Drugs Treating Mood Disorders

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Physiology: neurons communicate from one neuron to another = neurotransmission
specific neurotransmitters (which affect mood) travel to specific neuroreceptor sites
the mind and the brain are the same organ

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

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Major Depressive Disorder: 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. 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

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Bipolar Disorder: 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
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.

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Selective Serotonin Reuptake Inhibitors: SSRIs = first choice for treating depression 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)

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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.

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Contraindications and precautions: Decreased liver function; Adverse effects:
Gastrointestinal distress, headache, fatigue, insomnia, and sexual dysfunction
Drug interactions:
Administration with highly protein-bound drugs

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Core Patient Variables: Health status: Past medical, including drug use and physical assessment
Life span and gender:
Pregnancy category C
Lifestyle, diet, and habits:
Can affect sexual function
Culture and inherited traits:
Assess cultural background

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Nursing Diagnoses & 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. 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.
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.

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Planning & Interventions: Maximizing therapeutic effects:
Maximum effect not achieved for several weeks; Assess depression using a standard scale; Minimizing adverse effects (ID baseline): Assess for adverse effects; Assess for worsening of depression

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Teaching, Assessment & Evaluation: 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.

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Tricyclic Antidepressants: The tricyclics were named for their molecular structure.
Tricyclics have a very narrow therapeutic index. All TCAs enhance the activity of norepinephrine and serotonin by blocking neuronal reuptake of these neurotransmitters.
Prototype drug: nortriptyline (Pamelor)

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Nortriptyline Core Drug Knowledge: Pharmacotherapeutics:
Used to treat depression and chronic pain.
Pharmacokinetics:
Administered: oral. Metabolism: liver. Peak: 2-4 hours.
Pharmacodynamics:
Specifically blocks reuptake of NE into nerve terminals, thereby allowing increased concentration at postsynaptic effector sites.

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Contraindications and precautions: Cardiovascular disorders; Adverse effects:
Disturbed concentration and confusion, headache, tremors, nausea, vomiting, bone marrow depression, urinary retention, and sexual function disturbances; Drug interactions:Multiple drug interactions

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Core Patient Variables: Health status: Assess for pre-existing cardiovascular conditions; Life span and gender: May cause more side effects in elderly; Lifestyle, diet, and habits: Assess symptoms of depression before starting therapy; Culture and inherited traits:
Few data about the effects of the drug on races other than Caucasians of European descent.

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Nursing Diagnoses & 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.
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.

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Nortriptyline Planning & Interventions: Maximizing therapeutic effects; Monitor blood plasma drug levels; A single dose at bedtime may be used.
Minimizing adverse effects:
May need to dose the drug twice a day to avoid adverse effects; Older adults should receive a smaller initial dose.

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Teaching, Assessment & Eval:
Patient and family education:
Teach patients and families that the therapeutic response will not be immediate; Teach patients to take drug as prescribed.
Ongoing assessment and Eval:
Continually assess depressed patients for suicidal thoughts during nortriptyline therapy;
Obtain baseline and periodic laboratory blood tests during therapy

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Monoamine Oxidase Inhibitors:
MAO enzyme system widely distributed throughout the body
responsible for metabolizing amines such as dopamine, epinephrine, norepinephrine, and serotonin.
MAOIs inhibit MAO enzymes, thereby increasing the concentration of those amines
Prototype drug: phenelzine (Nardil).

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Phenelzine Core Drug Knowledge: Pharmacotherapeutics:
Used to treat depression.
Pharmacokinetics:
Administered: oral. Excreted: Urine (monitor BUN). Peak: 2-4 hours.
Pharmacodynamics:
Increases the concentrations of DA, NE, and serotonin within the neuronal synapse.

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Contraindications and precautions:
Decreased liver function and congestive heart failure.
Adverse effects: Liver damage, anticholinergic effects, agranulocytosis, leukopenia, thrombocytopenia, and sexual dysfunction
Drug interactions: Multiple drugs and certain foods

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Core Patient Variables: Health status: Cardiovascular assessment (EKG) and baseline labs.
Life span and gender: Pregnancy category C, not recommended for use <16 yrs
Lifestyle, diet, and habits:
Assess activities of daily living
Environment: Assess environment where drug will be given.
Culture and inherited traits:
Assess cultural background

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Nursing Diagnoses & 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.

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Planning & Interventions: Maximizing therapeutic effects:
Platelet MAO enzyme activity (mostly B subtype) is usually measured before therapy and during therapy.
Minimizing adverse effects:
Numerous dietary and medication restrictions;
Monitor for symptoms of hypertensive crisis

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Teaching, Assessment & Eval:
Patient and family education;
Warn all patients about not eating foods with high tyramine content or consuming alcohol.
Stress importance of not stopping medication.
Ongoing assessment and evaluation; Observation of the patient is necessary to identify the therapeutic effects of phenelzine; Perform frequent blood pressure monitoring during therapy.

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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).

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Lithium Core Drug Knowledge:
Pharmacotherapeutics:
Primary action is to prevent extreme mood swings.
Pharmacokinetics:
Administered: oral. Metabolism: liver. Excreted: kidneys. Onset: 5-7 days. Duration: 1-4 hours.
Pharmacodynamics:
Competes with calcium, magnesium, potassium, and sodium in body tissues and at binding sites; It alters sodium transport in nerve and muscle cells.

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Contraindications and precautions: Severe cardiovascular or renal disease
Adverse effects: Coarse hand tremor, severe gastrointestinal upset, blurred vision, drowsiness, and confusion
Drug interactions: Thiazide diuretics and angiotensin-converting enzyme inhibitors

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Core Patient Variables: Health status: Past medical and physical assessment
Life span and gender: Pregnancy category D
Lifestyle, diet, and habits:
Assess alcohol and caffeine intake.
Environment: Assess environment where drug will be given.
Culture and inherited traits:
Assess for Japanese heritage

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Nursing Diagnoses & 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.

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Planning & Interventions: Maximizing therapeutic effects:
Instruct the patient about early warning signs of a relapse of mania.
Minimizing adverse effects:
Monitor blood levels of medication; Assess for dehydration, which increases risk of toxicity.

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Teaching, Assessment & Eval:
Patient and family education:
Teach symptoms of toxicity.
Stress follow-up care.
Ongoing assessment and evaluation: Monitor drug levels;
Monitor behaviors before and during treatment.