Chapter 23 Antidepressants and Mood Stabilizers Copyright © 2021, Elsevier Inc. All Rights Reserved. Depression (1 of 2) Etiology Genetic predisposition Social and environmental factors Pathophysiology theories Decreased levels of monoamine neurotransmitters • Norepinephrine, serotonin, dopamine Signs and symptoms Depressed mood, despair, weight loss or gain Loss of interest in most activities Fatigue, insomnia, hypersomnia Decreased ability to think or concentrate Suicidal thoughts Copyright © 2021, Elsevier Inc. All Rights Reserved. 2 Depression (2 of 2) Types Reactive depression • Usually sudden onset after a precipitating event Death of a loved one • Usually lasts for months Major depression • May be primary or secondary to a health problem • Loss of interest in work or home • Inability to concentrate and complete tasks • Difficulty sleeping or excess sleeping • Feelings of fatigue and worthlessness • Deep depression Bipolar disorder • Mood swings between manic and depressive Copyright © 2021, Elsevier Inc. All Rights Reserved. 3 Complementary and Alternative Therapy for Depression Ginkgo biloba and St. John’s wort Discontinue use of herbal products 1 to 2 weeks before surgery. Check with the health care provider before taking herbal treatments. Copyright © 2021, Elsevier Inc. All Rights Reserved. 4 Major Antidepressants Antidepressant Groups Tricyclic antidepressants (TCAs) Selective serotonin reuptake inhibitors (SSRIs) Serotonin norepinephrine reuptake inhibitors (SNRIs) Atypical antidepressants Monoamine oxidase inhibitors (MAOIs) Copyright © 2021, Elsevier Inc. All Rights Reserved. 5 Tricyclic Antidepressants (1 of 3) Action Blocks uptake of neurotransmitters norepinephrine and serotonin in brain Elevates mood, increases interest in ADLs, decreases insomnia Blocks histamine receptors which leads to sedation Blocks cholinergic receptors which leads to anticholinergic effects Use Major depression Copyright © 2021, Elsevier Inc. All Rights Reserved. 6 Tricyclic Antidepressants (2 of 3) Side effects/adverse reactions Drowsiness, dizziness, blurred vision Dry mouth and eyes, GI distress Urinary retention, sexual dysfunction Weight gain, seizures Suicidal ideation Orthostatic hypotension, dysrhythmias Blood dyscrasias, cardiotoxicity EPS, NMS Copyright © 2021, Elsevier Inc. All Rights Reserved. 7 Tricyclic Antidepressants (3 of 3) Interactions Alcohol and other CNS depressants potentiate CNS depression MAOIs may lead to toxic psychosis, cardiotoxicity Antithyroid drugs may increase dysrhythmias Copyright © 2021, Elsevier Inc. All Rights Reserved. 8 Selective Serotonin Reuptake Inhibitors (1 of 2) Action Block uptake of neurotransmitter serotonin Uses Major depression Anxiety disorders • Obsessive-compulsive disorder • Panic disorders, phobias • Posttraumatic stress disorder Prevention of migraine headaches Decrease premenstrual tension syndrome Eating disorders Substance use disorder Copyright © 2021, Elsevier Inc. All Rights Reserved. 9 Selective Serotonin Reuptake Inhibitors (2 of 2) Interactions Increased sedation with alcohol and other CNS depressants Grapefruit juice with SSRIs can lead to toxicity Side effects/adverse reactions Headache, insomnia Blurred vision Dry mouth, GI distress Erectile dysfunction Suicidal ideation Side effects often decrease over 1 to 4 weeks Copyright © 2021, Elsevier Inc. All Rights Reserved. 10 Serotonin Norepinephrine Reuptake Inhibitors (1 of 2) Action Use Inhibit the reuptake of serotonin and norepinephrine Major depression Generalized anxiety disorder Social anxiety disorder Interactions Venlafaxine and St. John’s wort may increase the risk of serotonin syndrome and NMS Copyright © 2021, Elsevier Inc. All Rights Reserved. 