this is Professor Hoffman and uh contining our discussion on CNS medication classifications for this topic we're going to be looking at the anti-depressants so this will be the third in the series uh for topic eight on CNS agents so what we're looking at here again are the cap RN um components or information pieces is for a variety of classes that fall under anti-depressants first class that we want to look that would be in that General class of anti-depressants or over um overall classification are the tricyclic antidepressants or tcas uh the tricyclic antidepressants an example drug would be amitryptiline in general we're really not sure how it acts uh but it does seem to be involved D or include its involvement in inhibiting the reuptake of norepinephrine and serotonin specifically so again you'll remember that norepinephrine and serotonin are two of the camines or amino acid neurotransmitters and normally they would be released into the synapse so they're going to be received by the receptor and as they get used up by The receptors other um particles of the neurotransmitter are going to diffuse the we way some are going to be broken up um by the monoamine oxidase or Mao enzyme but some of it is going to be re um is going to attach The receptors on the originating neuron and put back into storage in that neuron so they can be used later so this class of drugs group of drugs as well as um the ones following are going to work by in inhibiting that re-uptake process so as tricyclics we're specifically looking at reuptake of norepinephrine and serotonin so it's going to be used for depression it's also going to be helpful with neuropathic pain so some um neuropathy type uh issues so for some diabetics uh for some others with nerve disease where they're having um abnormal pain sensitivities it's going to help with that because um the norepinephrine serotonin are involved in those senty nerves at their synapsis as well uh it can also be used to treat insomnia so it's going to just sort of be a calming effect serotonin we tend to think as as being a calming drug calming drug calming drug I'm sorry about that um just going to help us chill so that's the sort of things we're going to be looking at so again our action it seems to be primarily its involvement in inhibiting that reuptake of norepinephrine and serotonin so our reactions um the anti-depressants overall are going to have blackbox warnings on them particularly for um uh Youth and Young adults uh there can be an increased risk of um suicidal ideation and uh just so it just changes the way we process information that could causes that potential risk to become increased again in children youth and uh young adults primarily again what we're doing is we are trying to increase the amount of the camine serotonin and norepinephrine uh by blocking their reuptake so we would not want to take it with MAOI for the same reason that we looked at um with the CNS stimulants the maois are going to inhibit the action of the monoamine oxidase so it's also going to feed into an increase the availability of uh norepinephrine as well as epinephrine the serotonin and dopamine so as all those things um start building up we're going to start seeing an increased stimulation of the sympathetic nervous system with heart rate blood pressure those types of things um along with blocking the reuptake of Serotonin and um norepinephrine um this class of drugs has a little bit of a blocking action on some of the Paras parasympathetic receptor sites so what they're going to do is they're decreasing the responsiveness of that neurotransmitter which again just helps facilitate an increased responsiveness of the norepinephrine and the serotonin so we're going to see some anticholinergic side effects and you'll remember those from our discussions um several modules ago our generic or general anticholinergic effects we're going to be watching for include some Tac cardia some urinary retention constipation dry mouth and again it's going to be a concerned with anybody with narrow angle glaucoma because it can worsen that that's going to resor those peripheral nervous system the parasympathetic uh component of that where we'll see some effects from this because again these drugs are acting not just in the brain but they are also acting at receptor sites throughout the body uh within the brain central nervous system we're going to start seeing some impairment of cognitive function there's going to be some uh slowing of both psycho and motor uh activity so psychomotor slowing some confusion and some related sedation so we get into some of these other issues than some hypotension we're going to have a risk for some arism because we're going to be impacting the conduction system in the heart as well um our seizure threshold is going to be altered so it's going to make um change the degree to which triggers for seizures uh will be effective in bringing on seizure activity our nursing considerations uh this is going to be repe with each of the classes within this General group we want to make sure they're compliant we do not want them to stop abruptly uh the anti-depressants in general take um several days to a few weeks to actually become effective to get up to therapeutic dosing so it's going to be sort of a slow buildup once they're in our system they it also leaves the system slowly um but if we stop abruptly there will precipitate um um issues of um increased side effects from the abrupt stopping uh some cardiovascular issues so it' be another drug that we want to wean off we want to taper off um when we're stopping when the patient is stopping the medication uh we want to teach and assess and monitor for fall risks so again issues that are going to be fairly common with all the anti antidepressant groupings the next class of anti-depressants are this SSRI uh very common one now more common tricyclics have been around for a while the TCA ssris um came on because they're going to be a little bit more focused on serotonin and not so much the norepinephrine so we're going to have a um hopefully a little bit less concern uh on the side effects uh being as drastic as they possibly could be with a tricyclic so again the action is it's selective to focusing on the serotonin and that inhibiting the reuptake so again we're going to block that ability for the serotonin to attach the receptor sites on the originating cell neuron and being put back in storage for use it's going to stay in circulation in that synapse area uh we're going to use it for depression it can also help with some other behavior disorders as just sort of a calming type uh drug it does have some Effectiveness with migraines and there has been some demonstration it can be effective uh with some of the symptoms of premenstrual syndrome but again we're looking at its action being primarily that reup inhibiting the reuptake of the serotonin uh blackbox warning again increased risk of suicide suicidal ideation again contraindicated with maois we're going to see with this one a focus that they should not take it with grapefruit juice uh you'll remember from one of our very early discussions uh that there's an enzyme in circulation in produced in the liver um that is critical for metabolizing severals of drug classes this would be one of them grape fruit juice