1. Presented by :
Mohammad Al-oran
Mohammad Awad
Moussa Abo-Tabeekh
Ala’a Salem
Supervision by :
Dr.Ahmad Rayan

2. Outline :
 Depression :
Type
Signs & Symptoms
Treatment
 Anti-depressant drug :
Definition
Classification
Doses
Mechanism of action
Indication
Contra-indication
Side effect
Nursing intervention
Nursing care
Nursing diagnosis
 Summery
 References

3. **Mood : is prolonged emotional state that influences
the person's whole personality and life functioning
**Grief : is the subjective state that follows loss
** anxiety (sense of fear and intense worry) is other
mood accompanies

4. - Depression :is a type of mental disorder that
affects a person's mood
- it is a pathological grief reaction know as
melancholia
- -It is abnormal extension of sadness and
grief
- depression and anxiety may show diurnal
variation , certain time of the day
4

5.  Major depressive disorder (unipolar depression)
requires at least 2 weeks of depression/loss of interest
and 4 additional depressive symptoms, with one or
more major depressive episodes.
 Dysthymic disorder (Persistent Depression )
is an ongoing low-grade depression of at least 2
years’ duration for more days than not and does not
meet the criteria for major depression.
 Symptoms in the major and dythymia is the same the
different in severity and duration.

6. anger , anxiety , apathy, helplessness , hopelessness,
low self-esteem , overeating , sleep disturbances ,
nausea, vomiting , weight changes , confusion ,
lack of concentration , loss of interest and
motivation , self-blame
6

7. 7

8.  SSRI antidepressants
 Tricyclic antidepressants
 Atypical antidepressants
 MAOI antidepressants

9. SSRI antidepressants
Tricyclic antidepressants
Atypical antidepressants
MAOI antidepressants Selective Serotonin
Reuptake Inhibitor

10. Mechanism of action
 Inhibit serotonin reuptake so increase synaptic
serotonin levels
 Many SSRIs affect other receptors especially at high
doses
 Clinical effect usually takes weeks so mechanism
goes beyond simply increasing synaptic serotonin
levels
 Several serotonin (5-HT) receptor subtypes
 Serotonin receptors are located throughout the body
(especially GI tract)

12. Indications & off-label uses
 Various class members also approved to treat:
generalized anxiety , Obsessive Compulsive Disorder
(OCD), panic , Posttraumatic stress disorder PTSD,
eating disorders, social anxiety
 Off-label uses: Attention deficit-hyperactivity
disorder ADHD, insomnia, chronic pain syndromes,
seasonal affective , behavioral problems in
individuals with dementia and mental retardation, …
other uses

13. Half-life
 Short: paroxetine & fluvoxamine (missed doses can
result in uncomfortable symptoms)
 Moderate: sertraline, citalopram, escitalopram
 Long: fluoxetine (good for people who may miss
doses)

14.  Decreased sex drive and impaired sexual function tend
not to resolve with time
 Nausea, diarrhea, anorexia, vomiting
 - all increase with dose and can resolve with time
 Weight gain (esp. paroxetine) after initial GI effects
 Headache, dizziness, anxiety (esp. fluoxetine), rash,
insomnia, sedation, sweating, vivid dreams, tremor, dry
mouth (esp. paroxetine), bruising, ↑ prolactin

15. RouteUsual Adult Daily
Dose(mg/day)
Generic name (Trade
Name)
PO
PO
PO
PO
PO
PO
20-40
10-20
20-60
100-200
20-60
50-200
Selective serotonin
reuptake
inhibitors(SSRIs)
** Citalopram (Celexa)
Escitalopram (Lexapro)
** Floxetine (Prozac)
** Fluvoxamine ( Luvox
Paroxetine (Paxil)
Sertraline (Zoloft)
** venlafaxine (effexor)
15

16. 1. Citalopram and paroxetine with warfarin may lead to
increased bleeding
2. Citalopram may be excreted more rapidly with
carbamazepine
3. Fluoxetine increases the half-life of diazepam
4. Fluvoxamine with diltiazem may cause bradycardia
5. Paroxetine metabolism may be decreased by
cimetidine, phenobarbital, and phenytoin
6. Paroxetine shouldn’t be used with tryptophan because
headache, nausea, sweating and dizziness may occur.
Note :
Always check all medications that the patient is taking and notify the
practitioner of any possible interactions.
16

17. 1. Provide comfort measures for the patient so they can
tolerate the adverse effects.
2. Administer the medication in the morning to help prevent
insomnia.
3. Encourage the patient to change position slowly to help
prevent orthostatic hypotension.
4. Teach the patient about the risks of abruptly stopping
their medication. Encourage them to take the medication as
ordered.
17

