Drugs Used for Mood Disorders Chapter 17 Drugs Used for Mood Disorders Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 17 Lesson 17.1 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Discuss the mood swings associated with bipolar disorder Differentiate between the physiologic and psychological therapeutic responses seen with antidepressant therapy Compare drug therapy used during the treatment of the manic and depressive phases of bipolar disorder Describe the essential components of a baseline assessment of a patient with depression or bipolar disorder Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives (cont’d) Cite monitoring parameters used for patients taking monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or tricyclic antidepressants Identify the premedication assessments necessary before the administration of MAOIs, SSRIs, SNRIs, tricyclic antidepressants, and antimanic agents Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Mood Disorders Present when certain symptoms impair a person’s ability to function for a time Characterized by abnormal feelings of depression or euphoria Underlying causes still unknown Changes in brain neurotransmitters Negative life events Endocrine abnormalities Genetic factors Medications taken for other diseases 15% to 20% of the U.S. population has a diagnosable mood disorder in their lifetime. Divided into four primary types: major depressive disorder, dysthymia, bipolar disorder, and cyclothymia. Patients have a high incidence of attempting suicide. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Depression Emotional symptoms Physical symptoms Cognitive symptoms Sadness, no enjoyment of usual activities Physical symptoms Fatigue, sleep disturbances, appetite disturbances, stomach complaints, heart palpitations Cognitive symptoms Inability to concentrate, slowed thinking, poor memory, confusion Psychomotor symptoms Slowed movements, slowed speech, may exhibit agitation Both the patient and family must understand the importance of taking medications. Most people go untreated because of social stigma, financial barriers, underrecognition by health care providers, and underappreciation by the public about the benefits of treatment. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Bipolar Disorder Episodes of mania (euphoria) and depression, separated by intervals without mood disturbances Paranoid or grandiose delusions during manic phase Drug treatment includes mood stabilizing agents Lithium (Eskalith, Lithane) Anticonvulsant drugs Formerly known as manic depression. Mood swings are what differentiates bipolar disorder from depression. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Treatment of Mood Disorders Requires both nonpharmacologic and pharmacologic therapy Three phases occur before full functioning is restored: 1. Acute phase: 6 to 8 weeks Symptoms monitored Doses adjusted Psychotherapy initiated Cognitive-behavioral therapy, psychodynamic therapy, and interpersonal therapy are important treatments. Some patients become noncompliant during the acute phase. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Treatment of Mood Disorders (cont’d) 2. Continuation phase: 4 to 9 months Consolidates initial response into complete recovery Uses pharmacotherapy and psychotherapy Goal: Prevent relapse and have complete recovery (symptom free for 6 mos.) 3. Maintenance phase Recommended for individuals with history of three or more depressive episodes, chronic depression, or bipolar disorder Goal: Prevent recurrence Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Antidepressants Monoamine oxidase inhibitors (MAOIs) Selective serotonin reuptake inhibitors (SSRIs) Serotonin and norepinephrine reuptake inhibitors (SNRIs) Tricyclic antidepressants (TCAs) Miscellaneous agents Each antidepressant has varying degrees of effect. These drugs alter the availability of neurotransmitters within the brain. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Selecting Therapy Two factors Patient history of response to previously prescribed antidepressants Potential for adverse effects associated with different antidepressants No difference in overall efficacy but differences in adverse effects Physiologic manifestations alleviated within first week of therapy Psychological symptoms improve after 2 to 4 weeks It is not possible to predict which drug will be most effective in a patient. Some patients do not show a response with the first drug chosen but do with the second. It may take 4 to 6 weeks to adjust the dosage to optimize therapy and minimize adverse effects. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Assessment of Patients with Mood Disorders Baseline assessment History of mood disorder Basic mental status Interpersonal relationships Mood, clarity of thought Thoughts of death Psychomotor function Sleep pattern Dietary history Nonadherence Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Considerations for Mood Disorder Therapy Individualized interventions Environment of acceptance Remain calm and firm Provide safety for suicidal patients Use physical restraints within guidelines Provide for nutritional needs Handle manipulative behavior consistently Record observations; observing for suicidal ideation is a high priority. Administer PRN drugs when necessary. Use the least restrictive form of restraint; have sufficient staff available to control any situation. Provide positive reinforcement. Employ therapeutic communication techniques. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: MAOIs Actions Uses Block metabolic destruction of norepinephrine, dopamine, and serotonin neurotransmitters by the enzyme monoamine oxidase Uses Most effective in atypical depression, panic disorder, obsessive-compulsive disorder, and some phobias. When tricyclic antidepressant therapy is unsatisfactory Neurotransmitters are increased in concentration with these medications. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: MAOIs (cont’d) Drugs Phenelzine (Nardil) Tranylcypromine (Parnate) Isocarboxazid (Marplan) Selegiline (Emsam) Common adverse effects Orthostatic hypotension; drowsiness, sedation, restlessness, agitation, insomnia; blurred vision; constipation, dryness of mucosa of mouth, throat and nose; urinary retention Serious adverse effects Hypertension Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Considerations for MAOI Therapy Premedication assessment Obtain blood pressure and pulse rate Ensure patient has not recently ingested meals with a high tyramine content Check for medications taken before initiating therapy Monitor blood glucose of diabetic patients Most common adverse effect is orthostatic hypotension. There is potential for hypertensive crisis. Provide patient education of dietary products to avoid. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 17 Lesson 17.2 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Compare the mechanism of action of SSRIs to that of other antidepressant agents Cite the advantages of SSRIs over other antidepressant agents Examine the drug monograph for SSRIs to identify significant drug interactions Prepare a teaching plan for an individual receiving SSRIs Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: SSRIs Actions Uses Common adverse effects Inhibit reuptake and destruction of serotonin from the synaptic cleft, prolonging the action of the neurotransmitter Uses Widely used antidepressants Common adverse effects Restlessness, agitation, anxiety, insomnia, sedative effects; GI effects Serious adverse effects Suicidal actions For specific drugs, see Table 17-1. SSRIs do not have anticholinergic or cardiovascular adverse effects. Many drug interactions. Be alert for possible serotonin syndrome, which occurs with increased serotonin levels. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Interactions for SSRIs Tricyclic antidepressants – may cause dysrhythmias, seizure activity, CNS stimulation Lithium (Eskalith, Lithane) – monitor for lithium toxicity MAOIs – severe reactions including excitement, diaphoresis, rigidity, convulsions, death Warfarin – enhances anticoagulant effect Smoking – affects metabolism of fluvoxamine (Luvox) and may require higher dosage to be effective Potential for severe reactions with the concurrent use of MAOIs and SSRIs. Avoid bedtime doses to decrease insomnia. Advise patients and families of the sedative effects. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: SNRIs Drugs: desvenlafaxine (Pristiq), duloxetine (Cymbalta), venlafaxine (Effexor) Actions Inhibit reuptake and destruction of serotonin and norepinephrine from synaptic cleft Uses Widely used antidepressants Common adverse effects Dizziness, drowsiness, restlessness, agitation, anxiety, insomnia; nausea, anorexia Serious adverse effect Suicidal actions Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: TCAs Actions Uses Common adverse effects Prolong action of norepinephrine, dopamine, and serotonin by blocking reuptake Uses Antidepressant, mild tranquilizing effect, other uses Common adverse effects Orthostatic hypotension, sedative effects, blurred vision, constipation, dryness of the mouth, throat, and nose For specific drugs, see Table 17-1. All have anticholinergic activity. Serious adverse effects: tremors, parkinsonian symptoms, seizure activity, dysrhythmias, tachycardia, heart failure, suicidal actions. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Education for TCAs Drugs may cause orthostatic hypotension; monitor blood pressure daily Sedative effects may occur, especially at onset of therapy Rise slowly from sitting or supine position and lie down if feeling faint Dryness of the mouth may be relieved by sucking on hard candy, ice chips, and gum Blurred vision may occur Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Other Agents Bupropion hydrochloride (Wellbutrin, Zyban) Mirtazapine (Remeron) Nefazodone Trazodone hydrochloride Lithium carbonate (Eskalith, Lithane) Disadvantages of bupropion include seizure activity and multiple daily doses. Trazodone has a lower incidence of anticholinergic effects. Lithium is used to treat acute mania associated with bipolar disorder. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.