Mental Health Flashcards
Inpatient Admission Criteria
- clear risk of danger to self or others 2. dangerous decompensation of client under long-term treatment 3. failure of community based treatment with need for intensive treatment to prevent harmful consequences. 4. medical need- may or may not be associated with psychiatric treatment.
Inpatient outcomes/goals
- prevent harm to self and others 2. stabilize crisis and return to community 3. initiation or modification of medication. 4. brief and specific problem solving 5. Establishment of a plan for out-patient treatment.
Mental Status Examination (MSE)
personal information; appearance; behavior; speech; affect and mood; thought; perceptual disturbances and cognition.
cultural transference
the nurse’s reactions to a client that are based on the nurse’s unconscious needs, conflicts, problems, or views of the world.
The HEADSSS Psychosocial Interview Technique
HOME environment (relations with parents and siblings) Education and employment (school performance) ACTIVITIES (sports, participation, after-school activities, peer relations) DRUG, alcohol or tobacco use SEXUALITY (whether the patient is sexually active, practices safe sex, uses contraception, or practices alternative sexual lifestyles) SUICIDE risk or symptoms of depression or other mental disorder SAVAGERY (violence or abuse in home environment or in neighborhood)
The Institute of Medicine (IOM) and QSEN faculty have established mandates to prepare future nurses with the knowledge, skills, and attitudes (KSAs) necessary for achieving quality and safety they engage in the six competencies of nursing:
patient-centered care, teamwork, and collaboration, evidence-based practice (EBP), quality improvement (IQ), safety, and informatics.
The primary source of assessment
is the patient. Secondary sources of information include family, neighbors, friends, police, and other members of the health team.
Communication is a complex process. Berlo’s communication model has five parts:
stimulus, sender, message, medium, and receiver. Feedback is a vital component of the communication process for validating the accuracy of the sender’s message.
Communication has two levels:
the content level (verbal) and the process level (nonverbal behavior). When content is congruent process, the communication is said to be healthy. When the verbal message is not reinforced by the communicator’s actions, the message is ambiguous; we call this a double-bind (or mixed) message.
Cultural background (as well as individual differences) has a great deal to do with what nonverbal behavior means to different individuals.
The degree of eye contact and the use of touch are two nonverbal aspects that can be misunderstood by individuals of different cultures.
Attending behaviors ( eye contact, body language, vocal qualities and verbal tracking)
are a key element in effective communication
Cultural background (as well as individual values and beliefs) has a great deal to do with what nonverbal behavior means to different individuals.
The degree of eye contact and the use of touch are two nonverbal aspects that can be misunderstood by individuals of different cultures.
Pharmacological, Biological & Integrative Therapies
- Administration of meds. -Nurse must know action, dose and adverse reactions, therapeutic blood levels. -Patient teaching -Observation of client response
Milieu
- Specific structures activities that involves therapeutic communication, groups, and families. - communication and interpersonal feedback open and constructive: clear verbal messages, nonverbal messages congruent. - clients and staff responsible for own behavior.
Milieu Examples
-morning goal setting meetings -evening goal review -community meetings -education -group therapy - The nurses “manage” the milieu.
Therapeutic Communication
- Focus on client’s need. Not a social relationship -empathy -respect, non-judgemental - more effective than non-therapeutic communication techniques. - Communication is 10% Verbal and 90% nonverbal
Crisis management 1
- Nurses anticipate, prevent, and manage emergencies and crises on the unit - depending on the diagnoses of the clients, must be prepared for varying physical crises
crisis management 2
- Can lead to client violence -usually escalate through predictable stages - Nurse advocates for clients -Removes anyone not involved in the crisis from the area.
Four key assessment areas
- Adequacy of housing and stability - income and source of income -family and support system -substance abuse history and current use - cultural characteristics are also important.
