Central Nervous System Regulation, Mood, and Cognition
8.7 Antidepressants
Antidepressants are used to treat depression and other mental health disorders, as well as other medical conditions such as migraine headaches, chronic pain, and premenstrual syndrome. Antidepressants increase levels of neurotransmitters in the CNS, including serotonin (5-HT), dopamine, and norepinephrine. Treatment is based on the belief that alterations in the levels of these neurotransmitters are responsible for causing depression.[1]
This module will discuss four classes of antidepressants: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs). These medications are compared in Table 8.7.
TCAs and MAOIs are referred to as first-generation antidepressants because they were first marketed in the 1950s. SSRIs, SNRIs, and other miscellaneous medications such as bupropion are called second-generation antidepressants and are popular because of fewer side effects like sedation, hypotension, anticholinergic effects, or cardiotoxicity.[2]
Safety warnings (Black Box) are in place for all classes of antidepressants used with children, adolescents, and young adults for a higher risk of suicide. All clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.
For more information on different types of anti-depressants, watch this video.
Pharmacology – Antidepressants, SSRI, MAIO, TCA, SNRIs by Simple Nursing, is licensed under a Standard YouTube license
Tricyclic Antidepressants
Tricyclic antidepressants (TCAs) were one of the original first-generation antidepressants. Due to the popularity of SSRIs and SNRIs, TCAs are now more commonly used to treat neuropathic pain and insomnia.
Mechanism of Action
TCAs tend to have sedative and anticholinergic effects. They act by inhibiting presynaptic reuptake of NE and 5-HT into nerves. The choice of TCA depends on individual response and tolerance to the drug.
Indications for Use
TCAs are used to treat depression, chronic neuropathic pain, and insomnia.
Nursing Considerations Across the Lifespan
TCAs are often administered at bedtime due to sedating effects and are contraindicated with MAOIs.
Geriatric clients are particularly sensitive to the anticholinergic side effects of tricyclic antidepressants. Peripheral anticholinergic effects include tachycardia, urinary retention, constipation, dry mouth, blurred vision, and exacerbation of narrow-angle glaucoma. Central nervous system anticholinergic effects include cognitive impairment, psychomotor slowing, confusion, sedation, and delirium. Elderly clients taking amitriptyline may be at increased risk for falls. Elderly clients should be started on low doses of amitriptyline and observed closely.
After prolonged administration, abrupt cessation of treatment may produce nausea, headache, and malaise. The dose should be gradually tapered, but transient symptoms may still occur.
TCAs should not be used in children and those who are pregnant or lactating.
Adverse/Side Effects
Adverse effects of TCAs are a result of their blockade effects on various receptors, often resulting in anticholinergic adverse effects such as constipation, urinary retention, and drowsiness. Blockage of adrenergic and dopaminergic receptors can cause cardiac conduction disturbances and hypotension. Histaminergic blockage can cause sedation, and serotonergic blockade can alter the seizure threshold and cause sexual dysfunction.
Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.
TCAs are contraindicated as follows:
- Myocardial infarction.
- Concurrent use of MAOIs.
- Pregnancy, lactation.
- Preexisting cardiovascular disorders.
- Angle-closure glaucoma, urinary retention, prostate hypertrophy, GI or GU surgery.
- History of seizures.
- Hepatorenal diseases.
There are also several drug interactions such as cimetidine, fluoxetine, ranitidine: increased therapeutic and adverse effects of TCAs. Usage with oral anticoagulants can increase serum levels of anticoagulants and increase the risk of bleeding. TCAs should not be used concurrently with MAOIs, which increases the risk for a severe hyperpyretic crisis. [3]
Overdosage
Death may occur from overdosage with this class of drugs. Multiple drug ingestion (including alcohol) is common in deliberate tricyclic antidepressant overdose. If an overdose occurs, consult with a Poison Information Center (1-800-567-8911).
Client Teaching & Education: Due to the increased risk of suicidality with antidepressants, clients and their family members or caregivers should be instructed to immediately report any sudden changes in mood, behaviors, thoughts, or feelings. The potential side effects discussed above should be reviewed. [4],[5],[6]
Table 8.7 provides a closer look at this medication and compares TCAs with other classifications of antidepressants.
