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Antidepressant, Antimanic, & Antianxiety Medications
A. Introduction:
This lab will focuses on the use of antidepressant medication, antimanic
medication, and antianxiety medication in the treatment of clients who suffer from
mood and anxiety disorders.
B. Learning Objectives:
Upon completion of this lab the student will be able to:
1. List 4 Tricyclic , SSRI, and Atypical Antidepressants
2. Describe the Neurotransmitters each group effects
3. Discuss pros and cons of each category
4. Describe common side effects and nursing implications
5. List 4 Anti-Manic medications
6. Describe common side effects and Therapeutic range of each drug
7. Discuss safety issues with Lithium
8. List 5 Anti-anxiety medications
9. Describe neurotransmitters this drug effects
10. Discuss uses of these drugs and side effects
C. Learning Resources:
1. Keltner, N.L., Schwecke, L.H., & Bostrom, C.E. (2003). Psychiatric Nursing
(4th edition) St Louis: Mosby, pp. 233-26.
2. Read handout: Psychotropic Drugs
3. Film: Depression and Manic-Depression
Antidepressant Medication:
1. Herbal antidepressant
A. St. John’s Wort
B. Used in Germany more than Prozac
C. Be aware that different products can vary
D. Mode of action is similar to SSRI in that they promote serotonin in the synapse
E. Dosage - 900 mg daily with 3% hypercum in formula
F. Often divided into 300 mg doses or 300 in AM and 600 in PM
G. Side effects: upset stomach, take with food
H. Takes at least 3 weeks to feel positive effects
2. Nutraceutical - A natural product that promotes good health
A. SAM-e - S-adenosylmethionine - is found in all living cells and is formed from the
sulfur containing amino acid metionine and the molecule adenosine-triphosphate
B. Mode of action - enhances brain dopamine and serotonin metabolism and receptor
function.
C. SAM-e outsells Prozac in Italy
D. This product for mild to moderate depression
E. Expensive - Available in 100 and 200 mgs, usual dose is 400 mg
F. Source: Psychopharmocology Update, June, 1999
G. Article recommends 2 brands; Nature Made and GNC
3. Tricyclic or Typical Antidepressants - Effects norepinephrine, serotonin, and
acetylcholine
A. These are the “old” antidepressants. Their side effect profiles were difficult.
B. The most dangerous aspect of these drugs are their cardiotoxicity, making them
very dangerous in overdose situations.
C. Here is a list of these drugs:
TRADE NAME
Elavil®
Sinequan®, Adapin®
Pamelor®, Aventyl®
-Tricyclics Tofranil®
Norpramin®
Vivactyl®
Ludiomil®
Asendin®
GENERIC NAME
amitriptyline
doxepin
nortriptyline
imipramine
desipramine
protriptyline
maprotiline
amoxapine
4. Side effects of antidepressant medications-TricyclicsA. Drowsiness: may be a beneficial effect in patients with insomnia
B. Anticholinergic side effects:
- increase in heart rate
- dry mouth
- blurred vision
- constipation
- urinary retention
- nasal congestion
C. Cardiovascular side effects:
- postural hypotension
- arrhythmias
D. Miscellaneous side effects:
- agranulocytosis
- menstrual irregularities
- weight gain
- precipitation of mania in manic-depressive patients
- decrease seizure threshold - ie. increased seizure activity
- stomach upset
- sexual dysfunction
5. SSRI Antidepressants or Serotonin Specific Re-uptake Inhibitors
A. These medications effect serotonin only.
B. Better side effect profile
C. Low overdose lethality
D. These drugs are:
1. Prozac/Fluoxetine - 20 mg
2. Luvox/Fluvoxamine - 50-100 mg
3. Paxil/Paroxetine 20 mg
4. Zoloft/Sertraline 50-100 mg
5. Celexa - 20-60 mg
E. Individual side effect profiles exist, but some are typical for all
F. These are: GI upset, sexual dysfunction, dry mouth
G. Individual profiles are:
1. Prozac-Very energizing, decreases appetite, can cause anxiety, insomnia
2. Zoloft-Fewest side effects, Headaches are common problem and always take
with food for the best response
3. Paxil-most calming, used for patients with high anxiety, has more anticholinergic
effects, especially dry mouth and constipation
4. Celexa-Cheaper, less interactions with other medications, safer for elderly
6. Atypicals:
-Effexor/Venlafaxine
-Serzone/Nefazadone
-Wellburin/Bupropion, also called Zyban for smoking cessation
-Desyrel/Trazodone
-Remoran/Mirtzapine
-Rebaxetine/ Vesta
7. Facts about atypicals:
A. Venlafaxine- effexor-effects NE and 5HT (serotonin)
- Pros: minimal drug interaction risk, effective with geriatric pts., low sexual side
effects
- Cons: Increase diastolic BP. Nausea, requires BID dosing, dry mouth,
somnolence, dizziness.
