Helping Clients to Cope

Transcription

1 Chapter 3: Mental Health Disorders: Helping Clients to Cope 10 CE Hours By: Adrianne E. Avillion, D.Ed., RN Learning objectives Review the incidence and prevalence of mental illness among adults in the United States. Describe the effects of mental illness. Define major depression. Differentiate among the different types of depressive episodes. Discuss the incidence and prevalence of major depression. List risk factors of depression. Explain the possible causes of major depression. Describe how major depression is diagnosed. Discuss the risk of suicide in clients who are depressed. Discuss the treatment interventions for major depression. Identify important client care considerations pertaining to major depression. Define bipolar disorder. Differentiate among the different types of bipolar disorder Discuss the incidence and prevalence of bipolar disorder. Explain the possible causes of bipolar disorder. Describe how bipolar disorder is diagnosed. Evaluate treatment options for bipolar disorder. Identify important client care considerations pertaining to bipolar disorder. Define generalized anxiety disorder (GAD). Discuss the incidence and prevalence of GAD. Describe the probable causes of GAD. Discuss the process of diagnosing GAD. Review treatment options for GAD. Identify important client care considerations pertaining to GAD. Define schizophrenia. Describe the different types of schizophrenia. Review the incidence and prevalence of schizophrenia. Identify possible causes of schizophrenia. Discuss how schizophrenia is diagnosed. Describe treatment options for schizophrenia. Identify important client care considerations pertaining to schizophrenia. Define obsessive compulsive disorder. Discuss the incidence and prevalence of obsessive compulsive disorder. Identify possible causes of obsessive disorder. Explain how obsessive compulsive disorder is diagnosed. Evaluate treatment options for obsessive compulsive disorder. Discuss client care considerations for clients with obsessive compulsive disorder. Define post-traumatic stress disorder. Discuss the incidence and prevalence of post-traumatic stress disorder. Explain the probable causes of post-traumatic stress disorder. Describe how post-traumatic stress disorder is diagnosed. Evaluate the treatment options for post-traumatic stress disorder. Identify key client care considerations for the client with posttraumatic stress disorder. Review the role of healthcare professionals in mental health care provision. Define phobias. Review the causes and incidence of phobias. Discuss the diagnosis of phobias. Describe treatment interventions for phobias. Identify client care considerations for persons dealing with phobias. Review assessment tips for the mental health client. Incidence and Prevalence of Mental Illness Mental illness is a term that refers to all diagnosable mental disorders. According to the World Health Organization (WHO) mental illness is responsible for more disability in developing countries than any other group of illnesses, including malignancies and cardiovascular disease. 1 Published results of recent studies indicate that an estimated 25 percent of all adults in the United States (U.S.) have a mental illness, and that almost 50 percent of adults in the U.S. will have at least one mental illness at some point during their lifetimes. 1 The effects of mental illness range from minimal discomfort to serious consequences that interfere with a client s ability to function at home, at work, and/or at school and to maintain interpersonal relationships. The effects can be so devastating that the affected client attempts, or actually succeeds, at committing, suicide. Mental illness is also a serious public health problem that costs billions of dollars every year. Statistics from surveillance of mental illness show that: 1 Mental illness is linked to an increased incidence of chronic diseases. Mental illness is associated with decreased use of medical care and adherence to prescribed treatment for chronic illnesses, and increased risk for adverse outcomes. Mental illness is connected to tobacco use and alcohol abuse. Rates for the occurrence of intentional injuries such as murder and suicide, as well as unintentional injuries such as motor vehicle accidents, are two to six times higher in clients with mental illness than in the general population. Treatment of mental illness that is associated with chronic illness can decrease the effects of both and enhance desired outcomes. Since the prevalence of mental illness is so great, it is likely that healthcare professionals will encounter clients who have mental illness regardless of the healthcare settings in which they work. Therefore, all healthcare professionals must know about such illnesses, their causes and effects, and appropriate treatment regimens. SocialWork.EliteCME.com Page 45

2 Major Depression Major depression, also known as unipolar disorder, is a syndrome characterized by two or more weeks of a persistent sadness or lack of interest in normal activities of life, accompanied by at least four other symptoms of depression such as sleep disturbances, changes in appetite, lethargy, inability to concentrate, or decreased self-esteem. 2,3 There are several types of depressive episodes: single, recurrent, and seasonally patterned. 4 Single episode depression: A client experiences a single depressive episode according to diagnostic criteria but does not experience another episode of depression. 4 Recurrent depression: Recurrent depression is characterized as two or more depressive episodes that are separated by at least two months during which the client experiences normal or near normal functioning. To qualify as recurrent depression the client must have never had a manic or hypomanic episode. 4 A manic episode is defined as a hyperactive, euphoric state. A hypomanic episode is defined as a mild manic episode. 2 Seasonal Affective Disorder (SAD): SAD is defined as depression that is season-related. It usually affects clients during the fall and winter. However, there are reported cases of SAD occurring primarily during the spring and summer. Physicians may differentiate among levels of severity of depression. These include: 4 Mild depression: Symptoms are limited to the five required for diagnosis (see section on diagnosis), and existing symptoms do not interfere with the client s ability to work, attend school, or interact socially. Moderate: Five symptoms are present plus one or two more. These symptoms have a mild impact on the client s ability to work, attend school, and/or interact socially. Examples of mild impact include reduced ability to concentrate at school and absenteeism from work. Severe: Severe depression can be sub-divided into two categories: severe without psychosis and severe with psychosis. Severe without psychosis is described as having several or all of the major symptoms that significantly affect the client s ability to work, attend school, and/or interact socially. Severe with psychosis is characterized as having persistent delusions and hallucinations that make it impossible for the client to function at work, at school, and/or interact socially. Incidence, prevalence, and risk factors Approximately half of all persons diagnosed with depression experience a single episode, recover completely, and do not experience another episode. The remaining half experience at least one recurrence. 