Mood disorders and depression EXAM 3 Flashcards
Serotonin (5HT)
-Regulates sleep, appetite, pain, and libido
-Decrease in levels may result in poor impulse control, decreased appetite and sex drive +irritability
Decrease in Norepinephrine (NE)
-Anergia (lack of energy)
-Anhedonia (Lack of pleasure in life)
-Decreased concentration
-Decreased libido
Dopamine (DA)
-Reward and incentive process
Acetylcholine
Memory and learning
GABA
Calming
-Inhibiting neurotransmitter
Most common mental illness
Depression, also the leading cause of disability worldwide
Prevalence and co-morbidity, depression
-Number one mental illness
-Commonly occurs with other anxiety disorders or other psych disorders
-Depression can occur secondary to substance use or medical condition
-High risk of suicide (15%)
-Untreated depression is number one risk for suicide among youth
-Affects all family members
-Experience frustration, guilt and anger
-People dont understand the illness leading to difficulty living with people who are depressed, can lead to abuse
-Women more than men
-18-45 is common ages
What happens to the brain with chronic untreated depression
-Certain areas, such as the hippocampus can atrophy, it is unknown of the cause. But it is suspected that it is due to cortisol levels or decreased use of the hippocampus causes atrophy
Selective Serotonin Reuptake inhibitors (SSRI): MOA
Blocks 5HT reuptake in the synapse, more 5HT in the synapse for longer
-Takes 6-8 weeks for the full effect, should see some improvement in 2 wks
-Low lethality for OD
Selective Serotonin Reuptake inhibitors (SSRI): Uses
-Depression
-Bipolar
-Bulimia, panic, OCD and other anxiety disorders as well
Selective Serotonin Reuptake inhibitors (SSRI): Drugs names
-Fluoxetine (Prozac)
-Paroxetine (Paxil)
-Fluvoxamine (Luvox)
-Sertraline (Zoloft)
-Citalopram (Celexa)
-Escitalopram( Lexapro)
Selective Serotonin Reuptake inhibitors (SSRI): Common SE
-Nausea
-Diarrhea
-Fatigue
-Dizziness
-Dry mouth
-Sexual dysfunction
-Lower anticholinergic effects (Dry mouth, Blurred Vision, Urinary retention)
-Increased blood sugar
How to help with dry mouth SSRI
Hard candy, super common side effect
-Take with something else too
Selective Serotonin Reuptake inhibitors (SSRI): Other SE
-Insomnia
-Agitation
-Anxiety
-Weight changes
-Hyponatremia (with older adults on diuretics)
-Rash
-GI bleed
-Bruxism (Teeth grinding)
-Sleepiness
-Faintness
-Lightheaded
Selective Serotonin Reuptake inhibitors (SSRI): Symptoms to report to provider right away
-Onset or increase in suicidal thoughts
-Unusual bleeding
-Severe headache
-Rash or hives
-Weight loss
-Rapid HR
-Activation/impulsivity
Selective Serotonin Reuptake inhibitors (SSRI): Patient education
-Need to monitor glucose, SSRI increase glucose
-Cant stop abruptly, withdrawal
-Abstain from alc
-Watch for increased bruising, GI bleeds, Nosebleeds
-Grapefruit juice can increase plasma level of Zoloft
-Contraindicated in pt taking MAOI and TCA (5HT syndrome)
-Fluoxetine and Paroxetine can increase birth defects
-Late preg use of SSRI can increase risk of withdrawal or pulmonary HTN in newborn
SSRI why abstain from alc
Counteracts the effect of the drug
What meds are a concern for increased bruising, nosebleeds and GI bleeds for a pt taking SSRI
-ASA
-NSAIDS
-Steroids
-Anticoagulants
Grapefruit juice increases the plasma level of what SSRI
-Sertraline( Zoloft)
