Antidepressants
Introduction to Depression
With Professor Rhonda Lawes
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Depression
Clinical features:
•
Sad or depressed mood
•
Loss of pleasure or interest
•
•
Mental slowing and loss of
concentration
•
Feelings of guilt, worthlessness,
helplessness
•
Thoughts of death and suicide
and/or overt suicidal behavior
•
Symptoms must be present most
of the day, nearly every day, for at
least 2 weeks
Insomnia (or sometimes
hypersomnia)
Anorexia (or sometimes
hyperphagia)
Taeler Tucker, sdtaelertucker@student.rsu.edu
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•
Depression
Treatment Modalities
Pharmacotherapy
Primary therapy
Electroconvulsive therapy (ECT)
Vagus nerve stimulation
When drugs and psychotherapy
have not worked
Only after treatment with at
least 4 drugs has failed
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Depression-specific
psychotherapy
(e.g., cognitive
behavioral therapy)
Suicide Risk with Antidepressants
Antidepressants may increase suicidal
tendency early in the treatment.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Suicide Risk with Antidepressants
Patients should be observed closely for:
•
Suicidality
•
Worsening mood
•
Changes in behavior
Precautions:
•
Prescriptions should
be the smallest
number of doses
•
Dosing of inpatients
should be directly
observed
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In a Nutshell
✓ Symptoms of depression must be present
most of the day, nearly every day, for at
least 2 weeks before a diagnosis of
depression.
✓ Risk of suicide should be assessed in
patients experiencing depression.
✓ Treatment modalities for depression
include pharmacotherapy, depressionspecific psychotherapy, electroconvulsive
therapy, or vagus nerve stimulation.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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In a Nutshell
✓ Antidepressants are a group of
medications used to lessen the symptoms
of depression.
✓ Patients taking antidepressants should be
observed closely for suicidality, worsening
mood, or changes in behavior.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Antidepressants
Selective Serotonin Reuptake Inhibitors
With Professor Rhonda Lawes
Taeler Tucker, sdtaelertucker@student.rsu.edu
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SSRIs
SSRIs increase circulating serotonin in
the synapses by blocking the reuptake
of serotonin in the neuron.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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SSRIs
Examples:
•
Paroxetine (Paxil)
•
Sertraline (Zoloft)
•
Citalopram (Celexa)
•
Fluvoxamine (Luvox)
•
Fluoxetine (Prozac)
•
Escitalopram (Lexapro)
Taeler Tucker, sdtaelertucker@student.rsu.edu
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SSRIs
Treatment for:
•
Depression
•
Eating disorders
•
Obsessive-compulsive
disorder, social anxiety
disorder, post-traumatic
stress syndrome, panic
disorder
•
Premenstrual dysphoric
disorder
•
Enuresis
Taeler Tucker, sdtaelertucker@student.rsu.edu
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SSRIs
•
Effects take 10 21 days
•
Wean SSRIs when discontinuing
them.
•
Give with food at bedtime to
minimize anticholinergic effects,
unless sleep is disturbed
Taeler Tucker, sdtaelertucker@student.rsu.edu
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10 21 days
SSRIs Side Effects
•
Insomnia, anxiety, nervousness
•
Headache
Weight gain, nausea,
GI distress, dry mouth
Sexual dysfunction
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Serotonin Syndrome
•
Life threatening
•
•
Sweating, agitation, confusion,
hyperreflexia, hallucinations,
fever, tremor, incoordination,
myoclonus, delirium, seizures,
coma; can lead to death
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Antidepressants SNRI and NDRI
Serotonin-norepinephrine
reuptake inhibitor (SNRI)
Norepinephrine-dopamine
reuptake inhibitor (NDRI)
Venlafaxine (Effexor)
Bupropion (Wellbutrin) (smoking
cessation)
Taeler Tucker, sdtaelertucker@student.rsu.edu
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In a Nutshell
✓ Selective serotonin reuptake inhibitors
increase circulating serotonin in
the synapses by blocking the reuptake of
serotonin in the neuron.
✓ Serotonin is a neurotransmitter believed to
help regulate mood and social behavior,
appetite and digestion, sleep, memory, and
sexual desire and function.