2 The incidence of depression is quite significant, with a reported increase every year since early in the 20 th century. Western countries generally report the highest rates: France 16 percent, New Zealand 11 percent, Canada 7 percent, and the United States 6 percent. The lowest rates of depression are reported in Asian and Southeast Asian countries: For example Korea reports a rate of 3 percent and Taiwan reports a rate of less than 2 percent. Countries involved in ongoing civil strife such as in Bosnia and Northern Ireland report higher rates of depression. 5 However, it is difficult to determine a truly accurate rate of worldwide depression since its definition varies among countries and cultures, and in some countries and cultures depression is not publicly acknowledged. Some countries, such as Eastern countries, may describe depression as a series of pains or energy imbalances instead of a mental health issue. 5 In the United States it is estimated that one in 10 adults report depression at some point in their lives. 6 Certain groups of Americans are more likely to meet the diagnostic criteria for major depression than others. These groups include: 5,6,7 Women: It is estimated that women are 70 percent more likely than men to experience depression at some point in their lives. Age-specific groups: When compared to adults over the age of 60, persons years of age are 70 percent more likely to experience depression at some point in their lives, persons years of age are 120 percent more likely, and year olds are 100 percent more likely. Racial/ethnic groups: Blacks, Hispanics, non-hispanic persons of other races or multiple races who have less than a high school education are more likely to experience depression. Persons of specific marital status: Persons who have been previously married (e.g. widowed, separated, or divorced) are more likely to experience depression. Persons of specific employment status: Persons who are unemployed or who are unable to work are more likely to experience depression. Persons without health insurance: Persons who do not have health insurance coverage are more likely to experience depression. Persons with a history of trauma: Persons who have had to deal with trauma (such as injury, sexual abuse, physical abuse, physical disability, loss of a loved one at a young age), alcoholism, and lack of family support are all more likely to experience depression. Possible causes of depression Carolyn is a 30-year-old marketing executive who has recently been diagnosed with diabetes. For the past two months she has been taking an oral anti-diabetic agent to control her glucose levels. Lately her colleagues notice that Carolyn is frequently withdrawn and has stopped attending social gatherings. She complains of feeling tired and sad. Her friends encourage her to discuss her feelings with her physician. When she does so, Carolyn s physician suspects that her anti-diabetic agent may be triggering symptoms of depression. A number of factors can contribute to the development of a major depressive episode. These range from biochemical influences, genetic influences, personal, physical or psychological trauma, other diseases, and medications. Page 46 Neurochemistry: Neurotransmitters, chemicals that carry information between nerve cells in the brain, seem to have an impact on the development of depression. Insufficient availability of certain neurotransmitters such as norepinephrine, serotonin, and dopamine may lead to depression. Recent research also indicates that specific structures of the brain may be linked to the development of depression. For example, neurochemical imbalances are believed to affect the brain s limbic system, which is the center of human emotions. 8 Genetic influences: Research shows that genetics influences the development of depression. For example, if a person has one parent with a mood disorder he/she has a 27 percent chance of inheriting such a disorder. 8 Psychosocial influences: As explained in the previous section on incidence, prevalence, and risk factors, certain psychosocial SocialWork.EliteCME.com

3 influences can lead to, or place a person at higher risk for, depression. These include physical and/or emotional abuse, bereavement, and lack of family support. Additionally, people who live in areas impacted by war, poverty, and/or natural disasters are more likely to develop depression. 8 Other medical conditions: Depression may develop as a secondary problem to some medical conditions such as metabolic disturbances, endocrine disorders, malignancies, viral and bacterial infections, Alzheimer s disease, and degenerative arthritis. The stress, impact on activities of daily living, and cost of chronic medical problems may also lead to depression. 2 Medications: A number of prescription drugs can trigger depression. Examples include anti-hypertensives, some cardiovascular medications, oral anti-diabetic drugs, cimetidine, and steroids, just to name a few. 2 Depression Alert! Commonly abused substances such as alcohol and illegal drugs are also associated with the development of depression. 2 Diagnosing depression David is a 22 year-old college senior. Popular and intelligent David is expected to pursue a successful career in the business world. As graduation approaches David complains of not feeling ready to leave school. I ll never be able to make it in the real world. I m just not good enough. He loses confidence in his ability to find a job and make a success out of a career. His friends don t understand his feelings. David has always been self-confident, and they attribute his sudden loss of self-esteem to a normal reluctance to see his college years, which have been fun as well as rewarding, come to an end. David begins to avoid social functions and complains of feeling tired all the time. He goes to bed by 8 pm and sleeps well into the next day, often missing classes. His friends want him to go to the campus health service, but David refuses. What s the point? Nothing matters anymore. His friends finally decide to call David s parents, who make the 5-hour drive to campus. With difficulty, they persuade David to