08.01 Antidepressants

Overview

1. Antidepressant medications work on different neurotransmitters in the brain to improve mood.
2. The fewer neurotransmitters it works on, the safer it is.  
3. These are listed in safest/first-line, to more aggressive.

Nursing Points

General

1. 2-4 weeks to therapeutic levels
2. Taper down, don’t stop abruptly.
3. Many drug-drug interactions.
4. ↑ risk for suicide due to ↑ energy/motivation they didn’t have before
5. MD may change drug if intolerable side effects occur
6. Caution:
   1. Avoid alcohol
   2. They shouldn’t drive until they know how the med affects them;
   3. Watch for sedative effects
7. With long term use, monitor liver and kidney function
8. Therapy is recommended in conjunction with antidepressant usage

Nursing Considerations

1. Selective serotonin reuptake inhibitors (SSRI’s)
   1. 1. Limits the reabsorption of serotonin, therefore increasing levels
      2. Side effects:
         1. Weight loss/gain
         2. Decreased libido
         3. Dizziness
         4. Photosensitivity
      3. Serotonin Syndrome / Serotonin Toxicity: excess levels of serotonin, typically caused by drug interactions (i.e. SSRI’s given with MAOI’s).  
         1. Rapid onset
         2. Tachycardia
         3. Diaphoresis
         4. Shivering
         5. Overactive reflexes
         6. Myoclonus (intermittent jerking/twitching)
         7. Severe → Hallucinations, coma, hyperthermia, and death if not addressed.  
         8. Treatment
            1. Serotonin antagonists
            2. Symptom management   
      4. Discontinuation Syndrome:
         1. GI upset
         2. Sleep disturbance
         3. Loss of balance
         4. Sensory disturbances
         5. Nausea
         6. Flu-like symptoms
         7. These will quickly resolve if med is restarted.
2. Tricyclic antidepressants (TCA’s)
   1. 1. Limits reabsorption of serotonin AND norepinephrine, therefore increasing the levels
      2. Sedative effect
         1. Caution with other meds with sedative effect (i.e. antihistamines)
         2. Best given at night.
      3. Cardiac effects
         1. Arrhythmias – Get an EKG prior to initiation and routinely during therapy.
      4. Anticholinergic effects: The 4 Can’ts
         1. Can’t pee (difficulty voiding)
            1. Assess voiding patterns
            2. Watch for retention
         2. Can’t see (blurred vision)
         3. Can’t spit (dry mouth)
            1. Encourage use of hard candies
            2. Mouthwashes
            3. Good oral hygiene
         4. Can’t sh*t (slowed gastric motility)
            1. Assess bowel sounds and pattern
      5. Priorities with Overdose:
         1. Maintain airway
         2. Give supplemental O2
         3. Get a full set of vitals
         4. Check an EKG
         5. Administer a cholinesterase inhibitor (Physostigmine)
         6. Administer cardiac meds (Metoprolol, Labetalol, Cardizem, etc.)
      6. Seizure precautions
         1. Lowers the patient’s threshold for seizures
3. Monoamine oxidase inhibitors (MAOI’s)
   1. 1. Work by inhibiting the entire monoamine oxidase family:
         1. Serotonin
         2. Melatonin
         3. Epinephrine
         4. Norepinephrine
         5. Dopamine
         6. Tyramine
      2. Last Resort option
      3. MANY drug-drug interactions
         1. Opioids – coma, hypo/hypertension, seizures
         2. Vasoconstrictors, nasal decongestants, dopamine, other antidepressants, amphetamines, or tyramine-containing foods – Hypertensive Crisis
            1. Antidote for hypertensive crisis is IV Phentolamine
            2. BP monitoring essential
      4. Strict compliance is essential
      5. Should wear an alert bracelet
      6. 3+ weeks to therapeutic effects
      7. Must taper down to discontinue
      8. Avoid tyramine-containing foods (cured or fermented foods most often) due to risk for Hypertensive Crisis or arrhythmias
         1. Vegetables – Avocadoes, Eggplant, Sauerkraut, Beans
         2. Alcohol: beer, red wine, sherry
         3. Fruits – Bananas, Raisins, Overripe fruits
         4. Anything with caffeine
         5. Meats – Beef, Chicken liver, Sausage, Bologna, Pepperoni, Salami
         6. Dairy – Cheese, particularly aged, Sour cream, Yogurt
         7. Soy sauce

Patient Education

1. Foods and activities to avoid when taking these meds
2. Do not stop taking abruptly, discuss with provider