PHARM chap 16 [drugs 4 emotional/mood disorders]

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mood disorder

-mood changes that become severe & result in impaired functioning w/in relationships.
-categories: depression, bipolar, ADHD

depression

disorder characterized by sad/despondent mood

major depressive disorder

-affects 5-10% adults in the U.S.
*definition: a depressed affect plus at least 5 of the following symptoms lasting at least 2 wks:
-diff sleeping or sleeping too much
-xtremely tired; w/o energy
-abnormal eating patterns
-vague phys symptoms (ie GI pain)
-inab to concentrate or make decisions
-feelings of despair, guilt, misery, lack of self worth
-obsessed w/ death
-avoiding psychosocial/interpersonal interaction
-lack of interest in personal appearance or sex
-delusions or hallucinations

dysrhythmic disorder

less severe depressive symptoms that prevent a person frm feeling well or functioning normally

postpartum depression

-women exp this 1st sevrl weeks after delivering
-some states mandate that women receive info about mood shifts prior 2 discharge

seasonal affective disorder (SAD)

depression during dark winter months incl enhanced release of melatonin due to lower light levels.
-solution: light therapy

cultural influences & treatment of depression

-Asians ignore depression. Emotions are suppressed & they seek help late, by this time they may be hopeless. They metabolize antideps slowly so start off w/ low doses
-AfAmericans metabolize antideps slowly so start off w/ low doses
-Hisp Americans use teas & believe religious practices will solve mental health probs
-Some ppl of Euro origin deny mental illness exists & believe depression will subside. They can tolerate higher doses of antideps

psychotic depression

intense mood shifts and unusual behaviors. characterized by loss of contact w/ reality, hallucinations, delusions, disorganized speech patterns

assessment & treatment of depression

-certain drugs have the same symptoms (ie glucocorticoids) so hcp should rule out this possibility. depression can also be mimicked by some medical & neurologic disorders (ie early Alzheimers) so do a physical evaluation FIRST
-ask about alcohol & drug use or any thoughts about death & suicide
-interpersonal therapy: focus on pt's disturbed personal relationships that both cause & worsen depression
-cognitive-behavioral therapy: help pt change neg styles of thought & behavior often assoc'd w/ depression
-psychodynamic therapies: focus on resolving pt's internal conflicts
-electroconvulsive therapy (ECT): for pts unresponsive to pharmacotherapy & with srs and life threatening mood disorders
-rTMS: surgical implantation of device to treat MDD

antidepressants

-enhance mood by making catecholamines more avail by either inhibiting MAO enzymes or inhibiting neurotransmitter uptake, enhancing activation of adrenergic receptors
-also treat phobia, OCD, panic, anxiety
-must have black box warning to advise for warning signs of suicide (esp for children)
-classes: tricyclic antideps (TCAs), selective serotonin reuptake inhibs (SSRIs), atypical antideps incl serotonin-norepinephrine reuptake inhibs (SNRIs), monoamine oxidase inhibs (MAOIs)

tricyclic antidepressants (TCAs)

-inhibit the presynaptic reuptake of both norE and serotonin
-major depression & sometimes situational depression, and enuresis (bed wetting)
-side effects: orthohypo, sedation, anticholinergic effects
-less frqtly used as 1stline drugs

selective serotonin reuptake inhibitors (SSRIs)

-drugs of choice! (bc of less side effects)
-target serotonin
-side effects: sexual dysfunction, nausea, headache, wt gain, anxiety, insomnia

serotonin syndrome (SES)

-occurs when pt is taking another med that affects the metabolism, synthesis, or reuptake of serotonin, causing it to accumulate
-side effects: mental status changes, hypertn, tremors, sweating, hyperpyrexia, ataxia
-treatment; discontinue & provide supportive care!!

serotonin-norE reuptake inhibitors (SNRIs)

-inhibit serotonin & norE; but dopamine levels are also affected
-duloxetine (Cymbalta) treats neuropathic pain
-venlafaxine (Effexor) can be taken intermediate release or extended release
-buproprion (Wellbutrin) caution w/ seizure pts

St John's wort

-antidepressant
-contains hypericin & hyperforin - both selectively inhibit serotonin reuptake
-interacts w/ oral contraceptives, warfarin, digoxin, cyclosporine
-mild s.e.: GI distress, fatigue, allergic skin rxns
-pts should wear sunscreen

monoamine oxidase inhibitors (MAOIs)

-inhibit monoamine oxidase, enzyme that terminates adction of dopamine, norE, and serotonin
-low safety margin, reserved 4 pts who are unresponsive to TCAs or SSRIs
-side effects: orthohypo, headache, insomnia, diarrhea, hypertensive crisis (if used w/other antideps or symps), severe hypotn (if used w/antihypertns), hypoglycemia (w/insulin & oral antidiabs), hyperpyrexia (w/meperidine (Demerol))
-with tyramine, acute hypertension can occur! (stiff neck, flushing, palpitations, disphoresis, nausea) Give a CCB as an antidote.....foods that contain tyramine: avocados, bananas, raisins, figs, cheese, yogurt, beer & wine, beef, pepporoni, sausage, fava beans, soysauce, all yeast, chocolate

bipolar disorder

characterized by extreme & opposite moods, alternating depression and mania. manic symptoms must be present for at least 1 wk

Mania

-Emotional state characterized by high psychomotor activity & irritability
*symptoms:
-inflated self esteem/grandiosity
-decreased need for sleep
-increased talkativeness
-racing thoughts
-distractability
-excessive involvement in pleasurable activities that have potential for harmful consequences

