NURS 6521 Week 5: Neurological System

Sample Answer for NURS 6521 Week 5: Neurological System Included After Question

Neurological disorders, such as headaches, seizure disorders, sleep disorders, depression, and dementia can present several complications for patients of all ages. These disorders affect patients physically and emotionally, impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders may have drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to manage the diagnosis, treatment, and education of patients with neurological disorders. 

To prepare: 
Review this week’s media presentation on pharmacology for the nervous system. 
Select one of the following neurological disorders: headaches, seizure disorders, sleep disorders, depression, or dementia. Consider the types of drugs that would be prescribed to patients to treat symptoms associated with this disorder. 
Select one of the following factors: genetics, gender, ethnicity, age, or behavior. Reflect on how this factor might impact the effects of prescribed drugs, as well as any measures you might take to help reduce negative side effects. 

With these thoughts in mind: 

By Day 3 

Post a description of the neurological disorder you selected including types of drugs that would be prescribed to patients to treat associated symptoms. Then, explain how the factor you selected might impact the effects of prescribed drugs, as well as any measures you might take to help reduce negative side effects. 

By Day 6 

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who selected a different neurological disorder than you did. Provide recommendations for alternative drug treatments and patient education strategies for treatment and management. 

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! 

According to an article published in the Los Angeles Times, drug misuse is the leading cause of accidental death in the United States. Some of the most common drugs found in association with drug-related deaths are drugs prescribed to treat neurological disorders. These prescription drug-related deaths are often attributed to painkillers such as OxyContin and Vicodin, as well anti-anxiety drugs such as Valium and Xanax (Girion, Glover, & Smith, 2011). This issue emphasizes the importance of the regulation and management of prescription drugs. You must be aware of this when prescribing controlled drugs commonly used to treat neurological disorders such as headaches, sleep disorders, anxiety, and depression. As an advanced practice nurse, you have the responsibility to carefully diagnose and prescribe treatment, as well as to closely monitor the effects of drug therapies on the physical and mental health of your patients. 

In the previous weeks of this course, you began to explore disorders and treatments as they relate to specific body systems. This week, you continue this exploration with the nervous system, but with special considerations in mind. Treatments for nervous system disorders present unique issues not just because of the scope and breadth of the disorders, but also because the types of drugs that are often used for treatment. You examine types of drugs prescribed to treat neurological disorders, as well as the impact of patient factors on the effects of the drugs. 

NURS 6521 Week 5: Neurological System
Learning Objectives 

By the end of this week, students will: 

Analyze types of drugs prescribed to treat neurological disorders 
Evaluate the impact of patient factors on the effects of prescribed drugs for neurological disorders 
Evaluate drug therapy plans for neurological disorders 
Analyze patient education strategies for treatment and management of neurological disorders 
Understand and apply key terms, concepts, and principles related to prescribing drugs to treat neurological disorders 

Photo Credit: akindo/DigitalVision Vectors/Getty Images 

Learning Resources 

This page contains the Learning Resources for this week. Be sure to scroll down the page to see all of this week’s assigned Learning Resources. To access select media resources, please use the media player below. 

Required Readings 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

Chapter 7, “Principles of Pharmacology in Pain Management” (pp. 93-109)
This chapter begins by examining acute and chronic pain. It also explores the pathophysiology of pain, general principles for managing pain, and drugs used in pain management.  

Chapter 38, “Headaches” (pp. 629-654)
This chapter covers the causes, pathophysiology, and diagnostic criteria for tension and migraine headaches. It then outlines the process of selecting, administering, and managing drug therapy for headaches, including migraines and cluster headaches.  

Chapter 39, “Seizure Disorders” (pp. 655-680)
This chapter explores the causes, pathophysiology, and diagnostic criteria of seizures. It also describes the process of selecting, administering, and managing drug therapy for patients with seizures.  

Chapter 40, “Major Depressive Disorder” (pp. 681-699)
This chapter begins by identifying the causes, pathophysiology, and diagnostic criteria of major depressive disorder (MDD). It then examines types of depressions and drugs prescribed to treat patients suffering from MDD.  

Chapter 41, “Anxiety” (pp. 701-718)
This chapter examines the causes, pathophysiology, and diagnostic criteria for anxiety. It also outlines the process of selecting, administering, and managing drug therapy for patients with anxiety.  

Chapter 42, “Insomnia and Sleep Disorders” (pp. 721-755)
This chapter covers the causes, pathophysiology, and diagnostic criteria of three sleep disorders: insomnia, restless leg syndrome and periodic limb movement disorder, and narcolepsy. It also examines the process of selecting, administering, and managing drug therapy for patients with these sleep disorders.  

