Pharmacological Treatment for Depression

Functions of serotonin

mood, focus, basic drives (hunger, sex), digestion, sleep, arterial constriction 

how does serotonin play a role in sleep?

it makes melatonin for the normal sleep/wake cycle

how long might it take for a patient to respond to SSRIs?

1-3 weeks to 3 months

serotonin syndrome symptoms

sweating, fever, tachycardia, HTN, myoclonus, delirium, increased motor movements, irritability, hostility, cardiovascular shock

serotonin syndrome interventions

STOP the medication and treat the symptoms

• vasodilators for blood pressure

• benzodiazepines for hyperactivity

• dantrolene and diazepam for muscle rigidity

• anticonvulsants

SSRI teaching

do NOT abruptly discontinue

common AE: dizziness, insomnia, nervousness, irritability, nausea, agitation

akathisia (inner restlessness)

Fluoxetine (Prozac) indications 

MDD, PMDD

Pregnancy category of Prozac?

C. can cause birth defects

Half life of Prozac?

Longest of the SSRIs… so the discontinuation syndrome is the worst. Teach patient to taper off 

Common AE of Prozac?

insomnia and nervousness. also may increase anxiety initially, but the patient will adjust. most activating of the SSRIs.

Paroxetine (Paxil) pregnancy indications

do NOT take during pregnancy, can cause heart defects

Paxil contraindications

MOST anticholinergic of the SSRIs… so not for mawmaw with glaucoma. Not for any patients with anticholinergic contraindications

Sertraline (Zoloft) common AE

causes the most GI issues

When do you take Fluvoxamine?

at BEDTIME. most sedating of the SSRIs

Citalopram (Celexa) metabolism and AE notes

20% of Asians are poor metabolizers

Can prolong the QT interval

Escitalopram (Lexapro) indications

MDD, PDD, GAD, OCD

helps the MOST with co-occurring anxiety

when do you take Mirtazapine (Remeron)

at NIGHT!

sedation is adverse effect

benefits of mirtazapine?

both antianxiety and antidepressant effects. minimal sexual dysfunction, better GI tolerance, and improved sleep

patient teaching for vilazodone

take with FOOD - common AE are diarrhea and nausea

AE of vilazodone?

insomnia. don’t take at nighT

indications for bupropion

depression, smoking cessation

2 major contraindications for bupropion and why

seizure disorders and eating disorders

this med lowers seizure threshold and decreases appetite

why is bupropion not good for anxiety?

it can cause insomnia, tremors, and weight loss (increasing feelings of anxiety)

nefazodone (Serzone) risks and patient teaching

MANY drug interactions

what is trazodone (Desryl) used for?

it treats depression but it’s used off label for sleep

unique side effects of trazodone

headache, bradycardia, sedation, dizziness, priapism

dangers of trazodone toxicity

can cause cardiac conduction issues

how is esketamine (Spravato) administered?

as a nasal spray

process of esketamine administration and what to look for

patient comes in to receive nasal spray and has to stay to be monitored for two hours

the patient WILL DISSOCIATE - it blocks a lot of neurotransmitters and essentially resets the brain

monitor for hypertension

Vortioxetine (Trintellix) treats depression and also…

co-occurring dementia. this med is good for elderly

does vorioxetine have sexual side effects?

nope

what unique adverse effects can SNRIs cause?

hyponatremia, especially with older adults

cardiac issues - HTN and HoTN

SNRIs treat depression and…

chronic pain

venlafaxine (Effexor) discontinuation syndrome presents as what?

flu-like symptoms in addition to insomnia, nausea, dizziness, paresthesia and anxiety

duloxetine (Cymbalta) commonly prescribed for…

diabetic peripheral neuropathy, fibromyalgia, chronic musculoskeletal pain

duloxetine contraindications

liver disease and chronic alcohol use

how long does it take for TCAs to work?

7-28 days

this makes them really hard to monitor - so not used so much inpatient anymore

how long does it take TCAs to reach their full effect?

6-8 weeks

what can TCAs cause in older adults?

memory issues and confusion

TCA contraindications

recent MI, glaucoma, seizures

TCA cautions

can be LETHAL in overdose - do NOT give to a suicidal patient

TCAs can cause what effect?

anticholinergic (blurred vision, dry mouth, tachycardia, urinary retention, constipation)

indications for doxepin (Silenor)

insomnia. it turns off histamines

avoid doxepin if…

severe urinary retention

on MAOI or a CNS depressant or sedating antihistamine (Benadryl!)

rule with MAOIs

STOP TAKING 14 days before surgery, switching to a different medication, or starting a supplement

biggest and most dangerous complication with MAOIs

hypertensive crisis!!!

what should you NOT take while on an MAOI?

OTC cough or decongestant meds

dextromethorphan and pseudoephedrine

early symptoms of HTNsive crisis

severe headache, flushing, sweating, irritability, anxiety

what foods to avoid when on MAOIs?

tyramine-rich food

cheese, processed meat, beer, wine, chocolate, bananas, avocados, figs, fish

medical conditions contraindicated with MAOIs

CVD, HTN, CHF, liver disease, bad headache, 10-14 days postop, younger than 16