Depressive disorder meds

UNIT 2: CHAPTER 7 - AFFECTING THE MIND: DEPRESSIVE DISORDERS

Overview of Depressive Disorders

  • Depressive disorders are a prevalent issue, ranking high among causes of disability.
  • Clients with major depression may need hospitalization with close observation and suicide precautions until antidepressants reach peak effect.

Classification of Antidepressant Medications

Antidepressant medications are categorized into five main groups:

  1. Selective Serotonin Reuptake Inhibitors (SSRIs)
  2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
  3. Atypical Antidepressants
  4. Tricyclic Antidepressants (TCAs)
  5. Monoamine Oxidase Inhibitors (MAOIs)

Atypical Antipsychotic Medications

  • Used as monotherapy or adjunct therapy for depression and bipolar depressive disorders.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Prototype Medication: Fluoxetine

  • Other SSRIs include Citalopram, Escitalopram, Paroxetine, Sertraline, and Fluvoxamine.

Purpose and Expected Pharmacological Action

  • SSRIs selectively block the reuptake of serotonin, enhancing its effects in the synaptic space.
  • Considered first-line treatment for depression; benefits may take 1 to 3 weeks to manifest.

Therapeutic Uses

  • Major depression
  • Obsessive-compulsive disorder
  • Bulimia nervosa
  • Premenstrual Dysphoric Disorder
  • Panic disorder
  • Posttraumatic stress disorder
  • Social anxiety disorder
  • Generalized anxiety disorder
  • Bipolar disorder

Complications

  1. Sexual Dysfunction
    • Anorgasmia, impotence, decreased libido.
    • Client Education: Notify provider for intolerable effects; manage with dosage adjustments or adjunct medications (e.g., sildenafil, buspirone).
  2. CNS Stimulation
    • Symptoms include insomnia, agitation, and anxiety.
    • Client Education: Notify provider; consider adjusting dosage.
  3. Neuroleptic Malignant Syndrome
    • Symptoms: fever, respiratory distress, tachycardia.
    • Nursing Actions: Monitor client closely.
  4. Suicidal Thoughts
    • Higher risk in children/adolescents and adults under 24.
    • Nursing Actions: Observe for tendencies, especially during early therapy.
  5. Weight Fluctuations
    • Follow early weight loss by weight gain with long-term treatment.
    • Nursing Actions: Monitor weight; encourage regular exercise and balanced diet.

Additional Adverse Effects

  • Serotonin Syndrome: Symptoms can be lethal and include confusion, agitation, seizures, tachycardia, and coma (may occur 2 to 72 hours after starting treatment).
    • Nursing Actions: Start symptomatic treatment (e.g., cooling blankets, anticonvulsants, artificial ventilation).
    • Client Education: Observe for symptoms and notify the provider.
  • Withdrawal Syndrome: Symptoms begin days to weeks post-discontinuation; manifestations include headache, nausea, anxiety, and tremors.
    • Client Education: Gradually taper the dose.
  • Hyponatremia: More common in older adults taking diuretics.
    • Nursing Actions: Monitor sodium levels periodically.
  • Rash: Usually treatable with antihistamines or medication withdrawal.
  • Gastrointestinal Effects: Potential for bleeding; avoid in clients with a history of GI bleeding.
  • Bruxism: Potential side effect managed by switching medications or using a mouth guard.

Contraindications/Precautions

  • Use cautiously in clients with:
    • Liver and kidney dysfunction
    • Cardiac disease
    • Seizure disorders
    • Previous gastrointestinal ulcers or bleeding
  • SSRIs contraindicated in clients taking MAOIs; discontinuation required 2 weeks prior.

Drug Interactions

  • Concurrent Use: MAOIs, TCAs, and St. John's wort can increase serotonin syndrome risk.
  • Anticoagulants and NSAIDs: Increased bleeding risk due to fluoxetine's effect on platelet aggregation.
  • Other Medications: Monitor PT and INR levels if using with warfarin.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Prototype Medication: Venlafaxine

  • Other SNRIs: Desvenlafaxine, Duloxetine, Levomilnacipran.

Purpose and Expected Pharmacological Action

  • SNRIs block the reuptake of norepinephrine as well as serotonin, with similar effects to the SSRIs.

Therapeutic Uses

  • Major depression, generalized anxiety disorder, social anxiety disorder, panic disorder, and off-label uses for fibromyalgia and diabetic neuropathy.

