Antidepressant Agents

Question 1

What are the signs and symptoms of depression?

Answer 1

• Low energy
• Sleep disturbances
• Altered appetite
• Altered libido
• Inability to perform activites of daily living
• Overwhelming feelings of sadness, despair, hopelessness, and disorganization
• Altered affect

Question 2

What is the
Biogenic Theory of Depression?

Answer 2

• Depression results from a deficiency of norepinephrine (NE), dopamine, and serotonin (5HT)
• Monamine oxidase may break them down to be recycled or restored in the neuron
• Rapid fire of neurons may lead to their depletion
• The # or sensitivity of receptors may increase, depleting neurotransmitter levels.

Question 3

Antidepressant Therapy
Mechanisms of Action

Answer 3

• Inhibit the effects of MAO => increased NE or 5HT in the synaptic cleft
• BLOCK reuptake by the releasing nerve => increased neurotransmitters in the synaptic cleft
• Regulate receptor sites and breakdown of neurotransmitters, leading to an accumulation of neurotransmitters in the synaptic cleft

Question 4

Types of Antidepressants

Answer 4

• Triclycic antidepressants (TCAs)
• MAO inhibitors (MAOIs)
• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin neorepinephrine inhibitors (SNRIs)
• Others

Question 5

Considerations for use of antidepressants
in Children

Answer 5

• Rule out medical reasons first
• First choice: SSRIs and SNRIs
• Response is unpredictable
• Possible long term effects
• Studies have not proven efficacy
• Many black box warnings r/t increased sucidal ideation/behavior
• Avoid MAOIs d/t drug-food interactions

Question 6

Considerations for use of antidepressants
in Adults

Answer 6

• Rule out medical reasons first
• Effects may not be seen for 4 weeks or more
• Caution during pregnancy/lactation

Question 7

Considerations for use of antidepressants
in Older Adults

Answer 7

• Rule out medical reasons first
• More susceptible to adv. effects (especially CNS effects)
• Renal and hepatic impairment: Start LOW and Go SLOW
• TCAs can worsen Benign Prostatic Hyperplasia (BPH) because they decrease bladder contractions

Question 8

TCAs
Mechanism of Action

Answer 8

Reduces the reuptake of 5HT AND NE into the nerves => increase in the synaptic cleft

Question 9

TCAs
Indications

Answer 9

• Depression
• Sleep disorders
• Enuresis (nightime bedwetting)
• Anxiety
• Chronic Pain

Question 10

TCAs
Drug Names

Answer 10

“-triptyline”
* Amitriptyline
* Nortriptyline

“-pramine”
* Clomipramine
* Despramine
* Imipramine
* Trimipramine

Doxepin

Question 11

TCAs
Contraindications

Answer 11

Absolute:
* Allergy

Relative:
* Recent MI (can cause it to worsen or reoccur)

Cautions:
* CV disease
* Anticholinergic conditions (BPH, glaucoma, urinary retention)
* Manic-depression/ bipolar (can shift into manic phase)
* Seizure disorders (can lower the threshold for seizures)

Question 12

TCAs
Adverse Effects

Answer 12

• CNS: sedation, sleep disturbances, fatigue, hallucinations, ataxia (lack of voluntary muscle control)
• GI: Dry mouth, constipation, n&v, anorexia, decreased salivation
• CV: tachycardia, hypertension, arrhythmias

Question 13

TCAs
Drug Interactions

Answer 13

• MAOIs
• Cimetidine (Histamine-2 antagonist)
• Fluoxetine (SSRI)

Risk of death

Question 14

TCAs
Assessment

Answer 14

History:
* Cardiac dysfunction/disease

Labs:
* ECG

Question 15

TCAs
Implementation/Patient Teaching

Answer 15

• Limit drug access if pt is suicidal (dec. risk of overdose)
• Parenteral form only if Oral is not feasible
• Reduce dose if minor adv. effects occur
• Discontinue slowly if major adv. effects occur
• Take at bedtime if drowsiness occurs
• Void before meds if urinary retention occurs
• sugarless lozenges for dry mouth
• small meals/take with meal for GI upset
• Takes 4 weeks to take effect

Question 16

MAOIs
Mechanism of Action

Answer 16

Irreversibly inhibits monoamine oxidase
Allows NE, 5HT, and dopamine to accumulate in the synaptic cleft

NOT 1st line/1st choice

Question 17

MAOIs
Indications

Answer 17

Depression

Question 18

MAOIs
Drug Names

Answer 18

Isocarboxazid
Phenelzine
Tranylcypromine
Selegiline (transdermal)

Question 19

MAOIs
Contraindications

Answer 19

Absolute:
* Allergy
* Pheochromocytoma (adrenal gland tumor)

Relative: (made worse)
* CV disease
* Headaches
* Renal or Hepatic impairment

Cautions:
* Bipolar disease (can lead to mania)
* Seizure disorder (lowers the threshold for seizures)
* Hyperthyroidism (made worse)

Question 20

MAOIs
Adverse Effects

Answer 20

CNS: dizziness, diaphoresis, excitement, nervousness, mania, hyperreflexia, tremors, confusion, insomnia, agitation
CV: Hypertension, tachycardia, arrhythmia
Black Box warning: suicidal ideation and behavior (especially in children and young adults)

Question 21

MAOIs
Drug Interactions

Answer 21

Drug:
* Other antidepressants: Hypertensive crisis, coma, convulsions, serotonin syndrome
* Sympathomimetics: CV effects increase
* Antidiabetic agents: Increased risk of HYPOglycemia

Food:
* Tyramine: Increase in BP, possible hypertensive crisis
* Foods high in tyramine: aged cheeses and meats, red wine, soy sauce

