ANTIDEPRESSANTS
·
Interact
with norepinephrine and serotonin, neurotransmitters that regulate mood,
arousal, attention, sensory processing and appetite.
·
Indication:
o
Treatment
of major depressive illness, anxiety disorders, depressed phase of bipolar
disorder, and psychotic depression
·
Contraindication:
o
Used
with caution in patients with acute schizophrenia, mixed mania and depression,
suicidal tendencies, severe renal, hepatic or cardiovascular disease,
narrow-angle glaucoma and seizure disorders
TRICYCLIC ANTIDEPRESSANTS (TCA)
·
Prevent
reuptake of serotonin and norepinephrine and cause them to build-up in the
brain; the amassing of these neurotransmitters is thought to diminish
depression
·
Indication:
o
Depression,
depression accompanied by insomnia and anxiety, children less than 6 years of age
with enuresis, chronic, intractable pain, Obsessive- compulsive disorders
(OCDs)
·
Contraindication:
o
Concurrent
use with alcohol or antihistamines can cause CNS depression
o
Concurrent
use with MAO inhibitors can cause hypertensive crisis
|
Example:
|
|
imipramine (Tofranil®)
|
|
desipramine (Norpramin®)
|
|
amitriptyline (Elavil®)
|
|
nortriptyline (Pamelor®)
|
|
doxepin (Sinequan®)
|
|
trimipramine (Surmontil®)
|
|
protriptyline (Vivactil®)
|
|
maprotiline (Ludiomil®)
|
|
mirtazapine (Remeron®)
|
|
amoxapine (Asendin®)
|
|
clomipramine (Anafranil®)
|
Side Effects:
Anticholinergic effects:
|
ü
Dry
mouth
|
ü
Dry
nasal passages
|
|
ü
Blurred
vision
|
ü
Constipation
|
|
ü
Agitation
|
ü
Urinary
hesitancy or retention
|
|
ü
Delirium
|
ü
Ileus
in older adults
|
Other side effects:
|
ü
Orthostatic
hypotension
|
ü
Tachycardia
|
|
ü
Sedation
|
ü
Sexual
dysfunction
|
|
ü
Weight
gain
|
ü
Weight
gain
|
Nursing Consideration:
ü
Switch
to a different tricyclic antidepressant if the patient develops intolerable
adverse effects.
ü
Notify
the physician if the QT interval widens.
ü
Monitor
a suicidal patient closely until the drug takes effect.
ü
Provide
patient and caregiver information about the prescribed drug:
o
Full
therapeutic effect may take for up to 30 days for some drugs and 10-14 days for
amitriptyline use.
o
Caution
patient not to abruptly stop TCA therapy (can cause nausea, headache, malaise).
o
Take
with food or milk if gastrointestinal distress occurs.
o
Advise
not to operate motor vehicle or dangerous machinery (if blurred vision and
sedation occurs.
o
Teach
how to manage hypotension.
o
Include
high fiber food in the diet.
o
Provide
reassurance that drug-induced decreased libido and inhibited ejaculation should
resolve when TCA is discontinued.
o
Instruct
patient to take daily dose at bedtime to avoid sedation and anticholinergic
effect, unless otherwise prescribed.
o
Alcohol
and other CNS antidepressants may increase sedation.
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRIs)
·
Prevent
reuptake of serotonin thus elevating its levels in the brain thus reducing
depression
·
Indication:
o
Depression,
bulimia, panic attacks, OCDs, post-traumatic stress syndrome, premenstrual
dysphoric disorder, social phobias, smoking cessation (fluoxetine)
·
Contraindication:
o
Concomitant
use of MAOIs that can lead to increased serotonin levels which can cause
Serotonin Syndrome (contraindicated within 14 days of taking MAOIs); renal or
hepatic disorders
|
Example:
|
|
fluoxetine (Prozac®)
|
|
fluvoxamine (Luvox®)
|
|
paroxetine (Paxil®)
|
|
sertraline (Zoloft®)
|
|
citalopram (Celexa®)
|
|
escitalopram (Lexapro®)
|
Side Effects:
|
·
Anxiety
|
·
Diarrhea
|
|
·
Agitation
|
·
Sweating
|
|
·
Hand
tremor
|
·
Insomnia
|
|
·
Headache
|
·
Nausea
|
|
·
Weight
gain
|
·
Akathisia
(motor restlessness)
|
|
·
Sexual
dysfunction (diminished sexual drive, difficulty achieving erection or
orgasm)
|
|
Nursing Consideration:
ü
Administer
SSRI before bedtime or with food to minimize anticholinergic effect.
ü
Give
reduced paroxetine dosage to patient with renal and hepatic impairment.
ü
Give
fluoxetine dosage that exceeds that exceeds 20 mg daily in two divided doses-
in the morning and at noon .
ü
Withhold
fluoxetine if rash develops. Notify physician.
ü
Avoid
abrupt withdrawal of SSRIs.