18. SSRI antidepressants
Tricyclic antidepressants
Atypical antidepressants
MAOI antidepressants

19. Mechanism of action :
Serotonin, histamine, muscarinic (cholinergic)
and α-adrenergic receptor activity although in
differing ratios
Anticholinergic activity leads to many of the
side effects of these drugs

20.  Indications & off-label uses for TCAs
Depression and similar spectrum of disorders as SSRIs
Especially helpful with chronic pain and depression
secondary to medical conditions such as AIDS
enuresis, narcolepsy, premature ejaculation,
insomnia, migraine prophylaxis
 Blood levels: May be obtained to monitor dose
effectiveness

21.  Drug-drug interactions (DDI) :
Multiple significant interactions in each direction with potentially
serious consequences
 Side effects (SE) :
Anticholinergic SE include: dry mouth, constipation, blurred
vision and urinary retention
Cardiac arrhythmias and conduction changes
Orthostatic hypotension
Sedation
Weight gain
urinary retention and sever constipation
 Cautions :
Overdose is frequently fatal
Pts with bipolar d/o may be pushed into mania or rapid cycling

22.  Patient received MAOIs should wait 2-3 weeks
before starting TCAs becaused MOAIs slowly
excreted from the body
 - Enlarge prostate and glucoma
 - Epileptic client
 - Cardiovascular disorder and recent myocardial
infarction
 - CNS depressant as phenothiazenes , barbitural,
alcohol , anticholinergic agents
 - Pregnancy and lactaion

23. PO,IM
PO
PO
PO
PO
PO
PO
PO
PO
PO
150-300
100-250
150-300
150-300
150-300
150-300
50-150
15-60
150-300
75-200
Tricyclic Antidepressant` Drugs (TCAs)
Tertiary(Parent)
** Amitriptyline (Elavil)
** Clomipramine (Anafranil)
Doxepin (Sinequan)
** Imipramine (Tofranil)
Trimipramine (Surmontil)
Secondary (Metabolite)
Desipramine (Norpramin)
** Nortriptyline (Pamelor)
Protriptyline (Vivactil)
Tetracmilyclics
Amoxapine (Asendin)
(Maprotiline (Ludio

24.  1. TCAs taken with amphetamines and
sympathomimetics may cause hypertension.
 2. TCA metabolism is increased when taken with
barbiturates.
 3. TCA metabolism is decreased when taken with
cimetidine.
 4. TCAs taken with anticholinergics increase adverse
effects such as dry mouth, constipation, and urine
retention.
 5 .TCAs decrease the antihypertensive effects of
clonidine.
24

25.  1. If the patient has diabetes, or is on an oral hypoglycemic
agent carefully monitor their glucose level; it may be altered
by the TCA.
 2. Give the patient ice chips, hard candy, or sugarless gum to
help relieve their dry mouth.
 3. Carefully monitor the patient’s blood pressure before,
during, and after therapy.
 4. Tell the patient to avoid exposure to sunlight or artificial
ultraviolet light because of the risk of photosensitivity
reactions.
 5. TCAs can be lethal when taken in large doses- carefully
monitor a suicidal patient and make sure they aren’t hoarding
the pills for a suicide attempt.
25

26. SSRI antidepressants
Tricyclic antidepressants
Atypical antidepressants
MAOI antidepressants

27. Mechanism of action :
Atypical antidepressants ease depression by
affecting chemical messengers
(neurotransmitters) used to communicate
between brain cells. Most antidepressants work
by changing the levels of one or more of these
naturally occurring brain chemicals.
Atypical antidepressants affect neurotransmitters
including dopamine, serotonin and
norepinephrine . Changing the balance of these
chemicals seems to help brain cells send and
receive messages, which in turn boosts mood.
27
Atypical antidepressants

28. Mechanism of action
venlafaxine and duloxetine are both serotonin and
norepinepherine reuptake inhibitors- “SNRIs”
mirtazapine has serotonin subtype & norepinephrine
activity
trazodone, nefazodone have different serotonin
activity than SSRIs
bupropion has dopamine and norepinephrine activity
28

29. Indications & off-label uses
All have FDA approval to treat depression
SNRIs shown effective in chronic neuropathic pain
(pain produced by normally non-painful stimuli )
Nicotine addiction (bupropion)
Insomnia (mirtazepine, trazodone)
Many similar uses to SSRIs
bupropion, mirtazepine, trazodone & nefazodone do
not usually have associated sexual dysfunction
29

