Psych / Mental Health · Psychopharmacology
Psychopharmacology Overview: SSRIs, Lithium, Antipsychotics, MAOIs & Benzodiazepines
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.
If you or someone you know is in crisis: call or text 988 (Suicide & Crisis Lifeline, U.S.) or call 911 for immediate danger. This guide is for exam study, not for diagnosing or treating anyone.
Drug references change. Doses, ranges, and boxed warnings here are for study. Always verify with a current drug reference, pharmacist, and provider orders.
1. Antidepressants
| Class / examples | Key nursing considerations |
|---|---|
| — sertraline, fluoxetine, escitalopram, citalopram, paroxetine | First-line. 2–6 weeks for full effect. GI upset, insomnia or drowsiness, sexual dysfunction, hyponatremia (older adults), bleeding risk with NSAIDs/anticoagulants. Citalopram: dose-related QT prolongation. Boxed warning: suicidality < 25 yr. Taper to avoid discontinuation syndrome (fluoxetine least, paroxetine most) |
| SNRIs — venlafaxine, duloxetine | Like SSRIs + increased BP (venlafaxine); duloxetine helps neuropathic pain; liver caution |
| Bupropion | Less sexual dysfunction/weight gain; smoking cessation; lowers seizure threshold — avoid in seizure disorders and eating disorders |
| Mirtazapine | Sedation and weight gain/appetite (useful in older adults with poor appetite) |
| Tricyclics (TCAs) — amitriptyline, nortriptyline | Anticholinergic (dry mouth, constipation, urinary retention, blurred vision), orthostasis, sedation. Overdose is lethal (arrhythmias, wide QRS) — limit supply in suicidal patients |
| — phenelzine, tranylcypromine, selegiline patch | -restricted diet (aged cheese, cured/smoked meats, tap beer, soy sauce, sauerkraut, overripe/spoiled foods) → hypertensive crisis. Many interactions: no SSRIs/SNRIs, meperidine, dextromethorphan, decongestants, St. John’s wort. Washout ~2 weeks between MAOI and other antidepressants (5 weeks after fluoxetine) |
2. Mood Stabilizers
- Lithium: narrow range (commonly ~0.6–1.2 mEq/L; trough ~12 hr post-dose); monitor kidneys, thyroid, sodium; NSAIDs, thiazides, ACE inhibitors raise levels; dehydration/low sodium → toxicity. See the Bipolar guide
- Valproate: hepatotoxicity, pancreatitis, thrombocytopenia, teratogenic
- Carbamazepine: SJS/TEN, blood dyscrasias, enzyme inducer (many interactions)
- Lamotrigine: slow titration; any rash → report (SJS)
3. Antipsychotics
- First-generation (haloperidol, chlorpromazine, fluphenazine): high risk; anticholinergic and sedation vary
- Second-generation (risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, lurasidone, clozapine): monitoring (weight, waist, BP, glucose/A1C, lipids); ziprasidone and others — ; risperidone — prolactin elevation
- Clozapine: ANC monitoring for ; seizures, myocarditis, severe constipation
- Boxed warning: increased mortality in older adults with dementia-related psychosis
- EPS treatment: anticholinergics (benztropine, diphenhydramine) for dystonia/parkinsonism; propranolol for akathisia; VMAT2 inhibitors for tardive dyskinesia; AIMS screening
- Long-acting injectables improve adherence
4. Anxiolytics & Hypnotics
- Benzodiazepines (lorazepam, diazepam, alprazolam, clonazepam): rapid relief, alcohol withdrawal, seizures. Sedation, falls (Beers list — avoid in older adults), respiratory depression with opioids/alcohol (boxed warning), dependence; taper — withdrawal seizures. Reversal: flumazenil (seizure risk)
- Buspirone: GAD; weeks to work; non-sedating; not PRN
- Z-drugs (zolpidem): complex sleep behaviors (sleep-driving) — stop if they occur
5. ADHD Medications (quick hits)
- Stimulants (methylphenidate, amphetamines): appetite loss/weight, insomnia (give early in day), increased HR/BP, growth monitoring in children, controlled substances (misuse)
- Non-stimulants: atomoxetine (boxed warning for suicidal thoughts in youth), guanfacine/clonidine (hypotension; don’t stop abruptly)
6. Toxicity Emergencies — Compare
| MAOI hypertensive crisis | ||||
|---|---|---|---|---|
| Cause | Serotonergic combos (SSRI + MAOI, tramadol, linezolid, triptans, St. John’s wort, dextromethorphan) | Antipsychotics (dopamine blockade) | Tyramine or interacting drugs with MAOI | High level, dehydration, low Na, NSAIDs/diuretics |
| Onset | Rapid (hours) | Days | Minutes–hours after exposure | Gradual or acute |
| Hallmarks | Agitation, hyperreflexia, clonus, tremor, diaphoresis, diarrhea, hyperthermia, mydriasis | Lead-pipe rigidity, high fever, altered mental status, autonomic instability, high CK | Severe occipital headache, stiff neck, very high BP, palpitations, sweating, nausea | GI upset, coarse tremor, confusion, ataxia → seizures, arrhythmias |
| Actions | Stop serotonergic drugs, supportive care, cooling, benzodiazepines; cyproheptadine per provider | Stop antipsychotic, cooling, fluids; dantrolene/bromocriptine per provider | Hold MAOI; emergency BP control per provider; monitor neuro status | Hold lithium, stat level, IV NS, ECG; dialysis if severe |
Anticholinergic toxicity (TCAs, diphenhydramine): “hot as a hare, dry as a bone, red as a beet, blind as a bat, mad as a hatter, full as a flask.”
