Mental Health Medications Exam 1

Question 1

Antidepressants

Answer 1

1. Selective Serotonin Reuptake inhibitors (SSRIs)
2. Cyclic Compounds (TCAs)
3. Atypical Antidepressants
4. Serotonin-Norepinephrine
   Reuptake inhibitors (SNRIs)
5. MAOIs

Question 2

Antidepressants: MOA

Answer 2

1. Increases levels of serotonin in the brain by blocking the reabsorption (reuptake) of serotonin into neurons, therefore increasing the amount of serotonin available to improve transmission of messages between neurons
2. Increases levels of serotonin & norepinephrine in the (CNS) & blocks the action of acetylcholine, resulting in anticholinergic effects
3. Each atypical med has its own MOA
4. Increases levels of serotonin & norepinephrine, in the brain
5. Elevates levels of norepinephrine, serotonin, & dopamine by inhibiting an enzyme: monoamine oxidase (MAO)

Question 3

Antidepressants: Common Indications

Answer 3

• Depression
• Anxiety
• PTSD
• Panic Disorder
• GAD
• OCD
• Social Phobia
• Neuropathy
• Fibromyalgia
• Insomnia

Question 4

Antidepressants Common Side Effects

Answer 4

Weight gain
* Obtain & a baseline for weight, then monitor, encourage balanced diet with regular exercise.
Insomnia
* Take first thing in am (may add trazodone).
Nausea
* Take with food to reduce GI upset
Sexual dysfunction
* May take several trials of different meds
Bruxism
* Night guard, no evening caffeine, stop smoking

Question 5

SSRIs

Answer 5

Oxetine, pram & ine
* paroxetine (Paxil)
* fluoxetine (Prozac)
* escitalopram (Lexapro)
* citalopram (Celexa)
* sertraline (Zoloft)
* fluvoxamine (Luvox)
If you are the parent of a teen, you may need an SSRI (i.e. paroxetine, fluoxetine) to cope with depression/anxiety.

Question 6

SSRI Unique S/E, Teaching, Monitoring, Restrictions

Answer 6

• Fewest side effects of all antidepressants
• Causes least weight gain
• Produce few sedating, anticholinergic, or cardiovascular s/e (safer for older adults)
• Good for use in adults with SI, as 30-day supply has least risk of suicide by OD
• Increased SI noted in children/adolescents
• Increased bleeding risk when used w/certain pain relievers like aspirin, NSAIDs & blood thinners
• Contraindications: MAOIs ● TCAs ● St. John’s wort ● Warfarin ● NSAIDs
• Avoid anticoagulants, other antidepressants, opiate derivative pain meds: meperidine (Demerol) or tramadol (Ultram), meds used to treat migraine headaches (triptans), lithium, & (street drugs like cocaine)
• Contraindicated with MAOIs or TCAs.
• Do not stop abruptly, taper gradually.
• Use cautiously w/ liver, renal, cardiac, or seizure dysfunction; diabetes or ulcers/hx of GI bleeding.
• Risk of Serotonin Syndrome
• S/S may include anxiety, restlessness, sweating, muscle spasms, shaking, fever, rapid heartbeat, vomiting, & diarrhea.
  Paroxetine (Paxil)
• Main s/e sedation, also sweating, diarrhea, hand tremor, headaches & risk of birth defects
  Fluoxetine (Prozac)
• Category C Pregnancy risk (risk of birth defects)

Question 7

Tricyclic Antidepressants

Answer 7

triptyline & mine
Aka: TCAs, Cyclic Compounds
* amitriptyline (Elavil)
* nortriptyline (Pamelor)
* imipramine (Tofranil)
* clomipramine (Anafranil)
* desipramine (Norpramin)
* doxepin (Sinequan)

Amy tripped over a tricycle in the desert. It is DRY in the desert, like the anticholinergic effects of amitriptyline.

NOTE: Suicide prevention is facilitated by prescribing only 1 week of medication for an acutely ill client, & following that, only prescribing 1 month of medication at a time, especially with TCAs, which have a high risk for lethality with a toxic dose. Assess clients for suicide risk.