What two SSRI increase risk of birth defects
Fluoxetine and Paroxetine
SSRI interactions
-MAOI, TCA, ST john’s wort (all increase serotonin)
-Warfarin also increases 5HT
-Lithium increases 5HT
How long after taking a MAOI, it do need to wait to take an SSRI
14 days, washout period to avoid serotonin syndrome
Serotonin Syndrome
-Toxic state caused by increased 5HT in brain
Serotonin Syndrome: S+S
-Hyperactive or restless
-Tachycardia
-SUPER high fever
-Increased BP
-AMS (Delirium)
-Myoclonus (Muscle spasms)
-Mood swings
- GI disturbances, Diarrhea
-Seizures
-Abdominal pain
-Apnea
Greatest Risk of Serotonin Syndrome
-when combining drugs that both enhance serotonin levels
-MAOI and SSRI, Trazodone
When should you take SSRI
Morning because of sleep disturbances
Serotonin Syndrome mgmt
-Its a medical emergency
-Stop those 5HT drugs
-Cooling blankets for hyperthermia
-Anticonvulsants to prevent seizures
-Block the 5HT receptors
-Dantrolene or Diazepam
-Stop med
-Calm environment
-Safety (seizure precautions, anti psych)
-Fever: cooling blankets (she said tylenol but it isn’t effective for serotonin syndrome)
Dual action reuptake inhibitors (SNRI) MOA
-Inhibit the reuptake of 5HT and NE, more available in the synaptic space
Early signs of Serotonin Syndrome
-Muscle rigidity
-Tachycardia
-Fever
Late signs of Serotonin Syndrome
-Apnea
-Seizures
SNRI SE
-Weight loss can occur
-Fatigue
-Sweating
-Yawning
-Sexual dysfunction
-HA
-Hyponatremia (Older adults)
SNRI drugs
-Venlafaxine (Effexor)
-Duloxetine (Cymbalta)
-Desvenlafaxine (Pristiq)
Duloxetine SE
Hypoglycemia and orthostatic hypotension in the first week
-Should not be used in those with heavy alc consumption or liver disease
Desvenlafaxine SE
GI bleed
-increased intraocular pressure
-Increased cholesterol
SNRI education: BP
-Blood pressure MUST be taken often: risk of increased systolic BP
SNRI education: Risk for withdrawal
Dizziness, nausea, headache, sweating, irritability, fatigue can occur
Bupropion (Wellbutrin, Zyban)
-Atypical Antidepressant
-Used for depression, alt to SSRI in clients with sexual dysfunction, smoking cessation (reduces cravings), seasonal depression
Bupropion (Wellbutrin, Zyban) MOA
Inhibits the reuptake of dopamine and NE
Bupropion (Wellbutrin, Zyban) SE
-Insomnia
-HA
-Nausea
-Weight loss*
-Vision Loss*
-Dizziness
-Agitation
-GI distress
-restlessness
-Tachycardia
-Arrhythmias
-HTN
-Insomnia
-Seizures in high doses*
-SI
-Mood changes
-Abnormal dreams
-May exacerbate tics
Bupropion (Wellbutrin, Zyban) Contraindications
-Pt with eating disorders (weight loss)
-History of seizures
-Use of MAOI
Trazodone (Desyrel)
-Atypical antidepressant
Used for
-Sleep inducing in older adults
-Depression and all that
-SSRI induced insomnia
-Usually used joint with other AD
-Taken at bedtime
Trazodone (Desyrel)MOA
-Moderate selective blockage of 5HT receptor, increased amount of 5HT for impulse transmission
-Caution in cardiac disease
Trazodone (Desyrel) SE
-Priapism (Immediate medical attention)
-Vivid dreams, nightmares, nervousness, dry mouth, N/V EKG changes orthostatic hypotension, urine retention
-Liver levels
-QT prolongation
-May trigger mania
Why do you need EKG for SSRI/ Trazodone
QT prolongation
Tricyclics (TCA) MOA
-Inhibits reuptake of NE and 5HT
-Sedative effect from antihistamine action H1 receptors
Tricyclics (TCA) Drugs
Amitriptyline (Elavil)