Intervention Strategies
-Inpatient= stabilization defined by staff - Community = treatment foals and interventions negotiated
Working Phase
- Promote problem-solving skills, self-esteem - Facilitate behavioral change -Overcome resistance behaviors - Evaluate problems and goals and redefine if necessary - Promote practice and expression of alternative behaviors -Can elicit intense emotions - Strong transference or counter-transference feelings may occur.
beneficence
duty to act to benefit others
autonomy
respecting rights of others to make decisions
justice
duty to distribute resources equally
Fidelity
maintaining loyalty and commitment to patient.
veracity
duty to communicate truthfully
voluntary admission
sought by the client or client’s guardian have the right to demand discharge possible conversion to involuntary status
involuntary admission
when presents danger to self/others unable to meet own basic needs commitment procedures (judicial, administrative, agency) (must be certified by multiple physicians to justify detention).
The core concepts of patient- and family-centered care consists of
- dignity and respect. 2. information sharing 3. patient and family participation. 4. the feeling of being heard and understood by patients.
Goals in a therapeutic relationship include the following:
- facilitating communication of distressing thoughts and feelings - assisting patient with problem solving to help facilitate activities of daily living. - helping patients examine self-defeating behaviors and test alternatives. - promoting self-care and independence
Within the context of a helping relationship, the following occur:
- The needs of the patient are identified and explored. - Alternative problem-solving approaches are taken. - New coping skills may develop. - Behavioral change is encouraged.
narcissism
having to find weakness, helplessness, and/or disease in patient’s to feel helpful, at the expense of recognizing and supporting patient’s healthier, stronger, and more competent features.
Transference
is the process whereby a person unconsciously and inappropriately displaces onto individuals in his or her current life those patterns of behavior and emotional reactions that originated in relation to significant figures in childhood.
countertransferance
refers to the tendency of the nurse to displace onto the patient feelings related to people in his or her past.
Values
are abstract standards and represent an ideal, either positive or negative.
preorientation phase
preparing yourself professionally for the interaction Reading the chart Getting your mind around what the patient is facing Checking your own biases
orientation phase
Start working on trust, develop rapport. Verbalize boundaries in a matter of fact, non judgmental way. Your purpose/function is explained. Goals are agreed upon, established. Start talking about what the end of the relationship will look like (time frame, etc) - an atmosphere is established in which rapport can grow. - the nurse’s role is clarified, and the responsibilities of both the patient and the nurse are defined. - the contract containing the time, lace, date and duration of the meetings is discussed. - confidentiality is discussed and assumed. - the terms of termination are introduced (these are also discussed throughout the orientation phase and beyond). - the nurse becomes aware of transference and countertransference issues. -patient problems are articulated, and mutually agreed goals are established.
Working Phase
- maintain the relationship -gather further data -promote the patient’s problem-solving skills, self-esteem, and the use of language. -facilitate behavioral change -overcome resistance behaviors. - evaluate problems and goals and redefine them as necessary. - promote practice and expression of alternative adaptive behaviors.
kinesics
physical characteristics such as body movements and postures.
poxemics
personal space and what distance between oneself and others is comfortable for an individual.
intimate distance in US
0-18 inches and reserved for those we trust most and with whom we feel safe.
personal distance in US
18-40 inches id for personal communications such as those with friends or colleagues.
social distance
4-14 feet is applied to strangers or acquaintances, often in public places or formal social gatherings.
Public distance
12 feet or more. relates to public space (public speaking)
The 5 A’s of process integrating best evidencwe into clinical practice includes
1- asking, 2- acquiring, 3- appraising, 4-applying and 5-assessing.
Application of the recovery model
assists people with psychiatric disabilities to effectively manage symptoms, reduce psychosocial disability, and find meaningful life in a community of their choosing.
With the current knowledge that many common mental disorders
are biologically based, they are now recognized as medical diseases.
Nursing diagnoses help
to systematically target symptoms patients may experience.
The way symptoms are expressed may reflect
a person’s cultural patterns and should be evaluated in this context.
Theoretical models and therapeutic strategies
provide a useful framework for the delivery of psychiatric nursing care.
The psychoanalytic model is based on
unconscious motivations and the dynamic interplay between the primitive brain (ID), the sense of self (ego), and the conscience (superego). The focus of the psychoanalytic theory is on understanding the unconscious mind.