Question 8

Tricyclic Antidepressants Unique S/E, Teaching, Monitoring, Restrictions

Answer 8

• Takes 4-8 weeks to take full effect
• Take at night in a single daily dose
• Avoid dehydration, increases hypotension risk.
• More S/E effects than SSRIs & newer meds
• Common S/E: sedation, hypotension, increased appetite/weight gain, & toxicity, decreased seizure threshold & excessive sweating
• Contraindicated for client’s w/seizure disorders
• Use cautiously in client’s w/ CAD; diabetes; liver, kidney, & respiratory disorders; urinary retention; angle closure glaucoma; BPH; & hyperthyroidism.
• TCAs can increase suicide risk (see NOTE).
• Cause Anticholinergic S/E:
  Blurred vision & Photophobia (can’t see)
• Wear sunglasses when outdoors
  Urinary retention (can’t pee)
• Instruct to report any frequency or burning with urination, void prior to taking med.
  Dry mouth (can’t spit)
• Use ice chips, sugar-free drinks or hard candy
  Constipation (can’t poop)
• Increase fluid & dietary fiber intake
  Orthostatic hypotension
• Instruct rising slowly from sitting or lying
  Tachycardia
• Beta blocker may be prescribed
  Amitriptyline (Elavil)
• Can cause enuresis under age 6 (take at bedtime)
• Can cause black hairy tongue
• Pregnancy Risk Category C
  Imipramine (Tofranil)
• Can be used for kids with depression & also for bedwetting, off label for panic disorder
• Void prior to taking medication

Question 9

Atypical Antidepressants

Answer 9

• bupropion (Wellbutrin)
• mirtazapine (Remeron)
• vortioxetine (Trintellix)
• trazodone (Oleptro)
• vilazodone (Viibryd)
• nefazodone (Serzone)
  Bupropion… “be appropriate” and don’t smoke.

NOTE: Evaluate risk for suicide after treatment with ANY anti-depressant is initiated. The client may feel more energized but still have suicidal thoughts, which increases the likelihood of a suicide attempt. Also, because it often takes weeks
before the medications have a full therapeutic effect, clients may become discouraged and tired of waiting to feel better, which can result in suicidal behavior.

Question 10

Atypical Antidepressants Unique SE

Answer 10

• May take 1 to 3 weeks for therapeutic effects w/full therapeutic effects up to 2 to 3 months.
  Bupropion (Wellbutrin, Zyban)
• Inhibits reuptake (reabsorption) of dopamine, serotonin, & norepinephrine
• Zyban brand of bupropion is used to help people stop smoking by reducing cravings & other withdrawal effects r/t its effect on dopamine, which is linked to brain’s habit-reward system
• S/E: insomnia, headache, GI upset, weight loss, agitation, & increase in risk for seizures (avoid if hx of head injury).
• Contraindicated in client’s w/seizures, taking MAOIs or w/anorexia or bulimia.
• Pregnancy Risk Category B medication.
  Trazodone (Oleptro, Desyrel)
• Used to treat depression, alleviate anxiety & insomnia, may help improve mood, appetite & energy levels (advise to take at bedtime).
• Often used w/another antidepressant.
• Priapism can be a serious adverse effect.
• Key S/E sedation, hypotension & dry mouth (often prescribed for sleep aid).
• Use caution in clients w/cardiac disease.
  Mirtazapine (Remeron)
• Therapeutic effects can occur sooner, w/less sexual dysfunction, than with SSRIs.
• S/E sleepiness (avoid other CNS depressants)
• Increased appetite, weight & cholesterol
  Vilazodone (Viibryd)
• Administer with food to increase absorption
• Can cause male/female sexual dysfunction
• Risk for serotonin syndrome & NMS
• Monitor for hyponatremia

Question 11

SNRIs Serotonin-Norepineprine Reuptake Inibitors

Answer 11

faxine
* duloxetine (Cymbalta)
* venlafaxine (Effexor)
* desvenlafaxine (Pristiq)
I don’t need a deluxe apartment to be happy, I just need to take duloxetine for my depression.

Question 12

SNRIs Unique SEs

Answer 12

• S/E fatigue, HA, GI upset, nausea, dry mouth, constipation, dysuria, agitation, anxiety, sleep disturbances, & decreased libido.
• Monitor for hyponatremia (especially elderly)
• Monitor for weight loss & increases in B/P
• Discuss ways to manage sexual dysfunction.
• Avoid abrupt cessation, d/c gradually.
• Risk for serotonin syndrome
  Duloxetine (Cymbalta)
• Can cause liver issues: avoid in clients w/hepatic disease or who consume excess alcohol.

Question 13

MAOIs

Answer 13

• Selegiline (Emsam) *Patch
• Phenelzine (Nardil)
• Tranylcypromine (Parnate)
• Isocarboxazid (Marplan)
  With “Phenelzine” you can’t eat life’s finer things because they contain tyramines.

Tyramine is found in:
* Mature or aged cheeses or dishes made with cheese (All cheese is considered aged except cottage cheese, cream cheese, ricotta cheese, & processed cheese slices.
* Yogurt, sour cream, peanuts, Brewer’s yeast, & MSG
* Aged meats such as pepperoni, salami, summer sausage, beef logs, meat extracts, and similar products.
* Fermented products: Sauerkraut, soy sauce or soybean condiments, or marmite (concentrated yeast).
* All tap beers and microbrewery beer Drink no more than two cans or bottles of beer (including nonalcoholic beer) or 4 ounces of wine per day
* Fava beans, bean curd (tofu), banana peel, overripe fruit, & avocado

For hypertensive crisis:
Administer phentolamine IV, a rapid-acting alpha-adrenergic blocker, or nifedipine. Provide continuous cardiac monitoring & respiratory support as needed.