-Imipramine (Tofranil)
-Nortriptyline (Pamelor, Aventyl)
-Doxepin (Sinequan)
Tricyclics (TCA)
-Used for neuropathic pain, fibromyalgia, anxiety, insomnia, bipolar
-Takes 10-14 days to be effective, 4-8 weeks for full effect
-Given at night for that sedative effect
-INCREASES SUICIDE RISK
Tricyclics (TCA) Caution
-CAD
-DM
-Liver disease
-Kidney disease
-Resp disorders
-Glaucoma
-BPH
-Hyperthyroid
-Urinary retention
Tricyclics (TCA) Contraindications
-Seizure disorder
-MI
-Narrow angle glaucoma
-Preg
Tricyclics (TCA) Interactions
Basically anything with a sedative effect
-MAOI
-Antihistamines
-Anticholinergics
-Sympathomimetics
-Alc
-Benzo
-Opioids
-CNS depressants
Tricyclics (TCA) SE
-Anticholinergics
-Sedation, Sexual dysfunction, weight GAIN, orthostatic hypotension, decreased seizure threshold, excessive sweating, hyponatremia, increased appetite
-Increased suicide ideations
Tricyclics (TCA) Toxicity
-Cardiac effects are the most serious
-Tachycardia, dysrhythmias, ECG changes, mental confusion, seizure, , coma , death
Tricyclics (TCA): overdose
-Overdose is highly lethal and easy
-Only given 10 day supply at a time (1 wk)
-Monitor VS , baseline ECG is needed
-Increased suicide risk
Monoamine Oxidase Inhibitors (MAOI) MOA
-Blocks MAOI in the brain, Preventing breakdown of 5HT, NE and DA
-Increased levels for impulse transmission
MOAI Indications
-Refractory depression and anxiety
-Atypical depression
-Those who didnt respond to other treatment
-Panic disorder, social phobia,GAD, OCD, PTSD, Bulimia (Mainly anxiety)
MAOI Drugs
-Phenelzine (Nardil)
-Tranylcypromine (Parnate)
-Selegiline transdermal system (STS)
MAOI SE
-Anxiety
-Agitation
-Hypomania/mania
-Orthostatic hypotension
-HTN crisis (Tyramine)
-Rash
MAOI HTN crisis
-If pt complains of severe headache, go to er
-Caused by foods high in tyramine
-Characterized by HA, nausea, increase in BP/HR
-Inhibtion of tyramine breakdown in the liver
-Can lead to HTN, CVA And DEATH
Tyramine sources
-Anything old, smoked, yeasty, fermented, avocado
HTN crisis antidote
-Phentolamine (Regitine)
-Nifedipine (Procardia)
MAOI Contraindications
-CV disease
-HTN
-CHF
-Liver disease
-Use of SSRI
MAOI interactions
-INdirect acting sympathomimetic (Epi)
-TCA
-Antihypertensive meds
-Meperidine
-Vasopressors
How long does lithium take to kick in
-5-7 days for initial effect and 3 weeks for control of mania
Lithium
-Mood stabilizer
-Less effective for rapid cycling, mixed mania or atypical features
-NARROW THERAPEUTIC window
-Need blood draws every 2-3 days initially until therapeutic levels
-1-3 months when on maintenance
-At least 9-12 mo of therapy but it can be lifelong
Lithium effects
Reduces
-Elation, grandiosity, expansiveness
-Flight of ideas
-Irritability or manipulativeness
-Anxiety
-Insomnia
-Psychomotor agitation
-Threatening behaviors
-Hypersexuality
-Paranoia
Lithium brand names
-Eskalith
-Lithane
-Lithobid
-Carbolith
Lithium Toxicity: Mild
Level is less than 1.5 but higher than 1
Mild lithium tox symptoms
-Metal taste in mouth
-Fine hand tremor at rest
-Nausea
-Polyuria
-Polydipsia
-Diarrhea
-Muscular weakness or fatigue
-Weight gain
-Edema
-Memory impairments
Lithium Toxicity: Moderate
Level is 1.5-2.5
Moderate lithium tox symptoms
-SEVERE diarrhea
-Dry mouth
-N+V
-Mild to moderate ataxia
-Incoordination
-Dizziness, sluggish
-Slurred speech
-Tinnitus
-Blurred vision
-Increasing tremor