ü
Provide
patient and caregiver teachings:
o
SSRIs
may take a few weeks to take full therapeutic effect.
o
Advise
patient to avoid operating motor vehicles or dangerous machinery due to
sedation.
o
Teach
patient to take daily dose at bedtime.
o
Instruct
patient to take the drug with meals or snacks to enhance absorption and avoid
dizziness.
o
Consult
physician before taking any herbal remedy.
MONOAMINE OXIDASE (MAO) INHIBITORS
·
Stop
the enzyme monoamine oxidase from dissolving serotonin and norepinephrine in
the brain
·
Indication:
o
Depression
not responding to other antidepressants
·
Contraindication:
o
Food
rich in tyramine
o
Sympathomimetic
drugs
|
Example:
|
|
|
phenelzine (Nardil®)
|
isocarboxacid (Marplan®)
|
|
tranylcypromine (Parnate®)
|
selegiline (Eldepryl®, Emsam®)
|
Side Effects:
·
Daytime
sedation
·
Insomnia
·
Weight
gain
·
Dry
mouth
·
Orthostatic
hypotension
·
Sexual
dysfunction
·
*hypertensive
crisis if taken with food that contains tyramine and sympathomimetic drugs
Hypertensive crisis:
|
·
Hypertension
|
·
Diaphoresis
|
|
·
Hyperpyrexia
|
·
Tremulousness
|
|
·
Tachycardia
|
·
Cardiac
dysrhythmias
|
Nursing Consideration:
ü
Monitor
blood pressure.
ü
Monitor
for signs of hypertensive crisis.
ü
phentolamine
(Regitine) 5 to 10 mg IV - antidote for hypertensive crisis
ü
Review
these points with patient and caregiver:
o
Avoid
foods rich in tyramine.
|
Foods Containing Tyramine
|
|
Mature or aged cheeses or dishes made with cheese,
such as lasagna or pizza (all cheese is considered aged except cottage
cheese, cream cheese, ricotta cheese, and processed cheese slices)
|
|
Aged meats such as pepperoni, salami, mordatella,
summer sausage, beef logs, meat extracts, and similar products; make sure
that meat and chicken are fresh and have been properly refrigerated
|
|
Italian broad beans (fava), bean curd (tofu),
banana peel, over ripe fruit, avocado
|
|
All tap beers and microbrewery beer (drink no more
than two cans or bottles of beer, including nonalcoholic beer or 4 ounces of
wine per day
|
|
Sauerkraut, soy sauce or soybean condiments, or
marmite (concentrated yeast)
|
|
Yogurt, sour cream, peanuts, Brewer’s yeast, MSG
|
|
Caffeine such as coffee, tea, or chocolate
|
o
Sit
up for 1 minute before getting out of bed to avoid dizziness.
o
Avoid
overexertion because MAO inhibitors may suppress angina.
o
Consult
physician before taking OTCs, SSRIs tricyclic compounds, busperone (BuSpar),
dextromethorphan, and opiate derivatives such as meperedine.
o
Avoid
abrupt withdrawal of medication.
OTHER COMPOUNDS (Miscellaneous Antidepressants)
·
Exert
different effects on dopamine, serotonin and norepinephrine
·
Indication:
o
Smoking
cessation (Bupropion), depression, anxiety disorders
·
Contraindication:
o
Patients
with seizure disorders, those undergoing discontinuation of alcohol or
benzodiazepines, prior diagnosis of bulimia or anorexia nervosa
o
Avoid
taking drug with MAOIs
|
Example:
|
|
bupropion (Wellbutrin®)
|
|
venlafaxine (Effexor®)
|
|
trazodone (Desyrel®)
|
|
nefazodone (Serzone®)
|
|
duloxetine (Cymbalta®)
|
|
amoxapine (Asendin®)
|
Side Effects:
|
·
Sedation
|
·
Headache
|
|
·
Dry
mouth
|
·
Nausea
|
|
·
Loss
of appetite
|
·
Agitation
|
|
·
Photosensitivity
|
·
Insomnia,
seizures(bupropion)
|
|
·
Priapism
(trazodone)
|
|
|
·
Liver
damage and orhtostaic hypotension (nefazodone)
|
|
|
·
ECG
changes, extrapyramidal symptoms/EPS and neuroleptic malignant syndrome/NMS
(amoxapine)
|
|
Nursing Consideration:
ü
Observe
and teach patient about side effects especially signs and symptoms of EPS and
NMS.
ü
Monitor
ECGs at onset and during treatment.
ü
Monitor
liver function tests.
ü
Monitor
BP and glucose treatment.
ü
Monitor
patient’s weight.
ü
Be
alert for increased risk of seizures.
ü
Provide
patient teaching:
o
Teach
patient about therapeutic effects.
o
Avoid
use of alcohol and other CNS depressants.
o
Wear
sunscreen because of photosensitivity.
o
Rise
slowly from sitting or lying position.
o
Avoid
abrupt withdrawal of drug.
