ppt chapter 16

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 16

Drugs Treating Mood Disorders


Physiology • The brain contains billions of specialized cells called

neurons.

• The communication from one neuron to another is called neurotransmission.

• Several neurotransmitters exist, each of which travels to a specific neuroreceptor site.

• Neurotransmission plays a role in both normal and abnormal brain function.

• What seems obvious, but is often forgotten, is that the mind and the brain are the same organ.

• Certain activities are often thought of as belonging to either the mind or the brain.


Pathophysiology

• Genetic studies identified a specific gene that predisposes some people to develop depression when exposed to emotional stressors.

• Specific neurotransmitters are believed to affect mood.

• Illnesses resulting in mood disorder are associated with an imbalance or dysregulation of neurotransmitters.

• Research also shows an association between arterial stiffness and depression in the elderly.


Major Depressive Disorder

• Specific criteria to describe and diagnose depressive disorders are outlined by the American Psychiatric Association in the Diagnostic and Statistical Manual for Mental Disorders, fourth edition, text revision (DSM-IV-TR).

• Diagnosing major depression is partly a process of elimination.

• A pattern of other signs and symptoms must be present to complete an accurate diagnosis of major depression.


Major Depressive Disorder (cont.)

• Risk factors for depression include

– Having previously been depressed

– Having a first-degree relative diagnosed with depression

– Being a woman, an adolescent, or a young adult


Drugs that Cause Depression


Dysthymic Disorder• Similar symptoms to major depression: depressed mood,

sleep disturbance, low energy, and poor concentration

• The defining feature is chronicity of symptoms.

– 2 years in adults

– Minimum of 1 year in children and adolescents

• Serious disorder, can be very disabling, often occurs with other psychiatric disorders.

• Other symptoms include low self-esteem, inability to make decisions, and feelings of hopelessness.

• Can progress to major depressive episode


Bipolar Disorder

• Bipolar disorder is diagnosed when a person experiences symptoms of depression at some times and symptoms of mania at others.

• Throughout their lifetimes, approximately 0.5% to 2% of the general population is at risk for developing bipolar disorder.

• This mood disorder affects approximately 5.7 million American adults in a given year.

• Bipolar disorder affects men and women evenly.

• With treatment, 70% to 80% of people are able to live meaningful, productive lives.


Selective Serotonin Reuptake Inhibitors

• Currently, the selective serotonin reuptake inhibitors (SSRIs) are the first choice for treating depression.

• They are preferred over the tricyclics and the MAOIs because they can cause less side effects.

• Their effectiveness, combined with the increasing social acceptance of antidepressant use, led many patients to ask their physicians for Prozac.

• Prototype drug: sertraline (Zoloft)


Sertraline: Core Drug Knowledge

• Pharmacotherapeutics

– Treatment of depression, anxiety, and PTSD

• Pharmacokinetics

– Administered: oral. Metabolism: liver. Steady state: 7 days.

• Pharmacodynamics

– Potent and selective inhibitor of neuronal serotonin reuptake and has a weak effect on norepinephrine and dopamine neuronal reuptake


Sertraline: Core Drug Knowledge (cont.)

• Contraindications and precautions

– Decreased liver function

• Adverse effects

– GI distress, headache, fatigue, insomnia, and sexual dysfunction

• Drug interactions

– Administration with highly protein-bound drugs


Sertraline: Core Patient Variables

• Health status

– Past medical, including drug use and physical assessment

• Life span and gender

– Pregnancy Category C drug

• Lifestyle, diet, and habits

– Can affect sexual function

• Culture and inherited traits

– Assess cultural background.


Sertraline: Nursing Diagnoses and Outcomes • Risk for Suicide related to increased energy from sertraline

without relief of suicidal ideations or low mood

– Desired outcome: The patient will identify alternative coping mechanisms.

• Restlessness related to psychomotor agitation secondary to sertraline use

– Desired outcome: The patient will identify appropriate interventions to promote relaxation.

• Sleep Pattern Disturbance: Less than Body Requirements related to psychomotor agitation secondary to sertraline use

– Desired outcome: The patient will identify appropriate interventions to promote sleep.


Sertraline: Nursing Diagnoses and Outcomes (cont.)• Nausea, abdominal pain, or both related to abnormal

peristalsis secondary to sertraline use

– Desired outcome: The patient will report a decrease of nausea.

• Diarrhea and loose stools related to adverse effects of medication secondary to sertraline use

– Desired outcome: The patient will re-establish and maintain normal pattern of bowel functioning.

