Psychopharmaceuticals Flashcards
How long does it take for many antidepressants to take effect?
1-3 weeks
What class of drug do the following medications belong to:
* citalopram (celexa)
* escitalopram (cipralex)
* fluoxetine (prozac)
* fluvoxamine (Luvox)
* Sertraline (Zoloft)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Why are SSRIs less dangerous than older antidepressants when taken in overdose?
Because they cause reatively fewer adverse effects and have lower cardiotoxicity
What are signs of serotonin syndrome?
- hyperactivity or restlessness
- tachycardia, can lead to cardiovascular shock
- fever
- elevated blood pressure
- altered mental status (delirium)
- irrantionality, mood swings, hostility
- seizures (status epileptucs)
- myoclonus (sudden, brief involuntary twitching or jerong of a muscle or group of muscles)
- incoordination, tonic rigidity
- Abdominal pain, diarrhea, bloating
- apnea - leading to death
What interventions are there for serotonin syndrome?
- Stop medication
- Initiate symptomatic treatment:
- serotonin receptor blockade with cyproheptadine, methysergide, propanolol
- Colling blankets, chlorpromazine for hyperthermia
- Dantrolene, diazepam for muscle rigidity or rogours
- Anticonvulsants
- Artificial ventilation
- Paralysis
What are common adverse reactions to SSRIs?
- May induce agitation, anxiety, sleep disturbamce, tremor, sexual disturbance, or tension headache
- Sexual dysfunction most undesireable and main cause of non-adherence
- Autonomic reactions such as dry mouth, sweating, weight change, mild nausea, loose bowel movements can also occur
When taking an SSRI, when is the risk of serotonin syndrome the greatest?
When administered in combination with a second serotonin-enhancing agent, such as an MAOI. Patient should discontinue all SSRIs for 2 -5 weeks before starting an MAOI.
What does the acronym SHIVERS stand for when remembering the symptoms of serotonin syndrome?
Shivering: Neuromuscular symptom that is unique to serotonin syndrome
Hyperreflexia and myoclonus: Seen in mild to moderate cases. Most prominent in the lower extremities. This can help differentiate from neuroleptic malignant syndrome which would present with lead-pipe rigidity
Increased temperature: Not always present, but usually observed in more severe cases
Vital sign abnormalities: Tachycardia, tachypnea, and labile blood pressure
Encephalopathy: Mental status changes such as agitation, delirium, and confusion
Restlessness: Common due to excess serotonin activity
Sweating: Autonomic response to excess serotonin
What does a medication that is an agonist do?
Drugs that bind to and activate response from the targeted receptor
What do medications that are antagonists do?
drugs that bind to, BUT DO NOT activate targeted response. No effect. They kind of act like a bully “I’m here so you can’t be” to other drugs.
What is involved in the pharmacokinetics of drugs?
1) Absorption (how much in circulation)
2) Distribution
3) Metabolism (chemical change: metabolites)
4) Excretion of metabolites (most metabolized in liver and excreted through urine)
What do drugs that treat depression generally do?
Generally Drugs used to treat depression increase synaptic levels of norepinephrine and/or serotonin
What are the four main classes of anti-depressants?
a. Tricyclic antidepressants (old ones)
b. Selective Serotonin Reuptake Inhibitors (SSRI’s)
c. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s)
d. Monoamine Oxidase Inhibitors (MAOI’s)
Outside of the four main classes, what are the other types of anti-depressant medications?
e) Serotonin Modulator and Stimulator
f) Serotonin and Norepinephrine Disinhibitors (SNDI’s)
g) Norepeinephrine-Dopamine Reuptake Inhibitors
h) Serotonin receptor antagonist and reuptake inhibitor (SARI)
Give one example of a Serotonin Modulator and Stimulator
Vortioxetine (Trintellix)
Give one example of a Serotonin and Norepinephrine Disinhibitors (SNDI’s).
