Psychopharmocology
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| First line treatment for major depression. Prevents re-uptake of serotonin | Selective Serotonin Reuptake Inhibitors i.e. Zolft, Paxil, Prozac, Celexa
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| Nursing Considerations for SSRI | Taken once in am, avoid ETOH, CI with MAOIs, Assess for serotonin syndrome and discontinuation syndrome.
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| Side Effects of SSRIs | N/V/D, insomnia, fatigue, agitation, dry mouth, hyponatremia, sexual side effects (anorgasmia, low libido)
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| Serotonin Syndrome | Life threatening syndrome caused by too high a dose or interaction with other drugs. AMB Abdominal pain, diarrhea, bloating, fever, tachycardia, elevated BP, delirium, muscle spams, seizures. Can induce high fever, cardiovascular shock, death.
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| Interventions for Serotonin Syndrome | Remove offending agent, initiate treatment: cyproheptadine, methysergide, propranolol, clooing blankets, anticonvulsants, artificial ventilation.
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| Discontinuation Syndrome | AKA Serotonin Withdrawal. AMB dizziness, insomnia, irritability, nervousness, nausea, agitation. TX: wean on schedule.
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| Celexa (citalopram) | SSRI
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| Lexapro (Escitalopram) | SSRI
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| Prozac (fluoxetine) | SSRI
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| Luvox (Fluvoxamine) | SSRI
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| Paroxetine (paxil) | SSRI
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| Sertraline (Zoloft) | SSRI
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| SNRI - Serotonin Norepinephrine Reuptake Inhibitor | Popular next step after SSRIs. Prevents reuptake of serotonin and norepinephrine.
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| Side Effects of SNRIs | Nausea, insomnia, dry mouth, sweating, agitation, headache, sexual dysfunction.
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| Venlafaxine (Effexor) | SNRI. Causes hypertension. Monitor blood pressure. Do not exceed 150 mg/day
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| Duloxetine (Cymbalta) | SNRI. Has advantage of decreasing neuropathic pain.
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| Nursing considerations with SNRIs. | Monitor blood pressure with effexor, discontinuation syndrome.
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| Norepinephrine Reuptake Inhibitors (NRIs) | Blocks reuptake of norepinephrine and enhances its transmission. Useful with severe depression and impaired social functioning.
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| ADEs of NRIs | Insomnia, sweating, dizziness, dry mouth, constipation, urinary hesitancy, tachycardia, decreased libido.
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| Reboxetine (Vestra) | NRI
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| Serotonin Receptor Antagonists/agonists | Selective blockage of serotonin receptors and alpha-adrenergic receptors. Lower risk of long-term weight gain than SSRIs and TCAs. Lower risk of sexual ADEs than SSRI.
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| Serotonin Receptor Antagonists/agonists ADEs | Sedation, hepatotoxicity, dizziness, hypotension, paresthesias.
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| Nursing Considerations with Serotonin Receptor Antagonists/agonists | Life-threatening liver failure possible, priapism of penis and clitoris is rare, CI with MAOIs
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| Nefaxodone (Serzone) | Serotonin Receptor Antagonists/Agonist
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| Norepinephrine Dopamine Reuptake Inhibitor (NDRI) | Blocks reuptake of norepinephrine and dopamine. Stimulant action may reduce appetite, and increase sexual desire. Also used as an aide to quit smoking.
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| ADES for NDRI | Agitation, insomnia, headache, nausea, and vomiting. May have seizures (low risk) CI if high risk for seizure
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| Bupropion (Wellbutrin) | NDRI
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| Serotonin Norepinephrine Disinhibitors (SNDIs) | Blocks alpha 1 adrenergic receptors that normally inhibit norepinephrine and serotonin. Antidepressant effects equal SSRIs and may occur faster.
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| Side effects of SNDIs | Weight gain, sedation, dizziness, headache, sexual dysfunction (rare)
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| Nursing Considerations for SNDIs | Drug-induced somnolence exaggerated by ETOH, Benzos and other CNS depressants. CI with MAOIs.
