{"id":351,"date":"2019-11-19T16:58:42","date_gmt":"2019-11-19T21:58:42","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/8-7-antidepressants\/"},"modified":"2022-02-24T11:58:10","modified_gmt":"2022-02-24T16:58:10","slug":"8-7-antidepressants","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/8-7-antidepressants\/","title":{"raw":"8.7 Antidepressants","rendered":"8.7 Antidepressants"},"content":{"raw":"<div class=\"1.7-antidepressants\">\r\n\r\nAntidepressants are used to treat depression and other mental health disorders, as well as other medical conditions such as migraine headaches, chronic pain, and premenstrual syndrome. Antidepressants increase levels of neurotransmitters in the CNS, including serotonin (5-HT), dopamine, and norepinephrine. Treatment is based on the belief that alterations in the levels of these neurotransmitters are responsible for causing depression.<sup>[footnote]Lilley, L., Collins, S., &amp; Snyder, J. (2014). <em>Pharmacology and the Nursing Process.<\/em> pp. 246-272. Elsevier.[\/footnote] <\/sup>\r\n\r\nThis module will discuss four classes of antidepressants: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs). These medications are compared in Table 8.7.\r\n\r\nTCAs and MAOIs are referred to as first-generation antidepressants because they were first marketed in the 1950s. SSRIs, SNRIs, and other miscellaneous medications such as bupropion are called second-generation antidepressants and are popular because of fewer side effects like sedation, hypotension, anticholinergic effects, or cardiotoxicity.<sup>[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 227-305. Elsevier.[\/footnote]<\/sup>\r\n\r\nSafety warnings (Black Box) are in place for all classes of antidepressants used with children, adolescents, and young adults for a higher risk of suicide. All clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.\r\n\r\nFor more information on different types of anti-depressants, watch this video.\r\n\r\nhttps:\/\/www.youtube.com\/watch?v=kBV3rGv6B6Q\r\n<p style=\"text-align: center\"><sup><a href=\"https:\/\/www.youtube.com\/watch?time_continue=2&amp;v=kBV3rGv6B6Q&amp;feature=emb_logo\">Pharmacology - Antidepressants, SSRI, MAIO, TCA, SNRIs<\/a> by <a href=\"https:\/\/www.youtube.com\/channel\/UCUxQWmWk1_Hk9iDRKvhH29Q\">Simple Nursing<\/a>, is licensed under a <a href=\"https:\/\/www.youtube.com\/t\/terms\" target=\"_blank\" rel=\"noopener\">Standard YouTube license<\/a><\/sup><\/p>\r\n\r\n<h2>Tricyclic Antidepressants<\/h2>\r\nTricyclic antidepressants (TCAs) were one of the original first-generation antidepressants. Due to the popularity of SSRIs and SNRIs, TCAs are now more commonly used to treat neuropathic pain and insomnia.\r\n\r\n<strong>Mechanism of Action<\/strong>\r\n\r\nTCAs tend to have sedative and anticholinergic effects. They act by inhibiting presynaptic reuptake of NE and 5-HT into nerves.\u00a0The choice of TCA depends on individual response and tolerance to the drug.\r\n\r\n<strong>Indications for Use<\/strong>\r\n\r\nTCAs are used to treat depression, chronic neuropathic pain, and insomnia.\r\n\r\n<strong>Nursing Considerations Across the Lifespan<\/strong>\r\n\r\nTCAs are often administered at bedtime due to sedating effects and are contraindicated with MAOIs.\r\n\r\nGeriatric clients are particularly sensitive to the anticholinergic side effects of tricyclic antidepressants. Peripheral anticholinergic effects include tachycardia, urinary retention, constipation, dry mouth, blurred vision, and exacerbation of narrow-angle glaucoma. Central nervous system anticholinergic effects include cognitive impairment, psychomotor slowing, confusion, sedation, and delirium. Elderly clients taking amitriptyline may be at increased risk for falls. Elderly clients should be started on low doses of amitriptyline and observed closely.\r\n\r\nAfter prolonged administration, abrupt cessation of treatment may produce nausea, headache, and malaise. The dose should be gradually tapered, but transient symptoms may still occur.\r\n\r\nTCAs should not be used in children and those who are pregnant or lactating.\r\n\r\n<strong>Adverse\/Side Effects <\/strong>\r\n\r\nAdverse effects of TCAs are a result of their blockade effects on various receptors, often resulting in anticholinergic adverse effects such as constipation, urinary retention, and drowsiness. Blockage of adrenergic and dopaminergic receptors can cause cardiac conduction disturbances and hypotension. Histaminergic blockage can cause sedation, and serotonergic blockade can alter the seizure threshold and cause sexual dysfunction.\r\n\r\nBlack Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.\r\n\r\nTCAs are contraindicated as follows:\r\n<ul>\r\n \t<li>Myocardial infarction.<\/li>\r\n \t<li>Concurrent use of MAOIs.<\/li>\r\n \t<li>Pregnancy, lactation.<\/li>\r\n \t<li>Preexisting cardiovascular disorders.<\/li>\r\n \t<li>Angle-closure glaucoma, urinary retention, prostate hypertrophy, GI or GU surgery.<\/li>\r\n \t<li>History of seizures.<\/li>\r\n \t<li>Hepatorenal diseases.<\/li>\r\n<\/ul>\r\nThere are also several drug interactions such as cimetidine, fluoxetine, ranitidine: increased therapeutic and adverse effects of TCAs. Usage with oral anticoagulants can increase serum levels of anticoagulants and increase the risk of bleeding. TCAs should not be used concurrently with MAOIs, which increases the risk for a severe hyperpyretic crisis. <sup>[footnote]RNpedia. (2022). Antidepressants. <a href=\"https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/antidepressants\/\">https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/antidepressants\/<\/a>[\/footnote]<\/sup>\r\n\r\n<strong>Overdosage<\/strong>\r\n\r\nDeath may occur from overdosage with this class of drugs. Multiple drug ingestion (including alcohol) is common in deliberate tricyclic antidepressant overdose. If an overdose occurs, consult with a\u00a0<a href=\"http:\/\/www.dpic.org\/\">Poison Information Center<\/a> (1-800-567-8911).\r\n\r\n<strong>Client Teaching &amp; Education:<\/strong> Due to the increased risk of suicidality with antidepressants, clients and their family members or caregivers should be instructed to immediately report any sudden changes in mood, behaviors, thoughts, or feelings. The potential side effects discussed above should be reviewed. <sup>[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0[\/footnote],[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 227-305. Elsevier.[\/footnote],[footnote]Lilley, L., Collins, S., &amp; Snyder, J. (2014). <em>Pharmacology and the Nursing Process.<\/em> pp. 246-272. Elsevier.