NUR 426 Lecture Notes - Lecture 9: Treatment-Resistant Depression, Orthostatic Hypotension, Tricyclic Antidepressant

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14 Nov 2017
Medications in Psychiatry: Treating Depression, Bipolar Disorder and Psychosis
Psychiatric Medication Prototypes
o SSRI: Sertraline (Zoloft)
o SNRI: Venlafaxine
o NDRI: Bupropion
o TCA: Imipramine
o MAOI: Phenelzine
Mood Stabilizers:
o Lithium
o Valproic acid (Depakote)
o FGA: Haloperidol (Haldol)
o SGA: Clozapine
o SGA: Olanzapine
Movement Disorder Medications
o Ach: Benztopine
o Antihistamine: Diphenhydramine
Concepts in Psychiatric Nursing
1. Disruptive Mood Dysregulation: Depression
- Refers to symptoms in the affective, behavioral, cognitive and emotional domains of
everyday functioning. Potential triggers for these changes include upsetting life events, life
transitions, physical transitions or illness and chronic stress
- Depressive episodes can occur across the lifespan. Depression has been described as the
oo old of etal illess
Vocabulary: Depressive Disorders
Tricyclic antidepressants
Monoamine Oxidase Inhibitors (MAOIs)
Selective serotonin Reuptake Inhibitors (SSRIs) effect
Serotonin and Norepinephrine reuptake inhibitors (SNRIs)
Norepinephrine Dopamine Reuptake Inhibitors (NDRIs)
Hypertensive crisis
Serotonin syndrome
Tricyclic Prototype: Imipramine
o Depression, anxiety, insomnia, enuresis, neuropathic pain, treatment resistant
depression for patients older than 6
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o Blocks reuptake of serotonin and norepinephrine/noradrenaline, anticholinergic
o Peak in 2-4 hours. Liver metabolism, renal excretion
Adverse effects
o ACH: blurred vision, constipation, urinary retention, dry mouth
o CNS: anxiety, fatigue, restlessness, dizzy, headache, sweating
o GI/GU: nausea, vomiting, diarrhea, increase in weight/appetite, constipation
o Sexual impotence, decrease in libido
Drug-Drug Interactions: result in toxic accumulation of active metabolite (too much active
Nursing Alert
- These drugs have many uncomfortable and unwanted side effects
- Common: sedation, orthostatic hypotension, anticholinergic
- Others: tremors, restlessness, insomnia, nausea and vomiting, confusion, pedal edema,
headache, seizure
- Have narrow therapeutic window: can be dangerous in overdose
- Potential cardiotoxicity: QT prolongation (most prevalent), precipitation of heart failure, MI,
arrhymias, stroke
- Contraindications: 2nd degree AV block
Patient should have baseline EKG if over 50
Stop smoking
MAOI Prototype: Phenelzine
Indications: treatment resistant depression/panic/social anxiety disorders, other medications
Actions: inhibits MAO enzyme from breaking down neurotransmitters, allow DA, NE, 5HT in
synapse, creating clinical effects
Pharmacokinetics: duration of action up to 14 days due to irreversible enzyme inhibition
Last resort medication, cannot be switched quickly
Need 2-week washout of other drugs before starting
Adverse effects
- CNS: dizzy, sedation, headache, insomnia, fatigue, tremor
- Ach: blurred vision, increased sweating, dry mouth, constipation, urinary retention
- GI: nausea, appetite changes, weight gain
- GU: sexual dysfunction; erectile dysfunction, anorgasmia
- CV: orthostatic hypotension (dose related)
- Drug-drug interactions: TCA, SSRI, sympathomimetic, carbamazepine, mirtazapine
Nursing alert
- Not used with pediatric or pregnant patients
- Be watchful if your patient is elderly or has CV disease
- Patient must follow a low tyramine diet
- Monitor blood pressure
- Provide clear patient teaching on dietary restrictions
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- Possibility of hypertensive crisis: occipital headache, palpitations, stiff neck, nausea,
vomiting, dilated pupils, photophobia
- Possibility of fatal serotonin syndrome
Elements of the low tyramine diet
- Patients should avoid aged cheese
- Patients a’t eat fresh meats, poultry, and fish
- Vegetables to avoid are fava beans
- Patients who wish to drink alcohol should choose pasteurized tap or craft beer
- “hould’t e eatig isellaneous food/condiments include soy sauce and sourkruate
SSRI Prototype: Sertraline
Indication: depression, anxiety disorders, GAD, OCD, PTSD, social phobia, social anxiety- first line
treatment in many anxiety disorders
Actions: blocks presynaptic reuptake of serotonin, therefore increase serotonin in synaptic
Dose range: 50-200mg/day
Pharmacokinetics: therapeutic half live is 22-36 hours, liver metabolism, renal excretion
Side effects
- CNS: insomnia, sedation, agitation, tremors, dizziness, headache, sweating
- GI: nausea, diarrhea, constipation, dry mouth, deceased appetite
- GU: sexual dysfunction
- Possible SIADH (syndrome of inappropriate antidiuretic hormone secretion)
- Combination with other serotonergic drugs increase risk serotonin syndrome
- Do not mix with over the counter
- Do not combine with St. John Wort
Nursing Alert
- All SSRIs carry black box warning for suicide; be vigilant with child/adolescent population
- Teach patient to not abruptly stop medications
- 1. Serotonin syndrome causes HARM
o Hyperthermia, automatic instability, rigidity, yolous har, “t. joh’s wart/cold
meds is a common medication that can precipitate serotonin syndrome
- 2. Serotonin discontinuation syndrome: uncomfortable but not fatal
o Caused by rapid or sudden discontinuation of meds. Symptoms include agitation,
ausea, dysphoria, eletri shok sesatio – pis ad eedles
SNRI Prototype: Venlafaxine
Indication: depression, PTSD, GAD, social anxiety, panic, disorders, pain, fatigue
Actions: inhibition reuptake of serotonin and norepinephrine/noradrenaline
Pharmacokinetics: extended release available, liver metabolism, renal excretion
Common side effects: headache, anxiety, insomnia, transient nausea, vomiting, and diarrhea,
possible increased blood pressure
Patients with hypertension may need BP monitoring
Little effect on acetylcholine or histamine; may have mild sedation and anticholinergic
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