The interpersonal model maintains
that the personality and disorders are created by social forces and interpersonal experiences. Interpersonal therapy aims to provide positive and repairing interpersonal experiences.
The behavioral model suggests that
because behavior is learned, behavioral therapy should improve behavior through rewards and reinforcement of adaptive behavior.
The humanist model is based on
human potential, and therapy is aimed at maximizing this potential. Maslow developed a theory of personality that is based on the hierarchical satisfaction of needs. Roger’s person centered theory uses self-actualizing tendencies to promote growth and healing.
The cognitive model posits that
disorders, especially depression, are the result of faulty thinking. Cognitive behavioral therapy is empirically supported and focuses on the recognition of distorted thinking and the replacement with more accurate and positive thoughts
The biological model is currently
the dominant model and focuses on physical causation for personality problems and psychiatric disorders. Medication is the primary biological therapy.
A variety of nursing theories are useful to psychiatric nursing.
Hildegard Peplau developed an important interpersonal theory for the provision of psychiatric nursing care.
long-term/formal commitment
-primary purpose is extended care and treatment of the mentally ill. -admitted through judicial or administrative action or medical certification. -competency related to the capacity to understand the consequences of one’s own decisions.
involuntary outpatient commitment
outpatient commitment alternative to forced inpatient treatment. -preventive measure -AOT assisted outpatient treatment
Patient’s Rights
-right to be treated with dignity -right to refuse treatment - right to informed consent -right to legal counsel -right to request to leave the hospital -rights regarding restraint and seclusion -right to be involved in treatment planning/decisions. - right to keep personal belongings unless they can cause harm.
Exceptions to patient confidentiality
-duty to warn and protect third parties - most states have similar laws regarding duty to warn third parties of potential life threats. -staff nurse reports threats by patient to the treatment team
Ethical Issues
- right to refuse medication 2. right to the least restrictive treatment. (exception court ordered inpatient)
Use of restraint and seclusion
legislation provides strict guidelines for use: - when behavior is physically harmful to patient/others - when least restrictive measures are insufficent - when decrease in sensory overstimulation (seclusion only is needed) - when patient anticipates that controlled environment would be helpful and requests seclusion.
Liability Issues
- protection of clients -defamation of character -supervisory liability -staffing issues
Assault
no physical contact but fear and apprehension; words, verbal threats.
battery
touching another person without consent (hitting, etc)
false imprisonment
many issues in psychiatric nursing
Violence
- The responsibility for safety is entirely the nurse’s - Nurses must protect themselves by creating safe environments. -responsible for protecting client and third parties.
negligence
-act or an omission to act that results in or is responsible for a person’s injuries.
Situation of Professional Negligence
1-Failure to warn 2- Failure to recognize suicidal risk 3- sexual involvement 4- breach of confidentiality 5- failure to honor individual rights 6- failure to use least restrictive alternative 7- failure to protect
Concept of Resiliency
-important component of mental health - ability to recover or adjust to misfortune and change - helps people facing tragedy, loss, trauma, and severe stress
resilient people
recognize feelings deal with feelings learn from experiences
evidence-based practice
scientifically grounded or evidence based medical model
recovery model
management of symptoms and psychosocial disability social model nurse-patient partnership
trauma-informed care
ask “What has happened to you?” recognizes that trauma is almost universally found in histories of mental health patients and is a contributor to mental health issues, substance abuse, chronic health conditions, and contact with the criminal justice system.
DSM 5 Diagnostic and Statistical Manual of Mental Disorders
was published in May 2013 manual that classifies mental disorders focuses on research and clinical observation
Culture and Mental Illness
- has been included in DSM 5 - Must consider the norms and influence of culture - Lack of cultural knowledge can result in lack of services or inappropriate services
Theories and Therapies
Freuds psychoanalytic theory (level of awareness and defense mechanisms) - Sullivan’s interpersonal Theory -Erikson’s Ego Theory - Maslow’s Humanistic Psychology Theory -Pavlov’s Classic Conditioning theory -Watson’s Behaviorism Theory - Skinner’s Operant Conditioning Theory
Freud psychoanalytic
unconscious thoughts; psychosexual development psychoanalysis to learn unconscious thoughts; therapist is nondirective and interprets meaning
Sullivan interpersonal
relationships as basis for mental health or illness therapy focuses on here and now and emphasizes relationships; therapist is an active participant.
