1. Antidepressants and Mood Stabilizers Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc. Chapter 28

2. Depression  A mood disorder that involves  Depressed mood, despair, insomnia  Loss of interest in normal activities  Fatigue, decreased ability to think  Suicidal thoughts  Pathophysiology  Insufficient amount of monamine neurotransmitters (norepinephrine, serotonin, dopamine)  Other etiology  Genetic predisposition  Social and environmental factors 2 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

3. Depression (Cont.)  Types  Reactive Usually sudden onset resulting from precipitating event (e.g., death of a loved one)  Major Characterized by loss of interest in work or home Inability to complete tasks Deep depression  Bipolar Mood swings between manic (euphoric) and depressive (dysphoria) 3 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

4. Herbal Supplements for Depression  St. John’s wort  Can decrease reuptake of the neurotransmitters serotonin, norepinephrine, and dopamine  Gingko biloba  The use of these and many herbal products should be discontinued 1 to 2 weeks before surgery.  The patient should check with the health care provider regarding herbal treatments. 4 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

5. Major Antidepressants Agents  Tricyclic antidepressants (TCAs)  Selective serotonin reuptake inhibitors (SSRIs)  Serotonin norepinephrine reuptake inhibitors (SNRIs)  Atypical antidepressants  Monoamine oxidase inhibitors (MAOIs) 5 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

6. Tricyclic Antidepressants  Amitriptyline, imipramine, trimipramine, doxepin, desipramine, nortriptyline, and protriptyline  Action  Blocks uptake of neurotransmitters norepinephrine and serotonin in brain  Blocks histamine receptors  Elevates mood, increases interest in ADLs, decreases insomnia  Use  Major depression and agitated depression 6 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

7. Tricyclic Antidepressants (Cont.)  Amitriptyline (Elavil)  Interactions  Increased CNS effects with alcohol and other CNS depressants  Increased sedation and anticholinergic effects with phenothiazines, haloperidol  Side effects/adverse reactions  Sedation, dizziness, blurred vision, dry mouth and eyes, urinary retention, constipation, weight gain, GI distress, sexual dysfunction  Orthostatic hypotension, dysrhythmias, EPS, blood dyscrasias 7 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

8. Selective Serotonin Reuptake Inhibitors  Fluvoxamine (Luvox)  Fluoxetine (Prozac)  Sertraline (Zoloft)  Paroxetine (Paxil)  Citalopram (Celexa)  Escitalopram (Lexapro)  Action  Block uptake of neurotransmitter serotonin  Uses  Major depression  Anxiety disorders Obsessive-compulsiveness Panic Phobias  Prevention of migraine headaches 8 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

9. Selective Serotonin Reuptake Inhibitors (Cont.)  Interactions  Increased CNS effects with alcohol and other CNS depressants  Side effects/adverse reactions  Headache, nervousness, restlessness  Insomnia, tremors, seizures  GI distress  Sexual dysfunction  Suicidal ideation  Side effects often decrease over 2 to 4 weeks. 9 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

10. Serotonin Norepinephrine Reuptake Inhibitors  Venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq)  Action: Inhibit the reuptake of serotonin and norepinephrine, increasing these substances in nerve fibers  Use: Major depression as well as generalized anxiety disorder and social anxiety disorder  Interactions: concurrent interaction of venlafaxine and St. John’s wort may increase the risk of serotonin syndrome and neuroleptic malignant syndrome 10 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

11. Serotonin Norepinephrine Reuptake Inhibitors (Cont.)  Side effects of venlafaxine (Effexor) include drowsiness, dizziness, insomnia, headache, euphoria, amnesia, blurred vision, photosensitivity, and ejaculation dysfunction.  Adverse effects of venlafaxine (Effexor) include hyponatremia, bleeding, hypertension, angioedema, blood dyscrasias, suicidal ideation, and Stevens-Johnson syndrome. 11 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

12. Atypical Antidepressants  Amoxapine (Asendin), maprotiline (Ludiomil), nefazodone, trazodone (Desyrel)  Action: affect one or two of the three neurotransmitters: serotonin, norepinephrine, and dopamine.  Interaction: Do not take with MAOIs and do not use within 14 days after discontinuing MAOIs.  Trazodone may have a potential drug interaction with ketoconazole, ritonavir, and indinavir that may lead to increased trazodone levels and adverse effects. 12 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

13. Monoamine Oxidase Inhibitors  Tranylcypromine sulfate (Parnate), isocarboxazid (Marplan), selegiline (Emsam), phenelzine sulfate (Nardil)  Action  Monamine oxidase enzyme inactivates norepinephrine, dopamine, epinephrine, and serotonin.  Use: depression not controlled by TCAs and second-generation antidepressants 13 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

14. Monoamine Oxidase Inhibitors (Cont.)  Drug interactions:  Vasoconstrictors and cold medications containing phenylephrine and pseudoephedrine can cause a hypertensive crisis when taken with an MAOI.  Food interactions:  Foods that contain tyramine Some cheeses, cream, yogurt, coffee, chocolate, bananas, raisins, Italian green beans, liver, pickled foods, sausage, soy sauce, yeast, beer, and red wines, can cause a hypertensive crisis. 14 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

15. Monoamine Oxidase Inhibitors (Cont.)  Side effects/adverse effects  Agitation, restlessness, insomnia  Anticholinergic effects  Orthostatic hypotension  Hypertensive crisis from fatal tyramine interaction 15 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