Chapter 44, “Alzheimer’s Disease” (pp. 757-780)
This chapter examines the causes and pathophysiology of Alzheimer’s disease (AD). It also describes various drugs used to treat symptoms of AD, including proper dosages and possible adverse reactions.  

American Academy of Family Physicians. (2012). Dementia. Retrieved from http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=5 

This website provides information relating to diagnosis, treatment, and patient education of dementia. It also presents information on complications and special cases of dementia. 

Required Media 

Laureate Education, Inc. (Executive Producer). (2012). Pharmacology for the nervous system. Baltimore, MD: Author. 

This media presentation outlines drug treatment options for disorders of the nervous system. 

Note: The approximate length of this media piece is 7 minutes. 

Optional Resources 

Refer to the Optional Resources listed in Week 1. 

A Sample Answer For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System

Headaches are among the top complaints that patients have when they see their primary care providers (Arcangelo, Peterson, Wilbur & Reinhold, 2017,  p.629). There are several types of headaches. When there is no identifiable underline disease process the headache is considered a primary headache, and with secondary headaches, the primary cause is identified (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.629).  Within the two groups are subgroups, primary headaches include tension-type headaches (TTH), migraine, and cluster headache (CH) and secondary headaches have another cause that must be determined first before an acute diagnosis of primary or secondary can be made (Arcangelo, Peterson, Wilbur & Reinhold, 20017, p.629).  

The medication prescribed to treat the head would be determined by the type of headache the patient is experiencing.  If a headache is a secondary headache, the underlying illness would be treated which would most likely relieve the headache. In tension-type headaches, the provider would initiate be medications that the patient could purchase over the counter (OTC).  These medications include acetaminophen, aspirin, non-steroidal Anti-inflammatory drugs (NSAIDs), antiemetic agents, and combinations medications that contain caffeine such as Excedrin (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.632-633).  The aim of treatment for a headache is to decrease the number of attacks and the intensity so that the patient can function as normal as possible.   

Treating migraine headaches take a slightly different approach.  The drug therapy is tailored to the patient because each patient can have different triggers, different levels of intensity, and a different amount of attacks. While medications are used to manage migraines, the provider may also suggest therapies that are not pharmacological such as stress management, relaxation techniques, and recognizing triggers early (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.638). Migraines often require more than OTC medications to make the headaches.  Medications used in treatment include NSAIDs, caffeine-containing compounds, Triptans, Ergot derivatives, barbiturates, opioids, steroids, antiemetic agents (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.644-648). 

Medications for Migraines: 

First Line: 

Ibuprofen and aspirin are among the first line of therapy when trying to bring relief from a migraine headache.  Ibuprofen is an NSAID used to treat mild to moderate pain. Its mechanism of action is that it reversibly inhibits COX-1 and COX02 enzymes, causing a decrease formation of prostaglandin precursors (Kizior, 2018, p.561).  It helps to relieve pain and decrease inflammation.  The pharmacokinetics of ibuprofen is that it is absorbed from the GI tract, protein binding 90-99%, broken down by the liver and eliminated in the urine, and cannot be removed by hemodialysis, with a half-life of 2-4 hours (Kizior, 2018, p.561).  Ibuprofen must be used with caution in children and the elderly population. Older patients may require a lower dose to avoid toxicity.  In children who are less than six months safety has not been determined.   

For the acute treatment of a migraine that is of moderate to severe intensity Triptans are used.  One of the Triptans used is sumatriptan its therapeutic effect is to relieve migraine headaches.  Its mechanism of action is that it binds selectively to serotonin 5-HT1receptors in cranial arteries, to achieve vasoconstrictive effect on cranial blood vessels, the pharmacokinetics of sumatriptan is that it is quickly absorbed after subcutaneous administration; after oral absorption is not complete; a majority is broken down by the liver causing a low bioavailability, protein binding of 10%-21%, it is widely distributed, the amount of medication is decreased before it reaches the systemic circulation with a half-life of 2 hours (Kizior, 2018, p.1095).  If the first line of treatment does not work the provider will then move to the second line of treatment.  The third line of treatment is much stronger medications in the class containing butalbital and opioids.   