see a physician, who, after evaluating David, makes a diagnosis of major depressive disorder. Depression affects all age groups and all types of persons, even those who, like David, seem confident and successful. That may be one of the reasons that depression can be a challenge to diagnosis. Even some healthcare professionals believe that depression is something that the client can just get over especially if the client seems to have a successful life and no reason to be depressed. Accurate diagnosis depends on an objective, supportive evaluation and a non-judgmental attitude. A complete history and physical is indicated to rule out other conditions, both physical and emotional, that can mimic or contribute to depression. It is also imperative that a medication history be obtained. As previously mentioned, certain drugs contribute to the development of depression. Some drug interactions may also trigger depression. Depression Alert! Never limit medication history to prescription drugs. Over-the-counter drugs as well as herbal supplements, vitamins, minerals, and illegal drugs can all have side effects and interact with each other in a dangerous fashion! It is also important to distinguish normal grief from a major depressive episode. Grief is a normal experience that often follows loss of a loved one or other traumatic experiences. Many of the characteristics of grief, such as sadness, fatigue, difficulty concentrating, sleep disturbances, and loss of energy, are similar to those of depression. However, there are some distinguishing factors. With grief, the person s mood can shift between anger, sadness, and normal functioning in one day. Depressed persons do not generally exhibit these mood shifts in a single day. Persons affected by grief often (although not always) respond to affection and support of others and are comforted by it and stay connected to family and friends. A depressed person is not able to experience comfort from others and loses connections to others. 9 Depression Alert! Persons experiencing normal grief should be monitored for depression. If symptoms persist from two weeks to several months, the affected person is unable to experience enjoyment, exhibits inappropriate guilt, and has a persistent negative view of him/herself and the world, depression may be developing. 9 The primary characteristics of a major depression episode are: 2,10 Dominant feelings of sadness. Lack of interest or pleasure in normal daily activities. Decreased self-esteem. Trouble concentrating and focusing. Changes in appetite. Sleep disturbances (e.g. sleeping too much or having trouble falling asleep or staying asleep). Decreased interest in sexual activity. There are specific diagnostic criteria that have been published in the Diagnostic and Statistical manual of Mental Disorders, 4 th edition. 2,10 When a patient meets the following criteria, he/she is diagnosed with major depression. These include: Five of the following symptoms must exist during the same two-week period. These symptoms must be a change from the client s usual behavior and one of the symptoms must be either a depressed mood or a loss of interest in activities that were formerly pleasurable. Depressed mood that exists most of the day nearly every day. Significantly reduced interest in or enjoyment of normal activities most of the day almost every day. Noteworthy weight loss or weight gain even though the client is not dieting or attempting to gain weight deliberately. Sleep disturbances such as sleeping too much, having trouble falling asleep or staying asleep. Psychomotor agitation or retardation that occurs almost every day. Fatigue or energy loss almost every day. Significant feelings of worthlessness or guilt almost every day. Reduced ability to concentrate or think almost every day. Persistent thoughts of death including suicidal thoughts without a specific plan, a suicide attempt, or the development of a specific plan for suicide. Symptoms do not meet the criteria for a mixed episode (symptoms of mania as well as depression exist). The client s symptoms significantly impact the ability to function at work, in social situations, or in other important activities of daily living. The symptoms are not caused by the direct influence of a particular substance or general medical condition. The symptoms are not more likely attributed to bereavement, they have existed for more than two months, or the symptoms are characterized by significant inability to function, obsessed with feelings of worthlessness, suicidal thoughts, psychotic symptoms, or psychomotor retardation. Depression Alert! A toxicology screening may help to identify drug-induced depression. 2 Psychology screening tests such as the Beck Depression inventory are used to help identify onset, duration, severity, and progression of the depression. 2 Additionally, certain populations may need specific types of testing for other diseases that may cause depression. These include: 10 SocialWork.EliteCME.com Page 47

4 It is recommended that teenagers and young adults be tested for mononucleosis and chronic fatigue syndrome. Elderly clients should be evaluated for dementia, Parkinson s disease, epilepsy, and stroke. Clients who are overweight should be evaluated for thyroid and adrenal disease, sleep apnea, and narcolepsy. Homosexual male clients, persons with multiple sexual partners, and those who use intravenous drugs should be tested for HIV. Depression and suicide risk Wendy is an 18 year old student at a prestigious school for culinary arts. She hopes to eventually become a pastry chef at a prestigious resort near her home town. Wendy is obsessed with succeeding and wants to make my family proud. There is a history of depression in her family, both her mother and sister experienced episodes of depression, and Wendy has recently been diagnosed as well. After taking an antidepressant for several weeks Wendy tells friends that she no longer feels so tired all the time and says, Now I have the energy to just put an end to all of my problems. Victor is the sales manager for a large automobile dealership. After having some trouble concentrating at work, losing interest in home and family, and expressing feelings of self-doubt and worthlessness he is diagnosed as suffering from depression. Victor is reluctant to take the antidepressant prescribed by his physician. Instead his symptoms become worse and he begins to talk about killing himself. His wife thinks that he is just looking for attention. However, one evening when she returns home from work she finds her husband slumped over the kitchen table, an empty bottle of sleeping pills next to his hand. Either of these scenarios is all too possible for persons experiencing depression. In Wendy s case, her risk for suicide increased after starting antidepressant therapy, a risk that often manifests itself in children and young adults after initiating such therapy. 