Depressive Disorder & Suicide Meds

Depressive Disorders Psychopharmacological Therapies (STaMiNa)

General Teaching for All Antidepressants

• Do not discontinue suddenly (risk of withdrawal)

• Therapeutic effect = delayed, may take weeks

• Avoid hazardous activities (sedation risk)

• Report suicidal thoughts immediately

• Avoid alcohol while on antidepressants

Tricyclic Antidepressants (TCA)

Example: Amitriptyline

• Change positions slowly (↓ orthostatic hypotension risk)

• Reduce anticholinergic effects: chew sugarless gum, eat high-fiber foods, ↑ fluids (2–3 L/day)

Monoamine Oxidase Inhibitors (MAOI)

Example: Phenelzine

• Avoid tyramine foods (risk of hypertensive crisis) → ripe avocados, figs, fermented/smoked meats, liver, aged cheese, some beer/wine, protein supplements

• Avoid all other meds (OTC, herbal, etc.) unless cleared by provider (drug interaction risk)

Atypical Antidepressants

Example: Bupropion

• Monitor for: headache, dry mouth, GI distress, constipation, ↑ HR, nausea, restlessness, insomnia

• Notify provider if adverse effects become intolerable

• Monitor food intake/weight (appetite suppression possible)

• Contraindicated in clients with seizure risk

SSRIs (Selective serotonin reuptake inhibitors): Paroxetine, Sertraline, Fluoxetine, Escitalopram, Fluvoxamine

SNRI (Serotonin norepinephrine reuptake inhibitor): Venlafaxine

Antidepressants (STaMiNA)

Antidepressants enhance my STAMINA

• S

  • SSRIs (Selective serotonin reuptake inhibitors): Paroxetine, Sertraline, Fluoxetine, Escitalopram, Fluvoxamine

  • SNRI (Serotonin norepinephrine reuptake inhibitor): Venlafaxine

• T

  • Tricyclic antidepressants: Amitriptyline, Imipramine

• M

  • MAOI (Monoamine oxidase inhibitor): Phenelzine

• N

  • NaSSA (Noradrenergic & specific serotonergic antidepressant): Mirtazapine

• A

  • Atypical Antidepressants (Bupropion)

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Taper

Takes weeks for full effects

No ETOH or hazards (sedation risk)

Report suicidal thoughts

Nursing Evaluation of Medication Effectiveness (All Antidepressants)

Less anxiety, improved mood, improved memory

Normal sleep pattern

Improved participation in social & occupational activities

Better coping with stressors

Ability to perform ADLs

Increased well-being

Tricyclic Antidepressants (TCAs) vs Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Nonselective (indirectly affects more neurotransmitters)

Wider range of side effects

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Selective

Newer and preferred 1st/2nd-line

Tricyclic Antidepressants (TCAs) (Amitriptyline/Nortriptyline) Action/Use

Inhibit norepinephrine and serotonin reuptake (nonselective)

• Improves mood

• Relieves depression

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Major depression

Tricyclic Antidepressants (TCAs) (Amitriptyline/Nortriptyline) Contraindications / Complications (Trilogy - O DO AS SW)

Children under 12

Recent heart attack

Cardiac dysrhythmias

Seizure disorders

Concurrent MAOI use

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Overdose risk (life-threatening dysrhythmias)

Drowsiness, sedation

Orthostatic hypotension

Anticholinergic effects (dry mouth, constipation, blurred vision)

Seizure disorders contraindication/increase

Suicide risk increase (especially in children, adolescents)

Withdrawal symptoms (anxiety, headache, nausea)

Tricyclic Antidepressants (TCAs) Complications: Trilogy - O DO AS SW

Overdose risk (life-threatening dysrhythmias)

Drowsiness, sedation

Orthostatic hypotension

Anticholinergic effects (dry mouth, constipation, blurred vision)

Seizure disorders contraindication/increase

Suicide risk increase (especially in children, adolescents)

Withdrawal symptoms (anxiety, headache, nausea)

Tricyclic Antidepressants (TCAs) Meds: the IPRA MINES bitcoin and DOXs PINs for AMOXAPINE and TRICYCLES on TRIPLINES

Imipramine

Trimipramine

Doxepin

Amoxapine

Amitriptyline

Nortriptyline

Tricyclic Antidepressants (TCAs) (Amitriptyline/Nortriptyline) Interactions / Admin

CNS depressants increase sedation; MAOIs cause hypertensive crisis.