Cluster headaches should be evaluated quickly because they could be an indication of a serious issue, so it is best to follow up with a neurologist.  The most severe primary headache form is cluster headaches. Treating cluster headaches are done with sumatriptan and may be administered in different routes including subcutaneous and nasal spray (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.651).  There are medications that are used as in chronic and episodic cluster headaches — Verapamil, lithium, melatonin, topiramate, gabapentin, valproic acid, DHE, leuprolide intranasal capsaicin and baclofen (Leone, Giustiniani, Cecchini, 2017, pS46).   

Factor: Age 

Age is a factor when it comes to the medications that are prescribed to patients who suffer from headaches.  Medications have to be prescribed cautiously in children and the elderly population for several reasons.  Children usually require a much smaller weight-based medication, and the elderly population often metabolize medical different because of natural aging and another underlying disease that affects the kidney and liver.  In children and adolescence headaches are common, and they need to see a pediatric neurologist (Jeong, Lee, Lee & Han, 2018, p.1).  Sumatriptan can cause heart arrhythmias in patient’s with hypertension, obesity, who are smokers, has diabetes, and a family history of coronary artery disease (Kizior, 2018, p.1096).  These are all many diseases that elderly patients suffer from due to normal aging. 

Reference: 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).  

Pharmacotherapeutics for advanced practice: A practical approach(4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

Jeong, Y. J., Lee, Y. T., Lee, I. G., & Han, J. Y. (2018). Primary headaches in children and  

adolescents – experiences at a single headache center in Korea. BMC Neurology, 18(1), 70. https://doi-org.ezp.waldenulibrary.org/10.1186/s12883-018-1073-9 

Kizior, R. (2018). Saunders Nursing Drug Handbook 2019. Elsevier – Health Sciences Division. 

Leone, M., Giustiniani, A., & Cecchini, A. (2017). Cluster headache: present and future  

therapy. Neurological Sciences, 38, 45–50. https://doi-org.ezp.waldenulibrary.org/10.1007/s10072-017-2924-7 

Özge, A., Abu-Arafeh, I., Gelfand, A. A., Goadsby, P. J., Cuvellier, J. C., Valeriani, M., …  

Guidetti, V. (2017). Experts’ opinion about the pediatric secondary headaches diagnostic criteria of the ICHD-3 beta. The Journal Of Headache And Pain, 18(1), 113. https://doi-org.ezp.waldenulibrary.org/10.1186/s10194-017-0819-x 

A Sample Answer 2 For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System

               Depression is a disorder of mood that where cognition, behavior, and physical function is altered that tends to be more prevalent in the fourth decade of life (Arcangelo, Peterson, & Reinhold, 2017). The classic symptoms tend to be a depressed mood, sadness, hopelessness, change in appetite and weight, guilt, difficulty concentrating, loss of interest, sleep disturbances, and suicidal ideation (Arcangelo, Peterson, & Reinhold, 2017). The cause is a interplay of multiple factors including social, genetic, biochemical, physiological, and environmental factors (Arcangelo, Peterson, & Reinhold, 2017). Physiologically, theories have indicated an abnormality and/or decrease in neurotransmitter (Serotonin, norepinephrine, or dopamine) release or postsynaptic sensitivity (Arcangelo, Peterson, & Reinhold, 2017). Types of depression include persistent depressive disorder, postpartum depression, psychotic depression, seasonal affective disorder, and bipolar depressive disorder (U.S. Department of Health and Human Services, 2018). 

               Persistent depressive disorder occurs when the patient has five or more symptoms that last for two or more years (U.S. Department of Health and Human Services, 2018). Postpartum depression occurs during pregnancy or after delivery, and is characterized by anxiety, extreme sadness, and exhaustion that make it hard for mothers to care for themselves and their babies (U.S. Department of Health and Human Services, 2018). Psychotic depression is severe depression accompanied by psychosis (U.S. Department of Health and Human Services, 2018). Seasonal affect disorder is when depression occurs during the winter months, and bipolar depressive disorder occurs when the patient with bipolar disorder experiences symptoms of depression during their times of low moods (U.S. Department of Health and Human Services, 2018). Non-pharmacological and pharmacological methods of treatment exist, which can be used simultaneously. For the purposes of this discussion, pharmacological treatment with be discussed. 

Pharmacological Treatment of Depression 

               Over the past 25 years, the use of antidepressants has been correlated to the decrease in suicidal mortality associated with depression (Vuorilehto, Melartin, Isometsa, & Riikimaki, 2016). The selection of the pharmacological treatment of the depression is contingent of the side effect profile, symptomology of the patient compared to the desired outcome, and the patient preference (Arcangelo, Peterson, & Reinhold, 2017). The classes of antidepressants that exist are Selective Serotonin Reuptake Inhibitor (SSRI), Serotonin Norepinephrine Reuptake Inhibitor (SNRI), Tricyclic Antidepressant (TCAs), Monoamine Oxidase (MAO) inhibitors, and atypical agents.   