• Sexual Dysfunction related to disrupted sexual response pattern, such as impotence or anorgasmia, secondary to sertraline use

– Desired outcome: The patient will identify satisfying and acceptable sexual practices and some alternative ways of dealing with sexual expression.


Sertraline: Planning and Interventions

• Maximizing therapeutic effects

– Maximum effect not achieved for several weeks

– Assess depression using a standard scale.

• Minimizing adverse effects

– Assess for adverse effects.

– Assess for worsening of depression.


Sertraline: Teaching, Assessment, and Evaluations

• Patient and family education

– Educate patients and families about realistic expectations for antidepressant therapy.

– Do not abruptly stop medication.

• Ongoing assessment and evaluation

– Continue to assess the patient’s mood and observe any increase in anxiety, nervousness, restlessness, or insomnia.


Question

• When providing patient teaching about sertraline, what would the nurse instruct the patient about the maximum effect of the drug?

– A. The drug will achieve maximum effectiveness in the first few days of therapy.

– B. The drug will achieve maximum effectiveness in the first week of therapy.

– C. The drug will achieve maximum effectiveness in several weeks of therapy.

– D. The drug will achieve maximum effectiveness in 6 months of therapy.


Answer

• C. The drug will achieve maximum effectiveness in several weeks of therapy.

• Rationale: The patient does not experience the maximum therapeutic effect for several weeks.


Tricyclic Antidepressants

• The tricyclics were named for their molecular structure.

• Tricyclics have a very narrow therapeutic index.

• All tricyclics enhance the activity of norepinephrine and serotonin by blocking neuronal reuptake of these neurotransmitters.

• Prototype drug: nortriptyline (Pamelor)


Nortriptyline: Core Drug Knowledge


– Used to treat depression and chronic pain


– Administered: oral. Metabolism: liver. Peak: 2 to 4 hours.


– Specifically blocks reuptake of NE into nerve terminals, thereby allowing increased concentration at postsynaptic effector sites.


Nortriptyline: Core Drug Knowledge (cont.)


– Cardiovascular disorders

• Adverse effects

– Disturbed concentration and confusion, headache, tremors, nausea, vomiting, bone marrow depression, urinary retention, and sexual function disturbances


– Multiple drug interactions


Nortriptyline: Core Patient Variables • Health status

– Assess for preexisting cardiovascular conditions.


– May cause more side effects in elderly


– Assess symptoms of depression before starting therapy.


– There are very few data about the effects of the drug on races other than whites of European descent.


Nortriptyline: Nursing Diagnoses and Outcomes

• Constipation or diarrhea related to medication use

– Desired outcome: The patient will establish normal bowel habits.

• Disturbed Sleep Pattern related to medication-induced somnolence or insomnia

– Desired outcome: The patient will report a satisfactory balance of rest and activity.


Nortriptyline: Nursing Diagnoses and Outcomes (cont.)

• Risk for Poisoning related to TCA toxicity

– Desired outcome: The patient will identify factors that increase the risk for and verbalize practices to prevent poisoning.

• Risk for Injury related to adverse effects (e.g., blurred vision, drowsiness, and hypotension) secondary to nortriptyline use

– Desired outcome: The patient will identify factors that increase the risk for and elated intent to practice safety measures to prevent injury.


Nortriptyline: Nursing Diagnoses and Outcomes (cont.)

• Imbalanced nutrition: More than Body Requirements, related to adverse effects of nortriptyline

– Desired outcome: The patient will verbalize reasons for a risk for weight gain, identify normal nutritional needs, and discuss methods to control weight.

• Disturbed Sensory Perception related to chemical alterations secondary to nortriptyline therapy

– Desired outcome: The patient will experience normal sensory perception.


Nortriptyline: Planning and Interventions


– Monitor blood plasma drug levels.

– A single dose at bedtime may be used.


– May need to dose the drug twice a day to avoid adverse effects

– Older adults should receive a smaller initial dose.


Nortriptyline: Teaching, Assessment, and Evaluations


– Teach patients and families that the therapeutic response will not be immediate.

– Teach patients to take the drug as prescribed.


– Continually assess depressed patients for suicidal thoughts during nortriptyline therapy.

– Obtain baseline and periodic laboratory blood tests during therapy.


Question

• What is the most significant side effect of nortriptyline?

– A. Weight gain

– B. Hypotension

– C. Sedation

– D. Constipation


Answer

• B. Hypotension

• Rationale: Hypotension is the most serious side effect of nortriptyline.


Monoamine Oxidase Inhibitors

• The monoamine oxidase (MAO) enzyme system is widely distributed throughout the body.

