Anti-depressant Drugs

Anti-depressant Drugs Presented by : Mohammad Al-oran Mohammad AwadMoussa Abo-TabeekhAlaa Salem

Supervision by : Dr.Ahmad Rayan

Outline :

Depression :

TypeSigns & SymptomsTreatment

Anti-depressant drug :

Definition Classification Doses Mechanism of action IndicationContra-indicationSide effectNursing interventionNursing care Nursing diagnosis Summery References

**Mood : is prolonged emotional state that influences the person's whole personality and life functioning

**Grief : is the subjective state that follows loss

** anxiety (sense of fear and intense worry) is other mood accompanies

Depression & some definitions

Depression - Depression :is a type of mental disorder that affects a person's mood- it is a pathological grief reaction know as melancholia -It is abnormal extension of sadness and grief- depression and anxiety may show diurnal variation , certain time of the day 4

Major depressive disorder (unipolar depression) requires at least 2 weeks of depression/loss of interest and 4 additional depressive symptoms, with one or more major depressive episodes.

Dysthymic disorder (Persistent Depression) is an ongoing low-grade depression of at least 2 years duration for more days than not and does not meet the criteria for major depression.

Symptoms in the major and dythymia is the same the different in severity and duration.

Type of Depression

Signs and symptoms of depression anger , anxiety , apathy, helplessness , hopelessness,

low self-esteem , overeating , sleep disturbances ,

nausea, vomiting , weight changes , confusion ,

lack of concentration , loss of interest and motivation , self-blame

6

Antidepressants drugs Definition

7

SSRI antidepressantsTricyclic antidepressantsAtypical antidepressantsMAOI antidepressants

**classification of antidepressants drugs

SSRI antidepressantsTricyclic antidepressantsAtypical antidepressantsMAOI antidepressants

SSRI antidepressants

Selective Serotonin Reuptake Inhibitor

Mechanism of action

Inhibit serotonin reuptake so increase synaptic serotonin levels Many SSRIs affect other receptors especially at high dosesClinical effect usually takes weeks so mechanism goes beyond simply increasing synaptic serotonin levels Several serotonin (5-HT) receptor subtypesSerotonin receptors are located throughout the body (especially GI tract)

SSRI antidepressants

Indications & off-label usesVarious class members also approved to treat: generalized anxiety , Obsessive Compulsive Disorder (OCD), panic , Posttraumatic stress disorder PTSD, eating disorders, social anxiety Off-label uses: Attention deficit-hyperactivity disorder ADHD, insomnia, chronic pain syndromes, seasonal affective , behavioral problems in individuals with dementia and mental retardation, other uses

SSRI antidepressants

Half-lifeShort: paroxetine & fluvoxamine (missed doses can result in uncomfortable symptoms)

Moderate: sertraline, citalopram, escitalopram

Long: fluoxetine (good for people who may miss doses)

SSRI antidepressants

Decreased sex drive and impaired sexual function tend not to resolve with timeNausea, diarrhea, anorexia, vomiting - all increase with dose and can resolve with timeWeight gain (esp. paroxetine) after initial GI effectsHeadache, dizziness, anxiety (esp. fluoxetine), rash, insomnia, sedation, sweating, vivid dreams, tremor, dry mouth (esp. paroxetine), bruising, prolactin

Side Effect of SSRI

SSRI Antidepressant DrugsRoute Usual Adult Daily Dose(mg/day)Generic name (Trade Name) POPOPOPOPOPO20-4010-2020-60100-20020-6050-200Selective serotonin reuptake inhibitors(SSRIs)

** Citalopram (Celexa)Escitalopram (Lexapro)** Floxetine (Prozac)** Fluvoxamine ( Luvox Paroxetine (Paxil)Sertraline (Zoloft)** venlafaxine (effexor)

15

Drug interaction for SSRI 1. Citalopram and paroxetine with warfarin may lead to increased bleeding2. Citalopram may be excreted more rapidly with carbamazepine3. Fluoxetine increases the half-life of diazepam4. Fluvoxamine with diltiazem may cause bradycardia5. Paroxetine metabolism may be decreased by cimetidine, phenobarbital, and phenytoin6. Paroxetine shouldnt be used with tryptophan because headache, nausea, sweating and dizziness may occur.

Note : Always check all medications that the patient is taking and notify the practitioner of any possible interactions.

16

Nursing care of patient taking SSRI :1. Provide comfort measures for the patient so they can tolerate the adverse effects. 2. Administer the medication in the morning to help prevent insomnia.3. Encourage the patient to change position slowly to help prevent orthostatic hypotension.4. Teach the patient about the risks of abruptly stopping their medication. Encourage them to take the medication as ordered.