[\/footnote]<\/sup>\r\n\r\n<span style=\"text-align: initial;font-size: 14pt;background-color: #ffffff\">Table 8.7 provides a closer look at this medication and compares TCAs with other classifications of antidepressants.\u00a0<\/span>\r\n<h2>Selective Serotonin Reuptake Inhibitor (SSRI)<\/h2>\r\nSelective Serotonin Reuptake Inhibitors (SSRIs) are second-generation antidepressants and have fewer side effects than TCAs and MAOIs. Fluoxetine and citalopram are commonly used SSRIs.\r\n\r\n<strong>Mechanism of Action<\/strong>\r\n\r\nSSRIs inhibit the reuptake of serotonin.\r\n\r\n<strong>Indications for Use<\/strong>\r\n\r\nSSRIs are primarily used to treat depression but are also used to treat obsessive-compulsive disorder, bulimia, panic disorder, posttraumatic stress disorder, other forms of anxiety, premenstrual syndrome, and migraines.\r\n\r\n<strong>Nursing Considerations Across the Lifespan<\/strong>\r\n\r\nThe onset of fluoxetine\u2019s antidepressant effect develops slowly for up to 12 weeks.\r\n\r\nUse caution in clients who are taking other CNS medications or who have liver dysfunction. This drug is contraindicated with MAOIs. Monitor for increased suicide ideation in all populations, as well as for the development of serotonin syndrome. Clients should avoid grapefruit juice due to its effect on the CYP3A4 enzyme that affects the bioavailability of the medication.\r\n\r\n<strong>Adverse\/Side Effects<\/strong>\r\n\r\nBlack Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.\r\n\r\nThe development of a potentially life-threatening serotonin syndrome or neuroleptic malignant syndrome (NMS)-like reactions has been reported with SNRIs and SSRIs, particularly with concomitant use of serotonergic drugs, drugs that impair the metabolism of serotonin (including MAOIs), or with antipsychotics or other dopamine antagonists. Symptoms of <strong>[pb_glossary id=\"620\"]serotonin syndrome[\/pb_glossary]<\/strong> may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination), and\/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Serotonin syndrome, in its most severe form, can resemble <strong>[pb_glossary id=\"644\"]neuroleptic malignant syndrome[\/pb_glossary]<\/strong> (NMS), which includes hyperthermia, muscle rigidity, autonomic instability with possible rapid fluctuation of vital signs, and mental status changes. Clients should be monitored for the emergence of serotonin syndrome or NMS-like signs and symptoms.<sup>[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. [\/footnote]<\/sup>\r\n\r\nOther side effects include rash; mania; seizures; decreased appetite and weight; increased bleeding associated with the concomitant use of fluoxetine and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation; hyponatremia; anxiety; and insomnia.\r\n\r\nAbrupt discontinuation may cause several adverse effects, so a gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. <sup>[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0[\/footnote],<\/sup><sup>[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 227-305. Elsevier.[\/footnote],[footnote]Lilley, L., Collins, S., &amp; Snyder, J. (2014). <em>Pharmacology and the Nursing Process.<\/em> pp. 246-272. Elsevier.[\/footnote]\u00a0<\/sup>\r\n\r\n<strong>Client Teaching &amp; Education<\/strong>\r\n\r\nClients should be careful to take medications as directed. Abrupt discontinuation may cause anxiety, insomnia, and increased nervousness. Additionally, orthostatic blood pressure changes are common during medication therapy. Clients may also be increasingly drowsy or exhibit some confusion. Use of SSRI medications with alcohol or other CNS depressant drugs should be avoided.\r\n\r\nClients, family, and caregivers should monitor clients carefully for suicidality.\u00a0 Other side effects include possible decreased libido, urinary retention, constipation, and increased photosensitivity.\r\n\r\n<span style=\"text-align: initial;font-size: 14pt;background-color: #ffffff\">Table 8.7 provides a closer look at this medication and compares SSRIs with other classifications of antidepressants.\u00a0<\/span>\r\n\r\n<\/div>\r\n<div class=\"__UNKNOWN__\">\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<h2>Clinical Reasoning and Decision-Making Activity 8.7<img class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\" style=\"text-align: left\">\r\n\r\nA 32-year-old female visits the nurse practitioner with concerns about \u201cfeeling tired all the time,\u201d \"having difficulty concentrating,\u201d \u201cproblems sleeping,\u201d and \u201cjust generally feeling down.\u201d The nurse practitioner prescribed fluoxetine.\r\n\r\nThe client tells the nurse, \u201cOne of my friends told me I have to be careful or I might get serotonin syndrome if I take medication.\u201d\r\n\r\n1. What places a client at risk for serotonin syndrome, and what symptoms should the nurse teach the client about this condition?\r\n\r\n2. The nurse knows that anyone starting an antidepressant is at risk for suicidal thoughts. How should the nurse therapeutically discuss this potential adverse effect with the client?\r\n\r\n3. What potential common side effects should the nurse discuss with the client?\r\n\r\nThe client states, \u201cI can\u2019t wait to feel better again. How soon will this medication work?\u201d\r\n\r\n4.\u00a0 What is the nurse\u2019s best response?\r\n\r\nNote: Answers to the Critical Thinking activities can be found in the \"<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-8\/\">Answer Key<\/a>\" sections at the end of the book.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<div class=\"1.7-antidepressants\">\r\n<h2>Serotonin Norepinephrine Reuptake Inhibitor (SNRI)<\/h2>\r\nVenlafaxine is an example of a Serotonin Norepinephrine Reuptake Inhibitor (SNRI).\r\n\r\n<strong>Mechanism of Action<\/strong>\r\n\r\nVenlafaxine inhibits the reuptake of serotonin and norepinephrine, with weak inhibition of dopamine reuptake.\r\n\r\n<strong>Indications for Use<\/strong>\r\n\r\nSNRIs are indicated for the treatment of a major depressive disorder.\r\n\r\n<strong>Nursing Considerations Across the Lifespan<\/strong>\r\n\r\nSNRIs are contraindicated with MAOIs or within 14 days of use of an MAOI. Dosage adjustment is required for use in clients with renal and\/or liver disease. Elderly clients are at greater risk for developing hyponatremia. Use with caution with other serotonin medications.\r\n\r\n<strong>Adverse\/Side Effects<\/strong>\r\n\r\nBlack Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.