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NU670 STUDY NOTES – EXAM 2
Mood disorder
- Placing pts in quieter part of unit can be therapeutic when they are displaying aggressive and disruptive behaviors. ANTICONVULSANTS AND MOOD STABILIZERS: VALPROIC ACID (Depakote, divalproex sodium, Valproate, VPA, Depakene) – Anticonvulsant and Mood Stabilizer (used in treatment of seizure disorders or mood disorders) ▪ Works by 2 mechanisms: o 1. Inhibits voltage-gated sodium channels – this accounts for anticonvulsant properties. o 2. Increases amount of GABA – this creates benzo-like sedative effect ▪ Primary considerations before starting pt on valproic acid: o Contraindicated in pregnancy – it is a known teratogen often causing neural tube disorders such as spina bifida. Folate deficiency is also related to neural tube defects. (Think ‘Valpro-ATE the Fol-ATE’ – eats up folate that mother ingests leaving none for fetus and causing neural tube defects). o Rare – but can cause fatal Hepatic Necrosis. ▪ 3 drugs can cause hepatic necrosis: Halothane, Valproic acid, Acetaminophen. ▪ (Think: Butler invites you to ‘HA-Ve a Seat (ACET)’ at dinner table, serving liver (hepatic necrosis). HA-lothane, V-alproic acid, ACETaminophen). ▪ Risk for trigonocephaly and protein-binding interactions with aspirin and warfarin. CARBAMAZEPINE (Tegretol) – anticonvulsant and mood stabilizer. Approved for use in Bipolar Disorder. ▪ Acts primarily by inhibiting voltage-gated sodium channels and augmenting (increases) GABA transmission. ▪ 3 main uses clinically are: trigeminal neuralgia, bipolar, seizures (epilepsy). (Think
- carbamazepine is often abbreviated CBZ – C ranial nerve V, B ipolar, Z eizures).
▪ Risk for Agranulocytosis – severe form of neutropenia, it is a deficiency of granulocytes (type of WBC) in the blood, causing increased vulnerability to infection. (Not as great a risk for mortality as it is with Clozapine -used for schizo, so use is not restricted in registry as it is with Clozapine but should be included in education to pts when starting on Carbamazepine. LAMOTRIGINE (Lamictal) – anticonvulsant and mood stabilizer ▪ chemically unrelated to other anticonvulsants. Does inhibit sodium channels but does NOT activate GABA receptor like others. Clinically this means that Lamotrigine is more suited to helping bipolar in depressed episode, other anticonvulsants have GABA increase which also helps with manic episodes. ▪ Side effect: Widespread itchy rash – occurs in 5-10% of pts – very common, so educate pts what to do if notice skin changes. (Think ‘Lam-ITCH-tal’!) o Rash can sometimes progress to less common and rare (1 in a 1000 pts) - Stevens-Johnson Syndrome = serious dermatologic disease where epidermis sloughs off dermis. If pt has signs of mucous membrane involvement – must consider Stevens-Johnson in differential dx. OXCARBAZEPINE (Trileptal) – only Anticonvulsant NOT FDA approved for mood stabilizer! ▪ Is close relative of Carbamazepine – but has Not been shown to reduce mood cycling in bipolar disorder. ▪ Does not have risk of agranulocytosis TOPIRAMATE (Topamax) - only Anticonvulsant NOT FDA approved for mood stabilizer! ▪ Side effects: weight loss in more than 10% of pts. - can lose 5-15lbs., mental dulling – and in some pts word-finding difficulty (Think ‘DOPE-amax’!). ▪ Greater risk for kidney stones and metabolic acidosis. GABAPENTIN (Neurontin) - only Anticonvulsant NOT FDA approved for mood stabilizer! ▪ Evidence-based to be effective to treat neuropathic pain – diabetic peripheral neuropathy. ▪ Sometimes used to treat mood disorders but not proven to be effective compared to placebo. Promoting rest in a patient with depression - An inappropriately dressed has not slept for 3 days while making excessive phone calls. When pt can be heard singing loudly in examination room, the PMHNP makes initial plans to focus on assessing needs for food, liquids, and rest. Biological needs must be met before mental health. Nefazodone – watch carefully for bradycardia when giving nefazodone for depression
Depending on culture pts may experience different s/s of grief that may appear to be depression. Major depression disorder = to diagnose a major depressive episode must have DEPRESSION + SIGECAPS for 2 ‘blue weeks’
- Depressed mood or anhedonia (loss of interest) along with any 5 of the following:
- Sleep disturbance – too much or too little
- Interest - decreased
- Guilt - increased
- Energy - decrease