17

SSRI antidepressantsTricyclic antidepressantsAtypical antidepressantsMAOI antidepressants

Tricyclic antidepressants

Mechanism of action :Serotonin, histamine, muscarinic (cholinergic) and -adrenergic receptor activity although in differing ratios Anticholinergic activity leads to many of the side effects of these drugs

Tricyclic antidepressants

Indications & off-label uses for TCAs

Depression and similar spectrum of disorders as SSRIs

Especially helpful with chronic pain and depression secondary to medical conditions such as AIDSenuresis, narcolepsy, premature ejaculation, insomnia, migraine prophylaxisBlood levels: May be obtained to monitor dose effectiveness

Drug-drug interactions (DDI) : Multiple significant interactions in each direction with potentially serious consequencesSide effects (SE) :Anticholinergic SE include: dry mouth, constipation, blurred vision and urinary retentionCardiac arrhythmias and conduction changesOrthostatic hypotension SedationWeight gainurinary retention and sever constipationCautions :Overdose is frequently fatalPts with bipolar d/o may be pushed into mania or rapid cycling

Tricyclic antidepressants

Patient received MAOIs should wait 2-3 weeks before starting TCAs becaused MOAIs slowly excreted from the body- Enlarge prostate and glucoma- Epileptic client- Cardiovascular disorder and recent myocardial infarction- CNS depressant as phenothiazenes , barbitural, alcohol , anticholinergic agents- Pregnancy and lactaion

Contraindication for TCAs :

PO,IMPOPOPOPO

POPOPO

POPO

150-300100-250150-300150-300150-300

150-30050-15015-60

150-30075-200Tricyclic Antidepressant` Drugs (TCAs)

Tertiary(Parent)** Amitriptyline (Elavil)** Clomipramine (Anafranil)Doxepin (Sinequan)** Imipramine (Tofranil)Trimipramine (Surmontil)

Secondary (Metabolite)Desipramine (Norpramin)** Nortriptyline (Pamelor)Protriptyline (Vivactil)

TetracmilyclicsAmoxapine (Asendin)(Maprotiline (Ludio

23

Drug interaction for TCAs :1. TCAs taken with amphetamines and sympathomimetics may cause hypertension.2. TCA metabolism is increased when taken with barbiturates.3. TCA metabolism is decreased when taken with cimetidine.4. TCAs taken with anticholinergics increase adverse effects such as dry mouth, constipation, and urine retention.5 .TCAs decrease the antihypertensive effects of clonidine.24

Nursing care of patient taking TCAs :1. If the patient has diabetes, or is on an oral hypoglycemic agent carefully monitor their glucose level; it may be altered by the TCA.2. Give the patient ice chips, hard candy, or sugarless gum to help relieve their dry mouth.3. Carefully monitor the patients blood pressure before, during, and after therapy.4. Tell the patient to avoid exposure to sunlight or artificial ultraviolet light because of the risk of photosensitivity reactions.5. TCAs can be lethal when taken in large doses- carefully monitor a suicidal patient and make sure they arent hoarding the pills for a suicide attempt.25

SSRI antidepressantsTricyclic antidepressantsAtypical antidepressantsMAOI antidepressants

Atypical antidepressants

Mechanism of action :Atypical antidepressants ease depression by affecting chemical messengers (neurotransmitters) used to communicate between brain cells. Most antidepressants work by changing the levels of one or more of these naturally occurring brain chemicals.

Atypical antidepressants affect neurotransmitters including dopamine, serotonin and norepinephrine . Changing the balance of these chemicals seems to help brain cells send and receive messages, which in turn boosts mood.

27Atypical antidepressants

Atypical antidepressants

Mechanism of actionvenlafaxine and duloxetine are both serotonin and norepinepherine reuptake inhibitors- SNRIsmirtazapine has serotonin subtype & norepinephrine activitytrazodone, nefazodone have different serotonin activity than SSRIsbupropion has dopamine and norepinephrine activity

28

28

Atypical antidepressantsIndications & off-label usesAll have FDA approval to treat depressionSNRIs shown effective in chronic neuropathic pain (pain produced by normally non-painful stimuli )Nicotine addiction (bupropion)Insomnia (mirtazepine, trazodone)Many similar uses to SSRIs bupropion, mirtazepine, trazodone & nefazodone do not usually have associated sexual dysfunction 29