Pavlov, Watson & Skinner Behavioral
Behavior is learned through conditioning Behavioral modification addresses maladaptive behaviors by rewarding adaptive behavior
Beck Cognitive
Negative and self-critical thinking causes depression Cognitive behavior therapists assist in identifying negative thought patterns and replacing them with rational ones, and often involves homework.
Biological
Psychiatric disorders are heavily influenced by and/or cause changes to the brain and/or neurotransmitter(s) resulting in changes in thinking and behavior. Neurochemical imbalances are corrected through medication and talk therapy. (cognitive behavior therapy)
Oral birth to 18 months
Id, pleasure seeking, mouth fixation
Anal 18 month to 3 years
Ego is our sense of self and acts as an intermediary between the id and the world using defense mechanisms (potty training)
Phallic 3-7 years
superego conscience of right and wrong sexual identity through identification with same-sex parent
Latency 7 to 12 years
Peer group loyality begins growing independence from family sexuality is represses close friendships with same sex peers
genital phase 13-20 years
dependence vs independence form close relationships with opposite sex based on genuine caring and pleasure in interaction
Maslow’s Hierarchy of Needs
1- Physiological Needs (food, water, oxygen, rest, sex, elimination). 2. safety needs ( security, protection, stability, structure, order and limits) 3. Love and Belonging Needs (Affiliation, affectionate relationships, and love) 4. Esteem Needs ( self-esteem related to competency, achievement, and esteem from others) 5. Self-Actualization Needs (Becoming everything one is capable of) 6. Self-Transcendent Needs
Infancy birth to 18 months,
trust vs mistrust egocentric danger: during second half of first year, an abrupt and prolonged separation may intensify the natural sense of loss and may lead to a sense of mistrust that may last throughout life. Task: develop a sense of trust that leads to hope
Early childhood 18 months to 3 years
autonomy vs shame/doubt develop confidence in physical and mental abilities that leads to the development of autonomous will danger: development of a deep sense of shame/doubt is child is deprived of the opportunity to rebel; learns to expect defeat in any battle of wills with those who are bigger and stronger Task: gain self-control of and independence within the environment.
Peplau
-developed the first theory for psychiatric nursing - described the nurse-patient relationship as the foundation of nursing practice -shifted focus from what nurses do “to” patients to what nurses do “with” patients
Classical psychoanalysis
-developed by Freud - importance of early life trauma in later mental disorders - uses dream analysis and free association - two concepts still important to understand : transference and counter transference.
Psychodynamic Therapy
- Based on psychoanalysis -less sessions (10-12) - focus on present instead of early life - Best candidates: relatively healthy, well-functioning, experiencing well-defined difficulty, well motivated for change.
interpersonal psychotherapy
- personality disorders are caused by personal interactions. Early relationships with significant others are crucial in personality development. - healthy relationships = healthy personality - focus on reassurance and clarification of feelings, and interpersonal communication. - help client become aware of dysfunctional patterns which leads to change in behavior.
Behavior Therapy
- Personality traits (adaptive and maladaptive) are learned - changes in maladaptive behavior can occur without knowing the underlying cause. - works best when directed at specific problems (phobias, alcoholism).
systematic desensitization
developing specific tasks specific to the client’s fears
aversion therapy
used widely to treat unacceptable social behaviors - is based on both classical and operant conditioning and is used to eradicate unwanted habits by associating unpleasant consequences with them. (Antabuse- medication for alcoholism)
Biofeedback
is a technique in which individuals learn to control physiological responses such as breathing rates, heart rates, blood pressure, brain waves, and skin temperature. This control is achieved by providing visual or auditory biofeedback of the physiological response and then using relaxation techniques such as slow, deep breathing or meditation.
extinction
decrease in behavior when reinforcement is withheld ex. temper tantrum- parent leaves the room.
Cognitive therapy
- an individual’s cognitive thinking/evaluation of stimulus leads to the emotional response - cognitive distortions (overgeneralization, jumping to conclusion, magnification, etc.) - active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders.
