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dysphoric or depressed state.
What changes can be a manifestation of depression? (8)
- Psychomotor retardation
- Suicidal ideations
What is endogenous depression?
Depression that occurs without apparent precipitating cause.
List (7) other uses for antidepressants.
- Anxiety: doxepin
- Enuresis: imipramine
- Chronic pain syndrome: amitriptyline
- Smoking cessation: bupropion
- Bulimia: fluoxetine
- OCD: fluoxetine, sertraline
- GAD: venlafaxine, paroxetine
What is the general action of antidepressants:
- Antidepressants prevent the reuptake or breakdown of neurotransmitters.
List (6) types of antidepressants.
- SSRI: Selective Serotonin Reuptake Inhibitor
- SNRI: Serotonin Norepinephrine Reuptake Inhibitor
- MAOI: Monoamine Oxidase Inhibitor
- TCA: Tricyclic antidepressant
- Tetracyclic: e.g. Mirtazapine (Remeron)
- Other: e.g. buproprion (Welbutrin)
What are are (5) contraindications to antidepressants?
- Narrow-angle glaucoma
- Immediately after MI
What are (6) precautions of antidepressant use?
- Older clients with cardiovascular disease
- Elderly with prostate enlargement (urinary retention)
- Anticholinergic effects may require dosage modifications or d/c
- Dosage - slow titration
- Full therapeutic effect may take 3-4 weeks
- May ↓SZ threshold especially with burpropion (Wellbutrin)
What risk is there when using antidepressants with a suicidal client?
There is an increased risk of suicide as antidepressants start to work, secondary to an increased energy level.
What are some "red flags" with suicidal clients?
- Sudden sense of well being
- Giving away prized objects
What are two classifications of MAO Inhibitors?
- Hydrazines: phenelzine sulfate (Nardil)
- Nonhydrazines: tranylcypromine sulfate (Parnate)
What are the pharmacokinetics of MAOIs?
- Absorbed rapidly from the GI tract
- Metabolized in the liver into metabolites
- Excreted mainly in the urine
What are the pharmacodynamics of MAOIs?
- MAOIs appear to work by inhibiting monoanimine oxidase.
- Monoanimine oxidase normally metabolizes norepinephrine and serotonin, making these neurotransmitters more available to the receptors.
What are the pharmacotherapeutics of MAOIs?
- Treatment of choice for atypical depression
- Used to treat typical depression when other treatments are unsuccessful; phobic anxieties, neurodermatitus, hypochondriasis, refactory narcolepsy
What are some precautions with MAOIs?
- Tyramine: Hypertensive crisis
- merperidine (opiod analgesics): hypo- or hypotensive coma or death
- Hypotensive: Additive effect with antihypertensives or spinal anasthesia
- Hypoglycemic: additive effect with oral hypoglycemic or insulin
Where is tyramine found?
- sympathomimetric drugs
What foods have tyramines?
- Red wines - beer - liqueurs
- aged cheese
- processed meats - smoked or pickled fish
- chicken or beef liver pate
- yeast, yogurt
- fava beans
What may be used to treat hypertensive crisis?
phentolalamine (Regitine) - off label use
Describe the first-pass effect.
- Many oral drugs undergo deactivation and sometimes activation when altered by hepatic metabolism.
- Alternative routes can bypass the first-pass effect e.g. sublingual, rectal, or parenteral.
What are (4) common TCAs?
- imipramine hydrochloride (Tofranil)
- amitriptyline hydrochloride (Elavil)
- amoxapine (Acendin)
- nortriptyline hydrochloride (Aventyl, Pamelor)
What are the pharmacokinetics of TCAs?
- Absorbed completely when PO
- First-pass effect
- Metabolized in liver
- excreted in urine
- Extremely fat-soluble (long half-life)
What are the pharmacodynamics of TCAs?
Increases NOR and serotonin by preventing reuptake and storage in presynaptic nerves.
What are the pharmacotherapeutics of TCAs?
- Treat episodes of major depression
- Less effective with:
- .... hypochondriasis
- .... atypical depression
- .... depression with delusions
- Inverstigated for use with:
- .... migraine headaches
- .... phobias
- .... urinary incontinence
- .... attention deficit disorder
- .... ulcers
- .... diabetic neuropathy
What are TCA drug-drug interactions?
