Anxiolytics and Insomnia Study Notes

Verse (Intro)

  • Be anxious for nothing, but in everything by prayer and supplication, with thanksgiving, let your requests be made known to God; 7 and the peace of God, which surpasses all understanding, will guard your hearts and minds through Christ Jesus.

Anxiety and Pathophysiology

  • Anxiety Disorders
    • Characterized by severe anxiety that is prolonged and impairs the patient’s ability to function in activities of daily living.
  • Origins of Anxiety
    • Genetics, brain chemistry, overactive amygdala, medical conditions, personality traits, learned behaviors, stressful life events/trauma, social pressure.
  • Neurotransmitter Imbalances
    • Imbalance between the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and the excitatory transmitter glutamate contributes.

Manifestations

  • Headaches
  • Palpitations
  • Hyperglycemia
  • Decreased immune system
  • Decreased libido
  • Muscle tension
  • Difficulty sleeping or staying asleep
  • Tachypnea
  • Abdominal pain
  • Erectile dysfunction
  • Difficulty conceiving
  • Pregnancy
  • Missed menstruation

Effects on Client Health

  • Stress Response disrupts homeostasis
  • Manifestations differ by sex:
    • Female patients: may experience physical discomfort, fatigue, muscle tension, and more severe mood changes.
    • Male patients: more likely to develop alcohol and substance use disorders.

Classes of Anxiolytic Medications

Selective Serotonin Reuptake Inhibitors (SSRI)

  • Indications for Use: GAD, panic disorder, social anxiety disorder, and posttraumatic stress disorder.
  • Mechanism of Action: inhibition of the presynaptic reuptake of serotonin, subsequently increasing serotonin at the postsynaptic membrane in the serotonergic synapse.
  • Contraindications: not specified in transcript.
  • Side Effects and Adverse Effects: not specified in transcript.
  • Client Education: not specified in transcript.
  • Notes: SSRI described as first-line treatment for many types of anxiety.

Selective Serotonin Reuptake Inhibitors – Example: Citalopram (Celexa)

  • Indications for Use: (listed under SSRI class in transcript)
  • Mechanism of Action: (listed under SSRI class in transcript)
  • Contraindications: (listed under SSRI class in transcript)
  • Side Effects and Adverse Effects: (listed under SSRI class in transcript)
  • Administration: (listed under Celexa section in transcript)
  • Client Education: (listed under Celexa section in transcript)
  • Notes: Celexa is identified as an SSRI in the materials.

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

  • Indications for Use: anxiety disorders.
  • Mechanism of Action: inhibits serotonin and norepinephrine reuptake in the CNS.
  • Contraindications: seizure disorder; uncontrolled hypertension; renal or hepatic impairment.
  • Side Effects and Adverse Effects: not specified in transcript.
  • Special Notes: SNRIs have a boxed warning due to increased risk of suicidal ideation and behavior.

Venlafaxine (SNRI)

  • Indications for Use: anxiety disorders.
  • Mechanism of Action: (not fully detailed beyond SNRI class in transcript).
  • Contraindications: seizure disorder; uncontrolled hypertension; renal or hepatic impairment.
  • Side Effects: not specified in transcript.
  • Adverse Effects: FDA pregnancy category C medication.

Discussion Question #2

  • A 41-year-old client is prescribed citalopram for posttraumatic stress disorder. The client has started taking St. John’s wort to help with sleep but hasn’t noticed a change in anxiety. How should the nurse respond?

Benzodiazepines

  • Mechanism of Action: (not detailed beyond class in transcript).
  • Effects on the Body: (not detailed beyond class in transcript).
  • Indications for Use: (not specified beyond general use for anxiety in the transcript).
  • Contraindications: caution in patients who have severe respiratory insufficiency (unless mechanically ventilated).
  • Side Effects and Adverse Effects: includes boxed warnings (not enumerated in transcript).
  • Administration: IV, IM, tablet, oral concentration.
  • Client Education: (not specified in transcript).

Benzodiazepines – Side Effects and Adverse Effects (as listed)

  • Benzodiazepine withdrawal
  • Delirium
  • Aches/pains
  • Anxiety
  • Seizures
  • Insomnia
  • Nausea
  • Muscle spasms
  • Depression
  • Unexpected body sensations
  • Depression (repeated in slide content)
  • Additional notes: mentions Lorazepam side effects.

