Mood Disorders Flashcards by Marie Bacungan

5HT Serotonin

regulates sleep, appetite, pain, and libido

dec –> poor impulse control, dec appetite, sex drive, + irritability

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NE decreased (norepinephrine)

anergia, anhedonia, dec concentration, dec libido

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dopamine (DA)

reward and incentive process

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acetylcholine

memory + learning

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GABA

calming, inhibiting neurotransmitter

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depression (prevalence + comorbidity)

most common mental illness
15% - commit suicide
untreated - #1 risk in youth for suicide
affects all family members
women 18 - 45 (majority)
*brain atrophy if undiagnosed for long time

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selective serotonin reuptake inhibitors (SSRI) pharmaco + use

Fluoxetine (Prozac)
Paroxetine (Paxil)
Fluvoxamine (Luvox)
Sertraline (Zoloft)
Citalopram (Celexa)
Escitalopram (Lexapro)
selectively blocks reuptake of serotonin = more seratonin in synaptic space

used for depression + bipolar disorder
can be used for OCD, bulimia, panic, PTSD

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SSRI s/s

Common: nausea (take w/ food), diarrhea, fatigue, dizziness, DRY MOUTH, sexual dysfunction

Other: insomnia, agitation, anxiety, weight change, hyponatremia (older on diuretics), rash, GI bleed, bruxism, sleepiness, faintness, lightheadedness

Immediate attention: onset/inc suicidal thoughts, unusual bleeding, severe HA, rash or hives, weight loss (rare), tachycardia, activation/impulsivity

Lower anticholinergic SE (dry mouth, blurry vision, urinary retention)
Low lethality for OD; full effect 6-8 wks (some 2 wks)

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SSRI patient education

dont stop abruptly - withdrawal s/s (HA, n/v, visual disturbances, anxiety, dizziness, tremors) - esp w/ Paxil (short half life)

NO alc - counteracts med

grapefruit juice –> inc plasma levels of Zoloft

contraindicated w/ MAOIs + TCAs (r/o serotonin syndrome), interacts w/ warfarin + lithium

fluoxetine + paroxetine –> inc birth defects

late use in preg –> inc withdrawal risk or pulmonary HTN (newborn)

**WEIGHT GAIN + watch for bruising, GI upset (esp w/ NSAIDS or anticoag), order EKG (QT prolongation)

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what is serotonin syndrome?

toxic state caused by inc serotonin in brain 5-HT

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serotonin syndrome s/s

hyperactivity or restlessness, tachycardia, HIGH FEVER, inc BP, delirium, myoclonus (muscle spasms), mood swings, GI disturbances, diarrhea, seizures (late), abdominal pain, apnea (late)

**greatest risk when combined w/ second serotonin enhancing agent (MAOI)

MEDICAL EMERGENCY

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serotonin syndrome interventions

MEDICAL EMERGENCY

discontinue serotonergic agents

cooling blankets (hyperthermia)

anticonvulsants (seizure preventions)

blockade of 5 HT receptors: propranolol (Dec BP)

dantrolene (Dantrium) or Diazepam (Valium) –> muscle rigidity

artificial ventilation

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dual-action reuptake inhibitors (SNRIs) pharmaco + use

Venlafaxine (Effexor)
Duloxetine (Cymbalta) - hypoglycemia, orthostatic hypotension (1st week)
Desvenlafaxine (Pristiq) - GI bleed, cholesterol, glaucoma

inhibits uptake of 5HT + NE = inc availability of serotonin + NE in synaptic space

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SNRI s/s

anticholinergic (dry mouth, blurry vision, constipation flushed face), fatigue, sweating, yawning, sexual dysfunction, HA, hyponatremia (older adults), WEIGHT LOSS

monitor BP often (risk for inc systolic BP)

risk for withdrawal: dizziness, nausea, HA, sweating, irritability, fatigue

**duloxetine should NOT be used if pt has liver disease or drinks excessive alcohol

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atypical antidepressants

Bupropion (Wellbutrin, Zyban)

