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What is the first line of treatment for antidepressants?
SSRIs (Selective Serotonin Reuptake Inhibitors)
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What is the second line of treatment for antidepressants?
Atypical Antidepressants
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What is the third line of treatment for antidepressants?
Tricyclic Antidepressants (TCAs)
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What line of treatment is rare for antidepressants?
MAOIs (Monoamine Oxidase Inhibitors)
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How do TCAs work?
Block the reuptake of serotonin and norepinephrine
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How do SSRIs work?
Block reuptake of serotonin
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How do atypical antidepressants work?
Effect balance of dopamine, serotonin, and norepinephrine
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What are 3 examples of atypical antidepressants?
- Bupropion (Wellbutrin)
- Mirtazapine (Remeron)
- Trazodone (Desyrel)
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How do MAOIs work?
Decrease MAO (monoamine oxidase) in the brain and GI system
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What is MAO and what does it do?
- Monoamine oxidase
- Removes norepinephrine, serotonin and dopamine from synapses
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What are examples of the tricyclic antidepressants and their trade names?
- Amitriptyline (Elavil)
- Desipramine (Norpramin)
- Doxepin (Sinequan)
- Imipramine (Tofranil)
- Nortriptyline (Pamelor)
- Trimipramine (Surmontil)
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Which tricyclic antidepressants are more likely to cause sedation?
- Amitriptyline (Elavil)
- Doxepin (Sinequan)
- Trimipramine (Surmontil)
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Which tricyclic antidepressants are more likely to cause weight gain?
- Amitriptyline (Elavil)
- Doxepin (Sinequan)
- Imipramine (Tofranil)
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What are the two tricyclic antidepressants that have better tolerated ASEs?
- Desipramine (Norpramin)
- Nortriptyline (Pamelor)
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What are the side effects of tricyclic antidepressants?
- Orthostatic Hypotension
- Anticholinergic effects
- Tremors
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What are the adverse side effects of tricyclic antidepressants?
- Tachycardia/irregular heart rate
- Increased appetite (weight gain)
- Disorientation/Confusion (watch for this in older adults on high doses)
- Sexual dysfunction
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What was the first TCA marketed and when?
Imipramine (Tofranil)
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How long does it take for a TCA to create a clinical response?
2-4 weeks
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What do you want to assess for early in antidepressant therapy?
Suicidal ideation
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Why are SSRIs chosen over TCAs?
TCAs are less effective than SSRIs
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What substances increase risk for increased CNS depression when taken with TCAs?
- ETOH
- Hypnotics
- Sedatives
- Barbiturates
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What substances increase risk for cardiac dysrhythmias when taken with tricyclic antidepressants?
- MAOIs
- Propylthiouracil (tx of hyperthyroidism)
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What are examples of SSRIs?
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
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What are the side effects of SSRIs?
- Dizziness
- Weight gain or loss
- V/D
- Nervousness, agitation or restlessnessDrowsiness (take at HS)
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As therapeutic effect of SSRIs increases, what happens to the ASEs?
Over 2-4 weeks they will decrease as therapeutic effect increases.
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What else are SSRIs used to treat besides depression?
- Anxiety
- Eating Disorders (Prozac)
- Selected drug use disorders
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What antidepressant comes in a delayed release tablet?
Fluoxetine (Prozac)
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What are the S/Sx of serotonin syndrome?
S/S: Anxiety, agitation, confusion, lack of coordination, tremors, seizures, sweating, restlessness, tachycardia, hypertension, hyperpyrexia
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What is serotonin syndrome?
- A rare disorder when taking antidepressants
- Specific risk is when taking two meds that raise serotonin levels (antidepressants, pain/HA meds, St.John's wort)
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What are examples of atypical antidepressants?
- Bupropion (Wellbutrin)
- Mitrazapine (Remeron)
- Trazodone (Desyrel)
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What antidepressant should you not give to someone with anorexia nervosa and what happens when you do?
- Bupropion (Wellbutrin)
- The SE can potentially exacerbate anorexia symptoms.
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What are the common side effects for atypical antidepressants?
- Dry mouth
- Constipation
- Dizziness/lightheadedness
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What side effect of Buproprion (Wellbutrin) has been used positively in the past?
Ease nicotine cravings
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What side effect is specific to Mirtazapine (Remeron)?
Increased cholesterol/triglycerides (may need extra labs)
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What are the side effects specific to Trazodone (Desyrel)?
- Extreme drowsiness
- Decreased anxiety
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What medical conditions are linked to Trazodone (Desyrel)?
Priapism, cardiac arrhythmias
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What is priapism?
Medial condition in which the erect penis does not return to its flaccid state within 4 hours.
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What are examples of MAOIs?
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Selegiline (Emsam)
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What is usually the first symptom of a hypertensive crisis?
Headache
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What medications should you avoid when taking MAOIs?
- other antidepressants
- certain pain meds
- certain cold and allergy meds
- some herbal supplements
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What are the characteristics of MAOIs that cause them to be rarely prescribed today?
- You need to avoid foods with tyramine
- Dangerous hypertensive crisis
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What is tyramine?
An amino acid that regulates BP
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What are some foods you want to avoid when taking MAOIs?
