Page 1 of 15
Chapter 14: Drugs for
Anxiety and Insomnia
ANTIDEPRESSANTS
3 D’s: Drowsiness, disorientation, dizziness
Types of Anxiety: situational, generalized anxiety disorder (GAD), panic disorder, phobias, social anxiety disorder,
(OCD), PTSD
- limbic system: emotional responses, learning, memory
- hypothalamus: unconscious responses connect w/ reticular formation. Stimulation causes awareness/arousal,
inhibition causes drowsiness/sleep. RAS thought to be responsible for anxiety, fear, restlessness, interrupted
sleeping patterns
- non pharmacologic therapies for anxiety include cognitive behavioral therapy, counseling, biofeedback
techniques, and meditation
- most CNS depressants can cause physical and psychological dependence
Nurse responsibility: obtain VS, medical/drug history, lifestyle/dietary habits, what caused feelings of anxiety?
Assess intensity/duration of symptoms, coping mechanisms, assess for sleep disorder, obtain drug history,
drug/ETOH use, st. john’s wort
*Use cautiously w elderly, suicidal, impaired renal liver failure
Selective Serotonin Reuptake Inhibitors (SSRIs)
MOA: increases availability of serotonin at specific postsynaptic receptor sites located within the CNS
- Too much serotonin: hypotension, sweating, tachycardia, fever
- Serotonin affects sleep, mood, digestion, nausea, wound healing, bone health, blood clotting, sexual
desire Primary Use: generalized anxiety and depression
SE: dizziness, nausea, insomnia, somnolence, confusion, seizures, dry mouth, disorientation, headaches,
nervousness, fatigue, agitation
AE: confusion, seizures, anxiety, GI disturbances, anorexia, sexual dysfunction, Stevens Johnson syndrome (SJS),
extreme mania/hypomania, abnormal bleeding, extreme psychomotor disturbances, severe hyperthermia, serotonin
syndrome NR: check if drug is working, has the pt. peaked interest in hygiene and nutrition, are symptoms still
present after 6 weeks? Admin Alert: Reduce dose in case of renal or liver impairments & older adults, DO NOT stop
abruptly
BBW: antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults
with major depressive disorder and other psychiatric disorders. The drug is not approved for pediatric patients less
than 12 years of age
Contraindications: this drug should not be used in patients who are breast-feeding or within 14 days of MAOI
therapy Drug-Drug: MAOIs should be avoided due to serotonin syndrome, marked by autonomic hyperactivity,
hyperthermia, rigidity, diaphoresis, neuroleptic malignant syndrome. Combination with MOAIs could result in
hypertensive crisis, hyperthermia, and autonomic instability. Escitalopram will increase plasma levels of
metoprolol and cimetidine, concurrent use of alcohol and other CNS depressants may enhance CNS depressant
effects – avoid alcohol Herbal/Food: St. John’s wort – may cause serotonin syndrome and increase the effects of
escitalopram
OD: no treatment – treat symptoms: dizziness, confusion, nausea, vomiting, tremor, sweating, tachycardia, and
seizures Serotonin Syndrome: autonomic hyperactivity, tremors, tachycardia, hyperthermia, hypersensitivity crisis,
agitationg,
confusion, disorientation, hallucinations
1. Prototype: escitalopram
[Lexapro]
2. citalopram [Celexa]
3. fluoxetine [Prozac]
4. paroxetine [Paxil]
5. sertraline [Zoloft]
- MOA: inhibits reuptake of serotonin in the brain
- Primary Use: depression
- AE: sexual dysfunction, nausea, headache, weight gain, anxiety, insomnia
- SE: sedation, anticholinergic effects, sympathomimetic effects
- BBW: Antidepressants increase the risk of suicidal thinking and behavior, especially in children,
adolescents, and young adults with major depressive disorder and other psychiatric disorders. This drug
is not approved for use in pediatric patients for major depressive disorder, but it is approved for
obsessive compulsive disorder in
children under 6 years of age
- Contraindications: concomitant use of sertraline and MAOIs or primozide is not advised. Antabuse
should be avoided because of the alcohol content of the drug
, Page 2 of 15
- Admin Alerts: give in the morning. Mix with water, ginger ale, lemon/lime soda, lemonade or orange
juice. Go not give concurrently with an MOAI or within 5 weeks of discontinuing MAOI medication
- Pregnancy Category: C
Atypical Antidepressants (SNRIs)
MOA: inhibit serotonin and norepinephrine reuptake, increasing its concentration in the synaptic cleft
Indications: major depressive disorder, generalized anxiety disorder, neuropathic pain
SE: anxiety, nervousness, agitation, dizziness, drowsiness, insomnia, loss of appetite,