✓ Antidepressants may increase suicidal
tendency early in the treatment.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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In a Nutshell
✓ Prescriptions should be the smallest
number of doses.
✓ Some patients on SSRIs can develop
serotonin syndrome autonomic instability.
✓ If SSRIs are not effective treatment for
depression, the health care provider may
consider a serotonin-norepinephrine
reuptake inhibitor or a norepinephrinedopamine reuptake inhibitor.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Antidepressants
Tricyclic Antidepressants
With Professor Rhonda Lawes
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Tricyclic Antidepressants
Tricyclic antidepressants block the neuronal
reuptake of 2 monoamine transmitters:
norepinephrine (NE) and serotonin.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Tricyclic Antidepressants
Examples:
•
Amitriptyline (Elavil)
•
Nortriptyline (Aventyl)
•
Imipramine (Tofranil)
•
Amoxapine (Asendin)
•
Clomipramine (Anafranil)
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Tricyclic Antidepressants
Treatment for:
•
Depression
•
Chronic pain
(fibromyalgia, migraine,
severe depression)
•
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Sedative/hypnotic
•
Equally effective tricyclic
antidepressants (TCAs)
•
Selection based on side
effects
Tricyclic Antidepressants
•
Sedation
•
Confusion, especially in the
elderly (half dosages)
Urinary retention (take at bedtime)
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Orthostatic hypotension,
arrhythmias, cardiac toxicity
•
Weight gain
•
Anticholinergic: dry
mouth, constipation,
blurred vision
In a Nutshell
✓ Tricyclic antidepressants (TCAs) block the
neuronal reuptake of 2 monoamine
transmitters: norepinephrine (NE) and
serotonin.
✓ TCAs are used to treat depression and
chronic pain.
✓ TCAs can cause confusion in the elderly.
✓ Common side effects include
anticholinergic effects and weight gain.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Antidepressants
Monoamine Oxidase Inhibitors
With Professor Rhonda Lawes
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Monoamine Oxidase Inhibitors (MAOIs)
Examples:
•
Isocarboxazid (Marplan)
•
Tranylcypromine (Parnate)
•
Phenelzine (Nardil)
•
Selegiline (Emsam)
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Monoamine Oxidase Inhibitors (MAOIs)
MAOIs inhibit Monoamine oxidase A (MAO-A)
in the nerve terminals, which increases the
amount of NE and 5-HT, or serotonin
available.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Monoamine Neurotransmitters
Monoamine neurotransmitters like serotonin,
norepinephrine, and dopamine are used to
relay signals between nerve cells and regulate
important functions throughout the body.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Monoamine Neurotransmitters
•
After neurotransmitters send a message in
the brain, they are absorbed by a protein
called monoamine oxidase (monoamine
transporter)
•
If too many monoamines are absorbed,
chemical imbalance occurs in the brain.
NIDA(NIH), PD
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Monoamine Oxidase Inhibitors
Tyramine is the building block of norepinephrine
and is commonly found in foods that are aged.
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Monoamine Oxidase Inhibitors
MAOIs inhibit monoamine oxidase,
so the body cannot rid itself of excess
norepinephrine.
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Raised levels of norepinephrine may lead
to a hypertensive crisis after consumption of
certain types of tyramine-containing foods or
drinks.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Foods to Avoid
Tyramine
•
Alcoholic beverages
and vermouth
•
Banana peels
•
Bean curd
•
Broad (fava) bean pods (contain
dopa)
•
Cheeses that are aged
•
Fish
Chianti wine
smoke, fermented, or pickled
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Foods to Avoid
•
Meat
•
•
Sausage, bologna,
pepperoni, and
salami
No problem with
fresh meat or liver
Tyramine
•
Protein dietary
supplements
•
Sauerkraut
•
Shrimp paste
•
Soups
•
Ginseng
•
Miso
•
Protein extracts
•
Yeast (baking is safe)
F.t.t.b.: Bru-nO, CC0; kalhh, CC0; jyleen21, CC0
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NCLEX/Exam-level Question
Which of the following client statements indicates an
appropriate understanding for a client who is receiving
phenelzine?
A.
B.
