Anti Depressants, Mood Stabilizers, and Anxiolytics

use of fluoxetine (prozac)

MDD, OCD, bulimia nervosa, panic disorder

action of fluoextine

selectively blocks reuptake of seratonin, increases the transmission of seratonin at the nerve synapse

admin fluextine

PO once daily (can have a weekly pill), as well as liquid

side effects of SSRIs

suicidality (BBW), anxiety, insomnia, headache, nausea, potential wt loss or gain, sexual dysfunction, activation of mania, serotonin syndrome, risk for hyponatremia, increased bleeding risk, SJS, EPS

timing of seratonin syndrome

can occur within minutes to hours of starting or increasing the dose of an SSRI or other serotonergic medications.

symptoms of serotonin syndrome

mild: restlessness, increased HR and diaphoresis, spasms (myoclonus)

moderate: agitatiojn and decreased LOC, HTN, shivering/hypothermia, rigidity

severe: coma, shock, tonic-clonic seizures, potentially fatal

contraindications of fluoxetine

pt taking MAOI, hypersensitivity to SSRI, caution with other serontonergic drugs/supplements (like St Johns Wort), cuation in poor CYP2D6 metabolizers

interactions of fluoextine

MAOI, anticoagulants, NSAIDs, lithium and other serotonergic agents. These can increase the risk of serotonin syndrome or bleeding.

nursing for fluoextine

monitor for SI or worsening mood, activation of mania, increasing anxiety, ask about sexual side effects

education on fluoextine

don’t stop just because you feel better, report SI or worsening sxs, report manic sxs, report sxs of seratonin syndrome

class of fluoextine

SSRI

class of Venlafaxine (effexor)

SNRI - seratonin norephinephrine reuptake inhibitor

use of venlafaxine

MDD, GAD, SAD, panic disorders

action of venlafaxine

Inhibits the reuptake of serotonin and norepinephrine, increasing their levels in the brain.

admin of venlafaxine

PO in IR and XR forms

complications of venlafaxine

SI, mania, HA, anorexia, insomnia, HTN, sexual dysfunction, discontinuation (withdrawal)

timeline of discontinuation syndrome

occurs abruptly, persists for 1-2 weeks and severity depends on dose, duration, and half life of medcation

discontinuation syndrome

withdrawal from prescribed medication including GI upset, flu like sxs, HA, electric shock sensations, anxiety and irritability

contraindications of venlafaxine

liver disease, HTN, cardiac illness

interactions of venlafaxine

MAOIs, other seratonin increasing drugs and supplements, hypertensive medications or substances

nursing for venlafaxine

monitor for SI or worsening mood, activation of mania, increasing anxiety, ask about sexual side effects, monitor BP and HR

education on venlafaxine

don’t stop because you feel bettter, missing doses will cause you to feel seriously ill, report SI and worsening sxs, report manic sxs, report sxs of seratonin syndrome and avoid alcohol.

use of amitrptyline

depression, frequent off label use for sleep

action of amitriptyline

block reuptake of seratonin and norepinephrine

admin of amitriptyline

PO

Complications of amitriptyline

hypotension, anticholinergic, sedation, siaphoresis, cardiotoxicity leading to arrhythmias, seizures, mania, yawngasm

toxicity of amitriptyline

early toxicity = agitation and confusion

late toxicity = seizures and coma

toxic levels >500ng/ml

overdose can be lethal and may require hospitalization for supportive care.

contraindications of amitriptyline

MI recovery, arrhythmias, taking MAOI, SZ disorder, anticholinergic sxs

interactions of amitryptyline

CNS depressants, anticholinergics, sympathomimetics, MAOIs

nursing for amitryptline

titration when discontinuation

baseline ECG

plasma levels

prevent falls

monitor for SI and mania

in case of overdose —> gastric lavafe, activated charcoal and NaHCO3 (for arrythmias)

education on amitryptline

take at bedtime, tips for fall prevention, fluid intake is important, SI monitoring, and potential side effects.

use of phenelzine (nardil)

depression, off label for bulimia

class of phenelzine (nardil)

MAOI

action of phenelzine

MAO inactivates NE and 5HT after reuptake, and so MAOI prevents this inactivation allowing increased levels of NE and 5HT, but the inhibition is irreversible (10-14 days)

admin of phenelzine

PO TID

complications of phenelzine

SI, orthostatis, GI (NV, constipation), significant food interactions since some foods require MAO for digestion, sudden and severe increase in BP caused by high tyramine levels (risk of ICH and requires immediate BP drop)

contraindications of phenelzine

those who cannot follow tyramine free diet, substace use, other psych meds

interactions with phenelzine

everything

nursing for phenelzine

monitor BP, prevent falls, food selection, IV phentolamine or SL nidfedipine for HTN crisis

education on phenelzine

diet, no chocolate or caffiene, SI, report increased anxiety and depressionand potential side effects.

