The nurse is giving medications to a client. Which drug or drug class, when administered with lithium, increases the risk for lithium toxicity?

Citalopram (Celexa) is a selective serotonin reuptake inhibitor (SSRI) used for depression. Overdose of SSRIs can lead to serotonin toxicity, which manifests with neurologic, autonomic, and psychiatric disturbances. The nurse must quickly recognize these symptoms to prevent complications such as seizures and cardiovascular instability.

A. Seizures, hypertension, tachycardia, extreme anxiety. SSRI overdose increases serotonin levels, leading to CNS overstimulation, autonomic instability, and neuromuscular hyperactivity. Seizures, agitation, tachycardia, and hypertension are common.

B. Hypotension, bradycardia, hypothermia, sedation.
This cluster is more consistent with CNS depressants (e.g., benzodiazepines, barbiturates, opioids), not SSRIs.

C. Miosis, respiratory depression, absent bowel sounds, hypoactive reflexes.
These are classic signs of opioid toxicity, not SSRI overdose.

D. Manic behavior, paranoia, delusions, tremors.
These findings are more associated with stimulant toxicity (e.g., amphetamines, cocaine) or untreated mania, not SSRI overdose.

Take-home points:

• SSRI overdose can lead to serotonin syndrome: seizures, hyperthermia, agitation, hypertension, and tachycardia.
• It must be differentiated from opioid and CNS depressant overdose presentations.
• Early recognition is critical because untreated serotonin toxicity can progress to life-threatening complications.

Bipolar affective disorder is commonly managed with mood stabilizers. While lithium remains a first-line therapy, not all patients tolerate it due to side effects, drug interactions, or contraindications. In such cases, anticonvulsants such as divalproex (Depakote) are used as alternatives or adjuncts for mood stabilization.

D. divalproex (Depakote)
– Divalproex is an anticonvulsant that is also FDA-approved for bipolar disorder. It is especially effective in managing acute mania, mixed episodes, and rapid cycling. It is considered a reliable alternative for patients who cannot tolerate lithium due to renal impairment, toxicity risk, or lack of response.

A. thiopental
– Thiopental is a barbiturate used for induction of anesthesia and rapid sedation. It does not have a role in mood stabilization or long-term psychiatric management.

B. gingko biloba
– Ginkgo is an herbal supplement sometimes used to improve memory and circulation. It is not approved or effective for treating bipolar disorder and could potentially interact with psychiatric medications.

C. fluvoxamine (Luvox)
– Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI) used for depression and obsessive-compulsive disorder. While it can treat depressive symptoms, SSRIs alone can trigger manic episodes in bipolar patients, making them inappropriate as primary treatment.

Take-Home Points:

• Lithium is first-line for bipolar disorder, but divalproex is a widely used alternative.
• Anticonvulsants such as valproate and carbamazepine can stabilize mood in patients who cannot take lithium.
• SSRIs and herbal supplements are not used as primary therapy for bipolar affective disorder.