- Many commonly used drugs
- May prevent therapeutic response to some antihypertensives
- Additive effect with drugs with anticholineric effects
- cimetidine (Tagamet) impairs metabolism
What are some adverse reactions with TCAs?
- Orthostatic hypertension
- Increase risk in the elderly
What is the advantage of SSRIs?
They have fewer side effects TCAs and MAOIs
List (3) common SSRIs.
- fluoxetine hydrochloride (Prozac)
- paroxatine hydrochloride (Paxil)
- sertraline hydrochloride (Zoloft)
What are the pharmacokinetics of SSRIs?
- Almost completely absorbed when PO
- Highly protein bound
- metabolized in liver
- excreted in urine
What are the pharmacodynamics of SSRIs?
Selectively inhibits neuronal reuptake of the neurotransmitter serotonin
What are the pharmacotherapeutics of SSRIs?
- Treat major depressive episodes.
- Depending on the SSRI:
- .... anxiety disorders
- .... eating disorders
- .... personality disorders
- .... impulse control disorders
What are SSRIs drug-drug interactions?
- Competitively inhibits a liver enzyme that is responsible for the oxidation of numerous drugs.
- MAOIs: can cause serious and potentially fatal reactions.
What are some adverse reactions with SSRIs?
- Serotonin Syndrome
What causes Serotonin Syndrome?
- The excessive accumulation of serotonin.
- May be due to Rx and/or OTC meds
What are signs and symptoms of Serotonin Syndrome?
- At least three of the following:
- .... change in MS
- .... agitation
- .... myoclonus
- .... hyperreflexia
- .... fever
- .... diaphoresis
- .... ataxia
- .... diarrea
- May include:
- .... abdominal pain
- .... ↑BP
- .... tachycardia
- .... ↑ motor activity
- .... mood changes
- Severe reactions:
- .... high fever
- .... cardiovascular shock → death
List (5) miscellaneous antidepressants.
- maprotiline hydrochloride (Ludiomil)
- mirtazapine (Remeron)
- bupropion hydrochloride (Wellbutrin)
- venlafaxine hydrochloride (Effexor)
- trazodone hydrochlorine (Desyrel)
Define bipolar disorder.
- Mood swings of extreme euphoria and Depression
- Mania: catecholamine stimulation
- Depression: diminished catecholamine stimulation
What medications are used to treat bipolar disorder?
- lithium carbonate (Eskalith)
- divalproex (Depakote)
- lamotrigine (Lamictal)
- Carbamazepine (Tegretol)
- Oxcarbazepine (Trileptal)
- Topiramate (Topamax)
- Tiagabine (Gabitril)
What are the pharmacokinetics of lithium?
- Absorbed rapidly and completely when PO
- Distributed to body tissues.
- Crosses placenta; enters breast milk
- Not metabolized
- Excreted unchanged by kidneys
What are the pharmacodynamics of lithium?
- Regulates catecholamine release in CNS:
- .... increases NOR and serotonin uptake
- .... reduces the release of NOR from synaptic vesicles in presynaptic neuron
- .... inhibits NOR's action in postsynaptic neuron
What are the pharmacotherapeutics of lithium?
Treatment of acute mania and prophylaxis of recurrance
What are lithium drug-drug interactions?
- Therapeutic Range (TR): 0.5 - 1.5 mEq/L (narrow)
- Serious reactions can occur
What are some adverse reactions with lithium?
- Salt restricted diet can cause toxicity
- .... vomiting
- .... diarrhea
- .... tremor
- .... muscle weakness
- .... slurred speech
- .... decreased coordination
- .... drowsiness
What are neuroleptics?
What are the pharmacotherapeutics of neuroleptics?
- Acute mania
- Psychotic depression
- Schizoaffective disorders
- Drug induced psychosis
- Children with extreme behavior
What are some off label uses of neuroleptics?
- agressive, disruptive, and delusional behavior
- Insomnia that sometimes accompanies Alzheimer's disease
What is the action of antipsychotic drugs?
- Block dopamine receptors; D 1,2,3,4,5
- D 2,3,4 haave been associated with mental illness
What are the pharmacodynamics of aripiprazole (Abilify)?
- Dopamine stabilizer
- .... When dopamine is too low → Abilify enhances it
- .... When dopamine is too high → Abilify reduces it
What are some adverse reactions of antipsychotic drugs?