Anticholinergics increase side effects like dry mouth and constipation.

St. John’s wort, kava-kava, and valerian reduce drug efficacy.

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Take at bedtime to prevent daytime drowsiness; avoid driving if drowsy.

Move slowly from lying to sitting/standing.

Increase fluids and fiber to prevent constipation.

Report worsening depression or suicidal thoughts.

Taper medication over two weeks when discontinuing.

Selective Serotonin Reuptake Inhibitors (SSRIs) (-xetine, -pram) Action / Use

Inhibit serotonin reuptake → more serotonin remains at junction of neurons.

Do not block dopamine or norepinephrine uptake.

Can cause CNS stimulation (e.g., insomnia).

Long half-life → takes up to 4 weeks for therapeutic effect.

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General

• First-line treatment for panic disorder and trauma-/stressor-related disorders.

Paroxetine

• GAD

• Panic disorder (reduces frequency/intensity of attacks; prevents anticipatory anxiety)

• OCD (reduces serotonin-driven obsessions/compulsions)

• Social anxiety disorder

• PTSD

• Depressive disorders

• Adjustment disorders

• Associated dissociative disorder manifestations

Sertraline

• Panic disorder, OCD, social anxiety disorder, PTSD

Citalopram

• Panic disorder, OCD, GAD, PTSD, social anxiety disorder

Escitalopram

• GAD, OCD, panic disorder, PTSD, social anxiety disorder

Fluoxetine

• Panic disorder, social anxiety disorder, OCD, PTSD

Fluvoxamine

• OCD, GAD, social anxiety disorder, PTSD

Selective Serotonin Reuptake Inhibitors (SSRIs) Complications: EA TeNDS to LATEly GIB SW (HA)ters BRUtal depreSSion WITHout SALTINESS

Early Adverse

• Tremors, Nausea, Diaphoresis, Sleepiness

Late Adverse

• GI Bleeding, Sexual Dysfunction, Weight Gain, Headache

Serotonin Syndrome

Withdrawals

Hyponatremia (Without Saltiness)

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EA TeNDS to LATEly GIB SW HAters BRUtal depreSSion WITHout SALTINESS

Selective Serotonin Reuptake Inhibitors (SSRIs) (-xetine, -pram) Contraindications / Compllications

Pregnancy: Paroxetine = Category D (others lower risk).

Contraindicated with MAOIs or TCAs.

Avoid alcohol use while on SSRIs.

Use cautiously in clients with:

• Liver/renal dysfunction

• Seizure disorders

• GI bleeding history

Use cautiously in bipolar disorder (risk of mania).

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Early Adverse Effects

• First few days/weeks: Nausea, diaphoresis, tremor, fatigue, drowsiness.

• Client Education:

  • Report adverse effects.

  • Take as prescribed.

  • Usually subside.

  • Avoid driving if sedation occurs.

Later Adverse Effects

• After 5–6 weeks: Sexual dysfunction (impotence, delayed/absent orgasm, decreased libido), weight gain, headache.

• Client Education: Report sexual dysfunction (may be managed with dose changes, drug holidays, or switching meds).

Weight Changes

• Weight loss early → weight gain with long-term therapy.

• Nursing Actions: Monitor weight.

• Client Education: Balanced diet, regular exercise.

Gastrointestinal Bleeding

• Risk ↑ with history of GI bleed, ulcers, or anticoagulant use.

• Client Education: Report GI bleeding signs (dark stools, coffee-ground emesis).

Hyponatremia

• Likely in older adults taking diuretics

Serotonin Syndrome (2–72 hrs after start; can be lethal)

• Confusion, agitation, poor concentration, hostility

• Disorientation, hallucinations, delirium

• Seizures → status epilepticus

• Tachycardia → CV shock

• Labile BP

• Diaphoresis

• Fever → hyperpyrexia

• Incoordination, hyperreflexia

• Nausea, vomiting, diarrhea, abdominal pain

• Coma, death (severe cases)

Client Education: Observe for symptoms; withhold medication and notify provider immediately.