               SSRIs are a newer class of antidepressants that have replaced the TCAs as the first line pharmacological treatment of depression due to the need for fewer titrations and the reduction in the lethality of the in overdosing on the medication (Arcangelo, Peterson, & Reinhold, 2017). The mechanism of action includes the SSRI hindering the reuptake of the neurotransmitter into the presynaptic neuron by binding with the serotonin transporter (Arcangelo, Peterson, & Reinhold, 2017). The effects of this medication can be seen between 4 to 6 weeks with the full length of the treatment possibly being concluded at the 4 to 6 month period (Arcangelo, Peterson, & Reinhold, 2017). Adverse effects include the possibility of causing insomnia or anxiety, weight gain, and sexual dysfunction (Arcangelo, Peterson, & Reinhold, 2017). Caution should be utilized in patient with seizures and this medication should not be discontinued abruptly (Arcangelo, Peterson, & Reinhold, 2017). SSRIs also hinder various components of the cytochrome P-450 system which can cause elevations of other medications that are metabolized by this system (Arcangelo, Peterson, & Reinhold, 2017). Some drugs included in this class are citalopram, fluoxetine, and paroxetine. 

               SNRIs are potent protein inhibitors that inhibit the uptake of serotonin and norepinephrine and have a weak hindrance of dopamine reuptake (Arcangelo, Peterson, & Reinhold, 2017). The effect of SNRIs can be seen between 4 to 6 weeks, but can potentially take up to 12 weeks (Arcangelo, Peterson, & Reinhold, 2017). SNRIs are used to treat severe and treatment resistant depression (Arcangelo, Peterson, & Reinhold, 2017). Side effects include dry mouth, constipation, nausea, and insomnia (Arcangelo, Peterson, & Reinhold, 2017). Caution should be utilized when discontinuing this medication due the potential to evoke the discontinuation syndrome (Arcangelo, Peterson, & Reinhold, 2017). Serotonin syndrome ca be induced by the concurrent use with MAO inhibitors (Arcangelo, Peterson, & Reinhold, 2017).  Examples of drugs in this class include venlafaxine, desvenlafaxine, and duloxetine. 

               TCAs were a class considered the first line of treatment before SSRIs were created; however, the challenge with tolerability (secondary to the side effect profile) caused it to be the second or third choice of therapy (Arcangelo, Peterson, & Reinhold, 2017). It works by inhibiting serotonin and norepinephrine; however, the pharmacokinetics are patient based (Arcangelo, Peterson, & Reinhold, 2017). Adverse effects can include sedation (which can be beneficial for patients experiencing insomnia), hypotension (certain drugs in the class), weight gain, and life-threatening cardiac conduction abnormality (Arcangelo, Peterson, & Reinhold, 2017). It should not be used in patients with a history of epilepsy (Arcangelo, Peterson, & Reinhold, 2017). It should not be used with anticholinergic drugs, such as diphenhydramine, and can cause a hypertensive crisis if used concurrently with MAO inhibitors (Arcangelo, Peterson, & Reinhold, 2017). 

               MAO Inhibitors were the first effective drugs that worked by irreversibly, nonspecifically, inhibiting type A and type B monoamine oxidase which leads to a decreased breakdown of norepinephrine, serotonin, and dopamine in the synapse (Arcangelo, Peterson, & Reinhold, 2017). MAO Inhibitors can cause life-threatening hypertensive crisis, orthostatic hypotension (with certain meds), and is usually the last line of treatment due to the adverse effect profile (Arcangelo, Peterson, & Reinhold, 2017). A strict diet must be followed to eliminate the tyramine-containing foods out of the patients diet, such as aged cheese, beef-liver, chicken liver, and yeast products to prevent hypertensive crisis (Arcangelo, Peterson, & Reinhold, 2017). Concurrent utilization of MAO Inhibitors can cause hypertensive crisis that can result in seizures and death (Arcangelo, Peterson, & Reinhold, 2017). An example of a MAO Inhibitor would be phenelzine. 

Atypical antidepressants are ones that do not fit into the traditional classification. An example of an atypical antidepressant is Bupropion and Trazadone (U.S. Department of Health and Human Services, 2018). There mechanisms of actions vary from drug to drug. 