- Most are EPS
- Treat with anticholinergic meds:
- .... benztopine (Cogentin)
- .... diphenhydramin (Benadryl)
What are Extra-Pyramidal Symtoms (EPS)?
- Dystonia (acute)
- Tardive dyskinesia
- Neuroleptic Malignant Syndrome (NMS)
What is dystonia?
- Muscle rigidity and cramping
- .... stiff neck
- .... thick tongue
- .... swallowing issues
What is pseudo-parkinsonium?
What is akathisia?
- Intense desire to move
- "Can't stay still"
What is tardive dyskinesia?
- Permanent involuntary movement
- .... lip smacking, chewing, tongue protrusion,
- .... blinking, chorieform limb movements
What is Neuroleptic Malignant Syndrome (NMS)
- Can be fatal
- High fever
- unstable blood pressure
- elevated enzymes
What is psychosis?
A break from reality.
What is meant by positive or negative symptoms?
- Positive symptoms are thoughts, behaviors, or sensory perceptions present in a person with a mental disorder, but not present in people in the normal population.
- Negative symptoms are thoughts, feelings, or behaviors normally present that are absent or diminished in a person with a mental disorder.
What are positive symptoms of psychosis?
- Hallucinations: can effect any of the senses
- Delusions: a false or fixed belief.
What are negative symptoms of psychosis?
- Affect disturbance
What is anergia?
- A lack of energy
- (Taber's Dictionary of Medical Terms)
What is alogia?
- Completely speechless.
- (Taber's Dictionary of Medical Terms)
What is avolition?
- "A general lack of desire, drive, or motivation to pursue meaningful goals".
What is ambivalence?
Simultaneous opposite feelings regarding something
What is anhedonia?
Inability to experience pleasure
What is the general action of typical (traditional) antipsychotic drugs and what are they used to treat?
They block D 2,3,4 dopamine receptors. They are used to treat negative symptoms of schizophrenia and have no effect of positive symptoms
What is the general action of atypical antipsychotic drugs and how are they used?
- They are weaker D2 dopamine receptor blockers so:
- .... less risk of EPS
- .... less risk of TD (Tardive Dyskinesia)
- They effectively treat positive and negative symptoms
What are the two major groups of typical antipsychotics drugs and their attributes?
- Phenothiazines: chloropromazine (Thorazine)
- .... low potency
- .... high sedation
- .... low EPS
- Nonphenothiazines: haloperidol (Haldol)
- .... high potency
- .... low sedation
- .... high EPS
List (6) atypical antipsychotic drugs and their main adverse reactions.
- clozapine (Clozaril): argranulocytosis, seizures (monitor WBCs)
- olanzapine (Zyprexa): weight gain
- aripiprazole (Abilify): anxiety
- risperidone (Risperdal): can have prolactin issues
- quetiapine (Seroquel): sedation
- ziprasidone (Geodon): Q-T wave prolongation
What is/are nursing interventions for dystonic Rxn?
- Administer medication
- Reassure client
What is/are nursing interventions for Tardive Dyskinesia?
Use AIMS scale, report score
What is the AIMS scale?
Abnormal Involuntary Movement Scale
What is/are nursing interventions for NMS?
- Stop antipsychotic meds
- Notify PCP immediately
What is/are nursing interventions for akathisia or EPS?
- Administer meds as ordered
- Assess for effectiveness
What is/are nursing interventions for seizures?
- Protect client from injury
- Stop meds
- Notify PCP
- provide privacy
What is/are nursing interventions for sedation?
Caution about alert activities (car driving)
What is/are nursing interventions for photosensitivity?
- Avoid exposure
- Wear sunscreen
- Wear protective clothing
What is/are nursing interventions for sexual dysfunction?
Teach client to inform PCP or impotence or diminished libido
What is/are nursing interventions for weight gain?
- Encourage balanced diet
- Encourage regular exercise
- Focus on minimizing gain
What is/are nursing interventions for anticholinergic effects?
- Ice chips
- Sugarless hard candy
- Should decrease with time, if not notify PCP
What is/are nursing interventions for constipation?
- Increase fluid
- Increase dietary fiber
- May need stool softener
What is/are nursing interventions for urinary retention?
Teach to report if no improvement
What is/are nursing interventions for orthostatic hypotension?
- Teach to rise slowly from lying to sitting or standing
- Do not ambulate until no longer dizzy or light headed.