Medications for Mood
Disorders
Nursing 213
Antidepressants – How they work
• Restore neurotransmitters while client learns
coping
• https://www.youtube.com/watch?v=G4r3qCkLUD
Q
• May have other indications:
• Anxiety/ Anxiety disorders
• Chronic pain
• Eating disorders
• Affects:
• Serotonin (5-HT2)
• Norepinephrine
Antidepressant categories
• Selective Serotonin Reuptake Inhibitors (SSRI’s)
• Selective Serotonin-Norepinephrine Reuptake
Inhibitors (SSNRI’s) OR… Non-selective Reuptake
Inhibitors (NSRI’s)
• Heterocyclic Antidepressants (tricyclics – TCA’s)
• Monamine Oxidase Inhibitors (MAOI’s)
• Miscellaneous Antidepressants
Facts common to most
antidepressants
• Take 1- 6 weeks to improve mood, although
serotonin levels rise sooner
• 30% clients need different drug
• First-time treatment 6 – 12 months*
• Some clients need longer treatment
Adverse effects common to most
antidepressants
•Anticholinergic effects
•Weight gain
•Sexual side effects
Antidepressants
•No addiction
•Withdrawal effects may (will!) occur
•Clients at greater risk for suicide when they
begin to have more energy!
•***ALL now have black box warning: watch
for extreme personality changes leading to
suicide!!!!
Monamine Oxidase Inhibitors
(MAOI’s)
• Inhibit monamine oxidase, enzyme that breaks
down NE & 5-HT2
• Effective
• Not used often 2nd interactions
• Examples:
• phenelzine (Nardil)
• Isocarboxazid (Marplan)
• tranylcypromine (Parnate)
Monamine Oxidase Inhibitors
(MAOI’s): Side effects
• Orthostatic hypotension
• Edema
• Constipation
• Hypomania
• Insomnia
• Usual s/e
Tyramine
•Natural product of bacterial fermentation
•Displaces NE from storage vessels =
INCREASED BP
•Must be AVOIDED
•Long list of foods/ drugs to be avoided
Some foods containing tyramine
• Anything aged: cheeses, meats, extracts, fish, some
wines
• Flavor cubes
• Bananas
• Sauerkraut
• Soy
• Draft beer
• Brewer’s yeast
Interactions with MAOI’s
•Assume drugs not safe with
ANYTHING (RX or OTC) else
unless you have other
information!!
•Give adequate “washout”
time (10 days) prior to OR,
other meds
Hypertensive Crisis
• It’s what happens when you mix tyramine with
MAOI’s
• S/S are same as those of severe HTN:
• Headache
• Nosebleeds
• Tachycardia
• N/V
• Diaphoresis
• Chest pain/ coma/ stroke
Heterocyclics/ TCA’s
•Oldest class
•Effective 70% of time
•Also inhibit NE & 5-HT2 reuptake
•Start low, go slow
•4 – 8 weeks before full effect
•Also for chronic pain
Heterocyclics/TCA’s
•Examples:
•Amitriptyline (Elavil)
•Clomipramine (Anafranil)
•Imipramine (Tofranil)
Heterocyclics (TCA’s): adverse effects
• **Anticholinergic effects – review them!!!
• Other:
• Photosensitivity
• Decreased seizure threshold
• Sedation (gets better with time)
• *Orthostatic hypotension
• OVERDOSE DANGEROUS! (one-week prescriptions)
Miscellaneous:
•Buproprion (Wellbutrin, Zyban) seizures
•Trazodone (Desyrel) - sleep
•Mirtazapine (Remeron)
•{New meds: Viibryd (Vilazodone),
Brintellix (Vortioxetine), Emsam patch
(selegiline)}
Treatment Modalities (cont’d)
2. When teaching about the tricyclic
group of antidepressant medications,
which information should the nurse include?
a) Strong or aged cheese should not be eaten
while taking this group of medications.
b) The full therapeutic potential of tricyclics may not be
reached for 4 weeks.
c) Long-term use may result in physical
dependence.
d) Tricyclics should not be given with anti-anxiety agents.