29

Atypical antidepressantsVenlafaxine (Effexor)Similar to TCAs with less safety & side effect concernsFDA approval for depression and generalized anxiety & social anxiety SNRI- activity depends on doseMinimal DDISE with missed dosesdose is 75 mg per daymaximum of 375 mg per day

30

30

Atypical antidepressants

Mirtazapine (Remeron, Avanza, Zispin)Complex serotonin, NE (2) & histamine activityReceptor activity changes with changes in doseSedation & weight gain especially at lower dose Lipid abnormalitiesMinimal DDIs (except MAOIs) Avoid alcohol while taking Remeron as it can worsen these side effects.starting dose is 15 (mg) once a day taken as a single dose, may increase the dose up to 45 mg once a day

31

31

Atypical antidepressantsNefazodone (Serzone, Nefadar)Rarely used due to irreversible liver toxicityPulled from market by initial manufacturer in 2004 although still available as genericStill popular with some patientsstart at 100 mg twice daily (200 mg/day) to a maximum of 600 mg/day (300 mg twice daily), Food and Drug Administration (FDA) regulations

32

32

Atypical antidepressant

Trazodone (Desyrel)- Sedation, weight gain, low blood pressure- Used most commonly (off label) for insomnia.Rare reports of sustained painful erection (priapism) that should be treated in ER (can lead to impotence)starting dose is 150 (mg) per day in divided dosesincrease the dose by 50 mg per day every 3 to 4 days if needed. The maximum daily dose should not exceed 400 mg per day.33

Atypical antidepressant

Bupropion (Welibutrin)-NE, dopamine reuptake inhibition- Zyban to toxic smoking addiction- Seizure risk in certain patients ( risk at dose)Potential DDIs not often significant (except MAOIs) starting dose is 200 (mg) a day, taken as 100 mg twice a day. 300 mg a day, taken as 100 mg three times a day. The maximum daily dose is 450 mg. Taking doses greater than 450 mg a day may increase the risk of serious side effects, including seizures.

34

Duloxetine (Cymbalta ) - SNRI profile minimally dose dependent- Indicated for depression & chronic neuropathic painThe recommended dose is 60 milligrams (mg) once a day. A lower starting dose of 30 mg once a day for 1 week may be desirable for some patients.Atypical antidepressant

35

Monoamine Oxidase InhibitorsSSRI antidepressantsTricyclic antidepressantsAtypical antidepressantsMAOI antidepressants

Monoamine Oxidase InhibitorsMonoamine oxidase inhibitors (MAOIs) were the first type of antidepressant developed. They're effective, but have generally been replaced by antidepressants that are safer and cause fewer side effects. MAOIs generally require diet restrictions because they can cause dangerously high blood pressure when taken with certain foods.

In spite of side effects, these medications are still a good option for some people. In certain cases, they relieve depression when other treatments have failed.

37

Tyramine is a naturally occurring amino acid that forms from the breakdown of protein in food. Though tyramine helps regulate blood pressure, it can also affect the human body in many different negative ways.

What is tyramine?

Tyramine (TIE-ruh-meen) is an amino acid that helps regulate blood pressure. It occurs naturally in the body and is found in certain foods. When taking a monoamine oxidase inhibitor (MAOI), you need to avoid consuming foods high in tyramine. These foods can cause a dangerous increase in blood pressure when combined with MAOIs38

Antidepressants such as MAOIs ease depression by affecting chemical messengers (neurotransmitters) used to communicate between brain cells. Most antidepressants work by changing the levels of one or more of these naturally occurring brain chemicals.

How MAOIs work

MAOIs block an enzyme called monoamine oxidase, which breaks down excess tyramine in the body. Blocking this enzyme helps relieve depression. However, tyramine can quickly reach dangerous levels if you eat high tyramine foods, which may cause a spike in blood pressure and require emergency treatment.

39

The enzyme monoamine oxidase is involved in removing the neurotransmitters norepinephrine, serotonin and dopamine from the brain. MAOIs prevent this from happening, which makes more of these brain chemicals available.

This is thought to boost mood by improving brain cell communication. MAOIs also affect other neurotransmitters in the brain and digestive system, causing side effects.

On the other hand ,monoamine oxidase is also responsible for the metabolism of tyramine, therefore persons who take MAOIs can not metabolize tyramine and with the ingestion of foods high in tyramine a hypertensive crisis can result, as tyramine can cause the release of stored monoamines, such as dopamine, norepinephrine and epinephrine Therefore, dietary restrictions are required for patients receiving MAOIs

41

42

43 Nursing CareSide Effect

Discontinuing of drug immediately when physician ordersMonitor vital signsAdminister short _ acting antihypertensive medication as orderedUse external cooling measures to control hyperpyrexia

hypertensive crisisSymptoms:Severe occipital headache , palpitationFever , sweating , increase blood pressure ,chest pain , coma

Contraindicated with hypersensitivity to the drugs .Use cautiously with impaired hepatic or renal function, diabetes mellitus, lactation, seizures, history of suicide attempts.