Cognitive-Behavior Therapy (CBT)
- modify negative thoughts, feelings, and behaviors. -methods: identify negative patterns of thinking (cognitive distortions); use ABC format for recording and analyzing. - then reframe negative thinking
ABC’s of irrational beliefs
Activating Event Belief Consequences Reframing
Recovery Model
Focus is NOT cure living and managing a chronic disease Nurse’s role is to assist with…… - increased individual and family involvement -advocate for self-administration of meds with community supports -develop personal relapse prevention plans -recommend supported employment.
Piaget’s STages of Cognitive Development
Sensorimotor (birth to 2 years) preoperational (2-7 years) concrete operational (7 to 11 years) Formal operational (11 years to adulthood)
Sensorimotor birth to 2 years
begins with basic reflexes and culminated with purposeful movement, spatial abilities, and hand-eye coordination. Around 9 months object permanence is achieved and the child can conceptualize objects that are no longer visible.
Preoperational 2-7 years
Language develops, yet children think in a concrete fashion. Expecting others to view the world as they do is call egocentric thinking. Children begin to think in images and symbols and engage in such activities as playing house.
Concrete operational 7-11 years
The child is able to think logically and use abstract problem solving. He/she is able to see another’s point of view and is able to see a variety of solutions to the problem. Conservation is possible.
Formal operational (11 years to adulthood)
Conceptual reasoning beings at approximately the same time as puberty. At this stage, the child’s basic abilities to think abstractly and problem solve are similar to those of an adult.
Kohlberg Stages of Moral Development
Pre-conventional Conventional Post-Conventional
Biological Model
- Mental disorders believed to have physical causes - Treatments directed toward physical interventions; pharmacological/psychopharmacology, electroconvulsive therapy (ECT), and transcranial magnetic stimulation (TMS).
Milieu Therapy
-scientific restructuring of the environment -central is a living, learning, or working environment - basic intervention in nursing practice: major focus - one-to-one relationships; major task-developing trust; major responsibility- setting limits on unacceptable behavior; and client teaching also of utmost importance. -example: providing safety for a suicidal patient.
Biological basis for understanding psychopharmacology
most medications have their effects at the neuronal synapse, producing changes in neurotransmitter release and the receptors they bind to.
Frontal lobe
thought processes, decision making
temporal lobe
allows appropriate expression of emotion
occipital lobe
visual memory and language formation
parietal lobe
body awareness and concept formation, ability for processing abstract concepts/decisions
limbic system
emotional brain
excessive dopamine
schizophrenia
insufficient GABA activity
anxiety
deficient norepinephrine and/or serotonin
depression
antianxiety/anxiolytics
- bind to a receptor adjacent to GABA receptor which enhances GABA’s effect - produce a calming effect by depressing the CNS - Sedative/hypnotic
anxiolytics used for
- anxiety and panic -insomnia -alcohol withdrawals - Two classes: benzodiazepines and non-benzo
Benzodiazapines (Drug suffices: -PAM, -LAM)
Alprazolam (Xanax) Chlordiazepoxide (Librum) Clonazepam (Klonopin) Diazepam (Valium) Lorazepam (Ativan)
Benzodiazapines Side Effects
- CNS depression (lethargy, confusion, blurred vision) -Withdrawal symptoms (tremor, agitation, nervousness, sweating, insomnia, anorexia, muscle cramps) - Insomnia, Euphoria, excitation - Tolerance, Dependence…….Potential abuse
Non- Benzodiazepines
Buspirone (BuSpar) Hydroxyzine (Vistaril) - less addictive than benzodiazepines
Buspirone (BuSpar)
Does not cause sedation but….. - takes about 2 weeks before patient notices effect - will not reduce anxiety in patient that is use to taking benzos because there is no sedation effect to “take the edge off”.