\r\n\r\nSNRI medication may cause a sustained increase in blood pressure. Other side effects include serotonin syndrome, insomnia, anxiety, decreased appetite, weight loss, mania, hyponatremia, increased bleeding (especially with the concomitant use of fluoxetine and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation), elevated serum cholesterol, somnolence, and nausea. <sup>[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0[\/footnote]<\/sup>\r\n\r\n<strong>Client Teaching &amp; Education<\/strong>\r\n\r\nClients should be careful to take medications as directed.\u00a0 The dose should be tapered prior to discontinuation. Clients may also be increasingly drowsy or dizzy.\u00a0 Use of SNRI medications with alcohol or other CNS depressant drugs should be avoided. Clients, family, and caregivers should monitor clients carefully for suicidality.\r\n\r\n<span style=\"text-align: initial;font-size: 14pt;background-color: #ffffff\">Table 8.7 provides a closer look at this medication and compares SSRIs with other classifications of antidepressants.\u00a0<\/span>\r\n<h2>Monoamine Oxidase inhibitors (MAOI)<\/h2>\r\nMonoamine oxidase inhibitors (MAOIs) are first-generation antidepressants.\u00a0 A significant disadvantage to MAOIs is their potential to cause a hypertensive crisis when taken with stimulant medications or foods containing tyramine.\r\n\r\n<strong>Mechanism of Action<\/strong>\r\n\r\nThe mechanism of action of MAOIs is not fully understood but is presumed to be linked to the potentiation of monoamine neurotransmitter activity in the central nervous system resulting from its inhibition of the enzyme monoamine oxidase (MAO).<sup>[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0[\/footnote]<\/sup> MAO inactivates norepinephrine, dopamine, epinephrine, and serotonin. By inhibiting MAO, the levels of these transmitters rise thus creating anti-depressive effects.<sup>[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 227-305. Elsevier.[\/footnote]<\/sup>\r\n\r\n<strong>Indications for Use<\/strong>\r\n\r\nMAOIs are indicated for the treatment of major depressive disorder in adult clients who have not responded adequately to other antidepressants.\r\n\r\n<strong>Nursing Considerations Across the Lifespan<\/strong>\r\n\r\nSerious interactions with several medications, as well as foods and beverages containing tyramine, have been reported; check drug labeling before administering. Safety has not been established with the pediatric population. The elderly population is at increased risk for postural hypotension and serious adverse effects. Misuse and dependence have been reported. Withdrawal effects can continue for several weeks after discontinuation.\r\n\r\n<strong>Adverse\/Side Effects<\/strong>\r\n\r\nBlack Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.\r\n\r\nUse with caution due to the risks of hypertensive crisis, serotonin syndrome, and increased suicidality. <strong>[pb_glossary id=\"642\"]Hypertensive crisis[\/pb_glossary]<\/strong> is defined by severe hypertension (blood pressure greater than 180\/120 mm Hg) with evidence of organ dysfunction. Symptoms may include occipital headache (which may radiate frontally), palpitations, neck stiffness or soreness, nausea or vomiting, sweating, dilated pupils, photophobia, shortness of breath, or confusion. Either tachycardia or bradycardia may be present and may be associated with constricting chest pain. Seizures may also occur. Intracranial bleeding, sometimes fatal, has been reported in association with the increase in blood pressure. See more information about serotonin syndrome in the \"SSRI\" section.\r\n\r\nOther potential side effects include mania, <strong>[pb_glossary id=\"650\"]orthostatic hypotension[\/pb_glossary]<\/strong>, hepatotoxicity, seizures, hypoglycemia in diabetic clients, decreased appetite and weight loss, dizziness, headache, drowsiness, and restlessness. Clients should be advised it may impair their ability to operate machinery or drive. MAOIs should be discontinued if hepatotoxicity occurs.<sup>[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0[\/footnote]<\/sup>\r\n\r\n<strong>Client Teaching &amp; Education<\/strong>\r\n\r\nClients should be careful to take medications as directed. It may take up to 4 weeks to see the effects of the drug. They should avoid abrupt cessation of therapy to avoid withdrawal symptoms. Clients should avoid alcohol, other CNS depressants, and tyramine-containing products for two weeks after therapy is discontinued.\u00a0 Clients should be advised regarding the signs of hypertensive crisis and to immediately report headache, chest or throat tightness, and palpitations to the provider.\r\n\r\n<\/div>\r\n<span style=\"text-align: initial;font-size: 14pt\">Now let's take a closer look at a medication grid that compares these classifications of anti-depressants in Table 8.7a.<\/span><sup style=\"text-align: initial\">[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0[\/footnote],<\/sup><sup style=\"text-align: initial\">[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 227-305. Elsevier.[\/footnote],[footnote]Lilley, L., Collins, S., &amp; Snyder, J. (2014). <em>Pharmacology and the Nursing Process.<\/em> pp. 246-272. Elsevier.[\/footnote]\u00a0<\/sup>\r\n\r\nMedication cards like this are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below.\u00a0 Prototype or generic medication examples are also hyperlinked to a free resource at <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/index.cfm\">Daily Med<\/a>. On the home page, enter the drug name in the search bar to read more about the medication.\r\n<div class=\"1.7-antidepressants\">\r\n\r\nTable 8.7 Comparing Types of Anti-depressants <sup><span style=\"text-align: initial\">[footnote] <\/span><\/sup><sup><span style=\"text-align: initial\">This work is a derivative of\u00a0 <\/span><a style=\"text-align: initial\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener\">Daily Med <\/a><span style=\"text-align: initial\">by\u00a0<\/span><a style=\"text-align: initial\" href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener\">U.S. National Library of Medicine<\/a><span style=\"text-align: initial\">\u00a0in the\u00a0<\/span><a style=\"text-align: initial\" href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener\">public domain<\/a><span style=\"text-align: initial\">.