Selective Serotonin Reuptake Inhibitor (SSRI)
Selective Serotonin Reuptake Inhibitors (SSRIs) are second-generation antidepressants and have fewer side effects than TCAs and MAOIs. Fluoxetine and citalopram are commonly used SSRIs.
Mechanism of Action
SSRIs inhibit the reuptake of serotonin.
Indications for Use
SSRIs are primarily used to treat depression but are also used to treat obsessive-compulsive disorder, bulimia, panic disorder, posttraumatic stress disorder, other forms of anxiety, premenstrual syndrome, and migraines.
Nursing Considerations Across the Lifespan
The onset of fluoxetine’s antidepressant effect develops slowly for up to 12 weeks.
Use caution in clients who are taking other CNS medications or who have liver dysfunction. This drug is contraindicated with MAOIs. Monitor for increased suicide ideation in all populations, as well as for the development of serotonin syndrome. Clients should avoid grapefruit juice due to its effect on the CYP3A4 enzyme that affects the bioavailability of the medication.
Adverse/Side Effects
Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.
The development of a potentially life-threatening serotonin syndrome or neuroleptic malignant syndrome (NMS)-like reactions has been reported with SNRIs and SSRIs, particularly with concomitant use of serotonergic drugs, drugs that impair the metabolism of serotonin (including MAOIs), or with antipsychotics or other dopamine antagonists. Symptoms of serotonin syndrome may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination), and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Serotonin syndrome, in its most severe form, can resemble neuroleptic malignant syndrome (NMS), which includes hyperthermia, muscle rigidity, autonomic instability with possible rapid fluctuation of vital signs, and mental status changes. Clients should be monitored for the emergence of serotonin syndrome or NMS-like signs and symptoms.[7]
Other side effects include rash; mania; seizures; decreased appetite and weight; increased bleeding associated with the concomitant use of fluoxetine and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation; hyponatremia; anxiety; and insomnia.
Abrupt discontinuation may cause several adverse effects, so a gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. [8],[9],[10]
Client Teaching & Education
Clients should be careful to take medications as directed. Abrupt discontinuation may cause anxiety, insomnia, and increased nervousness. Additionally, orthostatic blood pressure changes are common during medication therapy. Clients may also be increasingly drowsy or exhibit some confusion. Use of SSRI medications with alcohol or other CNS depressant drugs should be avoided.
Clients, family, and caregivers should monitor clients carefully for suicidality. Other side effects include possible decreased libido, urinary retention, constipation, and increased photosensitivity.
Table 8.7 provides a closer look at this medication and compares SSRIs with other classifications of antidepressants.
A 32-year-old female visits the nurse practitioner with concerns about “feeling tired all the time,” “having difficulty concentrating,” “problems sleeping,” and “just generally feeling down.” The nurse practitioner prescribed fluoxetine.
The client tells the nurse, “One of my friends told me I have to be careful or I might get serotonin syndrome if I take medication.”
1. What places a client at risk for serotonin syndrome, and what symptoms should the nurse teach the client about this condition?
2. The nurse knows that anyone starting an antidepressant is at risk for suicidal thoughts. How should the nurse therapeutically discuss this potential adverse effect with the client?
3. What potential common side effects should the nurse discuss with the client?
The client states, “I can’t wait to feel better again. How soon will this medication work?”
4. What is the nurse’s best response?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.
Serotonin Norepinephrine Reuptake Inhibitor (SNRI)
Venlafaxine is an example of a Serotonin Norepinephrine Reuptake Inhibitor (SNRI).
Mechanism of Action
Venlafaxine inhibits the reuptake of serotonin and norepinephrine, with weak inhibition of dopamine reuptake.
Indications for Use
SNRIs are indicated for the treatment of a major depressive disorder.
Nursing Considerations Across the Lifespan
SNRIs are contraindicated with MAOIs or within 14 days of use of an MAOI. Dosage adjustment is required for use in clients with renal and/or liver disease. Elderly clients are at greater risk for developing hyponatremia. Use with caution with other serotonin medications.
Adverse/Side Effects
Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.