Question 22

MAOIs
Assessment

Answer 22

History:
* Cardiac dysfunction, seizure disorders, pheochromocytoma, headaches, hyperthryoidism

Labs:
* ECG

Question 23

MAOIs
Implementation/Patient Teaching

Answer 23

• Limit drug access (potential overdose)
• Monitor BP and Ortho BP
• Discontinue drug at any complaint of severe headache (potential hypertensive crisis)
• Have phentolamine or adrenergic blocker on standby (antidote)
• Void before admin if at risk of urinary retention
• take with food for GI upset
• Patient Teaching - what to report to provider, follow up appts., emergency services for SI

Question 24

Selective Serotonin Reuptake Inhibitors

SSRIs
Mechanism of Action

Answer 24

Specifically blocks the reuptake of 5HT, with little to no known effect on NE

Question 25

# Selective Serotonin Reuptake Inhibitors **SSRIs** Adverse Effects

Answer 25

* Not many because there is no effect on norepinephrine Related to increase in 5HT: * **CNS**: Headache, drowsiness, dizziness, insomnia, anxiety, tremor, agitation * **GU**: Painful menstruation, sexual dysfunction, impotence, urgency * **Serotonin Syndrome**

Question 26

# Selective Serotonin Reuptake Inhibitors **SSRIs** Indications

Answer 26

* Depression * OCD * Panic attacks * bulimia * PMDD * post-traumatic stress disorders * social phobias * social anxiety disorders

Question 27

# Selective Serotonin Reuptake Inhibitors **SSRIs** Drug names

Answer 27

**"-italopram"** * Citalopram * Escitalopram **"-oxetine"** * Fluoxetine * Paroxetine **Sertraline**

Question 28

# Selective Serotonin Reuptake Inhibitors **SSRIs** Drug Interactions

Answer 28

**Drug:** *(Increases risk of serotonin syndrome)* * MAOIs * TCAs * SNRIs * St. John's Wort

Question 29

# Selective Serotonin Reuptake Inhibitors **SSRIs** Contraindications

Answer 29

**Absolute:** * Allergy **Cautions:** * impaired renal or hepatic function * Pregnancy/lactation —> congenital abnormalities in animal studies

Question 30

What is Serotonin Syndrome?

Answer 30

agitation, confusion, diaphoresis, increased BP, increased HR, diarrhea, headache, high fever, muscle rigidity, death

Question 31

# Serotonin Norepinephrine Reuptake Inhibitors **SNRIs** Mechanism of Action

Answer 31

Decreases neuronal reuptake of both serotonin and norepinephrine and more weakly inhibit dopamine reuptake

Question 32

# Serotonin Norepinephrine Reuptake Inhibitors **SNRIs** Indications

Answer 32

* Depression * Neuropathic pain * Fibromyalgia * Anxiety *(generalized and social)*

Question 33

# Serotonin Norepinephrine Reuptake Inhibitors **SNRIs** Drug Names

Answer 33

* Desvenlafaxine * Duloxetine * Venlafaxine

Question 34

# Serotonin Norepinephrine Reuptake Inhibitors **SNRIs** Contraindications

Answer 34

**Absolute:** * Allergy * MAOIs use *(increases risk of hypertenisve crisis and serotonin syndrome)* **Cautions:** * Severe depression, suicidality *(black box warning)* * Bipolar disorder *(manic phase)* * Seizure disorder *(lowers threshold)*

Question 35

# Serotonin Norepinephrine Reuptake Inhibitors **SNRIs** Adverse effects

Answer 35

* Hyperhidrosis * Erectile Dysfunction * Cardiac: tachycardia, palpitations, hypertension * abnormal bleeding * anticholinergic: glaucoma, urinary retention, BHP * Serotonin Syndrome

Question 36

# Serotonin Norepinephrine Reuptake Inhibitors **SNRIs** Drug Interactions

Answer 36

* MAOIs * SSRIs, TCAs, serotonergic drugs (including St. John's Wort) * Anything that increases serotonin

Question 37

**SSRIs and SNRIs** Interventions/Patient Teaching

Answer 37

* Establish suicide precautions for severely depressed patients * Limit the access to drugs (overdose risk) * Administer the drug once a day, in the morning to achieve optimal Therapeutic effect *(unless pt does better with the sedative effect at night)* * If severe GI effects, dose can be divided * Can take 4 weeks to work * Void before taking * Risk of HT crisis, serotonin syndrome

Question 38

**Bupropion**

Answer 38

**Other antidepressant** Low doses: smoking cessation Available in ER and SR formulas

Question 39

**Mirtazapine**

Answer 39

**Other Antidepressant** Atypical antidepressant MANY anticholinergic effects

Question 40

**Trazadone**

Answer 40

**Other antidepressant** MANY CNS effects Black Box warning for suicidality, hypotension, and priapism

Question 41

**Esketamine**

Answer 41

**Other Antidepressant** Nasal spray is approved for depression CNS effects and increased BP

Question 42

**Antidepressants** General Nursing Assessment

Answer 42

**History:** * Allergy, severe depression and suicidality, bipolar disorder, contraindications and cautions for specific drug class, impaired liver or kidney function, pregnancy/lactation **Physical:** * Vital signs and weight * CNS, including vision * Abdomen (GI issues) **Labs:** * Renal and hepatic * EKG (for MAOIs and TCAs)

Question 43

**Antidepressants** General Nursing Conclusions

Answer 43

* Impaired comfort *(r/t adverse effects)* * Altered thought process and sensory perception *(r/t CNS effects)* * Malnutrition risk *(r/t GI effects)* * Knowledge deficit