Question 14

MAOIs Unique SEs +

Answer 14

• Takes 2-4 weeks for therapeutic effects
• Must follow a tyramine-free diet
• MAO is an enzyme that breaks down excess tyramine in the body. When MAO is inhibited, the excess tyramine is not being broken down, & can lead to too much tyramine in the body, which can spike blood pressure or hypertensive crisis r/t intensive vasoconstriction & heart stimulation.
• Monitor BP & heart rate for orthostatic changes
  (advise clients to change positions slowly).
• Use cautiously in client’s w/diabetes or seizure disorders, or those taking antihypertensives as it could further lower BP.
• Contraindications: taking SSRIs, TCAs, buspirone (BuSpar), opiate derivatives such as meperidine (Demerol), dextromethorphan (avoid OTC decongestants & cold remedies).
• Contraindicated in clients who have pheochromocytoma (hormone-secreting adrenal tumor), heart, vascular or kidney issues.
• MAOIs should not be used within 10 to 14 days before or after surgery.

Selegiline
* MAOI used for atypical & treatment-resistant major depression.
* *ONLY Antidepressant that comes in a patch.
* Transdermal selegiline is contraindicated for clients taking carbamazepine (Tegretol) or oxcarbazepine (Trileptal). Concurrent use can increase blood levels of the MAOI.
Phenelzine
* Can cause CNS stimulation such as anxiety, agitation, hypomania, mania
* Risk of orthostatic HTN
* Pregnancy Risk Category C

Question 15

Bipolar Medications Types

Answer 15

1. Antimanic agent/Mood stabilizer
2. Antiepileptic/Anticonvulsant (used for mood stabilization)
3. Other med classes used:
   * Antipsychotics: Aripiprazole, olanzapine, quetiapine are useful in early treatment to promote sleep & decrease anxiety/agitation.
   * Anxiolytics: Clonazepam & lorazepam can be useful in treating acute mania & managing the psychomotor agitation often seen in mania.
   * Antidepressants: Bupropion, venlafaxine, SSRIs can be useful during depressive phase

Question 16

Bipolar Meds MOA

Answer 16

Mood stabilizers work by decreasing abnormal activity in the brain. Lithium reduces excitatory (dopamine & glutamate) but increases inhibitory (GABA) neurotransmission. It alters sodium transport across cell membranes in nerve & muscle cells, & modulates glutamate neurotransmission by acutely stimulating the NMDA receptor.
2. Slows the entrance of sodium & calcium back into the neuron, thus extending the time it takes for the nerve to return to its active state. Potentiates the inhibitory effects of (GABA), inhibits glutamic acid (glutamate), which in turn suppresses (CNS) excitation.

Question 17

Bipolar Medications Common Indications

Answer 17

• Bipolar
• Mania
• Seizures
• Mood stabilization
• Depression (usually along with an antidepressant)
• Schizoaffective Disorder
• Disorders of impulse control

Question 18

Antimanic Agent/ mood stabilizer

Answer 18

• Lithium carbonate (Lithium)

Lithium compliance is complicated by Litany of frequent & specific lab monitoring, 2-3x/day dosing & Literal risk for toxicity.

(Think High/Low Opposites)
High Salt = Low Lithium level
Low Salt = High Lithium level