- Dosing: Comes is XR form. Can dose all in AM. Range is from 75 - 225 mg.
B. Nefazadone- serzone -effects NE and 5HT ( lower effects of 5HT)
- Pros: low anxiety and insomnia, no sexual side effects, low mania induction,
safe for elderly
- Cons: BID dosing, modest somnolence, dry mouth nausea, dizziness,
bradycardia
- Dosing: Range from 150 mg to 300 mg
C. Buproprion - wellbutrin - effects unclear, some NE
- Pros: Lowest side effects, unique mechanism; therefore works in depressions
where no other drug work. Low mania induction, low sexual side effects
- Cons: SEIZURES, especially in high-risk individuals (bulimics, head injury,
multiproblem pts.) Divide doses to decrease risk. Also, seizure release has
great decrease in seizures.
- Dosing: Bupropion SR Begin at 100 Mg BID, then 150 BID
D. Trazodone- Desyrel: very weak NE and 5ht
- Pros: Great for sleep induction. Nonaddicting
- Cons: Can cause anticholenergic side effects, can cause priapism (continues
erection) rare side effect, but very painful
- Dosing: Range is from 25 to 150 mg. Usually dosed HS
E. Mirtazapine - Remoran: Decrease re-uptake of serotonin and to a lesser extent,
Norepinephrine
- Pros: Great for sleep induction and increases appetite. Also, has a low
interaction profile with other medications. Once daily dosing at night. Low
sexual side effects
- Cons: Can cause platelets to decrease in a few cases. Increase in wt. and
sedation
- Dosing: range is from 15 Mg to 45 Mg at HS
F. Rebaxetine/ Vesta ® a selective presynaptic haradrenergie reputable inhibition.
Very little effect on other neurotransmitters.
- Pros: activating, less stomach upset than Prozac, works in 10 day s or
less- improves social functioning
- Cons: Cardiotoxic in overdose, Tayhycardia , insomnia dry mouth,
constipation, urinary hesitancy and retention, increased sweating
-
Dosing-8-10 mg Bid
1. Anti-manic medications for the manic phase of Bipolar disorder
A. Lithium
1. Dosage forms
- Lithium carbonate capsules or tablets - Eskalith® (1 capsule or
tablet=300mg =8mEq Lithium)
- Lithium carbonate time- released tablets - Lithobid® (1 tablet=300mg=8mEq
Lithium)
- Lithium citrate syrup - lithionate® (1 teaspoonful = 5ml=560mg=8mEq
Lithium)
2. Time course of response to drug therapy
Acute manic episode subsides within 1 week to 10 days. A time lag of 5 to
10 days is often seen before therapeutic effect of lithium is observed.
Antipsychotics are used initially to quickly abort the manic episode. The
antipsychotic is tapered off as the lithium takes effect.
3. Lithium blood concentrations
During the acute phase:
During the maintenance phase:
0.8-1.2 mEq/liter
0.6-1.0 mEq/liter
4. Side effects of lithium therapy
a. Early side effects: common; they usually go away after several days of
treatment
- stomach upset: nausea, vomiting, diarrhea, stomach pain; taking
medication with meals helps. If this effect occurs later in therapy or
persists for more than 2 days, it may be a sign of toxicity and
professional advice should be sought.
- fine hand tremor: usually seen during activity
- fatigue, muscle weakness, dazed feeling
- increased thirst and frequent urination: patients should be instructed to
maintain a consistent daily intake of fluid and salt, as lithium excertion
is dependent on these substances. Dehydration and salt restriction can
increase lithium blood concentrations leading to toxicity consumption of
fluid and salt can cause decreased lithium blood concentrations and
loss of therapeutic effect.