11 In Victor s case he avoided antidepressant therapy, his symptoms escalated, and his suicidal ideation increased to the point where he took an over-dose of sleeping pills. Even though he openly talked about killing himself, his wife failed to take this threat seriously. Any threat of suicide MUST be taken seriously. Suicide is the eighth leading reported cause of death in the United States. 12 More than 90 percent of persons who commit suicide have clinical depression or another diagnosed mental health disorder. 13 Other risk factors for suicide include: Age: The adult at highest risk for suicide is at least 85 years old, is depressed, and needs to control his own life. 2 Family history: Family history of suicide, mental health disorder, or substance abuse increases the risk of suicide. 13 Family violence: A history of family violence, including physical or sexual abuse, increases the risk of suicide. 13 Keeping firearms: The presence of firearms in the home increases the risk of suicide. 13 Chronic illness: Persons who are dealing with chronic illness have a greater risk for suicide. 13 Witnessing suicidal behavior: Persons who are exposed to suicidal behavior in others are at increased risk for suicide. 13 Suicide Alert! Even the frailest older adults, including residents of long-term care facilities, may be able to find the strength to take their own lives! 2 In 2003 the Food and Drug Administration (FDA) issued a public health advisory pertaining to reports of suicide in pediatric clients who were being treated for major depressive disorder with antidepressant medication. After a thorough analysis was completed, the FDA determined that the risk of suicidal ideation in children and adolescents taking selective serotonin-reuptake inhibitors (SSRIs) was genuine. Therefore, in September 2004, the FDA recommended the following actions: 12 Place a black-box warning label on all antidepressants indicating that they increase the risk of suicidal thoughts and actions. Provide clients and caregivers a patient Medication Guide with every prescription. Include the results of controlled pediatric trials of depression in the labeling of antidepressant drugs. These actions, while helpful, are no substitute for careful observation and client/family education. It is important to assess clients for suicidal ideation and be alert to clues for possible suicidal behaviors. Client clues include: 2,13 Talking about feelings of hopelessness. Giving away valued possessions. Making or changing a will. Talking about death. Taking dangerous risks that could lead to death. Describing a suicide plan. Calling or writing people to say goodbye. Suddenly displaying a switch in mood from sadness to happiness. Depression Alert! An abrupt mood switch from sadness to happiness indicates a possible lifting of the depression. As the depression begins to lift, the client has more energy and ability to focus, thus increasing his/her ability to plan and carry out a suicidal act. 2,13 There are a number of actions healthcare professionals should take when suicidal ideation exists or when the potential for suicide is suspected. These include: 2,12,13 Assess for clues as identified above. Ask the client if he/she is thinking about suicide; ask if a plan for committing suicide has been thought about. Really listen to what the client is saying. Don t discount his/her concerns with comments such as, Everything will be all right. Never leave the suicidal client alone. Make the environment as safe as possible. Remove dangerous objects such as belts, razors, suspenders, light cords, glass, scissors, knives, clippers, and electrical cords. If the client is in an inpatient or outpatient setting follow hospital policy and procedures regarding suicide precautions. In the home setting call 911 or local suicide hotline(s) immediately. Teach clients and their families to recognize clues to possible suicidal behaviors. Teach families what to do if they suspect their loved one is contemplating suicide. Suicide Alert! Always take any suicidal behaviors or words seriously! The most common treatment initiative for depression is antidepressant drug therapy. Additional options include psychotherapy and, for select groups of patients, electroconvulsive therapy (ECT). 2,14 Treatment of Depression Page 48 SocialWork.EliteCME.com

5 Antidepressant medications Robert is a 42-year old college professor. Diagnosed with depression he began taking prescribed antidepressant about two weeks ago. He arrives at his local pharmacy accompanied by his wife. Robert looks tired and sad, and his wife is quite upset. She angrily tells the pharmacist, My husband isn t any better! He s so sad and tired all of the time, and he doesn t pay any attention to me or the kids! This medicine isn t working! Robert s wife expected that the antidepressant would have immediate positive effects. An important part of client education includes an explanation of how quickly an antidepressant may work. Antidepressants may take one to eight weeks to have an impact, depending on the particular antidepressant, its dosage, and the client. Antidepressant therapy is generally prescribed at a low dose to assess client tolerance. Generally, the dose is slowly increased according to the client s tolerance and responsiveness to the drug. 14 It is estimated that 80 percent of clients who take antidepressants report an improvement in their symptoms. The length of antidepressant therapy varies among clients. Treatment for an initial episode of depression may last from six months to a year, and recurrent episodes may require two years of treatment. Chronic depression may require life-long treatment. 14 In fact, recent research suggests that antidepressant drug therapy should continue for a longer period of time than the three to six months traditionally thought to be sufficient for an episode of major depression. Evidence from studies indicates that clients who take antidepressants for 18 to 24 months have fewer relapses. And some clients may need to remain on antidepressant therapy for years or even a lifetime. 3 Antidepressant Alert! Antidepressants are sometimes prescribed to treat conditions other than depression. Such conditions include post-traumatic stress disorder (PTSD), anxiety disorders, obsessivecompulsive disorder, and premenstrual dysphoric disorder. 11,15 There are a number of age-related concerns associated with antidepressant therapy. Children and adolescents may have different reactions and side effects than adults and are at somewhat greater risk for suicidal ideation. It is critically important that children and adolescents be monitored for any signs of suicidal ideation when taking antidepressants. However, the increased risk of suicide is not limited to children and adolescents. The FDA has mandated a black box warning on antidepressants advising families and caregivers to carefully monitor clients for increased thinking and suicidal behavior. 