n/v/d AE: HTN, tachycardia, closed-angle glaucoma, urinary retention
BBW: suicidal thinking in children, adolescents, and young adults
Contraindications: combination with MAOIs, pregnancy, diabetes, glaucoma, severely depressed with suicidal thinking
6. duloxetine [Cymbalta]
7. venlafaxine [Effexor]
Tricyclic Antidepressants
MOA: inhibition of serotonin and norepinephrine reuptake into nerve endings
Indications: major depressive disorder, phobic, panic, anxiety disorders, OCD, neuropathic pain, migraine prevention,
fibromyalgia syndrome, chronic insomnia, ADHD, OCD
SE: sedation, orthostatic hypotension, lower seizure threshold, serotonin syndrome, urine retention (older adults), dry
mouth , blurred vision
AE: Orthostatic hypotension; Anticholinergic effects; Cardiac Toxicity: decrease vagal influence and slows conduction
= dysrhythmias)
Admin Alerts: do not abruptly stop, give at bedtime to minimize problems with
sedation BBW: suicidal thinking in children, adolescents, and young adults
Contraindications: administration within 14 days of MAOIs, history of heart attack, heart dysrhythmias, renal/hepatic
impairment
Drug-Drug: CNS depressants can lead to more sedation, St. John’s wort, alcohol
Pregnancy Category: D
8. amitriptyline [Elavil]
9. imipramine [Tofranil]
10. nortriptyline [Pamelor]
Monoamine Oxidase Inhibitors
MOA: monoamine oxidase inhibition to prevent the breakdown of serotonin, norepinephrine, and dopamine
Indications: major depressive disorder, Parkinson disease, panic, anxiety
- can potentiate the effects of insulin and diabetic drugs
- given as last resort when other antidepressants do not work
SE: serotonin syndrome, dizziness, drowsiness, disorientation, anxiety, agitation, hypomania, mania,
constipation AE: lowered RR, coma-like state, falling, lack of muscle coordination, ataxia, dyspnea,
hypertensive crisis
NR: check HR, BP, therapeutic effectiveness, monitor SE
PT: avoid OTC cold remedies, nasal decongestants, and asthma
meds BBW: suicidal thinking in children, adolescents, and young
adults
Contraindications: pheochromocytoma, cerebrovascular diseases, severe hepatic/renal impairment
Food: avoid tyramine rick foods, avoid foods containing phenylalanine, caffeine, avoid ETOH and St. John’s wort
11. phenelzine [Nardil]
12. tranylcypromine [Parnate]
ANXIETY & INSOMNIA
Chapter 14: Drugs for
Anxiety and Insomnia
ANTIDEPRESSANTS
3 D’s: Drowsiness, disorientation, dizziness
Types of Anxiety: situational, generalized anxiety disorder (GAD), panic disorder, phobias, social anxiety disorder,
(OCD), PTSD
- limbic system: emotional responses, learning, memory
- hypothalamus: unconscious responses connect w/ reticular formation. Stimulation causes awareness/arousal,
inhibition causes drowsiness/sleep. RAS thought to be responsible for anxiety, fear, restlessness, interrupted
sleeping patterns
- non pharmacologic therapies for anxiety include cognitive behavioral therapy, counseling, biofeedback
techniques, and meditation
- most CNS depressants can cause physical and psychological dependence
Nurse responsibility: obtain VS, medical/drug history, lifestyle/dietary habits, what caused feelings of anxiety?
Assess intensity/duration of symptoms, coping mechanisms, assess for sleep disorder, obtain drug history,
drug/ETOH use, st. john’s wort
*Use cautiously w elderly, suicidal, impaired renal liver failure
Selective Serotonin Reuptake Inhibitors (SSRIs)
MOA: increases availability of serotonin at specific postsynaptic receptor sites located within the CNS
- Too much serotonin: hypotension, sweating, tachycardia, fever
- Serotonin affects sleep, mood, digestion, nausea, wound healing, bone health, blood clotting, sexual
desire Primary Use: generalized anxiety and depression
SE: dizziness, nausea, insomnia, somnolence, confusion, seizures, dry mouth, disorientation, headaches,
nervousness, fatigue, agitation
AE: confusion, seizures, anxiety, GI disturbances, anorexia, sexual dysfunction, Stevens Johnson syndrome (SJS),
extreme mania/hypomania, abnormal bleeding, extreme psychomotor disturbances, severe hyperthermia, serotonin
syndrome NR: check if drug is working, has the pt. peaked interest in hygiene and nutrition, are symptoms still
present after 6 weeks? Admin Alert: Reduce dose in case of renal or liver impairments & older adults, DO NOT stop
abruptly
BBW: antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults
with major depressive disorder and other psychiatric disorders. The drug is not approved for pediatric patients less
than 12 years of age
Contraindications: this drug should not be used in patients who are breast-feeding or within 14 days of MAOI