SNRI medication may cause a sustained increase in blood pressure. Other side effects include serotonin syndrome, insomnia, anxiety, decreased appetite, weight loss, mania, hyponatremia, increased bleeding (especially with the concomitant use of fluoxetine and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation), elevated serum cholesterol, somnolence, and nausea. [11]
Client Teaching & Education
Clients should be careful to take medications as directed. The dose should be tapered prior to discontinuation. Clients may also be increasingly drowsy or dizzy. Use of SNRI medications with alcohol or other CNS depressant drugs should be avoided. Clients, family, and caregivers should monitor clients carefully for suicidality.
Table 8.7 provides a closer look at this medication and compares SSRIs with other classifications of antidepressants.
Monoamine Oxidase inhibitors (MAOI)
Monoamine oxidase inhibitors (MAOIs) are first-generation antidepressants. A significant disadvantage to MAOIs is their potential to cause a hypertensive crisis when taken with stimulant medications or foods containing tyramine.
Mechanism of Action
The mechanism of action of MAOIs is not fully understood but is presumed to be linked to the potentiation of monoamine neurotransmitter activity in the central nervous system resulting from its inhibition of the enzyme monoamine oxidase (MAO).[12] MAO inactivates norepinephrine, dopamine, epinephrine, and serotonin. By inhibiting MAO, the levels of these transmitters rise thus creating anti-depressive effects.[13]
Indications for Use
MAOIs are indicated for the treatment of major depressive disorder in adult clients who have not responded adequately to other antidepressants.
Nursing Considerations Across the Lifespan
Serious interactions with several medications, as well as foods and beverages containing tyramine, have been reported; check drug labeling before administering. Safety has not been established with the pediatric population. The elderly population is at increased risk for postural hypotension and serious adverse effects. Misuse and dependence have been reported. Withdrawal effects can continue for several weeks after discontinuation.
Adverse/Side Effects
Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.
Use with caution due to the risks of hypertensive crisis, serotonin syndrome, and increased suicidality. Hypertensive crisis is defined by severe hypertension (blood pressure greater than 180/120 mm Hg) with evidence of organ dysfunction. Symptoms may include occipital headache (which may radiate frontally), palpitations, neck stiffness or soreness, nausea or vomiting, sweating, dilated pupils, photophobia, shortness of breath, or confusion. Either tachycardia or bradycardia may be present and may be associated with constricting chest pain. Seizures may also occur. Intracranial bleeding, sometimes fatal, has been reported in association with the increase in blood pressure. See more information about serotonin syndrome in the “SSRI” section.
Other potential side effects include mania, orthostatic hypotension, hepatotoxicity, seizures, hypoglycemia in diabetic clients, decreased appetite and weight loss, dizziness, headache, drowsiness, and restlessness. Clients should be advised it may impair their ability to operate machinery or drive. MAOIs should be discontinued if hepatotoxicity occurs.[14]
Client Teaching & Education
Clients should be careful to take medications as directed. It may take up to 4 weeks to see the effects of the drug. They should avoid abrupt cessation of therapy to avoid withdrawal symptoms. Clients should avoid alcohol, other CNS depressants, and tyramine-containing products for two weeks after therapy is discontinued. Clients should be advised regarding the signs of hypertensive crisis and to immediately report headache, chest or throat tightness, and palpitations to the provider.
Now let’s take a closer look at a medication grid that compares these classifications of anti-depressants.[15],[16],[17]
Medication cards like this are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below. Prototype or generic medication examples are also hyperlinked to a free resource at Daily Med. On the home page, enter the drug name in the search bar to read more about the medication.
Table 8.7 Comparing Types of Anti-depressants [18][19][20][21]
Class
Generic Prototype (Brand)
Mechanism
Indication & Therapeutic Effect
Contraindications
Side Effects
Administration and Nursing Considerations
Tricyclic antidepressants (TCA)
amitriptyline (Elavil) nortriptyline (Aventyl)
Inhibits presynaptic reuptake of NE and 5-HT
Treat depression and insomnia.