Typical Anti-Psychotics 1st Generation
- block dopamine receptors. Some effect acetylcholine, histamine, and norepinephrine receptors. - Problem side effects
Typical Anti-Psychotics 1st Generation Drugs
Chlorpromazine (Thorazine) Fluphenazine (Prolixin) Haloperidol (Haldol)
Antipsychotic Adverse Effects
- Tardive Dyskinesia (TD) - Neuroleptic Malignant Syndrome - Extrapyramidal Side Effects - Anticholinergic Effects - Agranulocytois
Tardive Dyskinesia (TD)
-late EPS which can require months to years of medication therapy for TD to develop -involuntary movements of the tongue and face, such as lip smacking and tongue fasciculations - involuntary movements of the arms, legs and trunk involuntary muscle movements that may not resolve with drug discontinuation- risk approx. 5% per year treatment –Valbenazine (Ingrezza)
Neuroleptic Malignant Syndrome
Characterized by severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC, CPK (creatine phosphokinase) and liver function tests. Potentially fatal. administer dantrolene or bromocriptine to induce muscle relaxation. take vital signs, cooling blankets antipyretics medications to treat arrhythmias transfer to ICU
Extrapyramidal side effects
acute Dystonia, Parkinson syndrome, akathisia treatment- give Benztropine (Cogentin)
acute dystonia
severe spasms of the tongue, neck, face and back. crisis situation that requires rapid treatment. treat with benztropine diphenhydramine also, IM or IV
parkinson syndrome
-bradykinesia, rigidity, shuffling gait, drooling, tremors treat with antiparkinson agent, such as benztropine or trihexyphenidyl. implement interventions to reduce risk for falling.
anticholinergic effect
can’t see, can’t pee, can’t shit, can’t spit - dry mouth - blurred vision -photophobia -urinary hesitancy or retention -constipation -tachycardia
agranulocytosis
- advise clients to observe for indications of infection (fever, sore throat) and to notify the provider if these occur. - if indications of infection appear, obtain a CBC. Medication should be discontinued if WBC count is less than 3,000 mm3.
akathisia
inability to sit or stand still continual passing and agitation - manage with antiparkinsonian agents, beta blockers, or lorazepam/diazepam. - monitor for increased risk for suicide in clients who have severe akathisia.
Pseudoparkinsonism
stooped posture shuffling gait rigidity bradykinesia tremors at rest pilling motion of the hand
Acute Dystonia
- facial grimacing -involuntary upward eye movement - muscle spasms of the tongue, face, neck and back (back muscle spasms cause trunk to arch forward) -laryngeal spasms
Akathisia
-restless -trouble standing still -paces the floor -feet in constant motion, rocking back and forth.
Tardive Dyskinesia
- Protrusion and rolling of the tongue -sucking and smacking movements of the lips - chewing motion -facial dyskinesia -involuntary movements of the body and extremities
Atypical Anti-psychotics: 2nd Generation
- Bind to dopamine receptors in the limbic system so are able to exert psychiatric action without motor side effects. - are also antagonists at the receptors for serotonin, which makes them a drug of choice for treating Schizophrenia and delaying progression. - may improve cognitive function
Atypical Anti-psychotics: 2nd Generation Drugs
Clozapine (Clozaril) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)
Risperidone (Risperdal)
- Functions more like a 1st gen antipsychotic at higher doses -increased extrapyramidal side effects - most likely atypical to induce hyperprolactinemia - weight gain and sedation
Olanazapine ( Zyprexa)
- may cause hypertriglyceridemia, hypercholesterolemia, hyperglycemia (even without weight gain) - weight gain (can be as much as 30-50 lbs with even short term use)
Quetiapine (Seroquel)
- most likely to cause orthostatic hypotension - may cause liver dysfunction - may cause hypertriglyceridemia, hypercholesterolemia, hyperglycemia (even without weight gain), however less than olanzapine. - May be associated with weight gain, though less than seen with olanzapine.
Ziprasidone (Geodon)
- Clinically significant QT prolongation in susceptible patients - may cause hyperprolactinemia (less than risperidone) - no associated weight gain -absorption is increased with food.
Aripiprazole (Abilify)
- Partial dopamine/serotonin antagonist -low EPS, no QT prolongation, low sedation, no weight gain - interaction with fluoxetine (Prozac), Paroxetine (Paxil), Carbamazepine (Tegretol) could cause potential intolerability due to akathisia.