Treatment Modalities (cont’d)
Correct answer: B
A client needs to be advised that it may take several
weeks for tricyclic medications to reach their full
therapeutic effect and for relief of symptoms to be
noted.
Selective Serotonin Reuptake
Inhibitors
Selective Serotonin Reuptake
Inhibitors: Examples
•Fluoxetine (Prozac, Sarafem)
•Paroxetine (Paxil)
•Sertraline (Zoloft)
•Citalopram (Celexa)
•Escitalopram (Lexapro)
Selective Serotonin Reuptake
Inhibitors
• First line therapy for depression
• Useful for anxiety, eating disorders, OCD
• Less side effects than older antidepressants
• Watch “washout” for fluoxetine (Prozac)
• *SSRI discontinuation syndrome – flu-like
symptoms, vivid dreams, agitation – self-limiting
Selective Serotonin Reuptake
Inhibitors: side effects
•Insomnia/ somnolence
•Anxiety/ agitation/ restlessness
(especially at start of therapy)
•Nausea
Serotonin Syndrome
•Potentially life-threatening
•Related to serotonin overdose
•Other medications contribute:
•MAOI’s
•St. John’s Wort
•Lithium
No lab test, just supportive treatment
Serotonin Syndrome
Symptoms
clinical triad:
• Cognitive: mental confusion, hypomania,
hallucinations, agitation, headache, coma.
• Autonomic: shivering, sweating, fever, labile
blood pressure, tachycardia, nausea, diarrhea.
• Somatic : myoclonus/clonus (muscle twitching),
hyperreflexia, tremor.
Treatment Modalities (cont’d)
3. A client has been diagnosed with major
depression. The psychiatrist prescribes Paroxetine
(Paxil). Which of the following medication
information should the nurse include in discharge
teaching?
a) Do not eat chocolate while taking this
medication.
b) The medication may cause priapism.
c) The medication should not be discontinued
abruptly.
d) The medication may cause photosensitivity.
Copyright © 2014. F.A. Davis Company
Treatment Modalities (cont’d)
Correct answer: C
Antidepressants such as paroxetine must be
tapered and not stopped abruptly. All classifications
of antidepressants have varying potentials to cause
discontinuation syndromes. Abrupt withdrawal
from SSRIs, such as paroxetine, may result in
dizziness, lethargy, headache, and nausea.
Copyright © 2014. F.A. Davis Company
Selective Serotonin/ Norepinephrine
Reuptake Inhibitors (SSNRI’s, NSRI’s)
•Serotonin & Norepinephrine
•Venlafaxine (Effexor)
•Duloxetine (Cymbalta)
Selective Serotonin/ Norepinephrine
Reuptake Inhibitors
• Less weight gain
• Less sexual dysfunction
• May be more anxiolytic (also may produce
anxiety)
• May increase BP (venlafaxine -Effexor)
• Duloxetine (Cymbalta): treat fibromyalgia
Antipsychotics = adjuncts
•“atypical antipsychotic medications” such as
quetiapine (Seroquel), aripiprazole (Abilify),
or olanzapine (Zyprexa) are now being used
to supplement antidepressant drugs in
severely depressed people.
