Antidepressants – Nursing Notes (SSRIs, SNRIs, TCAs, MAOIs, Atypicals)

Antidepressants – Nursing Notes (SSRIs, SNRIs, TCAs, MAOIs, Atypicals)

4 Universal NCLEX Rules for Antidepressants

1. Increased Suicide Risk

   • Energy ↑ before mood improves → higher risk of carrying out suicide.

   • Highest risk: ages 18–24 and during first few weeks or dose changes.

   • Monitor for:

     • New thoughts of suicide

     • Worsening depression

     • Sudden mood changes

     • Unusual behavior

   • Action: Notify provider immediately.

2. Slow Onset, Slow Taper

   • Takes 2–4 weeks for therapeutic effect.

   • Never stop abruptly → withdrawal symptoms.

   • Teach: Be patient, continue taking meds despite early side effects.

3. Never Mix

   • SSRIs + St. John’s Wort → serotonin syndrome.

   • MAOIs + other antidepressants (SSRIs, SNRIs, TCAs) → serotonin syndrome.

   • 2-week washout period required when switching.

4. Psych Med Side Effects

   • ↓ Blood pressure → orthostatic hypotension → risk for falls.

   • Weight gain common.

   • Teach: slow position changes.

SSRIs

Examples: Sertraline, Citalopram, Escitalopram, Paroxetine, Fluoxetine
Indications: Depression, Anxiety, PTSD
MOA: Blocks serotonin reuptake → ↑ serotonin levels.

Key Side Effects:

• Weight gain

• Sexual dysfunction (NCLEX favorite)

• Insomnia (not sedation)

Priority Acronym: SSRI

• S = Suicide risk (esp. age 18–24)

• S = Slow onset & taper (2–4 weeks for effect)

• S = Serotonin syndrome (never mix with St. John’s Wort, MAOIs, Tramadol)

  • SRI Symptoms:

    • S: Sweaty, hot (fever)

    • R: Rigid muscles, restlessness, agitation, tremors, ↑ reflexes

    • I: Increased HR (tachycardia >100 bpm)

SNRIs

Example: Duloxetine (Cymbalta)
Indications: Depression + chronic pain (neuropathy, fibromyalgia)
Memory trick: Duloxetine = Dual purpose (depression + pain)

Teaching:

• Helps with sleep in fibromyalgia patients.

• Educate patients refusing med: it treats pain, not just depression.

TCAs

Examples: Amitriptyline, Imipramine
Indications: Depression, anxiety, neuropathic pain (diabetes, fibromyalgia)

Side Effects: The Big Dry (anticholinergic)

• Can’t see = blurred vision, photophobia

• Can’t pee = urinary retention (priority!)

• Can’t spit = dry mouth

• Can’t poop = constipation

• Other: sedation, sweating, seizures, orthostatic hypotension

Memory tricks:

• Amitriptyline = “Amy trips on things” → sedation, fall risk

• Imipramine = “Inhibits my peeing” → urinary retention

Teaching: Sunglasses for photophobia, gum for dry mouth, fluids/fiber for constipation.
Never mix with MAOIs → 2-week washout.

MAOIs

Examples: Phenelzine (Nardil), Isocarboxazid, Tranylcypromine
Indications: Resistant depression, panic disorder, social phobia

Acronym: MAOI

• M = Massive HTN crisis risk

  • Trigger: tyramine foods (cheese, wine, beer, sausage, salami, chocolate)

  • S/S: severe headache → stroke/MI risk

• A = Avoid OTC meds (esp. cold meds, NSAIDs, acetaminophen, antacids, calcium)

• O = Other antidepressants avoided (SSRIs, SNRIs, TCAs)

  • 2-week washout required

• I = Increased suicide risk in first few weeks

Teaching: Tyramine-free diet 2 weeks before starting and 2 weeks after stopping.

Atypical Antidepressants

Trazodone

• Indication: Depression + insomnia (sedating)

• Memory trick: “TraZzzodone” → sleep

• Side effects: sedation, orthostatic hypotension, priapism (ER if >4 hrs)

• Teaching: Take at night, avoid alcohol/benzos/antihistamines, slow position changes.

Bupropion (Wellbutrin, SR/XL)

• Indications: Depression, smoking cessation

• Side effects: insomnia, headache, weight loss

• Teaching:

  • Never double doses

  • Do not crush/chew SR or XL forms (swallow whole)

  • May be combined with nicotine gum

Top Risks for Injury

• Amitriptyline (sedating)

• Diphenhydramine (Benadryl – sedating)

• Alprazolam (benzo – sedating)

• MAOI + tyramine foods → HTN crisis

• SSRIs + St. John’s Wort → serotonin syndrome

• Switching SSRI ↔ MAOI without 2-week washout → serotonin syndrome

• Clozapine (antipsychotic, not antidepressant) → agranulocytosis (infection risk)