Clozapine (Clozaril)
-Is reserved for treatment resistant patients because of side effects. - agranulocytosis….. requires weekly blood draws x 6 months, then every 2 weeks x 6 months - increased risk of seizures (especially in combination with lithium) - associated with the most sedation, weight gain and liver dysfunction. - increased risk of hypertriglyceridemia, hypercholesterolemia, hyperglycemia, including ono-ketotic hyperosmolar coma and death with and/or without weight gain.
Antidepressants
- Most work by blocking the reuptake of neurotransmitters serotonin and norepinephrine. - some also block receptor sites.
General Guidelines for antidepressant use
- there is a delay typically of 3-6 weeks after a therapeutic dose is achieved before symptoms improve. - if no improvement is seen after a trial of adequate length (at least 2 months) and adequate dose, either switch to another antidepressant or augment with another agent.
selective serotonin reuptake inhibitors (SSRIS)
- blocks serotonin reuptake - treat both anxiety and depression - most common side effects include GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia, fatigue or sedation, dizziness, suicidal ideations. -can develop a discontinuation syndrome with agitation, nausea, disequilibrium and dysphoria. - side effects often decrease after 2-4 weeks.
SSRIS (Drug Suffixes: Pram, INE)
Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft)
Citalopram (Celexa)
- May cause prolonged QT interval -sedation -GI side effects
Escitalopram (lexapro)
- more effective than Citalopram in acute response and remission -Prolonged QT interval prolongation -Nausea, headache
Fluoxetine (Prozac)
- long half life and active metabolite may build up (not a good choice in patients with hepatic illness) - initial activation may increase anxiety and insomnia - more likely to induce mania
Paroxetine (Paxil)
- sedation - weight gain - more anticholinergic effects
Sertaline (Zoloft)
- Max absorption requires a full stomach - increased number of GI side effects
Tricyclic Antidepressants
Amitriptyline (Elavil) Doxepin (Sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor, Aventyl)
Tricyclic Antidepressants
- inhibits serotonin and norepinephrine reuptake. Plus blocks other receptor sites. - Very effective but potentially unacceptable side effects - sedation and weight gaint - anticholinergic (Dry moth, dry eyes, constipation, memory deficits and potentially delirium) - orthostatic hypotension, sedation, sexual dysfunction - lethal in overdoze (even a one week supply can be lethal) - can cause prolonged QT even at a therapeutic serum level.
Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)
Desvenlafaxine (Pristiq) Duloxetine (Cymbalta) Venlafaxine (Effexor)
SNRI
- Dual action…..inhibit both serotonin and norepinephrine reuptake like the TCAS but without the antihistamine or anticholinergic side effects
Desvenlafaxine (Pristiq) side effects
increase in total cholesterole, LDL and triglycerides & BP
Venlafaxine (Effexor) side effects
- can cause a 10-15 point increase in diastolic BP - QT prolongation -Sexual side effects
Monoamine Oxidase Inhibitor (MAOI)
- binds to monamine oxidase thereby preventing inactivation of norepinephrine, dopamine and serotonin leading to increased synaptic levels. - Side effects: orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction and sleep disturbance. - hypertensive crisis can develop when MAOI’ are taken with tyramine-rich foods. - Serotonin syndrome if taken with SSRIs
Monoamine Oxidase Inhibitors (MAOIs)
Isocarboxacid (Marplan) Pheneizine (Nardil) Tranylcypromine (Parnate)
MAOI + Tyramine = Hypertensive Crisis
Tyramine Foods: -Strong or aged cheeses, such as aged cheddar, Swiss and Parmesan; blue cheeses such as Stilton and Gorgonzola; and Camembert. Cheeses made from pasteurized milk are less likely to contain high levels of tyramine — for example, American cheese, cottage cheese, ricotta, farmer cheese and cream cheese. -Cured meats, which are meats treated with salt and nitrate or nitrite, such as dry-type summer sausages, pepperoni and salami. -Smoked or processed meats, such as hot dogs, bologna, bacon, corned beef or smoked fish. -Pickled or fermented foods, such as sauerkraut, kimchi, caviar, tofu or pickles. -Sauces, such as soy sauce, shrimp sauce, fish sauce, miso and teriyaki sauce. -Soybeans and soybean products. -Snow peas, broad beans (fava beans) and their pods. -Dried or overripe fruits, such as raisins or prunes, or overripe bananas or avocados. -Meat tenderizers or meat prepared with tenderizers. -Yeast-extract spreads, such as Marmite, brewer’s yeast or sourdough bread. -Alcoholic beverages, such as beer — especially tap or homebrewed beer — red wine, sherry and liqueurs. -Combination foods that contain any of the above ingredients. -Improperly stored foods or spoiled foods. While you’re taking an MAOI, your doctor may recommend eating only fresh foods — not leftovers or foods past their freshness dates. -Beverages with caffeine also may contain tyramine, so your doctor may recommend limits.