11,14,15 Older adults also have particular age-related concerns when it comes to antidepressants. These clients often have co-existing medical conditions, which require them to take multiple medications including prescription drugs, over-the-counter medications, nutritional supplements, and herbal preparations. Taking multiple medications increases the risk of adverse interactions and side effects. Older adults also tend to be more sensitive to medications because their bodies process drugs more slowly. Thus, lower and less frequent doses may be prescribed for older adults. 3,11,14,16 Memory problems may affect older clients, making it easy to forget to take medications as prescribed. A good way to keep track of medicine is to use a seven-day pillbox, which can be bought at any pharmacy. At the beginning of each week, older adults and/or their caregivers fill the box so that it is easy to remember what medicine to take. Many pharmacies also have pillboxes with sections for medications that must be taken more than once a day. 3,14,16 Antidepressants include the following classifications: 3,11,15 SSRIs: Selective Serotonin Reuptake Inhibitors. Cyclic Antidepressants. Atypical Antidepressants. MAOIs: Monoamine Oxidase Inhibitors. Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs). Selective serotonin reuptake inhibitors (SSRIs) Most clients are effectively treated with the newest classification of antidepressants, selective serotonin reuptake inhibitors (SSRIs). 3 SSRIs are the most commonly prescribed antidepressants as well as the newest classification of antidepressants. They are considered to be generally safe and cause fewer side effects than other classifications of antidepressants. 3,17 SSRIs are believed to work by blocking central nervous system (CNS) reabsorption (reuptake) of the neurotransmitter serotonin in the brain. This makes more serotonin available for use by the brain. Research indicates that people who suffer from depression don t have adequate levels of neurotransmitters, such as serotonin. 3 Altering the balance of serotonin is believed to increase the brain s ability to send and receive various chemical messages. This helps to alleviate depression. These drugs are referred to as selective because they primarily have an impact on serotonin, not on other types of neurotransmitters. 11,14,17,15 SSRIs have been shown to have positive effects in as little as just a few days in some cases. Examples of such positive effects include: 3 Sleep disturbances may decrease within three to four days. Energy begins to return within four to seven days. Mood, concentration, ability to focus, and interest in life s activities begin to improve within seven to 10 days. Examples of SSRIS used for the treatment of depression include: 3,11,15,17 Citalopram (Celexa). Escitalopram (Lexapro). Fluoxetine (Prozac, Prozac Weekly, Sarafem). Paroxetine (Paxil, Paxil CR, Pexeva). Sertraline (Zoloft). Fluoxetine combined with the atypical antipsychotic olazapine (Symbayax). Antidepressant Alert! In March, 2012 the generic form of Lexapro (escitalopram) was approved by the FDA to treat depression and general anxiety disorder in adults. 17 Depression Reminder! The importance of monitoring for suicidal thoughts and behaviors cannot be stated often enough! All clients, especially children, adolescents, and young adults, must be monitored for an increase in suicidal thoughts and actions after starting antidepressant drug therapy. As energy levels increase, the ability to concentrate improves, and clients may have both the energy and focus to plan and carry out a suicide plan. Parents, other family members, teachers, and friends may be relieved to see that a client s symptoms are diminishing. But an important aspect of client/ family education is to explain why the danger of suicide actually increases just as the depression starts to lift. Some SSRIs are available in the extended-release or controlled release forms. These are usually designated with the letters XR or CR. Such drugs enable a controlled release of medication throughout the day or even for a week at a time with just a single dose. 11,17 Side effects commonly experienced by clients who take SSRIs include: 11,15,17 Fatigue. Headache. Tremor. Dizziness. SocialWork.EliteCME.com Page 49

6 Insomnia. Dry mouth. Nausea. Diarrhea. Agitation or restlessness. Reduced libido. Difficulty reaching orgasm. Erectile dysfunction. Rash. Diaphoresis. Weight gain. Drowsiness. Vaginal dryness. Antidepressant Alert! Sexual side effects often affect those clients taking SSRIs. About 50 percent of clients report adverse sexual side effects. 14 Clients and, as appropriate, their families, must be taught about antidepressant side effects, when to report them, and how to deal with them. The potential for side effects, including those of an especially sensitive nature such as sexual side effects, should be discussed with the client prior to prescribing the medication. Antidepressant Alert! Fluoxetine (Prozac) causes a somewhat higher rate of mild agitation and loss of weight compared to other SSRIs, but produces less drowsiness. 3 Women who are pregnant or are thinking about becoming pregnant must carefully weigh the risks of antidepressant therapy to the baby compared to the benefit of taking the medication. Some antidepressants may place the fetus at risk or the medications may pass to the baby during breast-feeding. Paroxetine (Paxil) in particular seems to be associated with an increased risk of birth defects, including cardiac and respiratory problems. 17 It is important that women of child-bearing age discuss treatment options prior to becoming pregnant. In these cases, counseling about the potential risk to the fetus should be carefully implemented. Potential interactions with other drugs are also important considerations for the client taking antidepressants. Consider the following scenario: Sandy is a 45-year old biology professor at a large university. Both of her parents died in their 40 s from heart disease, and her younger brother has already had a heart attack. Sandy is on an aspirin regimen as part of a treatment strategy to prevent heart attack. She is also taking an SSRI for depression. After six months of antidepressant drug therapy Sandy arrives at work complaining of feeling dizzy and weak. She also notes that her gums bleed when brushing her teeth and that her bowel movements have become black in color. One of her colleagues insists on taking her to the emergency room where she is found to be bleeding internally as well as having a dangerously increased coagulation time. Drugs that increase coagulation time, such as aspirin, taken in conjunction with an SSRI, can cause significant bleeding. 