- Concentration - decrease
- Appetite - change
- Psychomotor slowing
- Suicide o Depression is more common in women than in men. o ATYPICAL DEPRESSION – can include leaden paralysis. o Pts with major depression commonly display signs of worthlessness. o Can have psychosis with MDD and Bipolar I – but not with bipolar II. Treatment response of antidepressants = ❖ Often an outward change in appearance may indicate antidepressant is working (ex. They take a shower!) Also pt completing self-care activities shows signs that antidepressant is working. ❖ Pts need to be taught that when starting antidepressants they may need to be on the medication for several months after the symptoms have resolved. ❖ Although it may take 6-8 weeks for all symptoms of depression to resolve following initiation of medication, appetite and sleep may improve within 1 week. ❖ Social withdrawal will improve in response to antidepressant therapy. CBT and depression: Activities for depressed clients – melancholic depression pt paces and wrings hands for hours at a time when repeating ‘ I am a bad person.’ Staff members have not been successful at getting her to rest. Asking her to perform an activity like folding towels may help her to rest. Interventions for patients with depression and Therapeutic communication ▪ Well-defined, structured interactions work well when caring for a pt with major depression at the beginning of treatment.
▪ Establishing one small goal to accomplish that day can be an intervention for depressed pts. ▪ Establishing trust is a great first step when you admit a new pt who is depressed. ▪ Suicide -When pts state they find no pleasure in living (passive ideation), the provider should be concerned and place a high priority on that pts care. Active ideation – would be a more definitive plan or idea of ending life. o An appropriate nursing strategy to assist pt who was involuntarily admitted after a suicide attempt is encouraging patient to verbalize personal feelings. ▪ Arranging to spend time with a pt at pre-arranged intervals will facilitate communication with a pt who is depressed and evidencing psychomotor retardation and withdrawal. ▪ Sitting with a pt and gently offering your availability to help will be therapeutic for a pt with MDD that sits in her room for hours staring out the window. ▪ Caring for an extremely depressed pt who is withdrawn and want to assist them to become more interactive. Best approach would be: “I need another person for card game. I want you to be my partner.” Dysthymic disorder (dysthymia) = a chronic low-level depression that lasts for years, while major depression is more severe. (This is when a pt does not meet criteria for major depression.) Dysthymic d/o differs from major depression in that it includes chronic low-level depression. Positive outcome with taking SSRIs – inhibits uptake of serotonin allowing more serotonin to be active and available in synaptic cleft.
- Serotonin = Positive effect is not reached until 4-6 weeks, but negative effects (diarrhea, restlessness) can occur immediately. Includes the following effects: o Head (psychological effects): increased satisfaction, sociality, migraine and decreased anxiety, impulsivity, and sex drive (decrease sex drive is #1 reason ppl stop taking SSRIs) o Red : Effects on platelets, can occasionally cause prolonged bleeding o Fed : GI motility, nausea – another reason ppl stop taking SSRIs
- Nor-epinephrine – boosts energy and focus
- Dopamine – boosts drive and attention ❖ SEROTONIN SYNDROME = is a serious drug reaction. I t is caused by medications that build up high levels of serotonin in the body. o contraindicated drug combinations include: ▪ SRIs + MAOIs ▪ Antidepressants + Sibutramine
amount of time. (Think ‘Pair-oxetine’ – moves faster, has pair of oxen than with just one!) o Important to educate pt to expect initial negative s/e will be seen before desired effect. o Educate pt – if suddenly stop taking drug, withdrawal will happen much faster and result in more severe and uncomfortable withdrawal state. Not good for pregnancy – can produce severe withdrawal symptoms in babies when born, can result in seizures.
- CITALOPRAM (Celexa) – Considered first-line drug – less enzyme interaction. o Concern for QTC interval change- dose not to exceed 40mg/day adults and 20mg/day elderly. Should get yearly EKG on these pts. o (Think ‘ce-lexus’ it is first-line brand name and CAR – need electro-CAR-diogram!)