Trazodone (Desyrel)

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Bupropion (Wellbutrin, Zyban)

inhibits reuptake of dopamine + NE

indications: depression, alt to SSRI in clients w/ sexual SE, smoking cessation, seasonal depressoin

SE: insomnia, HA, nausea, dizziness, WEIGHT LOSS, agitation, GI distress, restlessness, tachycardia, arrhythmias, HTN, insomnia, seizures (high doses), SI, mood changes, abnormal dreams

may exacerbate tics

contraindicated w/ eating disorders or hx of seizures; MAIOs

reduces craving in smoking cessation

*dont crush, split or chew

Trazodone (Desyrel)

moderate selective blockade of serotonin receptor = inc amount of serotonin available for impulse transmission

indications: sleep inducing effects (older adults), SSRI induced insomnia

usually used w/ other AD (taken @ bedtime); caution w/ cardiac disease

can cause priaprism - painful persistent erection (EMERGENCY) - ice or needle

SE: vivid dreams, nightmares, nervousness, dry mouth, N/V, EKG changes, nervous ness, orthostatic hypotension

Inc liver levels, QT prolongation, mon mood + BP (WEIGHT LOSS)

tricyclic antidepressants (TCA)

Amitriptyline (Elavil)
Imipramine (Tofranil)
Nortriptyline (Pamelor, Aventyl)
Doxepin (Sinequan)

inhibits reuptake of 5HT + NE = inc serotonin + NE in synaptic gap; sedative effect from antihistamine action

indications: neuropathic pain, fibromyalgia, anxiety, insomnia, bipolar

10 - 14 days to see effectiveness; full effect 4 - 8 wks; usually given @ night

contraindication: in seizure disorders, MI, narrow angle glaucoma, preg

INC SUICIDE RISK

interactions: MAOIs, antihistamines, anticholinergic, sympathomimetic, alcohol, benzos, opioids, CNS depressants

TCA s/s

anticholinergic SE: dry mouth, blurry vision (constipation, urinary retention, immediate attn)

sedation, sexual dysfunction, weight gain, orthostatic hypotension, dec seizure threshold, excess sweat, hyponatremia, inc appetite

toxicity: CARDIAC EFFECTS (SERIOUS) - tachycardia, dysrhythmias, ECG changes, mental confusion, seizure, coma, death

Lethal in OD: 10 day supply - only give 1 week supply, monitor VS, baseline ECG

monoamine oxidase inhibitors (MAOI)

Phenelzine (Nardil)
Tranylcypromine (Parnate)
Selegiline transdermal system (STS)

prevent breakdown of 5HT, NE, DA = inc levels available for transmission impulses

effective for refractory depression + anxiety, atypical depression

indications: panic disorder, social phobias, GAD, OCD, PTSD, bulimia

MAOI s/s

SE: anxiety, agitation, hypomania, orthostatic hypotension, HTN crisis, rash

avoid food w/ high tyramine! aged, smoked, or fermented meats/fish, protein dietary supplements, yeast extract, beers, red wine, soy sauce/soybean paste, avocado, fava bean, aged cheese
RISK FOR HTN CRISIS, CVA - HA, nausea, inc HR/BP

interactions: indirect-acting sympathomimetric (ephedrine), TCAs, antihypertensive, meperidine, vasopressors

bipolar disorders

mania + depression

alternating mood episodes characterized by mania, hypomania, depression, concurrent mania + depression

lithium carbonate

eskalith, lithane, lithobid, carbolith

5 - 7 days to notice; up to 3 wks (control mania)

less effective for rapid cycling, mixed mania, or atypical features
NARROW THERAPEUTIC WINDOW OF TOXICITY
draw q 2/3 days until therapeutic –> 1-3 mo when maintaining

at least 9 - 12 months of therapy; usually life long

reduces: elation, grandiosity, expansiveness, flight of ideas, irritability + manipulativeness, anxiety, insomnia, psychomotor agitation, threatening behavior, hypersexuality, paranoia

mild lithium toxicity

<1.5 mEq/L

metallic taste in mouth, fine hand tremor (resting), nausea, polyuria, polydipsia, diarrhea or loose stools, muscular weakness or fatigue, weight gain, edema, memory impairment