5-HT1A Partial Agonists

  • Buspirone
    • Mechanism of Action: strong affinity for multiple serotonin receptors, including 5-HT1A receptors, acts as a partial agonist.
    • Effects on the Body: reduction of anxiety.
    • Indications for Use: generalized anxiety disorder (GAD).
    • Contraindications: use of MAOIs within 14 days.
    • Side Effects/Adverse Effects: not detailed in transcript.
    • Client Education: not detailed in transcript.

Discussion Question #3

  • Why is buspirone contraindicated for use with MAOIs, and what serious adverse effects could occur if they are taken together?

Antihistamines

  • Hydroxyzine
    • Indications for Use: only antihistamine that is FDA approved for use in anxiety.
    • Mechanism of Action: not specified in transcript.
    • Contraindications: cardiotoxic in some users, QTc-prolonging effects.
    • Side Effects and Adverse Effects: not detailed in transcript.
    • Administration: available for IM injection; should be given in a large muscle (e.g., ventrogluteal).
    • Note: Sound-alike/look-alike confusion listed as Hydroxyzine vs Hydralazine.

Beta-Adrenergic Antagonists

  • Propranolol
    • Indications for Use: social anxiety disorder, performance anxiety, situational anxiety.
    • Mechanism of Action: suppression of physiological hyperarousal.
    • Side Effects and Adverse Effects: not detailed in transcript.
    • Client Education: not detailed in transcript.

Discussion Question #4

  • A client with a history of substance use disorder is prescribed hydroxyzine for acute anxiety. How should the nurse respond to address concerns and explain the rationale for this choice?

Alpha2 Adrenergic Receptor Antagonists

  • Mirtazapine
    • Indications for Use: anxiety disorders, GAD, panic disorder, social anxiety disorder, and posttraumatic stress disorder.
    • Mechanism of Action: increases circulating serotonin and norepinephrine by inhibiting alpha2 adrenergic receptors.
    • Contraindications: not specified in transcript.
    • Side Effects and Adverse Effects: not detailed in transcript.
    • Client Education: not detailed in transcript.

Norepinephrine Dopamine Reuptake Inhibitors

  • Bupropion
    • Indications for Use: (listed under SNRI class in transcript).
    • Mechanism of Action: decreases neuronal reuptake of dopamine in the CNS; diminishes neuronal uptake of serotonin and norepinephrine.
    • Contraindications: not specified in transcript.
    • Side Effects and Adverse Effects: not specified in transcript.

Tricyclic Antidepressants (TCAs)

  • Amitriptyline
    • Indications for Use: (listed under TCA class in transcript).
    • Mechanism of Action: works in the CNS by inhibiting the reabsorption (reuptake) of these neurotransmitters by presynaptic terminals.
    • Contraindications: not specified in transcript.
    • Side Effects and Adverse Effects: not specified in transcript.
    • Client Education: not specified in transcript.

Discussion Question #5

  • Why are tricyclic antidepressants generally not considered first-line treatment for anxiety?

GABA Analogs

  • Indications for Use: (listed under GABA analogs in transcript).
  • Mechanism of Action: (listed under GABA analogs in transcript).
  • Contraindications: (listed under GABA analogs in transcript).
  • Side Effects and Adverse Effects: (listed under GABA analogs in transcript).
  • Client Education: (listed under GABA analogs in transcript).

Medications to Treat Insomnia

Pathophysiology of Insomnia

  • Stages of Sleep:
    • N1, N2, N3, REM.
  • Insomnia: disrupts sleep patterns, leading to increased time to fall asleep, frequent awakenings, and reduced sleep efficiency.

Effects on Client Health (Insomnia)

  • Weakened immune system
  • Asthma
  • Hypertension
  • Cardiovascular disease
  • Diabetes mellitus
  • Obesity

Discussion Question #1

  • A client off-handedly mentions that they “haven’t been sleeping great.” Upon further questioning, the nurse learns that the client falls asleep easily but then wakes after an hour or two and can’t get back to sleep for hours. The client dismisses it, making a joke about “who needs sleep anyway.” How should the nurse respond?

Classes of Medication: Nonbenzodiazepine Receptor Agonists

  • Zolpidem
    • Mechanism of Action: (listed under nonbenzodiazepine receptor agonists in transcript).
    • Effects on the Body: helps fall asleep faster.
    • Indications for Use: (listed under Zolpidem in transcript).
    • Contraindications: severe liver disease, pregnancy, breastfeeding, and complex sleep behaviors (boxed warning).
    • Special cautions: not recommended for pediatric clients or older adults; use with caution in sleep apnea and those with history of substance or alcohol use disorder.
    • Drug interactions: alcohol, CNS depressants, opioids, chlorpromazine, sertraline, ciprofloxacin, fluvoxamine can cause respiratory depression or increased sedation; rifampin and St. John’s Wort can decrease medication levels/effectiveness.
    • Side Effects and Adverse Effects: not detailed in transcript.
    • Client Education: not detailed in transcript.