C.
taking
phenelzine
D.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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phenelzine
NCLEX/Exam-level Question
Which of the following client statements indicates an
appropriate understanding for a client who is receiving
phenelzine?
A.
B.
C.
taking
phenelzine
D.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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phenelzine
Serotonin Syndrome
Serotonin syndrome is a rare but potentially life-threatening
hyperserotonergic medical condition.
MAOIs and serotonergic drugs (SSRIs, MDMA, or other
phenylethylamines) are likely to lead to serotonin syndrome.
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Serotonin Syndrome
Serotonin syndrome can also occur when combining MAOIs
with certain opioids like meperidine.
MAOIs may not be combined with other antidepressants,
most notably tricyclics, because this may result in
hypertensive crisis.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Monoamine Oxidase Inhibitors (MAOIs)
Used against:
•
Depression
•
Bulimia nervosa
•
Obsessive-compulsive
disorder
•
Panic attacks
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MAOIs Drug Interactions
Indirect-acting
sympathomimetic
agents
Antihypertensive
drugs
MAOI
Antidepressants:
TCAs and SSRIs
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Meperidine
In a Nutshell
✓ MAOIs inhibit MAO-A in the nerve terminals,
which increases the amount of NE and
5-HT available.
✓ Monoamine neurotransmitters like
serotonin, norepinephrine, and dopamine
are used to relay signals between nerve
cells and regulate important functions
throughout the body.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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In a Nutshell
✓ MAOIs inhibit monoamine oxidase, so the
body cannot rid itself of excess
norepinephrine, serotonin, and dopamine.
✓ Raised levels of norepinephrine may lead
to a hypertensive crisis after consumption
of certain types of tyramine-containing
foods or drinks.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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In a Nutshell
✓ Serotonin syndrome is a rare but potentially
life-threatening hyperserotonergic medical
condition.
✓ MAOIs and serotonergic drugs (SSRIs,
MDMA, or other phenylethylamines) are
likely to lead to serotonin syndrome.
✓ Serotonin syndrome can also occur when
combining MAOIs with certain opioids, such
as meperidine.
✓ MAOIs may not be combined with other
antidepressants, most notably tricyclics,
because this may result in hypertensive
crisis.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Mood Stabilizers
Lithium
With Professor Rhonda Lawes
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Mood Stabilizers
Schizoaffective
disorder
Adjunct to
depression therapy
Manic
disorders
Bipolar
disorder
Impulse control disorder, conduct disorders
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Mood Stabilizers
Lithium
Lithium carbonate is a salt that may modify
second messenger systems.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Lithium
Monitor blood levels
regularly
Drink 2 3 liters of
fluid a day
Eat well with normal
sodium intake
Takes 2 3 weeks
before lithium is
effective
Psychotic patients
should be put on
antipsychotic while
waiting
Should be taken
with food
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Lithium Toxicity
+
How does a low serum sodium,
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Lithium Toxicity
Sedation, confusion, severe tremor,
drowsiness, seizures
N/V, diarrhea
Muscular weakness,
loss of coordination
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Therapeutic range
0.4 1.3 mEq/L
Toxic levels
> 1.5 mEq/L
NCLEX/Exam-level Question
Mr. Yoes has a history of bipolar disorder, has been taking lithium daily, and
has called the clinic to discuss a concern with the nurse working with the
health care provider.
Which of the following statements is most important for you to follow up
on?
A.
B.
C.
D.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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NCLEX/Exam-level Question
Mr. Yoes has a history of bipolar disorder, has been taking lithium daily, and
has called the clinic to discuss a concern with the nurse working with the
health care provider.
Which of the following statements is most important for you to follow up
on?
A.
B.
C.
D.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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In a Nutshell
✓ Mood stabilzers are used to treat multiple
diagnoses.
✓ Lithium is a mood stabilizer that can take
2 3 weeks for a patient to feel an impact.
✓ Lithium can antagonize ADH and cause an
increase in diuresis.
✓ Hyponatremia puts the patient at an
increased risk of lithium toxicity.
Taeler Tucker, sdtaelertucker@student.rsu.edu
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Note: This document is copyright protected. It may not be copied, reproduced, used, or
distributed in any way without the written authorization of Lecturio GmbH.
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