11 Serotonin Norepinephrine Reuptake Inhibitors (2 of 2) Side effects Drowsiness, dizziness Insomnia, euphoria Headache, amnesia Blurred vision Erectile/ejaculation dysfunction Adverse effects Tachycardia, hypertension Orthostatic hypotension Seizures, suicidal ideation Copyright © 2021, Elsevier Inc. All Rights Reserved. 12 Atypical Antidepressants Action Use Major depression, reactive depression, anxiety Interaction Affects neurotransmitters: serotonin, norepinephrine, and dopamine. MAOIs, ketoconazole, ritonavir, and indinavir Side effects/adverse effects Dry mouth, blurred vision, orthostatic hypotension Constipation, erectile/ejaculatory dysfunction Copyright © 2021, Elsevier Inc. All Rights Reserved. 13 Monoamine Oxidase Inhibitors (1 of 3) Action Monoamine oxidase enzyme inactivates norepinephrine, dopamine, epinephrine, and serotonin Use Depression not controlled by TCAs and secondgeneration antidepressants Copyright © 2021, Elsevier Inc. All Rights Reserved. 14 Monoamine Oxidase Inhibitors (2 of 3) Drug interactions CNS stimulants such as vasoconstrictors and some cold medications containing phenylephrine and pseudoephedrine can cause a hypertensive crisis when taken with an MAOI Food interactions Foods containing 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. Copyright © 2021, Elsevier Inc. All Rights Reserved. 15 Monoamine Oxidase Inhibitors (3 of 3) Side effects/adverse effects Agitation, restlessness, insomnia Anticholinergic effects Orthostatic hypotension Hypertensive crisis from tyramine interaction Suicidal ideation Copyright © 2021, Elsevier Inc. All Rights Reserved. 16 Nursing Process: Antidepressant Agents (1 of 2) Concept Assessment Assess the patient’s baseline vital signs and weight for future comparisons. Obtain a health history and drug history Assess for mental status and suicidal ideation. Patient problems Mood and affect Anxiety, confusion, social isolation Planning Patient will interact with others Copyright © 2021, Elsevier Inc. All Rights Reserved. 17 Nursing Process: Antidepressant Agents (2 of 2) Nursing interventions Observe patient for signs of depression, mood changes, insomnia, apathy, or lack of interest in activities. Monitor vital signs. Monitor for drug-drug and food-drug interactions. Provide patient with a list of foods to avoid. Caution patient not to consume alcohol or other CNS depressant concurrently. Evaluation Copyright © 2021, Elsevier Inc. All Rights Reserved. 18 Mood Stabilizer: Lithium (1 of 3) Lithium Therapeutic serum range 0.8 to 1.2 mEq/L Serum lithium levels greater than 1.5 mEq/L may lead to toxicity Action Alteration of ion transport in muscle and nerve cells Increased receptor sensitivity to serotonin Use Bipolar disorder, manic episodes Copyright © 2021, Elsevier Inc. All Rights Reserved. 19 Mood Stabilizer: Lithium (2 of 3) Side effects/adverse reactions Drowsiness, dizziness Blurred vision, headache Restlessness, tremors Memory impairment Dry mouth, thirst, metallic taste, GI distress, weight gain/loss Hypotension, dysrhythmias Edema of hands and ankles Increased urination, dehydration Copyright © 2021, Elsevier Inc. All Rights Reserved. 20 Mood Stabilizer: Lithium (3 of 3) Interactions Increased lithium level with • Thiazides, methyldopa, haloperidol, NSAIDs, antidepressants, phenothiazines, carbamazepine, spironolactone, sodium bicarbonate, ACE inhibitors, calcium channel blockers Decreased lithium level with • Caffeine, loop diuretics, theophylline Copyright © 2021, Elsevier Inc. All Rights Reserved. 21 Nursing Process: Lithium (1 of 2) Concept Assessment Assess for suicidal ideation. Assess for baseline vital signs. Obtain health history and drug history. Patient problems Mood and affect Anxiety, confusion, decreased ability to cope Planning The patient will interact with others. Copyright © 2021, Elsevier Inc. All Rights Reserved. 