- ESCITALOPRAM (Lexapro) – younger sibling of celexa o Is the s-antiomer of citalopram – so 10mg dose of escitalopram is equivalent to 20mg dose of citalopram. o Cleanest SSRI in terms of enzyme interactions
- FLUVOXAMINE (Luvox) – unique in that it is only SSRI that is FDA approved in US for OCD. But other SSRIs are beneficial for ocd as well. (Think ‘Flu-vOC-amine’ for OC -obsessive compulsive!) SNRIs:
- VENLAFAXINE (Effexor) – Inhibits reuptake of both Serotonin and Norepinephrine. (Think ve’N’lafaxine – ‘N’orepinephrine!) o Side effect = HTN – pts have 50-100% higher risk in developing HTN, likely due to norepinephrine’s effects on peripheral vascular system. Usually is short-lived so is ok as long as no history of HTN.
- DULOXETINE (Cymbalta) - Inhibits reuptake of both Serotonin and Norepinephrine. (Think ‘Dual-oxetine’ for both SE and NE!) o Also used for pts with chronic pain conditions ex: fibromyalgia, diabetic neuropathy, premenstrual symptoms – as it diminishes pain sensation. (Think ‘Dull’-oxetine as it ‘dulls’ pain!) - MIRTAZAPINE (Remeron) - Inhibits reuptake of both Serotonin and Norepinephrine. a- 2 adrenergic receptor antangonist o Used to stimulate appetite to counteract cachexia seen in cancer pts, HIV, elderly. (Think MEAL-tazapine!)
o Helps to decrease nausea (different than standard SSRIs that increase nausea). o Also helps depressive symptoms ATYPICAL ANTIDEPRESSANTS
- BUPROPION (Wellbutrin, Zyban) – NDRI - norepinephrine dopamine reuptake inhibitor (Think butane lighter – ‘BU-DA-NE’ bupropion/dopamine/norepinephrine!) o Like a butane lighter – think fire-birthday candles – increase happiness, hot sex (no sexual s/e), cigarette lighter- helps to quit smoking o Due to excitatory properties, has propensity to lower seizure threshold. Strongly contraindicated with bulimia dx = Can cause seizures in bulimic pts especially sec to electrolyte imbalance r/t frequent vomiting – causing increased risk for seizures.
- TRAZADONE (Desyrel) – SARI - Serotonin antagonist and reuptake inhibitor (serotonin modulator) o Used as antidepressant and commonly as a sleeping aid (think ‘tra-zzzz-adone’!). But works best as sleeping aid for pts with depression, so not an all-purpose sleep aid for just anyone. Often used for insomnia – doses for insomnia are much lower. o Side effect – Priapism = prolonged erection lasting several hours - this is a medical emergency !! (Think ‘Traza-BONE’!) o Watch for sedation when prescribing trazodone.
- Vilazodone (Viibryd) – SPARI - cannot take GRAPEFRUIT JUICE while on this med. o Combines SERT (serotonin transporter) inhibition with 5HT (serotonin receptor) partial agonism. That is why it is called SPARI – serotonin partial agonist reuptake inhibitor. o This combination of SERT inhibition and 5HT partial agonism has long been known to enhance unipolar antidepressant properties and tolerability of SSRIs/SNRIs in some pts. With Vilazodone- this can be accomplished with just one drug as an adjunct and avoids drug interactions and various off-target receptor actions that the following drugs used for this same action can have. (ex: using as adjuncts – buspirone, aripiprazole, brexpiprazole, cariprazine, quetiapine). o Vilazodone – less noted side effects of sexual dysfunction and weight gain Tricyclic antidepressants = TCAs are oldest class of antidepressants– complex mechanism of action- inhibits reuptake of SE and NE while antagonizing ACh and HIS and at the same time inhibiting Na and Ca ion channels.
3 squares width.) ❖ Treatment for TCA overdose = SODIUM BICARBONATE is treatment for TCA overdose. (Think a bi-CAR-bonate, can beat a Tricycle (tryciclic overdose) every time!) Symptoms of a client with bipolar disorder – must have at least 3 to diagnose per DSM and symptoms occurring for 1 week to qualify as a manic episode (Think ‘One Fun Week’ – mania). Must have elevated mood and 3 or more of following, if only irritable mood then must have 4 or more.