30. Venlafaxine (Effexor)
Similar to TCAs with less safety
& side effect concerns
FDA approval for depression and
generalized anxiety & social
anxiety
SNRI- activity depends on dose
Minimal DDI
SE with missed doses
dose is 75 mg per day
maximum of 375 mg per day
30

31. Mirtazapine (Remeron, Avanza, Zispin)
Complex serotonin, NE (α2) & histamine
activity
Receptor activity changes with changes in
dose
Sedation & weight gain especially at lower
dose
Lipid abnormalities
Minimal DDIs (except MAOIs)
Avoid alcohol while taking Remeron as it can
worsen these side effects.
starting dose is 15 (mg) once a day taken as a
single dose,
may increase the dose up to 45 mg once a day
31

32. Nefazodone (Serzone, Nefadar)
Rarely used due to irreversible liver
toxicity
Pulled from market by initial
manufacturer in 2004 although still
available as generic
Still popular with some patients
start at 100 mg twice daily (200
mg/day) to a maximum of 600
mg/day (300 mg twice daily),
Food and Drug Administration
(FDA) regulations
32

33. Trazodone (Desyrel)
- Sedation, weight gain, low blood
pressure
- Used most commonly (off label) for
insomnia.
Rare reports of sustained painful
erection (priapism) that should be
treated in ER (can lead to
impotence)
starting dose is 150 (mg) per day in
divided doses
increase the dose by 50 mg per day
every 3 to 4 days if needed. The
maximum daily dose should not
exceed 400 mg per day.
33

34. Bupropion (Welibutrin)
-NE, dopamine reuptake inhibition
- Zyban to toxic smoking addiction
- Seizure risk in certain patients (↑
risk at ↑ dose)
Potential DDIs not often significant
(except MAOIs)
starting dose is 200 (mg) a day, taken
as 100 mg twice a day. 300 mg a day,
taken as 100 mg three times a day.
The maximum daily dose is 450 mg.
Taking doses greater than 450 mg a
day may increase the risk of serious
side effects, including seizures.
34

35. Duloxetine (Cymbalta )
- SNRI profile minimally dose
dependent
- Indicated for depression & chronic
neuropathic pain
The recommended dose is 60
milligrams (mg) once a day. A lower
starting dose of 30 mg once a day
for 1 week may be desirable for
some patients.
35

36. Monoamine Oxidase Inhibitors
SSRI antidepressants
Tricyclic antidepressants
Atypical antidepressants
MAOI antidepressants

37. Monoamine Oxidase Inhibitors
Monoamine oxidase inhibitors (MAOIs) were the first
type of antidepressant developed. They're effective,
but have generally been replaced by antidepressants
that are safer and cause fewer side effects. MAOIs
generally require diet restrictions because they can
cause dangerously high blood pressure when taken
with certain foods.
In spite of side effects, these medications are still a
good option for some people. In certain cases, they
relieve depression when other treatments have
failed.

38. Tyramine is a naturally occurring amino acid that
forms from the breakdown of protein in food.
Though tyramine helps regulate blood pressure, it
can also affect the human body in many different
negative ways.
What is tyramine?

39.  Antidepressants such as MAOIs ease
depression by affecting chemical messengers
(neurotransmitters) used to communicate
between brain cells.
 Most antidepressants work by changing the
levels of one or more of these naturally
occurring brain chemicals.
How MAOIs work

40. The enzyme monoamine oxidase is involved in
removing the neurotransmitters norepinephrine,
serotonin and dopamine from the brain. MAOIs
prevent this from happening, which makes more of
these brain chemicals available.
This is thought to boost mood by improving brain cell
communication. MAOIs also affect other
neurotransmitters in the brain and digestive system,
causing side effects.

41. On the other hand ,monoamine oxidase is also responsible
for the metabolism of tyramine, therefore persons who
take MAOIs can not metabolize tyramine and with the
ingestion of foods high in tyramine a hypertensive
crisis can result, as tyramine can cause the release of
stored monoamines, such as dopamine, norepinephrine
and epinephrine
Therefore, dietary restrictions are required
for patients receiving MAOIs
41

42. 42

43. 43
Nursing CareSide Effect
Discontinuing of drug
immediately when physician
orders
Monitor vital signs
Administer short _ acting
antihypertensive medication
as ordered
Use external cooling
measures to control
hyperpyrexia
hypertensive crisis
Symptoms:
Severe occipital
headache , palpitation
Fever , sweating ,
increase blood pressure
,chest pain , coma