Bruxism

• Grinding/clenching teeth (usually during sleep).

• Nursing Actions:

  • Report to provider (may change med class).

  • Treat with buspirone or mouth guard.

Withdrawal Syndrome

• Sensory disturbances, anxiety, tremor, malaise, unease.

• Client Education:

  • Taper slowly; avoid abrupt discontinuation.

Until I reached a point in my life where like oh you and I are nurse want to help you OK this is something that I can cause the girl was talking the same hobbies same hobbies and same upbringing is not no it’s work all

SNRI vs SSRI Complications

Anxiety

Anorexia / Weight loss

Sexual dysfunction

Headache, nausea, agitation, dry mouth, sleep disturbances

Hypertension

Hyponatremia (esp. older adults on diuretics)

AN ANOREXIC SEXUAL HANDSy SNaps depression and HYPERTENSION like a DIURETIC

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Early Adverse

• Tremors, Nausea, Diaphoresis, Sleepiness

Late Adverse

• GI Bleeding, Sexual Dysfunction, Weight Gain, Headache

Bruxism (teeth grinding/clenching)

Serotonin Syndrome

Withdrawals

Hyponatremia (Without Saltiness)

EA TeNDS to LATEly GIB SW HAters BRUtal depreSSion WITHout SALTINESS

Selective Serotonin Reuptake Inhibitors (SSRIs) (-xetine, -pram) Interactions / Admin

TCAs, MAOIs, St. John’s Wort → ↑ risk of serotonin syndrome.

• Discontinue MAOIs 14 days before starting SSRI.

• Discontinue fluoxetine 5 weeks before starting MAOI.

• Avoid concurrent TCA/St. John’s Wort use.

Warfarin → displacement → ↑ bleeding risk.

• Nursing Actions: Monitor PT/INR, assess for bleeding, dosage adjustment may be needed.

TCAs + Lithium → ↑ levels of both.

• Client Education: Avoid concurrent use.

NSAIDs + Anticoagulants → ↑ bleeding risk (platelet suppression).

• Client Education: Monitor for bleeding (bruising, hematuria), notify provider.

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Take with food to minimize GI upset.

Take in morning to reduce sleep disturbances.

Daily dosing required to establish plasma levels.

May take up to 4 weeks to achieve therapeutic effects.

Selective Serotonin Reuptake Inhibitors (SSRIs) Meds: DepreSSed moms need a SERT (special emergency reaction team) and PRAMS (pregnancy risk assessment monitoring system) for PAROXysmal FLU symptoms

Prototype Medication

• Paroxetine

Other Medications

• Sertraline

• Citalopram

• Escitalopram

• Fluoxetine

• Fluvoxamine

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) (-loxetine, -faxine) Action / Use

Inhibit reuptake of serotonin and norepinephrine (minimal dopamine inhibition).

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Major depression

Panic disorder

Generalized anxiety disorder (GAD)

Serotonin Norepinephrine Reuptake Inhibitors Complications: AN ANOREXIC SEXUAL HANDSy SNaps depression and HYPERTENSION like a DIURETIC

Anxiety

Anorexia / Weight loss

Sexual dysfunction

Headache, nausea, agitation, dry mouth, sleep disturbances

Hypertension

Hyponatremia (esp. older adults on diuretics)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) (-loxetine, -faxine) Contraindications / Complications

Pregnancy Risk: Category C.

Contraindicated with MAOIs.

Duloxetine contraindicated in hepatic disease or heavy alcohol use.

Client Education

• Avoid abrupt discontinuation.

• Avoid alcohol.

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Headache, nausea, agitation, anxiety, dry mouth, sleep disturbances

Hyponatremia (esp. older adults on diuretics)

• Nursing Action: Monitor sodium levels.

Anorexia / Weight loss

• Nursing Action: Monitor weight.

• Client Education: Maintain balanced diet, exercise.

Hypertension

• Nursing Action: Monitor blood pressure.