[\/footnote][footnote]RNPedia. (2021). <a href=\"https:\/\/www.rnpedia.com\">https:\/\/www.rnpedia.com<\/a>[\/footnote][footnote]OpenMD.Com at <a href=\"http:\/\/www.openmd.com\">www.openmd.com<\/a>[\/footnote][footnote]uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\">https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote] <\/span><\/sup><span style=\"text-align: initial\"><a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=a4d012a4-cd95-46c6-a6b7-b15d6fd5269d\">amitriptyline<\/a><\/span><span style=\"text-align: initial\">, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=1e0060e6-8c5f-4ddf-8a11-6d158c412f5d\">nortriptyline<\/a>, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=9de65da4-73f8-4c88-8198-c92e63224ddb\">fluoxetine<\/a>, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=2632b547-2e13-447f-ac85-c774e437d6a8\">citalopram<\/a>, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=8c8bcba9-eaeb-aa44-f9ea-b580de55a439\">sertraline<\/a>, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=6c7c6190-b35f-4228-ba3d-2cb3149c81b3\">venlafaxine<\/a>, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=6a0b609b-0625-4c26-91a1-59ee3ece3ddf\">tranylcypromine<\/a><\/span>\r\n\r\n<\/div>\r\n<img class=\"alignnone wp-image-2323\" src=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/11\/comparing-antidepressants.png\" alt=\"\" width=\"788\" height=\"597\" \/>","rendered":"<div class=\"1.7-antidepressants\">\n<p>Antidepressants are used to treat depression and other mental health disorders, as well as other medical conditions such as migraine headaches, chronic pain, and premenstrual syndrome. Antidepressants increase levels of neurotransmitters in the CNS, including serotonin (5-HT), dopamine, and norepinephrine. Treatment is based on the belief that alterations in the levels of these neurotransmitters are responsible for causing depression.<sup><a class=\"footnote\" title=\"Lilley, L., Collins, S., &amp; Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 246-272. Elsevier.\" id=\"return-footnote-351-1\" href=\"#footnote-351-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a> <\/sup><\/p>\n<p>This module will discuss four classes of antidepressants: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs). These medications are compared in Table 8.7.<\/p>\n<p>TCAs and MAOIs are referred to as first-generation antidepressants because they were first marketed in the 1950s. SSRIs, SNRIs, and other miscellaneous medications such as bupropion are called second-generation antidepressants and are popular because of fewer side effects like sedation, hypotension, anticholinergic effects, or cardiotoxicity.<sup><a class=\"footnote\" title=\"McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier.\" id=\"return-footnote-351-2\" href=\"#footnote-351-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><\/sup><\/p>\n<p>Safety warnings (Black Box) are in place for all classes of antidepressants used with children, adolescents, and young adults for a higher risk of suicide. All clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.<\/p>\n<p>For more information on different types of anti-depressants, watch this video.<\/p>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"Pharmacology - Antidepressants - SSRI, MAOI, TCA, SNRIs) nursing RN PN (MADE EASY)\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/kBV3rGv6B6Q?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p style=\"text-align: center\"><sup><a href=\"https:\/\/www.youtube.com\/watch?time_continue=2&amp;v=kBV3rGv6B6Q&amp;feature=emb_logo\">Pharmacology &#8211; Antidepressants, SSRI, MAIO, TCA, SNRIs<\/a> by <a href=\"https:\/\/www.youtube.com\/channel\/UCUxQWmWk1_Hk9iDRKvhH29Q\">Simple Nursing<\/a>, is licensed under a <a href=\"https:\/\/www.youtube.com\/t\/terms\" target=\"_blank\" rel=\"noopener\">Standard YouTube license<\/a><\/sup><\/p>\n<h2>Tricyclic Antidepressants<\/h2>\n<p>Tricyclic antidepressants (TCAs) were one of the original first-generation antidepressants. Due to the popularity of SSRIs and SNRIs, TCAs are now more commonly used to treat neuropathic pain and insomnia.<\/p>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p>TCAs tend to have sedative and anticholinergic effects. They act by inhibiting presynaptic reuptake of NE and 5-HT into nerves.\u00a0The choice of TCA depends on individual response and tolerance to the drug.<\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>TCAs are used to treat depression, chronic neuropathic pain, and insomnia.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>TCAs are often administered at bedtime due to sedating effects and are contraindicated with MAOIs.<\/p>\n<p>Geriatric clients are particularly sensitive to the anticholinergic side effects of tricyclic antidepressants. Peripheral anticholinergic effects include tachycardia, urinary retention, constipation, dry mouth, blurred vision, and exacerbation of narrow-angle glaucoma. Central nervous system anticholinergic effects include cognitive impairment, psychomotor slowing, confusion, sedation, and delirium. Elderly clients taking amitriptyline may be at increased risk for falls. Elderly clients should be started on low doses of amitriptyline and observed closely.<\/p>\n<p>After prolonged administration, abrupt cessation of treatment may produce nausea, headache, and malaise. The dose should be gradually tapered, but transient symptoms may still occur.<\/p>\n<p>TCAs should not be used in children and those who are pregnant or lactating.<\/p>\n<p><strong>Adverse\/Side Effects <\/strong><\/p>\n<p>Adverse effects of TCAs are a result of their blockade effects on various receptors, often resulting in anticholinergic adverse effects such as constipation, urinary retention, and drowsiness. Blockage of adrenergic and dopaminergic receptors can cause cardiac conduction disturbances and hypotension. Histaminergic blockage can cause sedation, and serotonergic blockade can alter the seizure threshold and cause sexual dysfunction.<\/p>\n<p>Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.<\/p>\n<p>TCAs are contraindicated as follows:<\/p>\n<ul>\n<li>Myocardial infarction.<\/li>\n<li>Concurrent use of MAOIs.<\/li>\n<li>Pregnancy, lactation.<\/li>\n<li>Preexisting cardiovascular disorders.<\/li>\n<li>Angle-closure glaucoma, urinary retention, prostate hypertrophy, GI or GU surgery.<\/li>\n<li>History of seizures.<\/li>\n<li>Hepatorenal diseases.<\/li>\n<\/ul>\n<p>There are also several drug interactions such as cimetidine, fluoxetine, ranitidine: increased therapeutic and adverse effects of TCAs. Usage with oral anticoagulants can increase serum levels of anticoagulants and increase the risk of bleeding. TCAs should not be used concurrently with MAOIs, which increases the risk for a severe hyperpyretic crisis. <sup><a class=\"footnote\" title=\"RNpedia. (2022). Antidepressants. https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/antidepressants\/\" id=\"return-footnote-351-3\" href=\"#footnote-351-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><\/sup><\/p>\n<p><strong>Overdosage<\/strong><\/p>\n<p>Death may occur from overdosage with this class of drugs. Multiple drug ingestion (including alcohol) is common in deliberate tricyclic antidepressant overdose. If an overdose occurs, consult with a\u00a0<a href=\"http:\/\/www.dpic.org\/\">Poison Information Center<\/a> (1-800-567-8911).