11,17 Aspirin products, other non-steroidal anti-inflammatory drugs (NSAIDs), Coumadin, and other drugs that increase coagulation time may increase the risk of bleeding if taken in conjunction with SSRIs. Clients who take such drugs should be cautioned about this risk and monitored closely. 11,17 When possible, alternatives to these types of drugs should be investigated while the client is taking SSRIs. Monoamine Oxidase Inhibitors (MAOIs) such as phenelzine (Nardil), which are also used to treat depression, must not be used in conjunction with SSRIs. If SSRIs are prescribed, they must not be taken until 14 days after MAOI therapy has been discontinued. 11 Taking SSRIs and MAOIs within 14 days of each other can lead to neuroleptic malignant syndrome, a potentially fatal development. This syndrome is characterized by hyperthermia, rigidity, muscle cramps and tremors, and instability of the autonomic nervous system causing such problems as unstable blood pressure, agitation, delirium, and/or coma. 11,15,17,18 Serotonin syndrome is also a serious adverse reaction to antidepressant therapy. It is most likely to occur when two medications that raise serotonin are used in combination. This includes the herbal supplement St. John s wort, sometimes used in the treatment of depression. Serotonin syndrome is characterized by confusion, hallucinations, restlessness, loss of coordination, vomiting, tachycardia, irregular heart rates, dilated pupils, fever, changes in blood pressure, and unconsciousness. 11,15,17 In summary, there are a number of possible dangerous drug interactions between antidepressants and other medications. That is why it is so important to explain to clients that they must inform their healthcare providers and other members of the healthcare team about all of the medications they take, including not only prescription drugs, but overthe-counter medications, herbal preparations, vitamins, minerals, and even nutrition supplements and weight loss products. Many clients assume that non-prescription medications and substances such as aspirin, herbal preparations and vitamins are not really medicines, so they do not bother to inform their healthcare providers that they are taking them. Clients need to be told that any or all of these substances may interact negatively with antidepressants. Even weight-loss products have the potential to interact with some medications! When taking a patient history, it is absolutely necessary for healthcare providers to question clients specifically about non-prescription medications, herbs, vitamins, nutritional supplements, and weight loss products. It is imperative that clients (and their families as appropriate) be taught that SSRIs must be taken exactly as prescribed and never discontinued abruptly. When discontinuing SSRIs, the dosage must be tapered gradually under the supervision of the prescriber. Abrupt discontinuation can cause symptoms of withdrawal that include: 11,15,17 Nausea. Headache. Dizziness. Lethargy. Flu-like symptoms. Cyclic antidepressants: Tricyclic antidepressants (TCAs) and tetracyclics Tricyclic antidepressants (TCAs) and tetracyclics are among the earliest identified antidepressants and are sometimes referred to as cyclic antidepressants. TCAs were first used as a treatment for depression in the mid-1950 s. 3 Although effective, they have been replaced by antidepressants that cause fewer side effects. However, TCAs and tetracyclics may still be prescribed for clients who do not respond to other classifications of antidepressants. 15 TCAs cost less than many other types of antidepressants because they have been in existence for a longer period of time and therefore are available in generic forms. 19 Cyclic antidepressants work by increasing the amount of norepinephrine, serotonin, or both in the central nervous system. 11 Page 50 This increased availability helps the brain cells to send and receive messages more efficiently. However, cyclic antidepressants also affect other types of neurotransmitters, which, in turn, causes several significant side effects. 11,15 Route of administration of these types of antidepressants vary. Some are available in injectable formats as well as orally. 11,15 Cyclic Antidepressant Alert! Cyclics may take from days to cause improvement of symptoms. It may take six weeks for them to be fully effective. 3 SocialWork.EliteCME.com

7 Cyclics used in the treatment of depression include: 11,14,15,19 Amitriptyline (Elavil). Amoxapine (Asendin). Desipramine (Norpramin). Doxepin (Sinequan). Imipramine (Tofranil). Maprotiline (Ludiomil). Nortriptyline (Pamelor). Protriptyline (Vivactil). Trimipramine (Surmontil). Cyclic Antidepressant Alert! Some cyclics are linked to certain side effects more often than others. For example, amoxapine (Asendin) can cause extrapyramidal symptoms such as extreme restlessness, tremors, and involuntary movements as well as neuroleptic malignant syndrome. It can also increase appetite leading to weight gain. Maprotiline (Ludiomil) is associated with a risk for seizures (especially in clients who consume large amounts of alcohol), severe constipation, and retention of urine. 3 Side effects vary depending on the specific medication. Remember that clients and their families (as appropriate) should be counseled about the benefits and risks and side effects of drugs prior to starting therapy. Common side effects of cyclic antidepressants include: 3,11,15 Photophobia. Dry mouth. Drowsiness. Blurred vision. Constipation. Urinary retention. Dizziness. Delayed orgasm. Decreased sex drive. Tachycardia. Confusion. Hypotension. Increased appetite and weight gain. Fatigue. Headache. Nausea. Seizures. There are a number of pregnancy-related concerns with cyclic antidepressants. Some of these drugs may harm the fetus and/or pass to the baby during breast feeding. As with SSRIs (and any classification of antidepressant) women of child-bearing age should be counseled about the risks to the unborn child and to the baby during breast feeding. Such counseling should, ideally, take place before pregnanacy. 11,15,19 Drug interactions are a matter of concern as well. Serotonin syndrome is a possible consequence, just as it is with SSRIs. Other potential drug interactions include: 11,15,19 Barbiturates, alcohol, and other CNS depressants: Can significantly increase CNS depression and drowsiness. St. John s wort, SAM-e, and yohimbe (herbal preparations): Can cause serotonin syndrome and decrease drug levels. Evening primrose: Can cause additive effects and lower seizure threshold. Cimetidine: May increase drug levels. Clonidine (Catapres): May decrease the anti-hypertensive effect of Catapres and cause severe, life-threatening hypertension. Quinolones (broad-spectrum antibiotics): May increase the risk of life-threatening arrhythmias. Cyclics may also have an impact on some lab studies. These drugs may alter blood glucose levels. Such levels should be carefully monitored, especially if the client is a diabetic. Liver function should also be monitored as well as white and red blood cell counts. 