Mirtazipine (Remeron)
Give one example of a Norepeinephrine-Dopamine Reuptake Inhibitors (NDRI’s).
Bupropion (Wellbutrin)
Give one example of a Serotonin receptor antagonist and reuptake inhibitor (SARI).
Trazodone (Desyrel)
How do MAOI’s generally work?
MAOI’s: Inhibits monoamine oxidase which would normally
break down serotonin and norepinephrine
Give two examples of MAOIs.
a. Phenelzine (Nardil)
b. Tranylcypromine (parnate)
Which type of anti-depressant should not be given with any other type of anti-depressnat?
MAOIs
When are MAOI antidepressants used?
Often used when all else has failed (for atypical
depression, phobias, anxiety, OCD, PTSD, bulimia)
What are the side effects of MAOI’s?
Side effects: Insomnia, nausea, agitation, confusion,
hypotension, weight gain, cardiac rhythm changes,
sexual impotence, constipation
What dietary change is required for a patient taking an MAOI?
Must avoid tyramine-rich food
What might happen if people on MAOIs have tyramine-rich foods?
May result in a hypertensive crisis
Which tyramine-rich foods should be avoided when taking MAOIs?
- Vegetables: Avocados, fermented bean curd, fermented soybean or soybean paste
- Fruits: Figs, bananas in larged amounts
- Meats: meats that are fermented, smoked or otherwise aged
- Sausages: fermented, bologna, pepperoni, salami
- Fish: Dried or cured fish, fish that is fermented, smoked, or otherwise aged
- Milk, milk products: practically all cheeses
- Foods with yeast: yeast extract (Marmite, Bovril)
- Beer, wine: Some imported beers, Chianti wines
- Other: protein dietary supplements, soups, shrimp past, soy sauce
What can a patient develop if MAOIs are combined with other anti-depressants?
serotonin syndrome
Why does tyramine cause hypertensive crisis when combined with an MAOI medication?
The MAO enzyme is rendered ineffective in neuron with this medication.
Tyramine is usually metabolized in the liver by monoamine oxidase (MAO). The medication also renders it
ineffective in the liver.
So when you give an MAO inhibitor tyramine is not metabolized. And then if you consume high amounts of tyramine
it floods the system; competes with norepinephrine(remember norepinephrine was increased with this med) in the
presynaptic nerve terminals & wins; displacing norepinephrine.
Norepinephrine then surges around in high quantities causing vasoconstriction which leads to acute hypertension &
increased heart rate which leads to Adrenergic crisis (extreme tachycardia & hypertension) and death can occur.
How do you treat an hypertensive crisis?
May need gastric lavage, charcoal, ice packs, cooling blankets, IV, antihypertensive, benzodiazepines
Antidote: calcium channel blockers
What patient teaching is critical when a patient is starting or taking an MAOI?
- The diet of course…teach, teach…give information
-Monitor blood pressure: hypotension expected, teaching about orthostatic hypotension - If their MAOI is discontinued they must follow diet restriction for 14 more days
- These meds are often a last resort
- make sure they are not on any other antidepressants
In general how do tricyclic anti-depressants work?
Inhibit reuptake of
norepinephrine and serotonin
List three tricyclic antidepressants
a) Amitriptyline (Elavil)
b) Clomipramine (Anafranil)
C) Nortriptyline (Aventyl)
How long does it take to see effects from tricyclics?
Effects often not apparent for up to 2 months
True or false: tricyclics are often lethal in overdose.
True
What are the side effects of tricyclic antidepressants?
Anticholinergic: dry mouth, blurred vision,
tachycardia,, esophageal reflux, weight gain,
postural hypotension.
constipation, urinary retention: these ones may
warrant immediate attention
Which side effect of tricyclics requires th emost immediate attention?
urinary retention
What nursing teaching must be done for patients starting or taking a tricyclic anti-depressant?
- Sedating effect, best to take at night
- Cardiovascular risks: ensure there has been a cardiac work-up prior to
treatment - Teach about symptom relief: could be up to two months.