Complications

  1. Nausea/Anorexia/Weight Loss: Monitor weight and food intake.
  2. Headache/Insomnia/Anxiety: Monitor findings closely.
  3. Hypertension/Tachycardia: Regular monitoring of vital signs.
  4. Withdrawal Syndrome: Similar to SSRIs; taper medication gradually.
  5. Sexual Dysfunction: Same management strategies as SSRIs.

Contraindications/Precautions

  • Avoid during third trimester and in breastfeeding.
  • Monitor closely in older adults, clients with bipolar disorder, and those with cardiovascular issues.

Drug Interactions

  • MAOIs can lead to serotonin syndrome; two-week washout advised.

Atypical Antidepressants

Prototype Medication: Bupropion

  • Other Atypical Antidepressants: Vilazodone, Mirtazapine, Nefazodone, Trazodone ER.

Purpose and Expected Pharmacological Action

  • Bupropion inhibits norepinephrine and dopamine reuptake, classified as a norepinephrine-dopamine reuptake inhibitor.

Therapeutic Uses

  • Treatment of major depressive disorder, seasonal affective disorder, smoking cessation support, and as an alternative treatment for attention-deficit disorder.

Complications

  1. Headache/Dry Mouth/GI Distress: Monitor and treat as needed.
  2. Nausea/Vomiting/Weight Loss: Vigilant monitoring of intake.
  3. Seizures: Avoid in at-risk clients and closely monitor for any seizure activities.

Contraindications/Precautions

  • Contraindicated for clients with seizure and eating disorders, use cautiously in those with renal/hepatic impairment.

Drug Interactions

  • MAOIs increase the risk of toxicity if co-administered; avoid for 2 weeks before starting bupropion.

Tricyclic Antidepressants (TCAs)

Prototype Medication: Amitriptyline

  • Other TCAs include Imipramine, Doxepin, Nortriptyline, Amoxapine, Trimipramine, Desipramine, Clomipramine.

Purpose and Expected Pharmacological Action

  • TCAs block norepinephrine and serotonin reuptake in the synaptic space, enhancing neurotransmitter effects. Full efficacy observable in 4 to 8 weeks.

Therapeutic Uses

  • Depression, anxiety disorders, obsessive-compulsive disorder, insomnia, and neuropathic pain.

Complications

  1. Orthostatic Hypotension: Monitor blood pressure before and after administration.
  2. Anticholinergic Effects: Manage symptoms and educate clients on minimizing effects.
  3. Sedation: Usually diminishes over time, advise patients to take medication at bedtime.
  4. Toxicity Risks: Seek immediate help for signs of cholinergic blockade and cardiac toxicity.

Contraindications/Precautions

  • Cautions in pregnancy and lactation. Monitor for toxicity, especially in high-risk populations.

Drug Interactions

  • MAOIs and St. John's Wort can lead to serotonin syndrome; avoid co-administration.

Monoamine Oxidase Inhibitors (MAOIs)

Prototype Medication: Phenelzine

  • Other MAOIs include Isocarboxazid, Tranylcypromine, and Selegiline (transdermal).

Expected Pharmacological Action

  • MAOIs block their respective enzymes, leading to increased levels of neurotransmitters like norepinephrine, serotonin, and dopamine. Can result in hypertensive crisis if dietary restrictions are ignored.

Therapeutic Uses

  • Various forms of depression and anxiety disorders.

Complications

  1. Hypertensive Crisis: From dietary tyramine intake; require immediate intervention.
  2. Orthostatic Hypotension: Similar monitoring protocol as TCAs.
  3. CNS Stimulation: Watch for anxiety or agitation exacerbation.

Contraindications/Precautions

  • Avoid in pregnancy and lactation; contraindicated in severe cardiovascular disease.

Drug Interactions

  • Concomitant use with sympathomimetics can lead to hypertensive crisis; antihypertensives may have additive hypotensive effects.

Nursing Administration and Client Education for All Medications

  • Inform clients about the delayed therapeutic effects (1-3 weeks), and full effects can take up to 2-3 months.
  • Regularly assess for suicide risk, particularly in younger populations, and emphasize the importance of adherence and not abruptly discontinuing medication to avoid relapse.

Medication Management Strategies

  • Clients should be educated about diet restrictions specific to MAOIs and encouraged to report any side effects or medication interactions immediately.