11 Research shows that cyclics can exacerbate some chronic health problems. These drugs are contraindicated in clients who have received an MAOI inhibitor within the last 14 days, who have severe impairment of liver function, and/or who are in the acute recovery phase after suffering a heart attack. Cyclic antidepressants should be used with caution in clients who have narrow-angle glaucoma, enlarged prostate, history of seizures, cardiac problems, thyroid problems, or diabetes. 11,19 Some environmental and life-style issues can have an impact on the client who takes cyclic antidepressants. For example, smoking may lower drug levels. Clients who smoke must have their drug levels assessed more often than those who do not smoke. 11 Sunlight exposure may increase photophobia in clients who take cyclic antidepressants. Clients should be cautioned against over-exposure to sunlight. 11 Over-dosage of tricyclic antidepressants can have serious consequences. Consider the following scenario. Jasmine is a chemical engineer with an international corporation. Her job is quite demanding and requires frequent travel to Europe and Asia. Six months ago Jasmine was diagnosed as having depression and was placed on an SSRI. However, after several attempts with various SSRIs, Jasmine s physician determined that these drugs were not effective and, after extensive counseling, prescribed a cyclic antidepressant. During a recent office visit Jasmine is seen by the nurse practitioner. Jasmine tells her that, I am afraid this new drug won t work. I ve got to travel to Germany next week and really need to be able to concentrate on my work. I wonder if I should be taking a bigger dose of this new medication. The nurse practitioner explains the dangers of drug overdose and that it may take several more weeks for Jasmine to feel a difference in her symptoms. Jasmine agrees to take her medicine as prescribed. However, just a few days before she is to leave for Germany Jasmine s husband brings her to the office and asks to see the nurse practitioner or physician. Jasmine is confused and, according to her husband, had a seizure that morning. Stat blood tests are performed showing that there is a significantly high dose of the cyclic antidepressant in Jasmine s blood stream, suggesting that, despite counseling, she increased her intake of the drug. Tricyclic antidepressant overdose occurs over a period of as little as several days. Signs and symptoms of overdose include: 3,11,20 Confusion. Seizures. Coma. Tachycardia. Cardiovascular toxicity. Increased reflexes. Agitation. Hallucinations. Cyclic Antidepressant Alert! Cyclic antidepressants are not recommended for use in geriatric clients because of the potential for serious side effects and the potential for drug interactions. 3 Cyclics should never be discontinued abruptly. This can lead to withdrawal symptoms such as nausea, headache, dizziness, lethargy, and flu-like symptoms. 11,15 Atypical antidepressants Atypical antidepressants are generally used when SSRIs are ineffective or when clients cannot tolerate their side effects. These drugs are referred to as atypical because they do not fit into other classifications of antidepressants. Each is unique and works in different ways with different side effects and safety concerns. However, atypical antidepressants are believed to affect neurotransmitters including dopamine, serotonin, and norepinephrine. 3,11,15,21 SocialWork.EliteCME.com Page 51

8 Atypical antidepressants used in the treatment of depression include: 3,11,15 Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL. Mirtazapine (Remeron, Remeron SolTab). Nefazodone (Serzone). Trazodone (Oleptro). Since these types of antidepressants vary as to side effects and other issues a brief review of each atypical antidepressant is provided. Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL) Bupropion s exact action is unknown, but it is thought to weakly inhibit norepinephrine, dopamine, and serotonin reuptake. It does not inhibit MAO, but its noradrenergic or dopaminergic mechanisms may cause the drug s antidepressive effect. 11 Bupropion is believed to be a good choice for clients who have low energy caused by depression, but it can exacerbate or cause anxiety for some people. It is not associated with sexual side effects or weight gain as often as other antidepressants. 21 Atypical Antidepressant Alert! Bupropion is also prescribed as an aid to smoking cessation treatment. 11 Side effects of Bupropion include: 1,15,21 Confusion. Abnormal dreams. Insomnia. Headache. Tremor. Sedation. Agitation. Dizziness. Seizures. Tachycardia. Arrhythmias. Blurred vision. Sore throat. Rhinitis. Dry mouth. Constipation. Nausea. Vomiting. Fluctuations in weight. Excessive sweating. Contraindications include: 11,15 Clients who have taken MAOIs within the previous 14 days. Clients with seizure disorders. Clients with history of eating disorders (increases the risk of seizures). Atypical Antidepressant Alert! Bupropion is not approved for use in children. 11 Atypical Antidepressant Alert! Bupropion dosage and frequency should be reduced in clients who have impairment of kidney functioning or mild to moderate liver cirrhosis. 11,21 There are a number of potential adverse drug interactions with bupropion use. These include: 11 Other antidepressants: May lower seizure threshold. Beta blockers: Levels of beta blockers may be increased and cause adverse reactions. Nicotine replacement agents: May cause hypertension. Alcohol: May alter seizure threshold. Atypical Antidepressant Alert! Excessive sun exposure may increase the risk of photosensitivity. 11 Mirtazapine (Remeron, Remeron SolTab) Mirtazapine is believed to act by enhancing central noradrenergic and serotonergic activity. Like bupropion, mirtazapine may help to counter sexual side effects that are caused by other antidepressants. Since it often causes drowsiness, it is usually taken at bedtime. 21 Side effects include: 11,15,21 Somnolence. Dizziness. Increased appetite. Weight gain. Increased cholesterol levels. Increase or decrease in blood pressure. Decreased white blood cell count. Weakness. Drug interactions include: 11,15 If used with MAOIs fatal reactions may occur. Avoid use within 14 days of MAOI therapy. CNS depressants including alcohol may cause additive CNS effects. Mirtazapine should be used with caution in clients with cardiovascular disease, cerebrovascular disease, seizure disorders, hepatic or renal impairment, or history of mania or hypomania. It is not approved for use in children. 