- Teach to avoid alcohol as it blocks the effects of the antidepressant
- Do not stop abruptly: likely to cause nausea, altered heartbeat, nightmares and
cold sweats. Will occur within 2-4 days. Advise to take one dose of med again and see physician.
In general, how do SSRIs work?
: Block reuptake of serotonin (the 5-HT2
receptors)
List 6 different SSRIs.
a) Citalopram (celexa)
b) Escitalopram (cipralex)
c) Fluoxetine (prozac)
d) Fluvoxamine (luvox)
e) Paroxetine (paxil)
f) Setraline (zoloft)
What are some facts and characteristics about SSRIs?
- First line treatment in depression.
- Frequently used for anxiety.
- Cannot give with MAOI
- Fewer side effects but still some significant
ones: Serotonin Syndrome
Smaller risk of lethality on overdose when compared to tricyclics
Often the biggest patient concern is sexual dysfunction side effects, remember to ask and report
Drowsiness initially with treatment, often later people experience insomnia
Do not stop abruptly, will experience withdrawal symptoms: dizzy, can’t sleep, nervous, nauseous,
irritable. Taper slowly off. - Make sure they are not on an MAOI
What are common side effects of SSRIs?
Insomnia, low libido, failure to orgasm, nausea
and vomiting, ventricular arrhythmias in high
doses
What interventions are done for serotonin syndrome?
Hold SSRI, MAOI’s
Call for orders (anticipate serotonin receptor
blocker: cyproheptadine, methysergide or
propranolol)
Cooling blankets
Dantrolene or valium for muscle rigidity
Anticonvulsants
Artificial ventilation
How long does it take for SSRIs to take effect?
Effects 3 -4 weeks or less
In general, how do selective norepinephrine reuptake inhibitors work?
Inhibit reuptake of both serotonin and norepinephrine and to a lesser degree inhibit dopamine
List two SNRIs.
a) Venlafaxine (Effexor) in low doses acts as an
SSRI (often tried after no response with SSRI)
b) Duloxetine (Cymbalta): indicated in
maintenance treatment of depression,
generalized anxiety, fibromyalgia, neuropathic
pain
What are the side effects of SNRIs?
Hypertension (Effexor), nausea, insomnia, dry mouth, sweating, agitation, headache, sexual dysfuntion
These are often prescribed for major depression
Serotonin syndrome
What do you need to monitor when a patient is on Effexor?
Monitor blood pressure when on Effexor
WHat drug is being used as an emerging treatment for depression/suicidal ideation?
ketamine
What nursing interventions may be used for a Dx of ineffective coping?
. Spend time with patient
. Be comfortable with silence. Use active listening.
. Avoid asking too many questions
. Do not be too cheerful and do not use platitudes.
.Encourage to ventilate feelings
. Talk with patient about past coping techniques/stress mgmt. Encourage to utilize.
. Teach about positive coping strategies.
.Provide positive feedback.
What are nursing interventions for self care deficit?
.Closely observe food/fluid intake
. Offer foods easily chewed, ie liquids
. Determine food likes/dislikes
.Observe/record bowel patterns
. Encourage a routine for getting up, dressing, grooming
.Be gentle but firm about time spent in bed
What are nursing interventions for risk of suicide?
. Increase observation level
. Accompany off unit by staff
. Assess suicide potential and level of precaution at least daily
. Ask patient if has a plan for suicide
. Explain precautions to patient
. Know whereabouts of patient at all times
.Be alert to objects in patients possession
. Seclusion/restraint may be necessary
. Observe, record, report any changes in mood
.Convey that you care and that you believe they are worthwhile
Discourage continued talk about suicide, focus on feelings, relationships or life situation
What are the characteristics of persistent depressive disorder?