Age and Treatment of Depression 

               Age plays a significant factor in the selection of pharmacological treatment of depression. In patients 25 years old and younger, SSRIs can increase the suicidal attempts and completion (Arcangelo, Peterson, & Reinhold, 2017). SSRIs have no impact on the rate of suicidal attempts and completion in 25-65 years old patients (Arcangelo, Peterson, & Reinhold, 2017) and they have a decreased rate of suicidal attempts and completion in patients greater than 65 years old (Arcangelo, Peterson, & Reinhold, 2017). SNRIs can cause sexual dysfunction, which is particularly important to the sexually active individual. TCAs are contraindicated in the elderly due to the increased incidence of cardiovascular adverse effects. Caution should be utilized with all individuals with certain disabilities, which the presence of comorbidities are usually increased in the elderly population. 

Measures to Decrease Side Effects 

               Medication review and reconciliation would be the first step to decreasing the potential for side effects. Ensuring there are not any drugs that can interact with the prescribed medication is crucial. Monitoring the effects and potential side effects of the antidepressants is another method, especially MAO inhibitors, would be another method through frequent follow-ups (especially in the beginning of prescribing the medication) to ensure the patient is taking the medications and gauge the side effects versus he benefits. Patient education about all of the potential side effects, the length of time it takes for the medication to take effect, and the impact abruptly stopping the medication can have on the body would be crucial. Lastly, when prescribing MAO Inhibitors, prescription of support stockings, stimulants or mineralocorticoids can help decrease the hypotensive effect (Arcangelo, Peterson, & Reinhold, 2017). 

Summary 

               In summary, depression is a mood disorder that can be treated pharmacologically or non-pharmacologically. Drug classes used to treat depression are Selective Serotonin Reuptake Inhibitor (SSRI), Serotonin Norepinephrine Reuptake Inhibitor (SNRI), Tricyclic Antidepressant (TCAs), Monoamine Oxidase (MAO) inhibitors, and atypical agents. Selection of the agent is based on the side effect profile, the desire of the patient, and the symptomology of the patient in comparison to the desired outcome. Age has a significant impact on the effects of the medication. Medication review, patient education, and appropriate treatments would be prescribed to minimize the effects of the medications prescribed. 

Reference 

Arcangelo, V. P., Peterson, A. M., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: A Practical Approach. Ambler, PA: Lippincott Williams & Wilkins. 

U.S. Department of Health and Human Services. (2018). Deppression. Retrieved from National Institue of Mental Health: https://www.nimh.nih.gov/health/topics/depression/index.shtml 

Vuorilehto, M. S., Melartin, T., Isometsa, E. T., & Riikimaki, K. (2016). Pharmacological and psychosocial treatmet of depression in primary care: Low intensity ad poor adherence and continuity. Journal of Affective Disorders, 145-152. 

A Sample Answer 3 For the Assignment: NURS 6521 Week 5: Neurological System
Title: NURS 6521 Week 5: Neurological System

     The theories behind what causes depression vary, but primarily suggest that imbalances of the monoamine catecholamines norepinephrine, serotonin, and dopamine play a leading role (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Drugs that may be prescribed for major depressive disorder (MDD) include medications from selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and atypical antidepressants. Because the drugs from all classes have similar efficacy, prescribing from these drug classes is primarily based on patient preference, focused treatment of symptoms, and avoidance of side effects (Arcangelo et al., 2017). While a decrease of 50 percent of pretreatment symptoms is considered a meaningful response, the treatment goal is complete relief (Saltiel & Silverstein, 2015). 

     SSRIs selectively inhibit serotonin reuptake by the presynaptic neuron leaving more serotonin (5HT) in the synaptic cleft (Whalen, Finkel, & Panavelil, 2015). This change occurs rapidly, but clinical results take four to six weeks to show; this gap in the change of available serotonin to positive result challenge the theories that an imbalance of monoamine catecholamines are the primary cause of MDD and this applies to traditional classes of antidepressants (Arcangelo et al., 2017). SSRIs are associated with causing sexual dysfunction and weight gain; this is a common cause for noncompliance (Arcangelo et al., 2017). 

     SSRIs are well absorbed orally and operating at their peak level in two to eight hours, and dosage should be adjusted for patients with liver disease (Whalen et al., 2015). SSRIs inhibit pieces to the cytochrome P-450 (CYP450) system; other medications that rely on this metabolism pathway may need to have their dosage decreased, and SSRIs should not be given with a MAOI (Arcangelo et al., 2017). Escitalopram is an example of an SSRI; over fifty percent is protein bound, metabolized mainly in the liver, and has a half-life of 27-32 hours (DrugBank, n.d.) 