11 Nefazodone (Serzone) Nefazodone is thought to work by affecting neurotransmitters to enhance communication between brain cells. It may help to decrease anxiety in addition to alleviating depression. It is likely to cause drowsiness but is less likely to cause sexual side effects than other types of antidepressants. 21 Atypical Antidepressant Alert! Nefazodone has the advantage of being able to be prescribed for clients with liver and kidney disease. 3 However, there have been some reports of liver failure in some clients taking this drug, so it should be prescribed with caution. 21 Side effects include: 21,22 Orthostatic hypotension (Clients should be taught to change positions slowly, especially when they first start taking the drug). Dizziness. Headache. Dry mouth. Blurred vision. Confusion. Nausea. Sleepiness. Weakness. Flushing. Heartburn. Constipation. Pain, burning, numbness, or tingling in the hands and/or feet. Trazodone (Oleptro) Trazodone is a rather weak antidepressant thought to work by inhibiting the CNS neuronal uptake of serotonin. It is likely to cause sleepiness so is usually taken at bedtime. In addition to helping to alleviate depression it can also help to reduce anxiety. Trazodone is not approved for use in children. 11,15,21, Atypical Antidepressant Drug Alert! Trazodone is also prescribed for the treatment of insomnia and migraine prevention. 11 Side effects include: 11,15,21 Drowsiness. Confusion. Dizziness. Orthostatic hypotension. Dry mouth. Headache. Page 52 SocialWork.EliteCME.com

9 Nausea. Weakness. Blurred vision. Arrhythmias. Fatigue. Constipation. Diarrhea. Atypical Antidepressant Alert! Trazodone has been linked to a rare condition called priapism. Priapism is a persistent, painful erection not associated with sexual arousal. Clients who have an erection that lasts longer than four hours should seek emergency medical treatment. 21 There are a number of potentially dangerous drug interactions with trazodone. These include: 11,15 Other antidepressants: May increase the risk of serotonin syndrome. Antihypertensives: May increase the antihypertensive effect of trazodone. Digoxin and phenytoin: Trazodone may increase the levels of these drugs. MAOIs: Avoid concurrent use. Warfarin: May increase PT. Dosage may need to be adjusted. Herbs: Ginkgo biloba may increase sedation effects. St. John s wort may lead to serotonin syndrome. Alcohol: May increase CNS depression. Atypical Antidepressant Alert! Trazodone may decrease hemoglobin level. 11 Monoamine oxidase inhibitors (MAOIs) Sylvia has been dealing with major depression for several years. After trying other classifications of antidepressants without success, she and her physician discuss the option of taking an MAOI. Sylvia asks for time to think about this option. Before she makes up her mind she is hospitalized for emergency surgery for the removal of an infected ovarian cyst. Post-operatively, Sylvia tells her nurse that she is considering taking one of those MAOI drugs to treat my depression. But there s something about not being able to eat certain kinds of foods if I do take it. I don t really remember what the doctor said. Sylvia s nurse asks some questions about her diet. Sylvia tells the nurse that she tries to avoid eating meat but does love all kinds of cheeses and drinks a glass or two of beer several times a week. Sylvia also has a family history of heart disease and hypertension. The nurse realizes that if Sylvia does take an MAOI she must make some significant dietary changes! This scenario is an example of a client who is at risk for complications from MAOI therapy because of her diet and family history of hypertension. MAOIs were the first type of antidepressant drug developed, although effective, they, like TCAs, have been replaced by other types of antidepressants that are safer and cause fewer side effects. 8 One of the major concerns related to MAOIs is that they generally necessitate dietary restrictions. If these drugs are taken in conjunction with a diet high in tyramine containing-foods life-threatening hypertension may occur. 11,15,23, However, MAOIs may still be prescribed if the client does not respond to other types of antidepressants. Monoamine oxidase is an enzyme that helps to remove the neurotransmitters serotonin, dopamine, and norepinephrine from the brain. MAOIs work by inhibiting this removal, making more of these neurotransmitters available in the brain and enhancing brain cell communication. However, MAOIs also affect other neurotransmitters in the brain and in the digestive system, causing significant side affects. 23 MAOIs used in the treatment of depression include: 11,15,23 Isocarboxazid (Marplan). Phenelzine (Nardil). Selegiline ( Emsam, Zelapar). Tranylcypromine (Parnate). MAOI Antidepressant Alert! Selegiline (Emsam, Zelapar) is available as a transdermal patch. Administering the drug via the patch may cause fewer side effects compared to the oral form of the drug. 11,15,23 Side effects of MAOIs include: 11,15,23 Headache. Insomnia. Dizziness. Nausea. Arrhythmias. Low blood pressure. Diarrhea. Dry mouth. Changes in sense of taste. Nervousness. Muscle aches. Weight gain. Difficulty urinating. Paresthesia. Erectile dysfunction. Reduced sexual desire. Difficulty reaching orgasm. As with other classifications of antidepressants, MAOIs may place a fetus at risk and may pass to the infant during breast-feeding. Women of child-bearing age should be counseled about the risks to the unborn child and to the baby during breast-feeding prior to becoming pregnant. 11,15,23 MAOIs should never be taken in conjunction with other types of antidepressants or with St. John s Wort, an herb, because of the risk of dangerously high levels of serotonin (serotonin syndrome). Ginseng in combination with MAOIs may cause headache, tremors, and/or mania. Concurrent use should be avoided. 11,15 Clients taking MAOIs must restrict foods that contain high levels of Tyramine. Tyramine is an amino acid found naturally in the body and in certain foods and helps in the regulation of blood pressure. Interaction of Tyramine and MAOIs can cause dangerous, even lifethreatening hypertension. 23 MAOI Antidepressant Alert! Hypertensive crisis is the most serious side effect of the interaction between tyramine-containing foods and MAOIs. Symptoms include: 3 Occipital headache Sweating. (headache at the lower back Restlessness. of the head). Stiff neck. Nausea. Fever. Vomiting. Dilated pupils. Chills. The crisis can be so severe that it can eventually cause brain hemorrhage and death. 3 SocialWork.EliteCME.com Page 53