<\/p>\n<p><strong>Client Teaching &amp; Education:<\/strong> Due to the increased risk of suicidality with antidepressants, clients and their family members or caregivers should be instructed to immediately report any sudden changes in mood, behaviors, thoughts, or feelings. The potential side effects discussed above should be reviewed. <sup><a class=\"footnote\" title=\"This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. \u00a0\" id=\"return-footnote-351-4\" href=\"#footnote-351-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a>,<a class=\"footnote\" title=\"McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier.\" id=\"return-footnote-351-5\" href=\"#footnote-351-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a>,<a class=\"footnote\" title=\"Lilley, L., Collins, S., &amp; Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 246-272. Elsevier.\" id=\"return-footnote-351-6\" href=\"#footnote-351-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/sup><\/p>\n<p><span style=\"text-align: initial;font-size: 14pt;background-color: #ffffff\">Table 8.7 provides a closer look at this medication and compares TCAs with other classifications of antidepressants.\u00a0<\/span><\/p>\n<h2>Selective Serotonin Reuptake Inhibitor (SSRI)<\/h2>\n<p>Selective Serotonin Reuptake Inhibitors (SSRIs) are second-generation antidepressants and have fewer side effects than TCAs and MAOIs. Fluoxetine and citalopram are commonly used SSRIs.<\/p>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p>SSRIs inhibit the reuptake of serotonin.<\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>SSRIs are primarily used to treat depression but are also used to treat obsessive-compulsive disorder, bulimia, panic disorder, posttraumatic stress disorder, other forms of anxiety, premenstrual syndrome, and migraines.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>The onset of fluoxetine\u2019s antidepressant effect develops slowly for up to 12 weeks.<\/p>\n<p>Use caution in clients who are taking other CNS medications or who have liver dysfunction. This drug is contraindicated with MAOIs. Monitor for increased suicide ideation in all populations, as well as for the development of serotonin syndrome. Clients should avoid grapefruit juice due to its effect on the CYP3A4 enzyme that affects the bioavailability of the medication.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.<\/p>\n<p>The development of a potentially life-threatening serotonin syndrome or neuroleptic malignant syndrome (NMS)-like reactions has been reported with SNRIs and SSRIs, particularly with concomitant use of serotonergic drugs, drugs that impair the metabolism of serotonin (including MAOIs), or with antipsychotics or other dopamine antagonists. Symptoms of <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_351_620\">serotonin syndrome<\/a><\/strong> may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination), and\/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Serotonin syndrome, in its most severe form, can resemble <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_351_644\">neuroleptic malignant syndrome<\/a><\/strong> (NMS), which includes hyperthermia, muscle rigidity, autonomic instability with possible rapid fluctuation of vital signs, and mental status changes. Clients should be monitored for the emergence of serotonin syndrome or NMS-like signs and symptoms.<sup><a class=\"footnote\" title=\"This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain.\" id=\"return-footnote-351-7\" href=\"#footnote-351-7\" aria-label=\"Footnote 7\"><sup class=\"footnote\">[7]<\/sup><\/a><\/sup><\/p>\n<p>Other side effects include rash; mania; seizures; decreased appetite and weight; increased bleeding associated with the concomitant use of fluoxetine and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation; hyponatremia; anxiety; and insomnia.<\/p>\n<p>Abrupt discontinuation may cause several adverse effects, so a gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. <sup><a class=\"footnote\" title=\"This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. \u00a0\" id=\"return-footnote-351-8\" href=\"#footnote-351-8\" aria-label=\"Footnote 8\"><sup class=\"footnote\">[8]<\/sup><\/a>,<\/sup><sup><a class=\"footnote\" title=\"McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier.\" id=\"return-footnote-351-9\" href=\"#footnote-351-9\" aria-label=\"Footnote 9\"><sup class=\"footnote\">[9]<\/sup><\/a>,<a class=\"footnote\" title=\"Lilley, L., Collins, S., &amp; Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 246-272. Elsevier.\" id=\"return-footnote-351-10\" href=\"#footnote-351-10\" aria-label=\"Footnote 10\"><sup class=\"footnote\">[10]<\/sup><\/a>\u00a0<\/sup><\/p>\n<p><strong>Client Teaching &amp; Education<\/strong><\/p>\n<p>Clients should be careful to take medications as directed. Abrupt discontinuation may cause anxiety, insomnia, and increased nervousness. Additionally, orthostatic blood pressure changes are common during medication therapy. Clients may also be increasingly drowsy or exhibit some confusion. Use of SSRI medications with alcohol or other CNS depressant drugs should be avoided.<\/p>\n<p>Clients, family, and caregivers should monitor clients carefully for suicidality.\u00a0 Other side effects include possible decreased libido, urinary retention, constipation, and increased photosensitivity.<\/p>\n<p><span style=\"text-align: initial;font-size: 14pt;background-color: #ffffff\">Table 8.7 provides a closer look at this medication and compares SSRIs with other classifications of antidepressants.\u00a0<\/span><\/p>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Clinical Reasoning and Decision-Making Activity 8.7<img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-197\" src=\"https:\/\/pressbooks.bccampus.ca\/knowinghome\/wp-content\/uploads\/sites\/1167\/2019\/09\/ORN-Icons_lightbulb-300x300-1.png\" alt=\"Image of lightbulb in a circle\" width=\"200\" height=\"200\" \/><\/h2>\n<\/header>\n<div class=\"textbox__content\" style=\"text-align: left\">\n<p>A 32-year-old female visits the nurse practitioner with concerns about \u201cfeeling tired all the time,\u201d &#8220;having difficulty concentrating,\u201d \u201cproblems sleeping,\u201d and \u201cjust generally feeling down.\u201d The nurse practitioner prescribed fluoxetine.