LITH Pneumonic:
* L leukocytosis.
* I insipidus
* T tremors
* H hypothyroidism

Question 19

Antimanic Agent/ Mood stabilizer UNIQUE S/E

Answer 19

Lithium carbonate (Lithium)
* Requires frequent lab monitoring
* Plasma levels should stay under 1.5 (above 1.5 can cause toxicity) high risk of toxicity r/t narrow therapeutic range.
* During initial tx higher levels (1 to 1.5 mEq/L) can be required w/maintenance range of (0.6 to 1.2 mEq/L)
* S/S of toxicity: coarse tremors, confusion, hypotension, seizures, & tinnitus.
* At initiation of tx monitor levels q 2-3 days until stable, then q 1-3 months (closely monitor levels after any dosage change).
* Lithium blood levels should be obtained in the morning, 10 -12 hr after last dose.
* Older adults are at increased risk for toxicity & require more frequent monitoring of levels.
* Effects in 5-7 days, max benefits 2-3 weeks.
* Use cautiously in older adults & thyroid disease, seizure disorder, or diabetes.
* Take as prescribed (administer in 2 -3 doses daily r/t short half-life)
* Half-life: 24 hours & 36 hours for elderly
* Labs: Assess baseline BUN and creatinine, & monitor kidney function periodically.
* Obtain baseline T3, T4, and TSH levels prior to starting treatment, and then annually.
* S/E: GI upset (take with meals or milk), nausea, diarrhea, abdominal pain, & fatigue.
* Also weight gain, fine hand tremors (can be exacerbated by factors like stress & caffeine), electrolyte imbalances, leukocytosis, hypothyroidism, as well as polyuria (r/t nephrogenic diabetes insipidus, lithium causes).
* Contraindications: hypovolemia, cardiac disease, schizophrenia & kidney disease (r/t high risk for nephrotoxicity
* Teaching: Maintain consistent & adequate intake of both sodium & fluids (monitor salt intake, excessive sweating, & fluid intake).
* Avoid (diuretics & NSAIDS) r/t toxicity
* Avoid anticholinergics [antihistamines, tricyclic antidepressants] to prevent toxicity (abdominal discomfort can result from anticholinergic induced urinary retention & polyuria).
* Pregnancy Risk Category D (considered teratogenic, especially 1st Trimester) breastfeeding discouraged.

Question 20

Antieplileptics/Anticonvulsants

Answer 20

• Valproic acid (Depakene)
• Topiramate (Topamax)
• Carbamazepine (Tegretol)
• Oxcarbazepine (Trileptal)
• Lamotrigine (Lamictal)
• Pregabalin (Lyrica)
  Val’s Valproic acid stabilizes Valuable moods, but Vacillates between risk for Valid liver problems or risk for Valid birth defects.

Topher talks about too many Topic’s when the Topic goes to his Topiramate and his Top weight loss. He Topples after getting metabolic acidosis and kidney stones that look like Topiaries.

Carol’s Car, full of Cargo, Carelessly Careening over a Caravan, is less of a risk than Carbamazepine’s risk for Caring a blood disorder or Carousing with SIDAH.

Lamotrigine would make a Lamma lament over the risk for a serious skin rash that Lamisil can’t fix.

Pregabalin prevents Gabby’s neuropathy pain.

Question 21

Antiepileptics/Anticonvulsants S/E

Answer 21

• S/E: Common are similar lithium, but may also include HA, sexual problems, abdominal pain, fever, confusion, blurred vision & abnormal bruising & bleeding.
  Valproic acid (Depakene)
• Works to increase inhibitory GABA in the CNS to prevent seizures & reduce bipolar symptoms.
• Monitor liver function regularly, including AST, ALT, and bilirubin levels.
• S/E: hepatotoxicity, pancreatitis, GI upset, & thrombocytopenia, neural tube defects
• Pregnancy Category D.
  Topiramate (Topamax)
• S/E: dizziness, sedation, weight loss (rather than gain), vision issues & increased risk of renal calculi (drink water).
• Can cause metabolic acidosis (monitor bicarbonate levels while taking).
  Carbamazepine (Tegretol)
• S/E: vision problems (nystagmus, double vision) vertigo, staggering gait, HA & serious skin rashes
• Administer at bedtime, in low doses initially, then gradually increase.
• Serious S/E: blood dyscrasias: anemia, leukopenia, & thrombocytopenia (monitor CBC).
• Can cause aplastic anemia & agranulocytosis at a rate 5-8x > general population
• Contraindications bone marrow suppression or bleeding disorders, oral contraceptive use, & warfarin use.
• Avoid intake of grapefruit juice
• Risk for infection r/t WBC count impact (monitor & report S/S of infection i.e.; fever or lethargy).
• Monitor blood sodium, for edema, decrease in urine output, & HTN
• Can cause syndrome of inappropriate ADH (SIADH), which causes retention of water, diluting the bloodstream & resulting in hypo-osmolarity (blood diluted w/too much water).
• Promotes secretion of antidiuretic hormone, which inhibits water excretion by the kidneys, & places client w/heart failure at risk for fluid overload.
  Lamotrigine (Lamictal)
• S/E: rash, dizziness, GI upset, & photosensitivity.
• Risk of serious skin conditions: Stevens-Johnson Syndrome & Toxic Epidermal Necrolysis (life-threatening dermatological conditions)
• Risk for serious rashes is greater <16 years of age
• Any rash should be promptly reported to PCP
• Avoid concurrent use of carbamazepine, phenytoin, phenobarbital, other anticonvulsants valproate & oral contraceptives
  Pregabalin (Lyrica)
• Binds to calcium channels in the CNS decreasing release of excitatory neurotransmitters (causing decrease in action potential that communicates things like pain or an involuntary movement).
• S/E: drowsiness, dry mouth, dizziness, & possible edema.
• Do not consume alcohol.
• Do not stop abruptly, r/t risk of withdrawal symptoms like dizziness