then neutralizes that enzyme so the concern with anytime you see grapefruit juice as being a concern or something to be um avoided with the medications because that particular drug class in this case the ssris are metabolized by that enzyme the grapefruit juice is going to inhibit or inactivate that enzyme so it's going to result in an increased amount of SSR and circulation so we're going to have an increased amount of responsiveness increased amount of Serotonin building up um so that puts us at risk for serotonin syndrome serotonin syndrome involves some mental status changes basically towards the areas of agitation some confusion hallucinations uh when we get into the autonomic nervous system we're basically going to be triggering the sympathetic side so we're going to have some Tac of cardia blood pressure is going to start going extremely high in the neuromuscular activity we're going to see hyper reflexes that's going to cause some coordination issues it's going to be some GI issues of nausea vomiting and diarrhea if serotonin syndrome continues to escalate it can lead to a neuroleptic malignant syndrome U this is really tied into hyp extreme hypothermia U muscle rigidity and extreme fluctuations of Vital Signs particularly going towards the high range and more extreme mental St status changes so again that's why we want to really monitor drug to drug interactions in this case drug and food interactions with the grapefruit juice um ssris again takes several weeks to get to full therapeutic effect so if an individual starts on an SSRI and reports back in the first week that they're not feeling that much different that's normal what's going to take uh again a period of several weeks to get up to the therapeutic level to where they're going to actually be aware of the benefits of it again it's a drug we don't want to stop quickly we want to taper it off we're going to monitor compliance because um again we need to maintain those um therapeutic levels on a consistent basis and we're going to be teaching them the diet issues with the grapefruit juice for example going to be teaching them to monitor for any of these adverse reactions to catch them early a related class is going to be serotonin nor epinephrine reuptake inhibitor so it's going to be similar to the tcas so it's inhibiting reuptake of serotonin norepinephrine it has a weak inhibition of the reuptake of dopamine so we're have some dopamine effect as well uh this is going to be not be used for mild or moderate depression this is going to be used for a major depressive disorder so we get in the snris we're looking at a more extreme level of depression um a lot of the issues carrying over from the ssris um and even the tcas because again we're blocking that reuptake so we're increasing the amount of catacol amines in those synapsis so as you go through you're going to see a lot of the same issues coming down through here on our nursing considerations again several weeks to get to therapeutic level taper to discontinue again our considerations for all the anti-depressants that we've looked at so far are going to be pretty much the same um and um our risks of side effects and adverse reactions are going to be very similar because again we're focusing on increasing the amount of the catacol amines at the neuros synaps site next class we will to look at then are the maois that I talked about earlier so this is monoamine oxidase inhibitor so this drug is going to block the action of monoamine oxidase the monoamine oxidase or Mao is that um enzyme responsible for breaking down catacol amines to help uh take them out of um the synapse so um by taking inactivating this enzyme now then that's going to allow the norepinephrine epinephrine dopamine and serotonin to in to maintain higher levels some of it's still going to diffuse away some of it may is still going to be taken back in through reuptake process some of it's going to be used by receptor sites but that part of the neurotransmitter that would have normally been degraded by the enzyme is now going to stay uh present um monom oxidase Inhibitors or maois is going to be used for major depressive disorders it's not going to be a firstline choice or first round choice of drugs for depression and it's going to be held off until we see if the depression is responsive to the other classes uh the reason for that is the risks associated with monoamine oxid Inhibitors or the mois again we have that risk of suicide inity that same blackbox warning we have a risk now for hypertensive crisis because not only are we increasing the serotonin epinephrine or epinephrine in those areas of the brain that are dealing with depression mood changes that sort we're also blocking the Mao out in the autonomic nervous system so we're going to start seeing increased amounts of norepinephrine epinephrine dopamine out in the cardiovascular system other we're going to have the risk for hypertensive crisis um we don't want to combine it with the CNS stimulant drugs because again they were also increasing the action of epinephrine norepinephrine a big issue with monoamine oxidase Inhibitors is that they interact with tyramine containing foods and tyramine containing foods are prevalent in our diet they include things like aged cheese cured or processed Meats um vegetables that have been pickled or fermented so think of things like sauerkraut those kinds of things or anytime we've pickled a vegetable for storage Citrus and tropical fruits are high high in tyramine and alcohol including beer and red wines are high in tyramine tyramine um also encourages um or stimulates the catacol amines so taking the maois along with a diet that's high in tyramine Foods uh which we may not realize or think about when we're planning our diet is going to increase the risk for that serotonin syndrome for that hypertensive crisis situation so again because there are so many food and drug interactions going on so much risk for the hypertensive crisis that type thing Mai maois are only going to be used when other um classifications of anti-depressants have not been effective and again as you go through you can see uh some of the other reactions that are going to be similar to ones we've looked at already and when we look at the nursing considerations uh again tapering it to discontinu we want to monitor compliance a lot of teaching on diet to recognize tyramine containing foods a very accurate medication and over the- counter drug history to make sure we're not dealing with any other drugs that are going to stimulate the autonomic nervous system in particular and put us at risk fore uh hypertensive crisis attac cardia at a high rate that type of thing and just a very clear Awareness on the part of the patients for our teaching of the adverse reactions to be w u watching out for so again those are our classes of anti-depressants the majority of them are dealing with uh inhibiting the reuptake of catacol amines the monoamine oxidation Inhibitors or maois are going to be focused on blocking the action of that enzyme net effect is the same we're going to have an increased amount of C at colam means the epinephrine norepinephrine serotonin and dopamine um had the synapse areas of the nerves throughout the body so we'll move on to some other in classifications in the next video