Sexual dysfunction

• Nursing Action: Report issues (can manage with dose change, med holiday, or switching meds).

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) (-loxetine, -faxine) Interactions / Admin

MAOIs & St. John’s Wort → risk of serotonin syndrome.

• Nursing Action: Discontinue MAOIs 14 days before starting SNRI.

• Client Education: Avoid St. John’s Wort.

CNS Depressants (alcohol, opioids, antihistamines, sedatives/hypnotics) → ↑ CNS depression.

• Nursing Action: Avoid concurrent use.

NSAIDs & Anticoagulants → ↑ risk of bleeding.

• Client Education: Monitor for bleeding (bruising, hematuria), notify provider.

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Duloxetine contraindicated in hepatic disease or heavy alcohol use.

Client Education:

• Avoid abrupt cessation.

• May take with food.

• Take daily to maintain therapeutic plasma levels.

• Takes up to 4 weeks for therapeutic effect.

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Meds: SportsNet (SN)’s DULO smart wear sponsored BJJ champ VENLA luukkonen.

Prototype Medication

• Venlafaxine

Other Medication

• Duloxetine

Contraindiction: MAOIs

(Almost Everything)

Atypical Antidepressants (Bupropion hydrochloride)

Tricyclic Antidepressants (TCAs)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin Agonists (-triptans)

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Centrally Acting Muscle Relaxants

Carbamazepine

Opioids (w/in 2 weeks)

Amphetamines (w/in 2 weeks)

Methylphenidate (w/in 2 weeks)

Dopamine-Replacements (-dopa)

Monoamine Oxidase Type B Inhibitors (-gilines)

Avoid most cheeses, fish (cured/dried), pepperoni, salami, because BOUGIE Foods = High Tyramine = Hypertensive Crisis

• Inhibiting this enzyme prevents tyramine breakdown

Beef and other fresh meats do not interact

Monoamine Oxidase Inhibitors (MAOIs) (Phenelzine)

Monoamine Oxidase Inhibitors (MAOIs) (Phenelzine) Action/Use

Blocks the enzyme that breaks down neurotransmitters like serotonin, norepinephrine, and dopamine.

• Increases serotonin, norepinephrine, dopamine

  • Improves mood and alleviates depression.

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Depression unresponsive to other treatments

Depression in bipolar disorder

Monoamine Oxidase Inhibitors (MAOIs) (Phenelzine) Complications (GIorgio armani MONOcles and ORTHOtics use A.I. SIgnals for HYPERTENSIVE CRISIS)/ Contraindications

Orthostatic hypotension

Anxiety, insomnia, agitation

Hypertensive crisis (with tyramine-containing foods)

GI disturbances (constipation, nausea, vomiting)

Increased suicidal ideation (children, young adults)

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Inability to follow a tyramine-free diet, renal failure, liver disorders

Suicidal ideation, cardiac disease, concurrent SSRI use, glaucoma

Monoamine Oxidase Inhibitors (MAOIs) (Phenelzine) Complications: GIorgio armani MONOcles and ORTHOtics use A.I. SIgnals for HYPERTENSIVE CRISIS

GI disturbances (constipation, nausea, vomiting)

Orthostatic hypotension

Anxiety, insomnia, agitation

Increased suicidal ideation (children, young adults)

Hypertensive crisis (with tyramine-containing foods)

Monoamine Oxidase Inhibitors (MAOIs) (Phenelzine) Meds: TRANYa earbuds made of SELEnium produce MONOphonic and ISOChronic tones

Tranylcypromine

Selegiline transdermal

Isocarboxid

Atypical Antidepressants Action/Use

Inhibits the reuptake of norepinephrine and dopamine (Bupropion hydrochloride) - NDRI

Inhibits the presynapse receptors of serotonin and norepinephrine (Mirtazapine) - NaSSA

Inhibits the reuptake of norepinephrine (Reboxetine) - SNRI

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Treats depression

Prevents seasonal affective disorder (SAD)

Smoking cessation adjunct

Inhibits the reuptake of norepinephrine and dopamine (NDRI)

Bupropion hydrochloride

Inhibits the presynapse receptors of serotonin and norepinephrine (NaSSA)