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| Mirtazapine (Remeron) | SNDI
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| Tricyclic Antidepressants (TCAs) | Inhibits the reuptake of serotonin and norepinephrine.
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| TCA ADEs | ANTICHOLINERGIC EFFECTS: Dry mouth, constipation, urinary retention, blurred vision, orthostatic hypotension, cardiac toxicity sedation.
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| Length of time before mood elevation occurs with TCAs | 7-28 days. Full response may take 3-8 weeks.
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| Nursing considerations with TCAs | Lethal in OD, use cautiously in older adults, cardiac dx, elevated intraocular pressure, hyperthyroidism, seizure disorders, liver/kidney dysfunction. CI with MAOIs
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| When to administer TCAs | At bedtime r/t dizziness, drowsiness
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| Suddenly stopping TCAs can cause: | nausea, altered heartbeat, nightmares, and cold sweats in 2-4 days.
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| Amitriptyline (Elavil) | TCA
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| Clomipramine (Anafranil) | TCA
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| Desipramine (Norpramin) | TCA
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| Doxepin (Adapin, Sinequan) | TCA
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| Imipramine (Tofranil) | TCA
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| Nortiptyline (Aventyl, Pamelor) | TCA
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| Protriptyline (Vivactil) | TCA
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| Monoamine Oxidase Inhibitors (MAOIs) | Inhibits the enzyme monoamine oxidase, which normally breaks down neurotransmitters, including serotonin and norepinephrine.
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| ADES for MAOIs | Insomnia, nausea, agitation, and confusion, weight gain. Potential for hypertensive crises or serotonin syndrome with concurrent use of other antidepressants.
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| Nursing Considerations for MAOIs | Monitor BP routinely for first 6 weeks, avoid TOH, CNS depressants, OTC decongestant drugs, excessive caffeine, foods containing tyramine. CI for 2 wks following surgery
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| Hypertensive crisis with MAOIs | Occurs within a few hours of ingestion of substance, begins with HA, stiff/sore neck, palpitations, increase or decrease in HR, N/V, pyrexia. TX: emergency...CCBs, phentolamine, nifedipine
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| MAOI dietary restrictions | Avocados, bananas, figs, raisins. Pickles, sauerkraut. Beer, soy sauce, yeast, meat tenderizers, licorice, sour cream, yogurt, snails. Avoid chinese restaurants, aged cheeses (camembert, brie, cheddar, gruyere, processed american cheese) Avoid aged meats.
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| Phenelzine (Nardil) | MAOI
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| Selegiline Transdermal System Patch (EMSAM) | MAOI
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| Tranylcypromine (Parnate) | MAOI
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| Lithium Carbonate | Tx of bipolar disorder. Limits about 80% of manic and hypomanic episodes within 10-21 days. Reduces elation, grandiosity, flight of ideas, manipulation, anxiety.
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| Lithium therapeutic levels | Takes 7-14 days to reach level During active phase = 0.8-1/4 mEq/L. During maintenance phase = 0.4-1.3 mEq/L
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| Lithium Toxicity level and intervention | Serious toxicity occurs at levels> 2.0 mEq/L. Interventions: gastric lavage and tx with urea, mannitol, aminophylline can increase lithium excretion.
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| How often should lithium levels be checked? | within 5 days of initiating therapy or after dose change. Once therapeutic level is reached, check monthly for 6 months, after 6 months to a year measure every 3 months.
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| What time of day should lithium be checked? | Blood should be drawn in the am, 8-12 hours after last dose of lithium is taken.
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| Two major long-term risks of lithium therapy are... | Hypothyroidism and impairment of the kidney's ability to concentrate urine.
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| S/Sx of lithium toxicity | Tremor, ataxia, confusion, convulsions, N/V/D, arrthymias, polyuria, polydipsia, edema
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| Anticonvulsant drugs for bipolar disorder | valproate (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal). Superior for continuously cycling patients.
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| Valproate (Depakote) | Anticonvulsant for bipolar d/o. IND for lithium non responders in acute mania. MONITOR liver fx and platelet count periodically.