7. General Nursing Considerations
- Assess baseline vitals, weight, labs, ECG, pregnancy status before starting
- Screen for suicide risk when starting/changing antidepressants
- Check for interactions (including OTC and herbals like St. John’s wort)
- Teach about delayed onset, adherence, not stopping abruptly, avoiding alcohol, and fall precautions
- Older adults: “start low, go slow”; avoid strongly anticholinergic drugs and benzodiazepines when possible
8. Memory Aids
- MAOI = “Must Avoid Over-aged Items” (aged/fermented foods)
- Serotonin syndrome = “Shivering, Shaking, Sweating, Spasming (clonus)” — fast onset; NMS = “Stiff and Slow”
- Lithium: watch the 3 “Ds” — Dehydration, Diuretics, Drugs (NSAIDs)
- Clozapine = Counts; Lamotrigine = Look for rash; Valproate = liVer
9. NCLEX-Style Practice Questions
1. A patient taking sertraline was prescribed tramadol and now has agitation, diaphoresis, temperature 101.5 °F (38.6 °C), and ankle clonus. The nurse suspects:
A. Neuroleptic malignant syndrome
B. Serotonin syndrome
C. Lithium toxicity
D. Anticholinergic toxicity
Answer: B. Rapid onset with clonus/hyperreflexia after adding a serotonergic drug.
2. Which meal choice indicates the patient on phenelzine understands dietary teaching?
A. Aged cheddar on crackers
B. Salami sandwich
C. Fresh roasted chicken with rice and green beans
D. Soy sauce stir-fry with tap beer
Answer: C. Fresh foods are low in tyramine.
3. A patient on an MAOI reports a sudden severe occipital headache and stiff neck. The nurse should first:
A. Give acetaminophen and have the patient rest
B. Check blood pressure
C. Offer a snack
D. Encourage fluids
Answer: B. These suggest hypertensive crisis; assess BP and notify the provider.
4. Which statement by a patient starting olanzapine shows understanding?
A. “I don’t need any blood tests on this medicine.”
B. “I’ll have my weight, blood sugar, and cholesterol checked regularly.”
C. “It will cure my illness within a week.”
D. “I can stop it whenever I feel better.”
Answer: B. SGAs require metabolic monitoring.
5. Which patient is at greatest risk for harm from a 30-day supply of amitriptyline?
A. A patient with chronic neuropathic pain
B. A patient with depression who has a recent suicide attempt
C. A patient with insomnia
D. A patient with migraines
Answer: B. TCA overdose is highly lethal; dispense limited quantities.
References
Edinoff, A. N., Akuly, H. A., Hanna, T. A., Ochoa, C. O., Patti, S. J., Ghaffar, Y. A., Kaye, A. D., Viswanath, O., Urits, I., Boyer, A. G., Cornett, E. M., & Kaye, A. M. (2021). Selective serotonin reuptake inhibitors and adverse effects: A narrative review. Neurology International, 13(3), 387–401. https://doi.org/10.3390/neurolint13030038
Simon, L. V., Torrico, T. J., & Keenaghan, M. (2024). Serotonin syndrome. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482377/
National Institute of Mental Health. (n.d.). Mental health medications. Retrieved October 15, 2026, from https://www.nimh.nih.gov/health/topics/mental-health-medications
U.S. Food and Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. Retrieved October 15, 2026, from https://www.accessdata.fda.gov/scripts/cder/daf/
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page