• This system is responsible for metabolizing amines such as dopamine, epinephrine, norepinephrine, and serotonin.

• Drugs described as MAOIs inhibit MAO enzymes, thereby increasing the concentration of those amines.

• Prototype drug: phenelzine (Nardil).


Phenelzine: Core Drug Knowledge


– Used to treat depression


– Administered: oral. Excreted: Urine. Peak: 2 to 4 hours.


– Increases the concentrations of DA, NE, and serotonin within the neuronal synapse


Phenelzine: Core Drug Knowledge (cont.)


– Decreased liver function and congestive heart failure

• Adverse effects

– Liver damage, anticholinergic effects, agranulocytosis, leukopenia, thrombocytopenia, and sexual dysfunction


– Multiple drugs and certain foods


Phenelzine: Core Patient Variables • Health status

– Cardiovascular assessment and baseline labs


– Pregnancy Category C drug, not recommended for use <16 yrs


– Assess activities of daily living.

• Environment

– Assess environment where the drug will be given.


– Assess cultural background.


Phenelzine: Nursing Diagnoses and Outcomes • Risk for Injury related to drug–nutrient, drug–drug, or

drug–environment interactions or hypertensive crisis secondary to phenelzine antidepressant therapy

– Desired outcome: The patient will remain safe.

• Ineffective Therapeutic Regimen Management related to MAOI-required dietary restrictions

– Desired outcome: The patient will acknowledge an understanding of the need to follow a low-tyramine diet.

• Imbalanced nutrition: More than Body Requirements related to adverse effect of phenelzine

– Desired outcome: The patient will understand and acknowledge the risk for weight gain.


Phenelzine: Planning and Interventions


– Platelet MAO enzyme activity (mostly B subtype) is usually measured before therapy and during therapy.


– Numerous dietary and medication restrictions

– Monitor for symptoms of hypertensive crisis.


Phenelzine: Teaching, Assessment, and Evaluations


– Warn all patients about not eating foods with high tyramine content or consuming alcohol.

– Stress importance of not stopping medication.


– Observation of the patient is necessary to identify the therapeutic effects of phenelzine.

– Perform frequent blood pressure monitoring during therapy.


Question

• What laboratory test should be done prior to starting phenelzine?

– A. CBC and PT

– B. CBC and LFT

– C. LFT and BUN

– D. Lipase and creatinine


Answer

• B. CBC and LFT

• Rationale: A complete blood count (CBC) and liver function tests (LFT) should be assessed before and during therapy due to the adverse effects of the drug.


Mood Stabilizers

• During episodes of mania, the patient is treated with mood-stabilizing medication.

• Treatment with these drugs decreases the extreme range of mood experienced by the patient.

• Prototype drug: lithium carbonate (Eskalith)


Lithium: Core Drug Knowledge


– Primary action is to prevent extreme mood swings.


– Administered: oral. Metabolism: liver. Excreted: kidneys. Onset: 5 to 7 days. Duration: 1 to 4 hours.


– It competes with calcium, magnesium, potassium, and sodium in body tissues and at binding sites.

– It alters sodium transport in nerve and muscle cells.


Lithium: Core Drug Knowledge (cont.)


– Severe cardiovascular or renal disease

• Adverse effects

– Coarse hand tremor, severe gastrointestinal upset, blurred vision, drowsiness, and confusion


– Thiazide diuretics and angiotensin-converting enzyme inhibitors


Lithium: Core Patient Variables• Health status

– Past medical and physical assessment


– Pregnancy Category D drug


– Assess alcohol and caffeine intake.

• Environment

– Assess environment where the drug will be given.


– Assess for Japanese heritage.


Lithium: Nursing Diagnoses and Outcomes

• Ineffective Therapeutic Regimen Management related to questions about the benefits of the regime

– Desired outcome: The patient will adhere to taking lithium as prescribed to maintain a therapeutic serum lithium level.

• Excess Fluid Volume related to water retention secondary to lithium therapy

– Desired outcome: The patient will adopt strategies to restore and maintain proper fluid balance.

• Risk for Poisoning related to effects of lithium toxicity

– Desired outcome: The patient will comply with regular monitoring of blood lithium levels to maintain a therapeutic serum level.


Lithium: Planning and Interventions


– Instruct the patient about early warning signs of a relapse of mania.


– Monitor blood levels of medication.

– Assess for dehydration, which increases the risk of toxicity.


Lithium: Teaching, Assessment, and Evaluations


– Teach symptoms of toxicity.

– Stress follow-up care.


– Monitor drug levels.

– Monitor behaviors before and during treatment.

ppt chapter 16

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