use of bupropion

MDD, SAD

class of burpoprion (wellbutrin)

NDRI

action of bupropion

enhances noadrenergic and dopaminergic neurotransmission via reuptake inhibition of the norepinephrine transport adn the dopamine transporter

admin of bupropion

PO in IR, SR, and XL

complications of bupropion

SI, NV, weight loss, increase to BP and HR, strange dreams

contraindications of bupropion

pt with eating disorder (high risk of electrolyte inbalanace and increase sz risk), HTN, cardiac disease, pt with sz disorder

interactions of bupropion

MAOIs, sz control drugs - will actually increase sz risk

nursing for bupropion

give with food, monitor BP and HR, monitor for SI and psychosis, screen for eating disorder

education on bupropion

appetite disturbance, monitor for SI and report

use of lithium

bipolar disorder, maintenence of mania

action of lithium,

unknown but alters distribution of ions in neurons and influences messanger system in neurons

admin of lithium

PO, tablets and liquid

complications of lithium

early: transient HA, GI, muscle weakness, fatigue, confusion

general: tremor, goiter and hypothyroidism, weight gain, ECG changes, renal toxicity, fetal effects,

persistent: polyurisa, polydipsia, diabetes insipidous, leuokocytosis

lithium toxicity

early indicators: thirst and polyuria, lethary and slurred speech, muscle twitching and fine tremor (new), NV, diarrhea

progressing:: oliguria, anuria, confusion, imparied conciousness, poor coordination, frank twitching, seizures, blurred vision, tinnitus, coma and death

lithium levels

narrow therapeutic window

0.6 to 1.2 mEq/L (possibily higher for acute manic phases up to 1,5)

1.5-1.9 = intoxication (tremor, NVD or blurred vision)

2.0 or > = life threatening toxicity (neurotoxicity, delirium, and encephalopathy) though renally impaired pts can go toxic at less

tx of lithium toxicity

heomdialysis, gastric lavage, level monitoring AND HOLD LITHIUM

contraindications of lithium

renal impairment, pregnancy, NA wasting diuretic, thyroid disorders, dehydration or low NA

interactions with lithium

ibuprofen (increase levels), ACE inhibitors (increase levels), thiazide diuretics

nursing for lithium

monitor lithium levels (trough 12 hours after last dose), monitor ins and outs, watch for hyponatremia

educaiton on lithium

monitor for toxicity, hydration and adequate Na intake, no ibuprofen, sxs of hypothyroidism

other mood stabilization

valproic acid (depakote) - plasma levels req

carbamazepine (tegretol) - plasam levels req

oxcarbazepine (trilptal) - more liver friendly, possible hyponatremia

adjunctive use with other mood stabilizers

gabapentin (neurontin) - anxiety and mood

lamotrigine (lamictal) - Bipolar depression but can cause SJS

topiramate (topamax) - uncommon

use of valproic acid (depakote)

seizures, bipolar disorders and acute mania

action of valproic acid and depakote

supresses sodium channels and calcium influx, increases GABA effects, and may inhibit glutamate/NMDA receptor mediated neuronal excitation.

admin of valproic acid

PO in divided doses (BID or TID)

complications of valproic acid

hyperammonemia, hepatotoxicity, pancreatitis, PCOS, possible SJS, stomach upset, increased liver enzymes

contraindications of valproic acid

prengancy, hepatic disease or impairments

interactions of valproic acid

phenytoin - increased drug levels, phenobarbital, topomax - increase ammonia levels

contraindications of alprazolam

caution in older adults, hx of substance use d/o, renal or hepatic impairment

interactions of aprazolam

CNS depressants - participarly opiates

cimetidine, disulfiram,fleuxetine - can all increase aprazolam levels

nursing for alprazolam

fall precautions, assess memory, monitor for paradoxical rxn, monitor VS, taper to d/c

education for alprazolam

fall precaution, caution while driving, monitor for paradoxical rxn, orthostasis, combining with opiates, tolerance and dependence

class of buspirone

non benzo anxiolytic

use of buspirone (buspar)

anxiety

action of buspirone

inhibits seratonin reuptake and acts as a dopamine agonist in the brain, increase NE metabolism in the brain, DOESNT EFFECT GABA

admin of buspirone

PO given BID, does not work if given PRN

complications of buspirone

paradoxical rxn (insomnia, anxiety, restlessness), dizziness, nausea

contraindications buspirone

hypersensitivity to drug, MAOI in the last two weeks

interactions of buspirone

MAOIs, grapefruit juice

nursing and education for buspirone

monitor for /report paradoxical rxn, GI upset, dizziness