

Sedation

Orthostatic hypotension

excessive sweating

Anticholinergic effects:
blurred vision
constipation
dry mouth
tachycardia
urinary retention
photophobia
toxicity - CARDIAC DYSRHYTHMIAS, confusion, seizures

Question 18

What are some nursing considerations for TCAs?

Answer 18

Sedation: take at night, usually diminishes with time

constipation: drink 2-3L water daily

dry mouth: suck on hard candy, chew gum

tachycardia: monitor HR

urinary retention: void before taking medication

Toxicity: take vitals, monitor ECG and call physician with changes

orthostatic hypotension: monitor, fall risk

Avoid use of st. johns wort (serotonin syndrome), SSRI (serotonin syndrome), and MAOI (HTN crisis) in concurrecnce

excessive sweating - change linens frequently

Question 19

What are some patient teaching points for TCAs?

Answer 19

sedation: avoid driving or operating heavy machinery, take at night, avoid other CNS depressants
blurred vision: avoid driving; report if severe
Constipation: drink 2-3L daily, high fiber foods
dry mouth: suck on hard candy, chew gum
Tachycardia: REPORT HEART PALPITATIONS
urinary retention: void before taking medication, report if unable to void
photophobia: wear sunglasses
toxicity: REPORT SYMPTOMS
orthostatic hypotension: change positions slowly, peripheral vascular relaxation
REPORT ANY ANTICHOLINERGIC SYMPTOMS
Suicide watch!!!
No st. johns wort - serotonin syndrome risk
2-6 weeks for full effect
antihistamines and TCAs togther increase anticholinergic symptoms

Question 20

What is the therapeutic actions and outcome of MAOIs?

Answer 20

limits the breakdown of norepinephrine, dopamine, and serotonin making more of it available. this improves depressive symptoms as well as bulimia.

NOT USED OFTEN BECAUSE OF SAFETY AND DIET CONCERNS.

Question 21

How long does it take for MAOIs to take full effect?

Answer 21

4-6 weeks

Question 22

What are some adverse effects of MAOIs?

Answer 22

CNS stimulation: anxiety, agitation, mania, hypomania

orthostatic hypotension

hypertensive crisis

Question 23

What are some nursing considerations for MAOIs?

Answer 23

monitor for adverse effects of CNS stimulation

Monitor orthostatic hypotension

No foods high in tyramine (HTN crisis), patient will spend a lot of time with dietician

cannot be taken within 2 weeks of SSRIs

avoid giving sympathomimetic medications (phenylephrine) or other vasopressors (alpha stimulants) and PO decongestants (sudafed) because of increased risk for HTN and tachycardia

Question 24

LOOK AT TYRAMINE HANDOUT

Answer 24

DO IT NOW!!!

Question 25

What are some signs of HTN crisis? What causes this?

Answer 25

HA, stiff neck, blurred vision, chest pain, stroke symptoms

Vasoconstriction from the drug-food interaction causes a very high BP and elevated HR

Question 26

How do we treat HTN crisis?

Answer 26

phentolamine (regitine) - IV alpha adrenergic blocker

or

nifedipine (procardia) - selective calcium channel blocker

Question 27

What drugs cannot be taken along with MAOIs?

Answer 27

TCAs - HTN crisis

SSRIs - serotonin syndrome

Question 28

What are some patient teaching points for MAOIs?

Answer 28

avoid tyramine foods

avoid st. johns wort/ herbal remedies

avoid OTC medications unless approved by provider

allow time for full effect (4-6 weeks)

get up slowly

avid caffeine, chocolate, herbal remedies - increased risk for HTN

Question 29

What is the patient teaching that is consistent with all of the antidepressants?

Answer 29

take every day to gain therapeutic levels

most take 1-2 to begin and 6-8 for full effects

dont stop suddenly; continue once symptoms improve

dont take MAOIs with SSRIs of TCAs

SUICIDE WATCH

avoid st. johns wort and other herbal remedies