Antidepressants

Treatments

CBT, interpersonal therapy, exercise, meds, ECT, EMT, vagus nerve stimulation, deep brain stimulation

Antidepressants

SSRIs, SNRIs, Heterocyclics, MAO inhibitors, Tricyclics (TCAs)

most commonly prescribed antidepressants

SSRIs, SNRIs, heterocyclics

Which antidepressant is most risky?

Tricyclics - potentially fatal arrythmia in overdose by prolongation of QT interval

how long for response to med?

4 weeks for 50% improvement

how long for remission?

4 months, but don’t stop taking

how long to take?

if 1st episode: ~1 year after reaching remission

if 2nd episode: lifelong

black box warning for antidepressants

increased risk of suicidal thinking and behavior in children, adolescents, and young adults

if undiagnosed bipolar?

antidepressants can trigger manic/hypomanic episode

which antidepressant CAN NOT be given with any other antidepressant

MAOI & requires 2 week wash out period

how long to have a response (50% improvement) to antidepressants

4 weeks (really 6-8)

how long to be in remission (no sx) via antidepressants

4 months. keep taking even if feeling better

1st episode of depression, how long to stay on antidepressants?

9-12 months after reaching remission. taper off during a non high stress time

2nd episode of depression, how long to stay on antidepressants?

lifelong

apathy syndrome/apathetic responder

can happen when first starting med, feel really unmotivated & numb. will switch meds

SSRI mechanism of action

Block 5-HT (serotonin) reuptake transporter to increase availability of serotonin in synapse

SSRI unique side effect

tachyphylaxis/poop out syndrome: all of a sudden (no trigger) meds stop working and sx come back

SSRIs

fluoxetine (Prozac, Serafem), Sertraline (Zoloft), Fluvoxamine (Luvox), Paroxetine (Paxil, Brisdelle), Citalopram (Celexa), Escitalopram HBr (Lexapro), Vilazodone (Viibryd), Vortioxetine (Trintellix)

SSRI indications

Panic, OCD, PTSD, GAD, Social Phobia, Bulimia

SSRI common side effects

usually gets better over time

nausea, loss of appetite, diarrhea, constipation, dry mouth, sweating, anxiety, palpitations, yawning, insomnia, headache, decreased sex drive/impotence (ongoing), vertigo

SNRI mechanism of action

block reuptake of serotonin and norepinephrine (selective)

SNRI side effects

unique: urinary retention, increased BP & HR (check BP)

common: nausea, dry mouth, constipation

SNRIs

Venlafaxine HCl (Effexor), Desvenlafaxine (Pristiq), Duloxetine (Cymbalta), Levomilnacipran (Fetzima)

TCAs/tricyclics mechanism of action

Block reuptake of serotonin and norepinephrine (non-selective: also affect muscarinic, histaminic, alpha-1 adrenergic receptors = more side effects)

TCAs indications

depression, fibromyalgia, sleep

TCAs Contraindications

(get EKG before) heart disease, acute MI, epilepsy, narrow-angle glaucoma

TCAs side effects

Arrhythmia, anticholinergic (dry mouth, blurred vision, urinary retention, constipation, in elderly = confusion), EPS (most common is pill rolling), photosensitivity, orthostatic hypotension, sedation (think histamine receptor), increased appetite and weight gain, sexual dysfunction, tremors

Lethal in overdose, 1 month’s worth taken at once is fatal = NOT good for suicidal

TCAs

-triptyline (Amitriptyline, Nortriptyline, Protriptyline) -pramine (Imipramine, Desipramine, Trimipramine, Clomipramine), Doxepin, Amoxapine

MAOIs mechanism of action

inhibits MAO (the enzyme that breaks down neurotransmitters) to increase norepinephrine, dopamine, serotonin

Last resort for depression

MAOIs - lots of interactions, dietary considerations. MUST have 2 week wash out period if switching

MAOIs

Phenelzine (Nardil), Tranylcypromine (Parnate), Selegine (EMSAM), Isocarboxazid (Marplan)

MAOI side effects

sweating, tremors, dizziness, increase BP, palpitations

MAOI diet

avoid foods high in tyramine: aged/fermented/pickled foods = aged cheese, caviar, wine, beer, raisins, chocolate, colas, pickled herring, coffee, tea, yeast products, sour cream, yogurt, broad beans, smoked/processed meats, soy sauce, liver, canned figs

What happens if eat foods w/ tyramine & taking a MAOI

Hypertensive crisis!!! severe occipital headache, palpitations, N/V, nuchal rigidity, fever, sweating (seems like meningitis), very high BP, chest pain, coma.

Tx: hold MAOI, call provider, monitor vitals, ice packs, anti-HTN

Heterocyclics/other

Trazodone (Desyrel), Nefazodone (Serzone), Mirtazepine (Remeron), Bupropion (Wellbutrin, Zyban)

St John’s Wort

used for depression, anxiety, sleep disorder. interacts with some drugs.

functions like an MAOI

side effects: anxiety, dry mouth, dizziness, GI sx, fatigue, headache, sexual dysfunction, photosensitivity

SAM-E

not an herb/hormone, is an amino acid that increases availability of serotonin and dopamine

serotonin syndrome

too much stimulation at serotonin receptor sites, caused by 2+ meds that increase CNS serotonin by different mechanisms

Usually mild & caught early but can be serious & fatal

serotonin syndrome sx

changes in mental status, restlessness, myoclonus (muscle twitching), hyperreflexia, tachycardia, labile BP, diaphoresis, shivering, tremors, hyperthermia, muscle rigidity

Life threatening complications: seizures, coma, hypotension, ventricular arrhythmias, DIC, rhabdomyolysis, metabolic acidosis, renal failure

serotonin syndrome tx

cyproheptadine (Periactin)

Discontinuation syndrome

all antidepressants can cause this. abrupt withdrawal can cause:

with SSRIs/SNRIs: dizziness, lethargy, headache, nausea, flu-like sx, anxiety, insomnia, tingles/electric shocks, GI upset, vivid/bizarre dreams, difficulty with memory and concentration

with TCAs: hypomania, akathisia, cardiac arrhythmias, GI upset, panic attacks. DANGEROUS

with MAOIs: flu-like sx, confusion, hypomania, worsening of depressive sx

ALL antidepressants should be tapered gradually to prevent withdrawal sx