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| Carbamazepine (Tegretol) | Monitor liver function and platelet count periodically. Blood levels of carbamazepine should be monitored weekly for first 8 weeks. Can cause bone marrow suppression and liver inflammation.
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| Tegretol Toxic Level | > 12mcg/mL
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| Lamictal (Lamotrigine) | First-line treatment for bipolar depression (can worsen mania). A potentially Life-threatening rash may occur. Seek medical attn.
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| Clozapine (Clozaril) | Atypical Antipsychotic. Causes agranulocytosis, higher risk for seizure. Pt must have weekly WBC for first 6 months, and frequent monitoring thereafter.
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| Atypical Antipsychotics | First-line treatment because they treat both positive and negative symptoms of schizophrenia and produce little EPS or tardive dyskinesia.
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| Risperidone (Risperdal) | Atypical antipsychotic
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| olanzapine (Zyprexa) | Atypical Antipsychotic. High weight gain, high ACh effect.
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| Quetiapine (Seroquel) | Atypical Antipsychotic
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| ziprasidone (Geodon) | Atypical Antipsychotic
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| Aripiprazole (Abilify) | Atypical Antipsychotic
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| ADEs of Atypical Antipsychotics | tendency to cause significant weight gain, metabolic syndrome (weight gain, dyslipidemia, altered glucose metabolism), sedation, low to moderate EPS symptoms
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| Conventional antipsychotics | Blocks dopamine receptor sites in motor areas and causes extrapyramidal side effects (EPS). Treats positive symptoms of schizophrenia. May take 2-6 weeks for full effect.
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| ADES of Conventional Antipsychotics | Anticholinergic effect, sedation, weight gain, sexual ADEs, tardive dyskinesia, orthostatic hypotension, photosensitivity, lowered seizure threshold.
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| Haloperidol (Haldol) | Conventional Antipsychotic. High EPS.
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| Chlorpromazine (Thorazine) | Conventional Antipsychotic. High sedation and ortho HOTN.
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| Thioridazine (Mellaril) | Conventional Antipsychotic. High sedation, ortho HOTN, ACh.
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| Loxapine (Loxitane), Molindone (Moban), Perphenazine (Trilafon) | Medium potency conventional antipsychotics.
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| Thiothixene (Navane) | High potency conventional antipsychotic
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| Fluphenazine (Prolixin) | High potency conventional antipsychotic
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| Pimozide (Orap) | High potency conventional antipsychotic.
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| Drugs that decrease EPS | Centrally acting antiACh drugs i.e. cogentin, benadryl and symmetrel.
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| Anticholinergic toxicity s/sx and interventions | Dry mucous membranes, mydriasis, nonreacctive pupils, hot, dry, red skin, unstable V/S, delirium, seizure. LIFE THREATENING: Hold med/call PCP, emergency cooling measures, benzos, physostigmine.
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| Pseudoparkinsonism s/sx and interventions | Masklike facies, stiff and stooped posture, shuffling gait, drooling, tremor, "pill-rolling" Intervention: admin antiparkinsonian agent (trihexyphenidyl or benztropine), call pcp.
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| Acute dystonic reactions s/sx and interventions | Acute contractions of tongue, face, neck, and back. Administer trihexyphenidyl or benztropine. Or benadryl.
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| Tardive Dyskinesia s/sx and interventions | Protruding and rolling tongue, smacking lips, rapid purposeless movements. Interventions: No known tx, may continue after D/C drug, teach pt ways to conceal movements
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| Agranulocytosis s/sx and interventions | Sore throat, fever, malaise, and mouth sores. Usually occurs during first 12 weeks of therapy. Blood work done Q week for 6 months, then every 2 months. If test positive, D/C drug and reverse isolation.
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| Neuroleptic Malignant Syndrome (NMS) s/sx and interventions | Severe EPS, Hyperprexia (high temp), Autonomic dysfunction (HTN, Tachycardia, diaphoresis, incontinence) Delirium. MEDICAL EMERGENCY: stop drug, Parlodel (relieves muscle rigidity and lowers fever), Dantrium, cool body maintain hydration
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