Chronic neuropathic pain
MI & CVS disease Pregnancy, lactation, glaucoma, urine retention, BPH, GI/GU surgery. Hx of seizures. Hepatorenal diseases. Drug Interaction: Cimetidine, fluoxetine, ranitidine Anticoagulants MAOIs
Anticholinergic effects, CVS effects, Sedation, Sexual dysfunction, Altered seizure threshold
SAFETY: Increased risk of suicidality
Taper for D/C Monitor orthostatic BP Effect may take 4 wks Caution for hepato/renal toxicitygive at bedtime Immediately report S&S of suicidality
Selective serotonin reuptake inhibitors (SSRIs)
fluoxetine (Prozac) citalopram (Celexa) sertraline (Effexor)
Inhibits reuptake of serotonin.
Primarily used to treat depression,Also, for OCD, and other forms of anxiety and stress disorders
Contraindicated with MAOIs. Use caution with liver dysfunction
Drug Interaction: Caution with use of NSAIDS and other drugs that affect coagulation
Rash, mania, seizures, decreased appetite and weight, increased bleeding, anxiety, insomnia, photosensitivity SAFETY: Increased risk of suicidality and serotonin syndrome.
Taper for D/C Orthostatic BP Effect may take 12 wks May cause drowsiness No alcohol/CNS depressants. Immediately report S&S suicidality or serotonin syndrome Avoid grapefruit
Serotonin norepinephrine reuptake inhibitors (SNRIs)
venlafaxine (Effexor)
Inhibits the reuptake of serotonin and norepinephrine, with weak inhibition of dopamine reuptake.
For treatment of a major depressive disorder.
Contraindicated with MAOIs Caution with use of NSAIDS and other medications that affect coagulation
Caution in elderly
CVS effects: sustained high BP, high cholesterol, Rash, mania, decreased appetite and weight, increased bleeding, anxiety, insomnia, Somnolence Nausea and constipation
SAFETY: Increased risk of suicidality and serotonin syndrome.
Taper for D/CEffect may take 8 wks. May cause drowsiness. No alcohol/CNS depressants. Immediately report S&S suicidality or serotonin syndrome. Avoid grapefruit
Caution for hepato/renal toxicity
Monoamine oxidase inhibitors (MAOI)
tranylcypromine (Parnate)
Inhibits the enzyme monoamine oxidase therefore allowing for increased levels of norepinephrine, dopamine, epinephrine, and serotonin.
Major depressive disorder in adults who have not responded a to other antidepressants.
Contraindicated with SSRIs, SRNIs, and many other drugs
Caution in elderly, pregnancy, lactation, children
Food interaction: foods containing tyramine
mania, decreased appetite and weight, drowsy/restless, Hepatotoxicity, Seizures Hypoglycemia in diabetic clients
SAFETY: Increased risk of suicidality, serotonin syndrome and hypertensive crises.
Taper for D/C Effect may take 4 wks. May cause drowsiness No alcohol/CNS depressanty.
Immediately report S&S suicidality, serotonin syndrome, hypertensive crises.
Caution with liver dysfunction.
Avoid tyramine
- Lilley, L., Collins, S., & Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 246-272. Elsevier. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier. ↵
- RNpedia. (2022). Antidepressants. https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/antidepressants/ ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier. ↵
- Lilley, L., Collins, S., & Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 246-272. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier. ↵
- Lilley, L., Collins, S., & Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 246-272. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier. ↵
- Lilley, L., Collins, S., & Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 246-272. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- RNPedia. (2021). https://www.rnpedia.com ↵
- OpenMD.Com at www.openmd.com ↵
- uCentral from Unbound Medicine. https://www.unboundmedicine.com/ucentral ↵
Symptoms associated with serotonin syndrome may include the following combination of signs and symptoms: mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, with or without gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea).
Potentially life-threatening adverse effect that includes high fever, unstable blood pressure, and myoglobinemia.
Severe hypertension (blood pressure greater than 180/120 mm Hg) with evidence of organ dysfunction. Symptoms may include occipital headache (which may radiate frontally), palpitations, neck stiffness or soreness, nausea or vomiting, sweating, dilated pupils, photophobia, shortness of breath, or confusion. Either tachycardia or bradycardia may be present and may be associated with constricting chest pain. Seizures may also occur. Intracranial bleeding, sometimes fatal, has been reported in association with the increase in blood pressure.
A significant change in blood pressure from lying to sitting to standing.