44CONTRAINDICATION

Drug interaction of MAOIs :1. MAOIs administered with meperidine may lead to excitation, hyper- or hypotension, hyperthermia, and coma.2. MAOIs and doxapram may cause hypertension and arrhythmias.3. MAOIs with amphetamines, methylphenidate, levodopa, or sympathomimetics may cause a hypertensive crisis by increasing the catecholamine release.4. MAOIs with fluoxetine, TCAs, citalopram, trazodone, sertraline, paroxetine, and fluvoxamine may cause an increased body temperature and excitation and seizures.

45

Nursing care of patients taking MAOIs :1. Closely monitor the patients blood pressure and be alert for signs of hypertensive crisis.2. Continue to monitor the patient for adverse reactions for up to 10 days after stopping the medication because of its long-lasting effects.3. Teach the patient about tyramine-containing foods and stress the importance of avoiding them.4. Help the patient slowly change position to minimize orthostatic hypotension.5. Watch patient older than 60 because they are more prone to adverse reactions.

46

Foods that can interact with monoamine oxidase inhibitors (MAOIs)47

Foods that contain tyramine Safe foodsUnsafe foodscategoryMost vegetablesAvocados, especially if overripe fermented bean curdVegetablesMost fruitsFigs, especially if overripeBananas ,in large amountsfruitsMeats that are known to be fresh Meats that are fermented, smoked or otherwise aged ,liver ,unless very freshmeatsUn Fermented varietiesFermented varieties ,bologna,pepperoni,salamiSausagesfish that are known to be freshDried or cured fish, otherwise aged ,liverfishMilk,yogurt,cottage cheese,cream cheese Practically all cheesesMilk, milk productsBaked goods that contain yeastYeast extract (Bovril)Food with yeastMajor domestic of beer most wineSome imported beers ,chianti winesBeer, wine

48

commentsFoodsContains phenylethylamine ,a pressor agent, large amount can cause a reaction chocolateContains dopamine, a pressor agent, reaction are most likely with overripe beans Fava beansHeadache, tremulousness, mania-like reaction have occurred ginsengCaffeine is a weak pressor agent, large amount may cause a reaction Caffeinated beverages

food that contain other vasopressors 49

Nursing interventions for antidepressants drugs :Provide explanations of drug action and side effects.Monitor vital signs and observe for orthostatic hypotensionAdvise to change positions slowlyAdminister with food or milk to avoid gastrointestinal upset.Assist with ambulation or activity requiring mental alertness.Encourage increase in fluid intake.50

Nursing interventions for antidepressants drugs :7. Offer hard candy or sugarless gum for dry mouth.8. Assess for suicidal ideation9. Monitor mood at frequent intervals10. Ensure use of protective sunscreen and wear sun glasses when outdoors (TCAs).11. Discourage caffeinated beverages.

51

Client and family teaching:1. take medication exactly as directed by physician. 2. Not use more of the drug, use it more often, or for a longer period than the physician ordered.3. Take the drug for several weeks to see the therapeutic effect.4. Take the medication with food or milk to avoid stomach upset.5. Use caution when driving, operating dangerous equipment, or engaging in activities that require mental alertness.6. Not mix with alcohol, or other CNS depressants.52

Client and family teaching:7. Report any side effects to physician.8. Not suddenly stop taking the medication, it must be withdrawn gradually.9. Take a missed dose as soon as possible, if several hours have lapsed or it is nearing the time for the next dose, the dose should not be doubled to catch up.10. Avoid smoking when taking TCAs, smoking can enhance the metabolism and increased dosage may be required.11. Wear protective sunscreen when outdoors (TCAs).12. Rise slowly from a reclining position

53

Summary:** Depression: - Types. - Symptoms. -Treatment.** Antidepressants drugs: - Definition. - Classification. - Doses. - Mechanism of action. - Indication. - Side effects. - Contraindications. - nursing intervention

54

ReferencesTownsend, M. (2008). Essentials of psychiatric mental health nursing. ( 4th ed.) Philadelphia: F.A. Davis.

. Greenstein, B. & Gould, d. (2007) : Trounces clinical Pharmacology for nurses (18th ed.).

nurse clinical pocket guide (PsychNotes )

55