- DIGFAST: o Distractibility o Irresponsibility o Grandiosity: experienced by pts with bipolar d/o during manic or hypomanic episodes. Pts experiencing grandiose delusions often describe larger-than-life feelings of superiority and invulnerability. o Flight of ideas = most likely indicates pt has bipolar d/o and is in a manic episode. o Agitation o Sleep o Talkativeness
- Must be treated by psychiatrist as lithium requires close monitoring and the illness has highs and lows. Education about lithium
- Med Management: Acute Manic phase – treat with antipsychotics initially concurrently with mood stabilizers as mood stabilizers don’t work fast enough for acute manic episode – antipsychotics are used to bridge the time for mood stabilizer to begin working which takes about 10 days. Chronic manic – mood stabilizers only. Depressive phase – acute and chronic – treat with mood stabilizers.
- Why we don’t treat bipolar with antidepressants: Antidepressants have been shown to be ineffective at treating bipolar depression and also will induce a shift into manic episodes and create a ‘rapid cycling’ type of bipolar. Never give antidepressants to pt with known bipolar d/o.
- Medications used to treat: o olanzapine-fluoxetine o quetiapine o Lurasidone – most widely used to treat bipolar depression o Cariprazine- approved for acute bipolar mania and acute bipolar depression Important differentiation between bipolar and borderline : Timing, Mood, Frequency, Treatment o Timing : Bipolar – mood changes for weeks to months. Borderline - mood changes within seconds to hours. o Mood : Bipolar – often independent of life events. Borderline – highly dependent on life events. o Frequency : Bipolar – rare – 1-3%. Borderline – more common – 6-10%. o Treatment : bipolar can be helped with meds and therapy. Borderline cannot be helped with meds but primarily with therapy – DBT dialectic behavioral therapy has been shown to be effective. Lithium (Eskalith) = pts with bipolar who are effectively controlled with lithium will probably need to take it the rest of their lives. ▪ List of labs to be checked before starting lithium: o Lithium level o Electrolytes
Treatment resistance depression and treatment options = TCAs (second-line: used only if other treatments do not work), MAOIs, Genotyping – several genetic forms of numerous cytochrome P450 (CYP450) drug metabolizing enzymes can be obtained to predict high or low levels of drug, and therefore lack of efficacy (low drug levels) or side effects (high drug levels). Genotyping can be combined with phenotyping (obtaining actual plasma drug levels) – together these can help explain side effects and lack of therapeutic effect in some pts. Drugs that are FDA approved for MDD – treatment resistant: o Olanzapine – Fluoxetine combination o Quetiapine – as an adjunct o Brexpiprazole – as an adjunct o Aripiprazole – as an adjunct o (Cariprazine) as an adjunct ❖ Drugs not specifically approved but have been used as adjunct with other antidepressants: o Lithium o Buspirone o Thyroid hormones o Triple-action combo: SSRI/SNRI+NDRI – combining serotonin, norepinephrine, and dopamine o SNRI + mirtazapine o Arousal combo – to combat fatigue, loss of energy, sex drive, motivation: SNRI
- stimulant ex. DAT (dopamine transporter) inhibitor – to increase dopamine. Or modafinil (also a DAT inhibitor) + SNRI. Main purpose is to enhance dopamine. ▪ Repetitive transcranial magnetic stimulation (rTMS). This type of treatment uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. An electromagnetic coil is placed against your scalp near your forehead. The electromagnet used in rTMS creates electric currents that stimulate nerve cells in the region of your brain involved in mood control and depression. Typically, this treatment is delivered over 30-minute sessions in rapid bursts. This treatment can now be delivered over briefer sessions with dosing called intermittent theta burst stimulation. ▪ Ketamine o Mechanism of action: blocks NMDA receptors via upstream NMDA antagonism which produces burst of Glutamate release which stimulates AMPA receptors and dendritic spine proliferation
indicates new
▪ Prior to initiating Nardil – determine the pts cognitive ability to understand information about the med (such as avoiding tyramine – can cause hypertensive crisis , and also drug-drug interactions that can cause