Mirtazapine

Inhibits the reuptake of norepinephrine (SNRI)

Reboxetine

Atypical Antidepressants Complications: ATYPICAL ANOREXIC psychics SEIZE IDEATION but DEPRESS their GI, MIND, and CNS / Contraindications

GI effects: Nausea, vomiting, weight loss

Increased risk for seizures

CNS effects: insomnia, agitation, tremor, headache

Psychosis, hallucinations, delusions

Increased risk for suicidal ideation (children, young adults)

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History of eating disorder, seizure disorder, suicidal ideation

Concurrent MAOI use

Head trauma or CNS tumors

Atypical Antidepressants (Bupropion hydrochloride) Complications ATYPICAL ANOREXIC psychics SEIZE IDEATION but DEPRESS their GI, MIND, and CNS

Increased risk for seizures

Increased risk for suicidal ideation (children, young adults)

GI effects: Nausea, vomiting, weight loss

Psychosis, hallucinations, delusions

CNS effects: insomnia, agitation, tremor, headache

Atypical Antidepressants Meds MIRTA sells ATYPICAL ANTIDEPRESSANTS like REBOXEd
BUPROPRION illegally

Mirtazapine

Reboxetine

Bupropion hydrochloride

Antidepressants – SSRIs (Citalopram, Fluoxetine, Sertraline)

Nursing Actions

• Lower lethality risk compared to other antidepressants

• Do not stop medication suddenly (risk of withdrawal)

• Onset: 1–3 weeks for initial effects, up to 2 months for full response

• Avoid hazardous activities until side effects known (driving, machinery)

• Common adverse effects: nausea, headache, CNS stimulation (agitation, insomnia, anxiety)

• Possible sexual dysfunction → notify provider if intolerable

• Encourage healthy diet (risk of weight gain with long-term use)

• Monitor for worsening depression or suicidal intent

Sedative Hypnotic Anxiolytics (Benzodiazepines: Diazepam, Lorazepam)

Client Education

• Watch for CNS depression: sedation, lightheadedness, ataxia, ↓ cognition

• Avoid other CNS depressants (alcohol)

• Avoid hazardous activities (driving, machinery)

• Avoid caffeine (interferes with medication effectiveness)

• Taper gradually under provider supervision (risk of withdrawal seizures if stopped abruptly)

Mood Stabilizers (Lithium carbonate)

Nursing Actions

• Encourage healthy diet and regular exercise (minimize weight gain).

• Maintain fluid intake 2–3 L/day (food + beverages).

• Maintain adequate sodium intake (prevents lithium toxicity).

Client Education

• Take with food/milk to reduce GI upset.

• Keep lab appointments (monitor lithium levels and adverse effects).

Second-Generation Antipsychotics (Risperidone, Olanzapine)

Nursing Actions

• Preferred over first-generation antipsychotics → fewer adverse effects.

Client Education

• Maintain healthy diet + regular exercise (prevents weight gain).

• Report adverse effects: agitation, dizziness, sedation, sleep disruption (medication adjustment may be required).

SSRIs vs Benzos vs Mood Stabilizers vs 2nd Gen Antipsychotics (Table)

Class	Examples	Primary Use	Key Nursing Actions	Client Education	Major Concerns
SSRIs (Antidepressants)	Citalopram, Fluoxetine, Sertraline	First-line for depression, anxiety, suicidal ideation	- Monitor for ↑ depression/suicide risk at start - Do not stop suddenly - Takes 1–3 weeks for initial effect, up to 2 months for full effect - Watch for CNS stimulation, sexual dysfunction	- Avoid hazardous activities until side effects known - Healthy diet (prevent weight gain) - Report intolerable side effects	- Risk of serotonin syndrome - Sexual dysfunction - Weight gain
Benzodiazepines (Sedative Anxiolytics)	Diazepam, Lorazepam	Short-term relief of anxiety, agitation, insomnia	- Observe for CNS depression - Avoid abrupt discontinuation (risk of withdrawal seizures)	- Avoid alcohol & other CNS depressants - Avoid caffeine (interferes) - Do not stop suddenly, taper only under provider	- Sedation, dependence, withdrawal risk - Cognitive impairment
Mood Stabilizers	Lithium carbonate	Bipolar disorder, impulsivity, mood stabilization (suicide prevention)	- Monitor fluid intake (2–3 L/day) & sodium intake - Labs: lithium levels, kidney, thyroid	- Take with food/milk (reduce GI upset) - Keep lab appointments - Report side effects promptly	- Lithium toxicity (GI upset, tremor, confusion, seizures) - Weight gain
Second-Generation Antipsychotics	Risperidone, Olanzapine	Schizophrenia, bipolar disorder, adjunct for depression	- Preferred over first-gen due to fewer side effects - Monitor weight, metabolic changes	- Maintain healthy diet + exercise - Report agitation, dizziness, sedation, or sleep disruption	- Metabolic syndrome (weight gain, diabetes, dyslipidemia) - Sedation