Mood stabilizers

Drugs for bipolar disorder

Attention deficit hyperactivity disorder

-Behavioral disorder
-boys more likely to have. Boys are more aggressive while girls show more anxiety & mood swings
-some causes incl exposure to lead in childhood or prenatal exposure to drugs and alcohol
-both child & fam should be assessed
*symptoms:
-easy distractability
-failure to receive or follow instructions properly
-inability to focus
-diff remembering
-excessive talking
-impulsiveness
-sleep disturbance

CNS stimulants for ADHD

-stimulate part of brain to increase focus & alertness
-1st line choice, other drugs not as effective
-side effects: insomnia, nervousness, anorexia, wt loss, dizziness, depression, nausea, abd pain
-sched II, pcat C
-atomexetine (Stattera) is a norE reuptake inhibitor, good alt for parents who don't want to use a CNS stimulant

Imipramine

-aka Tofranil
-antidep, TCA, treatment for nocturnal enuresis
-2 wks for effectiveness
-alerts: diaphoresis may it be reliable indicator of disease states, anticholinergic effects, don't discontinue abruptly, pcat C
-adv effects: sedation, drowsiness, blurred vision, dry mouth, dysrhythmias, hrt block, hypertn, photosensitivity
-contraind: acute recovery after MI, defects in bundle-branch conduction, glaucoma, renal/hepatic, 14 days MAOI therapy
-interactions: CNS deps, alcohol, Cimetidine, oral contraceptives, disulfiram, antithyroid agents, phenothiazines, sympathomimetics, methylphenidate, phenytoin
-lab: altered blood glucose tests, bilirubin, alk phos
-herbal/food: evening primrose oil, ginkgo, st johns wort
-overdose: charcoal, ensure airway

Sertraline

-aka Zoloft
-antidep, SSRI
-depression, anxiety, OCD, panic
-alerts: give in morn or eve, when liquid mix w/ water or ginger ale or OJ, don't give with MAOI or w/in 14 days, pcat C
-adv effects: agitation, insomnia, headache, dizziness, somnolence, fatigue
-contraind: MAOIs, primozide, Antabuse
-interactions: digoxin, warfarin, neuroleptic malignant syndrome
-lab: a symptomatic elevated liver function tests, uric acid
-herbal/food: st johns wort, L-tryptophan

Phenelzine

-aka Nardil
-antidep, MAOI
-irreversible inhib of MAO, sometimes used for panic
-alerts: drug effects may persist for 2-3wks, must do a wash-out pd from other drugs, abrupt discontinuation may cause rebound hypertn, pcat C
-adv effects: constipation, dry mouth, orthohypo, insomnia, increased hrt rate, increased neural activity
-contraind: cardiovascular or cerebrovascular, renal or hepatic, pheochromocytoma
-interactions: TCAs and SSRIs, opiates, sympathomimetics, caffeine
-lab: bilirubin, check CBC results!
-herbal/food: ginseng, ma huang, ephedra, st johns wort
-overdose: emesis or charcoal, IV diazepam (slowly) for seizures, CCBs for hypertn, IV fluids for vascular collapse, body temp monitoring

Lithium

-aka Eskalith
-mood-stabilizing drug, bipolar affective disorder drug, glutamate inhib
-effective for purely manic or purely depressive
-alerts: risk of tox high, pcat D, serum levels must be monitored (0.6-1.5 mEq/L), acts like sodium
-adv effects: dizziness, fatigue, short term mem loss, increased urination, nausea, vomiting, loss of appetite, dry mouth, slight tremors
-contraind: debilitated pts, pts w/ cardiovascular disease, dehydration, renal, sodium depletion (no salt free diet!!)
-interactions: diuretics, sodium bicarbonate, probenecid, methyldopa, anticholinergics, alcohol
-overdose: gastric lavage, electrolyte treatment, renal regulation, hemodialysis

Methylphenidate

-aka Ritalin
-ADHD drug, CNS stimulant
-alerts: SR tabs must be swallowed whole, sched II drug, pcat C
-adv effects: irreg hrtbeat, high bp, liver tox, drg free "holidays" recommended
-contraind: history of anxiety or psychosis or suicidal ideation,Tourette's
-interactions: anticoagulant, anticonvulsants, guanethidine, clonidine, antihypertns, MAOIs
-herbal/food: admin times need indiv titration

Patients receiving antidepressant therapy: NPF

-dep drugs may take 2-8wks b4 full effects are realized
-use objective measures to quantify therapeutic results
-have pt sign no harm/no suicide contract
-monitor vitals & mental
-CBC
-LOC
-visual
-cardiovascular
-bruising/bleeding/infection
-anticholinergic effects
-for MAOIs: dietary intake and teach pt foods to avoid
-avoid abrupt discntinuation
-take missed dose imm'ly but don't take xtra, take with food, take at bedtime

Patients receiving therapy for bipolar disorder (Eskalith): NPF

-monitor drug levels
-electrolytes
-weigh pt daily
-pt should consume enuf liquids but not to much
-CBC, BUN, creatinine, uric acid, urinalysis
-take w food
-take missed dose ASAP but don't take xtra
-report dilute urine, fever
-practice reliable contraception

Patients receiving treatment for ADHD, ADD

-teach pt to keep behavioral diary
-weigh pt daily
-assess nutrition and use of stimulating products ie caffeine
-have pt take dose early in the day and b4 4pm to combat insomnia unless XR is used (XR in the morning)
-use drug holidays
-don't take xtra doses to heighten alertness or combat sleepiness
-don't abruptly discontinue

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