-Muscle irritability or twitching
-ASymmetric deep tendon reflexes
-Increased muscle tone
Lithium Toxicity: Severe level
2.5+
Severe lithium tox S+S
-Cardiac arrhythmias
-Blackouts
-Nystagmus
-Coarse tremor
-Fasciculations (twitching muscles)
-Visual or tactile hallucinations
-Oliguria, renal failure
-Peripheral vascular collapse
-Confusion
-Seizures
-Coma and death
Moderate to severe lithium tox mgmt
-Hold lithium, do not admin lithium till you get another blood draw
-Obtain a blood lithium level stat
-Push fluids
-Contact the provider for further direction about reliving the symptoms
-Treatments can include emetics, gastric lavage or hemodialysis
Teaching points about lithium
-Maintain diet with CONSISTENT salt and fluid intake, If your salt is out of wack thats bad
-Need to drink 2-3 L a day
-if your salt levels drop can lead to lithium tox
-Teach pt S+S lithium tox
-If pt takes in too much salt, Lithium will be less effective
-Avoid diuretics
-GI irritant: Take with food
-Do not stop lithium after manic episode is over, you can relapse
-Importance of monitoring blood levels of lithium
-Drug drug interactions with lithium
-Caution in preg
-Need ECG
Anxiolytics
Used for treatment resistant mania and psychomotor agitation
-All end in PAM
Anxiolytics drugs
-Clonazepam (Klonopin)
-Lorazepam (Ativan)
-Diazepam (Valium)
-Alprazolam (Xanax)
Atypical antipsychotics, 2nd gen
-Used for psychosis, manic symptoms, affective instability, acute agitation
-Sedative properties
Atypical antipsychotics, 2nd gen: Drug names
-Olanzapine (Zyprexa)
-Risperidone (Risperdal)
-Aripiprazole (Abilify)
-Ziprasidone (Geodon)
-Quetiapine (seroquel)
Atypical antipsychotics, 2nd gen: Targeting which symptoms
-Hallucinations
-Delusions
-Paranoia
-Bizarre thinking
-Assaultive behavior
-Mood stabilization
Valproate (Depakote)
-Decreases impulsive aggressive behavior
-Anticonvulsant
-Need to monitor for Tox
-Not advised for women of childbearing age
Valproate (Depakote) SE
-Sedation
-weight gain
-HA
-Tremor
-Dizziness
-GI S+S (Self limiting)
Valproate (Depakote) Adverse effects
-Agranulocytosis (Increased risk of infection)
-Hepatotoxicity
-Pancreatitis
- Teratogenesis (Can cause neural tube defects in fetus)
-Need to monitor for tox
Carbamazepine (Tegretol)
-Anticonvulsant
-Better used for rapid cycling and paranoid hostile S+S
-Need to monitor blood levels of drug
-Lots of drug interactions
-Interferes with oral contraception
-Slight weight gain
Carbamazepine (Tegretol): SE
-Sedation, HA, Nystagmus vertigo, double vision
-Slight weight gain
-Interferes with oral contraception
Carbamazepine (Tegretol) Adverse effects
-Agranulocytosis and aplastic anemia teratogenesis and hypoosmolality
-Steven johnson syndrome
Neuroleptic Malignant Syndrome (NMS)
-Life threatening condition developing from antipsych meds
-Primary symptoms are mental status changes, severe status changes , severe muscle rigidity and autonomic changes
Primary symptoms of NMS
-Mental status change (Agitation/delirium)
-Rigidity
-High fever (101-103)
-Autonomic instability (Tachycardia,tachypnea, elevated BP, diaphoresis , dysrhythmias)
Treatment of NMS
-Early recognition is key
-Stop medication and any dopamine antagonist (reflux meds)
-Control cardiac and resp status
-Apply cooling blankets for hyperthermia, ice pack, ASAP
-Rehydrate
-Muscle relaxants
-Frequent vitals
-Monitor labs