*norm 0.6 - 1.0

moderate lithium toxicity

1.5 - 2.5 mEq/L severe diarrhea, dry mouth, nausea/vomiting, mild to mod ataxia, incoordination, dizziness, sluggishness, giddiness, vertigo, slurred speech, tinnitus, blurred vision, inc tremor, muscle irritability/twitching, asymmetric deep tendon reflexes, inc muscle tone *norm 0.6 - 1.0

severe lithium toxicity

>2.5 mEq/L cardiac arrhythmias, blackout, nystagmus, coarse tremor, fasciculations, visual or tactile hallucinations, oliguria, renal failure, peripheral vascular collapse, confusion, seizures, coma/death

lithium toxicity tx

moderate to severe tx hold lithium immediately obtain a blood lithium level push fluids contact physician

lithium interventions

edema - monitor I/Os, sodium, and weight, elevate legs fine hand tremor - provide support + reassurance, more freq smaller doses mild diarrhea - take lithium w/ meals, fluid replacement, notify prescriber muscle weakness, fatigue, or memory - provide support + reassurance, short term memory aids metallic taste - sugarless candies/throat lozenges, freq oral hygiene

lithium patient education

maintain norm diet w/ CONSISTENT salt + fluid intake (1500 - 3000 mL/day) - 6 12 oz glasses if Na intake falls - lithium tox if dehydrated, sweating, vomiting, diarrhea - discontinue + call prescriber if too much Na, lithium will be less effective avoid diuretics GI irritant - take w/ food dont dc after manic episode, risk of relapse MONITOR LITHIUM BLOOD LEVELS drug-drug interactions: diuretics, NSAIDs, TCAs, Antihistamines, ETOH severe caution in pregnancy

anxiolytics

Clonazepam (Klonopin) Lorazepam (Ativan) Diazepam (Valium) Alprazolam (Xanax) tx: resistant mania psychomotor agitation

atypical antipsychotics

2nd gen olanzapine (Zyprexa) risperidone (Risperdal) – avail IM aripiprazole (Abilify) ziprasidone (Geodon) quetiapine (Seroquel) Sedative properties Indications: psychosis, manic symptoms, affective instability, acute agitation Target s/s: hallucinations, delusions, paranoia, bizarre thinking, assaultive behavior & mood stabilization

anticonvulsants (antiepileptic)

Valproate (Depakote) Carbamazepine (Tegretol)

Carbamazepine (Tegretol)

Better for rapid-cycling, paranoid hostile s/s Mon blood level – can increase liver enzymes Many drug interactions Little weight gain Interferes with oral contraceptives Common SE: sedation, HA, nystagmus vertigo, double vision Adverse effects: agranulocytosis & aplastic anemia, teratogenesis, hypoosmolality Stevens-Johnson syndrome

Valproate (Depakote)

Effective at decreasing impulsive, aggressive behavior Common SE: sedation, weight gain, headache, tremor, dizziness, GI s/s (usually self-limiting) Adverse effects: agranulocytosis & aplastic anemia, hepatoxicity, pancreatitis, teratogenesis Neural tube defects in fetus Not advised for women of child-bearing age MONITOR LEVEL FOR TOXICITY

Neuroleptic malignant syndrome (NMS)

Life threatening emergency from antipsychotic medications Changes in mental status (agitation, delirium) Rigidity High Fever (101F-103F) Autonomic instability (tachycardia, elevated BP, tachypnea, diaphoresis, dysrhythmias)

NMS tx

Recognize s/s early Stop medication & any dopamine antagonists (gastric reflux med) Control cardiac and respiratory status ****Apply cooling blankets for hyperthermia, ice packs, APAP Rehydrate Muscle relaxants Frequent monitoring of VS Monitor labs