Plasma half-lives are between 16-36 hours for most SSRIs except fluoxetine which has a half-life of 50 hours; this information is essential for the clinician discontinuing patient treatment with these medications. 

     SNRIs work by inhibiting both serotonin and norepinephrine reuptake and may be useful in patients with MDD who also have chronic pain because pain is also modulation by these pathways (Whalen et al., 2015); there is some discussion that SNRIs may be more effective than SSRIs for those with severe MDD because of their broader action (Arcangelo et al., 2017). 

     SRNIs are metabolized by the CYP450 system as well and drug-drug interactions must be considered; dry mouth, constipation, insomnia, and nausea are side effects secondary to noradrenergic activity (Arcangelo et al., 2017). They also weakly inhibit reuptake of dopamine (Arcangelo et al., 2017). 

     An example of an SRNI is venlafaxine. Venlafaxine primarily inhibits serotonin reuptake with higher doses also inhibiting norepinephrine intake (Whalen et al., 2015). Its absorption is not affected by food intake, has a bioavailability of about 45 percent, is metabolized by the liver, excreted by the kidneys, and has a half-life of five hours (DrugBank, n.d.). 

     TCAs are like SNRIs in that they block the reuptake of both serotonin and norepinephrine but differ in that they block the action of serotonergic, alpha-adrenergic, histaminic, and muscarinic receptors (Whalen et al., 2015). The side effects associated with their broader spectrum of action is also responsible for increased adverse side effects, and as a result, TCAs are no longer considered first-line treatment for MDD (Arcangelo et al., 2017). This class of drugs is associated with sedation as well as anticholinergic effects because of muscarinic blocking action of the drugs (Whalen et al., 2015). TCAS can also be lethal in amounts equaling five to six times the standard dose; drugs should be prescribed in small quantities (Whalen et al., 2015). 

     Nortriptyline is a TCA and is an active metabolite of amitriptyline but has fewer anticholinergic effects than amitriptyline and is an active inhibitor or norepinephrine reuptake (DrugBank, n.d.). Over ninety percent of the drug is protein bound, metabolized by the liver, and excreted by the kidneys; it has a half-life of twenty-six hours (DrugBank, n.d.). Nortriptyline is less likely to cause orthostatic hypotension which may make it a good choice for elderly patients (Arcangelo et al., 2017). 

     MAOIs inhibit monoamine oxidase (MAO) which is a mitochondrial enzyme that inactivates neurotransmitters including norepinephrine, serotonin, and dopamine (Arcangelo et al., 2017). Inactivation of the enzyme is caused the formation of stable complexes of the MAO and MAOI; this may be irreversible, and because MAOs are also utilized in the liver and gut, high drug-drug and drug-food interactions are associated with MAOI use. For example, patients taking MAOIs should be counseled to avoid foods high in tyramine (cured meats are one example) to avoid a hypertensive crisis (Arcangelo et al., 2017). MAOIs are well absorbed by oral intake and enzyme regeneration can take up to two weeks after the drug is stopped to occur (Whalen et al., 2015). TCAs and MAOIs should not be prescribed together, and extreme caution used when using MAOIs in combination with SSRIs or SSNIs (Arcangelo et al., 2017). This class of drug is second or third choice and may be useful in those patients with refractory depression when drugs from other classes have failed to effect a therapeutic response (Arcangelo et al., 2017). 

     Phenelzine is one example of an MAOI and also increases catecholamines and gamma-aminobutyric acid (GABA) in the brain (DrugBank, n.d.). It is readily absorbed after oral administration and has a half-life of less than twelve hours (DrugBank, n.d.). 

     Atypical antidepressants have diverse areas of action, and do not fit into the SSRI, SNRI, TCA, or MAOI classes (Whalen et al., 2015). Bupropion is a commonly prescribed drug from this class and is metabolized by the CYP2D6 pathway (Whalen et al., 2015). It is believed to block dopamine reuptake, is highly protein bound, and excreted by the kidneys (DrugBank, n.d.). 

    Treatment of children follows the basic rule of all pharmacological treatment choices for MDD; because most anti-depressants have similar efficacy, choosing one with the least side effects for the patient is a central piece to drug choice (Arcangelo et al., 2017). For example, fluoxetine is the only SSRI approved for treatment of MDD in children eight years and older because of increased risks of mania and suicide associated with SSRI use in children and teens (Arcangelo et al