serotonin syndrome ).Provider must stay up to date on latest warnings of drug interactions. ▪ When a depressed pt starts Nardil, ensure the family is taught about the many food-drug interactions. o SELEGILINE – selective for ‘b’ subtype of MAOI (MAOI-B) and causes increase of DA only – think ‘Select-tiline’! Good for Parkinson’s. ➢ Severe s/e = HYPERTENSIVE CRISIS – requires emergency treatment o Caused by taking MAOI and eating foods with tyramine – an amino acid (protein) found in body and in foods. (Think of being on island of ‘Maui (Maoi)’ on a date with ‘Tyra’mine eating aged wine and cheese!) o How it works: catecholamines build up to such an extent that all blood vessels constrict causing incredibly high blood pressure. o If take MAOI and eat foods high in tyramine, the tyramine can quickly reach dangerous levels. This causes a spike in blood pressure and requires emergency treatment. ➢ Diet restrictions and MAOI = must avoid foods containing TYRAMINE – such as aged wine and cheeses. Any food that is aged, cured, pickled, smoked, fermented, tap or unpasteurized beer, red wine, dried fruit, and fresh citrus. ➢ Must wait 14 days from last dose of MAOI if discontinuing the MAOI before starting anything else (concern for serotonin issue) Treatment for OCD ➢ FLUVOXAMINE (Luvox) – unique in that it is only SSRI that is FDA approved in US for OCD. But other SSRIs are beneficial for ocd as well. (Think ‘Flu-vOC-amine’ for OC -obsessive compulsive!) ➢ CLOMIPRAMINE (Anaranil) – TCA. Considered the ‘Gold Standard’ for treatment of OCD. Found to be most effective compared to Fluvoxamine or Fluoxetine. Due to bad s/e Clomipramine is reserved for more severe or refractory cases of OCD. RECENT ANXIETY symptoms – pts will most likely respond to benzodiazepines. Self-care deficit sec to possible depression may be a nursing diagnosis applicable to a pt who recently experienced surgery and is saddened by the rehabilitation process. INTRAMUSCULAR BENZODIAZEPINE – Pts experiencing nausea and vomiting due to alcohol withdrawal will have to be given benzo intramuscularly as oral route not effective. Benzodiazepines are metabolized by liver. Lorazepam, oxazepam, temazepam – do not go through cytochrome P450 metabolism (Phase I metabolism), they are only metabolized via
o Barbiturates – increase duration of time GABA channels stay open (think ‘barbi- DURATEs’) ▪ Not used as much due to risk of overdose. Used with physician- assisted suicide and lethal injections as capitol punishment. (Serax) - Oxazepam is a benzodiazepine. Benzodiazepines belong to the group of medicines called central nervous system (CNS) depressants, which are medicines that slow down the nervous system.
- bipolar disorder, schizophrenia—Should not be used in patients with this condition.
- Do not use with Flumazenil (Flumazenil is a benzodiazepine antagonist. The primary FDA-approved clinical uses for flumazenil include reversal agents for benzodiazepine overdose and postoperative sedation from benzodiazepine anesthetics. Flumazenil injection is indicated for a complete or partial reversal of the sedative effects of benzodiazepines in conscious sedation and general anesthesia in adult and pediatric populations.
- Do not use and eat Cabbage
- Kidney disease or Liver disease—Use with caution. The effects may be increased because of slower removal of the medicine from the body. Librium / Chlordiazepoxide hydrochloride -- is a benzodiazepine. It is used to relieve symptoms of anxiety, including nervousness or anxiety that happens before a surgery. It may also be used to treat symptoms of alcohol withdrawal.
- Do not use with Flumazenil (Flumazenil is a benzodiazepine antagonist.)
- Kidney disease or Liver disease—Use with caution. The effects may be increased because of slower removal of the medicine from the body. Valium / Diazepam – benzodiazepine. is used to relieve symptoms of anxiety and alcohol withdrawal. This medicine may also be used to treat certain seizure disorders and help relax muscles or relieve muscle spasm.
- Do not use with Flumazenil (Flumazenil is a benzodiazepine antagonist.)
- Do not drink GRAPEFRUIT JUICE
- Kidney disease or Liver disease—Use with caution. The effects may be increased because of slower removal of the medicine from the body.
- Breathing problems, severe or
- Glaucoma, narrow-angle or
- Liver disease, severe or
- Myasthenia gravis or
- Sleep apnea (temporary stopping of breathing during sleep)—
Should not be used in patients with these conditions.
