Final Exam:NR 546 Final: Final Exam Study Guide: Updated A+ Score Solution

MDD-- Monoamine hypothesis of depression, prescribing considerations- the theory is that depression is caused by a deficiency in monoamine neurotransmission. And mania is the opposite - due to an excess of monoamine neurotransmission. This hasn't really been proven yet, so then the focus shifted to the monoamine receptor hypothesis - that the abnormality of receptors for monoamine NTs cause depression. In that case, the lack of NT causes upregulation of receptors. Also not proven yet. Right now the focus is on regulation of gene expression, growth factors, environmental factors, and epigenetic changes. Prescribing considerations - do not give antidepressants as monotherapy for bipolar - always combine with mood stabilizer. Must rule out mania or hypomania so don't confuse MDD with BPD and induce mania. Monitor infant irritability when prescribe SNRI for breastfeeding. Also keep in mind: client preference, prior treatment response, anticipated adverse effects, comorbidities, half life and interactions (if they will forget to take med, choose something longer acting), cost. Start patient on drug for 4-8 weeks, on lowest recommended dose. If doesn't work, first increase dose, then switch to diff drug in same class and give adequate trial of high enough dose, then switch to a drug in a different class, then add a second med. For older people - citalopram and escitalopram should be ½ dose, avoid paroxetine if have history of falls, avoid TCAs prescribed with out CNS depressants. SSRIs what screens should be completed prior to prescribing a SSRI? - for SNRIs need to check BP before and during treatment. Which age group is most at risk when prescribed a SSRI? Why? Kids and adults under 25 - increased risk of suicide Which SSRI has the least CYP interactions - escitalopram (Lexapro). Good for forgetful people - fluoxetine (has 2-3 day half life). Also sertraline (27-36 hour ½ life). Longest acting fluoxetine has the longest half life 1-2 weeks. When adding or switching antidepressants use caution for 5 weeks after stopping fluoxetine More likely to cause discontinuation syndrome. - paroxetine Safe in nursing and pregnancy and breastfeeding sertraline Contraindicated in pregnancy paroxetine (risk of atrial septal defect). Which medications are used as adjuncts? Buproprion, Lowest risk of sexual side effects buproprion, mirtazapine What is serotonin syndrome When use two serotonergic drugs together. Symptoms: mental status changes (agitation, hallucinations, delirium, coma), autonomic instability (tachycardia, dizziness, diaphoresis, hyperthermia), neuromuscular symptoms (tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (nausea, vomiting, diarrhea). Treatment - stop med, supportive care, benzos. MAOIs black box warning Suicidal ideation in children, adolescents and young adults MAOI half life 2-4 hours SSRIs black box warning suicidal tendencies MAOIs (monoamine oxidase inhibitors) Antidepresents durgs that inhibit the enzyme that deatctiviates dopamine, norepiniphrine, and serotonin. MAOIs appear to be most effective for treating non-endogenous and atypical depressions. Side-effects include anticholnergic effects, insomnia, agitation, confusion, and wieght gain. when taken in conjuction with other drugs or foods containing tyramine, they can cause a hypertensive crisis. • Lithium levels can be increased by nonsteroidal anti-inflammatory drugs (NSAIDs) and angiotensin-converting enzyme (ACE) inhibitors and decreased by caffeine and mania. Role of L-Methylfolate in depression treatment is necessary for the synthesis of monoamines. We generally get l-methylfolate from dietary folic acid, but about 50% of people are deficient. There are small studies that say that supplementing l-methylfolate or regular OTC folate may help as adjunctive treatment of depression. Recommended to try the OTC folate first. Role of L-Methylfolate in depression tx Suboptimal folate levels in depressed patients (adjunct to antidepressant) • L-Methylfolate is a bioavailable form of folate