<\/p>\n<p>The client tells the nurse, \u201cOne of my friends told me I have to be careful or I might get serotonin syndrome if I take medication.\u201d<\/p>\n<p>1. What places a client at risk for serotonin syndrome, and what symptoms should the nurse teach the client about this condition?<\/p>\n<p>2. The nurse knows that anyone starting an antidepressant is at risk for suicidal thoughts. How should the nurse therapeutically discuss this potential adverse effect with the client?<\/p>\n<p>3. What potential common side effects should the nurse discuss with the client?<\/p>\n<p>The client states, \u201cI can\u2019t wait to feel better again. How soon will this medication work?\u201d<\/p>\n<p>4.\u00a0 What is the nurse\u2019s best response?<\/p>\n<p>Note: Answers to the Critical Thinking activities can be found in the &#8220;<a href=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/chapter\/chapter-8\/\">Answer Key<\/a>&#8221; sections at the end of the book.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"1.7-antidepressants\">\n<h2>Serotonin Norepinephrine Reuptake Inhibitor (SNRI)<\/h2>\n<p>Venlafaxine is an example of a Serotonin Norepinephrine Reuptake Inhibitor (SNRI).<\/p>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p>Venlafaxine inhibits the reuptake of serotonin and norepinephrine, with weak inhibition of dopamine reuptake.<\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>SNRIs are indicated for the treatment of a major depressive disorder.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>SNRIs are contraindicated with MAOIs or within 14 days of use of an MAOI. Dosage adjustment is required for use in clients with renal and\/or liver disease. Elderly clients are at greater risk for developing hyponatremia. Use with caution with other serotonin medications.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.<\/p>\n<p>SNRI medication may cause a sustained increase in blood pressure. Other side effects include serotonin syndrome, insomnia, anxiety, decreased appetite, weight loss, mania, hyponatremia, increased bleeding (especially with the concomitant use of fluoxetine and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation), elevated serum cholesterol, somnolence, and nausea. <sup><a class=\"footnote\" title=\"This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. \u00a0\" id=\"return-footnote-351-11\" href=\"#footnote-351-11\" aria-label=\"Footnote 11\"><sup class=\"footnote\">[11]<\/sup><\/a><\/sup><\/p>\n<p><strong>Client Teaching &amp; Education<\/strong><\/p>\n<p>Clients should be careful to take medications as directed.\u00a0 The dose should be tapered prior to discontinuation. Clients may also be increasingly drowsy or dizzy.\u00a0 Use of SNRI medications with alcohol or other CNS depressant drugs should be avoided. Clients, family, and caregivers should monitor clients carefully for suicidality.<\/p>\n<p><span style=\"text-align: initial;font-size: 14pt;background-color: #ffffff\">Table 8.7 provides a closer look at this medication and compares SSRIs with other classifications of antidepressants.\u00a0<\/span><\/p>\n<h2>Monoamine Oxidase inhibitors (MAOI)<\/h2>\n<p>Monoamine oxidase inhibitors (MAOIs) are first-generation antidepressants.\u00a0 A significant disadvantage to MAOIs is their potential to cause a hypertensive crisis when taken with stimulant medications or foods containing tyramine.<\/p>\n<p><strong>Mechanism of Action<\/strong><\/p>\n<p>The mechanism of action of MAOIs is not fully understood but is presumed to be linked to the potentiation of monoamine neurotransmitter activity in the central nervous system resulting from its inhibition of the enzyme monoamine oxidase (MAO).<sup><a class=\"footnote\" title=\"This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. \u00a0\" id=\"return-footnote-351-12\" href=\"#footnote-351-12\" aria-label=\"Footnote 12\"><sup class=\"footnote\">[12]<\/sup><\/a><\/sup> MAO inactivates norepinephrine, dopamine, epinephrine, and serotonin. By inhibiting MAO, the levels of these transmitters rise thus creating anti-depressive effects.<sup><a class=\"footnote\" title=\"McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier.\" id=\"return-footnote-351-13\" href=\"#footnote-351-13\" aria-label=\"Footnote 13\"><sup class=\"footnote\">[13]<\/sup><\/a><\/sup><\/p>\n<p><strong>Indications for Use<\/strong><\/p>\n<p>MAOIs are indicated for the treatment of major depressive disorder in adult clients who have not responded adequately to other antidepressants.<\/p>\n<p><strong>Nursing Considerations Across the Lifespan<\/strong><\/p>\n<p>Serious interactions with several medications, as well as foods and beverages containing tyramine, have been reported; check drug labeling before administering. Safety has not been established with the pediatric population. The elderly population is at increased risk for postural hypotension and serious adverse effects. Misuse and dependence have been reported. Withdrawal effects can continue for several weeks after discontinuation.<\/p>\n<p><strong>Adverse\/Side Effects<\/strong><\/p>\n<p>Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.<\/p>\n<p>Use with caution due to the risks of hypertensive crisis, serotonin syndrome, and increased suicidality. <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_351_642\">Hypertensive crisis<\/a><\/strong> is defined by severe hypertension (blood pressure greater than 180\/120 mm Hg) with evidence of organ dysfunction. Symptoms may include occipital headache (which may radiate frontally), palpitations, neck stiffness or soreness, nausea or vomiting, sweating, dilated pupils, photophobia, shortness of breath, or confusion. Either tachycardia or bradycardia may be present and may be associated with constricting chest pain. Seizures may also occur. Intracranial bleeding, sometimes fatal, has been reported in association with the increase in blood pressure. See more information about serotonin syndrome in the &#8220;SSRI&#8221; section.<\/p>\n<p>Other potential side effects include mania, <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_351_650\">orthostatic hypotension<\/a><\/strong>, hepatotoxicity, seizures, hypoglycemia in diabetic clients, decreased appetite and weight loss, dizziness, headache, drowsiness, and restlessness. Clients should be advised it may impair their ability to operate machinery or drive. MAOIs should be discontinued if hepatotoxicity occurs.