Suicide Meds: Suicide Boys touring from Los Angeles to San Bernadino (Suicide = LA2SB)

Lithium (Mood Stabilizer)

• Encourage healthy diet and regular exercise (minimize weight gain).

• Maintain fluid intake 2–3 L/day (food + beverages).

• Maintain adequate sodium intake (prevents lithium toxicity).

Antipsychotics (2nd gen, -idone, -apine)

• Maintain healthy diet + regular exercise (prevents weight gain).

• Report adverse effects: agitation, dizziness, sedation, sleep disruption (medication adjustment may be required).

SSRIs (Antidepressant)

• Lower lethality risk compared to other antidepressants

• Do not stop medication suddenly (risk of withdrawal)

• Onset: 1–3 weeks for initial effects, up to 2 months for full response

Benzodiazepines (Sedative-Hypnotics)

• Watch for CNS depression: sedation, lightheadedness, ataxia, ↓ cognition

• Avoid other CNS depressants (alcohol)

• Avoid hazardous activities (driving, machinery)

• Avoid caffeine (interferes with medication effectiveness)

• Taper gradually under provider supervision (risk of withdrawal seizures if stopped abruptly)

Complication: Increased Suicide Ideation

SSRIs (more so Paroxetine)

SNRIs (more so Venlafaxine)

TCAs

MAOIs

Bupropion (Atypical NDRI  - low risk)

Complication: Weight Loss / Anorexia (Avoid with eating disorders)

Bupropion (Atypical NDRI)

SNRIs

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ANOREXIC BUtts need SNacks

Complication: Weight Gain (1)

SSRIs

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SS Cruises Fatten people

Use: Smoking cessation

Bupropion (Atypical NDRI)

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Cigarette BUtts

Complication: Anticholinergic Effects

TCAs

SNRIs

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TRICYCLE hikes with DRY SNacks

Complication: Hypertension (2)

SNRIs

MAOIs (w/ tyramine)

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MONOsaturated fat, low salt SNacks prevent HYPERTENSION

Complication: Increased Seizure risk (or contraindication) (2)

Bupropion (Atypical NDRI)

TCAs

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SEIZE BUtts on TRIcycles

St. John’s Wort Complications: JOHN gets GAS from PT

GI issues

Abdominal Pain

Skin Rash

Photosensitivity

Tachycardia

Serotonin Syndrome S/S

Onset: Immediate (2 hours to 3 days)

Tachycardia → CV shock

BP fluctuations (labile BP)

Diaphoresis

Fever → hyperpyrexia

Seizures → status epilepticus

Hyperreflexia (Incoordination)

GI upset: n/v/d, abdominal pain

↓ LOC / Coma / death (severe cases)

• Confusion, agitation, poor concentration, hostility

• Disorientation, hallucinations, delirium

What are the 8 progressive symptoms of Serotonin Syndrome?

Diarrhea (n/v) -> Fever -> Diaphoresis -> Shivering -> Hyperreflexia -> Seizure -> Coma -> Death

Complication: Hyponatremia, Sexual dysfunction (2)

SSRIs

SNRIs

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Selective Sexual Salt Suckers

Maintain fluid intake 2–3 L/day (food + beverages).

Maintain adequate sodium intake (prevents toxicity).

Lithium (Mood Stabilizer)