Serotonin Syndrome (Can’t sit still)
- symptoms: abdominal pain, diarrhea, sweats, tachycardia, HTN, muscle spasm/twitching, irritability, delirium. Can lead to hyperpyrexia (high fever), cardiovascular shock and death. - Need to wait 2 weeks before switching from an SSRI to an MAOI. Wait 5 weeks after fluoxetine due to longer half-life. - Can happen when current SSRI dose is increased.
Differences between Serotonin Syndrome and Neuroleptic Malignant Syndrome
Atypical Antidepressants
- Bupropion (Wellbutrin): common use- smoking cessation
- Mirtazapine (Remeron)
- Trazodone (Desyrel): common use- sleep aid
- affect one or two of the three neurotransmitters: serotonin, norepinephrine, and dopamine.
- do not take with MAOIs and do not use within 14 days after discontinuing MAOIs.
Serotonergic (SSRIs)
side effects
- insomnia
- sexual side effects
- weight gains
- anxiety
- nausea/ diarrhea.
Dopaminergic- buproprion side effects
- anxiety
- insomnia
- no sexual SE
- no weight gain
- seizure risk
Norepinephrine (TCAs) side effects
- blood pressure
- sedation
- weight gain
- cardiac in overdose
SNRI
- combo SSRI and TCA
- nausea
- weight gain
- blood pressure changes
Mood Stabilizers
(Anti-manic)
- Lithium (Eskalith, Lithobid)
- Lithium affects the flow of sodium through nerve and muscle cells. Impacts sodium/potassium shift.
- increased receptor sensitivity to serotonin
- Therapeutic serum range: 0.4 to 1.4 mEq/L
- Side Effects: GI distress (reduced appetite, nausea/vomiting, diarrhea, metallic taste), thyroid abnormalities, polyuria/polydipsia…. chronic kidney disease?, reduces seizure threshold, cognitie slowing, tremor.
Mood Stabilizers: Anticonvulsants
All treat mania, not the depression
- Valproate (Depakote, Depakene)
- side effects: thrombocytopenia, weight gain, tremors, liver dysfunction, sedation, decreased folic acid
- Carbamazepine (Tegretol)
- side effects: rash, sedation, confusion, ataxia, aplastic anemia, weight gain. many drug-drug interactions.
- Lamotrigine (Lamictal)
- side effects: rash, sedation, confusion, ataxia
Lamotrigine (Lamictal)
- Anticonvulsant
- rash (Steven-Johnson’s syndrome) call HCP
ANXIETY
feeling of apprehension, uneasiness, uncertainty or dread resulting from real or perceived threat whose actual source is unknown or unrecognized
fear
reaction to specific danger
anxiety
- effects us at deeper level than fear does
- invades central core of personality
- erodes away at our self-esteem and personal worth
normal anxiety
motivating force that provides energy to carry out tasks of living
acute anxiety
anxiety that precipitated by imminent loss or change that threatens one’s security (crisi)
Chronic anxiety
anxiety that persists over time
mild anxiety
- sees, hears, and grasps more information
- problem-solving more effective
- may display physical symptoms:
- slight discomfort
- restlessness
- irritable
- nail biting
- fidgeting