16. Nursing Process: Antidepressant Agents  Assessment  Nursing diagnosis  Planning  Nursing interventions  Patient teaching  Cultural considerations  Evaluation 16 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

17. Antidepressant Agents  Nursing interventions  Monitor vital signs.  Monitor mood for drug effectiveness.  Monitor for suicidal tendencies, seizures.  Warn that foods that contain tyramine can cause a hypertensive crisis with MAOIs.  Encourage taking drug as prescribed.  Encourage avoiding alcohol, CNS depressants, and cold medicines.  Teach to take drug with food if GI distress occurs. 17 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

18. Antidepressant Agents (Cont.)  Nursing interventions  Warn patient against driving or using dangerous mechanical equipment until drug effect is known.  Warn patient against abruptly stopping drug.  Instruct patient to take drug at bedtime.  Advise patient that a therapeutic response usually occurs in 2 to 4 weeks.  Inform patient that herbs (e.g., St. John’s wort, ginseng) may interact with antidepressants. 18 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

19. Mood Stabilizers  Bipolar disorders  Lithium (Lithibid)  Carbamazepine (Tegretol)  Divalproex (Depakote, Valproate)  Lamotrigine (Lamictal)  Olanzapine (Zyprexa)  Ziprasidone (Geodon)  Aripiprazole (Abilify) 19 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

20. Mood Stabilizer: Lithium  Lithium (Eskalith)  Therapeutic serum range: 0.5 to 1.5 mEq/L  Serum lithium levels greater than 1.5 to 2 mEq/L are toxic.  Action  Alteration of ion transport in muscle and nerve cells  Increased receptor sensitivity to serotonin  Use  Treat manic episodes in bipolar psychosis 20 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

21. Mood Stabilizer: Lithium (Cont.)  Interactions  Increased lithium level with thiazides, methyldopa, haloperidol, NSAIDs, antidepressants, theophylline, phenothiazines  Side effects/adverse reactions  Headache, drowsiness, dizziness  Hypotension, dysrhythmias  Restlessness, slurred speech  Dry mouth, metallic taste, GI distress  Tremors, muscle weakness  Edema of hands and ankles  Increased urination, blood dyscrasias, nephrotoxicity 21 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

22. Nursing Process: Lithium  Assessment  Nursing diagnosis  Planning  Nursing interventions  Patient teaching  Cultural considerations  Evaluation 22 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

23. Mood Stabilizer: Lithium (Cont.)  Nursing interventions  Monitor vital signs, sodium levels.  Monitor for drug effectiveness, suicidal tendencies.  Monitor urine output, renal function tests.  Encourage adequate fluid intake (1 to 2 L daily).  Take with food to decrease GI irritation.  Monitor lithium levels every 1 to 2 months (0.5 to 1.5 mEq/L); toxic range is greater than 2 mEq/L. Toxic side effects: persistent nausea, vomiting, severe diarrhea, blurred vision, tinnitus, ataxia, increasing tremors, confusion, dysrhythmias, seizures 23 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

24. Mood Stabilizer: Lithium (Cont.)  Nursing interventions  Teach patient to wear medical alert identification.  Teach patient to take drug as prescribed and keep medical appointments.  Warn against driving motor vehicles or operating dangerous equipment until drug effect is known.  Advise patient that drug effect may take 1 to 2 weeks.  Encourage patient to avoid caffeine, crash diets, NSAIDs, diuretics.  Advise patient against getting pregnant because of teratogenic effects. 24 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

25. Practice Question #1 A patient with major depression has been prescribed fluoxetine (Prozac). What appropriate dosing regimen would the nurse expect? A.20 mg every morning B.40 mg 3 times per day C.50 mg at bedtime D.100 mg 4 times per day 25 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

26. Practice Question #2 A patient with major depression has been prescribed fluoxetine (Prozac). What nursing diagnosis would be most appropriate? A. Social isolation B. Impaired physical mobility C. Impaired urinary elimination D. Disturbed sensory perception 26 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

27. Practice Question #3 A patient with reactive depression is ordered to receive fluoxetine (Prozac). Which information will the nurse include when teaching this patient? A.The medication takes effect in 1 week. B.The medication increases libido. C.The medication should be taken with grapefruit juice. D.The medication may cause headaches and insomnia. 27 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

28. Practice Question #4 Before administering an MAO inhibitor, it is most important for the nurse to assess the patient’s A.sexual history. B.socioeconomic status. C.dietary intake. D.hydration status. 28 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

29. Practice Question #5 Which laboratory test is most important for the nurse to monitor when a patient is receiving lithium (Lithobid)? A. Urinalysis B. Serum glucose C. Serum electrolytes D. Complete blood count 29 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

30. Practice Question #6 When providing dietary teaching for a patient taking monamine oxidase inhibitors (MAOIs), the nurse should teach the patient to avoid which food? A.Yogurt B.Avocado C.Grapefruit D.Potato chips 30 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

31. Practice Question #7 Which advice will the nurse include when teaching the patient about lithium therapy? A.Take the drug on an empty stomach. B.Eliminate all sodium from your diet. C.Stop taking the lithium when you feel better. D.It may take 1 to 2 weeks before you have any benefits from taking the medication. 31 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

32. Practice Question #8 Which statement about amitriptyline (Elavil) does the nurse identify as being true? A. The drug is administered first thing in the morning. B. The drug should be discontinued slowly. C. The onset of antidepressant effect is 48 hours. D. Hypertension is a frequent side effect of this drug. 32 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.