22 Nursing Process: Lithium (2 of 2) Nursing interventions Observe patient for depression, mood changes, insomnia, apathy, or lack of interest in activities. Monitor vital signs. Monitor lithium levels. Monitor sodium levels. Check cardiac status. Advise patient to avoid caffeine products. Advise patient to maintain adequate sodium intake. Evaluation Copyright © 2021, Elsevier Inc. All Rights Reserved. 23 Practice Question #1 (1 of 2) A patient with major depression has been prescribed fluoxetine. What nursing diagnosis would be most appropriate? A. B. C. D. Social Isolation Mobility, Impaired Physical Urinary Elimination, Impaired Sensory Perception, Disturbed Copyright © 2021, Elsevier Inc. All Rights Reserved. 24 Practice Question #1 (2 of 2) Answer: A. Social Isolation Copyright © 2021, Elsevier Inc. All Rights Reserved. 25 Practice Question #2 (1 of 2) A patient with reactive depression is ordered to receive fluoxetine. Which information will the nurse include when teaching this patient? A. B. C. D. The medication takes effect in 1 to 2 days. The medication increases libido. The medication should be taken with grapefruit juice. The medication may cause headaches and insomnia. Copyright © 2021, Elsevier Inc. All Rights Reserved. 26 Practice Question #2 (2 of 2) Answer: D. The medication may cause headaches and insomnia. Copyright © 2021, Elsevier Inc. All Rights Reserved. 27 Practice Question #3 (1 of 2) Before administering an monoamine oxidase inhibitor, it is most important for the nurse to assess the patient’s A. B. C. D. sexual history. socioeconomic status. dietary intake. hydration status. Copyright © 2021, Elsevier Inc. All Rights Reserved. 28 Practice Question #3 (2 of 2) Answer: C. dietary intake. Copyright © 2021, Elsevier Inc. All Rights Reserved. 29 Practice Question #4 (1 of 2) Which laboratory test is most important for the nurse to monitor when a patient is receiving lithium? A. B. C. D. Urinalysis Serum glucose Serum electrolytes Complete blood count Copyright © 2021, Elsevier Inc. All Rights Reserved. 30 Practice Question #4 (2 of 2) Answer: C. Serum electrolytes Copyright © 2021, Elsevier Inc. All Rights Reserved. 31 Practice Question #5 (1 of 2) When providing dietary teaching for a patient taking monoamine oxidase inhibitors, the nurse should teach the patient to avoid which food? A. B. C. D. Yogurt Avocado Grapefruit Potato chips Copyright © 2021, Elsevier Inc. All Rights Reserved. 32 Practice Question #5 (2 of 2) Answer: A. Yogurt Copyright © 2021, Elsevier Inc. All Rights Reserved. 33 Practice Question #6 (1 of 2) Which advice will the nurse include when teaching the patient about lithium therapy? A. B. C. D. Take the drug on an empty stomach. Eliminate all sodium from your diet. Stop taking the lithium when you feel better. It may take 1 to 2 weeks before you have any benefits from taking the medication. Copyright © 2021, Elsevier Inc. All Rights Reserved. 34 Practice Question #6 (2 of 2) Answer: D. It may take 1 to 2 weeks before you have any benefits from taking the medication. Copyright © 2021, Elsevier Inc. All Rights Reserved. 35 Practice Question #7 (1 of 2) Which statement about amitriptyline does the nurse identify as being true? A. B. C. D. The drug is administered first thing in the morning. The drug should be discontinued slowly. The onset of antidepressant effect is 48 hours. Hypertension is a frequent side effect of this drug. Copyright © 2021, Elsevier Inc. All Rights Reserved. 36 Practice Question #7 (2 of 2) Answer: B. The drug should be discontinued slowly. Copyright © 2021, Elsevier Inc. All Rights Reserved. 37