therapy Drug-Drug: MAOIs should be avoided due to serotonin syndrome, marked by autonomic hyperactivity,
hyperthermia, rigidity, diaphoresis, neuroleptic malignant syndrome. Combination with MOAIs could result in
hypertensive crisis, hyperthermia, and autonomic instability. Escitalopram will increase plasma levels of
metoprolol and cimetidine, concurrent use of alcohol and other CNS depressants may enhance CNS depressant
effects – avoid alcohol Herbal/Food: St. John’s wort – may cause serotonin syndrome and increase the effects of
escitalopram
OD: no treatment – treat symptoms: dizziness, confusion, nausea, vomiting, tremor, sweating, tachycardia, and
seizures Serotonin Syndrome: autonomic hyperactivity, tremors, tachycardia, hyperthermia, hypersensitivity crisis,
agitationg,
confusion, disorientation, hallucinations
1. Prototype: escitalopram
[Lexapro]
2. citalopram [Celexa]
3. fluoxetine [Prozac]
4. paroxetine [Paxil]
5. sertraline [Zoloft]
- MOA: inhibits reuptake of serotonin in the brain
- Primary Use: depression
- AE: sexual dysfunction, nausea, headache, weight gain, anxiety, insomnia
- SE: sedation, anticholinergic effects, sympathomimetic effects
- BBW: Antidepressants increase the risk of suicidal thinking and behavior, especially in children,
adolescents, and young adults with major depressive disorder and other psychiatric disorders. This drug
is not approved for use in pediatric patients for major depressive disorder, but it is approved for
obsessive compulsive disorder in
children under 6 years of age
- Contraindications: concomitant use of sertraline and MAOIs or primozide is not advised. Antabuse
should be avoided because of the alcohol content of the drug
, Page 2 of 15
- Admin Alerts: give in the morning. Mix with water, ginger ale, lemon/lime soda, lemonade or orange
juice. Go not give concurrently with an MOAI or within 5 weeks of discontinuing MAOI medication
- Pregnancy Category: C
Atypical Antidepressants (SNRIs)
MOA: inhibit serotonin and norepinephrine reuptake, increasing its concentration in the synaptic cleft
Indications: major depressive disorder, generalized anxiety disorder, neuropathic pain
SE: anxiety, nervousness, agitation, dizziness, drowsiness, insomnia, loss of appetite,
n/v/d AE: HTN, tachycardia, closed-angle glaucoma, urinary retention
BBW: suicidal thinking in children, adolescents, and young adults
Contraindications: combination with MAOIs, pregnancy, diabetes, glaucoma, severely depressed with suicidal thinking
6. duloxetine [Cymbalta]
7. venlafaxine [Effexor]
Tricyclic Antidepressants
MOA: inhibition of serotonin and norepinephrine reuptake into nerve endings
Indications: major depressive disorder, phobic, panic, anxiety disorders, OCD, neuropathic pain, migraine prevention,
fibromyalgia syndrome, chronic insomnia, ADHD, OCD
SE: sedation, orthostatic hypotension, lower seizure threshold, serotonin syndrome, urine retention (older adults), dry
mouth , blurred vision
AE: Orthostatic hypotension; Anticholinergic effects; Cardiac Toxicity: decrease vagal influence and slows conduction
= dysrhythmias)
Admin Alerts: do not abruptly stop, give at bedtime to minimize problems with
sedation BBW: suicidal thinking in children, adolescents, and young adults
Contraindications: administration within 14 days of MAOIs, history of heart attack, heart dysrhythmias, renal/hepatic
impairment
Drug-Drug: CNS depressants can lead to more sedation, St. John’s wort, alcohol
Pregnancy Category: D
8. amitriptyline [Elavil]
9. imipramine [Tofranil]
10. nortriptyline [Pamelor]
Monoamine Oxidase Inhibitors
MOA: monoamine oxidase inhibition to prevent the breakdown of serotonin, norepinephrine, and dopamine
Indications: major depressive disorder, Parkinson disease, panic, anxiety
- can potentiate the effects of insulin and diabetic drugs
- given as last resort when other antidepressants do not work
SE: serotonin syndrome, dizziness, drowsiness, disorientation, anxiety, agitation, hypomania, mania,
constipation AE: lowered RR, coma-like state, falling, lack of muscle coordination, ataxia, dyspnea,
hypertensive crisis
NR: check HR, BP, therapeutic effectiveness, monitor SE
PT: avoid OTC cold remedies, nasal decongestants, and asthma
meds BBW: suicidal thinking in children, adolescents, and young
adults
Contraindications: pheochromocytoma, cerebrovascular diseases, severe hepatic/renal impairment
Food: avoid tyramine rick foods, avoid foods containing phenylalanine, caffeine, avoid ETOH and St. John’s wort
11. phenelzine [Nardil]
12. tranylcypromine [Parnate]
ANXIETY & INSOMNIA