Discussion Question #2 (Zolpidem)

  • In what clinical situations or client populations would zolpidem use be contraindicated or require caution, and why?

Classes of Medication: Benzodiazepines (Sleep-related)

  • Mechanism of Action: causes relaxation of skeletal muscle; reduces anxiety and creates physical and mental relaxation.
  • Effects on the Body: (sleep-related effects described).
  • Indications for Use: short-term treatment of insomnia.
  • Contraindications: (not specified beyond general contraindications in transcript).
  • Side Effects: (not specified beyond general side effects).
  • Adverse Effects: (not specified beyond boxed warnings in benzodiazepine section).

Classes of Medication: Selective Melatonin Receptor Agonist

  • Ramelteon
    • Mechanism of Action: mimics endogenous melatonin, facilitating sleep onset without causing significant sedation.
    • Effects on the Body: promotes sleep onset.
    • Indications for Use: insomnia (as per transcript’s section).
    • Contraindications: history of angioedema or allergy to the medication; severe liver impairment; concurrent use of fluvoxamine, ketoconazole, or fluconazole.
    • Side Effects and Adverse Effects: can cause anaphylaxis or angioedema.
    • Client Education: take within 30 minutes before bedtime; do not take with or after high-fat meals.

Discussion Question #4 (Ramelteon)

  • A client is prescribed fluvoxamine. Why is ramelteon contraindicated for this client?

Classes of Medication: Orexin Receptor Antagonists

  • Mechanism of Action: antagonizes the effects of orexin A and B, neuropeptides that promote wakefulness.
  • Effects on the Body: (listed under orexin receptor antagonists in transcript).
  • Indications for Use: (listed under orexin receptor antagonists in transcript).
  • Contraindications: (listed under orexin receptor antagonists in transcript).
  • Side Effects and Adverse Effects: (listed under orexin receptor antagonists in transcript).
  • Client Education: (listed under orexin receptor antagonists in transcript).
  • Administration: administer 30 minutes before bedtime; administer only when client has at least 7 hours before needing to awaken.

Medications to Treat Bipolar Disorders

  • (Content not detailed in transcript beyond the heading.)

Additional Notes on Presentation and Education

  • Throughout the material, several discussion prompts simulate nursing judgment and counseling scenarios:
    • Discussion Question #2 (PTSD and SSRI interactions with St. John’s wort)
    • Discussion Question #3 (buspirone and MAOIs)
    • Discussion Question #4 (hydroxyzine use in a client with SUD)
    • Discussion Question #5 (TCAs as a first-line consideration)
    • Insomnia-related prompts about patient responses to sleep concerns

Summary of Key Points

  • Anxiety disorders arise from genetic, biochemical, and psychosocial factors, with imbalances in GABA and glutamate contributing to excessive neuronal excitability.
  • SSRIs are first-line pharmacotherapy for many anxiety disorders, primarily by increasing serotonergic activity through presynaptic reuptake inhibition.
  • SNRIs add norepinephrine reuptake inhibition to serotonin modulation, with boxed warnings for suicidality.
  • Buspirone offers anxiolysis via 5-HT1A partial agonism, with MAOI interactions as a key contraindication.
  • Antihistamines like hydroxyzine provide rapid anxiolysis but carry cardiac safety considerations (QTc effects).
  • Beta-blockers such as propranolol reduce somatic anxiety symptoms (tachycardia, trembling) but do not treat core anxiety disorders.
  • Mirtazapine and bupropion present alternative mechanisms (noradrenergic/serotonergic modulation; dopaminergic and noradrenergic activity) with varying side effect profiles.
  • TCAs are generally not first-line due to side effects and safety concerns.
  • GABA analogs and nonbenzodiazepine receptor agonists (zolpidem) offer sleep-promoting options with risk considerations for dependence and complex sleep behaviors.
  • Ramelteon provides melatonin-receptor mediated sleep onset without significant daytime sedation but interacts with certain CYP inhibitors and MAOI-related drugs.
  • Orexin receptor antagonists add a novel mechanism for wakefulness suppression, requiring careful bedtime scheduling.
  • Insomnia pathophysiology involves multiple sleep stages (N1, N2, N3, REM) and sleep disruption leads to systemic health risks including immune and metabolic impacts.