<sup><a class=\"footnote\" title=\"This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. \u00a0\" id=\"return-footnote-351-14\" href=\"#footnote-351-14\" aria-label=\"Footnote 14\"><sup class=\"footnote\">[14]<\/sup><\/a><\/sup><\/p>\n<p><strong>Client Teaching &amp; Education<\/strong><\/p>\n<p>Clients should be careful to take medications as directed. It may take up to 4 weeks to see the effects of the drug. They should avoid abrupt cessation of therapy to avoid withdrawal symptoms. Clients should avoid alcohol, other CNS depressants, and tyramine-containing products for two weeks after therapy is discontinued.\u00a0 Clients should be advised regarding the signs of hypertensive crisis and to immediately report headache, chest or throat tightness, and palpitations to the provider.<\/p>\n<\/div>\n<p><span style=\"text-align: initial;font-size: 14pt\">Now let&#8217;s take a closer look at a medication grid that compares these classifications of anti-depressants in Table 8.7a.<\/span><sup style=\"text-align: initial\"><a class=\"footnote\" title=\"This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. \u00a0\" id=\"return-footnote-351-15\" href=\"#footnote-351-15\" aria-label=\"Footnote 15\"><sup class=\"footnote\">[15]<\/sup><\/a>,<\/sup><sup style=\"text-align: initial\"><a class=\"footnote\" title=\"McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier.\" id=\"return-footnote-351-16\" href=\"#footnote-351-16\" aria-label=\"Footnote 16\"><sup class=\"footnote\">[16]<\/sup><\/a>,<a class=\"footnote\" title=\"Lilley, L., Collins, S., &amp; Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 246-272. Elsevier.\" id=\"return-footnote-351-17\" href=\"#footnote-351-17\" aria-label=\"Footnote 17\"><sup class=\"footnote\">[17]<\/sup><\/a>\u00a0<\/sup><\/p>\n<p>Medication cards like this are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below.\u00a0 Prototype or generic medication examples are also hyperlinked to a free resource at <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/index.cfm\">Daily Med<\/a>. On the home page, enter the drug name in the search bar to read more about the medication.<\/p>\n<div class=\"1.7-antidepressants\">\n<p>Table 8.7 Comparing Types of Anti-depressants <sup><span style=\"text-align: initial\"><a class=\"footnote\" title=\"This work is a derivative of\u00a0 Daily Med by\u00a0U.S. National Library of Medicine\u00a0in the\u00a0public domain.\" id=\"return-footnote-351-18\" href=\"#footnote-351-18\" aria-label=\"Footnote 18\"><sup class=\"footnote\">[18]<\/sup><\/a><a class=\"footnote\" title=\"RNPedia. (2021). https:\/\/www.rnpedia.com\" id=\"return-footnote-351-19\" href=\"#footnote-351-19\" aria-label=\"Footnote 19\"><sup class=\"footnote\">[19]<\/sup><\/a><a class=\"footnote\" title=\"OpenMD.Com at www.openmd.com\" id=\"return-footnote-351-20\" href=\"#footnote-351-20\" aria-label=\"Footnote 20\"><sup class=\"footnote\">[20]<\/sup><\/a><a class=\"footnote\" title=\"uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral\" id=\"return-footnote-351-21\" href=\"#footnote-351-21\" aria-label=\"Footnote 21\"><sup class=\"footnote\">[21]<\/sup><\/a> <\/span><\/sup><span style=\"text-align: initial\"><a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=a4d012a4-cd95-46c6-a6b7-b15d6fd5269d\">amitriptyline<\/a><\/span><span style=\"text-align: initial\">, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=1e0060e6-8c5f-4ddf-8a11-6d158c412f5d\">nortriptyline<\/a>, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=9de65da4-73f8-4c88-8198-c92e63224ddb\">fluoxetine<\/a>, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=2632b547-2e13-447f-ac85-c774e437d6a8\">citalopram<\/a>, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=8c8bcba9-eaeb-aa44-f9ea-b580de55a439\">sertraline<\/a>, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=6c7c6190-b35f-4228-ba3d-2cb3149c81b3\">venlafaxine<\/a>, <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=6a0b609b-0625-4c26-91a1-59ee3ece3ddf\">tranylcypromine<\/a><\/span><\/p>\n<\/div>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-2323\" src=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/11\/comparing-antidepressants.png\" alt=\"\" width=\"788\" height=\"597\" srcset=\"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/11\/comparing-antidepressants.png 1962w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/11\/comparing-antidepressants-300x228.png 300w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/11\/comparing-antidepressants-1024x777.png 1024w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/11\/comparing-antidepressants-768x582.png 768w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/11\/comparing-antidepressants-1536x1165.png 1536w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/11\/comparing-antidepressants-65x49.png 65w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/11\/comparing-antidepressants-225x171.png 225w, https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-content\/uploads\/sites\/1167\/2019\/11\/comparing-antidepressants-350x265.png 350w\" sizes=\"auto, (max-width: 788px) 100vw, 788px\" \/><\/p>\n<div class=\"media-attributions clear\" prefix:cc=\"http:\/\/creativecommons.org\/ns#\" prefix:dc=\"http:\/\/purl.org\/dc\/terms\/\"><h2>Media Attributions<\/h2><ul><li >comparing antidepressants       <\/li><\/ul><\/div><hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-351-1\">Lilley, L., Collins, S., &amp; Snyder, J. (2014). <em>Pharmacology and the Nursing Process.<\/em> pp. 246-272. Elsevier. <a href=\"#return-footnote-351-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-351-2\">McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 227-305. Elsevier. <a href=\"#return-footnote-351-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-351-3\">RNpedia. (2022). Antidepressants. <a href=\"https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/antidepressants\/\">https:\/\/www.rnpedia.com\/nursing-notes\/pharmacology-drug-study-notes\/antidepressants\/<\/a> <a href=\"#return-footnote-351-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-351-4\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0 <a href=\"#return-footnote-351-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-351-5\">McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 227-305. Elsevier. <a href=\"#return-footnote-351-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-351-6\">Lilley, L., Collins, S., &amp; Snyder, J. (2014). <em>Pharmacology and the Nursing Process.<\/em> pp. 246-272. Elsevier. <a href=\"#return-footnote-351-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><li id=\"footnote-351-7\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>.  <a href=\"#return-footnote-351-7\" class=\"return-footnote\" aria-label=\"Return to footnote 7\">&crarr;<\/a><\/li><li id=\"footnote-351-8\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0 <a href=\"#return-footnote-351-8\" class=\"return-footnote\" aria-label=\"Return to footnote 8\">&crarr;<\/a><\/li><li id=\"footnote-351-9\">McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 227-305. Elsevier. <a href=\"#return-footnote-351-9\" class=\"return-footnote\" aria-label=\"Return to footnote 9\">&crarr;<\/a><\/li><li id=\"footnote-351-10\">Lilley, L., Collins, S., &amp; Snyder, J. (2014). <em>Pharmacology and the Nursing Process.<\/em> pp. 246-272. Elsevier. <a href=\"#return-footnote-351-10\" class=\"return-footnote\" aria-label=\"Return to footnote 10\">&crarr;<\/a><\/li><li id=\"footnote-351-11\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0 <a href=\"#return-footnote-351-11\" class=\"return-footnote\" aria-label=\"Return to footnote 11\">&crarr;<\/a><\/li><li id=\"footnote-351-12\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0 <a href=\"#return-footnote-351-12\" class=\"return-footnote\" aria-label=\"Return to footnote 12\">&crarr;<\/a><\/li><li id=\"footnote-351-13\">McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 227-305. Elsevier. <a href=\"#return-footnote-351-13\" class=\"return-footnote\" aria-label=\"Return to footnote 13\">&crarr;<\/a><\/li><li id=\"footnote-351-14\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0 <a href=\"#return-footnote-351-14\" class=\"return-footnote\" aria-label=\"Return to footnote 14\">&crarr;<\/a><\/li><li id=\"footnote-351-15\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">Daily Med<\/a> by <a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the <a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">public domain<\/a>. \u00a0 <a href=\"#return-footnote-351-15\" class=\"return-footnote\" aria-label=\"Return to footnote 15\">&crarr;<\/a><\/li><li id=\"footnote-351-16\">McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 227-305. Elsevier. <a href=\"#return-footnote-351-16\" class=\"return-footnote\" aria-label=\"Return to footnote 16\">&crarr;<\/a><\/li><li id=\"footnote-351-17\">Lilley, L., Collins, S., &amp; Snyder, J. (2014). <em>Pharmacology and the Nursing Process.<\/em> pp. 246-272. Elsevier. <a href=\"#return-footnote-351-17\" class=\"return-footnote\" aria-label=\"Return to footnote 17\">&crarr;<\/a><\/li><li id=\"footnote-351-18\"> <\/span><\/sup><sup><span style=\"text-align: initial\">This work is a derivative of\u00a0 <\/span><a style=\"text-align: initial\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener\">Daily Med <\/a><span style=\"text-align: initial\">by\u00a0<\/span><a style=\"text-align: initial\" href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener\">U.S. National Library of Medicine<\/a><span style=\"text-align: initial\">\u00a0in the\u00a0<\/span><a style=\"text-align: initial\" href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener\">public domain<\/a><span style=\"text-align: initial\">. <a href=\"#return-footnote-351-18\" class=\"return-footnote\" aria-label=\"Return to footnote 18\">&crarr;<\/a><\/li><li id=\"footnote-351-19\">RNPedia. (2021). <a href=\"https:\/\/www.rnpedia.com\">https:\/\/www.rnpedia.com<\/a> <a href=\"#return-footnote-351-19\" class=\"return-footnote\" aria-label=\"Return to footnote 19\">&crarr;<\/a><\/li><li id=\"footnote-351-20\">OpenMD.Com at <a href=\"http:\/\/www.openmd.com\">www.openmd.com<\/a> <a href=\"#return-footnote-351-20\" class=\"return-footnote\" aria-label=\"Return to footnote 20\">&crarr;<\/a><\/li><li id=\"footnote-351-21\">uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\">https:\/\/www.unboundmedicine.com\/ucentral<\/a> <a href=\"#return-footnote-351-21\" class=\"return-footnote\" aria-label=\"Return to footnote 21\">&crarr;<\/a><\/li><\/ol><\/div><div class=\"glossary\"><span class=\"screen-reader-text\" id=\"definition\">definition<\/span><template id=\"term_351_620\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_351_620\"><div tabindex=\"-1\"><p>Symptoms associated with serotonin syndrome may include the following combination of signs and symptoms: mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, with or without gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea).<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_351_644\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_351_644\"><div tabindex=\"-1\"><p>Potentially life-threatening adverse effect that includes high fever, unstable blood pressure, and myoglobinemia.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_351_642\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_351_642\"><div tabindex=\"-1\"><p>Severe hypertension (blood pressure greater than 180\/120 mm Hg) with evidence of organ dysfunction. Symptoms may include occipital headache (which may radiate frontally), palpitations, neck stiffness or soreness, nausea or vomiting, sweating, dilated pupils, photophobia, shortness of breath, or confusion. Either tachycardia or bradycardia may be present and may be associated with constricting chest pain. Seizures may also occur. Intracranial bleeding, sometimes fatal, has been reported in association with the increase in blood pressure.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_351_650\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_351_650\"><div tabindex=\"-1\"><p>A significant change in blood pressure from lying to sitting to standing.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><\/div>","protected":false},"author":103,"menu_order":7,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":["open-resources-for-nursing-open-rn"],"pb_section_license":""},"chapter-type":[48],"contributor":[68],"license":[],"class_list":["post-351","chapter","type-chapter","status-publish","hentry","chapter-type-numberless","contributor-open-resources-for-nursing-open-rn"],"part":331,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/351","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/wp\/v2\/users\/103"}],"version-history":[{"count":21,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/351\/revisions"}],"predecessor-version":[{"id":2386,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/351\/revisions\/2386"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/parts\/331"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/351\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/wp\/v2\/media?parent=351"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/pressbooks\/v2\/chapter-type?post=351"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/wp\/v2\/contributor?post=351"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/nursingpharmacology\/wp-json\/wp\/v2\/license?post=351"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}