- Aged cheeses
- Cured meats
- Pickled foods
- Snow peas
- Fava beans
- Yeast
- Fermented foods (soy sauce, miso, tofu)
- Red wine, beer
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What drugs are potentially fatal when mixed with MAOIs?
- Other antidepressants
- Carbamazepine (Tegretol)
- Cyclobenzaprine (Flexeril)
- Procarbazine (Matulane)
- Selegiline (Emsam)
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What are the S/S of MAOI overdose?
- Mood changes (↑)
- ALOC (↑)
- (↑) cardiovascular symptoms
- Feer, diaphoresis
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How do you treat an MAOI overdose?
- Induce vomiting
- Gastric lavage
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What are the nursing implications and education for MAOIs?
- Monitor BP/P before and frequently during therapy
- Educate on S/S of HTN crisis
- Check liver function, fasting BG, cholesterol levels in beginning and during therapy
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What do you want to avoid when taking MAOIs?
- ETOH
- CNS depressants
- OTC drugs
- foods/beverages containing tyramine
- excessive caffeine
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What are the S/S of a hypertension crisis?
- Headache
- BP 180/120
- Emergent: severe chest pain/HA, N/V, severe anxiety, SOB, seizures, unresponsiveness
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What are mood stabilizers and what are they used for?
- Used to treat Bipolar Disorders+ Schizoaffective disorder
- Controls hyperactivity and flight of ideas without impairing intellectual activity
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What is the first drug used for mood stabilizing?
Lithium
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What other drugs are used as mood stabilizers?
- Anticonvulsants: carbamazepine, lamotrigine, divalproex/valproic acid
- Antipsychotics: olanzapine, ziprasidone & aripiprazole
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What are the nursing implications for lithium?
- Monitor sodium intake (it can flush out the lithium, lead to dehydration due to ↑ urine output)
- Monitor fluid intake (1-2 liters/day)
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What is lithium and how long does it take to reach therapeutic levels?
- Antimania drug, mood stabilizer
- 5-6 days
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What are the adverse side effects of lithium?
- Dizziness
- Impaired vision
- Fine hand tremors
- Reversible leukocytosis
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What are the signs of lithium toxicity?
- N/V/D
- Drowsiness
- Dizziness
- Confusion
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What is the patient teaching for lithium?
- Labs q 2 weeks, then 2-3 months, draw in early AM before next dose
- Avoid caffeine (decreases serum lithium levels)
- Avoid large sodium intake
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What is the ideal lithium serum level?
0.6 - 1.2 mEq/L up to 1.5 mEq/L
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What are AED drugs?
- Antiepileptic medications
- Anticonvulsants
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What are the two sedating AEDs?
- Valproic acid
- Carbamazepine
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What is the activating AED?
Lamotrigine
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What other anticonvulsant is great for anxiety and might be effective for mood disorders?
Gabapentin
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What is Carbamazepine and how does it work?
- An anticonvulsant drug that is effective for mania and mood stabilization in bipolar disorder.
- It decreases synaptic transmission of the neurons' sodium channels.
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How is Carbamazepine metabolized in the body?
Absorbed into the blood stream → metabolized in the liver → crosses blood-brain barrier
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What is the patient teaching for Carbamazepine?
- CBC labs weekly for first 2 months, and routine serum blood levels
- Monitor: fever, sore throat, mouth ulcers, increased bruising, petechiae, unusual bleeding, abdominal pain, chills, rash, pale stools, dark urine, jaundice
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When is carbamazepine contraindicated?
- Bone marrow depression
- Pregnancy/Lactation
- Cardiac disease
- Liver disease
- Elderly (↑ BPH, intraocular pressure)
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How does APAP interact with carbamazepine?
Decreases efficacy, increases risk of toxicity
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How does lithium interact with carbamazepine?
Increases risk of neurotoxicity
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How does grapefruit juice interact with carbamazepine?
Increases serum levels and medication effect
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What is lamotrigine and what is it used for?
- An anticonvulsant, AED
- Great for refractory bipolar disorder (not responsive to meds)
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What is the other name for valproate and what is it used for?
- Valproic acid
- Anticonvulsant AED
- Effective for mania and mood stabilization in bipolar disorder
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How is valproate metabolized in the body?
- In liver, excreted in urine
- Caution in pts with liver/renal dysfunction
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How does valproate work?
Increases GABA
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What drugs interact with valproic acid?
- Clonazepam
- Diazepam
- Carbamazepine
- Lamotrigine
- Phenobarbital
- Warfarin
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What is the patient teaching for valproate?
- Monitor drug lab levels for therapeutic level and toxicity
- Monitor ammonia levels (↑)
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What is the trade name for olanzepine?
Zyprexa
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What is olanzepine?
Atypical antipsychotic used for psychotic disorders with a mood component
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What mood drugs can you combine with olanzepine?
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How does olanzepine work?
Antagonizes dopamine and serotonin
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What is the patient teaching for olanzepine?
- can worsen glucose control in DM
- risk of weight gain
- worsens narrow angle glaucoma
- don’t use in pregnancy or kids
- be cautious in CV disease or hx of seizures
- change dose for older adults
- educate on side effects
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