b. Persistent side effects: not dose related
- fine hand tremor: use of divided doses or a timed - released product is
often helpful
- increased thirst and urination
- increased white blood cell count
c. Late side effects: moderate toxicity. Lithium blood concentrations of 1.5
mEq/liter or greater
- more severe hand tremor, coarsening of the tremor
- reappearance of GI symptoms (nausea, vomiting, diarrhea) - see above
- confusion
- hypothyroidism; can give thyroid hormone supplement
- ataxia
- slurred speech
d. Severe toxicity: overdose effects. Lithium blood concentrations of 2.5
mEq/liter or greater
- seizures
- coma
- cardiovascular collapse
- death
5. Advantages and disadvantages of lithium therapy
Advantages
- will control a manic pa
- will normalize mood
- very good prophylactically to decrease mood swings
- relapses, when they occur, are less severe and usually shorter in duration
blood concentration monitoring allows careful titration to therapeutic
concentration
- low drug cost
Disadvantages
- narrow range of therapeutic blood concentrations, requires close monitoring to
prevent toxicity
- patient compliance and understanding of the warning signs of toxicity is
important
- lag period before therapeutic effect in manic patients
- prophylactic effect may take 6 months to 1 year to maximize
- rapid cyclers are poor responders
- expense of blood concentration
B. Depakote/ Divalproex Sodium
1. Blood test for level: Desired plasma concentration is between 50 and 125 mg
2. Acute side effects: GI DISTRESS, sedation, rashes, cognitive dulling, Decrease
granulocytes and platelets; do appropriate blood tests
3. Long term side effects: hair loss, (give zinc and selenium) increased appetite
and wt. gain and cognitive dulling
4. Drug is metabolized in the liver by the cytochrome P450 system
5. Sign and symptoms of toxicity are: ataxia, visual hallucinations, coma stupor,
and increased sedation
6. Onset of action for symptom relief: 5 days to two weeks after serum levels are
>50mcg/ml
7. Dosage: 750 to 1500 mg daily in divided doses
C. Tegretol/Carbamazepine
1. Blood test for level: Plasma level 4-12 is therapeutic range
2. Acute side effects: Cognitive dulling, sedation, tremor, GI distress
3. Maintenance therapy side effects: antoinduction after 4-6 weeks, hyponatremia,
check liver functions and CBC
4. Drug is metabolized in the liver by the cytochrome P450
5. Signs and symptoms of toxicity: dizziness, ataxia, diplopia, increased sedaton,
stupor, and coma
6. Onset of action for symptom relief: 1 to 2 weeks after serum levels are > 4
mcg/ml
7. Dosage: 200 Mg to 1400 Mg daily in divided doses
D. Neurontin/Gabapentin
1. Mechanism of action unknown; structurally similar to GABA
2. Does not require blood levels
3. Dizziness, fatigue, dry mouth, blurred vision, constipation are all side effects.
4. Dosage: 900 to 1800 mg per day in three doses
E. Klonapin/Clonazapam
1. Used to help augment the anti-manic regimen
2. Long acting benzodiazepine-take BID
3. Doseage - 1 - to - 2 mg
4. Aides in sleeping and helps to take the edge off the mania
5. Side effects: Clients can abuse drug, though they are less likely to abuse this
one due to its being long acting, thereby decreasing their need to take it for
symptom relief.
6. BEWARE: this drug should not be mixed with alcohol.
1. Anti-anxiety medications:
A. Herbal: Kava-Kava- used in Polynesia for years
1. Germans researched drug and compared it to Serax
2. Can cause stomach upset; take with food
3. Herbal resource is: The Complete German Commission E Monographs
B. Buspar/Buspirone
1. Dosage - 15 to 60 mg
2. Side effects: Drowsiness, dizziness, headache, and nervousness
3. Good drug for “worry”, does not give the muscle relaxant effect that benzo’s do
4. Slow onset of action: 3 to 4 weeks
5. Mechanism of action is unknown
C. Benzodiazepines
1. Class of medications potentates the effects of GABA
2. Has addictive potential
3. Has muscle relaxant anticonvulsant effects
4. Patients must be withdrawn for these drugs slowly or they will have seizures.
5. Side effects: drowsiness, dizziness, fatigue, and psychomotor impairment
6. Drugs in this class vary according to onset of action and length of time the drug
remains in the system.
7. Ativan and Klonopin are the most used in the psychiatric setting.
8. Ativan - is used for aggressive behavior because it is quick acting and available
in IM form.
9. Klonopin - for mania due to its long acting qualities
10. Libirium and Tranxene are used for withdrawal for alcohol and other drugs.
11. Restoril and Ambien are used for sleep.
12. Antacids interfere with absorption- give 1 hour before or after