44.  Contraindicated with
hypersensitivity to the drugs .
 Use cautiously with impaired hepatic
or renal function, diabetes mellitus,
lactation, seizures, history of suicide
attempts.
44

45.  1. MAOIs administered with meperidine may lead to
excitation, hyper- or hypotension, hyperthermia, and
coma.
 2. MAOIs and doxapram may cause hypertension and
arrhythmias.
 3. MAOIs with amphetamines, methylphenidate,
levodopa, or sympathomimetics may cause a
hypertensive crisis by increasing the catecholamine
release.
 4. MAOIs with fluoxetine, TCAs, citalopram,
trazodone, sertraline, paroxetine, and fluvoxamine
may cause an increased body temperature and
excitation and seizures.
45

46.  1. Closely monitor the patient’s blood pressure and
be alert for signs of hypertensive crisis.
 2. Continue to monitor the patient for adverse
reactions for up to 10 days after stopping the
medication because of its long-lasting effects.
 3. Teach the patient about tyramine-containing
foods and stress the importance of avoiding them.
 4. Help the patient slowly change position to
minimize orthostatic hypotension.
 5. Watch patient older than 60 because they are
more prone to adverse reactions.
46

47. Foods that can interact with
monoamine oxidase
inhibitors (MAOIs)
47

48. Safe foodsUnsafe foodscategory
Most vegetablesAvocados, especially if overripe
fermented bean curd
Vegetables
Most fruitsFigs, especially if overripe
Bananas ,in large amounts
fruits
Meats that are known to be
fresh
Meats that are fermented, smoked or
otherwise aged ,liver ,unless very fresh
meats
Un Fermented varietiesFermented varieties
,bologna,pepperoni,salami
Sausages
fish that are known to be
fresh
Dried or cured fish, otherwise aged ,liverfish
Milk,yogurt,cottage
cheese,cream cheese
Practically all cheesesMilk, milk products
Baked goods that contain
yeast
Yeast extract (Bovril)Food with yeast
Major domestic of beer
most wine
Some imported beers ,chianti winesBeer, wine
48

49. commentsFoods
Contains phenylethylamine ,a pressor agent, large
amount can cause a reaction
chocolate
Contains dopamine, a pressor agent, reaction are most
likely with overripe beans
Fava beans
Headache, tremulousness, mania-like reaction have
occurred
ginseng
Caffeine is a weak pressor agent, large amount may
cause a reaction
Caffeinated
beverages
food that contain other vasopressors
49

50. 1. Provide explanations of drug action and side
effects.
2. Monitor vital signs and observe for
orthostatic hypotension
3. Advise to change positions slowly
4. Administer with food or milk to avoid
gastrointestinal upset.
5. Assist with ambulation or activity requiring
mental alertness.
6. Encourage increase in fluid intake.
50

51. 7. Offer hard candy or sugarless gum for dry
mouth.
8. Assess for suicidal ideation
9. Monitor mood at frequent intervals
10. Ensure use of protective sunscreen and wear
sun glasses when outdoors (TCAs).
11. Discourage caffeinated beverages.
51

52. 1. take medication exactly as directed by
physician.
2. Not use more of the drug, use it more often, or
for a longer period than the physician ordered.
3. Take the drug for several weeks to see the
therapeutic effect.
4. Take the medication with food or milk to avoid
stomach upset.
5. Use caution when driving, operating dangerous
equipment, or engaging in activities that
require mental alertness.
6. Not mix with alcohol, or other CNS
depressants.
52

53. 7. Report any side effects to physician.
8. Not suddenly stop taking the medication, it must be
withdrawn gradually.
9. Take a missed dose as soon as possible, if several
hours have lapsed or it is nearing the time for the next
dose, the dose should not be doubled to catch up.
10. Avoid smoking when taking TCAs, smoking can
enhance the metabolism and increased dosage may be
required.
11. Wear protective sunscreen when outdoors (TCAs).
12. Rise slowly from a reclining position
53

54.  ** Depression:
 - Types.
 - Symptoms.
 -Treatment.
 ** Antidepressants drugs:
 - Definition.
 - Classification.
 - Doses.
 - Mechanism of action.
 - Indication.
 - Side effects.
 - Contraindications.
 - nursing intervention
54

55.  Townsend, M. (2008). Essentials of
psychiatric mental health nursing.
( 4th ed.) Philadelphia: F.A. Davis.
 . Greenstein, B. & Gould, d. (2007) :
Trounce’s clinical Pharmacology for
nurses (18th ed.).
 nurse clinical pocket guide (Psych
Notes )
55