Mood Stabilizing Drugs
For Bipolar Disorder
Drug Categories
•Lithium
•Anticonvulsants
•Antipsychotics
•Benzodiazepines
Lithium (Lithobid)
• 1st line for bipolar
• 90% effective in “pure” mania
• Less effective for rapid-cycling
• Affects: dopamine, NE, 5-HT2, acetylcholine, GABA
• *Takes 7-10 days to control hyperactivity
• Meanwhile, give antipsychotics to control
hyperactivity
Lithium
•Effective for:
•Elation, grandiosity
•Flight of ideas
•Irritability/ manipulativeness
•Anxiety
•Moderately effective:
•Insomnia
•Psychomotor agitation
•Assaultiveness
•Attention Deficit/ distractability
Lithium
• Works on electrolytes (it’s a salt)
• **Not metabolized by liver, goes straight to kidney
• **Affected by sodium/ fluid balance
• **Narrow therapeutic index
• Contraindicated:
• Renal/ thyroid/ heart disease
• Pregnancy
• Diuretics
• Many OTC meds
Lithium Monitoring
•ESSENTIAL
•Draw blood 12 hours after dose
•3 times a week
•Gradually decreasing
•Every 6 months for duration of treatment
•Include periodic renal/ thyroid tests
Lithium levels/ Side effects
•Therapeutic (maintenance level): 0.51.2mEq/L
•Expected S/E
•Initial GI upset (take with meals)
•FINE tremor
•MILD polyuria, polydipsia
•Increased WBC
•Weight gain
Lithium toxicity
(Think Neuro, M/S, GI, GU)
•Mild: approx 1.5mEq
•Lethargy, decreased concentration
•Weakness, slight ataxia
•Coarse hand tremors
•Return of GI upset
Lithium Toxicity
•Moderate: 1.5-2.5mEq
•Severe diarrhea, N/V
•Moderate ataxia, weakness
•Lethargy, slurred speech
•Irregular tremor
•Blurred vision
Lithium Toxicity
•Severe: > 2.5mEq/L
•Nystagmus
•Dysarthria
•Hyperreflexia
•Hallucinations
•Oliguria
•Confusion/ seizures/ coma/ death
•What will you do if you
see symptoms????
Lithium – client teaching
•Take with meals
•No diuretics – coffee
•Enough salt (Why?)
•Toxic effects
•Bloodwork
•Weight control
•Don’t discontinue
Anticonvulsants for Bipolar Disorder
•Rapid cycling
•Action not known
•Examples:
•*Divalproex (Depakote)
•*Carbemazepine (Tegretol)
•Gabapentin (Neurontin)
•Lamotrigine (Lamictal)
Anticonvulsants
•Drowsiness/ fatigue
•Drug interactions: **oral contraceptives
•Stevens-Johnson syndrome
Carbemazepine (Tegretol)
•Agranulocytosis
•More likely to cause S-J syndrome in Asians
•14 days before peak effect seen
•Labs for bone marrow/ hyponatremia:
•Baseline
•Every 2 weeks
•Every 3 months
Divalproex* (Depakote)
•Increases GABA
•Works in 1 – 2 weeks
•May be hepatotoxic: baseline liver studies
•Side effects:
•Tremors
•Weight gain
•GI upset
Antipsychotics for Bipolar disorder
• Used to only be used to control hyperactivity while
waiting for lithium to work
• Now can be used long-term instead of or in addition
to lithium
• Some approved drugs:
• Aripiprazole (Abilify)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon) – cardiac implications
• Olanzapine (Zyprexa)
Antispychotics for bipolar disorder
•Decrease hyperactivity, anxiety, psychosis of
mania
•May also be used as an adjunct for severe
depression
•Side effects:
•High blood sugar/ diabetes (metabolic
syndrome)
•Weight gain
•Anticholinergic effects
Antipsychotic Side effects
• Extrapyramidal symptoms (EPS):
• Do not occur as often with newer meds
(atypicals)
• Acute dystonia
• Parkinsonism
• Akathesia
• Tardive Dyskinesia (d/c drug!)
• Treated with anticholinergics (benztropine:
Cogentin)
Benzodiazepines
•Adjunct therapy for acute psychomotor
agitation
•Addicting, controlled substances
•Lorazepam (Ativan) short acting
•Clonazepam (Klonopin) longer acting
Remember:
• Manic symptoms help keep painful feelings out of
awareness
• Clients go to great lengths to prevent outside
controls from limiting manic behavior.
• “A little bit of mania is like a little bit of Christmas” (I
know, I said that already.)