The symptoms of persistent depressive disorder are often chronic (lasting at least 2 years) and are considered mild to moderate. Usually a person’s social or occupational functioning is not greatly impaired. The symptoms in persistent depressive disorder are often congruent with the person’s usual pattern of functioning
vortioxetine
serotonin modulator and stimulator; Trintellix
mirtazapine
Serotonin-norepinephrine disinhibitors, Remeron
bupropion
norepinephrine-dopamine reuptake inhibitor, Wellbutrin
trazadone
Serotonin receptor antagonist and reuptake inhibitor (SARI); Desyrel)
phenelzine
MAOI, Nardil
tranylcypromine
MAOI, parnate
amitriptyline
TCA, Elavil
clomipramine
TCA, Anafranil
nortriptyline
TCA, Aventyl
citalopram
SSRI, celexa
escitalopram
SSRI, cipralex
fluoxetine
SSRI, Prozac
fluvoxamine
SSRI, luvox
paroxetine
SSRI, paxil
sertraline
SSRI, zoloft
venlafaxine
SNRI, Effexor
duloxetine
SNRI, Cymbalta
What medication is commonly used to treat bipolar disorder?
Lithium (carbolith, lithane, lithmax)
How does lithium work in the body to help with bipolar disorder?
Exact mechanism of action not known. But we know it mimics the role of sodium in neurons and thus alters electrical
conductivity so body functions regulated by electrical currents are potential problems
What are some common physiological effects of lithium?
Cardiac contraction, which with therapeutic doses can induce sinus bradycardia and in overdose cerebral conductivity leads to convulsions. Nerve and muscle conduction changes so may see a tremor at therapeutic doses and extreme motor dysfunction with overdose
What is the therapeutic serum level of lithium?
0.6 - 1.2 mEq/L
What must be monitored in addition to serum blood levels with lithium?
Polyuria common: consequence of decreasing effectiveness of vasopression on renal function. So we must monitor RENAL
FUNCTIONS. Hyponatremia can increase risk of toxicity because increased kidney reabsorption of sodium leads to increased
reabsorption of lithium as well*
THYROID FUNCTION monitored (long term use possible enlargement and possible hypothyroidism)
At what serum level does lithium toxicity start?
1.4 - 1.5 = start of toxicity.
How long is the onset of action of lithium?
Onset of action 10 to 21 days and it usually takes 7 to 14 days to reach therapeutic levels
What other medication is used in the acute phase of a manic episode?
Often an antipsychotic (i.e. olanzapine or accuphase as brings mania under rapid control) or antianxiety used in acute phase of mania
What are some normal side effects of lithium?
- Common to have patient report polyuria. Encourage normal salt intake as low salt intake will increase lithium retention and possible toxicity.
- Mild tremor normal.
True or false: people taking lithium should decrease their sodium intake?
False. Encourage normal salt intake as low salt intake will
increase lithium retention and possible toxicity
What are signs of lithium toxicity?
Patients may have diarrhea, sweating and some vomiting. If persistent and patient becomes dehydrated this is worrying and physician needs to be notified as high risk for toxicity.
Extreme motor dysfunction (ataxia), confusion, convulsions, dehydrated, arrhythmias, polyuria, polydipsia, edema, goiter, hypothyroidism.
What is important to monitor with anticonvulsants?
Monitor liver function, CBC
Divalproex sodium
Epival
Which is used more often: lithium or divalproex sodium (Epival)
divalproex sodium (Epival)
What are the side effects and signs of toxicity for divalproex sodium (Epival) and valproic acid (Depakene)?
Can cause drowsiness and in some instances increased suicidal ideations. Must monitor levels for toxicity (confusion, fatigue, dizzy, hallucinations, headache,
ataxia).
divalproex sodium
Epival
valproic acid
Depakene
carbamazepine
Tegretol
When does carbamazepine (Tegretol) get used as a mood stabilizer?
Sometimes used when someone has been resistant to treatment, often added to something else (i.e. lithium, antipsychotic). Seem to work better in rapid cycling.
lamotrigine
Lamictal
When does lamotrigine (Lamictal) get used as a mood stabilizer?
First line treatment for bipolar. Effective for acute and maintenance phase. MUST watch for a rash.
What side effect must be watched for with lamotrigine (Lamictal)?
A rash
gabapentin
neurontin
topiramate
Topamax (anticonvulsant)
When do gabapentin (neurontin) and topiramate (Topamax) get used as mood stabilizers?
Used in acute mania and maintenance.
What nursing care/attention must be given to a patient using divalproex sodium (Epival) or valproic acid (Depakene)?
- Monitor serum levels, liver functions and platelet count
- Monitor for dizziness, drowsiness and increased suicidal ideations
- Toxic signs: confusion, fatigue, dizzy, hallucinating, headache, ataxia.
What nursing care/attention must be given to a patient using carbamazepine (Tegretol)?
- Monitor liver functions and CBC
- Electrolytes, in particular sodium as risk for hyponatremia
What are effective interventions for bipolar disorder?
. Provide safe environment
. PRN meds
. Set and maintain limits on behaviour that is destructive, inappropriate or adversely affects others.
. Decrease environmental stimuli whenever possible
. Consistent, structured environment
. Simple, direct explanations. Don’t argue.
. Encourage supervised physical activity.
. Ignore or withdraw attention from bizarre appearance/behaviour as much as possible.
. Give short-term simple projects or activities.
.Positive feedback when appropriate
chlorpromazine
thorazine, 1st gen antipsychotic
haldol
1st gen antipsychotic
trifluperazine
stelazine, 1st gen antipsychotic
zuclopenthixol
Clopixol acuphase, 1st gen antipsychotic
risperidone
risperidal, 2nd gen antipsychotic
lurasidone
latuda, 2nd gen antipsychotic
olanzapine
Zyprexa, 2nd gen antipsychotic
quetiapine
Seroquel, 2nd gen antipsychotic
ziprasidone
zeldox, 2nd gen antipsychotic
aripriprazole
Abilify, 3rd gen antipsychotic
cariprazine
Vraylar, 3rd gen antipsychotic
brexpiprazole
Rexulti, 3rd gen antipsychotic
What are benzodiazepines used for?
Used for treating seizures
Used for treating alcohol withdrawal (Ativan or Valium or Librium)
Used for treating anxiety
Never used prophylactically
What should you caution patients about with benzodiazepines?
Potential for dependency
Limit activity that requires quick reflexes, ie construction or driving
What is the new class of benzodiazepines called?
Z-drugs
Imovane
zoplicone, Z drug (benzo)
What are the characteristics of Imovane (zoplicone)?
A “sleeping pill”
Quick onset, short ½ life.
Potential for misuse and dependency, advise patients to not use more than 7-10 days consecutively.
What are the side effects of Imovane (zoplicone)?
- Sedation. The higher the dose the higher the sedation.
-Can cause respiratory depression, most often when paired with another benzo or alcohol.
Patient Teaching: May experience withdrawal syndrome after taking regularly for 3-4 months or even much earlier: insomnia, irritable, nervous, drymouth, tremors, confusion.
Diazepam
Valium
Clonazepam
rivotril
Alprazolam
xanex
lorazepam
Ativan
What is a non-benzodiazepine anti-anxiety medication?
a) Buspirone (Bustab)
What neurotransmitter is involved with buspirone?
Neurotransmitter involvement: serotonin increased, dopamine increased
What are some characteristics of buspiron (Bustab)?
Relieves anxiety with minimal sedative effects. No risk of dependency.
Does not have strong sedative effect.
What nursing care is required for someone taking a benzodiazepine?
- Ideally used for short term treatment due to dependency
- Monitor for excessive sedation
- Teach about not operating machinery
-Teach about not using alcohol - Observe for signs of dependency: asking for increased dose/increased frequency
- Monitor for changes in cognitive function
- Not recommended for persons with known substance abuse
- Not recommended for women who are pregnant/breastfeeding
